Coronary angiography after cardiac arrest.

PURPOSE OF REVIEW: Acute coronary syndromes represent the commonest cause of out-of-hospital cardiac arrest (OHCA) in adults. Coronary angiography (CAG) followed by percutaneous coronary intervention (PCI) has been established as the treatment strategy for these patients. In this review, we aim first to discuss the potential risks and expected benefits from it, the caveats in its implementation, and the current tools for patient selection. Then summarize the recent evidence on the group of patients without ST-segment elevation on post-return of spontaneous circulation (ROSC) ECG. RECENT FINDINGS: The implementation of this strategy still shows a wide variation among the various systems of care.The presence of ST-segment elevation on post-ROSC ECG remains the most reliable tool for patient selection for immediate CAG.A primary PCI strategy is currently recommended for patients with ST-segment elevation on post-ROSC ECG regardless of the conscious state of patients.Recently several randomised studies including patients without ST-segment elevation on post-ROSC ECG showed no benefit with immediate CAG compared to delayed/ elective CAG. This has led to a substantial although not uniform change in current recommendations. SUMMARY: Recent studies show no benefit with immediate CAG in groups of patients without ST-segment elevation on post-ROSC ECG. Further refinements in selecting the appropriate patients for immediate CAG seem necessary.

Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

The process for evaluating the resuscitation science has evolved considerably over the past 2 decades. The current process, which incorporates the use of the GRADE methodology, culminated in the 2015 CoSTR publication, which in turn will inform the international resuscitation councils' guideline development processes. Over the next few years, the process will continue to evolve as ILCOR moves toward a more continuous evaluation of the resuscitation science.

A systematic review and meta-analysis of the effect of routine early angiography in patients with return of spontaneous circulation after Out-of-Hospital Cardiac Arrest.

BACKGROUND: Early coronary angiography (CAG) has been reported in individual studies and systematic reviews to significantly improve outcomes of patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). METHODS: We undertook a systematic review and meta-analysis to evaluate the impact of early CAG on key clinical outcomes in comatose patients after ROSC following out-of-hospital CA of presumed cardiac origin. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from 1990 until April 2020. Eligible studies compared patients undergoing early CAG to patients with late or no CAG. When randomized controlled trials (RCTs) existed for a specific outcome, we used their results to estimate the effect of the intervention. In the absence of randomized data, we used observational data. We excluded studies at high risk of bias according to the Robins-I tool from the meta-analysis. The GRADE system was used to assess certainty of evidence at an outcome level. RESULTS: Of 3738 citations screened, 3 randomized trials and 41 observational studies were eligible for inclusion. Evidence certainty across all outcomes for the RCTs was assessed as low. Randomized data showed no benefit from early as opposed to late CAG across all critical outcomes of survival and survival with favourable neurologic outcome for undifferentiated patients and for patient subgroups without ST-segment-elevation on post ROSC ECG and shockable initial rhythm. CONCLUSION: These results do not support routine early CAG in undifferentiated comatose patients and patients without STE on post ROSC ECG after OHCA. REVIEW REGISTRATION: PROSPERO - CRD42020160152.

Expression profile of total VEGF, VEGF splice variants and VEGF receptors in the myocardium and arterial vasculature of diabetic and non-diabetic patients with coronary artery disease.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis and is implicated in the development of diabetic microvascular and macrovascular disease. METHODS: The expression of total VEGF, VEGF splice variants (VEGF(121), VEGF(145), VEGF(148), VEGF(165), VEGF(183) and VEGF(189)), VEGFR-1 and VEGFR-2, was investigated in biopsies from the right atrium and left internal mammary artery (LIMA) of 32 non-diabetic and 20 diabetic patients undergoing coronary artery bypass grafting. RESULTS: Diabetes was independently negatively correlated to total VEGF mRNA expression in atrium. Total VEGF, VEGF(121) and VEGF(165) mRNA levels were upregulated in the LIMA of diabetics vs. non-diabetics. The expression of VEGF receptors in atrium and LIMA was similar between these groups. VEGF(121) and VEGF(165) were the major variants expressed, followed by VEGF(189) and VEGF(183), while VEGF(148) and VEGF(145) were detected in small amounts. The expression profile of VEGF splice variants displayed significant heterogeneity between the examined tissues. CONCLUSIONS: This is the first study to quantify VEGF splice variants expression in cardiac and vascular tissue. Our results could help elucidate the role of VEGF splice variants in diabetic complications.

