Impact of recurrent COVID-19 disease waves on acute myocardial infarction epidemics: results from a regional network

Aims: To assess the impact of COVID-19 related public containment measures during recurrent COVID-19 waves on hospital admission rate for acute myocardial infarction (AMI).Methods and results: Clinical characteristics, reperfusion therapy modalities, COVID-19 status and in-hospital mortality of consecutive AMI patients who were admitted in a regional AMI network were recorded during one year starting in March 2020 and were compared with the year before. The COVID-19 study period encompassed two waves: the first in March-May 2020 and the second in October-December 2020. A total of 1349 AMI patients were hospitalised of which 725 during the pre-COVID period and 624 during the COVID period (incidence rate ratio of 1.16, p = 0,006). The impact was predominantly present in the first wave (32% reduction: n = 204 vs 152) and evanished during the second wave (3% increase (152 vs 156). A similar pattern was observed for ACS with cardiac arrest with a 92% reduction (n = 36 vs 3) during the first wave and no change during the second wave (18 vs 18). After correction for temperature and air quality, COVID-19 epidemic remained associated with a decrease of AMI hospitalisation (p = 0.046). Reperfusion strategy for AMI patients, were comparable between both study periods. The in-hospital mortality between the two periods was comparable (2.6% versus 1.9%), but COVID-19 positive ACS patients (n = 7) had a high mortality rate (14%).Conclusion: COVID-19 related public containment measures resulted during the first wave in a 32% reduction of AMI hospitalisation, but this impact was not visible anymore during the second wave.

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle's syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.

Incidence, management, and prognosis of post-ischaemic ventricular septal defect: Insights from a 12-year tertiary centre experience

Background

Among mechanical complications of acute myocardial infarction, ventricular septal defect (VSD) is uncommon but still serious. The evolution of emergency coronary revascularisation paradoxically decreased our knowledge of this disease, making it even rarer.

Aim

To describe ischaemic VSD incidence, management, and associated in-hospital and 1-year outcomes over a 12-years period.

Methods

A retrospective single-centre register of patients managed for ischaemic VSD between January 2009 and December 2020.

Results

Ninety-seven patients were included representing 8 patients/ years and an incidence of 0.44% of ACS managed. The majority of the patients were 73-years-old males (n = 54, 56%) with STEMI presentation (n = 75, 79%) and already presented with Q necrosis on ECG (n = 70, 74%). Forty-nine (51%) patients underwent PCI, 60 (62%) inotrope/vasopressors infusion, and 70 (72%) acute mechanical circulatory support (IABP 62%, ECMO 13%, and Impella® 3%). VSD surgical repair was performed for 44 patients (45%) and 1 patient was transplanted. In-hospital mortality was 71%, and 86% at 1 year, without significant improvement over the decade. Surgery appears to be a protective factor [0.51 (0.28-0.94) p = 0.003], whereas age [1.06 (1.03-1.09), p < 0.001] and lactate [1.16 (1.09-1.23), p < 0.001] were linked to higher 1-year mortality. None of the patients that were managed medically survived 1 year.

Conclusion

Post-ischaemic VSD is a rare but serious complication still associated with high mortality. Corrective surgery is associated with better survival, however, timing, patient selection, and a place for mechanical circulatory support need to be defined.

Externalized Reusable Permanent Pacemaker for Prolonged Temporary Cardiac Pacing in Critical Cardiac Care Units: An Observational Monocentric Retrospective Study

INTRODUCTION

The use of temporary cardiac pacing is frequent in critical care units for severe bradycardia or electrical storm, but may be associated with frequent and potentially severe complications, especially when indwelling for several days. In some cases, transient indication or ongoing contraindication for a permanent pacemaker justifies prolonged temporary pacing. In that case, the implantation of an active-fixation lead connected to an externalized pacemaker represents a valuable option to increase safety and patient comfort. Yet, evidence remains scarce. We aimed to describe the population receiving prolonged temporary cardiac pacing (PTCP) and their outcomes.

METHODS

We retrospectively included all consecutive patients, admitted to our hospital from 2016 to 2021, who underwent PTCP. We collected in-hospital and six-month outcomes.

RESULTS

Forty-six patients (median age of 73, 63% male) were included, and twenty-nine (63%) had prior heart disease. Indications for PTCP were found: seventeen (37%) potentially reversible high-grade conduction disorders, fourteen (30%) indications for permanent pacemaker but ongoing infection, seven (15%) cardiac implantable electronic device infections requiring extraction in pacing-dependent patients, seven (15%) severe vagal hyperreactivity in prolonged critical care hospitalizations, and one (2%) recurrent sustained ventricular tachycardia requiring overdrive pacing. The median PTCP duration was nine (5-13) days. Ten (22%) patients exhibited at least one complication during hospitalization. Twenty-six (56.5%) patients required definite device implantation (twenty-five pacemakers and one cardioverter-defibrillator) and twenty (43.5%) did not (fifteen PTCP device removal for recovery and five deaths under PTCP). At six months, two (5%) deaths and two (5%) new infections of a definite implanted device occurred, all in patients with initial active infection.

