Risk assessment in patients with an acute ST-elevation myocardial infarction

ST-elevation myocardial infarction (STEMI) is one of the leading causes of mortality and morbidity worldwide. While the survival after acute STEMI has considerably improved, mortality rate still remains high, especially in high-risk patients. Survival after acute STEMI is influenced by clinical characteristics such as age as well as the presence of comorbidities. However, during emergency care increasing access to tools such as the electrocardiogram, chest x-ray and echocardiography can provide additional information helping to further risk stratify patients. In the invasive setting, this can also include coronary angiography, invasive hemodynamic recordings and angiographic assessments of coronary flow and myocardial perfusion. We outline the common investigations used in STEMI and their role in risk assessment of patients with an acute STEMI

Journal of Shock and Hemodynamics, Vol. I, Iss. 2 (print version)

The print version of Volume I, Issue 2 of the Journal of Shock and Hemodynamics was published in February 2023. The PDF of the print version is downloadable here

Intra aortic balloon pumping in myocardial infarction and unstable angina

From 1972 to 1979 intra aortic balloon pumping (IABP) was attempted in 181 patients; catheter insertion failed in 13 (8%). More complications occurred with prolonged treatment but all three lethal complications (2%) were related to catheter insertion. Seventy-six patients had clinical cardiogenic shock after myocardial infarction (CSMI). Haemodynamically, 23 were classified as preshock: 15 (66%) could be weaned, 12 (53%) survived over 3 months; whereas only 27/51 patients (51%) haemodynamically classified as shock could be weaned and 21 (40%) survived over 3 months. Of forty-two patients with refractory angina at rest, 41 had prompt relief of pain after IABP, and subsequently underwent coronary artery bypasss grafting (CABG). Perioperative infarction rate was 8% (4/41), perioperative mortality was 7% (3/41). Total infarction rate was 11% (5/42), and total mortality 7% (3/41). Pain relief was prompt in 14/17 patients (82%) with refractory angina after infarction. Pain persisted in three patients: all three sustained an infarction, one died. Two patients were excluded from surgery. Twelve patients underwent CABG; none died, none developed MI. In eight patients persistence of pain suggested a slowly evolving MI, IABP abolished pain in seven. Conclusion: IABP has demonstrated its efficacy both in pump failure and in refractory ischaemia. However, its use is not without risks

Current management of peripartum cardiomyopathy: A review

Background: Demarkis et al in 1971 described 27 patients who presented during pueperium with cardiomegaly, abnormal electrocardiographic findings, congestive heart failure and named the syndrome “peripartum cardiomyopathy”.The aim of this review is to document the current concepts in the management of peripartum cardiomyopathy.Materials and Methods: A search of the literature was done using PubMed,Goggle scholar and books from authors' collections.Results: The cause of the disease might be environmental and genetic factors. Diagnostic echocardiographic criteria include left ventricular ejection fraction of less than 45% or a combination of M- mode fractional shortening of less than 30% 2 and end diastolic dimension of greater than 2.7cm/m2 . Electrocardiogram, magnetic resonance imaging, endomyocardial biopsy and cardiac catheterization aid in the diagnosis and management of peripartum cardiomyopathy. Treatment includes both conventional pharcomological heart failure and peripartum cardiomyopathy targeted therapies.Therapeutic decisions are influenced by drug safety profiles during pregnancy and lactation. Mechanical support and transplantation might be necessary in severe cases.Conclusion: Peripartum cardiomyopathy is an uncommon but life threatening cardiac failure of unknown aetiology encountered in late pregnancy or postpartum period. Management aims at improving heart failure symptoms through conventional therapies and then at administering targeted therapies.The risk of recurrence in future pregnancies should always be considered.Keywords: Cardiomyopathy,Heart failure,Peripartu

Cardiac health risk stratification system (CHRiSS): A Bayesian-based decision support system for left ventricular assist device (LVAD) therapy

