Cardiac Arrest Research Articles

Characterization and mid-term outcomes of current out-of-hospital cardiac arrest patients admitted to intensive cardiovascular care units

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Consell Català de Resuscitació. Background Out-of-hospital cardiac arrest (OHCA) accounts the 50% of cardiovascular deaths. Being aware of characteristics and outcomes of our OHCA population is important in order to apply measures in the weaker areas to improve the results of the process. Purpose To investigate current outcomes, at 6-month follow-up, of patients admitted to an Intensive Cardiac Care Unit (ICCU) in a mediterranean area during the 2020s. Current characteristics, prehospital management and factors related to outcomes were also analyzed. Methods PCR-Cat was a prospective observational multicentre registry. OHCA patients admitted to the ICCU of 8 hospitals were included from October/2020 to December/2021. Those who survived with good neurological status, no disabilities, and remained independent for usual life activities, were classified as Good Outcome (GO). Those patients who died or had a poor neurological status, with high dependency or rested in permanent vegetative status were classified as Poor Outcome (PO). A multinomial logistic regression was done to analyze the factors independently related to PO. Results 288 patients were included, only 50 (17.36%) were women. At 6-month follow-up, 48.95% of patients had GO. Most events happened in the first month (Figure 1). The cause of death was neurological in 72.9%. Patients with PO were significantly older (63.74 vs. 58.88, p=0.003) and had more comorbidities (Table 1A). The most frequent location was on a public space (54.84%) and most were witnessed (88.93%). Cardiopulmonary resuscitation maneuvers were initiated by a bystander in 69.18% until EMS arrival, being only 20.79% done by an experienced bystander. The medium no-flow time was low (2 min) but total time until ROSC was of 28 min. First rhythm was shockable in 80%, but an automatic external defibrillator was only used in 58% of cases. Statistically significant lower values of first pH and higher values of first lactate, glucose and creatinine were related to PO (Table 1B). Patients with PO had a higher APACHE II (26 vs. 20, p<0.001) and SOFA (10.39 vs. 7.14, p<0.001) scores at admission, and required a longer time on mechanical ventilation (6 vs. 3.5 days, p=0.001). The main cause of the OHCA was acute coronary syndrome (53.82%), followed by chronic coronary syndrome (7.64%) and dilated myocardiopathy (7.64%). In the multinomial logistic regression, older age (p=0.005), male sex (p=0.016), previous stroke (p=0.046), longer ROSC time (p<0.001) and non-shockable first rhythm (p<0.001) were independently related to PO. Receiving cardiopulmonary resuscitation maneuvers by an experienced bystander was related to a reduction of 17 min of ROSC (p=0.001). Conclusions Less than a half of patients admitted to an ICCU because of an OHCA had GO at 6-month follow-up. Age, male sex, previous stroke, longer ROSC time and non-shockable first rhythm were factors independently related to PO. Interventions addressed to reduce ROSC time are urgently needed.

Do air pollutants levels during the previous 48 hours predict out-of-hospital cardiac arrest incidence compared to same-day pollutants levels?

Abstract Funding Acknowledgements None. Introduction Association between air pollutants (APs) levels and out-of-hospital cardiac arrest (OHCA) at the same day of the measurements have been previously described. Whether APs levels measured during the previous 48 hours may predict OHCA occurrence is not known. Purpose To analyse whether same-day APs levels compared to APs levels during the previous 48 hours are associated with OHCA incidence. Methods OHCA admissions on five Cardiac Intensive Care Units of our city were assessed during September-2020 to December-2021. Free access data regarding particulate matter (PM10), carbon monoxide (CO), nitrogen dioxide (NO2) and ozone (O3) levels during the same period were also registered. APs measures occurred each hour daily at three different spots, delivering more than 31000 measurements. APs levels during the previous 48 hours and during the index day were compared between OHCA-free days (OHCA-Fd) and OHCA-days. Results 179 patients were included. Main demographic characteristics are shown on table 1. Daily OHCA incidence and APs mean levels/month are shown in Table 2. As shown at table 3 same-day higher NO2 and lower O3 levels were found on OHCA-days compared to OHCA-fd: 41 ±10 vs. 36 ±9 µg/m3, p=0.016 for NO2 and 45 ±13 vs. 51 ±11 µg/m3, p= 0.003 for O3. As shown on Table 2 same day mean O3 levels were also higher from April to September compared to the rest of the year (p<0.001). OHCA incidence was lower in this same period (p<0.001). There wasn’t any association between OHCA incidence and APs (NO2, O3, PM10 and CO) measured at any moment during the event's prior 48 hours. Conclusions Same-day higher NO2 and lower O3 levels were associated to a higher OHCA incidence in our city. On the other hand, association between OHCA and NO2, O3, PM10 or CO measurements during the previous 48 hours was not found in our cohort. Reducing production of NO2 (i.e., reducing fossil-fuel consumption) may reduce OHCA risk during that same day.

