Development Of Cardiogenic Shock Research Articles

Association between speckle tracking echocardiography and pressure-volume loops during cardiogenic shock development

BackgroundThe relationship between speckle tracking assessed global longitudinal strain (GLS) and Doppler-based echocardiography with basic physiological markers of cardiac function derived from pressure-volume loops is poorly elucidated.ObjectiveWe aimed to describe...

Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center.

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Development and external validation of a dynamic risk score for early prediction of cardiogenic shock in cardiac intensive care units using machine learning.

Myocardial infarction and heart failure are major cardiovascular diseases that affect millions of people in the US with the morbidity and mortality being highest among patients who develop cardiogenic shock. Early recognition of cardiogenic shock allows prompt implementation of treatment measures. Our objective is to develop a new dynamic risk score, called CShock, to improve early detection of cardiogenic shock in cardiac intensive care unit (ICU). We developed and externally validated a deep learning-based risk stratification tool, called CShock, for patients admitted into the cardiac ICU with acute decompensated heart failure and/or myocardial infarction to predict onset of cardiogenic shock. We prepared a cardiac ICU dataset using MIMIC-III database by annotating with physician adjudicated outcomes. This dataset that consisted of 1500 patients with 204 having cardiogenic/mixed shock was then used to train CShock. The features used to train the model for CShock included patient demographics, cardiac ICU admission diagnoses, routinely measured laboratory values and vital signs, and relevant features manually extracted from echocardiogram and left heart catheterization reports. We externally validated the risk model on the New York University (NYU) Langone Health cardiac ICU database that was also annotated with physician adjudicated outcomes. The external validation cohort consisted of 131 patients with 25 patients experiencing cardiogenic/mixed shock. CShock achieved an area under the receiver operator characteristic curve (AUROC) of 0.821 (95% CI 0.792-0.850). CShock was externally validated in the more contemporary NYU cohort and achieved an AUROC of 0.800 (95% CI 0.717-0.884), demonstrating its generalizability in other cardiac ICUs. Having an elevated heart rate is most predictive of cardiogenic shock development based on Shapley values. The other top ten predictors are having an admission diagnosis of myocardial infarction with ST-segment elevation, having an admission diagnosis of acute decompensated heart failure, Braden Scale, Glasgow Coma Scale, Blood urea nitrogen, Systolic blood pressure, Serum chloride, Serum sodium, and Arterial blood pH. The novel CShock score has the potential to provide automated detection and early warning for cardiogenic shock and improve the outcomes for the millions of patients who suffer from myocardial infarction and heart failure.

Myocardial salvage and infarct characteristics in patients with ST-elevation myocardial infarction classified by ORBI risk score

Abstract Background The Observatoire Régional Breton sur l'Infarctus (ORBI) [1] risk score was developed to predict in-hospital cardiogenic shock (CS) development in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. The association between infarct characteristics determined by cardiac magnetic resonance imaging (CMR) and ORBI risk classification have not previously been reported in patients with STEMI. Methods The Third DANish Study of Optimal Acute Treatment of Patients With ST-Segment Elevation Myocardial Infarction (DANAMI 3) trial investigated multiple revascularization strategies in patients with STEMI. CS on admission was an exclusion criterion, thus only low and intermediate scores were included. Stratification into ‘low’ (0-7) and ‘intermediate-high’ (>=8) ORBI risk score was performed (n=1,396), and CMR data from admission and three months follow-up at the largest participating centre were analysed using logistic- and Cox-regression (n=534, 38%). Results A total of 1,149 (82%) were ‘low’ risk, and 247 (18%) ‘intermediate-high’ risk. Patients with ‘intermediate-high’ risk were older (median age 71 (interquartile range (IQR) 61-78) vs. 60 (52-68), p<0.001), and more had an admission systolic blood pressure < 90 mm Hg (4.9% vs. 1.4%, p=0.002), and heart rate > 100 bpm (30% vs. 5%, p<0.001). Left ventricular ejection fraction was lower at discharge (40% (30-50%) vs. 50% (45-55%), p<0.001), and more had an anterior infarction (61% vs. 38%, p<0.001) compared to ‘low’ risk patients. Moreover, median peak troponin was higher (5010 ng/L (2195-9930) vs. 2820 ng/L (1138-5805), p<0.001). Aside from hypertension (52% vs. 39%, p<0.001), there were no differences in factors not covered by the ORBI score. In patients with ‘intermediate-high’ risk, both median acute and final infarct size were larger compared to those with ‘low’ risk (21% (12-28%) vs. 15% (7-24%), p=0.004, and 15% (10-26%) vs. 10% (4-17%), p<0.001). Median final salvage index was lower (0.66 (0.47-0.76) vs. 0.69 (0.55-0.87), p=0.048). ‘Intermediate-high’ risk was associated with higher odds of an above-median acute infarct size (odds ratio (OR) 2.02 (95% confidence interval (CI) 1.13-3.68) p=0.019), final infarct size (OR 3.00 (1.65-5.37), p<0.001), and lower odds of an above-median final salvage index (OR 0.52 (0.29-0.91), p=0.026). One-year mortality was higher in patients with ‘intermediate-high’ (9.7% (95%CI 5.9-13)) compared to "low" risk patients (1.9% (1.1-2.7), p<0.001). In univariate analyses, ‘intermediate-high’ risk was associated with a higher mortality risk (hazard ratio 5.31 (95%CI 2.98-9.48), p<0.001). Conclusions In patients with STEMI, an intermediate-high ORBI risk score of >=8 was associated with larger infarct size and less myocardial salvage, and a 5-time higher mortality risk relative to the overall favorable outcomes in those with a low-risk score.Kaplan-Meier Plot, one-year survival

