Search Results (58)

High-risk pulmonary embolism (PE) is a life-threatening condition characterized by hemodynamic instability, often leading to catastrophic outcomes such as cardiac arrest and cardiogenic shock. We conducted a retrospective analysis of patients diagnosed with high-risk PE at a single tertiary center between 2018 and 2024. Catastrophic PE was defined as high-risk PE with hemodynamic collapse, including cardiac arrest and/or the requirement for high-dose vasopressors. Data on clinical characteristics, treatments, and outcomes were analyzed. Catastrophic PE accounted for 59% of cases. Systemic thrombolysis was the most frequent reperfusion strategy (67%), while catheter-directed therapies (35.4%) and VA-ECMO (11.4%) were used selectively. Despite aggressive management, catastrophic PE exhibited significantly higher mortality rates at 7 days (40%) and 30 days (49%) compared to non-catastrophic cases (9% and 12.5%, respectively). These patients also showed higher rates of multiorgan failure and required more invasive support. This study underscores the importance of early recognition and tailored treatment strategies for catastrophic PE, highlighting its distinct clinical presentation and worse outcomes compared to non-catastrophic high-risk PE. Further research is essential to refine treatment protocols and improve survival in this critically ill population, emphasizing the utility of a standardized classification to enhance clinical management and research consistency. Full article

Background: Sickle cell disease (SCD) is a hereditary hemoglobinopathy associated with life-threatening complications such as acute chest syndrome (ACS), which may necessitate extracorporeal membrane oxygenation (ECMO) in refractory cases. Despite growing use, ECMO in SCD remains challenging due to risks of hemolysis, thrombosis, and anticoagulation complications. This systematic review consolidates existing evidence on ECMO outcomes in SCD, focusing on indications, complications, and survival. Methods: A systematic search of MEDLINE, Cochrane CENTRAL, and Google Scholar was conducted up to January 2025, identifying case reports/series on ECMO use in SCD. Studies reporting venovenous (VV) or venoarterial (VA) ECMO for acute cardiopulmonary failure were included. Data on demographics, laboratory findings, management, and outcomes were extracted. Quality assessment was performed using the Joanna Briggs Institute checklist. Results: Sixteen case reports (23 patients) were included. Most patients were female (65.2%), with ACS (47.8%) and pulmonary embolism (13.0%) as common ECMO indications. VV-ECMO (69.6% of cases) was primarily used for respiratory failure, with a 69% survival rate, while VA-ECMO (30.4%) had a 29% survival rate, often due to cardiogenic shock or cardiac arrest. Complications included hemorrhage (26.1%), neurological injury (21.7%), and thrombosis (13.0%). Exchange transfusion was frequently employed (43.5%), with post-ECMO echocardiography showing improved right ventricular function in survivors. Conclusions: VV-ECMO demonstrates favorable outcomes in SCD-related respiratory failure, whereas VA-ECMO carries higher mortality risks. Careful patient selection, anticoagulation management, and multidisciplinary coordination are essential. Larger prospective studies are needed to refine ECMO utilization in this high-risk population. Full article

Background/Objectives: To evaluate the safety and feasibility of continuous positive airway pressure (CPAP) in patients with acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) during percutaneous coronary intervention (PCI). Non-invasive ventilation (NIV) is an established treatment for ADHF. Methods: All consecutive patients admitted to Santa Croce Hospital of Cuneo, receiving CPAP for ADHF in the cath lab during PCI for AMI, were included in a case series. Results: Between December 2018 and March 2021, 25 pts were included (median age 78 yrs, 48% female), with 64% of patients presenting with ST-elevation AMI and 17 (69%) in cardiogenic shock. At admission median left ventricular ejection fraction was 35 (20–60)% and eight (32%) patients had severe mitral regurgitation. Median PaO₂/FiO₂ was 183 (141–261) mmHg/%, lactate level 2.4 (1.3–3.8) mmol/L, and NTproBNP 7882 (3139–35,000) ng/L. CPAP was positioned and managed by nurses in all cases. Median FiO₂ was 50 (35–100)% and median positive end-expiratory pressure was 7.5 (5–12) cmH₂O. CPAP was generally well tolerated in 22 (88%) patients. One patient suffered cardiac arrest that led to CPAP interruption due to resuscitation maneuvers. No patient required orotracheal intubation in the cath lab. The post-procedural PaO₂/FiO₂ ratio substantially improved to 230 (175–356) mmHg/% (p = 0.007) and lactate decreased to 1.5 (1.0–1) mmol/L (p = 0.002). One patient died during hospital stay due to underlying disease, unrelated to the study procedure. Conclusions: CPAP during PCI in patients with AMI and ADHF seems feasible, safe, and well tolerated. Larger studies are warranted to confirm these results. Full article

Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used to support patients with refractory cardiogenic shock or cardiac arrest. While femoral artery cannulation remains the most common arterial access, axillary artery cannulation has emerged as a valuable alternative in selected cases. Objective: This narrative review aims to synthesize current evidence and expert opinion on axillary artery cannulation in V-A ECMO, focusing on its technical feasibility, physiologic implications, and clinical outcomes. Methods: A comprehensive literature search was performed in PubMed and Scopus using relevant keywords related to ECMO, axillary artery, cannulation techniques, and outcomes. Emphasis was placed on prospective and retrospective clinical studies, expert consensus statements, and technical reports published over the past two decades. Results: Axillary cannulation provides antegrade aortic flow, potentially reducing the risk of differential hypoxia and improving upper body perfusion. However, the technique presents unique technical challenges and may carry risks such as hyperperfusion syndrome or arterial complications. Emerging data suggest favorable outcomes in selected patient populations when performed in experienced centers. Conclusions: Axillary cannulation represents a promising arterial access route in V-A ECMO, particularly in cases with contraindications to femoral cannulation or when upper-body perfusion is a concern. Further prospective studies are needed to better define patient selection criteria and long-term outcomes. Full article

Background: Mitochondrial DNA (mtDNA) has strong pro-inflammatory potential and was found to be associated with mortality in critically ill patients. The purine bases from circulating cell-free DNA, including mtDNA, are catabolised into uric acid, contributing to elevated systemic levels. However, the prognostic value of uric acid in unselected critically ill intensive care unit (ICU) patients remains unclear. We aimed to investigate the association between uric acid levels at admission and 30-day mortality, assess its correlation with mtDNA, and examine prognostic relevance based on the primary cause of admission. Methods: This prospective single-centre study included 226 patients admitted to a tertiary care ICU. Uric acid and mtDNA levels were assessed at admission. Survival analyses were performed in the overall cohort and in subgroups stratified by primary diagnosis. Results: Uric acid showed a U-shaped association with 30-day mortality, with both low and high levels linked to reduced survival. In multivariate analysis, the 4th quartile of uric acid remained associated with adverse outcomes, independent of sex, vasopressors, mechanical ventilation, and creatinine (HR 2.549, 95% CI: 1.310–4.958, p = 0.006). A modest correlation was observed between uric acid and mtDNA (r = 0.214, p = 0.020). However, prognostic relevance varied by diagnosis. While uric acid predicted mortality in patients following cardiac arrest (p = 0.017), mtDNA was found to bear prognostic value in cardiogenic shock and decompensated heart failure (p = 0.009). Conclusions: Uric acid was independently associated with mortality in critically ill patients, with both low and high levels carrying prognostic value. Its predictive capabilities differed from mtDNA but showed partial overlap. However, both markers exhibited varying prognostic performance depending on the primary cause of admission. Full article

Background/Objectives: Cangrelor, an intravenous P2Y12 inhibitor, is increasingly used during percutaneous coronary intervention (PCI) for rapid and reversible platelet inhibition in patients unable to take oral antiplatelet agents, particularly in emergencies such as ST-elevation myocardial infarction (STEMI), cardiac arrest, or cardiogenic shock. This single-centre study evaluates cangrelor and outcomes in a non-surgical centre. Methods: Between June 2017 and December 2021, all the patients for whom cangrelor was used at a district general hospital (DGH) in the UK were included in this study. Data collection included baseline characteristics, admission, procedural details, and patient outcomes. The primary outcome was a composite of all-cause mortality, bleeding, and cardiovascular events, including myocardial infarction, stent thrombosis, and stroke, within 48 h. Secondary outcomes included predictors of the composite outcome at 48 h. Results: During the study period, cangrelor was administered peri-procedurally to 93 patients. Males comprised 85% of the patients; the mean age was 65.5 ± 10.6 years. A total of 1 patient (1.1%) had a cardiovascular event within 48 h of cangrelor administration, whereas all-cause mortality occurred in 17 patients (18%) within 48 h. No major bleeding events were noted at 48 h following cangrelor administration. Regression analysis did not find predictors of composite outcomes at 48 h. Conclusions: Cangrelor offers a potential alternative to oral P2Y12 inhibitors in specific high-risk scenarios. Further research is needed to validate its role in broader populations. Full article

