Cardiac In-hospital Mortality Research Articles

Modeling creatine-kinase MB concentrations following coronary artery bypass grafting

An increase in cardiac biomarkers is a prerequisite to diagnose periprocedural myocardial infarction (PMI) after coronary artery bypass grafting (CABG). Early-phase risk detection may be aided by modeling time-dependent serum creatine kinase-MB (CK-MB) concentrations. This study aimed to model the kinetics of CK-MB, while identifying its influencing factors. Patients who underwent elective CABG and had CK-MB measurements within 72 hours postoperatively were included. The primary outcome was the modeled post-hoc kinetics of CK-MB in patients without potential PMI. These patients were defined as having no potential PMI in case of absence of: ischemic electrocardiographic abnormalities, imaging abnormalities, in-hospital cardiac arrest, mortality, or postoperative unplanned catheterization. A web-based application was created using mixed-effect modeling to provide an interactive and individualized result. 635 patients underwent elective isolated CABG, resulting in 1589 CK-MB measurements. Of these, 609 patients (96%) had no potential PMI, while 26 (4%) had potential PMI. Male sex, aortic cross-clamp time, and cardioplegia type significantly impacted CK-MB concentrations. The diagnostic accuracy of the model had an area under the ROC curve of 82.8% (72.6-90.2%). A threshold of 7 μg/L yielded a sensitivity of 94% and a specificity of 80% (positive predictive value, 17%; negative predictive value, 99%) for excluding potential PMI in our own study population. CK-MB release after CABG depends on the timing of measurement, sex, aortic cross-clamp time, and cardioplegia type. The model at https://www.cardiomarker.com/ckmb can be validated, reproduced, refined, and applied to other biomarkers.

Gender differences in presentation, management, and outcomes among Egyptian patients with acute coronary syndrome: a single-centre registry

BackgroundDespite a significant rise in cardiovascular disease (CVD)-related mortality in low- and middle-income countries (LMICs), data are scarce regarding the quality of care provided, particularly for women.MethodsThis is a prospective observational, cross-sectional study. Acute coronary syndrome (ACS) patients presented to the Cardiology Department at Tanta University, Egypt, between September 1, 2023, and December 31, 2023, were enrolled. The study assessed gender disparities by comparing men and women regarding presentation, management, and major adverse cardiovascular events (MACE) occurrence during hospitalization and 30 days after discharge.ResultsA total of 400 ACS patients were included, with 29.5% being women. Women were comparatively older (59 ± 9 years vs. 55 ± 13 years), with a significantly higher prevalence of hypertension (70.3% vs. 47.5%) and diabetes (55% vs. 36.8%). Non-ST-segment elevation myocardial infarction (Non-STEMI) was more common in women (35.29% vs. 21%). Dyspnea was expressed by 34.4% of women (vs. 21.35% of men). Women were hospitalized later (9.29 h vs. 6.74 h). In-hospital outcomes were poorer for women with worse NYHA classes III and IV. Additionally, the odds ratio (OR) for in-hospital cardiac mortality was 0.303 (95% CI 0.103–0.893) for women compared to men. However, a one-month follow-up for MACE post-hospital discharge did not indicate significant gender differences.ConclusionsThe current study suggests that women with ACS in Egypt exhibit a higher risk profile for CVD compared to men and tend to present later with atypical symptoms. Women additionally experience poorer in-hospital MACE and higher cardiac mortality. Therefore, increasing awareness about ACS syndrome and eliminating obstacles that delay hospital admission are imperative.

Full-Moon Coronary Calcification as Detected With Computed Tomography Angiography in Chronic Total Occlusion Percutaneous Coronary Intervention

