Long-term survival after cardiac arrest in patients undergoing emergent coronary angiography.

AIM: To determine long-term survival of patients after cardiac arrest undergoing emergent coronary angiography and therapeutic hypothermia. METHODS: We analysed data from patients treated within the regional STEMI Network from January 2015 to December 2020. The primary endpoint was all-cause mortality at median follow-up. Secondary endpoints were periprocedural complications (arrhythmias, pulmonary edema, cardiogenic shock, mechanical complication, stent thrombosis, reinfarction, bleeding) and 6-month all-cause death. A landmark analysis was performed, studying two time periods; 0-6 months and beyond 6 months. RESULTS: From a total of 24,125 patients in the regional STEMI network, 494 patients who suffered from cardiac arrest were included and divided into two groups: treated with (n = 119) and without therapeutic hypothermia (n = 375). At median follow-up (16.0 [0.2-33.3] months), there was no difference in the adjusted mortality rate between groups (51.3 % with hypothermia vs 48.0 % without hypothermia; HRadj1.08 95%CI [0.77-1.53]; p = 0.659). There was a higher frequency of bleeding in the hypothermia group (6.7 % vs 1.1 %; ORadj 7.99 95%CI [2.05-31.2]; p = 0.002), without difference for the rest of periprocedural complications. At 6-month follow-up, adjusted all-cause mortality rate was similar between groups (46.2 % with hypothermia vs 44.5 % without hypothermia; HRadj1.02 95%CI [0.71-1.47]; p = 0.900). Also, no differences were observed in the adjusted mortality rate between 6 months and median follow-up (9.4 % with hypothermia vs 6.3 % without hypothermia; HRadj2.02 95%CI [0.69-5.92]; p = 0.200). CONCLUSIONS: In a large cohort of patients with cardiac arrest within a regional STEMI network, those treated with therapeutic hypothermia did not improve long-term survival compared to those without hypothermia.

Spontaneous reperfusion enhances succinate concentration in peripheral blood from stemi patients but its levels does not correlate with myocardial infarct size or area at risk.

Succinate is enhanced during initial reperfusion in blood from the coronary sinus in ST-segment elevation myocardial infarction (STEMI) patients and in pigs submitted to transient coronary occlusion. Succinate levels might have a prognostic value, as they may correlate with edema volume or myocardial infarct size. However, blood from the coronary sinus is not routinely obtained in the CathLab. As succinate might be also increased in peripheral blood, we aimed to investigate whether peripheral plasma concentrations of succinate and other metabolites obtained during coronary revascularization correlate with edema volume or infarct size in STEMI patients. Plasma samples were obtained from peripheral blood within the first 10 min of revascularization in 102 STEMI patients included in the COMBAT-MI trial (initial TIMI 1) and from 9 additional patients with restituted coronary blood flow (TIMI 2). Metabolite concentrations were analyzed by 1H-NMR. Succinate concentration averaged 0.069 ± 0.0073 mmol/L in patients with TIMI flow ≤ 1 and was significantly increased in those with TIMI 2 at admission (0.141 ± 0.058 mmol/L, p < 0.05). However, regression analysis did not detect any significant correlation between most metabolite concentrations and infarct size, extent of edema or other cardiac magnetic resonance (CMR) variables. In conclusion, spontaneous reperfusion in TIMI 2 patients associates with enhanced succinate levels in peripheral blood, suggesting that succinate release increases overtime following reperfusion. However, early plasma levels of succinate and other metabolites obtained from peripheral blood does not correlate with the degree of irreversible injury or area at risk in STEMI patients, and cannot be considered as predictors of CMR variables.Trial registration: Registered at www.clinicaltrials.gov (NCT02404376) on 31/03/2015. EudraCT number: 2015-001000-58.

Clinical profile and prognosis of young patients with ST-elevation myocardial infarction managed by the emergency-intervention Codi IAM network.