Mechanical circulatory support in high-risk PE for more than a decade

Abstract Funding Acknowledgements None. Background/Introduction Absence of solid evidence in clinical practice guidelines on the management of patients with a severe pulmonary thromboembolism (PTE) in a situation of cardiogenic shock requiring mechanical circulatory support (veno-arterial ECMO). A registry has been carried out in a tertiary hospital of patients admitted to the Cardiological Critical Care Unit (CCCU) with a diagnosis of high-risk PTE and V-A ECMO implantation. Purpose The objective is to describe the experience of our center due to the paucity of evidence from current guidelines in this area iin terms of morbimortality and expected outcomes. Methods Data were collected from all patients admitted with a diagnosis of high-risk PE in the CCCU from 05/01/2010 to 05/01/2023. Of these, only those in whom V-A ECMO was implemented during admission were analyzed and described below. Clinical, analytical and survival variables were explored. Results A total of 11 patients were included, 3 (27.27%) being women. The mean age was 53 years (SD 10.64). Every V-A ECMO cannulation was performed in a femoro-femoral configuration by a surgical approach. The mean length of stay in the Critical Care Unit, total hospital stay length and circulatory support time were respectively: 8 days (SD 5.5); 20.7 days (DS 16.5) and 3 days (DS 1.9). The indication for the implantation of V-A ECMO was in a situation of SCAI-E in 7 patients (in 2 of them, V-A ECMO was implanted during cardiac arrest, and a 100% of mortality was described in the first 24 hours). On the other hand, in the remaining 4 patients, the indication for support was a deteriorating evolution despite amines. Of these, in 2 of them, there was a formal contraindication for the administration of systemic fibrinolytic treatment (recent major surgery, in one of them oncology). It should be noted that VA ECMO without adjuvant fibrinolysis was used in 6 of the patients (54.5%), and in 1 of them (16%) of them died (anoxic encephalopathy). However, the remaining 5 patients received combined VA ECMO therapy and systemic fibrinolysis (45.5%), with 2 deaths reported in this subgroup (40%). Those deceases happened both due to adequacy of the therapeutic effort in the context of multiple organ failure. No major bleeding was reported, even in the combination therapy group. Conclusions Support with V-A ECMO has allowed survival >70% in patients diagnosed with high-risk pulmonary embolism, including in those cases with absolute contraindication for systemic fibrinolysis. High safety profile in terms of bleeding even in those patients with a combined approach.

All lactate are not equal substudy of the BOX trial

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The BOX trial was supported by a grant (NNF17OC0028706) from the Novo Nordisk Foundation. Dr. Hassager's work is funded by a grant (R186-2015-2132) from the Lundbeck Foundation. Background Lactate levels following out-of-hospital cardiac arrest (OHCA) are associated with arrest duration (time to ROSC) and mortality. However, given the complexity of lactate generation and clearance, lactate levels assessed at hospital arrival represent not only time to ROSC but also the quality of resuscitation, circulatory stability following ROSC, dose of epinephrine administered, kidney, liver, and mitochondrial function in the early post-cardiac arrest phase. Accordingly, we describe the lactate levels at hospital arrival according to time to ROSC and one-year mortality. Method In this sub-study of the randomized clinical BOX trial, blood lactate levels were measured immediately at hospital arrival. Time to ROSC was registered in the medical records. Patients were divided into two groups according to median time to ROSC (≤ 18 min or > 18 min). The primary outcome was one-year mortality. Results The study included 768 (97% of the randomized population) patients of which 386 (50%) patients had ≤ 18 min and 382 (50%) patients had > 18 min to ROSC. The median age (64 (54-73) years) and sex distribution (81% men) was similar in both groups. One-year mortality was 76 (20%) and 199 (52%) in the ≤ 18 min and > 18 min to ROSC groups respectively. Mean lactate levels were 3.8 mmol/L (95%CI: 3.5-4.1) and 5.9 mmol/L (95%CI: 5.4-6.2), respectively. Lactate levels differed significantly between one-year survivors and non-survivors in the patients with ≤ 18 min to ROSC (mean difference: 1.9 mmol/L, 95%CI: 1.0 - 2.8) but not for patients with > 18 min to ROSC (mean difference: 0.6 mmol/L, 95%CI: -0.1-1.3), Figure 1. Further, lactate’s ability to predict one-year mortality was fair in the ≤ 18 min group with an Area Under Receiver Operating Characteristic Curve (AUC) of 0.68 (95%CI: 0.62-0.75) but poor for the > 18 min groups with an AUC of 0.55 (95%CI: 0.50-0.61) (DeLong's test for two ROC curves, p = 0.004), Figure 2. Conclusion Lactate's predictive value for one-year mortality decreases with increasing time to ROSC in OHCA. This highlights the importance of individualized clinical approaches based on lactate dynamics in OHCA patients.Figure 1Figure 2

Serial invasive hemodynamics and clinical characteristics of patients with shock with and without invasive mechanical ventilation

Abstract Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p <0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p <0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Long-term prognostic ability of the GRACE 3.0 risk score in patients hospitalized for acute coronary syndromes

Abstract Funding Acknowledgements None. Background The GRACE 3.0 (GRS 3.0) is a risk assessment tool for in hospital mortality for patients admitted with acute coronary syndrome (ACS). This study sought to validate the accuracy of GRS 3.0 in predicting long-term mortality following a hospitalization for ACS. Methods We measured retrospectively all various factors included in GRS 3.0 such as age, heart rate, systolic blood pressure, creatinine, sex, cardiac arrest, ST-segment deviation on ECG, troponin elevation, and Killip Class. Multivariable Cox regression analysis was used. The discriminative ability of the GRACE 3.0 risk score was calculated by the c-index, which corresponds to the area under the ROC curve. Results 223 patients with ACS were included. During a median follow-up of 3 years, 57 (25.6%) patients died. Among the variables of GRS 3.0, age, heart rate, and troponin elevation at admission were the only independent predictors of mortality. The score had good discrimination for all-cause mortality (c-index=0.82, 95% CI 0.75–0.89) [Figure]. It performed equally well in both sexes. Conclusions The newly developed GRS 3.0 is well-performing for predicting long-term mortality in patients hospitalized for ACS. Thus, it may assist in tailored risk stratification and management of these patients following hospital discharge.