"Full moon" is a central calcification that occludes the entire vessel on coronary computed tomography angiography (CCTA). We examined the association of “full moon” calcification as identified by CCTA, on clinical and procedural outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We studied patients who underwent elective CTO PCI in two European centers and had pre-procedural CCTA. The primary endpoint was the inability to cross the lesion and/or the need for extensive debulking techniques. Secondary endpoints were procedural success, in-hospital cardiac mortality, the need for extensive debulking techniques, myocardial infarction (MI), major adverse cardiac events (MACE, defined as in hospital death, MI and clinically driven target vessel revascularization) and stent thrombosis. Secondary procedural endpoints included procedural time, fluoroscopy time, number of guidewires and balloons, stent length, number and diameter and contrast volume. Multivariable logistic regression analysis was performed identifying potential covariates related to the primary outcome according to knowledge and prior studies. Subsequently, a stepwise selection approach was performed to select factors with the greatest predictive value. Among 140 patients included, 28 (20%) had a “full moon” calcified CTO-plaque. Patients in the full moon group were older and had more cardiovascular risk factors. There was not significant difference in the need for retrograde approach and antegrade dissection and re-entry (ADR) techniques in the “full moon” group vs the other groups (32.1% vs 37.5%, p=0.59 and 0% vs 1.7%, p=0.47 respectively). Compared with patients who did not have full moon morphology, full moon patients had higher incidence of the primary outcome (53.5% vs 12.5%;p<0.001). On multivariable analysis that included chronic kidney failure and prior coronary artery bypass surgery, full moon calcification was associated with higher incidence of the primary endpoint; OR 6.5;95% CI 2.1-20.5;p=0.001). Moreover, lower procedural success (71.4% vs 87.5%;p=0.03), higher incidence of coronary perforations (14.2% vs 3.5%;p<0.02) and higher procedural [172.5 (118.0-237.5) vs 144.0 (108.50-174.75); p=0.02] and fluoroscopic time [62.6 (38.1-83.0) vs 42.8 (29.5-65.7); p=0.03] were observed in the “full moon” group. Overall MACE did not differ between the two groups (1 patient in the “full moon” group vs 1 patient in the no “full moon” group; 3.5% vs 0.8%, p=0.29). In conclusion, “full moon” calcification on CCTA was independently associated with procedural complexity and adverse outcomes in CTO-PCI.

Rate-Pressure Product is a Novel Predictor for Short- and Long-Term Mortality in Patients with Acute Coronary Syndrome Undergoing Primary PCI/Immediate Invasive Strategy.

Rate-pressure product (RPP) calculated by multiplying heart rate by systolic blood pressure, is a convenient indicator closely associated with cardiac work or myocardial oxygen consumption. It has been reported to relate strongly to important indices of cardiovascular risk in patients with myocardial ischemia. However, its relationship with short- and long-term mortality in patients with acute coronary syndrome (ACS) undergoing primary PCI/immediate invasive strategy has not been defined. This study analyzed 1301 consecutive ACS patients who had undergone primary PCI, between January 2018 and September 2021. Patients with systolic BP < 90 mmHg were excluded to avoid the confounding effect of cardiogenic shock. RPP values were collected on admission and were divided into four groups: RPP ≤ 7.4, 7.4 ≤ 8.8, 8.8 <8.8 < RPP8, and RPP > 10.8. Clinical endpoints were in-hospital cardiac and long-term all-cause mortality. The predictive performance was assessed by C-statistic, multivariate analysis and survival analysis. Multivariate analysis showed that these in the highest vs lowest category of RPP (>10.8 vs ≤7.4) had OR of 4.33 (95% CI=1.10 -17.01; P = 0.036) in in-hospital cardiac mortality and 3.15 (95% CI=1.24 -8.00; P = 0.016) in long-term all-cause mortality. In C-statistic analyses, RPP was a strong predictor in ACS, STEMI or UA/NSTEMI group for in-hospital cardiac mortality (AUC = 0.746, 95% CI = 0.722-0.770, p < 0.001) and long-term all-cause mortality (AUC = 0.701, 95% CI = 0.675-0.725, p < 0.001). The Kaplan-Meier event rate for long-term survival of RPP > 10.8 was significantly lower than that of RPP ≤ 10.8. RPP showed a positive association with in-hospital cardiac or long-term all-cause mortality in ACS patients undergoing primary PCI/immediate invasive strategy, and RPP > 10.8 can be as an independent predictor.

