Acute Cardiac Care Unit Research Articles

Increased miRNA-related inflammation markers and pro-inflammatory circulating cell profile in patients with poor neurological outcome after out-of-hospital cardiac arrest

Abstract Background Out-of-Hospital Cardiac Arrest (OHCA) supposes a main cause of disability and mortality worldwide. Between patients suffering OHCA, only a 10-20% can be successfully resuscitated and, between them, a 50% suffers of neurological sequelae. Mechanisms underlying brain damage seems to be strongly related with neuroinflammation, mediated by classical (PCR, NLR) and novel (miRNAs) agents at play. Even there are studies suggesting the relevance of miRNA-mediated inflammatory response in ECA, no consistent conclusions about its role in ECA outcomes have been obtained. Purpose The aim of the present investigation is to study the temporal patterns of classical (PCR, NLR) and novel (miRNAs) inflammation markers during hospitalization of ECA patients and to correlate them with neurological outcome. Methods Consecutive OHCA patients were prospectively recruited at the Acute Cardiac Care Unit (ACCU) of the hospital Clinic of Barcelona from March 2019 to December 2023. Serum samples were obtained at 0, 24 and 72 hours after hospital admission. Patients were grouped according to their neurological outcome, measured by Cerebral Performance Category (CPC), at hospital discharge. Classical inflammation markers (PCR and NLR) were measured and in silico pre-targeted serum circulating-miRNAs were analysed by qPCR. Results A total of 120 patients (60 ± 13 years, 20% female) were included for the analysis. At hospital discharge, 55 (45%) patients survived with good NO (GNO; CPC 1-2) and 65 (55%) patients presented a poor NO (PNO; CPC 3-5). Classical inflammation markers such as PCR and NLR were significant higher in PNO than in GNO Group (P-value = 0.0042 and p-ANOVA = 0.0444, respectively) (Figure 1A). 11 inflammation-related miRNAs with strong correlation with OHCA-related conditions such as cardiovascular and coronary artery disease, hypoxic encephalopathy and neuro-inflammation were pre-targeted by in silico analysis. Five of the pre-targetedmiRNAs (miR-21-5p, miR-23a-3p, miR-146-5p, miR-155-5p and miR-181a-5p) presented significant differences between GNO and PNO groups (p-ANOVA = 0.0001, 0.0027, 0.0001, 0.0023 and 0.0002 respectively) in at least one time point, with an reduced expression in all cases in the PNO respect the GNO group (Figure 1B). Conclusions Patients with PNO after OHCA presents a downregulation of inflammation-regulatory miRNAs that leads an increase of clinical inflammation-related mediators such as PCR and NLR, with potential neuro-inflammatory consequences.

Impact of the guidelines recommendations in the management of non-ST-segment elevation myocardial infarction according to gender. Analysis of 30-day mortality

Abstract Funding Acknowledgements None. Background Current non-ST-segment elevation myocardial infarction (NSTEMI) guidelines recommend early invasive treatment (<24h) and simple antithrombotic treatment with aspirin (ASA). Classic studies describe a gender bias in the infarct treatment. Purpose To evaluate the impact of the guidelines recommendations in real-life management of NSTEMI in regards to invasive strategy and dual antiplatelet pretreatment (DAPT), and to analyze 30-day mortality according to gender. Methods A prospective unicentric registry of NSTEMI patients admitted to an Acute Cardiac Care Unit was conducted from January 2017 and December 2022. We analyzed the rates of early angiography (<24h) and pretreatment according to the guideline publication (01/09/2020). Patients were classified in two groups, depending on the time of admission in pre-guidelines (preCG) group (from January 2017 to September 1st 2020) and post-guidelines (postCG, admitted after September 1st 2020). We also analyzed the differences in management and 30-day mortality according to gender. Results A total of 787 consecutive NSTEMI patients were included, 24.9% women, mean age 65.3 years. Pretreatment with DAPT was routinely used in 90,2% of the cases, irrespective of gender or the new guidelines recommendation. Early angiography (<24 hours) was performed more frequently in men than women (61.6% vs 53.1%, p=0,035), although since the new guideline publication the early invasive management has increased in both genders (51.3% vs 72.6% in men, p<0,001; and 43.3% vs 64.1% in women, p=0,003). 30-day mortality tends to be higher in men, although the difference was not significant (4.6% in men vs 2.6% in women, p=0,212) and was not affected by the guideline publication (preCG 4.6% vs postCG 4.6% in men, p=0,994, preCG 2.9% vs post CG 2.2% in women, p=0,752). Conclusions In our NSTEMI registry there was an increase in the rates of early angiography, both in men and women, since the guideline publication, but there’s still a gender bias in the invasive treatment. Most NSTEMI patients still received DAPT pretreatment, without differences after the guideline publication. Despite the increase in early invasive management, 30-day mortality rates remain unchanged in both groups.

