Acute Heart Failure Syndromes Research Articles

Acute heart failure and acute coronary syndrome: not uncommon duo and dangerous

Abstract Funding Acknowledgements None. Introduction Acute Heart Failure (AHF) is a common cause of hospitalisation. Its ethology and triggering factors influence the prognosis and evolution. Methods and purpose Retrospective analysis of 6330 patients admitted to our hospital's Coronary Care Unit (CCU) between 2012 and 2022. The main objective was to analyse the characteristics during hospital progress and follow-up of patients with AHF after an Acute Coronary Syndrome (ACS) in class Killip III or IV, comparing it with those admitted for AHF not secondary to ACS. Results 698 patients with AHF after ACS and 384 with AHF not secondary to ACS were included. 68.8% of patients presented Acute Coronary Syndrome with ST elevation (STEMI), with a higher prevalence in the anterior location (34,3%). Angioplasty was performed in 53.4% of patiens with STEMI and in 40.3% of patients with NSTEMI. The Cardiovascular risk factors (Figure 1) were similar in both groups, while patients with AHF not secondary to ACS had a history of Coronary Heart Disease (CHD) and atrial fibrilación (AF) more frequently. Patients with AHF after ACS more frequently required treatment with dobutamine and norepinephrine (63.6% and 57.6%, respectively) as well as orotracheal intubation. At the same time, levosimendan was administered more frequently to patients with AHF not secondary to ACS, with non-invasive mechanical ventilation being more frequent in this group. Both groups similarly received neurohormonal treatment, with beta-blockers being used the most. Events during follow-up (Figure 2) were higher in patients with AHF after ACS, except HF events. Cardiovascular mortality was 21.9% in patients with AHF after ACS. Conclusions Patients admitted for ACS complicated with AHF Killip III-IV represented 11.02%. The majority presented previously STEMI. During their admission, compared to patients admitted for AHF not secondary to ACS, they more frequently required vasoactive drugs and orotracheal intubation. Cardiovascular complications and mortality during follow-up were higher in patients with AHF after ACS. Therefore, early identification of patients with ACS at risk of developing AHF and establishing a specific and optimal treatment is crucial in the evolution of these patients.

GDF-15: a novel biomarker of heart failure predicts short-term and long-term heart-failure rehospitalization and short-term mortality in patients with acute heart failure syndrome

BackgroundAcute heart failure (AHF) is a potentially life-threatening clinical syndrome, usually requiring hospital admission. Growth Differentiation Factor-15 (GDF-15) is a distant member of the transforming growth factor-β. The increased expression of GDF-15 has been observed during heart failure (HF) and is associated with worse outcomes. However, the relationship between GDF-15 and AHF is not well understood with limited evidence among Thai patients.PurposeInvestigate the correlation between biomarker levels (measured upon admission and discharge) and short- and long-term adverse outcomes, encompassing all-cause mortality and heart-failure (HF) rehospitalization (at 30, 90, and 180 days, as well as throughout the entire follow-up duration) in individuals experiencing acute HF.MethodsThis is a prospective single-center investigation involving patients admitted for AHF. Biomarkers, including GDF-15, high-sensitivity troponin T (hsTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP), were assessed upon admission and discharge. Outcomes, including all-cause mortality and HF rehospitalization, were examined. Logarithmic transformations were applied to the biomarker variables for subsequent analysis. Univariate and multivariate analyses of cause-specific hazards were conducted using the Cox proportional hazards regression model, while subdistribution hazards were assessed using the Fine-Gray regression model to evaluate outcomes.ResultsA total of 84 patients were enrolled (mean age of 69 years, 52% females). The GDF-15 level significantly decreased during admission (median at the time of admission 6,346 pg/mL, median at the time of discharge 5,711 pg/mL; p < 0.01). All-cause mortality at 30 days and 180 days were 6.0% and 16.7%, respectively. HF rehospitalization at 30 days and 180 days were 15.5% and 28.6%, respectively. Univariate analysis showed that total orthoedema congestion score (p = 0.02) and admission GDF-15 level (p = 0.01) were associated with 30-day all-cause mortality, whereas hsTnT or NT-proBNP levels did not show significant associations. However, higher levels of NT-proBNP upon admission were associated with all-cause mortality when considering the entire follow-up period (p < 0.01). Both univariate and multivariate analyses demonstrated that lower discharge GDF-15 levels and a greater reduction in GDF-15 levels from admission to discharge were associated with a lower risk of 30-day rehospitalization. Similarly, univariate analysis revealed that a greater reduction in NT-proBNP levels from admission to discharge was associated with lower 30-day rehospitalization rates. At 180 days, a greater reduction in GDF-15 levels remained associated with lower hazards and incidence of rehospitalization.ConclusionThe significant decrease in Growth Differentiation Factor-15 (GDF-15) levels during hospitalization suggests its potential as a dynamic marker reflecting the course of AHF. Importantly, higher GDF-15 levels at admission were associated with an increased risk of 30-day all-cause mortality, highlighting its prognostic value in this patient population. Moreover, lower discharge GDF-15 levels, reductions in GDF-15 from admission to discharge, and decreases in NT-proBNP from admission to discharge were associated with a reduced risk of 30-day rehospitalization.

