Cambio en la enolasa neuroespecífica de los supervivientes de parada cardiorrespiratoria extrahospitalaria: herramienta útil para predecir el pronóstico neurológico

Introduction and objectivesNeuron-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.MethodsMulticenter 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.ResultsWe 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 24 hours, 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).ConclusionsDynamic 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.     

Timing of Coronary Angiography in Patients Following Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review and Meta-Analysis of Randomized Trials

IntroductionOut-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear.ObjectiveWe performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation.MethodsWe searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG.ResultsA total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94–1.20; P = 0.32; I² = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90–1.13; P = 0.85, I² = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84–1.39; P = 0.56; I² = 49%).ConclusionIn patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.     

Long term clinical outcomes in survivors after out-of-hospital cardiac arrest

Introduction and objectivesInformation regarding long-term outcomes in patients surviving out-of-hospital cardiac arrest (OHCA) is scarce. Our aim was to study the long-term clinical outcomes of a large cohort of OHCA patients surviving until hospital discharge and to identify predictors of mortality and cardiovascular events.MethodsConsecutive OHCA patients admitted in the Acute Cardiac Care Unit who survived at least until hospital discharge between 2007 and 2019 were included. All received therapeutic hypothermia according to the local protocol. Pre- and intra-hospital clinical and analytical variables were analyzed, as well as the clinically relevant events during follow-up.ResultsA total of 201 patients were included, with a mean age of 57.6 ± 14.2 years, 168 (83.6%) were male. Thirty-six (17.9%) died during a median follow-up of 40.3 months (18.9–69.1), the most frequent causes of death being cardiovascular and neurological, followed by cancer. We calculated a predictive model for mortality during follow-up using Cox regression that included the following variables: poor neurological outcome [HR 3.503 (1.578–7.777)], non-shockable rhythm [HR 2.926 (1.390–6.163)], time to onset of CPR [HR 1.063 (0.997–1.134)], older age [1.036 (1.008–1.064)) and worse ejection fraction at discharge [1.033 (1.009–1.058)].ConclusionsEven though few patients experience recurrent cardiac arrest events, survivors after OHCA face high morbidity and mortality during long-term follow-up. Therefore, they may benefit from multidisciplinary teams providing an integral management and ensuring continuity of care.     

Time course and risk factors of evolution from potential to overt autoimmune gastritis

BackgroundThe natural history of patients with potential autoimmune gastritis (AIG), defined by the presence of serum anti-parietal cell antibody (PCA) positivity and no gastric histopathological alterations, is unknown. We therefore aimed to assess the natural history and clinical correlates of potential autoimmune gastritis (AIG).MethodsIn 2000–2019, we enrolled potential AIG patients by monitoring once a year (±6 months) histopathological evolution into overt AIG, defined as the occurrence of atrophy in the oxyntic mucosa. Factors affecting disease progression were assessed.ResultsFifty-one potential AIG patients (median age 57 years, IQR 43–73, F:M ratio 1.7:1) were monitored for up to 15 years (median 6 years, IQR 3–8). Of them, 24 (47.1%) evolved into overt AIG in a median time of 2 years (IQR 2–4.5). Having a concomitant autoimmune disorder (HR 4.09, 95% CI 1.52–11.00; p = 0.005), but not older age (HR 1.00, 95% CI 0.45–2.22; p = 0.992) and female sex (HR 1.19, 95% CI 0.51–2.78; p = 0.395), was associated with evolution into overt AIG.ConclusionsRoughly one in two potential AIG patients will evolve into overt AIG over a median time of two years, especially those with a concurrent autoimmune disorder.     