INTRODUCTION AND OBJECTIVES: Data on the clinical profile and outcomes of younger patients with ST-elevation myocardial infarction (STEMI) is scarce. This study compared clinical characteristics and outcomes between patients aged<45 years and those aged ≥ 45 years with STEMI managed by the acute myocardial infarction code (AMI Code) network. Sex-based differences in the younger cohort were also analyzed. METHODS: This multicenter study collected individual data from the Catalonian AMI Code network. Between 2015 and 2020, we enrolled patients with an admission diagnosis of STEMI. Primary endpoints were all-cause mortality within 30 days, 1 year, and 2 years. RESULTS: Overall, 18 933 patients (23% female) were enrolled. Of them, 1403 participants (7.4%) were aged<45 years. Younger patients with STEMI were more frequently smokers (P<.001) and presented with cardiac arrest and TIMI flow 0 before pPCI (P<.05), but the time from first medical contact to wire crossing was shorter than in the older group (P<.05). All-cause mortality rates were lower in patients aged<45 years (P<.001). Among younger patients, cardiogenic shock was most prevalent in women than in their male counterparts (P=.002), with the time from symptom onset to reperfusion being longer (P<.05). Compared with men aged<45 years, younger women were less likely to undergo pPCI (P=.004). CONCLUSIONS: Despite showing high-risk features on admission, young patients exhibit better outcomes than older patients. Differences in ischemia times and treatment were observed between men and women.

Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility.

INTRODUCTION AND OBJECTIVES: Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial. METHODS: We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC). RESULTS: We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001). CONCLUSIONS: FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.

Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention "Codi IAM" Network.

Background: Despite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the "Codi IAM" network in Barcelona. Methods: This is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality. Results: The mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p < 0.003), had longer reperfusion delays (p < 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7-1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84-1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76-1.56). Conclusion: Although the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.

Implications of Iron Deficiency in STEMI Patients and in a Murine Model of Myocardial Infarction.

In patients with a first anterior ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, iron deficiency (ID) was associated with larger infarcts, more extensive microvascular obstruction, and higher frequency of adverse left ventricular remodeling as assessed by cardiac magnetic resonance imaging. In mice, an ID diet reduced the activity of the endothelial nitric oxide synthase/soluble guanylate cyclase/protein kinase G pathway in association with oxidative/nitrosative stress and increased infarct size after transient coronary occlusion. Iron supplementation or administration of an sGC activator before ischemia prevented the effects of the ID diet in mice. Not only iron excess, but also ID, may have deleterious effects in the setting of ischemia and reperfusion.

Predictores de demora en el intervencionismo coronario percutáneo primario en el infarto de miocardio diagnosticado en hospitales sin hemodinámica / Time from electrocardiographic diagnosis of ST-elevation myocardial infarction to guidewire crossing in patients transferred to a hospital for primary angioplasty: factors associated with delay

Objetivos: Identificar variables predictoras del retraso hasta la angioplastia primaria, en los pacientes con infarto agudo de miocardio con elevación del ST (IAMEST) trasladados desde el medio extrahospitalario o desde hospitales sin hemodinámica. Método: Estudio de cohortes, retrospectivo, realizado entre 2008 y 2018 en un hospital universitario receptor de pacientes con diagnóstico de IAMEST y que requirieron angioplastia primaria. Se realizó un análisis multivariable de regresión logística y lineal para identificar variables predictoras de demora de tiempo de electrocardiograma (ECG) diagnóstico hasta el paso de guía. Resultados: Se incluyeron 1.039 pacientes en el estudio. Doscientos noventa y seis pacientes (28,4%) presentaban tiempos ECG diagnóstico-paso de guía > 120 minutos. Las variables asociadas a tiempos prolongados de angioplastia primaria fueron la edad avanzada [odds ratio (OR) = 1,02; IC 95%: 1,01-1,04] la insuficiencia cardiaca grave al ingreso (OR = 2,28; IC 95%: 1,23-4,22), la cirugía cardiaca previa de bypass (OR = 10,01; IC 95%: 2,60-41,81), la muerte súbita extrahospitalaria recuperada (OR = 4,34; IC 95%: 1,84-10,32), la localización lateral del infarto (OR = 1,64; IC 95%: 1,06-2,51), el primer contacto con hospital sin disponibilidad de hemodinámica (OR = 1,52; IC 95%: 1,05- 2,21), la atención fuera de horas (OR = 1,46; IC 95%: 1,06-2,02) y finalmente la distancia en kilómetros al centro con hemodinámica (OR = 1,04; IC 95%: 1,03-1,05). Conclusiones: En los pacientes con IAMEST que requirieron traslado a un centro con hemodinámica, la demora en la realización de la angioplastia primaria se relacionó con factores clínicos, con características del infarto y logísticas. (AU)