Comparison of troponin and natriuretic peptides in Takotsubo syndrome and acute coronary syndrome: a meta-analysis

ObjectiveTakotsubo syndrome (TTS) is an acute heart failure syndrome which resembles acute coronary syndrome (ACS) at presentation. Differentiation requires coronary angiography, but where this does not occur immediately, cardiac biomarkers...

Histological and functional assessment of a Takotsubo cardiomyopathy model established by immobilization stress.

Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, resembles acute heart failure syndrome but lacks disease-specific diagnosis and treatment strategies. TTC accounts for approximately 5-6% of all suspected cases of acute coronary syndrome in women. At present, animal models of TTC are often created by large amounts of exogenous catecholamines such as isoproterenol. However, isoproterenol injection cannot fully simulate the onset of stress-induced cardiomyopathy in humans since stress is not an instantaneous event. Rats were immobilized for 6h per day for 1-14 days. To examine whether the TTC model was successful, echocardiography was employed; Elisa detected serum sympathetic activation markers; and the Open-Field test (OFT) was used to analyze behavioral changes in rats after stress. Western blot and histology were used to assess sympathetic remodeling, inflammation levels, and fibrosis; qRT-PCR was used to explore the levels of fibrosis and myocardial hypertrophy. The electrical stability of ventricular was determined by electrophysiological testing. The rats showed severe stress behavior and local sympathetic remodeling of the heart after only 1 day of stress. After 3 days of stress, the induction of ventricular tachyarrhythmia increased prominently. The highest incidence of TTC in rats was at 5 days of immobilization stress. The pathological left ventricular remodeling caused by immobilization (IMO) stress includes inflammatory infiltration, fibrosis, and myocardial hypertrophy. Our study confirms the hypothesis that IMO stress can mimic Takotsubo cardiomyopathy, and the various effects on the heart depending on the duration of IMO stress. We observed the highest incidence of TTC occurred after 5 days of stress. Furthermore, there is a gradual occurrence of electrical and structural remodeling as the stress duration prolongs.

Clinical Characteristics, Treatment Patterns, And Trajectories Of Patients With Acute Heart Failure Syndromes Admitted To A Heart Failure Intensive Care Unit

Clinical Characteristics, Treatment Patterns, And Trajectories Of Patients With Acute Heart Failure Syndromes Admitted To A Heart Failure Intensive Care Unit

Insulin resistance in Takotsubo syndrome.

