Patient Population Research Articles

Admitting clinical department effect on outcomes for acute pulmonary embolism

Abstract Background Pulmonary embolism (PE) is the third most fatal cardiovascular disease and its management is often complex requiring multidisciplinary involvement. Aims To investigate whether there are differences between patient populations with acute PE and associated outcomes admitted to different clinical departments based on a German nationwide inpatient population. Methods We used the German nationwide inpatient sample to identify hospitalizations of patients with acute PE within the period 2005-2020. Patients were classified according to the department were they spent the longest duration of hospitalization (cardiology, general internal medicine, or pulmonology/critical care medicine). Patients admitted and treated to other departments were excluded from the analysis. Temporal trends of hospitalizations, as well as the impact of admitting departments on case-fatality were investigated with the cardiology department used as reference and after multivariable adjustment for age, sex, and comorbidities (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2020, own calculations). Results During the investigated period a total of 759,115 patients with acute PE were identified; of those 117,501 (15.5%) were admitted to cardiology, 37,726 (5.0%) were admitted to pulmonology/critical care, while the majority of 603,888 (79.5%) were admitted to internal medicine (Table 1). A trend towards increasing number of patients admitted to cardiology in recent years was observed as opposed to being admitted to internal medicine. The number of patients admitted to pulmonology/critical care appeared stable (Figure 1A). Patients admitted to cardiology were more likely to be younger (Figure 1B) and had less risk factors for acute PE, such as cancer and recent surgery. The PE severity indices were higher in patients admitted to cardiology with a higher prevalence of tachycardia, syncope, signs of right ventricular dysfunction and shock (Table 1). There was an overall trend towards decrease in systemic thrombolysis and increase in catheter-directed thrombolysis independent of the admitting department. Catheter-directed thrombectomy has increased when patients were admitted to cardiology and internal medicine, but not when patients were admitted to pulmonology/critical care. Trends for in-hospital mortality were decreasing linearly over time independent of the admitting clinical service. In the multivariable adjustment, admission to cardiology was associated with significantly reduced rates of in-hospital mortality (OR 0.73, 95% CI 0.71-0.74). Conclusion In this nationwide analysis, the majority of patients with PE were hospitalized in an internal medicine ward, while notably, cardiology admissions demonstrated unique patient characteristics compared to other departments and were associated with decreased in-hospital mortality, suggesting specialized care's potential benefits in PE management.Table 1Figure 1

Prevalance and impact of concomitant atrial fibrillation in patients undergoing percutaneous coronary intervention for acute myocardial infarction

Abstract Introduction Atrial fibrillation (AF) is a common cardiac arrhythmia associated with coronary artery disease (CAD) and myocardial infarction (MI). The prevalence of AF in patients following acute MI varies, with conflicting evidence on its impact on outcomes. Concomitant atrial fibrillation is associated with an adverse prognosis in patients with acute myocardial infarction (MI). However, it remains unclear whether this is due to a causal effect of AF, or whether AF acts as a surrogate marker for comorbidities in this population Also, there are limited data on whether coronary artery disease distribution impacts the risk of developing AF. Purpose This large cohort study aims to determine the prevalence of AF in acute MI patients treated with PCI, assess its independent prognostic value for MACCE, investigate the association of AF with CAD distribution patterns, and provide insights into the long-term outcomes of AF in this patient population. Methods A cohort of 1000 consecutive MI patients treated with PCI was retrospectively analyzed. Data on demographics, medical history, presentation, treatment, and outcomes was collected. Propensity score matching was used to adjust for baseline differences between AF and non-AF groups. CAD distribution, major adverse events, and MACCE were assessed using statistical analyses. Results Amongst the studied population, 6.5% people had AF (65/1000) and it was noted that those with AF had a worse outcome. However, on statistical analyses (both on multivariable cox and propensity matching) accounting for risk factors, outcomes were not significantly different between those with and without AF. Hence, this negated key baseline differences between AF and non-AF groups, with no significant differences in demographics or presentation. Patients with AF had a higher prevalence of severe CAD in the left main stem (LMS) and left circumflex artery (LCx). The association of AF with MACCE was not significant in the matched groups. Long-term follow-up revealed similar rates of MACCE between AF and non-AF groups. Discussion AF in acute MI patients undergoing PCI is associated with a higher prevalence of severe CAD in the LMS and LCx. AF appears to be a surrogate marker of other risk factors, rather than an independent risk factor for MACCE. The study highlights the need for tailored aggressive treatment for risk factor modification in AF patients with MI. Conclusions AF is associated with an increased risk of MACCE in acute MI patients undergoing PCI. However, this association is primarily driven by the burden of comorbidities associated with AF, emphasizing the importance of tailored treatment strategies for AF patients. Prospective studies with routine ambulatory monitoring are recommended to validate these findings and guide future practice.

