Safety of helicopter transport in patients with acute coronary syndrome.

BACKGROUND: ST-elevation myocardial infarction (STEMI) systems of care have reduced inter-hospital transfer times and facilitated timely reperfusion goals. Helicopters may be an option when land transportation is not feasible; however, the safety of air transport in patients with acute coronary syndrome (ACS) is a factor to consider. OBJETIVES: The aim of this study was to evaluate the safety of helicopter transport for patients with ACS. METHODS: Prospective, observational, and descriptive study including patients diagnosed with ACS within the STEMI network of a metropolitan city transferred by helicopter to a large cardiovascular center to undergo percutaneous coronary intervention. The primary outcome of the study was the incidence of air-travel-related complications defined as IV dislodgement, hypoxia, arrhythmia, angina, anxiety, bleeding, and hypothermia. Secondary outcomes included the individual components of the primary outcome. RESULTS: A total of 106 patients were included in the study; the mean age was 54 years and 84.9% were male. The most frequent diagnosis was STEMI after successful fibrinolysis (51.8%), followed by STEMI with failed fibrinolysis (23.7%) and non-reperfused STEMI (9.4%). Five patients (4.7%) developed at least one complication: IV dislodgement (1.8%) and hypoxemia (1.8%) in two patients and an episode of angina during flight (0.9%). A flight altitude of > 10,000 ft was not associated with complications. CONCLUSIONS: The results of this study suggest that helicopter transportation is safe in patients undergoing acute coronary syndrome, despite the altitude of a metropolitan area.

ANTECEDENTES: Los sistemas de atención de IAMCEST han reducido los tiempos de transferencia interhospitalaria y han facilitado las metas de reperfusión oportuna. Los helicópteros pueden ser una opción cuando el transporte terrestre no es factible; sin embargo, la seguridad del transporte aéreo en pacientes con síndrome coronario agudo (SICA) es un factor a considerar. OBJETIVOS: Evaluar la seguridad del transporte en helicóptero para pacientes con SICA. MÉTODOS: Estudio prospectivo, observacional, descriptivo. Se incluyeron pacientes con diagnóstico de SICA dentro de la red IAMCEST en metrópolis extensa, trasladados en helicóptero a un centro cardiovascular. El resultado primario del estudio fue la incidencia de complicaciones relacionadas con los viajes aéreos definidas cómo desalojo de catéter intravenoso, hipoxia, arritmia, angina, ansiedad, sangrado e hipotermia. RESULTADOS: Total de 106 pacientes; la edad media fue de 54 años y 84,9% eran hombres. La altitud media de vuelo fue de 10,100 pies y la distancia media de vuelo fue de 50,0 km. El diagnóstico más frecuente fue IAMCEST tras fibrinolisis exitosa (51,8%), seguido de IAMCEST con fibrinolisis fallida (23,7%). Cinco pacientes (4,7%) desarrollaron una complicación: desalojo IV (1,8%) e hipoxemia (1,8%) en dos pacientes y un episodio de angina durante el vuelo (0,9%). Una altitud de vuelo mayor de 10,000 pies no se asoció a complicaciones. CONCLUSIONES: Los resultados de este estudio sugieren que el transporte en helicóptero es seguro en pacientes con SICA, incluso en altitudes > 10,000 pies.

Long-Term Outcomes of Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: A Study from Mexico City.

Although primary percutaneous coronary intervention (pPCI) is the treatment of choice in ST-elevation myocardial infarction (STEMI), challenges may arise in accessing this intervention for certain geodemographic groups. Pharmacoinvasive strategy (PIs) has demonstrated comparable outcomes when delays in pPCI are anticipated, but real-world data on long-term outcomes are limited. The aim of the present study was to compare long-term outcomes among real-world patients with STEMI who underwent either PIs or pPCI. This was a prospective registry including patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary objective was cardiovascular mortality at 12 months according to the reperfusion strategy (pPCI vs PIs) and major cardiovascular events (cardiogenic shock, recurrent myocardial infarction, and congestive heart failure), and Bleeding Academic Research Consortium type 3 to 5 bleeding events were also evaluated. A total of 799 patients with STEMI were included; 49.1% underwent pPCI and 50.9% received PIs. Patients in the PIs group presented with more heart failure on admission (Killip-Kimbal >I 48.1 vs 39.7, p = 0.02) and had a lower proportion of pre-existing heart failure (0.2% vs 1.8%, p = 0.02) and atrial fibrillation (0.25% vs 1.2%, p = 0.02). No statistically significant difference was observed in cardiovascular mortality at the 12-month follow-up (hazard ratio for PIs 0.74, 95% confidence interval 0.42 to 1.30, log-rank p = 0.30) according to the reperfusion strategy used. The composite of major cardiovascular events (hazard ratio for PIs 0.98, 95% confidence interval 0.75 to 1.29, p = 0.92) and Bleeding Academic Research Consortium type 3 to 5 bleeding rates were also comparable. A low socioeconomic status, Killip-Kimball >2, age >60 years, and admission creatinine >2.0 mg/100 ml were predictors of the composite end point after multivariate analysis. In conclusion, this prospective real-world registry provides additional support that long-term major cardiovascular outcomes and bleeding are not different between patients who underwent PIs versus primary PCI.

