Temporal trends in mortality and provision of intensive care in younger women and men with acute myocardial infarction or stroke

BACKGROUND Timely management of acute myocardial infarction (AMI) and acute stroke has undergone impressive progress during the last decade. However, it is currently unknown whether both sexes have profited equally from improved strategies. We sought to analyze sex-specific temporal trends in intensive care unit (ICU) admission and mortality in younger patients presenting with AMI or stroke in Switzerland. METHODS Retrospective analysis of temporal trends in 16,954 younger patients aged 18 to ≤ 52 years with AMI or acute stroke admitted to Swiss ICUs between 01/2008 and 12/2019. RESULTS Over a period of 12 years, ICU admissions for AMI decreased more in women than in men (- 6.4% in women versus - 4.5% in men, p < 0.001), while ICU mortality for AMI significantly increased in women (OR 1.2 [1.10-1.30], p = 0.032), but remained unchanged in men (OR 0.99 [0.94-1.03], p = 0.71). In stroke patients, ICU admission rates increased between 3.6 and 4.1% per year in both sexes, while ICU mortality tended to decrease only in women (OR 0.91 [0.85-0.95, p = 0.057], but remained essentially unaltered in men (OR 0.99 [0.94-1.03], p = 0.75). Interventions aimed at restoring tissue perfusion were more often performed in men with AMI, while no sex difference was noted in neurovascular interventions. CONCLUSION Sex and gender disparities in disease management and outcomes persist in the era of modern interventional neurology and cardiology with opposite trends observed in younger stroke and AMI patients admitted to intensive care. Although our study has several limitations, our data suggest that management and selection criteria for ICU admission, particularly in younger women with AMI, should be carefully reassessed

Epidemiology and outcome predictors in 450 patients with hanging-induced cardiac arrest: a retrospective study

BackgroundCardiac arrest is the most life-threatening complication of attempted suicide by hanging. However, data are scarce on its characteristics and outcome predictors.MethodsThis retrospective observational multicentre study in 31 hospitals included consecutive adults admitted after cardiac arrest induced by suicidal hanging. Factors associated with in-hospital mortality were identified by multivariate logistic regression with multiple imputations for missing data and adjusted to the temporal trends over the study period.ResultsOf 450 patients (350 men, median age, 43 [34–52] years), 305 (68%) had a psychiatric history, and 31 (6.9%) attempted hanging while hospitalized. The median time from unhanging to cardiopulmonary resuscitation was 0 [0–5] min, and the median time to return of spontaneous circulation (ROSC) was 20 [10–30] min. Seventy-nine (18%) patients survived to hospital discharge. Three variables were independently associated with higher in-hospital mortality: time from collapse or unhanging to ROSC&gt;20 min (odds ratio [OR], 4.71; 95% confidence intervals [95%CIs], 2.02–10.96; p = 0.0004); glycaemia &gt;1.4 g/L at admission (OR, 6.38; 95%CI, 2.60–15.66; p &lt; 0.0001); and lactate &gt;3.5 mmol/L at admission (OR, 6.08; 95%CI, 1.71–21.06; p = 0.005). A Glasgow Coma Scale (GCS) score of &gt;5 at admission was associated with lower in-hospital mortality (OR, 0.009; 95%CI, 0.02–0.37; p = 0.0009).ConclusionIn patients with hanging-induced cardiac arrest, time from collapse or unhanging to return of spontaneous circulation, glycaemia, arterial lactate, and coma depth at admission were independently associated with survival to hospital discharge. Knowledge of these risk factors may help guide treatment decisions in these patients at high risk of hospital mortality

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Impact of endothelial and leukocyte senescence in circulatory shock states

