Fulminant myocarditis proven by early biopsy and outcomes.

BACKGROUND AND AIMS: While endomyocardial biopsy (EMB) is recommended in adult patients with fulminant myocarditis, the clinical impact of its timing is still unclear. METHODS: Data were collected from 419 adult patients with clinically suspected fulminant myocarditis admitted to intensive care units across 36 tertiary centres in 15 countries worldwide. The diagnosis of myocarditis was histologically proven in 210 (50%) patients, either by EMB (n = 183, 44%) or by autopsy/explanted heart examination (n = 27, 6%), and clinically suspected cardiac magnetic resonance imaging confirmed in 96 (23%) patients. The primary outcome of survival free of heart transplantation (HTx) or left ventricular assist device (LVAD) at 1 year was specifically compared between patients with early EMB (within 2 days after intensive care unit admission, n = 103) and delayed EMB (n = 80). A propensity score-weighted analysis was done to control for confounders. RESULTS: Median age on admission was 40 (29-52) years, and 322 (77%) patients received temporary mechanical circulatory support. A total of 273 (65%) patients survived without HTx/LVAD. The primary outcome was significantly different between patients with early and delayed EMB (70% vs. 49%, P = .004). After propensity score weighting, the early EMB group still significantly differed from the delayed EMB group in terms of survival free of HTx/LVAD (63% vs. 40%, P = .021). Moreover, early EMB was independently associated with a lower rate of death or HTx/LVAD at 1 year (odds ratio of 0.44; 95% confidence interval: 0.22-0.86; P = .016). CONCLUSIONS: Endomyocardial biopsy should be broadly and promptly used in patients admitted to the intensive care unit for clinically suspected fulminant myocarditis.

Tendencias en el tratamiento del shock cardiogénico e impacto pronóstico del tipo de centros tratantes / Trends in cardiogenic shock management and prognostic impact of type of treating center

INTRODUCCIÓN Y OBJETIVOS: Las guías recomiendan centralizar la atención del shock cardiogénico (SC) en centros altamente especializados. El objetivo de este estudio fue evaluar la asociación entre las características de los centros tratantes y la mortalidad en el SC secundario a infarto de miocardio con elevación del segmento ST (IAMCEST). MÉTODOS: Se seleccionaron los episodios de alta con diagnóstico de SC-IAMCEST entre 2003-2015 del Conjunto Mínimo Básico de Datos del Sistema Nacional de Salud español. Los centros se clasificaron según disponibilidad de servicio de cardiología, laboratorio de hemodinámica, cirugía cardiaca y disponibilidad de Unidad de Cuidados Intensivos Cardiológicos (UCIC). La variable objetivo principal fue la mortalidad hospitalaria. RESULTADOS: Se identificaron 19.963 episodios. La edad media fue de 73,4±11,8 años. La proporción de pacientes tratados en hospitales con laboratorio de hemodinámica y cirugía cardiaca aumentó del 38,4% en 2005 al 52,9% en 2015; p <0,005). Las tasas de mortalidad bruta y ajustada por riesgo se redujeron progresivamente (del 82 al 67,1%, y del 82,7 al 66,8%, respectivamente, ambas p <0,001). La revascularización coronaria, tanto quirúgica como percutánea, se asoció de forma independiente con una menor mortalidad (OR = 0,29 y 0,25, p <0,001); La disponibilidad UCIC se asoció con menores tasas de mortalidad ajustadas (el 65,3±7,9% frente al 72±11,7%; p <0,001). CONCLUSIONES: La proporción de pacientes con SC-IAMCEST tratados en centros altamente especializados aumentó, mientras que la mortalidad disminuyó a lo largo del periodo de estudio. La revascularización y el ingreso en UCIC se asociaron con mejores resultados