Real-World Evaluation of a Pharmacoinvasive Strategy for STEMI in Latin America: A Cost-Effective Approach with Short-Term Benefits.

Purpose: While pharmacoinvasive strategy (PI) is a safe and effective approach whenever access to primary percutaneous intervention (pPCI) is limited, data on each strategy's economic cost and impact on in-hospital stay are scarce. The objective is to compare the cost-effectiveness of a PI with that of pPCI for the treatment of ST-elevation myocardial infarction (STEMI) in a Latin-American country. Patients and Methods: A total of 1747 patients were included, of whom 470 (26.9%) received PI, 433 (24.7%) pPCI, and 844 (48.3%) NR. The study's primary outcome was the incremental cost-effectiveness ratio (ICER) for PI compared with those for pPCI and non-reperfused (NR), calculated for 30-day major cardiovascular events (MACE), 30-day mortality, and length of stay. Results: For PI, the ICER estimates for MACE showed a decrease of $-35.81/per 1% (95 confidence interval, -114.73 to 64.81) compared with pPCI and a decrease of $-271.60/per 1% (95% CI, -1086.10 to -144.93) compared with NR. Also, in mortality, PI had an ICER decrease of $-129.50 (95% CI, -810.57, 455.06) compared to pPCI and $-165.27 (-224.06, -123.52) with NR. Finally, length of stay had an ICER reduction of -765.99 (-4020.68, 3141.65) and -283.40 (-304.95, -252.76) compared to pPCI and NR, respectively. Conclusion: The findings of this study suggest that PI may be a more efficient treatment approach for STEMI in regions where access to pPCI is limited or where patient and system delays are expected.

Analysis of immortal-time effect in post-infarction ventricular septal defect.

Introduction: Time-fixed analyses have traditionally been utilized to examine outcomes in post-infarction ventricular septal defect (VSD). The aims of this study were to: (1) analyze the relationship between VSD closure/non-closure and mortality; (2) assess the presence of immortal-time bias. Material and methods: In this retrospective cohort study, patients with ST-elevation myocardial infarction (STEMI) complicated by VSD. Time-fixed and time-dependent Cox regression methodologies were employed. Results: The study included 80 patients: surgical closure (n = 26), transcatheter closure (n = 20), or conservative management alone (n = 34). At presentation, patients without VSD closure exhibited high-risk clinical characteristics, had the shortest median time intervals from STEMI onset to VSD development (4.0, 4.0, and 2.0 days, respectively; P = 0.03) and from STEMI symptom onset to hospital arrival (6.0, 5.0, and 0.8 days, respectively; P < 0.0001). The median time from STEMI onset to closure was 22.0 days (P = 0.14). In-hospital mortality rate was higher among patients who did not undergo defect closure (50%, 35%, and 88.2%, respectively; P < 0.0001). Closure of the defect using a fixed-time method was associated with lower in-hospital mortality (HR = 0.13, 95% CI 0.05-0.31, P < 0.0001, and HR 0.13, 95% CI 0.04-0.36, P < 0.0001, for surgery and transcatheter closure, respectively). However, when employing a time-varying method, this association was not observed (HR = 0.95, 95% CI 0.45-1.98, P = 0.90, and HR 0.88, 95% CI 0.41-1.87, P = 0.74, for surgery and transcatheter closure, respectively). These findings suggest the presence of an immortal-time bias. Conclusions: This study highlights that using a fixed-time analytic approach in post-infarction VSD can result in immortal-time bias. Researchers should consider employing time-dependent methodologies.

Clinical Characteristics and Outcomes in Adults With Moderate-to-Severe Complexity Congenital Heart Disease Undergoing Palliation or Surgical Repair.

Background: Congenital heart disease (CHD) survival rate has improved dramatically due to advances in diagnostic and therapeutic techniques. However, concerning the unrepaired CHD population of moderate and severe complexity, the data regarding risk predictors and surgical outcomes are scarce. Our aim was to describe the surgical results and predictors of in-hospital outcomes in adult patients with moderate-to-severe complexity CHD that were not repaired in childhood. Methods: We conducted a retrospective cohort study that included 49 adult patients with moderate-to-complex CHD who were treated in a single medical centre. Clinical and echocardiographic variables were obtained on admission, after surgical procedures and during follow-up. Results: Most of the patients were female (66%). Left ventricular ejection fraction and right ventricular outflow tract fractional shortening were within the normal range. The median pulmonary artery systolic pressure was 37 (27-55) mm Hg. The median time was 118 (80-181) minutes for extracorporeal circulation and 76 (49-121) minutes for aortic cross-clamping. The most frequent complication was postoperative complete atrioventricular block (12.2%). In-hospital survival rate was 87.7%. The development of low cardiac output syndrome with predominant right ventricle failure in the postoperative period was the most important predictor of in-hospital death (P = 0.03). Conclusions: Deciding to treat adults with CHD is challenging in moderate and severe unrepaired cases. Adequate clinical, functional, and imaging evaluation is essential to determine each patient's suitability for surgical management and to achieve the best clinical outcome for this population.