Clinical predictors of outcome in survivors of out-of-hospital cardiac arrest treated with hypothermia

BackgroundOut-of-hospital cardiac arrest (OHCA) is a leading cause of death and severe neurological disability. The objective of this study was to identify clinical predictors of early neurological outcome in survivors of OHCA managed according to recent recommendations for OHCA care.MethodsData from survivors of OHCA, admitted to a tertiary cardiac intensive care unit and treated with hypothermia in a 22 months period (n=46, age 60±13 years, 74% males) were retrospectively evaluated. At 1-month follow-up, patients were classified according to the best achieved Glasgow–Pittsburgh cerebral performance categories (CPC 1–5) and factors affecting the outcome were analysed.ResultsAt 1-month follow-up, 23 patients (50%) had favourable outcome (CPC 1–2), while 23 patients (50%) had poor outcome (CPC 3–5), including 19 with in-hospital death (41% of total). Patients with good outcome were younger (55±13 years vs. 66±10 years; P=0.003), had more often myocardial infarction as the cause of arrest (63% vs. 30%; P=0.018) and ventricular fibrillation/tachycardia as an initial rhythm (78% vs. 39%; P=0.007). Both groups differed by lactate level on admission (4.0±4.6 vs. 7.3±4.1 mmol/l, P=0.02), after 12 h (2.5±1.1 vs. 4.3±3.2 mmol/l, P=0.04) and after 24 h (1.9±1.2 vs. 3.2±1.9 mmol/l, P=0.04). Logistic regression revealed the following independent outcome predictors: age, acute myocardial infarction and admission lactate level.ConclusionFavourable outcome was observed in a half of OHCA survivors. Young age, acute myocardial infarction as underlying aetiology of cardiac arrest, and low lactate level on admission were the best predictors of favourable outcome.     

Inotrope Use and Outcomes Among Patients Hospitalized for Heart Failure: Impact of Systolic Blood Pressure,Cardiac Index,and Etiology

BackgroundInotropes are widely used in hospitalized systolic heart failure (HF) patients, especially those with low systolic blood pressure (SBP) or cardiac index. In addition, inotropes are considered to be harmful in nonischemic HF.Methods and ResultsWe examined the association of in-hospital inotrope use with (1) major events (death, ventricular assist device, or heart transplant) and (2) study days alive and out of hospital during the first 6 months in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness, which excluded patients with immediate need for inotropic therapy. Predefined subgroups of interest were baseline SBP <100 versus ≥100 mm Hg, cardiac index <1.8 vs ≥1.8 L min⁻¹ m⁻², and ischemic versus nonischemic HF etiology. Inotropes were frequently used in both the <100 mm Hg (88/165 [53.3%]) and the ≥100 mm Hg (106/262 [40.5%]) SBP subgroups and were associated with higher risk for major events in both subgroups (adjusted hazard ratio [HR] 2.85, 95% confidence interval [CI] 1.59–5.12 [P < .001]; and HR 1.86, 95% CI 1.02–3.37 [P = .042]; respectively). Risk with inotropes was more pronounced among those with cardiac index ≥1.8 L min⁻¹ m⁻² (n = 114; HR 4.65, 95% CI 1.98–10.9; P < .001) vs <1.8 L min⁻¹ m⁻² (n = 82; HR 1.48, 95% CI 0.61–3.58; P = .39). Event rates were higher with inotropes in both ischemic (n = 215; HR 2.64, 95% CI 1.49–4.68; P = .001) and nonischemic (n = 216; HR 2.19, 95% CI 1.18–4.07; P = .012) patients. Across all subgroups, patients who received inotropes spent fewer study days alive and out of hospital.ConclusionsIn the absence of cardiogenic shock or end-organ hypoperfusion, inotrope use during hospitalization for HF was associated with unfavorable 6-month outcomes, regardless of admission SBP, cardiac index, or HF etiology.     

Vascular Quality Initiative Surveillance of Femoropopliteal Artery Paclitaxel Devices