Abstract 310: Impact of "Cognitive Aids" on Responder Performance During Pediatric Code Blue Simulations - Results From Performance Improvement Project at a Tertiary Care Center in Saudi Arabia

Introduction: Despite advances such as high-fidelity code blue simulations, pediatric In-Hospital Cardiac Arrest mortality rate has plateaued at 62% in the USA. It is expected to be higher in low-income countries. Studies show deviations from the PALS guidelines despite regular PALS training due to skills and knowledge decay. Use of simple, easily accessible resources as “Cognitive Aids”, that decrease reliance on memory during stressful events, however, has not been studied well. Aim: To evaluate impact of cognitive aids on resuscitative capabilities of code-blue responders during simulations. Method: Performance Improvement (PI) project by Pediatrics Department at King Faisal Specialist Hospital and Research Centre, Madinah, Saudi Arabia. Simulations were run by Consultant, Pediatric Intensivist and PICU nurse on regular pediatric floors. A performance assessment checklist and a scoring tool were designed to evaluate team members for responsiveness, effective resuscitation, effective communication and resource utilization. Results: A total of 94 responders participated multiple times in 35 simulations that were conducted in two phases: Codes 1 - 19 as the Pre-PI phase and Codes 20 - 35 as Post-PI phase. Cognitive aids were not utilized during the Pre-PI codes and based on the assessment scores, interventions were introduced in the form of A3 size PALS resuscitation cards, “Pediatric Cardiac Arrest Resuscitation Direction” document with prompts to facilitate smooth running of the code and SBAR notes. Based on the scores, improvement was observed in responsiveness by 27% (Pre-PI:192/262 vs. Post-PI:222/223), effective resuscitation by 38% (Pre-PI:293/511 vs. Post-PI:409/431), effective communication by 46% (Pre-PI:94/245 vs. Post-PI:173/207) and resource utilization by 56% (PrePI:37/94 vs. Post-PI:76/80). Total of 36 (38%) responders participated in actual pediatric cardiac arrests after project completion and 97% (35/36) reported higher confidence. Conclusion: Cognitive aids were helpful supportive tools in overcoming skills and knowledge decay and enhance team performance and quality of resuscitation during code blue simulations. We suggest use of such tools wherever high-fidelity simulation training may not be available.

Mortality of in-hospital cardiac arrest among patients with and without preceding sepsis: A national inpatient sample analysis

IntroductionThe impact of preceding sepsis on in-hospital cardiac arrest (IHCA)-related mortality has not been established. This study aimed to determine the association between IHCA-related mortality and sepsis. MethodsThis retrospective study used the National Inpatient Sample data from 01/2017 to 12/2019. The study included adults (≥18 years) who suffered from IHCA. The study classified cardiac arrest rhythms as ventricular tachycardia/ventricular fibrillation or pulseless electronic activity/asystole. We compared the IHCA-related in-hospital mortality between sepsis and non-sepsis groups in all patients and subgroups divided by cardiac arrest rhythm and age. Multivariable logistic regression analysis was performed to assess the independent association between sepsis and in-hospital mortality. ResultsA total of 357,850 hospitalizations who suffered from IHCA were identified, with sepsis present in 17.6% of patients. IHCA-related in-hospital mortality was 84.8% in sepsis and 68.4% in non-sepsis-related hospitalizations (p < 0.001). IHCA-related in-hospital mortality was higher in sepsis than in non-sepsis groups, regardless of age or cardiac arrest rhythms. In multivariable logistic regression analysis, sepsis was significantly associated with higher mortality with an odds ratio of 2.27 (95% confidence interval: 2.07–2.50, p < 0.001). ConclusionSepsis was associated with higher in-hospital cardiac arrest mortality compared to non-sepsis cases, regardless of age and cardiac rhythm.

Peri-Intubation Arrest in High Risk vs. Standard Risk Pediatric Trauma Patients Undergoing Endotracheal Intubation

Background: While the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients.Methods: This was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post–return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10 minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success.Results: One third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1–46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8–59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4–46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5–30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3–70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0–523.8).Conclusions: The presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.

Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit

Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population. To investigate incidence, trends, and factors associated with IHCA and mortality in children with cardiac disease in the ICU. A systematic review was conducted using PubMed, Web of Science, EMBASE, and CINAHL, from inception to September 2021. Observational studies on IHCA in pediatric ICU patients with cardiac disease were selected (age cutoffs in studies varied from age ≤18 y to age ≤21 y). Quality of studies was assessed using the National Institutes of Health Quality Assessment Tools. Data on incidence, mortality, and factors associated with IHCA or mortality were extracted by 2 independent observers. Random-effects meta-analysis was used to compute pooled proportions and pooled ORs. Metaregression, adjusted for type of study and diagnostic category, was used to evaluate trends in incidence and mortality. Primary outcomes were incidence of IHCA and in-hospital mortality. Secondary outcomes were proportions of patients who underwent extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) and those who did not achieve return of spontaneous circulation (ROSC). Of the 2574 studies identified, 25 were included in the systematic review (131 724 patients) and 18 in the meta-analysis. Five percent (95% CI, 4%-6%) of children with cardiac disease in the ICU experienced IHCA. The pooled in-hospital mortality among children who experienced IHCA was 51% (95% CI, 42%-59%). Thirty-nine percent (95% CI, 29%-51%) did not achieve ROSC; in centers with ECMO, 22% (95% CI, 14%-33%) underwent ECPR, whereas 22% (95% CI, 12%-38%) were unable to be resuscitated. Both incidence of IHCA and associated in-hospital mortality decreased significantly in the last 20 years (both P for trend < .001), whereas the proportion of patients not achieving ROSC did not significantly change (P for trend = .90). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, prearrest mechanical ventilation or ECMO, and higher surgical complexity were associated with increased incidence of IHCA and mortality odds. This systematic review and meta-analysis found that 5% of children with cardiac disease in the ICU experienced IHCA. Decreasing trends in IHCA incidence and mortality suggest that education on preventive interventions, use of ECMO, and post-arrest care may have been effective; however, there remains a crucial need for developing resuscitation strategies specific to children with cardiac disease.

1169: THE EPIDEMIOLOGY AND OUTCOMES OF NEONATAL IN-HOSPITAL CARDIAC ARREST IN THE US DURING 2000-2019

Introduction: The primary objective was to evaluate the trend in the prevalence of in-hospital cardiac arrest (IHCA) and mortality among neonates in the U.S. between 2000 and 2019 using the Kids’ Inpatient Database (KID). Our secondary objective was to assess the influence of gestational age (GA). Methods: Neonates (< 29 days at the time of admission) in KID databases published in 2000, 2003, 2006, 2009, 2012, 2016, and 2019 were included in the study. Neonates who were transferred to another acute care hospital were excluded. IHCA was identified by ICD-9 or ICD-10 procedure codes for cardiopulmonary resuscitation. GA was grouped into extreme prematurity (EP; < 29 weeks), prematurity (P; 29-36 weeks), and term (T; >36 weeks). All analyses involving GA included neonates from 2003-2019. Linear trends were analyzed using the Extended Mantel-Haenszel test. The prevalence in each calendar year was adjusted for GA using binary regression analysis. For the national prevalence of IHCA, total yearly births in the U.S. were used. Results: The overall IHCA prevalence was 7.8 per 10,000 discharges and 6.62 per 10,000 live births in the U.S. The trend increased from 2000 to 2019 (p< 0.001). Most IHCA (72%) occurred on the day of admission. IHCA was more common in Black male infants, lower GA, urban teaching, and children’s hospitals (p< 0.05). Necrotizing enterocolitis and intraventricular hemorrhage were more often associated with IHCA (p< 0.001). The overall mortality rate for IHCA was 43.5%, and mortality increased from 34.7% in 2000 to 48% in 2019 (p< 0.001). In neonates with IHCA, extreme prematurity was present at 11% in 2003 and increased to 18.8% in 2019 (p< 0.001). The mortality rates for EP, P, and T neonates with IHCA were 72.8%, 39.6%, and 29.8%, respectively (p< 0.001). After adjusting for GA, the prevalence of IHCA was significantly higher from 2012 onwards (p< 0.05), and the mortality rate was higher in 2019 compared to 2003 (p=0.005). Conclusions: The prevalence of IHCA and associated mortality rate increased from 2000 to 2019 in neonates in the U.S. The increased prevalence of lower GA babies in IHCA may account for the increased mortality trend. A majority of IHCA occurring on the day of admission provides an opportunity for improvement in healthcare services in the delivery room.