Background and Objectives: Assessing risk is essential for optimal care in acute pulmonary embolism (PE). The present research seeks to evaluate the value of admission blood cellular indices as predictors of in-hospital outcome in acute PE and their utility in conjunction with validated risk tools such as the Pulmonary Embolism Severity Index (PESI) score and the European Society of Cardiology (ESC) risk stratification. Materials and Methods: A total of 1058 individuals hospitalized at Bihor County Emergency Hospital, Oradea, Romania, with a diagnosis of acute PE confirmed by contrast-enhanced computed tomographic pulmonary angiography were retrospectively evaluated. Results: A total of 165 patients (18.2%) experienced adverse outcomes, including in-hospital mortality, cardiac arrest, cardiogenic shock, or persistent hypotension, and required rescue thrombolytic therapy. The neutrophil-to-lymphocyte ratio (NLR) was an independent predictor for in-hospital adverse outcome OR = 1.071 (95% CI 1.01–1.137), p < 0.001. NLR as a predictor of adverse outcome had an AUC of 0.712 (95% CI 0.661–0.742), p < 0.001, sensitivity of 72.56%, and specificity of 64.19% for a cutoff value of >5.493. In a combined model with PESI or with ESC risk classification, NLR is leading to a significant improvement in their AUC (p < 0.001). Conclusions: Among hematological markers, NLR holds the greatest relevance for stratifying risk in acute pulmonary embolism and serves as an independent indicator of unfavorable in-hospital prognosis. NLR had an acceptable discriminative power to predict short-term complications and can increase the predictive value of the PESI score and of ESC risk classification. Full article

Background: Cardiogenic shock is a life-threatening condition characterized by the failure of the heart to maintain adequate circulation, leading to multi-organ dysfunction. While it is most commonly associated with acute myocardial infarction or cardiomyopathies, cardiogenic shock can also arise in unusual settings, such as severe malnutrition in patients with anorexia nervosa, a psychiatric disorder characterized by extreme restriction of food intake. Methods: Here, we describe the management of three patients with anorexia nervosa and severe cardiogenic shock, who were treated in our cardiological intensive care unit between December 2022 and January 2025. Two patients were successfully resuscitated after experiencing cardiac arrest, and two required mechanical circulatory support, including Venoarterial Extracorporeal Membrane Oxygenation and microaxial flow pump. The patients presented with a range of complications including multi-organ failure and respiratory distress. Due to the fragile balance between intensive cardiac and nutritional management, as well as the comorbidity of chronic malnutrition, therapeutic decisions were made carefully, including cautious electrolyte management, targeted nutritional therapy, and the use of advanced circulatory support. Conclusions: The treatment approach and beneficious outcomes underline the necessity of a multidisciplinary strategy in managing these critically ill patients with complex, interwoven pathologies. Our experience suggests that early recognition of cardiogenic shock and timely intervention with mechanical circulatory support may significantly improve patient survival in this high-risk cohort. Careful management of nutritional therapy and supplementation of trace elements and vitamins is crucial. Full article

Non-ST-segment elevation myocardial infarction (NSTEMI) can be managed by ischemia guide strategies or early invasive strategies. Here, we present the findings of an updated contemporary analysis regarding the use of intracoronary imaging (ICI)-guided PCI versus angiography-guided PCI and in-hospital mortality in patients with NSTEMI in the United States using the NIS database from 2016 to 2021. ICI use increased by nearly threefold between 2016 and 2021, without a significant difference in in-hospital mortality, though interestingly, mortality rates compared with angiography guidance were similar and relatively low. In this study, the use of ICI was associated with lower adjusted odds of in-hospital mortality, cardiogenic shock, and cardiac arrest, but with a longer length of stay and cost of hospitalization. Full article

