Optimal surgical timing after post-infarction ventricular septal rupture.

BACKGROUND: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dangerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis. METHODS: We designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Secondary endpoints were to determine which factors could influence mortality in the patients of the surgical group. RESULTS: A total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1-0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, particularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p < 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p < 0.001). CONCLUSIONS: In our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions.

Intracoronary Imaging of a Synergy Megatron Stent Fracture in Ostial Right Coronary Artery.

The Synergy Megatron stent confers enhanced axial and radial forces, which makes it an ideal choice for ostial and calcified lesions. However, in this case, the stent fractured. The mechanical stress due to severe calcification at the ostium, followed by a swinging segment, probably caused hinge effect and led to a stent fracture. The fluoroscopy and stent-enhancing techniques suggest and could confirm the diagnosis, but intracoronary imaging is mandatory for anatomy characterization in order to decide treatment and optimize the result.

Impact of renin-angiotensin system inhibitors on mortality during the COVID Pandemic among STEMI patients undergoing mechanical reperfusion: Insight from an international STEMI registry.

BACKGROUND: Concerns have been raised on a potential interaction between renin-angiotensin system inhibitors (RASI) and the susceptibility to coronavirus disease 2019 (COVID-19). No data have been so far reported on the prognostic impact of RASI in patients suffering from ST-elevation myocardial infarction (STEMI) during COVID-19 pandemic, which was the aim of the present study. METHODS: STEMI patients treated with primary percutaneous coronary intervention (PPCI) and enrolled in the ISACS-STEMI COVID-19 registry were included in the present sub-analysis and divided according to RASI therapy at admission. RESULTS: Our population is represented by 6095 patients, of whom 3654 admitted in 2019 and 2441 in 2020. No difference in the prevalence of SARSCoV2 infection was observed according to RASI therapy at admission (2.5% vs 2.1%, p = 0.5), which was associated with a significantly lower mortality (adjusted OR [95% CI]=0.68 [0.51-0.90], P = 0.006), confirmed in the analysis restricted to 2020 (adjusted OR [95% CI]=0.5[0.33-0.74], P = 0.001). Among the 5388 patients in whom data on in-hospital medication were available, in-hospital RASI therapy was associated with a significantly lower mortality (2.1% vs 16.7%, OR [95% CI]=0.11 [0.084-0.14], p < 0.0001), confirmed after adjustment in both periods. Among the 62 SARSCoV-2 positive patients, RASI therapy, both at admission or in-hospital, showed no prognostic effect. CONCLUSIONS: This is the first study to investigate the impact of RASI therapy on the prognosis and SARSCoV2 infection of STEMI patients undergoing PPCI during the COVID-19 pandemic. Both pre-admission and in-hospital RASI were associated with lower mortality. Among SARSCoV2-positive patients, both chronic and in-hospital RASI therapy showed no impact on survival.

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry.

BACKGROUND: It has been suggested the COVID pandemic may have indirectly affected the treatment and outcome of STEMI patients, by avoidance or significant delays in contacting the emergency system. No data have been reported on the impact of diabetes on treatment and outcome of STEMI patients, that was therefore the aim of the current subanalysis conducted in patients included in the International Study on Acute Coronary Syndromes-ST Elevation Myocardial Infarction (ISACS-STEMI) COVID-19. METHODS: The ISACS-STEMI COVID-19 is a retrospective registry performed in European centers with an annual volume of > 120 primary percutaneous coronary intervention (PCI) and assessed STEMI patients, treated with primary PCI during the same periods of the years 2019 versus 2020 (March and April). Main outcomes are the incidences of primary PCI, delayed treatment, and in-hospital mortality. RESULTS: A total of 6609 patients underwent primary PCI in 77 centers, located in 18 countries. Diabetes was observed in a total of 1356 patients (20.5%), with similar proportion between 2019 and 2020. During the pandemic, there was a significant reduction in primary PCI as compared to 2019, similar in both patients with (Incidence rate ratio (IRR) 0.79 (95% CI: 0.73-0.85, p < 0.0001) and without diabetes (IRR 0.81 (95% CI: 0.78-0.85, p < 0.0001) (p int = 0.40). We observed a significant heterogeneity among centers in the population with and without diabetes (p < 0.001, respectively). The heterogeneity among centers was not related to the incidence of death due to COVID-19 in both groups of patients. Interaction was observed for Hypertension (p = 0.024) only in absence of diabetes. Furthermore, the pandemic was independently associated with a significant increase in door-to-balloon and total ischemia times only among patients without diabetes, which may have contributed to the higher mortality, during the pandemic, observed in this group of patients. CONCLUSIONS: The COVID-19 pandemic had a significant impact on the treatment of patients with STEMI, with a similar reduction in primary PCI procedures in both patients with and without diabetes. Hypertension had a significant impact on PCI reduction only among patients without diabetes. We observed a significant increase in ischemia time and door-to-balloon time mainly in absence of diabetes, that contributed to explain the increased mortality observed in this group of patients during the pandemic. TRIAL REGISTRATION NUMBER: NCT04412655.

