Influenza-like illness in acute myocardial infarction patients during the winter wave of the influenza A H1N1 pandemic in London: a case-control study.

OBJECTIVE: To investigate recent respiratory and influenza-like illnesses (ILIs) in acute myocardial infarction patients compared with patients hospitalised for acute non-vascular surgical conditions during the second wave of the 2009 influenza A H1N1 pandemic. DESIGN: Case-control study. SETTING: Coronary care unit, acute cardiology and acute surgical admission wards in a major teaching hospital in London, UK. PARTICIPANTS: 134 participants (70 cases and 64 controls) aged ≥40 years hospitalised for acute myocardial infarction and acute surgical conditions between 21 September 2009 and 28 February 2010, frequency-matched for gender, 5-year age-band and admission week. PRIMARY EXPOSURE: ILI (defined as feeling feverish with either a cough or sore throat) within the last month. SECONDARY EXPOSURES: Acute respiratory illness within the last month not meeting ILI criteria; nasopharyngeal and throat swab positive for influenza virus. RESULTS: 29 of 134 (21.6%) participants reported respiratory illness within the last month, of whom 13 (9.7%) had illnesses meeting ILI criteria. The most frequently reported category for timing of respiratory symptom onset was 8-14 days before admission (31% of illnesses). Cases were more likely than controls to report ILI-adjusted OR 3.17 (95% CI 0.61 to 16.47)-as well as other key respiratory symptoms, and were less likely to have received influenza vaccination-adjusted OR 0.46 (95% CI 0.19 to 1.12)-although the differences were not statistically significant. No swabs were positive for influenza virus. CONCLUSIONS: Point estimates suggested that recent ILI was more common in patients hospitalised with acute myocardial infarction than with acute surgical conditions during the second wave of the influenza A H1N1 pandemic, and influenza vaccination was associated with cardioprotection, although the findings were not statistically significant. The study was underpowered, partly because the age groups typically affected by acute myocardial infarction had low rates of infection with the pandemic influenza strain compared with seasonal influenza

Cognitive outcomes in chronic obstructive pulmonary disease (COPD)/OSA overlap syndrome compared to obstructive sleep apnea (OSA) alone: a systematic review

Background: Obstructive Sleep Apnoea (OSA) and Chronic Obstructive Pulmonary Disease (COPD) are both independently associated with cognitive impairment. COPD/OSA overlap syndrome could potentially result in greater cognitive impairment that is more than additive. This systematic review evaluates attention, memory, executive function and global cognition in OSA alone compared to COPD/OSA overlap syndrome. Methods: Systematic searches in MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL identified studies assessing cognitive function in adults with OSA and/or COPD/OSA overlap syndrome. Inclusion criteria required validated diagnostic and cognitive assessment tools. Twelve studies, including 7,424 participants, were reviewed: 10 involving OSA alone and 2 involving overlap syndrome. A narrative synthesis was performed due to methodological heterogeneity. Registration number is: CRD42024557577. Results: OSA alone was primarily associated with mild to moderate cognitive impairment, with attention and executive function most affected, with nocturnal hypoxemia and sleep fragmentation thought to be underlying causative factors. Memory and global cognition were relatively preserved. In contrast, COPD/OSA overlap syndrome was associated with more severe impairments, particularly in memory and global cognition. Overlap patients had significantly lower cognitive scores and a higher prevalence of mild cognitive impairment compared to OSA alone. Conclusions: Whilst OSA alone is associated with mild to moderate cognitive impairments, COPD/OSA overlap syndrome associates with more pronounced impairments, particularly in memory and global cognition. Nocturnal hypoxemia and systemic inflammation may be important mechanisms. Early cognitive screening and targeted interventions could support clinicians in mitigating these risks

