European Heart Journal: Acute Cardiovascular Care最新文献

Background: Contemporary guidelines support the use of a pharmaco-invasive (PI) strategy with immediate transfer to a percutaneous coronary intervention (PCI)-capable hospital for ST-elevation myocardial infarction (STEMI) when timely primary PCI (pPCI) is unattainable. However, when reperfusion with fibrinolysis fails to occur, rescue PCI is recommended.

Methods: In a pre-specified analysis from STREAM-2, we explored patients randomized to PI treatment and compared those receiving half-dose tenecteplase who required rescue intervention to those with successful fibrinolysis undergoing scheduled angiography. To provide context for those randomized pPCI, we also explored the relationship between site of randomization, i.e., community hospital (CH) versus ambulance on clinical outcomes. Resolution of ST-elevation following angiography and the composite of 30-day all-cause death, shock, heart failure and reinfarction, as well as safety, reflected by stroke and non-intracranial bleeding, were measured.

Results: Of the 583 patients in the current study, 168 patients required rescue intervention [43.5%], 218 patients had successful fibrinolysis scheduled for angiography and 197 were randomized to pPCI. Rescue PCI patients, compared to those undergoing scheduled angiography, had less ST resolution ≥50% (76.3% versus 92.5%, P<0.001) and worse clinical composite outcomes at 30 days (16.7% versus 6.0%, P<0.001) with a higher risk of intracranial hemorrhage (2.4% versus 0.5%). Intermediate outcomes were observed for patients undergoing pPCI (ST resolution ≥50%: 78.7%; 30-day composite outcome: 12.2%). Rescue intervention deployed in CH patients required 10 minutes longer compared to ambulance patients: however, there was similar ST resolution ≥50% (72.2% versus 80.5%, P=0.219) and comparable 30-day composite outcome (17.6% versus 15.7%, relative risk [RR] 0.97, 95% confidence interval [CI] 0.50 - 1.87), irrespective of location. pPCI required 48 minutes longer in CH patients, but resulted in similar outcomes to ambulance patients (ST resolution ≥50%: 77.0% versus 80.2%, P=0.595; 30-day composite outcome: 9.3% versus 15.6%, RR 1.57, 95% CI 0.72-3.41, respectively).

Conclusion: Contemporary PI with half-dose tenecteplase in older patients requiring rescue intervention led to less ST resolution and worse 30-day outcomes compared to those with successful fibrinolysis receiving scheduled angiography. Notably, delays to deploying rescue PCI in CH patients were shortened over those previously achieved thereby resulting in similar outcomes to those randomized in the ambulance. Our results reinforce the benefits of functional hub and spoke models with rapid transfer to a PCI-capable facility.

Aims: Acute heart failure (AHF) is a leading cause of frequent hospitalizations and poor outcomes. While chronic HF is treated with guideline-directed medical therapy, acute hospital care often requires loop diuretics, vasodilators, inotropes, and vasopressors. This study aimed to evaluate the inpatient use, dosing, and determinants of guideline-recommended therapies in patients hospitalized with AHF.

Methods and results: This nationwide, register-based cohort study included 6,009 patients aged ≥45 years hospitalized with AHF with (left ventricular ejection fraction [LVEF] ≤40%) in Denmark from 2018-2023. Data from the Danish Heart Failure Registry were linked to national healthcare registers. The main outcomes were inpatient use and doses of loop diuretics, vasodilators, inotropes, and vasopressors. Loop diuretics were used in 88.7% of patients (median dose [MD] of furosemide: 50 mg parenteral, 40 mg oral). Vasodilators were administered to 36.1% (MD of nitroglycerin: 30 mg parenteral, 7.5 mg oral). Inotropes were administered to 3.0%, including dopamine (0.5%), dobutamine (1.0%), milrinone (0.9%), and levosimendan (1.1%). Vasopressors were used in 8.4%, with norepinephrine (7.3%) and epinephrine (2.0%). Older patients (≥75) had lower prevalence of vasodilator, inotrope, and vasopressor use. Severe HF (LVEF <25%) was associated with lower prevalence of vasodilator and vasopressor use. In contrast, chronic kidney disease and recurrent HF hospitalization were linked to higher prevalence of use of all AHF therapies.

Conclusions: Loop diuretics were widely used, while vasodilators, inotropes, and vasopressors had lower utilization. The observed variation in treatment reflects complexity of inpatient AHF management, warranting further studies to assess treatment outcomes.

Aims: There are limited clinical data for beta blockers in Takotsubo syndrome (TTS). This real-world analysis aims to evaluate the impact of beta-blockers on all-cause mortality in TTS.