Abstract 06: Feasibility Of Accelerated Code Team Activation With Code Button Triggered Smartphone Notifications

Introduction: In-hospital cardiac arrest mortality has improved only modestly in the past decade. Prior studies support the role of earlier defibrillation and epinephrine administration to improve outcomes. Timely code team activation facilitates expedient interventions and may provide an opportunity for quality improvement. We sought to accelerate the time to code team activation and increase the early distribution of patient-specific data to improve targeted treatments. Methods: We mapped code blue buttons present behind each patient bed to patient data through the Electronic Health Record. Use of the code blue button sent patient-specific data including admitting diagnosis, recent procedural history, presence of difficult airway, and most recent potassium, bicarbonate, troponin, and hemoglobin levels through a secure text messaging system to the code blue teams’ smartphones. Simultaneously, the code blue button contacted the hospital operator who activated the code blue team through traditional methods including overhead page and pager alerts. We piloted the system on four medicine inpatient units from November 2019 through May 2022. In our analysis, we evaluated the time from code blue button press to smartphone message receipt vs overhead page, time to epinephrine administration, and survival to hospital discharge. Results: There were 35 cardiac arrest events on the participating hospital units. The code blue button was the primary mode of code team activation for 12/35 (34.3%) of the events. The code team received smartphone notifications a median of 78 seconds (IQR = 47-127 seconds) before traditional notifications. The initial rhythm was non-shockable for 34/35 (97.1%) of the patients. The median time to documented epinephrine administration for codes activated with or without the code button was 2:57 and 4:00 (IQR = 0:34-6:07 vs. 2:07-4:30; p = 0.89). Survival to hospital discharge was 3/12 (25.0%) for codes activated with the code button and 4/23 (17.4%) when activated by other methods (p = 0.61). Conclusion: Implementation of a smartphone-based code button activated notification system reduced the time to code team activation by over one minute. Further evaluation in larger cohorts is necessary to assess the effect on patient outcomes.

Ethnic disparities in ST-segment myocardial infarction outcomes and processes of care in patients with and without standard modifiable cardiovascular risk factors: a nationwide cohort study

Abstract Background There is growing interest in patients presenting with ST-elevation myocardial infarction (STEMI) in the absence of `standard modifiable cardiovascular risk factors' (SMuRFs), which include current smoking, hypertension, diabetes and hypercholesterolaemia. Recent trials have demonstrated how these “SMuRFless” patients can have poorer outcomes after STEMI then those patients with SMuRFs, but these trials have not looked at the role of ethnicity in outcomes (1). Methods We analysed 118,177 STEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed using hierarchical logistic regression models according to the presence of ≥1 SMuRF (88,055) and compared to the “SMuRFless” cohort (30,122), with a subgroup analysis comparing the outcomes of white and ethnic minority patients (comprising Black, Asian, Mixed and other) depending on SMuRF status. Our primary outcomes were in-hospital mortality and major adverse cardiovascular events (MACE), and secondary outcomes were in-hospital cardiac mortality and major bleeding. Results SMuRFless patients had a higher incidence of MACE (OR 1.09, CI 1.02–1.16), in-hospital mortality (OR 1.09, CI 1.01–1.18), and cardiac-mortality (OR 1.08, CI 1.00–1.17) than those with SMuRFs after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. There were no statistically significant differences in our outcome measures between white and ethnic minority patients. Ethnic minority patients were more likely to undergo revascularisation by PCI or CABG (ethnic minority with SMuRFs 88%, ethnic minority SMuRFless 87%, white with SMuRFs 80%, white SMuRFless 77%). Conclusion SMuRFless patients have a higher incidence of MACE, in-hospital mortality, and cardiac-mortality than those with SMuRFs, which persists after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status but did not have poorer outcomes when compared to white patients. Funding Acknowledgement Type of funding sources: None.

Higher serum phosphorus and calcium levels provide prognostic value in patients with acute myocardial infarction.

