RESUMEN
BACKGROUND: Inflammation is a key factor of myocardial damage in reperfused ST-segment-elevation myocardial infarction. We hypothesized that colchicine, a potent anti-inflammatory agent, may reduce infarct size (IS) and left ventricular (LV) remodeling at the acute phase of ST-segment-elevation myocardial infarction. METHODS: In this double-blind multicenter trial, we randomly assigned patients admitted for a first episode of ST-segment-elevation myocardial infarction referred for primary percutaneous coronary intervention to receive oral colchicine (2-mg loading dose followed by 0.5 mg twice a day) or matching placebo from admission to day 5. The primary efficacy outcome was IS determined by cardiac magnetic resonance imaging at 5 days. The relative LV end-diastolic volume change at 3 months and IS at 3 months assessed by cardiac magnetic resonance imaging were among the secondary outcomes. RESULTS: We enrolled 192 patients, 101 in the colchicine group and 91 in the control group. At 5 days, the gadolinium enhancement-defined IS did not differ between the colchicine and placebo groups with a mean of 26 interquartile range (IQR) [16-44] versus 28.4 IQR [14-40] g of LV mass, respectively (P=0.87). At 3 months follow-up, there was no significant difference in LV remodeling between the colchicine and placebo groups with a +2.4% (IQR, -8.3% to 11.1%) versus -1.1% (IQR, -8.0% to 9.9%) change in LV end-diastolic volume (P=0.49). Infarct size at 3 months was also not significantly different between the colchicine and placebo groups (17 IQR [10-28] versus 18 IQR [10-27] g of LV mass, respectively; P=0.92). The incidence of gastrointestinal adverse events during the treatment period was greater with colchicine than with placebo (34% versus 11%, respectively; P=0.0002). CONCLUSIONS: In this randomized, placebo-controlled trial, oral administration of high-dose colchicine at the time of reperfusion and for 5 days did not reduce IS assessed by cardiac magnetic resonance imaging. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03156816.
Asunto(s)
Colchicina/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Remodelación Ventricular/efectos de los fármacos , Enfermedad Aguda , Adulto , Anciano , Medios de Contraste/farmacología , Femenino , Corazón/efectos de los fármacos , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Miocardio/patología , Derivación y ConsultaRESUMEN
BACKGROUND: Aging is associated with a chronic low-grade inflammatory state. This condition may affect the acute inflammatory response involved in ST-segment-elevation myocardial infarction (STEMI) or acute ischemic stroke (AIS). We sought to compare the profile of a set of circulating inflammatory markers between young and older patients admitted for STEMI or AIS. METHODS: HIBISCUS-STEMI (Cohort of Patients to Identify Biological and Imaging Markers of Cardiovascular Outcomes in ST Elevation Myocardial Infarction) and HIBISCUS-STROKE (Cohort of Patients to Identify Biological and Imaging Markers of Cardiovascular Outcomes in Stroke) are 2 cohort studies that enrolled patients with STEMI treated with primary percutaneous coronary intervention in the cardiac intensive care unit of Lyon and patients with AIS treated with mechanical thrombectomy in the Lyon Stroke Center, respectively from 2016 to 2019. Patients were classified as older if they were ≥65 years and as young if they were <65 years. In both cohorts, CRP (C-reactive protein), IL (interleukin)-6, IL-8, IL-10, MCP (monocyte chemoattractant protein), sTNF-RI (soluble tumor necrosis factor receptor I), sST2 (soluble form suppression of tumorigenicity 2), and VCAM-1 (vascular cellular adhesion molecule-1) were measured on serum collected at 5 time points using enzyme-linked immunosorbent assay. A multiple logistic regression model was performed to detect an association between area under the curve of circulating inflammatory markers within the first 48 hours and older age. RESULTS: A total of 260 patients with STEMI and 164 patients with AIS were included. Of them, there were 76 (29%) and 105 (64%) older patients with STEMI and AIS, respectively. Following multivariable analysis, a high area under the curve of IL-6 and sTNF-RI, a low lymphocyte count, and a high neutrophil-lymphocyte ratio at 24 hours were associated with older age in patients with STEMI and AIS. CONCLUSIONS: Older patients had higher IL-6 and sTFN-RI levels within the first 48 hours associated with a lower lymphocyte count and a higher neutrophil-lymphocyte ratio at 24 hours in both cohorts.
