Outcomes Associated With Peripheral Artery Disease in Myocardial Infarction With Cardiogenic Shock

Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Preliminary Cost-Effectiveness Analysis in the Italian Context

INTRODUCTION

Cardiogenic shock (CS) is a life-threatening failure of the heart to supply adequate blood, requiring immediate treatment. Although nowadays Impella® heart pumps and veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) are both widely employed in routine clinical practice for the management of patients with CS, extensive comparative information on their cost-effectiveness is lacking. The aim of the present study was to conduct a cost-effectiveness analysis comparing Impella to VA-ECMO in patients with CS from the National Healthcare Service (NHS) perspective in Italy. A secondary objective was to compare costs from both NHS and hospital perspectives.

METHODS

A Markov model projected, on a lifetime horizon, life years (LYs), quality-adjusted life years (QALYs), and costs associated with Impella and VA-ECMO. Costs from the NHS perspective were estimated mainly through Italian reimbursement rates, while hospital costs were derived from a clinical center in Italy.

RESULTS

From an NHS perspective, Impella showed lower costs and better life expectancy and patients' quality of life (€50,303, 1.544 LYs, 0.905 QALYs) compared to VA-ECMO (€76,795, 1.391 LYs, 0.784 QALYs). DRG overall reimbursements for Impella (€49,998) do not completely cover the hospital costs and the cost for the technology (€57,770). Conversely, the hospital cost for the strategy VA-ECMO (€52,190) is lower than the NHS overall reimbursements (€76,790).

CONCLUSIONS

Our analysis suggests that Impella may be cost-saving over VA-ECMO, while also providing better health outcomes for patients with CS; however, discrepancies in costs and reimbursement rates were observed, likely due to variability in patient care and hospital resource utilization. Future real-world studies are needed to confirm these findings, but decision-makers can use this data as an initial reference for health technology assessments in Italy.

Predictors and Impact of Cardiogenic Shock in Oldest-Old ST-Elevation Myocardial Infarction Patients

Background: Cardiogenic shock (CS) is the most frequent cause of in-hospital mortality after ST-elevation myocardial infarction (STEMI). Data about CS in very elderly (age ≥ 85 years) STEMI patients are scarce. We sought to assess the prognostic factors and the short- and mid-term impact of CS in this population. Methods: Consecutive very elderly STEMI patients undergoing invasive treatment were included in a retrospective multicenter registry. Results: Among 608 patients, 72 (11.8%) fulfilled experienced CS. Peripheral artery disease (PAD) (OR: 2.25, 95% CI: 1.29-3.92, p < 0.01) and cardiac arrest at presentation (OR: 4.36, 95% CI: 2.32-8.21, p < 0.01) were the major independent predictors of CS. Age (HR: 1.07, 95% CI: 1.03-1.11, p < 0.001), PAD (HR: 1.29, 95% CI: 1.01-1.66, p = 0.045), previous MI (HR: 2.16, 95% CI: 1.32-3.55, p = 0.002), and cardiac arrest at presentation (HR: 1.59, 95% CI: 1.29-1.96, p < 0.001) were the major independent predictors of death. CS was associated with a higher risk of mortality at 30 days (adjusted HR: 4.21, 95% CI: 2.19 to 7.78, p < 0.01) mostly driven by higher intraprocedural and in-hospital mortality. Among patients who survived the acute phase and hospitalization, CS at presentation was not associated with a higher mortality risk during the remaining follow-up period (log-rank p = 0.78). Conclusions: At short-term follow-up, very elderly STEMI patients presenting with CS had a higher risk of mortality when compared to non-CS patients. Interestingly, CS patients surviving the acute phase showed a similar survival rate to non-CS patients after discharge.

Mechanisms and Therapeutic Strategies for Myocardial Ischemia-Reperfusion Injury in Diabetic States

In patients with myocardial infarction, one of the complications that may occur after revascularization is myocardial ischemia-reperfusion injury (IRI), characterized by a depleted myocardial oxygen supply and absence of blood flow recovery after reperfusion, leading to expansion of myocardial infarction, poor healing of myocardial infarction and reversal of left ventricular remodeling, and an increase in the risk for major adverse cardiovascular events such as heart failure, arrhythmia, and cardiac cell death. As a risk factor for cardiovascular disease, diabetes mellitus increases myocardial susceptibility to myocardial IRI through various mechanisms, increases acute myocardial infarction and myocardial IRI incidence, decreases myocardial responsiveness to protective strategies and efficacy of myocardial IRI protective methods, and increases diabetes mellitus mortality through myocardial infarction. This Review summarizes the mechanisms, existing therapeutic strategies, and potential therapeutic targets of myocardial IRI in diabetic states, which has very compelling clinical significance.

Prognostic Factors Associated with Mortality in Cardiogenic Shock - A Systematic Review and Meta-Analysis

BACKGROUND

Cardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock.

METHODS

We performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock.

RESULTS

We identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality.

CONCLUSIONS

This analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

Comparative analysis of cardiogenic shock outcomes in acute myocardial infarction with polyvascular disease

Background

Cardiogenic shock (CS) is the leading cause of mortality in acute myocardial infarction (AMI) patients, especially in those with vascular disease. This study aimed to assess the association between extent of polyvascular disease and the in hospital management and outcome of patients with AMI-induced CS.

Method

Using the National Inpatient Sample from 2016 to 2019, adult patients with AMI and CS with known vascular disease were identified and stratified by number of diseased vascular beds and into STEMI and NSTEMI subgroups. The study assessed in-hospital major adverse cardiovascular and cerebrovascular events (MACCE), mortality, acute CVA and major bleeding, as well as invasive management by number of diseased vascular beds.