Association of Sleep Apnea and cardiovascular mortality in CAD patients

Abstract Background A growing body of epidemiological and clinical research has uncovered a significant relationship between sleep apnea and the exacerbation of cardiovascular outcomes, notably myocardial infarction, stroke, and cardiac death. Individuals diagnosed with coronary artery disease (CAD) alongside sleep apnea are identified to have a heightened likelihood of experiencing recurrent cardiovascular events. Despite these associations, the link between sleep apnea and an elevated risk of mortality among CAD patients remains insufficiently explored. Purpose Our study aims to shed light on the impact of sleep apnea on mortality rates within this patient population, potentially guiding future therapeutic strategies. Methods Our cohort study leveraged data from the TriNetX multinational electronic health record network, focusing on patients aged 18 and above diagnosed with coronary artery disease. Participants were stratified into two groups based on the diagnosis of sleep apnea. To ensure a fair comparison, we adjusted for prevalent risk factors such as hypertension, diabetes, dyslipidemia, obesity, and chronic kidney disease, which are commonly observed in CAD patients. Results The study encompassed 1,799,812 patients, equally divided into two groups of 899,906 individuals each, one with sleep apnea and the other without. Over a 5-year observation period, the primary endpoint, defined as event-free survival, was significantly lower in the sleep apnea group (74.385%) compared to the non-sleep apnea group (76.606%), with a Log Rank confidence interval of 1.128 to 1.148 and a p-value of <0.0001. This outcome highlights a association between sleep apnea and increased mortality rates in CAD patients. Conclusion The findings from our large cohort study underscore the critical impact of sleep apnea on mortality among patients with coronary artery disease. The diagnosis of sleep apnea in CAD patients within the TriNetX cohort was significantly associated with a higher mortality rate over a span of five years. These insights emphasize the need for integrated care strategies that not only address the primary cardiovascular conditions but also prioritize the diagnosis and management of sleep apnea to potentially improve survival outcomes in this vulnerable patient group. Our study calls for heightened clinical awareness and further research to elucidate the mechanisms behind this association and to explore the benefits of targeted sleep apnea interventions in reducing mortality rates among CAD patients.5-year Kaplan-Meier curves for mortality

National trends of left ventricular assist device therapy in Germany

Abstract Background The prevalence of advanced heart failure (HF) is increasing and prognosis remains poor. Although heart transplantation is still considered to be the gold standard for the treatment of advanced HF in selected patients, its use is limited by organ donor shortage and a growing burden of cormorbidities among potential recipients. The 2021 European Society of Cardiology (ESC) guidelines recommend consideration of long-term mechanical circulatory support with a left ventricular assist device (LVAD) in eligible patients with advanced heart failure (HF) who are refractory to medical/device therapy. Purpose The purpose of this study was to evaluate the national trends of LVAD in Germany. The main hypothesis was that LVAD therapy is still underutilized. Methods From the national database of the German Federal Statistical Office (DESTATIS), we identified all patients who underwent LVAD implantation in Germany between January 2011 and December 2022 (n = 9,232). We compared temporal trends and in-hospital outcomes. Results From 2011 to 2022, number of LVAD implantation was highest in the year 2017 (n = 914) and steadily decreased over the following years (2022: n = 617). Mean age of LVAD recipients was 56.2 years (2011-2015) and increased to 58.4 years (2020-2022). The majority of LVAD recipients are male (84,8 %), and this trend has been stable during the entire time period. In-hospital mortality after LVAD remains high, but has been decreasing (25.8% during 2011-2015 compared to 20.2% during 2020-2022). Conclusion Although LVAD is recommended in eligible patients with advanced HF, our study suggests an underutilization of LVAD in this patient population and especially in female patients.

Temporal trends in lipid management among Korean patients following acute myocardial infarction from 2011 to 2020

Abstract Background/Purpose Real-world data trends on dyslipidaemia prevalence and lipid management for patients following acute myocardial infarction (AMI) are lacking in South Korea, one of the Asia-Pacific nations. Our study aimed to evaluate the 10-year temporal trends of dyslipidaemia prevalence and lipid management in this patient population. Methods The study utilized datasets from two Korean AMI observational cohort (2011–2020) including a total of 26,751 participants (Figure 1A). The primary endpoints were as follows: (1) absolute low-density lipoprotein cholesterol (LDL-C) target of <70 mg/dL; (2) relative LDL-C target of >50% LDL-C reduction from the baseline; (3) absolute or relative LDL-C target (American target); and (4) both absolute and relative LDL-C targets (European target). Results The prevalence of dyslipidaemia increased from 11.1% to 17.1% (Table 1, Figure 1B), while the statin prescription rates increased from 92.9% to 97.0% from 2011 to 2020. High-intensity statin use increased from 12.80% in 2012 to 69.30% in 2020 (Table 1) Interestingly, the yearlong substantial increases in the prescription rates of high-intensity statins were prominent between 2013 (21.9%) and 2014 (37.7%) and between 2018 (52.4%) and 2019 (66.1%), which may have been influenced by major revisions to the international lipid management guidelines and their adoption (Figure 1C). Ezetimibe use increased from 4.50% in 2016 to 22.50% in 2020. The achievement rate of the absolute and relative LDL-C targets increased from 41.4% and 20.8% in 2012 to 62.5% and 39.5% in 2019, respectively (Table 1). The achievement rates of the American (45.7% in 2012 to 68.6% in 2019) and European (16.5% in 2012 to 33.8% in 2019) targets showed similar increasing trends (Table 1, Figure 1D). Conclusions Despite the adoption of lipid management guidelines in clinical practice has improved, some patients some patients are unable to reduce their LDL-C concentrations to their target levels. Our real-world analyses emphasise the need for multidirectional and continued efforts to optimise lipid management and improve the clinical outcomes in these patients.Figure 1

Usage patterns and outcomes of drug coated ballons at a tertiary care center - a cohort analysis in 462 patients