Asunto(s)
Accidente Cerebrovascular Isquémico , Infarto del Miocardio con Elevación del ST , Síndrome de Respuesta Inflamatoria Sistémica , Anciano , Biomarcadores/análisis , Proteína C-Reactiva , Humanos , Interleucina-6 , Accidente Cerebrovascular Isquémico/inmunología , Accidente Cerebrovascular Isquémico/terapia , Persona de Mediana Edad , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/inmunología , Infarto del Miocardio con Elevación del ST/terapia , Accidente Cerebrovascular/terapia , Síndrome de Respuesta Inflamatoria Sistémica/inmunologíaRESUMEN
Ventricular septal rupture (VSR) is a serious complication of ST-elevation myocardial infarction (STEMI) and surgery is the reference treatment. We aimed at describing trends in management and mortality during the last four decades and reporting mortality predictors in these patients. We conducted a single-center retrospective study of patients sustaining a VSR from 1981 to 2020. We screened 274 patients and included 265 for analysis. The number of patients decreased over the years: 80, 88, 56, and 50 in each 10-year time span. In-hospital mortality decreased significantly since 1990 (logrank 0.007). The median age was 72.0 years IQR [66-78] and 188 patients (70.9%) were operated on. IABP was used more routinely (p < 0.0001). In-hospital mortality was assessed at 66.8% (177 patients) and main predictors of death were a time from MI to surgery < 8 days HR 2.7 IC95% [1.9-3.8] p < 0.0001, a Killip class > 2 HR 2.5 IC [1.9-3.4] p < 0.0001 and Euroscore 2 > 20 HR 2.4 IC [1.8-3.2] p < 0.0001. A "time from MI to surgery" of 8 days offers the best ability to discriminate between patients with or without mortality. The ability of "Euroscore 2 and Killip" to detect the patients most likely to wait 8 days for surgery was at 0.81 [0.73-0.89] p < 0.0001. Mortality remains high over the years. Euroscore 2, Killip class, and time from MI to surgery are the main mortality predictors. Patients with a Killip < 3 and a Euroscore < 20 should be monitored at least 8 days since MI before being referred to surgery.
Asunto(s)
Infarto del Miocardio , Infarto del Miocardio con Elevación del ST , Rotura Septal Ventricular , Anciano , Humanos , Estudios Retrospectivos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/complicaciones , Resultado del Tratamiento , Rotura Septal Ventricular/diagnóstico , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/cirugíaRESUMEN
BACKGROUND: Experimental and clinical evidence suggests that cyclosporine may attenuate reperfusion injury and reduce myocardial infarct size. We aimed to test whether cyclosporine would improve clinical outcomes and prevent adverse left ventricular remodeling. METHODS: In a multicenter, double-blind, randomized trial, we assigned 970 patients with an acute anterior ST-segment elevation myocardial infarction (STEMI) who were undergoing percutaneous coronary intervention (PCI) within 12 hours after symptom onset and who had complete occlusion of the culprit coronary artery to receive a bolus injection of cyclosporine (administered intravenously at a dose of 2.5 mg per kilogram of body weight) or matching placebo before coronary recanalization. The primary outcome was a composite of death from any cause, worsening of heart failure during the initial hospitalization, rehospitalization for heart failure, or adverse left ventricular remodeling at 1 year. Adverse left ventricular remodeling was defined as an increase of 15% or more in the left ventricular end-diastolic volume. RESULTS: A total of 395 patients in the cyclosporine group and 396 in the placebo group received the assigned study drug and had data that could be evaluated for the primary outcome at 1 year. The rate of the primary outcome was 59.0% in the cyclosporine group and 58.1% in the control group (odds ratio, 1.04; 95% confidence interval [CI], 0.78 to 1.39; P=0.77). Cyclosporine did not reduce the incidence of the separate clinical components of the primary outcome or other events, including recurrent infarction, unstable angina, and stroke. No significant difference in the safety profile was observed between the two treatment groups. CONCLUSIONS: In patients with anterior STEMI who had been referred for primary PCI, intravenous cyclosporine did not result in better clinical outcomes than those with placebo and did not prevent adverse left ventricular remodeling at 1 year. (Funded by the French Ministry of Health and NeuroVive Pharmaceutical; CIRCUS ClinicalTrials.gov number, NCT01502774; EudraCT number, 2009-013713-99.).
Asunto(s)
Ciclofilinas/antagonistas & inhibidores , Ciclosporina/administración & dosificación , Inhibidores Enzimáticos/administración & dosificación , Infarto del Miocardio/tratamiento farmacológico , Intervención Coronaria Percutánea , Remodelación Ventricular/efectos de los fármacos , Anciano , Terapia Combinada , Ciclosporina/efectos adversos , Método Doble Ciego , Electrocardiografía , Inhibidores Enzimáticos/efectos adversos , Femenino , Insuficiencia Cardíaca/epidemiología , Humanos , Inyecciones Intravenosas , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Mortalidad , Infarto del Miocardio/terapiaRESUMEN
PURPOSE OF REVIEW: Despite many advances in the management of critically ill patients, cardiogenic shock remains a challenge because it is associated with high mortality. Even if there is no universally accepted definition of cardiogenic shock, end-perfusion organ dysfunction is an obligatory and major criterion of its definition.Organ dysfunction is an indicator that cardiogenic shock is already at an advanced stage and is undergoing a rapid self-aggravating evolution. The aim of the review is to highlight the importance to diagnose and to manage the organ dysfunction occurring in the cardiogenic shock patients by providing the best literature published this year. RECENT FINDINGS: The first step is to diagnose the organ dysfunction and to assess their severity. Echo has an important and increasing place regarding the assessment of end-organ impairment whereas no new biomarker popped up. SUMMARY: In this review, we aimed to highlight for intensivists and cardiologists managing cardiogenic shock, the recent advances in the care of end-organ dysfunctions associated with cardiogenic shock. The management of organ dysfunction is based on the improvement of the cardiac function by etiologic therapy, inotropes and assist devices but will often necessitate organ supports in hospitals with the right level of equipment and multidisciplinary expertise.