Gender differences in ST-segment elevation myocardial infarction: an analysis on treatment, complications and acute-phase mortality

Abstract Funding Acknowledgements None. Background Primary angioplasty is the gold-standard treatment in ST-segment elevation myocardial infarction (STEMI). Previous studies have shown differences in the treatment of STEMI between men and women. Purpose To analyze the differences in the management of STEMI between both genders in a mediterranean settlement when it comes to angioplasty, timing of revascularization, complication rates and 30-day mortality. Methods A prospective, unicentric study of consecutive STEMI patients that were admitted to an Acute Cardiac Care Unit was performed from January 2010 to December 2022. We compared the differences between genders on timing of revascularization, complication rates and 30-day mortality. Results A total of 4616 patients were included between 01/01/2010 and 31/12/2022, 21.75% were women. Women were older than men (68.5 vs 61.4 years, p<0,001), but there were no differences on cardiovascular risk factors, infarct location or ejection fraction. Female sex was associated with higher Killip class (Killip ≥2 on admission 22.6% vs 17.9%, p=0.005), less angioplasty rates (88.4% vs 93.1%, p<0.001), longer timing of revascularization (median time 223 minutes vs 178 minutes, p<0.001), higher rates of heart failure during admission (16.2% vs 11.3%, p<0,001), mechanical complications (2.9% vs 1.4%, p=0.001) and higher 30-day mortality (8.8% vs 5.7%, p<0,001). Conclusions Women with STEMI are less likely to receive revascularization therapy, are admitted with a higher Killip class and have higher rates of post-STEMI complications and 30-day mortality than men.

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

Abstract Funding Acknowledgements None. Background Cardiogenic shock (CS) is a heterogenous, life-threatening disease burdened by a mortality up to 50%. An increasing incidence of the CS related to other etiological causes, including acute decompensated heart failure, has been reported. However, most of the epidemiological data are derived from patients admitted to dedicated acute cardiac care units. Epidemiology and management of CS patients admitted to general intensive care unit (ICU) in Italy is yet unexplored. Purpose To describe the epidemiology, patients feature, management and outcome of CS patients admitted to Italian general ICUs. Methods Prospective multicentric epidemiological study. Over 600 thousand patients admitted to 316 hundred Italian general intensive care units from 2011 to 2018 were screened trough PROSAFE software. The Margherita PROSAFE project is an observational project for the continuous electronic collection of data on patients admitted to ICUs; it is developed by the GiViTI (Gruppo italiano per la valutazione degli interventi in terapia intensiva - Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The primary outcome of the analysis was hospital mortality. Secondary outcomes included description of patients features and management. Results 11661 patients (72.1±12.1 years old.; 39.5% women) with a diagnosis of CS were included in the analysis. ICU and in-hospital mortality were respectively 45.5 % and 53.9%. Highest mortality was observed for pulmonary embolism (58.4%), right heart failure (56.3%) and acute decompensated heart failure (ADHF) (44.2%). 46.9% of patients presented with more than 3 organ failure (panel A). CS commonest aetiologies were ADHF (63,3%), acute myocardial infarction (19.8%) and right heart failure (11%). Invasive mechanical ventilation was used in the 88.6% of cases. Intra-aortic balloon pump was placed in 15.2%, with higher frequency in ischemic aetiologies (43.9%) and ADHF (13.7%); VA-ECMO was most frequently placed in the right heart failure (3.7%) and acute myocardial infarction (2.6%) groups. The factors independently associated with increased hospital mortality were increasing age (p <0.001), lower Glasgow coma scale (p <0.001), hypoxemia (PaO2 <100, OR: 1.91; 95% Cl: 1.58 – 2.3; p <0.001), bradycardia (OR: 1.84; 95% Cl: 1.49 – 2.26; p <0.001), hypotension (OR: 1.27; 95% Cl: 1.12 – 1.43; p <0.001), bilirubin above 12 mg/dl (OR: 7.90; 95% Cl: 2.56 – 24.3), increased creatinine (p <0.001) and reduced platelets (<50000 U/mL, OR: 2.43; 95% Cl: 1.78 – 3.31; p <0.001) (panel B). Curiously, in the predictive model a BMI above normal values was protective as well as tachycardia compared to severe bradycardia (panel C). Conclusions The etiology of CS in general intensive care units is heterogeneous with acute heart failure being the commonest. The mortality rate remains unacceptably high with right heart failure and acute heart failure being burden by the worst outcome.

Is there a role for intra-aortic balloon pump in patients with cardiogenic shock? predictors of success