Abstract 13516: Outcomes Among Heart Failure Patients Hospitalized for Infective Endocarditis: A United States National Cohort Study

Introduction: We aim to investigate the impact of heart failure (HF) among hospitalized patients with infective endocarditis (IE) in terms of in-hospital outcomes including the risk for mortality, development of cardiogenic shock (CS) and certain arrythmias, as well as hospital length of stay (LOS). Methods: We queried the 2018-2020 United States National Inpatient Sample (NIS) Database in conducting this retrospective cohort study. We identified hospitalized adult patients greater than 18 years of age with HF and IE using appropriate ICD-10 CM codes. Those with HF were subsequently stratified into systolic and diastolic HF. A survey multivariable logistic and linear regression analysis was used to calculate adjusted odds ratios (ORs) for the outcomes of interest. Results: A total of 150,059 hospitalized patients with IE were identified in the years 2018-2020, of which 33.58% (50,390/150,059) had HF. The overall in-hospital mortality rate among hospitalized patients with IE is 12.13% (18,185/150,059). Among those with HF, the in-hospital mortality rate was significantly higher at 15.11% (7,614/50,390, p<0.001). Using a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, HF among hospitalized patients with IE increased the risk for adverse in-hospital outcomes. (Table 1) Conclusions: Our study showed that concomitant HF among hospitalized patients with IE increased the risk for in-hospital mortality, longer LOS, development of CS and certain arrythmias including atrial fibrillation, ventricular tachycardia, and ventricular fibrillation. This highlights the significant impact of HF as a potential predictor of worse outcomes among hospitalized IE patients.

Abstract 14988: Clinical Impact of Biventricular vs. Isolated Left Ventricular Involvement Among Patients With Takotsubo Cardiomyopathy- An Updated Meta-Analysis

Introduction: Takotsubo Cardiomyopathy (TC) is a form of acute nonischemic cardiomyopathy manifesting as a transient state of cardiac dysfunction. Isolated left ventricular TC (ILVTC) is most commonly observed, less frequently, superimposed right ventricular involvement is apparent - referred to as biventricular TC (BVTC). Few analyses have been done to characterize the implications of biventricular TC on hospital courses and outcomes. Methods: A literature search was conducted on PubMed and Google Scholar to identify qualifying studies. Inclusion criteria were adult patients with TC, and studies reporting comparison of outcomes (cardiogenic shock, use of inotropes, all causes of mortality, and length of hospital stay) between patients with BVTC and ILVTC. Exclusion criteria were any studies that reported on patients younger than 18 years or did not report all the outcomes for BVTC vs ILVTC. Results: A total of 1,156 patients with TC were analyzed from 6 included studies, of which 15% had BVTC (n=175), and 85% had ILVTC (n=981). Patients with BVTC were found to have a higher incidence of cardiogenic shock patients (OR:3.3; 95% CI=1.40-7.77) and use of inotropes (OR:3.66; 95% CI =1.60-8.35). All-cause mortality did not reach statistical significance between the two groups (OR:2.05; 95% CI=0.81 - 5.22; p <0.13). There was also no significant difference in length of hospital stay (Hedges’ g = 0.22; 95% CI = -0.01 to +0.45; p = 0.0593). Conclusions: In comparison to ILVTC, BVTC increasingly predisposes to cardiogenic shock development. Yet, the presence of biventricular involvement does not impact the risk of mortality or hospital length of stay when compared to ILVTC.

