Acute Coronary Syndrome Death Research Articles

Heterogeneous body compositions and all-cause mortality in acute coronary syndrome patients: a ten-year retrospective cohort study.

The association of different body components, including lean mass and body fat, with the risk of death in acute coronary syndrome (ACS) patients are unclear. We enrolled adults diagnosed with ACS at our center between January 2011 and December 2012 and obtained follow-up outcomes via telephone questionnaires. We used restricted cubic splines (RCS) with the Cox proportional hazards model to analyze the associations between body mass index (BMI), predicted lean mass index (LMI), predicted body fat percentage (BF), and the value of LMI/BF with 10-year mortality. We also examined the secondary outcome of death during hospitalization. During the maximum 10-year follow-up of 1398 patients, 331 deaths (23.6%) occurred, and a U-shaped relationship was found between BMI and death risk (P nonlinearity = 0.03). After adjusting for age and history of diabetes, the overweight group (24 ≤ BMI < 28 kg/m2) had the lowest mortality (HR = 0.53, 95% CI: 0.29-0.99). Predicted LMI and LMI/BF had an inverse linear relationship with a 10-year death risk (P nonlinearity = 0.24 and P nonlinearity = 0.38, respectively), while an increase in BF was associated with increased mortality (P nonlinearity = 0.64). During hospitalization, 31 deaths (2.2%) were recorded, and the associations of the indicators with in-hospital mortality were consistent with the long-term outcome analyses. Our study provides new insight into the "obesity paradox" in ACS patients, highlighting the importance of considering body composition heterogeneity. Predicted LMI and BF may serve as useful tools for assessing nutritional status and predicting the prognosis of ACS, based on their linear associations with all-cause mortality.

ОСТРЫЙ КОРОНАРНЫЙ СИНДРОМ И КОРОНАВИРУСНАЯ ИНФЕКЦИЯ: ПЕРЕСЕЧЕНИЕ ДВУХ ПАНДЕМИЙ

Вackground Acute coronary events (ACEs) in combination with SARS-COV 2 infection have their own distinctive features that determine the dynamics of the disease and differences in therapy. Since at present there are no generally recognized algorithms for the management of such patients, there is a need to search for approaches to determine the risk of adverse outcomes of this disease phenotype. Aim of the study. To study the peculiarities of clinical course and to build a prognostic model of lethal outcomes risk in patients with ACS combined with SARS-COV 2 infection at the hospital stage Characteristics of patients and methods of research. The study included 225 patients admitted to a regional vascular center with a diagnosis of ACS who had a verified diagnosis of SARS-Cov 2 infection. Initially, 120 general clinical, biochemical and instrumental parameters were evaluated. Results and Conclusion. A predictive model was constructed with the identification of eight variables most influencing outcomes: age, the presence of atrial fibrillation (except for the first time detected in ACS), severe and extremely severe course of SARS-COV 2 infection, AKI, CKD, ferritin, albumin and glycemia in blood serum on admission. Conclusion. The proposed author's approach for assessing the risk of death in acute coronary syndrome in combination with SARS-CoV 2 has good predictive accuracy and is easy to use.

Circulating dipeptidyl peptidase 3 predicts hemodynamic impairment and premature death in acute coronary syndromes: insights from the prospective multicenter SPUM-ACS study