Modulation of cytokine response in post-cardiac arrest syndrome through prehospital high-dose glucocorticoid treatment

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation Research Foundation of Rigshospitalet. Background Post-cardiac arrest syndrome (PCAS) following out-of-hospital cardiac arrest (OHCA) is a life-threatening condition, characterized by a cascade of pathological events, including the development of a severe cytokine response. This inflammatory response may be associated with secondary brain injury and multi-organ dysfunction. In the randomized STEROHCA trial, high-dose glucocorticoid was administered immediately following resuscitation in the prehospital setting. The intervention exhibited a significant decrease in interleukin (IL) 6 levels, but its effect on other cytokines has yet to be assessed. Purpose We aimed to investigate the effects of high-dose glucocorticoid treatment in mitigating the cytokine response observed in PCAS after OHCA. Methods The modified intention-to-treat population of the double-blind, randomized STEROHCA trial consisted of 137 OHCA patients, who were randomized to a single prehospital injection of methylprednisolone 250 mg or placebo. Of these, this sub-study included 112 patients who were comatose and admitted to an ICU. Cytokine profiling was performed with a 17-plex assay, including pro- and anti-inflammatory cytokines, which were measured at 0, 24, 48, and 72h after admission. We applied mixed-model analyses to assess the effect of the intervention over time with log-transformed data. To maintain an exploratory approach, we chose not to correct for multiple testing. Results The intervention induced a reduction in the levels of several cytokines, with a significant treatment over time effect for IL-4, IL-8, IL-10, Monocyte Chemoattractant Protein-1 (MCP-1), Macrophage Inflammatory Protein-1 Beta (MIP-1β), and Tumor Necrosis Factor Alpha (TNF-α), all p<0.01. These cytokines, except for IL-10, exhibited lower values in the glucocorticoid group after 24h, Figure 1. Higher levels of IL-10 were observed in the glucocorticoid group at 0h. We found no differences in cytokine levels after 48-, and 72h between the two groups. Conclusion High-dose glucocorticoid treatment administered promptly after resuscitation from OHCA reduced several pro-inflammatory cytokines after 24h. TNF-α has previously been associated with poor outcomes following OHCA, whereas the exact role of the other cytokines following OHCA is unclear.Cytokines at 0-, 24-, 48-, and 72 hours

Midazolam as mean sedative agent in out-of-hospital cardiac arrest shock: is it associated to increased mortality?

Abstract Funding Acknowledgements None. Background The choice of a sedative agent for patients undergoing invasive ventilation has been widely studied. However, data regarding the optimal sedation strategy after Out-of-Hospital Cardiac Arrest (OHCA) when the patients are suffering from post-OHCA shock is sparse. Aim To explore whether the use of midazolam in patients admitted for OHCA that are additionally haemodynamically unstable increases in-hospital mortality, cardiovascular (CV) mortality, cerebral performance status (CPC) at discharge, and days of intubation or admission, when used selectively during the acute phase of deteriorating post-OHCA shock patients. Methods We report a prospective, observational, single-centre cohort that included all-comers admitted due to OHCA of presumed cardiac cause between May-2019 and July-2023, that remained comatose at admission. Midazolam was only administrated as the mean sedation agent when the patient was in a hemodynamically deteriorating situation (SCAI D-E). Baseline characteristics, OHCA features, blood samples measurements, in-hospital treatments and neurological condition at discharge were registered. Primary outcome was in-hospital death from any cause. Secondary outcomes included CPC at discharge (1-2 VS 3-5), CV mortality, days of admission, days of intubation, need of tracheostomy, myopathy, enolase at 48h and heart transplant during admission. Patients were stratified according to whether they had received midazolam as mean sedation agent at some stage of admission or not. Results 103 patients of the 109 admitted were included (6 refused consent), 45 of them (43%) received midazolam at some stage of admission. No differences in baseline characteristics were found. Mean age was 60.6 years, 79.6% were male, most frequent comorbidities were hypertension (53.4%) and dyslipidaemia (46.6%), and 20,4% had had a previous myocardial infarction. OHCA characteristics, shock parameters and administered treatments did not significantly differ between the two groups (Table 1). In-hospital mortality was numerically higher in the midazolam group but did not reach statistical significance (56% vs. 38%, p=0.075) (Figure 1). There were no differences neither in secondary outcomes (CV mortality 4% vs. 5%, p=0.865; CPC 1-2 70% vs. 83%, p=0.244; days of intubation 6 vs. 4, p=0.203; tracheostomy 18% vs. 10%, p=0.275; days of admission 14 vs. 15, p=0.851; 48h enolase 38 vs. 29, p=0.919; heart transplant during admission 0% vs. 1,7%, p=0.376; myopathy 30% vs. 21% p=0.282). Conclusion In patients admitted due to OHCA, even though the administration of midazolam is given in unstable patients, it is not related to a higher in-hospital mortality nor poorer outcomes.Table 1.OHCA and shock characteristicsFigure 1.Cumulative Survival

