Noncardiac Causes Research Articles

Analysis of factors affecting the return of spontaneous circulation in elderly patients with out-of-hospital cardiac arrest

To investigate the factors that influence the return of spontaneous circulation (ROSC) in elderly patients suffering from out-of-hospital cardiac arrest (OHCA). A retrospective study was used to collect the clinical data of OHCA patients admitted to the emergency center of Zhengzhou People's Hospital from July 2016 to July 2019 based on the pre-hospital emergency database of Utstein model. Patients' gender, age, cardiac arrest (CA) etiology, presence or absence of bystander cardiopulmonary resuscitation (CPR), emergency response time, initial cardiac rhythm, ventilation method, use of epinephrine, defibrillation and ROSC were included. The patients were divided into elderly and young groups according to whether age ≥ 60 years old, and the differences in various indicators between the two groups were compared. Univariate Logistic regression analysis was used to analyze the relationship between emergency response time and ROSC in elderly patients and multivariate Logistic regression analysis was used to identify factors influencing ROSC in elderly patients. A total of 3 429 adult OHCA patients were enrolled in this study, including 2 105 elderly patients (61.39%), and 1 324 young and middle-aged patients (38.61%). Compared to the young group, the proportion of females, non-cardiac causes and asystole as the initial rhythm was higher in the elderly group, the emergency response time was shorter, the rate of defibrillation and tracheal intubation, and the success rate of ROSC were lower (all P < 0.05). Among them, the proportion of cardiac arrest as the initial rhythm in elderly male patients was significantly higher than that of young male patients (P < 0.05); the proportion of non-cardiac causes in elderly female patients was significantly higher than that of young female patients, and the proportion of defibrillation was significantly lower than that of young female patients (all P < 0.05). Multivariate Logistic regression analysis showed that cardiac arrest as the initial rhythm was strongly associated with ROSC in elderly male patients [odds ratio (OR) = 0.126, 95% confidence interval (95%CI) was 0.045-0.352, P < 0.05]. Univariate Logistic regression analysis of the relationship between emergency response time and ROSC in elderly patients showed that although there was no significant difference in the ROSC success rate among elderly patients with various emergency response times, an emergency response time within 10 minutes was beneficial for ROSC in elderly patients. The success rate of ROSC is very low in elderly OHCA patients aged ≥60 years. Although the CPR-related indicators of elderly patients are significantly different from those of young patients, there are gender differences. The association between the elderly male patients and cardiac arrest as the initial rhythm is stronger, while OHCA caused by non-cardiac diseases is more common and defibrillable rhythm is less common in elderly female patients. It may be more beneficial for elderly patients to shorten the emergency response time and increase bystander CPR.

Recurrent Takotsubo Syndrome: How Frequent, and How Does It Present?

Recurrent Takotsubo syndrome (TS) is not uncommon but experience with TS recurrence is inherently limited by the infrequency of the condition itself and incomplete long-term follow-up. There is limited published data on the clinical features and outcomes of patients with recurrent TS. We aimed to describe the clinical characteristics and outcomes of patients with recurrent TS in a large Auckland cohort. The clinical profile, in-hospital, and long-term outcomes were prospectively assessed in consecutive patients with recurrent TS presenting to Auckland's three major hospitals between January 2006 and January2023. During the study period, 472 TS patients were identified. Of the 467 patients discharged alive after the index event, 45 (9.6%) patients (mean age 62.3±11.0 years), all women, experienced recurrent TS. Median time interval from index event to the first recurrence was 3.14 years (range 27 days to 13.8 years). In 27 (60%) of the 45 patients, the subsequent events involved a stressor (physical triggers, n=8; emotional triggers, n=19). The stressor type differed between the index and recurrent event in 18 (40%) of the 45 patients. Thirteen (28.9%) had a different echocardiographic variant of TS at first recurrence. All patients with recurrent TS were discharged alive. Four patients died late after discharge from the first recurrence, all but one from a non-cardiac cause. One in 10 patients with TS experience recurrent events. These may occur many years later, and both the stressor type and the echocardiographic variant may be different at the recurrent event.

New categorization of chest pain: noncardiac is in, atypical is out!

Chest pain poses adiagnostic challenge in the emergency department and requires athorough clinical assessment. The traditional distinction between "atypical" and "typical" chest pain carries the risk of not addressing nonischemic clinical pictures. The newly conceived subdivision into cardiac, possibly cardiac, and (probably) noncardiac causes of the presenting symptom complex addresses amuch more interdisciplinary approach to asymptom-oriented diagnostic algorithm. The diagnostic structures of the chest pain units in Germany do not currently reflect this. An adaptation should therefore be considered.

