Cardiac Etiology Research Articles

393 Why do patients develop in-hospital cardiac arrest? A prospective, single-center observational study of in-hospital cardiac arrest aetiologies (WHY-IHCA) - preliminary results in non-survivor cases

393 Why do patients develop in-hospital cardiac arrest? A prospective, single-center observational study of in-hospital cardiac arrest aetiologies (WHY-IHCA) - preliminary results in non-survivor cases

Allogeneic Hematopoietic Cell Transplantation with Non-Myeloablative Conditioning and Post-Transplant Cyclophosphamide Prophylaxis in Patients with Reduced Systolic Function

Post-transplantation cyclophosphamide (PTCy) has become standard of care for graft-versus-host disease (GVHD) prophylaxis after allogeneic hematopoietic cell transplantation (alloHCT), allowing for expanded donor options. However, there is scant literature examining outcomes of patients with reduced systolic function receiving PTCy. The present study aimed to describe our experience in performing alloHCT in patients with reduced systolic function, including their nonrelapse mortality (NRM), overall survival (OS), and cumulative incidence of early cardiac events (ECEs). We performed a retrospective descriptive analysis using the Johns Hopkins Hematologic Malignancy database. From 2017 through 2021, 1118 consecutive patients underwent alloHCT with nonmyeloablative (NMA) conditioning and PTCy. Forty-three of those patients had a pretransplantation left ventricular ejection fraction (LVEF) ≤45% measured by transthoracic echocardiography. Patients whose LVEF improved on treatment prior to transplantation were also included. These 2 cohorts were stratified into 2 groups-heart failure with reduced ejection fraction (HFrEF) and heart failure with recovered ejection fraction (HFrecEF)-and subgroup analyses compared NRM, OS, and cumulative incidence of ECEs, including arrhythmia, coronary artery disease, reduction in LVEF, and pericardial effusion, within 100 days post-transplantation. The median LVEF was 40% to 45% (range, 30% to 45%) for the 31 patients undergoing transplantation with HFrEF and 35% to 40% (range, 20% to 45%) for the 12 patients with HFrecEF. The NRM for all 43 patients was 16% (95% confidence interval [CI], 5% to 27%) at 100 days and 23% (95% CI, 11% to 36%) at 2 years. The NRM was 23% (95% CI, 8% to 38%) at 100 days and 26% (95% CI, 10% to 42%) at 2 years for the HFrEF cohort and 0 at 100 days and 18% (95% CI, 0 to 41%) at 2 years for the HFrecEf cohort. The OS at 3 years was 41% (95% CI, 26% to 62%), 40% (95% CI, 25% to 65%) and 38% (95% CI, 14% to 100%) in the combined, HFrEF, and HFrecEF cohorts, respectively. The cumulative incidence of any ECE was 37.2% (95% CI, 22% to 51.9%), including 39% of HFrEF subjects and 33% of HFrecEF subjects. Grade ≥3 toxicities were seen in 56% of patients. Reduced ejection fraction was the most common ECE. One death was attributable to a cardiac etiology. Cardiac toxicities seemed to be more frequent and severe in patients with a history of systolic dysfunction, but this did not lead to worse survival outcomes. This study adds to and extends the existing literature supporting the use of NMA conditioning and PTCy in patients with systolic dysfunction.

Congenital neuroblastoma presenting as profound neonatal metabolic acidosis with systemic hypertension: Case report.

Clinical collapse in the newborn most often occurs secondary to sepsis, delivery complications, congenital cardiac defects, or inborn errors of metabolism. We report on a neonate with respiratory, cardiac, and hepatic failure, with disproportionate metabolic acidosis and systemic hypertension, found to be caused by a congenital neuroblastoma. A term infant presented to our Level IV NICU via emergent transport at 12 hours of life with clinical and laboratory findings consistent with respiratory, cardiac, and hepatic failure. Typical workup for sepsis and cardiac etiology was unrevealing. The infant was noted to have systemic hypertension despite prolonged capillary refill. A profound metabolic acidosis led the primary team to pursue a genetics consult. In the course of the workup for disorders of metabolism, a urine organic acids panel revealed an elevated HVA (homovanillic acid) and VMA (vanillylmandelic acid), the metabolites of the neurotransmitters epinephrine, norepinephrine and dopamine. Subsequent abdominal ultrasound and chest/abdomen CT revealed a large heterogeneous mass with internal vascular flow and scattered calcifications arising from the medial limb of the left adrenal gland, consistent with neuroblastoma. Although rare, neuroblastomas can present clinically in the perinatal period in a manner requiring immediate life-saving intervention. Providers should consider the diagnosis in the setting of a newborn with a sepsis-like syndrome or profound metabolic acidosis presenting along with systemic hypertension without clear underlying etiology.

Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

AimOut-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults. We evaluated its 10-year trends in epidemiology and management in Singapore. MethodsUsing the national OHCA registry we studied the trends of 20,844 Emergency Medical Services-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Trends and outcomes were analyzed using linear and logistic regression, respectively. ResultsIncidence rates of adult OHCAs increased during the study period, driven by non-shockable OHCA. Compared to shockable OHCA, non-shockable OHCAs were significantly older, had more co-morbidities, unwitnessed and residential arrests, longer no-flow time, and received less bystander cardiopulmonary resuscitation (CPR) and in-hospital interventions (p < 0.001). Amongst non-shockable OHCA, age, co-morbidities, residential arrests, no-flow time, time to patient, bystander CPR and epinephrine administration increased during the study period, while presumed cardiac etiology decreased (p < 0.05). Unlike shockable OHCA, survival for non-shockable OHCA did not improve (p < 0.001 for trend difference). The likelihood of survival for non-shockable OHCA significantly increased with witnessed arrest (adjusted odds ratio (aOR) 2.02) and bystander CPR (aOR 3.25), but decreased with presumed cardiac etiology (aOR 0.65), epinephrine administration (aOR 0.66), time to patient (aOR 0.93) and age (aOR 0.98). Significant two-way interactions were observed for no-flow time and residential arrest with bystander CPR (aOR 0.96 and 0.40 respectively). ConclusionThe incidence of non-shockable OHCA increased between 2010 and 2019. Despite increased interventions, survival did not improve for non-shockable OHCA, in contrast to the improved survival for shockable OHCA.

Prevalence and risk factors of ischemic monocular vision loss and concurrent brain ischemia.

We performed a retrospective cohort study to identify predictors of concurrent asymptomatic brain ischemia in patients with ischemic monocular vision loss. An inpatient database research of admissions to the Helios University Hospital Wuppertal, Germany between 01/2016 and 12/2020 was conducted. Inclusion criteria were confirmed diagnosis of transient monocular vision loss (MVL), retinal artery occlusion (RAO), and magnetic resonance imaging (MRI) of the brain within 10 days of MVL. Silent brain ischemia (SBI) was defined as diffusion restrictions with corresponding reduced apparent diffusion coefficient in MRI and an absence of neurological deficits besides those complying with MVL in clinical examination. The prevalence and cardiovascular predictors of SBI were analyzed with logistic regression and an artificial neural network. One hundred fourteen out of 475 patients treated with monocular vision loss were included in this study. The mean age was 67.7 ± 13.6 years. 48.2% were male and 47.4% had RAO. MRI scan of the brain was performed after 3.9 ± 2.3 days and detected SBI in 17%. Age ⩾67 years, cardiac etiology of MVL, and cerebral ischemia in medical history were revealed as predictors of SBI in MRI. Patients older than 66 years, with a suspected cardiac embolism as the cause of RAO and previous cerebral ischemia, are more likely to present SBI in cerebral MRI. Therefore, MR imaging, particularly in these patients, can be useful.

Association of B-Type Natriuretic Peptide Level with Clinical Outcome in Out-of-Hospital Cardiac Arrest in Emergency Department Patients.

