Background:Little is known about the effect of the coronavirus disease 2019 (COVID-19) pandemic and the outbreak response measures on door-to-balloon time (D2B). This study examined both D2B and ...clinical outcomes of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).Methods and Results:This was a retrospective study of 303 STEMI patients who presented directly or were transferred to a tertiary hospital in Singapore for PPCI from October 2019 to March 2020. We compared the clinical outcomes of patients admitted before (BOR) and during (DOR) the COVID-19 outbreak response. The study outcomes were in-hospital death, D2B, cardiogenic shock and 30-day readmission. For direct presentations, fewer patients in the DOR group achieved D2B time <90 min compared with the BOR group (71.4% vs. 80.9%, P=0.042). This was more apparent after exclusion of non-system delay cases (DOR 81.6% vs. BOR 95.9%, P=0.006). Prevalence of both out-of-hospital cardiac arrest (9.5% vs. 1.9%, P=0.003) and acute mitral regurgitation (31.6% vs. 17.5%, P=0.006) was higher in the DOR group. Mortality was similar between groups. Multivariable regression showed that longer D2B time was an independent predictor of death (odds ratio 1.005, 95% confidence interval 1.000–1.011, P=0.029).Conclusions:The COVID-19 pandemic and the outbreak response have had an adverse effect on PPCI service efficiency. The study reinforces the need to focus efforts on shortening D2B time, while maintaining infection control measures.
The pandemic has led to adverse short-term outcomes for patients with ST-segment elevation myocardial infarction (STEMI). It is unknown if this translates to poorer long-term outcomes. In Singapore, ...the escalation of the outbreak response on February 7, 2020 demanded adaptation of STEMI care to stringent infection control measures. A total of 321 patients presenting with STEMI and undergoing primary percutaneous coronary intervention at a tertiary hospital were enrolled and followed up over 1-year. They were allocated into three groups based on admission date—(1) Before outbreak response (BOR): December 1, 2019–February 6, 2020, (2) During outbreak response (DOR): February 7–March 31, 2020, and (3) control group: November 1–December 31, 2018. The incidence of cardiac-related mortality, cardiac-related readmissions, and recurrent coronary events were examined. Although in-hospital outcomes were worse in BOR and DOR groups compared to the control group, there were no differences in the 1-year cardiac-related mortality (BOR 8.7%, DOR 7.1%, control 4.8%, p = 0.563), cardiac-related readmissions (BOR 15.1%, DOR 11.6%, control 12.0%, p = 0.693), and recurrent coronary events (BOR 3.2%, DOR 1.8%, control 1.2%, p = 0.596). There were higher rates of additional PCI during the index admission in DOR, compared to BOR and control groups (p = 0.027). While patients admitted for STEMI during the pandemic may have poorer in-hospital outcomes, their long-term outcomes remain comparable to the pre-pandemic era.
Left ventricular vortex formation time (VFT) is a novel dimensionless index of flow propagation during left ventricular diastole, which has been demonstrated to be useful in heart failure and ...cardiomyopathy. In mitral stenosis (MS), flow propagation in the LV may be suboptimal. We studied VFT in varying degrees of MS. Echocardiography was performed on 20 healthy controls and 50 cases of rheumatic MS. Patients with atrial fibrillation, LV ejection fraction < 50% and other valvular heart diseases were excluded. VFT was obtained using the length-to-diameter ratio (L/D), where L is the continuous-wave Doppler velocity time integral stroke distance, divided by D, the mitral leaflet separation index. This was correlated against varying degrees of MS severity, left atrial (LA) volume and function. In controls, VFT was 3.92 ± 2.00 (optimal range) and was higher (suboptimal) with increasing severity of mitral stenosis (4.98 ± 2.43 in mild MS; 7.22 ± 2.98 in moderate MS; 11.55 ± 2.67 in severe MS, p < 0.001). VFT negatively correlated with mitral valve area (R
2
= 0.463, p < 0.001) and total LA emptying fraction (R
2
= 0.348, p < 0.001), and positively correlated with LA volume index (R
2
= 0.440, p < 0.001) and mean transmitral pressure gradient (R
2
= 0.336, p < 0.001). More severe MS correlated with suboptimal (higher) VFT. The restricted mitral valve opening may disrupt vortex formation and optimal fluid propagation in the LV. Despite the compensatory increase in LA size with increasingly severe MS, reduced LA function also contributed to the suboptimal LV vortex formation.