Takotsubo syndrome (TTS) is an acute heart failure (AHF) syndrome mimicking the symptoms of acute myocardial infarction. Impaired outcome has been shown, making risk stratification and novel therapeutic concepts a necessity. We hypothesized insulin resistance with elevated plasma glucose and potentially myocardial glucose deprivation to contribute to the pathogenesis of TTS and investigated the therapeutic benefit of insulin in vivo. First, we retrospectively analysed patient data of n=265 TTS cases (85.7% female, mean age 71.1±14.1years) with documented initial plasma glucose from the Department of Cardiology of the University Hospital Heidelberg in Germany (May 2011 to May 2021). Median split of the study population according to glucose levels (≤123mg/dL vs. >123mg/dL) yielded significantly elevated mean heart rate (80.75±18.96 vs. 90.01±22.19b.p.m., P<0.001), left ventricular end-diastolic pressure (LVEDP, 18.51±8.35 vs. 23.09±7.97mmHg, P<0.001), C-reactive protein (26.14±43.30 vs. 46.4±68.6mg/L, P=0.006), leukocyte count (10.12±4.29 vs. 15.05±9.83/nL, P<0.001), peak high-sensitive Troponin T (hs-TnT, 515.44±672.15 vs. 711.40±736.37pg/mL, P=0.005), reduced left ventricular ejection fraction (EF, 34.92±8.94 vs. 31.35±8.06%, P<0.001), and elevated intrahospital mortality (2.3% vs. 12.1%, P=0.002) in the high-glucose group (Student's t-test, Mann-Whitney U test, or chi-squared test). Linear regression indicated a significant association of glucose with HR (P<0.001), LVEDP (P=0.014), hs-TnT kinetics from admission to the next day (P<0.001), hs-TnT the day after admission (P<0.001), as well as peak hsTnT (P<0.001). Logistic regression revealed significant association of glucose with a composite intrahospital outcome including catecholamine use, respiratory support, and resuscitation [OR 1.010 (1.004-1.015), P=0.001]. To further investigate the potential role of glucose in TTS pathophysiology experimentally, we utilized an in vivo murine model of epinephrine (EPI)-driven reversible AHF. For this, male mice underwent therapeutic injection of insulin (INS, 1IU/kg) or/and glucose (GLU, 0.5g/kg) after EPI (2.5mg/kg), both of which markedly improved mean EF (EPI 34.3% vs. EPI+INS+GLU 43.7%, P=0.025) and significantly blunted mean hs-TnT (EPI 14393pg/mL vs. EPI+INS 6864pg/mL at 24h, P=0.039). Particularly, insulin additionally ameliorated myocardial pro-inflammatory gene expression, suggesting an anti-inflammatory effect of acute insulin therapy. Elevated initial plasma glucose was associated with adverse outcome-relevant parameters in TTS and may present a surrogate parameter of heightened catecholaminergic drive. In mice, insulin- and glucose injection both improved EPI-induced AHF and myocardial damage, indicating insulin resistance rather than detrimental effects of hyperglycaemia itself as the underlying cause. Future studies will investigate the role of HbA1c as a risk stratifier and of insulin-based therapy in TTS.

Case report: Takotsubo syndrome following percutaneous coronary intervention

BackgroundTakotsubo syndrome (TTS), which is frequently secondary to severe emotional (fear, anxiety, etc.) or physical stress, is an acute reversible heart failure syndrome characterized by temporary left ventricular regional systolic dysfunction. Nevertheless, TTS after percutaneous coronary intervention (PCI) is rare, and its clinical characteristics are easily confused with complications after PCI.Case presentationThis article reports a case of TTS induced by psychological and physical pressure after successful PCI in our institution. The patient had symptoms comparable to complications after PCI, including V1-V5 ST segment elevation and T wave changes of electrocardiogram (ECG) and troponin elevation. Coronary angiogram, left ventricle opacification (LVO), and cardiac magnetic resonance (CMR) were performed to exclude postoperative complications. Diagnosis of TTS was eventually achieved.ConclusionWe cannot dismiss the risk of TTS in patients who have unexplained V1-V5 ST segment elevation and T wave changes of ECG and troponin elevation following successful PCI. Meanwhile, medical personnel should provide mental, cultural, and emotional services to patients in addition to essential diagnostic and treatment technical services during the perioperative period.