Contexte: Grâce aux avancées réalisées en matière de techniques diagnostiques et thérapeutiques, la survie des patients atteints d'une cardiopathie congénitale s'est considérablement améliorée. Cependant, en ce qui concerne les personnes atteintes d'une cardiopathie congénitale non corrigée présentant une complexité modérée ou extrême, les données portant sur les facteurs de risque prédictifs ainsi que sur les résultats chirurgicaux sont rares. Notre objectif était de décrire les résultats chirurgicaux ainsi que les facteurs prédictifs des résultats obtenus en milieu hospitalier chez les patients adultes atteints d'une cardiopathie congénitale présentant une complexité modérée ou extrême qui n'a pas été corrigée pendant l'enfance. Méthodologie: Nous avons mené une étude de cohorte rétrospective comprenant 49 patients adultes atteints d'une cardiopathie congénitale modérée ou complexe qui ont reçu leurs traitements dans un seul centre médical. Les variables cliniques et échocardiographiques ont été obtenues au moment de l'admission, après les interventions chirurgicales et pendant la période de suivi. Résultats: Les patients étaient en majorité des femmes (66 %). La fraction d'éjection du ventricule gauche ainsi que la fraction de raccourcissement de la voie d'éjection ventriculaire droite sont demeurées dans les limites de la normale. La pression systolique médiane de l'artère pulmonaire a été de 37 mmHg (27-55 mmHg). Le temps médian écoulé pour la circulation extracorporelle a été de 118 minutes (80-181 minutes) et pour le clampage de la crosse aortique, de 76 minutes (49-121 minutes). Le bloc auriculo-ventriculaire postopératoire complet a été la complication la plus fréquente (12,2 %). Le taux de survie en milieu hospitalier a été de 87,7 %. Le développement du syndrome du faible débit cardiaque accompagné d'une insuffisance prédominante du ventricule droit durant la période postopératoire a constitué le principal facteur prédictif de décès à l'hôpital (p = 0,03). Conclusion: Il est difficile de traiter les adultes qui présentent une cardiopathie congénitale modérée ou sévère non corrigée. Il est essentiel que les évaluations cliniques, fonctionnelles et par imagerie soient réalisées de façon adéquate pour déterminer si une prise en charge chirurgicale convient aux patients et pour garantir les meilleurs résultats cliniques chez ces derniers.

Assessing the venous system: Correlation of mean systemic filling pressure with the venous excess ultrasound grading system in cardiac surgery.

BACKGROUND: Evaluation of the venous system has long been underestimated as an important component of the circulatory system. As systemic venous pressure increases, the perfusion pressure to the tissues is compromised. During initial resuscitation in cardiac surgery, excessive fluid administration is associated with increased morbidity and mortality. METHODS: We conducted a cross-sectional study of 60 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain the venous excess ultrasound (VExUS) grading system and mean systemic filling pressure (Pmsf) in the postoperative period upon admission, at 24 and 48 h. We then determined the correlation between VExUS grading and Pmsf. RESULTS: On admission, patients with VExUS grading 0 predominated, with a progressive increase in venous congestion and an increase in Pmsf over the course of the first 48 h. There was a strong positive correlation between VExUS grading and the invasive measurement of Pmsf at 24 and 48 h after arrival. The presence of grade 2 or grade 3 venous congestion in the postoperative period poses an increased risk of developing acute kidney injury. CONCLUSION: The VExUS grading system indicates a high degree of systemic venous congestion in the first 48 h of the postoperative period after cardiac surgery and correlates with the Pmsf, which is the best surrogate of stressed circulatory volume.

Invasive Phenoprofiling of Acute-Myocardial-Infarction-Related Cardiogenic Shock.

BACKGROUND: Studies had previously identified three cardiogenic shock (CS) phenotypes (cardiac-only, cardiorenal, and cardiometabolic). Therefore, we aimed to understand better the hemodynamic profiles of these phenotypes in acute myocardial infarction-CS (AMI-CS) using pulmonary artery catheter (PAC) data to better understand the AMI-CS heterogeneity. METHODS: We analyzed the PAC data of 309 patients with AMI-CS. The patients were classified by SCAI shock stage, congestion profile, and phenotype. In addition, 24 h hemodynamic PAC data were obtained. RESULTS: We identified three AMI-CS phenotypes: cardiac-only (43.7%), cardiorenal (32.0%), and cardiometabolic (24.3%). The cardiometabolic phenotype had the highest mortality rate (70.7%), followed by the cardiorenal (52.5%) and cardiac-only (33.3%) phenotypes, with significant differences (p < 0.001). Right atrial pressure (p = 0.001) and pulmonary capillary wedge pressure (p = 0.01) were higher in the cardiometabolic and cardiorenal phenotypes. Cardiac output, index, power, power index, and cardiac power index normalized by right atrial pressure and left-ventricular stroke work index were lower in the cardiorenal and cardiometabolic than in the cardiac-only phenotypes. We found a hazard ratio (HR) of 2.1 for the cardiorenal and 3.3 for cardiometabolic versus the cardiac-only phenotypes (p < 0.001). Also, multi-organ failure, acute kidney injury, and ventricular tachycardia/fibrillation had a significant HR. Multivariate analysis revealed that CS phenotypes retained significance (p < 0.001) when adjusted for the Society for Cardiovascular Angiography & Interventions score (p = 0.011) and ∆congestion (p = 0.028). These scores independently predicted mortality. CONCLUSIONS: Accurate patient prognosis and treatment strategies are crucial, and phenotyping in AMI-CS can aid in this effort. PAC profiling can provide valuable prognostic information and help design new trials involving AMI-CS.