B-type natriuretic peptide (BNP) is used for outcome assessment of various diseases. We designed this study to investigate whether BNP, which has been proven useful in the risk stratification of sudden cardiac arrest (SCA) of cardiac etiology, can also prove to be a valuable prognostic tool for SCA also included with non-cardiac etiology. In this study, we aim to investigate the relationship between measured BNP levels and clinical outcomes in SCA, regardless of the cause of SCA. This retrospective multicenter observational study was performed in two tertiary university hospitals and one general hospital between January 2015 and December 2020. The total number of SCA patients was 1625. The patients with out-of-hospital cardiac arrest over 19 years old and acquired laboratory data, including BNP at emergency department (ED) arrival, were included. BNP was measured during advanced Cardiovascular Life Support (ACLS). The exclusion criteria were age under 18 years, traumatic arrest, and without BNP. The median BNP was 171.8 (range; 5-5000) pg/mL in the return of Spontaneous Circulation (ROSC), higher than No-ROSC (p = 0.007). The median BNP concentration was 99.7 (range; 5-3040.68) pg/mL in the survival to discharge, which was significantly lower than the death group (p = 0.012). The odds ratio of survival to discharge decreased proportionally to the BNP level. The odds ratio of neurologic outcome was not correlated with the BNP level. In patients with SCA of all origins, low BNP concentration measured during ACLS correlated with an increased ratio of survival to discharge. However, BNP measured during ACLS was not found to be an independent factor.

Association between post-cardiac arrest treatments and clinical outcomes according to scene time interval in out-of-hospital cardiac arrest: Retrospective cross-sectional study

BackgroundPrevious studies have reported that Post-Cardiac arrest (PCA) treatments including targeted temperature management (TTM), coronary reperfusion therapy (CRT), and extracorporeal membrane oxygenation (ECMO) are time-sensitive; however, there are no reports of the clinical outcomes of PCA treatment according to the scene time interval (STI). Our study aimed to investigated the clinical outcomes of PCA treatment according to the STI. MethodsWe used a Korean nationwide OHCA cohort database from January 2017 to December 2020. The inclusion criteria were all adult OHCA patients with a presumed cardiac etiology, bystander-witnessed arrest, and prehospital return of spontaneous circulation (ROSC). The outcomes were survival to discharge and good neurological recovery. The main exposure of interest was PCA treatment. We compared the outcomes using multivariable logistic regression, and interaction terms were included in the final model to assess whether the STI modified the effect of PCA treatment on clinical outcomes of OHCA. ResultsTTM and CRT were associated with high survival to discharge and good neurological recovery. In the interaction analysis, ECMO had an interaction effect with the STI on a good CPC among patients with OHCA [short STI (0 to 11 min) (1.16 (0.77—1.75)), middle STI (12 to 15 min) (0.66 (0.41—1.06)), and long STI (16 to 30 min) (0.59 (0.40—0.88)) (p for interaction <0.05)]. ConclusionIn adult bystander-witnessed patients with OHCA with prehospital ROSC, an STI of >16 min was a risk factor for poor neurological outcome in those patients who underwent ECMO.

Syncope and unresponsiveness in an adolescent with comorbid cardiac disease: an illustrative case report and literature review of Functional Neurologic Symptom Disorder.

This case report with associated literature review explores the challenges, opportunities, and current evidence in creating a thoughtful diagnostic and management plan for an adolescent with Functional Neurologic Symptom Disorder and comorbid cardiac disease. We perform a literature review utilizing PubMed to identify the current evidence base related to Pediatric Functional Neurologic Symptom Disorder in the setting of comorbid cardiac disease. Ultimately, 25 manuscripts were identified for inclusion in this study. We report the recent epidemiology, screening, diagnostic, and treatment measures utilized in pediatric syncope with a focus on differentiating psychogenic causes from serious cardiac and benign etiologies. We further describe how psychiatric and psychological factors influence assessment, management, and outcomes. This study provides current, evidence-based suggestions for the assessment, diagnosis, and management of pediatric syncope with emphasis on recognizing psychogenic causes of syncope. It includes description of a novel case of Functional Neurologic Symptom Disorder in a pediatric patient with structural cardiac disease. The study highlights how the absence of standardized guidelines, heterogeneity in care delivery, and lack of concurrent mental health management led to worse outcomes.