BackgroundAlthough traditional cardiovascular risk factors are closely related to the poor prognosis of acute myocardial infarction (AMI) patients, there are few studies on the relationship of serum phosphorus and calcium with prognosis in AMI patients. The relationship of serum phosphorus and calcium with prognostic biomarkers in AMI remains unclear.Methods and resultsA total of 3,891 AMI patients were enrolled from a prospective cohort study. We investigated the association of serum phosphorus and calcium with prognostic biomarkers. The risk of in-hospital heart failure (HF), post-discharge HF, all-cause mortality and cardiac mortality was estimated across quartiles of serum phosphorus and calcium levels. Serum phosphorus and calcium levels were associated with biomarkers of prognosis. Overall, 969 patients developed in-hospital HF during hospitalization, 549 patients developed post-discharge HF during a median follow-up of 12 months, and 252 patients died, with 170 cardiac deaths since admission. In the fully adjusted model, compared with patients in quartile 2 (Q2), patients with serum phosphorus levels in Q4 were at greater risk of post-discharge HF [sub-distributional hazard ratios (SHR) 1.55; 95% confidence interval (CI), 1.21–1.99], in-hospital HF [odds ratio (OR) 1.84; 95% CI, 1.47–2.31], all-cause mortality (HR 1.59; 95% CI, 1.08–2.32), and cardiac mortality (SHR 1.68; 95% CI, 1.03–2.75). Compared with patients in Q2, patients with corrected calcium levels in Q4 had a higher risk of in-hospital HF (OR 1.62; 95% CI, 1.29–2.04), all-cause mortality (HR 1.99; 95% CI, 1.37–2.88), and cardiac mortality (SHR 1.87; 95% CI, 1.19–2.96; all p-trend < 0.05).ConclusionSerum phosphorus and calcium levels were associated with AMI prognostic biomarkers in AMI. Higher serum phosphorus was independently related to the increased risk of in-hospital HF, postdischarge HF, all-cause mortality and cardiac mortality, and higher serum calcium was independently related to the increased risk of in-hospital HF, all-cause mortality and cardiac mortality after AMI.

Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study.

The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes. We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P < 0.001), male (62% vs. 61%, P < 0.001), and Caucasian (95% vs. 92%, P < 0.001). Those without SMuRFs less frequently received statins (71% vs. 81%, P < 0.001), had their left ventricular (LV) function recorded (62% vs. 65%, P < 0.001) or for those with moderate or severe LV systolic dysfunction were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (80% vs. 85%, P < 0.001). Following propensity score matching the odds of all-cause mortality [odds ratio (OR): 0.85, 95% confidence interval (CI): 0.77-0.93], cardiac mortality (OR: 0.85, 95% CI: 0.76-0.94), and major adverse cardiovascular events (MACE) (OR: 0.85, 95% CI: 0.77-0.93) were lower in patients without SMuRFs. More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.

Hyperoxia after pediatric cardiac arrest: Association with survival and neurological outcomes

ObjectiveTo evaluate the association between hyperoxia in the first 24 hours after in-hospital pediatric cardiac arrest and mortality and poor neurological outcome. MethodsThis is a retrospective cohort study of inpatients in a freestanding children’s hospital. We included all patients younger than 18 years of age with in-hospital cardiac arrest between December 2012 and December 2019, who achieved return of circulation (ROC) for longer than 20 minutes, survived at least 24 hours after cardiac arrest, and had documented PaO2 or SpO2 during the first 24 hours after ROC. Hyperoxia was defined as having at least one level of PaO2 above 200 mmHg in the first 24 hours after cardiac arrest. ResultsThere were 187 patients who met eligibility criteria, of whom 48% had hyperoxia during the first 24 hours after cardiac arrest. In-hospital mortality was 41%, with similar mortality between oxygenation groups (hyperoxia 45% vs no hyperoxia 38%). We did not observe an association between hyperoxia and in-hospital mortality or poor neurological outcome after adjusting for confounders (odds ratio 1.2, 95% confidence interval 0.5–2.8). On sensitivity analysis using two additional cutoffs of PaO2 (>150 mmHg and > 300 mmHg), there was also no association with in-hospital mortality or poor neurological outcome after adjusting for confounders. Similarly, on multivariable logistic regression using SpO2 > 99% as the exposure, there was no difference in the frequency of death or poor neurological outcome at hospital discharge. ConclusionHyperoxia after pediatric cardiac arrest was common and was not associated with worse in-hospital outcomes.

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

ObjectivesGender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI). Materials and MethodsWe analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03–6.03 years). ResultsThere were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p < 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p < 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders. ConclusionsFemales were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.

Myocardial infarction throughout 1 year of the COVID-19 pandemic: French nationwide study of hospitalization rates, prognosis and 90-day mortality rates