[Acute myocardial infarction patients without COVID-19 manifestations in the pandemic may have high thrombus burden]. / Pacientes con infarto agudo de miocardio sin manifestaciones de COVID-19 pueden tener alta carga de trombo.

Objective: The objective of the study is to identify clinical and angiographic characteristics of patients with ST-segment elevation myocardial infarction (STEMI) but without clinical manifestations of COVID-19 infection during the pandemic, compared with patients 1 year before the pandemic. Methods: Observational study that included 138 consecutive patients hospitalized with STEMI who underwent primary percutaneous coronary intervention (PCI) without COVID-19 infection during the 2020 pandemic. A group of 175 STEMI patients treated with PCI in the year before the pandemic served as the control group. Results: During the periods analyzed, compared with the control group, patients admitted during the pandemic without clinical manifestations of COVID-19 did not have significant differences in demographic characteristics, comorbidities, or delayed time and location of the acute myocardial infarction. Furthermore, there were no differences between the two groups concerning levels of CK-MB and NT-proBNP, or in inflammation markers and left ventricular ejection fraction. In patients without COVID-19 during the pandemic compared with control, we found a higher intracoronary thrombus burden (thrombus grade 5; 78.3% vs. 62.9%, respectively. p = 0.002). Accordingly, the use of glycoprotein IIB/IIIa inhibitors (37.7% vs. 26.3%, p = 0.03) was higher in these patients. Conclusions: This study demonstrates an increased thrombus burden in STEMI patients without clinical manifestation of COVID-19 during the pandemic compared with the same time period in the previous year.

Objetivo: Identificar las características clínicas y angiográficas de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) sin manifestaciones clínicas de COVID-19 durante la pandemia y compararlos con los pacientes en el año previo. Métodos: Estudio observacional que incluyó 138 pacientes consecutivos que fueron hospitalizados por IAMCEST y que fueron tratados con angioplastía primaria (ACTP) sin manifestaciones clínicas de COVID-19 durante la pandemia de 2020. Se seleccionó a un grupo control de 175 pacientes con IAMCEST tratados con ACTP en el año previo a la pandemia. Resultados: Los pacientes atendidos durante la pandemia no tuvieron diferencias significativas en cuanto a las características clínicas, demográficas, comorbilidades, tiempo de retraso y localización del infarto. Además, no hubo diferencias entre ambos grupos en los niveles de CK-MB, NT-proBNP, marcadores de inflamación ni en la fracción de eyección del ventrículo izquierdo. En los pacientes sin COVID-19 tratados durante la pandemia encontramos mayor carga trombótica intracoronaria (trombo grado 5; 78.3% vs. 62.9%, respectivamente. p = 0.002). De igual manera, el uso de inhibidores de la glucoproteina IIB/IIIa (37.7% vs. 26.3%, p = 0.03) fue mayor. Conclusiones: Este studio demostró un aumento en la carga trombótica en los pacientes con IAMCEST sin manifestaciones clínicas de COVID-19 durante la pandemia al compararlos con los pacientes tratados por la misma patología en el año previo.

Usefulness of the velocity-time integral of the left ventricular outflow tract variability index to predict fluid responsiveness in patients undergoing cardiac surgery.

BACKGROUND: Haemodynamic monitoring of patients after cardiac surgery using echocardiographic evaluation of fluid responsiveness is both challenging and increasingly popular. We evaluated fluid responsiveness in the first hours after surgery by determining the variability of the velocity-time integral of the left ventricular outflow tract (VTI-LVOT). METHODS: We conducted a cross-sectional study of 50 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain VTI-LVOT measurements. We then determined the variability and correlations with our pulse pressure variation (PPV) measurements to predict fluid responsiveness. RESULTS: A strong positive correlation was seen between the VTI-LVOT variability index absolute values and PPV for predicting fluid responsiveness in the first hours after cardiac surgery. We also found that the VTI-LVOT variability index has high specificity and a high positive likelihood ratio compared with the gold standard using a cut-off point of ≥ 12%. CONCLUSIONS: The VTI-LVOT variability index is a valuable tool for determining fluid responsiveness during the first 6 postoperative hours in patients undergoing cardiac surgery.