Thyroid gland and heart: a cardiologist’s view on an endocrinological pathology. Review

The review of the literature considered the mechanism of action and the role of thyroid hormones (TH) on cardiovascular hemodynamics and, subsequently, on changes in the myocardial structure. A brief description of the genomic and non‑genomic mechanisms of thyroid hormones is provided. The mechanisms of thyroid hormones’ effects on the development of arterial and pulmonary hypertension, atrial fibrillation are highlighted. Attention is focused on the fact that congestive heart failure of the dilatation type develops against the background of hyperthyroidism. A possible connection between thyroid hyperfunction and Takotsubo stress‑induced cardiomyopathy was investigated. The impact of subclinical hyperthyroidism on the development and progression of cardiac pathology is illustrated. The mechanism of influence of hypothyroidism on the parameters of the lipid spectrum, acute phase proteins, insulin sensitivity, but not only the contractile function of the myocardium was considered. Changes in the electrical activity of the heart and its structural and functional changes were determined. Attention is focused on the importance of achieving euthyroidism in both hyperthyroidism and hypothyroidism. Stress‑induced Takotsubo cardiomyopathy is closely related to the hyperthyroid state and is often accompanied by the development of cardiogenic shock. Hyperthyroidism is associated with an increased risk of permanent atrial fibrillation and hypercoagulability. The achievement of euthyroid state can result in the reversal of left ventricular hypertrophy and decrease in the heart chamber dilatation. Even subclinical hyperthyroidism increases the risks of overall mortality and cardiovascular events, especially in the elderly persons. Patients with hypothyroidism are characterized by the development of anemia, dyslipidemia, decreased sensitivity to insulin, which is associated with endothelial dysfunction. In hypothyroidism, in contrast to hyperthyroidism, the risk of atrial fibrillation development is lower due to an increase in the arrhythmogenic threshold, but more typical disorders include sinus bradycardia, atrioventricular blocks of various degrees and prolongation of the QT interval, which are associated with the early development of impaired myocardial relaxation. For patients with thyroid pathology, the achievement of euthyroidism is mandatory to ensure cardio‑ and vasoprotection.

State of Shock: Contemporary Vasopressor and Inotrope Use in Cardiogenic Shock.

Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.

ORBI Risk Score as a predictor of in-hospital mortality and long-term outcomes in patients with ST-segment elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction ST-elevation myocardial infarction (STEMI) encompasses a heterogeneous group of patients with distinct prognoses. In worse clinical scenarios with the development of cardiogenic shock (CS), mortality may ascend to 40%. Observatoire Régional Breton sur l'Infarctus risk score (ORBIs) was developed to predict the development of in-hospital CS in patients with STEMI treated with primary percutaneous coronary intervention (PCI). Aim To validate ORBI score as a predictor of in-hospital mortality (IHM) and long-term outcomes in STEMI. Methods Retrospective analysis of 296 patients admitted for STEMI and treated with PCI. Patients presenting with CS at admission were excluded. ORBIs evaluates the presence of 11 variables: age >70 years, prior stroke/transient ischemic attack, cardiac arrest upon entry, anterior STEMI, first medical contact-to-PCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycemia>10 mmol/L, culprit lesion of the left main coronary artery, and post-PCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7 points), low-to-intermediate (8-10 points), intermediate-to-high (11-12 points), and high (≥13 points). The Mann-Whitney U test was used for median comparison between groups. Kaplan-Meier survival plots were used to evaluate the predictive power of ORBIs on INM and on 12-month cardiovascular events (12MH). Results Mean age was 63,9±13 years; 75% were men. 11% had a history of coronary artery disease, and 8% had been submitted to PCI previously. Mean LVEF was 54±12%. 69% had radial artery access. Left anterior descending artery disease was present in 68% of patients. Mean time since beginning of symptoms and hospital admission was 369±492 minutes. Mean duration of hospitalization was 5,68±3,5 days. ORBIs was calculated, and the population was divided into 2 groups: 45% were included in low and low to intermediate risk group (LR) (n=134), and 55% in intermediate to high- and high-risk group (HR). IHM was 3,7%. HR ORBIs was significantly associated with in-hospital mortality (6,2% vs 0,7%; p<0,01; OR 8,8 IC 95% 1,1;69,7). HR ORBIs was also significantly associated with long-term events (mortality and hospitalizations) (15% vs 6%; p<0,01). In univariate analysis, HR group showed significantly different LV ejection fraction (53,6±14,3 vs 61,0±13,1; p<0,01), troponin I at admission (33,3±94,12 vs 15,2±41,9; p<0,01), BNP (424,9±533,4 vs 194,1±170,1; p<0,01), duration of hospitalization (6,1±3,1 vs 5,2±3,9; p<0,01) and age (68,2±12,7 vs 58,9±11,5; p<0,01). Conclusion Higher ORBIs is associated with increased mortality in patients with STEMI. ORBIs may be a simple predictive model for short and long-term mortality and cardiovascular events in STEMI patients.

