Welcome to EHJ-ACVC Highlights, which spotlights articles from the European Heart Journal - Acute Cardiovascular Care that have recently captured the attention of the general cardiology community.
Delve into groundbreaking research and insights driving progress in acute cardiovascular and intensive care medicine.
Visuals credit: content is developed by Maria Bergami, Young ACVC Member and the visual is created by Biorender.
November 2024 Highlights
Welcome to the November issue of the European Heart Journal Acute Cardiovascular Care! As we transition into the final months of the year, the days may be getting shorter, but the warmth in our field remains as we shine a spotlight on groundbreaking developments in cardiovascular care. This month’s edition brings a fresh perspective to some of the most pressing challenges in acute cardiovascular care, from innovative treatments for electrical storm (ES) to novel insights into the microcirculation in cardiogenic shock (CS). With each study, we edge closer to improving patient outcomes in life-threatening scenarios.
1. Enrico Baldi et al. demonstrated that the early use of percutaneous stellate ganglion block (PSGB) led to a dramatic reduction in arrhythmic events within the first hour, paving the way for safer, more effective interventions. PSGB offers new hope with potential to prevent progression to refractory ES—a breakthrough in an area where rapid intervention is critical. Although the study invites further exploration through randomized trials, the results are promising and may redefine how we approach ES in its early stage.
2. Maxwell Hockstein et al. shed the light into often-underdiagnosed condition of cor pulmonale in acute respiratory distress syndrome (ARDS). Their analysis reveals that cor pulmonale is associated with a 50% higher mortality rate, emphasizing the need for early identification. By examining factors such as pulmonary artery pulsatility index and arterial elastance (Ea), the study highlights that traditional metrics, including pH and PaO2, are less reliable predictors. This work stresses the necessity for multimodal diagnostics to better understand right ventricular-pulmonary artery coupling and prevent complications in ARDS—a call for greater awareness and proactive management.
3. Guido Tavazzi et al. offer a broad view of the evolving epidemiology of CS, examining data from over 11 000 ICU admissions in Italy. Their study reveals a shift from the traditional ischaemic causes to non-ischaemic etiologies and that right heart failure portends the highest mortality risk among CS patients. This trend potentially highlights the importance of early recognition and tailored interventions. As CS remains a condition with mortality rates hovering near 50%, this study underscores the need for integrated, multidisciplinary care strategies to improve survival outcomes.
4. On the front of mental health Leissner et al. tackle an often-overlooked consequence of cardiac care: the psychological impact of beta-blockers on patients recovering from myocardial infarction (MI). Drawing from the REDUCE-AMI trial, the authors found that while beta-blockers are associated with an increase in depressive symptoms, anxiety levels remain largely unaffected. Although the rise in depressive symptoms was modest, this finding reminds us of the importance of considering the mental health implications when managing MI patients, especially in those with preserved left ventricular ejection fraction. As we deepen our understanding of the interplay between cardiovascular and mental health, this study highlights the need for a holistic approach to cardiovascular patient care.
5. In a fascinating diagnostic advance, Juhani K.E. Airaksinen's study presents a novel way to distinguish between Takotsubo syndrome (TTS) and MI using cardiac troponin T (cTnT) immunoassays. The study’s discovery that TTS patients exhibit a significantly lower ratio of long to total cTnT compared to MI patients could offer a more precise diagnostic tool. While further research is needed to validate these findings with this investigational method, the potential for early differentiation between these two conditions could have a profound impact on treatment decisions, offering clinicians a powerful future tool in their diagnostic arsenal.
6. Rounding out this month’s issue is our educational paper from Christian Jung et al.9, which advocates for a more nuanced approach to CS management. By shifting focus from macrocirculation to microcirculatory dysfunction, this paper makes a compelling case for integrating microcirculation assessments into clinical practice. The authors emphasize that while advances in microcirculation-guided therapies hold great promise, their full potential has yet to be realized. More research is needed to bridge the gap between theoretical benefits and practical application in the ICU setting.