Asunto(s)
Cuidados Críticos , Insuficiencia Multiorgánica/terapia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Choque Cardiogénico/terapia , Cardiólogos , Cuidados Críticos/métodos , Oxigenación por Membrana Extracorpórea , Corazón Auxiliar , Hemodinámica , Humanos , Insuficiencia Multiorgánica/mortalidad , Insuficiencia Multiorgánica/fisiopatología , Choque Cardiogénico/mortalidad , Choque Cardiogénico/fisiopatologíaRESUMEN
BACKGROUND: Up to 25% of patients with ST elevation myocardial infarction (STEMI) have ST segment re-elevation after initial regression post-reperfusion and there are few data regarding its prognostic significance.MethodsâandâResults:A standard 12-lead electrocardiogram (ECG) was recorded in 662 patients with anterior STEMI referred for primary percutaneous coronary intervention (PPCI). ECGs were recorded 60-90 min after PPCI and at discharge. ST segment re-elevation was defined as a ≥0.1-mV increase in STMax between the post-PPCI and discharge ECGs. Infarct size (assessed as creatine kinase [CK] peak), echocardiography at baseline and follow-up, and all-cause death and heart failure events at 1 year were assessed. In all, 128 patients (19%) had ST segment re-elevation. There was no difference between patients with and without re-elevation in infarct size (CK peak [mean±SD] 4,231±2,656 vs. 3,993±2,819 IU/L; P=0.402), left ventricular (LV) ejection fraction (50.7±11.6% vs. 52.2±10.8%; P=0.186), LV adverse remodeling (20.1±38.9% vs. 18.3±30.9%; P=0.631), or all-cause mortality and heart failure events (22 [19.8%] vs. 106 [19.2%]; P=0.887) at 1 year. CONCLUSIONS: Among anterior STEMI patients treated by PPCI, ST segment re-elevation was present in 19% and was not associated with increased infarct size or major adverse events at 1 year.
Asunto(s)
Infarto de la Pared Anterior del Miocardio , Electrocardiografía , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Volumen Sistólico , Función Ventricular Izquierda , Anciano , Infarto de la Pared Anterior del Miocardio/sangre , Infarto de la Pared Anterior del Miocardio/fisiopatología , Infarto de la Pared Anterior del Miocardio/cirugía , Creatina Quinasa/sangre , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Infarto del Miocardio con Elevación del ST/sangre , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/cirugía , Remodelación VentricularRESUMEN
AIMS: The use of opioids is recommended for pain relief in patients with myocardial infarction (MI) but may delay antiplatelet agent absorption, potentially leading to decreased treatment efficacy. METHODS AND RESULTS: In-hospital complications (death, non-fatal re-MI, stroke, stent thrombosis, and bleeding) and 1-year survival according to pre-hospital morphine use were assessed in 2438 ST-elevation MI (STEMI) patients from the French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2010. The analyses were replicated in the 1726 STEMI patients of the FAST-MI 2005 cohort, in which polymorphisms of CYP2C19 and ABCB1 had been assessed. Specific subgroup analyses taking into account these genetic polymorphisms were performed in patients pre-treated with thienopyridines. The 453 patients (19%) receiving morphine pre-hospital were younger, more often male, with a lower GRACE score and higher chest pain levels. After adjustment for baseline differences, in-hospital complications and 1-year survival (hazard ratio = 0.69; 95% confidence interval: 0.35-1.37) were not increased according to pre-hospital morphine use. After propensity score matching, 1-year survival according to pre-hospital morphine was also similar. Consistent results were found in the replication cohort, including in those receiving pre-hospital thienopyridines and whatever the genetic polymorphisms of CYP2C19 and ABCB1. CONCLUSION: In two independent everyday-life cohorts, pre-hospital morphine use in STEMI patients was not associated with worse in-hospital complications and 1-year mortality. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00673036 (FAST-MI 2005); NCT01237418 (FAST-MI 2010).