Objective: To identify predictors of primary angioplasty delay in patients with ST-elevation myocardial infarction (STEMI) transported from out-of-hospital sites or from hospitals without percutaneous coronary intervention (PCI) suites. Methods: Retrospective cohort study of cases between 2008 and 2018 in a university hospital receiving patients diagnosed with STEMI who required a PCI. We performed linear and multivariate regression analyses to identify factors that predicted delay in interpreting a diagnostic electrocardiogram (ECG) until the guidewire passed the lesion (diagnosis–guidewire-crossing time). Results: A total of 1039 cases were studied; 296 patients (28.4%) had delays of more than 120 minutes between STEMI diagnosis and guidewire crossing. Factors associated with PCI delay were advanced age (odds ratio [OR] = 1.02; 95% CI, 1.01–1.04]), severe heart failure on admission (OR = 2.28; 95% CI, 1.23–4.22), history of cardiac bypass surgery (OR = 10.01; 95% CI, 2.60–41.81), out-of-hospital cardiac arrest (OR = 4.34; 95% CI, 1.84–10.32), lateral ischemia (OR, 1.64; 95% CI, 1.06–2.51), first medical attention in a hospital without a PCI suite (OR = 1.52; 95% CI, 1.05–2.21), first medical attention outside regular working hours (OR = 1.46; 95% CI, 1.06–2.02), and distance in kilometers to a PCI suite (OR = 1.04; 95% CI, 1.03–1.05). Conclusions: Patients with STEMI who required transport to a hospital with a PCI suite experienced primary angioplasty delays. Delays were related to logistical and clinical factors as well as to infarction characteristics. (AU)

Predictors of primary percutaneous coronary intervention delay in cases of myocardial infarction diagnosed in hospitals without hemodynamic support systems / Predictores de demora en el intervencionismo coronario percutáneo primario en el infarto de miocardio diagnosticado en hospitales sin hemodinámica.

OBJECTIVES: The need for primary percutaneous coronary intervention in hospitals without hemodynamic support capability is associated with delays between first medical contact (FMC) and reperfusion. It is important to identify factors involved in delays, particularly if they are relevant to the organization of emergency services. MATERIAL AND METHODS: Analysis of a registry of patients treated in hospitals without advanced hemodynamic support systems in a catchment area with an established care network for acute ST-segment elevation myocardial infarction (STEMI). The registry included care times. RESULTS: The network served 2542 patients with a mean (SD) age of 63 (13) years. FMC-to-reperfusion time was within 120 minutes in 42% of the cases. Nine of the hospitals had a chest-pain unit in the emergency department, and this factor was an independent predictor of FMC-to-reperfusion times of 120 minutes or less (odds ratio, 0.64; 95% CI, 0.54­0.77; P < .0001); the time was shortened by 11 minutes in such hospitals. FMC-to-reperfusion was delayed beyond 120 minutes in relation to the following factors: shock and need for intubation at start of care, age, gender, FMC at night, left bundle branch block, and Killip class. One-month and 1-year mortality rates increased in hospitals without hemodynamic support systems in proportion to reperfusion delay, by 1.7% and 3.5% if the delay was 106 minutes or less and by 7.3% and 12.4% if the delay was 176 minutes or longer (P < .0001). CONCLUSION: FMC-to-reperfusion time in STEMI exceeds recommendations in 58% of the hospitals without hemodynamic support systems and delay is inversely proportional to the availability of an emergency department chest pain unit. One-month and 1-year mortality is proportional to the degree of delay.

