Oxidized high-density lipoprotein associates with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common heart arrhythmia and considered to be a progressive chronic disease associated with increased morbidity and mortality. Recent data suggest a link between inflammation, oxidative stress, and AF, although the underlying mechanisms are not fully understood. Because oxidized lipoproteins cause structural damage and electrophysiologic changes in cardiomyocytes, it is feasible that the transformation of atheroprotective high-density lipoprotein (HDL) into dysfunctional HDL contributes to the development of AF. OBJECTIVE: The purpose of this study was to determine whether a reduced antioxidant function of HDL is associated with the presence of AF. METHODS: In this multicenter cross-sectional cohort study, we assessed HDL function in sera of 1206 participants. Patients were divided into groups according to the presence of AF (n = 233) or no AF (n = 973). A validated cell-free biochemical assay was used to determine reduced HDL antioxidant function as assessed by increased normalized HDL lipid peroxide content (nHDLox). RESULTS: Participants with AF had a 9% higher mean relative nHDLox compared to persons without AF (P = .025). nHDLox was strongly associated with AF in all models of logistic regression, including the analysis adjusted for age, sex, and risk factors for AF (all P ≤.01). CONCLUSION: Reduced antioxidant HDL function is associated with the presence of AF, which supports growing evidence that impaired lipoprotein function is linked to electrophysiological changes in cardiomyocytes. nHDLox is one of several contributors to the initiation and perpetuation of AF.

Impact of the Educational Level on Non-Fatal Health Outcomes following Myocardial Infarction.

Notwithstanding a decrease in the incidence and mortality of cardiovascular diseases during the last decades, notable disparities in health outcomes depending on a patient´s socioeconomic position persist and are most visible in acute myocardial infarction and ischemic heart disease. Education is a pivotal indicator of the socioeconomic position. Effects of the social determinants of health on the incidence, prevalence and mortality of cardiovascular diseases were previously effectually investigated and shown to be inversely associated but evidence on non-fatal health outcomes such as heart failure, ability to return to work or rehospitalizations still remain insufficiently examined. We provide a literature review dealing with the impact that formal education has on non-fatal health outcomes including major adverse cardiovascular events, clinical outcomes, depression, use of cardiac rehabilitation, quality of life, self-perceived health and social participation after a myocardial infarction from a global and comprehensive perspective.

Urgent Coronary Artery Bypass Grafting Complicated by Systemic Inflammatory Response from Fulminant Herpes Zoster Successfully Managed with Adjunct Extracorporeal Hemoadsorption: A Case Report.

Blood purification by hemoadsorption therapy seems to improve outcomes in selected patients undergoing cardiac surgery with cardiopulmonary bypass. Here, we report the successful application of hemoadsorption in the severe systemic inflammatory response during coronary artery bypass surgery in a patient with reactivated herpes zoster.

Immediate unselected coronary angiography versus delayed triage in survivors of out-of-hospital cardiac arrest without ST-segment elevation: Design and rationale of the TOMAHAWK trial.

Patients experiencing out-of-hospital cardiac arrest (OHCA) without ST-segment elevation are a heterogenic group with a variety of underlying causes. Up to one-third of patients display a significant coronary lesion compatible with myocardial infarction as OHCA trigger. There are no randomized data on patient selection and timing of invasive coronary angiography after admission. METHODS AND RESULTS: The TOMAHAWK trial randomly assigns 558 patients with return of spontaneous circulation after OHCA with no obvious extracardiac origin of cardiac arrest and no ST-segment elevation/left bundle-branch block on postresuscitation electrocardiogram to either immediate coronary angiography or initial intensive care assessment with delayed/selective angiography in a 1:1 ratio. The primary end point is 30-day all-cause mortality. Secondary analyses will be performed with respect to initial rhythm, electrocardiographic patterns, myocardial infarction as underlying cause, neurological outcome, as well as clinical and laboratory markers. Clinical follow-up will be performed at 6 and 12 months. Safety end points include bleeding and stroke. CONCLUSION: The TOMAHAWK trial will address the unresolved issue of timing and general indication of angiography after OHCA without ST-segment elevation.

Size matters: An observational study investigating estimated height as a reference size for calculating tidal volumes if low tidal volume ventilation is required.