Asunto(s)
Analgésicos Opioides/uso terapéutico , Morfina/uso terapéutico , Infarto del Miocardio sin Elevación del ST/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Subfamilia B de Transportador de Casetes de Unión a ATP/genética , Anciano , Citocromo P-450 CYP2C19/genética , Interacciones Farmacológicas/genética , Servicios Médicos de Urgencia/métodos , Femenino , Francia/epidemiología , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/genética , Infarto del Miocardio sin Elevación del ST/mortalidad , Dolor/prevención & control , Inhibidores de Agregación Plaquetaria/uso terapéutico , Polimorfismo Genético/genética , Sistema de Registros , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/genética , Infarto del Miocardio con Elevación del ST/mortalidad , Resultado del TratamientoRESUMEN
Kidney dysfunction during congestive heart failure, although frequent, is often neglected. Yet, it represents a life-threatening condition, oven when the kidney dysfunction is moderate. The initial approach involvus strict application of recommendations, cardiologic and nephrologic joined management and close follow-up involving patient's general practitioner. Cases of true diuretics resistance are infrequent and late. Yet, it represents a significant turning point. Mortality is high, with a major individual unpredictability. A multidisciplinary approach is needed, which has to take into account patient's preferences. Several treatments may be discussed and are sometimes joined: cardiac transplantation, water and salt extraction (using ultrafiltration, hemodialysis or peritoneal dialysis), vasoconstrictive drugs, ventricular assistance devices and palliative care. Water and salt extraction techniques seem to space out hospitalizations and to provide symptomatic relief even though no benefit on patient survival has been demonstrated to date. The need for randomized clinical trials is mandatory.
Asunto(s)
Síndrome Cardiorrenal/diagnóstico , Síndrome Cardiorrenal/terapia , HumanosRESUMEN
BACKGROUND: Both acute myocardial ischemia and reperfusion contribute to cardiomyocyte death in ST-elevation myocardial infarction (STEMI). The final infarct size is the principal determinant of subsequent clinical outcome in STEMI patients. In a proof-of-concept phase II trial, the administration of cyclosporine prior to primary percutaneous coronary intervention (PPCI) has been associated with a reduction of infarct size in STEMI patients. METHODS: CIRCUS is an international, prospective, multicenter, randomized, double-blinded, placebo-controlled trial. The study is designed to compare the efficacy and safety of cyclosporine versus placebo, in addition to revascularization by PPCI, in patients presenting with acute anterior myocardial infarction within 12 hours of symptoms onset and initial TIMI flow ≤1 in the culprit left anterior descending coronary artery. Patients are randomized in a 1:1 fashion to 2.5 mg/kg intravenous infusion of cyclosporine or matching placebo performed in the minutes preceding PCI. The primary efficacy end point of CIRCUS is a composite of 1-year all-cause mortality, rehospitalization for heart failure or heart failure worsening during initial hospitalization, and left ventricular adverse remodeling as determined by sequential transthoracic echochardiography. Secondary outcomes will be tested using a hierarchical sequence of left ventricular (LV) ejection fraction and absolute measurements of LV volumes. The composite of death and rehospitalization for heart failure or heart failure worsening during initial hospitalization will be further assessed at three years after the initial infarction. RESULTS: Recruitment lasted from April 2011 to February 2014. The CIRCUS trial has recruited 975 patients with acute anterior myocardial infarction. The 12-months results are expected to be available in 2015. CONCLUSIONS: The CIRCUS trial is testing the hypothesis that cyclosporine in addition to early revascularization with PPCI compared to placebo in patients with acute anterior myocardial infarction reduces the incidence of death, heart failure and adverse LV remodeling at one-year follow-up.
Asunto(s)
Ciclosporina/efectos adversos , Ciclosporina/uso terapéutico , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea , Biomarcadores/sangre , Angiografía Coronaria , Método Doble Ciego , Ecocardiografía , Electrocardiografía , Femenino , Humanos , Masculino , Infarto del Miocardio/fisiopatología , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: The aim of this study was to evaluate bioimpedance vector analysis (BIVA) for the diagnosis of acute heart failure (AHF) in patients presenting with acute dyspnea to the emergency department (ED). METHODS: Patients with acute dyspnea presenting to the ED were prospectively enrolled. Four parameters were assessed: resistance (R), reactance (Ra), total body water (TBW), and extracellular body water (EBW). Brain natriuretic peptide (BNP) measures and cardiac ultrasound studies were performed in all patients at admission. Patients were classified into AHF and non-AHF groups retrospectively by expert cardiologists. RESULTS: Seventy-seven patients (39 men; age, 68±14years; weight, 79.8±20.6 kg) were included. Of the 4 BIVA parameters, Ra was significantly lower in the AHF compared to non-AHF group (32.7±14.3 vs 45.4±19.7; P<.001). Brain natriuretic peptide levels were significantly higher in the AHF group (1050.3±989 vs 148.7±181.1ng/L; P<.001). Reactance levels were significantly correlated to BNP levels (r=-0.5; P<.001). Patients with different mitral valve Doppler profiles (E/e'≤8, E/e' ≥9 and <15, and E/e'≥15) had significant differences in Ra values (47.9±19.9, 34.7±19.4, and 31.2±11.7, respectively; P=.003). Overall, the sensitivity of BIVA for AHF diagnosis with a Ra cutoff at 39Ω was 67% with a specificity of 76% and an area under the curve at 0.76. However, Ra did not significantly improve the area under the curve of BNP for the diagnosis of AHF (P=not significant). CONCLUSION: In a population of patients presenting to the ED with dyspnea, BIVA was significantly related to the AHF status but did not improve the diagnostic performance for AHF in addition to BNP alone.
