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Introduction: On-scene detection of acute coronary occlusion (ACO) during ongoing ventricular fibrillation (VF) may facilitate patient-tailored triage and treatment during cardiac arrest. Experimental studies have demonstrated the diagnostic potential of the amplitude spectrum area (AMSA) of the VF-waveform to detect myocardial infarction (MI). In follow-up, we performed this clinical pilot study on VF-waveform based discriminative models to diagnose acute MI due to ACO in real-world VF-patients.Methods: In our registry of VF-patients transported to a tertiary hospital (Nijmegen, The Netherlands), we studied patients with high-quality VF-registrations. We calculated VF-characteristics prior to the first shock, and first-to-second shock changes (Δ-characteristics). Primary aim was to assess the discriminative ability of the AMSA to detect patients with ACO. Secondarily, we investigated the discriminative value of adding ΔAMSA-measures using machine learning algorithms. Model performances were assessed using C-statistics.Results: In total, there were 67 VF-patients with and 34 without an ACO, and baseline characteristics did not differ significantly. Based on the AMSA prior to the first defibrillation attempt, discrimination between ACO and non-ACO was possible, with a C-statistic of 0.66 (0.56-0.75). The discriminative model using AMSA + ΔAMSA yielded a C-statistic of 0.80 (0.69-0.88).Conclusion: These clinical pilot data confirm previous experimental findings that early detection of MI using VF-waveform analysis seems feasible, and add insights on the diagnostic impact of accounting for first-to-second shock changes in VF-characteristics. Confirmative studies in larger cohorts and with a variety of VF-algorithms are warranted to further investigate the potential of this innovative approach. [ABSTRACT FROM AUTHOR]

Background: There have been limited large scale studies assessing sex disparities in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI).Methods and Results: Using the National Inpatient Sample (2000-2017), we identified adult admissions (≥18 years) with AMI and CA. Outcomes of interest included sex disparities in coronary angiography (early [hospital day zero] and overall), time to angiography, percutaneous coronary angiography (PCI), mechanical circulatory support (MCS) use, in-hospital mortality, hospitalization costs, hospital length of stay and discharge disposition. In the period between January 1, 2000-December 31, 2017, 11,622,528 admissions for AMI were identified, of which 584,216 (5.0%) were complicated by CA. Men had a higher frequency of CA compared to women (5.4% vs. 4.4%; p < 0.001). Women were on average older (70.4 ± 13.6 vs 65.0 ± 13.1 years), of black race (12.6% vs 7.9%), with higher comorbidity, presenting with non-ST-segment-elevation AMI (36.4% vs 32.3%) and had a non-shockable rhythm (47.6% vs 33.3%); all p < 0.001. Women received less frequent coronary angiography (56.0% vs 66.2%), early coronary angiography (32.0% vs 40.2%), PCI (40.4% vs 49.7%), MCS (17.6% vs 22.0%), and CABG (8.3% vs 10.8%), with a longer median time to angiography (all p < 0.001). Women had higher in-hospital mortality (52.6% vs 40.6%, adjusted odds ratio 1.13 [95% confidence interval 1.11-1.14]; p < 0.001), shorter length of hospital stays, lower hospitalization costs and less frequent discharges to home.Conclusion: Despite no difference in guideline recommendations for men and women with AMI-CA, there appears to be a systematic difference in the use of evidence-based care that disadvantages women. [ABSTRACT FROM AUTHOR]

Background: Utilization of inpatient palliative care services (PCS) has been infrequently studied in patients with cardiac arrest complicating acute myocardial infarction (AMI-CA).Methods: Adult AMI-CA admissions were identified from the National Inpatient Sample (2000-2017). Outcomes of interest included temporal trends and predictors of PCS use and in-hospital mortality, length of stay, hospitalization costs and discharge disposition in AMI-CA admissions with and without PCS use. Multivariable logistic regression and propensity matching were used to adjust for confounding.Results: Among 584,263 AMI-CA admissions, 26,919 (4.6%) received inpatient PCS. From 2000 to 2017 PCS use increased from <1% to 11.5%. AMI-CA admissions that received PCS were on average older, had greater comorbidity, higher rates of cardiogenic shock, acute organ failure, lower rates of coronary angiography (48.6% vs 63.3%), percutaneous coronary intervention (37.4% vs 46.9%), and coronary artery bypass grafting (all p < 0.001). Older age, greater comorbidity burden and acute non-cardiac organ failure were predictive of PCS use. In-hospital mortality was significantly higher in the PCS cohort (multivariable logistic regression: 84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; propensity-matched analysis: 84.7% vs. 66.2%, p < 0.001). The PCS cohort received a do- not-resuscitate status more often (47.6% vs. 3.7%), had shorter hospital stays (4 vs 5 days), and were discharged more frequently to skilled nursing facilities (73.6% vs. 20.4%); all p < 0.001. These results were consistent in the propensity-matched analysis.Conclusions: Despite an increase in PCS use in AMI-CA, it remains significantly underutilized highlighting the role for further integrating of these specialists in AMI-CA care. [ABSTRACT FROM AUTHOR]

