Hemoglobin A1C as a prognostic factor and the pre-diabetic paradox in patients admitted to a tertiary care medical center intensive cardiac care unit : The Jerusalem platelets thrombosis and intervention in cardiology (JUPITER-6) study group.

BACKGROUND: Hemoglobin A1C (HbA1c) is a form of glycated hemoglobin used to estimate glycemic control in diabetic patients. Data regarding the prognostic significance of HbA1c levels in contemporary intensive cardiac care unit (ICCU) patients is limited. METHODS: All patients admitted to the ICCU at a tertiary care medical center between January 1, 2020, and June 30, 2021, with documented admission HbA1c levels were included in the study. Patients were divided into 3 groups according to their HbA1c levels: < 5.7 g% [no diabetes mellitus (DM)], 5.7-6.4 g% (pre-DM), ≥ 6.5 g% (DM). RESULTS: A total of 1412 patients were included. Of them, 974 (69%) were male with a mean age of 67(± 15.7) years old. HbA1c level < 5.7 g% was found in 550 (39%) patients, 5.7-6.4 g% in 458 (32.4%) patients and ≥ 6.5 g% in 404 (28.6%) patients. Among patients who did not know they had DM, 81 (9.3%) patients had high HbA1c levels (≥ 6.5 g%) on admission. The crude mortality rate at follow-up (up to 1.5 years) was almost twice as high among patients with pre-DM and DM than in patients with no DM (10.6% vs. 5.4%, respectively, p = 0.01). Interestingly, although not statistically significant, the trend was that pre-DM patients had the strongest association with mortality rate [HR 1.83, (95% CI 0.936-3.588); p = 0.077]. CONCLUSIONS: Although an HbA1c level of ≥ 5.7 g% (pre-DM & DM) is associated with a worse prognosis in patients admitted to ICCU, pre-DM patients, paradoxically, have the highest risk for short and long-term mortality rates.

Left Ventricular Thrombus Management After Acute Myocardial Infarction in Clinical Practice: Results from LEVITATION Survey and Narrative Review.

PURPOSE: Left ventricular thrombus (LVT) after ST-elevation myocardial infarction still presents diagnostic and therapeutic challenges. The LEVITATION survey was designed to take a picture of LVT management in current clinical practice. METHODS: The survey covered diagnostic, therapeutic, and prophylactic issues and was completed by 104 European cardiac centers. Most of them (59%) were university or tertiary centers. RESULTS: The survey showed anterior apical a-/dyskinesia, large MI, spontaneous echo-contrast, late presentation with delayed PCI, and TIMI flow 0-1 as the most important perceived risk factors for LVT formation. Serial ultrasound imaging is the most used tool to diagnose LVT (88% of the centers), with contrast-enhanced ultrasound and cardiac MR performed in case of poor apex visualization or spontaneous echo-contrast. One third (34%) of the centers uses prophylactic anticoagulation to prevent LVT formation. In the presence of LVT, low molecular weight heparin is the most used in-hospital therapy. At discharge, vitamin K antagonist and direct oral anticoagulants are used in 67 and 32% of the cases, respectively. Triple antithrombotic therapy with aspirin plus clopidogrel and VKA is the most used strategy at discharge (55%), whereas a single antiplatelet therapy is preferred only in the case of moderate-to-high risk of bleeding. To assess LVT total regression, half of the centers use contrast-enhanced ultrasound and/or cardiac-MR. The duration of anticoagulation is usually 3-6 months (55%), with long-term prolongation in case of LVT persistence or recurrence. CONCLUSION: The survey has depicted for the first time the current real-world management of this neglected topic and has highlighted several grey zones that are still present and not supported by evidence.

Identifying nursing sensitive indicators from electronic health records in acute cardiac care-Towards intelligent automated assessment of care quality.

AIM: The aim of this study is to explore the potential of using electronic health records for assessment of nursing care quality through nursing-sensitive indicators in acute cardiac care. BACKGROUND: Nursing care quality is a multifaceted phenomenon, making a holistic assessment of it difficult. Quality assessment systems in acute cardiac care units could benefit from big data-based solutions that automatically extract and help interpret data from electronic health records. METHODS: This is a deductive descriptive study that followed the theory of value-added analysis. A random sample from electronic health records of 230 patients was analysed for selected indicators. The data included documentation in structured and free-text format. RESULTS: One thousand six hundred seventy-six expressions were extracted and divided into (1) established and (2) unestablished expressions, providing positive, neutral and negative descriptions related to care quality. CONCLUSIONS: Electronic health records provide a potential source of information for information systems to support assessment of care quality. More research is warranted to develop, test and evaluate the effectiveness of such tools in practice. IMPLICATIONS FOR NURSING MANAGEMENT: Knowledge-based health care management would benefit from the development and implementation of advanced information systems, which use continuously generated already available real-time big data for improved data access and interpretation to better support nursing management in quality assessment.

