Electrical storm is a medical emergency characterized by ventricular arrythmia recurrence that can lead to hemodynamic instability. The incidence of this clinical condition is rising, mainly in implantable cardioverter defibrillator patients, and its prognosis is often poor. Early acknowledgment, management and treatment have a key role in reducing mortality in the acute phase and improving the quality of life of these patients. In an emergency setting, several measures can be employed. Anti-arrhythmic drugs, based on the underlying disease, are often the first step to control the arrhythmic burden; besides that, new therapeutic strategies have been developed with high efficacy, such as deep sedation, early catheter ablation, neuraxial modulation and mechanical hemodynamic support. The aim of this review is to provide practical indications for the management of electrical storm in acute settings.
Background the neutrophil to lymphocyte ratio (NLR) is an indicator of systemic inflammation and a prognostic marker in patients undergoing percutaneous coronary intervention (PCI) that has been demonstrated to be related to in-hospital complications and long-term mortality in patients with ST segment elevation myocardial infarction (STEMI). Aims to assess the correlation between NLR and in-hospital complications and mortality, as well as long-term mortality in a population of oldest old (i.e. >85 years old) STEMI patients. Methods we enrolled every oldest old patient admitted in two Hub hospitals with a diagnosis of STEMI who underwent an invasive strategy (coronary angiography ± percutaneous coronary intervention) between January 2010 and June 2021. Blood samples were performed at the first medical contact (in the emergency room or in the cath-lab according to presentation). Follow-up data were collected with phone calls or with revision of computer registries. In-hospital MACCE was defined as a composite of death, heart failure, in-stent thrombosis, relapsing angina, stroke, BARC 3 to 5 bleedings during hospital stay. Results four hundred fifty-eight patients accessed the Hub hospitals for STEMI during the selected period. Among them, 355 patients were eligible for this analysis. One hundred fifty-five patients (44%) experienced an in-hospital MACCE. Patients with in-hospital MACCE had a significantly higher NLR at baseline (10,2±7,4 vs 7,0±4,7 p<0,001), this was also true when in-hospital mortality was considered per se (11,1±8,3 vs 8,0±5,8 p=0,002). Conclusions in our multicentre registry of oldest old STEMI patients, NLR has demonstrated to be an easy access, useful tool to predict in-hospital MACCE and in-hospital mortality.
Introduction Contrast-induced acute kidney injury (CI-AKI) is a well-known complication of ST-elevation acute myocardial infarction (STEMI) with an adverse impact on prognosis. Elderly patients are at higher risk for cardiovascular events. Moreover, renal function decreases with age. We sought to evaluate the incidence of CI-AKI in very elderly STEMI patients undergoing primary PCI (pPCI) and its impact upon outcomes in these patients. Methods We retrospectively evaluated all very elderly patients (i.e. age above 85 years) treated with pPCI for STEMI in two hub-centers between January 2010 and June 2021. We defined CI-AKI as a rise in serum creatinine of ≥0.30 mg/dL over baseline during the first 48h from procedure. Follow-up data were determined from local clinical records during a twelve-months period. Results Among 451 patients referred for STEMI at our institutions, 404 patients underwent pPCI. Overall, the incidence of CI-AKI was 16.3%. There was no significant age difference between CI-AKI and non CI-AKI groups (89.3 ± 2.9 vs 88.6 ± 2.7, p=0.11). Baseline features were similar except for higher prevalence of diabetes mellitus (31.1% vs 18.7%, p=0.03) and chronic kidney disease (CKD) (77% vs 25.7%, p< 0.01) in CI-AKI vs non CI-AKI group. CKD appeared to be strongly associated to higher risk of CI-AKI (OR 9.69, 95% CI: 5.0–18.5; p<0.01). Time-to-first composite MACE (all cause death, stroke, heart failure hospitalization) tended to be shorter without a significant difference between CI-AKI vs non CI-AKI group (252.3 vs 296.2 days, p=0.06) at one year follow-up, Conclusions Underlying CKD is strongly associated with CI-AKI in oldest-old STEMI patients. CI-AKI group had a nonsignificant trend toward a reduction in time-to-first MACE.
Introduction The balance between thrombotic and bleeding events after myocardial revascularization is of paramount importance. Patients with higher bleeding risk are at high risk for complications. Age and frailty are also major risk factors for complications. We sought to evaluate the incidence of major bleeding events (BE) and their impact on prognosis in a real life oldest old (i.e. >85 years) ST elevation myocardial infarction (STEMI) patients population. Methods We evaluated all consecutive oldest old STEMI patients hospitalized in two hub-centers between January 2010 and June 2021. Patients were stratified according to Academic Research Consortium for High Bleeding Risk (ARC-HBR) in high bleeding risk (HR) and non-HR (nHR) patients. BE were defined according to the Bleeding Academic Research Consortium (BARC) criteria, BARC 3 or 5. Patients were also divided in groups according to anti-thrombotic therapy (AT) regimens at discharge: single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus oral anticoagulation) (TT). Net adverse clinical event (NACE) was defined as a composite of all-cause mortality, myocardial infarction, stroke, or major bleeding. Follow-up data were determined from local clinical records during a twelve-months period. Results 340 oldest old (mean age 88.6 ± 2.9 years, 52.6% female) STEMI patients were eligible for the analysis. 161 patients (47.4%) were categorized as nHR and 179 patients (52.6%) as HR. AT regimens at discharge were: 28 patients with SAPT (8.2%), 276 with DAPT (81.2%) and 36 with TT (10.6%). The overall incidence of BE was 4.6% within 12 months, without difference between nHR and HR patients (3.0% vs 5.9%, p=0.16). No BE were found in the SAPT group while the incidence of BE in the HR group was not statistically different between the DAPT and TT regimens (11.2% vs 9.5%; p=0.8). The incidence of NACE was statistically higher in HR than nHR patients (40.9% vs 25.5%, p<0.01) at 1-year. In addition, time-to-NACE was statistically inferior in HR group than nHR group (256.2 days vs 294.2 days, p<0.01) (Figure). Conclusions Our oldest old STEMI population was characterized by a large proportion of HR patients according to ARC-HBR criteria. This population experienced a higher rate of NACE in a shorter time when compared to nHR patients in the same age group.
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