Clinical characteristics of children and adolescents admitted with chest pain

Abstract Background: Chest pain is a common disease in children. Chest pain is the second most common symptom referred to by paediatric cardiologists after cardiac murmurs. Objective: In this prospective study, we aimed to evaluate clinical characteristics and causes of chest pain in children admitted to our paediatric cardiology outpatient clinics. Methods: We conducted this prospective study among 446 patients with chest pain in a tertiary care hospital from 1 June 2017 to 1 June 2020. The demographic data and clinical characteristics of the patients were analysed. All patients were evaluated with a medical history, physical examination, laboratory tests, electrocardiogram and echocardiogram and if necessary telecardiogram, 24-hour electrocardiogram monitoring, exercise stress test and psychological evaluation were made. Results: The ratio of admissions with acute pain was 4% when 20% of the patients had chronic chest pain. The most common symptoms associated with chest pain were shortness of breath and palpitations. The non-cardiac causes were as follows: 25% musculoskeletal, 14% psychological, 9% respiratory, and 7% gastrointestinal, respectively. We found cardiac chest pain in 49 (11%) of patients. Idiopathic chest pain was found in 153 (34%) patients. Conclusions: Our study showed that the aetiology of chest pain in children and adolescents admitted with chest pain is mostly due to non-cardiac causes. We found the slightly frequency of elevated rate for cardiac aetiologies of paediatric chest pain compared to the literature. We suggest that in addition to anamnesis and careful examination, further investigation, if necessary, is important in determining the aetiology of chest pain.

Study of Sudden Natural Death: An Autopsy Based Cross Sectional Study in a Tertiary Care Medical College and Hospital of Assam

Sudden natural death accounts for significant portion of mortality. Autopsy is the only solution for finding the definite cause of sudden deaths. The aim of this study is to find out the causes of sudden natural death and to evaluate associated factors. Study comprise 64 cases of Sudden Death autopsies performed in Silchar Medical College during the period 1st May 2022 to 30th November 2022. The organs were retained for histopathological examination. Information gathered from available documents in departmental records. Inferences made after analyzing data. Out of 514 autopsies during the study period, 64 cases were sudden natural death. Male dominated over female victims. The maximum death occurred in the age group 40-50 years followed by 30-40 years. The cause of deaths in 39% were attributed to cardiac causes and the remaining were due to non-cardiac causes. Sudden unexpected death requires significant health concern as most death occurs in the age ranging from 30 to 50 years. Cardiac causes contribute the maximum and male population are mostly affected. This kind of death of adulthood affects the financial stability of whole family as well as the Society.

Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure.

The prognostic value of right ventricular (RV) function in chronic heart failure (HF) has lately been well established. However, research on its role in acute heart failure (AHF) is sparse. This study comprised 195 patients, aged between 18 and 80years, with acute left-sided heart failure (HF) and a left ventricular ejection fraction (LVEF) < 50%. Patients with LVEF ≥ 50%, mechanical ventilatory or circulatory support, poor echocardiographic windows, prosthetic valves, congenital heart diseases, infective endocarditis, and/or life expectancy < 1year due to non-cardiac causes were excluded. The study participants' mean age was 57.7 ± 10.9years, and 74.9% were males. Coronary artery disease was present in 80.5% of patients. The mean LVEF was 31% ± 8.7. RV dysfunction (RVD), defined as tricuspid annular plane systolic excursion (TAPSE) < 17mm, RV S' < 9.5cm/s and/or RV fractional area change (FAC) < 35%, was identified in 48.7% of patients. The RV was dilated in 67.7% of the patients. RVD was significantly associated with a longer HF duration, atrial fibrillation, and idiopathic dilated cardiomyopathy. The primary outcome, a 6-month composite of cardiovascular death or hospitalization for worsening HF (HHF), occurred in 42% of the participants. Cardiovascular mortality and HHF occurred in 30.5% and 23.9% of the patients, respectively. The primary endpoint and longer CCU stays were significantly more common in patients with RVD than in those with normal RV function. RV dilatation was significantly associated with the primary outcome, whether alone or in combination with RVD. Multivariate regression analysis showed that only RV global longitudinal strain (GLS) independently predicted poor outcomes. RVD and RV dilatation strongly predict CV death and HHF in patients with AHF and LVEF < 50%. Multivariate analysis showed that RV GLS was the only predictor of a composite of CV death and HHF.

Troponin Elevation in Patients Undergoing Percutaneous Hepatic Perfusion for Metastatic Uveal Melanoma.

