Clinical picture, management and risk stratification in patients with cardiogenic shock: does gender matter?

Background: Early recognition and risk stratification are crucial in cardiogenic shock (CS). A lower adherence to recommendations has been described in women with cardiovascular diseases. Little information exists about disparities in clinical picture, management and performance of risk stratification tools according to gender in patients with CS. Methods: Data from the multicenter Red-Shock registry were used. All consecutive patients with CS were included. Both CardShock and IABP-SHOCK II risk scores were calculated. The primary end-point was in-hospital mortality. The discriminative ability of both scores according to gender was assessed by binary logistic regression, calculating Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC). Results: A total of 793 patients were included, of whom 222 (28%) were female. Women were significantly older and had a lower proportion of chronic obstructive pulmonary disease and prior myocardial infarction. CS was less often related to acute coronary syndromes (ACS) in women. The use of vasoactive drugs, renal replacement therapy, invasive ventilation, therapeutic hypothermia and mechanical circulatory support was similar between both groups. In-hospital mortality was 346/793 (43.6%). Mortality was not significantly different according to gender (p = 0.194). Cardshock risk score showed a good ability for predicting in-hospital mortality both in man (AUC 0.69) and women (AUC 0.735). Likewise, the IABP-II successfully predicted in-hospital mortality in both groups (man: AUC 0.693; women: AUC 0.722). Conclusions: No significant differences were observed regarding management and in-hospital mortality according to gender. Both the CardShock and IABP-II risk scores depicted a good ability for predicting mortality also in women with CS

Optimal surgical timing after post-infarction ventricular septal rupture

Background: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dan-gerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis. Methods: We designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Second- ary endpoints were to determine which factors could influence mortality in the patients of the surgical group. Results: A total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1 & ndash;0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, par- ticularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p < 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p < 0.001). Conclusions: In our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions. (Cardiol J 2022; 29, 5: 773 & ndash;781

Criteria for admitting elderly patients with acute coronary syndrome to critical care units from Spanish hospital emergency departments: a LONGEVO-SCA cohort study

Objetivo: la información sobre los condicionantes de ingreso en unidades de críticos (UC) de pacientes ancianos con síndrome coronario agudo (SCA) es escasa. El objetivo de este estudio fue describir los factores asociados al ingreso en UC en una serie de ancianos no seleccionados con SCA en España. Métodos: el registro LONGEVO-SCA incluyó prospectivamente pacientes 80 años con SCA sin elevación del segmento ST (SCASEST), realizándose una valoración geriátrica intrahospitalaria y analizándose la evolución clínica a los 6 meses. Se analizaron los condicionantes de ingreso en UC mediante regresión logística binaria. Resultados: de un total de 508 pacientes (edad media 84,3 años), 150 (29,5%) fueron ingresados en UC. Los pacientes ingresados en UC presentaban menor edad, mayor proporción de insuficiencia cardíaca aguda, troponina positiva y peor función ventricular izquierda, así como puntuaciones superiores en las escalas de riesgo GRACE y ACTION-ICU. Estos pacientes presentaban, asimismo, una mejor situación funcional y una menor prevalencia de fragilidad, y fueron sometidos a coronariografía con mayor frecuencia (p < 0,001). No se apreciaron diferencias en mortalidad hospitalaria ni evolución a los 6 meses entre ambos grupos. Los predictores independientes de ingreso en UC fueron la ausencia de insuficiencia cardíaca previa, troponina positiva al ingreso, disfunción ventricular izquierda, valores elevados en la escala GRACE y en el índice de Charlson, y ausencia de fragilidad. Conclusiones: alrededor de un tercio de los ancianos con SCASEST son ingresados en UC. Los pacientes ingresados en UC presentan mayor perfil de riesgo al ingreso y menor prevalencia de síndromes geriátricos

Optimal surgical timing after post-infarction ventricular septal rupture

Background: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dangerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis. Methods: We designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Secondary endpoints were to determine which factors could influence mortality in the patients of the surgical group. Results: A total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1–0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, particularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p &lt; 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p &lt; 0.001). Conclusions: In our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions

Evolución temporal del tratamiento del infarto agudo de miocardio en pacientes ancianos y su impacto en la supervivencia a corto y largo plazo

Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 27-11-2012Depto. de MedicinaFac. de MedicinaTRUEunpu