An increasing proportion of patients with acute myocardial infarction (AMI) are presenting without standard modifiable risk factors (SMuRFs) of hypertension, hypercholesterolemia, diabetes, and ...smoking, but with an unexpectedly increased mortality. This study examined the SMuRF-less patients presenting with AMI in a multiethnic Asian population.
We recruited patients presenting with AMI from 2011 to 2021 and compared the prevalence, clinical characteristics, and outcomes of SMuRF-less and SMuRF patients. Multivariable analysis was used to compare the outcomes of 30-day cardiovascular mortality, all-cause mortality, readmission, cardiogenic shock, stroke, and heart failure. Kaplan-Meier curves were constructed for 30-day cardiovascular mortality, with stratification by ethnicity, gender and AMI type, and 10-year all-cause mortality.
Standard modifiable risk factor-less patients, who made up 8.6% of 8,680 patients, were significantly younger with fewer comorbidities that include stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI: 1.09-1.86,
= 0.048), cardiogenic shock (RR: 1.31, 95% CI: 1.09-1.52,
= 0.015), and stroke (RR: 2.51, 95% CI: 1.67-3.34,
= 0.030) among SMuRF-less patients. A 30-day cardiovascular mortality was raised in the SMuRF-less group, with similar trends in men, patients with ST-segment elevation myocardial infarction (STEMI), and the three Asian ethnicities. All-cause mortality remains increased in the SMuRF-less group for up to 5 years.
There is a significant proportion of patients with AMI without standard risk factors in Asia, who have worse short-term mortality. This calls for greater focus on the management of this unexpectedly high-risk subgroup of patients.
Cardiogenic shock (CS) complicating myocardial infarction is associated with poor outcomes. Data among Asian populations are scarce. We aimed to investigate the long-term outcomes, prognostic ...factors, and predictors of CS among Asian ST elevation myocardial infarction (STEMI) patients.
This was a retrospective cohort study of consecutive patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI within our regional STEMI network between 2015 and 2019. The long-term outcomes of those with and without CS were compared. Clinical predictors of outcomes and development of CS were investigated.
A total of 1791 patients who underwent PPCI were included. Patients completed at least 2 years’ follow-up with a median follow-up period of 2.6 years (IQR 1.0, 3,9). Overall, 208/1791 (11.6 %) STEMI patients developed CS. These patients were older (61.1 ± 12.5 vs 57.8 ± 12.2, P < 0.001) and mostly men (87.0 %). All-cause mortality (59.9 % vs 4.7 % P < 0.001), cardiac mortality (43.8 % vs 2.2 %, P < 0.001) and major adverse cardiovascular events (MACE) was significantly higher in the CS group (59.1 % vs 14.0 %, P < 0.001). Independent predictors of survival were higher index LVEF (adjusted hazards ratio aHR 0.967, 95 %CI 0.951–0.984, p < 0.001) and higher arterial pH at onset of shock (aHR 0.750, 0.626–0.897, p = 0.002). Increased serum lactate concentration independently predicts poor prognosis (aHR 1.084, 95 % CI 1.046–1.124, p < 0.001).
In Asian STEMI patients who underwent PPCI, CS was associated with poor outcomes. Higher LVEF on index admission was associated with better outcomes; while lactic acidosis independently predicted mortality.
Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) mortality remains high despite revascularization and the use of the intra-aortic balloon pump (IABP). Advanced mechanical ...circulatory support (MCS) devices, such as catheter-based ventricular assist devices (cVAD), may impact mortality. We aim to identify predictors of mortality in AMI-CS implanted with IABP and the proportion eligible for advanced MCS in an Asian population.
