Neurological outcome and modifiable events after out-of-hospital cardiac arrest in patients managed in a tertiary cardiac centre: A ten years register.

OBJECTIVE: A study was made of the events occurring in the early post-resuscitation phase that may help to improve the outcomes at hospital discharge. DESIGN: A retrospective cohort study (2007-2017) of a prospective Utstein type registry database was carried using multivariate logistic regression analysis. Pre- and post-hospital admission events were investigated. SETTING: A tertiary cardiac centre. PARTICIPANTS: Unconscious victims of out-of-hospital cardiac arrest (OHCA) with documented ventricular tachycardia or fibrillation. MAIN VARIABLES OF INTEREST: Events occurring before and within 72h after intensive care unit (ICU) admission were recorded. The variables were analyzed to determine their impact on hospital survival and poor neurological outcome. One-year follow-up survival was also considered. Results are presented as odds ratio (OR) and 95% confidence interval (95%CI). RESULTS: Of 245 patients admitted to our ICU after OHCA, 152 (62%) were alive and 131 (86.2%) presented good neurological outcomes (cerebral performance categories≤2) at hospital discharge. The one-year follow-up survival rate was 95.9%. Age >70 years (OR 2.0; 95%CI 1.1-4.1), previous myocardial infarction (OR 2.7; 95%CI 1.2-6.1), shock upon hospital admission (OR 2.9; 95%CI 1.3-6.2), time from call to return of spontaneous circulation (ROSC) >25min (OR 3.1; 95%CI 1.6-6.0) and anticonvulsant therapy (OR 18.2; 95%CI 5.5-60) were independent predictors of poor neurological outcome. Immediate admission to the cardiac centre (OR 0.5; 95%CI 0.3-0.9) and lactate clearance reaching plasma levels <2.5mmol/l at 12h (OR 0.4; 95%CI 0.2-0.8) were associated with better outcomes. CONCLUSIONS: Unconscious OHCA patients with documented ventricular tachycardia or fibrillation may benefit from direct admission to a reference cardiac centre. Initial haemodynamic support, urgent coronary angiography and targeted management in the cardiac ICU seem to increase the likelihood of good neurological outcomes.

Blood transfusion and ischaemic outcomes according to anemia and bleeding in patients with non-ST-segment elevation acute coronary syndromes: Insights from the TAO randomized clinical trial.

BACKGROUND: The benefits and risks of blood transfusion in patients with acute myocardial infarction who are anemic or who experience bleeding are debated. We sought to study the association between blood transfusion and ischemic outcomes according to haemoglobin nadir and bleeding status in patients with NST-elevation myocardial infarction (NSTEMI). METHODS: The TAO trial randomized patients with NSTEMI and coronary angiogram scheduled within 72h to heparin plus eptifibatide versus otamixaban. After exclusion of patients who underwent coronary artery bypass surgery, patients were categorized according to transfusion status considering transfusion as a time-varying covariate. The primary ischemic outcome was the composite of all-cause death or MI within 180 days of randomization. Subgroup analyses were performed according to pre-transfusion hemoglobin nadir and bleeding status. RESULTS: 12,547 patients were enrolled. Among these, blood transfusion was used in 489 (3.9%) patients. Patients who received transfusion had a higher rate of death or MI (29.9% vs. 8.1%, p<0.01). This excess risk persisted after adjustment on GRACE score and nadir of hemoglobin (HR 3.36 95%CI 2.63-4.29 p<0.01). Subgroup analyses showed that blood transfusion was associated with a higher risk in patients without overt bleeding (adjusted HR 6.25 vs. 2.85; p-interaction 0.001) as well as in those with hemoglobin nadir > 9.0 g/dl (HR 4.01; p-interaction<0.0001). CONCLUSION: In patients with NSTEMI, blood transfusion was associated with an overall increased risk of ischaemic events. However, this was mainly driven by patients without overt bleeding and those hemoglobin nadir > 9.0g/dl. This suggests possible harm of transfusion in those groups.

[Cell therapies in cardiology: results from the first randomized clinical trials]. / Thérapie cellulaire en cardiologie: bilan des premiers essais cliniques randomisés.

Following acute myocardial infarction, necrotic cardiac tissue is replaced by scar leading to ventricular remodeling and pump failure. Transplantation of autologous bone marrow-derived cells into the heart, early post-infarct, aims to prevent ventricular remodeling. This strategy has been evaluated in four controlled, randomized clinical trials, which provided mixed results. A transient improvement in ventricular function was observed in one trial, and a modest improvement (the duration of which remains to be determined) in an additional trial, whereas two trials showed negative results. A modest benefit of bone marrow cell transplantation was also observed in patients with chronic ischemic heart disease. Despite mixed results reported so far, cell therapy of heart disease still is in its infancy and has considerable room for improvement.