Background/Objectives: Current evidence suggests that levosimendan may have a beneficial effect in the treatment of acute heart failure (AHF) or cardiogenic shock following primary percutaneous coronary intervention (PCI). However, there is a paucity of data on the use of levosimendan prior to PCI. Therefore, our pilot study aimed to assess the short-term prognosis of a new therapeutic protocol involving preprocedural infusion of levosimendan in patients with reduced left ventricular ejection fraction undergoing high-risk PCI for acute coronary syndrome (ACS). Methods: The study is a retrospective observational study, and the population includes all subjects who received levosimendan infusion prior to high-risk PCI for ACS. Subjects requiring urgent revascularization (cardiogenic shock, cardiac arrest) or with mechanical complications of ACS were excluded. Results: The study cohort consisted of 90 subjects, predominantly men (91.1%) with significantly reduced left ventricular function (28.7% (12)) and advanced coronary artery disease, mean SYNTAX Score 25.8 (19.3–33). During in-hospital follow-up, we observed 2 primary outcomes—death. The major adverse cardiac and cerebrovascular events (MACCE) rate was 7.8%. Two clinical adverse events that did not lead to discontinuation were observed during the in-hospital period. Both were related to hypotension. Conclusions: In short-term observation, novel therapeutic approach in the management of high-risk PCI in ACS patients—pre-procedural levosimendan—was a relatively safe approach. No significant adverse events were reported. Full article

Myocardial Bridging (MB) is typically a benign congenital coronary anomaly. MB can infrequently result in complications such as myocardial ischemia, arrhythmias, and sudden cardiac death. Recent studies suggest an underlying genetic component for MB involving DES, FBN1, SCN2B, or NOTCH1. The role of percutaneous coronary intervention (PCI) in managing MB, compared to optimal medical therapy (OMT), remains uncertain. Our study used the National Inpatient Sample (NIS) Database to identify patients aged 18 or older with myocardial bridging who were managed with PCI versus medical therapy. We compared the outcomes between both groups including in-hospital mortality, the trend of management of MB and other in-hospital outcomes or complications. Our results showed no statistically significant difference between both subgroups when comparing in-hospital mortality and secondary outcomes of cardiac arrest and the development of an acute kidney injury (AKI). Patients with myocardial bridging treated with PCI had a higher risk of developing cardiogenic shock, requiring LVAD, and requiring the use of intra-aortic balloon pump (IABP) compared to the medical therapy subgroup. Our study suggests the decision to perform PCI in myocardial bridging patients should be individualized such as in patients with refractory symptoms despite medical therapy or those with known high-risk features. Full article

Background: Cardiogenic shock (CS) is a frequent presentation of anterior ST-elevation myocardial infarction (STEMI); however, data regarding disease progression and outcomes in inferior STEMI complicated by CS are scarce. The present study aims to analyze the prevalence, patterns of disease progression, and outcomes of inferior STEMI-CS. Methods: The INSTINCT (Inferior ST-elevation myocardial Infarction complicated by Cardiogenic shock) Registry retrospectively included consecutive patients who developed CS following inferior STEMI treated at three centers in Italy from 2015 to 2023. Data regarding CS stage according to the Society of Cardiovascular Angiography and Interventions (SCAI) upon diagnosis of shock and during disease progression and in-hospital outcomes were collected. Patients were defined “worsening” (WPs) if the SCAI stage increased. Results: A total of 130 patients developed CS after inferior STEMI and were included in the analysis, the mean age was 69.8 ± 12.4 years, and 31.5% were female. The rate of in-hospital mortality was 22.3%; predictors of in-hospital mortality were cardiopulmonary resuscitation (CPR) > 20 min or refractory cardiac arrest (CA) (OR [CI]: 9.67 [3.17–29.51]), persistently low systolic blood pressure (SBP) (OR [CI]: 12.91 [2.47–68.82]), and increase in lactates (OR [CI]: 3.53 [1.42–7.87]) during medical management. Twenty (15.4%) patients experienced worsening CS; WPs had a significantly higher rate of in-hospital mortality (13 [65%] vs. 15 [13.6%], p < 0.001), major bleeding (4 [20%] vs. 7 [6.4%], p = 0.044), and mechanical circulatory support weaning failure (7 [35%] vs. 3 [2.7%], p = 0.032). Conclusions: The in-hospital mortality rate of inferior STEMI complicated by CS was 22.3%. Predictors of in-hospital mortality included prolonged CPR, persistently low SBP, and elevated lactates. Progression through SCAI stages was rare but associated with significantly higher mortality and complication rates. Full article