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Clínico San Carlos Madrid. Background Cardiogenic shock (CS) remains a clinical challenge associated with unacceptable high mortality rates. Early revascularization is the cornerstone for CS management. However, CS patients usually requires further advanced therapies such as vasopressors and mechanical circulatory support devices. Intra-aortic balloon pump (IABP) is not routinely used in patients with CS according to the current recommendations. However, this device could be associated with potential benefit in selected patients and we believe it is underutilized. Our aim was to assess for potential predictors of success after IABP implantation in patients with CS. Methods From 2013 to 2023, 136 consecutive patients diagnosed with CS and admitted to an Acute Cardiac Care Unit in a tertiary care hospital were recruited. Demographic, clinical, and analytical variables were retrospectively collected. SCAI classification was used to define shock state. Patient were followed-up to November-2023 and clinical events were also recorded. For purposes of analysis, patients were classified in two groups: IABP success (N=70) and IABP failure (N=66). Success, in terms of IABP use, was defined as patient’s survival to the index event. Failure of IABP was defined as in-hospital death. A multivariate logistic regression analysis was performed to identify potential predictors of success. Results Mean age was 67.2±12.2 years and 64.7% were females. There were no significant differences in cardiovascular risk factors and comorbidities between groups: hypertension (56.6% vs 43.5%, p 0.132), diabetes (40.9% vs 59.1%, p 0.088), chronic kidney disease (50% vs 50%, p 0.800), previous stroke (53.9% vs 41.2%, p 0.857) in "Success-group" vs "Failure-group" respectively. STEMI was the most frequent cause of CS requiring an IABP (65.9%). Non-ST elevation myocardial infarction was more common in the "Success-group", whereas cardiac arrest was more common in the "Failure-group" (Table 1). Regarding the CS classification, patients with IABP failure were more frequently in SCAI D and E categories (Table 1). In addition, patients in the failure-group had worse hemodynamic and analytic parameters (Table 1) and the IABP failed to significantly improve them. There were no significant differences in coronary artery disease burden and treatment. Complete revascularization was accomplished in a similar proportion of patients in both groups (Table 1). The multivariate analysis showed that SCAI B&C states were independently associated with success after IABP implantation, whereas lactate level prior to IABP implantation was associated with failure (Table 2). Conclusion Selecting the appropriate timing for IABP implantation is critical for the prognosis, as success rates are higher in less advanced stages of cardiogenic shock. Preimplantation lactate levels are also associated with success rates.

Gender differences in cardiogenic shock: characteristics and prognosis

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Clinico San Carlos. Background Cardiogenic shock (CS) is a life-threatening condition caused by severe heart dysfunction. While significant advances have been made in the management and treatment of cardiogenic shock, there is growing recognition of the importance of considering gender-specific differences in the presentation and outcomes of this condition. Recent research highlights gender-related variations in how the condition is presented, managed, and its outcomes. Understanding these differences is crucial for tailored and effective treatment. Our goal is to identify potential gender differences in terms of the characteristics and prognosis of CS. Methods From 2013 to 2023, 142 consecutive patients diagnosed with CS in and admitted to an Acute Cardiac Care Unit in a tertiary care hospital were recruited. Demographic, clinical, and analytical variables were retrospectively collected. Patient were followed-up to November-2023 and clinical events were also recorded. For purposes of analysis, patients were classified in woman (N=95) and men (N=47). Success, in terms of IABP use, was defined as patient’s survival to the index event. Failure of IABP was defined as in-hospital death. A multivariate logistic regression analysis was performed to identify potential predictors of success. A descriptive analysis of clinical, analytical, and demographic parameters was performed in both groups, followed by a survival curve analysis to assess differences in prognosis between both sexes. Results Mean age was 67.3±12.2 years and 67.0% were females. There were no significant differences in cardiovascular risk factor and comorbidities between groups: hypertension (61.2% vs 38.8%, p 0.077), diabetes (65.9% vs 34.1%, p 0.866), chronic kidney disease (75% vs 25%, p 0.465), previous stroke (61.5% vs 38.5%, p 0.666) in woman vs men group respectively. STEMI was the most frequent cause of CS requiring an IABP in men (33.7%) but NSTEMI was in women (67.7%). Regarding the CS classification, both groups had a similar distribution of the severity and complexity of the shock (Figure 1). There were also no differences in hemodynamic parameters, analytical results, complete revascularization, and left ventricular ejection fraction (LVEF) between men and women (Figure 1). There were also no differences in hemodynamic parameters, analytical results, complete revascularization, and left ventricular ejection fraction (LVEF) between men and women (Figure 1). The complications, mortality (Figure 2), and long-term mortality were also similar in both groups. Conclusions In our observational study, there were no differences between genders in terms of characteristics, shock complexity, and prognosis.

Enhanced Safety and Efficiency of Ambulatory Cardiology Admissions: A Quality Improvement Initiative.

Pediatric cardiac patients have experienced evolving illnesses progressing to instability while awaiting inpatient admission from ambulatory settings. Admission delays and communication breakdowns increase the risk for tenuous patients. This quality improvement initiative aimed to improve safety and efficiency for patients admitted from an ambulatory Clinic to the Acute Cardiac Care Unit (ACCU) using standardized communication and admission processes within one year. An admission process map, in-clinic nurse monitoring, and communication pathways were developed and implemented. A standardized team handoff occurred via virtual huddle using illness severity, patient summary, action list, situational awareness, and synthesis. Escalation of care events and timeliness were compared pre- and postimplementation. There was a reduction of transfers to the intensive care unit within 24 hours of ACCU admission from 9.2% to 3.8% (P = 0.26), intensive care unit evaluations (without transfer) from 5.6% to 0% (P = 0.06), and arrests from 3.7% to 0% (P = 0.16). After the pilot, clinic nurses monitored 100% of at-risk patients. Overall mean time from admission decision to virtual huddle decreased from 81 to 61 minutes and mean time to admission from 144 to 115 minutes, with 41% (n = 33) arriving ≤ 60 minutes (goal). The COVID-19 pandemic negatively affected admission timeliness while safety metrics remained optimized. Implementing a standardized admission process between the Clinic and ACCU enhanced safety by reducing admission wait time and escalation of care post-admission. Sustainable, reliable handoff processes, in-clinic monitoring, and standardized admission processes were established. The pandemic hindered admission efficiency without compromising safety.

