Long-Term Outcome After Out-of-Hospital Cardiac Arrest: An Utstein-Based Analysis.

Background: No data are available regarding long-term survival of out-of-hospital cardiac arrest (OHCA) patients based on different Utstein subgroups, which are expected to significantly differ in terms of survival. We aimed to provide the first long-term survival analysis of OHCA patients divided according to Utstein categories. Methods: We analyzed all the 4,924 OHCA cases prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 2015 to 2019. Pre-hospital data, survival, and cerebral performance category score (CPC) at 1, 6, and 12 months and then every year up to 5 years after the event were analyzed for each patient. Results: A decrease in survival was observed during the follow-up in all the Utstein categories. The risk of death of the "all-EMS treated" group exceeded the general population for all the years of follow-up with standardized mortality ratios (SMRs) of 23 (95%CI, 16.8-30.2), 6.8 (95%CI, 3.8-10.7), 3.8 (95%CI, 1.7-6.7), 4.05 (95%CI, 1.9-6.9), and 2.6 (95%CI, 1.03-4.8) from the first to the fifth year of follow-up. The risk of death was higher also for the Utstein categories "shockable bystander witnessed" and "shockable bystander CPR": SMRs of 19.4 (95%CI, 11.3-29.8) and 19.4 (95%CI, 10.8-30.6) for the first year and of 6.8 (95%CI, 6.6-13) and 8.1 (95%CI, 3.1-15.3) for the second one, respectively. Similar results were observed considering the patients discharged with a CPC of 1-2. Conclusions: The mortality of OHCA patients discharged alive from the hospital is higher than the Italian standard population, also considering those with the most favorable OHCA characteristics and those discharged with good neurological outcome. Long-term follow-up should be included in the next Utstein-style revision.

Risk stratification of the patients with Brugada type electrocardiogram: a community-based prospective study.

AIMS: Risk stratification of patients with Brugada electrocardiogram (ECG) is being strongly debated. Conflicting results have been suggested from international registries, which enrolled non-consecutive cases, studied with different programmed electrical stimulation (PES) protocols. The aim of this study was to prospectively evaluate the incidence of arrhythmic events and the prognostic role of clinical presentation, ECG, and of a standardized PES protocol in consecutive cases from a community-based population. METHODS AND RESULTS: A total of 166 consecutive patients (45 +/- 14 years) with Brugada ECG were enrolled. Type 1 ECG was observed spontaneously in 72 (43%) and after pharmacological testing in 94 (57%). One hundred and three (62%) were asymptomatic, 58 (35%) had syncope, and five (3%) had a prior cardiac arrest. One hundred and thirty-five (81%) underwent PES with two extra stimuli up to ventricular refractoriness and 34% had ventricular fibrillation (VF) induced. Arrhythmic events occurred in nine patients at a mean follow-up of 30 +/- 21 months (2.2 events per 100 person-year): in three (60%) patients with aborted sudden death (aSD), five (8.6%) of those with syncope, and one (1%) of the asymptomatic. The only predictors of events were a history of syncope or aSD (P = 0.02) and induction at PES (P = 0.004). CONCLUSION: Clinical presentation is the most important parameter in the risk stratification of patients with Brugada ECG. Programmed electrical stimulation seems valuable, particularly in patients with previous syncope.

[Wearable cardioverter-defibrillators: clinical experience and future perspectives]. / Il defibrillatore indossabile: evidenze cliniche e prospettive future.

Sudden cardiac death (SCD) can affect patients with ischemic or non-ischemic left ventricular dysfunction. Automatic implantable cardioverter-defibrillator (ICD) implantation is the most effective option for the treatment of malignant ventricular tachyarrhythmias; however, the procedure is burdened with known significant risks, even in the long term.In patients at high risk of SCD, either real or perceived, without a definite indication to ICD implantation, wearable cardioverter-defibrillators have been shown to offer effective temporary protection in different clinical settings, for patients with recent high-risk myocardial infarction with left ventricular dysfunction, even after myocardial revascularization procedures, heart failure with reduced ejection fraction, newly diagnosed dilated cardiomyopathy, ICD post-explant phase for infection, and bridge to cardiac transplantation.The purpose of this review is to describe the technical aspects and clinical results available in the literature on the use of wearable cardioverter-defibrillators, with particular reference to safety, efficacy, costs and patient selection, together with current and unconventional indications.The authors also report the first data related to their personal experience.