Validation of electrocardiographic artificial intelligence model for outcome prediction in patients with heart failure

Abstract Introduction Although several valuable biomarkers have been introduced for heart failure (HF) patients, their utilization in routine clinical practice is often constrained by cost and limited availability. Electrocardiogram (ECG) is an essential and cost-effective tool for evaluating cardiovascular diseases. We tested artificial intelligence (AI) algorithm analyzing a printed ECG image for the outcome prediction in patients with acute HF. Methods Two tertiary centers prospectively enrolled 1,254 patients with acute HF syndrome. Baseline ECG images were analyzed using a deep learning system called Quantitative ECG (QCG™), which features a CNN-based binary classifier trained to detect several urgent clinical conditions including shock, cardiac arrest, myocardial infarction, and HF, in addition to rhythm diagnosis. Results Patients with reduced left ventricular ejection fraction (LVEF, &amp;lt;40%) had significantly higher QCG scores for LV dysfunction (QCG-LVdys) (0.80 ± 0.20 vs. 0.38 ± 0.27, P &amp;lt; 0.001), and the AUC of QCG-LVdys for low LVEF was 0.884. Fifty-three patients (4.2%) resulted in in-hospital cardiac death (IHCD), and QCG score for critical events (QCG- Critical) was significantly higher in these patients than in survivors (0.57 ± 0.23 vs. 0.29 ± 0.20, P &amp;lt; 0.001). QCG-Critical was an independent predictor for IHCD after adjustment for age, sex, comorbidities, etiology/type of HF, atrial fibrillation, and QRS widening (adjusted OR = 1.68 [95% CI, 1.47 – 1.92], P &amp;lt;0.001, per 0.1). After further adjustments for echocardiographic LVEF and NTproBNP, QCG-Critical was still significantly correlated with IHCD (adjusted OR = 1.59 [95% CI, 1.36 – 1.87], P &amp;lt;0.001, per 0.1). The AUC of QCG-Critical for IHCD was 0.821 which was higher than the AUC of echocardiographic LVEF (P&amp;lt;0.001) or NTproBNP (P=0.07) (Fig 1A). The AUC of the multivariate model with QCG-Critical and other covariates was 0.866 (Fig 1B). During long-term follow-up, patients with higher QCG-Critical scores (&amp;gt;0.5) showed higher all-cause mortality rate compared to those with low QCG-Critical scores (&amp;lt;0.25) (adjusted HR = 2.69 [2.14 – 3.38], P &amp;lt; 0.001) (Fig 2). Conclusion Predicting outcomes in patients with acute HF appeared feasible using the newly developed Quantitative ECG (QCG) scores. These results suggest the possibility that QCG may serve as a novel biomarker for HF patients.ROC curves for In-hospital cardiac deathSurvival curves according to QCG scores

Empagliflozin treatment prevented oxidative stress, macrophage infiltration, pro-inflammatory and pro-fibrotic responses in the left ventricle of isoprenaline-induced Takotsubo-like syndrome in rats

