Funding Acknowledgements Type of funding sources: None. Background Differences in outcome between men and women among patients with acute myocardial infarction (AMI) have previously been investigated[1–4], while evidence concerning sex differences in patients with AMI complicated by cardiogenic shock (AMICS) is limited. Purpose The aim of this study was to investigate sex differences in patients with AMICS related to demographics, treatment and long-term outcome. Methods All adult patients (age ≥18 years) with AMICS hospitalized at one of two tertiary heart centers with a catchment area corresponding to 4 million citizens were included in this study. In the study period from January 1st, 2010 to December 31st, 2017, a total of 1716 AMICS patients were identified following individual validation. Data regarding patient characteristics, treatment and clinical outcome including short-term follow-up were extracted from medical records and an 8,5-year long-term follow-up were obtained from the national patients registry. A multivariate cox regression model was used to adjust for significant sex differences known to be associated with outcome in AMICS including age and an out-of-hospital cardiac arrest (OHCA) presentation. Results Of the 1716 included AMICS patients, 438 (26%) were women. Women were older than men, 71±12 years and 66±11 years, P=<0.0001, respectively. Patients characteristics were similar between sex except for hypertension which was more common among women. Women were more often initially admitted to a local hospital (41% women and 30% men, P=<0.0001), while more men presented with OHCA (25% women and 48% men, P=<0.0001), which persisted after adjustment for age. At the time of shock development, women and men were comparable regarding blood pressure (mean: both 82 mmHg, P=0.44), heart rate (mean: 88 vs. 85 bpm, P=0.10), p-lactate (median: 5.2 vs. 5.5 mM, P=0.07), and left ventricular ejection fraction (median: both 30%, P=0.11). However, fewer women were treated with mechanical circulatory support (19% women and 26% men, P=0.002), which persisted following multivariate adjustment. Additionally, women were associated with a lower use of acute revascularization (83% women and 88% men, P=0.006) including percutaneous coronary intervention (n=1405) and coronary artery bypass graft (n=101) and mechanical ventilation (67% women and 82% men, P=<0.0001). These significant signals did not remain following cox regression analysis. Women had a significantly higher short-term as well as long-term mortality rate, which persisted in the multivariate model (Figure 1). Conclusion Women were associated with lower use of mechanical circulatory support devices among AMICS patients. Women had a significantly higher short- and long-term mortality rate compared to men.
Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Righospitalets Forskningsfond (07IO) Lundbeck Foundation (R186-2015-2132). Background Neurohormonal activation and inflammation is associated with mortality in STEMI patients. We sought to assess, whether AFIB – a known risk factor in MI – also was associated with increased 1-year mortality as well as neurohormonal activation and inflammation in STEMI patients. Methods In 1892 consecutive STEMI patients from two danish tertiary heart centers biomarkers reflecting neurohormonal activation (copeptin, pro-atrial natriuretic peptide (proANP), and mid-regional pro-adrenomedullin (MRproADM)) and inflammation (ST2) was measured. Patients were stratified according to known AFIB or new onset AFIB on admission vs no AFIB. Results In total, 198 (10%, 100 known/98 new onset) patients had AFIB, which was associated with increased 1-year mortality (19% vs. 8.4%, p<0.0001). Patients with AFIB were older (mean (SD) age 70 (13) vs 63 (13) years, p<0.0001), had more comorbidity (e.g. hypertension 61% vs. 43%, p<0.0001; stroke 13% vs 6.4%, p=0.002; heart failure 11% vs 2.3%, p<0.0001), lower left ventricular ejection fraction (LVEF) (mean (SD) 41 (13) vs 45 (13), p<0.0001), were more often comatose after cardiac arrest (12% vs 6%, p=0.001), and in cardiogenic shock (CS) (20% vs 9.1%, p<0.0001). Plasma concentration (median (IQR)) of all four biomarkers were higher in AFIB patients (copeptin 124 (39; 298) vs 66 (21; 170) pmol/L; proANP 1678 (1018; 2439) pmol/L; MRproADM 0.96 (0.76; 1.41) vs 0.70 (0.58; 0.90) nmol/L; ST2 48 (34; 74) vs 39 (29; 55) ng/ml, p<0.0001 for all). When adjusting for age, sex, hypertension, previous stroke, LVEF, CS, and being comatose after cardiac arrest, AFIB remained associated with increased plasma concentration of all four biomarkers (two-fold increase – OR (95% CI): Copeptin 1.21 (1.02-1.23); proANP 2.22 (1.82-2.72); MRproADM 2.01 (1.56-2.60); ST2 1.21 (1.03-1.43)). Conclusion AFIB in STEMI patients is associated with increased admission biomarkers reflecting neurohormonal activation and inflammation and 1-year mortality.