In-hospital mortality analysis in patients with acute cardiovascular pathology and co-infection with COVID-19: a registry of one site

Abstract Funding Acknowledgements Type of funding sources: None. Patients with cardiovascular pathology have a significantly higher risk of adverse events and death when complicated by concomitant COVID-19. The aim of this study was to analyze in-hospital mortality in pts with acute cardiovascular pathology (ACP) and a co-infection with COVID-19. 139 pts with ACP who were diagnosed with COVID-19 were examined. 69 (49.6%) pts had ACS (47 pts with AMI), 33 (23.7%) pts - hypertensive urgency, 24 (17.3%) pts - ADHF, 9 (6.5%) pts - tachysystolic paroxysm of atrial fibrillation, 2 (1.4%) pts - acute pulmonary embolism, and 2 (1.4%) pts - syncope. The average age was 67.9±12.7 y.o., 70 (50.4%) pts were male. Concomitant arterial hypertension was found in 87.1%, DM – 20.9%, CHF - 30.9%, COPD – 9.4% of pts, history of AMI – 20.1% and ischemic stroke – 9.4% of pts. In 79 (56.8%) pts COVID-19 was diagnosed and laboratory confirmed before hospitalization (hospitalized in 5.3±3.6 days after symptoms onset). 31 (22.3%) pts were diagnosed with COVID-19 upon admission, and 29 (20.9%) - during their stay in the hospital. 20 (15.6%) pts were vaccinated against COVID-19. The initial SpO2 level was 91.6±10.3%, while more than half of pts (53.2%) had SpO2<95% and almost every fourth (23.2%) patient had SpO2<90%. During the hospital period, 20 (14.4%) pts died. The mortality rate was 28.0% in pts with ADHF, 19.1% in pts with AMI and significantly less in pts hospitalized for unstable angina, hypertensive urgency or atrial fibrillation - 5.2% (p<0.05 in comparison with pts with AMI or ADHF). The main cause of death was the development of cardiopulmonary failure – 14 (70.0%) pts. 4 (20.0%) pts died from AMI complications, 1 - from pulmonary embolism and 1 - from acute ischemic stroke. Two critical periods of in-hospital mortality can be distinguished: 1 - the first two days of hospitalization (mainly complications of acute cardiovascular pathology and thrombotic events); 2 – from 7 to 10 days after hospitalization (development of multiple organ failure due to hypoxia and heart failure progression). The mortality rate of patients with ACP and COVID-19 was significantly higher than that of simultaneously hospitalized patients without comorbid respiratory infection (14.4% vs. 6.4%, p=0.012) and patients who were hospitalized before the pandemic (14.4% vs. 2.9%, p<0.001). Vaccinated patients were significantly less likely to develop acute kidney injury, acute hypoxic delirium, had higher average blood spO2, and less often required non-invasive ventilation. Only 1 vaccinated patient died from the development of cardiogenic shock against the background of anterior AMI and multivessel coronary artery disease (mortality – 15.7% in unvaccinated pts vs 5.0% in vaccinated, p=0.076). Co-infection with COVID-19 worsens treatment outcomes and in-hospital mortality of patients with ACP. Vaccination significantly reduces the likelihood of complications and tends to reduce mortality.

Low-dose dobutamine infusion and single-dose tocilizumab in acute myocardial infarction patients with high risk of cardiogenic shock development - rationale and design of the DOBERMANN trial

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Fonden Background Cardiogenic shock (CS) is seen in up to 10% of patients with ST-elevation myocardial infarction (STEMI) and is associated with a high mortality rate of up to 50%. Approximately 1/3 of STEMI-patients developing CS are not in overt shock at time of hospital admission but will develop hemodynamical instability within the following hours to days. Patients at risk of CS development may be clinically stable but with normal lactate levels (Society for Cardiovascular Angiography and Interventions classification, SCAI A/B). The Observatoire Régional Breton sur l'Infarctus (ORBI) clinical risk score has recently been developed and validated for predicting the risk of in-hospital (late) CS. STEMI-patients with an ORBI score >=10 have a risk of in-hospital CS development of more than 8-10%. NTproBNP is a biomarker released from the myocardium reflecting neurohormonal activation which is strongly correlated with hemodynamic parameters. Neurohormonal activation as well as a systemic inflammatory response are present acutely at hospital admission in STEMI patients developing late CS compared to non-CS patients suggesting an early subclinical hemodynamic deterioration. Dobutamine induces significant positive inotropic- and dose-dependent chronotropic effects and decreases afterload by peripheral vasodilatation, which increases cardiac output and organ perfusion. The interleukin-6 receptor antagonist Tocilizumab has been shown to reduce troponin leakage and increase myocardial salvage in acute MI patients. The effects of Dobutamine and Tocilizumab in a high-risk population have not previously been investigated. Methods DOBERMANN is an investigator-initiated, double blinded randomized clinical trial. Consecutive patients with acute MI admitted for acute coronary angiography and treated with percutaneous coronary intervention are screened with the ORBI risk score in the catheterization laboratory. One hundred adult patients presenting without CS at hospital admission with an intermediate-high risk of CS development (ORBI risk score of >=10) will be randomized 2x2 to receive a continuous intravenous infusion of dobutamine (5 micrograms/kg/minute, 24h) vs. placebo, and a single dose of Tocilizumab (280 mg, 1h) vs. placebo. NTproBNP as a proxy for development of CS and hemodynamic instability will be sampled for primary endpoint analysis. Effects on clinical parameters, mortality, morbidity as well as specific indicators of inflammation, cardiac function, and infarct size will secondarily be assessed noninvasively at 48h and at three months follow-up. Enrollment began in March 2022 and is commencing as planned. Discussion We hypothesize that inflammatory and neurohormonal responses are associated with subclinical hemodynamic instability in patients with AMI with intermediate/high risk of CS. The potentially unstable condition may be targeted pharmacologically as an add-on to existing therapy.