Parmi les conséquences à long terme du sepsis (également appelé "syndrome post-sepsis"), l'augmentation du risque de développer des complications cardiovasculaires inexpliquées et/ou un épisode infectieux récurrent sont des préoccupations émergentes. Ces complications expliquent en grande partie la morbi-mortalité chez les survivants d’un choc septique. Récemment, la sénescence, définie comme l’arrêt irréversible du cycle cellulaire, a été identifiée comme un mécanisme de dysfonction cellulaire qui perdure dans le temps. Habituellement liée à l’âge lorsqu’il s’agit de sénescence réplicative, elle peut aussi être « induite » de manière « prématurée » par un stress majeur. Ainsi,une sénescence prématurée induite par le choc septique au niveau du système cardio-vasculaire et immunitaire pourrait en partie contribuer à la physiopathologie et aux conséquences à long terme du syndrome post-sepsis. Ce travail de thèse a pour objectif d’appréhender les relations potentielles entre le sepsis et la sénescence prématurée induite (ou sénescence accélérée). En particulier, les mécanismes cellulaires clés contribuant aux infections récurrentes et aux événements cardiovasculaires chez des patients convalescents déjà lourdement affectés par un choc septique. Les principaux résultats de nos travaux sont que le sepsis induit un dysfonctionnement artériel avec une acquisition in situ, dépendante du temps, d'un phénotype d'inflammation et de sénescence dans les artères de conduction et de résistance, ce qui indique un effet systémique persistant pouvant expliquer en partie la physiopathologie des conséquences cardio-vasculaires à long terme.Among the long-term consequences of sepsis (also called "post-sepsis syndrome"), the increased risk of developing unexplained cardiovascular complications and/or a recurrent infectious episode are emerging concerns. These complications account for much of the morbidity and mortality in survivors of septic shock. Recently, senescence, defined as irreversible cell cycle arrest, has been identified as a mechanism of cell dysfunction that persists over time. Usually linked to age when it is replicative senescence, it can also be "induced" in a "premature" way by a major stress. Thus, premature senescence induced by septic shock at the level of the cardiovascular and immune system could partly contribute to the pathophysiology and long-term consequences of the post-sepsis syndrome.The aim of our work is to understand the potential relationship between sepsis and induced premature senescence (or accelerated senescence). In particular, the key cellular mechanisms contributing to recurrent infections and cardiovascular events in convalescent patients already heavily affected by sepsis. The main finding of our work is that sepsis induced arterial dysfunction with a time dependent in situ acquisition of inflammation and senescence phenotype in both conductance and resistance arteries, therefore pointing at a systemic long-lasting effect that may partly explain the pathophysiology of long-term cardiovascular consequences

Évaluation de la sénescence endothéliale et leucocytaire dans le choc septique

Among the long-term consequences of sepsis (also called "post-sepsis syndrome"), the increased risk of developing unexplained cardiovascular complications and/or a recurrent infectious episode are emerging concerns. These complications account for much of the morbidity and mortality in survivors of septic shock. Recently, senescence, defined as irreversible cell cycle arrest, has been identified as a mechanism of cell dysfunction that persists over time. Usually linked to age when it is replicative senescence, it can also be "induced" in a "premature" way by a major stress. Thus, premature senescence induced by septic shock at the level of the cardiovascular and immune system could partly contribute to the pathophysiology and long-term consequences of the post-sepsis syndrome.The aim of our work is to understand the potential relationship between sepsis and induced premature senescence (or accelerated senescence). In particular, the key cellular mechanisms contributing to recurrent infections and cardiovascular events in convalescent patients already heavily affected by sepsis. The main finding of our work is that sepsis induced arterial dysfunction with a time dependent in situ acquisition of inflammation and senescence phenotype in both conductance and resistance arteries, therefore pointing at a systemic long-lasting effect that may partly explain the pathophysiology of long-term cardiovascular consequences.Parmi les conséquences à long terme du sepsis (également appelé "syndrome post-sepsis"), l'augmentation du risque de développer des complications cardiovasculaires inexpliquées et/ou un épisode infectieux récurrent sont des préoccupations émergentes. Ces complications expliquent en grande partie la morbi-mortalité chez les survivants d’un choc septique. Récemment, la sénescence, définie comme l’arrêt irréversible du cycle cellulaire, a été identifiée comme un mécanisme de dysfonction cellulaire qui perdure dans le temps. Habituellement liée à l’âge lorsqu’il s’agit de sénescence réplicative, elle peut aussi être « induite » de manière « prématurée » par un stress majeur. Ainsi,une sénescence prématurée induite par le choc septique au niveau du système cardio-vasculaire et immunitaire pourrait en partie contribuer à la physiopathologie et aux conséquences à long terme du syndrome post-sepsis. Ce travail de thèse a pour objectif d’appréhender les relations potentielles entre le sepsis et la sénescence prématurée induite (ou sénescence accélérée). En particulier, les mécanismes cellulaires clés contribuant aux infections récurrentes et aux événements cardiovasculaires chez des patients convalescents déjà lourdement affectés par un choc septique. Les principaux résultats de nos travaux sont que le sepsis induit un dysfonctionnement artériel avec une acquisition in situ, dépendante du temps, d'un phénotype d'inflammation et de sénescence dans les artères de conduction et de résistance, ce qui indique un effet systémique persistant pouvant expliquer en partie la physiopathologie des conséquences cardio-vasculaires à long terme

