A significant decline in the admission to intensive cardiac care unit (ICCU) has been noted in Italy during the COVID-19 outbreak. Previous studies have provided data on clinical features and outcome ...of these patients, but information is still incomplete. In this multicenter study conducted in six ICCUs, we enrolled consecutive adult patients admitted to ICCU in three specific time intervals: from February 8 to March 9, 2020 before national lockdown (pre-LD), from March 10 to April 9, 2020 during the first period of national lockdown (in-LD) and from May 18 to June 17, 2020 soon after the end of all containment measures (after-LD). Compared to pre-LD, in-LD was associated with a significant drop in the admission to ICCU for all causes (− 35%) and acute coronary syndrome (ACS; − 49%), with a rebound soon after-LD. The in-LD reduction was greater for women (− 49%) and NSTEMI (− 61%) compared to men (− 28%) and STEMI (− 33%). Length-of-stay, and in-hospital mortality did not show any significant change from to pre-LD to in-LD in the whole population as well as in the ACS group. This study confirms a notable reduction in the admissions to ICCUs from pre-LD to in-LD followed by an increment in the admission rates after-LD. These data strongly suggest that people, particularly women and patients with NSTEMI, are reluctant to seek medical care during lockdown, possibly due to the fear of viral infection. Such a phenomenon, however, was not associated with a rise in mortality among patients who get hospitalization.
Sacubitril/valsartan (Sac/Val) reduces mortality in patients with heart failure with reduced ejection fraction (HFrEF) compared to enalapril. However, its effects on functional capacity remain ...uncertain; consequently, we sought to compare Sac/Val vs. standard medical therapy, in terms of effects on prognostically significant CPET parameters, in HFrEF patients during a long follow-up period. We conducted a single-center, observational study in an HF clinic; specifically, we retrospectively identified that 12 patients switched to Sac/Val and 13 patients that managed with standard, optimal medical therapy (control group). At each visit, baseline, and follow-up (median time: 16 months; IQ range: 11.5-22), we collected demographic information, medical history, vital signs, cardiopulmonary exercise testing, standard laboratory data, pharmacological treatment information, and echocardiographic parameters. The study's primary end-point was the change from baseline in peak VO
(adjusted to body weight). We did not observe significant differences between the two study groups at baseline. Similarly, we did not observe any significant differences during the follow-up in mean values of peak VO
corrected for body weight: Sac/Val baseline: 12.2 ± 4.6 and FU: 12.7 ± 3.3 vs. control group: 13.1 ± 4.2 and 13.0 ± 4.2 mL/kg/min;
= 0.49. No significant treatment differences were observed for changes in VE/VCO
slope: Sac/Val baseline: 35.4 ± 7.4 and FU: 37.2 ± 13.1 vs. control group: 34.6 ± 9.1 and 34.0 ± 7.3;
= 0.49. In conclusion, after a median follow-up period of 16 months, there was no significant benefit of Sac/Val on peak VO
and other measures of CPET compared with standard optimal therapy in patients with HFrEF.
Abstract Background Elderly patients display higher on clopidogrel platelet reactivity as compared to younger patients. Treatment with prasugrel 5 mg has been shown to provide more predictable and ...homogenous antiplatelet effect, as compared to clopidogrel, suggesting the possibility of reducing ischemic events after an acute coronary syndrome (ACS) without increasing bleeding. Study design The Elderly-ACS 2 study is a multicenter, randomized, parallel-group, open-label trial designed to demonstrate the superiority of a strategy of dual antiplatelet treatment using a reduced 5 mg daily dose of prasugrel over a standard strategy with a daily clopidogrel dose of 75 mg in patients >74 years of age with ACS (either ST- or non ST-elevation myocardial infarction) undergoing early percutaneous revascularization. The primary endpoint is the composite of all-cause mortality, myocardial re-infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year. Taking advantage of the planned size of 2000 patients, the secondary objective is to assess the prognostic impact of selected pre-randomization variables (age, sex, diabetic status, serum creatinine level, ECG changes, abnormal troponin levels, basal and residual SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery SYNTAX score). Conclusion The Elderly-ACS 2 study is a multicenter, randomized trial comparing a strategy of dual antiplatelet therapy with a reduced dose of prasugrel with a standard dose of clopidogrel in elderly patients with ACS undergoing percutaneous revascularization. (The Elderly ACS 2 trial: NCT01777503 )
Aims
The angiotensin receptor‐neprilysin inhibitor (ARNI) sacubitril/valsartan (Sac/Val) demonstrated to be superior to enalapril in reducing hospitalizations, cardiovascular and all‐cause mortality ...in patients with ambulatory heart failure and reduced ejection fraction (HFrEF), in particular when it is maximally up‐titrated. Unfortunately, the target dose is achieved in less than 50% of HFrEF patients, thus undermining the beneficial effects on the outcomes. In this study, we aimed to evaluate the role of Sac/Val and its titration dose on reverse cardiac remodelling and determine which echocardiographic index best predicts the up‐titration success.
