Impact of COVID-19 pandemic on the occurrence and outcome of cardiogenic shock complicating acute myocardial infarction

Background

The COVID-19 pandemic had influenced the patient's behavior and impacted the homeostasis to a pro-thrombotic niveau.

Aim

The study aimed to follow the impact of COVID-19 on the incidence and prognosis of cardiogenic shock complicated initially acute myocardial infarction (CS-AMI).

Methods

We used data entered into a large national all-comers registry of coronary intervention over five years. From 1/2016 to 12/2020, 50,745 AMI patients were included, and 2,822 (5.6%) initially had CS.

Results

The incidence of CS-AMI was significantly higher in the COVID period (2020) than the mean incidence in 2016–2019 (5.5% vs 6%, p=0.032). The difference was caused by significant increase of CS in acute STEMI (7.6% vs. 8.7%, p=0.011); it was 7.1% in 2016, 7.8% (2017), 7.6% (2018), 7.8% (2019), and 8.7% (2020). The CS complicated 2.3% (2016), 2.7% (2017), 2.7% (2018), 2.8% (2019), and 2.8% (2020) of NSTEMI.

The observed rise in CS-STEMI incidence each month during the pandemic compared to the average incidence in non-pandemic years correlated with the substantial increase in the number of COVID infected/hospitalized (Table 1). In these months, no changes in time delay to reperfusion layout were observed in CS-STEMI patients (Table 2).

Except of less frequent history of previous PCI (13.9% and 8.2%, p<0.001), we found no significant differences in the followed CS-STEMI patient characteristics in 2016–2019 and 2020; men 72.7% and 75.4% (p=0.1), mean age (SD) 66.3 (12.3)yrs and 66.3 (12.2) yrs, Diabetes 20.9% and 19.1% (p=0.2), CKD 5.4% and 5.7% (p=0.4), previous CABG 4.5 and 4.2% (p=0.5), left main disease (14.3% and 16%, p=0.5), one vessel disease 24.9% and 32.1% (p=0.9), pre-PCI TIMI flow 0 64.4% and 66.2% (p=0.6), post-PCI TIMI flow 3 76.7% and 76.9%.

The COVID pandemic didn't influence the proportions of pre-hospital resuscitated CS-AMI patients (57.5% and 58.7%, p=0.6) and those on mechanical ventilation (67.8% and 68.3%, p=0.8).

The 30-day mortality trend of CS-AMI was 53.7% in 2016, 51.6% (2017), 49.7% (2018), 49.3% (2019), and 47.9% (2020). And in CS-STEMI it was 50.8%, 47.1%, 46.4%, 44.1%, and 45.3% (P2019 vs. 2020 =0.8), respectively.

Conclusion

Data from a large national all-comer registry showed an increase in the proportion of patients admitted to hospitals with STEMI complicated by CS in the year of the COVID pandemic. The CS rise correlated with the increase in the COVID infected population. Factors other than the patient's cardiovascular risk profile or prolongation of a time delay to reperfusion influenced this trend. We suggest that the availability of health care and patient adherence may have affected the risks control. We did not observe any effect of the pandemic on CS-AMI mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic

All-cause mortality of patients with STEMI, cardiogenic shock and multivessel coronary disease treated with culprit vessel only versus multivessel primary PCI

Background

Patients with ST elevation myocardial infarction (STEMI) and cardiogenic shock (CS) treated with primary percutaneous coronary intervention (pPCI) have high mortality. A recent trial demonstrated that a culprit vessel-only strategy (CV-pPCI) was superior to immediate multivessel PCI (MV-pPCI) for patients with CS and multivessel coronary artery disease (MVD). Irrespective of it and current guidelines, multivessel PCI is still often used in these patients.

Purpose/Methods

The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and MVD treated with culprit vessel only pPCI or multivessel PCI during initial procedure. From 2016 to 2020, 23703 primary PCI patients with STEMI were included in the national all-comers registry of cardiovascular interventions. From them, a total of 1213 (5.1%) patients had cardiogenic shock and MVD at admission to the hospital. Initially 921 (75.9%) patients were treated with CV-pPCI and 292 (24.1%) with MV-pPCI.

Results

CV-pPCI was a preferred strategy to MV-pPCI in men (74.6% vs 25.4%; p<0,001) and women (79.8% vs 20.2%; p<0,001) with CS-STEMI and MVD. Patients with 3-vessel disease and left main disease had higher probability to be treated with MV-pPCI than patients with 2-vessel disease and without left main disease (28.5% vs 18.6%; p<0,001 and 37.7% vs 20.6%; p<0,001).The CV-pPCI and MV-pPCI group patients did not differ in age (68.1±11.2 vs 66.2±11.4 years; p=0.780), previous PCI (16.1% vs 12.0%; p=0.890) and CABG (6.2% vs 4.8%; p=0.376), chronic kidney disease (6.8% vs 8.2%; p=0.426), cardiopulmonary resuscitation (60.4% vs 58.9%; p=0.657) and pulmonary ventilation (66.8% vs 70.5%; p=0.227) at admission, localization of myocardial infarction (anterior 50.8.% vs 58.9%; p=0.671), time to reperfusion (<2 hours 5.2% vs 4.8%; p=0.722) and TIMI flow 0 before PCI (63.1% vs 64.0%; p=0.675). Based on the results of logistic regression analysis, 30-days (odds ratio, 0.99; 95% CI 0.76 to 1.29; p=0.937) and 1-year (odds ratio, 0.91; 95% CI 0.69 to 1.19; p=0.477) all-cause mortality rates were similar in CV-pPCI and MV-pPCI groups. The presence of 3-vessel disease was the strongest adjusted predictor of 30-days (odds ratio, 1.61; 95% CI 1.27 to 2.04; p<0.001) and 1-year (odds ratio, 1.64; 95% CI 1.30 to 2.08; p<0.001) all-cause mortality in patients with STEMI and CS treated with pPCI.