Percutaneous Hepatic Perfusion (PHP) is a liver directed regional therapy recently FDA approved for metastatic uveal melanoma to the liver involving percutaneous isolation of liver, saturation of the entire liver with high-dose chemotherapy and filtration extracorporeally though in line filters and veno-venous bypass. The procedure is associated with hemodynamic shifts requiring hemodynamic support and blood product resuscitation due to coagulopathy. To assess the cardiac safety and subsequent clinically significant sequalae of this therapy. Consecutive PHP procedures done at our center between 2010-2022 were assessed retrospectively. Cardiac risk factors, post procedural cardiac enzymes, electrocardiograms, and transthoracic echocardiograms along with 90-day cardiac outcomes were reviewed. All data were reviewed by cardio-oncologists at our institution. Of 37 patients reviewed, mean age was 63years and 57% were women. 132 procedures were performed with an average of 3.57 procedures per patient. 68.6% of patients had elevated troponin during at least 1 procedure. No patients were found to have acute coronary syndrome, heart failure, unstable arrhythmias, or cardiac death. No patients had notable echocardiographic changes. 10.8% of patients with positive troponin had asymptomatic transient electrocardiographic changes not meeting criteria for myocardial infarction. One patient had non-sustained ventricular tachycardiac intra-operatively which did not recur subsequently. Three patients died from non-cardiac causes within 90-days. There was no oncology treatment interruption, even in those with troponin elevation. In multivariable analysis, a history of hyperlipidemia was a predictor of postoperative troponin elevation. (P = .042). Percutaneous Hepatic Perfusion is safe and associated with a transient, asymptomatic troponin elevation peri-operatively without major adverse cardiac events at 90days. The observed troponin elevation is likely secondary to coronary demand-supply mismatch related to procedural hemodynamic shifts, hypotension, and anemia.

Survival prediction for heart failure complicated by sepsis: based on machine learning methods.

Heart failure is a cardiovascular disorder, while sepsis is a common non-cardiac cause of mortality. Patients with combined heart failure and sepsis have a significantly higher mortality rate and poor prognosis, making early identification of high-risk patients and appropriate allocation of medical resources critically important. We constructed a survival prediction model for patients with heart failure and sepsis using the eICU-CRD database and externally validated it using the MIMIC-IV database. Our primary outcome is the 28-day all-cause mortality rate. The Boruta method is used for initial feature selection, followed by feature ranking using the XGBoost algorithm. Four machine learning models were compared, including Logistic Regression (LR), eXtreme Gradient Boosting (XGBoost), Adaptive Boosting (AdaBoost), and Gaussian Naive Bayes (GNB). Model performance was assessed using metrics such as area under the curve (AUC), accuracy, sensitivity, and specificity, and the SHAP method was utilized to visualize feature importance and interpret model results. Additionally, we conducted external validation using the MIMIC-IV database. We developed a survival prediction model for heart failure complicated by sepsis using data from 3891 patients in the eICU-CRD and validated it externally with 2928 patients from the MIMIC-IV database. The LR model outperformed all other machine learning algorithms with a validation set AUC of 0.746 (XGBoost: 0.726, AdaBoost: 0.744, GNB: 0.722), alongside accuracy (0.685), sensitivity (0.666), and specificity (0.712). The final model incorporates 10 features: age, ventilation, norepinephrine, white blood cell count, total bilirubin, temperature, phenylephrine, respiratory rate, neutrophil count, and systolic blood pressure. We employed the SHAP method to enhance the interpretability of the model based on the LR algorithm. Additionally, external validation was conducted using the MIMIC-IV database, with an external validation AUC of 0.699. Based on the LR algorithm, a model was constructed to effectively predict the 28-day all-cause mortality rate in patients with heart failure complicated by sepsis. Utilizing our model predictions, clinicians can promptly identify high-risk patients and receive guidance for clinical practice.

Trends and Predictors of Readmission among Coronary Artery Disease Patients in a Community Heart Hospital in Nepal

Introduction: Patients of Coronary artery disease after index hospitalization gets readmitted to the same or different hospital for cardiac or noncardiac causes. To study trends of readmission pattern and different factors determining readmission . Methodlogy: The study is retrospective hospital based study for one year. Result: Out of 749 admitted patient with coronary artery disease, 143(19%) patients were readmitted. Mean age was 63.3 ± 13.4. There were 88(61.5%) male and 55(38.5%) female. Readmission rate for 30 days was 2.9%, 6 month 7.3% and 1 year 11.2 %. Forty (38%) of readmitted patients had been admitted more than one time. Common presentations were chest pain 60(42%), shortness of breath 42(29.4%), fever 11(7.7%), epigastric pain 9(6.3%), hemiparesis 8(5.6%), dizziness 4(2.8%), hematemesis 2(1.4%), hempoptysis 2(1.4%), black stool 1(0.7%), palpitation 1(0.7%) and loose stool 1(0.7%). Top factors were enlisted were presence of wall motion abnormalities 96(67.1%), anemia 83(58%), diagnostic invasive procedure in past 80 (55.9%), hypertension 76(52.4%), low systolic function 75 (52.4%) , angina 60(43%), diabetes 59(41.3%), heart failure 50(35%) , revascularization( PCI) 50 (35%), infarction 39(27.3 ), COPD 32(22.4%), infections 29(20.3%),acute kidney injury 25 (17.5), hypothyroidism 16(11.2), dyslipidemia 15(10.5), CKD 14(9.8), CVA 13(9.1), APD 12 (8.4), arrhythmia 10 (7%) h/o CABG,10(7%) and UGI bleeding 10 (7%). Conclusion: Readmission forms nineteen percentage of total admissions and readmission rate calculated within 30 days of admission as 2.9%.