Collapse-related traumatic intracranial hemorrhage following out-of-hospital cardiac arrest: A multicenter retrospective cohort study

BackgroundSudden loss of consciousness as a result of cardiac arrest can cause severe traumatic head injury. Collapse-related traumatic intracranial hemorrhage (CRTIH) following out-of-hospital cardiac arrest (OHCA) may be linked to poor neurological outcomes; however, there is a paucity of data on this entity. This study aimed to investigate the frequency, characteristics, and outcomes of CRTIH following OHCA. MethodsAdult patients treated post-OHCA at 5 intensive care units who had head computed tomography (CT) scans were included in the study. CRTIH following OHCA was defined as a traumatic intracranial injury from collapse due to sudden loss of consciousness associated with OHCA. Patients with and without CRTIH were compared. The primary outcome assessed was the frequency of CRTIH following OHCA. Additionally, the clinical features, management, and consequences of CRTIH were analyzed descriptively. ResultsCRTIH following OHCA was observed in 8 of 345 enrolled patients (2.3%). CRTIH was more frequent after collapse outside the home, from a standing position, or due to cardiac arrest with a cardiac etiology. Intracranial hematoma expansion on follow up CT was seen in 2 patients; both received anticoagulant therapy, and one required surgical evacuation. Three patients (37.5%) with CRTIH had favorable neurological outcomes 28 days after collapse. ConclusionsDespite its rare occurrence, physicians should pay special attention to CRTIH following OHCA during the post-resuscitation care period. Larger prospective studies are warranted to provide a more explicit picture of this clinical condition.

Association between the COVID-19 pandemic in 2020 and out-of-hospital cardiac arrest outcomes and bystander resuscitation efforts for working-age individuals in Japan: a nationwide observational and epidemiological analysis

BackgroundImproving out-of-hospital cardiac arrest (OHCA) prognosis within the working-age population is important, but no studies have investigated the effects of COVID-19 pandemic specifically on the working-age population with OHCAs. We...

Lack of Association of Initial Vasopressor Dosing with Survival and Cardiac Re-Arrest Likelihood After Return of Spontaneous Circulation

BackgroundCardiac arrest occurs in approximately 350,000 patients outside the hospital and approximately 30,000 patients in the emergency department (ED) annually in the United States. When return of spontaneous circulation (ROSC) is achieved, hypotension is a common complication. However, optimal dosing of vasopressors is not clear. ObjectiveThe objective of this study was to determine if initial vasopressor dosing was associated with cardiac re-arrest in patients after ROSC. MethodsThis was a retrospective, single-center analysis of adult patients experiencing cardiac arrest prior to arrival or within the ED. Patients were assigned to one of four groups based on starting dose of vasopressor: low dose (LD; < 0.25 µg/kg/min), medium dose (MD; 0.25–0.49 µg/kg/min), high dose (HD; 0.5–0.99 µg/kg/min), and very high dose (VHD; ≥ 1 µg/kg/min). Data collection was performed primarily via manual chart review of medical records. The primary outcome was incidence of cardiac re-arrest within 1 h of vasopressor initiation. Multivariate logistic regression analysis was conducted to identify any covariates strongly associated with the primary outcome. ResultsNo difference in cardiac re-arrest incidence was noted between groups. The VHD group was significantly more likely to require a second vasopressor (p = 0.003). The HD group had lower survival rates to hospital discharge compared with the LD and MD groups (p = 0.0033 and p = 0.0147). In the multivariate regression, longer duration of pre-vasopressor re-arrests and hyperkalemic cardiac arrest etiology were significant predictors of cardiac re-arrest after vasopressor initiation. ConclusionsInitial vasopressor dosing was not found to be associated with risk of cardiac re-arrest or, conversely, risk of adverse events.

Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest

Background/ObjectivePost-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. MethodsThis is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. ResultsA total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01–1.11, p < 0.01). ConclusionSigns of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.