Prediction of adverse cardiac outcomes in high-risk Mexican patients with chest pain in the emergency department / Desenlaces adversos cardiovasculares en pacientes mexicanos de alto riesgo con dolor torácico en el servicio de urgencias

Abstract Objective: The aim of the study was to compare the discriminative power and accuracy for prediction of MACE of five commonly used scoring tools in Mexican patients with chest pain who present to the ED. Methods: A single-center, prospective, observational, and comparative study of patients admitted to the ED with chest pain as the chief complaint. Five chest pain scoring systems were calculated. The primary endpoint was the composite of cardiovascular death, myocardial infarction, coronary intervention, coronary artery bypass grafting, or readmission for cardiovascular causes within 30 days. Results: A total of 168 patients were studied. The score which provided the highest area under the curve of 0.76 (95% CI: 0.70-0.85) was history, ECG, age, risk factors, and troponin (HEART) score. In addition, the integrated discrimination index for the HEART score was 6% higher when compared to the other four scores. Conclusions: The HEART score provided the best classification tool for identifying those patients at highest risk for MACE, either alone or by adding their results to other classification scores, even in a comorbid population.

Resumen Objetivo: Comparar el poder discriminativo y precisión diagnóstica de Eventos Cardiovasculares Mayores (ECVM) de cinco escalas de clasificación de dolor torácico de uso común en pacientes mexicanos con dolor torácico que acuden al servicio de urgencias. Métodos: Estudio prospectivo, observacional y comparativo que incluyó a pacientes ingresados en urgencias que presentaban dolor torácico como síntoma cardinal. Se calcularon cinco escalas de puntuación de dolor torácico. El desenlance principal fue el compuesto de muerte cardiovascular, infarto de miocardio, intervención coronaria, injerto de derivación de arteria coronaria o reingreso por causas cardiovasculares dentro de los 30 días. Resultados: Se estudió un total de 168 pacientes. La escala de puntuación que proporcionó el área bajo la curva más alta de 0.76 (IC de 95%: 0.70-0.85) fue la escala de historia clínica, ECG, edad, factores de riesgo y troponina (HEART, por sus siglas en inglés). Además, el indice de discriminación efectiva para la puntuación HEART fue un 6% más alto en comparación con las otras cuatro escalas de puntuación. Conclusiones: La escala de HEART proporcionó la mejor herramienta de clasificación para idenfiticar a los pacientes con mayor riesgo de ECVM, ya sea solo a agregando sus resultados a otros puntajes de clasificación, incluso en una población comórbida.

Venous excess ultrasound score and acute kidney injury in patients with acute coronary syndrome.

AIMS: Systemic venous congestion is associated with an increased risk of acute kidney injury (AKI) in critically ill patients. Venous Excess Ultrasound Score (VExUS) has been proposed as a non-invasive score to assess systemic venous congestion. We aimed to evaluate the association between VExUS and AKI in patients with acute coronary syndrome (ACS). METHODS AND RESULTS: This is a prospective study including patients with the diagnosis of ACS (both ST elevation and non-ST elevation ACS). VExUS was performed during the first 24 h of hospital stay. Patients were classified according to the presence of systemic congestion (VExUS 0/≥1). The primary objective of the study was to determine the occurrence of AKI, defined by KDIGO criteria. A total of 77 patients were included. After ultrasound assessment, 31 (40.2%) patients were categorized as VExUS ≥1. VExUS ≥1 was more frequently found in inferior vs. anterior myocardial infarction/non-ST-segment elevation acute myocardial infarction (48.3 vs. 25.8 and 22.5%, P = 0.031). At each increasing degree of VExUS, a higher proportion of patients developed AKI: VExUS = 0 (10.8%), VExUS = 1 (23.8%), VExUS = 2 (75.0%), and VExUS = 3 (100%; P < 0.001). A significant association between VExUS ≥1 and AKI was found [odds ratio (OR): 6.75, 95% confidence interval (CI): 2.21-23.7, P = 0.001]. After multivariable analysis, only VExUS ≥1 (OR: 6.15; 95% CI: 1.26-29.94, P = 0.02) remained significantly associated with AKI. CONCLUSION: In patients hospitalized with ACS, VExUS is associated with the occurrence of AKI. Further studies are needed to clarify the role of VExUS assessment in patients with ACS.

Women with Acute Myocardial Infarction: Clinical Characteristics, Treatment, and In-Hospital Outcomes from a Latin American Country.

Background: Women are underrepresented in acute myocardial infarction (AMI) studies. Furthermore, there is scarce information regarding women with AMI in Latin America. Aims: To describe the presentation, clinical characteristics, risk factor burden, evidence-based care, and in-hospital outcome in a population of women with AMI admitted to a coronary care unit (CCU) in Mexico. Methods: Retrospective cohort study including patients with AMI admitted from January 2006 to December 2021 in a CCU. We identified patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). We described demographic characteristics, clinical variables, treatment, and in-hospital outcomes according to gender. Cox regression analysis was used to identify predictors of mortality. Results: Our study included 12,069 patients with AMI, of whom 7,599 had STEMI and 4,470 had NSTEMI. Women represented 19.6% of the population. Women had higher rates of hypertension, diabetes, stroke, and atrial fibrillation than men. For STEMI, women were less likely to receive reperfusion therapy (fibrinolysis; 23.7 vs. 28.5%, p < 0.001 and primary percutaneous coronary intervention (PCI); 31.2 vs. 35.1%, p = 0.001) and had more major adverse events than men: heart failure (4.2 vs. 2.5%, p = 0.002), pulmonary edema (3.4% vs. 1.7%, p < 0.001), major bleeding (2.1% vs. 1%, p = 0.002), stroke (1.3% vs. 0.6%, p = 0.008), and mortality (15.1% vs. 8.1%, p < 0.001). For NSTEMI, women were less likely to undergo coronary angiography or PCI and had more major bleeding and mortality. Multivariate Cox regression analysis revealed that females had an increase in mortality in STEMI and NSTEMI (HR 1.21, CI 1.01-1.47, p = 0.05 and HR 1.39, CI 1.06-1.81, p = 0.01). Conclusion: Real-world evidence from a hospital in a Latin American low- to middle-income country (LMIC) showed that women with AMI had more comorbidities, received less reperfusion treatment or invasive strategies, and had worse outcomes. In STEMI and NSTEMI, female gender represented an independent predictor of in-hospital mortality.