PURPOSE: Acute lung injury is a life threatening condition often requiring mechanical ventilation. Lung-protective ventilation with tidal volumes of 6 mL/kg predicted body weight (PBW, calculated on the basis of a patient's sex and height), is part of current recommended ventilation strategy. Hence, an exact height is necessary to provide optimal mechanical ventilation. However, it is a common practice to visually estimate the body height of mechanically ventilated patients and use these estimates as a reference size for ventilator settings. We aimed to determine if the common practice of estimating visual height to define tidal volume reduces the possibility of receiving lung-protective ventilation. METHODS: In this prospective observational study, 28 mechanically ventilated patients had their heights visually estimated by 20 nurses and 20 physicians. All medical professionals calculated the PBW and a corresponding tidal volume with 6 ml/kg/PBW on the basis of their visual estimation. The patients' true heights were measured and the true PBW with a corresponding tidal volume was calculated. Finally, estimates and measurements were compared. RESULTS: 1033 estimations were undertaken by 153 medical professionals. The majority of the estimates were imprecise and resulting data comprised taller body heights, higher PBW and higher tidal volumes (all p≤0.01). When estimates of patients´ heights are used as a reference for tidal-volume definition, patients are exposed to mean tidal volumes of 6.5 ± 0.4 ml/kg/PBW. 526 estimation-based tidal volumes (51.1%) did not provide lung-protective ventilation. Shorter subjects (<175cm) were a specific risk group with an increased risk of not receiving lung protective ventilation (OR 6.6; 95%CI 1.2-35.4; p = 0.02), while taller subjects had a smaller risk of being exposed to inadequately high tidal volumes (OR 0.15; 95%CI 0.02-0.8; p = 0.02). Furthermore, we found an increased risk of overestimating if the assessor was a female (OR 1.74; 95%CI 1.14-2.65; p = 0.01). CONCLUSION: The common practice of visually estimating body height and using these estimates for ventilator settings is imprecise and potentially harmful because it reduces the chance of receiving lung-protective ventilation. Avoiding this practice increases the patient safety. Instead, height should be measured as a standard procedure.

Kounis syndrome induced by amoxicillin following vasospastic coronary event in a 22-year-old patient: a case report.

This article reports the case of a 22-year-old male patient presented with electrocardiographic ST elevation and elevated cardiac biomarkers. The clinical cascade set into events within an hour of administration of a single-dose of amoxicillin on being diagnosed with acute tonsillitis. The case was preliminarily diagnosed and treated according to the acute coronary syndrome protocol, but on performing coronary angiography no abnormalities in the coronary artery were found. Acute myocarditis was excluded in cardiac MRI. Considering possible hypersensitive reaction of amoxicillin in the absence of major cardiovascular risk in the young patient, diagnosis of Kounis syndrome (KS) was inferred. A thorough clinical observation of the patient after stopping the administration of amoxicillin revealed that there was a resolution of ST-elevation towards baseline. It coincided with falling cardiac biomarkers concomitant with subsided pain. The asymptomatic patient was discharged after 5 days of hospital stay. Telephonic follow-up one week after discharge from the hospital confirmed his pain-free and overall normal clinical status. Aim of the present report is to emphasize the need for increased awareness of KS induced by amoxicillin.

The combination of electroanatomic mapping and minielectrodes in a series of cases of redo procedures.

BACKGROUND: In patients with supraventricular tachycardia, catheter ablation is an important treatment option. However, approximately one quarter of these patients remain symptomatic, so sustainable strategies for the treatment of those patients who do not benefit from the first catheter ablation are required. METHODS: In a series of redo procedures, we investigated the combined use of an electro-anatomic mapping system and an ablation catheter with mini-electrodes. RESULTS: Catheter ablation was successful in two patients with recurrent common type atrial flutter and one patient with recurrent ectopic atrial tachycardia. In a patient with recurrent perimitral flutter, the ablation procedure had to be stopped early, due to pericardial effusion. CONCLUSION: The combination of electro-anatomic mapping and mini-electrodes might be useful, especially in the treatment of ectopic atrial tachycardias, but also in redo procedures of CTI ablations, that require not only the visualization of the tachycardia, but also the detection of a local focus or a local gap. For an optimal use of the ME ablation catheter, the generator settings should be evaluated in further studies.