INTRODUCTION AND OBJECTIVES: Current guidelines recommend centralizing the care of patients with cardiogenic shock in high-volume centers. The aim of this study was to assess the association between hospital characteristics, including the availability of an intensive cardiac care unit, and outcomes in patients with ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). METHODS: Discharge episodes with a diagnosis of STEMI-related CS between 2003 and 2015 were selected from the Minimum Data Set of the Spanish National Health System. Centers were classified according to the availability of a cardiology department, catheterization laboratory, cardiac surgery department, and intensive cardiac care unit. The main outcome measured was in-hospital mortality. RESULTS: A total of 19 963 episodes were identified. The mean age was 73.4±11.8 years. The proportion of patients with CS treated at hospitals with a catheterization laboratory and cardiac surgery department increased from 38.4% in 2005 to 52.9% in 2015 (P <.005). Crude- and risk-adjusted mortality rates decreased over time, from 82% to 67.1%, and from 82.7% to 66.8%, respectively (both P <.001). Coronary revascularization, either percutaneous or coronary artery bypass grafting, was independently associated with a lower mortality risk (OR, 0.29 and 0.25; both P <.001, respectively). Intensive cardiac care unit availability was associated with lower adjusted mortality rates (65.3%±7.9 vs 72±11.7; P <.001). CONCLUSIONS: The proportion of patients with STEMI-related CS treated at highly specialized centers increased while mortality decreased during the study period. Better outcomes were associated with the increased performance of revascularization procedures and access to intensive cardiac care units over time

Trends in cardiogenic shock management and prognostic impact of type of treating center.

INTRODUCTION AND OBJECTIVES: Current guidelines recommend centralizing the care of patients with cardiogenic shock in high-volume centers. The aim of this study was to assess the association between hospital characteristics, including the availability of an intensive cardiac care unit, and outcomes in patients with ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). METHODS: Discharge episodes with a diagnosis of STEMI-related CS between 2003 and 2015 were selected from the Minimum Data Set of the Spanish National Health System. Centers were classified according to the availability of a cardiology department, catheterization laboratory, cardiac surgery department, and intensive cardiac care unit. The main outcome measured was in-hospital mortality. RESULTS: A total of 19 963 episodes were identified. The mean age was 73.4±11.8 years. The proportion of patients with CS treated at hospitals with a catheterization laboratory and cardiac surgery department increased from 38.4% in 2005 to 52.9% in 2015 (P <.005). Crude- and risk-adjusted mortality rates decreased over time, from 82% to 67.1%, and from 82.7% to 66.8%, respectively (both P <.001). Coronary revascularization, either percutaneous or coronary artery bypass grafting, was independently associated with a lower mortality risk (OR, 0.29 and 0.25; both P <.001, respectively). Intensive cardiac care unit availability was associated with lower adjusted mortality rates (65.3%±7.9 vs 72±11.7; P <.001). CONCLUSIONS: The proportion of patients with STEMI-related CS treated at highly specialized centers increased while mortality decreased during the study period. Better outcomes were associated with the increased performance of revascularization procedures and access to intensive cardiac care units over time.

Impacto del tipo de hospital en el tratamiento y evolución de los pacientes con síndrome coronario agudo sin elevación del ST / Influence of hospital type on treatment and prognosis in patients with non-ST elevation acute coronary syndrome

Introducción y objetivos. Las guías de práctica clínica del síndrome coronario agudo sin elevación del ST (SCASEST) no valoran la infraestructura hospitalaria y la facilidad de acceso a la sala de hemodinámica. Este estudio analiza la influencia del tipo de hospital, con o sin sala de hemodinámica, en la forma de tratamiento de pacientes con SCASEST y su posible impacto en el pronóstico a medio plazo. Métodos. El GYSCA es un registro multicéntrico (15 hospitales) que analiza la aplicación de las guías en pacientes con SCASEST: 6 con sala de hemodinámica (hospitales centrales) y 9 sin hemodinámica (hospitales comarcales). Se realizó seguimiento clínico al alta y a los 3 y a los 12 meses. Resultados. Se reclutó a 1.133 pacientes consecutivos; 599 (52,9%) en hospitales centrales y 534 (47,1%) en hospitales comarcales. El uso de intervenciones de clase I fue mayor en los centrales (aspirina, clopidogrel, bloqueadores beta, IECA y estatinas; p < 0,01) y se revascularizó a más pacientes durante la hospitalización (el 43 frente al 30%; p < 0,01). El número de pacientes de hospitales comarcales que reingresaron por SCASEST al año fue 5 veces mayor que en los centrales (el 12,8 frente al 2,3%; p < 0,01), y el tipo de hospital fue uno de los predictores de eventos. Conclusiones. Los pacientes que ingresan por SCASEST en hospitales que no disponen de sala de hemodinámica son tratados de forma menos invasiva y con un tratamiento farmacológico menos ajustado a lo recomendado en las guías. Junto con los conocidos factores predictivos del pronóstico, el tipo de hospital puede tener un impacto adicional en la evolución (AU)