Abstract #1396724: Cryptic Catecholamines

The textbook presentation of a pheochromocytoma is the pentad of severe headache, palpitations, significant perspiration, hypertension (HTN), and pallor. However, many patients present with subclinical findings, adding to the challenge for physicians to make this diagnosis. The following case is unusual in the patient’s history of three procedures under general anesthesia, with one being an ablation in 2019. A review of previous CT images showed an adrenal adenoma from 2019. This demonstrates that pheochromocytomas may have biochemically silent periods further complicating the diagnosis and management of pheochromocytoma. 78-year-old female presents s/p elective ablation with atrial tachycardia. PMH is remarkable for T2D, HTN, hypothyroidism, CAD, and atrial fibrillation/AVNRT. In 2019 patient had the first ablation without any complications related to blood pressure fluctuations. Due to unknown reasons, the patient had persistent atypical atrial fibrillation with dyspnea, with a plan to redo ablation for worsening symptoms of shortness of breath. Then in 2022 patient underwent a second ablation and developed labile blood pressure with initial findings of 77/48 with signs of cardiogenic shock and subsequent pulmonary edema. Due to the patient’s presentation of hypovolemia secondary to the development of cardiogenic shock, the patient required vasopressors. The patient was started on a beta-blockade in response to vasopressor treatment, which caused her blood pressure to increase significantly, with systolic pressures ranging between 230-240. The metoprolol was stopped, and the patient was transitioned to doxazosin, due to high suspicion of a pheochromocytoma. Initial stabilization of BP was achieved after starting an alpha blockade. BP remained somewhat labile but continued a downward trend with doxazosin. CT was later ordered and appreciable for a left adrenal mass. Past imaging records showed the mass had been present since 2019. Metanephrine labs were collected and found to be 6332 pg/ml, confirming the diagnosis of a pheochromocytoma. The patient was further stabilized with doxazosin and adequate volume resuscitation then transitioned to metoprolol with tight control of blood pressure. Her hospital course proved to be difficult due to prior comorbidities and age, but she was ultimately stabilized and discharged after a three-week hospital stay. A vast majority of patients with AFib have chronic HTN. There are many different etiologies of secondary HTN, including a more uncommon cause, pheochromocytomas. Common subclinical symptoms are as follows: headache, palpitations, sweating, HTN, and anxiety, which are also common presentations of AFib. Long-term management for pheochromocytomas would improve significantly if screenings were done in a patient presenting with symptomatic Afib and history of HTN. Positive screening would initiate early treatment, consisting of a short alpha blockade followed by a chronic, low-dose beta blockade. In this patient, the pheochromocytoma might have contributed to the failure of ablation treatments and the persistence of atrial fibrillation.

НАРУШЕНИЯ СЕРДЕЧНОГО РИТМА И ПРОВОДИМОСТИ У МУЖЧИН МОЛОЖЕ 50 ЛЕТ С КАРДИОГЕННЫМ ШОКОМ ПРИ ИНФАРКТЕ МИОКАРДА

Relevance. Cardiogenic shock remains one of the most common causes of death in myocardial infarction. Aim. To evaluate the features of cardiac rhythm and conduction disturbances in myocardial infarction complicated by cardiogenic shock, as well as their significance for the development of this complication in males under 50 years old to improve prevention and outcomes. Material and methods. The study included males aged 19-49 years old with type I myocardial infarction. The patients were divided into age- comparable groups. The study group consisted of seven patients with cardiogenic shock, the control group - without cardiogenic shock - 223 patients. A comparative analysis of arrhythmias among the variants of the clinical course, complications, as well as their structure in selected groups were performed. The influence of the studied parameters on the risk of cardiogenic shock development in the examined patients was assessed by the method of risk analysis using the Pearson Chi-square test. Results. In the study group, a higher incidence of arrhythmias in the structure of MI complications (85.7%) was revealed than in the control group (24.2%; p=0.003). They were observed in combination with complications of the group of contractile myocardial insufficiency and its mechanical failure (57.1% and 6.3%, respectively; р˂0.0001) and only contractile insufficiency (28.6% and 11.2%; р˂0,0001). In the structure of arrhythmias in the study group, the frequency of observation of atrial fibrillation and flutter (66.7%) prevailed over the control group (4.9%; р˂0.0001), ventricular fibrillation (50.0 and 2.4%, respectively; р˂ 0.0001), supraventricular tachycardias (33.3% and 1.5%; р˂0.0001), supraventricular (33.3% and 8.3%; р=0.03) and polytopic extrasystoles (33.3% and 3 .9%; p=0.0003), ventricular tachycardias (16.7% and 2.0%; p=0.02), complete atrioventricular blockades (16.7% and 2.0%; p=0.02) and asystole (16.7% and 1.5%; p=0.007). The risk of cardiogenic shock development increased with these arrhythmias. Conclusions. The listed types of arrhythmias should be used in the formation of high-risk groups for the cardiogenic shock development in myocardial infarction for monitoring and timely implementation of the necessary treatment. It is also expedient to take them in the prognostic modeling of this complication.