ObjectivesThis study sought to determine the safety and efficacy of paclitaxel (PTX) devices in the treatment of peripheral artery disease involving the femoropopliteal artery.BackgroundA meta-analysis of PTX devices for the treatment of femoropopliteal artery disease reported a mortality signal.MethodsThis was a multicenter cohort study using an integrated clinical data surveillance system to conduct a prospective, propensity score–matched survival analysis of 2,456 patients in the Society for Vascular Surgery Vascular Quality Initiative from January 2017 to May 2020. The study compared PTX drug-coated balloon angioplasty versus percutaneous transluminal balloon angioplasty, PTX drug-eluting stents versus bare-metal stents, and any PTX device versus any non-PTX device. The primary outcome was 2-year survival. Secondary endpoints were successful ambulation and interventional success.ResultsTreatment with any PTX device versus any non-PTX device was associated with increased 2-year survival (89.5% vs 86.7%; HR: 0.79; 95% CI: 0.72-0.87; P = 0.004), improved interventional success (81.6% vs 77.6%; HR: 0.82; 95% CI: 0.74-0.91; P < 0.001), and higher rates of independent ambulation at 1 year (86.0% vs 83.4%; HR: 0.85; 95% CI: 0.79-0.91; P = 0.008). Treatment with PTX drug-coated balloon angioplasty was associated with improved survival at 2 years (88.9% vs 85.7%; HR: 0.77; 95% CI: 0.70-0.86; P = 0.005), while PTX drug-eluting stent therapy was associated with similar survival compared with bare-metal stent therapy (91.3% vs 89.6%; HR: 0.84; 95% CI: 0.70-1.01; P = 0.36).ConclusionsIn this prospective, active surveillance of a national clinical registry, PTX-containing devices were associated with increased survival at 2 years and improved clinical outcomes at 1 year. (VQI DELTA Paclitaxel Device Safety Analysis [VQI-PTX]; NCT04110288)     

Differential associations between body mass index and outcome in different age groups in patients with myocardial infarction

ObjectiveTo investigate the association between age and body mass index (BMI) and mortality in patients with myocardial infarction (MI). Methods We divided 6453 patients into three age groups (<60, 60–75, >75 years) and five BMI categories. Thirty-day and long-term all-cause mortality were assessed.ResultsNo association was found between the BMI category and 30-day mortality in any age group. The association between BMI and long-term multivariable-adjusted mortality risk was age-dependent. Overweight patients had a lower risk than patients with BMI <25 kg/m² in all age groups (HR 0.62; 95%CI 0.45–0.85; p = 0.003, HR 0.78; 95%CI 0.65–0.93; p = 0.005, HR 0.82; 95%CI 0.70–0.95; p = 0.011 for ages <60, 60–75, >75 years, respectively). The lower risk of death as a function of BMI shifted upward with age, and the risk was also lower in patients with obesity grade I (HR 0.81; 95% CI 0.66–0.98; p = 0.035 and HR 0.78; 95% CI 0.63–0.97; p = 0.023 for ages 60–75, >75 years, respectively). Excessive obesity was harmful only in the oldest group. Patients with obesity grade III had more than a 2.5 times higher mortality risk than patients with BMI <25 kg/m² only in this group (HR 2.58; 95%CI 1.27–5.24; p = 0.009). An obesity paradox was found in all age groups.ConclusionOur results suggest that moderate weight gain with age improves long-term survival after MI and that the magnitude of this “protective” weight gain is greater in older compared to younger patients. However, excessive weight gain (obesity grade III) is particularly harmful in the oldest age group. The exact relationship between BMI, age, and mortality remains unclear.     

Factors associated with survival in older patients affected by COVID-19: A retrospective cohort study

AimMortality is high in Coronavirus disease 2019 patients with pre-existing comorbidities and advanced age. Associated complications have added to the negative prognosis. Nevertheless, many have fully recovered, even among the most fragile. Factors associated with their survival was investigated.MethodsRetrospective study of patients aged ≥90 years admitted for COVID-19 to the Internal Medicine wards of two hospitals in Lombardy, Italy.ResultsAmong 34 patients with SARS-CoV-2 pneumonia, 33 (97.1%) had respiratory failure. Eighteen patients (52.9%) survived and 16 (47.1%) died during hospital stay. Survivors compared to deceased had a significantly longer hospitalization (19 vs. 10 days respectively; p = 0.02), a better PaO2:FiO2 ratio (241 vs. 171 respectively; p = 0.003), higher lymphocyte counts (p = 0.01) and lower serum LDH levels (p < 0.001) at admission. At multivariate analysis only higher PaO2:FiO2 was associated with survival (OR 1.06 [95%CI 1.0–1.03]; p = 0.02). Kaplan-Meier analysis showed a significant difference in event-free survival between patients treated or not with LMWH (p < 0.0001) and between those treated or not with beta-blockers (p = 0.008). Cox regression, performed in the subgroup of patients who received LMWH, did not show significant difference for sex (HR 2.7 [95% CI 0.53–14.3], p = 0.23), CCI (HR 0.7 [95% CI 0.37–1.45], p = 0.38), PaO2:FiO2 ratio (HR 0.98 [95% CI 0.97–1.0], p = 0.07), corticosteroid therapy (HR 0.99 [95% CI 0.22–4.5], p = 0.99) and beta-blocker therapy (HR 2.8 [95% CI 0.56–14,7], p = 0.21).ConclusionsDespite higher mortality in elderly, treatment with LMWH and betablockers might be associated with better survival. Dedicated studies are required to confirm our result.     

