Cardiac Arrest Research Articles

Characteristics of Pediatric In-Hospital Cardiac Arrests and Resuscitation Duration

Cardiopulmonary resuscitation (CPR) duration is associated with cardiac arrest survival. To describe characteristics associated with CPR duration among hospitalized children without return of circulation (ROC) (patient-level analysis) and determine whether hospital median CPR duration in patients without ROC is associated with survival (hospital-level analysis). This retrospective cohort study of patients undergoing pediatric in-hospital CPR between January 1, 2000, and December 31, 2021, used data from the Get With the Guidelines-Resuscitation registry. Children receiving chest compressions for at least 2 minutes and/or defibrillation were included in the patient-level analysis. For the hospital-level analysis, sites with at least 20 total events and at least 5 events without ROC were included. Data were analyzed from December 1, 2022, to November 15, 2023. For the patient-level analysis, the exposure was CPR duration in patients without ROC. For the hospital-level analysis, the exposure was quartile of median CPR duration in events without ROC at each hospital. For the patient-level analysis, outcomes were patient and event factors, including race and ethnicity and event location; we used a multivariable hierarchical linear regression model to assess factors associated with CPR duration in patients without ROC. For the hospital-level analysis, the main outcome was survival to discharge among all site events; we used a random intercept multivariable hierarchical logistic regression model to examine the association between hospital quartile of CPR duration and survival to discharge. Of 13 899 events, 3859 patients did not have ROC (median age, 7 months [IQR, 0 months to 7 years]; 2175 boys [56%]). Among event nonsurvivors, median CPR duration was longer in those with initial rhythms of bradycardia with poor perfusion (8.37 [95% CI, 5.70-11.03] minutes; P < .001), pulseless electrical activity (8.22 [95% CI, 5.44-11.00] minutes; P < .001), and pulseless ventricular tachycardia (6.17 [95% CI, 0.09-12.26] minutes; P = .047) (vs asystole). Shorter median CPR duration was associated with neonates compared with older children (-4.86 [95% CI, -8.88 to -0.84] minutes; P = .02), emergency department compared with pediatric intensive car7 e unit location (-4.02 [95% CI, -7.48 to -0.57] minutes; P = .02), and members of racial or ethnic minority groups compared with White patients (-3.67 [95% CI, -6.18 to -1.17]; P = .004). Among all CPR events, the adjusted odds of survival to discharge differed based on hospital quartile of median CPR duration among events without ROC; compared with quartile 1 (15.0-25.9 minutes), the adjusted odds ratio for quartile 2 (26.0-29.4 minutes) was 1.22 (95% CI, 1.09-1.36; P < .001); for quartile 3 (29.5-32.9 minutes), 1.23 (95% CI, 1.08-1.39; P = .002); and for quartile 4 (33.0-53.0 minutes), 1.04 (95% CI, 0.91-1.19; P = .58). In this retrospective cohort study of pediatric in-hospital CPR, several factors, including age and event location, were associated with CPR duration in event nonsurvivors. The odds of survival to discharge were lower for patients at hospitals with the shortest and longest median CPR durations among events without ROC. Further studies are needed to determine the optimal duration of CPR during pediatric in-hospital cardiac arrest and to provide training guidelines for resuscitation teams to eliminate disparities in resuscitation care.

Drug-Eluting Balloons and Drug-Eluting Stents in Diabetic Patients Undergoing Percutaneous Coronary Intervention Due to Restenosis—DM-Dragon Registry