A Retrospective Review of Cardiogenic Shock Development in Patients With ST-Elevation Myocardial Infarction and Percutaneous Coronary Intervention Receiving Early Beta-Blockers.

Beta-blockers (BBs) have proven to improve morbidity and mortality in patients after an ST elevation myocardial infarction (STEMI). Guidelines suggest initiating a BB within 24 hours, except in those with risk factors for developing cardiogenic shock, although published literature is conflicting regarding the true association of these risk factors with shock. This retrospective cohort study aimed to assess whether the presence of defined risk factors was associated with cardiogenic shock after early BB administration in patients with a STEMI and percutaneous coronary intervention. The primary outcome determined the rate of cardiogenic shock development and secondarily determined any characteristics associated with cardiogenic shock in patients who received beta blockers. The population included 299 patients and cardiogenic shock occurred in 8 patients (2.7%). There were no median (interquartile range) differences in age [63 years (60-71) versus 62 years (52-71); P = 0.4965], systolic blood pressure [110 mm Hg (105-115) versus 109 mm Hg (103-114); P = 0.6027], or heart rate [90 (78-104) versus 76 (64-90); P = 0.0697] before BB administration in patients who developed shock versus those who did not, respectively. Hours to BB administration from arrival [15.6 (6.0-54.8) versus 21.9 (10.6-42; P = 0.6968] and the number (%) with anterior infarction [3 (37.5%) versus 107 (36.8%); P = 1.000] were similar between groups. There was a statistically significant higher median (interquartile range) peak troponin [140 ng/mL (54-304) versus 49 ng/mL (16-132); P = 0.0354] in patients who developed shock. Early initiation of a BB in patients with STEMI and percutaneous coronary intervention with risk factors for cardiogenic shock does not seem to be associated with shock in most patients.

Analysis of in-hospital complications in patients with acute cardiovascular pathology and co-infection with COVID-19: a registry of one center

The aim – to analyze in-hospital mortality in pts with acute cardiovascular pathology (ACP) and a co-infection with COVID-19.Materials and methods. 139 pts with ACP who were diagnosed with COVID-19 were examined. 69 (49.6 %) pts had ACS (47 pts with AMI), 33 (23.7 %) pts – hypertensive urgency, 24 (17.3 %) pts – ADHF, 9 (6.5 %) pts – tachysystolic paroxysm of atrial fibrillation, 2 (1.4 %) pts – acute pulmonary embolism, and 2 (1.4 %) pts – syncope. The average age was 67.9±12.7 y.o., 70 (50.4 %) pts were male. Concomitant arterial hypertension was found in 87.1 %, DM – 20.9 %, CHF – 30.9 %, COPD – 9.4 % of pts, history of AMI – 20.1 % and ischemic stroke – 9.4 % of pts. In 79 (56.8 %) pts COVID-19 was diagnosed and laboratory confirmed before hospitalization (hospitalized in 5.3±3.6 days after symptoms onset). 31 (22.3 %) pts were diagnosed with COVID-19 upon admission, and 29 (20.9 %) – during their stay in the hospital. 20 (15.6 %) pts were vaccinated against COVID-19. The initial SpO2 level was 91.6±10.3 %, while more than half of pts (53.2 %) had SpO2 < 95 % and almost every fourth (23.2 %) patient had SpO2 < 90 %.Results and discussion. During the hospital period, 20 (14.4 %) pts died. The mortality rate was 28.0 % in pts with ADHF, 19.1 % in pts with AMI and significantly less in pts hospitalized for unstable angina, hypertensive urgency or atrial fibrillation – 5.2 % (p<0.05 in comparison with pts with AMI or ADHF). The main cause of death was the development of cardiopulmonary failure – 14 (70.0 %) pts. 4 (20.0 %) pts died from AMI complications, 1 – from pulmonary embolism and 1 – from acute ischemic stroke. Two critical periods of in-hospital mortality can be distinguished: 1 – the first two days of hospitalization (mainly complications of acute cardiovascular pathology and thrombotic events); 2 – from 7 to 10 days after hospitalization (development of multiple organ failure due to hypoxia and heart failure progression). The mortality rate of patients with ACP and COVID-19 was significantly higher than that of simultaneously hospitalized patients without comorbid respiratory infection (14.4 % vs. 6.4 %, p=0.012) and patients who were hospitalized before the pandemic (14.4 % vs. 2.9 %, p<0.001). Vaccinated patients were significantly less likely to develop acute kidney injury, acute hypoxic delirium, had higher average blood SpO2, and less often required non-invasive ventilation. Only 1 vaccinated patient died from the development of cardiogenic shock against the background of anterior AMI and multivessel coronary artery disease (mortality – 15.7 % in unvaccinated pts vs 5.0 % in vaccinated, p=0.076).Conclusions. Co-infection with COVID-19 worsens treatment outcomes and in-hospital mortality of patients with ACP. Vaccination significantly reduces the likelihood of complications and tends to reduce mortality.