Introduction and objectives. Clinical practice guidelines on non-ST-segment elevation acute coronary syndrome (NSTEACS) do not take either hospital infrastructure or the availability of a catheterization laboratory into account. The aim of this study was to determine the influence of hospital type, either with or without a catheterization laboratory, on treatment and medium-term prognosis in patients with NSTEACS. Methods. The GYSCA multicenter study (covering 15 hospitals) investigated the implementation of clinical practice guidelines in patients with NSTEACS at six hospitals with catheterization laboratories (i.e. tertiary-care hospitals; THs) and nine without (i.e. secondary-care hospitals; SHs). Patients were assessed clinically at hospital discharge and after 3 and 12 months. Results. In total, 1133 consecutive patients were recruited: 599 (52.9%) in THs and 534 (47.1%) in SHs. The use of specific class-I interventions (i.e. aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors and statins) was more common in THs (P < .01) and more patients in THs underwent revascularization while in hospital (43% vs. 30%; P < .01). The number of SH patients who were readmitted for NSTEACS at 1 year was 5-fold greater than the number of TH patients (12.8% vs. 2.3%; P < .01), and hospital type was a predictor of an adverse event. Conclusions. Patients admitted for NSTEACS to a hospital without a catheterization laboratory were managed less invasively and their drug treatment was less likely to have been modified to match guideline recommendations. In addition to other well-known prognostic factors, hospital type can also have an influence on patient outcomes (AU)

[Influence of hospital type on treatment and prognosis in patients with non-ST elevation acute coronary syndrome]. / Impacto del tipo de hospital en el tratamiento y evolución de los pacientes con síndrome coronario agudo sin elevación del ST.

INTRODUCTION AND OBJECTIVES: Clinical practice guidelines on non-ST-segment elevation acute coronary syndrome (NSTEACS) do not take either hospital infrastructure or the availability of a catheterization laboratory into account. The aim of this study was to determine the influence of hospital type, either with or without a catheterization laboratory, on treatment and medium-term prognosis in patients with NSTEACS. METHODS: The GYSCA multicenter study (covering 15 hospitals) investigated the implementation of clinical practice guidelines in patients with NSTEACS at six hospitals with catheterization laboratories (i.e. tertiary-care hospitals; THs) and nine without (i.e. secondary-care hospitals; SHs). Patients were assessed clinically at hospital discharge and after 3 and 12 months. RESULTS: In total, 1133 consecutive patients were recruited: 599 (52.9%) in THs and 534 (47.1%) in SHs. The use of specific class-I interventions (i.e. aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors and statins) was more common in THs (P< .01) and more patients in THs underwent revascularization while in hospital (43% vs. 30%; P< .01). The number of SH patients who were readmitted for NSTEACS at 1 year was 5-fold greater than the number of TH patients (12.8% vs. 2.3%; P< .01), and hospital type was a predictor of an adverse event. CONCLUSIONS: Patients admitted for NSTEACS to a hospital without a catheterization laboratory were managed less invasively and their drug treatment was less likely to have been modified to match guideline recommendations. In addition to other well-known prognostic factors, hospital type can also have an influence on patient outcomes.