Abstract Introduction Takotsubo Syndrome (TTS) is an acute heart failure (HF) syndrome induced by both emotional and physical stressors involving a surge of catecholamines and apical ballooning. Currently, there is no specific treatment for TTS. Sodium-glucose cotransporter2 inhibitors (SGLT2i) showed major cardiovascular protective effects in patients with HF independent of glycemic control. SGLT2i have also been shown to have anti-inflammatory and anti-oxidant effects, and to improve the endothelial function in experimental models of cardiac disease. However, a possible protective role of SGLT2i in TTS is unclear. Thus, this study evaluated the effect of SGLT2i on isoprenaline-induced TTS-like syndrome in rats, and determined the underlying mechanism. Methods 32 female Sprague-Dawley rats (10 weeks old) were divided into 4 groups: control, empagliflozin (30 mg/kg/day provided in the diet for 2 weeks), isoprenaline (Iso, 100 mg/kg, i.p.) to induce a TTS-like syndrome, and Iso plus empagliflozin (IE group). After 6 h of Iso injection, echocardiography was performed to determine left ventricular (LV) ejection fraction (EF) by area and heart rate (HR). At day 3, rats were sacrificed, main mesenteric artery and microvessels were collected for vascular reactivity studies, and LV was divided into base and apex to study mRNA expression levels using RT-qPCR, macrophage infiltration by in situ CD68 immunofluorescence staining, and oxidative stress using dihydroethidium. Results The injection of Iso to rats caused at 6 h an increased LVEF and HR in the Iso and the IE groups as compared to their corresponding controls. The HR response was significantly smaller in the IE group compared to Iso group whereas LVEF was similar. In addition, in mesenteric microvessels but not the main mesenteric artery, Iso group showed significant decreased relaxations to acetylcholine and increased contractile responses to phenylephrine in intact rings both of which were not observed in the IE group. Hearts showed significantly increased mRNA levels of IL-1β, TNF-α, NOX2, VCAM-1, MMP-9, TGF-β1 and collagen-1, oxidative stress levels and CD68 staining in the apex compared to the base in the ISO group, all of which were significantly reduced in IE group. Conclusions The present findings indicate that ISO injection caused in the LV elevated levels of oxidative stress, macrophage infiltration, pro-inflammatory, pro-remodeling and pro-fibrosis responses that were more pronounced in the apex compared to the base, and also endothelial dysfunction in the systemic microcirculation, all of which were significantly prevented by the empagliflozin treatment. They further suggest that SGLT2 appears as an interesting target in TTS.

The prognostic role of urea-to-creatinine ratio in patients with acute heart failure syndrome: a case–control study

BackgroundRecent research has shown that the blood urea/creatinine ratio (BUN/Cr) rather than BUN or Cr alone can predict the prognosis of individuals with acute heart failure (AHF). The objective of this study was to estimate the urea-to creatinine serum ratio (BUN/Cr) in patients with acute decompensated heart failure (ADHF) and correlate the results with patient outcome, length of hospitalization, and mortality.ResultsSixty ADHF patients were included and categorized into four groups; Group I: non-AKI with low BUN/Cr (n = 25); Group II: non-AKI with high BUN/Cr (n = 5); Group III: AKI with low BUN/Cr (n = 14); Group IV: AKI with high BUN/Cr (n = 16). Regarding urea and BUN levels, the first reading showed a considerable rise in urea and BUN levels in groups III and IV compared to group 1 and in group IV compared to groups I and III. Similar results were recorded in the second and third readings. Regarding the BUN/Cr ratio, the three readings revealed a significant elevation in group IV compared to groups I and II and in group IV compared to group III. Mortality was significantly higher in group IV compared to group I. Additionally, MACE was significantly more frequent in group IV compared to groups I and III. Multivariable logistic regression analysis revealed that hypertension, creatinine, and BUN were independent predictors of AKI.ConclusionsBUN/Cr may predict prognosis in AHF patients since AHF with an elevated BUN/Cr is associated with a higher death rate.

Beta-blockers and renin-angiotensin system inhibitors for Takotsubo syndrome recurrence: a network meta-analysis

IntroductionTakotsubo syndrome (TTS) is an acute heart failure syndrome, featured by transient left ventricular systolic dysfunction. Recurrences of TTS are not infrequent and there is no standard preventive therapy. The...

