Optimum Blood Pressure in Patients With Shock After Acute Myocardial Infarction and Cardiac Arrest

BACKGROUND In patients with shock after acute myocardial infarction (AMI), the optimal level of pharmacologic support is unknown. Whereas higher doses may increase myocardial oxygen consumption and induce arrhythmias, diastolic hypotension may reduce coronary perfusion and increase infarct size. OBJECTIVES This study aimed to determine the optimal mean arterial pressure (MAP) in patients with AMI and shock after cardiac arrest. METHODS This study used patient-level pooled analysis of post-cardiac arrest patients with shock after AMI randomized in the Neuroprotect (Neuroprotective Goal Directed Hemodynamic Optimization in Post-cardiac Arrest Patients; NCT02541591) and COMACARE (Carbon Dioxide, Oxygen and Mean Arterial Pressure After Cardiac Arrest and Resuscitation; NCT02698917) trials who were randomized to MAP 65 mm Hg or MAP 80/85 to 100 mm Hg targets during the first 36 h after admission. The primary endpoint was the area under the 72-h high-sensitivity troponin-T curve. RESULTS Of 235 patients originally randomized, 120 patients had AMI with shock. Patients assigned to the higher MAP target (n = 58) received higher doses of norepinephrine (p = 0.004) and dobutamine (p = 0.01) and reached higher MAPs (86 +/- 9 mm Hg vs. 72 +/- 10 mm Hg, p <0.001). Whereas admission hemodynamics and angiographic findings were all well-balanced and revascularization was performed equally effective, the area under the 72-h high-sensitivity troponin-T curve was lower in patients assigned to the higher MAP target (median: 1.14 mu g.72 h/l [interquartile range: 0.35 to 2.31 mu g.72 h/l] vs. median: 1.56 mu g.72 h/l [interquartile range: 0.61 to 4.72 mu g. 72 h/l]; p = 0.04). Additional pharmacologic support did not increase the risk of a new cardiac arrest (p = 0.88) or atrial fibrillation (p = 0.94). Survival with good neurologic outcome at 180 days was not different between both groups (64% vs. 53%, odds ratio: 1.55; 95% confidence interval: 0.74 to 3.22). CONCLUSIONS In post-cardiac arrest patients with shock after AMI, targeting MAP between 80/85 and 100 mm Hg with additional use of inotropes and vasopressors was associated with smaller myocardial injury. (C) 2020 by the American College of Cardiology Foundation.Peer reviewe

Clinical value of echocardiographic Doppler-derived right ventricular dp/dt in patients with pulmonary arterial hypertension

Right ventricular (RV) dp/dt is the instantaneous rate of RV pressure rise during early systole and is a surrogate marker of RV contractility. The main objective of this study was to evaluate the ability of echocardiographic Doppler obtained RV dp/dt to predict long-term survival in patients with pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH).status: publishe

Rotational angiography (LARCA) during electrophysiological examination detects pulmonary vein stenosis

peerreview_statement: The publishing and review policy for this title is described in its Aims & Scope. aims_and_scope_url: http://www.tandfonline.com/action/journalInformation?show=aimsScope&journalCode=tacd20status: publishe

From therapeutic hypothermia towards targeted temperature management: a decade of evolution

More than a decade after the first randomised controlled trials with targeted temperature management (TTM), it remains the only treatment with proven favourable effect on postanoxemic brain damage after out-of-hospital cardiac arrest. Other well-known indications include neurotrauma, subarachnoidal haemorrhage, and intracranial hypertension. When possible pitfalls are taken into consideration when implementing TTM, the side effects are manageable. After the recent TTM trials, it seems that classic TTM (32−34°C) is as effective and safe as TTM at 36°C. This supports the belief that fever prevention is one of the pivotal mechanisms that account for the success of TTM. Uncertainty remains concerning cooling method, timing, speed of cooling and rewarming. New data indicates that TTM is safe and feasible in cardiogenic shock, one of its classic contra-indications. Moreover, there are limited indications that TTM might be considered as a therapy for cardiogenic shock per se