[Organ Donation in Victims of Non-Traumatic Out-of-Hospital Cardiac Arrest]. / Organspende bei Patienten nach nicht traumatischem außerklinischem Herzstillstand.

INTRODUCTION: The out-of-hospital cardiac-arrest (OHCA) is one of the leading causes of death. However, although previous studies showed the possibility to transplant organs from resuscitated donors, organ donation following OHCA remains seldom. We therefore initiated this study to investigate the current percentage of organ donation in victims of OHCA in a german university hospital. MATERIAL AND METHODS: We analyzed data from all victims of OHCA who were admitted to our hospital between January 1st 2008 and May 31st 2017. RESULTS: Altogether, there were 385 victims of OHCA admitted to our hospital. 126 victims of OHCA (32.8 %) survived until hospital discharge, 259 died (67.2 %), hereunder 7 victims of OHCA (1.8 %) with proven brain death. 5 victims of OCHA (1.5 %) donated their organs, and altogether 14 organs could be transplanted successfully. DISCUSSION: Organ donation following OHCA is seldom. We therefore would appreciate a more frequent diagnostics of brain death as currently not even all victims of OHCA with proven signs of brain damage in the computed tomography receive further diagnostics to confirm the diagnosis of brain death.

The Value of Arterial Blood Gas Parameters for Prediction of Mortality in Survivors of Out-of-hospital Cardiac Arrest.

CONTEXT: Sudden cardiac death is one of the leading causes of death in Europe, and early prognostication remains challenging. There is a lack of valid parameters for the prediction of survival after cardiac arrest. AIMS: This study aims to investigate if arterial blood gas parameters correlate with mortality of patients after out-of-hospital cardiac arrest. MATERIALS AND METHODS: All patients who were admitted to our hospital after resuscitation following out-of-hospital cardiac arrest between January 1, 2008, and December 31, 2013, were included in this retrospective study. The patient's survival 5 days after resuscitation defined the study end-point. For the statistical analysis, the mean, standard deviation, Student's t-test, Chi-square test, and logistic regression analyses were used (level of significance P < 0.05). RESULTS: Arterial blood gas samples were taken from 170 patients. In particular, pH < 7.0 (odds ratio [OR]: 7.20; 95% confidence interval [CI]: 3.11-16.69; P < 0.001) and lactate ≥ 5.0 mmol/L (OR: 6.79; 95% CI: 2.77-16.66; P < 0.001) showed strong and independent correlations with mortality within the first 5 days after hospital admission. CONCLUSION: Our study results indicate that several arterial blood gas parameters correlate with mortality of patients after out-of-hospital resuscitation. The most relevant parameters are pH and lactate because they are strongly and independently associated with mortality within the first 5 days after resuscitation. Despite this correlation, none of these parameters by oneself is strong enough to allow an early prognostication. Still, these parameters can contribute as part of a multimodal approach to assessing the patients' prognosis.

[Relevance of Living Wills During Post-Resuscitation Care]. / Stellenwert der Patientenverfügung in der Postreanimationsbehandlung.

Background There is hardly any evidence about the influence of living wills on acute life-threatening disease like out-of-hospital cardiac-arrest (OHCA). We therefore initiated this study to quantify the percentage of victims of OHCA who's living wills are available during post-resuscitation care. Methods All victims of OHCA who were admitted to our hospital between January 1st 2008 and July 31th 2016 were identified by analysis of our central admission register. Data from individual patients were collected from the patient's health records and anonymously stored on a central database. Results Altogether, there were 343 victims of OHCA admitted to our hospital between January 1st 2008 and July 31th 2016, including 16 patients (4.7 %) with living wills and 18 patients (5.2 %) with legal health care proxy. Survival rates were 31.2 % in patients with living wills, 27.8 % in patients with legal health care proxy and 33.3 % in patients without such a document. Conclusion In this study, the percentage of victims of OHCA with available living wills during post-resuscitation care was low. The presentation of living wills or legal health care proxies during post-resuscitation care of victims from OHCA was not equivalent to the patient`s death. Most often, discussion with relatives led to the decision to withdraw further therapy.

[ECG score to predict ICD therapies in patients with nonischemic cardiomyopathy and primary prophylactic CRT-D]. / EKG-Score zur Vorhersage von ICD-Therapien bei nichtischämischer Kardiomyopathie und primärprophylaktischem CRT-D.