Virtual histology intravascular ultrasound assessment of cardiac allograft vasculopathy from 1 to 20 years after heart transplantation.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the main cause of graft loss and death in heart transplant (HTx) recipients surviving >1 year. There is a dual etiology for coronary disease in HTx: classic atherosclerosis and an immunologically mediated disease. Intravascular ultrasound (IVUS) is highly sensitive for CAV detection; however, gray-scale IVUS is of limited value for identification of specific plaque components. We sought to characterize graft coronary artery disease by means of IVUS-virtual histology (IVUS-VH) at different time-points of follow-up and to correlate plaque composition with clinical factors. METHODS: In our study we included 67 patients, who were 7.6 +/- 5.7 years post-HTx. IVUS gray-scale evaluation was performed on all patients. IVUS-VH analysis was done in those patients showing intimal thickening >0.5 mm at the three more significant lesions (three cross-sections for each) of the left anterior descending artery. RESULTS: IVUS-VH analysis was obtained done on 58 patients (86.5%). We found a significant correlation between time of HTx and IVUS gray-scale parameters (plaque area and plaque burden), with both increasing over time. We also found a significant correlation between time and IVUS-VH-derived plaque components, necrotic core and calcium, which increased with time, and fibrous and fibrofatty components, both decreased at follow-up. IVUS-VH results were also related to donor age and cardiovascular risk factors. CONCLUSIONS: We observed a time-related change in IVUS-VH-derived plaque composition. Necrotic core and calcium, typical atheromatous components, become more prevalent with time after HTx, especially when influenced by cardiovascular risk factors. The presence of a necrotic core in the early stages was linked to older donor age.

[Two-year clinical follow-up in 200 patients receiving sirolimus-eluting stents in lesions at a high risk of restenosis]. / Seguimiento clínico a 2 años de 200 pacientes tratados con stent liberador de rapamicina en lesiones de alto riesgo de reestenosis.

INTRODUCTION AND OBJECTIVES: Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. PATIENTS AND METHOD: Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. RESULTS: The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. CONCLUSIONS: Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies.

Seguimiento clínico a 2 años de 200 pacientes tratados con stent liberador de rapamicina en lesiones de alto riesgo de reestenosis / Two-year clinical follow-up in 200 patients receiving sirolimus-eluting stents in lesions at a high risk of restenosis

Introducción y objetivos. Los stents de rapamicina (SR) han demostrado reducir la tasa de reestenosis en múltiples estudios, pero se han descrito algunos casos de reestenosis y trombosis tardías que proyectan dudas sobre sus resultados a largo plazo (> 2 años). Nos planteamos estudiar retrospectivamente la evolución a largo plazo de pacientes tratados con SR en lesiones de alto riesgo de reestenosis. Pacientes y método. Desde su introducción, hemos utilizado SR en los casos con lesiones de mayor riesgo de reestenosis. Estudiamos la evolución clínica de los pacientes en los que se implantaron SR y que cuentan con un seguimiento clínico superior a 2 años. Resultados. Se estudió a 200 pacientes (edad 60 ± 11 años, un 22% diabéticos) tratados entre junio de 2002 y abril de 2003 en 309 lesiones: un 16%, oclusiones totales; un 16,8%, reestenosis intra-stent; un 28%, difusas, y un 30%, en vaso pequeño. La longitud total de stent por paciente fue de 29 ± 16 mm y el diámetro del stent, de 2,78 ± 0,27 mm. En el seguimiento clínico de 29 ± 3,2 meses se produjeron los siguientes eventos: 4 muertes, de las que 2 (1%) fueron cardiacas; 4 infartos (2%); 4 trombosis de stent documentadas (2%), todas tardías a los 3, 7, 26 y 31 meses; 4 casos (2%) de revascularización por reestenosis del segmento tratado a los 3, 5, 14 y 15 meses, y 6 casos (3%) de revascularización de otra lesión. Conclusiones. La evolución a largo plazo de los pacientes con SR en lesiones de alto riesgo reestenótico muestra una tasa de reestenosis clínica muy baja. La incidencia de trombosis tardía parece resultar algo elevada y debería ser evaluada en series más amplias

Introduction and objectives. Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. Patients and method. Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. Results. The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. Conclusions. Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies

Comparison of C-reactive protein levels after coronary stenting with bare metal versus sirolimus-eluting stents.

We evaluated C-reactive protein increases after implantation of bare metal stents in 200 patients and sirolimus-eluting stents in 100 patients. The magnitude of change in C-reactive protein was comparable between groups. Clinical follow-up showed a relation between the postprocedural C-reactive protein increase and outcome that was significant in the bare metal stent group, which accounted for the most of events, but not in the sirolimus-eluting stent group.