In-hospital and long term neurological outcome prognostication using an algorithm based on the analysis of ventricular fibrillation from the EKG of patients with sudden cardiac death (AWAKE)

Abstract Background Sudden cardiac death (SCD) is a leading cause of mortality and carries a dismal neurological outcome (NO) among patients admitted alive to acute cardiac care units (ACCU). A big share of SCD are found in ventricular fibrillation (VF). VF waveform is dynamic and it can be characterized by spectral analysis at the very time of ACCU admission. Purpose To validate in a multicenter cohort an algorithm based on spectral variables of VF waveform to early predict neurological outcome at hospital discharge and follow-up, and to compare its performance with currently established prognostic tools. Methods Multicenter study in which 5 hospitals recruited patients, resuscitated from SCD due to VF whose EKG was available, and admitted to ACCU with expertise in SCD. EKG tracings were scanned and analyzed with a custom MATLAB script delivering spectral variables to be entered in an algorithm to predict NO. NO was assessed by Cerebral Performance Category (CPC) during admission and after a minimum 6-month follow-up period. The primary endpoint was favorable neurological outcome (FNO, defined as CPC 1 and 2) during hospital admission, and the secondary endpoint was FNO at long-term follow-up. Statistical data were analyzed with SPSS and EPIDAT. Results We included 168 patients out of 678 screened in participant hospitals among admissions from 2007 to 2022. The main cause of exclusion was a rhythm different from VF at the time of medical assistance (n=329, 48%) or VF EKG unavailable (n=151, 22%). Ninety-five patients (57%) were admitted in comatose status (Glasgow <9). Baseline characteristics are depicted in Picture 1. FNO during admission was documented in 136 patients (81%). Twenty-nine patients (17%) died during hospitalization. A spectral-based model using VF tracings early predicted FNO with an area under the curve (AUC) value of 0.85 (CI95% 0.77-0.93). There was overlap with the predictive performance obtained with the peak value of neuron-specific enolase (NSE) (0.85; CI95% 0.74-0.95) (Picture 2, A). Other prognostic tools showed similar or lower diagnostic yield and results were obtained at a later time after admission (Picture 2, B,D). Long-term follow-up was obtained for 166 cases (2 foreign patients were impossible to retrieve). Patients discharged alive were followed for 17 (± standard deviation 21) months. FNO was present in 136 (82%). The spectral-based model predicted FNO with AUC 0.83 (CI95% 0.74-0.92), similar to NSE (AUC 0.87, CI95% 0.77-0.97) (Picture 2, C). Other tools performed in follow-up similar to during admission (Picture 2, D). CONCLUSION A model based on VF spectral analysis predicts neurological outcome after SCD with an accuracy similar to current validated tools, but with no requirement for drug withdrawal or waiting period in comatose patients. This model estimates outcomes at the earliest moment of hospital admission and its predictions remain valid in the long run.Baseline characteristicsDiagnostic yield of model vs other tools

Abstract 12920: Double Peak of Cardiac Troponin T in Non ST-Segment Elevation Myocardial Infarction

Introduction: cardiac biomarkers are the cornerstone of the biological definition of acute myocardial infarction. In previous literature it was shown that hs-Troponin T blood assay follows a typical biphasic kinetic in patients (pts) affected by ST segment elevation myocardial infarction (STEMI), treated by primary percutaneous coronary intervention (PCI), while this does not appear to be the case for creatinphosphokinase (CPK) and hs-Troponin I assays. Hypothesis: According to these previous data, we studied hs-troponin T and CPK kinetics in pts suffering from non-ST segment elevation myocardial infarction (NSTEMI). Methods: we retrospectively analysed blood samples for cardiac biomarkers in NSTEMI pts consecutively admitted to the coronary care unit of our institution from January 2022 to May 2023. Results: A total of 83 pts were included. 89% of pts were treated by PCI; 98% of these pts received PCI within 24 hours from hospital admission. Among the 83 enrolled pts, only 11% was treated by surgical revascularization and/or anti-ischemic pharmacological therapy. A double peak of hs-troponin T was observed only in pts treated by PCI (p=0,0001). In these pts the mean time to first hs-troponin T peak was at 35,84 ± 4,4 hours while the mean time to second hs-troponin T peak was at 78,62 ± 8,7 hours. CPK value at hospital admission was 208,6 ± 34,8 U/L while first hs-troponin T peak was 560,1 ± 112,9 ng/L; the second hs-troponin T peak was 240,3 ± 33,7 ng/L, in absence of CPK double peak. Conclusions: similarly to previous studies in STEMI pts, our data confirm the presence of hs-troponin T double peak, in the absence of CPK second dispersion, also in NSTEMI pts. The hs-troponin T second peak is strongly related to PCI procedure while pts undergoing conservative treatment or surgical coronary revascularization do not show such a kinetic. Another interesting issue is the absence of CPK second dispersion. This could suggest a potential trivial meaning of hs-troponin T second peak. Therefore, the second peak could not be of any significance for prognostic evaluation and appropriate timing of pts discharge from acute cardiac care units.