Abstract Background Dipeptidyl peptidase 3 (DPP3) is mechanistically involved in the degradation of angiotensin II and in the depression of systolic left ventricular function thereby disturbing peripheral blood pressure regulation. Small pilot studies suggested that circulating DPP3 (cDPP3) portends poor outcomes in acute heart failure and may refine risk assessment in patients with acute coronary syndromes (ACS). Purpose We aimed to assess the predictive value of cDPP3 in contemporary patients with ACS. Methods Circulating DPP3 was studied in 4311 patients with ACS in the prospective multicentre SPUM-ACS study. DPP3 levels were centrally measured in EDTA plasma by blinded study personnel using an established sandwich-type luminometric immunoassay. Kaplan-Meier survival curves and multivariable-adjusted regression models adjusted for sex, age, heart rate, systolic blood pressure, history of diabetes, levels of creatinine, centrally measured high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and high-sensitivity C-reactive protein, and the Global Registry of Acute Coronary Events (GRACE) risk score. Results At baseline, median cDPP3 levels were 19.0 ng/ml (interquartile range [IQR] 15.0-26.0) with higher levels observed in patients with ST-segment elevation myocardial infarction than in those with non-ST-segment elevation ACS (20.1 [15.9-28.2] vs. 18.0 [14.1-23.9], respectively, P&amp;lt;0.001). High cDPP3 was linked to longer hospitalization and higher risk to require vasopressor use or mechanical circulatory support (per log2 increase: odds ratio [OR] 1.91, 95% confidence interval [CI] 1.62-2.24, P&amp;lt;0.001; adjusted OR 1.35 95% CI 1.08-1.69, P=0.008). In line, high cDPP was strongly associated with increased mortality at 30 days (per log2 increase: hazard ratio [HR] 1.96, 95% CI 1.48-2.59, P&amp;lt;0.001) and at 1 year (HR 1.51, 95% CI 1.24-1.83, P&amp;lt;0.001). When accounting for established risk factors, cDPP3 remained an independent predictor of premature death with doubling in cDPP3 levels translating into an 58% and 40% increase in 30-day and 1-year mortality risk, respectively (adjusted HR 1.58, 95% CI 1.06-2.34, P&amp;lt;0.023, adjusted HR 1.40, 95% CI 1.10-1.77, P=0.006, respectively). Conclusion We identified cDPP3 as a novel marker of cardiogenic shock and increased mortality in patients with ACS. Circulating DPP3 provides prognostic information beyond established risk factors and improves early risk assessment.DPP3 is linked to hemodynamic impairmentDPP3 independently predicts mortality

Characteristics and predictive factors of death in acute coronary syndromes among the elderly: data from the Acute coronary syndrome registry at the Abidjan Heart Institute

Acute coronary syndromes (ACS) are the leading cause of death among the elderly in sub-Saharan Africa. The aim of this study was to analyze the characteristics of ACS among the elderly at the Abidjan Heart Institute. Cross-sectional study from January 1, 2015, to December 31, 2019. All patients aged 18 or more admitted to the Abidjan Heart Institute for ACS were included. These patients were divided into two groups: elderly (≥ 65 years old) and non-elderly (< 65 years old). Clinical data, management and outcomes were compared and analyzed in both groups. A total of 570 patients were included, of which 137 (24%) were elderly. Sixty percent (60%) of elderly patients presented with ST Segment Elevation Myocardial Infarction (STEMI). Percutaneous coronary intervention (PCI) was less performed among elderly patients (21.1% vs 30.2%, p = 0.039). Heart failure was the most important complication among the elderly group (56.9% vs 44.6%, p = 0.012). In-hospital mortality was 8% among the elderly. Predictive factors for in-hospital mortality were history of hypertension (HR 2.58; CI95% 1.10-6.08) and STEMI presentation (OR 11.60; CI95% 2.70-49.76). PCI was a protective factor for in-hospital mortality (OR 0.14; IC95% 0.03-0.62). ACS occur with increasing frequency with age. Poor outcomes among the elderly are determined by the clinical presentation and comorbidities. PCI appears to significantly reduce in-hospital mortality.