Background: Limited studies have evaluated regional disparities in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). This study sought to evaluate 18-year national trends, resource utilization, and geographical variation in outcomes in AMI-CA admissions.Methods and Results: Using the National Inpatient Sample (2000-2017), we identified adults with AMI and concomitant CA admitted to the United States census regions of Northeast, Midwest, South, and West. Clinical outcomes of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs and length of stay. Of 9,680,257 admissions for AMI, 494,083 (5.1%) had concomitant CA. The West (6.0%) had higher prevalence compared to the Northeast (4.4%), Midwest (5.0%), and South (5.1%), p < 0.001. Admissions in the West had higher rates of STEMI, cardiogenic shock, multiorgan failure, mechanical ventilation, and hemodialysis. Northeast admissions had lower use of coronary angiography (52.0% vs. 67.9% vs. 60.9% vs. 61.5%), PCI (38.7% vs. 51.9% vs. 44.8% vs. 46.7%), and MCS (18.4% vs. 21.8% vs. 18.1%, vs. 20.0%) compared to the Midwest, West and South (all p < 0.001). Compared with the Northeast, adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR] 1.06 [95% confidence interval {CI} 1.03-1.08]), South (OR 1.11 [95% CI 1.09-1.13]) and highest in the West (OR 1.16 [95% CI 1.13-1.18]), all p < 0.001. Temporal trends showed a decline in in-hospital mortality except in the West, which showed a slight increase.Conclusions: There remain significant regional disparities in the management and outcomes of AMI-CA. [ABSTRACT FROM AUTHOR]

Introduction: We evaluated the incidence of change in serial 12-lead electrocardiogram (ECG) diagnostic classifications in patients resuscitated from out-of-hospital (OH) cardiac arrest (OHCA) comparing OH to emergency department (ED) ECGs.Methods: This retrospective case series included: 1) adults (≥ 18 years old), 2) resuscitated from OHCA, 3) ≥ 1 OH and 1 ED ECG/patient, and 4) emergency medical services (EMS) transport to the study hospital. OH and ED ECGs were classified as: 1) STEMI (ST-segment Elevation Myocardial Infarction), 2) Ischemic, and 3) Non-ischemic. Two ED physicians and one cardiologist independently classified all ECGs, then generated a consensus opinion classification for each ECG based on American Heart Association's 2018 Expert Consensus criteria. The most ischemic OH ECG classification was compared with the last ED ECG classification.Results: From 7/27/12 to 7/18/19, 176 patients were entered with a mean age of 61.2 ± 16.6 years; 102/176 (58%) were male. Overall, 504 OH and ED 12-lead ECGs were acquired (2.9 ECGs/patient). ECG classification inter-rater reliability kappa score was 0.63 ± 0.02 (substantial agreement). Overall, 86/176 (49%) changed ECG classification from the OH to ED setting; 69/86 (80%) of these ECGs changed from more to less ischemic classifications. Of 49 OH STEMI ECG classifications, 33/49 (67%) changed to a less ischemic (non-STEMI) ED ECG classification.Conclusions: Change in 12-lead ECG classification from OH to ED setting in patients resuscitated from OHCA was common (49%). The OH STEMI classification changed to a less ischemic (non-STEMI) ED classification in 67% of cases. [ABSTRACT FROM AUTHOR]