Prediction of adverse cardiac outcomes in high-risk Mexican patients with chest pain in the emergency department.

OBJECTIVE: The aim of the study was to compare the discriminative power and accuracy for prediction of MACE of five commonly used scoring tools in Mexican patients with chest pain who present to the ED. METHODS: A single-center, prospective, observational, and comparative study of patients admitted to the ED with chest pain as the chief complaint. Five chest pain scoring systems were calculated. The primary endpoint was the composite of cardiovascular death, myocardial infarction, coronary intervention, coronary artery bypass grafting, or readmission for cardiovascular causes within 30 days. RESULTS: A total of 168 patients were studied. The score which provided the highest area under the curve of 0.76 (95% CI: 0.70-0.85) was history, ECG, age, risk factors, and troponin (HEART) score. In addition, the integrated discrimination index for the HEART score was 6% higher when compared to the other four scores. CONCLUSIONS: The HEART score provided the best classification tool for identifying those patients at highest risk for MACE, either alone or by adding their results to other classification scores, even in a comorbid population.

OBJETIVO: Comparar el poder discriminativo y precisión diagnóstica de Eventos Cardiovasculares Mayores (ECVM) de cinco escalas de clasificación de dolor torácico de uso común en pacientes mexicanos con dolor torácico que acuden al servicio de urgencias. MÉTODOS: Estudio prospectivo, observacional y comparativo que incluyó a pacientes ingresados en urgencias que presentaban dolor torácico como síntoma cardinal. Se calcularon cinco escalas de puntuación de dolor torácico. El desenlance principal fue el compuesto de muerte cardiovascular, infarto de miocardio, intervención coronaria, injerto de derivación de arteria coronaria o reingreso por causas cardiovasculares dentro de los 30 días. RESULTADOS: Se estudió un total de 168 pacientes. La escala de puntuación que proporcionó el área bajo la curva más alta de 0.76 (IC de 95%: 0.70-0.85) fue la escala de historia clínica, ECG, edad, factores de riesgo y troponina (HEART, por sus siglas en inglés). Además, el indice de discriminación efectiva para la puntuación HEART fue un 6% más alto en comparación con las otras cuatro escalas de puntuación. CONCLUSIONES: La escala de HEART proporcionó la mejor herramienta de clasificación para idenfiticar a los pacientes con mayor riesgo de ECVM, ya sea solo a agregando sus resultados a otros puntajes de clasificación, incluso en una población comórbida.

Non-reperfused ST-elevation myocardial infarction: notions from a low-to-middle-income country / Infarto de miocardio con elevación del ST no reperfundido: nociones de un país de ingresos bajos a medios

Abstract Objective: The objective of the study was to analyze the differences between survivors and non-survivors with non-reperfused ST-segment elevation myocardial infarction (STEMI) and to identify the predictors of in-hospital mortality. Methods: A retrospective cohort study included non-reperfused STEMI patients from October 2005 to August 2020. Patients were classified into survivors and non-survivors. We compared patient characteristics, treatments, and outcomes among the groups and identified factors associated with in-hospital mortality. Results: We included 2442 patients with non-reperfused STEMI and we found a mortality of 12.7% versus 7.2% in reperfused STEMI. The main reason for non-reperfusion was delayed presentation (96.1%). Non-survivors were older, more often women, and had diabetes, hypertension, or atrial fibrillation. The left main coronary disease was more frequent in non-survivors as well as three-vessel disease. Non-survivors developed more in-hospital heart failure, reinfarction, atrioventricular block, bleeding, stroke, and death. The main predictors for in-hospital mortality were renal dysfunction (HR 3.41), systolic blood pressure < 100 mmHg (HR 2.26), and left ventricle ejection fraction < 40% (HR 1.97). Conclusion: Mortality and adverse outcomes occur more frequently in non-reperfused STEMI. Non-survivors tend to be older, with more comorbidities, and have more adverse in-hospital outcomes.

