Low ALT levels are associated with poor outcomes in acute coronary syndrome patients admitted to the intensive cardiac care unit

Background

Frailty is an under recognized and important entity that bears worse prognosis.

Purpose

Although low serum alanine aminotransferase (ALT) can serve as a novel marker of frailty, its use was never assessed in acute coronary syndrome (ACS) patients.

Methods

A retrospective analysis of hospitalized ACS patients in the intensive cardiac care unit (ICCU) between 1/5/2011 and 1/12/2020 at a single tertiary medical center.

Results

The study included 3956 patients after excluding patients with ALT >40 IU/L, cirrhosis and missing data, followed for a median duration of 47 months (IQR 20–77). Patients were stratified into two groups based on their first ALT measurement within the index hospitalization: low-normal ALT group (ALT ≤10 IU/L) vs. high-normal ALT group (ALT >10 IU/L). Patients with ALT≤10 IU/L were older (mean age 71 vs. 65, P<0.001), presented more frequently with non-ST elevation myocardial infarction (66.4% vs. 53.2%, P<0.001), had higher rates of comorbidities at baseline, and had a lower Norton score upon admission. Hospitalization length was longer in the low-normal ALT group (P<0.001). Although the in-hospital mortality rate was similar between the groups (0.9% vs. 0.7%, P=0.99), long-term mortality was significantly higher in the low-normal ALT group (22.7% vs. 7.9%, P<0.001). In a multivariate regression model ALT ≤10 IU/l was associated with increased mortality (HR 2.1, 95% CI 1.46–3).

Conclusion

Lower serum ALT is associated with worse outcomes in ACS patients admitted to the ICCU.

Funding Acknowledgement

Type of funding sources: None. 5-year survival according to baseline ALForest plot of variables associated with

HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge

The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.

Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device-supported patients for the non-left ventricular assist device specialist healthcare provider: Part 2: at the emergency department

The improvement in left ventricular assist device (LVAD) technology and scarcity of donor hearts have increased dramatically the population of the LVAD‐supported patients and the probability of those patients to present to the emergency department with expected and non‐expected device‐related and patient–device interaction complications. The ageing of the LVAD‐supported patients, mainly those supported with the ‘destination therapy’ indication, increases the risk for those patients to suffer from other co‐morbidities common in the older population. In this second part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the LVAD‐supported patient presenting to the emergency department with bleeding, neurological event, pump thrombosis, chest pain, syncope, and other events are presented. The very challenging issue of declaring death in an LVAD‐supported patient, as the circulation is artificially preserved by the device despite no other signs of life, is also discussed in detail.

Guidance on the management of left ventricular assist device (LVAD) supported patients for the non-LVAD specialist healthcare provider: executive summary

The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD supported patients. Device-related, and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of LVAD implanting centres. The probability of an LVAD supported patient presenting with medical emergency to a local ambulance team, emergency department medical team and internal or surgical wards in a non-LVAD implanting centre is increasing. The purpose of this paper is to supply the immediate tools needed by the non-LVAD specialized physician - ambulance clinicians, emergency ward physicians, general cardiologists, and internists - to comply with the medical needs of this fast-growing population of LVAD supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department, and from the emergency department to the internal or surgical wards and eventually back to the general practitioner.

Platelets reactivity as a predictor of the extent of myocardial infarct damage and poor outcomes in STEMI patients undergoing primary PCI

Background

Despite optimized management of STEMI patients including primary PCI (PPCI) and use of novel anti-platelet agents, a substantial proportion still display a large infarct size and microvascular damage. The extent of MI and presence of microvascular damage as determined by cardiac MRI (CMR) are considered as powerful prognostic factors in predicting both early and long-term prognosis in those patients. Platelets reactivity has been implicated in pathogenesis of microvascular and subsequent myocardial damage including distal embolization, microvascular platelets plugging and inflammation.

Methods

We prospectively evaluated 105 consecutive STEMI patients, with no prior MI, who underwent PPCI. Patients underwent 2D-echocardiography within 48 hours of admission and cardiac MRI (CMR) 5±1 day post admission. All Patients were treated with dual antiplatelet agents and blood sample were analyzed for platelets reactivity (PA) at 72 hours post admission, using arachidonic acid (AA) and adenosine diphosphate (ADP) as agonists. Aspirin hypo-responsiveness was defined as AA-PA≥30%, and P2Y12 non-responsiveness as ADP-PA ≥50%. CMR was evaluated for late gadolinium enhancement (LGE) and microvascular obstruction (MVO), which reflects MI size and microvascular damage respectively. Both parameters were quantified as % of the LV mass. Major adverse cardiac events (MACE) were defined as the composite of death, MI, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year post AMI.