A patient-specific multi-modality abdominal aortic aneurysm imaging phantom

PURPOSE: Multimodality imaging of the vascular system is a rapidly growing area of innovation and research, which is increasing with awareness of the dangers of ionizing radiation. Phantom models that are applicable across multiple imaging modalities facilitate testing and comparisons in pre-clinical studies of new devices. Additionally, phantom models are of benefit to surgical trainees for gaining experience with new techniques. We propose a temperature-stable, high-fidelity method for creating complex abdominal aortic aneurysm phantoms that are compatible with both radiation-based, and ultrasound-based imaging modalities, using low cost materials. METHODS: Volumetric CT data of an abdominal aortic aneurysm were acquired. Regions of interest were segmented to form a model compatible with 3D printing. The novel phantom fabrication method comprised a hybrid approach of using 3D printing of water-soluble materials to create wall-less, patient-derived vascular structures embedded within tailored tissue-mimicking materials to create realistic surrounding tissues. A non-soluble 3-D printed spine was included to provide a radiological landmark. RESULTS: The phantom was found to provide realistic appearances with intravascular ultrasound, computed tomography and transcutaneous ultrasound. Furthermore, the utility of this phantom as a training model was demonstrated during a simulated endovascular aneurysm repair procedure with image fusion. CONCLUSION: With the hybrid fabrication method demonstrated here, complex multimodality imaging patient-derived vascular phantoms can be successfully fabricated. These have potential roles in the benchtop development of emerging imaging technologies, refinement of novel minimally invasive surgical techniques and as clinical training tools

Morphological and Physiological Characteristics of Ruptured Plaques in Native Arteries and Neoatherosclerotic Segments: An OCT-Based and Computational Fluid Dynamics Study.

Background Intravascular imaging has been used to assess the morphology of lesions causing an acute coronary syndrome (ACS) in native vessels (NV) and identify differences between plaques that ruptured (PR) and caused an event and those that ruptured without clinical manifestations. However, there is no data about the morphological and physiological characteristics of neoatherosclerotic plaques that ruptured (PR-NA) which constitute a common cause of stent failure. Methods We retrospectively analyzed data from patients admitted with an acute myocardial infarction that had optical coherence tomography (OCT) imaging of the culprit vessel before balloon pre-dilation. OCT pullbacks showing PR were segmented at every 0.4 mm. The extent of the formed cavity, lipid and calcific tissue, thrombus, and macrophages were measured, and the fibrous cap thickness (FCT) and the incidence of micro-channels and cholesterol crystals were reported. These data were used to reconstruct a representative model of the native and neoatherosclerotic lesion geometry that was processed with computational fluid dynamics (CFD) techniques to estimate the distribution of the endothelial shear stress and plaque structural stress. Result Eighty patients were included in the present analysis: 56 had PR in NV (PR-NV group) and 24 in NA segments (PR-NA group). The PR-NV group had a larger minimum lumen area (2.93 ± 2.03 vs. 2.00 ± 1.26 mm2, p = 0.015) but similar lesion length and area stenosis compared to PR-NA group. The mean FCT (186 ± 65 vs. 232 ± 80 μm, p = 0.009) and the lipid index was smaller (16.7 ± 13.8 vs. 25.9 ± 14.1, p = 0.008) while the of calcific index (8.3 ± 9.5 vs. 2.2 ± 1.6%, p = 0.002) and the incidence of micro-channels (41.4 vs. 12.5%, p = 0.013) was higher in the PR-NV group. Conversely, there was no difference in the incidence of cholesterol crystals, thrombus burden or the location of the rupture site between groups. CFD analysis revealed higher maximum endothelial shear stress (19.1 vs. 11.0 Pa) and lower maximum plaque structural stress (38.8 vs. 95.1 kPa) in the PR-NA compared to the PR-NV model. Conclusion We reported significant morphological and physiological differences between culprit ruptured plaques in native and stented segments. Further research is needed to better understand the causes of these differences and the mechanisms regulating neoatherosclerotic lesion destabilization

A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest:the ARREST pilot randomised trial