Pulmonary embolism associated with acute ST-segment elevation myocardial infarction

Pulmonary embolism (PE) is a potentially fatal condition that presents with shortness of breath and chest pain. Although an electrocardiogram (ECG) may show changes associated with PE, ST elevation mimicking ST elevation myocardial infarction is not common in patients with acute PE. This presentation documents the case of a 67-year-old man who presented to the emergency department with dyspnea and chest pain. ECG data indicated anterior septal myocardial infarction and acute ischemia of the lower parts of the left ventricle. Cardiac catheterization did not reveal atherosclerotic lesions of the coronary arteries, but revealed an anomaly in the filling of the right coronary artery with embolic masses. Further examination of the patient revealed massive bilateral pulmonary embolism. In this presentation, we emphasize the need to evaluate patients with PE who present with chest pain, dyspnea, or both, even when ECG findings suggest a cardiac etiology. We also present a brief discussion of possible mechanisms for ST elevation in pulmonary embolism

De novo ADGRV1 variant in a patient with ictal asystole provides novel clues for increased risk of SUDEP

BackgroundVarious cardiac and autonomic manifestations are frequently reported during seizures. Among the seizure-related arrhythmia, ictal tachycardia is the most common, followed by ictal bradycardia, with ictal asystole being the rarest. The occurrence of ictal asystole may obscure the clinical presentation and delay the diagnosis, representing a life-threatening presentation of epilepsy, with an elevated risk of sudden unexpected death in epilepsy patients (SUDEP). These cardiac abnormalities are being increasingly recognized as the key to elucidating the mechanisms of SUDEP.Case presentationWe present a 35-year-old man with a history of focal-onset seizures with impaired consciousness since his mid-20 s. He developed different types of seizures for 2 years, described as tonic seizure and atonic seizure (drop attack). During such clinical events, he suffered from falls and cardiac arrest. However, thorough cardiac electrophysiology and imaging workup failed to reveal a cardiac etiology. Subsequent video electroencephalograph (EEG) monitoring was performed, and ictal bradycardia and ictal asystole were discovered. A cardiac pacemaker was implanted, and at 3-year follow-up, the patient did not suffer more atonic seizures, or falls. Genetic tests discovered a de novo variant of Adhesion G Protein-Coupled Receptor V1 (ADGRV1), which may provide a clue for the patient’s ictal asystole and the increased risk of SUDEP.ConclusionsConsidering the important impact of ictal bradycardia and asystole on the morbidity and potential mortality of epileptic patients, it is important to simultaneously utilize EEG and electrocardiogram to confirm the diagnosis. This case report highlights the link between the de novo variant of ADGRV1 and the ictal bradycardia/asystole phenotype and implicates the importance of genetic testing in adult epilepsy patients.

P86 WHEN THE HEMATOLOGIST HAS THE SOLUTION – A RARE CASE OF HEART FAILURE

Abstract Introduction Cardiologists are confident with heart failure due to cardiac etiology, but sometimes this may be due to other organs‘ dysfunction (e.g. endocrine problems); in this case we report a very rare cause of anasarca due to hematologic disease. Case report A 33 year old man with a known complete left bundle branch block and without other pathologies is admitted to the ED for sickness and abdominal pain. Low platelet count, splenomegaly and an anterior mediastinal mass (53x54mm) are found. A Positron Emission Tomography (PET) reveals multiple lymphnodes captation above and under the diaphragm and at mediastinal level. Bone marrow biopsy is consistent with myelofibrosis. During the hospitalization the patient experiences an important weight gain (14 kg) with edema and worsening renal function suspected for heart failure; echocardiogram shows a globally hypokinetic left ventricle with moderately reduced ejection fraction (EF 37%), mild pericardial effusion, no relevant valve anomalies; cardiac MRI confirmed moderately depressed EF with global hypokinesia and no LGE anomalies of the myocardial wall; a clinical benefit is noted with high dose i.v. diuretics, and echocardiogram findings rapidly improve with therapy, EF 49% after decongestion; a discrepancy is noted between the severity of anasarca and echocardiographic data; ultimately, lymph node biopsy is performed, which is consistent with Castleman disease, HHV 8 negative. TAFRO (Thrombocytopenia, Anasarca, Fever, Reticulin myelofibrosis/Renal dysfunction, Organomegaly) syndrome is therefore diagnosed. Therapy with siltuximab (anti IL–6) is started with good clinical response on lymph nodes enlargement and on anasarca, and the patient is currently followed–up by the hematologists of our institution. Discussion TAFRO syndrome is a very rare hematologic disease that can manifest with severe anasarca; usually it presents with non–cardiac features, but cardiologists should be aware of this disease as they could be involved in the management of this condition, especially in the fist stages when the diagnosis has not yet been made.