Abstract Background The usage of drug coated ballons (DCB) in percutaneous coronary interventions (PCI) is rising. Initially applied in in-stent restenosis (ISR), wider clinical applications especially in de novo lesions (DNL) are discussed. Here we aim to assess the pattern of usage as well as the clinical and angiographic outcomes associated with DCB. Methods For this analysis we included all patients treated with DCB during PCI, at a tertiary care centre between 01/2015 and 12/2021. Cath lab results of all patients were screened to assess the DCB indication. Patients were followed up until 09/2022 to assess clinical as well as angiographic complications. Results A total of 7608 interventions were carried out between 2015 and 2021, in 462 (6.1%) a DCB was used. The median follow-up time were 3.1 years (IQR 1.6 to 4.4 years), the median age of our patient population was 66 (IQR 58-75) and 24.7% (n=114) were female. There were 92 of 462 (19.9%) cases including a DNL preparation, 335 (72.5%) cases treating an ISR, in 6 (1.3%) cases both, DNL and ISR were treated, and in 29 (6.3%) cases DCB were used for other reasons (e.g. pre-/ postdilatation in coronary stenting). The mean DCB inflation diameter was significantly higher in ISR with 3.50mm (IQR 3.0-3.5mm) compared to DNL with 2.50mm (2.00-2.50mm, p-value <0.001 ) While the number of DCBs used is rising over time (179 cases [38.7%] in 2015-2018, 283 cases [61.3%] in 2019-2021), the proportion of de novo lesions showed no significant difference (37/179 [20.7%] in 2015-2018, 61/282 [21.6%] in 2019-2021, p-value 0.806, Figure 1). Patients with DCB for ISR had significantly higher rates of arterial hypertension (ISR: 255 [76.1%], DNL: 57 [62.0%], both: 3 [50.0%], other: 20 [69.0%] p value 0.029), hyperlipidaemia (ISR: 228 [68.1%], DNL: 56 [60.9%], both: 2 [33.3%], other: 14 [48.3%], p value 0.041) and previous myocardial infarction (ISR: 231 [69.0%], DNL: 33 [35.9%], both: 2 [33.3%], other: 8 [27.6%], p-value <0.001). When analysing the outcomes, patients with DNL showed lower rates of acute myocardial infarction (8 [8.2%] vs 51 [15.0%]) as well as target lesion (6 [6.1%] vs 56 [16.5%]) and any revascularization (27 [27.6%] vs 122 [35.9%])%]), yet a higher rate of cardiovascular mortality (19 [5.6] vs 9 [9.2%]) during the follow up period compared to patients treated for ISR (Figure 2). Both groups showed a very low rate of target lesion thrombosis within 30 days after PCI (1 [1.0%] vs 1 [0.3%], p-value 0.745). Conclusions The use of DCB in PCIs is increasing, yet as we were able to emphasize with our data, they are primarily used in ISR as well as lesions with a small vessel diameter with favourable outcomes indicated by low event rates. Research should expand beyond small-vessel disease and ISR to assess safety and outcomes of DCB in DNL, larger vessels and bifurcation interventions with one stent to further assess its potential benefits in a wider field of indications.

The diagnostic role of myocardial work indices in stable coronary disease - global wasted work as a novel important non-invasive parameter?

Abstract Introduction Although the non-invasive diagnostic tools for stable coronary artery disease (CAD) have developed significantly over the past years, there is no resting parameter available to recognize functionally significant CAD. The role of the novel myocardial work index (myocardial work index - MWI) calculated by the pressure-strain loop created with the help of speckle-tracking analysis and blood pressure measurement in the diagnosis of ischemic heart disease is not yet fully clarified. In our research, we examined the parameters of myocardial work analysis in stable coronary disease patients. Purpose Clarification of the diagnostic role of the myocardial work analysis, in patients with stable coronary artery disease. Methods In our prospective, single-center study, we examined 13 patients who had at least moderate stenosis (≥50%) in one main coronary branch detected on coronary CTA. A fractional flow reserve (FFR) test was performed for functional coronary assessment. Based on this measurement, we divided our patients into FFRneg (FFR value>0.8) and FFRpos groups. Echocardiography was performed before coronary angiography in all patients. In addition to the standard echocardiographic parameters, global myocardial work index (GWI), global constructive work (GCW) and global wasted work (GWW) were calculated. In the case of the FFRpos group, we performed the above examination both before and after revascularization (2 months). Results Our results show that neither the standard parameters (GLS, EF), nor the GWI and GCW showed any difference between the FFRpos and FFRneg groups. However, there was a significant difference regarding GWW (172.3±21.8 FFRneg vs. 258.2±38.4 FFRpos, p=0.048) at baseline. In the case of the FFRpos group, the analysis of our data showed that there was no significant difference in EF, GLS, GWI and GWE parameters before and after revascularization. However, global wasted work (GWW) showed a significant improvement after revascularization (preGWW 258.2±38.4 vs. postGWW 139.5±14.5, p=0.041). NT-proBNP levels were normal in our patient population and we could not detect. Conclusion Based on our results, the GWW may be suitable for non-invasive assessment of the functional significance of stable coronary disease, as it showed a significant difference in the case of functionally significant and non-significant stenosis and improved after revascularization in patients with single-vessel CAD.