Results

AA and ADP inhibition were 22±17, and 34±16 respectively. Aspirin hypo-responsiveness was associated with significantly higher extent of LGE (p=0.04) and MVO (p=0.003). A multivariate logistic regression analysis revealed that AA-PA hypo-responsiveness is an independent predictor of both MI size as reflected in LGE (OR 3.87; 95% CI: 1.47–10.5, p=0.031), and higher extent of microvascular damage as reflected by MVO% of LV mass (OR 3.6; 95% CI: 1.15–10.3, p=0.027). Patients with aspirin hypo-responsiveness were significantly more likely to sustain MACE (36% vs 12%, HR 4.13, 95% CI: 1.52–10.2, p=0.003). As opposed to AA related platelets reactivity, no significant correlation was demonstrated between ADP induced platelets reactivity and either measures of MVO or LGE.

Conclusions

In patients undergoing PPCI for STEMI, platelets reactivity in response to AA is an independent predictor of the extent of both myocardial and microvascular damage. Aspirin hypo-responsiveness is associated with higher rate of adverse events during 1-year follow-up.

Funding Acknowledgement

Type of funding source: None

Right atrium to pulmonary capillary wedge pressure ratio is associated with right ventricular failure and mortality after left ventricular assist device surgery

Introduction

Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. We investigated the role of right atrium to pulmonary capillary wedge pressure (RA/PCWP) ratio as a preoperative predictor of postoperative RVF after LVAD surgery.

Methods

A retrospective analysis of all consecutive patients who received continuous-flow LVADs (HeartMate 2, 3, and HVAD) between August 2012 and May 2018 in a single tertiary center. INTERMACS profile 1 patients were excluded. RA/PCWP ratio was calculated for the entire cohort and divided into quartiles (Q). Patients were stratified into high (Q4) vs. low (Q1–3) RA/PCWP ratio. The primary end point was the composite of in hospital mortality and RVF (defined as the need for a right ventricular assist device or inotrope dependence for >7 days). The secondary endpoint was readmission within 14 days after discharge.

Results

The study cohort consisted of 59 patients (15 patients in the high RA/PCWP group and 44 patients in the low RA/PCWP group) with a median follow-up of 21 months (Interquartile range 14–31). The mean age was 56±11 years and the majority of patients were male (88%). Patients were classified as INTERMACS profile 2 (34%), 3 (19%) or 4 (47%).

Preoperative clinical, laboratory, and echocardiographic parameters were similar in both groups except for a larger proportion of patients with a dilated right ventricle and above moderate tricuspid regurgitation in the high compared to the low RA/PCWP group (73% vs. 29%; P=0.006 and 40% vs. 2%; P=0.001, respectively). Overall, 7 patients (12%) developed the primary end-point and 9 patients (15%) developed the secondary end-point.

Univariate analysis demonstrated that high RA/PCWP is associated with both primary and secondary end-points (odds ratio [OR], 7.6; 95% confidence interval [CI] 1.2–47.2, P=0.029 and OR, 6.25; 95% CI 1.3–28.5, P=0.018, respectively). On multivariable analysis, the association remained significant after adjustment for INTERMACS score (OR, 10.6; 95% CI 1.4–80.9, P=0.022 and OR, 7.9; 95% CI 1.5–42.2, P=0.015, respectively).

Using receiver operating characteristic curve (ROC) derived cut-points, RA/PCWP >0.57 provided 67% sensitivity and 79% specificity (C-statistic = 0.73) for the prediction of in hospital mortality and RVF and 56% sensitivity and 84% specificity (C-statistic = 0.69) for the prediction of readmissions within 14 days after discharge. In comparison, in our cohort using ROC-derived cut points, pulmonary artery pulsatility index, an established RVF predictor, of less than 1.84 provided 40% sensitivity and 20% specificity (C-statistic = 0.3) for the prediction of inhospital death and RVF.

Conclusion

RA/PCWP ratio may help to identify patients at high risk of developing adverse clinical outcomes, including RVF and mortality, after LVAD surgery.

Funding Acknowledgement

Type of funding source: None

P4650Sex differences in clinical presentation and in hospital outcomes among myocarditis and peri-myocarditis patients

Background

Data are scarce regarding sex differences among patients with myocarditis and peri-myocarditis. Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to myocarditis and peri-myocarditis.

Methods and results

We analyzed data of 322 consecutive patients between January 2007 and October 2017 who were hospitalized with the diagnosis of myocarditis or peri-myocarditis at our medical center. Eighty-four percent of the patients were males. Both males as well as females had similar rates of chronic medical conditions. However, males were more likely to present with ST elevation (75% vs. 44%. P<0.001) as well as PR depression in ECG compared to women and have higher admission troponin levels (7.6±11 vs. 2.3±4, P<0.001). Women were older (45±17 vs. 36±14, P<0.001) and tended to present with a rather normal ECG. There were no differences in the incidence of in-hospital mortality or the need for escalation therapy between male and female patients. However, males were more likely to have ventricular arrhythmias (7% vs. 0%, P=0.05). no differences in long term mortality were observed among males and females.