Evaluation of Socioeconomic Position and Survival After Out-of-Hospital Cardiac Arrest in Korea Using Structural Equation Modeling

The association between low socioeconomic position (SEP) and poor survival after out-of-hospital cardiac arrest (OHCA) has not been thoroughly investigated. To evaluate the association between individual SEP and survival after OHCA and to identify any mediating pathways using structural equation modeling (SEM). This is a retrospective cohort study that used data collected from January 2013 to December 2019. Participants were adults with OHCA with a presumed cardiac etiology. The study was conducted in Korea, which has a universal health insurance system. Data were analyzed from January 2022 to February 2023. Individual SEP was measured by insurance type (National Health Insurance [NHI] and medical aid [MA]) and premiums. SEP was categorized into 5 groups, in which NHI beneficiaries were divided into quartiles (Q1, highest quartile; Q4, lowest quartile), and MA was the lowest SEP group. The primary outcome was survival to discharge. The association between SEP and OHCA survival was examined using multivariable logistic regression, and mediating factors were identified using SEM. A total of 121 516 patients (median [IQR] age, 73 [60-81] years; 43 912 [36.1%] female patients) were included. Compared with the NHI Q1 group, individuals with lower SEP had lower odds of survival to discharge. The adjusted odds ratios of survival to discharge were 0.97 (95% CI, 0.94-1.00), 0.88 (95% CI, 0.85-0.91), 0.91 (95% CI, 0.88-0.94), and 0.53 (95% CI, 0.50-0.56) for the NHI Q2, NHI Q3, NHI Q4, and MA groups, respectively. Several factors were found to mediate the association of SEP and survival in the total study population, with mediating proportions of 15.1% (95% CI, 11.8%-18.4%) for witnessed status, 4.8% (95% CI, 3.5%-6.0%) for bystander cardiopulmonary resuscitation provision, 41.8% (95% CI, 35.4%-48.1%) for initial rhythm, and 9.4% (95% CI, 7.4%-11.4%) for emergency department level. Among patients who survived to hospital admission, the mediation proportions were 11.8% (95% CI, 6.7%-16.9%) for witnessed status, 3.7% (95% CI, 1.3%-6.1%) for bystander cardiopulmonary resuscitation provision, 56.2% (95% CI, 41.0%-71.4%) for initial rhythm, 10.7% (95% CI, 6.1%-15.3%) for emergency department level, 20.2% (95% CI, 14.0%-26.5%) for coronary angiography, and 4.2% (95% CI, 2.2%-6.1%) for targeted temperature management. In this cohort study of patients with OHCA, lower individual SEP was significantly associated with lower survival to discharge. Potentially modifiable mediators can be targeted for public health interventions to reduce disparities in survival among patients with OHCA of different SEP.