Rates of therapeutic interventions in a large real-world cohort with insertable cardiac monitors

Abstract Background Insertable cardiac monitors (ICMs) provide up to several years of continuous monitoring and have demonstrated high diagnostic yields for arrhythmia detection. However, the rates of arrhythmia-related therapeutic interventions following ICM implant have not been comprehensively characterized across indicated patient populations. Purpose To quantify rates of arrhythmia therapies in a large, real-world U.S. cohort of ICM patients. Methods De-identified patients receiving a Reveal LINQ ICM between Oct 1, 2016 – Sept 30, 2020 with no prior cardiac implantable electronic devices (CIEDs) and ≥1 year of follow-up in the Optum Clinformatics® Data Mart claims database were identified (N=17,037). Patients were stratified by indication for ICM placement: N=431 (2.5%) of patients were indicated for AF ablation monitoring, 2,193 (12.9%) for AF management, N=4,852 (28.5%) Cryptogenic stroke, N=1,252 (7.3%) Palpitations, 1,346 (7.9%) Suspected AF, 6,716 (39.4%) Unexplained syncope, and 247 (1.4%) Ventricular tachycardia (VT). Each patient was followed in the claims database after ICM insertion until end of continuous claims enrollment, end of database, or death. Therapeutic interventions for arrhythmias were characterized during follow-up, including procedures (CIED implants, cardioversion, and ablation) and arrhythmia medication initiation (antiarrhythmics, rate-control medications, and oral anticoagulants). Results Mean(SD) follow-up in the claims database post ICM placement was 3.4(1.3) years; 52.4% of patients were female, and mean age was 70.8(11.9) years. Overall, 54.5% of patients received a therapeutic intervention during follow-up, with 25.0% of patients receiving a therapeutic procedure and 44.0% initiating an arrhythmia-related medication (table). The highest procedure rates included implantable pulse generator (IPG) implants in the Unexplained syncope population (21.4% of patients) and cardiac ablations in the populations receiving ICM for known AF (27.8% of AF ablation monitoring patients and 23.5% of AF management patients). Medication initiation rates were highest for oral anticoagulants in the Cryptogenic stroke population (31.0% of patients). The mean time from ICM insertion to therapeutic action was 13(13) months for procedures and 7(11) months for medication initiation. Conclusions In a large sample of real-world ICM patients, more than half received a therapeutic intervention after ICM placement. Time to intervention was lengthy and showed substantial variability amongst patients, underscoring the importance of long-term continuous monitoring to uncover clinically-relevant arrhythmia findings.

Lipid-lowering therapy with Inclisiran in the real-world setting: initial data from a national health care service

Abstract Introduction Inclisiran, a first-in-class siRNA enabling long-term inhibition of PCSK9 synthesis, demonstrates good safety and efficacy profile in randomized clinical trials. Challenges for real-life use of inclisiran include limited access to therapy, injections by medical staff, lack of cardiovascular outcome data, and concern from adverse effects considering the novel mechanism and long-term activity. Real-life data on the potential to attain lipid-goals and reduce treatment gaps is lacking. We investigated the implementation of inclisiran in real-world clinical setting in Israel. Methods Data from a nationwide healthcare organization on patients initiating inclisiran therapy during the period of 3/2022-11/2023. Patients’ characteristics, efficacy, use of combination lipid-lowering therapies, and attainment of low-density lipoprotein cholesterol (LDL-C) goals, were evaluated. Results Inclisiran was initiated by 503 patients (57% women; mean age 66±11 years). Atherosclerotic cardiovascular disease was present in 54%, and peak historical LDL-C levels >190 mg/dL documented in 64%. Prior exposure to PCSK9 monoclonal antibodies was evident in 28%. Follow-up lipid profile >2 months after filling first prescription, was available in 397 patients (347 with ≥2 injections). In patients treated by inclisiran only (n=254), median LDL-C reduction from peak historical levels was 57% (IQR, 48%-67%), and from pre-injection levels 40% (19%-54%). In those with concomitant oral lipid-lowering therapies (n=143), median LDL-C reduction from peak levels was 66% (IQR, 55%-73%), and from pre-injection levels 46% (23%-59%) (Figure). LDL-C <70 mg/dL was attained by 39% and LDL-C <55 mg/dL by 21.9%. Of those treated with concomitant statin therapy, 38% attained LDL-C <55 mg/dL. Overall, 6.5% did not persist with inclisiran therapy after initial injection. Conclusions In real-life practice, inclisiran showed good efficacy with positive short-term adherence. However, attainment rates of lipid-goals were suboptimal due to limited use of combination lipid-lowering therapy and high-rates of severe hypercholesterolemia in our patient population cohort.Waterfall Plot of LDL-C (%) Reduction

Subclinical left ventricular dysfunction detected by speckle tracking echocardiography predicts mortality in COVID-19 patients

Abstract In COVID-19 patients, both preexisting cardiovascular disease and cardiac injury resulting from SARS-CoV-2 infection are associated with increased mortality. In this patient population the value of speckle tracking echocardiography (STE) for detecting high-risk patients has not been evaluated thoroughly. Aim The aim of study was to determine the prevalence of subclinical myocardial dysfunction revealed by STE and its association with in-hospital and two-year mortality in patients with COVID-19 and preserved left ventricular ejection fraction (LVEF). Methods The study group comprised 163 consecutive patients with preserved LVEF(>/=50%) and maintained right ventricular function evaluated by assessment of tricuspid annular plane systolic excursion (TAPSE >14 mm) hospitalized in the cardiology department due to COVID-19 in 2020 and 2021. All patients underwent transthoracic echocardiographic examination with off-line analysis using STE. Left ventricular global longitudinal strain(GLS), right ventricular global longitudinal strain (RV-GLS), right ventricular free wall strain(RV-FWS) and myocardial work parameters: global work index(GWI), global wasted work(GWW), global constructive work(GCW) and global work efficiency(GWE) were measured. The primary outcome was in-hospital and two-year mortality. Results 96 patients (mean age 66 years, 59 [61%] male) had adequate image quality to evaluate deformation-derived parameters.19 patients (19.8%) died during hospitalization and 9 (9,4%) patients died within two years after discharge. In-hospital non-survivors were older, had lower baseline oxygen saturation(SpO2) and had higher NTproBNP. In non-survivors STE revealed significant impairment of LV and RV function compared to the group of survivors(Table 1). The independent predictors of in-hospital death were: age (OR 1.1 [95% CI 1.01 – 1.19]), SpO2 on admission (OR 0.83 [95% CI 0.75 – 0.93]), NTproBNP (OR 1.0003 [95% CI 1.0001 – 1.0006]) and LV-GLS (OR 1.45 (1.06 – 1.99)]. Based on the analysis of the ROC curves, the cut-off points optimal for predicting in-hospital death were identified: age >71 years (sensitivity [sens.] 74%, specificity [spec.] 68%) , baseline SpO2 value ≤ 89% (sens. 89%, spec. 74%,) NTproBNP >951 pg/ml (sens. 79%, spec. 58%) and GLS >-16% (sens. 63%, spec. 89%). The independent predictors of two-year mortality were: age (OR 1.10 [95% CI 1.02 – 1.19]), Sp02 on admission (OR 0.82 [95% CI 0.73 – 0.91]) and NTproBNP (OR 1.0006 [95% CI 1.0001 – 1.0011]).Based on the ROC curve analysis, the cut-off points optimal for predicting death within 24 months after COVID-19 were also identified: age>71 years (sens. 71%; spec. 72%), Sp02 <89% (sens. 69%, spec. 73%), NTproBNP >520 pg/ml (sens. 89%, spec. 48%). Conclusions STE allows for the detection of subclinical myocardial dysfunction in COVID-19 patients with preserved LVEF. However, LV GLS is the only independent STE-based predictor of in-hospital mortality in this patient population.