Calcineurin signaling promotes takotsubo syndrome

Takotsubo syndrome (TTS) is an acute heart failure syndrome that mimics the symptoms of acute myocardial infarction and is often preceded by emotional and/or physical stress. There is currently no treatment for TTS. Here we show that injection of 2.5 mg kg−1 of epinephrine (EPI) into mice recapitulates numerous features of human TTS, including increased myocardial damage and mortality in males. Gene set enrichment analysis of myocardial RNA sequencing after EPI injection revealed significant enrichment of calcineurin-dependent pro-inflammatory gene networks, which was more pronounced in male than in female mice, in agreement with observed sex discrepancies in the mouse phenotype. An increase in calcineurin activity was detected in the circulating cells of patients with TTS, suggesting a systemic nature of the syndrome. Preventive and therapeutic treatment of mice injected with EPI using calcineurin inhibitors cyclosporine and tacrolimus improved heart function and reduced myocardial injury. Our findings suggest that calcineurin inhibition could be a potential therapy for TTS.

How different triggers affect CMR parameters in takotsubo syndrome

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Ospedale Sant'Orsola (Bologna) Background Takotsubo syndrome (TTS) is an acute and transient heart failure syndrome characterized by a temporary wall motion abnormality of the left ventricle. Cardiac magnetic resonance (CMR) has a crucial role to assess ventricles function, regional wall motion abnormalities (RWMA), myocardial edema, late gadolinium enhancement (LGE) and complications. To date, there is a lack of how trigger events impact CMR parameters. Purpose To evaluate the clinical presentation, triggers of TTS and CMR parameters in patients hospitalized for Takotsubo Syndrome (TTS). Methods In our study we evaluated 128 patients hospitalized with TTS between January 2016 and December 2021 in Italy. Diagnosis of Takotsubo syndrome was based on the international Takotsubo diagnostic criteria (InterTAK Diagnostic Criteria). Results The mean age of the study population was 68.7 ± 11.1 years, and 81 % were females. Concerning the event trigger of TTS, 44% of patients experimented with an emotional event and 56% with physical stress. CMR was available in 66 patients, performed 7.5 ± 3.7 days after admission during hospitalization. CMR confirmed that most patients had typical TTS with apical ballooning (87%) while only 4.5% had a midventricular pattern. Left ventricular ejection fraction (LV-EF) mean was 55.3 ± 10.9 %. Mean LV-EF did not significant differ between emotional and physical trigger populations (51±12.5 vs 56.3±7.7; p = 0.12). Myocardial edema was present in 64.2% of patients and the mean number of segments involved was 6.2. ± 5.9. No statistical correlation between TTS trigger and the presence of edema at T2-weighted imaging was noticed. Spotty LGE was observed in 23.1 % of CMR exams, most evidenced in lateral (11.9 %) and inferior segments (10.4 %). LGE was evidenced more frequently in TTS triggered by physical events (38.1% vs 13%; p value=0.04) unlike pericardial effusion (0% vs 14%; p value= 0.04). Moreover, Hs-troponin I peak value was higher in the TTS physical triggered population than TTS with emotional trigger (3413 ± 4457 ng/l vs 2018 ± 2064 ng/l; p value= 0.04). Conclusions Early execution of CMR is essential in suspected TTS because several parameters are relatively time-dependent and derived from dynamic alterations that might resolve over time (such as myocardial edema). In our study patients with a physical trigger had a higher Hs-Troponin I max peak value and, more frequently spotty LGE on CMR. This could be the manifestation of more consistent myocardial damage compared to emotional triggers. However, the physiopathological and prognostic role of LGE in TTS remains unclear.

Pomegranate Peel Extract Attenuates Isoprenaline-Induced Takotsubo-like Myocardial Injury in Rats.