Endothelial dysfunction predicts bleeding and cardiovascular death in acute coronary syndrome

BackgroundsRecently, there has been increasing awareness that bleeding may lead to adverse outcomes. Endothelial dysfunction is associated with increased risk of cardiovascular and bleeding events. This study aimed to investigate the association of endothelial dysfunction with major bleeding and specific causes of death in addition to major adverse cardiovascular events in patients with acute coronary syndrome. MethodsThis single-centre retrospective observational study was conducted at a tertiary-care hospital; patients with acute coronary syndrome were included between June 2010 and November 2014 (median follow-up, 6.1 years). The reactive hyperaemia index was assessed before their discharge; reactive hyperaemia index <1.67 was defined as endothelial dysfunction. The main outcomes were the incidence of major bleeding, all-cause death, cardiovascular death, non-cardiovascular death, resuscitated cardiac arrest, non-fatal myocardial infarction, non-fatal stroke, and hospitalisation for heart failure. ResultsAmong the included 674 patients with acute coronary syndrome, 264 (39.2%) had endothelial dysfunction. Multivariable Cox-hazard analyses revealed an independent predictive value of endothelial dysfunction for major bleeding (hazard ratio 2.29, 95% confidence interval 1.17–4.48, P = 0.016) and major adverse cardiovascular events (hazard ratio 2.04, 95% confidence interval 1.43–2.89, P < 0.001). The endothelial dysfunction group patients had a 2.5-fold greater risk of cardiovascular death; however, no association was found with non-cardiovascular death. ConclusionEndothelial dysfunction assessed using reactive hyperaemia index predicted future major cardiovascular event as well as major bleeding and cardiovascular death in patients with acute coronary syndrome.

Neurohumoral response and stress hyperglycemia in myocardial infarction

BackgroundHyperglycemia is associated with an increased risk for death in acute coronary syndromes. This could be related to underlying glucose metabolism abnormalities or be caused by a counter-regulatory stress response. However, there is a paucity of data on the relationship between stress hormones, hyperglycemia, and clinical outcomes in myocardial infarction. MethodsSingle-center, prospective, observational study. Patients admitted to the coronary care unit with a diagnosis of myocardial infarction were included. On admission, blood samples were obtained to measure serum glucose, cortisol, and catecholamines. A second sample was obtained at 8 AM after 48 h from admission. ResultsThere was a mild and positive correlation between serum cortisol and glucose (Spearman's rho = 0.24, p = 0.005), and no significant correlation was found between glucose and catecholamines. A similar correlation between cortisol and glucose among diabetics and non-diabetics was observed. Significantly higher serum cortisol and glucose levels were present in patients who developed heart failure or died during hospitalization. The association between glycemia and mortality lost significance in multivariate analysis, with a significant interaction term with cortisol (p = 0.003). ConclusionCortisol is a key responsible for stress hyperglycemia, and its deleterious effects on the cardiovascular system could be the cause for worst outcomes associated with hyperglycemia in ACS. Further research is warranted to ascertain this relationship and to investigate potential therapeutic targets.

Soluble lectin-like oxidized low-density lipoprotein receptor-1 predicts premature death in acute coronary syndromes.

The lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) and its shedding product [soluble LOX-1 (sLOX-1)] are implicated in atherosclerotic cardiovascular disease (ASCVD) pathogenesis. Herein, we examined the relationship of sLOX-1 with both fatal events and plaque progression in patients with acute coronary syndromes (ACS). Plasma sLOX-1 was assessed at baseline in ACS and chronic coronary syndrome (CCS) patients prospectively recruited in the multicentre SPUM-ACS study, with sex- and age-matched healthy subjects serving as additional controls (n = 2924). Compared with both CCS and controls, ACS patients showed markedly elevated sLOX-1 levels (median, 2.00 and 2.00 vs. 35.08 pg/mL; P < 0.0001) which were independently associated with increased mortality risk over 30-day [tertile (T)3: adjusted hazard ratio (HR), 3.11; 95% confidence interval (CI), 1.44-10.61; P = 0.0055] and 1-year intervals (T3: adjusted HR, 2.04; 95% CI, 1.19-3.92; P = 0.0098). Results remained consistent after adjustment for GRACE 2.0 (T3: adjusted HR, 1.86; 95% CI, 1.04-3.74; P = 0.0391) and were primarily driven by the pronounced relationship of sLOX-1 with cardiovascular mortality at 30 days (T3: adjusted HR, 3.81; 95% CI, 1.62-19.62; P = 0.0036) and at 1 year (T3: adjusted HR, 2.29; 95% CI, 1.19-5.34; P = 0.0148). In ACS patients undergoing serial intracoronary imaging and statin therapy, sLOX-1 dropped significantly in those with coronary plaque regression at 1 year (ΔsLOX-1: -4.64 ± 1.80; P = 0.0057), and showed a good discrimination for predicting plaque progression (area under the curve = 0.74; 95% CI, 0.59-0.86; P = 0.0031). Plasma sLOX-1 levels are increased during ACS and predict fatal events beyond traditional and emerging risk factors. Persistently high sLOX-1 associates with coronary plaque progression in patients with established ASCVD. NCT01000701.

