Dynamic Invasive Hemodynamic Congestion Profile Impacts Acute Myocardial Infarction Complicated by Cardiogenic Shock Outcomes: A Real-World Single-Center Study.

BACKGROUND: Cardiogenic shock (CS) commonly complicates the management of acute myocardial infarction (AMI), and it results in high mortality rates. Pulmonary artery catheter (PAC) monitoring can be valuable for personalizing critical-care interventions. We hypothesized that patients with AMI-CS experiencing persistent congestion measures during the first 24 hours of the PAC installment would exhibit worse in-hospital survival rates. METHODS AND RESULTS: We studied 295 patients with AMI-CS between January 2006 and December 2021. The first 24-hour PAC-derived hemodynamic measures were divided by the congestion profiling and the proposed 2022 Cardiovascular Angiography and Interventions (SCAI) classification. Biventricular congestion was the most common profile and was associated with the highest patient mortality rates at all time points (mean 56.6%). A persistent congestive profile was associated with increased mortality rates (hazard ratio [HR] = 1.85; P = 0.002) compared with patients who achieved decongestive profiles. Patients with SCAI stages D/E had higher levels of right atrial pressure (RAP): 14-15 mmHg) and pulmonary capillary wedge pressure (PCWP): 18-20 mmHg) compared with stage C (RAP, 10-11 mmHg, mean difference 3-5 mmHg; P < 0.001; PCWP 14-17 mmHg; mean difference 1.56-4 mmHg; P = 0.011). In SCAI stages D/E, the pulmonary artery pulsatility index (0.8-1.19) was lower than in those with grade C (1.29-1.63; mean difference 0.21-0.73; P < 0.001). CONCLUSIONS: Continuous congestion profiling using the SCAI classification matched the grade of hemodynamic severity and the increased risk of in-hospital death. Early decongestion appears to be an important prognostic and therapeutic goal in patients with AMI-CS and warrants further study.

Application of the SCAI classification to admission of patients with cardiogenic shock: Analysis of a tertiary care center in a middle-income country.

AIMS: The Society of Cardiovascular Angiography and Interventions (SCAI) shock stages have been applied and validated in high-income countries with access to advanced therapies. We applied the SCAI scheme at the time of admission in order to improve the risk stratification for 30-day mortality in a retrospective cohort of patients with STEMI in a middle-income country hospital at admission. METHODS: This is a retrospective cohort study, we analyzed 7,143 ST-segment elevation myocardial infarction (STEMI) patients. At admission, patients were stratified by the SCAI shock stages. Multivariate analysis was used to assess the association between SCAI shock stages to 30-day mortality. RESULTS: The distribution of the patients across SCAI shock stages was 82.2%, 9.3%, 1.2%, 1.5%, and 0.8% to A, B, C, D, and E, respectively. Patients with SCAI stages C, D, and E were more likely to have high-risk features. There was a stepwise significant increase in unadjusted 30-day mortality across the SCAI shock stages (6.3%, 8.4%, 62.4%, 75.2% and 88.3% for A, B, C, D and E, respectively; P < 0.0001, C-statistic, 0.64). A trend toward a lower 30-day survival probability was observed in the patients with advanced CS (30.3, 15.4%, and 8.3%, SCAI shock stages C, D, and E, respectively, Log-rank P-value <0.0001). After multivariable adjustment, SCAI shock stages C, D, and E were independently associated with an increased risk of 30-day death (hazard ratio 1.42 [P = 0.02], 2.30 [P<0.0001], and 3.44 [P<0.0001], respectively). CONCLUSION: The SCAI shock stages applied in patients con STEMI at the time of admission, is a useful tool for risk stratification in patients across the full spectrum of CS and is a predictor of 30-day mortality.

Dual Antiplatelet Therapy Versus Antiplatelet Monotherapy Plus Oral Anticoagulation in Patients with Acute Coronary Syndrome and Coronary Artery Ectasia: Design and Rationale of OVER-TIME Randomized Clinical Trial.

INTRODUCTION: The optimal anti-thrombotic therapy to prevent recurrent ischemic events in patients with acute coronary syndrome and coronary artery ectasia (CAE) remains unclear. AIM: To assess the efficacy and safety of antiplatelet plus anticoagulant therapy versus dual antiplatelet therapy in patients with acute coronary syndromes and coronary artery ectasia. METHODS: OVER-TIME is an investigator initiated, exploratory, open label, single center, randomized clinical trial comparing dual antiplatelet therapy (acetyl-salicylic acid plus a P2Y12 inhibitor) with the combination of an antiplatelet monotherapy (a P2Y12 inhibitor) plus a low dose anticoagulant (rivaroxaban, 15mg oral dose) for the prevention of recurrent ischemic events among patients with CAE. We aim to enroll approximately 60 patients with CAE and acute coronary syndromes. After recruitment, patients are randomized to (a) standard of care (dual antiplatelet regimen) or (b) the combination of antiplatelet monotherapy and low dose anticoagulant. Patients will be followed for at least 12 months. The OVER-TIME study aims to assess the efficacy of the regimen in prevention of major cardiovascular events and its security in bleeding events in acute coronary syndromes among patients with CAE. Expected results and conclusions: OVER-TIME is the first randomized controlled trial to assess different antithrombotic strategies in patients with CAE and acute coronary syndrome, and its results will offer preliminary data for the prevention of major cardiovascular events and bleeding events in this group of patients. TRIAL REGISTRATION NUMBER: NCT05233124 (ClinicalTrials.gov), date of registration: February 10, 2022.