Coronavirus: the geriatric emergency of 2020. Joint document of the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.

SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.

[Coronavirus: the geriatric emergency of 2020. Joint document of the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology]. / Coronavirus: la emergencia geriátrica de 2020. Documento conjunto de la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología y la Sociedad Española de Geriatría y Gerontología.

SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.

Effect of part-time cardiac catheterization facilities in patients with acute myocardial infarction.

BACKGROUND: Although the easy availability of invasive cardiac care facilities is associated with an increase in their use, their influence on outcomes is not clear. We sought to investigate whether a newly available cardiac catheterization laboratory (CCL) performing percutaneous coronary intervention (PCI) on a part-time (PT) basis might improve outcomes in patients with acute myocardial infarction (AMI). METHODS: This was an observational cohort study that included all consecutive patients with AMI admitted to a secondary-level hospital in Spain before and after the PT-CCL opened in January 2006: during 1998-2005 and 2006-2014, respectively. All-cause in-hospital and long-term mortality were the co-primary endpoints. In-hospital complications and length of stay were secondary endpoints. For the analyses, patients were stratified according to propensity-score (PS) quintiles. RESULTS: A total of 5339 patients were recruited, and 50.3% were managed after the opening of the PT-CCL. The PT-CCL was associated with greater use of PCI (81.2 vs. 32.5%, p<0.001) and guidelines-recommended medication (all p<0.001), lower risk of recurrent angina (PS-adjusted RR=0.160, 95% CI 0.115-0.222) and shorter length of hospital stay (PS-adjusted RR for length of stay <8days=0.357, 95% CI 0.301-0.422). In patients with NSTEMI, PT-CCL was associated with improved long-term survival (PS-adjusted HR=0.764, 95% CI 0.602-0.970). CONCLUSIONS: In patients with AMI, a new PT-CCL was associated with greater use of PCI and guideline-recommended medication, lower risk of recurrent angina and shorter length of hospital stay. In a subset of patients with NSTEMI, PT-CCL was associated with improved long-term survival.

[Red cell distribution width and mortality risk in acute heart failure patients]. / Amplitud de distribución eritrocitaria y riesgo de mortalidad en pacientes con insuficiencia cardiaca aguda.

BACKGROUND AND OBJECTIVE: Red cell distribution width (RDW) is a quantitative measure of the variability in size of erythrocytes, and it is used for the differential diagnosis of anemia. Recent reports have suggested that high RDW could play a role for risk stratification in patients with chronic heart failure. However, the prognostic role of RDW in unselected population with acute heart failure (AHF), after a thoroughly multivariate adjustment, has not been well established. The aim of this study was to establish the association between RDW and long-term mortality in patients admitted for AHF. PATIENTS AND METHOD: We analyzed 1,190 consecutive patients admitted for AHF in our center. RDW measurement was performed on admission. RDW values were stratified into quartiles (Q) and the association of RDW with total mortality was assessed using Cox regression. RESULTS: After a median follow-up of 15 months (interquartile range 3-33 months) 458 (38%) deaths were identified. There was a progressive increase in mortality rates from Q1 to Q4: 1.34, 1.82, 2.56 and 3.53 per 10 patients-year of follow-up (for Q1, Q2, Q3 and Q4 respectively, P for trend <.001). In the multivariate analysis, this association remained independent for patients in Q3 (15-16%) and Q4 (>16%) versus Q1 (≤14%), hazard ratio (HR): 1.66, 95% confidence interval (95% CI) 1.24-2.22, P<.01, HR: 1.80, 95% CI 1.33-2.43, p<.01, respectively, in a model adjusted for established prognostic markers in AHF. CONCLUSION: In patients with AHF, higher RDW values were associated with increased long-term mortality.