CONCLUSION

The use of prolonged temporary cardiac pacing, with an active -fixation lead connected to an externalized pacemaker, is possible and reasonable; this would allow for the possible recovery or resolution of contraindication for definite device implantation.

Identifying nursing sensitive indicators from electronic health records in acute cardiac care-Towards intelligent automated assessment of care quality

AIM

The aim of this study is to explore the potential of using electronic health records for assessment of nursing care quality through nursing-sensitive indicators in acute cardiac care.

BACKGROUND

Nursing care quality is a multifaceted phenomenon, making a holistic assessment of it difficult. Quality assessment systems in acute cardiac care units could benefit from big data-based solutions that automatically extract and help interpret data from electronic health records.

METHODS

This is a deductive descriptive study that followed the theory of value-added analysis. A random sample from electronic health records of 230 patients was analysed for selected indicators. The data included documentation in structured and free-text format.

RESULTS

One thousand six hundred seventy-six expressions were extracted and divided into (1) established and (2) unestablished expressions, providing positive, neutral and negative descriptions related to care quality.

CONCLUSIONS

Electronic health records provide a potential source of information for information systems to support assessment of care quality. More research is warranted to develop, test and evaluate the effectiveness of such tools in practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Knowledge-based health care management would benefit from the development and implementation of advanced information systems, which use continuously generated already available real-time big data for improved data access and interpretation to better support nursing management in quality assessment.

EuroEcho 2019: highlights

The annual meeting of the European Association of Cardiovascular Imaging, EuroEcho 2019, was held in Vienna, Austria, in December 2019. In this article, we present a summary of the 'Highlights' session.

Serum S100 Protein Is a Reliable Predictor of Brain Injury After Out-of-Hospital Cardiac Arrest: A Cohort Study

Purpose: To evaluate serum S100 protein at hospital admission and after 48 h in early neuroprognostication of comatose survivors of out-of-hospital cardiac arrest (OHCA). Methods: The study included 48 consecutive patients after OHCA, who survived for at least 72 h after the event. The patients were divided based on their best cerebral performance category (CPC) achieved over a 30 day follow-up period: favorable neurological outcome (CPC 1-2) vs. unfavorable neurological outcome (CPC 3-4). Predictors of an unfavorable neurological outcome were identified by multivariable regression analysis. Analysis of the receiver operating characteristic curve (ROC) was used to determine the cut-off value for S100, having a 0% false-positive prediction rate. Results: Of the 48 patients, 30 (63%) had a favorable and 18 (38%) had an unfavorable neurological outcome. Eleven patients (23%) died over the 30 day follow-up. Increased S100 levels at 48 h after OHCA, but not the baseline S100 levels, were independently associated with unfavorable neurological outcome, with an area under the ROC curve of 0.85 (confidence interval 0.74-0.96). A 48 h S100 value ≥0.37 μg/L had a specificity of 100% and sensitivity of 39% in predicting an unfavorable 30 day neurological outcome. Conclusion: This study showed that S100 values assessed 48 h after an OHCA could independently predict an unfavorable neurological outcome at 30 days.

Treatment and Prognosis of Myocardial Infarction Outside Cardiology Departments

Aim: Our aim was to investigate the characteristics, treatment and prognosis of patients with myocardial infarction (MI) treated outside a cardiology department (CD), compared with MI patients treated at a CD. Methods: A cohort of 1310 patients diagnosed with MI at eight Swedish hospitals in 2011 were included in this observational study. Patients were followed regarding all-cause mortality until 2018. Results: A total of 235 patients, exclusively treated outside CDs, were identified. These patients had more non-cardiac comorbidities, were older (mean age 83.7 vs. 73.1 years) and had less often type 1 MIs (33.2% vs. 74.2%), in comparison with the CD patients. Advanced age and an absence of chest pain were the strongest predictors of non-CD care. Only 3.8% of non-CD patients were investigated with coronary angiography and they were also prescribed secondary preventive pharmacological treatments to a lesser degree, with only 32.3% having statin therapy at discharge. The all-cause mortality was higher in non-CD patients, also after adjustment for baseline parameters, both at 30 days (hazard ratio (HR) 2.28; 95% confidence interval (CI) 1.62–3.22), one year (HR 1.82; 95% CI 1.39–2.36) and five years (HR 1.62; 95% CI 1.32–1.98). Conclusions: MI treatment outside CDs is associated with an adverse short- and long-term prognosis. An improved use of percutaneous coronary intervention (PCI) and secondary preventive pharmacological treatment might improve the long-term prognosis in these patients.