Background: Frailty, with a high prevalence of 40–80% in heart failure, may have a significant bearing on outcomes in patients. This study utilizes the Hospital Frailty Risk Score (HFRS), a validated tool derived from the administrative International Classification of Diseases, 10th Revision, Clinical Modifications (ICD-10-CM) codes, in investigating the mortality, morbidity, and healthcare resource utilization among heart failure hospitalizations using the Nationwide Inpatient Sample (NIS). Methods: A retrospective analysis of the 2021 NIS database was assessed to identify adult patients hospitalized with heart failure. These patients were stratified by the HFRS into three groups: low frailty (LF: <5), intermediate frailty (IF: 5–15), and high frailty (HF: >15). The outcomes analyzed included inpatient mortality, length of stay (LOS), hospitalization charges, and complications including cardiogenic shock, cardiac arrest, acute kidney injury, and acute respiratory failure. These outcomes were adjusted for age, race, gender, the Charlson comorbidity score, hospital location, region, and teaching status. Multivariate logistic and linear regression analyses were used to assess the association between frailty and clinical outcomes. STATA/MP 18.0 was used for statistical analysis. Results: Among 1,198,988 heart failure admissions, 47.5% patients were in the LF group, whereas the IF and HF groups had 51.1% and 1.4% patients, respectively. Compared to the LF group, the IF group showed a 4-fold higher (adjusted OR = 4.60, p < 0.01), and the HF group had an 11-fold higher (adjusted OR 10.90, p < 0.01) mortality. Frail patients were more likely to have a longer length of stay (4.24 days, 7.18 days, and 12.1 days in the LF, IF, and HF groups) and higher hospitalization charges (USD 49,081, USD 84,472, and USD 129,516 in the LF, IF, and HF groups). Complications were also noticed to be significantly (p < 0.01) higher with increasing frailty from the LF to HF groups. These included cardiogenic shock (1.65% vs. 4.78% vs. 6.82%), cardiac arrest (0.37% vs. 1.61% vs. 3.16%), acute kidney injury (19.2% vs. 54.9% vs. 74.6%), and acute respiratory failure (29.6% vs. 51.2% vs. 60.3%). Conclusions: This study demonstrates the application of HFRS in a national dataset as a predictor of outcome and resource utilization measures in heart failure admissions. Stratifying patients based on HFRS can help in holistic assessment, aid prognostication, and guide targeted interventions in heart failure. Full article

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. Full article

Background/Objectives: Heart failure is the leading cause of hospital admission and mortality. Racial disparities have been demonstrated in various cardiovascular disorders; however, the data for in-hospital outcomes, complications, and procedural rates are limited. Methods: Utilizing the National Inpatient Sample (NIS) database, this retrospective cohort study included adult patients admitted with a principal diagnosis of heart failure. Coding for race and ethnicity in the NIS combines self-reported race and ethnicity provided by the data source into 1 data element (“RACE”). We compared the outcomes between various racial groups, focusing on mortality, the length of stay (LOS), hospital charges, and complications. Differences in the utilization of advanced therapies, including implantable cardiac defibrillators, cardiac resynchronization therapy (CRT), ventricular assist devices (VADs), and heart transplant, were also analyzed. Results: Out of 1,107,860 patients hospitalized with heart failure, 715,345 (64.57%) patients were White, 244,394 (22.06%) patients were Black, and 97,063 (8.31%) patients were Hispanic. Compared to White people, the odds of in-hospital mortality were lower among Black (aOR 0.74; 95% CI 0.68–0.81; p < 0.001) and Hispanic (aOR 0.78; 95% CI 0.69–0.88; p < 0.001) people. Complication rates including cardiogenic shock were found to be significantly lower in Black people (aOR 0.86; 95% CI 0.77–0.96; p < 0.001) and in Hispanic (aOR 0.72; 95% CI 0.63–0.81; p < 0.001) people. The rates of acute respiratory failure were also lower in Black (aOR 0.72; 95% CI 0.69–0.74; p < 0.001) and Hispanic (aOR 0.77; 95% CI 0.73–0.81; p < 0.001) people as opposed to White people. However, Black people were found to have higher rates of acute kidney injury (aOR 1.11; 95% CI 1.07–1.14; p < 0.001) and cardiac arrest (aOR 1.17; 95% CI 1.03–1.34; p = 0.02) compared to White people. Black people were less likely to receive advanced interventions, including cardiac resynchronization therapy (aOR 0.71; 95% CI 0.60–0.83; p < 0001), a ventricular assist device (aOR 0.45; 95% CI 0.34–0.59; p < 0.001), and heart transplants (aOR 0.57; 95% CI 0.42–0.77; p < 0.001), than White people. Hispanic people were found to have lower rates of ventricular assist device (aOR 0.49; 95% CI 0.33–0.72; p < 0.001) use than White people. Conclusions: These findings highlight significant racial disparities in mortality, secondary outcomes, and advanced therapy utilization in heart failure admissions. Further research is needed to identify the root factors for these disparities in order to guide targeted interventions to reduce this racial gap. Full article