Asunto(s)
Agua Corporal , Disnea/diagnóstico , Ecocardiografía , Insuficiencia Cardíaca/diagnóstico , Péptido Natriurético Encefálico/sangre , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Disnea/etiología , Impedancia Eléctrica , Servicio de Urgencia en Hospital , Femenino , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
INTRODUCTION: There are little data about patients with cardiogenic shock (CS) who survive the early phase of acute myocardial infarction (AMI). The aim of this study was to assess long-term (5-year) mortality among early survivors of AMI, according to the presence of CS at the acute stage. METHODS: We analyzed 5-year follow-up data from the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 registry, a nationwide French survey including consecutive patients admitted for ST or non-ST-elevation AMI at the end of 2005 in 223 institutions. RESULTS: Of 3670 patients enrolled, shock occurred in 224 (6.1%), and 3411 survived beyond 30 days or hospital discharge, including 99 (2.9%) with shock. Early survivors with CS had a more severe clinical profile, more frequent concomitant in-hospital complications, and were less often managed invasively than those without CS. CONCLUSIONS: In patients surviving the early phase of AMI, CS at the initial stage carries an increased risk of death up to one year after the acute event. Beyond one year, however, mortality is similar to that of patients without shock. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT00673036, Registered May 5, 2008.
Asunto(s)
Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Sistema de Registros , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/mortalidad , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
RATIONALE: Apart from hypoxic hepatitis (HH), the hepatic consequences of out-of-hospital cardiac arrest (OHCA) have been little studied. This cohort study aimed to investigate the characteristics of liver dysfunction resulting from OHCA and its association with outcomes. METHODS: Among the conventional static liver function tests used to define acute liver failure (ALF), we determined which one correlated more closely with the reference indocyanine green (ICG) clearance test in a series of OHCA patients from the CYRUS trial (NCT01595958). Subsequently, we assessed whether ALF, in addition to HH (i.e., acute liver injury), was an independent risk factor for death in a large cohort of OHCA patients admitted to two intensive care units between 2007 and 2017. RESULTS: ICG clearance, available for 22 patients, was impaired in 17 (77.3%) cases. Prothrombin time (PT) ratio was the only static liver function test that correlated significantly (r = -0.66, p < 0.01) with ICG clearance and was therefore used to define ALF, with the usual cutoff of < 50%. Of the 418 patients included in the analysis (sex ratio: 1.4; median age: 64 [53-75] years; non-shockable rhythm: 73%), 67 (16.0%) presented with ALF, and 61 (14.6%) had HH at admission. On day 28, 337 (80.6%) patients died. Following multivariate analysis, ALF at admission, OHCA occurring at home, absence of bystander, non-cardiac cause of OHCA, low-flow duration ≥ 20 min, and SOFA score excluding liver subscore at admission were independently associated with day 28 mortality. CONCLUSIONS: ALF occurred frequently after OHCA and, unlike HH, was independently associated with day 28 mortality.
Asunto(s)
Reanimación Cardiopulmonar , Hepatitis , Fallo Hepático Agudo , Paro Cardíaco Extrahospitalario , Humanos , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/complicaciones , Estudios de Cohortes , Fallo Hepático Agudo/complicaciones , Hepatitis/complicacionesRESUMEN
Inflammatory processes are involved not only in coronary artery disease but also in heart failure (HF). Cardiogenic shock (CS) and septic shock are classically distinct although intricate relationships are frequent in daily practice. The impact of admission inflammation in patients with CS is largely unknown. FRENSHOCK is a prospective registry including 772 CS patients from 49 centers. One-month and one-year mortalities were analyzed according to the level of C-reactive protein (CRP) at admission, adjusted on independent predictive factors. Within 406 patients included, 72.7% were male, and the mean age was 67.4 y ± 14.7. Four groups were defined, depending on the quartiles of CRP at admission. Q1 with a CRP < 8 mg/L, Q2: CRP was 8-28 mg/L, Q3: CRP was > 28-69 mg/L, and Q4: CRP was > 69 mg/L. The four groups did not differ regarding main baseline characteristics. However, group Q4 received more often antibiotics in 47.5%, norepinephrine in 66.3%, and needed more frequently respiratory support and renal replacement therapy. Whether at 1 month (Ptrend = 0.01) or 1 year (Ptrend < 0.01), a strong significant trend towards increased all-cause mortality was observed across CRP quartiles. Specifically, compared to the Q1 group, Q4 patients demonstrated a 2.2-fold higher mortality rate at 1-month (95% CI 1.23-3.97, p < 0.01), which persisted at 1-year, with a 2.14-fold increase in events (95% CI 1.43-3.22, p < 0.01). Admission CRP level is a strong independent predictor of mortality at 1 month and 1-year in CS. Specific approaches need to be developed to identify accurately patients in whom inflammatory processes are excessive and harmful, paving the way for innovative approaches in patients admitted for CS.NCT02703038.