[COVID-19 pandemic : Effects on clinical care of cardiovascular patients in spring 2020]. / COVID-19-Pandemie : Effekte auf die klinische Versorgung von Herz-Kreislauf-Patienten im Frühling 2020.

The coronavirus disease 2019 (COVID-19) pandemic has led to a focus of acute medical care on the treatment of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and pneumonia with consequences for all other medical specialties. Between March and May 2020 a decline in the number of admissions for elective cardiac procedures as well as for cardiac emergencies was observed. The number of patients hospitalized for acute myocardial infarction decreased, especially those with non-ST elevation myocardial infarction (NSTEMI), while time intervals between symptom onset and admission sometimes increased. In some studies an increase in infarct-related mortality was reported. There are multiple possible reasons for these findings, which include fear of patients to become infected with SARS-CoV­2 in hospital, misinterpretation of symptoms and focusing of the healthcare system on the pandemic. In addition, SARS-CoV­2 can lead to a higher proneness to thrombosis and therefore induce more severe courses of myocardial infarction.

Association of fine particulate matter exposure with acute noncardiovascular critical illnesses and in-hospital outcomes in patients receiving intensive cardiac care.

BACKGROUND: The effect of short-term exposure to fine particulate matter (PM2.5) on the incidence of acute noncardiovascular critical illnesses (ANCIs) and clinical outcomes is unknown in patients with acute cardiovascular diseases. METHODS: We conducted a retrospective study in 2337 admissions to an intensive cardiac care unit (ICCU) from June 2016 to May 2017. We used the 2-day average PM2.5 concentration before ICCU admission to estimate the individual exposure level, and patients were divided into 3 groups according to the concentration tertiles. Major ANCI was defined as the composite of acute respiratory failure, acute kidney injury, gastrointestinal hemorrhage, or sepsis. The primary endpoint was all-cause death or discharge against medical advice in extremely critical condition. RESULTS: During the 12-month study period, the annual median concentration of PM2.5 in Chengdu, China was 48 µg/m3 (IQR, 33-77 µg/m3). More than 20% of admissions were complicated by major ANCI, and the primary endpoints occurred in 7.6% of patients during their hospitalization. The association of short-term PM2.5 exposure levels with the incidence of acute respiratory failure (adjusted OR [odds ratio] =1.31, 95% CI [confidence interval]1.12-1.54) and acute kidney injury (adjusted OR = 1.20, 95% CI 1.02-1.41) showed a significant trend. Additionally, there were numerically more cases of sepsis (adjusted OR = 1.21, 95% CI 0.92-1.60) and gastrointestinal hemorrhage (adjusted OR = 1.29, 95% CI 0.94-1.77) in patients with higher exposure levels. After further multivariable adjustment, short-term PM2.5 exposure levels were still significantly associated with incident major ANCI (adjusted OR = 1.32, 95% CI 1.12-1.56), as well as a higher incidence of the primary endpoint (adjusted OR = 1.52, 95% CI 1.09-2.12). CONCLUSION: Short-term PM2.5 exposure before ICCU admission was associated with an increased risk of incident major ANCI and worse in-hospital outcomes in patients receiving intensive cardiac care.

Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome.

BACKGROUND: Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. METHODS: From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). RESULTS: Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03). CONCLUSIONS: Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

Prehospital clinical presentation in patients with acute coronary syndrome complicated by cardiogenic shock: A single center study.