As we close this November issue, we invite our readers to engage with these pioneering studies, which collectively push the boundaries of cardiovascular care. We are excited about the discoveries shared in this edition, and we thank the authors for their invaluable contributions to our understanding of acute cardiovascular conditions. Together, let us continue to explore new horizons, expanding the possibilities of what can be achieved in the care of critically ill patients. Stay with us as we move into the final months of the year, energised, and optimistic about the future of our field.
October 2024 Highlights
In this month’s edition of the European Heart Journal - Acute Cardiovascular Care, we engage with some of the most critical issues facing contemporary acute cardiovascular medicine, including cardiogenic shock, out-of-hospital cardiac arrest, and the pressing need for sustainable practices in our healthcare systems. As we navigate these complex challenges, the insights shared by esteemed authors in this issue illuminate pathways towards improved patient outcomes and enhanced healthcare delivery. Enjoy!
- Christian Jung contributes significantly to the discourse on acute myocardial infarction (AMI) and cardiogenic shock through his Bayesian reanalysis of the CULPRIT-SHOCK trial
This nuanced understanding underscores the necessity for personalized risk-benefit assessments in clinical practice, illustrating the value of Bayesian methods in interpreting complex trial data to enhance decision-making in high-risk populations.
Read more - The outcomes for survivors of out-of-hospital cardiac arrest (OHCA) are thoroughly explored by Christopher Fordyce et al who utilizes data from the British Columbia Cardiac Arrest Registry. Among 1,325 survivors, the study demonstrates that those with a reversible ischemic cause exhibit the highest three-year event-free survival rate of 91%, compared to only 62% for those with reversible non-ischemic causes. Conversely, heightened attention is warranted for patients with non-ischemic causes. Fordyce’s research not only sheds light on the long-term outcomes of OHCA survivors but also calls for a more refined approach to their management.
Read more - In a comprehensive analysis of the epidemiology of cardiogenic shock within a cardiac intensive care unit setting, David Berg et al utilizes the Shock Academic
Research Consortium (SHARC) definitions to classify distinct patient populations. Berg’s study highlights the utility of SHARC definitions in identifying distinct cardiogenic shock subpopulations with varying clinical outcomes, ultimately informing clinical practice and future research directions.
Read more - The risk of sudden cardiac death (SCD) following early-onset myocardial infarction (MI) is explored by Serena Bricoli who leverages a large cohort of 2,000 patients under the age of 45 and followed for a median of 19.9 years. Key independent predictors identified through multivariable analysis include diabetes, hypertension, previous thromboembolic events, a high Syntax score, and a lower left ventricular ejection fraction (LVEF) post-MI. Bricoli’s findings underscore the need for proactive monitoring and targeted interventions for individuals at risk.
Read more - At the forefront of this edition, Mahmoud Ismayl et al. present a nationwide study analyzing outcomes of 16,072 patients with aortic stenosis complicated by cardiogenic shock who underwent either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) from 2016 to 2021. Ismayl’s study not only highlights the increasing adoption of TAVR but also underscores the need for randomized controlled studies, which could ultimately help to refine our understanding of optimal management strategies for these patients.
Read more - And last, but not least, explore this month’s statistical spotlight which delves into best practices and clinical guidance in extension studies for revascularization in left main coronary artery disease. Understanding the intricacies of statistical analysis not only enhances the quality of clinical research but also informs evidence-based practice, ultimately driving improvements in patient care.
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September 2024 Highlights
Welcome to the September 2024 edition of the European Heart Journal - Acute Cardiovascular Care.
As the world revels in the afterglow of the spectacular 2024 Olympic Games in Paris, celebrating human endurance and triumph, we also mark the incredible breakthroughs presented at the 2024 European Society of Cardiology (ESC) congress in London. This issue of the European Heart Journal - Acute Cardiovascular Care (EHJ-ACVC) features major advancements and insights in cardiac care, echoing the Olympic spirit of striving for excellence.
- STOP-or-NOT, TIGHT-K, ABYSS, SCOFF are the trials presented at 2024 ESC congress in London and in this issue are put in perspective due to its relevance to acute cardiac and intensive care medicine. These studies are investigating critical decision regarding the use of RAAS inhibitors, potassium supplementation in preventing atrial fibrillation post-cardiac surgery, the implication of beta blockers interruption in patient with history of myocardial infarction and last, but not least, fasting vs non-fasting before catheterization procedure.