Background: The rate of in-stent restenosis (ISR) is decreasing; however, it is still a challenge for contemporary invasive cardiologists. Therapeutic methods, including drug-eluting balloons (DEBs), intravascular lithotripsy, excimer laser coronary atherectomy, and imaging-guided percutaneous coronary intervention (PCI) with drug-eluting stents (DES), have been implemented. Patients with diabetes mellitus (DM) are burdened with a higher risk of ISR than the general population. Aims: DM-Dragon is aimed at evaluating the clinical outcomes of ISR treatment with DEBs vs. DES, focusing on patients with co-existing diabetes mellitus. Methods: The DM-Dragon registry is a retrospective study comprising data from nine high-volume PCI centers in Poland. A total of 1117 patients, of whom 473 individuals had DM and were treated with PCI due to ISR, were included. After propensity-score matching (PSM), 198 pairs were created for further analysis. The primary outcome of the study was target lesion revascularization (TLR). Results: In DM patients after PSM, TLR occurred in 21 (10.61%) vs. 20 (10.1%) in non-diabetic patients, p = 0.8690. Rates of target vessel revascularization (TVR), target vessel myocardial infarction, device-oriented composite endpoint (DOCE), and cardiac death did not differ significantly. Among diabetic patients, the risk of all-cause mortality was significantly lower in the DEB group (2.78% vs. 11.11%, HR 3.67 (95% confidence interval, CI) [1.01–13.3), p = 0.0483). Conclusions: PCI with DEBs is almost as effective as DES implantation in DM patients treated for ISR. In DM-Dragon, the rate of all-cause death was significantly lower in patients treated with DEBs. Further large-scale, randomized clinical trials would be needed to support these findings.

Bivalirudin Versus Heparin Monotherapy in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Study-level Meta-analysis of Randomized Controlled Trials.

The present meta-analysis focused on investigating whether bivalirudin plus post-PCI infusion was safer and more effective than heparin monotherapy in patients who developed ST-segment elevation myocardial infarction (STEMI) and who underwent primary percutaneous coronary intervention (PCI). The PubMed, EMBASE, Cochrane Library, and Web of Science databases were systemically searched to identify randomized controlled trials (RCTs) comparing bivalirudin and heparin for treating STEMI patients who underwent primary PCI. The Cochrane quality assessment tool was used to assess the quality of the enrolled studies. The primary and secondary outcomes included net adverse clinical events (NACEs, comprising all-cause death or major bleeding), major adverse cardiovascular events (MACEs, comprising all-cause death, stroke, MI, and TVR), in-stent thrombosis (IST), and bleeding of Bleeding Academic Research Consortium (BARC) types 2, 3, and 5. The four RCTs, comprising 10,695 events, included 5350 patients who received bivalirudin combined with post-PCI infusion and 5345 patients who received heparin monotherapy. Compared with those in the heparin group, the number of NACEs (RR 0.84, 95% CI 0.73-0.96, P = 0.009), MACEs (RR 0.82, 95% CI 0.67-0.99, P = 0.04), and ISTs (RR 0.66, 95% CI 0.49-0.91, P < 0.0001) in the bivalirudin group was significantly lower. There were no significant differences in all-cause death, cardiac death, stroke, MI, TVR, or BARC type 2, 3, or 5 bleeding between the two groups. In STEMI patients undergoing primary PCI, bivalirudin plus post-PCI infusion significantly reduced the incidence of NACEs, MACEs, and ISTs compared with heparin monotherapy, without increasing the risk of MI or TVR. Bivalirudin may also contribute to a potential reduction in stroke, death, and BARC type 2, 3, and 5 bleeding rates.

Vitamin-K antagonist versus dual antiplatelet therapy in management of isolated and non-obstructive atherosclerotic coronary artery ectasia

BackgroundTreatment of isolated and non-obstructive atherosclerotic coronary artery ectasia (CAE) is still controversial. AimTo assess the efficacy and safety of vitamin-K antagonist (VKA) versus dual antiplatelet (DAPT) therapy in management of patients with isolated and non-obstructive atherosclerotic CAE. MethodsWe prospectively enrolled 79 patients diagnosed on elective coronary angiography to have either isolated CAE or non-obstructive atherosclerotic CAE. Patients were assigned in 1:1 pattern to receive either VKA (warfarin) or DAPT (aspirin plus clopidogrel). Patients were followed-up for nine-months. The primary endpoint was the cumulative events rate including acute coronary event, target vessel intervention, or cardiac death. Analysis of cumulative events at different time intervals, its individual components, and bleeding were considered secondary endpoints. ResultsCumulative events rate was 33%, with mortality rate of 2.5%. Both treatment groups showed comparable cumulative events during the nine-months follow-up duration. Nevertheless, Kaplan-Meier analysis beyond the first 3-months of follow-up showed significantly higher event-free survival among the VKA-group. Recurrent events (≥2) were significantly higher among the DAPT-group. Both groups showed no major bleeding events. Multivariable cox-regression analysis showed that presence of significant coronary tortuosity, use of DAPT in reference to VKA, and lower percent time in therapeutic range (%TTR) among those receiving VKA were significant independent predictors of clinical adverse events beyond the first 3-months of follow-up. ConclusionCumulative adverse events were comparable among both treatment groups for isolated non-obstructive CAE. However, adverse events were significantly more frequent in the DAPT-group beyond the first three months.