Resumen Objetivo: Analizar las diferencias entre los sobrevivientes y no sobrevivientes con infarto agudo de miocardio no reperfundido y conocer los predictores de mortalidad intrahospitalaria. Métodos: Estudio de cohorte retrospectiva que incluyó pacientes con infarto agudo de miocardio no reperfundido de octubre de 2005 a agosto de 2020. Se clasificaron los pacientes de acuerdo a su estado de sobrevida y se compararon las características clínicas, tratamientos y desenlaces para poder identificar los predictores de mortalidad intrahospitalaria. Resultados: Se incluyeron 2442 pacientes con infarto agudo de miocardio no reperfundido, en los que se encontró una mortalidad de 12.7% vs 7.2% los que si recibieron tratamiento de reperfusión. La principal razón para no recibir tratamiento de reperfusión fue el retraso en la atención médica (96.1%). Los no sobrevivientes tuvieron mayor edad, fueron mujeres y tuvieron mayor frecuencia de diabetes, hipertensión y fibrilación atrial. El tronco de la coronaria izquierda y la enfermedad trivascular fueron más frecuentes en los que no sobrevivieron. Los pacientes que no sobrevivieron desarrollaron más insuficiencia cardiaca, reinfarto, bloqueo atrioventricular, sangrados, evento vascular cerebral y muerte. Los principales predictores de mortalidad intrahospitalaria fueron: insuficiencia renal (HR 3.41), tensión arterial sistólica al ingreso < 100 mmHg (HR 2.26) y fracción de eyección del ventrículo izquierdo < 40% (HR 1.97). Conclusiones: Los pacientes con infarto de miocardio no reperfundido tienen mayor mortalidad y desenlaces adversos. Los no sobrevivientes fueron mayores, con más comorbilidades y desarrollaron más desenlaces adversos intrahospitalarios.

Non-reperfused ST-elevation myocardial infarction: notions from a low-to-middle-income country.

OBJECTIVE: The objective of the study was to analyze the differences between survivors and non-survivors with non-reperfused ST-segment elevation myocardial infarction (STEMI) and to identify the predictors of in-hospital mortality. METHODS: A retrospective cohort study included non-reperfused STEMI patients from October 2005 to August 2020. Patients were classified into survivors and non-survivors. We compared patient characteristics, treatments, and outcomes among the groups and identified factors associated with in-hospital mortality. RESULTS: We included 2442 patients with non-reperfused STEMI and we found a mortality of 12.7% versus 7.2% in reperfused STEMI. The main reason for non-reperfusion was delayed presentation (96.1%). Non-survivors were older, more often women, and had diabetes, hypertension, or atrial fibrillation. The left main coronary disease was more frequent in non-survivors as well as three-vessel disease. Non-survivors developed more in-hospital heart failure, reinfarction, atrioventricular block, bleeding, stroke, and death. The main predictors for in-hospital mortality were renal dysfunction (HR 3.41), systolic blood pressure < 100 mmHg (HR 2.26), and left ventricle ejection fraction < 40% (HR 1.97). CONCLUSION: Mortality and adverse outcomes occur more frequently in non-reperfused STEMI. Non-survivors tend to be older, with more comorbidities, and have more adverse in-hospital outcomes.

OBJETIVO: Analizar las diferencias entre los sobrevivientes y no sobrevivientes con infarto agudo de miocardio no reperfundido y conocer los predictores de mortalidad intrahospitalaria. MÉTODOS: Estudio de cohorte retrospectiva que incluyó pacientes con infarto agudo de miocardio no reperfundido de octubre de 2005 a agosto de 2020. Se clasificaron los pacientes de acuerdo a su estado de sobrevida y se compararon las características clínicas, tratamientos y desenlaces para poder identificar los predictores de mortalidad intrahospitalaria. RESULTADOS: Se incluyeron 2442 pacientes con infarto agudo de miocardio no reperfundido, en los que se encontró una mortalidad de 12.7% vs 7.2% los que si recibieron tratamiento de reperfusión. La principal razón para no recibir tratamiento de reperfusión fue el retraso en la atención médica (96.1%). Los no sobrevivientes tuvieron mayor edad, fueron mujeres y tuvieron mayor frecuencia de diabetes, hipertensión y fibrilación atrial. El tronco de la coronaria izquierda y la enfermedad trivascular fueron más frecuentes en los que no sobrevivieron. Los pacientes que no sobrevivieron desarrollaron más insuficiencia cardiaca, reinfarto, bloqueo atrioventricular, sangrados, evento vascular cerebral y muerte. Los principales predictores de mortalidad intrahospitalaria fueron: insuficiencia renal (HR 3.41), tensión arterial sistólica al ingreso < 100 mmHg (HR 2.26) y fracción de eyección del ventrículo izquierdo < 40% (HR 1.97). CONCLUSIONES: Los pacientes con infarto de miocardio no reperfundido tienen mayor mortalidad y desenlaces adversos. Los no sobrevivientes fueron mayores, con más comorbilidades y desarrollaron más desenlaces adversos intrahospitalarios.

COMPARISON OF THE PREDICTIVE PERFORMANCE OF CARDIOGENIC SHOCK SCORES IN A REAL-WORLD LATIN AMERICA COUNTRY.