OBJETIVO: La indicación de intervencionismo coronario percutáneo primario (ICPP) en hospitales sin hemodinámica (HSH) se asocia con tiempos primera asistencia-apertura de la arteria (TPA) prolongados. Es pertinente identificar los factores implicados, especialmente aquellos relacionados con la organización de los servicios de urgencias. METODO: Análisis de un registro de pacientes atendidos en HSH en una región sanitaria con una red asistencial para infarto agudo de miocardio con elevación del segmento ST (IAMEST) establecida y de sus tiempos de actuación. RESULTADOS: En 2.542 pacientes, de edad 63 ± 13 años, se alcanzó un TPA 120 minutos en un 42% de casos. En 9 de los 16 HSH analizados existía un box de dolor torácico en el área de urgencias, que se comportó como factor predictor independiente de un TPA 120 minutos [OR 0,64 (IC 95% 0,54-0,77), p 0,001], con una reducción de 11 minutos de este. Se asociaron de forma independiente con un TPA superior a 120 minutos la intubación y shock durante la primera asistencia, edad, sexo, atención en horario nocturno, bloqueo de rama izquierda y la clase Killip. La mortalidad al mes y al año aumentó en los HSH proporcionalmente al TPA (1,7% y 3,5% si TPA 106 minutos y del 7,3% y 12,4% si TPA 176 minutos, p 0,001). CONCLUSIONES: El TPA alcanzado en activaciones procedentes de HSH supera las recomendaciones en el 58% de casos y se relaciona inversamente con la disponibilidad de un box de dolor torácico en urgencias. La mortalidad al mes y al año es proporcional al grado de retraso en la reperfusión.

Evolución en el diagnóstico, el tratamiento y la mortalidad del síndrome aórtico agudo en los últimos 20 años / Changes in the diagnosis and management of acute aortic syndrome and associated mortality in the last 20 years

Introducción y objetivos El síndrome aórtico agudo (SAA) tiene una alta mortalidad que obliga a un tratamiento precoz. El propósito del presente estudio es analizar los cambios en el abordaje y el tratamiento del SAA a lo largo de 20 años.MétodosSe incluyó prospectivamente a 451 pacientes (336 varones; media de edad, 60,9±12,4 años) diagnosticados de SAA, 270 con el tipo A y 181 con el tipo B, desde 1999 hasta 2018. Se analizaron variables clínicas, diagnósticas y del tratamiento y las complicaciones hospitalarias.ResultadosEl uso de la tomografía computarizada (TC) como primera técnica diagnóstica se incrementó del 62,8 al 94,2% (p <0,001). El tratamiento quirúrgico del SAA tipo A aumentó del 67,4 al 82,5% (p=0,09). La mortalidad del SAA tipo A disminuyó del 53,1 al 26,3% (p <0,001) como consecuencia de la reducción de la mortalidad del tratamiento quirúrgico (del 45,4 al 17,0%; p <0,001). El tratamiento exclusivamente médico del SAA tipo B disminuyó del 91,8 al 61,7% (p <0,001), debido al aumento del tratamiento endovascular. La mortalidad del SAA tipo B no mostró una disminución significativa (del 16,2 al 10,6%; p=0,15).ConclusionesEl diagnóstico y el tratamiento del SAA han presentado importantes cambios en las últimas 2 décadas. La TC se ha consolidado como la técnica diagnóstica de elección. La mortalidad del SAA tipo A ha disminuido de manera muy importante debido a la mejora de los resultados del tratamiento quirúrgico. En el SAA tipo B, el tratamiento médico solo se ha reducido debido a la aparición del tratamiento endovascular, pero la mortalidad hospitalaria no ha disminuido de manera significativa. (AU)

Introduction and objectives Mortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center.MethodsFrom 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed.ResultsThe use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15).ConclusionsThe diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly. (AU)

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016.

INTRODUCTION AND OBJECTIVES: ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI. METHODS: This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality. RESULTS: From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95). CONCLUSIONS: Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

Impact of pre-angioplasty antithrombotic therapy administration on coronary reperfusion in ST-segment elevation myocardial infarction: Does time matter?

