Acute myocardial infarction complicated by cardiogenic shock in Ukraine: multicentre registry analysis 2021-2022

Background

Data on the results and management strategies in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) in the Low and Lower-Middle Income Countries (LLMICs) are limited. This lack of understanding of the situation partially hinders the development of effective cardiogenic shock treatment programs in this part of the world.

Materials and methods

The Ukrainian Multicentre Cardiogenic Shock Registry was analyzed, covering patient data from 2021 to 2022 in 6 major Ukrainian reperfusion centres from different parts of the country. Analysis was focusing on outcomes, therapeutic modalities and mortality predictors in AMI-CS patients.

Results

We analyzed data from 221 consecutive patients with CS from 6 hospitals across Ukraine. The causes of CS were ST-elevated myocardial infarction (85.1%), non-ST-elevated myocardial infarction (5.9%), decompensated chronic heart failure (7.7%) and arrhythmia (1.3%), with a total in-hospital mortality rate for CS of 57.1%. The prevalence of CS was 6.3% of all AMI with reperfusion rate of 90.5% for AMI-CS. In 23.5% of cases, CS developed in the hospital after admission. Mechanical circulatory support (MCS) utilization was 19.9% using intra-aortic balloon pump alone. Left main stem occlusion, reperfusion deterioration, Charlson Comorbidity Index >4, and cardiac arrest were found to be independent predictors for hospital mortality in AMI-СS.

Conclusions

Despite the wide adoption of primary percutaneous coronary intervention as the main reperfusion strategy for AMI, СS remains a significant problem in LLMICs, associated with high in-hospital mortality. There is an unmet need for the development and implementation of a nationwide protocol for CS management and the creation of reference CS centers based on the country-wide reperfusion network, equipped with modern technologies for MCS.

[The role of epicardial obesity in the development of left ventricular diastolic dysfunction]

AIM

To study the effect of epicardial adipose tissue on risk of left ventricular (LV) diastolic dysfunction (DD) in patients with visceral obesity.

MATERIAL AND METHODS

Obesity leads to the development of LV DD and is a major cause of heart failure with preserved LV ejection fraction (HFpEF). However, the contribution of epicardial adipose tissue to DD is understudied. This study included 101 men with general obesity (body weight index, 32.9±3.6 kg /m2). Based on severity of epicardial obesity (EO), two groups were formed: group 1, patients with an epicardial adipose tissue thickness (EATt) >7 mm (n=70), and group 2, patients with EATt <7 mm (n=31). Arterial hypertension, diabetes mellitus, coronary atherosclerosis, and disorders of LV diastolic function according to echocardiography (EchoCG) were the exclusion criteria. Diastolic function and LV mechanics were evaluated by speckle-tracking EchoCG for all patients at the start of the study and again at 4.7±0.3 years.

RESULTS

At baseline, none of the patients of either group had significant differences in EchoCG characteristics of LV diastolic function (left atrial volume index, LV early diastolic longitudinal lengthening velocity, peak tricuspid regurgitation velocity, and the ratio of diastolic transmitral flow velocity to mean mitral annular velocity (E / e'). However, there were significant increases in the LV untwisting velocity to -122.11 [-142.0; -116.0 degrees /s -1] degrees/s and the time to LV peak untwisting velocity to 472.3 ms. Repeated EchoCG showed an increase in left atrial volume index in group 1 to 35.04 [33.0; 39.7] ml /m2. Repeated evaluation of the LV mechanics revealed increases in the times to LV peak untwisting and twisting and decreases in the LV twisting and untwisting velocities. The logistic regression analysis showed that EATt was a risk factor for LV DD in obesity. Furthermore, the ROC analysis determined the optimal EATt cut-off threshold of ≥9 mm as a predictor for LV DD development.

CONCLUSION

EO facilitates the development of LV DD and, thus, represents a major cause for HFpEF. An EATt value of ≥9 mm can be considered as a risk factor for LV DD development in patients with EO.

