Cardiac Causes Research Articles

Emerging Evidence in Out-of-Hospital Cardiac Arrest-A Critical Appraisal of the Cardiac Arrest Center.

The morbidity and mortality of out-of-hospital cardiac arrest (OHCA) due to presumed cardiac causes have remained unwaveringly high over the last few decades. Less than 10% of patients survive until hospital discharge. Treatment of OHCA patients has traditionally relied on expert opinions. However, there is growing evidence on managing OHCA patients favorably during the prehospital phase, coronary and intensive care, and even beyond hospital discharge. To improve outcomes in OHCA, experts have proposed the establishment of cardiac arrest centers (CACs) as pivotal elements. CACs are expert facilities that pool resources and staff, provide infrastructure, treatment pathways, and networks to deliver comprehensive and guideline-recommended post-cardiac arrest care, as well as promote research. This review aims to address knowledge gaps in the 2020 consensus on CACs of major European medical associations, considering novel evidence on critical issues in both pre- and in-hospital OHCA management, such as the timing of coronary angiography and the use of extracorporeal cardiopulmonary resuscitation (eCPR). The goal is to harmonize new evidence with the concept of CACs.

Effects of pre-existing type 1 diabetes mellitus on survival outcome following out-of-hospital cardiac arrest: a registry-based observational study in Sweden

BackgroundIt has been estimated that 80% of cases of out-of-hospital cardiac arrest (OHCA) are due to cardiac causes. It is well-documented that diabetes is a risk factor for conditions associated...

Splenic infarction may be the first sign of granulomatosis with polyangiitis: case reports

Granulamatous polyangiitis (GPA) is a rare systemic vasculitis that makes up most of the antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The disease is more likely to affect the upper and lower respiratory tract, kidney and skin. The gastrointestinal tract involvement is more rare. In the general population, spleen infarction is a rare condition. Most spleen infarcts are asymptomatic, and most patients receive a diagnosis by chance during the evaluation. The most common causes of non-traumatic spleen infarction in the general population include cardiac causes such as atrial fibrillation, infections, thrombophilic conditions, and malignancies. In rheumatic diseases, various spleen involvement has been identified, such as splenomegaly, spleen rupture, spleen abscess, asplenia and spleen infarction. The development of spleen infarct in antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) is well known. It is not well known whether GPA is a risk factor for spleen infarction. However, publications including cases of developing spleen infarction due to GPA are increasing. This review highlights the occurrence of spleen infarction in patients with GPA, by presenting two GPA cases with splenic infarction. It also emphasizes that spleen infarction can occur in GPA and may frequently be without symptoms.

Echocardiography-Derived Forward Left Ventricular Output Improves Risk Prediction in Systolic Heart Failure

Although it is widely used to classify patients with heart failure (HF), the prognostic role of left ventricular ejection fraction (LVEF) is debated. The aim of this study was to test the hypothesis that echocardiographic measures of forward left ventricular (LV) output, being more representative of cardiac hemodynamics, might improve risk prediction in a large cohort of patients with HF with systolic dysfunction. Consecutive stable patients with HF with LVEF <50% on guideline-recommended therapies undergoing echocardiography including the evaluation of forward LV output (i.e., LV outflow tract [LVOT] velocity-time integral [VTI], stroke volume index [SVi], and cardiac index) over a 6-year period were selected and followed for the end point of cardiac and all-cause death. Among the 1,509 patients analyzed (mean age, 71±12years; 75% men; mean LVEF, 35±9%), 328 (22%) died during a median follow-up period of 28 months (interquartile range, 14-40 months), 165 (11%) of cardiac causes. On multivariable regression analysis, LVOT VTI (P<.001), SVi (P<.001), and cardiac index (P<.001), but not LVEF (P>.05), predicted cardiac and all-cause death. The optimal prognostic cutoffs for LVOT VTI, SVi, and cardiac index were 15cm, 38mL/m2, and 2L/min/m2, respectively. Adding each of these measures to a multivariable risk model (including clinical, biohumoral, and echocardiographic markers) improved risk prediction (P<.001). Among the different measures of forward LV output, cardiac index was less accurate than LVOT VTI and SVi. The echocardiographic evaluation of forward LV output improves risk prediction in patients with HF across a wide LVEF spectrum over other well-established clinical, biohumoral, and echocardiographic prognostic markers.