- Frea et al. go one huge step forward exploring comprehensive non-invasive hemodynamic assessment in acute heart failure-related cardiogenic shock. They introduce a first prospective validation of echocardiographic estimation of PAPi, affirming its prognostic significance and advocation for broader use of echocardiography in assessing hemodynamics during HF-CS.
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- In another pivotal study, sub-study of BOX trial Byrne et al. exlore the relevance of age and previous hypertension on MAP targets in comatose survivors of OHCA. The study showed that older patients and the ones with history of hypertension didn’t significantly benefit from a higher MAP target. Also, younger patients might have more benefit from lower MAP strategy, underscoring the need for personalized blood pressure management, particularly considering patient age.
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- Finally, the manuscript by Uwe Zyemer et al. explores whether patients with infarct-related cardiogenic shock, like those in the Dan-Ger-Shock trial, benefit from VA-ECMO treatment. This individual patient data meta-analysis included 202 patients from four randomized clinical trials. Despite the study’s limited sample size, it provides the most comprehensive data to date on this topic.
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August 2024 Highlights
This month, we spotlight pivotal research unveiling key insights into cardiogenic shock prognosis, personalised management of myocardial infarction, and innovative strategies in platelet inhibition.
As you prepare for THE cardiology event of the year this month in London, check the latest groundbreaking research that our editorial team prepared for you. Enjoy
- Rikken et al. present the evidence from On –TIME 2 trial demonstrating that prehospital tirofiban is independetly associated with higher risk of disrupted MI in STEMI pateints. This opens a new area for research in order to obtain inovative strategies of pre-hospital management for these patients.
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- Samuel A. Watson et al.’s groundbreaking study introduces the validated CREST model, designed to predict circulatory etiology death (CED) following out-of-hospital cardiac arrest (OHCA). By comparing its efficacy with the SCAI shock classification, this study offers clinicians a refined tool for prognostication and therapeutic decision-making in OHCA, highlighting the potential to enhance patient selection for invasive interventions.
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- Further enriching this issue, Siddharth M. Patel, MD, MPH, and Mathew S. Lopes, MD, MPH present pioneering insights into proteomic profiling of cardiogenic shock within the cardiac intensive care unit. Their study identifies nine biomarkers associated with CS, including sST2, FGF-23, CTSD, and GDF-15, thereby establishing a robust multi-marker model with diagnostic potential to facilitate early detection and personalized treatment strategies in critical care settings.
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- Serena Bricoli and Giulia Magnani’s longitudinal cohort study on post-MI sudden cardiac death unveils a paradigm shift in risk stratification. (ref) By examining 2,000 young MI patients over two decades, their findings underscore the chronic nature of coronary atherosclerosis and emphasize tailored management strategies to mitigate traditional risk factors like diabetes and hypertension. This study, conducted in collaboration with leading European institutions, promises to reshape global prevention efforts and redefine clinical paradigms in cardiology.
5. Manning et al. introduce us into complexities of end-of-life care discussions within cardiac care units, unveiling evidence-based approaches to enhance shared decision-making for seriously ill older adults. Their insights offer structured frameworks to mitigate common pitfalls, ensuring patient-centered care aligns with individual values and preferences amidst the challenges of advanced heart disease.
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July 2024 Highlights
Read this month's selection
- Hong et al. present a study where they deal with the importance of residual ischaemia in AMICS undergoing VA-ECMO. In those cases residual ischaemia was associated with increased risk of 1-year mortality. However, further studies are needed to evaluate efficacy and future management of those patients.
- The correlation between hsTnT CV medications and long-term outcomes? – Can it have an effect on MAE?
- Elevated hs-cTnT levels pose a significant diagnostic hurdle, necessitating tailored diagnostic thresholds for accurate MI diagnosis in CKD patients. This study heralds a paradigm shift towards personalized diagnostic approaches to optimize patient care in this vulnerable population.