Assessment of knowledge, attitude and practice for oxygen therapy among medical staff at the Colonial War Memorial Hospital in Fiji.

Oxygen therapy (OT) is a commonly prescribed essential medicine for people of all ages in the management of hypoxia. The adverse effects of inappropriate OT supplementation may be underestimated by health professionals and lead to poor health outcomes among hospitalised patients. Knowledge, attitude and practice (KAP) assessments of medical staff members to OT guidelines are essential to ensure optimal patient care. To perform a KAP assessment of OT administration among doctors and nurses employed at the national hospital of Fiji in 2021. Prospective cross-sectional study design. KAP assessment was performed with an online questionnaire and clinical observation. The study population (N = 116) consisted of doctors (20.7%) and nurses (79.3%) representing the acute medical, burns, cardiac care, intensive care, surgical and postanaesthetic recovery units. Overall, the proportion of participants who obtained a good score (>70%) was 87% for knowledge, 87.93% for attitudes and 84% for practice. Best knowledge scores were obtained for general OT indications (71%) and scenarios where immediate oxygen application is required (70%). Lowest knowledge scores were for OT contraindications (14%) and oxygen saturation for acute myocardial infarction (32%), asthma (36%) and healthy newborns (43%). The most positive attitudes were in response to the statement that OT guidelines are essential (96%). A total of 78 (80.4%) patients were being cared for with good OT practice. Good KAP scores were obtained for medical staff in Fiji regarding OT administration. Ongoing professional education activities should include updated training of OT contraindications and optimal oxygen saturation levels for special patient groups.

Wearable Cardioverter Defibrillator Shortens the Lengths of Stay in Patients with Left Ventricular Dysfunction after Myocardial Infarction: A Single-Centre Real-World Experience.

The wearable cardioverter defibrillator (WCD) has been proven to be effective in preventing sudden cardiac death (SCD) in patients soon after acute myocardial infarction (AMI) and left ventricular ejection fraction (LVEF) ≤35%. The aim of this study was to assess whether a WCD may shorten the length of an initial hospital stay (total length, days in the intensive care unit (ICU) and in the acute cardiac care unit (ACCU)) among these patients. This was a single-centre, retrospective observational study of patients referred for the management of SCD risk post-AMI and LVEF ≤35%, in a tertiary care hospital. The clinical characteristics and length of index hospitalization of the group of patients discharged, with or without WCD, were compared. A propensity score analysis was performed, then weighted regression models were conducted. A total of 101 patients in the WCD group and 29 in the control group were enrolled in the analysis. In the weighted regression models, WCD significantly reduced the days spent in ACCU (p < 0.001). WCD patients had significantly fewer days spent in ACCU (5.5 ± 2.6 vs. 8.4 ± 12.8 days, p < 0.001) and shorter hospitalizations (10.2 ± 5.7 vs. 13.4 ± 17.6 days, p = 0.005), compared with the control group. It was concluded that the WCD appears to reduce the total length of hospitalization and lengths of stay in ACCU for patients post-AMI and with left ventricular dysfunction.

Feasibility of the Age-Friendly Health System in Acute Cardiac Care Units for Delirium Detection and Management

Background Optimal delirium care requires a multicomponent approach. However, implementation of such comprehensive care in a fast-paced specialized unit like acute cardiac care unit is challenging. The Age-Friendly Health System (AFHS) 4Ms initiative focuses on four key components, What Matters, Medication, Mentation, and Mobility, and provides a simple but comprehensive framework for optimal delirium care. However, studies reporting the application of AFHS 4Ms focusing on delirium care are lacking. Objective We aimed to evaluate the feasibility of the AFHS 4Ms on delirium detection and management among older adults in acute cardiac care units. Methods We conducted a quality improvement (QI) project using the AFHS 4Ms framework and implemented specific strategies for each M in the acute cardiac care units at a tertiary teaching hospital. Then, we assessed the changes in the rates of delirium screening and the rates of positive screening results during the QI project period using Cochran-Armitage test, and compared the percentages of older adults who received delirium-related orders before and after the initiative using Fisher’s exact test. Results The overall rate of delirium screening was 79.5% (68.3% in August, 81.0% in September, 87.2% in October, 87.9% in November, and 72.9% in December). The overall rate of positive delirium screening results was 9.3% (6.3% in August, 10.8% in September, 8.5% in October, 6.0% in November, and 5.0% in December). The utilization of all of the delirium-related orders was reduced, 2.4% to 1.9% for haloperidol, 6.9% to 5.1% for lorazepam, 6.5% to 3.0% for a physical restraint order, and 4.1% to 2.6% for a sitter order, before and after the initiative. However, all of the decreasing trends were not statistically significant. Conclusion We showed that it is feasible to apply AFHS 4Ms for delirium detection and management in acute cardiac care units. Future prospective studies are needed.

