Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock.

INTRODUCTION AND OBJECTIVES: Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV). METHODS: Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis. RESULTS: Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage. CONCLUSIONS: NIV seems to be relatively effective and safe in the treatment of early-stage CS.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support.

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome.

Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema?

INTRODUCTION AND PURPOSE: The impact of hypocapnia in the prognosis of cardiogenic acute pulmonary edema (CAPE) has not been sufficiently studied. The aim of this study was to analyse whether hypocapnia is a risk factor for non-invasive ventilation (NIV) failure and hospital mortality, in CAPE patients CAPE. METHODS: Retrospective observational study of all patients with CAPE treated with NIV. Patients were classified in three groups according to PaCO2 level (hypocapnic, eucapnic and hypercapnic). NIV failure was defined as the need for endotracheal intubation and/or death. RESULTS: 1138 patients were analysed, 390 (34.3%) of which had hypocapnia, 186 (16.3%) had normocapnia and 562 (49.4%) had hypercapnia. NIV failure was more frequent in hypocapnic (60 patients, 15.4%) than in eucapnic (16 pacientes, 8.6%) and hypercapnic group (562 pacientes, 10.7%), with statistical significance (p = 0.027), as well as hospital mortality, 73 (18.7%), 19(10.2%) and 83 (14.8%) respectively (p = 0.026). The predicted factors for NIV failure were the presence of do-not-intubate order, complications related to NIV, a lower left ventricular ejection fraction, higher SAPS II and SOFA score and a higher HACOR score at one hour of NIV initiation. CONCLUSIONS: Hypocapnia in patients with CAPE is associated with NIV failure and a greater in-hospital mortality.

Outcome of patients with acute heart failure secondary to acute myocardial infarction treated with noninvasive mechanical ventilation.

INTRODUCTION AND OBJECTIVES: Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies. METHODS: Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death. RESULTS: A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P=.031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P=.478). CONCLUSIONS: The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support.

Effect of part-time cardiac catheterization facilities in patients with acute myocardial infarction.

BACKGROUND: Although the easy availability of invasive cardiac care facilities is associated with an increase in their use, their influence on outcomes is not clear. We sought to investigate whether a newly available cardiac catheterization laboratory (CCL) performing percutaneous coronary intervention (PCI) on a part-time (PT) basis might improve outcomes in patients with acute myocardial infarction (AMI). METHODS: This was an observational cohort study that included all consecutive patients with AMI admitted to a secondary-level hospital in Spain before and after the PT-CCL opened in January 2006: during 1998-2005 and 2006-2014, respectively. All-cause in-hospital and long-term mortality were the co-primary endpoints. In-hospital complications and length of stay were secondary endpoints. For the analyses, patients were stratified according to propensity-score (PS) quintiles. RESULTS: A total of 5339 patients were recruited, and 50.3% were managed after the opening of the PT-CCL. The PT-CCL was associated with greater use of PCI (81.2 vs. 32.5%, p<0.001) and guidelines-recommended medication (all p<0.001), lower risk of recurrent angina (PS-adjusted RR=0.160, 95% CI 0.115-0.222) and shorter length of hospital stay (PS-adjusted RR for length of stay <8days=0.357, 95% CI 0.301-0.422). In patients with NSTEMI, PT-CCL was associated with improved long-term survival (PS-adjusted HR=0.764, 95% CI 0.602-0.970). CONCLUSIONS: In patients with AMI, a new PT-CCL was associated with greater use of PCI and guideline-recommended medication, lower risk of recurrent angina and shorter length of hospital stay. In a subset of patients with NSTEMI, PT-CCL was associated with improved long-term survival.

Relation of New Permanent Right or Left Bundle Branch Block on Short- and Long-Term Mortality in Acute Myocardial Infarction Bundle Branch Block and Myocardial Infarction.

The aim of this study was to investigate the prognosis associated with bundle branch block (BBB) depending on location, time of appearance, and duration in patients with myocardial infarction (MI). From January 1998 to January 2008, we recruited 5,570 patients with acute MI. Thirty-day and 7-year all-cause mortality, according to BBB location, time of appearance, and duration were analyzed by multivariable analyses. BBB was present in 964 patients (17.3%); right BBB (RBBB) 10.6% and left BBB (LBBB) 6.7%. Overall mortality rate at 30 days was 13.2% (n = 738) and 7 years was 6.34 deaths per 100 patient-year. Both RBBB and LBBB were more frequently previous, 42.9% and 58.8%. Compared with non-BBB, all BBB groups showed higher prevalence of co-morbidities, especially rates of diabetes (49.0% vs 34.3%, p <0.001) and more often heart failure during hospitalization (54.5% vs 26.6%, p <0.001). Compared with RBBB, patients with LBBB had a higher prevalence of co-morbidities and a higher mortality, especially the new BBB, 30 days: 52.5% versus 31.6% and 7 years (incident rate): 27.2 versus 13.3 per 100 patient-year. New transient BBB had lower heart failure on admission (42.6% vs 58.3%, p = 0.008) and 30-day mortality (20.3% vs 69.6%, p <0.001) compared with permanent in both locations. New permanent RBBB was independently associated with 30-day (hazard ratio [HR] 2.01, 95% confidence interval [CI] 1.45 to 2.79) and 7-year mortality (HR 3.12, 95% CI 2.38 to 4.09). New-permanent LBBB was independently associated with 30-day (HR 2.15, 95% CI 1.47 to 3.15) and 7-year mortality (HR 2.91, 95% CI 2.08 to 4.08). In conclusion, in patients with acute MI, the appearance of a new BBB was independently associated with a higher 30-day and 7-year all-cause mortality.