Management of Ventricular Arrhythmias in Heart Failure: Can Less Be More?

Ventricular arrhythmias (VAs) affect many patients with heart failure and underlying structural heart disease and are associated with significant morbidity and mortality. Antiarrhythmic drugs are often the initial treatment, but medication alone often fails to sufficiently suppress VAs. While catheter ablation (CA) remains the gold standard for treatment of VAs, CA is an invasive procedure and can be associated with periprocedural complications including acute clinical decompensation. Thus, there is an important need for alternative therapies. Recent advances in risk stratification and the development of new ablation technologies may reduce some of the periprocedural complications and limitations of CA. In addition, less invasive therapies for VAs may provide an alternative treatment strategy for patients in both the acute and chronic setting. For patients acutely admitted with ventricular tachycardia electrical storm (VT-ES) or recurrent VT and cardiogenic shock, risk stratification tools have been developed to identify patients at high risk of acute hemodynamic decompensation during CA. These patients require a multidisciplinary approach and might need mechanical circulatory support (MCS) if CA is selected as the treatment strategy. Alternatively, less invasive therapies targeting the autonomic nervous system may be reasonable. In the chronic setting, developments in medical therapy have reduced the risk of sudden cardiac death in heart failure patients and stereotactic whole-body radiation (SBRT) has evolved as a potential, non-invasive therapy. Further research is needed to personalize VA therapy for individual patients.

Sex disparities in cardiac sarcoidosis patients undergoing implantable cardioverter-defibrillator implantation.

In patients with cardiac sarcoidosis (CS), implantable cardioverter-defibrillators (ICDs) are important for preventing sudden cardiac death. This study aimed to investigate sex disparities in CS patients undergoing ICD implantation. The 2016-2020 National Inpatient Sample (NIS) database compared the characteristics and outcomes of males and females with CS receiving ICDs. Among 760 CS patients who underwent inpatient ICD implantation, 66.4% were male. Males were younger (55.0vs. 56.9 years, p<.01), had higher rates of diabetes (31.7%vs. 21.6%, p<.01) and chronic kidney disease (CKD) (16.8%vs. 7.8%, p<.01) but lower prevalence of atrial fibrillation (AF) (11.9%vs. 23.5%, p<.01), sick sinus syndrome (4.0%vs. 7.8%, p=.024), ventricular fibrillation (VF) (9.9%vs. 15.7%, p=.02), and black ancestry (31.9%vs. 58.0%, p<.01). Unadjusted major adverse cardiovascular events (MACE), defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke, was higher in females (11.8%vs. 6.9%, p=.024), but when adjusted for age and tCharlson Comorbidity Index (CCI), females demonstrated significantly lower odds of experiencing MACE (aOR: 0.048, 95% CI: 0.006-0.395, p=.005). Incidence of acute kidney injury (AKI) post-ICD was significantly lower in females (15.7%vs. 23.8%, p=.01) as was the adjusted odds (aOR: 0.282, 95% CI: 0.146-0.546, p<.01). There was comparable mean length of stay and hospital charges. ICD utilization in CS patients is more common among males, who have a higher prevalence of diabetes and CKD but a lower prevalence of AF, sick sinus syndrome, and VF. Adjusted MACE and AKI were significantly lower in females.