BACKGROUND AND PROBLEM: Recently published results of the DANISH study raise concerns, if primary prophylactic ICD implantations in patients with nonischemic cardiomyopathy (NICM) and severe reduced left ventricular ejection fraction (LVEF) should be performed without further risk stratification. There was no significant difference in the overall mortality of patients with or without ICD and CRT defibrillator (CRT-D) or CRT pacemaker (CRT-P), respectively. Clinical risk scores to identify patients with ischemic cardiomyopathy (ICM) who benefit most from an ICD have been recommended. The need for risk stratification systems concerning patients with NICM has been emphasized. STUDY DESIGN AND METHODS: A retrospective study of 434 consecutive patients with CRT-D implantation was performed. Patients with no regular follow-up at our institution (n = 132), secondary prophylactic ICD indication (n = 61), and upgrade to CRT (n = 95) were excluded. The occurrence of an adequate ICD therapy was defined as the endpoint. Left ventricular ejection fraction (LVEF), genesis of the cardiomyopathy as well as the modified Selvester ECG score (MSES) for evaluation of the left ventricular scar burden were documented among other characteristics. RESULTS: Within a median follow-up of 605 days, 24% of the patients experienced an adequate ICD therapy. These patients had significantly lower LVEF (20% vs. 23%), and the MSES was higher (7 vs. 3 points). There was no significant difference in patients suffering from ICM vs NICM. A receiver-operating-characteristic (ROC) analysis revealed a sensitivity of 0.914 and a specifity of 0.586 for MSES ≥4 to predict the occurrence of an ICD therapy. None of 35 patients suffering from NICM with MSES <4 experienced an ICD therapy. INTERPRETATION: The evaluation of the left ventricular scar burden using MSES can be useful for the decision between CRT-D and CRT-P in patients suffering from NICM.

[Predictors for need of antibradycardia and antitachycardia pacing after ICD implantation : Implications for the subcutaneous ICD]. / Prädiktoren für die Notwendigkeit antibradykarder und antitachykarder Stimulation nach ICD-Implantation : Implikationen für den subkutanen ICD.

BACKGROUND: Little is known about the incidence and risk factors for progression to pacemaker dependency or the need for cardiac resynchronization in typical patients with an implanted defibrillator with regard to an alternative implantation of a subcutaneous ICD (S-ICD). STUDY DESIGN AND METHODS: After retrospective analysis of 291 patients with first implantation of a transvenous single chamber ICD (VVI-ICD) from 2010-2016 and excluding those with an indication for pacemaker or lack of follow-up data, 121 patients were included and investigated with regard to the following endpoints: need for pacemaker stimulation, upgrade for cardiac resynchronization (CRT), and secondary occurrence and effectiveness of antitachycardia pacing (ATP). We compared the results with those of fundamental S­ICD studies and tried to determine risk factors on the basis of medical history and pre-implant data. RESULTS: The study population and the rate of endpoints were significantly different to those of fundamental S­ICD studies. Within a 2.2-year follow-up, 14.9 % of the patients developed a need for pacemaker stimulation and 0.8 % the need for cardiac resynchronization. Excluding patients who at implantation were already at high risk for pacemaker dependency, 7.4 % remained with a reached endpoint. We identified atrial fibrillation and bundle-branch-block as risk factors. All episodes of ventricular tachycardia (VT) could be terminated by ATP in 9.9 % of the patients. They more often had ischemic heart disease and a secondary prophylactic indication for an ICD. CONCLUSION: The low rate of conversions from S­ICD to a transvenous ICD in case of pacemaker-dependency as stated in fundamental S­ICD studies should not be transferred to other typical collectives of ICD recipients. The latter group is at significantly higher risk for developing pacemaker-dependency.

Hyperoxia Early After Hospital Admission in Comatose Patients with Non-Traumatic Out-of-Hospital Cardiac Arrest.