Systemic Immune-inflammation Index in Acute Coronary Syndrome and its Role in Predicting Disease Severity: A Cohort Study

Introduction: Systemic Immune-inflammation Index (SII) is a novel marker of inflammation, used extensively in prognosticating various cancers. Recent studies have shown SII to be a predictor of adverse events and death in Acute Coronary Syndrome (ACS) patients who undergo intervention. The role of SII in medically managed SII patients has not been studied. There are no Indian studies available which study the prognosticative role of SII in ACS. Aim: To study systemic immune-inflammation index in acute coronary syndrome and its role in predicting disease severity and mortality. Materials and Methods: This prospective cohort study was conducted in Department of General Medicine at Father Muller Medical College Hospital, Mangaluru, India between February 2021 and July 2021. The study included 45 ST Elevation Myocardial Infarction (STEMI) and 45 Non ST Elevation Myocardial Infarction (NSTEMI)/Unstable Angina (UA) patients, aged 30 years or more. The SII, Neutrophil-to-Lymphocyte Ratio (NLR) and Total Leucocyte Count (TLC) were compared using independent sample t-test. Killip class, Thrombolysis In Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) 2.0 scores were used to determine disease severity. Pearson’s and Spearman’s correlation coefficient were used to determine correlation between parametric and non parametric parameters, respectively. Receiver Operator Curve (ROC) was used to see for predictability of outcomes. The role of SII to predict Major Adverse Cardiac Events (MACE) and death at one month follow- up period was assessed by Kaplan-Meier analysis and Cox regression analysis. Results: The mean SII was significantly higher in the STEMI group (20.9 vs 9.79; t-value= 3.65, p-value &lt;0.001). SII correlated significantly with Killip class (r=0.502), TIMI (r=0.417) and GRACE 2.0 scores (r=0.529), better than NLR or TLC. High SII were associated with a higher risk of MACE (Odds ratio=13.82, p-value &lt;0.001) and death (OR=4.413, p-value=0.015). The SII had an Area Under the Curve of 0.67 for predicting MACE and had a negative predictive value of 96%. Kaplan-Meier analysis showed that patients with higher SII had a lower survival at one month (median: 24.5 days vs 29.32 days, Log-rank=6.44, p-value=0.011). The SII predicted MACE and death better than left ventricular Ejection Fraction (EF) and troponin I. Conclusion: The SII is a cost-effective, novel marker of inflammation that can predict short term outcomes in ACS. This was the first cohort study which studied the role of SII in ACS in patients undergoing any type of intervention.

Strong independent association between hospital bleeding and death in acute coronary syndromes: causal relationship or coexistence of two phenomena?