ОСОБЕННОСТИ КЛИНИЧЕСКОГО ТЕЧЕНИЯ ОСЛОЖНЕННОГО КАРДИОГЕННЫМ ШОКОМ ИНФАРКТА МИОКАРДА У МУЖЧИН МОЛОЖЕ 50 ЛЕТ

Relevance. Cardiogenic shock remains the most common cause of death in myocardial infarction. Aim. To evaluate the myocardial infarction complicated by cardiogenic shock clinical course features in males under 50 years old (y.o.) to clarify their significance for the development of this complication to improve prevention and outcomes. Material and methods. The study included males aged 19-49 y.o. with type I myocardial infarction. The patients were divided into age-matched groups. The study group consisted of seven patients with cardiogenic shock, the control group - without cardiogenic shock - 223 patients. Comparative analysis of the clinical course variants, complications in selected groups was performed. The influence of the studied parameters on the probability of cardiogenic shock development in the examined patients was assessed by the method of risk analysis using the Pearson Chi-square test. Results. In the study group, there was a predominance of kidney dysfunction (100 in the study group and 10.3% in the control group; p=0.004), chronic heart failure in history less than one year old (50.0 and 15.3%, respectively; p=0, 04), non-anginal variants (abdominal (16.7 and 1.5%; p = 0.0497), arrhythmic (16.7 and 2.5% p = 0.0497) and according to the type of increase in heart failure (16.7 and 1.5%; p=0.0497)) of the clinical course of myocardial infarction, the presence of two or more complications (100 and 38.1%; p=0.005) and combinations of all groups of myocardial lesions (57.1 and 6.3% ; р˂0.0001). The risk of developing cardiogenic shock increased in addition to the above situations with diastolic blood pressure ˂70 mm Hg (Absolute risk: 18.8%; relative: 13.3; p˂0.0001), systolic˂110 mmHg (14.3%; 9.9, respectively; p=0.0004), total peripheral resistance (37.5%; 35.8; p˂0.0001). Conclusions. These factors should be used in the formation of high-risk groups for the cardiogenic shock in myocardial infarction development for monitoring and timely implementation of the necessary treatment. It is also expedient to take them into account in the prognostic modeling of this complication.

Analysis of results from intra-aortic balloon pump counterpulsation in patients with myocardial infarction and cardiogenic shock

Aim. To build a clinical and instrumental profile of patients with myocardial infarction (MI) complicated by the development of cardiogenic shock (CS) who underwent intra-aortic balloon pump (IABP) counterpulsation and evaluate the results of this treatment.Material and Methods. The single-center observational registry study comprised patients with admitting diagnosis of MI complicated by CS who were admitted to Cardiology Research Institute of Tomsk NIMC from 01.01.2020 to 12.31.2021. All patients received emergency IABP at admission, and reperfusion of infarct-related artery was achieved. According to these criteria, a total of 23 patients were included in the analysis.Results. The average age of patients was 79 years. There were comparable numbers of men and women in study group. Vast majority of patients (78.2%) had postinfarction cardiosclerosis; 86.9% of patients had hypertension; third of patients had diabetes mellitus; and almost half of patients were obese. Most of these patients (73.9%) had MI with ST segment elevation; the rest of patients had MI without ST segment elevation. 60.9% of patients had anterior wall MI, and the rest of patients had inferior wall MI. The pain-to-door time was 223 minutes on average. Thrombolysis was performed in 9 cases (39%) at the prehospital stage with an efficiency of 55%. The majority of patients (n = 22) underwent coronary stenting of infarct-related artery. The duration of IABP was 52.5 hours an average, and the mortality rate was 69.5%. All fatal outcomes occurred as a result of CS progression. There were no statistically significant differences in the main clinical and anamnestic characteristics between the groups with the administration of IABP before and after PCI, although the patients in the group of IABP before PCI were younger, had a lower level of troponin at admission, more often achieved coronary reperfusion TIMI-2-3 at PCI, and had lower mortality.Conclusion. The frequency of IABP administration to patients with MI and CS in our department was 8%. The mortality rate among patients who underwent IABP insertion reached 69.5%, which was not lower than the corresponding rate in the general group of CS (55%). The combination of IABP installation before PCI in the presence of achieved coronary reperfusion (spontaneous or due to thrombolysis) was associated with a tendency to decrease in mortality compared with the installation of IABP after PCI.