Brain natriuretic peptide increases in septic patients without severe sepsis or shock.

BACKGROUND: B-type natriuretic peptide (BNP) production increases in critically ill septic patients. We assessed the hypothesis that BNP is elevated in patients with community-acquired infections without severe sepsis or septic shock. METHODS: We studied 54 patients [20 males, median age 39 (interquartile range 23, 71)] without heart disease, persistent arrhythmias, or renal failure. BNP was measured in all patients at hospital admission and at pre-discharge and in a control group of 52 individuals. Myoglobin levels were also measured in septic patients. RESULTS: The infection was microbial in 40 patients, viral in 11, and of undefined etiology in 3. A systemic inflammatory response was evident in 38 patients on the initial evaluation. BNP on admission was higher in patients than in controls [25 (10, 82) pg/ml vs. 13 (5, 30) pg/ml, p=0.01] and it decreased to 16 (5, 47) pg/ml pre-discharge (p=0.0002). Multiple logistic regression identified the presence of microbial infection as the only independent predictor of an elevated BNP value on admission [adjusted odds ratio 9.8 (1.02-93.8), p=0.04]. In patients with microbial infection, location of infection in the lower respiratory tract and the presence of diabetes mellitus were independent predictors of the magnitude of BNP increase. Myoglobin was also increased on hospital admission 80 (37, 231) ng/ml and decreased pre-discharge to 59 (38, 94) ng/ml, p=0.004. Myoglobin level changes from admission to discharge were more prominent with increasing age and in females. CONCLUSION: BNP levels are elevated in the acute phase of community-acquired microbial infections without severe sepsis or septic shock.

Multiple coronary micro-aneurysm formation after drug-eluting stent implantation.

Although there are limited data regarding the formation of coronary artery aneurysms (CAAs) after drug-eluting stent (DES) implantation, CAAs appear to be a rare complication of coronary stenting. The exact mechanism of CAA formation is unknown, but several hypotheses have been proposed. As the use of DES increases, the clinical significance of these findings will become clearer. We report on a patient who developed multiple CAAs in 2 different locations after sirolimus-eluting stent implantation.

EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe.

INTRODUCTION: The aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe. METHODS: This was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries. RESULTS: Data on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge. CONCLUSION: The results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe. EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events.

Early brain natriuretic peptide increase reflects acute myocardial ischemia in patients with ongoing chest pain.

BACKGROUND: Plasma brain natriuretic peptide levels increase during acute ischemic events. In this study we tested the diagnostic performance of brain natriuretic peptide measurements in the detection of acute myocardial ischemia. METHODS: Blood brain natriuretic peptide was measured in 101 patients with ongoing chest pain but no heart failure or an ST-segment elevation myocardial infarction on arrival at the emergency department (baseline) and at 2 and 6 h later. After diagnostic testing and 1-month follow-up for ischemia, patients were classified as either ischemic or non-ischemic. RESULTS: In the ischemic group median (25th, 75th percentiles) brain natriuretic peptide values (pg/ml) were 122 (20, 349) at baseline, 116 (36, 347) at 2 h, increasing to 148 (52, 428) at 6 h (p<0.001 vs. baseline). Non-ischemic patients had 12 (5, 32) at baseline, 9 (6, 30) at 2 h, and 13 (5, 29) at 6 h (p<0.001 vs. corresponding values of the ischemic group). Receiver operator characteristic curves were constructed for brain natriuretic peptide values at baseline 2 and 6 h and for the increase of peptide levels from baseline to 6 h. All areas under curve indicated a significant diagnostic ability for the detection of ischemia. The 6-h measurement had better diagnostic performance than baseline and 2-h measurements. The subgroup of ischemic patients without myocardial necrosis also had higher brain natriuretic peptide values and could thus be discriminated from non-ischemic subjects. CONCLUSIONS: Brain natriuretic peptide values may detect acute myocardial ischemia in patients with ongoing chest pain but without ST-segment elevation, and distinguish ischemic patients from those with pain of non-ischemic origin.