Variable Male (N=272) Female (N=50) P-value Age 36±14 45±17 <0.001 Cardiology Department 243 (90%) 39 (78%) 0.03 Dyspnea 63 (23%) 22 (44%) 0.002 Pericardial chest pain 94 (35%) 20 (40%) 0.52 Admission SBP (mmhg) 122±16 116±16 0.02 Admission HR (b/min) 82±16 89±21 0.04 Normal ECG 37 (14%) 12 (24%) 0.06 ST elevation 204 (75%) 22 (44%) <0.001 LVEF <50% 215 (80%) 45 (90%) 0.08 LGE 176 (88%) 20 (69%) 0.009 Albumin 4±0.3 3.6±0.4 <0.001 Troponin admission 7.6±11 2.3±4 <0.001

Conclusions

Male patients, which constitute the majority of patients. Admitted with myocarditis are younger, with higher troponin levels at admission, are more likely to present with ST elevation, and have a higher rate of ventricular arrythmias when compared to women. However, there are no differences in early as well as long term mortality rates between men and women.

P6460The significance of syncope as a presenting symptom in patients with intermediate risk pulmonary embolism

Background

Intermediate risk pulmonary emboli patients are a challenging group with high risk of recurrent VTE, hemodynamic instability and mortality. A gap of knowledge has emerged regarding predictors of clinical deterioration. The prognostic role of syncope presentation is debatable. We thought to investigate the ability of syncope to predict in-hospital complications and the need of escalation therapy among intermediate risk PE patients admitted to the ICCU.

Methods

Consecutive cohort of all patients hospitalized with a diagnosis of PE, classified as intermediate risk and admitted to the intensive cardiac care unit at the Sheba medical center between the years 2008–2016. Primary outcome: MACE consisting of either one of or a combination of: mechanical ventilation, hemodynamic instability and need for inotropic support, Secondary reperfusion and in-hospital mortality. Secondary outcomes: Each of the individual components including major bleeding and renal failure

Results

213 intermediate risk PE patients were analyzed. 40 patients (19%) presented with syncope. Syncope patients had significant higher RV/LV ratio upon computed tomography (1.7±0.6 vs. 1.4±0.4, p=0.011). The presence of either moderate or severe RV dysfunction was more prevalent, without statistical significance (57.5% vs. 41%, p=0.076).

Syncope patients had higher prevalence of escalation therapy (28.9% vs 9.4%, p=0.003), as well as in the following individual secondary endpoints: mechanical ventilation (10% vs 1.8%, p=0.026), hemodynamic instability (17.9% vs 2.9%, p=0.02), bleeding rates (15% vs 2.4%, p=0.004), and increased need of inotropic support (10% vs 0.6%, p=0.005). There was no significant difference in the need for reperfusion therapy, both surgical (5% vs. 0.6%, p=0.093) and non- surgical (7.5% vs 6.4%, p=0.732), and in-hospital mortality (2.5% vs 0%, p=0.190).

Secondary Outcomes

Conclusion

The presence of syncope as a presenting symptom is associated with more complicated in-hospital clinical course. These patients warrant more aggressive monitoring and assessment for the need of escalation therapy.

Long-Term Effects of Pregnancy on Renal Graft Function in Women After Kidney Transplantation Compared With Matched Controls

BACKGROUND

An important benefit associated with kidney transplantation in women of child-bearing age is increased fertility. We retrospectively evaluated the maternal and fetal complications and evolution of graft function associated with 22 pregnancies post-kidney and kidney-pancreas transplantation, compared with controls without pregnancy post-transplantation, who were matched for gender, year of transplantation, type of donor, age at transplantation, number of transplants, type of transplant (kidney vs kidney-pancreas), and cause of native kidney failure, as well as for renal parameters including serum creatinine and urine protein excretion 1 year before delivery.

RESULTS

The mean age at time of transplantation was 22.32 (range, 19.45-33.1) years. The mean interval between transplantation and delivery was 75.7 (range, 34-147.8) months. Main maternal complications were pre-eclampsia in 27.3%. The main fetal complications included delayed intrauterine growth (18.2%), preterm deliveries (89.4%), and one death at 3 days postdelivery. The mean serum creatinine level pre-pregnancy was 1.17 (range, 0.7-3.1) mg/dL. Graft failure was higher in the pregnancy group (6 vs 3) but did not differ statistically from the control group, and was associated with creatinine pre-pregnancy (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.15-3.45; P = .04), age at transplantation (1.13 [1.03-1.21]; P = .032), and time of follow-up (2.14 [1.27-2.98]; P = .026). Delta serum creatinine was not different in both groups: 1.05 ± 0.51 versus 0.99 ± 0.92 mg/dL, study versus control group, respectively (P = .17).

