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Funding Acknowledgements Type of funding sources: None. Introduction The incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF) in the acute phase of infarction (first 24-48 hours) has declined over recent decades, probably due to the uptake of reperfusion strategies and the early use of beta-blockers. However, according to some series, 6–8% of patients still develop hemodynamically significant VT or VF during this phase. Purpose The objective of our study was to evaluate the baseline characteristics of patients who suffered VT or VF in the acute phase of the infarction and to create a predictive model of ventricular arrhythmias in this setting which allow us to anticipate arrhythmic events. Methods We performed an observational, retrospective, and single-centre study carried out through the review of clinical records of patients who suffered an acute myocardial infarction with ST-segment elevation (STEMI) and were admitted in our Coronary Care Unit between July 2011 and August 2022. Results In our cohort we observed 179 episodes of VT/VF (10,7%) in a population of 1668 patients underwent STEMI. The mean age in this subgroup was 61,69±12,61 years old, 78% were males and 56% smokers. Approximately a quarter of the patients were diabetic or obese. There was a very low percentage of previous myocardial infarction (12%) and heart failure (3%) (Table 1). We estimated the best prediction model (Mallows’ Cp=5.12) for VT/VF. The variables included in our model (LL=-435,43) were: male sex, absence of diabetes, smoking habit, use of fibrinolysis, worst Killip at admission and hypotension at admission (Table 2). Conclusion The presence of VT or VF in the acute phase of infarction is still considered a controversial factor in the prognosis of these patients. In our cohort we identified that males, smokers, non-diabetics, and the use of fibrinolysis and the worst haemodynamical situation at admission were independent predictors of developing VT/VF in this context.

Funding Acknowledgements Type of funding sources: None. Introduction Inotropic support is frequently needed after acute coronary syndromes(ACS) at coronary care units(CCU). Despite it has being long time since approval of levosimendan(LV) as inotropic support to cardiogenic shock, dobutamine(DB) still being the basis of this treatment. We think levosimendan is a secure and effective alternative. Purpose To analyse the use of levosimendan and dobutamine done in our ACS patients to determine if we have followed some clear criteria of selection, and try to draw a defined pattern for future use. Method Retrospective, analytic, observational study of all ACS admitted to our CCU between 08/2011- 02/2022. We confront patients treated with dobutamine versus levosimendan. X2, U-Mann Whitney and T-Student were used when necessary. Statistical significance: p-value Result 2881patients were admitted with ACS, 6.49%of them(n: 187) needed ionotropic support. Out of these, 60.96%(n: 114) were supported with dobutamine, 28.88%(n: 54) with levosimedan and 10.16%(n: 19)received in some time both drugs, so were excluded from the analysis. Mean age: 68.43±11.48years old. 66.66%(n: 112) men. 54.76%(n: 92)with persistent ST-segment elevation. No difference was found between groups, neither in past medical history, including cardiovascular risk factors, history of arrhythmias(11.3% of patients), previous use of betablockers(30.4%), antiarrhythmic drugs(0.6%) or having pacemaker(1.2%). 114 patients(67.86%)needed norepinephrine(70.17%with DB and 62.96% LV, p:0.35); 29(17.26%) were supported with intra-aortic balloon pump(20.18% in DB group and 11.11% in LV group, p:0.134), without differences by drug. 62 patients(36.9%) presented atrial fibrillation(33.33% in DB and 44.44% in LV, p:0.166), 58(34.52%)ventricular arrhythmias[sustained ventricular tachycardia/ventricular fibrillation](33.33% in DB and 37.04% in LV, p:0.638). In-hospital mortality of these patients was 29.17%(n:49), 29.82% in DB and 27.77% in LV, p:0.785. In multivariate analysis adjusted by clinic and epidemiologic factors, only cardiogenic shock resulted an independent predictor of in-hospital death. Pattern of use we use DB in those patients with worst Killip-kimball(KK) state(73.54%in DB group with KK-IV vs53.70%in LV´s) and LV in those in intermediate states of instability(38.88%LV in KK-II/III vs 8.84%DB in KK-II/III),p Conclusion In our experience, dobutamine has been the most frequent ionotropic drug used in last 11 years after an acute coronary syndrome. Nevertheless, a substitution by levosimendan trend is evolving. We did not detect differences in complications or prognosis dependent on the inotropic drug used, but the use of dobutamine were predominant in those patients with more severe situation.