The relationship between patients’ age and prognosis outcome after cardiopulmonary resuscitation in adults: A meta-analysis

ObjectiveTo assess the relationship between patients’ age and prognosis outcome after cardiopulmonary resuscitation (CPR) in adults.MethodsRelevant observational studies were identified by a search of PubMed and ISI databases from their beginning to 30 January 2014. Survival to discharge was used as the prognosis outcome. The weighted mean difference (WMD) for patients’ age were calculated for survival to discharge and death in hospital. We also carried out a dose-response meta-analysis for assessing summary odds ratio (OR) of survival by patients’ age.ResultsA total of 27 studies included in the meta-analysis. The WMD of age between those who survived or not was 5.294 (95% CI 3.150 to 7.438; Z = 4.84, P = 0.000). No publication bias was found (Begg test P = 0.228 and Egger test P = 0.101). Sensitivity analyses by only included prospective cohorts showed the WMD of age between those who survived or not was 4.236 (95% CI 1.652 to 6.821; Z = 3.21, P = 0.001). Association between patients’ age and survival to discharge risk after CPR was observed statistically significant (χ² = 23.54, P = 0.000). In linear model, the summary OR was 0.976 (95% CI 0.966–0.986) for every 1-year increase in patients’ age. In spline model, the OR decreased along with the patients’ age, especially when patients’ age over 70 years.ConclusionsOld age is an important pre-arrest predictor for poor prognosis after CPR in adults. When patients’ age over 70 years, the survival to discharge risk decreased rapidly along with the patients’ age increase.     

Neck circumference for predicting the occurrence of future cardiovascular events: A 7.6-year longitudinal study

Background & aimsThis study aimed to investigate whether neck circumference (NC) could be used to predict future cardiovascular (CV) events in a community-based Chinese cohort.Methods and resultsWe enrolled 1435 participants aged 50–80 years (men, 43.62%) from communities in Shanghai. High NC was defined as NC ≥ 38.5 cm in men and NC ≥ 34.5 cm in women. Kaplan-Meier analysis and Cox proportional hazards regression were performed to explore the association between NC and CV events. During a mean follow-up period of 7.6 years, 148 CV events (10.31%) occurred. The incidence of CV events was higher in men than in women (83 (13.26%) vs. 65 (8.03%), P = 0.002). Multivariable-adjusted Cox regression analysis showed that for every 1-SD increase in NC in the whole population, the hazard ratio (HR) of CV events was 1.45 (95% confidence interval [CI], 1.15–1.83). The dose-response association between NC and CV events was significant in men (HR, 1.37, 95% CI, 1.10–1.71) but not in women (HR, 1.19, 95% CI, 0.94–1.52). In comparison with participants showing low baseline NC, those with high baseline NC showed a significantly higher risk of CV events (HR, 1.59, 95% CI, 1.14–2.22). Further stratified by sex, the positive association remained significant in men (HR, 1.90, 95% CI, 1.21–2.98) but not in women (HR, 1.25, 95% CI, 0.75–2.07).ConclusionNC was significantly associated with the risk of future CV events in middle-aged and elderly populations in the community and was a better predictor in men.     