HT), early-and long-term outcomes, and risk factors for need of VA-ECMO and for early mortality in these patients. Methods: We included 135 adult heart recipients who met the criteria of the last ISHLT definition for GD from 3 cardiac centers over a 10-year period. Pre-transplant, intra-operative, post-transplant, and donor characteristics were analyzed and compared between GD recipients treated with (n=66) or without VA-ECMO (n=69). Multivariate analysis for the need of VA-ECMO and hospital mortality were performed. The mean follow-up was 66.2 §45 months and was 100% complete. Results: The overall incidence of GD (30%) and of VA-ECMO use increased over time. We did not identify any predictive factors for VA-ECMO use, but patients who required VA-ECMO had higher serum lactate levels and higher inotrope doses after HT. In the medical and VA-ECMO groups, the overall survival rates were 83% and 42% at 1 year, and 78% and 40% at 5 years, respectively. Delayed implantation of VA-ECMO and post-operative bleeding were strongly associated with increased hospital mortality. Conclusion:The incidence of GD increased over the time, and the need of VA-ECMO for patients with GD remains difficult to predict. The early mortality decreased over the time but remains high in patients who required VA-ECMO, especially in patients with a delayed implantation.
Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Unrestricted research grant from Abiomed Background No strong evidence exists regarding the treatment of cardiogenic shock (CS) caused by acute right ventricular (RV) failure which has mainly consisted of vasoactive drugs. There is expert agreement that treatment with the recently developed Impella RP is feasible, but no previous studies have compared vasoactive treatment strategies with the Impella RP in terms of cardiac unloading and end-organ perfusion. Hypothesis Treatment with the Impella RP device will be associated with lower RV myocardial workload (pressure-volume area) compared to vasoactive treatment strategies and can furthermore be achieved without compromising organ perfusion. Methods CS was induced by a stepwise injection of polyvinyl alcohol microspheres into the right coronary artery in twenty adult female Danish landrace pigs weighing 75-80 kg. After induction of CS, the pigs were allocated to one of the two interventions for 180 minutes: 1) vasoactive therapy comprised a continuous infusion of norepinephrine (0.1 µg/kg/min) for the first 30 minutes, supplemented by an infusion of milrinone (0.4 µg/kg/min) for the remaining 150 minutes or 2) immediate insertion of and treatment with the Impella RP. The results are presented as median [Q1;Q3]. Results Treatment with the Impella RP was associated with a lower RV workload compared to the vasoactive group, while no difference was observed with regards to left ventricular workload among intervention groups, Figure 1. Renal venous oxygen saturation increased to a similar degree following both interventions compared to the state of CS. A trend towards a higher cerebral venous oxygen saturation was observed with norepinephrine compared to Impella RP (Impella RP 51 [47;61] % vs Norepinephrine 62 [57;71] % ; p = 0.07), which became significantly higher with the addition of milrinone (Impella RP 45 [32;63] % vs Norepinephrine +Milrinone 73 [66;81] %; p = 0.002). Conclusion In this large animal model of profound CS caused by predominantly RV failure the Impella RP unloaded the failing RV. The vasoactive treatment, however, caused a higher cerebral venous oxygen saturation, while both interventions increased renal venous oxygen saturation to a similar degree. Abstract Figure 1
Introduction Cardiogenic shock (CS) due to myocardial infarction (MI) carries 30-day mortality rates as high as 50%. The vast majority of study cohorts assessing mortality in CS comprise both patients presenting with and without out-of-hospital cardiac arrest (OHCA). Patients with and without OHCA are likely to represent two distinctive entities, which may be problematic to combine in an intervention trial. Purpose The aim of the study was to compare CS due to MI patients presenting with and without OHCA in terms of patient characteristics and outcome. Methods In the period from 2010–2017 all patients admitted at two tertiary heart centres in Denmark with CS following MI were individually identified and validated through patient records. The two centres have a catchment area of 3.9 million citizens corresponding to two-thirds of the Danish population. Results A total of 1716 CS patients were identified, of which 42% presented with OHCA. OHCA patients were younger (mean 63 vs 67 years), more frequently male (85 vs 67%), had higher lactate concentration (median 6.2 vs 5.0 mmol/L) on admission and higher left ventricular ejection fraction (median 30 vs 25%) compared to patients without OHCA (p<0.0001 for all). Patients presenting with OHCA had lower 30-day mortality compared to patients without OHCA (49% vs. 57%, respectively, plogrank<0.0001, Figure). Cause of in hospital death differed markedly between the two groups. Not surprisingly, anoxic brain damage was the leading cause of in hospital death in the OHCA group (56%) and only seen in 4% of patients without OHCA. In contrast, cardiac failure was the main cause of death in hospital death among patients without OHCA (60%), compared to 27% in patients with OHCA (p<0.0001). Figure 1 Conclusion Among patients with CS due to MI, overall 30-day mortality was significantly lower in patients presenting with OHCA. Anoxic brain damage was the main cause of in hospital death among OHCA patients, whereas fatal heart failure prevailed in patients without OHCA. Combining these two groups in a single trial with one specific intervention seems inappropriate and likely to cause an imbalance in the signal-to-noise ratio. Acknowledgement/Funding The Danish Heart Foundation and a research grant from Abiomed