Asunto(s)
Biomarcadores , Proteína C-Reactiva , Choque Cardiogénico , Humanos , Masculino , Choque Cardiogénico/mortalidad , Choque Cardiogénico/sangre , Proteína C-Reactiva/metabolismo , Proteína C-Reactiva/análisis , Femenino , Anciano , Biomarcadores/sangre , Persona de Mediana Edad , Factores de Riesgo , Estudios Prospectivos , Anciano de 80 o más Años , Pronóstico , Sistema de Registros , Admisión del PacienteRESUMEN
After acute myocardial infarction, the presence of no-reflow (or microvascular obstruction: MVO) has been associated with adverse left ventricular (LV) remodeling and worse clinical outcome. This study examined the effects of mechanical ischemic postconditioning on early and late MVO size in acute ST-elevation myocardial infarction (STEMI) patients. Fifty patients undergoing primary coronary angioplasty for a first STEMI with TIMI grade flow 0-1 and no collaterals were randomized to ischemic postconditioning (PC) (n = 25) or control (n = 25) groups. Ischemic PC consisted in the application of four consecutive cycles of a 1-min balloon occlusion, each followed by a 1-min deflation at the onset of reperfusion. Early (3 min post-contrast) and late (10 min post-contrast) MVO size were assessed by contrast-enhanced cardiac-MRI within 96 h after reperfusion. PC was associated with smaller early and late MVO size (3.9 ± 4.8 in PC versus 7.8 ± 6.6% of LV in controls for early MVO, P = 0.02; and 1.8 ± 3.1 in PC versus 4.1 ± 3.9% of LV in controls for late MVO; P = 0.01). This significant reduction was persistent after adjustment for thrombus aspiration, which neither had any significant effect on infarct size, nor on early or late MVO (P = NS for all). Attenuation of MVO was associated to infarct size reduction. Mechanical postconditioning significantly reduces MVO in patients with acute STEMI treated with primary angioplasty.
Asunto(s)
Poscondicionamiento Isquémico/métodos , Infarto del Miocardio/terapia , Angioplastia Coronaria con Balón , Femenino , Humanos , Interpretación de Imagen Asistida por Computador , Imagen por Resonancia Magnética/métodos , Masculino , Microcirculación , Persona de Mediana Edad , Infarto del Miocardio/patología , Resultado del TratamientoRESUMEN
BACKGROUND: The diagnosis and management of atrial fibrillation (AF) in emergency departments (EDs) have not been well described in France, with limited EU research. This study aimed to describe the diagnosis, management, and prognosis of AF patients in French EDs. METHODS: A prospective, observational 2-month study in adults diagnosed with AF was conducted at 32 French EDs. Data regarding patient characteristics, diagnosis, and treatment at EDs were collected, with 12-month follow-up. RESULTS: The study included a total of 1369 patients diagnosed with AF at an ED: 279 patients (20.4%) with idiopathic AF (no identified cause of the AF) and 1090 (79.6%) with secondary AF (with a principal diagnosis identified as the cause of AF). Patients were aged 84 years (median) and 51.3% were female. Significantly more idiopathic AF patients than secondary AF patients underwent CHA
Asunto(s)
Fibrilación Atrial , Adulto , Humanos , Femenino , Masculino , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/terapia , Estudios Prospectivos , Anticoagulantes/uso terapéutico , Pronóstico , Servicio de Urgencia en HospitalRESUMEN
BACKGROUND: Beta blockers (BBs) are a cornerstone for patients with heart failure (HF) and ventricular dysfunction. However, their use in patients recovering from a cardiogenic shock (CS) remains a bone of contention, especially regarding whether and when to reintroduce this class of drugs. METHODS: FRENSHOCK is a prospective multicenter registry including 772 CS patients from 49 centers. Our aim was to compare outcomes (1-month and 1-year all-cause mortality) between CS patients taking and those not taking BBs in three scenarios: (1) at 24 h after CS; (2) patients who did or did not discontinue BBs within 24 h; and (3) patients who did or did not undergo the early introduction of BBs. RESULTS: Among the 693 CS included, at 24 h after the CS event, 95 patients (13.7%) were taking BB, while 598 (86.3%) were not. Between the groups, there were no differences in terms of major comorbidities or initial CS triggers. Patients receiving BBs at 24 h presented a trend toward reduced all-cause mortality both at 1 month (aHR = 0.61, 95% CI 0.34 to 1.1, p = 0.10) and 1 year, which was, in both cases, not significant. Compared with patients who discontinued BBs at 24 h, patients who did not discontinue BBs showed lower 1-month mortality (aHR = 0.43, 95% CI 0.2 to 0.92, p = 0.03) and a trend to lower 1-year mortality. No reduction in outcomes was observed in patients who underwent an early introduction of BB therapy. CONCLUSIONS: BBs are drugs of first choice in patients with HF and should also be considered early in patients with CS. In contrast, the discontinuation of BB therapy resulted in increased 1-month all-cause mortality and a trend toward increased 1-year all-cause mortality.