Abstract Background Bleeding and hospital death have an independent association in observational records of acute coronary syndromes (ACS), leading to interpretation of this relationship as causal. However, association does not guarantee causality, and better exploitation of this phenomenon is necessary. Purpose To describe the association between bleeding and death of patients with ACS, exploring causality through the cascade of events that separate these two phenomena. Methods Patients consecutively admitted to Coronary Unit by objective criteria of ACS were included prospectively. Major bleeding during hospitalization was defined according to types 3 and 5 of the Universal Bleeding Classification. Logistic regression and sequence analysis of events were used to evaluate the association between bleeding and death. Results A total of 1104 patients were studied, age 65±14 years, 58% male, 23% with ST elevation. The incidence of major bleeding was 4.7% (52 cases). Bleeding patients presented mortality of 31% (16 deaths), compared to 4.7% death in the non-bleeding group (RR=6.6, 95% CI: 4.0–11). Those who bled had a GRACE score significantly higher than those free of bleeding (157±39 versus 121±38, P&amp;lt;0.001). After adjustment for this score, bleeding remained strongly associated with death (OR=4.5, 95% CI: 2.1–9.7, P&amp;lt;0.001). However, among the 16 deaths that occurred after bleeding, in 56% of the patients the death was due to hemorrhage, while the remainder was a consequence of the myocardial injury of the infarct or natural evolution of noncardiac morbidities. Conclusion The independent association between major bleeding and death in acute coronary syndromes is only partially mediated by causality. In the same proportion, deaths coexist with bleeding without a causal relationship. Funding Acknowledgement Type of funding source: None

Acute coronary syndromes in nonagenarians: do we have reliable risk scores?

Abstract Introduction GRACE score is strongly validated to determine the probability of death in acute coronary syndrome (ACS), nevertheless its usefulness in nonagenarians, a population with frequently associated comorbidities, is less stablished. BARTHEL and CHARLSON scores might be useful tools to predict outcomes in this population. Objective The aim of this study was to evaluate the potential applicability of GRACE score and two comorbidity scores (CHARLSON and BARTHEL) to estimate prognosis in nonagenarians with ACS. Material and methods We retrospectively included all consecutive patients equal to or older than 90 years old admitted with non-ST (NSTEMI) or ST segment elevation myocardial infarction (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristics and procedural data. In-hospital and at 1-year follow-up all-cause and cardiovascular mortality were assessed. Risk score accuracy was evaluated by area under the curve ROC (AUC). Results A total of 444 patients (mean age 92.6±2.4 years, 60% females) were analyzed. Approximately half of them (n=241, 54%) with STEMI and the remainder (n=203, 46%) with NSTEMI. Global GRACE-AUC for in-hospital and 1-year all-cause mortality were moderate (0.64; 95% CI: 0.59–0.69 and 0.62; 95% CI: 0.57–0.67, respectively). Only in the NSTEMI group, the GRACE-AUC was better to predict in-hospital mortality, 0.70 (95% CI: 0.63–0.77). Neither CHARLSON nor BARTHEL showed better predictive results than GRACE score (AUC ≤0.60). Conclusion GRACE score has moderate accuracy to estimate mortality in nonagenarian patients with ACS. BARTHEL and CHARLSON scores do not improve the predictive value of GRACE score. An individualized approach is required to make therapeutic decisions in this special population. Figure 1. ROC-GRACE curves Funding Acknowledgement Type of funding source: None

Competência Prognóstica Distinta entre Modelo Clínico e Anatômico em Síndromes Coronarianas Agudas: Comparação por Tipo de Desfecho

ResumoFundamento Eventos isquêmicos recorrentes decorrem de instabilidade de placa aterosclerótica, enquanto morte após um evento isquêmico decorre da gravidade do insulto. A natureza diversa desses tipos de eventos pode fazer com que dados clínicos e anatômicos tenham diferentes capacidades prognósticas a depender do tipo de desfecho.Objetivo Identificar as predileções prognósticas de dados clínicos e dados anatômicos em relação a desfechos coronários fatais e não fatais durante hospitalização de pacientes com síndromes coronarianas agudas (SCA).Métodos Pacientes consecutivamente admitidos por SCA que realizaram coronariografia foram recrutados. O escore SYNTAX foi utilizado como modelo anatômico e o escore GRACE como modelo clínico. A capacidade preditora desses escores foi comparada quando à predição de desfechos isquêmicos não fatais (infarto ou angina refratária) e de morte cardiovascular durante hospitalização. Significância estatística foi definida por p < 0,05.Resultados Entre 365 indivíduos, 4,4% foi a incidência de óbito hospitalar e 11% de desfechos isquêmicos não fatais. Para morte cardiovascular, ambos os escores — SYNTAX e GRACE — apresentaram capacidade discriminatória, com estatísticas-C similares: 0,80 (95%IC: 0,70–0,92) e 0,89 (95%IC 0,81–0,96), respectivamente — p=0,19. Quantos aos desfechos isquêmicos não fatais, o escore SYNTAX apresentou valor preditor (estatística-C = 0,64; 95%IC 0,55–0,73), porém o escore GRACE não mostrou associação com esse tipo de desfecho (estatística-C = 0,50; 95%IC: 0,40–0,61) — p=0,027.Conclusão Os modelos clínico e anatômico predizem satisfatoriamente morte cardiovascular em SCA, enquanto a recorrência de instabilidade coronária é melhor prevista por características anatômicas do que por dados clínicos. (Arq Bras Cardiol. 2020; 115(2):219-225)

