Sex bias in admission to tertiary-care centres for acute myocardial infarction and cardiogenic shock.

BACKGROUND: There are limited data on sex-specific outcomes and management of cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI). We investigated whether any sex bias exists in the admission to revascularization capable hospitals (RCH) or intensive cardiac care units (ICCU) and its impact on in-hospital mortality. METHODS: We used the Spanish National Health System Minimum Basic Data from 2003 to 2015 to identify patients with CS-STEMI. The primary outcome was sex differences in in-hospital mortality. RESULTS: Among 340 490 STEMI patients, 20 262 (6%) had CS and 29.2% were female. CS incidence was higher in women than in men (7.9% vs 5.1%, P = .001). Women were older and had more hypertension and diabetes, and were less often admitted to RCH than men (from 58.7% in 2003 to 79.6% in 2015; and from 61.9% in 2003 to 85.3% in 2015; respectively, P = .01), and to ICCU centres (25.7% vs 29.2%, P = .001). Adjusted mortality was higher in women than men over time (from 79.5 ± 4.3% to 65.8 ± 6.5%; and from 67.8 ± 6% to 58.1 ± 6.5%; respectively, P < .001). ICCU availability was associated with higher use of Percutaneous coronary intervention (PCI) in women (46.8% to 67.2%; P < .001) but was even higher in men (54.8% to 77.4%; P < .001). In ICCU centres, adjusted mortality rates decreased in both sexes, but lower in women (from 74.9 ± 5.4% to 66.3 ± 6.6%) than in men (from 67.8 ± 6.0% to 58.1 ± 6.5%, P < .001). Female sex was an independent predictor of mortality (OR 1.18 95% CI 1.10-1.27, P < .001). CONCLUSIONS: Women with CS-STEMI were less referred to tertiary-care centres and had a higher adjusted in-hospital mortality than men.

Rational and design of ST-segment elevation not associated with acute cardiac necrosis (LESTONNAC). A prospective registry for validation of a deep learning system assisted by artificial intelligence.

BACKGROUND: Patients with chest pain and persistent ST segment elevation (STE) may not have acute coronary occlusions or serum troponin curves suggestive of acute necrosis. Our objective is the validation and cost-effectiveness analysis of a diagnostic model assisted by artificial intelligence (AI). METHODS: Prospective multicenter registry in two groups of patients with STE: I) coronary arteries without significant lesions and without serum troponin curve suggestive of acute necrosis, II) myocardial infarction with acute coronary occlusion. The inclusion criteria are the following: 1) age ≥ 18 years, 2) chest pain or symptoms suggestive of myocardial ischemia, 3) STE at point J in two contiguous leads ≥0.1 mV, in V2 and V3 ≥ 0,2 mV and 4) signature of informed consent. The exclusion criteria are the following: 1) left bundle branch block, 2) acute cardiac necrosis in the absence of significant epicardial coronary artery stenosis, 3) STE ≤ 0.1 mV with pathologic Q wave, 4) severe anemia (hemoglobin <8.0 g/dl). For each patient without acute cardiac necrosis, the next patient from that center of the same sex and similar age (± 5 years) with myocardial infarction and acute coronary occlusion will be included. A manual centralized electrocardiographic analysis and another by deep learning AI will be performed. CONCLUSIONS: The results of the study will provide new information for the stratification of patients with STE. Our hypothesis is that an AI analysis of the surface electrocardiogram allows a better distinction of patients with STE due to acute myocardial ischemia, from those with another etiology.

Step by step daily management of short-term mechanical circulatory support for cardiogenic shock in adults in the intensive cardiac care unit: a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology SC, the European Society of Intensive Care Medicine, the European branch of the Extracorporeal Life Support Organization, and the European Association for Cardio-Thoracic Surgery.

The use of mechanical circulatory support using percutaneous ventricular assist devices (pVAD) has increased rapidly during the last decade without substantial new evidence for their effect on outcome. In addition, many gaps in knowledge still exist such as timing and duration of support, haemodynamic monitoring, management of complications, concomitant medical therapy, and weaning protocols. This clinical consensus statement summarizes the consensus of an expert panel of the Association for Acute CardioVascular Care, European Society of Intensive Care Medicine, European Extracorporeal Life Support Organization, and European Association for Cardio-Thoracic Surgery. It provides practical advice regarding the management of patients managed with pVAD in the intensive care unit based on existing evidence and consensus on best current practice.

Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility.

INTRODUCTION AND OBJECTIVES: Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial. METHODS: We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC). RESULTS: We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001). CONCLUSIONS: FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.

Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention "Codi IAM" Network.

Background: Despite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the "Codi IAM" network in Barcelona. Methods: This is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality. Results: The mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p < 0.003), had longer reperfusion delays (p < 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7-1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84-1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76-1.56). Conclusion: Although the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.

Frailty and prognosis of older patients with chronic heart failure.

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is prevalent in advanced ages. Our objective was to assess the impact of frailty on 1-year mortality in older patients with ambulatory HF. METHODS: Our data come from the FRAGIC study (Spanish acronym for "Study of the impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly outpatients with heart failure"), a multicenter prospective registry conducted in 16 Spanish hospitals including outpatients ≥ 75 years with HF followed up by cardiology services in Spain. RESULTS: We included 499 patients with a mean age of 81.4±4.3 years, of whom 193 (38%) were women. A total of 268 (54%) had left ventricular ejection fraction <40%, and 84.6% was in NYHA II functional class. The FRAIL scale identified 244 (49%) pre-frail and 111 (22%) frail patients. Frail patients were significantly older, were more frequently female (both, P <.001), and had higher comorbidity according to the Charlson index (P=.017) and a higher prevalence of geriatric syndromes (P <.001). During a median follow-up of 371 [361-387] days, 58 patients (11.6%) died. On multivariate analysis (Cox regression model), frailty detected with the FRAIL scale was marginally associated with mortality (HR=2.35; 95%CI, 0.96-5.71; P=.059), while frailty identified by the visual mobility scale was an independent predictor of mortality (HR=2.26; 95%CI, 1.16-4.38; P=.015); this association was maintained after adjustment for confounding variables (HR=2.13; 95%CI, 1.08-4.20; P=.02). CONCLUSIONS: In elderly outpatients with HF, frailty is independently associated with mortality at 1 year of follow-up. It is essential to identify frailty as part of the comprehensive approach to elderly patients with HF.

Clinical Outcomes of Severe COVID-19 Patients Admitted to an Intermediate Respiratory Care Unit.

Introduction: Many severe COVID-19 patients require respiratory support and monitoring. An intermediate respiratory care unit (IMCU) may be a valuable element for optimizing patient care and limited health-care resources management. We aim to assess the clinical outcomes of severe COVID-19 patients admitted to an IMCU. Methods: Observational, retrospective study including patients admitted to the IMCU due to COVID-19 pneumonia during the months of March and April 2020. Patients were stratified based on their requirement of transfer to the intensive care unit (ICU) and on survival status at the end of follow-up. A multivariable Cox proportional hazards method was used to assess risk factors associated with mortality. Results: A total of 253 patients were included. Of them, 68% were male and median age was 65 years (IQR 18 years). Ninety-two patients (36.4%) required ICU transfer. Patients transferred to the ICU had a higher mortality rate (44.6 vs. 24.2%; p < 0.001). Multivariable proportional hazards model showed that age ≥65 years (HR 4.14; 95%CI 2.31-7.42; p < 0.001); chronic respiratory conditions (HR 2.34; 95%CI 1.38-3.99; p = 0.002) and chronic kidney disease (HR 2.96; 95%CI 1.61-5.43; p < 0.001) were independently associated with mortality. High-dose systemic corticosteroids followed by progressive dose tapering showed a lower risk of death (HR 0.15; 95%CI 0.06-0.40; p < 0.001). Conclusions: IMCU may be a useful tool for the multidisciplinary management of severe COVID-19 patients requiring respiratory support and non-invasive monitoring, therefore reducing ICU burden. Older age and chronic respiratory or renal conditions are associated with worse clinical outcomes, while treatment with systemic corticosteroids may have a protective effect on mortality.

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016.

INTRODUCTION AND OBJECTIVES: ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI. METHODS: This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality. RESULTS: From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95). CONCLUSIONS: Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

The Effect of Age on Mortality in Patients With COVID-19: A Meta-Analysis With 611,583 Subjects.

