European Heart Journal: Acute Cardiovascular Care最新文献

Background: E-wave propagation index (EPI) could be a simple echocardiographic parameter to identify patients at increased risk of left ventricular (LV) thrombus following ST-elevation myocardial infarction (STEMI). We aimed to investigate the association between EPI and LV thrombus as assessed by cardiac magnetic resonance imaging (MRI).

Methods: We included 665 STEMI patients treated with percutaneous coronary intervention from the MARINA-STEMI study. EPI was measured using transthoracic echocardiography at 3 (IQR 2-4) days post-STEMI and calculated as the ratio of the E-wave velocity-time integral to the LV end-diastolic length, measured in the apical four-chamber view. LV thrombus was evaluated with cardiac MRI at 4 (IQR 3-5) days post-STEMI.

Results: A total of 665 STEMI patients (17% female) with a median age of 58 [IQR 52-66] years were included. Patients with LV thrombus (n=32, 5%) had a significantly lower EPI than those without (0.92 versus 1.29, p<0.001). EPI independently predicted LV thrombus with an adjusted odds ratio of 0.84 (95% CI 0.74-0.95; p=0.007). The area under the curve for EPI in detecting LV thrombus was 0.73 (95% CI 0.64-0.82, p<0.001). EPI of 0.95 emerged as best cut-off to identify patients at high risk of LV thrombus formation (15.9% thrombus rate in patients with EPI<0.95 as compared to 2.5% in patients with EPI≥0.95).

Conclusion: EPI emerged as significant and independent predictor of LV thrombus formation in STEMI patients. These findings highlight the usefulness of EPI as simple echocardiographic parameter to optimize LV thrombus screening in routine STEMI care.

Aims: Periodic breathing (PB) is characterized by cyclic fluctuations in ventilation and expired gases. PB is observed at rest or during exercise and is a marker of poor prognosis. In this study, we investigated whether PB affects oxygen availability in peripheral muscles.

Materials and results: This pilot, prospective, single-centre study enrolled severe reduced ejection fraction heart failure (HF) patients exhibiting PB. Oxygenated (O2Hb) and deoxygenated haemoglobin (HHb) in the quadriceps femoralis were measured using near-infrared spectroscopy (NIRS), along with ventilation and expired gases. NIRS and ventilation data were collected at rest and analysed for cyclic patterns. Clinical evaluations, including the cardiopulmonary exercise test (CPET) and echocardiography, were performed. The Metabolic Exercise Combined with Cardiac Kidney Indexes (MECKI) score was used for prognosis evaluation. Twenty HF patients with PB were evaluated. NIRS revealed two distinct periodic behaviours: in 7 patients, O2Hb and HHb fluctuated in-phase; in 13, they were out-of-phase. In-phase patients had higher left ventricular ejection fraction, lower LV volumes, and lower BNP and soluble interleukin 1 receptor family member ST2 concentrations. Out-of-phase patients had more severe HF, with longer, less variable cycles and a higher MECKI score. Six of 13 out-of-phase patients died within 6 months, compared with 2 of 7 in-phase patients.

Conclusion: PB is associated with distinct peripheral oxygenation patterns, potentially representing disease progression stages. In-phase O2Hb and HHb suggest blood flow cycling, while out-of-phase behaviour suggests periodicity in ventilation/perfusion mismatching. These findings provide novel insights into the dynamic effects of PB on peripheral oxygenation.

Dual antiplatelet therapy (DAPT) remains a key element of secondary prevention after percutaneous coronary intervention. However, its optimal duration and intensity continue to pose challenges due to the trade-off between ischemic protection and bleeding risk. Over the past decade, evidence has progressively emerged for strategies of DAPT modulation, with particular emphasis on de-escalation approaches. Randomized trials have consistently shown that reducing antiplatelet intensity, whether by lowering the dose, discontinuing one drug, or switching to a less potent agent, can mitigate bleeding events without jeopardizing ischemic outcomes in selected patients. In contrast, escalation strategies have received less widespread adoption, reflecting more limited evidence, weaker guideline support, and the fact that most contemporary patients are at greater risk of bleeding than thrombosis. This review aims to summarize the evidence supporting DAPT modulation strategies, to critically appraise available trials, and to highlight ongoing studies in the field.

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.