Educational Level and Long-term Mortality in Patients With Acute Myocardial Infarction.

INTRODUCTION AND OBJECTIVES: The value of socioeconomic status as a prognostic marker in acute myocardial infarction is controversial. The aim of this study was to evaluate the impact of educational level, as a marker of socioeconomic status, on the prognosis of long-term survival after acute myocardial infarction. METHODS: We conducted a prospective, observational study of 5797 patients admitted to hospital with acute myocardial infarction. We studied long-term all-cause mortality (median 8.5 years) using adjusted regression models. RESULTS: We found that 73.1% of patients had primary school education (n=4240), 14.5% had secondary school education (including high school) (n=843), 7.0% was illiterate (n=407), and 5.3% had higher education (n=307). Patients with secondary school or higher education were significantly younger, more were male, and they had fewer risk factors and comorbidity. These patients arrived sooner at hospital and had less severe heart failure. During admission they received more reperfusion therapy and their crude mortality was lower. Their drug treatment in hospital and at discharge followed guideline recommendations more closely. On multivariate analysis, secondary school or higher education was an independent predictor and protective factor for long-term mortality (hazard ratio=0.85; 95% confidence interval, 0.74-0.98). CONCLUSIONS: Our study shows an inverse and independent relationship between educational level and long-term mortality in patients with acute myocardial infarction.

[Prognostic importance of cardiomegaly in patients with acute myocardial infarction]. / Importancia de la presencia de cardiomegalia en el pronóstico de los pacientes con infarto agudo de miocardio.

OBJECTIVES: To assess the in-hospital and long-term prognostic importance of cardiomegaly demonstrated by a simple admission radiograph in patients hospitalized for acute myocardial infarction. MATERIAL AND METHODS: Prospective study of 7644 patients admitted for acute myocardial infarction; 2 hospitals participated. We recorded detailed clinical data, especially noting the presence or absence of cardiomegaly in the chest radiograph. Adjusted predictive models for all-cause mortality in hospital or after discharge were constructed. The median followup was 6 years. RESULTS: Cardiomegaly was detected in 1351 (17.7%) of the patients. Hospital mortality was 11.2% overall; the incidence of long-term mortality was 5.7 per 100 patient-years. Patients with cardiomegaly were older and had more cardiovascular risk factors other than current smoking; they also had more concomitant conditions, had undergone fewer revascularization procedures, and received suboptimal care after discharge. Cardiomegaly was associated with higher in-hospital rates of adverse events, especially heart failure (70.8% in patients with cardiomegaly vs 21.4% in others, P<.001) and death (27.8% vs 7.7%, P<.001). Cardiomegaly was also an independent predictor of hospital mortality (odds ratio, 1.34; P=.02) as well as mortality after discharge (hazard ratio, 1.16; P<.01). CONCLUSION: Cardiomegaly was an independent predictor of both hospital mortality and long-term mortality after discharge in this series.

OBJETIVO: Conocer el significado pronóstico intrahospitalario y a largo plazo de la presencia de cardiomegalia en la radiología simple inicial de los pacientes ingresados por infarto agudo de miocardio. METODO: Estudio prospectivo de 7.644 pacientes ingresados por un infarto agudo de miocardio en dos hospitales. Se obtuvo información clínica detallada y se prestó especial atención a la presencia/ausencia de cardiomegalia en la radiografía de tórax. Realizamos modelos ajustados para predecir mortalidad (por cualquier causa) hospitalaria y tras el alta con una mediana de 6 años. RESULTADOS: 1.351 (17,7%) pacientes presentaron cardiomegalia. La mortalidad hospitalaria global fue 11,2% y la densidad de incidencia de mortalidad a largo plazo fue de 5,7 por cada 100 pacientes-año. Los pacientes con cardiomegalia presentaron mayor edad y más factores de riesgo cardiovascular excepto tabaquismo activo, mayor comorbilidad, fueron menos revascularizados y tratados al alta de forma subóptima. Durante la hospitalización, la cardiomegalia se asoció a mayores tasas de complicaciones, especialmente insuficiencia cardiaca (70,8 vs 21,4%, p < 0,001) y mortalidad (27,8 vs 7,7%, p < 0,001). La cardiomegalia resultó predictor independiente sobre la mortalidad hospitalaria (odds ratio = 1,34; p = 0,02) y tras el alta (hazard ratio = 1,16, p < 0,01). CONCLUSIONES: En pacientes con infarto agudo de miocardio la cardiomegalia resultó predictor independiente de mortalidad hospitalaria y a largo plazo tras el alta.