The effect of ethnicity and social deprivation on outcomes after resuscitated out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This work was part funded by King’s College Hospital R&amp;D Grant and was supported by the Department of Health via a National Institute for Health Research Biomedical Research Centre award to Guy’s &amp; St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. Background Out-of-hospital cardiac arrest (OOHCA) is a common cause of morbidity and mortality. There is substantial ethnic variation in OOHCA outcomes, though it is unclear if these discrepancies are due to arrest circumstances or socioeconomic and biological factors. Purpose To investigate the association of ethnicity, social deprivation and co-morbidities with rates of coronary artery disease, subsequent treatment and outcome in resuscitated OOHCA patients with primary cardiac aetiology. Methods 526 patients with resuscitated OOHCA of suspected cardiac aetiology were included in the study registry between 1-May-2012 and 31-December-2020. Ethnicity, social deprivation, arrest circumstances, comorbidities and extent of coronary artery disease (CAD) were measured. The primary endpoint was 12-month mortality. Results Of 526 patients (median age 62.0±21.1, 74.1% male), 78.1% had shockable rhythms, 83.6% were witnessed and 77.6% had bystander cardiopulmonary resuscitation (CPR). 414 patients (78.7%) were White, 35 (6.7%) were Asian, and 77 (14.6%) were Black. Black patients had more co-existent hypertension and cardiomyopathy, but less prior coronary revascularisation compared with White/Asian patients. There were no ethnic differences in location, witnesses, or bystander CPR, but Black patients had more non-shockable rhythms. Admission serum lactate and creatinine levels were higher in Black patients, but troponin levels were lower than in White/Asian patients. Black patients received less immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI), but had lower rates of CAD, with less CAD complexity (lower SYNTAX and Jeopardy scores) than White/Asian patients. Mortality at 12 months was highest amongst Black followed by Asian and then White patients. In Black patients, this excess mortality was driven by higher rates of multi-organ dysfunction but lower cardiac death than White, and in particular Asian patients, amongst whom cardiac death was highest. Stratifying patients by socioeconomic status showed that higher social deprivation was associated with non-shockable and unwitnessed OOHCA but other demographics, arrest circumstances, rates of CAG and PCI were similar and no difference in mortality or cause of death at 12 months was observed. In a multi-variable logistic regression analysis, age, location of OOHCA, witnessed arrest and Black compared to White ethnicity were independent predictors of 12-month mortality, whilst social deprivation was not. Conclusion Black patients have higher mortality after resuscitated OOHCA than White patients due to differing underlying aetiology rather than differences in arrest circumstances or social deprivation. This should be reflected in cardiac arrest pathways, and patients conveyed to cardiac arrest centres should have access to coronary angiography but also advanced 24/7 imaging, renal replacement therapy and other advanced critical care therapies.

Temporal trends in Singapore for out-of-hospital cardiac arrest with an initial non-shockable rhythm

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Singapore Background Out-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults, yet outcomes are dismal. We evaluated its 10-year trends in epidemiology and management in Singapore. Methods Using the national OHCA registry we studied the trends of 20,844 Emergency Medical Services (EMS)-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Analyses of the trends and outcomes were performed with linear regression and logistic regression, respectively. Results Incidence rates of EMS-attended adult OHCAs increased during the study period, with increasing proportion of adult OHCA being non-shockable OHCA (Figure 1). Compared to shockable OHCA, non-shockable OHCAs were significantly older (median age 71 vs 61 years), had more comorbidities (median Charlson Comorbidity Index 4 vs 3), more likely unwitnessed (46% vs 25%) and residential arrests (77% vs 53%) (all p&amp;lt;0.001); non-shockable OHCAs had longer no-flow time (median 16 vs 13 minutes), and received less bystander cardiopulmonary resuscitation (CPR) (49% vs 61%) and in-hospital interventions (coronary revascularization 1% vs 18%, targeted temperature management (TTM) 3% vs 14%) (all p&amp;lt;0.001). Amongst non-shockable OHCA, age, comorbidities, residential arrests, no-flow time and time to patient increased during the study period, while presumed cardiac etiology decreased; bystander CPR, epinephrine use and TTM increased (all p&amp;lt;0.05) (Figure 2). Survival for non-shockable OHCA did not improve (1% in 2010 to 1.3% in 2019, p=0.107), unlike shockable OHCA (10% to 26%, p&amp;lt;0.001). The likelihood of survival for non-shockable OHCA increased with witnessed arrest (adjusted odds ratio (aOR) 2.281) and bystander CPR (aOR 3.569), but decreased with presumed cardiac etiology (aOR 0.553), epinephrine administration (aOR 0.646), time to patient (aOR 0.938) and comorbidity burden (aOR 0.897). Significant two-way interactions were observed for no-flow time and arrest location with bystander CPR. Cardiac revascularization improved the odds of survival in patients who survived to admission (aOR 2.63). Conclusion Singapore saw increasing incidence and interventions for non-shockable OHCA between 2010 and 2019 but limited gains in survival, partly explained by ageing population with increasing comorbidity burden. This contrasts with the improvement in survival for shockable OHCA over the same period. The interactions of location and no-flow time with bystander CPR highlight opportunities to improve pre-hospital care for residential and non-shockable OHCA.