Funding Acknowledgements Type of funding sources: None. Introduction Acute coronary syndrome (ACS) is one of the most common health problems in the world, and the leading cause of death. The goals of this study are to determine ACS incidence and the seasonal distribution of ocurrence (Spring/Summer/Autumn/Winter) as well as clinical outcomes per season. Methods Retrospective and observational analysis of consecutive patients hospitalized for ST-elevation myocardial infarction (STEMI) in the Critical Coronary Care Unit (CCCU) of a tertiary center with Mediterranean climate from July 2011 to September 2022. We analyzed the influence of the seasons on the incidence and characteristics of ACS. Results We enrolled a total of 1668 patients: 431 in Winter, 382 in Spring, 405 in Summer and 450 in Autumn, with the baseline characteristics summarized in Table 1. There were no differences in baseline characteristics among the 4 seasons, except for the higher prevalence of obesity in Autumn. There was no statistically significant difference in the incidence of STEMI among seasons, although numerically the highest incidence was recorded in Autumn. The occurrence of ACS was not different according to age or sex. ACS complications were not statistically different among seasons with similar incidence of ventricular arrythmias (VT, VF), invasive mechanical ventilation support, need for inotrope/vasopressor support or development of de-novo atrial fibrillation. In-hospital mortality is less frequent in Autumn, but the differences did not reach statistical significance. Conclusions In this Mediterranean climate cohort, STEMI incidence was higher in Autumn, although no differences in clinical profile or outcomes were found among seasons.

Funding Acknowledgements Type of funding sources: None. Introduction According to the literature, cardiogenic shock in the setting of right ventricular infarction (RV) has a high mortality, even equal to that related to left ventricular anterior infarction in some series. However, as well as many of the topics in acute cardiovascular care, more information is still necessary. Purpose We aim to assess the presence of differences in a cohort of patients with cardiogenic shock due to RV infarction versus anterior infarction. In order to achieve it, we analyzed the differences in baseline characteristics, in-hospital complications and mortality. Methods Descriptive, retrospective, observational, and single-center analysis of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock admitted to our Coronary Care Unit between July 2011 and August 2022. We collected the data of patients with cardiogenic shock and compared basal characteristics and prognosis according to the infarction location (anterior or RV). Results A total of 241 patients were included, 30.7% with RV infarction. The mean age of our patients was 68.6 years and 68% were male. There were no differences in the main cardiovascular risk factors between the two groups. Regarding complications during their hospitalization, there was a significantly higher percentage of patients requiring invasive mechanical ventilation and hemodialysis in patients with shock due to anterior infarction. There was also no significant differences in the frequency of ventricular arrhythmias or atrioventricular block. At last, in our cohort, there is a higher in-hospital mortality rate among patients with shock associated with anterior infarction. Conclusions Despite the fact that in some series the high mortality in shock due to RV infarction is similar to the shock caused by anterior infarction, in our study cardiogenic shock related to anterior infarction involve worse prognosis with higher in-hospital mortality, as well as a higher need of mechanical ventilation and renal replacement therapy.