Acute ischemic stroke and troponin elevation: update of the Mannheim clinical algorithm

Elevated high-sensitivity cardiac troponin (hs-cTn) levels should be expected in about half of all patients with acute ischemic stroke (AIS). Since those patients are at risk of increased morbidity and mortality, often attributable to cardiac causes, an adequate work-up of the underlying etiology is required. This can only be achieved by ateam of cardiologists and neurologists. Since underlying causes of hs-cTn elevation in AIS patients are diverse, often atypical or silent in their clinical presentation and some, such as an accompanying myocardial infarction, can be acutely life-threatening, the work-up should follow astandardized clinical algorithm. The vast majority of hs-cTn elevations are caused by non-ischemic myocardial injury associated with AIS. This work presents apractice-oriented approach to differential diagnosis with the update of the Mannheim clinical algorithm for acute ischemic stroke and troponin elevation.

Thirty-day unplanned readmissions following hospitalization for atrial fibrillation in a tertiary Syrian center: a real-world observational cohort study

BackgroundAtrial fibrillation (AF) is the most common arrhythmia worldwide. Data regarding 30‐day readmission following index admission for AF in the developing world are poorly described. ObjectivesThe study aimed to assess the rate, predictors, and trends of 30-day readmission after index admission for AF in Syria. MethodsWe included adult patients who had an index admission with AF to Latakia’s tertiary center between June 2021 and October 2023. Patients were monitored for readmission for 30 days after index discharge. Data were taken from patients’ medical notes. ResultsA total of 661 patients were included in the final analysis, of which 282 (43%) were readmitted to hospital within 30 days following index admission. Cardiac causes were the most common cause of readmission in 72% of patients, of which 60% were AF. Readmitted patients had a higher median age (62 vs 57; P=0.001) and fewer males (58% vs 51%; P=0.001). In multivariate analysis, factors that independently increased 30-day readmission risk were older age (HR: 1.5, 95% CI: 1.1-1.9), female sex (HR: 1.3, 95% CI: 1.02-1.4), diabetes mellitus (DM) (HR: 1.7, 95% CI: 1.3-2.3) and congestive heart failure (CHF) (HR: 2.2, 95% CI: 1.7-2.9). Most cardiac readmissions happened during the first 15 days (79%). ConclusionAlmost one in two patients were readmitted within 30 days after an index admission for AF. Female sex, advancing age, DM and CHF were independently associated with an increased risk of 30-day readmission.

Multi-Marker Approach in Patients with Acute Chest Pain in the Emergency Department.

Chest pain is a prevalent reason for emergency room referrals and presents diagnostic challenges. The physician must carefully differentiate between cardiac and noncardiac causes, including various vascular and extracardiovascular conditions. However, it is crucial not to overlook serious conditions such as acute coronary syndrome (ACS). Diagnosis of acute myocardial infarction (AMI) and early discharge management become difficult when traditional clinical criteria, ECG, and troponin values are insufficient. Recently, the focus has shifted to a "multi-marker" approach to improve diagnostic accuracy and prognosis in patients with chest pain. This observational, prospective, single-center study involved, with informed consent, 360 patients presenting to the emergency department with typical chest pain and included a control group of 120 healthy subjects. In addition to routine examinations, including tests for hsTnI (Siemens TNIH kit), according to the 0-1 h algorithm, biochemical markers sST2 (tumorigenicity suppression-2) and suPAR (soluble urokinase plasminogen activator receptor) were also evaluated for each patient. A 12-month follow-up was conducted to monitor outcomes and adverse events. We identified two groups of patients: a positive one (112 patients) with high levels of hsTnI, sST2 > 24.19 ng/mL, and suPAR > 2.9 ng/mL, diagnosed with ACS; and a negative one (136 patients) with low levels of hsTnI, suPAR < 2.9 ng/mL, and sST2 < 24.19 ng/mL. During the 12-month follow-up, no adverse events were observed in the negative group. In the intermediate group, patients with hsTnI between 6 ng/L and the ischemic limit, sST2 > 29.1 ng/mL and suPAR > 2.9 ng/mL, showed the highest probability of adverse events during follow-up, while those with sST2 < 24.19 ng/mL and suPAR < 2.9 ng/mL had a better outcome with no adverse events at 12 months. Our data suggest that sST2 and suPAR, together with hsTnI, may be useful in the prognosis of cardiovascular patients with ACS, providing additional information on endothelial damage. These biomarkers could guide the clinical decision on further diagnostic investigations. In addition, suPAR and sST2 emerge as promising for event prediction in patients with chest pain. Their integration into the standard approach in PS could facilitate more efficient patient management, allowing safe release or timely admission based on individual risk.