Long-Term Results of Stenting in Patients with Hemodynamically Significant Lesions of the Left Main Coronary Artery

The aim. To study the long-term results of stenting in patients with coronary artery disease with hemodynamically significant left main coronary artery (LMCA) stenoses.&#x0D; Materials and methods. The study included 67 patients (56 men, 11 women) with a mean age of 63 ± 2.1 years.&#x0D; Results. Among the 67 patients included in the study, 29 patients (43.3%) underwent percutaneous coronary inter-vention using a single-stent technique. These were patients with ostial LMCA lesions, lesions of the middle third of the LMCA and some patients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to establish contact with 25 patients (86.2%). Among these, 1 patient (3.4%) died of non-cardiac causes and 7 patients (24.1%) had a recurrence of angina within 2 years. The causes of angina recurrence in 2 cases (6.9%) were restenosis in the stent with transition to the mouth of the side branch, which required repeated stenting of the LMCA with transition to the left circumflex artery. In 5 patients (17.2%), angina recur-rence was associated with progression of coronary atherosclerosis of another localization.&#x0D; Among 67 patients with LMCA stenting, the two-stent technique was used in 38 patients (56.7%). These were pa-tients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to contact 35 patients (92.1%). Among these, 4 patients (10.5%) died, but only one of them due to cardiac causes (2.6%), and 3 patients (7.9%) had recurrent angina within 2 years, two of whom underwent stenting by the T and protrusion (TAP) technique and one by culotte. The first two patients underwent angioplasty of restenosis in stents using balloons with a therapeutic coating. In the last patient, stent recoil in the left circumflex artery mouth was observed due to severe calcification, so this patient underwent re-implantation of the stent system in the recoil zone.&#x0D; Conclusions. The problem of choosing a method of revascularization for patients with hemodynamically significant LMCA lesions remains controversial to this day, despite the wide range of evidence. Doctors should jointly decide on the choice of treatment methodology solely in the interests of the patient, taking into account all the factors that may affect the patient’s quality of life in the long term.

Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study

BackgroundEpinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA.MethodsWe used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other.ResultsOf the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01–5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52–20.06] for 2–5 mg; and 23.71, 95% CI [11.02–50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent.ConclusionsIn non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.

Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm

International guidelines recommend body temperature control below 37.8 °C in unconscious patients with out-of-hospital cardiac arrest (OHCA); however, a target temperature of 33 °C might lead to better outcomes when the initial rhythm is nonshockable. To assess whether hypothermia at 33 °C increases survival and improves function when compared with controlled normothermia in unconscious adults resuscitated from OHCA with initial nonshockable rhythm. Individual patient data meta-analysis of 2 multicenter, randomized clinical trials (Targeted Normothermia after Out-of-Hospital Cardiac Arrest [TTM2; NCT02908308] and HYPERION [NCT01994772]) with blinded outcome assessors. Unconscious patients with OHCA and an initial nonshockable rhythm were eligible for the final analysis. The study cohorts had similar inclusion and exclusion criteria. Patients were randomized to hypothermia (target temperature 33 °C) or normothermia (target temperature 36.5 to 37.7 °C), according to different study protocols, for at least 24 hours. Additional analyses of mortality and unfavorable functional outcome were performed according to age, sex, initial rhythm, presence or absence of shock on admission, time to return of spontaneous circulation, lactate levels on admission, and the cardiac arrest hospital prognosis score. Only patients who experienced OHCA and had a nonshockable rhythm with all causes of cardiac arrest were included. Variables from the 2 studies were available from the original data sets and pooled into a unique database and analyzed. Clinical outcomes were harmonized into a single file, which was checked for accuracy of numbers, distributions, and categories. The last day of follow-up from arrest was recorded for each patient. Adjustment for primary outcome and functional outcome was performed using age, gender, time to return of spontaneous circulation, and bystander cardiopulmonary resuscitation. The primary outcome was mortality at 3 months; secondary outcomes included unfavorable functional outcome at 3 to 6 months, defined as a Cerebral Performance Category score of 3 to 5. A total of 912 patients were included, 490 from the TTM2 trial and 422 from the HYPERION trial. Of those, 442 had been assigned to hypothermia (48.4%; mean age, 65.5 years; 287 males [64.9%]) and 470 to normothermia (51.6%; mean age, 65.6 years; 327 males [69.6%]); 571 patients had a first monitored rhythm of asystole (62.6%) and 503 a presumed noncardiac cause of arrest (55.2%). At 3 months, 354 of 442 patients in the hypothermia group (80.1%) and 386 of 470 patients in the normothermia group (82.1%) had died (relative risk [RR] with hypothermia, 1.04; 95% CI, 0.89-1.20; P = .63). On the last day of follow-up, 386 of 429 in the hypothermia group (90.0%) and 413 of 463 in the normothermia group (89.2%) had an unfavorable functional outcome (RR with hypothermia, 0.99; 95% CI, 0.87-1.15; P = .97). The association of hypothermia with death and functional outcome was consistent across the prespecified subgroups. In this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 °C did not significantly improve survival or functional outcome.