BACKGROUND: Optimal timing of antithrombotic therapy for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) is unclear. We analyzed the impact of pre-angioplasty administration of unfractionated heparin (UFH) on infarct-related artery (IRA) patency and mortality. METHOD: Multicenter prospective observational study of 3520 STEMI patients treated with PPCI from 2016 to 2018. Subjects were divided into four groups according to the elapsed time from heparin administration to PPCI: Group 1: Upon arrival at catheterization laboratory or ≤ 30 min (n = 800; 22.7%); Group 2: 31 to 60 min (n = 994; 28.2%); Group 3: 61 to 90 min (n = 1091; 31%); Group 4: >90 min (n = 635; 18%). IRA patency was defined as thrombolysis in myocardial infarction (TIMI) flow grade 2-3. Multivariate analyses assessed factors associated with IRA patency and both 30-day and 1-year mortality. RESULTS: UFH administration at STEMI diagnosis was an independent predictor of IRA patency especially when administered more than 60 min before the PPCI (OR 1.43; 95% CI 1.14-1.81), either an independent predictor of 30-day (HR 0.63; 95% CI 0.42-0.94) and 1-year (HR 0.57; 95% CI 0.41-0.80) mortality. The effect of UFH on IRA patency was higher when administered earlier from the symptom onset. CONCLUSION: UFH administration at STEMI diagnosis improves coronary reperfusion prior to PPCI and this benefit seems associated with superior clinical outcomes. The presented results highlight a time-dependent effectiveness of UFH, since its reported effect is greater the sooner UFH is administered after symptom onset.

Changes in the diagnosis and management of acute aortic syndrome and associated mortality in the last 20 years.

INTRODUCTION AND OBJECTIVES: Mortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center. METHODS: From 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed. RESULTS: The use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15). CONCLUSIONS: The diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly.

Benefit of primary percutaneous coronary interventions in the elderly with ST segment elevation myocardial infarction.

OBJECTIVE: Primary percutaneous coronary intervention (P-PCI) has demonstrated its efficacy in patients with ST segment elevation myocardial infarction (STEMI). However, patients with STEMI ≥75 years receive less P-PCI than younger patients despite their higher in-hospital morbimortality. The objective of this analysis was to determine the effectiveness of P-PCI in patients with STEMI ≥75 years. METHODS: We included 979 patients with STEMI ≥75 years, from the ATención HOspitalaria del Síndrome coronario study, a registry of 8142 consecutive patients with acute coronary syndrome admitted at 31 Spanish hospitals in 2014-2016. We calculated a propensity score (PS) for the indication of P-PCI. Patients that received or not P-PCI were matched by PS. Using logistic regression, we compared the effectiveness of performing P-PCI versus non-performance for the composite primary event, which included death, reinfarction, acute pulmonary oedema or cardiogenic shock during hospitalisation. RESULTS: Of the included patients, 81.5 % received P-PCI. The matching provided two groups of 169 patients with and without P-PCI. Compared with its non-performance, P-PCI presented a composite event OR adjusted by PS of 0.55 (95% CI 0.34 to 0.89). CONCLUSIONS: Receiving a P-PCI was significantly associated with a reduced risk of major intrahospital complications in patients with STEMI aged 75 years or older.

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

Cumplimiento previo de los objetivos recomendados de control lipídico para pacientes que ingresan por síndrome coronario agudo / Prior adherence to recommended lipid control targets in patients admitted for acute coronary syndrome

INTRODUCCIÓN Y OBJETIVOS: El control lipídico óptimo es difícil de conseguir. Se evalúa el cumplimiento previo de los objetivos de la Sociedad Europea de Cardiología para el control del colesterol unido a lipoproteínas de baja densidad (cLDL) de los pacientes que ingresaron por síndrome coronario agudo. MÉTODOS: Se midió el cLDL en ayunas de 3.164 pacientes ingresados entre 2010 y 2017 y se analizó la frecuencia de un control adecuado, con objetivos según el riesgo cardiovascular individual, y los predictores de control inadecuado. RESULTADOS: La mediana de cLDL fue 104 (80-130) mg/dl. La mayoría de los pacientes tenían un riesgo cardiovascular alto o muy alto y solo el 34,2% tenía un cLDL dentro del objetivo recomendado para su nivel de riesgo. Se apreció un pequeño aumento en la consecución de los objetivos de cLDL a lo largo del periodo estudiado. El control adecuado de cLDL se relacionó inversamente con el riesgo de los pacientes. La dislipemia, el tabaquismo, la diabetes mellitus o un índice de masa corporal ≥ 25 fueron predictores independientes de un control lipídico inadecuado, mientras que el tratamiento previo con estatinas se asoció con un control apropiado. CONCLUSIONES: Poco más de un tercio de los pacientes ingresados por síndrome coronario agudo tiene valores de cLDL al ingreso acordes con los objetivos recomendados. Hay un amplio campo de mejora en prevención primaria y secundaria, especialmente para los pacientes con exceso de peso u otros factores de riesgo cardiovascular