A novel predictive model for differentiating cardiac and non-cardiac syncope in syncope-admitted patients

Abstract Background Syncope due to cardiac causes presents a higher risk for mortality or other adverse events compared to those with non-cardiac causes. Thus, a critical focus in syncope management must be the early identification of these patients. Purpose This study sought to explore the predictive role of readily available clinical features for cardiac syncope and develop a diagnostic nomogram to facilitate its adoption in practice. Methods 877 patients who were hospitalized with syncope and had a confirmed cause were included in this retrospective study at a tertiary heart center. They were randomly divided into the training set and validation set and were categorized into two groups based on their underlying cause: cardiac syncope and non-cardiac syncope. A wide range of clinical features were analyzed and selected using LASSO regression. Subsequently, we utilized multivariable logistic regression analysis to identify independent predictors and construct a nomogram. The receiver operating characteristic (ROC) curves and the area under the curves (AUCs) were used to assess the predictive accuracy of the predictive model. Furthermore, calibration curves were used to measure the alignment between the predicted and actual observed probability, and decision curve analysis (DCA) was used to evaluate the clinical benefit of the nomogram. Results Within the entire cohort, 521 patients were diagnosed with cardiac syncope and 356 patients were diagnosed with non-cardiac syncope. Among 36 candidate variables, five independent predictors for cardiac syncope were selected using the LASSO logistic regression analysis, including BMI (OR 1.088; 95%CI 1.022-1.158), LVEF (OR 0.940; 95%CI 0.908-0.973), logarithmic NT-proBNP (OR 1.463; 95%CI 1.240-1.727), chest symptoms preceding syncope (OR 5.251; 95%CI 3.326-8.288), and abnormal electrocardiogram (OR 6.171; 95%CI 3.966-9.600). Subsequently, a nomogram based on the five independent predictors was developed, yielding AUC of 0.873 (95% CI 0.845–0.902) and 0.856 (95%CI 0.809-0.903) in the training set and the validation set, respectively. The calibration curves showcased the nomogram's strong calibration, and DCA curves revealed its potential as a highly effective tool in clinical practice. Conclusions This study has successfully developed and internally validated a novel predictive nomogram for distinguishing between cardiac and non-cardiac syncope, which holds a promise to serve as an effective tool to help facilitate early identification of such patients in clinical practice.ROC curves of the training and test setThe nomogram and web-based calculator

RESCUED (REgistry for Sudden Cardiac and UnExpected Death): the German registry for families affected by sudden cardiac death in the young