Sudden death related to sexual activity: A multicenter study based on forensic autopsies (2010–2021)

Introduction and objectivesTo investigate the epidemiological characteristics, clinic-pathological findings and recent use of substances of abuse and prescribed drugs in sexual activity-related sudden death (SArSD). MethodsMulticenter population-based study on forensic autopsies conducted in 27 provinces of Spain over 12 years (2010–2021). ResultsOut of 18046 autopsied natural deaths, 64 cases (0.35 %) of SArSD were investigated (87 % males). Women were younger than males (50.5 ± 13.4 years vs 37.2 ± 14.2; p = 0.017). Sudden cardiac deaths (SCD) accounted for 87 % of cases. Ischemic heart disease was the predominant pathology (58 %), mainly affecting men ≥ 36 years of age. Cerebral haemorrhage (8 %) and asthma (5 %) were the leading non-cardiac causes. In young adults, SADS (36 %) and asthma (27 %) were the main causes The disease responsible of SCD was diagnosed in life in 7 subjects. In 64 % there were cardiovascular risk factors, mainly obesity. Toxicological analysis detected illicit drugs (23 %), mainly cocaine, medications for erectile dysfunction (9 %), and ethanol ≥ 0.5 g/L (8 %). Deaths occurred usually in the context of heterosexual intercourse and during or immediately after sexual activity. The most common location was at home (63 %). In 12 men the sexual partner was a sex worker. ConclusionsSArSD has a low incidence in the general population affecting middle-aged males during intercourse with a heterosexual partner. It is of cardiovascular origin, mainly due to ischemic heart disease that frequently remained silent during life. There is a frequent association with obesity, use of cocaine (and, to a lesser extent, medications for erectile dysfunction) and performing unconventional sexual practices. Forensic investigation is useful for developing prevention strategies.

Prevalence of Multiple Causes of Death Within Young and Middle-Aged People Experiencing Sudden Cardiac Arrest

Multiple causes of death are increasingly reported, particularly in older populations. Rates of multiple causes of young sudden death have not been quantified. The End Unexplained Cardiac Death (EndUCD) registry was utilised to identify cases of young sudden death (aged 1-50 years) referred for forensic assessment from April 2019 to April 2022. Causes of death were coded according to whether one or more underlying causes of death were identified. Patients were compared according to the number of causes of death, with significant predictors assessed using logistic regression analysis. 1,085 cases of sudden death were identified. 263 (24.2%) cases had more than one competing cause of their sudden death. The most common multi-causal associations identified were dual non-cardiac causes of the sudden death (n=68), cardiomyopathy with non-cardiac event (n=64) and coronary artery disease with non-cardiac cause (n=63). Multi-causal death was more common in those undergoing comprehensive autopsy examination (95.8% vs 77.6%, p<0.0001), and in the setting of higher body mass index (median 31.3 kg/m2 vs 29.9 kg/m2, p=0.01), older age (44.3 years vs 41.4 years, p<0.0001), non-ventricular cardiac arrest rhythm (93.2% vs 87.3%, p=0.009), and smoking (22.8% vs 14.2%, p=0.001). The strongest predictor of multiple pathologies was comprehensive autopsy examination compared with external inspection, full-body post-mortem computed tomography and review of ancillary documentation and investigations (odds ratio 6.49, 95% confidence interval 3.47-12.14). One-quarter of young sudden deaths have more than one underlying cause, highlighting the value of comprehensive investigations including autopsy. Awareness of the complexity of young sudden death is important, along with multidisciplinary involvement to ensure all contributors to death are identified.