Assessment of three minimally invasive continuous cardiac output measurement methods in critically ill patients and a review of the literature

BACKGROUND: In this study we compared the accuracy of three continuous cardiac output (CCO) measurement methods, with intermittent transcardiopulmonary thermodilution (TPTD-CO) as the gold standard. The three studied CCO measurement methods were: uncalibrated peripheral pulse contour measurement (FCCO), calibrated central pulse contour measurement (PCCO), and CCO obtained by indirect Fick principle (NCCO).METHODS: We performed an observational study in 23 critically ill patients. Statistical analysis was done using Pearson’s correlation and Bland-Altman analysis. A review of the relevant medical literature was performed.RESULTS: Only PCCO showed good correlation (R = 0.9) and agreement with a bias of 0.0 ± 0.8 L min-1 and percentage error of 24.5% when compared to TPTD-CO. In patients with normal systemic vascular resistance index (SVRI &gt; 1,700 dyne sec cm-5 m-2), NCCO (R = 0.8 and bias 0.4 ± 1.3 L min-1) and FCCO (R = 0.8 and bias 0.1 ± 1 L min-1) also produced reliable results.CONCLUSIONS: These results indicate that in our patient population, CCO can be most reliably monitored by calibrated central pulse contour measurements. All other methods appeared less accurate, especially in situations of low SVRI.BACKGROUND: In this study we compared the accuracy of three continuous cardiac output (CCO) measurement methods, with intermittent transcardiopulmonary thermodilution (TPTD-CO) as the gold standard. The three studied CCO measurement methods were: uncalibrated peripheral pulse contour measurement (FCCO), calibrated central pulse contour measurement (PCCO), and CCO obtained by indirect Fick principle (NCCO).METHODS: We performed an observational study in 23 critically ill patients. Statistical analysis was done using Pearson’s correlation and Bland-Altman analysis. A review of the relevant medical literature was performed.RESULTS: Only PCCO showed good correlation (R = 0.9) and agreement with a bias of 0.0 ± 0.8 L min-1 and percentage error of 24.5% when compared to TPTD-CO. In patients with normal systemic vascular resistance index (SVRI &gt; 1,700 dyne sec cm-5 m-2), NCCO (R = 0.8 and bias 0.4 ± 1.3 L min-1) and FCCO (R = 0.8 and bias 0.1 ± 1 L min-1) also produced reliable results.CONCLUSIONS: These results indicate that in our patient population, CCO can be most reliably monitored by calibrated central pulse contour measurements. All other methods appeared less accurate, especially in situations of low SVRI

Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial

AIMS: During the first 6-12 h of intensive care unit (ICU) stay, post-cardiac arrest (CA) patients treated with a mean arterial pressure (MAP) 65 mmHg target experience a drop of the cerebral oxygenation that may cause additional cerebral damage. Therefore, we investigated whether an early goal directed haemodynamic optimization strategy (EGDHO) (MAP 85-100 mmHg, SVO2 65-75%) is safe and could improve cerebral oxygenation, reduce anoxic brain damage, and improve outcome when compared with a MAP 65 mmHg strategy. METHODS AND RESULTS: A total of 112 out-of-hospital CA patients were randomly assigned to EGDHO or MAP 65 mmHg strategies during the first 36 h of ICU stay. The primary outcome was the extent of anoxic brain damage as quantified by the percentage of voxels below an apparent diffusion coefficient (ADC) score of 650.10-6 mm2/s on diffusion weighted magnetic resonance imaging (at day 5 ± 2 post-CA). Main secondary outcome was favourable neurological outcome (CPC score 1-2) at 180 days. In patients assigned to EGDHO, MAP (P < 0.001), and cerebral oxygenation during the first 12 h of ICU stay (P = 0.04) were higher. However, the percentage of voxels below an ADC score of 650.10-6 mm2/s did not differ between both groups [16% vs. 12%, odds ratio 1.37, 95% confidence interval (CI) 0.95-0.98; P = 0.09]. Also, the number of patients with favourable neurological outcome at 180 days was similar (40% vs. 38%, odds ratio 0.98, 95% CI 0.41-2.33; P = 0.96). The number of serious adverse events was lower in patients assigned to EGDHO (P = 0.02). CONCLUSION: Targeting a higher MAP in post-CA patients was safe and improved cerebral oxygenation but did not improve the extent of anoxic brain damage or neurological outcome.status: publishe