ALCAM predicts future cardiovascular death in acute coronary syndromes: Insights from the PLATO trial

Background and aimsActivated leukocyte cell adhesion molecule (ALCAM) is upregulated during inflammation and involved in transmigration of leukocytes and T-cell activation. We hypothesized that ALCAM might be associated with recurrent events in patients with acute coronary syndromes (ACS). MethodsALCAM was measured in serum obtained on admission, at discharge, 1 month and 6 months in a subgroup of 5165 patients admitted with ACS and included in the PLATelet inhibition and patient Outcomes (PLATO) trial (NCT00391872). The association between ALCAM and the composite endpoint and its components, including cardiovascular (CV) death, non-procedural spontaneous myocardial infarction (MI) or stroke during 1-year follow-up, was assessed by Cox proportional hazards models with incremental addition of clinical risk factors and biomarkers (including high-sensitivity troponin T, N-terminal pro−B-type natriuretic peptide and growth differentiation factor-15). ResultsThe median (Q1-Q3) concentration of ALCAM at admission was 97 (80–116) ng/mL. A 50% higher level of ALCAM on admission was associated with a hazard ratio (HR) of 1.16 (95% confidence interval [1.00–1.34] p = 0.043) for the composite endpoint in fully adjusted analysis, mainly driven by the association with CV death (HR 1.45 [1.16–1.82] p = 0.0012). ConclusionsIn patients with ACS, admission level of ALCAM was independently associated with adverse outcome including CV death even after adjustment for established inflammatory and cardiac biomarkers.

Predictive value of GRACE discharge score for long-term out-of-hospital death in acute coronary syndrome after percutaneous coronary intervention

Objective: To evaluate the prognostic value of Global Registry of Acute Coronary Events(GRACE) discharge score for long-term out-of-hospital death in acute coronary syndrome (ACS) after drug-eluting stents (DES) and with Dual-antiplatelet Therapy (DAPT). Methods: Our study was a prospective, observational, single center (Fuwai Hospital of China) study.A total of 6 431consecutive ACS patients underwent percutaneous coronary intervention(PCI)between January 2013 and December 2013 were involved.The primary endpoint was all-cause death and second endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) as a composite of all-cause death, myocardial infarction, revascularization, stent thrombosis or stroke. Results: Finally, 5 867 ACS patients who were received DES with DAPT and had no in-hospital event included in this study, and 59 (1.01%) death and 608 (10.36%) MACCE were reported during 2-year follow-up after discharge.GRACE score was significantly higher among death patients than those survivalpatients (94± 28 vs 78± 24, P<0.001). According to risk stratification of GRACE discharge score, as compared to the low-risk group, death risk in high-risk group was 6.73 times (HR=6.73, 95%CI 3.53-12.84; P<0.001) higher, but could not distinguish between the moderate and low risk group (HR=1.61, 95%CI 0.88-2.95; P=0.124). The GRACE score showed predictive value in ACS patients after DESand with DAPT (area under the receiver operating characteristic curve (AUROC)=0.661; 95%CI 0.586-0.736, P<0.001). In subgroup analysis, GRACE score also showed predictive value both in unstable angina pectoris (UAP)(AUROC=0.660, 95%CI 0.576-0.744; P<0.001) and acute myocardial infarction(AMI)subgroup (AUROC=0.748, 95%CI 0.631-0.864; P=0.001). Conclusion: GRACE discharge score shows prognostic value for long-term out-of-hospital death in ACS patients undergoing PCI with DES and DAPT, and demonstrates good risk stratification of high and low-risk of death.