Isolated Uvular Angioedema

Relevancia: Los inhibidores de la enzima convertidora de angiotensina (IECA) pueden causar angioedema uvular aislado y, aunque esta respuesta a los IECA es infrecuente, es importante tenerla en cuenta, ya que puede provocar dificultad respiratoria obstructiva si no se reconoce y trata con prontitud.: presentamos el caso de un varón de 59 años ingresado en la unidad coronaria con un infarto de miocardio con elevación del segmento ST inferior. No tomaba medicación y no tenía antecedentes de alergias ni angioedema. Se realizó una angioplastia primaria y se implantó con éxito un stent metálico en la arteria coronaria circunfleja. Se inició el tratamiento con 6,25 mg de captopril 6 horas después de la finalización del procedimiento, y 30 minutos después de la administración el paciente refirió dificultad para tragar y dolor de garganta. La auscultación pulmonar eran normal y no presentaba dificultad respiratoria. A la exploración, la úvula estaba marcadamente edematosa y eritematosa. Se diagnosticó angioedema uvular, o enfermedad de Quincke, y se inició tratamiento con antihistamínicos y glucocorticoides. glucocorticoides. La mejoría fue rápida, y el edema se resolvió por completo en 24 horas. El angioedema uvular aislado suele estar causado por una reacción de (tipo I) de hipersensibilidad inmediata. La degranulación de los mastocitos puede producirse tras la exposición a un estimulante inmunológico o no inmunológico, como un fármaco, como en el caso de este paciente. Los inhibidores de la enzima convertidora de la angiotensina (IECA) pueden causar angioedema uvular aislado, como en el caso de este paciente.Depto. de MedicinaFac. de MedicinaTRUEpu

External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients

Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy. The CardShock and the Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk scores have shown good results in predicting short-term mortality in cardiogenic shock. However, to date, they have not been compared in a large cohort of ischaemic and non-ischaemic real-world cardiogenic shock patients. The Red-Shock is a multicentre cohort of non-selected cardiogenic shock patients. We calculated the CardShock and IABP-SHOCK II risk scores in each patient and assessed discrimination and calibration. Results: We included 696 patients. The main cause of cardiogenic shock was acute coronary syndrome, occurring in 62% of the patients. Compared with acute coronary syndrome patients, non-acute coronary syndrome patients were younger and had a lower proportion of risk factors but higher rates of renal insufficiency; intra-aortic balloon pump was also less frequently used (31% vs 56%). In contrast, non-acute coronary syndrome patients were more often treated with mechanical circulatory support devices (11% vs 3%, p=0.001 for both). Both risk scores were good predictors of in-hospital mortality in acute coronary syndrome patients and had similar areas under the receiver-operating characteristic curve (area under the curve: 0.742 for the CardShock vs 0.752 for IABP-SHOCK II, p=0.65). Their discrimination performance was only modest when applied to non-acute coronary syndrome patients (0.648 vs 0.619, respectively, p=0.31). Calibration was acceptable for both scores (Hosmer-Lemeshow p=0.22 for the CardShock and 0.68 for IABP-SHOCK II). In our cohort, both the CardShock and the IABP-SHOCK II risk scores were good predictors of in-hospital mortality in acute coronary syndrome-related cardiogenic shock.Depto. de MedicinaFac. de MedicinaTRUEpu

Hypothermia in Comatose Survivors From Out-of-Hospital Cardiac Arrest

Se recomienda que los supervivientes en coma de una parada cardiaca extrahospitalaria se sometan a hipotermia terapéutica a una temperatura entre 32° y 34°C durante 12 a 24 horas. Sin embargo, se desconoce el nivel óptimo de enfriamiento. El objetivo de este estudio piloto era obtener datos iniciales sobre el efecto de distintos niveles de hipotermia. Nuestra hipótesis era que temperaturas más bajas se asociarían con mejor supervivencia y resultado neurológico. Métodos y resultados: los pacientes se incluían en el estudio si habían sufrido una parada cardiaca extrahospitalaria presenciada entre marzo de 2008 y agosto de 2011. La temperatura objetivo se asignó aleatoriamente a 32 °C o 34 °C. La estratificación se realizó en función del ritmo inicial como desfibrilable o asistolia. La temperatura objetivo se mantuvo durante 24 horas, seguidas de 12 a 24 horas de recalentamiento controlado. El objetivo primario fue la supervivencia libre de dependencia grave a los 6 meses. Se incluyeron 36 pacientes en el ensayo (26 con ritmo desfibrilable, 10 en asistolia), 18 de los cuales fueron asignados a 34 °C y 18 a 32 °C. Ocho de los 18 pacientes del grupo de 32 °C (44,4%) alcanzaron el objetivo primario, frente a con 2 de 18 en el grupo de 34 °C (11,1%) (log-rank P=0,12). Todos los pacientes cuyo ritmo inicial fue asistolia murieron antes de los 6 meses en ambos grupos. Ocho de 13 pacientes con ritmo inicial desfibrilable asignados a 32 °C (61,5%) estaban vivos sin dependencia grave a los 6 meses en comparación con 2 de 13 (15,4%) asignados a 34 °C (log rank P=0,029). La incidencia de complicaciones fue similar en ambos grupos, excepto la incidencia de convulsiones, que fue inferior (1 frente a 11; P=0,0002) en los pacientes asignados a 32°C en comparación con los asignados a 34°C. Por el contrario, hubo una tendencia hacia una mayor incidencia de bradicardia (7 frente a 2; P=0,054) en los pacientes asignados a 32°C .Background: It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. Methods and results: Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P=0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P=0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P=0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P=0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. Conclusions: The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms.Depto. de MedicinaFac. de MedicinaTRUEpu

Intimal Sarcoma of the Pulmonary Artery:Diagnostic Value of Different Imaging Techniques

Depto. de MedicinaFac. de MedicinaTRUEpu