Utility of venoarterial extracorporeal membrane oxygenation in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Background Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) continues to portend poor clinical prognosis and remains a major cause of morbidity and mortality. Although venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is frequently used in the treatment of AMI-CS, studies evaluating its benefit compared to percutaneous ventricular assist devices (pVAD) or standard medical therapy in this patient population have yielded conflicting results. Purpose The goal of this meta-analysis is to evaluate the use of ECMO compared to either pVAD or medical therapy with or without intra-aortic balloon counterpulsation (IABP) in patients presenting with AMI-CS. Methods A database search was performed for studies reporting on the association of ECMO compared to pVAD or medical therapy with or without IABP with clinical outcomes in patients with AMI-CS. The endpoints of interest were 30-day all-cause mortality and long term all-cause mortality. The databases searched included Pubmed, Web of Science, and Embase. The search was not restricted by time or publication status. Registry studies were excluded from this analysis. Results A total of 8 studies with 937 participants (447 treated with ECMO, 243 treated with pVAD, 247 treated with medical therapy with or without IABP) met inclusion criteria. Mean age was 63 years old, 80.5% were men, mean left ventricular ejection fraction was 26%, mean follow-up was 6.3 months (ranging 1-12 months). Treatment of AMI-CS patients with ECMO was not associated with lower risk of 30-day all-cause mortality compared to pVAD or standard medical therapy with or without IABP placement (OR 1.29, 95% CI 0.87-1.90; p=0.21; OR 0.58, 95% CI 0.25-1.35; p=0.13). Heterogenetic was low to moderate for each subgroup. Test for subgroup differences did not demonstrate statistically significant differences in the results for pVAD and for standard medical therapy with or without IABP (p=0.10, I2=64.1%). Compared to pVAD, ECMO was not associated lower risk of long-term mortality (OR 1.27, 95% CI 0.85-1.90; p=0.24). The heterogeneity for this analysis was low (I2=0%). Conclusion In patients presenting with AMI-CS, use of VA-ECMO is not associated with lower risk of mortality compared to pVAD or standard medical therapy with or without IABP placement. The risks and benefits of ECMO should be carefully considered compared to other forms of temporary mechanical circulatory support.Figure 1

Double product derived from exercise stress echocardiography (ESE) or dobutamine stress echocardiography (DSE) in patients with a history of breast cancer and radiotherapy (RXT) exposure and MACE

Abstract Background Breast cancer survivorship has markedly improved in the last two decades due to improved therapies. Among these, adjuvant chest radiotherapy stands out as an integral part of the current treatment. Chest radiotherapy can trigger accelerated atherosclerosis, which, coupled with cardiovascular (CV) risk factors common to this population, can lead to increased rates of coronary artery disease (CAD). ESC 2022 guidelines have established both Exercise Stress Echocardiography (ESE) and Dobutamine Stress Echocardiography (DSE) as cost-efficient and reliable tools for screening this patient population. Recommendations include ESE or DSE 5 years after radiotherapy as a screening tool. Double product (DP), an index common to both tests, parallels myocardial oxygen consumption. It has been used to predict major adverse cardiovascular events (MACE) in other cohorts. Purpose We sought to evaluate if DP could be used as a prognostic indicator for MACE (myocardial infarction, stroke, cardiovascular death, and heart failure) in this population. Methods Breast cancer patients treated with adjuvant radiotherapy from 2000 to 2022 were included. ESE or DSE was done after a mean of 5.4 years (1Q-2.2, 3Q-7.5) post-radiotherapy. Uni and multivariable adjusted Cox regression models were performed to evaluate the association between DP quartiles achieved and the risk of MACE in DSE and ESE groups. MACE-free survival among different quartiles was plotted with the Kaplan Meier method. Results 696 patients were included, with a mean age of 65 (SD 10.0) and 72 (SD 9.4) in ESE and DSE respectively. 61% of patients had ESE. In ESE, we observed increased rates of MACE in the 1st quartile when compared to the other quartiles (Figure 1a). On the other hand, univariate and multivariate Cox models established that for every increase of 1000 units of DP achieved during ESE, there is a risk-reduction of 9% [HR=0.91 (0.86-0.95); p=<0.01] in the future incidence of MACE, thus establishing DP as a protective marker. Additionally, advanced age was shown to be a major risk factor as well [HR=4.58 (1.91-10.9); p=<0.01]. In the DSE cohort however, the development of MACE was equally distributed across DP quartiles even after adjusting for existing comorbidities (Figure 1b). Cox analysis did not establish DP as a prognostic tool in this cohort (Table 1). Conclusion DP is established as an excellent prognostic tool for the detection of MACE in patients who underwent ESE. Patients who achieve higher DP quartiles during these tests have lower future rates of MACE. Regarding DSE, DP is not a good prognostic tool. This could be explained by higher burden of cardiovascular risk factors in this patient population. ESE should be recommended when possible.