PTX3, A prototypical long pentraxin, is an early indicator of acute myocardial infarction in humans.

BACKGROUND: Inflammation is an important component of ischemic heart disease. PTX3 is a long pentraxin whose expression is induced by cytokines in endothelial cells, mononuclear phagocytes, and myocardium. The possibility that PTX3 is altered in patients with acute myocardial infarction (AMI) has not yet been tested. METHODS AND RESULTS: Blood samples were collected from 37 patients admitted to the coronary care unit (CCU) with symptoms of AMI. PTX3 plasma concentrations, as measured by ELISA, higher than the mean+2 SD of age-matched controls (2.01 ng/mL) were found in 27 patients within the first 24 hours of CCU admission. PTX3 peaked at 7.5 hours after CCU admission, and mean peak concentration was 6.94+/-11.26 ng/mL. Plasma concentrations of PTX3 returned to normal in all but 3 patients at hospital discharge and were unrelated to AMI site or extent, Killip class at entry, hours from symptom onset, and thrombolysis. C-reactive protein peaked in plasma at 24 hours after CCU admission, much later than PTX3 (P<0.001). Patients >64 years old and women had significantly higher PTX3 concentrations at 24 hours (P<0.05). PTX3 was detected by immunohistochemistry in normal but not in necrotic myocytes. CONCLUSIONS: PTX3 is present in the intact myocardium, increases in the blood of patients with AMI, and disappears from damaged myocytes. We suggest that PTX3 is an early indicator of myocyte irreversible injury in ischemic cardiomyopathy.

Epidemiologic variables and outcome of 1972 young patients with acute myocardial infarction. Data from the GISSI-2 database. Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2).

BACKGROUND: Acute myocardial infarction in younger patients is uncommon, occurring mainly in men. The recent introduction of thrombolysis improved survival, left ventricular function, and infarct size. OBJECTIVE: To evaluate characteristics and clinical outcome of the patients younger than 50 years randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico study. All patients received a thrombolytic treatment. METHODS: The 11483 patients were divided into 3 age subgroups: younger than 50 years (17.2%), between 50 and 70 years (60.2%), and older than 70 years (22.6%). All relations between variables were first determined by an unadjusted analysis. An adjusted analysis was performed by multiple logistic regression models for in-hospital and 6-month mortality. RESULTS: While older patients had a significantly higher rate of a history of hypercholesterolemia, diabetes, and hypertension, smoking and a positive family history were significantly more frequent in younger patients. Total in-hospital and 6-month mortality were significantly lower in patients younger than 50 years (2.7% and 1.2%, respectively) than in patients between 50 and 70 years old (6.9% and 2.7%) and those older than 70 years (21.1% and 8.4%). After multivariate analysis, the predictive value of age was confirmed. CONCLUSIONS: Our findings, based on a large group of patients who received thrombolytic treatment, suggest that younger age is a significant independent indicator of a favorable prognosis after acute myocardial infarction.

Italian BiodivYsio open registry (BiodivYsio PC-coated stent): study of clinical outcomes of the implant of a PC-coated coronary stent.

UNLABELLED: Rapid technological developments have made new materials available for percutaneous coronary intervention procedures. The coronary stent in particular has undergone progressive structural improvements leading to the recent availability of a third generation of stents, namely, coated stents. The rapid evolution of the stent has often made its evaluation problematical, since trials are frequently confined to small groups of patients in single centers. The purpose of this registry was to verify the safety and efficacy of the BiodivYsio stent (a stent coated with phosphorylcholine polymer) in a broad population of patients who reflect the daily reality of coronary intervention in a cardiac catheterization laboratory. METHODS AND RESULTS: The registry was designed to collect the principal angiographic and clinical data of a consecutive series of Oreal worldO patients. Patients were treated with a BiodivYsio stent (Biocompatibles, Galway, United Kingdom) in 12 centers (11 Italian and 1 Swiss) between January 1998 and January 1999. Procedural, in-hospital, 30-day and six-month follow-up data were collected. The monitoring, data entry and statistical analyses were carried out by an independent center. During the study, 218 patients were enrolled; 165 (76%) male and 53 (24%) female, with an average age of 61.6 +/- 9.4 years (range, 36Eth 84 years). A total of 258 stents were implanted in 233 lesions (1.1 stents per lesion), of which 233 (90%) were the BiodivYsio PC coated stent, the remaining 25 implants were of other stent types. The percutaneous transluminal coronary angioplasty and stenting procedure were carried out in 109 (50%) patients with unstable angina, 65 (30%) with stable angina, 29 (13%) with acute myocardial infarction, and 15 (7%) patients with silent ischemia. Procedural success was achieved in 217/218 (99.5%) patients. Optimal results were achieved in 212 (97.7%) patients. In 34 (15.6%) cases, patients were treated with periprocedural abciximab. During the hospitalization period, one (0.4%) death occurred on day 7 due to subacute occlusion of the stent, and 3 (1.4%) myocardial infarctions were reported. At 30-day follow-up, 211 (97.2%) patients were asymptomatic, as were 189 (87%) patients at clinical follow-up at 6 months. CONCLUSIONS: This study evaluated the safety and efficacy of a third-generation stent. The results demonstrate a high procedural success rate and a low incidence of major adverse cardiac events at short- and medium-term follow-up. It appears that the BiodivYsio stent should be considered safe in clinical and/or anatomical situations with a high risk of complications, confirming the hypothesis that PC may have non-thrombogenic properties. To corroborate these results, an appropriately designed study would be required to measure the stentOs efficacy in the most suitable clinical context, i.e., clinical situations that are at the highest risk of ischemic relapse.

