Out of hospital cardiac arrest - new insights and a call for a worldwide registry and guidelines.

INTRODUCTION: Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. METHOD: We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020-2023. RESULTS: A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1-2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. CONCLUSION: Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.

Appropriateness of direct oral anticoagulant dosing and its relation to drug levels in atrial fibrillation patients.

Direct oral anticoagulants (DOACs) are commonly administered at a level that is lower than that recommended by dose reduction criteria. This raises concern regarding the adequacy of anticoagulation achieved. To evaluate the relationship between inappropriate dosing and DOAC levels. Medical records of atrial fibrillation patients who underwent DOAC level testing during 2013-2017 were reviewed. The primary outcomes were drug levels under and above the expected steady-state range, and in the lowest and highest quartiles. Of 143 patients who underwent DOAC measurements, only 87 (60.8%) received the appropriate dose. Levels under the expected range and in the lowest quartile were found in 11.9% and 15.0% of patients treated with appropriate dosing compared to 21% and 41.5% of patients treated with inappropriately low dose. DOAC levels were above the expected range and in the highest quartile in 23.8% and 32.5% of patients treated with the appropriate dose compared to 7.1% and 9.4% treated with inappropriately low dose. In multivariate analysis, the administration of an appropriate DOAC dose was associated with a lower rate of DOAC in the lowest level (adjusted odds ratio [95% CI] 0.30 (0.12, 0.76), P = 0.011). On the other hand, appropriate dose was associated with drug levels in the highest quartile (odds ratio [95% CI] 3.77 (0.12, 0.76), P = 0.011). Treatment with inappropriately low DOAC dosing compared to appropriate dose is associated with lower DOAC levels. However, among those treated with appropriate dosing, a higher proportion had high DOAC levels above the expected range.

Direct-acting oral anticoagulant drug level monitoring in clinical patient management.

The role of drug-level monitoring among patients using direct-acting oral anticoagulant (DOAC) is unclear. We aimed to investigate its 'real-life' utilization and effect on clinical management. A review of records of patients who underwent DOAC level testing during 2013-2017. Overall, 212 patients (median age 77 years) underwent 292 DOAC measurements [apixaban (n = 147), rivaroxaban (n = 102), dabigatran (n = 43)]. Monitoring volume increased by 460% during study period. DOAC level testing was performed during routine follow-up in 51 (17.5%) cases, whereas the remaining 241 (82.5%) measurements were performed due to selected clinical circumstances, most commonly: bleeding (n = 60), perioperative status (n = 45), breakthrough thrombosis (n = 37) and renal failure (n = 35). Drug levels were within the expected range in 210 (71.9%), above the expected range in 62 (21.2%) and lower than expected range in 20 (6.8%). In multivariate analysis, older age (P = 0.005), lower glomerular filtration rate (P = 0.001) and lower body mass index (P = 0.006) were associated with DOAC levels above the expected range. Clinical decisions were affected by DOAC monitoring following most (140/241, 58.1%) measurements for which we identified an indication for testing; yet only rarely when monitoring was performed during routine follow-up (7.8%, 4/51) (P < 0.0001). While no benefit of routine DOAC monitoring was observed, drug level measurement has an important role in the management of patients in selected circumstances. Age, body weight and creatinine clearance were found to be significant predictors of drug levels. Future studies are warranted to establish associations between drug levels and outcomes, and better delineate the role of DOAC monitoring.

Drug interaction as a predictor of direct oral anticoagulant drug levels in atrial fibrillation patients.

Data are limited on the effects of drug interactions on direct-acting oral anticoagulant (DOAC) levels. We evaluated the effects of the use of interacting drugs on DOAC levels in patients with atrial fibrillation (AF). We reviewed data of AF patients tested for DOAC levels in 2013-2017. The primary outcomes were drug levels exceeding the expected steady-state range, and in the highest quartile. A multivariate analysis was performed to evaluate the correlation of treatment by the use of interacting drugs, CYP3A4 and P-glycoprotein (P-gp) inhibitors, with the primary outcomes. Overall, 147 patients underwent DOAC level measurement [dabigatran (n = 31), rivaroxaban (n = 29), apixaban (n = 87)]. Thirty-three (22.4%) had drug levels exceeding the expected range. Seventy-nine (53.7%) patients were treated with at least one interacting drug. In multivariate analysis, the concomitant use of interacting drugs was an independent predictor for drug levels exceeding the expected range (OR 3.3, 95% CI 1.20-9.05). The defined daily dose of the interacting drug correlated positively with DOAC levels (r = 0.29, P = 0.001). Co-treatment with interacting drugs was associated with extremely high levels of dabigatran, (OR 16.6, 95% CI 1.29-215.18) but not of the other DOAC examined. Concomitant use of interacting drugs is associated with high DOAC levels in patients with AF. Further investigation is warranted to establish the differences between specific DOAC, evaluate the effect on patient outcomes, and characterize the role of DOAC monitoring in this setting.

The Effect of War on STEMI Incidence: Insights from Intensive Cardiovascular Care Unit Admissions.