[Palliative care in the intensive cardiac care unit: a new competence for the cardiac intensivist]. / Cure palliative in unità di terapia intensiva cardiologica: una nuova competenza per il cardiologo intensivista.

Admissions to the intensive care unit at the end of life of patients with chronic non-malignant diseases are increasing. This involves the need for the development of palliative care culture and competence, also in the field of intensive cardiology. Palliative care should be implemented in the treatment of all patients with critical stages of disease, irrespective of prognosis, in order to improve the quality of care at the end of life.This review analyzes in detail the main clinical, ethical and communicational issues to move toward the introduction of basics of palliative care in cardiac intensive care units. It outlines the importance of shared decision-making with the patient and his family, with special attention to withholding/withdrawing of life-sustaining treatments, palliative sedation, main symptom control, patient and family psychological support.

[Implantable cardioverter-defibrillator deactivation at the end of life: ethical, clinical and communication issues]. / La disattivazione del defibrillatore impiantabile alla fine della vita: etica, clinica, comunicazione.

The number of cardioverter-defibrillator implants is increasing worldwide, with the main indication being primary prevention of sudden cardiac death. During the follow-up, patients may die from progression of their underlying heart disease or from nonarrhythmic causes, such as malignancies, dementia and lung disease, without receiving appropriate shocks until the last few days or weeks of their life. These events occur roughly in 30% of patients, mainly in the last 24 hours before death. In this case, inappropriate and even appropriate shock deliveries can no longer prolong life and may simply lead to pain and reduced quality of life. Therefore, it appears important to discuss early with the patients and their relatives about deactivation of the implantable cardioverter-defibrillator (ICD) at the end of life.The goal of this review is to provide an overview of the ethical, clinical and communication issues of ICD deactivation, with a special focus on patients' wishes. It is outlined that patients are not adequately informed about risks and benefits of ICD and the option of ICD deactivation; the doctors are not used to discuss with the patients the topics of end-of-life decisions. Complete information must be part of current informed consent before ICD implantation and should be updated during the follow-up, with special attention to patients with heart failure in relation to their prognosis and advance directives, as suggested by international guidelines.

[Left internal mammary artery graft stenosis. Atherosclerosis, spasm or kinking?]. / Stenosi del corpo del graft di arteria mammaria interna sinistra. Aterosclerosi, spasmo o "kinking"?

The internal mammary artery is the most frequently used bypass conduit for the left anterior descending coronary artery in patients treated with bypass surgery, with excellent long-term patency rates. However, the mammary artery may also be affected by functionally significant stenoses. Most stenoses of the mammary artery are secondary to the surgical procedure at the anastomosis site, but atherosclerotic lesions may also develop. The mammary artery is often tortuous and extreme kinking of the vessel may cause flow obstruction. The treatment of such kind of stenoses is not codified. The clinical course and interventional procedure of 2 patients with previous mammary artery bypass graft and severe angina due to kinking stenosis of the graft are described. The 2 cases are characterized by the short time frame during which the stenosis became apparent, suggesting a vasoactive component in the first case that was resolved with medical treatment and an aggressive atherosclerotic progression in the second that required a percutaneous intervention. Therefore, etiology of the stenosis of the body of the mammary artery graft may differ from that of the native circulation. The role of marked bends in bypass grafts could deserve selective studies to determine whether they are associated with the development of functional stenosis. This information may be useful when performing mammary artery bypass graft surgery for avoiding extremely twisted vessel courses.

Takotsubo cardiomyopathy as an early complication of drug-induced suicide attempt.

Takotsubo cardiomyopathy typically presents in menopausal women following episodes of intense physical or mental stress. To our knowledge, the literature contains only two documented cases of Takotsubo cardiomyopathy arising following a suicide attempt, neither of which involved pharmaceutical poisoning. Here, however, we document the case of a young male patient with borderline personality disorder and a clinical and angiographic presentation compatible with Takotsubo cardiomyopathy arising following a suicide attempt by voluntary drug intoxication (risperidone, barbiturates, and benzodiazepine). The potential pathophysiological mechanisms behind this unusual clinical picture are discussed.