Takotsubo syndrome (TTS) is an acute heart failure syndrome characterised by catecholamine-induced oxidative tissue damage. Punica granatum, a fruit-bearing tree, is known to have high polyphenolic content and has been proven to be a potent antioxidant. This study aimed to investigate the effects of pomegranate peel extract (PoPEx) pre-treatment on isoprenaline-induced takotsubo-like myocardial injury in rats. Male Wistar rats were randomised into four groups. Animals in the PoPEx(P) and PoPEx + isoprenaline group (P + I) were pre-treated for 7 days with 100 mg/kg/day of PoPEx. On the sixth and the seventh day, TTS-like syndrome was induced in rats from the isoprenaline(I) and P + I groups by administering 85 mg/kg/day of isoprenaline. PoPEx pre-treatment led to the elevation of superoxide dismutase and catalase (p < 0.05), reduced glutathione (p < 0.001) levels, decreased the thiobarbituric acid reactive substances (p < 0.001), H2O2, O2- (p < 0.05), and NO2- (p < 0.001), in the P + I group, when compared to the I group. In addition, a significant reduction in the levels of cardiac damage markers, as well as a reduction in the extent of cardiac damage, was found. In conclusion, PoPEx pre-treatment significantly attenuated the isoprenaline-induced myocardial damage, primarily via the preservation of endogenous antioxidant capacity in the rat model of takotsubo-like cardiomyopathy.

Potential association between fentanyl, propofolinduced acute heart failure and Kounis syndrome: A case report and review of the literature

Potential association between fentanyl, propofolinduced acute heart failure and Kounis syndrome: A case report and review of the literature

C25 TEMPORAL TREND MORTALITY AND IN–HOSPITAL MORTALITY PREDICTORS IN AN ISCHEMIC CARDIOGENIC SHOCK POPULATION: A 10 YEARS SINGLE–CENTRE RETROSPECTIVE STUDY

Abstract Background Cardiogenic shock (CS) after acute myocardial infarction (AMI) represents the most severe form of acute heart failure (AHF) syndromes with an high rate of in–hospital mortality. Purpose describe predictors of in–hospital mortality; evaluate ten years mortality temporal trend in our CICU; assess the feasibility of CARDSHOCK risk score; elaborate a simpler version of CARDSHOCK risk score. Methods All consecutive patients with CS after AMI admitted at our CICU from March 2012 to July 2021 were included in this single–centre retrospective study. Results We included 167 patients [males 67%; age 71 years] with ischemic CS. Patients had severe LV dysfunction in 66%. Baseline serum lactate was 5,2 mmol/L. All patients required inotropes: 71% required dopamine, 65% noradrenaline, 32% dobutamine; 32% adrenalina,17,4% received levosimendan alone. Mechanical cardiac support (MCS) was pursued in 91,1% [65% IABP, 23% Impella CP, 4% VA–ECMO]. From March 2012 to July 2021 we observed a significative temporal trend mortality reduction (p=0.0015) from 57% of first time–quartile to 29% of the fourth quartile (fig1). In addition we noted a significant increase in Impella catheter use (p=0,0005) with a consequent reduction of IABP (p=0,01), a reduction in dopamine administration (p=0,007) and a greater use of inotropic drugs with vasodilatory action (p=0,015 and p=0,001). In our population of AMI–CS patients CARDSHOCK risk score was a reliable in–hospital mortality predictor tool (p=0.00011). After the multivariate analysis only EF at baseline (p=0,009), lactate level at presentation (p=0,015) and presence of three–vessels CAD (p=0,0038) resulted to be in–hospital mortality predictors. A new prediction model composed by those three variables was created and it exhibited better predictive performance for in–hospital mortality than Cardshock risk score (AUC 0,94 vs 0,72 respectively, p=0,015) (fig2). Conclusions In our retrospective single–centre study a significant reduction of mortality through the years is observed, probably due to more extensive use of micro axial pumps and a greater use of inodilators drug therapies. Cardshock risk score represents a feasible tool to predict in–hospital mortality also in our sample composed only of ischemic CS patients. A new prediction model composed by three clinical variables demonstrates at least the same predictive performance but future validation in a larger population could be advisable to validate the simplified score.