Prognostic impact of early coronary angiography in patients with non-ST-elevation acute myocardial infarction

Introduction and objectives: According to the recommendations of the latest clinical practice guidelines, non-ST-elevation acute myocardial infarction (NSTEMI) patients should undergo an invasive coronary angiography. However, the best moment to perform this coronary angiography has not been stablished yet. Our main objective was to see if performing an early angiography (within the first 24 h) in NSTEMI patients was associated with better prognosis compared to delayed angiography (beyond the first 24 h). Methods: From January 2014 to June 2016, 447 consecutive patients were admitted to the acute cardiac care unit of a tertiary hospital with a diagnosis of NSTEMI. They all underwent catheterization. We classified them into 3 groups depending on the moment when the coronary angiography was performed (within the first 24 h after diagnosis, 24 h to 72 h later, and > 72 h after diagnosis). Results: Coronary angiography was performed within the first 24 h in 285 patients (63.8%). There were no differences among the groups regarding gender, distribution of cardiovascular risk factors, past medical history of coronary disease or presence of other comorbidities. We found no differences among the 3 groups in variables with known prognostic impact. The cardiovascular events and 1-year mortality at follow-up were similar among the 3 groups. Conclusions: In our study, in the whole spectrum of NSTEMI, early coronary angiography (within the first 24 h) did not show any clinical benefits regarding survival or fewer major adverse cardiovascular events.

Women take longuer to seek help when suffering a STEMI

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Historically, the prognosis of those women suffering a STelevation myocardial infarction (STEMI), has been worse compared to men. Some causal factors are presentation at later ages, atypical symptoms, lower perception of risk and less sensitivity of the health care providers. Purpose Our hypothesis is that there are still differences in the presentation of STEMI based on gender, which could be identified to guide new public campaigns in this perspective. Therefore our primary outcome is to find gender differences in symptoms and time delays in a cohort of STEMI patients, and secondary outcomes are differences in mortality and bleeding. Methods We conducted a retrospective analysis carried out in the Acute Cardiac Care Unit (ACCU) of a tertiary care hospital, where 50% of the medical staff are women. Patients hospitalized for STEMI for one year were included and a detailed caracterization of symptoms, time delays, and adverse events was recorded. Finally, the patients were classified according to gender, and differences in primary and secondary outcomes between both groups were analyzed. Results Between May/2020 and May/2021, 1056 patients were admitted to the ACCU, 33% were women. A total of 115 STEMI patients were included for the analysis, 21% were women. Basal characteristics of both groups were equivalent, except for a non significand trens towards less prevalence of peripheral arterial disease in women (0% vs. 11%; OR 0.890, IC 95% 0.828-0.957; p=0.089). Opressive chest pain was the most frequent symptom, but it was less frequent in women (75% vs. 91.4%, OR 0.284, IC 95% 0.085-0.948; p=0.033), whereas they presented more frequently with stabbing pain (13% vs. 2.4%, OR 6, IC 95% 1.073-38.35; p=0.035), and their pain was more frequently radiated towards the neck (28.6% vs. 4.9%, OR 7.7, IC 95% 1.1936-30.631; p=0.001), and associated to nausea/vomiting (45% vs. 1.3%, OR 5.809, IC 95% 1.930-17.486; p=0.001). There was a non-significant trend towards a longer time delay between pain onset and seek for help in women (185min IQR 747 vs. 60min IQR 454, p=0.098), being the other system time delays equivalent between both gender groups. Women had an increased bleeding risk, with a higher CRUSADE score (47.48 ± 22.92 vs. 28.60 ± 16.72, p=0.001) and higher incidence of bleeding events (12.55% vs. 0%, OR 11.68, IC 95% 9.82-13.29, p=0.001). There were no differences in the treatments administered or in mortality (12.5% vs. 14.3%, p=0.822). Conclusions Women suffering a STEMI more often reported stabbing chest pain, radiating to the neck, and associated to nausea/vomiting compared with men, and took longer to seek for help. These findings could help in the design of future campaigns to minimize time delays, targeting these different symptoms in female population.

Identifying nursing sensitive indicators from electronic health records in acute cardiac care-Towards intelligent automated assessment of care quality.

The aim of this study is to explore the potential of using electronic health records for assessment of nursing care quality through nursing-sensitive indicators in acute cardiac care. Nursing care quality is a multifaceted phenomenon, making a holistic assessment of it difficult. Quality assessment systems in acute cardiac care units could benefit from big data-based solutions that automatically extract and help interpret data from electronic health records. This is a deductive descriptive study that followed the theory of value-added analysis. A random sample from electronic health records of 230 patients was analysed for selected indicators. The data included documentation in structured and free-text format. One thousand six hundred seventy-six expressions were extracted and divided into (1) established and (2) unestablished expressions, providing positive, neutral and negative descriptions related to care quality. Electronic health records provide a potential source of information for information systems to support assessment of care quality. More research is warranted to develop, test and evaluate the effectiveness of such tools in practice. Knowledge-based health care management would benefit from the development and implementation of advanced information systems, which use continuously generated already available real-time big data for improved data access and interpretation to better support nursing management in quality assessment.

