Out of hospital cardiac arrest - new insights and a call for a worldwide registry and guidelines.

INTRODUCTION: Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. METHOD: We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020-2023. RESULTS: A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1-2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. CONCLUSION: Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.

Nonagenarians admission and prognosis in a tertiary center intensive coronary care unit - a prospective study.

BACKGROUND: With increasing life expectancy, the prevalence of nonagenarians with cardiovascular disease is steadily growing. However, this population is underrepresented in randomized trials and thus poorly defined, with little quality evidence to support and guide optimal management. The aim of the present study was to evaluate the clinical management, therapeutic approach, and outcomes of nonagenarians admitted to a tertiary care center intensive coronary care unit (ICCU). METHODS: We prospectively collected all patients admitted to a tertiary care center ICCU between July 2019 - July 2022 and compared nonagenarians to all other patients. The primary outcome was in-hospital mortality. RESULTS: A total of 3807 patients were included in the study. Of them 178 (4.7%) were nonagenarians and 93 (52%) females. Each year the prevalence of nonagenarians has increased from 4.0% to 2019, to 4.2% in 2020, 4.6% in 2021 and 5.3% in 2022. Admission causes differed between groups, including a lower rate of acute coronary syndromes (27% vs. 48.6%, p < 0.001) and a higher rate of septic shock (4.5% vs. 1.2%, p < 0.001) in nonagenarians. Nonagenarians had more comorbidities, such as hypertension, renal failure, and atrial fibrillation (82% vs. 59.6%, 23% vs. 12.9%, 30.3% vs. 14.4% p < 0.001, respectively). Coronary intervention was the main treatment approach, although an invasive strategy was less frequent in nonagenarians in comparison to younger subjects. In-hospital mortality rate was 2-fold higher in the nonagenarians (5.6% vs. 2.5%, p = 0.025). CONCLUSION: With increasing life expectancy, the prevalence of nonagenarians in ICCU's is expected to increase. Although nonagenarian patients had more comorbidities and higher in-hospital mortality, they generally have good outcomes after admission to the ICCU. Hence, further studies to create evidence-based practices and to support and guide optimal management in these patients are warranted.

Symptomatic pelvic hematoma following hysterectomy: risk factors, bacterial pathogens and clinical outcome.

BACKGROUND: Pelvic hematoma is a common finding following hysterectomy which at times may become infected causing substantial morbidity. The aim of this study was to describe the incidence, clinical manifestation and identify risk factors for infected pelvic hematoma. We also attempted to identify specific bacterial pathogens which may cause this phenomenon. METHODS: We conducted a retrospective cohort study at a tertiary university teaching hospital. Included were all women who underwent hysterectomy and were diagnosed with a pelvic hematoma following surgery from 2013 to 2018. In an attempt to assess possible risk factors for infected pelvic hematoma women with asymptomatic pelvic hematoma were compared to women with an infected pelvic hematoma. RESULTS: During the study period 648 women underwent hysterectomy at our medical center. Pelvic hematoma was diagnosed by imaging in 50 women (7.7%) including 41 women who underwent vaginal hysterectomy and 9 women who underwent abdominal hysterectomy. In 14 (2.2%) cases the hematoma became infected resulting in need for readmission and further treatment. Women who underwent vaginal surgery were more likely to return with infected pelvic hematoma compared to women who underwent open abdominal or laparoscopic surgery (4.5% vs. 1.1%, p < 0.05). In 8 women bacterial growth from hematoma culture was noted. Enterococcus faecalis, was the most abundant pathogen to be isolated in this sub-group. CONCLUSION: Vaginal route of hysterectomy is a risk factor for infected pelvic hematoma following hysterectomy. Most of these infections were caused by anaerobic bacteria which may not be sufficiently covered by current antibiotic prophylactic regimens.

Pulmonary venous flow patterns associated with long-term mitral transcatheter edge-to-edge outcomes.