Methods and results
From January 2020 to June 2021, we retrospectively identified 95 patients (65.6 59.1–72.8 years; 15.8% females) with chronic HFrEF who were prescribed Sac/Val from the HF Clinics of 5 Italian University Hospitals and evaluated the tolerability of Sac/Val high dose (the ability of the patient to achieve and stably tolerate the maximum dose) as the primary endpoint in the cohort. We used a multivariable logistic regression analysis, with a stepwise backward selection method, to determine the independent predictors of Sac/Val maximum dose tolerability, using, as candidate predictors, only variables with a P‐value < 0.1 in the univariate analyses. Candidate predictors identified for the multivariable backward logistic regression analysis were age, sex, body mass index (BMI), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), dyslipidaemia, atrial fibrillation, systolic blood pressure (SBP), baseline tolerability of ACEi/ARBs maximum dose, left ventricle global longitudinal strain (LVgLS), LV ejection fraction (EF), tricuspid annulus plane systolic excursion (TAPSE), right ventricle (RV) fractional area change (FAC), RV global and free wall longitudinal strain (RVgLS and RV‐FW‐LS). After the multivariable analysis, only one categorical (ACEi/ARBs maximum dose at baseline) and three continuous (younger age, higher SBP, and higher TAPSE), resulted significantly associated with the study outcome variable with a strong discriminatory capacity (area under the curve 0.874, 95% confidence interval (CI) (0.794–0.954) to predict maximum Sac/Val dose tolerability.
Conclusions
Our study is the first to analyse the potential role of echocardiography and, in particular, of RV dysfunction, measured by TAPSE, in predicting Sac/Val maximum dose tolerability. Therefore, patients with RV dysfunction (baseline TAPSE <16 mm, in our cohort) might benefit from a different strategy to titrate Sac/Val, such as starting from the lowest dose and/or waiting for a more extended period of observation before attempting with the higher doses.
Aims
The present analysis from the multicentre prospective Altshock‐2 registry aims to better define clinical features, in‐hospital course, and management of cardiogenic shock complicating acutely ...decompensated heart failure (ADHF‐CS) as compared with that complicating acute myocardial infarction (AMI‐CS).
Methods and results
All patients with AMI‐CS or ADHF‐CS enrolled in the Altshock‐2 registry between March 2020 and February 2022 were selected. The primary objective was the characterization of ADHF‐CS patients as compared with AMI‐CS. In‐hospital length of stay and mortality were secondary endpoints. One‐hundred‐ninety of the 238 CS patients enrolled in the aforementioned period were considered for the present analysis: 101 AMI‐CS (80% ST‐elevated myocardial infarction and 20% non‐ST‐elevated myocardial infarction) and 89 ADHF‐CS. As compared with AMI‐CS, ADHF‐CS patients were younger 63 (IQR 59–76) vs. 67 (IQR 54–73) years, P = 0.01, but presented with higher creatinine 1.6 (IQR 1.0–2.6) vs. 1.2 (IQR 1.0–1.4) mg/dL, P < 0.001, bilirubin 1.3 (IQR 0.9–2.3) vs. 0.6 (IQR 0.4–1.1) mg/dL, P = 0.01, and central venous pressure values 14 mmHg (IQR 8–12) vs. 10 mmHg (IQR 7–14),P = 0.01. Norepinephrine was the most common catecholamine used in AMI‐CS (79.3%), whereas epinephrine was used more commonly in ADHF‐CS (65.5%); 75.8% vs. 46.6% received a temporary mechanical support in AMI‐CS and ADHF‐CS, respectively (P < 0.001). Length of hospital stay was longer in the latter 28 (IQR 13–48) vs. 17 (IQR 9–29) days, P = 0.001. Heart replacement therapies were more frequently used in the ADHF‐CS group (heart transplantation 13.5% vs. 0% and left ventricular assist device 11% vs. 2%, P < 0.01 and 0.01, respectively). In‐hospital mortality was 41.1% (38.6% AMI‐CS vs. 43.8% ADHF‐CS, P = 0.5).
