Assessment of Individualized Mean Perfusion Pressure Targets for the Prevention of Cardiac Surgery-Associated Acute Kidney Injury-The PrevHemAKI Randomized Controlled Trial.

BACKGROUND: Retrospective studies support that mean perfusion pressure (MPP) deficit in cardiac surgery patients is associated with a higher incidence of acute kidney injury (CS-AKI). The aim of our study was to apply an algorithm based on MPP in the postoperative period to determine whether management with an individualized target reduces the incidence of CS-AKI. METHODS: Randomized controlled trial of patients undergoing cardiac surgery with extracorporeal circulation. Adult patients submitted to valve replacement and/or bypass surgery with a high risk of CS-AKI evaluated by a Leicester score >30 were randomized to follow a target MPP of >75% of the calculated baseline or a standard hemodynamic management during the first postoperative 24 h. RESULTS: Ninety-eight patients with an eGFR of 54 mL/min were included. There were no differences in MAP and MPP in the first 24 h between the randomized groups, although a higher use of noradrenaline was found in the intervention arm (38.78 vs. 63.27, p = 0.026). The percentage of time with MPP < 75% of measured baseline was similar in both groups (10 vs. 12.7%, p = 0.811). MAP during surgery was higher in the intervention group (73 vs. 77 mmHg, p = 0.008). The global incidence of CS-AKI was 36.7%, being 38.6% in the intervention group and 34.6% in the control group (p = 0.40). There were no differences in extrarenal complications between groups as well. CONCLUSION: An individualized hemodynamic management based on MPP compared to standard treatment in cardiac surgery patients was safe but did not reduce the incidence of CS-AKI in our study.

A possible role for the venous-to-arterial CO2 difference in cardiogenic shock: an exploratory study. / Estudio exploratorio del rol de la diferencia venoarterial de dióxido de carbono en el shock cardiogénico.

OBJECTIVES: The venous-to-arterial CO2 partial pressure difference (CO2) is a marker of how adequately capillary blood flow is able to remove CO2 from tissues, but evidence regarding its usefulness in patients with cardiogenic shock (CS) is scarce The main objective of this study was to describe the changes in CO2 in patients with cardiogenic shock during the 48 hours after hospital admission. A secondary objective was to analyze the association between CO2 and in-hospital mortality due to cardiovascular disease (CVD) and cardiogenic shock refractory to treatment. MATERIAL AND METHODS: Prospective observational exploratory study in a single hospital. Patients in cardiogenic shock who were admitted to a cardiology critical care unit were included. We measured CO2 on inclusion and 6, 12, 24, and 48 hours after admission to the unit. Variables were explored with logistic regression analysis and areas under the receiver operating characteristic curves were calculated. RESULTS: A total of 50 patients were included. In-hospital mortality due to CVD was 20%. CO2 peaked initially and decreased gradually over the first 48 hours of care. In-hospital mortality tended to be higher in patients with the highest CO2 values, but the difference was not significant. High CO2 values at 24 hours were associated with refractory cardiogenic shock. The negative predictive value of a CO2 value lower than 6 mmHg at 12 hours was 87% for mortality due to CVD. CONCLUSION: This exploratory study suggests that CO2 could be a helpful additional marker to measure when managing cardiogenic shock. CO2 lower than 6 mmHg between 12 and 24 hours after admission may identify patients at low risk of death due to CVD or refractory cardiogenic shock.

OBJETIVO: La diferencia venoarterial de dióxido de carbono (CO2) representa la adecuación del flujo capilar para eliminar CO2 tisular, sin embargo, su evidencia en pacientes con shock cardiogénico (SC) es escasa. El objetivo primario fue caracterizar la cinética de la diferencia venoarterial de CO2 en pacientes con SC durante las primeras 48 horas de ingreso. El objetivo secundario fue analizar la asociación de la CO2 con la mortalidad intrahospitalaria de causa cardiovascular y el SC refractario. METODO: Estudio exploratorio, observacional, prospectivo y unicéntrico. Se incluyeron pacientes en SC ingresados en una unidad de cuidados críticos cardiológicos. Se determinó la CO2 a la inclusión, a las 6, 12, 24 y 48 horas y se realizó un análisis de regresión logística y curvas de la característica operativa del receptor. RESULTADOS: Se incluyeron 50 pacientes. La mortalidad cardiovascular intrahospitalaria fue del 20%. La cinética de la CO2 mostró un pico inicial y un progresivo descenso durante las primeras 48 horas. Los pacientes con valores más altos de CO2 tuvieron una mayor mortalidad cardiovascular intrahospitalaria, pero esta diferencia no fue significativa. A las 24 horas, valores elevados de CO2 se asociaron significativamente con SC refractario. Un valor inferior a 6 mmHg a las 12 horas mostró un valor predictivo negativo del 87% para mortalidad cardiovascular. CONCLUSIONES: Este estudio exploratorio sugiere la potencial utilidad de la CO2 como biomarcador adicional en el manejo del SC. La CO2 permite identificar pacientes con bajo riesgo de mortalidad cardiovascular y SC refractario cuando sus valores son inferiores a 6 mmHg a las 12-24 horas de evolución.