OBJECTIVES: Initial data on COVID-19 infection has pointed out a special vulnerability of older adults. DESIGN: We performed a meta-analysis with available national reports on May 7, 2020 from China, Italy, Spain, United Kingdom, and New York State. Analyses were performed by a random effects model, and sensitivity analyses were performed for the identification of potential sources of heterogeneity. SETTING AND PARTICIPANTS: COVID-19-positive patients reported in literature and national reports. MEASURES: All-cause mortality by age. RESULTS: A total of 611,1583 subjects were analyzed and 141,745 (23.2%) were aged ≥80 years. The percentage of octogenarians was different in the 5 registries, the lowest being in China (3.2%) and the highest in the United Kingdom and New York State. The overall mortality rate was 12.10% and it varied widely between countries, the lowest being in China (3.1%) and the highest in the United Kingdom (20.8%) and New York State (20.99%). Mortality was <1.1% in patients aged <50 years and it increased exponentially after that age in the 5 national registries. As expected, the highest mortality rate was observed in patients aged ≥80 years. All age groups had significantly higher mortality compared with the immediately younger age group. The largest increase in mortality risk was observed in patients aged 60 to 69 years compared with those aged 50 to 59 years (odds ratio 3.13, 95% confidence interval 2.61-3.76). CONCLUSIONS AND IMPLICATIONS: This meta-analysis with more than half million of COVID-19 patients from different countries highlights the determinant effect of age on mortality with the relevant thresholds on age >50 years and, especially, >60 years. Older adult patients should be prioritized in the implementation of preventive measures.

Dexmedetomidine in medical cardiac intensive care units. Data from a multicenter prospective registry.

BACKGROUND: Dexmedetomidine induces cooperative and arousable sedation. Our aim was to analyze dexmedetomidine use in medical cardiac intensive care units (CICU). METHODS: Multicenter prospective registry of patients treated with dexmedetomidine in CICU. Consecutive inclusion during a 12-month period. RESULTS: A total of 410 patients were included, mean age was 67.4 ± 13.9 years, and 94 (22.9%) were women. Before using dexmedetomidine, 247 patients (60.2%) had delirium, 48 developed delirium after dexmedetomidine use. In 178 (43.4%) dexmedetomidine was used during weaning from mechanical ventilation, with a reintubation rate of 10.1%, early reintubation rate (<24 h) 1.7%. Seventy-seven patients (18.8%) died during admission. Dexmedetomidine mean dose infusion was 0.51 ± 0.25 µ/kg/h, during a median of 34 h (interquartile range 12-78 h). Three hundred forty-eight patients received adjuvant sedatives (84.9%). Sixty-eight patients (16.6%) had adverse effects. The most frequent adverse effects were hypotension with systolic blood pressure <80 mmHg (44 patients - 10.7%), bradycardia <40 beats per minute (15 patients - 3.7%), and both bradycardia and hypotension (4 patients - 1.0%). Patients with adverse effects received more frequently inotropes (53 [81.6%] vs. 212 [65.4%], p = 0.02) and fewer adjuvant sedatives (49 [75.4%] vs. 282 [87.0%], p = 0.01). The independent predictors of adverse effects were inotropes use (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.30-5.74, p = 0.008) and lack of adjuvant sedatives (OR 3.03, 95% CI 1.49-6.26, p = 0.002). CONCLUSION: Dexmedetomidine safety for medical CICU patients seems to be similar to that for general intensive care unit patients. Inotropes and lack of adjuvant sedatives were associated with adverse effects.

External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients.

BACKGROUND: Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy. The CardShock and the Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk scores have shown good results in predicting short-term mortality in cardiogenic shock. However, to date, they have not been compared in a large cohort of ischaemic and non-ischaemic real-world cardiogenic shock patients. METHODS: The Red-Shock is a multicentre cohort of non-selected cardiogenic shock patients. We calculated the CardShock and IABP-SHOCK II risk scores in each patient and assessed discrimination and calibration. RESULTS: We included 696 patients. The main cause of cardiogenic shock was acute coronary syndrome, occurring in 62% of the patients. Compared with acute coronary syndrome patients, non-acute coronary syndrome patients were younger and had a lower proportion of risk factors but higher rates of renal insufficiency; intra-aortic balloon pump was also less frequently used (31% vs 56%). In contrast, non-acute coronary syndrome patients were more often treated with mechanical circulatory support devices (11% vs 3%, p<0.001 for both). Both risk scores were good predictors of in-hospital mortality in acute coronary syndrome patients and had similar areas under the receiver-operating characteristic curve (area under the curve: 0.742 for the CardShock vs 0.752 for IABP-SHOCK II, p=0.65). Their discrimination performance was only modest when applied to non-acute coronary syndrome patients (0.648 vs 0.619, respectively, p=0.31). Calibration was acceptable for both scores (Hosmer-Lemeshow p=0.22 for the CardShock and 0.68 for IABP-SHOCK II). CONCLUSIONS: In our cohort, both the CardShock and the IABP-SHOCK II risk scores were good predictors of in-hospital mortality in acute coronary syndrome-related cardiogenic shock.