Temporal trends in neurologically intact survival after paediatric out-of-hospital cardiac arrest: a nationwide population-based observational study in Japan

Abstract Background/Introduction Out-of-hospital cardiac arrest (OHCA) in children is associated with poor outcomes. However, the temporal trends in survival, especially neurologically intact survival in paediatric patients with OHCA, remain unclear. Purpose To examine temporal trends in neurologically intact survival in paediatric patients with OHCA for over 16 years. Methods We reviewed the data of 27,202 children (age &amp;lt;18 years) who experienced OHCA and were treated by emergency medical service providers. Data were obtained from the All-Japan Utstein Registry from January 2005 to December 2020. We analysed the temporal trends in the 1-month neurologically intact survival (cerebral performance category scale 1 or 2: CPC 1–2) rate over time. Subgroup analyses for outcomes were performed by type of bystander cardiopulmonary resuscitation (CPR), dispatcher-assisted CPR, age group (infant [&amp;lt;1 year], child [1–11 years], adolescent [12–17 years]), witnessed status, and cause of arrest. The primary endpoint was the 1-month neurologically intact survival. Results The frequency of bystander CPR significantly increased from 50.0% in 2005 to 63.1% in 2020 and the frequency of dispatcher-assisted chest compression-only CPR (CC-CPR) significantly increased from 7.7% to 40.6% (both p for trend &amp;lt;0.0001). The rate of initial shockable rhythm significantly decreased from 5.0% to 3.4% (p for trend &amp;lt;0.0001). The multivariate logistic regression model showed that calendar year, age, witnessed arrest, presence of bystander CPR, initial shockable rhythm, and non-cardiac causes were associated with increased odds of CPC 1–2. The overall crude rates of 1-month CPC 1–2 significantly increased from 4.9% in 2005 to 11.0% in 2020 (p for trend &amp;lt;0.0001). In patients who received standard CPR with rescue breathing and CC-CPR, the 1-month CPC 1–2 rate significantly increased from 8.0% to 24.2% and 4.7% to 10.8% (p for trend &amp;lt;0.0001), respectively. The rate of CPC 1–2 in patients who underwent dispatcher-assisted CPR also increased from 4.4% to 9.2% (p for trend &amp;lt;0.0001). With regards to patient age groups, the rate of 1-month CPC 1–2 significantly increased from 2.4% in 2005 to 7.5% in 2020 for infants, 6.0% to 14.8% for children, and 6.5% to 11.4% for adolescents (all p for trend &amp;lt;0.0001). For witnessed arrest, the rate of 1-month CPC 1–2 significantly increased from 9.9% to 24.9% for witnessed arrest and 2.7% to 3.1% for unwitnessed arrest. The rate of 1-month CPC 1–2 significantly increased from 4.9% to 13.8% for presumed cardiac causes and 5.0% to 9.6% for non-cardiac causes. Conclusions The 1-month neurologically intact survival rate significantly increased from 2005 to 2020 for paediatric patients with OHCA in Japan, regardless of bystander CPR type, age, witnessed status, and cause of arrest. A frequency of dispatcher-assisted CC-CPR rate increase of almost five-fold over time was associated with a two-fold increase in the overall 1-month CPC 1–2 rate over time.

The challenge of risk stratification in hypertrophic cardiomyopathy: clinical, genetic and imaging insights from a quaternary referral centre

Abstract Background Hypertrophic cardiomyopathy (HCM) is the commonest genetic cardiomyopathy and may result in sudden cardiac death (SCD). Clinical risk stratification scores are utilised to estimate SCD risk and determine potential utility of a primary prevention implantable cardioverter defibrillator (ICD). Methods Patients with a confirmed diagnosis of HCM from a quaternary HCM service were defined according to clinical characteristics, genetic profiles and cardiac imaging results. European Risk-SCD score and American Heart Association / American College of Cardiology (AHA/ACC) Score were calculated. The primary outcome was cardiac arrest. Results 380 patients with HCM were followed up for a median of 6.4 years. 18 patients (4.7%) experienced cardiac arrest, with predictive factors being younger age (37.2 vs 54.4 years, p=0.0041), unexplained syncope (33.3% vs 9.4%, p=0.007), non-sustained ventricular tachycardia (50.0% vs 12.7%, p&amp;lt;0.0001), increased septal thickness (21.5 vs 17.5mm, p=0.0003), and presence of a sarcomeric gene mutation (100.0% vs 65.8%, p=0.038). The Risk-SCD and AHA/ACC scores had poor agreement (kappa coefficient 0.38). Risk-SCD score had poor sensitivity (44.4%), classifying 55.6% of patients with cardiac arrest as low-risk but was highly specific (93.7%). AHA/ACC risk score did not discriminate between groups significantly. 20 patients (5.3%) died, with most &amp;gt;60-year-olds having a non-cardiac cause of death (p=0.0223). Conclusion This study highlights limited (38%) agreement between the Risk-SCD and AHA/ACC scores. Most cardiac arrests occurred in ostensibly low or medium-risk patients under both scores. Appropriate ICD selection remains challenging. Utilising newer markers such as cardiac MRI and genetic findings may assist future risk refinement.