[Progression of coronary sclerosis demonstrated by repeated coronarography. Experience with 80 cases]. / Progressione della sclerosi coronarica in base a coronarografie ripetute Esperienza di 80 casi

Coronary and left ventricular angiography repeated after an interval of 19 months in 84 patients showed progression of coronary sclerosis in 42 and of ventricular lesions in 7. No relation between the morphology and seriousness of the initial coronary lesions and their progression was noted. No significant differences were observed between patients with and without progression as far as the clinical data and risk factors (angina pectoris, prior myocardial infarct, cholesterol, arterial hypertension, and diabetes) were concerned, though there was a significantly higher percentage in obese subjects.

[Electrocardiographical changes and rhythm disorders in Barlow's syndrome]. / Altérations électrocardiographiques et troubles du rythme dans le syndrome de Barlow.

Mitral valve prolapse ( MVP ) , responsible for most of the symptoms which had previously been interpreted as being due to neurocirculatory disorders or cardiac neurosis , is being recognised more often and has an incidence of about 6-8 % in an unselected population . Although this condition was considered for a long time to be a benign auscultatory abnormality , it may be the cause of serious cardiac complication . Arrhythmias predominate with an incidence of 60 to 80 % on continuous electrocardiography . In a series of 245 patients with mitral valve prolapse confirmed on echocardiography , 52 patients chosen at random were studied to determine the incidence pf ST changes , disturbances of heart rate , QT interval , changes of QRS , arrhythmias with resting , exercise and continuous ECG over 24 hours ( HMS = Holter Monitoring System ) . Abnormalities of ventricular repolarisation , especially flattening of the T wave and , less commonly , St depression were observed in about one third of the patients . These changes were more common in the inferior but were also found in the left precordial leads . 73 % of the 52 patients had a heart rate of 75/mn and their QT intervals showed the following changes : 30.7 % Had a duration greater than the 120 th percentile ; 19.2 % had a duration greater than the upper limit of normal . The other 50 % had a QT interval of around the 100 th percentile . None had a duration of less than the 90 th percentile . In 22.5 % patients , QRS changes due to conduction defects were recorded ( 15 % right bundle branch block - RBBB - , 7.5 % incomplete RBBB ) . HMS is the method of choice for detection of arrhythmias . Resting ECG only showed premature ventricular contractions ( PVCs ) in 12.5 % , compared to 32.5 % on exercise ECG and 62.5 % on HMS . 50 % PVCs were monomorphic , 5 % polymorphic , 7.5 % in salvos and 7.4 % supraventricular in origin . The circadian variation of PVC was striking with a high incidence during periods of activity . There was no statistical correlation between the incidence of PVCs , age , sex , type of MVP and the symptoms and auscultatory findings . The theories on the pathogenesis of the arrhythmias are divided between that based on an underlying cardiomyopathy ( confirmed by the presence of degenerated myocytes on electron microscopy ) and the mechanical hypothesis ( chordae tendinae irritating the endocardium or traction on the papillary muscle with resulting ischaemia ) which provide a better explanation of the clear predominance of monomorphic PVCs . The treatment of Barlow's syndrome is discussed . In our opininon , therapy is only required for ventricular arrhythmias detected by a sufficiently sensitive method such as HMS . Most authors use beta blockers , eventually in association with quinidine Therapeutic successes have also been observed with mexiletine , amiodarone , aprindine and less commonly with disopyramide .