[Extracellular matrix of the heart and its changes in myocardial fibrosis]

Neurohumoral changes have recently attracted much attention as a part of the pathogenesis of heart failure. Activation of neurohumoral factors triggers processes resulting in changes of extracellular matrix composition and, thus, development of myocardial fibrosis. This article addresses a number of factors that directly contribute to the development of myocardial fibrosis.

A natural orbital analysis of the long range behavior of chemical bonding and van der Waals interaction in singlet H2: the issue of zero natural orbital occupation numbers

This paper gives a natural orbital (NO) based analysis of the van der Waals interaction in (singlet) H2 at long distance. The van der Waals interaction, even if not leading to a distinct van der Waals well, affects the shape of the interaction potential in the van der Waals distance range of 5-9 bohrs and can be clearly distinguished from chemical bonding effects. In the NO basis the van der Waals interaction can be quantitatively covered with, apart from the ground state configurations (1σ(g))(2) and (1σ(u))(2), just the 4 configurations (2σ(g))(2) and (2σ(u))(2), and (1π(u))(2) and (1π(g))(2). The physics of the dispersion interaction requires and explains the peculiar relatively large positive CI coefficients of the doubly excited electron configurations (2σ(u))(2) and (1π(g))(2) (the occupancy amplitudes of the 2σ(u) and 1π(gx, y) NOs) in the distance range 5-9 bohrs, which have been observed before by Cioslowski and Pernal [Chem. Phys. Lett. 430, 188 (2006)]. We show that such positive occupancy amplitudes do not necessarily lead to the existence of zero occupation numbers at some H-H distances.

[Epicardial adiposity as risk factor of coronary atherosclerosis]

AIM

To study effect of epicardial adiposity on risk of development and severity of coronary atherosclerosis.

MATERIAL AND METHODS

We registered classical metabolic risk factors (RF) and additional factors of cardiovascular risk in 138 men aged 55.47+/-9.07 years with ischemic heart disease (IHD), functional class (FC) II-III angina, and I-III degree obesity. Diagnostic coronary angiography (CAG) was performed in all patients. Thickness of epicardial fat (tEF) in millimeters was measured at transthoracic echocardiography (ECG).

RESULTS

Average tEF indexes were highest (10 [8; 10] mm) in the group of patients with multiple stenoses in coronary arteries (CA). According to ROC-analysis tEF appeared to be a predictor of significant coronary atherosclerosis. Its sensitivity was 80.4%, specificity - 67.6 % (cut-off value 6 mm). Epicardial adiposity was among factors associated with presence of coronary atherosclerosis (odds ratio [OR] 4.44, 95% confidence interval [CI] 2,06 to 9.59; p<0,001) along with age (OR 6.56; 95% CI 2.59 to 16.60; p=0,001), leptin (OR 3.50; 95% CI 1.46 to 8.37; p <0,001), resistin (OR 3.13; 95% CI 1.32 to 7.42; p <0,001) and waist circumference (OR 1.65; 95% CI 0.72 to 3.80; p=0.018).

Response calculations with an independent particle system with an exact one-particle density matrix

We use the natural orbitals to define an independent particle system, from which the exact one-particle density matrix can be obtained with an ensemble of degenerate determinantal ground states. Also defining explicit phases for the orbitals, and admitting functionals that are dependent on those phases, time-dependent equations for the orbitals and occupation numbers are obtained from an action principle. The wrong polarizability and lack of double excitations of straightforward adiabatic time-dependent density matrix functional theory are then corrected, and the important symmetry χ(ω)=χ{*}(-ω), lost in previous ad hoc improvements, is restored. The extension of the response calculations beyond the occupied-virtual pairs, which are the only ones admitted in time-dependent density functional theory, leads to greatly improved response properties.

