European Heart Journal: Acute Cardiovascular Care最新文献

Aims: Contemporary data on the impact of high-grade atrioventricular blocks (HAVB) in acute myocardial infarction (AMI) are scarce. Therefore, we investigated this in the Swiss national AMI registry (AMIS Plus) cohort.

Methods and results: We included all AMI patients enrolled from January 2005 to September 2024 with available ECG information. Primary outcome was in-hospital mortality; secondary outcomes included in-hospital major adverse cardiac or cerebrovascular events (MACCE) defined as cardiogenic shock, stroke, re-infarction or death. Among 50 279 AMI patients, 747 (1.5%) patients presented with HAVB and 407 (0.8%) developed HAVB during hospitalization. Patients presenting with HAVB had increased in-hospital mortality (15% vs. 4.9%; P < 0.001) and MACCE (17% vs. 6.0%; P < 0.001) compared with those without HAVB. High-grade atrioventricular blocks on admission was an independent predictor for in-hospital mortality (OR 1.89; 95% CI, 1.42-2.49; P < 0.001), with a stronger impact on mortality in the setting of anterior compared to non-anterior AMI (OR 3.69; 95% CI, 1.99-6.81; pinteraction = 0.02). Independent predictors for HAVB on admission included STEMI and female sex. Rates of permanent pacemaker implantation during hospitalization in patients with HAVB on admission were higher in NSTEMI than STEMI patients (20% vs. 4.4%; P < 0.001). High-grade atrioventricular blocks occurring during hospital stay was associated with higher mortality (20% vs. 15%; P = 0.031) and higher permanent pacemaker rate (25% vs. 8%; P < 0.001) than HAVB on admission.

Conclusion: High-grade atrioventricular blocks in AMI was associated with high in-hospital mortality, especially in anterior AMI or if occurring during hospitalization. Permanent pacemaker implantation was more frequent in the setting of NSTEMI and among patients developing HAVB during hospital stay.

Aims: A 0 and 2 h strategy using novel point-of-care high-sensitivity troponin I (POC hs-cTnI) measurements may provide rapid and accurate risk stratification for acute myocardial infarction (AMI) in the emergency department (ED) by reducing time to troponin results and improving clinical decision-making.

Methods and results: A prospective multicentre diagnostic accuracy study enrolled 1021 patients presenting to EDs with symptoms suggestive of AMI. POC hs-cTnI measurements were obtained from stored plasma samples at presentation (0 h) and 2 h later using the Abbott i-STAT® hs-TnI assay and compared with central laboratory assay results. A risk stratification algorithm was derived. The primary endpoint was AMI (type 1 and 2) or cardiac death during the index presentation. The primary safety endpoint was 30 day major adverse cardiac events (MACE), incorporating AMI and cardiac death. AMI was diagnosed in 80 patients (7.8%). When identifying low-risk patients, the 0/2 h strategy using the POC hs-cTnI assay demonstrated 98.8% sensitivity (95% CI: 93.2-100%) with an NPV of 99.9% (95% CI: 99.2-100%) for the primary endpoint. For high-risk patients, specificity was 97.7% (95% CI: 96.5-98.5) and PPV 74.7% (95% CI: 64.3-83.4%) for the primary endpoint. The protocol safely identified 66.7% of patients as low-risk within 2 h, with 6 low risk patients (0.9%) having a MACE diagnosis at 30 day follow-up.

Conclusion: A 0/2 h protocol using the Abbott i-STAT® hs-TnI assay safely risk stratified emergency patients with suspected ACS and had comparable performance to two central laboratory-based assays. The use of POC testing supports timely results and may improve the time to clinical decision-making.

Aims: There is no specifically developed model to predict the risk of major adverse cardiac events (MACEs) in patients with new-onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI). We aimed to develop and validate a prediction model for 5-year risk of MACE in patients with post-MI NOAF.

Methods and results: The derivation cohort comprised 457 patients, and the external validation cohort consisted of 206 patients between January 2014 and January 2022. Stepwise multivariable Cox regression analysis was used to identify candidate predictors and to establish the model for 5-year MACE prediction. Model performance was assessed using time-dependent area under the receiver-operating characteristic curve (AUC), C-index, and calibration curves. According to the stepwise multivariable Cox regression analysis, 7 variables were included in the prediction model (NOAFCAMI score): age, prior HF, Killip class, undergoing percutaneous coronary intervention, peak level of NT-pro BNP, AF burden, and symptomatic AF. The 5-year AUC was 0.83 [95% confidence interval (CI): 0.77 to 0.88]. Internal validation by optimism bootstrap-corrected C-index was 0.72 (95% CI: 0.68 to 0.76). External validation showed a 5-year AUC of 0.79 (95% CI: 0.69 to 0.89). The calibration of the NOAFCAMI score for 5-year MACE prediction was acceptable in the derivation [Brier score: 0.17 (95% CI: 0.15 to 0.19)] and the external validation [Brier score: 0.19 (95% CI: 0.16 to 0.22)] cohorts, respectively.

Conclusion: The NOAFCAMI score is the first externally validated prediction model to personalize MACE risk assessment in patients with post-MI NOAF, offering actionable insights for tailored management.

Aims: Out-of-hospital cardiac arrest (OHCA) represents a major public health challenge, with high mortality and significant neurological impairments among survivors. Haemodynamic instability, particularly hypotension (a mean arterial blood pressure <65 mmHg), may be a key contributor to post-resuscitation morbidity and mortality.

Methods and results: After return of spontaneous circulation, hypotension can result from various causes, including arrhythmias, mechanical complications, thromboembolism, or different types of shock, as well as sedation, temperature control and positive pressure ventilation. Differentiating between hypotension with vs. without hypoperfusion is critical to avoid unnecessary interventions while ensuring adequate cerebral and myocardial perfusion. Clinical assessment and repeated echocardiography should be routine in all patients. Therapeutic targets should include evidence of preserved end-organ function, including urine output, and normal or decreasing lactate. In selected cases, advanced haemodynamic monitoring with pulmonary artery catheters may be necessary to diagnose the shock-type and monitor treatment effects. Causal treatment of the precipitating cause of hypotension is crucial as well as symptomatic treatment with fluids, vasopressors and inotropes if needed. Mechanical circulatory support may be employed for refractory shock unresponsive to other treatment.

Conclusion: This clinical consensus statement by the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology (ESC) provides clinical guidance for the haemodynamic monitoring and management of hypotension in OHCA patients in intensive care. The document advocates for a multidisciplinary approach that integrates clinical assessment, imaging, and haemodynamic parameters to guide treatment, with the overarching goal of improving survival rates and neurological outcomes.

Mortality in severe forms of cardiogenic shock (CS) remains above 50%, despite substantial advances in mechanical circulatory support strategies that have enabled clinicians to manage levels of patient complexity once thought unattainable. A key obstacle to effectively implementing and individualizing these sophisticated treatments lies in the continued reliance on outdated safety monitoring strategies that apply uniform cut-off values to a limited set of clinical variables. Such approaches fail to account for the dynamic and patient-specific nature of "safe" hemodynamics. To overcome this, we propose an aviation-inspired safety framework, referred to by "the hemodynamic envelope", designed to continuously and automatically compute patient- and time-specific thresholds across nine interrelated dimensions. This framework defines a dynamic safety window analogous to the systems that transformed flight safety.