Inflammatory infiltration of the cardiac conduction system in acute lymphocytic myocarditis.

A 53-year-old man with prior history of bone marrow transplant after acute myeloblastic leukaemia was admitted in the acute cardiac care unit due to suspected acute myocarditis. At admission, his electrocardiogram (ECG) showed right bundle branch block and left anterior fascicular block (Panel A). Previously, he had been assessed regularly in a dedicated cardio-oncology clinic, with normal ECG and transthoracic echocardiography (see Supplementary material online, Videos S1 and S2). Despite high-dose pulses of methylprednisolone, he developed both complete atrio-ventricular (AV) block and progressive left ventricular systolic dysfunction (see Supplementary material online, Videos S3 and S4), leading to cardiogenic shock requiring temporary transvenous pacing and mechanical circulatory support with VA-ECMO. However, he died on day 9 due to multiorgan failure. Gross examination of the heart (Panel B) was normal, but histopathology and immunohistochemistry showed significant infiltration of the ventricular myocardium (Panel C), AV node (Panel D) left anterior fascicle (Panel E), and right bundle branch (Panel F) by mononuclear CD3 + T cells, consistent with the diagnosis of lymphocytic myocarditis. High-definition images S1-S8 are included in the Supplementary material online.

Cardiogenic shock prognosis according to the type of infarction: STEMI vs non-STEMI. Acute-phase and 5-year mortality

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Germans Trias i Pujol Background Cardiogenic shock (CS) is a severe complication of myocardial infarction (MI) and carries a high mortality. Clinical profile and prognosis of these patients could differ depending on the electrocardiographic pattern at admission. The objective of this study is to demonstrate these differences. Methods Prospective register of patients with MI complicated with CS admitted to the acute cardiac care unit of a tertiary hospital between 2010 and 2019. Clinical characteristics and mortality at 30-day and 5-year were compared according to the presence (STEMI) or absence (NSTEMI) of ST-segment elevation. Results This study included 239 patients, 79.5% had STEMI and 20.5% had NSTEMI. There were no differences in age (69 vs. 71 years, p=0.330), gender distribution (22.4% vs. 27.4% women, p=0.486) and ejection fraction (33% vs. 30%, p=0.231). However, patients with STEMI had more extensive MI (CK-MB peak 279 vs. 85 ng/ml, p&amp;lt;0.001) and mechanical complications (17.9% vs. 0% p&amp;lt;0.001). Nevertheless, patients with NSTEMI had greater prevalence of hypertension (81.6% vs. 62.6%, p=0.012), diabetes (53.1 vs. 36.3%, p=0.033), peripheral arteriopathy (34.7% vs. 13.7%, p=0.001), previous heart failure (14.3% vs. 3.7%, p=0.005), previous MI (44.9% vs. 10.0%, p&amp;lt;0.001), percutaneous coronary angioplasty (20.4% vs. 10.0%, p=0.047) and coronary artery bypass grafting (10.2% vs. 2.1%, p=0.020). This last group had more prevalence of three-vessel disease (80.4% vs. 34.9%, p&amp;lt;0.001) and main left artery (58.7% vs. 20.6%, p&amp;lt;0.001). STEMI patients had higher 30-day mortality (59.5% vs 36.7%; p=0.004), but this difference progressively diminished. As a result, 5-year survival had no significant differences. After adjusting for main clinical predictors, STEMI was independently associated with 30-day mortality (HR 1.99), but this association disappeared when the follow-up was extended to 5 years. Conclusions Patients with CS and STEMI had more extensive infarcts and with more mechanical complications than NSTEMI. Patients with NSTEMI and CS had more cardiovascular risk factors, previous coronary artery disease, and multi-vessel involvement. 30-day mortality of STEMI with CS was higher than in NSTEMI, although 5-year mortality did not offer significant differences.

Time-dependent prognostic value of bispectral index and suppression ratio during targeted temperature management: an early triage tool for treatment escalation plans