BACKGROUND The clinical effect of hyperoxia in patients with non-traumatic out-of-hospital cardiac arrest (OHCA) remains uncertain. We therefore initiated this study to find out whether there is an association between survival and hyperoxia early after return of spontaneous circulation (ROSC) in OHCA patients admitted to our hospital. MATERIAL AND METHODS All OHCA patients admitted to our hospital between 1 January 2008 and 30 June 2015 were identified by analysis of our central admission register. Data from individual patients were collected from patient health records and anonymously stored on a central database. RESULTS Altogether, there were 280 OHCA patients admitted to our hospital between 1 January 2008 and 30 June 2015, including 35 patients (12.5%) with hyperoxia and 99 patients (35.4%) with normoxia. Comparison of these 2 groups showed lower pH values in OHCA patients admitted with normoxia compared to those with hyperoxia (7.10±0.18 vs. 7.21±0.17; p=0.001) but similar rates of initial lactate (7.92±3.87 mmol/l vs. 11.14±16.40 mmol/l; p=0.072). Survival rates differed between both groups (34.4% vs. 54.3%; p=0.038) with better survival rates in OHCA patients with hyperoxia at hospital admission. CONCLUSIONS Currently, different criteria are used to define hyperoxia following OHCA, but if the negative effects of hyperoxia in OHCA patients are a cumulative effect over time, hyperoxia < 60 min after hospital admission as investigated in this study would be equivalent to a short period of hyperoxia. It may be that the positive effect of buffering metabolic acidosis early after cardiac arrest maintains the negative effects of hyperoxia in general.

Early-Onset Pneumonia in Non-Traumatic Out-of-Hospital Cardiac Arrest Patients with Special Focus on Prehospital Airway Management.

BACKGROUND More than half of all non-traumatic out-of-hospital cardiac arrest (OHCA) patients die in the hospital. Early-onset pneumonia (EOP) has been described as one of the most common complications after successful cardiopulmonary resuscitation. However, the expanded use of alternative airway devices (AAD) might influence the incidence of EOP following OHCA. MATERIAL AND METHODS We analyzed data from all OHCA patients admitted to our hospital between 1 January 2008 and 31 December 2014. EOP was defined as proof of the presence of a pathogenic microorganism in samples of respiratory secretions within the first 5 days after hospital admission. RESULTS There were 252 patients admitted: 155 men (61.5%) and 97 women (38.5%), with a mean age of 69.1±13.8 years. Of these, 164 patients (77.6%) were admitted with an endotracheal tube (ET) and 62 (27.4%) with an AAD. We found that 36 out of a total of 80 respiratory secretion samples (45.0%) contained pathogenic microorganisms, with Staphylococcus aureus as the most common bacteria. Neither bacterial detection (p=0.765) nor survival rates (p=0.538) differed between patients admitted with ET and those with AAD. CONCLUSIONS Irrespective of increasing use of AAD, the incidence of EOP remains high.

Early computed tomography in victims of non-traumatic out-of-hospital cardiac arrest.

Although early cranial and thoracic computed tomography (CT) is recommended in the early in-hospital treatment of victims of out-of-hospital cardiac arrest (OHCA), hardly anything is known regarding the proportions of therapy-relevant findings with this method. Victims of OHCA who were admitted to our hospital between January 1, 2008 and December 31, 2014 were studied. CT was classified as early if performed within the first 4 h following hospital admission. There were 32 (12.7 %) cranial, 31 (12.3 %) thoracic and 15 (6.0 %) abdominal CT. The major findings and associated number of patients were: intracranial bleeding in two patients (0.8 %), acute cerebral ischemia in two (0.8 %), cerebral oedema in four (1.6 %), pulmonary emboli in three (1.2 %), hemothorax in two (0.8 %), tracheal rupture in one (0.4 %), pneumonia in 11 (4.4 %), paralytic ileus in one (0.4 %), ascites in three (1.2 %), pneumoperitoneum in one (0.4 %), acute cholecystitis in two (0.8 %), mesenteric vascular occlusion in one (0.4 %) and ruptured abdominal aortic aneurysm in one (0.4 %). In victims of OHCA, early diagnostic CT provides therapy-relevant findings in a high proportion (42.3 %) of patients examined.

[Acute kidney injury and renal replacement therapy in victims from out-of-hospital cardiac arrest with administration of contrast agent]. / Akute Nierenfunktionsstörung und Nierenersatztherapie bei Patienten nach außerklinischer Reanimation und Kontrastmittelgabe.