CMR-derived pulmonary artery to aorta ratio as a predictor of adverse outcome in patients with cardiac transthyretin amyloidosis

Abstract Introduction Cardiac transthyretin amyloidosis (ATTR) represents a heart failure phenotype often accompanied by pulmonary hypertension. The pulmonary artery to aorta ratio (PA/Ao), as assessed on cardiac computed tomography or cardiac magnetic resonance (CMR), has demonstrated to indicate risk for adverse events in a variety of cardiovascular diseases, particularly in heart failure and pulmonary hypertension. However, its prognostic value in cardiac ATTR remains unknown. Aim We aimed to investigate the prognostic value of the PA/Ao ratio in patients with cardiac ATTR. Methods Data of consecutive patients diagnosed with cardiac ATTR undergoing CMR were prospectively collected. PA/Ao ratios were measured from CMRs using axial images (Figure 1A). Adverse outcome, defined as heart failure related hospitalizations and/or mortality, was recorded during follow-up. Results Among the 190 confirmed cardiac ATTR patients (mean age 76±11 years, 79% males), encompassing hereditary transthyretin (vATTR, n=22) and senile (wtATTR, n=168) types, the median pulmonary artery diameter was 28mm (IQR 25-31) and the median ascending aorta diameter was 35mm (IQR 33-39). Over the median follow-up period of 28 months (IQR 11-50 months), 84 (44%) patients experienced an adverse event. Kaplan Meier curves demonstrated an increased risk for adverse outcome in patients with PA/Ao ratios above the median of ≥0.8 (p<0.001 by log rank test, see Figure 1B). In univariate analysis, a high PA/Ao ratio was associated with adverse outcome (HR=10.3, 95% CI=2.59–41.1, p<0.001). When adjusted for age, sex, body mass index and right ventricular function, the PA/Ao ratio remained significantly related to adverse outcome (adj. HR=10.8, 95% CI=1.76–65.8, p=0.010). Conclusion A PA/Ao ratio ≥0.8 on CMR is associated with heart failure hospitalization and death in patients with cardiac ATTR. This threshold, notably lower than the commonly reported ≥1.0 in other patient populations, holds promise for future risk stratification.

Association of ticagrelor vs clopidogrel with net adverse clinical events in STEMI patients with mild thrombocytopenia

Abstract Backgrounds Current guidelines advocate for aspirin plus ticagrelor as the preferred dual antiplatelet therapy (DAPT) for ST-elevation myocardial infarction (STEMI). However, there is a lack of consensus or guidelines to direct clinicians on managing STEMI patients with mild thrombocytopenia, defined as a platelet count of 100~150×109/L. Purpose This study aims to investigate the association between ticagrelor and clopidogrel with ischemic and hemorrhagic events in STEMI patients with a platelet count of 100~150×109/L. Methods A retrospective cohort study was conducted using Health and Medical Big Data Super Platform from January 2010 to June 2023.The study included STEMI-patients with a platelet count of 100~150×109/L who received DAPT consisting of aspirin and a P2Y12 receptor antagonist (either clopidogrel or ticagrelor) All STEMI patients with a platelet count of 100~150×109/L were included in the analysis with a follow-up of at least one year. The inverse probability of treatment weighting (IPTW) approach based on propensity score was utilized to balance observed confounders between treatments. The primary endpoint was net adverse events (NACE) at 1 year, including ischemic events (recurrent myocardial infarction or ischemic stroke), Bleeding Academic Research Consortium (BARC) classification ≥ 3, and cardiac death. Secondary outcomes were cardiac death, recurrent myocardial infarction, and ischaemic stroke. Results The study cohort consisted 2941 participants with median age of 69 years, and 21.0% were female. Following adjustment using the inverse probability of treatment weighting, ticagrelor and clopidogrel demonstrated similar NACE (aHR, 0.86; 95%CI, 0.60-1.23). Cardiac death (aHR, 0.69; 95%CI, 0.36-1.31), recurrent myocardial infarction (aHR, 0.94; 95%CI, 0.50-1.78), and ischaemic stroke (aHR, 0.62; 95%CI, 0.34-1.14) did not significantly differ between the two groups. Conclusion In routine clinical practice, among STEMI patients with a platelet count of 100~150×109/L ticagrelor compared with clopidogrel, was not associated with a significant difference in the risk of NACE at 1 year. Further research is warranted to assess whether ticagrelor is more effective than clopidogrel in this particular patient population.