Background Wide variation exists in inter-hospital survival from out-of-hospital cardiac arrest (OHCA). Regionalisation of care into cardiac arrest centres (CAC) may improve this. We report a pilot randomised trial of expedited transfer to a CAC following OHCA without ST-elevation. The objective was to assess the feasibility of performing a large-scale randomised controlled trial. Methods Adult witnessed ventricular fibrillation OHCA of presumed cardiac cause were randomised 1:1 to either: (1) treatment: comprising expedited transfer to a CAC for goal-directed therapy including access to immediate reperfusion, or (2) control: comprising current standard of care involving delivery to the geographically closest hospital. The feasibility of randomisation, protocol adherence and data collection of the primary (30-day all-cause mortality) and secondary (cerebral performance category (CPC)) and in-hospital major cardiovascular and cerebrovascular events (MACCE) clinical outcome measures were assessed. Results Between November 2014 and April 2016, 118 cases were screened, of which 63 patients (53%) met eligibility criteria and 40 of the 63 patients (63%) were randomised. There were no protocol deviations in the treatment arm. Data collection of primary and secondary outcomes was achieved in 83%. There was no difference in baseline characteristics between the groups: 30-day mortality (Intervention 9/18, 50% vs. Control 6/15, 40%; P = 0.73), CPC 1/2 (Intervention: 9/18, 50% vs. Control 7/14, 50%; P &gt; 0.99) or MACCE (Intervention: 9/18, 50% vs. Control 6/15, 40%; P = 0.73). Conclusions These findings support the feasibility and acceptability of conducting a large-scale randomised controlled trial of expedited transfer to CAC following OHCA to address a remaining uncertainty in post-arrest care.</p

Expedited transfer to Emergency Department versus Cardiac Catheter Laboratory in a Cardiac Arrest Centre for non ST-elevation Out-Of-Hospital Cardiac Arrest: ARREST Trial as-treated analysis

BACKGROUND: The ARREST trial demonstrated that in adult patients, transfer to a cardiac catheter laboratory in a cardiac arrest centre (CAC) following resuscitated out-of-hospital cardiac arrest (OHCA) without ST-elevation did not reduce deaths at 30 days compared with delivery to the geographically closest emergency department (standard care). More than half of the CACs had a co-located emergency department to which patients were delivered as part of the standard care arm, which may have influenced outcomes. AIM: We performed a pre-specified as-treated analysis to determine if a CAC and the location patients were delivered to, either emergency department or cardiac catheter laboratory, reduced deaths. METHODS: Patients (aged ≥18 years) with resuscitated OHCA without ST elevation who were enrolled in the ARREST trial were grouped according to the location they were to delivered to- either an emergency department with or without a co-located CAC or a cardiac catheter laboratory within a CAC - at one of 32 hospitals in London, UK - by London Ambulance Service irrespective of randomised allocation. The as-treated population were therefore analysed as one of three groups: 1) emergency department in a CAC 2) direct to a cardiac catheter laboratory in a CAC and 3) emergency department in a non-CAC. The primary outcome of the trial was all-cause mortality at 30 days. Secondary outcomes included all-cause mortality at 3 months and neurological outcome at discharge and 3 months. A pre-specified analysis adjusting for age, sex, initial shockable rhythm, witnessed cardiac arrest, bystander CPR, the time from cardiac arrest until ROSC, and location of cardiac arrest was performed in the as-treated groups. RESULTS: Between January 15, 2018 and December 1, 2022; a total of 862 participants were enrolled into the trial. Data for the primary outcome for this analysis were available in 818/862 (94.9%). Patients delivered to an ED in a CAC had fewer deaths at 30 days compared with the ED in a non-CAC group (83/182, 45.6% versus 178/233, 76.4%; adjusted OR 0.43, 95% CI 0.24 to 0.76; P=0.0039). Patients delivered to a cardiac catheter laboratory in a CAC also had fewer deaths compared with the ED in a non-CAC group but there was no statistical difference (250/403, 62.0%: adjusted OR 0.72, 95% CI 0.44 to 1.18; P=0.19). Survival with a favourable neurological outcome at hospital discharge occurred in 88/177 (49.7%) of the ED in a CAC group, 130/406 (32%) of the catheter laboratory in a CAC group and 42/228 (18.4%) of the ED in a non-CAC group. CONCLUSIONS: In this as-treated analysis of the ARREST trial, in adult patients with resuscitated OHCA without ST-elevation, we observed a lower 30-day mortality and favourable neurological outcomes following delivery to an ED in a CAC and cardiac catheter laboratory in CAC, when compared with delivery to ED in a non-CAC

Effect of remote ischaemic conditioning on infarct size and remodelling in ST-segment elevation myocardial infarction patients: the CONDI-2/ERIC-PPCI CMR substudy.