OBJECTIVE: Transcatheter edge-to-edge repair (TEER) is a prominent therapeutic option for mitral regurgitation (MR) patients. However, it lacks objective parameters to assess procedural efficacy. This study aims to investigate pulmonary venous (PV) flow as a surrogate for valvular hemodynamics and its associations to clinical outcomes. METHODS: Consecutive MR patients who underwent TEER in our center from January 2020 to October 2021 were retrospectively investigated. PV flow parameters were measured before and after TEER, including velocity (cm/s), velocity time integral (VTI) (cm), and systolic/diastolic ratios. Primary outcomes were 1, 6, and 12 months heart failure hospitalizations (HFH) and 1 year all-cause mortality. RESULTS: The cohort consisted of 80 patients. The mean age was 74.76 ± 10.13 years, 26 with primary and 54 with secondary MR. Systolic wave parameters improved significantly after TEER: mean peak velocity increased from 9.94 ± 31.95 to 35.74 ± 15.03 cm/s, and VTI from 3.62 ± 5.99 to 8.33 ± 4.72 cm. Furthermore, systolic to diastolic VTI and peak-velocities ratios showed significant improvement of 0.39 ± 0.63 to 0.81 ± 0.47 and 0.23 ± 0.66 to 0.91 ± 0.43, respectively. Using multivariable analysis, higher post-procedural SVTI was associated with less HFH: 1-month (OR = 0.72, CI [0.52,0.98]), 6-months (OR = 0.8, CI [0.66,0.97]), 1-year (OR = 0.85, CI [0.73,0.99]), as well as reduced 1-year mortality (OR = 0.64 95% CI [0.45,0.91]). Furthermore, compared to patients with SVTI ≥ 3, patients with SVTI < 3 had a higher risk for HFH at: 1-month (OR = 16.59, CI [1.48,186.02]), 6-months (OR = 12.2, CI [1.69,88.07]), and 1-year (OR = 8.61, CI [1.27,58.27]), as well as elevated 1-year mortality (OR = 8.07, 95% CI [1.04,62.28]). CONCLUSION: PV flow was significantly improved following TEER, and several hemodynamic parameters were associated with HFH and mortality. These results may offer a basis for establishing future procedural goals to ensure better clinical outcomes.

Mitral valve gradient changes associate with outcomes of patients undergoing transcatheter edge-to-edge repair.

INTRODUCTION: Transcatheter edge-to-edge repair (TEER) is typically used to treat mitral regurgitation (MR) in patients with high surgical risk. Increased post-procedural mitral valve gradient (MVG) may impact mortality and hospitalizations. We aim to evaluate and compare the absolute postprocedural MVG and the change in the MVG effect on outcomes for patients undergoing TEER therapy. METHODS: Patients who underwent TEER for severe MR were divided into two groups, initially by postprocedural absolute MVG, TTE-based at discharge, and then by the difference between preprocedural and postprocedural MVG. Primary endpoints included all-cause mortality and heart failure hospitalization (HFH) during one year after the procedure. RESULTS: The study included 100 patients. The mean MVG increased from 3.39 mmHg immediately after the procedure to 4.83 mmHg the following day, an increase of 1.44 mmHg (p < 0.001). First stratification was by MVG on the day following the procedure - MVG ≤5 mmHg (n = 70) and MVG >5 mmHg (n = 30). There was no significant difference in rates of survival (88.6%, 93.3%, p = 0.716) or HFH (18.6%, 33.3%, p = 0.178). Second stratification was by the difference in preprocedural and postprocedural MVG- delta MVG <3 mmHg (n = 55) and delta MVG ≥3 mmHg (n = 45). While survival rates did not significantly differ (87.3% vs. 93.3%, p = 0.503), delta MVG ≥3 mmHg correlated with higher HFH rates (12.7% vs. 35.6%, p = 0.014). CONCLUSIONS: The MVG of patients undergoing TEER usually increases on the day after the procedure compared to the immediate post-procedure MVG. Higher delta MVG is associated with higher HFH rate.

Troponin level at presentation as a prognostic factor among patients presenting with non-ST-segment elevation myocardial infarction.