Charge transfer, double and bond-breaking excitations with time-dependent density matrix functional theory

Time-dependent density functional theory (TDDFT) in its current adiabatic implementations exhibits three remarkable failures: (a) completely wrong behavior of the excited state surface along a bond-breaking coordinate; (b) lack of doubly excited configurations; (c) much too low charge transfer excitation energies. These TDDFT failure cases are all strikingly exhibited by prototype two-electron systems such as dissociating H2 and HeH+. We find for these systems with time-dependent density matrix functional theory that: (a) Within previously formulated simple adiabatic approximations, the bonding-to-antibonding excited state surface as well as charge transfer excitations are described without problems, but not the double excitations; (b) An adiabatic approximation is formulated in which also the double excitations are fully accounted for.

The spin-unrestricted molecular Kohn-Sham solution and the analogue of Koopmans's theorem for open-shell molecules

Spin-unrestricted Kohn-Sham (KS) solutions are constructed from accurate ab initio spin densities for the prototype doublet molecules NO(2), ClO(2), and NF(2) with the iterative local updating procedure of van Leeuwen and Baerends (LB). A qualitative justification of the LB procedure is given with a "strong" form of the Hohenberg-Kohn theorem. The calculated energies epsilon(isigma) of the occupied KS spin orbitals provide numerical support to the analogue of Koopmans' theorem in spin-density functional theory. In particular, the energies -epsilon(ibeta) of the minor spin (beta) valence orbitals of the considered doublet molecules correspond fairly well to the experimental vertical ionization potentials (VIPs) I(i) (1) to the triplet cationic states. The energy -epsilon(Halpha) of the highest occupied (spin-unpaired) alpha orbital is equal to the first VIP I(H) (0) to the singlet cationic state. In turn, the energies -epsilon(ialpha) of the major spin (alpha) valence orbitals of the closed subshells correspond to a fifty-fifty average of the experimental VIPs I(i) (1) and I(i) (0) to the triplet and singlet states. For the Li atom we find that the exact spin densities are represented by a spin-polarized Kohn-Sham system which is not in its ground state, i.e., the orbital energy of the lowest unoccupied beta spin orbital is lower than that of the highest occupied alpha spin orbital ("a hole below the Fermi level"). The addition of a magnetic field in the -z direction will shift the beta levels up so as to restore the Aufbau principle. This is an example of the nonuniqueness of the mapping of the spin density on the KS spin-dependent potentials discussed recently in the literature. The KS potentials may no longer go to zero at infinity, and it is in general the differences nu(ssigma)( infinity )-epsilon(isigma) that can be interpreted as (averages of) ionization energies. In total, the present results suggest the spin-unrestricted KS theory as a natural one-electron independent-particle model for interpretation and assignment of the experimental photoelectron spectra of open-shell molecules.

Away from generalized gradient approximation: Orbital-dependent exchange-correlation functionals

The local-density approximation of density functional theory (DFT) is remarkably accurate, for instance, for geometries and frequencies, and the generalized gradient approximations have also made bond energies quite reliable. Sometimes, however, one meets with failure in individual cases. One of the possible routes towards better functionals would be the incorporation of orbital dependence (which is an implicit density dependency) in the functionals. We discuss this approach both for energies and for response properties. One possibility is the use of the Hartree-Fock-type exchange energy expression as orbital-dependent functional. We will argue that in spite of the increasing popularity of this approach, it does not offer any advantage over Hartree-Fock for energies. We will advocate not to apply the separation of exchange and correlation, which is so ingrained in quantum chemistry, but to model both simultaneously. For response properties the energies and shapes of the virtual orbitals are crucial. We will discuss the benefits that Kohn-Sham potentials can offer which are derived from either an orbital-dependent energy functional, including the exact-exchange functional, or which can be obtained directly as orbital-dependent functional. We highlight the similarity of the Hartree-Fock and Kohn-Sham occupied orbitals and orbital energies, and the essentially different meanings the virtual orbitals and orbital energies have in these two models. We will show that these differences are beneficial for DFT in the case of localized excitations (in a small molecule or in a fragment), but are detrimental for charge-transfer excitations. Again, orbital dependency, in this case in the exchange-correlation kernel, offers a solution.