BACKGROUND: The development of cardiogenic shock remains the most important factor affecting the prognosis of patients with acute coronary syndrome. Despite significant advances in treatment, achieved in the last two decades, the mortality rate is still very high. The development of knowledge about the pathophysiology of cardiogenic shock, necessitates a thorough and comprehensive assessment of its progress at all stages of medical care. OBJECTIVES: The aim of the study was to assess the prehospital clinical presentation in patients with acute coronary syndrome complicated by cardiogenic shock. METHODS: The population of our study consisted of 40 patients with acute coronary syndrome complicated by cardiogenic shock who were transported to the Intensive Cardiac Therapy Clinic by ambulances directly from place of the event in order to implement primary coronary intervention. The control group was selected among age, gender and infarct location-matched patients with acute coronary syndrome uncomplicated by shock. The clinical presentation in investigated patients was assessed on the basis of the data contained in the medical records of Emergency Medical Services teams. RESULTS: In univariate logistic regression analysis eight prehospital clinical symptoms proved to be statistically significant predictors of the development of cardiogenic shock: fainting and/or impaired consciousness, pale skin, cold skin, clammy skin, dyspnea, pulmonary congestion, peripheral cyanosis and hyperglycemia >11,1 mmol/l. In the multivariate model significant predictors of cardiogenic shock development were: pale skin and hyperglycemia >11.1 mmol/l. A risk prediction model was constructed. It proved to differentiate patients from study and control group highly significantly (p < 0.001). CONCLUSIONS: Patients with acute coronary syndrome who develop cardiogenic shock, present a different clinical symptoms at the moment of the first medical contact. The proposed 4S Scale can be used for quick assessment of risk in patients with acute coronary syndrome before the development of a fully-blown cardiogenic shock with severe, long-lasting hypotonia.

Acute ivabradine treatment reduces heart rate without increasing atrial fibrillation inducibility irrespective of underlying vagal activity in dogs.

Ivabradine, a bradycardic agent, has been shown to stably reduce patient's heart rate (HR) in the setting of acute cardiac care. However, an association between atrial fibrillation (AF) risk and acute ivabradine treatment remains a controversial clinical issue, and has not been thoroughly investigated. Bradycardia and abnormal atrial refractoriness induced by ivabradine treatment may enhance vulnerability to AF induction, especially when vagal nerve is concurrently activated. We aimed to experimentally investigate the effects of acute ivabradine treatment with/without concurrent vagal activation on AF inducibility. In 16 anesthetized dogs, cervical vagal nerves were prepared for electrical stimulation (VS). AF induction rate (AFIR) was determined by atrial burst pacing. HR, atrial action potential duration (APD), atrial effective refractory period (ERP), and AFIR were obtained consecutively at baseline, during delivery of VS (VS alone), after intravenous injection of ivabradine 0.5 mg/kg (n = 8, ivabradine group) or saline (n = 8, saline group), and again during VS delivery (drug+VS). In the ivabradine group, ivabradine alone significantly lowered HR compared to baseline, while ivabradine+VS significantly lowered HR compared to VS alone. Contrary to expectations, there were no significant differences in trends of APD, temporal dispersion of APD, ERP, and AFIR between ivabradine and saline groups. Irrespective of whether ivabradine or saline was injected, VS significantly shortened APD and ERP, and increased AFIR. Interestingly, although bradycardia in response to ivabradine injection was more intense than that to VS alone, AFIR was significantly lower after ivabradine injection than during VS alone. We conclude that, despite its intense bradycardic effect, acute ivabradine treatment does not increase AF inducibility irrespective of underlying vagal activity. This study may constitute support for the safety of using ivabradine in the setting of acute cardiac care.

Mechanical support with venoarterial extracorporeal membrane oxygenation (ECMO-VA): Short-term and long-term prognosis after a successful weaning. / Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. DESIGN: A single-center, retrospective cohort study was carried out. SETTING: The cardiovascular ICU of a tertiary hospital. PATIENTS: Forty-six patients consecutively subjected to VA-ECMO over 6 years. INTERVENTIONS: Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. RESULTS: Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. CONCLUSIONS: In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good.

Misdiagnosis of Myocardial Infarction Related to Limitations of the Current Regulatory Approach to Define Clinical Decision Values for Cardiac Troponin.

BACKGROUND: Misdiagnosis of acute myocardial infarction (AMI) may significantly harm patients and may result from inappropriate clinical decision values (CDVs) for cardiac troponin (cTn) owing to limitations in the current regulatory process. METHODS AND RESULTS: In an international, prospective, multicenter study, we quantified the incidence of inconsistencies in the diagnosis of AMI using fully characterized and clinically available high-sensitivity (hs) cTn assays (hs-cTnI, Abbott; hs-cTnT, Roche) among 2300 consecutive patients with suspected AMI. We hypothesized that the approved CDVs for the 2 assays are not biologically equivalent and might therefore contribute to inconsistencies in the diagnosis of AMI. Findings were validated by use of sex-specific CDVs and parallel measurements of other hs-cTnI assays. AMI was the adjudicated diagnosis in 473 patients (21%). Among these, 86 patients (18.2%) had inconsistent diagnoses when the approved uniform CDV was used. When sex-specific CDVs were used, 14.1% of female and 22.7% of male AMI patients had inconsistent diagnoses. Using biologically equivalent CDV reduced inconsistencies to 10% (P<0.001). These findings were confirmed with parallel measurements of other hs-cTn assays. The incidence of inconsistencies was only 7.0% for assays with CDVs that were nearly biologically equivalent. Patients with inconsistent AMI had long-term mortality comparable to that of patients with consistent diagnoses (P=NS) and a trend toward higher long-term mortality than patients diagnosed with unstable angina (P=0.05). CONCLUSIONS: Currently approved CDVs are not biologically equivalent and contribute to major inconsistencies in the diagnosis of AMI. One of 5 AMI patients will receive a diagnosis other than AMI if managed with the alternative hs-cTn assay. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.