- Introduction of Killip pLUS scale– integration of Killip class and LUS provides better risk stratification than any of these used alone
- Portal vein dopler- the one and only that can track volume removal in severe TR. Further studies will provide answers if this strategy have a strong effect on patients outcomes.
- In GULLIVE-R prospective study the main focus is on secondary prevention strategies after AMI. Despite high adherence to guideline-recommended medications, only half of the patients receive all key secondary preventative medications, signaling a pressing need for enhanced education and prevention strategies.
- Finally, be prepared to dive deep into non-invasive imaging strategies in HFpEF, the educational paper prepared by Dhont et al. This article may provide you with resources you are looking for to provide your patients the best quality of care possible.
June 2024 Highlights
From the cost-effectiveness of eCPR, antithrombotic management during MCS and introduction of CShock score to predict cardiogenic shock onset by using AI, to contemporary management of pulmonary embolism and frail patients in ICU.
- Cost-effectiveness of extracorporeal cardiopulmonary resuscitation vs. conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a pre-planned, trial-based economic evaluation
- European practices on antithrombotic management during percutaneous mechanical circulatory support in adults: a survey if the Association for Acute CardioVascular Care of the ESC and the European branch of the Extracorporeal Life Support Organisation
- Developement and external validation of a dynamic risk score for early prediction of cardiogenic shock in cardiac intensive care units using machine learning
- Relationship between the mixed venous-to-arterial carbon dioxide gradient and the cardiac index in acute pulmonary embolism
- Modeling costs of interventional pulmonary embolism treatment: implications of US trends for a European healthcare system
- Frailty in the intensive care unit: assessment and impact
May 2024 Highlights
What is the best time for tMCS in AMI-CS - earlier the better?
Buda et al. conducted a study comparing early vs. delayed initiation of MCS in AMI-CS. Their findings suggest that early initiation of tMCS is associated with fewer adverse events, lower mortality and fewer readmissions compared to delayed tMCS.
Future prospective randomised studies are needed to identify patients who would benefit the most from tMCS and to select the adequate type of tMCS for each patient.
April 2024 Highlights
Nutritional support during ICU stay - a stepwise approach towards better outcomes
Nutritional support plays an important role in management of critically ill patients, especially patients with acute heart failure, acute coronary syndrome, post-cardiac-arrest patients and patients with cardiogenic shock.
Nutritional support in acute heart failure
The nutritional risk and prevalence of malnutrition is high in patients with acute heart failure (up to 40%) due to bowel ischemia, microcirculatory failure, and malabsorption. Although adequate nutrition might play an important role in improving outcomes, studies on this matter are still lacking.
Nutritional support for these patients is based on general principles- early nutritional assessment, form of administration and assessment of nutritional risk. It is recommended to start enteral feeding in the first 48h upon CICU admission. In the acute phase (<72h) it is best to implement hypocaloric nutrition with adequate substitution of micronutrients.
Parenteral feeding can be associated with higher risk of infection, and it is recommended as first line in case of severe gastrointestinal dysfunction. However, early parenteral feeding is recommended in severely malnourished patients.
Nutritional support in acute coronary syndrome
Malnutrition is these patients may be associated with worsening outcomes. The same principles apply as for critically ill patients.
Nutritional support after cardiac arrest
Patients after suffering cardiac arrest may require close monitoring, especially if receiving ECLS for refractory cardiac arrest. In those patients’ enteral nutrition should be introduced with caution, as rates of intestinal ischemia are higher. Delayed feeding is associated with better outcomes. Studies on this field are needed to create uniform protocols of management of these patients.
Nutritional support in cardiogenic shock
As we all know, cardiogenic shock is a low cardiac output state secondary to cardiac dysfunction, leading to end-organ hypoperfusion and tissue hypoxia. During this condition mesenteric arteriolar vasoconstriction plays a major role in trying to maintain systemic blood pressure. Together with venous congestion it leads to decrease in local perfusion and increased risk of bowel ischemia.
If enteral feeding is started in this highly vulnerable hemodynamic state, there is a risk of mesenteric ischemia. Starting early enteral feeding is still controversial. It may be beneficial to do a permissive underfeeding in the first few days, especially in patients who require use of vasopressors. The incidence of proven bowel ischemia using those protocols was <1%.