Abstract Background Sudden cardiac death in the young (SCDY) refers to an abrupt and unexpected cardiac arrest at a young age due to an underlying cardiac cause. Previous studies have shown that estimated more than 10% of SCDY victims 1 to 35 years of age suffered from a – previously often undiagnosed – rare genetic cardiac disorder. Due to the inheritability of such sequence variations in disease-causing cardiac genes, blood relatives of the deceased may equally be carriers of the causative genetic variation and therefore have an increased risk for cardiac arrhythmia. Purpose Despite sudden cardiac death (SCD) increasingly gaining global awareness, systematic data collection in form of registries is sparse. The data sets collected in the RESCUED registry allow for the identification of leading causes of SCDY in Germany and offer unique opportunities for further scientific analyses with the aim of revealing unrecognized trends, risk factors and clinical warning signs of SCDY. Methods Our workflows are based on international guidelines for post mortem examination of SCDY victims and clinical assessment of their relatives. Post-mortem assessment of the index patient includes autopsy, histology, toxicology, genetic testing and review of pre-mortem clinical data. Biological relatives within the family of the index patient undergo a cardiogenetic consultation, a set of cardiological examinations and a cascade genetic screening to determine each individual´s cardiac risk profile. Data is recorded in the registry through the web-based interface of the OSSE registry software (Open Source Registry System for Rare Diseases). Results Based on our experience with complex cases of SCD (over 150 SCDY cases and more than 450 relatives) and an in-depth literature research regarding SCD registries, we have developed designated questionnaires for systematic data collection for the deceased index patient and their biological relatives, respectively. We will present insights from the design of this registry, which represents a novel, pedigree-based approach to SCDY as a consequence of a possible underlying genetic cause, and offers a new viewing angle of identifying a possible cause of SCDY. For illustrational purposes, two SCDY cases including clinical data of the family members will be shown. Conclusions RESCUED is Germany´s first registry with a holistic, pedigree-based approach to SCDY. Apart from thoroughly documenting the cardiac deaths of young individuals under the age of 50, the phenotypes of their relatives are equally recorded. Ultimately, insights gained from the RESCUED registry will lead to improved and targeted diagnostic possibilities, risk stratification and, if need be, therapy in susceptible individuals, working towards the prevention of tragic deaths in affected families. The registry will also give insights into possible preceding warning signs and symptoms of SCDY regardless of whether the underlying cause is a rare genetic disease or not.

#1657 Impact of cumulative fluid and sodium imbalance exposure on cause-specific mortality in hemodialysis

Abstract Background and Aims Even mild fluid overload and prolonged exposure to salt excess showed to be associated with all-cause mortality in hemodialysis patients. This analysis aims to estimate the effect of fluid and sodium imbalance on cause-specific mortality. Method The study followed 68,196 incident hemodialysis patients from 875 clinics in 25 countries for a decade (2010-2020) using the European Clinical Database 5. Fatal events (21,644) were classified through ICD10- codes and free text descriptions into different endpoints: cardiac death (7,926 events)—with subcomponents sudden cardiac death (2,815 events), coronary death (1,705 events) and heart failure death (3,248 events); cerebrovascular death (1,516 events), non-cardiovascular death (10,898 events)—with subcomponents death by sepsis (2,054) or other infection (1,217 events), cancer death (2,095), other non-cardiovascular death (5,532 events) and death of unknown origin (1,304 events). Time-varying cumulative exposure times (in months) of relative fluid overload/-depletion, hypo-/hypernatremia and low dialysate sodium (≤ 138) were assessed and hazard ratios (HR) were calculated using a multivariate Cox model. Results Fluid overload showed the most consistent exposure risk associations for cardiovascular endpoints with strongest associations in cardiac causes (arrythmia death: HR peak at 7.5 (95% CI: 4.2-3.6), heart failure death: HR peak at 4.2 (95% CI: 3.3-5.4) and sudden cardiac death: HR peak at 3.8 (95% CI: 2.6-4.5)). Fluid depletion was less important but consistently associated with all causes of death. By contrast, Hyponatremia showed heterogeneity of cause specific effects. We found slightly stronger associations for non- cardiovascular causes: Death by sepsis (HR peak at 2.3 (95% CI: 1.8-2.8)) or death by other infections (HR peak at 2.1 (95% CI: 1.6-2.7)) showed the strongest cumulative exposure risk association pattern. Hypernatremia was less important with substantially smaller effects and slightly higher associations for non-cardiovascular endpoints. For low dialysate sodium, we observed evidence of heterogeneity in cause specific effects. The risk of death due to heart failure was notably pronounced with low dialysate sodium (HR peak at 5.8 (95% CI: 1.9-17.9)), while other endpoints did not show this effect. Sensitivity analysis in patients with 48 or more months of follow-up indicated that HR in higher exposure categories might be biased downwards due to non-survival of high-risk individuals. Conclusion Cause-specific hazard models confirm the role of fluid and sodium imbalance as independently acting risk factors for mortality. Fluid overload has the most pronounced effect on cardiac death, especially death by heart failure, arrhythmia, or sudden death. In contrast, hyponatremia is a more critical risk factor for non-cardiovascular death, particularly death caused by sepsis or other infections. The significantly increased risk in patients on low dialysate sodium prescriptions is primarily driven by a dramatic increase in risk of death by heart failure.