"Missing" acute coronary syndrome hospitalizations during the COVID-19 era in Greece: Medical care avoidance combined with a true reduction in incidence?

Background

Reports from countries severely hit by the COVID‐19 pandemic suggest a decline in acute coronary syndrome (ACS)‐related hospitalizations. The generalizability of this observation on ACS admissions and possible related causes in countries with low COVID‐19 incidence are not known.

Hypothesis

ACS admissions were reduced in a country spared by COVID‐19.

Methods

We conducted a nationwide study on the incidence rates of ACS‐related admissions during a 6‐week period of the COVID‐19 outbreak and the corresponding control period in 2019 in Greece, a country with strict social measures, low COVID‐19 incidence, and no excess in mortality.

Results

ACS admissions in the COVID‐19 (n = 771) compared with the control (n = 1077) period were reduced overall (incidence rate ratio [IRR]: 0.72, P < .001) and for each ACS type (ST‐segment elevation myocardial infarction [STEMI]: IRR: 0.76, P = .001; non‐STEMI: IRR: 0.74, P < .001; and unstable angina [UA]: IRR: 0.63, P = .002). The decrease in STEMI admissions was stable throughout the COVID‐19 period (temporal correlation; R² = 0.11, P = .53), whereas there was a gradual decline in non‐STEMI/UA admissions (R² = 0.75, P = .026) following the progressively stricter social measures. During the COVID‐19 period, patients admitted with ACS presented more frequently with left ventricular systolic impairment (22.2 vs 15.5% control period; P < .001).

Conclusions

We observed a reduction in ACS hospitalizations during the COVID‐19 outbreak in a country with strict social measures, low community transmission, and no excess in mortality. Medical care avoidance behavior is an important factor for these observations, while a true reduction of the ACS incidence due to self‐isolation/quarantining may have also played a role.

Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome

BACKGROUND

Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients.

METHODS

From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models).

RESULTS

Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03).

CONCLUSIONS

Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

Outcomes of in-hospital treatment of cardiac patients who survived cardiac arrest and experienced coronary angiography

Introduction

As coronary artery disease is the most frequent cause of cardiac arrest, early invasive strategies may be beneficial for such patients. This study analyses the impact of in-hospital treatment on short-term outcomes of out-of-hospital cardiac arrest (OHCA) survivors.

Material and methods

Patients admitted to the Cardiac Intensive Care Unit of our hospital within 2-year period were prospectively included in the study.

Results

One hundred thirty-one patients were included in the study, which showed that in-hospital mortality increases uniformly with the severity of the coronary artery lesion (p = 0.044), but an effect of revascularization on number of deaths was not observed (p = 0.64). The presence of coma (p = 0.005) and the combination of male sex and age above 60-year as 2.2-fold (p = 0.048) increasing in-hospital mortality were found. The highest mortality rate occurred during the first 3 days and the death rate of the patients who survived this period is low. We found reduced left ventricular ejection fraction (OR = 6.54; 95% CI: 1.98-21.63; p = 0.002), non-ventricular fibrillation initial rhythm (OR = 2.94; 95% CI: 1.25-6.90; p = 0.014), unconscious at admission (OR = 6.46; 95% CI: 1.96-21.24; p = 0.002) and post-resuscitation coma (OR = 6.00; 95% CI: 2.63-13.66; p < 0.001) or encephalopathy (OR = 2.71; 95% CI: 1.9-6.72; p = 0.031) to be significant prognostic factors for higher in-hospital mortality rate.

Conclusions

We recommend immediate coronary interventions for all survivors of OHCA regardless of their state of consciousness and absence of ischaemic changes on ECG. Early intensive treatment for OHCA patients is indispensable, as the highest mortality rate is within the first 3 days after an event.

Acute heart failure in patients admitted to the emergency department with acute myocardial infarction

BACKGROUND

Acute heart failure (AHF), occurring as a complication of ongoing acute myocardial infarction (AMI), is a common predictor of worse clinical outcome. Much less is known about the unique subpopulation of patients who present these two life-threatening conditions in the emergency department (ED).

AIM

The aim of the study was to establish the prevalence of coexistence of AHF with AMI in the ED, to identify clinical factors associated with the higher prevalence of AHF at very early onset of AMI, and to assess the prognostic impact of the presence of AHF with AMI.

METHODS

A prospective study of 289 consecutive patients (mean age: 68 ± 11 years, 61% men) admitted to our institution (via the ED) with the diagnosis of AMI between May and October 2012 and followed-up for 2.5 years.