Quantification of aortic flow by phase-contrast magnetic resonance in patients with bicuspid aortic valve.

AIMS: Bicuspid aortic valve (BAV) causes complex flow patterns in the ascending aorta (AAo), which may compromise the accuracy of flow measurement by phase-contrast magnetic resonance (PC-MR). Therefore, we aimed to assess and compare the accuracy of forward flow measurement in the AAo, where complex flow is more dominant in BAV patients, with flow quantification in the left ventricular outflow tract (LVOT) and the aortic valve orifice (AV), where complex flow is less important, in BAV patients and controls. METHODS AND RESULTS: Flow was measured by PC-MR in 22 BAV patients and 20 controls at the following positions: (i) LVOT, (ii) AV, and (iii) AAo, and compared with the left ventricular stroke volume (LVSV). The correlation between the LVSV and the forward flow in the LVOT, the AV, and the AAo was good in BAV patients (r = 0.97/0.96/0.93; P < 0.01) and controls (r = 0.96/0.93/0.93; P < 0.01). However, in relation with the LVSV, the forward flow in the AAo was mildly underestimated in controls and much more in BAV patients [median (inter-quartile range): 9% (4%/15%) vs. 22% (8%/30%); P < 0.01]. This was not the case in the LVOT and the AV. The severity of flow underestimation in the AAo was associated with flow eccentricity. CONCLUSION: Flow measurement in the AAo leads to an underestimation of the forward flow in BAV patients. Measurement in the LVOT or the AV, where complex flow is less prominent, is an alternative means for quantifying the systolic forward flow in BAV patients.

Electronic cardiac medicine: present and future opportunities.

The second half of the 20th century witnessed a revolution in electronic medicine similar to that in pharmacology in the decades before. The advent of the implantable pacemaker, implantable cardioverter-defibrillators, cardiac resynchronisation therapies, insertable loop recorders and more, have improved diagnoses and reduced mortality and morbidity in millions of patients suffering from cardiac disease. The possibility to monitor patients continually without need for frequent office visits has the potential to reduce follow-up burden on physicians, facilitate increased use of home-based care and further improve the safety for patients. This review summarises the role of cardiac device therapies today and some of the developments which we can hope for in the nearest future.

Neurological outcome and modifiable events after out-of-hospital cardiac arrest in patients managed in a tertiary cardiac centre: A ten years register / Desenlaces neurológicos y acontecimientos modificables tras parada cardíaca extrahospitalaria en pacientes tratados en un centro de atención cardíaca terciaria: registro de 10 años

OBJECTIVE: A study was made of the events occurring in the early post-resuscitation phase that may help to improve the outcomes at hospital discharge. DESIGN: A retrospective cohort study (2007-2017) of a prospective Utstein type registry database was carried using multivariate logistic regression analysis. Pre- and post-hospital admission events were investigated. SETTING: A tertiary cardiac centre. PARTICIPANTS: Unconscious victims of out-of-hospital cardiac arrest (OHCA) with documented ventricular tachycardia or fibrillation. MAIN VARIABLES OF INTEREST: Events occurring before and within 72h after intensive care unit (ICU) admission were recorded. The variables were analyzed to determine their impact on hospital survival and poor neurological outcome. One-year follow-up survival was also considered. Results are presented as odds ratio (OR) and 95% confidence interval (95%CI). RESULTS: Of 245 patients admitted to our ICU after OHCA, 152 (62%) were alive and 131 (86.2%) presented good neurological outcomes (cerebral performance categories≤2) at hospital discharge. The one-year follow-up survival rate was 95.9%. Age >70 years (OR 2.0; 95%CI 1.1-4.1), previous myocardial infarction (OR 2.7; 95%CI 1.2-6.1), shock upon hospital admission (OR 2.9; 95%CI 1.3-6.2), time from call to return of spontaneous circulation (ROSC) >25min (OR 3.1; 95%CI 1.6-6.0) and anticonvulsant therapy (OR 18.2; 95%CI 5.5-60) were independent predictors of poor neurological outcome. Immediate admission to the cardiac centre (OR 0.5; 95%CI 0.3-0.9) and lactate clearance reaching plasma levels <2.5mmol/l at 12h (OR 0.4; 95%CI 0.2-0.8) were associated with better outcomes. CONCLUSIONS: Unconscious OHCA patients with documented ventricular tachycardia or fibrillation may benefit from direct admission to a reference cardiac centre. Initial haemodynamic support, urgent coronary angiography and targeted management in the cardiac ICU seem to increase the likelihood of good neurological outcomes