#2776 Monoclonal gammopathies and amyloidosis unit (UGAM-A): importance of the nephrologist in the multidisciplinary approach

Abstract Background and Aims The Monoclonal Gammopathies and Amyloidosis Unit (UGAM-A) is a multidisciplinary hospital subcommittee that discusses complex cases in relation to the diagnosis and treatment of patients with blood dyscrasia and amyloidosis. Method Retrospective observational study of the cohort of patients presented at UGAM-A The data were extracted from the minutes of the UGAM-A for the period Jan/18-Dec/22. Results 81 patients were assessed with a median age of 69 years, 52 men (64.2%). HT 58 (71.6%), DM 22 (27.2%), cardiovascular disease 14 (17.3%), Neoplasm 12 (14.8%). 56 patients (69.1%) had renal damage at the time of assessment, 54 with CKD criteria, with a mean creatinine of 1.7 ± 1.0 mg/dl and proteinuria of 1.3 ± 1.7 g/mg. Cardiac involvement was found in 19 patients. There were 37 (45.7%) diagnostic changes after assessment by the UGAM. A total of 22 (27.2%) therapeutic modifications, initiation or change were made. 17 (77.3%) occurred in patients with renal involvement. There were 10 (12.3%) treatment changes, with 22.7% of them improving renal function vs. 7% in the group with no change in treatment (p = 0.04). 8 (9.9%) patients required SDB, with a median time to onset of 452d. A total of 25 (30.9%) patients died, with a median time of 370d, with 12 being the most common cardiac cause, followed by infectious 8. Conclusion Nephrologists should be involved in the complex clinical cases that accompany hematologic diagnoses. In our study, almost 80% of patients had renal involvement concomitant with haematological pathology. The role of the nephrologist is fundamental in clarifying mechanisms of kidney damage and enhancing the initiation of treatment even when they do not meet criteria from the haematological point of view, so that more than 77% of the therapeutic actions took place in patients with renal involvement.

Acute kidney injury after out-of-hospital cardiac arrest

BackgroundAcute kidney injury (AKI) is a significant risk factor associated with reduced survival following out-of-hospital cardiac arrest (OHCA). Whether the severity of AKI simply serves as a surrogate measure of worse peri-arrest conditions, or represents an additional risk to long-term survival remains unclear.MethodsThis is a sub-study derived from a randomized trial in which 789 comatose adult OHCA patients with presumed cardiac cause and sustained return of spontaneous circulation (ROSC) were enrolled. Patients without prior dialysis dependent kidney disease and surviving at least 48 h were included (N = 759). AKI was defined by the kidney disease: improving global outcome (KDIGO) classification, and patients were divided into groups based on the development of AKI and the need for continuous kidney replacement therapy (CKRT), thus establishing three groups of patients—No AKI, AKI no CKRT, and AKI CKRT. Primary outcome was overall survival within 365 days after OHCA according to AKI group. Adjusted Cox proportional hazard models were used to assess overall survival within 365 days according to the three groups.ResultsIn the whole population, median age was 64 (54–73) years, 80% male, 90% of patients presented with shockable rhythm, and time to ROSC was median 18 (12–26) min. A total of 254 (33.5%) patients developed AKI according to the KDIGO definition, with 77 requiring CKRT and 177 without need for CKRT. AKI CKRT patients had longer time-to-ROSC and worse metabolic derangement at hospital admission. Overall survival within 365 days from OHCA decreased with the severity of kidney injury. Adjusted Cox regression analysis found that AKI, both with and without CKRT, was significantly associated with reduced overall survival up until 365 days, with comparable hazard ratios relative to no AKI (HR 1.75, 95% CI 1.13–2.70 vs. HR 1.76, 95% CI 1.30–2.39).ConclusionsIn comatose patients who had been resuscitated after OHCA, patients developing AKI, with or without initiation of CKRT, had a worse 1-year overall survival compared to non-AKI patients. This association remains statistically significant after adjusting for other peri-arrest risk factors.Trial registration: The BOX trial is registered at ClinicalTrials.gov: NCT03141099.