ISCHEMIA Trial and the Significance of MI.

During the past decade, the treatment of choice for chronic coronary syndromes (CCS) has been a contentious issue. Whether revascularisation, either percutaneous or surgical, or optimal medical therapy, offers better prognosis in terms of mortality, MI, and symptom relief, has yet to be confirmed. The long-awaited and recently published International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial randomised more than 5,000 patients into a revascularisation plus optimal medical therapy group and an optimal medical therapy alone group. The authors analyse the trial, with particular emphasis on the incidence of MI. They propose a patient-centred approach to incorporate the results of the ISCHEMIA trial into daily practice and determine the best treatment strategy for patients with CCS.

Systemic lupus erythematosus flare triggered by a spider bite.

Systemic lupus erythematosus is a chronic autoimmune disease with a relapsing and remitting course characterized by disease flares. Flares are a major cause of hospitalization, morbidity and mortality in patients with systemic lupus erythematosus. Some triggers for these exacerbations have been identified, including infections, vaccines, pregnancy, environmental factors such as weather, stress and drugs. We report a patient who presented with a lupus flare with predominantly mucocutaneous, serosal and cardiac involvement after being bitten by a spider and we present the possible mechanisms by which the venom elicited such a reaction. To the best of our knowledge, this is the first such case reported in the literature.

The -319C/+49G/CT60G haplotype of CTLA-4 gene confers susceptibility to rheumatoid arthritis in Mexican population.

Several single nucleotide polymorphisms (SNPs) within the CTLA-4 gene and elevated serum levels of soluble CTLA-4 (sCTLA-4) have been associated with autoimmunity including rheumatoid arthritis (RA). In this case-control study, we evaluated the relationship between the -319C/T (rs5742909) and CT60 G/A (rs3087243) SNPs and sCTLA-4 levels in 200 RA patients and 200 control subjects (CS) from Western Mexico. Both SNPs were genotyped with the polymerase chain reaction-restriction fragment length polymorphism technique and the sCTLA-4 levels were quantified using an enzyme-linked immunosorbent assay kit. In addition, we performed a haplotype analysis, including our previous data of the +49A/G (rs231775) SNP. The G/A genotype of the rs3087243 SNP was associated with a decreased risk of RA [odd ratio (OR) 0.61, 95% confidence interval (CI) 0.38-0.96, p = 0.024]. This protection was also observed in the negative anti-cyclic citrullinated peptide group of RA carriers of the A allele (OR 0.48, 95% CI 0.22-1.05, p = 0.042). On the contrary, we identified the -319C/+49G/CT60G haplotype of CTLA-4 gene as a risk factor for RA (OR 1.69, 95% CI 1.13-2.52, p = 0.01). The sCTLA-4 levels were not associated with RA (p = 0.377), but were correlated with the functional disability of these patients (r = 0.282, p = 0.012). However, in CS the C/T genotype of the rs5742909 SNP, as well as the G/G and G/A genotypes of the rs3087243 SNP were associated with higher sCTLA-4 levels (p < 0.001). In conclusion, our results suggest that the -319C/+49G/CT60G haplotype of CTLA-4 gene is a genetic marker of susceptibility to RA in Western Mexico, whereas the rs3087243 SNP confers protection against this disease. Moreover, both SNPs showed an effect on the sCTLA-4 production in our control population. However, further studies are required to evaluate the role of sCTLA-4 in RA, as well as the molecular and functional basis of the association between both CTLA-4 gene SNPs and soluble levels of CTLA-4 in CS.

-383 A/C tumor necrosis factor receptor 1 polymorphism and ankylosing spondylitis in Mexicans: a preliminary study.

The objective of this study was to evaluate the differences in allele and genotype frequencies of -383 tumor necrosis factor receptor 1 (TNFR1) polymorphism between ankylosing spondylitis (AS) and controls. Mexican Mestizos with AS were matched by gender, age, and ethnicity with healthy controls and compared in allele and genotype frequencies of the -383 TNFR1 polymorphism. Polymorphisms were genotyped using PCR-RFLP. The AA genotype occurred at a higher frequency in the AS group (92%) compared with controls (79%, P = 0.03). A allele was increased in AS (96% vs. 88%, P = 0.015) and was associated with genetic susceptibility for AS (odds ratio = 3.48, 95% CI = 1.23-10.61). This preliminary study is the first assessing the association of the -383 A/C TNFR1 polymorphism with AS, although it has the limitation of a small sample size. These data are of interest for the genetic epidemiology of AS in the Mexican population, requiring further investigation in other countries.