Utilizing a sutureless valve for prosthetic valve endocarditis after aortic root replacement

BackgroundReoperation following aortic root replacement is associated with significantly high operative mortality. Etiologies related to infection are known to increase the operative mortality rate more than other etiologies. In such a clinical setting, a sutureless valve could lower the operative mortality by shortening the cardiac arrest and the operative time.Case presentationA 61-year-old male underwent emergent aortic root and total arch replacement with an open stent graft for acute type-A aortic dissection. A bioprosthetic valve was employed for aortic root replacement using the double-sewing ring technique. A fungal infection by Candida parapsilosis was postoperatively detected and improved with intravenous antifungal drug administration. However, he developed congestive heart failure one year later, and the blood cultures turned positive repeatedly for Candida parapsilosis. The prosthetic valve infection was suspected upon identifying vegetation on the bioprosthetic valve through transthoracic echocardiography. The computed tomography scan and operative findings confirmed that the infection was localized on the prosthetic valve. Consequently, the infected valve was removed without a vascular conduit, and a sutureless valve was implanted. The postoperative course was uneventful, without any evidence of recurrent fungal infection, and the patient was discharged on postoperative day 28.ConclusionsDeploying a sutureless valve can facilitate a more straightforward and minimally invasive redo procedure. Preoperative computed tomography can predict the valve size, which is the key to implanting a sutureless valve successfully after the modified Bentall procedure.

Hypertrophic Cardiomyopathy Unmasked: The Hidden Danger of Left Ventricular Apical Aneurysm through Coronary Embolization

Hypertrophic Cardiomyopathy (HCM) is a genetic heart disease characterized by left ventricular (LV) hypertrophy, with outcomes ranging from asymptomatic to sudden cardiac death (SCD). Accurate diagnosis and risk stratification are essential. This case report discusses a 52-year-old female with family history of sudden deaths, presenting with acute coronary syndrome symptoms. Investigations revealed atrial fibrillation, ST-elevation, and a thrombus in the left anterior descending artery (LAD). Echocardiography and cardiac CT confirmed a left ventricular apical aneurysm, multiple apical thrombus, and hypertrophic septal wall with systolic LV dysfunction. The report highlights the risk of thromboembolic events and SCD in patients with LV apical aneurysms. Meta-analyses and guidelines emphasize the importance of integrating risk markers like LV apical aneurysms and late gadolinium enhancement into clinical assessments. Given the patient’s family history, aneurysm, and LV dysfunction, primary SCD prevention with an implantable cardioverter-defibrillator (ICD) was deemed suitable. HCM patients with LV apical aneurysms represent a high-risk phenotype requiring comprehensive management, including SCD and stroke prevention.

Persistent gender gaps in out-of-hospital cardiac arrest in Spain from 2013 through 2018

Persistent gender gaps in out-of-hospital cardiac arrest in Spain from 2013 through 2018

Time to initiation of extracorporeal membrane oxygenation in conventional cardiopulmonary resuscitation affects the patient survival prognosis.

Cardiopulmonary resuscitation (CPR) is the cornerstone intervention for cardiac arrest, with extracorporeal CPR (ECPR) demonstrating enhanced survival and neurologic outcomes in in-hospital cardiac arrest. This study explores the time interval between CPR initiation and the onset of extracorporeal membrane oxygenation (ECMO) in ECPR recipients, investigating its impact on survival outcomes. This retrospective analysis included 1950 adults who received CPR at a single medical center between March 2019 and April 2023. Data from 198 adult patients who had ECMO inserted during CPR were analyzed. The interval from CPR initiation to ECMO initiation was quantified and categorized as ≤20, 20-40, and >40min. Cox regression analysis assessed associations between CPR-to-ECMO time and short- and long-term mortalities. Among the 198 patients who underwent ECPR, 116 (58.6%) experienced 30-day mortality. Initiation of ECMO within 20min occurred in 46 (23.2%), whereas 74 (37.4%) had ECMO initiated after 40min. Cox regression revealed a significant association between time from CPR to ECMO initiation and 30-day mortality (adjusted hazard ratio [HR]: 2.20 in >40min, HR: 2.63 in 20-40min, p=0.006) and 6-month mortality (HR: 1.81, in >40min, HR: 1.99 in 20-40min, p=0.021). This study revealed that, in ECPR recipients, a shorter duration between CPR initiation and ECMO flow commencement is associated with improved short- and long-term patient prognoses. These findings emphasize the critical role of timely ECMO application in optimizing outcomes for patients undergoing ECPR.

Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome (ACS) is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited. The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI. After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, p = 0.05) and hospital survival, 56.4% vs 32.4%, p = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favorable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, p = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (p = 0.07). In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.

Incidence and predictors of adverse outcomes in patients with rheumatic mitral stenosis following percutaneous balloon mitral valvuloplasty: a study from a tertiary center in Thailand

BackgroundRheumatic mitral stenosis (MS) remains a common and concerning health problem in Asia. Percutaneous balloon mitral valvuloplasty (PBMV) is the standard treatment for patients with symptomatic severe MS and favorable valve morphology. However, studies on the incidence and predictors of adverse cardiac outcomes following PBMV in Asia have been limited. This study aims to evaluate the incidence and predictors of adverse outcomes in patients with rheumatic MS following PBMV.MethodsA retrospective cohort study was conducted on patients with symptomatic severe MS who underwent successful PBMV between 2002 and 2020 at a tertiary academic institute in Thailand. Patients were followed up to assess adverse outcomes, defined as a composite of cardiac death, heart failure hospitalization, repeat PBMV, or mitral valve surgery. Univariable and multivariable analyses were performed to identify predictors of adverse outcomes. A p-value of < 0.05 was considered statistically significant.ResultsA total of 379 patients were included in the study (mean age 43 ± 11 years, 80% female). During a median follow-up of 5.9 years (IQR 1.7–11.7), 74 patients (19.5%) experienced adverse outcomes, with an annualized event rate of 2.7%. Multivariable analysis showed that age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.008–1.05, p = 0.006), significant tricuspid regurgitation (HR 2.17, 95% CI 1.33–3.56, p = 0.002), immediate post-PBMV mitral valve area (HR 0.39, 95% CI 0.25–0.64, p = 0.01), and immediate post-PBMV mitral regurgitation (HR 1.91, 95% CI 1.18–3.07, p = 0.008) were independent predictors of adverse outcomes.ConclusionsIn patients with symptomatic severe rheumatic MS, the incidence of adverse outcomes following PBMV was 2.7% per year. Age, significant tricuspid regurgitation, immediate post-PBMV mitral valve area, and immediate post-PBMV mitral regurgitation were identified as independent predictors of these adverse outcomes.

The prevalence of complicated cervical injuries in near-hanging patients without abnormal levels of consciousness or neck signs

BackgroundCervical injuries are important complications of near-hanging, which is defined as self-injury by hanging if the patient survives at admission. Previous studies have reported that complicated cervical injuries due to near-hanging are uncommon. The primary aim of this study was to evaluate whether cervical imaging can be safely omitted for near-hanging patients who are alert and have no abnormal neck symptoms or signs. MethodsThis was a retrospective observational study to investigate the prevalence of cervical injuries among hospitalized near-hanging patients between April 2014 and June 2023. The primary outcome was the prevalence of any complicated cervical injuries, which included laryngeal fractures, laryngeal deviations, spinal cord injuries, cervical spine fractures, and blunt cerebrovascular injuries. The primary aim of this study was to determine the primary outcome among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. ResultsDuring the study period, a total of 63 near-hanging patients were hospitalized. Of these, 11 patients (18%) with normal levels of consciousness and no neck symptoms or signs at admission were included. The median age of the patients was 37 years (IQR 27 to 53); 5 (45%) were women, and none had cardiac arrest at the scene. For the primary outcome, no complicated cervical injuries (0%; 95% CI, 0% to 27%) occurred among the small number of near-hanging patients who had normal levels of consciousness and no abnormal neck symptoms or signs at admission. ConclusionsThere were no cases of complicated cervical injuries among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. Further prospective multicenter studies are warranted to investigate whether cervical imaging can be safely omitted in assessments of these patients.