External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients.

BACKGROUND: Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy. The CardShock and the Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk scores have shown good results in predicting short-term mortality in cardiogenic shock. However, to date, they have not been compared in a large cohort of ischaemic and non-ischaemic real-world cardiogenic shock patients. METHODS: The Red-Shock is a multicentre cohort of non-selected cardiogenic shock patients. We calculated the CardShock and IABP-SHOCK II risk scores in each patient and assessed discrimination and calibration. RESULTS: We included 696 patients. The main cause of cardiogenic shock was acute coronary syndrome, occurring in 62% of the patients. Compared with acute coronary syndrome patients, non-acute coronary syndrome patients were younger and had a lower proportion of risk factors but higher rates of renal insufficiency; intra-aortic balloon pump was also less frequently used (31% vs 56%). In contrast, non-acute coronary syndrome patients were more often treated with mechanical circulatory support devices (11% vs 3%, p<0.001 for both). Both risk scores were good predictors of in-hospital mortality in acute coronary syndrome patients and had similar areas under the receiver-operating characteristic curve (area under the curve: 0.742 for the CardShock vs 0.752 for IABP-SHOCK II, p=0.65). Their discrimination performance was only modest when applied to non-acute coronary syndrome patients (0.648 vs 0.619, respectively, p=0.31). Calibration was acceptable for both scores (Hosmer-Lemeshow p=0.22 for the CardShock and 0.68 for IABP-SHOCK II). CONCLUSIONS: In our cohort, both the CardShock and the IABP-SHOCK II risk scores were good predictors of in-hospital mortality in acute coronary syndrome-related cardiogenic shock.

Comparison of clinical outcomes in STEMI patients treated with primary PCI according to day-time of medical attention and its relationship with circadian pattern.

OBJECTIVE: Relationship between STEMI time of presentation, its circadian pattern and cardiovascular outcomes is unclear. Our objective is to analyze clinical outcomes of STEMI according to time of presentation and circadian pattern. METHODS: We analyzed data from patients treated within the regional STEMI Network from January 2010 to December 2015. On-hour group included patients treated between 8:00 h and 19:59 h on weekdays, the rest were catalogued as off-hour group. The primary endpoint was 1-year all-cause mortality. Secondary endpoints were 30-day all-cause mortality and in-hospital complications. RESULTS: A total of 8608 patients were included, 44.1% in the on-hour group and 55.9% in the off-hour group. We observed a shorter patient delay and longer system delay in the off-hour group compared to on-hour group with no difference in total ischemic time. At 30-day and 1-year follow-up there were no differences in adjusted all-cause mortality between groups [OR 0.91 (CI95%: 0.73-1.12; p = 0.35) and OR 0.99 (CI95%: 0.83-1.17; p = 0.87), respectively]. A circadian pattern was observed between 9:00 am and 12:30 pm, with no differences in 30-day and 1-year mortality between patients included in this time interval [OR 1.02 (IC95%: 0.81-1.30; p = 0.85) and OR 1.12 (IC95%: 0.92-1.36; p = 0.25) respectively]. CONCLUSIONS: Off-hour STEMI presentation was associated with a shorter patient delay and longer system delay without an increase in total ischemic time. The off-hour presentation was not related to an increase in 1-year all-cause mortality when compared to on-hour. A circadian pattern was found, without differences in 30-day and 1-year mortality.

Lower admission blood pressure as an independent predictor of 1-year mortality in elderly patients experiencing a first hospitalization for acute heart failure.