SGLT2 inhibition, venous thrombolism, and death due to cardiac causes: a mediation Mendelian randomization study.

To investigate the causal role of venous thrombolism mediating sodium-glucose cotransporter 2 (SGLT2) inhibition in death due to cardiac causes using Mendelian randomization (MR). A two-sample two-step MR was used to determine (1) the causal effects of SGLT2 inhibition on death due to cardiac causes; (2) the causal effects of venous thrombolism on death due to cardiac causes; and (3) the mediation effects of venous thrombolism. Genetic proxies for SGLT2 inhibition were identified as variants in the SLC5A2 gene that were associated with both levels of gene expression and hemoglobin A1c. Additionally, employing MR to investigate the causal association between SGLT2 inhibition and cardiac arrest as well as coronary heart disease (CHD). SGLT2 inhibition was associated with a lower risk of death due to cardiac causes (odds ratio [OR] = 0.983, [95% CI = 0.972, 0.993], P = 0.0016). Venous thrombolism was associated with death due to cardiac causes ([OR] = 1.031, [95% CI = 1.005, 1.057], P = 0.0199). Mediation analysis showed evidence of indirect effect of SGLT2 inhibition on death due to cardiac causes through venous thrombolism [β = -0.0015, (95% CI = -0.0032 -0.0002), P = 0.042], with a mediated proportion of 8.9% (95% CI = 1.2%, 18.7%) of the total. Furthermore, SGLT2 inhibition was linked to a lower risk of cardiac arrest ([OR] = 0.097, [95% CI = 0.013, 0.742], P = 0.025). SGLT2 inhibition was linked to a lower risk of CHD ([OR] = 0.957, [95% CI = 0.932, 0.982], P = 0.0009). Our study identified the causal roles of SGLT2 inhibition in venous thrombolism. SGLT2 inhibition may influence death due to cardiac causes through venous thrombolism. Additionally, SGLT2 inhibition was associated with reduced risk of cardiac arrest and CHD.

The influence of perceived stress in acute coronary syndromes presentation

Abstract Funding Acknowledgements None. Introduction Acute coronary syndrome (ACS) is the result of a complex pathophysiological process, influenced by multiple factors, including stress. The 10-item Perceived Stress Scale (PSS-10) is a validated instrument to estimate stress levels in clinical practice and may be useful in the assessment of ACS (Figure 1). Purpose We aimed to assess if perceived stress had influence on the presentation of an ACS as a ST-elevation myocardial infarction (STEMI) or a non-ST-elevation myocardial infarction (NSTEMI), at admission, during hospitalization for this event, and at follow-up. Methods Single-center prospective study engaging patients hospitalized for ACS from 20/03/2019 to 31/03/2020. The PSS-10 was completed during the hospitalization period. Patients were divided into two groups, according to the type of ACS: group A – STEMI patients - and group B - NSTEMI patients. Follow-up of these patients (regarding death, readmissions for cardiac causes and readmissions for other causes) was carried out until December 11, 2022. Logistic regression was performed to assess if stress was a predictor of NSTEMI. Results A total of 166 patients were included: 52 in group A and 94 in group B. In group A, mean age was 63 ± 18 years and 34.60% were women, while in group B mean age was 66 ± 20 years, and 38.70% were female. Group B presented more with preserved ejection fraction (79.30% vs 60.40% in group A, p=0.018). There were no other statistically significant differences regarding clinical presentation, or intrahospital complications between the two groups. PSS-10 score in group A was 17.17 ± 8.62, while group B scored 20.83 ± 6.10 (p=0.039). The follow-up of these two groups did not show significant differences in terms of death (7.70% in group A vs 16.10% in group B, p=0.149), readmissions for other causes (19.20% in group A vs 28.00% in group B, p=0.243) or readmissions for cardiac causes (group A 9.60% and group B 22.60%, p=0.051). Logistic regression revealed that perceived stress was a predictor of NSTEMI (odds ratio (OR) 1.006, p=0.025, confidence interval (CI) 1.001-1.011). There were no statistically significant differences in follow-up between the two groups. Conclusions This is the first prospective study carried out in the Portuguese population regarding this thematic, which showed that perceived stress was a predictor of NSTEMI and can influence patients with ACS manifestations.Figure 1