Methods and results: This retrospective analysis was conducted using the Global Collaborative Network of the TriNetX database. Patients with TTS were identified between 01/01/2005 and 06/06/2025 and stratified based on post-diagnosis beta-blocker use. Propensity-score matching using the greedy nearest-neighbor matching was utilized to balance the cohorts. Outcomes of interest was in-hospital mortality at 1-, 3-, and 5-years. During the study period, 54,855 patients with TTS were identified (beta-blocker group 39,108, control: 15,747). The beta blocker group was on average older (71 vs 69.7 years), of white race (74.2% vs 68.9%), and had higher rates of comorbidities. Following matching, both cohorts had 14,268 patients each with a mean age of 70 years and well balanced in demographics, comorbidities, medications, and laboratory data. Matched cohort analysis demonstrated beta blocker use was associated with lower all-cause mortality at 1-year (risk ratio [RR]: 0.67; 95% confidence interval [CI]: 0.63-0.71], 3 years (RR: 0.78; 95% CI: 0.74-0.82), and 5 years (RR: 0.81; 95% CI: 0.76-0.84).

Conclusions: Beta blocker use in patients with TTS was associated with a lower risk of short- and long-term mortality up to 5 years.

Background and aims: A 0- and 2- hour 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 improve clinical decision-making.

Methods: 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 hours) and 2 hours 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 event (MACE), incorporating AMI and cardiac death.

Results: AMI was diagnosed in 80 patients (7.8%). When identifying low-risk patients, the 0/2-hour 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 hours, with 6 low risk patients (0.9%) having a MACE diagnosis at 30-day follow-up.

Conclusions: A 0/2-hour 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.

Background: The optimal timing of coronary angiography in elderly patients after out-of-hospital cardiac arrest (OHCA) without ST-segment elevations after successful resuscitation remains uncertain. This substudy of the randomized TOMAHAWK trial investigated the prognostic impact of immediate versus delayed/selective coronary angiography in elderly versus younger OHCA survivors.

Methods: A total of 529 patients with successfully resuscitated OHCA of presumed cardiac origin without ST-segment elevations on post-resuscitation electrocardiograms were analyzed. Patients had been randomized to immediate or delayed/selective coronary angiography after 24 hours the earliest. Patients were stratified by age: elderly patients defined as >75 years versus younger patients as ≤75 years. The primary endpoint was 30-day mortality. Multivariable Cox regression models were applied.

Results: Elderly patients exhibited a greater burden of cardiovascular comorbidities, had higher 30-day mortality (69% vs. 43%, p<0.001) and higher rates of death or severe neurologic deficit (75% vs. 51%, p<0.001) compared to younger individuals. In adjusted analyses, the timing of coronary angiography was not significantly associated with mortality in either elderly patients (HR 0.96, 95% CI, 0.59-1.56, p=0.88) or younger patients (HR 0.88, 95% CI, 0.56-1.38, p=0.57), with no evidence of effect modification by age (p for interaction=0.758).

Conclusions: Routine immediate coronary angiography does not appear to modify mortality risk in both elderly and younger OHCA survivors without ST-segment elevations. The results do not support differential treatment strategies across age groups.

Patients with acute pulmonary embolism (PE) may present with cardiac arrest, overt or impending cardiogenic shock and/or severe respiratory insufficiency. Immediate evaluation and management of these patients require high clinical suspicion along with (bedside) imaging to confirm the diagnosis, targeted haemodynamic and/or respiratory support, appropriate anticoagulant treatment, and in many cases reperfusion therapy. The immediate treatment decision-making is largely driven by local expertise and resources and should be guided by the individual patient's characteristics such as cardiopulmonary comorbidities, risk of bleeding and location, extent and hemodynamic impact of the clot. Over the past years, treatment options for patients with severe PE have expanded substantially. For instance, several new catheter-guided reperfusion therapies have emerged and experience with circulatory mechanical support has increased. Along with the rise of new interventional therapies has come the introduction of expert multidisciplinary pulmonary embolism (EXPERT-PE) care teams, composed of multidisciplinary specialists involved in treating severe acute PE. This model of care provides a platform for rapid decisions on individualized treatment strategies, combining expert opinion from all involved specialties, setting the quality standards for modern local and regional equity PE care, and forming the base for future research in this area. Clinical decisions should be evidence-based where possible, and incorporate the individual patient's and their carer's preferences, values, and priorities, as well as those of the managing clinicians and care team. In this review, we summarize the evidence for the introduction of EXPERT-PE care teams and provide a practical manual for their successful implementation.