CONCLUSION

Pregnancy after kidney transplantation is associated with serious maternal and fetal complications. We did not observe a significantly increased risk of graft loss or reduced graft function in comparison with recipients with similar clinical characteristics.

Hyperuricemia attenuates aortic nitric oxide generation, through inhibition of arginine transport, in rats

OBJECTIVES

Hyperuricemia provokes endothelial dysfunction (ECD). Decreased endothelial nitric oxide synthase (eNOS) activity is an important source of ECD. Cationic amino acid transporter-1 (CAT-1) is the specific arginine transporter for eNOS. We hypothesize that hyperuricemia inhibits arginine uptake.

METHODS

Experiments were performed in freshly harvested aortas from untreated animals and rats fed with oxonic acid (hyperuricemia), and compared to hyperuricemic rats treated with either allopurinol, benzbromarone or arginine.

RESULTS

Arginine transport was significantly decreased in hyperuricemia. Benzbromarone and arginine prevented the decrease in arginine transport in hyperuricemic rats while allopurinol did not. Arginine transport was significantly decreased in control rats treated with allopurinol. Blood pressure response to acetylcholine was significantly attenuated in hyperuricemic rats, an effect which was prevented in all other experimental groups. L-NAME inhibitable cGMP response to carbamyl-choline was significantly decreased in hyperuricemic rats and this was completely prevented by both benzbromarone and arginine, while allopurinol partially prevented the aforementioned phenomenon. Hyperuricemia induced a significant increase in protein nitration that was prevented by benzbromarone, allopurinol, and arginine. Protein abundance of CAT-1, PKCα, and phosphorylated PKCα remained unchanged in all experimental groups.

CONCLUSIONS

In hyperuricemia, the decrease in aortic eNOS activity is predominantly the result of attenuated arginine uptake.

Sexual dimorphism in glomerular arginine transport affects nitric oxide generation in old male rats

Animal models suggest that decreased renal endothelial nitric oxide synthase (eNOS) activity in old males promotes renal injury, whereas females are protected. We aimed to explore whether aging alters glomerular arginine uptake by CAT-1, the selective arginine supplier to eNOS in rats. Arginine uptake by glomeruli from young males (3 mo) was significantly higher than in young females. Old males (19 mo) exhibited a significant decrease in arginine transport compared with young males, whereas no differences were observed between old and young females. CAT-1 abundance remained unchanged in all experimental groups. The abundance of PKCalpha (CAT-1 inhibitor) was significantly augmented in young females vs. young males, old vs. young males, and in old females vs. old males. No differences in PKCalpha content were detected between old and young females. Phosphorylated PKCalpha was significantly increased in old rats from both genders. alphaTocopherol, a PKC inhibitor, produced a significant increase in arginine transport and restored NO generation in old males only. Ex vivo incubation of glomeruli from old males with PMA (PKC stimulant) significantly attenuated the effect of tocopherol on arginine uptake. In conclusion, attenuated glomerular arginine transport by CAT-1 contributes to the age-dependent, NO-deficient state in old male rats through upregulation of PKCalpha. In old females glomerular arginine transport is protected from the effects of PKCalpha by an unknown mechanism.

Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence

INTRODUCTION

Prevention of venous thromboembolism and coronary events (with beta-blockers) during and after surgery is at the top of a list of safety practices for hospitalized patients, recommended by the Agency for Health Care Research and Quality (AHRQ). We wished to determine and improve adherence to clinical guidelines for these topics in our institution. PATIENTS, MATERIAL, AND METHODS: A prospective survey was conducted over several weeks on operated patients in a 1200-beds medical center (a teaching, community and referral hospital in Jerusalem, Israel). Eligibility for and actual administration of prophylactic treatment with anticoagulant and beta-blockers were determined. Following an intervention program, which included staff meetings, development of local protocols, and academic detailing by a nurse, the survey was repeated.

RESULTS

In general, adherence to recommended anticoagulation prophylaxis was low, found in only 29% [95% confidence interval (CI) = 23-36] of eligible patients. After the intervention, adequate anticoagulation increased to 50% (95% CI = 40-59) of eligible patients (P < 0.001). Initiation of beta-blockers in preventing perioperative cardiac events was very low (0%, 95% CI = 0-5%) and did not increase after intervention.

CONCLUSIONS

Adherence to guidelines for prevention of surgical complications was found to be low in our institution. A multifaceted intervention significantly increased use of prophylaxis for venous thromboembolism but not for coronary events. This differential response suggests that the success of a quality improvement project strongly depends on topic content and its phase of acceptance.