Oxygen targets following immediate percutaneous coronary intervention in comatose survivors of out-of-hospital cardiac arrest - a BOX sub-study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation The Lundbeck Foundation. Background Treatment with supplemental oxygen in patients with acute myocardial infarction (AMI) has previously been associated with poorer outcomes. However, in patients with AMI resuscitated from out-of-hospital cardiac arrest (OHCA) and undergoing immediate revascularization, evidence regarding specific oxygen targets is sparse. Purpose To assess the impact of a restrictive versus a liberal oxygen target on infarct size in OHCA patients undergoing immediate percutaneous coronary intervention (PCI). Methods The current study is a sub-study of the BOX trial, a randomized trial with a 2-by-2 factorial design, in which comatose OHCA patients with a presumed cardiac cause of arrest were randomly assigned to either a restrictive oxygen target (partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa) or a liberal oxygen target (Pao2 of 13 to 14 kPa). In this sub-study we included patients who underwent immediate revascularization with PCI. The primary outcome was myocardial infarct size as assessed by the cardiac enzyme troponin-T (TnT). TnT was measured repeatedly during the first 72 hours and analyzed with a repeated measures variance component model with baseline adjustment. Secondary outcome was one-year all-cause mortality assessed by Kaplan-Meier and Cox proportional hazards analyses. Results A total of 329 patients underwent immediate PCI, whereof 172 patients were randomized to the restrictive oxygen target and 157 to the liberal oxygen target. The oxygen intervention was successful with a significantly higher PaO2 in the liberal oxygen target group during the first 72 hours (p&amp;lt;0.0001). Baseline characteristics and findings on coronary angiography (CAG) were similar in the two oxygen target groups. Thus, median age was 63 (interquartile range (IQR) 55–71), 81% were male, and estimated left ventricular ejection fraction on arrival to hospital was 35% (IQR 25–45%). Further, 74% of the patients had an initial postresuscitation electrocardiogram with ST-segment elevations, and the left anterior descending artery was deemed as culprit lesion in 49% of the patients. There was no difference in peak TnT between the restrictive and liberal oxygen target group (median 2540 (IQR 925–6420) versus 3410 (792–8630), ng/l, p=0.23), nor did TnT differ between the groups during the first 72 hours after admission (Figure 1, p=1.00). Within one year from admission, 120 patients (36.5%) had died. There was no difference in mortality between the restrictive (34%) and liberal (39%) oxygen target group (hazard ratio, 0.80; 95% CI, 0.56-1.14; p=0.21) (Figure 2). Conclusion Targeting a restrictive versus a liberal oxygen level in comatose survivors of OHCA who underwent immediate revascularization did not affect infarct size nor did it result in a significant difference in one-year mortality rate.Figure 1:Troponin-T levelsFigure 2:Kaplan-Meier curves

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

L'activité sportive pour réduire le risque cardiovasculaire – Pourquoi s'en priverait-on ?