Attitudes of healthcare professionals involved in cardiology practice towards key points of contemporary guidelines on resuscitation.

Hellenic J Cardiol. 2014; 55: 378-385. At the request of the authors, the name of the second author of this Original Research article has been changed from Athanasios Patialakas to Athanasios Patialiakas.

Attitudes of healthcare professionals involved in cardiology practice towards key points of contemporary guidelines on resuscitation.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) is not always executed in compliance with contemporary guidelines and the quality of CPR may differ among hospitals within the same country or among categories of healthcare providers and medical specialties. The aim of this study was to assess attitudes of cardiology healthcare professionals towards CPR guidelines. METHODS: An anonymous questionnaire was posted online during 2009. Responders were asked about their age, gender, occupation, and training/experience in CPR. Responders' attitudes towards CPR were assessed using 7 questions regarding the accuracy of their opinions about the automated external defibrillator, public defibrillation programs, CPR performance, and therapeutic hypothermia. A score (0 to 7) was formed by assigning grade 1 to answers that accorded with European Resuscitation Council (ERC) guidelines and grade 0 to all other answers. The reliability analysis for this score yielded a Cronbach's alpha of 0.78. RESULTS: There were 544 responders (158 females), median age 34 years (30, 40). Median score was 5 (3, 6). Attending an ERC resuscitation course (beta=0.33, SE beta=0.05, p<0.001), age (beta=-0.15 SE beta=0.05, p=0.002), involvement in >10 CPRs /year (beta=0.19, SE beta=0.05, p<0.001), and being a physician (beta=0.17, SE beta=0.05, p=0.001) were all independent predictors of score. Attendance at an ERC course (OR: 2.7 [1.5 to 4.7]), being a physician (OR: 2 [1.3 to 5]) and involvement in >10 CPRs /year (OR: 1.7 [1.1 to 2.7]) were also independent predictors for attitudes that accorded with contemporary guidelines regarding therapeutic hypothermia. CONCLUSIONS: Attending an ERC resuscitation course, frequent involvement in CPR attempts, younger age, and being a physician were all independent predictors for more positive attitudes towards the guidelines. These factors, with the exception of age, were also associated with positive attitudes towards the implementation of therapeutic hypothermia.

Cardiac aetiology of cardiac arrest: percutaneous coronary interventions during and after cardiopulmonary resuscitation.

Management and prevention of cardiac arrest in the setting of heart disease is a challenge for modern cardiology. After reviewing the aetiology of sudden cardiac death and discussing the way to identify candidates at risk, we emphasise the role of percutaneous coronary interventions during and after cardiopulmonary resuscitation in the treatment of patients with return of spontaneous circulation after cardiac arrest.

Emerging pharmaceutical therapies in cardiopulmonary resuscitation and post-resuscitation syndrome.