Strach przed śmiercią w ostrych zespołach wieńcowych – częstość występowania i czynniki sprzyjające

Strach przed śmiercią w ostrych zespołach wieńcowych – częstość występowania i czynniki sprzyjające

Sudden Cardiac Death in Acute Coronary Syndromes.

Sudden cardiac death in acute coronary syndromes mostly results from complex ventricular arrhythmias. Although the incidence has fallen with contemporary management, they still pose a threat for many patients. Treatment consists of immediate termination by electrical cardioversion and prompt coronary revascularization for relief of ischemia. Beta-blockers administered prophylactically have a protective effect. For recurrent episodes, pharmacologic treatment consists of beta-blockers and amiodarone, or, in nonresponsive patients, lidocaine. Other antiarrhythmic drugs play only a marginal role. Catheter ablation performed in qualified centers can be effective in recurrent episodes of ventricular tachycardia or ventricular fibrillation triggered by premature ventricular contractions.

Cardiogenic shock: current epidemiology and management

AbstractCardiogenic shock (CS) is the most severe form of acute heart failure, characterized by low cardiac output, hypotension, and systemic hypoperfusion. CS is the leading cause of death in acute coronary syndrome (ACS) that accounts for about 80% of CS cases. In addition to acute cardiac cause, the diagnostic criteria for CS include persistent hypotension (systolic blood pressure &lt; 90 mmHg) and clinical signs of hypoperfusion. Mortality rates in CS remain as high as 35–50%. Severe left ventricular dysfunction usually triggers the shock and leads to the activation of systemic inflammatory response and hypothalamic‐pituitary‐adrenal axis. Immediately after detection of the shock, electrocardiography and echocardiography should be performed to determine the etiology of CS and to rule out mechanical complications. Urgent revascularization by percutaneous coronary intervention, or less often by coronary artery bypass graft, is the most important treatment in CS caused by ACS. In the case of mechanical complication, immediate surgical treatment is essential. Regardless of the etiology, the basic treatment strategy includes fluid challenge that aims at obtaining euvolemia and relieving tissue hypoperfusion. Inotropes and vasopressors are often needed to improve cardiac performance and to maintain sufficient blood pressure. Ventilation is often supported mechanically and CS patients are best treated in intensive cardiac care unit. Continuous invasive blood pressure monitoring, electrocardiography, and repeated echocardiography are required. In CS refractory to other treatments, mechanical circulatory support may be considered to maintain adequate perfusion pressure and to prevent multiorgan failure.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5608947/Activity.aspx

Percutaneous cardiac support during myocardial infarction drastically reduces mortality: perspectives from a swine model.

Background/AimsAcute myocardial infarction (AMI) with cardiogenic shock (CS) remains the leading cause of in-hospital death in acute coronary syndromes. In the AMI-CS pig model we tested the efficacy of temporary percutaneous cardiorespiratory assist device (PCRA) in rescuing the failing heart and reducing early mortality.MethodsIn open-chest pigs we induced AMI by proximal left anterior descending coronary artery (LAD) ligation. Eight animals without PCRA (C group) were compared with 12 animals otherwise treated with PCRA (T group), starting approximately at 60 minutes post-occlusion and lasting 120–180 minutes. In 3 animals of the T group, regional myocardial oxygen content was also imaged by two-dimensional near infrared spectroscopy (2D-NIRS) with and without PCRA, before and after LAD reperfusion.ResultsAll animals without PCRA died despite unrelenting resuscitation maneuvers (120 minutes average survival time). Conversely, animals treated with PCRA showed a reduction in life-threatening arrhythmia and maintenance of aortic pressure, allowing interruption of PCRA in all cases early in the experiments, with sound hemodynamics at the end of the observation period. During LAD occlusion, NIRS showed severe de-oxygenation of the LAD territory that improved with PCRA. After PCRA suspension and LAD reperfusion, the residual de-oxygenated area proved to be smaller than the initial risk area.ConclusionsIn AMI, PCRA initiated during advanced CS drastically reduced early mortality from 100% to 0% in a 4–5 hour observation period. PCRA promoted oxygenation of the ischemic area during LAD occlusion. Results support the use of PCRA as first line of treatment in AMI-CS, improving myocardial rescue and short-term survival.