Sports-related sudden death is an uncommon event, affecting mainly middle-aged men who practice leisure sports, and is related to unknown coronary artery disease. In athletes, cardiac causes are also predominant, with a greater proportion of structural and electrical heart disease. If first-aid resuscitation measures are initiated, survival easily exceeds 50%, and this is an excellent educational illustration of how to improve the prognosis of non-sport-related cardiac arrest. Prevention of a sport-related cardiovascular event remains difficult, and relies on clinical examination, questioning (including family history) and resting ECG in participants >35 years old. The non-contraindication visit is also an opportunity to pass on to the patient the rules of good sports "hygiene" and life-saving gestures in the event of sudden death during sport in one of the partners (and the importance of regularly educating oneself in life-saving gestures...).

All That Wheezes Is Not Asthma.

Wheezing is a high pitched, whistling sound generated when air flows through narrowed airways and is often equated with asthma. However, wheezing may be a presenting symptom of various other conditions including structural lesions of the airways, foreign body aspiration, pulmonary infections as well as cardiac causes. Underlying etiology of wheezing may also vary with age. Detailed history, physical examination, and laboratory investigations are often required to identify the underlying etiology of wheezing. Additional studies may sometimes be needed to accurately identify the underlying etiology such as pulmonary function test or spirometry, chest radiography (chest X-ray), and bronchoscopy. This review article discusses the common causes of wheezing encountered in clinical practice. [Pediatr Ann. 2024;53(5):e189-e194.].

Study of Postmortem Pericardial Fluid Concentrations of Troponin T (cTnT) in Sudden Natural Death

Background: Cardiovascular diseases are the most common cause of sudden natural deaths. Cardiac troponin T is a specific biochemical marker of myocardial injury. It may help in diagnosis of early myocardial ischemia when macroscopic or microscopic evidence of necrosis is not available after autopsy. Aim of this study was to assess the effectiveness of pericardial fluid troponin T in predicting the cause of death in sudden natural death and in estimating the post mortem interval. Materials and methods: It was a pilot study. Sudden natural deaths brought to Forensic Medicine department of GMCH Nagpur for autopsy were included in this observational cross sectional study. Deaths were grouped into cardiac and non cardiac deaths. Pericardial fluid samples were collected by opening pericardial sac with sterile syringe and processed on Roche Cobas e411 autoanalyzer for estimation of levels of Troponin T. Results: There was a statistically significant difference seen for the values between the groups (p&lt;0.05) for Trop-T (ng/ml) with higher values in Cardiac cause. There was a statistically non significant correlation between postmortem interval vs Trop T (p&gt;0.05). Conclusion: Estimation of pericardial fluid Troponin-T may be used to predict the cause of death in sudden natural death.

Assessment of Risk for Sudden Cardiac Death Among Adolescents and Young Adults After Receipt of COVID-19 Vaccine - Oregon, June 2021-December 2022.

COVID-19 vaccination has been associated with myocarditis in adolescents and young adults, and concerns have been raised about possible vaccine-related cardiac fatalities in this age group. In April 2021, cases of myocarditis after COVID-19 vaccination, particularly among young male vaccine recipients, were reported to the Vaccine Adverse Event Reporting System. To assess this possibility, investigators searched death certificates for Oregon residents aged 16-30 years who died during June 2021-December 2022 for cardiac or undetermined causes of death. For identified decedents, records in Oregon's immunization information system were reviewed for documentation of mRNA COVID-19 vaccination received ≤100 days before death. Among 1,292 identified deaths, COVID-19 was cited as the cause for 30. For 101 others, a cardiac cause of death could not be excluded; among these decedents, immunization information system records were available for 88, three of whom had received an mRNA COVID-19 vaccination within 100 days of death. Of 40 deaths that occurred among persons who had received an mRNA COVID-19 vaccine dose, three occurred ≤100 days after vaccination. Two of these deaths were attributed to chronic underlying conditions; the cause was undetermined for one. No death certificate attributed death to vaccination. These data do not support an association between receipt of mRNA COVID-19 vaccine and sudden cardiac death among previously healthy young persons. COVID-19 vaccination is recommended for all persons aged ≥6 months to prevent COVID-19 and complications, including death.