Conclusion

Immediate multivessel primary PCI is still used in patients with CS-STEMI and MVD in routine clinical practice. We did not find difference in 30-days and 1-year mortality among patients with CS-STEMI and MVD treated either with culprit vessel-only or multivessel primary PCI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NV19-02-00086 supported by Ministry of Health of the Czech Republic

Echocardiography is inferior to computed tomography in predicting balloon expandable transcutaneous implantation valve size in routine clinical setting-single centre study

Funding Acknowledgements

Type of funding sources: None.

Background

Transcatheter aortic valve replacement (TAVR) became standard of care for selected patients with severe aortic stenosis. Computed tomography (CT) and 2D/3D echocardiography (ECHO) are used for aortic annulus sizing. As a result of increasing number of TAVR more imaging specialists participate in pre-procedural TAVR assessment.

Purpose

The aim of this study was to compare accuracy of ECHO aortic annulus measurements vs CT based parameters for Edward Sapiens TAVR in such environment.

Methods

Data of 145 consecutive patients with TAVR (Sapiens XT or Sapiens 3S) were analysed retrospectively. One radiologist and six echocardiographers trained in aortic annulus size measurements participated in pre-procedural aortic anulus assessment. Aortic annulus area and area derived diameter were measured/calculated in each patient from 3D ECHO data set acquired from mid-oesophageal view and from CT data set, using multiplanar reconstruction. 2D ECHO aortic annulus size was measured from mid-oesophageal 120º view in early systole. 

Results

139 (96%) patients had favourable TAVR result (max. mild aortic regurgitation, single valve implanted). 3D ECHO aortic anulus area and area derived diameter were smaller than corresponding CT parameters (464 ± 99 vs 479 ± 88 mm2, p < 0.001 and 24.2 ± 2.7 mm vs 25.0 ± 5.5, p = 0.002, respectively) and differed between echocardiographers (p < 0.001). 2D ECHO anulus measurement were smaller in comparison to both CT and 3D ECHO area derived diameter (22.6 ± 2.9 vs 25.0 ± 5.5mm, p = 0,013 and 22.6 ± 2.9 vs 24.2± 2.7mm, p < 0.001, respectively). In implanted valves with favourable procedure result, concordance of CT and 3D ECHO aortic annulus area with manufacturer recommended ranges was 79.4% vs 61% (p= 0.001) and for area derived diameter 80.1% vs 61.7% (p = 0.001). Using 3D ECHO measurements 33% of the patients would have hypothetically received inappropriate valve size.

Conclusion

3D ECHO aortic annulus measurements are generally smaller then CT ones. If 3D ECHO based parameters only were used for TAVR (Edward Sapiens) size selection, it would have resulted in underestimation of the valve size in up to 1/3 of the patients. CT aortic annulus size assessment should be preferred method over 3D ECHO in daily practice. Abstract Figure 1  Abstract Table 1

Lipoprotein-associated phospholipase A₂ mass level is increased in elderly subjects with type 2 diabetes mellitus

OBJECTIVE. Lipoprotein-associated phospholipase A₂ (Lp-PLA₂) is extensively expressed by advanced atherosclerotic lesions and may play a role in plaque instability. We selected a group of elderly subjects that underwent transcatheter aortic valve implantation (TAVI) or balloon angioplasty (BA) and separated them into two groups, diabetic and nondiabetic, to compare the level of Lp-PLA₂ mass between them. METHODS. 44 patients aged 79.6 ± 5.6 years with symptomatic severe aortic valve stenosis underwent TAVI (n = 35) or BA (n = 9). 21 subjects had confirmed type 2 diabetes mellitus. Lp-PLA₂ mass was measured using an enzyme-linked immunosorbent assay kit (USCN Life Science, China) before and 3 days after the procedure. RESULTS. Lp-PLA₂ mass was significantly elevated in this population (1296 ± 358 ng/mL before TAVI; 1413 ± 268 ng/mL before BA) and further increased after TAVI (1604 ± 437 ng/mL, P < 0.01) or BA (1808 ± 303 ng/mL, P < 0.01). Lp-PLA₂ mass was significantly increased on the diabetic group before these interventions. CONCLUSION. Lp-PLA₂ may be a novel biomarker for the presence of rupture-prone atherosclerotic lesions in elderly patients. Levels of Lp-PLA₂ in diabetic patients may accompany the higher amount of small dense LDL particles seen in these subjects.