Lipid-associated macrophages infiltration is associated with cardiac remodeling in a NASH

Non-alcoholic steatohepatitis (NASH) refers to a fatty liver with lobular inflammation that can progress to liver fibrosis. Although a statistical association between NASH and cardiovascular disease has been demonstrated in epidemiological studies, the nature of the links between liver disease and cardiac remodeling remains to be established. We hypothesize that alterations in circulating and tissue-resident immune cells contribute to inappropriate cardiac remodeling during the development of NASH. We explore a cohort of patients candidates for cardiac surgery (POMI-AF – NCT03376165) comparing liver status and myocardial immune profile. We characterized the structural remodeling and contractile dysfunction using transthoracic echocardiogram (TTE) and histology in a diet-induced mouse model of NASH. Leukocyte infiltration in the mice heart is explored using flow cytometry and single cell RNA sequencing (scRNAseq) analysis. The specific role of the liver is studied using hepatocyte-PPARα KO mice under NASH-diet. In human myocardium, patients with high risk of NASH with fibrosis had an increased number of M2-like macrophages compared to control patients. In our NASH-diet mice, we showed left ventricular hypertrophy, dilated left ventricle and an impaired diastolic function. We also found more ventricular fibrosis and increased cardiomyocyte area. Using scRNAseq, we identified an increased expression of the pro-fibrotic marker Galectin-3 by pro-inflammatory macrophages, and finally we identified an enriched “lipid-associated Ly6C- TREML4+ myeloid cells” cluster within the heart of NASH mice. This subpopulation was also enriched in the blood of hepatocyte-PPARα KO mice after 24 weeks of NASH diet. Using a translational approach, we here describe an association between NASH and altered cardiac macrophages. Although fibrosis can be partially explained by the expression of Galectin-3 by macrophages, the potential involvement of lipid-associated myeloid cells in cardiac hypertrophy remains to be established. As macrophages are implicated in several cardiac remodeling etiologies, our new results could explain the adverse remodeling observed in NASH.

PO-05-234 AUTONOMIC DYSFUNCTION AFTER COVID-19 IMMUNIZATION - CASE REPORT

The infection caused by the SARS-CoV-2 continues affecting millions of people worldwide and vaccines to prevent the coronavirus disease (COVID-19) are considered the most promising approach for curbing the pandemic. Otherwise, cardiovascular and neurological complications associated with the vaccines were speculated and some few case reports were published. We describe a case of postural orthostatic tachycardia syndrome (POTS) after viral vector COVID-19 vaccination and the possible autoimmune process of the syndrome. A 35-year-old female, without previous symptoms or comorbidities, developed intermittent palpitation, intense fatigue and dyspnea, compromising her daily activities, triggered by upright position, seven days following the second dose of the Oxford vaccine. Physical examination was normal, except for a heart rate (HR) increase of 33 beats/min from supine to standing position, with no significant change in blood pressure and reproduction of symptoms. A 24-hour Holter monitoring revealed episodes of spontaneous sinus tachycardia correlated with palpitation and fatigue. Extensive diagnostic investigations excluded primary cardiac, endocrine, infectious and rheumatologic etiologies. The patient underwent an autonomic function test which demonstrated normal baroreflex sensitivity, as well as normal cardiovagal and adrenergic scores. Head-up tilt test showed persistent orthostatic tachycardia (HR increase from a medium of 84 beats/min in supine position to 126 beats/min during upright tilt), without hypotension, consistent with the diagnostic criteria for POTS. According to the current guidelines, general behavior recommendations, pharmacotherapy with low dose of propranolol associated with the autonomic rehabilitation were oriented. Along three months of follow-up, the patient reported a gradually improvement in her symptoms. POTS is a heterogeneous disorder of the autonomic nervous system characterized by orthostatic tachycardia associated with symptoms of orthostatic intolerance. Although the physiopathology of COVID-19 vaccine and autonomic disorders remains speculative, autoimmune response is one of the possible mechanisms. Based on clinic presentation, the time frame of symptom onset is consistent with other well-known post-vaccination syndromes, which may be an indicator of an autoimmune process induced by immunization. Further studies are needed to assess causal relationship between immunization and autonomic dysfunction.