Évaluation de la sénescence endothéliale et leucocytaire dans le choc septique

Among the long-term consequences of sepsis (also called "post-sepsis syndrome"), the increased risk of developing unexplained cardiovascular complications and/or a recurrent infectious episode are emerging concerns. These complications account for much of the morbidity and mortality in survivors of septic shock. Recently, senescence, defined as irreversible cell cycle arrest, has been identified as a mechanism of cell dysfunction that persists over time. Usually linked to age when it is replicative senescence, it can also be "induced" in a "premature" way by a major stress. Thus, premature senescence induced by septic shock at the level of the cardiovascular and immune system could partly contribute to the pathophysiology and long-term consequences of the post-sepsis syndrome.The aim of our work is to understand the potential relationship between sepsis and induced premature senescence (or accelerated senescence). In particular, the key cellular mechanisms contributing to recurrent infections and cardiovascular events in convalescent patients already heavily affected by sepsis. The main finding of our work is that sepsis induced arterial dysfunction with a time dependent in situ acquisition of inflammation and senescence phenotype in both conductance and resistance arteries, therefore pointing at a systemic long-lasting effect that may partly explain the pathophysiology of long-term cardiovascular consequences.Parmi les conséquences à long terme du sepsis (également appelé "syndrome post-sepsis"), l'augmentation du risque de développer des complications cardiovasculaires inexpliquées et/ou un épisode infectieux récurrent sont des préoccupations émergentes. Ces complications expliquent en grande partie la morbi-mortalité chez les survivants d’un choc septique. Récemment, la sénescence, définie comme l’arrêt irréversible du cycle cellulaire, a été identifiée comme un mécanisme de dysfonction cellulaire qui perdure dans le temps. Habituellement liée à l’âge lorsqu’il s’agit de sénescence réplicative, elle peut aussi être « induite » de manière « prématurée » par un stress majeur. Ainsi,une sénescence prématurée induite par le choc septique au niveau du système cardio-vasculaire et immunitaire pourrait en partie contribuer à la physiopathologie et aux conséquences à long terme du syndrome post-sepsis. Ce travail de thèse a pour objectif d’appréhender les relations potentielles entre le sepsis et la sénescence prématurée induite (ou sénescence accélérée). En particulier, les mécanismes cellulaires clés contribuant aux infections récurrentes et aux événements cardiovasculaires chez des patients convalescents déjà lourdement affectés par un choc septique. Les principaux résultats de nos travaux sont que le sepsis induit un dysfonctionnement artériel avec une acquisition in situ, dépendante du temps, d'un phénotype d'inflammation et de sénescence dans les artères de conduction et de résistance, ce qui indique un effet systémique persistant pouvant expliquer en partie la physiopathologie des conséquences cardio-vasculaires à long terme

Acute and Long-Term Cardiovascular Complications among Patients with Sepsis and Septic Shock

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death within intensive care units (ICUs) [...

Microcirculatory dysfunction in cardiogenic shock

Abstract Cardiogenic shock is usually defined as primary cardiac dysfunction with low cardiac output leading to critical organ hypoperfusion, and tissue hypoxia, resulting in high mortality rate between 40% and 50% despite recent advances. Many studies have now evidenced that cardiogenic shock not only involves systemic macrocirculation, such as blood pressure, left ventricular ejection fraction, or cardiac output, but also involves significant systemic microcirculatory abnormalities which seem strongly associated with the outcome. Although microcirculation has been widely studied in the context of septic shock showing heterogeneous alterations with clear evidence of macro and microcirculation uncoupling, there is now a growing body of literature focusing on cardiogenic shock states. Even if there is currently no consensus regarding the treatment of microcirculatory disturbances in cardiogenic shock, some treatments seem to show a benefit. Furthermore, a better understanding of the underlying pathophysiology may provide hypotheses for future studies aiming to improve cardiogenic shock prognosis. Graphical Abstrac

Changes in Body Temperature Patterns Are Predictive of Mortality in Septic Shock: An Observational Study

International audienceBiological rhythms are important regulators of immune functions. In intensive care unit (ICU), sepsis is known to be associated with rhythm disruption. Our objectives were to determine factors associated with rhythm disruption of the body temperature and to assess the relationship between temperature and mortality in septic shock patients; In a cohort of septic shock, we recorded body temperature over a 24-h period on day 2 after ICU admission. For each patient, the temperature rhythmicity was assessed by defining period and amplitude, and the adjusted average (mesor) of the temperature by sinusoidal regression and cosinor analysis. Analyses were performed to assess factors associated with the three temperature parameters (period, amplitude, and mesor) and mortality. 162 septic shocks were enrolled. The multivariate analysis demonstrates that the period of temperature was associated with gender (women, coefficient −2.2 h, p = 0.031) and acetaminophen use (coefficient −4.3 h, p = 0.002). The mesor was associated with SOFA score (coefficient −0.05 °C per SOFA point, p = 0.046), procalcitonin (coefficient 0.001 °C per ng/mL, p = 0.005), and hydrocortisone use (coefficient −0.5 °C, p = 0.002). The amplitude was associated with the dialysis (coefficient −0.5 °C, p = 0.002). Mortality at day 28 was associated with lower mesor (adjusted hazard ratio 0.50, 95% CI 0.28 to 0.90; p = 0.02), and higher amplitude (adjusted hazard ratio 5.48, 95% CI 1.66 to 18.12; p = 0.005) of temperature. Many factors, such as therapeutics, influence the body temperature during septic shock. Lower mesor and higher amplitude were associated with mortality and could be considered prognostic markers in ICU. In the age of artificial intelligence, the incorporation of such data in an automated scoring alert could compete with physicians to identify high-risk patients during septic shock