Clinical manifestations of cardiovascular disease in children as a sequela of coronavirus disease (COVID-19) (a clinical case)

The aim of the work: to provide medical practitioners with a clinical case of cardiovascular affection with ST-segment elevation in a child as a result of coronavirus disease (COVID-19). Materials and methods. Here is a clinical case of our own observation of the clinical course of post-COVID cardiovascular system involvement with ST-segment elevation in the child who was treated at the City Children’s Hospital No. 5 of Zaporizhzhia City Council. Results. The patient with severe post-COVID cardiovascular implication, COVID in anamnesis confirmed by COVID-19 IgG positivity with negative IgM and PCR test results. The following laboratory findings were also detected when the child was admitted to the hospital: Troponin I was 136 ƞg /ml (referent value – less than 0.32 ƞg/ml), Lactate Dehydrogenase – 4199 U/l (referent value – 110–295), Creatine Phosphokinase-MB – 25.4 U/l (referent value – 0–24), CRP was increased to 6.2 mg/l, D-dimer – to 3221.12 ng/mL (referent value – less than 500 ng/mL). ECG showed QS-waves in leads V3–V6, I, 2.0–2.5 mm ST-segment elevation in leads V4–V6, and Р-mitrale. The clinical course was characterized by cardiogenic shock development. During intensive care, there was moderate positive clinical and laboratory dynamics. Peculiarities of post-COVID myocarditis in children were characterized based on the comparative analysis of this clinical case and results of relevant clinical studies, world recommendations and guidelines. Conclusions. Peculiarity of the case is severe post-COVID syndrome after almost asymptomatic COVID-19. Physicians should be aware after coronavirus disease while providing a close follow-up for six months. Myocardial ischemia is among casuistic post-COVID manifestations in children. The basic treatment is a complex therapy of heart failure, anticoagulant and antiplatelet therapy, as well as corticosteroids administration, which is pathogenetically justified and leads to regression of major clinical and laboratory symptoms.

Readmission in Patients With ST-Elevation Myocardial Infarction in 4 Age Groups (45 to

The incidence of ST-elevation myocardial infarction (STEMI) among younger adults is increasing due to an increased prevalence of cardiometabolic risk factors. Readmissions after STEMI in young patients could lead to substantial health care costs and a significant burden on health care resources. Although STEMI readmissions are well studied in elderly patients, limited data are available regarding readmissions after STEMI in young patients and the etiologies remain poorly understood. Because younger patients with STEMI have different sociodemographic profiles th;an older patients with STEMI, one would postulate that the risk factors for readmissions in young patients would differ from that reported in the older patients with STEMI. We performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database to identify patterns of readmissions after STEMI in the young adult population. Our analysis of the Nationwide Readmissions Database revealed a total of 243,747 hospitalizations for STEMI between 2016 and 2017. Readmission rates demonstrated a steady increase from discharge, increasing to 7.8% at 30 days and 10.3% at 60 days before relatively plateauing at 12.1% at 90 days. Cardiovascular etiologies were the most common cause of readmission (53.6%). After multivariable analysis, development of cardiogenic shock (adjusted odds ratio 1.48, 95% confidence interval 1.11 to 1.97; p = 0.008) and acute renal failure (adjusted odds ratio 1.46, 95% confidence interval 1.14 to 1.87; p = 0.003) during the index admission were associated with significantly higher rates of readmission. In conclusion, close monitoring in young patients who presented with STEMI and concomitant with cardiogenic shock or acute renal failure, and possibly, aggressive therapy during index admission may be needed. However, this population may be heterogeneous and further research is needed.

COVID-19-Associated Biventricular Takotsubo Syndrome Complicated with Cardiogenic Shock (Clinical Case)

Acute myocardial dysfunction (AMD) remains prominent among extrapulmonary manifestations of COVID-19. Takotsubo syndrome (TS) is one of the causes of AMD development. TS incidence in patients with COVID-19 is currently unknown. The report presents a clinical case of an elderly female patient on maintenance hemodialysis with severe COVID-19. During the session of therapeutic plasma exchange (TPE), the patient had an episode of ventricular fibrillation followed by cardiogenic shock development and ECG changes, similar to myocardial infarction. Echocardiographic (Echo) data showed a distinctive pattern of biventricular TS with a significant systolic function decrease in both ventricles. Emergency CT angiography ruled out obstructive lesions of coronary arteries. Full recovery of both ventricles systolic function, regression of ECG changes, and complete resolution of cardiogenic shock were observed within the next week. The subsequent course of the disease was complicated by sepsis and multiple organ failure which determined the lethal outcome.The autopsy findings excluded coronarogenic and viral myocardial damage. The presented case demonstrates a life-threatening TS pattern in patients with severe COVID-19. TPE procedure should be treated as a possible trigger of TS.