BACKGROUND: Timely reperfusion within 120 min is strongly recommended in patients presenting with non-ST-segment myocardial infarction (NSTEMI) with very high-risk features. Evidence regarding the use of high-sensitivity cardiac troponin (hs-cTn) concentration upon admission for the risk-stratification of patients presenting with NSTEMI to expedite percutaneous coronary intervention (PCI) and thus potentially improve outcomes is limited. METHODS: All patients admitted to a tertiary care center ICCU between July 2019 and July 2022 were included. Hs-cTnI levels on presentaion were recorded, dividing patients into quartiles based on baseline hs-cTnI. Association between initial hs-cTnI and all-cause mortality during up to 3 years of follow-up was studied. RESULTS: A total of 544 NSTEMI patients with a median age of 67 were included. Hs-cTnI levels in each quartile were: (a) ≤122, (b) 123-680, (c) 681-2877, and (d) ≥2878 ng/L. There was no difference between the initial hs-cTnI level groups regarding age and comorbidities. A higher mortality rate was observed in the highest hs-cTnI quartile as compared with the lowest hs-cTnI quartile (16.2% vs. 7.35%, p = .03) with hazard ratio (HR) for mortality of 2.6 (95% confidence interval [CI]: 1.23-5.4; p = .012) in the unadjusted model, and HR of 2.06 (95% CI: 1.01-4.79; p = .047) with adjustment for age, gender, serum creatinine, and significant comorbidities. CONCLUSIONS: Patients with NSTEMI and higher hs-cTnI levels upon admission faced elevated mortality risk. This underscores the need for further prospective investigations into early reperfusion strategies' impact on NSTEMI patients' mortality, based on admission troponin elevation.

Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction: A Randomized Clinical Trial.

Importance: Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking. Objective: To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI. Design, Setting, and Participants: This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis. Intervention: Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI. Main Outcomes and Measures: A needle-to-balloon time of 10 minutes or less. Results: A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality. Conclusions and Relevance: In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT05415085.

Incidence and Predictors for Recurrence of Ventricular Arrhythmia Presenting During Acute Myocarditis: A Multicenter Study.

BACKGROUND: Management of acute myocarditis (AM) patients experiencing ventricular arrhythmia (VA) during acute illness is controversial, especially regarding early implantable cardioverter-defibrillator (ICD) implantation. OBJECTIVES: The purpose of this study was to evaluate the prevalence of and find predictors for long-term sustained VA recurrence and overall mortality among AM patients with VA. METHODS: This was a multicenter retrospective analysis of AM patients (verified by cardiac magnetic resonance imaging or myocardial biopsy) with documented VA during the acute illness ("initial VA"). Patients with history of myocardial infarction, heart failure, or VA were excluded. The study endpoint was a composite of sustained VA and overall mortality during follow-up. RESULTS: The study included 69 AM patients with initial VA: sustained monomorphic ventricular tachycardia (MMVT) (n = 25), sustained polymorphic ventricular tachycardia (VT)/ventricular fibrillation (n = 13), and nonsustained VT (n = 31). Age was 44 ± 13 years, and 23 of 69 (33.3%) were women. During median follow-up of 5.5 years, 27 of 69 (39%) patients reached the composite endpoint including sustained VA (n = 24) and death (n = 11). Initial MMVT, predischarge left ventricular dysfunction (left ventricular ejection fraction <50%), and anteroseptal delayed enhancement on cardiac magnetic resonance imaging were significantly associated with the composite endpoint. On multivariable analysis, initial MMVT (HR: 5.17; 95% CI: 1.81-14.6; P = 0.001) and predischarge LV dysfunction (HR: 4.57; 95% CI: 1.83-11.5; P = 0.005) were independently associated with the composite endpoint. Using these 2 predictors, we could delineate subgroups with low (∼4%), medium (∼42%), and high (∼82%) 10-year incidence of composite endpoint. CONCLUSIONS: AM patients presenting with VA have high incidence of sustained VA recurrence and mortality posthospitalization. Initial MMVT and predischarge LV dysfunction are independently associated with VA recurrence and mortality. Implantable cardioverter-defibrillator implantation may be considered in such high-risk patients.

Artificial intelligence based prediction model of in-hospital mortality among females with acute coronary syndrome: for the Jerusalem Platelets Thrombosis and Intervention in Cardiology (JUPITER-12) Study Group.