Short- and long-term prognosis of previous and new-onset atrial fibrillation in ST-segment elevation acute myocardial infarction.

INTRODUCTION AND OBJECTIVES: The impact of atrial fibrillation on the prognosis of myocardial infarction is still the subject of debate. We analyzed the influence of previous and new-onset atrial fibrillation on in-hospital and long-term prognosis in patients with acute myocardial infarction. METHODS: Prospective study of 4284 patients with ST-segment elevation acute myocardial infarction. We studied all-cause in-hospital and long-term mortality (median, 7.2 years) using adjusted models. RESULTS: In total, 3.2% of patients had previous atrial fibrillation and 9.8% had new-onset atrial fibrillation. In general, both groups of patients had a high baseline risk profile and an increased likelihood of in-hospital complications. The crude in-hospital mortality rate was higher in patients with previous atrial fibrillation than in those with new-onset atrial fibrillation (22% vs 12%; P<.001; 30% vs 10%; P<.001). The long-term mortality rate was 11.11/100 patient-years in patients with previous atrial fibrillation and 5.35/100 patient years in those with new-onset atrial fibrillation (both groups, P<.001). New-onset fibrillation alone (odds ratio=1.55; 95% confidence interval, 1.08-2.22) was an independent predictor of in-hospital mortality. Previous atrial fibrillation (hazard ratio=1.24; 95% confidence interval, 0.94-1.64) and new-onset atrial fibrillation (hazard ratio=0.98; 95% confidence interval, 0.80-1.21) were not independent predictors of long-term mortality. CONCLUSIONS: New-onset atrial fibrillation during hospitalization is an independent risk factor for in-hospital mortality in acute myocardial infarction.

Impact of previous vascular burden on in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: Patients with a current acute coronary syndrome and previous ischemic heart disease, peripheral arterial disease, and/or cerebrovascular disease are reported to have a poorer outcome than those without these previous conditions. It is uncertain whether this association with outcome is observed at long-term follow-up. METHODS: Prospective observational study, including 4247 patients with ST-segment elevation myocardial infarction. Detailed clinical data and information on previous ischemic heart disease, peripheral arterial disease, and cerebrovascular disease ("vascular burden") were recorded. Multivariate models were performed for in-hospital and long-term (median, 7.2 years) all-cause mortality. RESULTS: One vascular territory was affected in 1131 (26.6%) patients and ≥ 2 territories in 221 (5.2%). The total in-hospital mortality rate was 12.3% and the long-term incidence density was 3.5 deaths per 100 patient-years. A background of previous ischemic heart disease (odds ratio = 0.83; P = .35), peripheral arterial disease (odds ratio = 1.30; P = .34), or cerebrovascular disease (stroke) (odds ratio = 1.15; P = .59) was not independently predictive of in-hospital death. In an adjusted model, previous cerebrovascular disease and previous peripheral arterial disease were both predictors of mortality at long-term follow-up (hazard ratio = 1.57; P < .001; and hazard ratio = 1.34; P = .001; respectively). Patients with ≥ 2 diseased vascular territories showed higher long-term mortality (hazard ratio = 2.35; P < .001), but not higher in-hospital mortality (odds ratio = 1.07; P = .844). CONCLUSIONS: In patients with a diagnosis of ST-segment elevation acute myocardial infarction, the previous vascular burden determines greater long-term mortality. Considered individually, previous cerebrovascular disease and peripheral arterial disease were predictors of mortality at long-term after hospital discharge.

[Female sex is inversely and independently associated with marked ST-segment elevation. A study in patients with ST-segment elevation acute myocardial infarction and early admission]. / El sexo femenino se asocia de forma inversa e independiente a la marcada elevación del segmento ST. Estudio en pacientes con infarto agudo de miocardio con ST elevado e ingreso precoz.

INTRODUCTION AND OBJECTIVES: In patients with acute myocardial infarction, a number of variables in the initial ECG are useful prognostic indicators. The presence of ST-segment elevation, however, usually indicates the need for reperfusion therapy. The aims of this study were to investigate sex differences in the ECGs of patients with ST-elevation myocardial infarction (STEMI) and to look for a possible association between sex and marked ST-segment elevation. METHODS: A prospective observational longitudinal study of consecutive patients (n=1422) who were admitted early for a first STEMI to one of two coronary units was carried out. Initial ECG parameters were analyzed for sex differences. Multivariate analysis was performed to identify variables associated with marked ST-segment elevation (i.e., total ST-segment elevation >11 mm, according to the upper tertile of the frequency distribution). RESULTS: In women (n=336), Q-wave myocardial infarction was observed more often in the initial ECG (19% versus 15.6%; P< .03), the total ST-segment elevation was lower (10+/-6.6 mm versus 11.1+/-7.9 mm; P< .004), and marked ST-segment elevation was less common (26.4% versus 35.5%; P< .005). There was an independent inverse association between female sex and marked ST-segment elevation (odds ratio=0.70; 95% confidence interval, 0.52-0.96; P< .02). CONCLUSIONS: In patients with STEMI, female sex was associated with a lower total ST-segment elevation and there was an independent inverse association with marked ST-segment elevation.