BACKGROUND: Systolic blood pressure (SBP) is an acknowledged prognostic factor in patients with heart failure (HF). Admission SBP should be a risk factor for 1-year mortality even in elderly patients experiencing a first admission for HF, and this risk may persist in the oldest subset of patients. DESIGN: Methods: We reviewed the medical records of 1031 patients aged 70 years or older admitted within a 3-year period for a first episode of acute heart failure (AHF). The cohort was divided according to admission SBP values in quartiles. We analyzed all-cause mortality as a function of these admission SBP quartiles. RESULTS: Mean age was 82.2 ± 6 years; their mean admission SBP was 138.6 ± 25 mmHg. A statistically significant association was present between mortality at 30 (p < 0.0001), 90 (p < 0.0001), and 365 days (p < 0.0001) after hospital discharge and lower admission SBP quartiles. One-year mortality ranged from 14.7% for patients within the upper SBP quartile to 41.4% for those in the lowest quartile. The multivariate analysis confirmed this association (HR: 0.884; 95% CI: 0.615-0.76; p = 0.0001), which remained significant when admission SBP was evaluated as a continuous variable (HR: 0.980; 95% CI: 0.975-0.985; p = 0.0001). The association between SBP and 1-year mortality remained when the sample was divided into old (70-82 years) and "oldest-old" (>82 years) patients. CONCLUSIONS: Lower SBP at admission is an independent predictor of midterm postdischarge mortality for elderly patients experiencing a first admission for AHF.

Lymphocyte-to-white blood cells ratio in older patients experiencing a first acute heart failure hospitalization.

PURPOSE: Low lymphocyte counts are related to poor health results in heart failure (HF) patients. We assess whether a low lymphocyte-to-white blood cells ratio (LWR) is related to 1-year mortality in older patients experiencing a first hospitalization for acute HF. METHODS: We evaluated 859 patients > 75 years of age admitted within a 33-month period because of a first episode of acute HF. Patients were divided into four groups according to LWR quartiles. RESULTS: Patients' mean age was 83.5 ± 5.5 years and their median LWR was 16.7%. After 1 year of follow-up 270 patients (31.43%) died. Mean LWR values were significatively lower in the group of patients who died (15.1 vs. 17.4%; p = 0.001). Mortality rates were significantly higher in the lower LWR quartile either at 1 month, 3 months, and 1 year after the index acute HF episode. The univariate logistic regression analysis identified the LWR (either as quartiles or continuous variable) to be independently associated with higher risk of 1-year post-discharge mortality. Multivariate analysis confirmed this association (HR for LWR as a quartiles variable 1.525; 95% CI 1.161-2.003 and for LWR as a continuous variable 1.145; 95% CI 1.069-1854) besides older age, a higher comorbidity and higher admission potassium. CONCLUSIONS: As is the case in other HF scenarios, a simple routine admission laboratory test such as lymphocyte count can independently predict 1-year mortality for older patients hospitalized for first time due to acute HF.

Prevalence and clinical significance of interatrial block in very older persons.

PURPOSE: The presence in older patients of an interatrial block (IAB) may be a predictor of atrial fibrillation (AF). The objective of the study was to assess in a group of very older participants: the prevalence of IAB, its association with the presence of functional and cognitive status, of new AF diagnosis and mortality after 2-year of follow-up. METHODS: A prospective subcohort of the OCTABAIX population-based study with 75 inhabitants, all 85-year-olds, at baseline in sinus rhythm were assessed. Functional and cognitive status, nutritional risk, and previous falls were recorded. Participants were classified according to the presence or absence of IAB. RESULTS: 23 patients had IAB (30.7%). We did not observe significant differences regarding gender, comorbidity, functional status, nutritional risk and global geriatric assessment according to interatrial conduction. The patients with IAB had statistically significant better cognitive performance (p = 0.029) and a lower number of previous falls (p = 0.008). During the 2 years follow-up 3 participants (4%) died; without statistical differences between both groups. A non-significant trend to a higher incidence of new-onset AF was observed in patients with IAB (8.7 vs. 6.1%; p = 0.652). CONCLUSIONS: Nearly one-third of very older patients with sinus rhythm have IAB. They had a tendency to higher incidence of AF and no association with mortality after 2 years of follow-up.

A multicentre randomized pilot trial on the effectiveness of different levels of cooling in comatose survivors of out-of-hospital cardiac arrest: the FROST-I trial.