South Asians and coronary disease: is there discordance between effects on incidence and prognosis?

ObjectiveTo determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease.DesignSystematic literature review and meta-analysis, and cohort analysis from a national acute...

Reticulated platelets predict cardiovascular death in acute coronary syndrome patients

Reticulatedplatelets (RP)are newly-formed plateletswith a greater mass, a residual amount of RNA and an increased prothrombotic potential. No studies investigating the association between RP and the risk of cardiovascular death in acute coronary syndrome (ACS) patients are available. In the frame of the AMI-Florence 2 study, we investigated RP in 229 (154 M/ 75 F) ACS patients (125 ST-elevation myocardial infarction [STEMI]; 104 Non-STEMI/Unstable Angina). RP were measured by using the Sysmex XE-2100 haematology analyzer and were expressed as the percentage of RP out of the total optical platelet count (immature platelet fraction; IPF) and as the percentage of RP highly fluorescent (H-IPF). At one-year follow-up, 22 out of 229 patients (9.6%) died from cardiovascular causes. Higher values of IPF (p=0.05) and H-IPF (p=0.006) were detected in dead compared to alive patients. A receiver operating characteristics curve analysis identified IPF ≥3.3% and H-IPF ≥0.9% as optimal cut-off values to predict cardiovascular death. At the multivariate model adjusted for the Global Registry of Acute Coronary Events (GRACE) risk score, the association between RP and cardiovascular death remained significant for both IPF [OR (95%CI) : 4.15 (1.24-13.91) p=0.02] and H-IPF [OR (95%CI): H-IPF 5.03 (1.38-18.38) p=0.01]. In conclusion, RP are independent predictors of cardiovascular death and may be useful in improving risk stratification for ACS patients. Future prospective studies to evaluate the role ofRP in determiningcardiovascularevents are warranted.

Análise de causalidade da relação entre sangramento e letalidade de Síndromes Coronarianas Agudas

Hemorrhagic events in Acute Coronary Syndromes (ACS) have been independently associated with death in international multicenter registries. However, that association has not been tested in Brazil and the true causal relationship between bleeding and death has not been completely shown. To test the following hypotheses: (1) major bleeding is an independent predictor of in-hospital death in ACS; (2) the relationship between those two endpoints is causal. This study included patients meeting predefined criteria of unstable angina, non-ST-segment elevation myocardial infarction or ST-segment elevation myocardial infarction. Major bleeding during hospitalization was defined according to the Bleeding Academic Research Consortium (types 3 or 5). Logistic regression and analysis of the sequence of events were used to assess the association between bleeding and death. Of the 455 patients studied, 29 experienced major bleeding (6.4%; 95% CI = 4.3-9.0%). They had in-hospital mortality of 21%, as compared with 5.6% of those not experiencing bleeding (RR = 4.0; 95% CI = 1.8-9.1; P = 0.001). After adjusting for the propensity score, major bleeding remained as a predictor of in-hospital death (OR = 3.34; 95% CI = 1.2-9.5; P = 0.02). Of the 29 patients who experienced bleeding, six died. However, the detailed analysis of the sequence of events showed causal relationship only in one case. (1) Major bleeding is an independent predictor of in-hospital death in ACS; (2) the role of bleeding as a risk marker overcomes that as a risk factor for death. This conclusion should be seen as a hypothesis generator to be confirmed by larger-sample studies.