Estimated population prevalence of cardiac transthyretin amyloidosis as an incidental finding on bone scintigraphy in a university hospital in Colombia

Abstract Background Cardiac uptake in bone scintigraphy is highly sensitive and specific for transthyretin cardiac amyloidosis (ATTR), allowing a useful noninvasive diagnostic pathway even before echocardiographic or electrocardiographic abnormalities are present. Early diagnosis translates into early treatment and, thus, improves morbidity and mortality. In Colombia, ATTR diagnosis is still delayed or missed, and no studies have described incidental cardiac uptake on bone scintigraphy. Regarding health resources, the economic impact derived from the treatment of CA in Latam requires rigorous patient selection. This study aims to bridge this gap and improve the local clinical context. Methods We performed a retrospective cohort study which included all patients older than 65 who underwent bone scintigraphy using 99m Technetium labeled hydroxy-methylene- diphosphonate (HMDP) between January 2020 to December 2022 at our institution. Two independent physicians screened the bone scans, which a Nuclear Imaging specialist following the American Society of Nuclear Radiology guidelines then graded. Bone scans indicated for suspicion of ATTR were excluded. The prevalence of cardiac uptake and demographic characteristics were assessed. Results A total of 1206 patients were analyzed. Thirty-eight were excluded due to suspected CA. The study population, therefore, consisted of n=1168 patients with musculoskeletal (58%) and oncologic (40%) indications for scintigraphy. 55% of the sample were men; the median age was 75. Cardiac uptake was found in 1.5% of patients, from which 28% had Grade Perugini 1, 17% had Grade Perugini 2, and 56% had Grade Perugini 3. Among patients with incidental uptake, 78% were men, with a median age of 84 years; 17% had heart failure, 11% had aortic stenosis, 11% had dysautonomia, 6% had polyneuropathy, 22% had spinal stenosis, and 17% had carpal tunnel syndrome. Conclusion We describe the first South American cohort of incidental cardiac uptake in HMDP scintigraphy. The observed incidence in this cohort was 1.5%, in concordance with previously published data in other continents. Bone scintigraphy is highly available in all regions of Colombia, allowing the identification of subclinical ATTR before severe functional impairment occurs and prompt treatment initiation in CA patients. The development of reference centers for the healthcare of CA patients allows the incorporation of clinical pathways that facilitate the approach of patients with incidental myocardial uptake in bone scans requested for non-cardiac causes, which warrant further clinical assessment and follow-up.Clinical characteristicsIncidental cardiac uptake

Ten year evolution of clinical characteristics and short-term outcome of patients admitted with heart failure

Abstract Background/Introduction Heart failure (HF) continues to be a leading cause of morbidity, decreased quality of life (QoL) and mortality worldwide. Contributing to decreased QoL is the high rehospitalization rate, which is often related to non-cardiac causes, highlighting the important multimorbidity of the HF population. Detailed clinical and outcome data for HF admissions in Belgium over time are only scarcely available. Purpose We aimed to evaluate and compare two groups of patients admitted with HF ten years apart, regarding clinical characteristics, comorbidities, use of HF medication and devices, as well as rehospitalization rate and all-cause mortality three months post-discharge. Methods This is a monocentric retrospective observational cohort study conducted in Belgium. Two groups of patients admitted for acute decompensated HF who were discharged alive were included and compared: 340 patients during 2011-2012 and 319 patients during 2021-2022. Results The two cohorts did not differ significantly regarding age (77.3 vs. 78.4 years), gender (47.4 vs. 44.5% women), number of patients with HF with reduced ejection fraction (47.4 vs. 48.6%) and NT-proBNP on admission (8514 vs. 7398 pg/mL). Similarly, comorbidities including diabetes, chronic obstructive pulmonary disease, peripheral artery disease, stroke and renal failure were comparable in both groups. Concerning medical therapy at discharge, mineralocorticoid receptor antagonists (MRA) were used significantly more frequently in the latest cohort. However, there was no change in administration of beta-blockers or renin angiotensin aldosterone system antagonists. As part of the implementation of new therapies for heart failure with reduced ejection fraction, 29% of patients were prescribed sodium-glucose cotransporter-2 (SGLT-2) inhibitors, while sacubitril/valsartan was given in 13% of the cases. The use of internal defibrillators (ICD) and resynchronization devices (CRT) doubled from 2011-2012 to 2021-2022 (3.9 vs. 9.6%, p = 0.002). In-hospital length of stay decreased significantly over a ten-year period across all ejection fraction subgroups from 7 to 5 days (figure 1). The combined outcome of rehospitalization for HF and all-cause mortality three months post-discharge remained constant at approximately 20% (figure 2). Conclusion Clinical characteristics and comorbidities of patients admitted with acute decompensated HF did not change significantly between 2011 and 2022. Uptake of evidence-based medicine for HF increased, especially for MRA, SGLT-2 inhibitors and sacubitril/valsartan, as did the use of ICD and CRT, but still with considerable potential for improvement. Although in-hospital length of stay decreased significantly over time, rehospitalization rates for HF and all-cause mortality within 90 days post-discharge remained high and did not improve. These sobering results illustrate the need for continuing efforts to improve the care and outcome of HF patients.