The prognostic value of HEART score in patients with known heart failure evaluated at the emergency department for acute chest pain

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (United States). Background Chest pain is a common and concerning symptom in emergency care, often necessities further risk stratification for adverse cardiovascular events on short-term follow up. Patients with known heart failure (HF) constitutes a unique sub-population that would greatly benefit from short-term risk stratification to guide appropriate clinical interventions and optimize resource allocation. HEART (History, ECG, Age, Risk factors, Troponin) is a well-validated risk score that has been shown to outperform other clinical risk scores in patients with chest pain. It remains unknown if HEART score can be safely used in patients with known HF presenting to the emergency department with chest pain. Purpose We sought to evaluate the prognostic value of HEART score in patients with known HF compared to their counterparts. Method This was a prospective observational cohort study of consecutive adult patients evaluated at the emergency department for non-traumatic chest pain. HEART score was computed from charts by independent physician reviewers. The primary study outcome was major adverse cardiac events (MACE) defined as acute coronary syndrome, invasive revascularization, reinfarction, death, cardiac arrest, ventricular tachyarrhythmia, or acute exacerbation within 30 days of indexed admission. Outcomes were adjudicated by two independent reviewers (Kappa = 0.908). Classification performance between groups was compared using area under receiver operator characteristic curve (AUROC), sensitivity, and negative predictive value (NPV). Results Our cohort included 4,132 patients (age 59±16, 47% female, 33% Black). Overall, 921 patients (22.3%) experienced 30-day MACE. The classification performance of HEART score in those without HF (n = 3,329, 81%) was AUROC of 0.831 (95% CI 0.813-0.848), compared to only 0.633 (95% CI 0.592-0.673) in those with known HF (n = 803, 19%) (z score = 8.771, p < 0.001, Figure). The sensitivity and NPV of HEART score among those without HF were 87.4% and 95.3%, compared to 81.2% and 73.3%, respectively, among those with known HF. Conclusion Our findings suggest that the prognostic value of HEART score for predicting 30-day MACE is inferior and suboptimal in patients with known HF evaluated for chest pain at the emergency department compared to their counterparts. These findings emphasize the need for more tailored risk assessment and management strategies in this specific patient population. Further research is warranted to better understand the limitations and potential enhancements of the HEART score in patients with HF.Classification Performance of HEART score

Oxygen delivery and consumption in comatose out-of-hospital cardiac arrest patients are affected by blood pressure targets

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grosserer L. F. Foghts Fond Background Hemodynamic instability is common after resuscitated out-of-hospital cardiac arrest (OHCA). Preventing inadequate oxygen delivery (DO2) to the cells and thus not meeting oxygen demand is crucial to prevent further organ dysfunction. Additionally, oxygen uptake in the cells may be impaired. Oxygen consumption (VO2; the amount of oxygen consumed by the body per minute) could thus also be affected in OHCA. Purpose This study aimed to describe the effect of different mean arterial blood pressure (MAP) and partial arterial oxygen pressure (PaO2) targets on DO2 and VO2. Methods This post-hoc study is based on the BOX trial, a 2x2 factorial design that randomized OHCA patients to a MAP of either 63 mmHg (MAP63) or 77 mmHg (MAP77) and a partial pressure of arterial oxygen of 9 to 10 kPa or a liberal oxygen target of a PaO2 of 13 to 14 kPa at two cardiac centers in Denmark. Pulmonary artery catheters were placed to evaluate cardiac output and collect mixed venous blood samples at prespecified time points. Oxygen blood contents were calculated for arterial (CaO2) and mixed venous blood (CvO2) as Hgb (mg/dl) x 10 x 1.39 x Saturation O2 (proportion) + 0.0225 x PaO2. DO2 = CO x CaO2, and VO2 = CO x (CaO2-CvO2). Results This study included 715 patients (90% of the total cohort with a pulmonary catheter) for analysis. A restrictive or liberal oxygen supplement did not affect DO2 or VO2 during the initial 48 hours. The MAP77 group exhibited on average 11% higher DO2 (95%CI: 6%-15%) and on average a 6% higher VO2 in the first 48 hours (95%CI: 3%-10%) compared to the MAP63 group (see Figure 1). Conclusion Targeting a PaO2 of either 9 to 10 kPa or 13 to 15 kPa resulted in no significant changes in the provision of oxygen to the cells, nor did it increase the consumption of oxygen. In contrast, targeting a MAP of 77 mmHg resulted in an increase in both the provision of oxygen and consumption of oxygen compared to a MAP target of 63 mmHg.Figure 1

Current post-resuscitation management of out-of-hospital cardiac arrest patients admitted to intensive cardiovascular care units