Successful Resuscitation of Neonatal Kittens Delivered by a Perimortem Cesarean Section Following Maternal Cardiopulmonary Arrest.

A 9 yr old, unknown weight, intact female domestic shorthair presented for evaluation of dystocia with dyspnea. En route to the hospital for treatment, the owners noted the queen stopped breathing. On presentation, cardiopulmonary arrest was confirmed. The exact cause was unknown but suspected to be secondary to acute fulminant congestive heart failure or acute respiratory distress syndrome due to a large volume of serosanguineous fluid within the mouth and nose. Cardiopulmonary resuscitation (CPR) was immediately started. After 2 min of CPR without return of spontaneous circulation, the owners consented to perimortem Cesarean section. Two kittens were removed via emergency hysterotomy within 3-4 min. Both kittens were successfully resuscitated. CPR efforts were continued on the queen for 2 min after delivery of the kittens, at which time the owners elected to stop further resuscitative efforts. Both kittens were discharged from the hospital and were alive at last follow-up, 2 yr and 4 mo after birth. There are no previous reports regarding the use of a perimortem Cesarean section to deliver neonates in small animal medicine. Therefore, this report represents a novel treatment approach that can be considered in the case of maternal arrest during dystocia.

Kidney function changes in acute heart failure: a practical approach to interpretation and management.

Worsening kidney function (WKF) is common in patients with acute heart failure (AHF) syndromes. Although WKF has traditionally been associated with worse outcomes on a population level, serum creatinine concentrations vary greatly during episodes of worsening heart failure, with substantial individual heterogeneity in terms of their clinical meaning. Consequently, interpreting such changes within the appropriate clinical context is essential to unravel the pathophysiology of kidney function changes and appropriately interpret their clinical meaning. This article aims to provide a critical overview of WKF in AHF, aiming to provide physicians with some tips and tricks to appropriately interpret kidney function changes in the context of AHF.

Use of VA-ECMO successfully rescued a trauma patient with fat embolism syndrome complicated with acute heart failure and acute respiratory distress syndrome

Use of VA-ECMO successfully rescued a trauma patient with fat embolism syndrome complicated with acute heart failure and acute respiratory distress syndrome

Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema.

This simulation is appropriate for senior and junior emergency medicine residents. Shortness of breath is a very common presentation in the emergency department and can range from mild to severe as well as a chronic or acute onset. In sympathetic crashing acute pulmonary edema (SCAPE), patients typically present with acute onset of dyspnea occurring within minutes to hours and have significantly elevated blood pressure.1 The condition of SCAPE falls into the spectrum of acute heart failure syndromes such as fluid overload pulmonary edema and congestive heart failure exacerbation.1. At the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. This simulation was performed using a high-fidelity mannequin. In order to simulate the telemedicine aspect, the learner evaluated the patient using a video conferencing interface while the two confederates were present with the high-fidelity mannequin. A debriefing session was held immediately after the simulation. The educational content was evaluated by debriefing and verbal feedback provided immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. Post-simulation feedback was overall positive with participants and observers. Participants and observers felt this was a safe and realistic simulation of SCAPE and provided them with the opportunity to practice rapid recognition and treatment of this condition. Sympathetic crashing acute pulmonary edema falls into the spectrum of acute heart failure disorders, and rapid recognition and stabilization is vital for the patient's survival. This simulation case provided learners of all levels the chance to assess and treat a life-threatening condition with limited information in a safe and effective learning environment. The telemedicine component was used while conducting weekly didactics via zoom during the COVID-19 pandemic. Simulation is a large component of our didactic curriculum and implementing the telemedicine component into this case was worth the effort. It is important to familiarize our residents with telemedicine since we expect that it will become a larger part of the practice of emergency medicine in the future, allowing board-certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller hospitals that may be staffed with less experienced providers. Medical simulation, tele-medicine, pulmonary edema, respiratory distress, cardiac emergencies, resuscitation.