BackgroundStudies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 as a result of the coronavirus disease 2019 (COVID-19) crisis, mainly restricted to the beginning of the pandemic.AimsTo describe national trends in hospital admissions for MI in 2020, and to compare patient characteristics, in-hospital prognosis and 90-day mortality between patients who had an MI in 2020 and those admitted in 2017–2019.MethodsAll patients hospitalized for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Analyses compared temporal trends in MI admissions, in-hospital cardiac complications and mortality rates in 2020 versus 2017–2019.ResultsIn 2020, 94,747 patients were hospitalized for MI, corresponding to a 6% decrease in MI admissions compared with 2017–19. This decrease was larger during the first lockdown (–24%; P < 0.0001) than during the second lockdown (–8%; P < 0.0001). Reductions in MI admissions were more pronounced and longer among patients with non-ST-segment elevation MI, older people and women. An increase in ST-segment elevation MI admissions was observed between lockdowns (+4%; P = 0.0005). Globally, and after adjustment for age, sex and calendar year, in-hospital and 90-day post-discharge mortality rates did not differ in 2020 versus 2017–19: incidence rate ratio (IRR)adjin-hospital 1.03, 95% confidence interval (CI) (0.98–1.08); IRRadj90-daypost-discharge 1.06, 95% CI (0.98–1.13).ConclusionsIn 2020, a significant decrease in MI admissions was observed, and was marked at the beginning of the year. This highlights the need to disseminate public information on the importance of maintaining care and regular medical follow-up. The effect of the COVID-19 crisis on acute and 3-month outcomes of patients hospitalized for MI appears limited. Nevertheless, monitoring of chronic MI complications and the impact on non-hospitalized patients should continue.

The incidence of postoperative cardiac arrest and pre-resuscitation factors associated with post- cardiopulmonary resuscitation mortality: a single-center study in Thailand

Background: The author aimed to determine the incidence of in-hospital postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR), postoperative CPR mortality and pre-resuscitation factors associated with post CPR mortality. Method: A retrospective cohort study was conducted at King Chulalongkorn Memorial Hospital in Thailand from September 2018 through August 2020. A total of 34,590 adult patients underwent surgical procedures under anesthesia were recruited by electronic data recorded review. A subset of patients with postoperative CPR was collected for demographic data, comorbidities, ASA classification, operative time, functional class, types of surgery, postoperative complications, the number of deaths and survival, and SOS score at 4 hours preceding cardiac arrest. Results: A total of 34,590 adult surgical patients were recruited. In-hospital postoperative cardiac arrest incidence was 12 patients per 10,000 surgeries and predominated in emergency operation (28 per 10,000 surgeries; P&lt; 0.0001). Risk ratio of emergency operation resulted in postoperative CPR was 3.15 (95% CI 1.72-5.77; P&lt;0.001). Postoperative cardiac arrest patients aged 64.07 ± 16.58. The BMI was 23.46 ± 5.83. Mostly they were in ASA category 3 (44.2%). Everyone had general anesthetic procedures. The most common comorbidity was hypertension. In-hospital postoperative CPR mortality was 62.8%. Factors possibly predisposed to it were functional class &lt; 4 METS, colorectal surgery and SOS score at 4 hours prior to cardiac arrest of at least 8. Conclusion: Incidence of in-hospital postoperative cardiac arrest and mortality after CPR in the study tended to be lower than that of previous studies. Emergency operations predisposed to cardiac arrest. SOS score was possibly valuable as a prognostication tool, ICU triage, as well as, a part of the early warning score to prevent the overwhelming crisis. Surveillance for patient’s deterioration, effective rapid response system, and comprehensive preoperative rehabilitation should be emphasized.

Haematology department nurses training makes a positive shift in reduction of in-hospital cardiac mortality

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Due to general profile of emergency hospital it is lacking of regular specific training courses for nurses. Haematology department is the one that has a great number of complications after immunosuppressive and chemo-therapy that is why skills in acute cardiovascular care are crucial for haematology healthcare professionals. Training of basic skills of management of acute cardiac events for nurses that work with haematological patients should be considered as routine practice in order to improve patients’ care. Purpose Science is not a study, but an observation of what is around us, therefore we made a registry of acute cardiovascular events over the hospital departments and defined a need for acute cardiovascular training for nurses in haematology department. Methods Data analysis of 1 year observational study of acute cardiac events at emergency hospital was done. Nurses of haematology department were specifically instructed to provide first aid and contact internal medicine doctor on duty in case of signs of cardiovascular events in patients with acute lymphoblastic leukemia that were under 21-st day of chemotherapy due to high risk of thromboembolic complications. Among 573 cases, 110 cases were cardiovascular events diagnosed and managed at haematology department by emergency care multidisciplinary team of internal medicine doctor on duty and haematology nurses. For statistical analysis Microsoft Excel v.2019 was used. Results At haematology department of emergency hospital we detected 110 cases of cardiovascular events. Among them 50 cases of ST-elevation myocardial infarction (STEMI) treated in the first 10 minutes of the episode with successful outcome, 45 cases of ischemic stroke, only 5 of which were lethal due to severity of neurologic disorders, 15 cases of pulmonary embolism with successful outcome. Conclusion Training on acute cardiovascular care for haematology department nurses was beneficial and contributed to lower hospital mortality.