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Consell Català de Resucitació 2022. Background Out-of-hospital cardiac arrest (OHCA) accounts the 50% of cardiovascular deaths. Neuroprognostication must be done in a multimodal approach as recommended by ILCOR guidelines but its application in real life is challenging. Aim To investigate current post-resuscitation care and neurological prognostication of OHCA patients admitted to a mediterranean Intensive Cardiac Care Unit (ICCU) during the 2020s. Methods PCR-Cat was a prospective observational multicenter registry. OHCA patients admitted to the ICCU of 8 catalan hospitals were included from October/2020 to December/2021. Post-OHCA management in the ICCU was analyzed including neuroprognostication tools and targeted temperature management (TTM) approach. Patients were classified into 2 groups according to main outcome at 6-month follow-up: good (CPC 1-2, GO) or poor outcome (death or CPC 3-4, PO). Results 288 patients were included, mean age 61.45 ± 13.76 and only 17.36% were female. GO at 6-month follow-up occurred in 48.95% of patients. Total medium time until ROSC was 28 min and first rhythm was shockable in 80%. An emergent coronary angiography was done in 68.9% and during any moment of the hospitalization in 83.5% (PCI 56.5%). There was no association between the presence and type of significant coronary artery disease and the main outcome. TTM was applied in 65.33% and the target temperature was 33ºC in 71.76%, 34ºC in 3.53%, 35ºC in 2.35% and 36ºC in 22.35%, with no statistically significant differences between the GO and PO groups. The neuronal specific enolase (NSE) was determined in 57 % of patients at 24 hours, 45% at 48h and 57% at 72 h. Myoclonus were statistically significant more frequent in patients with PO (51.20% vs. 7.52%, p<0.001). Almost one electroencephalogram was performed in 60.4% of patients, somato-sensorial evoked potentials in 53.01%, a cerebral computed tomography in 57.75% and a cerebral magnetic resonance imaging in 19.38%. As expected, an abnormal result of all those neurological tests, when performed, were related to poor outcome (Table 1). In-hospital mortality was 46%. Main cause of death was neurological in 72.90%. The percentage of CPC 1-2 increased throughout the follow-up period (Figure 1). Conclusions Although ILCOR guidelines clearly indicate the use of a multimodal approach for neuroprognostication, in real-life setting, the conventional tests for neurological evaluation are used in a differently in every center, depending on their expertise and facility of resources.Figure 1

Exploring the utility of the CSWG SCAI classification in patients with HF-CS requiring inotropic therapy

Abstract Funding Acknowledgements None. Background The Society for Cardiovascular Angiography and Interventions (SCAI) classification has been a well-established tool for risk stratification in heart failure cardiogenic shock (HF-CS). The recent CSWG SCAI classification provides easily obtainable parameters to classify CS severity. However, its utility has been mostly investigated in an intensive care unit (ICU) setting. Therefore, data on a more broad cohort of patients in whom inotropic therapy is deemed necessary is lacking. Purpose This study aimed to analyze the trajectory of patients necessitating inotropic therapy due to HF-CS and the utility of the proposed CSWG SCAI criteria in time. Methods We retrospectively analyzed patients admitted with acute HF who received inotropic therapy due to developing HF-CS at any time during admission. Patients with out-of-hospital cardiac arrest and acute coronary syndrome were excluded. SCAI stages were assigned retrospectively using the latest CSWG SCAI criteria during admission, pre-inotropic therapy, and at worst SCAI. The diagnostic performance of the CSWG SCAI criteria for predicting mortality during admission was assessed. Results This study included 333 patients with HF-CS. Of these patients, 221 (66%) were male, with a mean age of 70 years. The majority of patients were admitted with SCAI A (45%) and B (36%), and inotropic therapy was most often initiated in SCAI stage B (46%). Notably, 21% patient of the patients at time of inotropic therapy were still in SCAI A. In 52% of all patients inotropes was initiated within 24 hours of admission. The most frequently observed worst SCAI classification was C (41%). Lactate and blood pressure (BP) were responsible for the majority of SCAI B-D classifications at admission and pre-inotropic therapy, while pH was an important determent for SCAI E. However, vasoactive therapy was the most common determent for worst SCAI (71%), followed by BP (24%). Mortality rates for pre-inotropic therapy SCAI for classes A-E were 30%, 39%, 47%, 55%, and 48%. Mortality rates for worst SCAI C-E were 29%, 39%, and 59%. The area under the curve for predicting mortality was higher for worst SCAI as compared to pre-inotropic therapy SCAI (0.633 vs. 0.573, p=0.03). There was no difference in mortality between early (<24h) vs. late (>24h) initiation of inotropic therapy (p=0.43). Conclusion In our study the CSWG SCAI criteria proved to be challenging to apply in patients in whom inotropic therapy is considered, especially for patients classified as SCAI E. However, improvement of the CSWG SCAI performance was observed when it was applied at the time corresponding to the worst SCAI stage to predict mortality. More studies are required to further optimize the SCAI criteria in this specific subset of patients. In summary, our study provides valuable insights into the application of the CSWG SCAI classification in a diverse HF-CS population, specifically those requiring inotropic therapy.

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.

