European Heart Journal: Acute Cardiovascular Care最新文献

Background: Platelet function testing (PFT)-guided de-escalation of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) has been shown to reduce bleeding risk without increasing ischemic events. Patients with high atherothrombotic risk (ATR) remain a challenging subgroup for such strategies. This study evaluated the safety and efficacy of early PFT-guided DAPT de-escalation according to ATR status.

Methods: In the TROPICAL-ACS trial, 2,610 ACS patients were randomized to standard 12-month prasugrel therapy or PFT-guided DAPT de-escalation. For this post hoc analysis, patients were stratified by ATR. High ATR was defined as age ≥65 years, polyvascular disease, or ≥2 risk factors (diabetes, smoking, or renal dysfunction). Hazard ratios (HR) for clinical endpoints were derived using multistate Cox regression.

Results: High-ATR patients (n=990) had a higher incidence of the primary net clinical benefit endpoint-composite of cardiovascular death, myocardial infarction, stroke, or BARC 2-5 bleeding-compared with low-ATR patients (n=1,620) (11.0% vs. 6.7%; HR 1.67, 95% CI 1.28-2.18; p<0.001). PFT-guided de-escalation showed no significant interaction by ATR status for the primary endpoint (high-ATR: 10.5% vs. 11.5%, HR 0.90 [0.61-1.32], p=0.586; low-ATR: 5.6% vs. 7.7%, HR 0.71 [0.48-1.04], p=0.082; p_interaction=0.394) or ischemic events (high-ATR: 3.7% vs. 4.4%, HR 0.83 [0.44-1.56]; low-ATR: 1.8% vs. 2.6%, HR 0.68 [0.35-1.34]; p_interaction=0.666).

Conclusion: Early PFT-guided de-escalation from prasugrel to clopidogrel was safe across atherothrombotic risk categories, supporting individualized DAPT optimization in ACS patients with both low and high ischemic risk.

Background: Multidisciplinary pulmonary embolism response teams (PERT) are being established in hospitals worldwide to address the increasing complexity in acute PE management.

Aim: To identify recent trends in PERT decisions regarding advanced treatment of acute severe PE.

Methods: We analysed data from the prospective multicentre PERTTM Consortium registry (years 2018-2024), focusing on catheter-directed treatment (CDT) and including systemic thrombolysis, surgical embolectomy, and extracorporeal membrane oxygenation (ECMO). An age-, sex-, and PE risk-matched population from the US Nationwide Inpatient Sample (NIS) was used for comparison.

Results: Among 11,436 patients enrolled at 51 sites (median age, 65 years; 13.7% high-risk and 62.5% intermediate-risk PE), 2,639 (23.1%) underwent CDT. Of those, 140 (5.3%) underwent catheter-directed thrombolysis without ultrasound, 851 (32.2%) ultrasound-assisted catheter thrombolysis, and 1,534 (58.1%) mechanical thrombectomy/aspiration. Systemic thrombolysis was used in 5.6%, surgical embolectomy in 1.1%, and ECMO in 1.6% of all patients. Trends of CDT increased over time (+0.36% quarterly by linear regression; P=0.002), with increase in mechanical thrombectomy (+0.83%; P<0.001) and decrease in catheter-directed thrombolysis (-0.4%; P=0.001). Matching 10,883 patients from the PERTTM Consortium registry to the NIS population, we found a 22% (95% CI, 21-23%) standardized mean difference in CDT use, 1.3% (0.6-2.0%) lower in-hospital mortality, and 0.75 (0.2-1.3) less days of hospital stay among PERTTM Consortium registry patients.

Conclusion: In a national quality assurance database of patients with PE included in the PERT registry, the use of catheter-directed treatment increased over time. Compared with a nationwide NIS sample, these patients had lower in-hospital mortality and shorter hospital length of stay.