INTRODUCTION AND OBJECTIVES: Optimal lipid control is difficult to attain. We assessed preadmission achievement of the European Society of Cardiology targets for low-density lipoprotein-cholesterol (LDL-C) control in patients admitted for acute coronary syndrome. METHODS: Fasting LDL-C levels were measured in 3164 patients admitted between 2010 and 2017. We assessed the frequency of adequate LDL-C control, with targets defined according to individual cardiovascular risk, and the predictors of inadequate control. RESULTS: The median LDL-C value was 104 (80-130) mg/dL. Most patients had high or very high cardiovascular risk and only 34.2% had LDL-C levels below the recommended target for their estimated risk. Achievement of LDL-C goals increased moderately throughout the study period. Adequate LDL-C control was inversely associated with patient risk. Dyslipidemia, active smoking, diabetes mellitus, and body mass index ≥ 25 were independent predictors of inadequate lipid control, while ongoing statin therapy was associated with adequate control. CONCLUSIONS: Only slightly more than one third of patients admitted for acute coronary syndrome meet recommended LDL-C targets on admission. There is broad scope for improvement in primary and secondary prevention, especially among patients who are overweight or have other cardiovascular risk factors

Cambio en la enolasa neuroespecífica de los supervivientes de parada cardiorrespiratoria extrahospitalaria: herramienta útil para predecir el pronóstico neurológico / Change in neuron specific enolase levels in out-of-hospital cardiopulmonary arrest survivors as a simple and useful tool to predict neurological prognosis

INTRODUCCIÓN Y OBJETIVOS: La enolasa neuronal específica (ENE) es un marcador pronóstico en pacientes con parada cardiorrespiratoria extrahospitalaria (PCR-EH) tratados con hipotermia moderada terapéutica (HMT). OBJETIVOS: analizar la correlación entre cambios dinámicos en ENE y eventos principales; y determinar los tiempos de medición de ENE que mejor pronostican el estado neurológico. MÉTODOS: Estudio de cohortes multicéntrico de pacientes ingresados después de un PCR-EH con ritmo desfibrilable y tratados con HMT. Se determinó la ENE sérica en dos fechas y se calculó DELTA-ENE (%) como 100 X (DELTA-ENE 2-DELTA-ENE 1) / DELTA-ENE 1. La mortalidad y el estado neurológico, según la escala Cerebral Performance Category (CPC), se evaluaron durante la hospitalización y a los 6 meses. RESULTADOS: Se incluyeron 166 pacientes ingresados en cuatro hospitales. La mortalidad intrahospitalaria fue del 31.9%. El 58,2% tuvo buena recuperación neurológica (CPC 1-2). El incremento de ENE se asoció, en el análisis de regresión logística, con mayor mortalidad hospitalaria y peor CPC al alta y a los 6 meses (p < 0,001). DELTA-ENE positiva obtuvo un OR=9,28 (95%IC 4,40-19,57) para mortalidad, OR=11,23 (95%IC 5,24-24,11) para CPC 3-5 al alta y OR=11,14 (95% IC 5,05-24,55) para CPC 3-5 a 6 meses (p < 0,001). Una primera determinación de ENE realizada 18 a 24 horas y una segunda 69 a 77 horas después del PCR-EH, mostraron una área bajo la curva ROC buena en la predicción de CPC al alta (0,9389 y 0,9909 respectivamente, 0,8096). CONCLUSIONES: El cambio dinámico de ENE es un buen marcador de eventos clínicos después de un PCR-EH por ritmo desfibrilable en pacientes tratados con HMT. Las mediciones de ENE en intervalos específicos después del PCR-EH pueden incrementar la precisión pronóstica