[Predictive value of chest pain score for the diagnosis of acute coronary syndromes]. / Valor predictivo de la presentación clínica del dolor torácico en el diagnóstico de los síndromes coronarios agudos.

BACKGROUND AND OBJECTIVE: We analyzed the diagnostic utility of a chest pain score in patients evaluated for chest pain of possible coronary origin. PATIENTS AND METHOD: We studied 1,068 consecutive patients coming to the emergency room with acute chest pain of possible coronary origin without ST-segment elevation, using a chest pain unit protocol. Chest pain was quantified by validated score (0-20 points). The diagnostic value of the chest pain score was analyzed for the diagnosis of acute myocardial infarction (AMI), unstable angina (UA) and acute coronary syndrome (ACS; AMI or UA). RESULTS: The diagnosis of ACS was established in 651 patients (61%), AMI in 439 (41%) and UA in 212 (20%). In the multivariate analysis a chest pain score > or = 10 was an independent predictor of ACS (odds ratio [OR] = 2.9; 95% confidence interval [CI] 2.1-4; p = 0.0001), along with an age older than 70 years (OR = 2.6; 95% CI,1.8-3.7; p = 0.0001), male gender (OR = 2; 95% CI, 1.4-2.8; p = 0.0001); insulin-dependent diabetes (OR = 2.3; 95% CI, 1.2-4.6; p = 0.016); previous myocardial infarction (OR = 1.6; 95% CI, 1.1-2.4; p = 0.022), ST depression (OR = 9.3; 95% CI, 5.2-16.7; p = 0.0001) and T wave inversion (OR = 2.5; 95% CI, 1.4-4.3; p = 0.0001). The chest pain score was associated with the diagnosis of both AMI (OR = 1.4; 95% CI, 1.1-1.9; p < 0.02) and UA (OR = 2.8; 95% CI, 1.8-4.2; p < 0.0001). CONCLUSIONS: The chest pain score allows independent information for the early diagnosis of patients coming to the emergency department with acute chest pain of possible coronary origin.

[Influence of comorbidity on admission management and pharmacological treatment prescribed at discharge in acute myocardial infarction]. / Influencia de la comorbilidad en el tratamiento intrahospitalario y al alta de los pacientes con infarto de miocardio.

BACKGROUND AND OBJECTIVE: The management of cardiac ischemic patients differs depending on their comorbidity. The Charlson Index (ChI) and its adaptations are well established and widely used tools to quantify a patient comorbidity. The aim of this study is to evaluate the influence of comorbidity quantified by the ChI in the treatment administered at admission and in the pharmacological treatment prescribed at discharge in the setting of an acute myocardial infarction with and without ST segment elevation. PATIENTS AND METHOD: We studied a total of 955 patients consecutively admitted in our hospital with the diagnosis of acute myocardial infarction. Comorbidity was obtained at the first day of admission applying the ChI. According to this value patients were classified from minor to major in 2 subgroups (ChI or= 2) and differences in the admission and discharge treatments between both groups were analyzed. RESULTS: Patients admitted with acute myocardial infarction without ST segment elevation and ChI > 2 received less frequently betablockers at discharge, but there were no significant differences in the use of ACE inhibitors, calcium channel blockers or statins. In addition they were submitted less frequently to revascularization procedures or treadmills, and no differences were found in the use of echocardiograms. Patients with ST segment elevation and ChI > 2 were less frequently treated with betablockers or statins at discharge, and were submitted to less treadmills or echocardiograms; furthermore, in these patients, there were no significant differences in the use of ACE inhibitors, calcium channel blockers, thrombolytics or revascularization procedures. CONCLUSIONS: Comorbidity quantified on admission by the ChI is an independent factor that modifies in-hospital and ambulatory management of patients with acute myocardial infarction. There is a lower use of invasive techniques as well as a lower prescription of betablockers at discharge in patients with greater comorbidity.