ABSTRACT: Background : Mortality in cardiogenic shock (CS) is up to 40%, and although risk scores have been proposed to stratify and assess mortality in CS, they have been shown to have inconsistent performance. The purpose was to compare CS prognostic scores and describe their performance in a real-world Latin American country. Methods : We included 872 patients with CS. The Society for Cardiovascular Angiography and Interventions (SCAI), CARDSHOCK, IABP-Shock II, Cardiogenic Shock Score, age-lactate-creatinine score, Get-With-The-Guidelines Heart Failure score, and Acute Decompensated Heart Failure National Registry scores were calculated. Decision curve analyses were performed to evaluate the net benefit of the different scoring systems. Logistic and Cox regression analyses were applied to construct area under the curve (AUC) statistics, this last one against time using the Inverse Probability of Censoring Weighting method, for in-hospital mortality prediction. Results: When logistic regression was applied, the scores had a moderate-good performance in the overall cohort that was higher AUC in the CARDSHOCK ( c = 0.666). In acute myocardial infarction-related CS (AMI-CS), CARDSHOCK still is the highest AUC (0.68). In non-AMI-CS only SCAI (0.668), CARDSHOCK (0.533), and IABP-SHOCK II (0.636) had statistically significant values. When analyzed over time, significant differences arose in the AUC, suggesting that a time-sensitive component influenced the prediction of mortality. The highest AUC was for the CARDSHOCK score (0.658), followed by SCAI (0.622). In AMI-CS-related, the highest AUC was for the CARDSHOCK score (0.671). In non-AMI-CS, SCAI was the best (0.642). Conclusions : Clinical scores show a time-sensitive AUC, suggesting that performance could be influenced by time and the type of CS. Understanding the temporal influence on the scores could provide a better prediction and be a valuable tool in CS.

Dynamic Invasive Hemodynamic Congestion Profile Impacts Acute Myocardial Infarction Complicated by Cardiogenic Shock Outcomes: A Real-World Single-Center Study.

BACKGROUND: Cardiogenic shock (CS) commonly complicates the management of acute myocardial infarction (AMI), and it results in high mortality rates. Pulmonary artery catheter (PAC) monitoring can be valuable for personalizing critical-care interventions. We hypothesized that patients with AMI-CS experiencing persistent congestion measures during the first 24 hours of the PAC installment would exhibit worse in-hospital survival rates. METHODS AND RESULTS: We studied 295 patients with AMI-CS between January 2006 and December 2021. The first 24-hour PAC-derived hemodynamic measures were divided by the congestion profiling and the proposed 2022 Cardiovascular Angiography and Interventions (SCAI) classification. Biventricular congestion was the most common profile and was associated with the highest patient mortality rates at all time points (mean 56.6%). A persistent congestive profile was associated with increased mortality rates (hazard ratio [HR] = 1.85; P = 0.002) compared with patients who achieved decongestive profiles. Patients with SCAI stages D/E had higher levels of right atrial pressure (RAP): 14-15 mmHg) and pulmonary capillary wedge pressure (PCWP): 18-20 mmHg) compared with stage C (RAP, 10-11 mmHg, mean difference 3-5 mmHg; P < 0.001; PCWP 14-17 mmHg; mean difference 1.56-4 mmHg; P = 0.011). In SCAI stages D/E, the pulmonary artery pulsatility index (0.8-1.19) was lower than in those with grade C (1.29-1.63; mean difference 0.21-0.73; P < 0.001). CONCLUSIONS: Continuous congestion profiling using the SCAI classification matched the grade of hemodynamic severity and the increased risk of in-hospital death. Early decongestion appears to be an important prognostic and therapeutic goal in patients with AMI-CS and warrants further study.

The prognostic importance of the angiotensin II/angiotensin-(1-7) ratio in patients with SARS-CoV-2 infection.

BACKGROUND: Information about angiotensin II (Ang II), angiotensin-converting enzyme 2 (ACE2), and Ang-(1-7) levels in patients with COVID-19 is scarce. OBJECTIVE: To characterize the Ang II-ACE2-Ang-(1-7) axis in patients with SARS-CoV-2 infection to understand its role in pathogenesis and prognosis. METHODS: Patients greater than 18 years diagnosed with COVID-19, based on clinical findings and positive RT-PCR test, who required hospitalization and treatment were included. We compared Ang II, aldosterone, Ang-(1-7), and Ang-(1-9) concentrations and ACE2 concentration and activity between COVID-19 patients and historic controls. We compared baseline demographics, laboratory results (enzyme, peptide, and inflammatory marker levels), and outcome (patients who survived versus those who died). RESULTS: Serum from 74 patients [age: 58 (48-67.2) years; 68% men] with moderate (20%) or severe (80%) COVID-19 were analyzed. During 13 (10-21) days of hospitalization, 25 patients died from COVID-19 and 49 patients survived. Compared with controls, Ang II concentration was higher and Ang-(1-7) concentration was lower, despite significantly higher ACE2 activity in patients. Ang II concentration was higher and Ang-(1-7) concentration was lower in patients who died. The Ang II/Ang-(1-7) ratio was significantly higher in patients who died. In multivariate analysis, Ang II/Ang-(1-7) ratio greater than 3.45 (OR = 5.87) and lymphocyte count ⩽0.65 × 103/µl (OR = 8.43) were independent predictors of mortality from COVID-19. CONCLUSION: In patients with severe SARS-CoV-2 infection, imbalance in the Ang II-ACE2-Ang-(1-7) axis may reflect deleterious effects of Ang II and may indicate a worse outcome.