Introduction: Despite ongoing efforts to minimize sex bias in diagnosis and treatment of acute coronary syndrome (ACS), data still shows outcomes differences between sexes including higher risk of all-cause mortality rate among females. Hence, the aim of the current study was to examine sex differences in ACS in-hospital mortality, and to implement artificial intelligence (AI) models for prediction of in-hospital mortality among females with ACS. Methods: All ACS patients admitted to a tertiary care center intensive cardiac care unit (ICCU) between July 2019 and July 2023 were prospectively enrolled. The primary outcome was in-hospital mortality. Three prediction algorithms, including gradient boosting classifier (GBC) random forest classifier (RFC), and logistic regression (LR) were used to develop and validate prediction models for in-hospital mortality among females with ACS, using only available features at presentation. Results: A total of 2,346 ACS patients with a median age of 64 (IQR: 56-74) were included. Of them, 453 (19.3%) were female. Female patients had higher prevalence of NSTEMI (49.2% vs. 39.8%, p < 0.001), less urgent PCI (<2 h) rates (40.2% vs. 50.6%, p < 0.001), and more complications during admission (17.7% vs. 12.3%, p = 0.01). In-hospital mortality occurred in 58 (2.5%) patients [21/453 (5%) females vs. 37/1,893 (2%) males, HR = 2.28, 95% CI: 1.33-3.91, p = 0.003]. GBC algorithm outscored the RFC and LR models, with area under receiver operating characteristic curve (AUROC) of 0.91 with proposed working point of 83.3% sensitivity and 82.4% specificity, and area under precision recall curve (AUPRC) of 0.92. Analysis of feature importance indicated that older age, STEMI, and inflammatory markers were the most important contributing variables. Conclusions: Mortality and complications rates among females with ACS are significantly higher than in males. Machine learning algorithms for prediction of ACS outcomes among females can be used to help mitigate sex bias.

The Effect of War on STEMI Incidence: Insights from Intensive Cardiovascular Care Unit Admissions.

(1) Background: The impact of armed conflicts on public health is undeniable, with psychological stress emerging as a significant risk factor for cardiovascular disease (CVD). Nevertheless, contemporary data regarding the influence of war on CVD, and especially on acute coronary syndrome (ACS), are scarce. Hence, the aim of the current study was to assess the repercussions of war on the admission and prognosis of patients admitted to a tertiary care center intensive cardiovascular care unit (ICCU). (2) Methods: All patients admitted to the ICCU during the first three months of the Israel-Hamas war (2023) were included and compared with all patients admitted during the same period in 2022. The primary outcome was in-hospital mortality. (3) Results: A total of 556 patients (184 females [33.1%]) with a median age of 70 (IQR 59-80) were included. Of them, 295 (53%) were admitted to the ICCU during the first three months of the war. Fewer Arab patients and more patients with ST-segment elevation myocardial infraction (STEMI) were admitted during the war period (21.8% vs. 13.2%, p < 0.001, and 31.9% vs. 24.1%, p = 0.04, respectively), whereas non-STEMI (NSTEMI) patients were admitted more frequently in the pre-war year (19.3% vs. 25.7%, p = 0.09). In-hospital mortality was similar in both groups (4.4% vs. 3.4%, p = 0.71; HR 1.42; 95% CI 0.6-3.32, p = 0.4). (4) Conclusions: During the first three months of the war, fewer Arab patients and more STEMI patients were admitted to the ICCU. Nevertheless, in-hospital mortality was similar in both groups.

Administration of Intravenous Furosemide in Patients with Acute Infection: Patient Characteristics and Impact on In-Hospital Outcome.

