Conduction System Stimulation to Avoid Left Ventricle Dysfunction.

BACKGROUND: Right ventricular apical pacing (RVAP) can produce left ventricle dysfunction. Conduction system pacing (CSP) has been used successfully to reverse left ventricle dysfunction in patients with left bundle branch block. To date, data about CSP prevention of left ventricle dysfunction in patients with preserved left ventricular ejection fraction (LVEF) are scarce and limited mostly to nonrandomized studies. Our aim is to demonstrate that CSP can preserve normal ventricular function compared with RVAP in the setting of a high burden of ventricular pacing. METHODS: Consecutive patients with a high-degree atrioventricular block and preserved or mildly deteriorated LVEF (>40%) were included in this prospective, randomized, parallel, controlled study, comparing conventional RVAP versus CSP. RESULTS: Seventy-five patients were randomized, with no differences between basal characteristics in both groups. The stimulated QRS duration was significantly longer in the RVAP group compared with the CSP group (160.4±18.1 versus 124.2±20.2 ms; p<0.01). Seventy patients were included in the intention-to-treat analyses. LVEF showed a significant decrease in the RVAP group at 6 months compared with the CSP group (mean difference, -5.8% [95% CI, -9.6% to -2%]; P<0.01). Left ventricular end-diastolic diameter showed an increase in the RVAP group compared with the CSP group (mean difference, 3.2 [95% CI, 0.1-6.2] mm; P=0.04). Heart failure-related admissions were higher in the RVAP group (22.6% versus 5.1%; P=0.03). CONCLUSIONS: Conduction system stimulation prevents LVEF deterioration and heart failure-related admissions in patients with normal or mildly deteriorated LVEF requiring a high burden of ventricular pacing. These results are only short term and need to be confirmed by further larger studies. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT06026683.

Geriatric Assessment and In-Hospital Economic Cost of Elderly Patients With Acute Coronary Syndromes.

BACKGROUND: Elderly patients with acute coronary syndromes (ACS) are at higher risk for complications and health care resources expenditure. No previous study has assessed the specific contribution of frailty and other geriatric syndromes to the in-hospital economic cost in this setting. METHOD: Unselected patients with ACS aged ≥75 years were prospectively included. A comprehensive geriatric assessment was performed during hospitalisation. Hospitalisation-related cost per patient was calculated with an analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in Euros (2019). The contribution of geriatric syndromes and clinical factors to the economic cost was assessed with a linear regression method. RESULTS: A total of 194 patients (mean age 82.6 years) were included. Mean length of hospital stay was 11.3 days. The admission-related economic cost was €6,892.15 per patient. Most of this cost was attributable to hospital length of stay (77%). The performance of an invasive strategy during the admission was associated with economic cost (p=0.008). Of all the ageing-related variables, comorbidity showed the most significant association with economic cost (p=0.009). Comorbidity, disability, nutritional risk, and frailty were associated with the hospital length of stay-related component of the economic cost. The final predictive model of economic cost included age, previous heart failure, systolic blood pressure, Killip class at admission, left main disease, and Charlson index. CONCLUSIONS: Management of ACS in elderly patients is associated with a significant economic cost, mostly due to hospital length of stay. Comorbidity mostly contributes to in-hospital resources expenditure, as well as the severity of the coronary event.

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.

FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes.

OBJECTIVES: No previous studies have assessed the role of the FRAIL scale in predicting long-term outcomes in older patients with acute coronary syndromes (ACS). DESIGN, SETTING AND PARTICIPANTS: The multicenter observational LONGEVO-SCA registry included unselected patients ≥80 years of age with ACS from 44 centers. A comprehensive geriatric assessment was performed during hospitalization. MEASURES: Frailty was measured by the FRAIL scale. For the purpose of this study, main outcome measured was mortality or readmission at 24 months. RESULTS: A total of 498 patients were included. Mean age was 84.3 years. A total of 198 patients (33.1%) were prefrail and 135 (27.1%) frail. Patients who were prefrail and frail had a higher degree of comorbidities, and higher prevalence of disability, cognitive impairment, and nutritional risk. A total of 165 out of 498 patients (33.1%) died, and 331 patients (66.7%) died or were readmitted at 24 months. Both prefrailty and frailty were associated with a higher mortality compared with robust patients (P < .001). The incidence of mortality or readmission was also higher in patients who were prefrail or frail (P < .001). After adjusting for potential confounders, the association between frailty and mortality or readmission remained significant (hazard ratio 1.28 for prefrailty and hazard ratio 1.96 for frailty, P < .001). The FRAIL scale showed an optimal ability for predicting mortality or readmission (area under the receiver operating characteristics curve 0.86, 95% confidence interval 0.83‒0.89). The area under the receiver operating characteristics curve from the Global Registry of Acute Coronary Events risk score was 0.89. No significant differences were observed between both AUC values (P = .163). CONCLUSIONS AND IMPLICATIONS: The FRAIL scale independently predicted long-term outcomes in older patients with ACS. The predictive ability of this scale was comparable to the strongly recommended Global Registry of Acute Coronary Events risk score. Frailty assessment is mandatory for improving risk prediction in these complex patients.