PURPOSE: To obtain initial data on the effect of different levels of targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA). METHODS: We designed a multicentre pilot trial with 1:1:1 randomization to either 32 °C (n = 52), 33 °C (n = 49) or 34 °C (n = 49), via endovascular cooling devices during a 24-h period in comatose survivors of witnessed OHCA and initial shockable rhythm. The primary endpoint was the percentage of subjects surviving with good neurologic outcome defined by a modified Rankin Scale (mRS) score of ≤ 3, blindly assessed at 90 days. RESULTS: At baseline, different proportions of patients who had received defibrillation administered by a bystander were assigned to groups of 32 °C (13.5%), 33 °C (34.7%) and 34 °C (28.6%; p = 0.03). The percentage of patients with an mRS ≤ 3 at 90 days (primary endpoint) was 65.3, 65.9 and 65.9% in patients assigned to 32, 33 and 34 °C, respectively, non-significant (NS). The multivariate Cox proportional hazards model identified two variables significantly related to the primary outcome: male gender and defibrillation by a bystander. Among the 43 patients who died before 90 days, 28 died following withdrawal of life-sustaining therapy, as follows: 7/16 (43.8%), 10/13 (76.9%) and 11/14 (78.6%) of patients assigned to 32, 33 and 34 °C, respectively (trend test p = 0.04). All levels of cooling were well tolerated. CONCLUSIONS: There were no statistically significant differences in neurological outcomes among the different levels of TTM. However, future research should explore the efficacy of TTM at 32 °C. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov unique identifier: NCT02035839 ( http://clinicaltrials.gov ).

Longitudinal deformation of drug-eluting stents: evaluation by multislice computed tomography.

BACKGROUND: Some modifications introduced in the design of the new generation of drug-eluting stent (DES) to improve their flexibility may entail a reduction in their longitudinal strength. This study sought to evaluate the longitudinal deformation of DESs by multislice computed tomography (MSCT). METHODS: This study included DESs that could have been potentially deformed by mechanical actions such as: (1) catheter impingement; (2) postdilation; (3) kissing balloon; and (4) intravascular imaging after implantation. Patients on atrial fibrillation or with overlapping stents were excluded. All patients underwent stent length evaluation by MSCT 9-12 months after implantation. RESULTS: Forty-five stents were included: 15 platinum chromium (PtCr-DES), 15 cobalt chromium (CoCr-DES), and 15 stainless-steel (SS-DES). The relative longitudinal deformation by stent type was 6.93 ± 5.82% for PtCr-DES, 6.19 ± 5.79% for CoCr- DES, and 4.03 ± 4.07% for SS-DES (P=.31). Among the mechanical actions studied, only catheter impingement was related to longitudinal stent deformation (P<.01). After adjustment, only catheter impingement (P<.01) and nominal stent length (P=.049) were independently related to longitudinal deformation. There were no stent fractures. CONCLUSIONS: Longitudinal deformation of DESs is common in all the studied platforms when subject to longitudinal forces. Guiding catheter impingement is the only mechanical action significantly associated with DES shortening.

Impact of mild hypothermia on platelet responsiveness to aspirin and clopidogrel: an in vitro pharmacodynamic investigation.

UNLABELLED: The combination of percutaneous coronary intervention (PCI) and therapeutic hypothermia in comatose patients after cardiac arrest due to an acute coronary syndrome has been reported to be safe and effective. However, recent investigations suggest that hypothermia may be associated with impaired response to clopidogrel and greater risk of thrombotic complications after PCI. This investigation aimed to evaluate the effect of hypothermia on the pharmacodynamic response of aspirin and clopidogrel in patients (n = 20) with ST elevation myocardial infarction undergoing primary PCI. Higher platelet reactivity (ADP stimulus) was observed in samples incubated at 33 °C compared with those at 37 °C (multiple electrode aggregometry, 235.2 ± 31.4 AU×min vs. 181.9 ± 30.2 AU×min, p < 0.001; VerifyNow P2Y12, 172.9 ± 20.3 PRU vs. 151.0 ± 19.3 PRU, p = 0.004). Numerically greater rates of clopidogrel poor responsiveness were also observed at 33 °C. No differences were seen in aspirin responsiveness. In conclusion, mild hypothermia was associated with reduced clopidogrel-mediated platelet inhibition with no impact on aspirin effects. CLINICAL RELEVANCE: Mild therapeutic hypothermia is associated with impaired response to clopidogrel therapy, which might contribute to increase the risk of thrombotic events in ACS comatose patients undergoing PCI.