Results

Out of 136,245 patients, 57.9 % attributed to STEMI and 42.1 % to NSTEMI. The study revealed that the likelihood of percutaneous coronary intervention (PCI) [(aOR for 2 beds 0.94, CI 0.91-0.96, p-value < 0.001; 3 beds 1.0, CI 0.94-1.06, p-value 0.96)] and coronary artery bypass grafting (CABG) [(aOR for 2 beds 0.66, CI 0.64-0.69, p-value < 0.001; 3 beds 0.76, CI 0.71-0.81, p-value < 0.001)] decreased as the number of diseased vascular sites increased. The study also highlighted a direct dose-response relationship between the number of diseased vascular beds and major adverse outcomes, including MACCE, mortality and acute CVA, underscoring the prognostic significance of polyvascular disease in this patient population.

Conclusion

The study demonstrated that polyvascular disease significantly worsens AMI-induced CS outcomes. The findings highlight the importance of early identification and aggressive management of polyvascular disease in these patients. Further research is needed to develop targeted treatment strategies for this high-risk population.

Development and validation of a major adverse limb events prediction model for peripheral arterial disease with frailty

OBJECTIVE

To investigate the risk factors for major limb adverse events (MALE) in peripheral arterial disease (PAD) combined with frailty and to develop and validate a risk prediction model of MALE.

METHODS

This prospective study was performed in the vascular surgery department of patients in six hospitals in southwest China. Prospective collection of patients with PAD combined with frailty from February 1 to December 20, 2021, with MALE as the primary outcome, and followed for 1 year. The cohort was divided into a development cohort and a validation cohort. In the development cohort, a multivariate risk prediction model was developed to predict MALE using random forests for variable selection and multivariable Cox regression analysis. The model is represented by a visualized nomogram and a web-based calculator. The model performance was tested with the validation cohort and assessed using the C-statistic and calibration plots.

RESULTS

A total of 1179 patients were prospectively enrolled from February 1 to December 20, 2021. Among 816 patients with PAD who were included in the analysis, the median follow-up period for this study was 9 ± 4.07 months, the mean age was 74.64 ± 9.43 years, and 249 (30.5%) were women. Within 1 year, 222 patients (27.2%) developed MALE. Target lesion revascularizations were performed in 99 patients (12.1%), and amputations were performed in 131 patients (16.1%). The mortality rate within the whole cohort was 108 patients (13.2%). After controlling for competing risk events (death), the cumulative risk of developing MALE was not statistically different. Prealbumin (hazard ratio [HR], 0.6; 95% confidence interval [CI], 0.41-0.89; P = .010), percutaneous coronary intervention (HR, 2.31; 95% CI, 1.26-4.21; P = .006), Rutherford classification (HR, 1.77; 95% CI, 1.36-2.31; P < .001), white blood cell (HR, 1.85; 95% CI, 1.20-2.87; P = .005), high altitude area (HR, 3.1; 95% CI, 1.43-6.75; P = .004), endovascular treatment (HR, 10.2; 95% CI, 1.44-72.50; P = .020), and length of stay (HR, 1.01; 95% CI, 1.00-1.03; P = .012) were risk factors for MALE. The MALE prediction model had a C-statistic of 0.76 (95% CI, 0.70-0.79). The C-statistic was 0.68 for internal validation and 0.66 for external validation for the MALE prediction model. The MALE prediction model for PAD presented an interactive nomogram and a web-based network calculator.

CONCLUSIONS

In this study, the MALE prediction model has a discriminative ability to predict MALE among patients with PAD in frailty. The MALE model can optimize clinical decision-making for patients with PAD in frailty.

Nomogram prediction model for the risk of intracranial hemorrhagic transformation after intravenous thrombolysis in patients with acute ischemic stroke

Background

Hemorrhagic transformation (HT) after intravenous thrombolysis (IVT) might worsen the clinical outcomes, and a reliable predictive system is needed to identify the risk of hemorrhagic transformation after IVT.

Methods

Retrospective collection of patients with acute cerebral infarction treated with intravenous thrombolysis in our hospital from 2018 to 2022. 197 patients were included in the research study. Multivariate logistic regression analysis was used to screen the factors in the predictive nomogram. The performance of nomogram was assessed on the area under the receiver operating characteristic curve (AUC-ROC), calibration plots and decision curve analysis (DCA).

Results

A total of 197 patients were recruited, of whom 24 (12.1%) developed HT. In multivariate logistic regression model National Institute of Health Stroke Scale (NIHSS) (OR, 1.362; 95% CI, 1.161-1.652; p = 0.001), N-terminal pro-brain natriuretic peptide (NT-pro BNP) (OR, 1.012; 95% CI, 1.004-1.020; p = 0.003), neutrophil to lymphocyte ratio (NLR) (OR, 3.430; 95% CI, 2.082-6.262; p < 0.001), systolic blood pressure (SBP) (OR, 1.039; 95% CI, 1.009-1.075; p = 0.016) were the independent predictors of HT which were used to generate nomogram. The nomogram showed good discrimination due to AUC-ROC values. Calibration plot showed good calibration. DCA showed that nomogram is clinically useful.

Conclusion

Nomogram consisting of NIHSS, NT-pro BNP, NLR, SBP scores predict the risk of HT in AIS patients treated with IVT.

Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.

Position Statement on Vascular Access Safety for Percutaneous Devices in AMI Complicated by Cardiogenic Shock

In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.