Early outcomes of total arch replacement in the treatment of aortic dissection

Abstract: Overview: Aortic dissection are severe pathologies with high mortality and complication rates post-surgery despite significant advancements in both diagnosis and surgical treatment. Aortic arch replacement surgery is a classic and highly effective treatment method at Cho Ray Hospital. Objectives: Describe clinical, paraclinical characteristics, postoperative results, general complications and early hospital mortality. Methods: Descriptive cross sectional study. Results: 102 patients underwent aortic arch replacement surgery due to aortic dissection. Males predominated at 72.5%. The male:female ratio was 2.5:1. The average age was 56.45 ± 11.79 years. A history of hypertension was present in 81.4% of cases. Most patients with aortic dissection were admitted in an acute condition, accounting for 95%. Patients with type A aortic dissection accounted for 87.3%, with the entry tear in the ascending aorta at 27.5%. Isolated aortic arch replacement was performed in 46.1% of patients, while 53.9% underwent aortic arch replacement with frozen elephant trunk technique. 7 patients required aortic root replacement, 7 needed aortic valve surgery, and 10 required CABG. Most patients were cooled to 25 degrees C with cerebral perfusion to three branches. Ascending aorta cannulation was established in 45.2% of cases. The average cardiopulmonary bypass time was 257.7 minutes, with selective cerebral perfusion time at 115.9 minutes and lower body circulatory arrest time averaging 57.2 minutes. Postoperative neurological complications occurred in 10.8%, and the rate of renal failure requiring dialysis was 17.8%. The mortality rate was 9.6%. Longer cardiopulmonary bypass times and body temperatures above 25 degrees significantly increased the rate of postoperative renal failure requiring dialysis. Patients with postoperative renal failure requiring dialysis had a statistically significant increase in postoperative mortality rates. Aortic root intervention surgery combined with arch replacement did not affect the rate of postoperative complications. Aortic arch replacement with frozen elephant trunk technique did not affect cardiopulmonary bypass time, clamping time, or the rate of postoperative complications. Conclusions: Total arch replacement at Cho Ray Hospital initially showed a safe and effective with acceptable mortality rate.

Evaluating the effectiveness of a sliding window technique in machine learning models for mortality prediction in ICU cardiac arrest patients

Extensive research has been devoted to predicting ICU mortality, to assist clinical teams managing critical patients. Electronic health records (EHR) contain both static and dynamic medical data, with the latter accumulating during ICU stays. Existing models often rely on a fixed time window (e.g., first 24 h) for prediction, potentially missing vital post-24-hour data. The present study aims to improve mortality prediction for ICU patients following Cardiac Arrest (CA) using a dynamic sliding window approach that accommodates evolving data characteristics.Our cohort included 2331 CA patients, of whom 684 died in the ICU and 1647 survived. Applying the sliding window technique, we created six different time windows and used each separately for model training and validation. We compared our results to a baseline accumulative window.The different time windows created by the sliding window technique differed in their prediction performance and outperformed the baseline 24-hour window significantly. The XGBoost model outperformed all other models, with the 30–42 h time window achieving the best results (AUC = 0.8, accuracy = 0.77).Our work shows that the sliding window technique is effective in improving mortality prediction. We demonstrated how important time-window selection is and showed that enhancing it can save time and thus improve mortality prediction. These findings promise to improve the clinical team’s efficiency in prioritizing patients and giving greater attention to higher-risk patients.To conclude, mortality prediction in the ICU can be improved if we consider alternative time windows instead of the 24-hour window, which is currently the most widely accepted among scoring systems today.

Cerebrovascular events and thrombolysis in pulmonary embolism-induced cardiac arrest: a case series and key challenges

Background and purposeCerebrovascular events during thrombolysis in cardiac arrest (CA) caused by pulmonary embolism (PE) is a life-threatening condition. However, the balance between cerebrovascular events and thrombolytic therapy in PE-induced CA remains a great challenge.MethodsIn this study, we reported three unique cases regarding main concerns surrounding cerebrovascular events in thrombolytic therapy in PE-induced CA.ResultsThe patient in the case 1 treated with thrombolysis during CPR and finally discharged neurologically intact. The patient in the case 2 received delayed thrombolysis and died eventually. The patient in the case 3 was contraindicated to thrombolysis due to the complication of subarachioid hemorrahage and died within days.ConclusionsOur case series highlights three proposed approaches to consider before administering thrombolysis as a treatment option in PE-induced CA patients: (1) prolonging the resuscitation, (2) administering thrombolysis promptly, and (3) ruling out cerebrovascular events.