The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest : a post hoc analysis of the COMACARE and NEUROPROTECT trials

Background: We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. Methods: A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. Results: A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). Conclusion: Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. Clinical trial registration: COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).Peer reviewe

Shockwave balloon or atherectomy with rotablation in calcified coronary artery lesions:Design and rationale of the SONAR trial

Background: The percutaneous treatment of calcified coronary lesions remains challenging and is associated with worse clinical outcomes. In addition, coronary artery calcification is associated with more frequent peri-procedural myocardial infarction. Study design and objectives: The ShOckwave ballooN or Atherectomy with Rotablation in calcified coronary artery lesions (SONAR) study is an investigator-initiated, prospective, randomized, international, multicenter, open label trial (NCT05208749) comparing a lesion preparation strategy with either shockwave intravascular lithotripsy (IVL) or rotational atherectomy (RA) before drug-eluting stent implantation in 170 patients with moderate to severe calcified coronary lesions. The primary endpoint is difference in the rate of peri-procedural myocardial infarction. Key secondary endpoints include rate of peri-procedural microvascular dysfunction, peri-procedural myocardial injury, descriptive study of IMR measurements in calcified lesions, technical and procedural success, interaction between OCT calcium score and primary endpoint, 30-day and 1-year major adverse clinical events. Conclusions: The SONAR trial is the first randomized controlled trial comparing the incidence of peri-procedural myocardial infarction between 2 contemporary calcium modification strategies (Shockwave IVL and RA) in patients with calcified coronary artery lesions. Furthermore, for the first time, the incidence of peri-procedural microvascular dysfunction after Shockwave IVL and RA will be evaluated and compared.</p

Safety of Selective Intracoronary Hypotheria during Primary Percutaneous Coronary Intervention in Patients with Anterior St-Elevation Myocardial Infarction

Objectives- The aim of this study was to determine the safety of selective intracoronary hypothermia during primary percutaneous coronary intervention (PPCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI). Background- Selective intracoronary hypothermia is a novel treatment designed to reduce myocardial reperfusion injury and is currently being investigated in the ongoing randomized controlled EURO-ICE (European Intracoronary Cooling Evaluation in Patients With ST-Elevation Myocardial Infarction) trial (NCT03447834). Data on the safety of such a procedure during PPCI are still limited. Methods- The first 50 patients with anterior STEMI treated with selective intracoronary hypothermia during PPCI were included in this analysis and compared for safety with the first 50 patients randomized to the control group undergoing standard PPCI. In-hospital mortality, occurrence of rhythm or conduction disturbances, stent thrombosis, onset of heart failure during the procedure, and subsequent hospital admission were assessed. Results- In-hospital mortality was 0%. One patient in both groups developed cardiogenic shock. Atrial fibrillation occurred in 0 and 3 patients (P = 0.24), and ventricular fibrillation occurred in 5 and 3 patients (P = 0.72) in the intracoronary hypothermia group and control group, respectively. Stent thrombosis occurred in 2 patients in the intracoronary hypothermia group; 1 instance was intraprocedural, and the other occurred following interruption of dual-antiplatelet therapy consequent to an intracranial hemorrhage 6 days after enrollment. No stent thrombosis was observed in the control group (P = 0.50). Conclusions- Selective intracoronary hypothermia during PPCI in patients with anterior STEMI can be implemented within the routine of PPCI and seems to be safe. The final safety results will be reported at the end of the trial