[Sirolimus-eluting stents to treat lesions with a high risk of restenosis. Six-month clinical follow-up in the first 100 patients]. / Stent liberador de rapamicina en el tratamiento de lesiones coronarias con alto riesgo de reestenosis. Seguimiento clínico a 6 meses de los primeros 100 pacientes.

INTRODUCTION: Sirolimus-eluting stents have been shown to be effective in de-novo coronary lesions, reducing restenosis strikingly in a subset of lesions with a low or moderate risk of restenosis. We decided to assess their usefulness in lesions with a high risk of restenosis. PATIENTS AND METHOD: We included consecutive patients with lesions that met at least one of the following criteria: a) in-stent restenosis; b) diffuse lesion (>20 mm); c) small vessel (< or =2.5 mm), and d) total occlusion. RESULTS: Between June 2002 to December 2002, 100 patients were included (61 [11] years, 84% men, 21% with diabetes). In all, 154 lesions were treated (34% diffuse lesions, 36% in small vessels, 20% in-stent restenosis and 20% occlusions). An average of 1.6 (0.7) stents were implanted per patient. Mean diameter was 2.74 (0.26) mm, mean length was 21 (8.5) mm and total stent length per patient was 33 (16) mm. The acute success rate was 98%. After the procedure 2 (2%) non-Q-wave infarctions were diagnosed. No episodes of acute or subacute thrombosis occurred. During a follow-up period of 8.5 (2) months (range 6-12 months) there were two (2%) late thromboses, one of which caused an infarction. Target lesion revascularization was required in 3 patients (3%), two of whom were the patients with late thrombosis. CONCLUSIONS: Sirolimus-eluting stents can be used in lesions with a high risk of restenosis. The rate of thrombosis was low, and the use of these stents was associated with a strikingly low rate of target lesion revascularization during follow-up.

Stent liberador de rapamicina en el tratamiento de lesiones coronarias con alto riesgo de reestenosis. Seguimiento clínico a 6 meses de los primeros 100 pacientes / Sirolimus-Eluting Stents to Treat Lesions With a High Risk of Restenosis. Six-Month Clinical FollowUp in the First 100 Patients

Introducción y objetivos. Los stents con rapamicina han demostrado reducir drásticamente la reestenosis en lesiones con un riesgo reestenótico entre ligero y moderado. No existen estudios amplios que evalúen su comportamiento en contextos lesionales de alto riesgo. Nos planteamos conocer el posible impacto de su empleo en este tipo de lesiones. Pacientes y método. Se incluyó a pacientes consecutivos con indicación de angioplastia con alguna lesión que reuniera al menos una de las siguientes características: a) reestenosis intra-stent; b) difusa (> 20 mm); c) vaso pequeño ( 2,5 mm), y d) oclusión total. Resultados. Entre junio y diciembre de 2002 se incluyó a 100 pacientes (61 ñ 11 años; un 84 por ciento varones; un 21 por ciento diabéticos) que tenían 154 lesiones tratadas (un 34 por ciento difusas, un 36 por ciento en un vaso pequeño, un 20 por ciento reestenosis intra-stent y un 20 por ciento oclusiones). Se implantaron 1,6 ñ 0,7 stents/paciente, con un diámetro de 2,74 ñ 0,26 mm, una longitud de 21 ñ 8,5 mm y una longitud total stent/paciente de 33 ñ 16 mm. Se obtuvo un éxito inmediato en el 98 por ciento. Se produjeron 2 infartos sin onda Q (2 por ciento) tras el procedimiento. No hubo ningún caso de trombosis agudas ni subagudas. Durante el seguimiento de 8,5 ñ 2 meses (rango, 6-12 meses) se produjeron 2 trombosis tardías (2 por ciento), a los 3 y 7 meses, una de las cuales ocasionó un infarto. Se efectuó revascularización de la lesión tratada en 3 casos (3 por ciento), 2 de los cuales correspondieron a las trombosis tardías. Conclusiones. La utilización de stents con rapamicina en lesiones de alto riesgo para reestenosis fue segura y la necesidad de nueva revascularización en el seguimiento fue notablemente baja (AU)