Comparative effectiveness of ultrathin vs. standard strut drug-eluting stents: insights from a large-scale meta-analysis with extended follow-up

BackgroundNewer generation ultrathin strut stents are associated with less incidence of target lesion failure (TLF) in patients undergoing percutaneous coronary intervention (PCI) in the short term. However, its long-term effect on different cardiovascular outcomes remains unknown.ObjectivesWe aim to identify the effects of newer-generation ultrathin-strut stents vs. standard thickness second-generation drug-eluting stents (DES) on long-term outcomes of revascularization in coronary artery disease.MethodsWe searched PubMed, Web of Science, Cochrane Library databases, and Scopus for randomized controlled trials (RCTs) and registries that compare newer-generation ultrathin-strut (< 70 mm) with thicker strut (> 70 mm) DES to evaluate cardioprotective effects over a period of up to 5 years. Primary outcome was TLF, a composite of cardiac death, target vessel myocardial infarction (TVMI) or target lesion revascularization (TLR). Secondary outcomes included the components of TLF, stent thrombosis (ST), and all-cause death were pooled as the standardized mean difference between the two groups from baseline to endpoint.ResultsWe included 19 RCTs and two prospective registries (103,101 patients) in this analysis. The overall effect on the primary outcome was in favor of second-generation ultrathin struts stents in terms of TLF at ≥ 1 year, ≥ 2 years, and ≥ 3 years (P value = 0.01, 95% CI [0.75, 0.96]), P value = 0.003, 95% CI [0.77, 0.95]), P value = 0.007, 95% CI [0.76, 0.96]), respectively. However, there was no reported benefit in terms of TLF when we compared the two groups at ≥ 5 years (P value = 0.21), 95% CI [0.85, 1.04]). Some of the reported components of the primary and secondary outcomes, such as TLR, target vessel revascularization (TVR), and TVMI, showed the same pattern as the TLF outcome.ConclusionUltrathin-strut DES showed a beneficial effect over thicker strut stents for up to 3 years. However, at the 5-year follow-up, the ultrathin strut did not differ in terms of TLF, TLR, TVR, and TVMI compared with standard-thickness DES, with similar risks of patient-oriented composite endpoint (POCE), MI, ST, cardiac death, and all-cause mortality.

Impact of depression on in-hospital outcomes for adults with type 2 myocardial infarction: A United States population-based analysis.

Type 2 myocardial infarction (T2MI) is an ischemic myocardial injury in the context of oxygen supply/demand mismatch in the absence of a primary coronary event. However, though there is a rising prevalence of depression and its potential association with type 1 myocardial infarction (T1MI), data remains non-existent to evaluate the association with T2MI. To identify the prevalence and risk of T2MI in adults with depression and its impact on the in-hospital outcomes. We queried the National Inpatient Sample (2019) to identify T2MI hospitalizations using Internal Classification of Diseases-10 codes in hospitalized adults (≥ 18 years). In addition, we compared sociodemographic and comorbidities in the T2MI cohort with vs without comorbid depression. Finally, we used multivariate regression analysis to study the odds of T2MI hospitalizations with vs without depression and in-hospital outcomes (all-cause mortality, cardiogenic shock, cardiac arrest, and stroke), adjusting for confounders. Statistical significance was achieved with a P value of < 0.05. There were 331145 adult T2MI hospitalizations after excluding T1MI (median age: 73 years, 52.8% male, 69.9% white); 41405 (12.5%) had depression, the remainder; 289740 did not have depression. Multivariate analysis revealed lower odds of T2MI in patients with depression vs without [adjusted odds ratio (aOR) = 0.88, 95% confidence interval (CI): 0.86-0.90, P = 0.001]. There was the equal prevalence of prior MI with any revascularization and a similar prevalence of peripheral vascular disease in the cohorts with depression vs without depression. There is a greater prevalence of stroke in patients with depression (10.1%) vs those without (8.6%). There was a slightly higher prevalence of hyperlipidemia in patients with depression vs without depression (56.5% vs 48.9%), as well as obesity (21.3% vs 17.9%). There was generally equal prevalence of hypertension and type 2 diabetes mellitus in both cohorts. There was no significant difference in elective and non-elective admissions frequency between cohorts. Patients with depression vs without depression also showed a lower risk of all-cause mortality (aOR = 0.75, 95%CI: 0.67-0.83, P = 0.001), cardiogenic shock (aOR = 0.65, 95%CI: 0.56-0.76, P = 0.001), cardiac arrest (aOR = 0.77, 95%CI: 0.67-0.89, P = 0.001) as well as stroke (aOR = 0.79, 95%CI: 0.70-0.89, P = 0.001). This study revealed a significantly lower risk of T2MI in patients with depression compared to patients without depression by decreasing adverse in-hospital outcomes such as all-cause mortality, cardiogenic shock, cardiac arrest, and stroke in patients with depression.