RESULTS

Acute heart failure was diagnosed in 13% of patients in the ED. In multivariable analysis, female sex, chronic obstruc-tive pulmonary disease, and chronic kidney disease significantly increased the risk of developing AHF together with AMI (all p < 0.05). Patients with AHF were hospitalised for longer (9.2 ± 6.1 vs. 6.3 ± 4.5 days, p < 0.001), had higher in-hospital cardiovascular mortality (8% vs. 0%, p < 0.001), and all-cause (34% vs. 15%, p = 0.004) and cardiovascular mortality (26% vs. 9%, p = 0.002) during long-term follow-up.

CONCLUSIONS

Despite good logistic- and evidence-based treatment, AHF is present in one in eight patients with AMI at the time of admission to the ED. Particularly poor outcomes characterise critically ill patients; therefore, great effort should be undertaken to improve their care.

Will sacubitril-valsartan diminish the clinical utility of B-type natriuretic peptide testing in acute cardiac care?

Since the approval of sacubitril-valsartan for the treatment of chronic heart failure with reduced ejection fraction, a commonly raised suspicion is that a wider clinical use of this new drug may diminish the clinical utility of B-type natriuretic peptide testing as sacubitril may interfere with B-type natriuretic peptide clearance. In this education paper we critically assess this hypothesis based on the pathophysiology of the natriuretic peptide system and the limited published data on the effects of neprilysin inhibition on natriuretic peptide plasma concentrations in humans. As the main clinical application of B-type natriuretic peptide testing in acute cardiac care is and will be the rapid rule-out of suspected acute heart failure there is no significant impairment to be expected for B-type natriuretic peptide testing in the acute setting. However, monitoring of chronic heart failure patients on sacubitril-valsartan treatment with B-type natriuretic peptide testing may be impaired. In contrast to N-terminal-proBNP, the current concept that the lower the B-type natriuretic peptide result in chronic heart failure patients, the better the prognosis during treatment monitoring, may no longer be true.

Misdiagnosis of Myocardial Infarction Related to Limitations of the Current Regulatory Approach to Define Clinical Decision Values for Cardiac Troponin

BACKGROUND

Misdiagnosis of acute myocardial infarction (AMI) may significantly harm patients and may result from inappropriate clinical decision values (CDVs) for cardiac troponin (cTn) owing to limitations in the current regulatory process.

METHODS AND RESULTS

In an international, prospective, multicenter study, we quantified the incidence of inconsistencies in the diagnosis of AMI using fully characterized and clinically available high-sensitivity (hs) cTn assays (hs-cTnI, Abbott; hs-cTnT, Roche) among 2300 consecutive patients with suspected AMI. We hypothesized that the approved CDVs for the 2 assays are not biologically equivalent and might therefore contribute to inconsistencies in the diagnosis of AMI. Findings were validated by use of sex-specific CDVs and parallel measurements of other hs-cTnI assays. AMI was the adjudicated diagnosis in 473 patients (21%). Among these, 86 patients (18.2%) had inconsistent diagnoses when the approved uniform CDV was used. When sex-specific CDVs were used, 14.1% of female and 22.7% of male AMI patients had inconsistent diagnoses. Using biologically equivalent CDV reduced inconsistencies to 10% (P<0.001). These findings were confirmed with parallel measurements of other hs-cTn assays. The incidence of inconsistencies was only 7.0% for assays with CDVs that were nearly biologically equivalent. Patients with inconsistent AMI had long-term mortality comparable to that of patients with consistent diagnoses (P=NS) and a trend toward higher long-term mortality than patients diagnosed with unstable angina (P=0.05).

CONCLUSIONS

Currently approved CDVs are not biologically equivalent and contribute to major inconsistencies in the diagnosis of AMI. One of 5 AMI patients will receive a diagnosis other than AMI if managed with the alternative hs-cTn assay.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.

First case of atypical takotsubo cardiomyopathy in a bilateral lung-transplanted patient due to acute respiratory failure

Takotsubo cardiomyopathy which is characterised by a transient left ventricular wall motion abnormality was first described in 1990. The disease is still not well known, and as such it is suggested that an emotional trigger is mandatory in this disease. We present the case of a 51-year old female patient seven years after bilateral lung transplantation, who developed acute respiratory distress syndrome and subsequently suffered from atypical takotsubo cardiomyopathy with transient severe reduction of ejection fraction and haemodynamic instability needing acute intensive care treatment. Acute respiratory failure has emerged as an important physical trigger factor in takotsubo cardiomyopathy. Little is known about the association of hypoxia and takotsubo cardiomyopathy which can elicit a life-threatening condition requiring acute intensive care. Therefore, experimental studies are needed to investigate the role of hypoxia in takotsubo cardiomyopathy.

Perspectives on the value of biomarkers in acute cardiac care and implications for strategic management

Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management.