RESUMEN
OBJECTIVE: There is still uncertainty about the management of patients with pheochromocytoma-induced cardiogenic shock (PICS). This study aims to investigate the clinical presentation, management, and outcome of patients with PICS. METHODS: We collected, retrospectively, the data of 18 patients without previously known pheochromocytoma admitted to 8 European hospitals with a diagnosis of PICS. RESULTS: Among the 18 patients with a median age of 50 years (Q1-Q3: 40-61), 50% were men. The main clinical features at presentation were pulmonary congestion (83%) and cyclic fluctuation of hypertension peaks and hypotension (72%). Echocardiography showed a median left ventricular ejection fraction (LVEF) of 25% (Q1-Q3: 15-33.5) with an atypical- Takotsubo (TTS) pattern in 50%. Inotropes/vasopressors were started in all patients and temporary mechanical circulatory support (t-MCS) was required in 11 (61%) patients. All patients underwent surgical removal of the pheochromocytoma; 4 patients (22%) were operated on while under t-MCS. The median LVEF was estimated at 55% at discharge. Only one patient required heart transplantation (5.5%), and all patients were alive at a median follow-up of 679 days. CONCLUSIONS: PICS should be suspected in case of a CS with severe cyclic blood pressure fluctuation and rapid hemodynamic deterioration, associated with increased inflammatory markers or in case of TTS progressing to CS, particularly if an atypical TTS echocardiographic pattern is revealed. T-MCS should be considered in the most severe cases. The main challenge is to stabilize the patient, with medical therapy or with t-MCS, since it remains a reversible cause of CS with a low mortality rate.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales , Corazón Auxiliar , Feocromocitoma , Masculino , Humanos , Persona de Mediana Edad , Femenino , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Volumen Sistólico , Feocromocitoma/complicaciones , Feocromocitoma/diagnóstico , Feocromocitoma/terapia , Estudios Retrospectivos , Función Ventricular Izquierda , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/terapia , Corazón Auxiliar/efectos adversos , Resultado del TratamientoRESUMEN
AIMS: Quality of care (QoC) is a fundamental tenet of modern healthcare and has become an important assessment tool for healthcare authorities, stakeholders and the public. However, QoC is difficult to measure and quantify because it is a multifactorial and multidimensional concept. Comparison of clinical institutions can be challenging when QoC is estimated solely based on clinical outcomes. Thus, measuring quality through quality indicators (QIs) can provide a foundation for quality assessment and has become widely used in this context. QIs for the evaluation of QoC in acute myocardial infarction are now well-established, but no such indicators exist for the process from resuscitation of cardiac arrest and post-resuscitation care in Europe. METHODS AND RESULTS: The Association of Acute Cardiovascular Care of the European Society Cardiology, the European Resuscitation Council, European Society of Intensive Care Medicine and the European Society for Emergency Medicine, have reflected on the measurement of QoC in cardiac arrest. A set of QIs have been proposed, with the scope to unify and evolve QoC for the management of cardiac arrest across Europe. CONCLUSION: We present here the list of QIs (6 primary QIs and 12 secondary Qis), with descriptions of the methodology used, scientific justification and motives for the choice for each measure with the aim that this set of QIs will enable assessment of the quality of postout-of-hospital cardiac arrest management across Europe.