Failure of noninvasive prediction of pulmonary hypertension in patients with idiopathic pulmonary fibrosis

BACKGROUND

Pulmonary hypertension (PH) in patients with advanced idiopathic pulmonary fibrosis (IPF) is a complication connected with unfavorable prognosis. Great efforts have been made in attempting to establish a reliable non-invasive method which would enable detection of this complication. In this context a formula using pulmonary function parameters was published with outstanding results.

METHODS

We tested the formula in 27 IPF patients who underwent a lung function examination, cardiac ultrasonography and catheterisation on the same day.

RESULTS

Pulmonary hypertension was detected by catheterisation in 17 patients (63%). In our group, contrary to the published data, the aforementioned formula was neither useful for detecting patients with a high probability of PH nor as a means of calculating the mean pulmonary artery pressure in individual patients (p = 0.502 and p = 0.833, respectively). Ultrasound examination reached borderline correlation with the values measured by catheterisation when we compare patients with relevant results (r = 0.531, p = 0.051). However, the examination gave no usable results in 13 patients (48%).

CONCLUSION

Our data suggests that no reliable, noninvasive method is currently available for detecting and confirming PH in IPF patients. We did not confirm the usefulness of the published formula. Further carefully organised studies will be necessary to verify or refute it.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Time-course of tissue factor plasma level in patients with acute coronary syndrome

Enhanced expression of tissue factor (TF) may result in thrombosis contributing to acute clinical consequences of coronary artery disease. Several studies demonstrated elevated plasma levels of TF in patients with acute coronary syndrome (ACS). The aim of our study was to compare the concentrations of TF in coronary sinus (CS), proximal part of the left coronary artery (LCA) and peripheral vein (PV) of patients with ACS and stable coronary artery disease (SCAD). Time course of the TF plasma levels in PV was followed on day 1 and day 7 after index event of ACS presentation and was compared to day 0 values. No heparin was given prior to the blood sampling. Twenty-nine patients in the ACS group (age 63.6+/-10.8 years, 20 males, 9 females) and 24 patients with SCAD (age 62.3+/-8.1 years, 21 males, 3 females) were examined. TF plasma level was significantly higher in patients with ACS than in those with SCAD (239.0+/-99.3 ng/ml vs. 164.3+/-114.2 ng/ml; p=0.016). There was no difference in TF plasma levels in PV, CS and LCA (239.0+/-99.3 ng/ml vs. 253.7+/-131.5 ng/ml vs. 250.6+/-116.4 ng/ml, respectively). TF plasma levels tended to decrease only non-significantly on the day 7 (224.4+/-109.8 ng/ml). Significant linear correlation between TF and high sensitivity CRP (hs-CRP) levels on day 0 was found. In conclusion, TF plasma levels are elevated in patients with ACS not only locally in CS but also in systematic circulation. Our data support the relationship between TF production and proinflammatory mediators.

Plasma tissue factor in coronary artery disease: further step to the understanding of the basic mechanisms of coronary artery thrombosis

Tissue factor is a cell surface protein that is expressed constitutively by monocytes, macrophages and fibroblasts, but also by some other cells in response to a variety of stimuli. The main function of the tissue factor is to form a complex with factor VII/VIIa that converts factors IX and X to their active forms. Tissue factor is also involved in the pathophysiology of systemic inflammatory disorders, coagulopathies, atherosclerotic disease, tumor angiogenesis and metastasis. Increased tissue factor expression either locally in the coronary plaques or systematically on circulating blood elements of patients with acute coronary syndromes may be responsible for increased thrombin generation, thus leading to platelet activation and fibrin formation. Tissue factor therefore plays a pivotal role in the initiation of thrombotic complications in patients with coronary artery disease.

[Cardiogenic shock in acute myocardial infarction--what we know in 2005]

Cardiogenic shock represents a complication in up to 10% of patients with acute myocardial infarction. Cardiogenic shock mortality remains high. In the contemporary treatment inhibitors of NO synthase are studied, apart from classic medications. Mechanical circulatory support is also important in majority of patients with cardiogenic shock: intraaortic balloon contrapulsation, left ventricular assist device systems. Prognosis is improved by percutaneous coronary intervention.

[Ischemia-modified albumin: new marker of myocardial ischemia?]

The Albumin Cobalt Binding Test is a quantitative in vitro diagnostic test used on human serum that detects ischemia-modified albumin by measuring the cobalt binding capacity of albumin in human serum. Ischemia modified albumin is intended for use in conjunction with ECG and cardiac troponin as an aid to short term risk stratification of patients presenting with chest pain suggestive of cardiac origin. Thus, in patients with chest pain or equivalent symptoms suggestive of cardiac origin, with non-diagnostic ECG and normal troponin, a negative IMA can be used as an aid to rule out acute coronary syndrome (ACS) in low risk patients.