BACKGROUND: Early coronary angiography and computed tomography are recommended in survivors of out-of-hospital cardiac arrest (OHCA). However, both techniques require iodinated contrast agent although the effects on incident acute kidney injury are unknown. The aim of this study was to explore the incidence of acute kidney injuries (AKI) and need for renal replacement therapy (RRT) in patients after nontraumatic OHCA with special regard to the administration of contrast agent during the early in-hospital diagnostic workup. MATERIALS AND METHODS: Data from all survivors of OHCA admitted to our hospital between 1 January 2008 and 30 June 2015 were retrospectively collected. Incidence of AKI and RRT between the contrast and no contrast groups were compared. RESULTS: Of 280 OHCA survivors, 133 (47.5 %) received contrast agent (227.0 ± 136.5 ml). Within 72 h after hospital admission, 47 of 129 survivors (36.4 %) developed AKI of any stage, but AKI was more common in patients without early contrast administration than in patients with early contrast administration (54.5 vs. 28.2 %; p = 0.011). Patients who survived until hospital discharge had higher serum creatinine levels at admission than at hospital discharge (1.17 ± 0.37 vs. 0.92 ± 0.35; p < 0.001). CONCLUSION: AKI is common in survivors of OHCA, and RRT following OHCA is needed more frequently than in other cardiac disease. Despite elevated serum creatinine levels at admission, we could not show an association between early contrast administration in survivors of OHCA and AKI incidence.

Earliest Bedside Assessment of Hemodynamic Parameters and Cardiac Biomarkers: Their Role as Predictors of Adverse Outcome in Patients with Septic Shock.

BACKGROUND: Early assessment and aggressive hemodynamic treatment have been shown to increase the survival of patients in septic shock. Current and past sepsis guidelines recommend a resuscitation protocol including central venous pressure (CVP), mean arterial blood pressure (MAP), urine output and central venous oxygen saturation (ScvO2) for resuscitation within the first six hours. Currently, the established severity score systems like APACHE II score, SOFA score or SAPS II score predict the outcome of critically ill patients on the bases of variables obtained only after the first 24 hours. The present study aims to evaluate the risk of short-term mortality for patients with septic shock by the earliest possible assessment of hemodynamic parameters and cardiac biomarkers as well as their role for the prediction of the adverse outcome. METHODS: 52 consecutive patients treated for septic shock in the intensive care unit of one centre (Marien Hospital Herne, Ruhr University Bochum, Germany) were prospectively enrolled in this study. Hemodynamic parameters (MAP, CVP, ScvO2, left ventricular ejection fraction, Hematocrit) and cardiac biomarkers (Troponin I) at the ICU admission were evaluated in regard to their influence on mortality. The primary endpoint was all-cause mortality within 28 days after the admission. RESULTS: A total of 52 patients (31 male, 21 female) with a mean age of 71.4±8.5 years and a mean APACHE II score of 37.0±7.6 were enrolled in the study. 28 patients reached the primary endpoint (mortality 54%). Patients presenting with hypotension (MAP <65 mmHg) at ICU admission had significantly higher rates of 28-day mortality as compared with the group of patients without hypotension (28-day mortality rate 74 % vs. 32 %, p<0.01). Furthermore, the patients in the hypotension present group had significantly higher lactate concentration (p=0.002), higher serum creatinin (p=0.04), higher NTproBNP (p=0.03) and after the first 24 hours higher APACHE II scores (p=0.04). A MAP <65 mmHg was the only hemodynamic parameter significantly predicting the primary endpoint (OR: 4.1, CI: 1.1 - 14.8, p=0.008), whereas the remaining hemodynamic variables CVP, ScvO2, Hematocrit, Troponin I and left ventricular ejection fraction (LVEF) seemed to have no influence on survival. Besides, non-survivors had a significantly higher age (74.1±9.0 vs. 68.4±6.9, p=0.01). If hypotension coincided with an age ≥72 years, the 28-day mortality rate escalated to 88%. CONCLUSIONS: In our study, we identified a risk group with an exceedingly high mortality rate: the patients with an age ≥72 years and presenting with hypotension (MAP <65 mmHg). These data can be easily obtained at the time of the very first patient contact. As a result, an aggressive and a more effective treatment can be initiated within the first minutes of the primary care, possibly reducing organ failure and short-term mortality in this risk group.