Improved 3-Year Cardiac Survival After IVUS–Guided Long DES Implantation: A Patient-Level Analysis From 2 Randomized Trials

ObjectivesThe present study aimed to evaluate long-term cardiac survival benefit for intravascular ultrasound (IVUS)- versus angiography-guided long drug-eluting stent (DES) implantation.BackgroundAlthough the long-term benefit of IVUS guidance for DES implantation has been reported from recent randomized trials, this benefit was primarily driven by the reduction in repeat revascularization. Thus, it remains uncertain whether IVUS guidance improved survival during long-term follow-up.MethodsWe pooled the data of 2 randomized trials (IVUS-XPL [Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions] and ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions]) and compared IVUS guidance versus angiography guidance in 2,577 patients with long lesions treated with an implanted stent length ≥28 mm. The primary end point was cardiac death at 3 years.ResultsA 3-year clinical follow-up was completed in 96%. The primary end point of cardiac death occurred in 12 patients (1.0%) in the IVUS-guided group vs 28 patients (2.2%) in the angiography-guided group (HR: 0.43; 95% CI: 0.22-0.84; P = 0.011). In addition, target lesion–related myocardial infarction occurred in 3 patients (0.2%) in the IVUS-guided group and in 9 patients (0.7%) in the angiography-guided group (HR: 0.33; 95% CI: 0.09-1.22; P = 0.081), stent thrombosis developed in 3 patients (0.2%) in the IVUS-guided group and 9 patients (0.7%) in the angiography-guided group (HR: 0.33; 95% CI: 0.09-1.23; P = 0.082), and ischemia-driven target lesion revascularization was observed in 47 patients (3.8%) in the IVUS-guided group and 80 patients (6.5%) in the angiography-guided group (HR: 0.57; 95% CI: 0.40-0.82; P = 0.002).ConclusionsIn this post hoc pooled patient-level analysis, the use of IVUS-guided long DES implantation compared with angiography-guided stent implantation improved long-term patient cardiac survival.     

Risk Stratification With the Use of Serial N-Terminal Pro–B-Type Natriuretic Peptide Measurements During Admission and Early After Discharge in Heart Failure Patients: Post Hoc Analysis of the PRIMA Study

ObjectiveThe aim of this work was to assess the prognostic value of absolute N-terminal-pro–B-type natriuretic peptide (NT-proBNP) concentration in combination with changes during admission because of acute heart failure (AHF) and early after hospital discharge.BackgroundIn AHF, readmission and mortality rates are high. Identifying those at highest risk for events early after hospital discharge might help to select patients in need of intensive outpatient monitoring.Methods and resultsWe evaluated the prognostic value of NT-proBNP concentration on admission, at discharge, 1 month after hospital discharge and change over time in 309 patients included in the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study. Primary outcome measures were mortality and the combined end point of heart failure (HF) readmission or mortality. In a multivariate Cox regression analysis, change in NT-proBNP concentration during admission, change from discharge to 1 month after discharge, and the absolute NT-proBNP concentration at 1 month after discharge were of independent prognostic value for both end points (hazard ratios for HF readmission or mortality: 1.71, 95% confidence interval [CI] 1.13–2.60, Wald 6.4 [P = .011] versus 2.71, 95% CI 1.76–4.17, Wald 20.5 [P < .001] versus 1.81, 95% CI 1.13–2.89, Wald 6.1 [P = .014], respectively.ConclusionsKnowledge of change in NT-proBNP concentration during admission because of AHF in combination with change early after discharge and the absolute NT-proBNP concentration at 1 month after discharge allows accurate risk stratification.     