Estudio exploratorio del rol de la diferencia venoarterial de dióxido de carbono en el shock cardiogénico / A possible role for the venous-to-arterial CO2 difference in cardiogenic shock: an exploratory study

Introducción y objetivos: La diferencia venoarterial de dióxido de carbono (ΔCO2) representa la adecuación del flujo capilar para eliminar CO2 tisular, sin embargo, su evidencia en pacientes con shock cardiogénico (SC) es escasa”. El objetivo primario fue caracterizar la cinética de la diferencia venoarterial de ΔCO2 en pacientes con SC durante las primeras 48 horas de ingreso. El objetivo secundario fue analizar la asociación de la ΔCO2 con la mortalidad intrahospitalaria de causa cardiovascular y el SC refractario. Método: Estudio exploratorio, observacional, prospectivo y unicéntrico. Se incluyeron pacientes en SC ingresados en una unidad de cuidados críticos cardiológicos. Se determinó la ΔCO2 a la inclusión, a las 6, 12, 24 y 48 horas y se realizó un análisis de regresión logística y curvas de la característica operativa del receptor. Resultados: Se incluyeron 50 pacientes. La mortalidad cardiovascular intrahospitalaria fue del 20%. La cinética de la ΔCO2 mostró un pico inicial y un progresivo descenso durante las primeras 48 horas. Los pacientes con valores más altos de ΔCO2 tuvieron una mayor mortalidad cardiovascular intrahospitalaria, pero esta diferencia no fue significativa. A las 24 horas, valores elevados de ΔCO2 se asociaron significativamente con SC refractario. Un valor inferior a 6 mmHg a las 12 horas mostró un valor predictivo negativo del 87% para mortalidad cardiovascular. Conclusiones: Este estudio exploratorio sugiere la potencial utilidad de la ΔCO2 como biomarcador adicional en el manejo del SC. La ΔCO2 permite identificar pacientes con bajo riesgo de mortalidad cardiovascular y SC refractario cuando sus valores son inferiores a 6 mmHg a las 12-24 horas de evolución. (AU)

Background and objectives: The venous-to-arterial CO2 partial pressure difference ('CO2) is a marker of how adequately capillary blood flow is able to remove CO2 from tissues, but evidence regarding its usefulness in patients with cardiogenic shock (CS) is scarce The main objective of this study was to describe the changes in 'CO2 in patients with cardiogenic shock during the 48 hours after hospital admission. A secondary objective was to analyze the association between 'CO2 and in-hospital mortality due to cardiovascular disease (CVD) and cardiogenic shock refractory to treatment. Methods: Prospective observational exploratory study in a single hospital. Patients in cardiogenic shock who were admitted to a cardiology critical care unit were included. We measured 'CO2 on inclusion and 6, 12, 24, and 48 hours after admission to the unit. Variables were explored with logistic regression analysis and areas under the receiver operating characteristic curves were calculated. Results: A total of 50 patients were included. In-hospital mortality due to CVD was 20%. 'CO2 peaked initially and decreased gradually over the first 48 hours of care. In-hospital mortality tended to be higher in patients with the highest 'CO2 values, but the difference was not significant. High 'CO2 values at 24 hours were associated with refractory cardiogenic shock. The negative predictive value of a 'CO2 value lower than 6 mmHg at 12 hours was 87% for mortality due to CVD. Conclusions: This exploratory study suggests that 'CO2 could be a helpful additional marker to measure when managing cardiogenic shock. 'CO2 lower than 6 mmHg between 12 and 24 hours after admission may identify patients at low risk of death due to CVD or refractory cardiogenic shock. (AU)

Venoarterial extracorporeal membrane oxygenation or standard care in patients with cardiogenic shock complicating acute myocardial infarction: the multicentre, randomised EURO SHOCK trial.

BACKGROUND: Cardiogenic shock (CGS) occurs in 10% of patients presenting with acute myocardial infarction (MI), with in-hospital mortality rates of 40-50% despite revascularisation. AIMS: The EURO SHOCK trial aimed to determine if early use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) could improve outcomes in patients with persistent CGS following primary percutaneous coronary intervention (PPCI). METHODS: This multicentre, pan-European trial randomised patients with persistent CGS 30 minutes after PPCI of the culprit lesion to receive either VA-ECMO or continue with standard therapy. The primary outcome measure was 30-day all-cause mortality in an intention-to-treat analysis. Secondary endpoints included 12-month all-cause mortality and 12-month composite of all-cause mortality or rehospitalisation due to heart failure. RESULTS: Due to the impact of the COVID-19 pandemic, the trial was stopped before completion of recruitment, after randomisation of 35 patients (standard therapy n=18, VA-ECMO n=17). Thirty-day all-cause mortality occurred in 43.8% of patients randomised to VA-ECMO and in 61.1% of patients randomised to standard therapy (hazard ratio [HR] 0.56, 95% confidence interval [CI]: 0.21-1.45; p=0.22). One-year all-cause mortality was 51.8% in the VA-ECMO group and 81.5% in the standard therapy arm (HR 0.52, 95% CI: 0.21-1.26; p=0.14). Vascular and bleeding complications occurred more often in the VA-ECMO arm (21.4% vs 0% and 35.7% vs 5.6%, respectively). CONCLUSIONS: Due to the limited number of patients recruited to the trial, no definite conclusions could be drawn from the available data. Our study demonstrates the feasibility of randomising patients with CGS complicating acute MI but also illustrates the challenges. We hope these data will inspire and inform the design of future large-scale trials.