Impact of recurrent COVID-19 disease waves on acute myocardial infarction epidemics: results from a regional network.

Aims: To assess the impact of COVID-19 related public containment measures during recurrent COVID-19 waves on hospital admission rate for acute myocardial infarction (AMI).Methods and results: Clinical characteristics, reperfusion therapy modalities, COVID-19 status and in-hospital mortality of consecutive AMI patients who were admitted in a regional AMI network were recorded during one year starting in March 2020 and were compared with the year before. The COVID-19 study period encompassed two waves: the first in March-May 2020 and the second in October-December 2020. A total of 1349 AMI patients were hospitalised of which 725 during the pre-COVID period and 624 during the COVID period (incidence rate ratio of 1.16, p = 0,006). The impact was predominantly present in the first wave (32% reduction: n = 204 vs 152) and evanished during the second wave (3% increase (152 vs 156). A similar pattern was observed for ACS with cardiac arrest with a 92% reduction (n = 36 vs 3) during the first wave and no change during the second wave (18 vs 18). After correction for temperature and air quality, COVID-19 epidemic remained associated with a decrease of AMI hospitalisation (p = 0.046). Reperfusion strategy for AMI patients, were comparable between both study periods. The in-hospital mortality between the two periods was comparable (2.6% versus 1.9%), but COVID-19 positive ACS patients (n = 7) had a high mortality rate (14%).Conclusion: COVID-19 related public containment measures resulted during the first wave in a 32% reduction of AMI hospitalisation, but this impact was not visible anymore during the second wave.

Role of multimodality cardiac imaging for evaluation of intramyocardial dissection, from dissecting haematoma to false-pseudoaneurysm: a case series.

Background: Intramyocardial dissection (ID) is an extremely rare myocardial infarction mechanical complication. Although both clinical and imaging assessment of this rare condition remains a challenge, recent multimodality imaging techniques may help to confirm and to assess the progressive nature of the disease. Diagnosis may be reached in different stages, from as early as the intramyocardial dissecting haematoma to the severe false-pseudoaneurysm. Case summary: This series describes five cases of ID and provides insights into imaging findings and clinical course of this extremely uncommon condition. Our patients represented a wide range of clinical stages, from asymptomatic course to cardiogenic shock. The imaging diagnostic approach was very different from case to case and involved techniques such as echocardiography, cardiac CT, and cardiac magnetic resonance. Discussion: Intramyocardial dissection is a challenging condition in terms of diagnosis and clinical management associated with high morbidity and mortality. Furthermore, the different nomenclature found in the literature may be confusing. This case series supports the need of a terminology standardization and a multimodal imaging approach, which might be determinant for an accurate differential diagnosis and a suitable therapeutic management.

Upholding te mana o te wa: Maori patients and their families' experiences of accessing care following an out-of-hospital cardiac event.

Objective: The purpose of this study was to explore the experiences of Maori patients and their families accessing care for an acute out-of-hospital cardiac event and to identify any barriers or enablers of timely access to care. Design: Eleven interviews with patients and their families were conducted either face-to-face or using online conferencing. Interviews were audio-recorded and transcribed for thematic analysis using Kaupapa Maori methodology. Results: Data analysis identified three themes: (1) me and the event, (2) the people (3) upholding te mana o te wa or self-determined heart wellbeing. Knowledge of symptoms and a desire to maintain personal dignity at the time of the event affected emergency medical service initiation. Participants described relationships with health professionals, the importance of good quality information, having family support, and drawing on cultural practices as vital for their health care journey. Conclusion: Systemic barriers including racism, discrimination, and inadequate resourcing exist for Maori journeying to and through care following an out of hospital cardiac event. Improving the cultural safety of health professionals, better access to community defibrillation, and improving understanding of the life-long impacts a cardiac event has on patients and whanau is recommended.

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement.

Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle's syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.