Exposure to hyperoxemia and mortality in cardiac intensive care unit patients

Abstract Funding Acknowledgements None. Background Hyperoxemia (a high PaO2, i.e. >200-300 mmHg) has been associated with adverse outcomes in general critical care settings as well as in acute cardiovascular care conditions. The association between hyperoxemia and mortality has not been characterized in the heterogeneous population admitted to the cardiac intensive care unit (CICU). We aimed to examine the association between hyperoxemia on CICU admission with in-hospital mortality. Methods We retrospectively analyzed Mayo Clinic CICU patients from January 2007 to April 2018. PaO2 closest on admission was analyzed as a continuous variable (per 100 mmHg) and categorized as: 60-100 mmHg (51.9%), 101-150 mmHg (28.6%), 151-200 mmHg (10.6%), 201-300 mmHg (6.4%), and >300 mmHg (2.5%). Those without PaO2 on admission and those with hypoxemia were excluded. The primary outcome was all-cause in-hospital mortality evaluated using logistic regression, after adjusting for age, Charlson Comorbidity Index, M-CARS, and use of IMV and NIPPV. Results A total of 3,368 patients were included (median 70.3 years, 39.4% women). Admission diagnoses included ACS (37.0%, with 19.8% STEMI), HF (67.8%), shock (33.0%) and cardiac arrest (25.3%). Median admission PaO2 was 99 (IQR 78, 136) mmHg, with no difference in median PaO2 between hospital survivors and inpatient deaths (99 versus 98, p = 0.38). A J-shaped relationship was observed between admission PaO2 and in-hospital mortality (Figure A), with slightly higher mortality below 100 mmHg and incrementally higher mortality above this threshold (esp. at >200 mmHg). The incremental association between higher PaO2 and mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, P = 0.03) was focused in the highest PaO2 group (i.e., >300 mmHg; Figure B). Conclusion Hyperoxia (esp. PaO2 >300 mmHg) on CICU admission is associated with increased in-hospital mortality, demonstrating a J-shaped association with an inflection point of lowest mortality around 100 mmHg. Further studies are warranted to assess if specific oxygen targets influence outcomes in critically ill cardiac patients.

Predicting survival with scales for in-hospital extracorporeal cardiopulmonary resuscitation

Abstract Funding Acknowledgements None. Background Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue option in cardiac arrest (CA) refractory to advanced life support. Patient selection is challenging, and anecdotal scores are specific to this situation. Purpose Our objective was to analyse the usefulness of different scales used in shock and venoarterial extracorporeal membrane oxygenator (VA-ECMO) support in in-hospital ECPR. Methods Retrospective analysis of consecutive ECPR cases in a referal center. The ECPR alert includes in-hospital cardiologist/intensivist, on-call interventional cardiologist/cardiac surgeon for cannulation, and on-call perfusionist. We analysed hospital survival based on our own and other literature-based mortality scales calculated prior to VA-ECMO implantation: SCAI, INTERMACS, CardShock, CSS, SAVE-ECMO, RESCUE-IHCA. Results Out of 222 VA-ECMO implanted, we included 66 ECPR cases between 2014-oct 2023. Baseline, admission and ECPR characteristics are collected in the table. Overall in-hospital survival was 16.7% (n=11) (cerebral performance cathegory 1-2). We developed a sumative mortality scale including factors related to survival in our population and the literature (lactate >10.05, >60 minutes CA, peripheral arterial disease (PAD), and on-call time for ECPR alert activation) (figure A). This scale was significantly related to survival to discharge (figure A). Regarding the scales and their association with survival, only RESCUE-IHCA showed a trend towards statistical significance (16 [15] points in survivors vs 19 [15] in died patients, p=0.096). The remaining scores showed no relationship with survival to discharge: SAVE-ECMO -15,73±4.8 in survivors vs -14,07±4.1 in died patients (p= 0.301), CSS 10,09±1.9 vs 10.40±2.7 (p=0.651), CardShock 4.82±1.3 vs 5.27±1.2 (p=0.287). INTERMACS (all patients 1) and SCAI classification (all patients stage E) are not valid for discriminating survival in this situation. We compared the scales using the ROC curve for hospital survival, and we found that our own scale had the best discriminatory ability (Figure B). Conclusions Scales developed for shock or VA-ECMO support were not significantly related to survival in patients undergoing in-hospital ECPR. The specific ECPR scale RESCUE-IHCA, and our own scale developed in this population showed better discriminatory ability in survival to discharge.Table.Baseline, admission and ECPRFigure.A: Own scale. B: ROC curves

Management and outcome of high-risk pulmonary embolism in intensive care units: results from a retrospective single-center analysis