Having in mind the incidence and severity of cardiovascular diseases requiring CICU admission, comprehensive multidisciplinary approach to nutritional support is needed to optimize care of critically ill patients. Further research is needed to try to obtain uniform and individualized protocols that could improve patient survival, duration of ICU stay and quality of life after CICU admission.
March 2024 Highlights
The light in the end of the tunnel – unrevealing mechanisms of ventricular fibrillation during the first ST elevation myocardial infarction by the use of proteonomics.
Stampe et al. conducted a study using proteonomics that unrevealed that 26 proteins are associated with ventricular fibrillation. Pending further analysis two of the proteins were strongly associated with VF (ACTBL2, F13A1). The findings of this study represent a groundbreaking moment that points the light towards further investigation of early VF in ST elevation myocardial infarction.
Embrace the challenge – the role of ventricular assist device in management of fulminant myocarditis
The study by Takahito Nasu et al. represent a pioneering large-scale registry study using data from Japanese Registry for Percutaneous Ventricular Assist Devices. Use of Impella device showed better success rate in comparison with ECPELLA. Having in mind the high percentage of adverse events further investigation is needed to optimize patient selection and treatment in this matter.
Deep dive into pulmonary embolism – identifying early predictors affects the outcome?
Zuin et al. deal with “Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism” Their educational paper is complemented by a clinical consensus statement from the Association for Acute Cardiovascular Care that outlines the diagnostic and treatment pathways for acute right ventricular failure secondary to acutely increased right ventricular afterload.
Triglyceride deposit cardiomyovasculopathy (TGCV) – rare or just undiagnosed condition?
Nakano et al. introduce us to TGCV by conducting a study on 400 patients with ACS and 148 patients with diabetes and ACS. The study reports 4.3-5.4% prevalence emphasizing the need for further investigation and risk stratification of these patients, having in mind that they may present with diffuse coronary artery stenosis.
February 2024 Highlights
Cardiogenic shock patients on VA-ECMO – individual approach as the solution in prediction and reduction of complications?
VA-ECMO is a well-established method of treating patients with cardiogenic shock. But the risk of complications is still very high. Benedict N. Beer et al. conducted a retrospective multicenter cohort study with the aim to accurately describe the risk of complications and mortality events and to evaluate possible predictors of such events in those patients.
The study showed that the majority of 30-day survival patients treated with VA-ECMO had favorable neurological outcome (CPC 1/2). The presence of AEs, which are more common in women, are strongly associated with worsened neurological outcome and 30-day survival.
Further studies are needed to identify patients that could benefit from this strategy, having in mind the high risk of complications, whose prediction is still challeging and in need for RCTs. One possible solution might be the use of ECMELLA strategy that may reduce typical VA-ECMO complications but the strong evidence is still lacking. Patient selection might be improved by forming the multidisciplinary cardiogenic shock teams worldwide.
January 2024 Highlights
Sex-specific 99th percentile high-sensitivity cardiac troponin assays – are we there yet?
Dr. Maria Rubini Gimenez discusses the diagnostic and prognostic value of sex-specific 99th percentiles in high sensitivity cardiac troponin assays for AMI.
The study by Lehmacher et al. reveals comparable diagnostic accuracy between uniform and sex-specific cutoffs, suggesting no clear advantage for the latter.
The results extend this message to uniform cutoffs for hs-cTnI, but the diagnostic accuracy’s reliance on hs-cTnT concentrations is acknowledged as a limitation which requires futher studies before recommending sex-specific cutoffs in clinical practice.
Climate change as a global health problem – are we too late to prevent the consequences?
The EHJ-ACVC joins over 200 heart journals and urges the United Nations, political leaders, and health professionals to address climate change and biodiversity loss together as an indivisible global health emergency.
Recognising the interconnectedness of climate and nature crisis, they emphasise the severe impact on health, from infectious diseases to mental health issues. The call urges the WHO to declare this crisis a global health emergency to be able to restore biodiversity and combat climate change.
Figures from Maria Bergami
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