OBJECTIVE: The medication used in cardiopulmonary resuscitation (CPR) has by no means yielded the expected prognostic benefit. This review focuses on drugs that are currently under investigation as part of novel therapeutic strategies in CPR and post-resuscitation care. DATA SOURCES: The main categories of drugs under investigation were identified in position papers regarding gaps in scientific knowledge and research priorities in CPR. The electronic bases of Medline via PubMed and the ClinicalTrials.gov registry were searched. Research terms were identified using the MESH database and were combined thereafter. Initial search terms were "cardiac arrest", "cardiopulmonary resuscitation", "post-cardiac arrest syndrome" combined with "drugs" and also the names of pharmaceutical categories and related drugs. RESULTS: Novel pharmaceutical approaches rely on a better understanding of the pathophysiology of cardiac arrest and post-resuscitation syndrome. Some medications are targeted primarily towards enhancing the return of spontaneous circulation and increasing survival rates, while others mostly aim at the attenuation of post-arrest myocardial and neurological impairment. Only a few of these therapies are currently being evaluated for clinical use. Despite the remarkable variability in study quality and success in achieving therapeutic targets, results for most therapies seem encouraging and support the continuation of research. CONCLUSION: New pharmaceutical modalities are being investigated for future use in CPR. Currently, none has been unequivocally accepted for clinical use, while only a few of them are undergoing clinical testing. This research is likely to continue, in view of the unsatisfactory results of current pharmaceutical therapies and the encouraging results of preliminary studies.

Marked troponin elevation after implantation of a permanent antibradycardia pacemaker.

INTRODUCTION: Transvenous insertion of endocardial leads for permanent pacing is often accompanied by minor myocardial damage, detected thanks to the high sensitivity of cardiac troponins. It is unknown whether higher troponin levels, commensurate with more severe myocardial damage, can be encountered after implantation procedures. METHODS: Over a 3-year period, 283 patients underwent an implantation of a full antibradycardia pacemaker system (pulse generator plus leads). Patients were required to have normal levels of cardiac troponin I (CTNI) on a venous blood sample taken immediately prior to elective pacemaker insertion. Post implantation CTNI levels were measured in all patients 6 hours after the procedure. Repeated samples were taken if high CTNI levels were found at 6 hours. RESULTS: Elevated CTN-I levels were found in 167 patients (59%, 95% CI: 0.53-0.64), but only 5 of them (1.8%, 95% CI=0.8 to 4.1%) had peak CTN-I levels far exceeding the range of minimal myocardial damage (i.e. CTN-I >1.5 ng/ml). Implantation of the devices was successful in all patients and we did not observe any complications. None had clinical evidence of an acute coronary event before or during the pacemaker implantation procedure and coronary angiography revealed no significant lesions in the coronary arteries. CONCLUSIONS: CTN-I elevations after pacemaker implantation may far exceed levels corresponding to minimal myocardial damage. This should be a matter of concern, especially if an early discharge is planned after pacemaker implantation.

B-type natriuretic peptide blood levels identify patients with non-ST elevation acute coronary syndromes at high risk for complications during intravenous beta-blocker infusion.

BACKGROUND: We hypothesized that measurement of B-type natriuretic peptide could identify patients with non-ST elevation acute coronary syndromes at high risk for complications during beta-blocker (esmolol) infusion. METHODS: We reviewed the records of 340 consecutive patients admitted with a non-ST elevation acute coronary syndrome. Seventy three (47 males, aged 62 ± 14 years) received esmolol up to a maximum dose of 300 µg/ kg/min until the symptoms were relieved or an adverse event occurred. RESULTS: The median infusion rate at steady state was 175 µg/kg/min (median infusion time 18 h). Infusion was halted in 14 patients. The frequency of drug discontinuation increased across admission BNP quartiles. BNP > 141 pg/ml at admission had a 95% predictive value for subsequent withdrawal of esmolol. The presence of BNP > 141 pg/ml in combination with systolic blood pressure < 130 mmHg and left ventricular ejection fraction < 50% identified a group of patients at high risk for drug interruption (interruption frequency = 83%, 95% CI: 55-95%). CONCLUSIONS: In conclusion, BNP measurement in combination with systolic blood pressure and 2D echocardiography may identify patients with non-ST elevation acute coronary syndromes at high risk for adverse events during esmolol infusion.