Abstract Funding Acknowledgements None. Background High-risk pulmonary embolism (PE) patients are exposed to hemodynamic/multiorgan compromise including hypotension, cardiogenic shock and/or cardiac arrest (CA). Few data exist on management and outcome in patients admitted to intensive care units (ICU) with high-risk PE. Purpose We sought to analyse the epidemiology, management and outcome of patients admitted to ICU due to high-risk PE. Methods Retrospective monocentric analysis of adult patients with high-risk PE admitted from 2017 to 2023; COVID-19 patients were excluded. Demographic, clinical presentation, management and outcome data have been collected. Descriptive analysis comparing means adjusted for organ involvement severity and Cox regression were performed. Results 85 patients (55 male, 63±12 years old, BMI 29.06± 6) were included in the analysis. All patients received the diagnosis through the computed tomography angiography except 4 of them who underwent extra-corporeal cardiopulmonary resuscitation (eCPR) and the diagnosis was made with trans-oesophageal echocardiography. Overall mortality was 32%, eCPR rate was 9%. 92% were treated with adrenergic drugs (norepinephrine 78%, dobutamine 65%, epinephrine 35%); 7 patients required VA-ECMO due to CA. 42 patients received mechanical ventilation (MV) during the first 12 hours; those patients had higher rate of CS (p <0.001), higher lactates (mean difference 1.45±3.2; p <0.001), higher SOFA and SAPS II scores (respectively, mean difference 12.5±0.49 and 7.9±3.4; p 0.004). 75 patients underwent systemic thrombolysis. 10 patients with contraindication to systemic thrombolysis, underwent catheter directed thrombolysis (CDT); in 6 cases CDT was preceded by mechanical suction thrombectomy. Patients undertaking CDT had higher SOFA score at admission (mean difference 2.45±1.6; p 0.04), worsen creatinine (p <0.001), lower PaCO2 (mean difference -0.54±5.3; p 0.01), higher PaO2 (mean difference 28.7±6.5; p 0.009), higher bilirubin (mean difference 3.2±1.6; p <0.001) and lower systolic blood pressure (mean difference -6.8±3.36; p 0.01). At the Cox regression, higher lactates (HR 1.45 [0.40-0.99], p 0.004, panel A), lower glomerular filtration rate (HR 1.1 [1.02-1.09], p 0.001, panel B), higher bilirubin (HR 2.6 [1.20-6.03,] p 0.016), higher ALT (HR 1.07 [0.95-0.99], p 0.04), lower PaO2/FiO2 ratio (HR 1.1 [0.97-0.99], p 0.024, panel C), MV (HR 1.1 [0.78-7.58], p 0.04, panel D) and VA-ECMO (HR 2.5 [1.25-3.54], p 0.002) were associated with increased mortality; CDT was associated with lower mortality (HR 0.82 [0.68-1.89], p 0.04). Conclusions High-risk PE was burdened by high mortality. Signs of worsen organ failure and respiratory and mechanical support are associated with increased mortality. In this monocentric population the use of CDT was performed when systemic thrombolysis contraindicated and it was associated with favourable outcome, although the small sample (10%) should warn contextualization in results’ interpretation.

Perfusion index and mean arterial pressure after return of spontaneous circulation in out-of hospital cardiac arrest (OHCA) and their relationship with perfusion and survival

Abstract Funding Acknowledgements None. Background Current guidelines for post-cardiac arrest care recommend targeting mean arterial pressure (MAP) to restore adequate perfusion indicated by adequate urine output (UO) and normal or decreasing lactate, avoiding hypotension (MAP < 65 mmHg). The peripheral perfusion index (PI) is the ratio of the pulsatile blood flow to the non-pulsatile blood flow measured peripherally by a standard pulse-oximeter, and it represents a promising non-invasive tool to assess perfusion. The goal of this study is to assess whether prehospital PI and MAP measurements are associated with lactate clearance (LC), adequate UO and 30-days survival with good neurological outcome. Methods A retrospective analysis of prospectively collected data (January 2018 - March 2023) in two cardiac arrest registries located in Italy and Belgium was performed. PI was automatically and continuously measured by the manual monitor/defibrillator. The mean PI value of each minute after ROSC was extracted from the monitor data report and the mean value of 30 min of PI monitoring (MPI30) was calculated and categorized in tertiles (MPI30 T1-T3). The lowest prehospital value for MAP recording was considered. LC was defined by a serum lactate level <2 mmol/L at 6 hours. Inadequate UO was defined as < 0.5mL/kg/h averaged at 12 hours. Neurological outcome was assessed with the Cerebral Performance Category (CPC) at 30 days. Results Out of the 397 OHCA patients admitted to the ICU after ROSC enrolled over the study period 206 had a MPI30 value available and were included in this study; MAP value was available in 186 patients. In the subgroup of patients with hypotension, patients with MPI30 in T1 showed higher incidence of inadequate UO at 12 hours (78.9% vs 25.8%, p<0.001). At multivariable logistic regression, after adjusting for MAP, shockable rhythm, age, and dosage of adrenaline administered, MPI30 was independently associated with inadequate UO (OR 0.68, 95% CI 0.50-0.91, p=0.01). Patients with hypotension and MPI30 in T1 showed lower LC at 6h (15.8% vs 43.4%, p=0.02) when compared to the remaining population. At multivariable Cox proportional-hazard regression, after correction for shockable rhythm, age, and total amount of adrenaline administered, patients with hypotension and MPI30 in T1 showed lower survival with CPC 1-2 at 30 days (HR 2.61, 95% CI 1.52-4.51, p=<0.001) when compared to patients without hypotension or with hypotension but MPI30 in T2-T3. No difference in LC, adequate UO and survival with good neurological outcome was found between patients with hypotension and MPI30 in T2-T3 compared to patients without hypotension. Conclusion PI is a useful indicator of perfusion in patients with hypotension after OHCA. Patients with hypotension and reduced PI showed higher incidence of inadequate UO and lower incidence of LC, as well as association with lower survival at 30 days with CPC 1-2.Lactate clearenceSurvival at 30days with CPC 1-2

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational multicentric prospective study