INTRODUCTION AND OBJECTIVES: Neuron-specific enolase (NSE) is a prognostic marker in out-of-hospital cardiopulmonary arrest (OHCA) survivors treated with mild therapeutic hypothermia (MTH). The objectives were to analyze the correlation between dynamic changes in NSE and outcomes and to determine the measurement timing that best predicts neurological status. METHODS: Multicenter cohort study including patients admitted after shockable rhythm OHCA and treated with MTH. Serum NSE was sampled at 2 different times and DELTA-NSE (%) was calculated as 100 X (NSE2-NSE1)/NSE1. In-hospital mortality and neurological outcome, as assessed by the Cerebral Performance Category (CPC) scale, were evaluated during admission and after a 6-month follow-up. RESULTS: We included 166 patients admitted to 4 hospitals. In-hospital mortality was 31.9%. Almost 60% of patients had a good neurological recovery (CPC 1-2). On univariate and multivariate logistic regression analyses, an increase in NSE levels was associated with higher in-hospital mortality and worse CPC on discharge and after 6-months (P<.001). Positive DELTA-NSE showed an OR=9.28 (95% CI 4.40-19.57) for mortality, OR=11.23 (95% CI 5.24-24.11) for CPC 3-5 at discharge and OR=11.14 (95% CI 5.05-24.55) for CPC 3-5 after 6-months' follow-up (P<.001). The first NSE measurement, conducted at 18 to 24hours, and the second measurement at 69 to 77 hours after OHCA showed a high area under the curve in predicting CPC at discharge (0.9389 and 0.9909, respectively; 0.8096 for the whole cohort). CONCLUSIONS: Dynamic changes in NSE serum levels are good markers of hard clinical outcomes after an OHCA due to shockable rhythm in an MTH-treated cohort. NSE measurements at specific intervals after OHCA may predict events even more precisely

External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients.

BACKGROUND: Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy. The CardShock and the Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk scores have shown good results in predicting short-term mortality in cardiogenic shock. However, to date, they have not been compared in a large cohort of ischaemic and non-ischaemic real-world cardiogenic shock patients. METHODS: The Red-Shock is a multicentre cohort of non-selected cardiogenic shock patients. We calculated the CardShock and IABP-SHOCK II risk scores in each patient and assessed discrimination and calibration. RESULTS: We included 696 patients. The main cause of cardiogenic shock was acute coronary syndrome, occurring in 62% of the patients. Compared with acute coronary syndrome patients, non-acute coronary syndrome patients were younger and had a lower proportion of risk factors but higher rates of renal insufficiency; intra-aortic balloon pump was also less frequently used (31% vs 56%). In contrast, non-acute coronary syndrome patients were more often treated with mechanical circulatory support devices (11% vs 3%, p<0.001 for both). Both risk scores were good predictors of in-hospital mortality in acute coronary syndrome patients and had similar areas under the receiver-operating characteristic curve (area under the curve: 0.742 for the CardShock vs 0.752 for IABP-SHOCK II, p=0.65). Their discrimination performance was only modest when applied to non-acute coronary syndrome patients (0.648 vs 0.619, respectively, p=0.31). Calibration was acceptable for both scores (Hosmer-Lemeshow p=0.22 for the CardShock and 0.68 for IABP-SHOCK II). CONCLUSIONS: In our cohort, both the CardShock and the IABP-SHOCK II risk scores were good predictors of in-hospital mortality in acute coronary syndrome-related cardiogenic shock.

Comparison of clinical outcomes in STEMI patients treated with primary PCI according to day-time of medical attention and its relationship with circadian pattern.