This study investigated the use of Bayesian Networks (BNs) for left ventricular assist device (LVAD) therapy; a treatment for end-stage heart failure that has been steadily growing in popularity over the past decade. Despite this growth, the number of LVAD implants performed annually remains a small fraction of the estimated population of patients who might benefit from this treatment. We believe that this demonstrates a need for an accurate stratification tool that can help identify LVAD candidates at the most appropriate point in the course of their disease. We derived BNs to predict mortality at five endpoints utilizing the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database: containing over 12,000 total enrolled patients from 153 hospital sites, collected since 2006 to the present day, and consisting of approximately 230 pre-implant clinical variables. Synthetic minority oversampling technique (SMOTE) was employed to address the uneven proportion of patients with negative outcomes and to improve the performance of the models. The resulting accuracy and area under the ROC curve (%) for predicted mortality were 30 day: 94.9 and 92.5; 90 day: 84.2 and 73.9; 6 month: 78.2 and 70.6; 1 year: 73.1 and 70.6; and 2 years: 71.4 and 70.8. To foster the translation of these models to clinical practice, they have been incorporated into a web-based application, the Cardiac Health Risk Stratification System (CHRiSS). As clinical experience with LVAD therapy continues to grow, and additional data is collected, we aim to continually update these BN models to improve their accuracy and maintain their relevance. Ongoing work also aims to extend the BN models to predict the risk of adverse events post-LVAD implant as additional factors for consideration in decision making

Advanced chronic heart failure: A position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Societyof Cardiology

Therapy has improved the survival of heart failure (HF) patients. However, many patients progress to advanced chronic HF (ACHF). We propose a practical clinical definition and describe the characteristics of this condition. Patients that are generally recognised as ACHF often exhibit the following characteristics: 1) severe symptoms (NYHA class III to IV); 2) episodes with clinical signs of fluid retention and/or peripheral hypoperfusion; 3) objective evidence of severe cardiac dysfunction, shown by at least one of the following: left ventricular ejection fraction1 HF hospitalisation in the past 6 months; 6) presence of all the previous features despite optimal therapy. This definition identifies a group of patients with compromised quality of life, poor prognosis, and a high risk of clinical events. These patients deserve effective therapeutic options and should be potential targets for future clinical research initiative

Acute Heart Failure Management

Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.Peer reviewe

Optimizing patient selection for cardiac resynchronization therapy: the role of cardiopulmonary exercise testing

Mestrado em Exercício e SaúdeBackground: Cardiac resynchronization therapy (CRT) is an established treatment modality for moderate to severe heart failure (HF) but 30–40% of patients treated with CRT do not experience clinical improvement. Purpose: the aim of this study was to identify predictors of response to CRT, in two different definitions of responders, by using the cardiopulmonary exercise testing (CPET) before CRT implantation. In definition A, responders were defined as ≥15% improvement in left ventricular ejection fraction (LVEF); in definition B combined parameters were defined as ≥5% improvement in LVEF and ≤1 level NYHA classification. Methods: this is a prospective observational study of 15 HF patients undergoing CRT. Clinical CPET and echocardiography assessment using standard methods were performed at baseline and 5 months. Results: the number of patients classified as responders in definition A was 9 (60%) and 6 (40%) as non-responders; the number of responders in definition B was 11 (73.3%) and 4 (26.7%) as non-responders at 5 months after CRT. The responders according to definition A did not present any statistically significant difference. According to definition B, the heart rate (HR) response during CPET was higher in non-responders: HR peak (157±13bpm vs. 118±18bpm, p<0.05) and HR recovery at minute 3 (54±13bpm vs. 31 ± 14bpm, p<0.05). Overall, the responders were older (68±9years vs. 55±9years, p<0.05). Conclusions: baseline measurements of CPET may be utilized to identify patients that benefit from CRT. The use of combined criteria is a better predictor than LVEF alone

Heart Transplant: Current Indications and Patient Selection

Heart transplant remains the gold standard treatment for end-stage heart failure, in spite of the recent advances in pharmacological treatment and device therapy. As expected, since the first heart transplant was performed 50 years ago, outcomes in heart transplant have continued to improve over the last decades focusing on perioperative management, the availability of newer and better mechanical circulatory support before and after heart transplant and immunosuppressive drug development. Nonetheless, in the last years we have witnessed a significant drop in the heart donor’s pool as the greatest limiting factor, coupled with a rising number of advanced heart failure patients. Moreover, the difficulty in handling these patients, with multiple and more complex comorbidities, is continuously increasing. More importantly and despite these difficulties, conditional half-life in transplanted patients has nowadays reached 12 years of life expectancy. Thus, besides trying to increase donor numbers, candidate selection emerges as one of the most challenging issues for heart transplant programs. In this chapter we review the latest knowledge on indications for heart transplant, as well as the available screening and optimization tools in candidate selection in order to continue improving outcomes