Abstract Funding Acknowledgements Type of funding sources: None. Background Post-cardiac arrest myocardial dysfunction contributes to morbidity in survivors of cardiac arrest (CA) and, in case of refractory shock, some patients will benefit from aggressive mechanical support. In this scenario, a non-invasive, reliable and real-time estimation of potential neurological recovery is required to establish personalized treatment escalation plans. Methods We prospectively collected data of bispectral index (BIS) and suppression ratio (SR) monitoring of adult comatose survivors of CA consecutively admitted to an acute cardiac care unit and managed with targeted temperature management (TTM). Neurological status was assessed according to the Cerebral Performance Category (CPC) scale. Results We included 340 patients, 72.1% had an initial shockable rhythm, 72 (21.2%) were females and their mean age was 61.7 ± 14.3 years. Throughout 3-month follow-up, 210 patients (61.8%) achieved a CPC of 1-2 and 130 (38.2%) a CPC of 3-5. Mean BIS values were significantly higher and median SR lower in patients with CPC 1-2 (Figure 1). An average BIS value &amp;gt;26 during first 12 hours of TTM predicted good outcome with 89.3% sensitivity and 75.2% specificity (AUC of 0.86), while average SR values &amp;gt;24 during first 12 hours of TTM predicted poor outcome (CPC 3-5) with 83.6% of sensitivity and 91.8% of specificity (AUC of 0.92). Hourly BIS and SR values exhibited a good predictive performance (AUC &amp;gt; 0.85), starting as soon as hour 2 for SR and 4 for BIS. Conclusions BIS and SR real-time monitoring correlates with patient´s potential of neurological recovery after CA. This finding could help establish personalized treatment escalation plans that reduce consequences of inappropriate interventions, economic costs and uncertainty burden of the patient´s family.

Sex Related Differences in the Treatment of ST-Segment Elevation Acute Myocardial Infarction in Patients Aged

Gender-related differences after ST-segment elevation myocardial infarction (STEMI) have been reported, but studies have generally focused on high-risk groups and results are inconsistent. This study aims to determine gender-related differences in the treatment of STEMI and in-hospital mortality in a contemporary cohort of young patients. We included patients aged <55 years admitted to the Acute Cardiac Care Unit with STEMI during an 11-year period. We retrospectively reviewed the clinical charts to register information on demographics, clinical and laboratory data, angiography, treatment received, complications, and in-hospital mortality. A total of 812 patients were included (712 men and 100 women). There were no gender-related differences in age or prevalence of cardiovascular risk factors. Women, as compared with men, had higher incidence of nonobstructive angiography (14.0% vs 2.4%) and coronary tortuosity (4.0% vs 0.8%), and lower incidence of multivessel disease (35.0% vs 49.6%) (p <0.05). Less frequently than men, women received percutaneous transluminal coronary angioplasty (94.0% vs 98.2%), and stent placement (82.0% vs 93.8%), inotropic agents (2.0% vs 8.3%), hypothermia after cardiac arrest (25.0% vs 84.0%), and mechanical ventilation (4.0% vs 11.0%) (p <0.05). These differences were not explained by the different angiographic findings. In-hospital mortality was 2.0% and 3.4%, in women and men, respectively (adjusted odds ratio 0.712, 95% confidence interval 0.164 to 3.093, p=0.650). In conclusion, women aged <55 years with STEMI were held to different treatment standards than men.

Diagnostic value of post-return of spontaneous circulation electrocardiogram for selection of candidates for primary percutaneous coronary intervention after out-of-hospital cardiac arrest

Abstract Background Once return of spontaneous circulation (ROSC) is achieved in cardiac arrest (CA) patients (pts), guidelines recommend immediate acquisition of a 12-lead electrocardiogram (ECG) in order to try to identify those with underlying ischemic heart disease that would benefit from an emergent coronary angiography. Nevertheless, post-ROSC ECG findings may be influenced by factors such as drugs used during CPR (e.g., adrenaline) or metabolic state of pts (e.g., lactic acidosis) and therefore its diagnostic value for identification acute coronary lesions has not yet been established. Objectives To describe the correlation between post-ROSC ECG findings and acute coronary angiography lesions in out-of-hospital CA (OHCA) pts. Methods Retrospective analysis from a prospective database of pts admitted consecutively to the acute cardiac care unit of a tertiary care hospital from September 2006 to April 2019. Post-ROSC ECG of OHCA pts who underwent emergent coronary angiography were blindly and separately classified by 2 cardiologists as follows 1) ST-s elevation, 2) ST-s depression, 3) LBBB, 4) T wave changes/unespecific and 5) normal ECG. If discordant diagnosis, a senior cardiologist made a third and separate analysis. Additionally, coronary lesions were considered to be acute in presence of thrombi or unstable plaque (with or without complete occlusion). Results From 412 pts, 211 had an available and interpretable post-ROSC ECG and underwent emergent coronary angiography. Mean age 60±13 years, male sex 183 (86.7%). Correlation between ECG findings and acute coronary lesions are shown in table 1. Pts with ST-s elevation had an underlying acute coronary lesion in 55.2%. Moreover ST-s elevation had a positive predictive value of 84% and sensitivity of 58.8% for identifying acute coronary lesions. Other post-ROSC ECG findings did not significantly associate acute coronary lesions, in fact LBBB had a high negative predictive value for acute lesions. Conclusion Among post-ROSC ECG findings, ST-s elevation is significantly associated with acute coronary lesions and when identified, an invasive strategy should be considered as established by current practice guidelines. On the contrary, LBBB rarely associates acute coronary lesions at least in OHCA scenario and when its “new onset” is not specified. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): University Hospital La Paz (Madrid) ECG findings and acute coronary lesions