Funding Acknowledgements Type of funding sources: None. Introduction Invasive mechanical ventilation (IMV) provides up to a 30% reduction in cardiac output requirements and is frequently used in patients with cardiogenic shock following acute myocardial infarction (AMICS). However, practice of IMV in the setting of AMICS is sparsely described. Purpose The aim was to evaluate the use of IMV in a contemporary cohort of patients with AMICS. Methods Between 2010 and 2017, all adult AMICS patients admitted to two tertiary heart centres, providing AMICS care for two thirds of the Danish population, were individually identified through patient records. Temporal changes in application of IMV were registered as well as patient characteristics. Real-time electronic ICU data were available for a subset of mechanically ventilated ICU patients (n=566), and were retrieved for the first 24 hours of IMV, following ICU admission, and described in relation to 30-day survival and the presence of out-of-hospital cardiac arrest (OHCA). Results A total of 1716 AMICS patients were retrospectively identified, of which 1274 (74%) received IMV during ICU admission (IMV-ICU). The proportion of IMV increased from 70% in 2010 to 78% in 2017. IMV-ICU patients were younger (67 vs 76 years), more frequently male (79% vs 61%), and more likely to have OHCA (54% vs 3%) and higher lactate at diagnosis of cardiogenic shock (5.8 vs 4.1 mmol/L) compared with non-intubated patients (p for all<0.001). Among IMV-ICU patients, 69% were intubated in the prehospital setting, of which three quarters presented with OHCA. Median PaO2 and PCO2 were both within normal ranges among 30-day survivors and non-survivors. However, non-survivors required 10-25% higher median fraction of inspired oxygen (p<0.001; FiO2), positive-end-expiratory pressure (p=0.002; PEEP), and minute ventilation (p<0.001; MV). Differences in IMV settings were mainly driven by non-survivors without OHCA (see table). Conclusion In a contemporary cohort of patients with AMICS, use of IMV increased during the observation period from 2010 to 2017. Observations did not reveal any association between 30-day mortality and IMV parameters in OHCA-patients, whereas FiO2, PEEP, and MV were significantly elevated in 30-day non-survivors without OHCA.
Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Lundbeck Foundation OnBehalf Critical Cardiac Care Research Group Background Approximately half of all patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) present with out-of-hospital cardiac arrest (OHCA). Cardiogenic shock due to OHCA is caused by abrupt cessation of circulation, whereas AMICS without OHCA is due to cardiac failure with low cardiac output. Thus, there may also be differences between the two conditions in terms of blood borne biomarkers. Purpose To explore the potential differences in the admission plasma concentrations of biomarkers reflecting tissue perfusion (lactate), neuroendocrine response (mid-regional proadrenomedullin [MRproADM], Copeptin, pro-atrial natriuretic peptide [proANP]), endothelial damage (Syndecan-1, soluble thrombomodulin [sTM]), inflammation (soluble suppression of tumorigenicity 2 [sST2]) and kidney injury (neutrophil gelatinase-associated lipocalin [NGAL]), in patients with AMICS presenting with or without OHCA. Method Consecutive patients admitted for acute coronary angiography due to suspected ST-elevation myocardial infarction (STEMI) were enrolled during a 1-year period. A total of 2,713 patients were screened. In the present study 86 patients with confirmed STEMI and CS at admission were included. Results Patients with OHCA (had significantly higher median admission concentrations of Lactate (6,9 mmol/L vs. 3.4 mmol/L p <0.001), NGAL (220 ng/ml vs 150 ng/ml p = 0.046), sTM (10 ng/ml vs. 8.0 ng/ml p = 0.026) and Syndecan-1 (160 ng/ml vs. 120 ng/ml p= 0.015) and significantly lower concentrations of MR-proADM (0.85 nmol/L vs. 1.6 nmol/L p <0.001) and sST2 (39 ng/ml vs. 62 ng/ml p < 0.001). After adjusting for age, sex, and time from symptom onset to coronary angiography, lactate (p = 0.008), NGAL (p = 0.03) and sTM (p = 0.011) were still significantly higher in patients presenting with OHCA while sST2 was still significantly lower (p = 0.029). There was very little difference in 30-day mortality between the OHCA and non-OHCA groups (OHCA 37% vs. non-OHCA 38%). Conclusion Patients with STEMI and CS at admission with or without concomitant OHCA had similar 30-day mortality but differed in terms of Lactate, NGAL, sTM and sST2 levels at the time of admission to catheterization laboratory. These findings propose that non-OHCA and OHCA patients with CS could be considered as two individual clinical entities. Abstract Figure. Level of biomarkers OHCA vs. non-OHCA
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