A prospective cohort study on risk of acute pancreatitis related to serum triglycerides,cholesterol and fasting glucose

Background/objectivesTo investigate risk for acute pancreatitis related to moderately elevated triglycerides, cholesterol and fasting glucose.MethodsThis was a prospective cohort study in Malmö, Sweden of 33 346 subjects investigated 1974–1992 and followed until December 31, 2006. Baseline investigation included a self-administered questionnaire and analysis of serum triglycerides, cholesterol and fasting glucose. Cases of acute pancreatitis (n = 277, median time since baseline investigation 15.6 years) were identified in diagnosis registries and validated retrospectively. Attacks were classified as obstructive or non obstructive (alcohol or non alcohol related). Cox proportional hazards analysis was used to calculate hazard ratios (HR) for acute pancreatitis related to relevant risk factors, adjusting for age, sex, smoking habits and alcohol consumption.ResultsTriglycerides were associated with overall, non obstructive and non obstructive non alcohol related acute pancreatitis with adjusted HRs of 1.21 (95% confidence interval (CI), 1.07–1.36), 1.23 (95% CI, 1.06–2.43) and 1.34 (95% CI, 1.11–1.62) per 1 mmol/l increment, respectively. Corresponding HRs for forth versus first quartile of triglycerides were 1.55 (95% CI, 1.09–2.21), 1.60 (95% CI, 1.60–1.01–1.35) and 2.07 (95% CI, 1.13–3.79). Triglycerides were not associated with obstructive acute pancreatitis and there were no associations between glucose or cholesterol and the risk of acute pancreatitis.ConclusionsWe found an association between prediagnostic levels of triglycerides and risk for acute pancreatitis. This association was most pronounced in the non obstructive non alcohol related group. Our findings suggest that triglycerides may be a more important risk factor for acute pancreatitis than what has previously been estimated.     

Long-Term Follow-Up of Hypoattenuated Leaflet Thickening After Transcatheter Aortic Valve Replacement

BackgroundEarly hypoattenuated leaflet thickening (HALT) occurs in at least 10% of all transcatheter aortic valve replacement (TAVR) patients. The long-term prognostic impact of HALT is uncertain.ObjectivesThe aim of this study was to assess the long-term risk of early HALT post-TAVR.MethodsWe report outcome data from our prospective observational registry with post-TAVR computed tomography angiography performed between May 2012 and December 2017. The outcomes were survival, cardiovascular mortality, ischemic cerebrovascular events, and symptomatic hemodynamic valve deterioration.ResultsEarly HALT was diagnosed in 115 (16.0%) of 804 patients. During a median follow-up of 3.25 years, survival rates did not differ significantly between patients with and without HALT (Kaplan-Meier 3-year estimates for survival 70.1% vs 74.0%, P = 0.597). The 3-year cardiovascular mortality rate was 13.2% versus 11.3% (with vs without HALT, P = 0.733). The 3-year event rate for cerebrovascular events was 2.0% versus 4.4% (with vs without HALT, P = 0.246), and the 3-year event rate of symptomatic hemodynamic valve deterioration was 9.4% versus 1.5% (with vs without HALT, P < 0.001). Multivariable analysis revealed the following predictors of symptomatic hemodynamic valve deterioration: HALT (HR: 6.10; 95% CI: 2.59-14.29; P < 0.001), the mixed valve–type group (HR: 6.51; 95% CI: 2.38-17.81; P < 0.001), and prosthesis diameter (HR valve size per 3 mm [HR: 0.37; 95% CI: 0.17-0.79]; P = 0.011).ConclusionsDuring a median follow-up of more than 3 years, HALT was not associated with mortality or cerebrovascular events. However, we observed an association of HALT with symptomatic hemodynamic valve deterioration.     

Acute Coronary Occlusion in Patients With Non-ST-Segment Elevation Out-of-Hospital Cardiac Arrest

BackgroundAccording to current guidelines, hemodynamic status should guide the decision between immediate and delayed coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation. A delayed strategy is advised in hemodynamically stable patients, and an immediate approach is recommended in unstable patients.ObjectivesThis study sought to assess the frequency, predictors, and clinical impact of acute coronary occlusion in hemodynamically stable and unstable OHCA patients without ST-segment elevation.MethodsConsecutive unconscious OHCA patients without ST-segment elevation who were undergoing CAG at Bern University Hospital (Bern, Switzerland) between 2011 and 2019 were included. Frequency and predictors of acute coronary artery occlusions and their impact on all-cause and cardiovascular mortality at 1 year were assessed.ResultsAmong the 386 patients, 169 (43.8%) were hemodynamically stable. Acute coronary occlusions were found in 19.5% of stable and 24.0% of unstable OHCA patients (P = 0.407), and the presence of these occlusions was predicted by initial chest pain and shockable rhythm, but not by hemodynamic status. Acute coronary occlusion was associated with an increased risk of cardiovascular death (adjusted HR: 2.74; 95% CI: 1.22-6.15) but not of all-cause death (adjusted HR: 0.72; 95% CI: 0.44-1.18). Hemodynamic instability was not predictive of fatal outcomes.ConclusionsAcute coronary artery occlusions were found in 1 in 5 OHCA patients without ST-segment elevation. The frequency of these occlusions did not differ between stable and unstable patients, and the occlusions were associated with a higher risk of cardiovascular death. In OHCA patients without ST-segment elevation, chest pain or shockable rhythm rather than hemodynamic status identifies patients with acute coronary occlusion.     