Rapid and non-invasive diagnosis of hyperkalemia in patients with systolic myocardial failure using a model based on machine learning algorithms

ABSTRACT Background: Hyperkalemia is a potentially life-threatening electrolyte disturbance that if not diagnosed on time may lead to devastating conditions and sudden cardiac death. Blood sampling for potassium level checks is time-consuming and can delay the treatment of severe hyperkalemia on time. So, we propose a non-invasive method for correct and rapid hyperkalemia detection. Methods: The cardiac signal of patients referred to the Pediatrics Emergency room of Shahid Rejaee Hospital was measured by a 12-lead Philips electrocardiogram (ECG) device. Immediately, the blood samples of the patients were sent to the laboratory for potassium serum level determination. We defined 16 features for each cardiac signal at lead 2 and extracted them automatically using the algorithm developed. With the help of the principal component analysis (PCA) algorithm, the dimension reduction operation was performed. The algorithms of decision tree (DT), random forest (RF), logistic regression, and support vector machine (SVM) were used to classify serum potassium levels. Finally, we used the receiver operation characteristic (ROC) curve to display the results Results: In the period of 5 months, 126 patients with a serum level above 4.5 (hyperkalemia) and 152 patients with a serum potassium level below 4.5 (normal potassium) were included in the study. Classification with the help of a RF algorithm has the best result. Accuracy, Precision, Recall, F1, and area under the curve (AUC) of this algorithm are 0.71, 0.87, 0.53, 0.66, and 0.69, respectively Conclusions: A lead2-based RF classification model may help clinicians to rapidly detect severe dyskalemias as a non-invasive method and prevent life-threatening cardiac conditions due to hyperkalemia.

Serum lactate/creatinine ratio and acute kidney injury in cardiac arrest patients

ObjectivesSerum lactate and creatinine levels upon admission in cardiac arrest (CA) patients significantly correlate with acute kidney injury (AKI) post-restoration of autonomic circulation. However, the association between serum lactate/creatinine ratio (LCR) and AKI in this population remains unclear. This study aimed to explore the relationship between LCR at admission and cardiac arrest-associated acute kidney injury (CA-AKI). Design and methodsWe conducted a secondary analysis of previously published data on CA patient resuscitation, categorizing them into tertiles based on LCR levels. Univariate and multivariate logistic regression models and subgroup analyses were employed to investigate the association between LCR and CA-AKI. Non-linear correlations were explored using restricted cubic splines, and a two-piece wise logistic proportional hazards model for both sides of the inflection point was constructed. ResultsA total of 374 patients (72.19 % male) were included, with intensive care unit mortality, in-hospital mortality, and neurologic dysfunction rates of 51.87 %, 56.95 %, and 39.57 %, respectively. The overall CA-AKI incidence was 59.09 %. Multivariate logistic proportional hazards analysis revealed a negative association between LCR and CA-AKI incidence (adjusted odds ratio [OR] 0.85, 95 % confidence intervals [CI] = 0.78–0.93, P=0.001). Triple spline restriction analysis depicted an L-shaped correlation between baseline LCR and CA-AKI incidence. Particularly, a baseline LCR<0.051 was negatively associated with CA-AKI incidence (OR 0.494, 95 % CI=0.319–0.764, P=0.002). Beyond the LCR turning point, estimated dose–response curves remained consistent with a horizontal line. ConclusionsBaseline LCR in CA patients exhibits an L-shaped correlation with AKI incidence following restoration of autonomic circulation. The threshold for CA-AKI is 0.051. This finding suggests that LCR may aid in identifying CA patients at high risk of AKI.