Using electronic health records in assessing the prevalence of hypertension in Kyrgyzstan

Abstract Background Non-communicable diseases are an increasing challenge in Kyrgyzstan as well as in other parts of Central Asia. However, there is very little epidemiological data on disease burden in the country. The development of electronic health records in primary health care provides an opportunity to assess the disease incidence and prevalence among patient population. Methods All patients with hypertension (HT) diagnoses (ICD-10 I10-I15) were identified from electronic health records used in primary health care in Kyrgyzstan from years 2021, 2022 and 2023 from all 7 regions and Bishkek and Osh cities (n = 132621-152743). Each year, all patients diagnosed with HT during that year or in previous years were included, while those who had passed away were excluded. The incidence and prevalence of patients was calculated using as denominator both the patients who had visited the services as well as registered patients. Results The prevalence of patients with hypertension calculated using patients with service use as denominator varied by region between 10.2% to 14.0% and was pretty stable during the observed period. The prevalence was the lowest in Chui region and the highest in Bishkek city. When the prevalence was calculated using the registered patient population the prevalence was only between 1.5% to 3.1%. Conclusions The observed prevalences were notably lower compared with data from WHO Steps surveys, which have reported a hypertension prevalence more than 40% among individuals aged 25 to 64. It is known that only approximately 25% of the population in Kyrgyzstan utilize primary healthcare services, with maternity care comprising the largest portion. This factor, coupled with cases that go undiagnosed, could potentially account for the observed low prevalence in electronic patient data. However, the electronic patient records provide useful information on diagnostics and disease burden in the country that can be used in developing the services. Key messages • Electronic health records have developed quickly in Kyrgyzstan and enable extraction of patient data from primary health care. • The low use of primary health care services complicates the use of register data in assessing the disease prevalences.

Associations between cardiac rehabilitation and clinical outcomes in patients with heart failure and cognitive frailty

Abstract Introduction Patients with heart failure (HF) often contend with various comorbidities, including cognitive impairment. Cognitive impairment has been increasingly recognised as cognitive frailty, which is reportedly associated with poor outcomes. On the other hand, cardiac rehabilitation (CR) for HF contributes to improved clinical outcomes. However, very few reports have examined whether CR is effective in patients with HF who have cognitive frailty. Purpose The present study aimed to investigate whether CR is associated with clinical outcomes in patients with HF, even in the presence of cognitive frailty. Methods This observational study analysed 1404 consecutive patients who admitted to a university hospital for the treatment of HF and received CR during hospitalisation. Patients who had dementia, did not perform the cognitive function evaluation, or died during hospitalisation were excluded from this study. All patients were encouraged to continue outpatient CR after hospital discharge. Cognitive function was assessed using the Mini-Cog© and a score ≤2 points was defined as the cognitive frailty. As physical function, quadriceps isometric strength (QIS) and 6-min walking distance (6MWD) were measured at the discharge and at the end of outpatient CR. The primary outcome was composite events, comprising all-cause death and re-admission due to HF. The secondary outcome was the change in physical function (ΔQIS and Δ6MWD) following outpatient CR. The association between participation in outpatient CR and composite events was assessed using the multivariate Cox proportional hazard models. We also compared the physical function changes between the presence or absence of cognitive frailty using analysis of covariance. Results The median age of the patients was 75 (interquartile range [IQR]: 66–81) years and 62.3% were males. Among them, 23.4% were identified as cognitive frailty. While 45.1% of overall population participated in outpatient CR, the cognitive frailty was relevant to a lower participation rate (P <0.001). Over a median follow-up period of 1.0 years (IQR: 0.3–2.4 years), a total of 544 composite events occurred. Participation in outpatient CR was associated with a reduced incidence of composite events in both the cognitive frailty and non-cognitive frailty, as well as in the overall patient population (Figure 1). Additionally, ΔQIS and Δ6MWD did not significantly differ between the cognitive frailty status (P = 0.655 and 0.573, respectively). Conclusions Participating in outpatient CR was linked to reduced rates of composite events and improved physical function in patients with HF, regardless of the presence or absence of cognitive frailty. Encouraging active participation in outpatient CR, even among patients with cognitive frailty, is essential as it is associated with favourable clinical outcomes.Survival analysisANCOVA

Plasma cytokines are associated with major adverse cardiovascular events in follow-up of patients undergoing carotid endarterectomy

Abstract Background Patients with carotid artery disease undergoing carotid endarterectomy (CEA) have a high risk of experiencing Major Adverse Cardiovascular Events (MACE) after surgery. The occurrence of MACE in CEA-treated patients is not predicted by common cardiovascular (CV) risk factors. Purpose We aimed to identify the association between plasma and plaque inflammatory cytokines and the incidence of MACE in the follow-up after CEA. We hypothesized that MACE is related to a higher level of circulating inflammatory cytokines at the time of surgery. Methods We prospectively enrolled patients with carotid artery disease undergoing CEA. Plasma and carotid plaques were collected during the surgery. Inflammatory cytokines (MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL-1beta/IL-1F2, IL-6, PDGF-AA, PDGF-AB/BB, TNF-alpha, VEGF) were measured in plasma and tissue homogenates using a customized 10-plex Luminex assay. Baseline demographics and clinical data for all the patients were extracted from electronic health records. MACE after CEA was defined as a composite measure of nonfatal cardiac events such as myocardial infarction with or without revascularization, cerebrovascular events (ischemic stroke, TIA, and amaurosis fugax), and all-cause mortality. Results Of 107 patients who underwent CEA with a median age of 73 (67-78) years, 57 (53.2%) experienced MACE during a median follow-up of 5.2 [2.2-9.3] years: 23 (40.3%) cardiac events, 9 (15.7%) CVA, and 25 (43.8%) all-cause mortality. Plaque cytokines levels did not differ between the groups with and without MACE in the follow-up after CEA. Instead, plasma cytokines were associated with MACE in the follow-up after CEA, as summarized in Figure 1. In the logistic regression analysis, plasma levels of MCP-1/CCL2, IFN-gamma, and TNF-alpha were independent predictors of MACE in follow-up post-CEA in univariate and multivariable models adjusted for CV risk factors such as age, BMI, systolic and diastolic blood pressure, low-density lipoprotein, high-density lipoprotein, and glucose level: MCP1/CCL2 (HR 1.009 [1.002-1.015]; p=0.007), IFN-gamma (HR 1.368 [1.014-1.845]; p=0.040), and TNF-alpha (HR 1.121 [1.022-1.228]; p=0.015) (Table 1). Conclusions Plasma levels of CCL2, IFN-gamma, and TNF-alpha are associated with the high incidence of MACE in the follow-up after CEA, indicating that these are potential biomarkers of MACE in this patient population and potential therapeutic targets in patients' progression of systemic atherosclerosis.Plasma cytokines and MACE after CEACytokines logistic regression analysis