OBJETIVO: Llevar a cabo un estudio de los acontecimientos ocurridos en la fase inmediatamente posterior a la reanimación que puedan ayudar a mejorar los desenlaces en el momento del alta hospitalaria. DISEÑO: Se realizó un estudio retrospectivo (2007-2017) de cohorte de una base de datos de registro de tipo Utstein prospectivo mediante un análisis de regresión logística multivariable. Se investigaron los acontecimientos previos y posteriores al ingreso hospitalario. Ámbito: Un centro de atención cardíaca terciaria. PARTICIPANTES: Víctimas inconscientes de parada cardíaca extrahospitalaria (OHCA) con fibrilación o taquicardia ventricular documentada. VARIABLES PRINCIPALES DE INTERÉS: Se registraron los acontecimientos ocurridos antes y durante las 72h posteriores al ingreso en la unidad de cuidados intensivos (UCI). Se analizaron las variables para determinar su impacto en la supervivencia hospitalaria y los malos desenlaces neurológicos. También se tuvo en consideración la supervivencia en el seguimiento a lo largo de un año. Los resultados se presentan con valores de oportunidad relativa (OR) e intervalo de confianza del 95% (IC del 95%). RESULTADOS: De los 245 pacientes ingresados en nuestra UCI tras una OHCA, 152 (62%) seguían vivos y 131 (86,2%) presentaban unos buenos desenlaces neurológicos (categorías de rendimiento cerebral≤2) en el momento del alta hospitalaria. La tasa de supervivencia en el seguimiento a lo largo de un año fue del 95,9%. La edad>70 años (OR: 2,0; IC del 95%: 1,1-4,1), los antecedentes de infarto de miocardio (OR: 2,7; IC del 95%: 1,2-6,1), el choque en el momento del ingreso hospitalario (OR: 2,9; IC del 95%: 1,3-6,2), el tiempo transcurrido entre la llamada y el regreso a la circulación espontánea (ROSC)>25min (OR: 3,1; IC del 95%: 1,6-6,0) y la administración de tratamiento anticonvulsivo (OR: 18,2; IC del 95%: 5,5-60) fueron factores predictivos independientes de un mal desenlace neurológico. El ingreso inmediato en un centro de cuidados cardíacos (OR: 0,5; IC del 95%: 0,3-0,9) y el hecho de que el aclaramiento de lactato alcanzase unos niveles plasmáticos<2,5mmol/l al cabo de 12h (OR: 0,4; IC del 95%: 0,2-0,8) se asociaron con unos mejores desenlaces. CONCLUSIONES: Los pacientes inconscientes tras OHCA y con fibrilación o taquicardia ventricular documentada podrían beneficiarse del ingreso directo en un centro cardíaco de referencia. El apoyo hemodinámico inicial, la angiografía coronaria urgente y el tratamiento dirigido en la UCI cardíaca parecen aumentar la probabilidad de obtener unos buenos desenlaces neurológicos

Estimates of lifetime attributable risk of cancer after a single radiation exposure from 64-slice computed tomographic coronary angiography.

AIMS: To estimate the life attributable risk (LAR) of cancer incidence over a wide range of dose radiation exposure and a large spectrum of possible diagnostic computed tomographic coronary angiography (CTCA) scenarios. METHODS: This study included 561 consecutive patients who underwent a successful prospective ECG-gating CTCA protocol (low-dose group) 64-slice CTCA and 188 patients who underwent retrospective ECG-gating CTCA with ECG-triggered dose modulation CTCA (high-dose group). LAR was computed, given the organ equivalent dose, for all cancers in both sexes. LAR was tabulated for each decile of dose-length product by 10-year age classes, separately for each sex. RESULTS: Estimates of LAR of any cancer for an exposure at age < or =40 year were lower in males than in females for any given quantile. At age >/ or =50 years, LAR was similar between sexes only at the lowest exposure doses, whereas at higher dosage, it was, in general, higher for women. At the median age of this case series (62 years) and for a radiation exposure ranging from 1.33 to 3.81 mSv, LAR was 1 in 4329 (or 23.1 per 10(5) persons exposed) and 1 in 4629 (or 21.6 per 10(5) persons) in men and women, respectively. For an exposure ranging from 10.34 to 18.97 mSv at the same median age, the LAR of cancer incidence was 1 in 1336 (or 74.8 per 10(5) persons) in men and doubled (1 in 614 or 162.8 per 10(5) persons) in women. CONCLUSIONS: This study provided an estimate of the LAR of cancer in middle-aged patients of both sexes after a single diagnostic CTCA, providing an easy-to-read table.