Comparative Outcomes After Percutaneous Coronary Intervention in Unconscious and Conscious Patients With Out-of-Hospital Cardiac Arrest

BackgroundUp to 70% of out-of-hospital cardiac arrest (OHCA) patients have a relevant coronary stenosis which may need revascularization. The short- and long-term ischemic and bleeding risk of unconscious and conscious OHCA patients undergoing percutaneous coronary intervention (PCI) is largely unknown.ObjectivesThis study sought to compare the occurrence of 1-year outcomes after PCI between OHCA patients, stratified on the basis of state of consciousness, with patients with acute coronary syndrome (ACS) not preceded by OHCA.MethodsThe study assessed the unadjusted and adjusted risk of cardiovascular events in a prospective single-center cohort of 9,303 consecutive PCI patients.ResultsAt 1 year, all-cause mortality was higher in unconscious (49.5%) but not in conscious OHCA (8.9%) patients than in ACS patients (8.0%), and both unconscious and conscious OHCA patients were more likely than ACS patients to experience definite stent thrombosis (4.4% and 3.5% vs 1.3%) and Bleeding Academic Research Consortium 3 or 5 bleeding (17.8% and 9.0% vs 5.1%). The higher hazards were largely determined by events occurring in the first 30 days. After multivariable adjustment, only unconscious OHCA patients remained at increased risk of death (adjusted HR: 3.27; 95% CI: 2.65-4.05), definite stent thrombosis (adjusted HR: 2.40; 95% CI: 1.30-4.43), and Bleeding Academic Research Consortium 3 or 5 bleeding (adjusted HR: 2.51; 95% CI: 1.82-3.47) at 1 year.ConclusionsAt 1 year after PCI, unconscious OHCA patients were at higher risk of death, definite stent thrombosis, and bleeding, while conscious OHCA patients had similar hazards compared with an all-comer ACS population without OHCA. Dedicated PCI strategies for OHCA patients taking into account their state of consciousness after resuscitation are warranted.     

Incidence of inflammatory bowel disease in the province of Styria,Austria, from 1997 to 2007: A population-based study

BackgroundThe incidence of inflammatory bowel disease (IBD) varies widely between different countries. This large variation is also observed for the incidence of its main two forms, ulcerative colitis (UC) and Crohn's disease (CD). Controversy exists whether IBD incidence is increasing, especially in western countries. Currently no data are available for Austria. This study therefore aimed to evaluate for the first time the incidence of IBD over an eleven-year period in Styria, a province of Austria with a population of 1.2 million.MethodsAll patients with an initial diagnosis of IBD between 1997 and 2007, who were Styrian residents, were eligible for this retrospective study. Data were acquired from electronically stored hospital discharge reports and individual reports by patients and physicians. According to population density Styria was divided into two rural and one urban area.ResultsThroughout the study period 1527 patients with an initial diagnosis of IBD were identified. The average annual incidence was 6.7 (95% CI 6.2–7.1) per 100,000 persons per year for CD and 4.8 (95% CI 4.5–5.2) for UC. The average annual incidence increased significantly (p < 0.01) for both diseases during the 11 year study period. Median age at initial diagnosis was 29 years (range 3–87) for CD and 39 years (range 3–94) for UC. At diagnosis, 8.5% of all IBD patients were < 18 years of age. The incidence of both CD and UC was significantly higher in the urban area than in rural areas (CD: 8.8, 95% CI 7.8–9.8 versus 5.5, 95% CI 4.7–6.4 and 5.9, 95% CI 5.3–6.7; [p < 0.001]; UC: 5.8, 95% CI 5.1–6.6 versus 4.0, 95% CI 3.4–4.7 and 4.7, 95% CI 4.1–5.4; [p = 0.04]).ConclusionWe observed an overall increase in the incidence of ulcerative colitis and Crohn's disease in a part of Austria during an eleven year period. IBD was more predominant in the largest urban area than in rural areas.     