Aim: Acute myocardial infarction (AMI) is the leading cause of out-of-hospital cardiac arrest (OHCA). A highly predictive marker is needed to identify AMI in survivors of OHCA without ST-segment elevation because the appropriate indication for emergency coronary artery angiography in patients without ST-segment segment elevation has not been determined. Accordingly, the aim of this study was to elucidate the clinical significance of coronary artery calcification in identifying survivors of OHCA without ST-segment elevation who could benefit from emergency coronary artery angiography.Methods: Survivors of OHCA without ST-segment elevation with no obvious extra-cardiac cause who underwent emergency computed tomography and coronary artery angiography were enrolled. Unstable coronary lesion was diagnosed using coronary artery angiography, and presence of coronary artery calcification and coronary artery calcium score were evaluated by non-contrast, non-electrocardiography gated computed tomography.Results: Thirty of 100 consecutive survivors of OHCA were diagnosed to have unstable coronary lesion. Sensitivity and specificity of coronary artery calcification in identifying unstable coronary lesion were 87% and 60%, respectively. Multivariate logistic regression analysis revealed that coronary artery calcification was an independent predictor of unstable coronary lesion (odds ratio: 7.28, 95% confidence interval: 2.00-26.56, p < 0.001).Conclusion: Evaluation of coronary artery calcification by computed tomography is useful in identifying patients with unstable coronary lesion who could benefit from emergency coronary artery angiography among survivors of OHCA without ST-segment elevation on post-resuscitation electrocardiography. [ABSTRACT FROM AUTHOR]

Aims: To assess characteristics and outcome of patients treated with Impella for acute myocardial infarction (AMI) complicated by severe cardiogenic shock (CS) or cardiac arrest (CA).Methods and Results: From 2008 through 2017, 92 patients with AMI complicated by CS were treated with Impella. Survival varied according to clinical presentation. Patients in cardiogenic shock without CA had a 75% 30-day survival. Patients with CA and return of spontaneous circulation (ROSC) had a 43% survival and those with CA and ongoing cardio-pulmonary resuscitation (CPR) had a 6% 30-day survival. Age, pre-existing hypertension, coronary disease, ventilatory support and use of adrenergic agents were associated with worse prognosis. Complications were predominantly access site related.Conclusions: In this registry of patients with AMICS treated with Impella, hypertension and older age were found to be negatively predictive for survival. Patients without CA had the highest 30-day survival. In patients with ROSC, survival was strongly related to age and comorbidity. Patients with ongoing CPR had very high mortality. [ABSTRACT FROM AUTHOR]

Introduction: Ischemic heart disease (IHD) is associated with a shockable rhythm in out-of-hospital cardiac arrest (OHCA). However, the impact of IHD severity on first recorded rhythm is unknown. We hypothesized that the strength of the association between IHD and shockable rhythm increases with increasing IHD severity.Methods: OHCA patients were identified in the Danish Cardiac Arrest Registry (2001-2014). Population-based registries were used to identify chronic diseases, drug prescriptions and cardiac procedures such as coronary angiography (CAG), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Severity of IHD was categorized as 1) No diagnosis of IHD, 2) IHD without previous CAG, PCI or CABG, 3) IHD with CAG, 4) IHD with PCI, and 5) IHD with CABG. Adjusted odds ratios (ORs) for a shockable rhythm was computed using multivariable logistic regression.Results: Of 34,749 patients with OHCA, 6325 (18.2%) patients had a diagnosis of IHD. The prevalence of a shockable rhythm was higher for patients with a previous diagnosis of IHD (25.6%) and for those with previous CAG (33.3%), PCI (36.4%) or CABG (34.0%) when compared to patients without IHD (21.2%). IHD was associated with shockable rhythm (OR = 1.69, 95%CI 1.55-1.85) when compared to patients without IHD. The association with shockable rhythm was higher for patients with a history of CAG (OR = 1.92, 95%CI 1.67-2.20) and PCI (OR = 1.93, 95%CI 1.67-2.23), but similar in patients with CABG (OR = 1.69, 95%CI 1.37-2.10).Conclusion: IHD was associated with a shockable rhythm, with a moderate increase in the association in patients with a CAG or PCI procedure. [ABSTRACT FROM AUTHOR]

Guidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI). This study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed. 95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31–0.91], P = 0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50–1.95], P < 0.001) and ICU LOS (IRR 1.81 [95% CI 1.57–2.08], P < 0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading. LV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes. [ABSTRACT FROM AUTHOR]