Advanced Practice Registered Nurses Student Cross-Specialty Procedural Training: Effective Collaboration and Student Experience.

Intraprofessional simulation and training in acute care nursing specialties can generate synergies that will promote safe, quality patient care. Implementation of multiple intraprofessional simulations across the life span allowed for sharing of faculty and simulation resources. Simulations encompassed both adult and pediatric patients and consisted of airway skills, point-of-care ultrasound, and a multi-skills day encompassing vascular access experiences, chest tube placement, and lumbar puncture. During 5 years, 235 graduate students across three advanced practice nursing specialties participated in the intraprofessional simulation. Learner feedback showed improved confidence, benefit to future practice, and improved clinical judgment via these intraprofessional simulations. Future development of standardized and validated assessments to evaluate each skill will provide quantitative metrics for each clinical skill set and patient population. Further, additional initiatives will include both continuing and expanding intraprofessional simulation offerings, as well as developing interprofessional simulations with physician assistant and perfusionist colleagues. [J Nurs Educ. 2024;63(X):XXX-XXX.].

Antiplatelet Agents in Endovascular Neurointerventional Procedures

Minimally invasive, image-guided endovascular procedures are becoming increasingly prevalent as techniques and technologies have advanced, particularly within the realm of neurovascular interventions. Endovascular approaches ubiquitously result in endothelial injury with subsequent risk of thromboembolic complications. Periprocedural antiplatelet agent use is an integral component of the management of patients undergoing endovascular neurointerventional procedures. This patient population has a unique risk profile encompassing thromboembolic and hemorrhagic complications simultaneously, and the precise balance of these risks impacts patient outcomes almost as much as the interventional procedure itself. Clinical experience and study consensus demonstrate overall improved outcomes with the use of periprocedural antiplatelet agents, though current practices remain highly institution and practitioner-dependent. This focused review will discuss the major mechanisms of action of antiplatelet agents, and their clinical indications and management in the periprocedural neurointerventional setting. Despite the importance of antiplatelet agents in the management of neurointerventional patients, many questions remain. Further research and clinical expertise are needed to establish standardized, procedure-specific, antiplatelet regimens as well as standardized monitoring of antiplatelet agent regimen efficacy and safety.

Anticoagulation status and left atrial appendage occlusion indications in hospitalized cardiology patients with atrial fibrillation: a Hellenic Cardiorenal Morbidity Snapshot (HECMOS) sub-study

Abstract Background Proper use of oral anticoagulants is crucial in the management of non-valvular atrial fibrillation (NVAF) patients. Left atrial appendage occlusion (LAAC) may be considered for stroke prevention in patients with NVAF and contraindications for long-term anticoagulant treatment. Purpose We aimed to assess the anticoagulation status and LAAC indications in patients with NVAF from HECMOS (Hellenic Cardiorenal Morbidity Snapshot) survey. Methods HECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. HECMOS used an electronic platform to collect demographic and clinically relevant information from all patients hospitalized on March 3, 2022, in 55 different cardiology departments. In this substudy, we included patients with known AF without mechanical prosthetic valves and moderate to severe mitral valve stenosis. Patients with poor adherence to anticoagulants, high bleeding risk, previous major bleeding, and previous stroke were considered candidates for LAAC. Results Two hundred fifty-six patients (mean age 76.6±11.7, 148 males) were included in our analysis. Most of them (n=159; 62%) suffered from persistent AF. Mean CHA 2 DS 2 - VASc score was 4.28±1.7, while mean HAS-BLED score was 1.47±0.9. Three out of 3 patients with a CHA 2 DS 2 -VASc 0 or 1 (female) received improperly anticoagulants. Sixteen out of 18 patients with a CHA 2 DS 2 -VASc 1 or 2 (female) received anticoagulants. Thirty-three out of 235 patients with a CHA 2 DS 2 -VASc > 1 or 2 (for female) did not receive improperly anticoagulants. Among 221 under anticoagulant therapy, 191 (86.4%) received non-vitamin K antagonist oral anticoagulants (NOACs) and 30 (13.6%) received vitamin K antagonists. Relative indications for LAAC were present in 77 patients with NVAF (53 had only one risk factor, while 22 had two and 2 patients had three concurrent risk factors). In detail, 15 reported poor or no adherence to the anticoagulant therapy, 17 patients had a history of major bleeding, 36 had a prior stroke and 35 had a HAS-BLED score ≥3. No LAAC treatment was recorded. Conclusion Αnticoagulation status was nearly optimal in a high thromboembolic risk population of cardiology patients, mainly treated with NOACs. Three out of ten AF patients should be screened for LAAC.Anticoagulation by thrombotic riskPotential LAAC candidates