How should we assess the cardiovascular system in patients presenting with bothersome nocturia? ICI-RS 2023.

The link between nocturia and cardiovascular disease (CVD) is frequently discussed in literature, yet the precise nature of this relationship remains poorly characterized. The existing literature was reviewed in order to address issues concerning the origin, diagnosis, management, and implications of the co-occurrence of CVD and nocturia. This review summarizes literature and recommendations regarding the link between CVD and nocturia discussed during a think-tank meeting held at the 2023 International Consultation on Incontinence-Research Society. Cardiovascular disorders are often underestimated contributors to nocturia, with various potential mechanisms influencing nighttime urination, such as impact on fluid retention, atrial natriuretic peptide, and glomerular filtration rate. The redistribution of fluid from leg edema in supine position can lead nocturnal polyuria (NP). Additionally, sleep disturbances due to nocturia in itself may lead to CVD through an increase in blood pressure, insulin resistance, and inflammation. Disrupted circadian rhythms (e.g., in sleep pattern and urine production) were identified as critical factors in most etiologies of nocturia, and their contribution is deemed imperative in future research and treatment approaches, particularly in the aging population. NP can be detected through a simple bladder diary and can even be used to distinguish cardiac from noncardiac causes of nocturia. For the treatment of NP, desmopressin can be effective in select patients, however, caution and close monitoring is warranted for those with CVD due to increased risk of side effects. Gaps were identified in the available evidence and clear cut recommendations were put forth for future research. It is essential to gain a deeper understanding of the mechanisms linking nocturia and CVD to develop optimal management strategies.

Clinical outcomes comparison between patients with residual severe and moderate-or-less tricuspid regurgitation after percutaneous edge-to-edge repair: which degree of reduction is significant?

Abstract Introduction Transcatheter tricuspid valve repair (TTVR) for high-grade regurgitation (TR) is an emerging option in inoperable patients, and can improve quality of life. Based on the new 5-grade TR classification(1), all studies have defined procedural success by at least one-grade reduction. While a higher degree of TR reduction should translate into better clinical outcomes, considerable reduction is not always possible. Most often, the regurgitant area is too large for coaptation devices, frequently 2- to 3-fold greater than in mitral regurgitation (MR). Difficult periprocedural guidance, suboptimal acoustic window, shadowing from pacemaker leads, leaflets with multiple scallops contribute to less than perfect results. This study compared long-term clinical outcomes of edge-to-edge TTVR in patients with residual severe TR (STR; III/V) vs moderate-or-less TR (MTR; ≤II/V), despite procedural success. Methods Eligible inoperable patients had chronic symptomatic functional TR despite diuretic therapy. Exclusion criteria were treatable left heart e.g., significant MR, and pulmonary arterial pressure ≥70mmHg, among others. The primary efficacy endpoint was at least one grade TR reduction at 30 days. The secondary endpoints related to long-term improvement in symptoms, quality of life and multiorgan function. Follow-up was carried out between January 2021 and January 2023. Results Forty-three patients, 51% females, had ≥severe (III/V) functional TR, 65% of them massive (IV/V) and 14% torrential (V/V). Mean age was 81.8±4.9 years, with 10.8±6.3% STS-Score. Patients were highly symptomatic e.g., 86% in NYHA stage III-IV, and multimorbid e.g., the majority had advanced kidney and liver disease. The primary efficacy endpoint was recorded in 91% of all patients, with 100% technical success and no device related complications. According to the degree of residual TR we defined 3 subgroups: STR (n=17), MTR (n=22), and no reduction (n=4). Two- or more-grade reduction was present in 91% of MTR and 24% of STR cases(Figure 1). By 12 months, 6 patients died, 2 from each group, 3 of non-cardiac cause. MACE rate was 18.6%. Long-term outcomes in the remaining 15 STR and 20 MTR patients were compared(Figure 2). Improvement in initial NYHA class III/IV occurred in 54% of STR and 77% of MTR patients. KCCQ Score increased by 21.6±17.9 pts. (p&amp;lt;0.001) vs 29.8±15.6 (p&amp;lt;0.001), six-minute walk test by 103.3±65.7 meters (p&amp;lt;0.001) vs 117.5±93.2 (p&amp;lt;0.001). Renal and liver function equally improved in both groups [GFR 51.3±16.5ml/min/1,73m2 to 56.4±21.6 (p=0.043) vs 59.9±17 to 60.1±18.2 (p=0.930); AST 27.4±9.9U/L to 22.2±6.9 (p=0.009) vs 37.5±26.9 to 29.7±10.3 (p=0.112)]. Conclusions Although TTVR should always aim for trace to mild TR, considerable reduction is not always possible. This study indicates that even one-grade TR reduction can significantly impact quality of life, functional capacity and multiorgan involvement, similarly in STR and MTR patients.Figure_1Figure_2