Asunto(s)
Cardiología , Medicina de Emergencia , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Indicadores de Calidad de la Atención de Salud , Cuidados CríticosRESUMEN
BACKGROUND: Soluble form suppression of tumorigenicity 2 (sST2) is known to have prognostic value in ST-elevation myocardial infarction (STEMI) and could impact mortality after acute ischemic stroke (AIS). However, before considering sST2 as a therapeutic target, the kinetics of release and its association with adverse clinical events in both STEMI and AIS patients have to be determined. METHODS: We prospectively enrolled 251 STEMI patients, treated with primary percutaneous coronary intervention, and 152 AIS patients treated with mechanical thrombectomy. We evaluated the level of sST2 in patient sera at five time point (admission, 4, 24, 48 h and 1 month from admission for STEMI patients and admission, 6, 24, 48 h and 3 months from admission for AIS patients). Major adverse clinical events (MACE) (all-cause death, acute myocardial infarction, stroke or hospitalization for heart failure) in STEMI patients and all-cause death in AIS patients were recorded during a 12-month follow-up. RESULTS: Mean age of the study population was 59 ± 12 and 69 ± 15 years in STEMI and AIS patients, respectively. In STEMI patients, sST2 peaked 24 h after admission (25.5 ng/mL interquartile range (IQR) [14.9-29.1]) whereas an earlier and lower peak was observed in AIS patients (16.8 ng/mL IQR [15.2-18.3] at 6 h). Twenty-five (10.0%) STEMI patients experienced a MACE and 12 (7.9%) AIS patients had all-cause death within the first 12 months. A high level of sST2 at 24 h was associated with MACE in STEMI patients (hazard ratio (HR) = 2.5; 95% confidence interval (CI) [1.1-5.6], p = 0.03) and all-cause death in AIS patients (HR = 11.7; 95% CI [3.8-36.2], p < 0.01) within the first 12 months. CONCLUSIONS: The study highlights that sST2 levels at 24 h are associated with an increased risk to adverse clinical events in both diseases.
Asunto(s)
Proteína 1 Similar al Receptor de Interleucina-1/sangre , Accidente Cerebrovascular Isquémico , Infarto del Miocardio con Elevación del ST , Humanos , Pronóstico , Reperfusión , Infarto del Miocardio con Elevación del ST/cirugíaRESUMEN
OBJECTIVES: The aim of this study is to compare the image quality of in vivo coronary stents between an energy integrating detectors dual-layer computed tomography (EID-DLCT) and a clinical prototype of spectral photon counting computed tomography (SPCCT). MATERIALS AND METHODS: In January to June 2021, consecutive patients with coronary stents were prospectively enrolled to undergo a coronary computed tomography (CT) with an EID-DLCT (IQon, Philips) and an SPCCT (Philips). The study was approved by the local ethical committee and patients signed an informed consent. A retrospectively electrocardiogram-gated acquisition was performed with optimized matching parameters on the 2 scanners (EID-DLCT: collimation, 64 × 0.625 mm; kVp, 120, automatic exposure control with target current at 255 mAs; rotation time, 0.27 seconds; SPCCT: collimation, 64 × 0.275 mm; kVp, 120; mAs, 255; rotation time, 0.33 seconds). The injection protocol was the same on both scanners: 65 to 75 mL of Iomeron (Bracco) at 5 mL/s. Images were reconstructed with slice thickness of 0.67 mm, 512 matrix, XCB (Xres cardiac standard) and XCD (Xres cardiac detailed) kernel, iDose 3 for EID-DLCT and 0.25-mm slice thickness, 1024 matrix, Detailed 2 and Sharp kernel, and iDose 6 for SPCCT. Two experienced observers measured the proximal and distal external and internal diameters of the stents to quantify blooming artifacts. Regions of interest were drawn in the lumen of the stent and of the upstream coronary artery. The difference (Δ S-C) between the respective attenuation values was calculated as a quantification of stent-induced artifacts on intrastent image quality. For subjective image quality, 3 experienced observers graded with a 4-point scale the image quality of different parameters: coronary wall before the stent, stent lumen, stent structure, calcifications surrounding the stent, and beam-hardening artifacts. RESULTS: Eight patients (age, 68 years [interquartile range, 8]; all men; body mass index, 26.2 kg/m2 [interquartile range, 4.2]) with 16 stents were scanned. Five stents were not evaluable owing to motion artifacts on the SPCCT. Of the remaining, all were drug eluting stents, of which 6 were platinum-chromium, 3 were cobalt-platinum-iridium, and 1 was stainless steel. For 1 stent, no information could be retrieved. Radiation dose was lower with the SPCCT (fixed CT dose index of 25.7 mGy for SPCCT vs median CT dose index of 35.7 [IQ = 13.6] mGy; P = 0.02). For 1 stent, the internal diameter was not assessable on EID-DLCT. External diameters were smaller and internal diameters were larger with SPCCT (all P < 0.05). Consequently, blooming artifacts were reduced on SPCCT (P < 0.05). Whereas Hounsfield unit values within the coronary arteries on the 2 scanners were similar, the Δ S-C was lower for SPCCT-Sharp as compared with EID-DLCT-XCD and SPCCT-Detailed 2 (P < 0.05). The SPCCT received higher subjective scores than EID-DLCT for stent lumen, stent structure, surrounding calcifications and beam-hardening for both Detailed 2 and Sharp (all P ≤ 0.05). The SPCCT-Sharp was judged better for stent structure and beam-hardening assessment as compared with SPCCT-Detailed 2. CONCLUSION: Spectral photon counting CT demonstrated improved objective and subjective image quality as compared with EID-DLCT for the evaluation of coronary stents even with a reduced radiation dose.