Suboptimal care for ST-elevation myocardial infarction (STEMI) in low- and middle-income countries is a significant problem. Registries from Latin America, Africa, and Asia show that <65% of patients receive reperfusion therapy, and widespread treatment delays and a lack of access to optimal therapies lead to preventable deaths and complications. While current guidelines provide a blueprint for care, their implementation in low-resource settings requires specific guidance that considers geographical, logistical, and economic realities. This clinical consensus offers a new framework for developing STEMI care systems in these countries. We propose a flexible, three-model pathway, based on the initiatives such as STEMI India and Stent - Save a Life. The models include a fibrinolysis model, a pharmaco-invasive strategy model, and a primary percutaneous coronary intervention (PCI) model. This approach emphasizes adaptability, allowing local STEMI systems to be tailored to specific circumstances. The framework also addresses specific, common challenges, such as delayed access to primary PCI, reperfusion in patients with cardiogenic shock and expected delayed PCI, fibrinolysis in patients with a high risk of bleeding, and the absence of fibrin-specific fibrinolytics, catheterization labs, or reperfusion therapies at all. The consensus also highlights the importance of continuous improvement, patient education, and adopting secondary prevention strategies. Ultimately, this framework is designed to help healthcare providers and leaders in developing countries improve their regional STEMI care systems.

Aims: Limited data are available regarding aetiology, clinical characteristics, and prognosis of coronary embolism (CE). This study aimed to describe the clinical features of embolic myocardial infarction (MI) and compare them with non-embolic MI.

Methods and results: All admissions for acute MI in a single tertiary centre between January 2010 and December 2023 were reviewed. Coronary embolism was diagnosed by established criteria. Among 8160 patients, 89 (1.1%) were diagnosed with CE. The most common attributable cause was atrial fibrillation (AF) (52.8%), followed by prosthetic valve thrombosis (11.2%) and endocarditis (7.9%). Compared with the remaining patients, those with CE were more frequently female, had a lower prevalence of cardiovascular risk factors, and presented more often with ST-segment elevation (79.8 vs. 58.6%, P < 0.001). Coronary embolism patients had a high frequency of unsuccessful reperfusion and higher rates of mechanical complications (5.6 vs. 2.2%, P = 0.031) and strokes/transient ischaemic attacks (6.7 vs. 1.3%, P < 0.001) than those with non-CE MI, although in-hospital mortality was not statistically different (9.0 vs. 6.4%, respectively, P = 0.321). In a propensity-matched analysis among hospital survivors (77 in each group), no differences were observed over a median follow-up of 59.6 months in overall mortality or thrombo-embolic events after discharge, although more patients in the CE group were admitted for heart failure.

Conclusion: Coronary embolism is mostly caused by AF, usually presents with ST-segment elevation, and is associated with higher rates of mechanical complications and in-hospital embolic events, but not of recurrent thromboembolism after discharge. No significant differences in mortality were observed between CE and non-CE MI.

Aims: Patients with advanced conduction disorders exhibit diverse haemodynamic profiles, from cardiogenic shock to severe hypertension. Peripheral vascular resistance (PVR) significantly contributes to compensatory mechanisms during bradycardia. This study aimed to assess the haemodynamic responses of patients presenting with high-degree atrioventricular (AV) block.

Methods and results: We retrospectively analyzed 261 consecutive patients with advanced conduction disorders who underwent pacemaker implantation from October 2020 to December 2022. Patients were classified into three groups: normotensive (<160 mmHg), hypertensive (≥160 mmHg), and unstable (requiring emergent temporary pacing). Additionally, 73 stable patients underwent non-invasive haemodynamic assessment. Of 261 patients, 99 (37.9%) were normotensive, 118 (45.2%) hypertensive, and 44 (16.9%) unstable. Hypertensive patients frequently had hypertension history (77.1%), presented with higher escape rhythms (39.1 ± 6.7 vs. 31.5 ± 10.4 and 38.1 ± 9.9 in unstable and normotensive patients, respectively), and exhibited higher ejection fractions (58.2 ± 8 vs. 53.2 ± 12 and 53.9 ± 11, respectively). They demonstrated fewer low cardiac output signs, including acute kidney injury and elevated lactate levels. PVR was significantly elevated in the hypertensive group. The unstable group experienced the highest 30-day mortality and higher 1-year mortality, though the latter did not reach statistical significance. Factors independently associated with a hypertensive response included higher heart rate, higher ejection fraction, and calcium channel blocker pre-treatment.

Conclusion: Haemodynamic presentations in high-degree AV block are heterogeneous. A hypertensive response represents a distinct clinical phenotype characterized by preserved cardiac function, higher escape rhythms, increased PVR, and fewer end-organ hypoperfusion signs.