OBJECTIVE: Relationship between STEMI time of presentation, its circadian pattern and cardiovascular outcomes is unclear. Our objective is to analyze clinical outcomes of STEMI according to time of presentation and circadian pattern. METHODS: We analyzed data from patients treated within the regional STEMI Network from January 2010 to December 2015. On-hour group included patients treated between 8:00 h and 19:59 h on weekdays, the rest were catalogued as off-hour group. The primary endpoint was 1-year all-cause mortality. Secondary endpoints were 30-day all-cause mortality and in-hospital complications. RESULTS: A total of 8608 patients were included, 44.1% in the on-hour group and 55.9% in the off-hour group. We observed a shorter patient delay and longer system delay in the off-hour group compared to on-hour group with no difference in total ischemic time. At 30-day and 1-year follow-up there were no differences in adjusted all-cause mortality between groups [OR 0.91 (CI95%: 0.73-1.12; p = 0.35) and OR 0.99 (CI95%: 0.83-1.17; p = 0.87), respectively]. A circadian pattern was observed between 9:00 am and 12:30 pm, with no differences in 30-day and 1-year mortality between patients included in this time interval [OR 1.02 (IC95%: 0.81-1.30; p = 0.85) and OR 1.12 (IC95%: 0.92-1.36; p = 0.25) respectively]. CONCLUSIONS: Off-hour STEMI presentation was associated with a shorter patient delay and longer system delay without an increase in total ischemic time. The off-hour presentation was not related to an increase in 1-year all-cause mortality when compared to on-hour. A circadian pattern was found, without differences in 30-day and 1-year mortality.

Prior adherence to recommended lipid control targets in patients admitted for acute coronary syndrome.

INTRODUCTION AND OBJECTIVES: Optimal lipid control is difficult to attain. We assessed preadmission achievement of the European Society of Cardiology targets for low-density lipoprotein-cholesterol (LDL-C) control in patients admitted for acute coronary syndrome. METHODS: Fasting LDL-C levels were measured in 3164 patients admitted between 2010 and 2017. We assessed the frequency of adequate LDL-C control, with targets defined according to individual cardiovascular risk, and the predictors of inadequate control. RESULTS: The median LDL-C value was 104 (80-130) mg/dL. Most patients had high or very high cardiovascular risk and only 34.2% had LDL-C levels below the recommended target for their estimated risk. Achievement of LDL-C goals increased moderately throughout the study period. Adequate LDL-C control was inversely associated with patient risk. Dyslipidemia, active smoking, diabetes mellitus, and body mass index ≥ 25 were independent predictors of inadequate lipid control, while ongoing statin therapy was associated with adequate control. CONCLUSIONS: Only slightly more than one third of patients admitted for acute coronary syndrome meet recommended LDL-C targets on admission. There is broad scope for improvement in primary and secondary prevention, especially among patients who are overweight or have other cardiovascular risk factors.

Change in neuron specific enolase levels in out-of-hospital cardiopulmonary arrest survivors as a simple and useful tool to predict neurological prognosis.

INTRODUCTION AND OBJECTIVES: Neuron-specific enolase (NSE) is a prognostic marker in out-of-hospital cardiopulmonary arrest (OHCA) survivors treated with mild therapeutic hypothermia (MTH). The objectives were to analyze the correlation between dynamic changes in NSE and outcomes and to determine the measurement timing that best predicts neurological status. METHODS: Multicenter cohort study including patients admitted after shockable rhythm OHCA and treated with MTH. Serum NSE was sampled at 2 different times and Δ-NSE (%) was calculated as 100 x (NSE2-NSE1)/NSE1. In-hospital mortality and neurological outcome, as assessed by the Cerebral Performance Category (CPC) scale, were evaluated during admission and after a 6-month follow-up. RESULTS: We included 166 patients admitted to 4 hospitals. In-hospital mortality was 31.9%. Almost 60% of patients had a good neurological recovery (CPC 1-2). On univariate and multivariate logistic regression analyses, an increase in NSE levels was associated with higher in-hospital mortality and worse CPC on discharge and after 6-months (P<.001). Positive Δ-NSE showed an OR=9.28 (95% CI 4.40-19.57) for mortality, OR=11.23 (95% CI 5.24-24.11) for CPC 3-5 at discharge and OR=11.14 (95% CI 5.05-24.55) for CPC 3-5 after 6-months' follow-up (P<.001). The first NSE measurement, conducted at 18 to 24hours, and the second measurement at 69 to 77hours after OHCA showed a high area under the curve in predicting CPC at discharge (0.9389 and 0.9909, respectively; 0.8096 for the whole cohort). CONCLUSIONS: Dynamic changes in NSE serum levels are good markers of hard clinical outcomes after an OHCA due to shockable rhythm in an MTH-treated cohort. NSE measurements at specific intervals after OHCA may predict events even more precisely.