The effect of limb remote ischaemic conditioning (RIC) on myocardial infarct (MI) size and left ventricular ejection fraction (LVEF) was investigated in a pre-planned cardiovascular magnetic resonance (CMR) substudy of the CONDI-2/ERIC-PPCI trial. This single-blind multi-centre trial (7 sites in UK and Denmark) included 169 ST-segment elevation myocardial infarction (STEMI) patients who were already randomised to either control (n = 89) or limb RIC (n = 80) (4 × 5 min cycles of arm cuff inflations/deflations) prior to primary percutaneous coronary intervention. CMR was performed acutely and at 6 months. The primary endpoint was MI size on the 6 month CMR scan, expressed as median and interquartile range. In 110 patients with 6-month CMR data, limb RIC did not reduce MI size [RIC: 13.0 (5.1-17.1)% of LV mass; control: 11.1 (7.0-17.8)% of LV mass, P = 0.39], or LVEF, when compared to control. In 162 patients with acute CMR data, limb RIC had no effect on acute MI size, microvascular obstruction and LVEF when compared to control. In a subgroup of anterior STEMI patients, RIC was associated with lower incidence of microvascular obstruction and higher LVEF on the acute scan when compared with control, but this was not associated with an improvement in LVEF at 6 months. In summary, in this pre-planned CMR substudy of the CONDI-2/ERIC-PPCI trial, there was no evidence that limb RIC reduced MI size or improved LVEF at 6 months by CMR, findings which are consistent with the neutral effects of limb RIC on clinical outcomes reported in the main CONDI-2/ERIC-PPCI trial

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI):a single-blind randomised controlled trial

Background: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. Methods: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age &gt;18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. Findings: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91–1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. Interpretation: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. Funding: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden.</p

Arrhythmia and death following percutaneous revascularization in ischemic left ventricular dysfunction: Prespecified analyses from the REVIVED-BCIS2 trial

BACKGROUND: Ventricular arrhythmia is an important cause of mortality in patients with ischemic left ventricular dysfunction. Revascularization with coronary artery bypass graft or percutaneous coronary intervention is often recommended for these patients before implantation of a cardiac defibrillator because it is assumed that this may reduce the incidence of fatal and potentially fatal ventricular arrhythmias, although this premise has not been evaluated in a randomized trial to date. METHODS: Patients with severe left ventricular dysfunction, extensive coronary disease, and viable myocardium were randomly assigned to receive either percutaneous coronary intervention (PCI) plus optimal medical and device therapy (OMT) or OMT alone. The composite primary outcome was all-cause death or aborted sudden death (defined as an appropriate implantable cardioverter defibrillator therapy or a resuscitated cardiac arrest) at a minimum of 24 months, analyzed as time to first event on an intention-to-treat basis. Secondary outcomes included cardiovascular death or aborted sudden death, appropriate implantable cardioverter defibrillator (ICD) therapy or sustained ventricular arrhythmia, and number of appropriate ICD therapies. RESULTS: Between August 28, 2013, and March 19, 2020, 700 patients were enrolled across 40 centers in the United Kingdom. A total of 347 patients were assigned to the PCI+OMT group and 353 to the OMT alone group. The mean age of participants was 69 years; 88% were male; 56% had hypertension; 41% had diabetes; and 53% had a clinical history of myocardial infarction. The median left ventricular ejection fraction was 28%; 53.1% had an implantable defibrillator inserted before randomization or during follow-up. All-cause death or aborted sudden death occurred in 144 patients (41.6%) in the PCI group and 142 patients (40.2%) in the OMT group (hazard ratio, 1.03 [95% CI, 0.82–1.30]; P =0.80). There was no between-group difference in the occurrence of any of the secondary outcomes. CONCLUSIONS: PCI was not associated with a reduction in all-cause mortality or aborted sudden death. In patients with ischemic cardiomyopathy, PCI is not beneficial solely for the purpose of reducing potentially fatal ventricular arrhythmias. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01920048