Factors associated with late presentation to the emergency department in patients complaining of chest pain.

OBJECTIVE: We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP). METHODS: All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS). RESULTS: The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS. CONCLUSION: Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS. PRACTICE IMPLICATIONS: Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

COVID-19 and aorto-enteric fistula.

We present the case of a 72-year-old male with upper gastrointestinal bleeding. He had been discharged from hospital two weeks before after severe COVID-19 infection, treated with lopinavir-ritonavir (L-R), hydroxychloroquine, tocilizumab, and methylprednisolone. On presentation, he was in hypovolemic shock. Esophagogastroduodenoscopy showed an ulcer in the third duodenal portion, which was sclerosed and hemodynamic stability was recovered. A scan was performed as it was in an atypical location for ulcers, showing an aortic aneurysm in close relationship to the duodenum, suggesting a primary aortoenteric fistula (PAEF).

Oxigenador extracorpóreo de membrana eficaz en una paciente con miocarditis lúpica fulminante / Successful extracorporeal membrane oxygenation in a patient with fulminant lupus myocarditis

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Prognostic Value of Left Atrial Strain in Outpatients with De Novo Heart Failure.

BACKGROUND: Left atrial (LA) dysfunction has been related to symptom onset in patients with heart failure (HF). However, the potential prognostic role of LA function has been scarcely studied in outpatients with new-onset HF symptoms. METHODS: Consecutive outpatients with suspected HF onset evaluated at a one-stop clinic were screened. HF diagnosis was performed according to current guidelines. LA function was analyzed in patients in sinus rhythm by speckle-tracking echocardiography, determining LA peak strain rate after atrial contraction (LASRa) as a surrogate of atrial contractile function. Yearly prospective follow-up was conducted to report cardiovascular hospital admission or death. Patients without HF in sinus rhythm were followed as a control group. Survival curves were estimated using the Kaplan-Meier method. RESULTS: One hundred fifty-four outpatients were included (mean age, 74 ± 10 years; 67% women) with a median follow-up duration of 44.4 months (interquartile range, 31-58 months). Final diagnosis was 29.9% non-HF and 70.1% HF. More than two in five patients with HF (44.4%) had AF (n = 48), and 55.6% (n = 60) were in sinus rhythm. The latter were divided according to LASRa tertile: highest, -1.93 ± 0.39 sec-1; middle, -1.08 ± 0.21 sec-1; and lowest, -0.47 ± 0.18 sec-1. At the end of follow-up, patients with atrial fibrillation had a low event-free survival rate (56.3%), similar to those in the lower LASRa tertile (55.0%). The non-HF group had the best prognosis, and the higher and middle LASRa tertiles had intermediate prognoses (event-free survival, 85%, 75%, and 70%, respectively). CONCLUSIONS: The study of contractile LA function in outpatients with new-onset HF provides prognostic stratification. The early identification of patients at higher risk on the basis of their atrial function would allow focusing on them independently of their final diagnoses.

Prognosis of new-onset heart failure outpatients and collagen biomarkers.

BACKGROUND: Prognosis of heart failure patients has been defined in hospital-based or retrospective studies. This study aimed to characterize prognosis of outpatients with new-onset preserved or reduced ejection fraction heart failure; to explore the role of collagen turnover biomarkers (MMP2, MMP9, TIMP1) in predicting prognosis; and to analyse their relationship with echocardiographic parameters and final diagnosis. METHODS: This is an observational, prospective, longitudinal study. Outpatients with new-onset heart failure symptoms referred to a one-stop clinic were included. Echocardiography and biomarkers plasma levels determination were performed at the inclusion. A prospective follow-up was conducted to report cardiovascular events. The discriminant analysis was applied to identify the parameters related to cardiovascular outcomes. RESULTS: A total of 172 patients (75 ± 9 years) were included, 67% with heart failure (64% preserved and 36% with reduced ejection fraction). During follow-up (median 34.5 months), 32.6% had at least one cardiovascular event and 9.9% died. Heart failure groups showed no differences in cardiovascular outcomes with a higher rate of events than nonheart failure patients. MMP2 and TIMP1 were correlated with diastolic dysfunction (Rho 0.349 and 0.294, P < 0.001). In the discriminant analysis, the combination of biomarkers with clinical, biochemical and echocardiographic parameters was useful to predict cardiovascular outcomes (AUC ROC 0.806, Wilks lambda 0.7688, P < 0.001). CONCLUSIONS: Prognosis of outpatients with new-onset heart failure symptoms is comparable between heart failure with preserved or reduced subgroups. The addition of biomarkers specially MMP2 and high sensitive troponin I to other clinical, biochemical and echocardiographic variables can predict cardiovascular prognosis at the time of diagnosis.