Conclusions
ADHF‐CS is characterized by a higher prevalence of end‐organ and biventricular dysfunction at presentation, a longer hospital length of stay, and higher need of heart replacement therapies when compared with AMI‐CS. In‐hospital mortality was similar between the two aetiologies. Our data warrant development of new management protocols focused on CS aetiology.
Background
The CHA2DS2‐VASc score predicts stroke in patients with atrial fibrillation and has been reported to have a prognostic role even in acute coronary syndrome patients. The Takotsubo syndrome ...is a condition that mimics acute coronary syndrome and may present several complications including stroke. We sought to assess the ability of CHA2DS2‐VASc score to predict adverse events in Takotsubo syndrome patients.
Methods and Results
Overall, 371 Takotsubo syndrome patients were enrolled in a prospective registry. Patients were divided into 3 groups according to the CHA2DS2‐VASc score: Group A (≤1), B (2–3), and C (≥4). The median CHA2DS2‐VASc score was 3 (interquartile range: 2–4). Overall, 9%, 42%, and 49% were included in Group A, B, and C, respectively. Follow‐up length was 26±20 months. The mortality rate was 6%, 7%, and 17% in Group A, B, and C, respectively (P=0.011). The stroke rate was 3% and not different among the 3 groups. Estimated major adverse cardiac and cerebrovascular events (the composite of death, myocardial infarction, and stroke) rates in the 3 groups were 6%, 9%, and 17% in Group A, B, and C, respectively (P=0.033). The CHA2DS2‐VASc score resulted as a predictor of major adverse cardiac and cerebrovascular events (odds ratio 2.1, 95% confidence interval, 1.2–3.6; P=0.01) and all‐cause mortality (odds ratio 1.5, 95% confidence interval, 1.2–1.9; P=0.001).
Conclusions
In Takotsubo syndrome, the CHA2DS2‐VASc score allows prediction of cardiovascular events and mortality at long‐term follow‐up.
The residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The ...aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events.
A post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS.
Event rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit.
In elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS.
Le fardeau résiduel de la coronaropathie après une intervention coronarienne percutanée (ICP) a été associé à de moins bons résultats sur le plan ischémique. Les données recueillies chez les patients âgés sont toutefois contradictoires. Cette étude avait donc pour objectif de valider la valeur ajoutée du score SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) résiduel (SSr) par rapport aux paramètres cliniques et au score SYNTAX initial (SSi) pour prédire la mortalité à 1 an et les manifestations cardiovasculaires.
Une analyse a posteriori des données de l’étude multicentrique avec répartition aléatoire Elderly-ACS 2 a été effectuée. Pour ce faire, 630 patients âgés de plus de 75 ans, atteints d’une coronaropathie multitronculaire et ayant subi une ICP pour traiter un syndrome coronarien aigu (SCA) ont été retenus. Le critère d’évaluation principal était composé du décès, de l’infarctus du myocarde récurrent et de l’accident vasculaire cérébral (AVC) au moment du suivi à 1 an. La variation de la statistique C et le bénéfice net normalisé ont servi à évaluer la valeur ajoutée du SSr.
Les manifestations étaient significativement plus fréquentes chez les patients dont la revascularisation était incomplète (SSr > 8). Lorsque le SSr a été pris en compte dans un modèle de régression de Cox de base ayant pour facteurs l’âge, les antécédents d’infarctus du myocarde et le type de SCA, le rapport des risques instantanés pour les patients ayant un score > 8 était de 2,47 (intervalle de confiance à 95 % : 1,51-4,06). L’intégration du SSr dans le modèle de base n’a toutefois pas donné lieu à une statistique C plus élevée que celle du SSi (0,70 vs 0,69) et conférait peu de valeur ajoutée sur le plan du bénéfice net normalisé.
Chez les patients âgés présentant un SCA et une atteinte multitronculaire, et subissant une ICP, la revascularisation incomplète a été associée à de moins bons résultats au moment du suivi à 1 an. Le SSr n’a toutefois pas été clairement associé à une valeur ajoutée pour prédire une issue défavorable à 1 an comparativement à un modèle reposant sur des paramètres cliniques et le SSi.
Pheochromocytoma can occur with a variety of cardiovascular signs and symptoms, and this tumor can also precipitate an acute heart failure associated with the typical clinical and instrumental ...findings of myocarditis. This peculiar etiology of acute myocarditis, known as “adrenergic myocarditis,” should be suspected when specific “red flags” of pheochromocytoma such as headache, palpitations, diaphoresis, hypertension, orthostatic hypotension, and left ventricular dysfunction suggesting Takotsubo syndrome are detected. In fact, its diagnosis allows a specific targeted therapy.
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