Racial differences in cardiopulmonary outcomes of hospitalized COVID-19 patients with acute kidney injury.

In-hospital acute kidney injury (IH-AKI) has been reported in a significant proportion of patients with COVID-19 and is associated with increased disease burden and poor outcomes. However, the mechanisms of injury are not fully understood. We sought to determine the significance of race on cardiopulmonary outcomes and in-hospital mortality of hospitalized COVID-19 patients with AKI. We conducted a retrospective cohort study of consecutive patients hospitalized in Grady Health System in Atlanta, Georgia between February and July 2020, who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on qualitative polymerase-chain-reaction assay. We evaluated the primary composite outcome of in-hospital cardiac events, and mortality in blacks with AKI versus non-blacks with AKI. In a subgroup analysis, we evaluated the impact of AKI in all blacks and in all non-blacks. Of 293 patients, effective sample size was 267 after all exclusion criteria were applied. The mean age was 61.4 ± 16.7, 39% were female, and 75 (28.1%) had IH-AKI. In multivariable analyses, blacks with IH-AKI were not more likely to have in-hospital cardiac events (aOR 0.3, 95% Confidence interval (CI) 0.04-1.86, p = 0.18), require ICU stay (aOR 0.80, 95% CI 0.20-3.25, p = 0.75), acute respiratory distress syndrome (aOR 0.77, 95% CI 0.16-3.65, p = 0.74), require mechanical ventilation (aOR 0.51, 95% CI 0.12-2.10, p = 0.35), and in-hospital mortality (aOR 1.40, 95% CI 0.26-7.50, p = 0.70) when compared to non-blacks with IH-AKI. Regardless of race, the presence of AKI was associated with worse outcomes. Black race is not associated with higher risk of in-hospital cardiac events and mortality in hospitalized COVID-19 patients who develop AKI. However, blacks with IH-AKI are more likely to have ARDS or die from any cause when compared to blacks without IH-AKI.

Transient time flow measurement in total arterial coronary revascularisation with internal thoracic arteries. Three years’ experience in 433 patients

Intraoperative graft flow measurement in coronary artery bypass grafting (CABG) is recommended, but its clinical impact is still controversial. We evaluated the effect of Transient Time Flow Measurement (TTFM) on Major Cardiac Adverse Events (MACE) in CABG surgery. Between January 2017 and February 2020, 959 patients underwent total arterial CABG with internal thoracic arteries (ITAs). Thirty-four patients with critical preoperative status according Euroscore II definition or redo procedures were excluded from the analysis. According to the surgeon preference, TTFM were assessed in 433 patients (TTFM) with Medistim system ( Fig. 1 ). They were compared with 492 patients without TTFM assessment (No TTFM). Complete arterial revascularisation with single or bilateral ITAs with a Y-configuration was planned for all patients. Patients’ data were extracted from the French Society of Thoracic and Cardiovascular Surgery database (EPICARD). Primary end-point was the occurrence of MACE, including in-hospital cardiac mortality, perioperative myocardial infarction, cardiac arrest and the need for extra-corporeal membrane oxygenation (ECMO). Preoperative characteristics, operative data and postoperative outcomes are resumed in Table 1 . TTFM is associated with longer cardio-pulmonary bypass (CPB) times, because of supplementary time needed for measurement (82 ± 24 vs. 78 ± 25 min., P = 0.023). Five patients in TTFM group underwent graft revision because of unsatisfying flow values. MACE were significantly lower in TTFM group (2.1% vs. 5.7%, P < 0.01). At multivariate analysis, TTFM was protective against MACE occurrence (OR 0.353, 95% CI 0.146–0.770, P = 0.013). Other independent risk factors for MACE occurrence were cross clamp time (OR 1.18, 95% CI 1.03–1.35, P = 0.016) and Euroscore II (OR 1.21, 95% CI 1.13–1.29, P < 0.001). TTFM reduces MACE occurrence and it should be mandatory for graft evaluation in coronary artery surgery.