Intravenous (IV) fluid is frequently used to treat patients who have been admitted with an acute infection; among these patients, some will experience pulmonary congestion and will need diuretic treatment. Consecutive admissions to the Internal Medicine Department of patients with an acute infection were included. Patients were divided based on IV furosemide treatment within 48 h after admission. A total of 3556 admissions were included: In 1096 (30.8%), furosemide was administered after ≥48 h, and in 2639 (74.2%), IV fluid was administered within <48 h. Mean age was 77.2 ± 15.8 years, and 1802 (50.7%) admissions were females. In a multivariable analysis, older age (OR 1.01 [95% CI, 1.00-1.01]), male gender (OR 0.74 [95% CI, 0.63-0.86]), any cardiovascular disease (OR 1.51 [95% CI, 1.23-1.85]), congestive heart failure (CHF) (OR 2.81 [95% CI, 2.33-3.39), hypertension (OR 1.42 [95% CI, 1.22-1.67]), respiratory infection (OR 1.38 [95% CI, 1.17-1.63]), and any IV fluid administration (OR 3.37 [95% CI, 2.80-4.06]) were independently associated with furosemide treatment >48 h after hospital admission. In-hospital mortality was higher in patients with furosemide treatment (15.9% vs. 6.8%, p < 0.001). Treatment with furosemide in patients admitted with an infection was found to be associated with prolonged hospital stay and increased in-hospital mortality.

Urgent transcatheter edge-to-edge repair for severe mitral regurgitation with flail leaflet in critically Ill patients.

Introduction: Degenerative mitral valve disease (DMR) is a common valvular disorder, with flail leaflets due to ruptured chordae representing an extreme variation of this pathology. Ruptured chordae can present as acute heart failure which requires urgent intervention. While mitral valve surgery is the preferred mode of intervention, many patients have significantly elevated surgical risk and are sometimes considered inoperable. We aim to characterize patients with ruptured chordae undergoing urgent transcatheter edge-to-edge repair (TEER), and to analyze their clinical and echocardiographic outcomes. Methods: We screened all patients who underwent TEER at a tertiary referral center in Israel. We included patients with DMR with flail leaflet due to ruptured chordae and categorized them into elective and critically ill groups. We evaluated the echocardiographic, hemodynamic, and clinical outcomes of these patients. Results: The cohort included 49 patients with DMR due to ruptured chordae and flail leaflet, who underwent TEER. Seventeen patients (35%) underwent urgent intervention and 32 patients (65%) underwent an elective procedure. In the urgent group, the average age of the patient was 80.3, with 41.8% being female. Fourteen patients (82%) received noninvasive ventilation, and three patients (18%) required invasive mechanical ventilation. One patient died due to tamponade, while echo evaluation of the other 16 patients demonstrated successful reduction of ≥2 in the MR grade. Left atrial V wave decreased from 41.6 mmHg to 17.9 mmHg (p < 0.001), and the pulmonic vein flow pattern changed from reversal (68.8%) to a systolic dominant flow in all patients (p = 0.001). After the procedure, 78.5% of patients improved to New York Heart Association (NYHA) class I or II (p < 0.001). There was no significant difference in the overall mortality between the urgent and elective groups, with similar 6 months survival rates for each group. Conclusion: Urgent TEER in patients with ruptured chordae and flail leaflets can be safe and feasible with favorable hemodynamic, echocardiographic, and clinical outcomes.

A prospective study on myocardial injury after BNT162b2 mRNA COVID-19 fourth dose vaccination in healthy persons.

AIMS: To prospectively evaluate the incidence of myocardial injury after the administration of the fourth dose BNT162b2 mRNA vaccine (Pfizer-BioNTech) against COVID-19. METHODS AND RESULTS: Health care workers who received the BNT162b2 vaccine during the fourth dose campaign had blood samples collected for high-sensitivity cardiac troponin (hs-cTn) during vaccine administration and 2-4 days afterward. Vaccine-related myocardial injury was defined as hs-cTn elevation above the 99th percentile upper reference limit and >50% increase from baseline measurement. Participants with evidence of myocardial injury underwent assessment for possible myocarditis. Of 324 participants, 192 (59.2%) were female and the mean age was 51.8 ± 15.0 years. Twenty-one (6.5%) participants had prior COVID-19 infection, the mean number of prior vaccine doses was 2.9 ± 0.4, and the median time from the last dose was 147 (142-157) days. Reported vaccine-related adverse reactions included local pain at injection site in 57 (17.59%), fatigue in 39 (12.04%), myalgia in 32 (9.88%), sore throat in 21 (6.48%), headache in 18 (5.5%), fever ≥38°C in 16 (4.94%), chest pain in 12 (3.7%), palpitations in 7 (2.16%), and shortness of breath in one (0.3%) participant. Vaccine-related myocardial injury was demonstrated in two (0.62%) participants, one had mild symptoms and one was asymptomatic; both had a normal electrocardiogram and echocardiography. CONCLUSION: In a prospective investigation, an increase in serum troponin levels was documented among 0.62% of healthy health care workers receiving the fourth dose BNT162b2 vaccine. The two cases had mild or no symptoms and no clinical sequela. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05308680.

Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit.

BACKGROUND: Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. METHODS: Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. OUTCOMES: A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 ± 14 years in the BT-group vs. 66.6 ± 16 years in the non-BT (NBT) group, p < 0.0001. Females were more likely to receive BT as compared with males (48.1% vs. 29.5%, respectively, p < 0.0001). The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p < 0.0001. Multivariate Cox analysis found that even one unit of BT was independently associated with more than two-fold the mortality rate [HR = 2.19 95% CI (1.47-3.62)] as compared with the NBT-group, p < 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760-0.852)]. CONCLUSIONS: BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted.

Mean Platelet Volume as a Predictor of Coronary Artery Disease Severity and its Association With Coronary Artery Calcification.

Coronary calcium score (CCS) is a highly sensitive marker for estimating coronary artery calcification (CAC) and detecting coronary artery disease (CAD). Mean platelet volume (MPV (is a platelet indicator that represent platelet stimulation and production. The aim of the current study was to examine the association between MPV values and CAC. We examined 290 patients who underwent coronary computerized tomography (CT) exam between the years 2017 and 2020 in a tertiary care medical center. Only patients evaluated for chest pain were included. The Multi-Ethnic Study of Atherosclerosis (MESA) CAC calculator was used to categorize patients CCS by age, gender, and ethnicity to CAC severity percentiles (<50, 50-74, 75-89, ≥90). Thereafter, the association between CAC percentile and MPV on admission was evaluated. Out of 290 patients, 251 (87%) met the inclusion and exclusion criteria. There was a strong association between higher MPV and higher CAC percentile (P = .009). The 90th CAC percentile was associated with the highest prevalence of diabetes mellitus (DM), hypertension, dyslipidemia, and statin therapy (P = .002, .003, .001, and .001, respectively). In a multivariate analysis (including age, gender, DM, hypertension, statin therapy, and low-density lipoprotein level) MPV was found to be an independent predictor of CAC percentile (OR 1.55-2.65, P < .001). Higher MPV was found to be an independent predictor for CAC severity. These findings could further help clinicians detect patients at risk for CAD using a simple and routine blood test.

The Added Value of a High CT Coronary Artery Calcium Score in the Management of Patients Presenting with Acute Chest Pain vs. Stable Chest Pain.

Background: Contrast computerized tomography (CT) scan is occasionally aborted due to a high coronary artery calcium score (CACS). For the same CACS in our clinical practice, we observed a higher occurrence of severe coronary artery disease (CAD) in patients with acute chest pain (ACP) compared to patients with stable chest pain (SCP). Since it is known that ACP differs in many ways from SCP, the aim of this study was to compare the predictive value of a high CACS for the diagnosis of severe CAD between ACP and SCP patients. Methods: This single center observational retrospective study included consecutive patients who underwent cardiac CT for chest pain and were found to have a CACS of >200 Agatston units. Patients were divided into two groups, ACP and SCP. Severe CAD was defined as ≥70% stenosis on coronary CT angiography or invasive coronary angiography. Baseline characteristics and final diagnosis of severe CAD were compared. Results: The cohort included 220 patients, 106 with ACP and 114 with SCP. ACP patients had higher severe CAD rates (60.4% vs. 36.8%; p < 0.001). On multivariate analysis including cardiac risk factors, CACS > 400 au (OR = 2.34 95% CI [1.32−4.15]; p = 0.004) and ACP (OR = 2.54 95% CI [1.45−4.45]; p = 0.001) were independent predictors of severe CAD. The addition of the clinical setting of ACP added significant incremental predictive value for severe stenosis. Conclusion: A high CACS is more associated with severe CAD in patients presenting with ACP than SCP. The findings suggest that the CACS could impact the management of patients during the scan.