(1) Background: The impact of armed conflicts on public health is undeniable, with psychological stress emerging as a significant risk factor for cardiovascular disease (CVD). Nevertheless, contemporary data regarding the influence of war on CVD, and especially on acute coronary syndrome (ACS), are scarce. Hence, the aim of the current study was to assess the repercussions of war on the admission and prognosis of patients admitted to a tertiary care center intensive cardiovascular care unit (ICCU). (2) Methods: All patients admitted to the ICCU during the first three months of the Israel-Hamas war (2023) were included and compared with all patients admitted during the same period in 2022. The primary outcome was in-hospital mortality. (3) Results: A total of 556 patients (184 females [33.1%]) with a median age of 70 (IQR 59-80) were included. Of them, 295 (53%) were admitted to the ICCU during the first three months of the war. Fewer Arab patients and more patients with ST-segment elevation myocardial infraction (STEMI) were admitted during the war period (21.8% vs. 13.2%, p < 0.001, and 31.9% vs. 24.1%, p = 0.04, respectively), whereas non-STEMI (NSTEMI) patients were admitted more frequently in the pre-war year (19.3% vs. 25.7%, p = 0.09). In-hospital mortality was similar in both groups (4.4% vs. 3.4%, p = 0.71; HR 1.42; 95% CI 0.6-3.32, p = 0.4). (4) Conclusions: During the first three months of the war, fewer Arab patients and more STEMI patients were admitted to the ICCU. Nevertheless, in-hospital mortality was similar in both groups.

Incidence of Ventricular Fibrillation and Sustained Ventricular Tachycardia Complicating Non-ST Segment Elevation Myocardial Infarction.

Background: Primary ventricular fibrillation (VF) and sustained ventricular tachycardia (VT) are potentially lethal complications in patients suffering from acute myocardial infarction (MI). In contrast with the profound data regarding the incidence and prognostic value of ventricular arrhythmias in ST elevation myocardial infarction (STEMI) patients, data regarding contemporary non-ST elevation myocardial infarction (NSTEMI) patients with ventricular arrhythmias is scarce. The aim of the current study was to investigate the incidence of VF/VT complicating NSTEMI among patients admitted to an intensive coronary care unit (ICCU). Methods: Prospective, single-center study of patients diagnosed with NSTEMI admitted to ICCU between June 2019 and December 2022. Data including demographics, presenting symptoms, comorbid conditions, and physical examination, as well as laboratory and imaging data, were analyzed. Patients were continuously monitored for arrhythmias during their admission. The study endpoint was the development of VF/sustained VT during admission. Results: A total of 732 patients were admitted to ICCU with a diagnosis of NSTEMI. Of them, six (0.8%) patients developed VF/VT during their admission. Nevertheless, three were excluded after they were misdiagnosed with NSTEMI instead of posterior ST elevation myocardial infarction (STEMI). Hence, only three (0.4%) NSTEMI patients had VF/VT during admission. None of the patients died during 1-year follow-up. Conclusions: VF/VT in NSTEMI patients treated according to contemporary guidelines including early invasive strategy is rare, suggesting these patients may not need routine monitoring and ICCU setup.

Association between peak troponin level and prognosis among patients admitted to intensive cardiovascular care unit.

INTRODUCTION: High-sensitivity cardiac troponin (hs-cTn) is a key biomarker for myocardial injury, yet its prognostic value in intensive cardiovascular care units (ICCU) remains poorly understood. We aimed to assess the association between peak hs-cTn levels and prognosis in ICCU patients. METHODS: All patients admitted to a tertiary care center ICCU between July 2019 - July 2023 were prospectively enrolled. Patients were divided into five groups according to their peak hs-cTnI levels: A) hs-cTnI <100 ng/L; B) hs-cTnI of 100-1000 ng/L; C) hs-cTnI of 1000-10,000 ng/L; D) hs-cTnI of 10,000-100,000 ng/L and E) hs-cTnI ≥100,000 ng/L. The primary outcome was all-cause mortality at one year. RESULTS: A total of 4149 patients (1273 females [30.7 %]) with a median age of 69 (IQR 58-79) were included. Group E was highly specific for myocardial infarction (97.4 %) and especially for ST segment elevation myocardial infarction (STEMI) (87.5 %). Patients in group E were 56 % more likely to die at 1-year in an adjusted Cox model (95 % CI 1.09-2.23, p = 0.014) as compared with group A. Subgroup analyses revealed that among STEMI patients, higher peak hs-cTnI levels were not associated with higher mortality rate (HR 1.04, 95 % CI 0.4-2.72, p = 0.9), in contrast to patients with NSTEMI (HR 7.62, 95 % CI 1.97-29.6, p = 0.003). CONCLUSIONS: Peak hs-cTnI levels ≥100,000 ng/L were linked to higher one-year mortality, largely indicative of large myocardial infarctions. Notably, the association between elevated hs-cTnI levels and mortality differed between STEMI and NSTEMI patients, warranting further investigation.