Impact of annual volume of cases and intensive cardiac care unit availability on mortality of patients with acute myocardial infarction-related cardiogenic shock treated at revascularization capable centres.

AIMS: Cardiogenic shock (CS) is associated with high mortality. The purpose of this study was to assess the impact of hospital structure-related variables on mortality in patients with CS treated at percutaneous and surgical revascularization capable centres (psRCC) from a large nationwide registry. METHODS AND RESULTS: Retrospective observational study including consecutive patients with main or secondary diagnosis of CS and ST elevation myocardial infarction (STEMI). Patients discharged from Spanish National Healthcare System psRCC were included (2016-20). The association between the volume of CS cases attended by each centre, availability of intensive cardiac care unit (ICCU) and heart transplantation (HT) programmes, and in-hospital mortality was assessed by multilevel logistic regression models. The study population consisted of 3074 CS-STEMI episodes, of whom 1759 (57.2%) occurred in 26 centres with ICCU. A total of 17/44 hospitals (38.6%) were high-volume centres, and 19/44 (43%) centres had HT programmes availability. Treatment at HT centres was not associated with a lower mortality (P = 0.121). Both high volume of cases and ICCU showed a trend to an association with lower mortality in the adjusted model [odds ratio (OR): 0.87 and 0.88, respectively]. The interaction between both variables was significantly protective (OR 0.72; P = 0.024). After propensity score matching, mortality was lower in high-volume hospitals with ICCU (OR 0.79; P = 0.007). CONCLUSION: Most CS-STEMI patients were attended at psRCC with high volume of cases and ICCU available. The combination of high volume and ICCU availability showed the lowest mortality. These data should be taken into account when designing regional networks for CS management.

Angiographic characteristics and long-term prognostic impact of coronary artery disease in survivors after sudden cardiac arrest with a non-diagnostic electrocardiogram.

OBJECTIVES: Our purpose was to describe the prevalence, distribution, extension, and prognostic value of coronary artery disease (CAD) in patients resuscitated from sudden cardiac arrest (SCA) with non-diagnostic electrocardiogram (ECG). BACKGROUND: The impact of CAD and the indication for cardiac catheterization (CC) in patients resuscitated from SCA with non-diagnostic ECG are uncertain. METHODS: We included prospectively and consecutively 545 patients resuscitated from SCA with at least one CC during hospitalization. From them, 203 patients with a non-diagnostic ECG formed our study population. Patients were followed-up 5 years after discharge. RESULTS: Overall, 125 (61.6%) patients had significant CAD, and at least one acute culprit lesion was found in 25 (12.4%). Regarding the burden and complexity of CAD, 78 (38.4%) patients had a CAD Prognostic Index of 0 and a SYNTAX score of 0. There was higher 5-year mortality only in patients with very high burden of CAD: three vessels with severe stenosis (P = 0.015) and CAD Prognostic Index Score ≥ 56 (P < 0.001). Tertiles of SYNTAX score did not predict higher 5-year mortality. CONCLUSIONS: In survivors from SCA with a non-diagnostic ECG, significant CAD is highly prevalent. SYNTAX score was not associated with a different long-term prognosis in this patient population. Patients with severe disease in the three main coronary vessels and patients with higher (≥56) CAD Prognostic Index Score had a worse long-term prognosis.

ST-segment deviation behavior during acute myocardial ischemia in opposite ventricular regions: observations in the intact and perfused heart.

BACKGROUND: Acute myocardial ischemia in opposite regions may attenuate ST-segment changes, but whether this effect is expressed differently in extracardiac compared to direct intramyocardial recordings is not well known. OBJECTIVE: The purpose of this study was to characterize ST-segment changes induced by opposite ischemic regions in intact and isolated perfused pig hearts. METHODS: Left anterior descending (LAD) and right coronary arteries (RCA) were occluded in 7 closed chest pigs and in 5 isolated pig hearts. ST-segment changes were analyzed in 12-lead ECG and in local extracellular electrograms. RESULTS: Isolated LAD or RCA occlusion induced maximal ST-segment elevation in leads V4 (0.84 ± 0.30 mV, P = .003) and III (0.16 ± 0.11 mV, P = .04), respectively. RCA occlusion also induced reciprocal ST-segment depression maximal in lead V4 (-0.40 ± 0.16 mV, P = .005). Simultaneous LAD and RCA occlusion reduced ST-segment elevation by about 60% and blunted reciprocal ST-segment changes. Reperfusion of 1 of the 2 occluded arteries induced immediate regional reversion of ST-segment elevation with concurrent beat-to-beat re-elevation in the opposite ischemic region and reappearance of reciprocal ST-segment changes. In the isolated heart, single LAD or RCA ligature induced regional transmural ST-segment elevation that was maximal in endocardial electrograms with no appreciable reciprocal ST-segment depression. Simultaneous LAD and RCA ligature reduced ST-segment elevation by about 30% with no appreciable re-elevation after 1-vessel selective reperfusion. CONCLUSION: Acute myocardial ischemia in opposite ventricular regions attenuated ST-segment elevation and blunted reciprocal depression in conventional ECG leads but not in direct local myocardial electrograms.