Abstract Funding Acknowledgements None. Background Although temporary mechanical circulatory support devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process from VA-ECMO although there are no standardized protocols. Purpose We sought to evaluate the accuracy of echocardiographic indices in predicting successful weaning from VA-ECMO in CS patients. We tested total isovolumic time (tIVT), an index of ventricular performance(1,2), and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; E/e’ at mitral valve; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Multicentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Waning trials were performed daily starting from 48 hours after VA-ECMO institution. A stepwise decrease of VA-ECMO blood flow was applied, until reaching 1 or 1.5 L/min. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died in hospital for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (Figure 1-A): stroke volume (SV) >13.2 ml (HR 4.12 [1.71-9.95], p 0.002), tIVT >23.6 min/sec (HR 0.14 [0.02-1.03], p 0.053), LV VTI >6.6 cm (HR 4.99 [1.94-12.87], p<0.001), MAPSE >6.15 mm (HR 4.42 [1.90-10.24], p 0.001), TAPSE >11 mm (HR 10.13 [1.37-7.02], p 0.023), RV S’ >7 cm (HR 5.40 [1.45-20.12], p 0.012). LVEF, E/e’ and S’ at mitral valve did not reach the statistical significance. Figure 1-B shows Kaplan-Meier analysis on echocardiographic indices collected during the last weaning trial; figure 2 details HR of all these parameters. Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Parameters reflecting ventricular activation and systo-diastolic interaction already demonstrated superiority in defining ventricular performance. Considering the known limitations of LVEF (HR, loading and LV dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation in the acute setting.

Impact of acute aortic pathology care process reengineering on mortality of type A acute aortic syndrome

Abstract Funding Acknowledgements None. Introduction Type A Acute aortic syndrome (AAS) is a life-threatening disease. Although emergent surgery is the treatment of choice, these procedures are highly complex and require a high level of expertise. Process reengineering has demonstrated prognostic benefit in acute cardiovascular pathology. Purpose The aim of the present work is to assess whether the reorganization of AAS care has an impact on patient prognosis. Methods The "Aorta Code" (AC) is a protocol for AAS-patients’ care within a network of 4 hospitals with a tertiary hospital as a referral center. A common diagnostic algorithm was specifically designed and periodical training programs were carried out in the different emergency departments at the 4 hospitals. Once activated, the out of hospital emergency service immediately transfers the patient to the Acute Cardiovascular Care Unit at the referral center. An Aortic Dissection Team was responsible for patients’ care. Only two cardiac surgeons and two vascular surgeons performed all AAS surgeries. All patients with AAS were prospectively and consecutively collected and patients with type A AAS were selected for analysis. Expected 30-day mortality was calculated using the GERAADA score. Results From April-2019 to April-2023, 113 patients with AAS were included. Of them, 75.9% (83) were type A. 12% (10) of the patients died before reaching the operating theatre. In 9% (8) of the sample, surgery was rejected due to comorbidities and unacceptable surgical risk, of whom 4 patients died. Mean age was 66.7±13.7 years and 71% were males. Patients with type A AAS presented a significant burden of pre-surgical complications: severe aortic regurgitation (35.6%), cardiac tamponade (26.8%), shock (32.9%), cardiorespiratory arrest (8.5%), need for intubation (26.8%), acute renal failure (27%), peripheral malperfusion (12.7%) and myocardial ischemia (9.52%). Although the AC included a high risk AAS population, the process reorganization, and concentration of patients’ care in an experienced medical and surgical team resulted in a significant reduction of surgical mortality of patients with type A AAS compared to the expected mortality based on risk (figure). Conclusion AAS process reengineering and concentration of AAS management in an experienced medical-surgical team is associated with an improvement in the expected prognosis and mortality.Pre-surgical type A AAS complications.

Clinical characteristics, complications and in-hospital mortality in patients in the coronary care unit requiring invasive mechanical ventilation

Abstract Funding Acknowledgements None. Introduction Mechanical ventilation (MV) is one of the most widely used life support techniques in critically ill patients and, due to the increasing number of coronary care units (CCU), adequate management of this technique is essential. Purpose The aim of our study was to describe the profile of patients requiring invasive MV (IMV) in our CCU, as well as the mode of ventilation, complications and in-hospital mortality. Methods Single-center retrospective observational study of a cohort of patients admitted to a CCU between January 2018 and March 2023 who required IMV. Baseline characteristics, reason for admission and intubation, as well as evolution and complications during admission were analyzed. Results A total of 157 patients were included, 113 (72%) men. The mean age was 66.9 years (SD 12.2). Table 1 summarizes the history and baseline characteristics of the patients. Image 1 summarizes the reasons for admission. Regarding the causes of oro-tracheal intubation, the most frequent was cardiopulmonary arrest (CPA) (49.7%), followed by respiratory failure (32.5%) and cardiogenic shock (CS) (16.6%). Regarding left ventricular ejection fraction (LVEF) on admission, 69.4% had LVEF<52%, with 32.5% of all patients having LVEF below 30%. The most used ventilation mode as initial mode was volume-controlled mode (VC/AC), used in 71.3% of patients. The mean stay in CCU was 11 (min 1-max 78, SD 12) and of orotracheal intubation was 5 days (min 1-max 64, SD 7). Mean days to weaning from VMI was 2 (min 0-max 8, SD 2). Failure on extubation occurred in 38 patients (19.1%), the most frequent reasons being need for reintubation (12.7%), need for noninvasive MV (8.9%) and self-extubation (2.5%). Only 7 patients (4.5%) required tracheostomy. Regarding complications, 49% developed sepsis, 61.1% had CS, and 7% required renal replacement therapy. In-hospital mortality was 38.2% (60 patients). Conclusions IMV is a technique that is increasingly used in our environment. Patients who require it are usually complex, with multiple comorbidities, with a high percentage of CPA and CS. These patients usually have prolonged stays in the CCU, with an average of more than 10 days, frequent complications and a high in-hospital mortality of almost 40%. It is essential to gather series as large as possible of these patients to improve our knowledge of their management and characteristics.