Performance of stent thrombosis and bleeding risk scores in out-of-hospital cardiac arrest due to acute coronary syndromes

BackgroundPatients with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI) are at high risk of bleeding and thrombosis. While predictive bleeding and stent thrombosis risk scores have been established, their performance in patients with OHCA has not been evaluated.MethodsAll consecutive patients admitted for OHCA due to ACS who underwent PCI between January 2007 and December 2019 were included. The ACTION and CRUSADE bleeding risk scores and the Dangas score for early stent thrombosis risk were calculated for each patient. A C-statistic analysis was performed to assess the performance of these scores.ResultsAmong 386 included patients, 82 patients (21.2%) experienced severe bleeding and 30 patients (7.8%) experienced stent thrombosis. The predictive performance of the ACTION and CRUSADE bleeding risk scores for major bleeding was poor, with areas under the curve (AUCs) of 0.596 and 0.548, respectively. Likewise, the predictive performance of the Dangas stent thrombosis risk score was poor (AUC 0.513). Using multivariable analysis, prolonged low-flow (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.05; P = 0.025), reduced haematocrit or fibrinogen at admission (OR 0.93, 95% CI 0.88–0.98; P = 0.010 and OR 0.61; 95% CI 0.41–0.89; P = 0.012, respectively) and the use of glycoprotein IIb/IIIa inhibitors (OR 2.10, 95% CI 1.18–3.73; P = 0.011) were independent risk factors for major bleeding.ConclusionThe classic bleeding and stent thrombosis risk scores have poor performance in a population of patients with ACS complicated by OHCA. Other predictive factors might be more pertinent to determine major bleeding and stent thrombosis risks in this specific population.     

Flow-Mediated Dilation Normalization Predicts Outcome in Chronic Heart Failure Patients

BackgroundReduced flow-mediated dilation (FMD) is a known prognostic marker in heart failure (HF), but may be influenced by the brachial artery (BA) diameter. Aiming to adjust for this influence, we normalized FMD (nFMD) by the peak shear rate (PSR) and tested its prognostic power in HF patients.Methods and ResultsBA diameter, FMD, difference in hyperemic versus rest brachial flow velocity (FVD), PSR (FVD/BA), and nFMD (FMD/PSR × 1000) were assessed in 71 HF patients. At follow-up (mean 512 days), 19 HF (27%) reached the combined endpoint (4 heart transplantations [HTs], 1 left ventricle assist device implantation [LVAD], and 14 cardiac deaths [CDs]). With multivariate Cox regression analysis, New York Heart Association functional class ≥III (hazard ratio [HR] 9.36, 95% confidence interval [CI] 2.11–41.4; P = .003), digoxin use (HR 6.36, 95% CI 2.18–18.6; P = .0010), FMD (HR 0.703, 95% CI 0.547–0.904; P = .006), PSR (HR 1.01, 95% CI 1.005–1.022; P = .001), FVD (HR 1.04, 95% CI 1.00–1.06; P = .02), and nFMD (HR 0.535, 95% CI 0.39–0.74; P = .0001) were predictors of unfavorable outcome. Receiver operating characteristic curve for nFMD showed that patients with nFMD >5 seconds had significantly better event-free survival than patients with nFMD ≤5 seconds (log-rank test: P < .0001).ConclusionsnFMD is a strong independent predictor of CD, HT, and LVAD in HF with left ventricular ejection fraction <40%. Patients with nFMD >5 seconds have a better prognosis than those with lower values.