We retrospectively analyzed a cohort of Society for Cardiovascular Angiography and Intervention (SCAI) stage C and above AMI-CS patients with IABP implanted from 2017-2019. We excluded patients who had IABP implanted for indications other than AMI-CS. Primary outcome was 30-day mortality. Binary logistic regression was used to calculate adjusted odds ratios (aOR) for patient characteristics.
Over the 3-year period, 242 patients (mean age 64.1 ± 12.4 years, 88% males) with AMI-CS had IABP implanted. 30-day mortality was 55%. On univariate analysis, cardiac arrest (
< 0.001), inotrope/vasopressor use prior to IABP (
= 0.004) was more common in non-survivors. Non-survivors were less likely to be smokers (
= 0.001), had lower ejection fraction, higher creatinine/ lactate and lower pH (all
< 0.001). On multi-variate analysis, predictors of mortality were cardiac arrest prior to IABP (aOR 4.00, CI 2.28-7.03), inotrope/vasopressor prior to IABP (aOR 2.41, CI 1.18-4.96), lower arterial pH (aOR 0.02, CI 0.00-0.31), higher lactate (aOR 2.42, CI 1.00-1.19), and lower hemoglobin (aOR 0.83, CI 0.71-0.98). Using institutional MCS criteria, 106 patients (44%) would have qualified for advanced MCS.
Early mortality in AMI-CS remains high despite IABP. Many patients would have qualified for higher degrees of MCS.
Sodium-glucose cotransporter 2-inhibitors, empagliflozin, have shown beneficial outcomes in reducing hospitalization and mortality in patients with heart failure. With its ability to reduce blood ...pressure, body mass index, and glycated haemoglobin (HbA1c), its addition along with the other guideline-directed management and therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF) will require adjustment of concomitant medications.
This study aimed to evaluate the GDMT utilization pattern in a multi-ethnic Singapore HFrEF population who were started on empagliflozin.
This is a single-center retrospective observational cohort study, conducted in a heart failure (HF) specialist outpatient clinic in a tertiary center in Singapore.
All patients aged 18 or more diagnosed with heart failure (HF) and diabetes between Jan 2015 and Dec 2019, who received their first dose of empagliflozin were recruited. Patients were followed-up for a year. Results A total of 37 patients were included in the final analysis. Empagliflozin was started at a median dose of 10mg daily, and was increased to a median of 25mg daily after 1 year. By the end of the study, 3 in 5 of the patients were receiving doses 50% or less than the recommended target. Eighty percent maintained their renal function stages, 14% deteriorated 1 or more stages while 6% improved by 1 stage. Fifty-seven percent were on 4 GMDT, and 43% were on at least 3 GDMT. Comparing these 2 groups, there were no significant difference between systolic blood pressure, body mass index, glycated haemoglobin, and estimated glomerular filtration rate. No significant difference was observed for cardiovascular- or heart failure-related hospitalization.
Findings from this preliminary study had provided a glimpse into the current GDMT utilization, involving empagliflozin in local population that is helpful in shaping clinical practice. Optimizing GDMT in HFrEF forms the main aim for HF medication management clinic. Its optimization should be correlated with clinical outcomes in future studies.
Isolated right ventricle infarction Woo, Jia Wei; Kong, William; Ambhore, Anand ...
Singapore Medical Journal/Singapore medical journal
60, Številka:
3
Journal Article
Recenzirano
Odprti dostop
We described two patients who were successfully resuscitated from out-of-hospital cardiac arrest. Their ECGs showed ST elevations in V1 and aVR, as well as diffuse ST depression. Their ST elevation ...in V1 was noted to be greater than in aVR. While one patient was found to have an occlusion of the right ventricular (RV) branch of the right coronary artery, the other was found to have an occlusion of a proximal non-dominant right coronary artery supplying the RV branch. Successful primary percutaneous coronary intervention was performed for each patient with angioplasty and implantation of a drug-eluting stent. Both patients made good physical and neurological recovery.
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