Funding Acknowledgements Type of funding sources: None. Introduction Inotropic support after Acute Coronary Syndrome (ACS) is commonly used in Cardiac Critical Care Units (CCU). In this context, dobutamine is widely used, given the large experience with this drug, however recently levosimendan has emerged as a safe and effective alternative. Objective Our objective is to analyze the clinical and prognostic differences between patients treated with dobutamine or levosimendan. We wanted to detect the pattern of use of these drugs and determine the best therapeutic option in our patients. Methods Retrospective observational study of patients admitted for ACS at our CCU between August 2011 and September 2022. Patients treated with dobutamine or levosimendan were included, excluding those who required both drugs. We compared baseline characteristics and clinical events in both therapy groups. Results Our sample included 184 patients admitted for ACS who needed inotropic support during the admission period, with either dobutamine or levosimendan. In our cohort, the mean age was 67.95 +/- 12.04 years. 126 (68.48%) patients received dobutamine and 58 (31.52%) levosimendan. Regarding baseline characteristics of our population, we only found statistically significant differences in Diabetes Mellitus as a Risk Factor (p=0.0172) and Congestive Heart Failure (p=0.0128). We tended to use dobutamine over levosimendan as an inotropic agent in shocked patients (p=0.036). No significant differences were found in other data collected in the clinical history, including noradrenaline or intra aortic balloon pump use, arrhythmic events or in-hospital mortality. Multivariate analysis adjusted for clinical and epidemiological factors detected cardiogenic shock as the only independient predictor of in-hospital mortality. Conclusions In our experience, comparing with levosimendan, dobutamine was the preferred inotropic support in shocked patients. We detected no differences in terms of complications and prognosis between both drugs use.

Funding Acknowledgements Type of funding sources: None. Introduction Shock is the main cause of in-hospital mortality in the setting of the Acute Coronary Syndromes (ACS). Shock Index (SI) Has been propposed as an useful predictor of shock and prognosis of the patients admitted because of an ACS. Not only this, a new index, derived from the previous one, which is known as Age Shock Index (ASI) seems to be even more accurate when evaluating these patients. Objetive Our first aim is to test if ASI is more accurate than SI to predict the occurrence of shock in patients admitted to the hospital with the diagnosis of ACS. Our second aim is to check if ASI is more accurate than SI, GRACE score and CRUSADE score to predict the in-hospital mortality of patients admitted to a hospital with the diagnosis of ACS and the presence of shock in the moment of the admission. Material and methods Observational, retrospective and single-center study including patients admitted to a Coronary Critical Care Unit (CCCU) between July 2.011 and March 2.021. ASI was calculated with the following formula: (heart rate x age) / systolic blood pressure. We calculated receptor-operative curves (ROC) of ASI and SI as predictors of shock for patients not presenting shock at the admision. We also calculated ROC of ASI, SI, GRACE and CRUSADE as predictors of in-hospital mortality of patients admitted in shock situation. We compared the area under the curve (AUC) between them. Results For the shock-prediction test we included 2.537 patients, who were admitted in Killip score For the in-hospital mortality in shock patients prediction test we included 240 patients admitted in Killip score = 4. As we show in Picture 2, ASI was found to be a better predictor than SI and GRACE score, but not better than CRUSADE score, being 49,2 the optimal cut point with better sensibility (0,71) and specificity (0,53) Conclusion ASI is a better predictor of shock in patients admitted because of ACS than SI and also a better predictor of in-hospital mortality than SI and GRACE score in patients admitted because of ACS and a situation of shock at the admision. Althoug it was not better that CRUSADE score for this purpose, in favour of this index we highlight its simplicity of calculation, which, together with his good prediction capability, make it very useful in the acute setting.

Funding Acknowledgements Type of funding sources: None. Introduction In the recent years, we have assisted to a change of the prototype of the patient admitted to a Critical Coronary Care Unit (CCCU), with an increasing number of patients admitted due to acute heart failure (AHF) and the reduction of the patients diagnosed of acute coronary syndrome (ACS). It is common in these patients the requirement of ventilatory support, both invasive (IMV) and non-invasive. As a consequence, our knowledge about this technique must be improved. Furthermore, we frequently observe differences in the profile and the prognosis of the patients according to their sex. Objective Our aim is to describe the differences according to the sex in patients treated with IMV. Methods Observational, retrospective study, using a cohort of patients admitted to a CCCU between January 2.018 and April 2.021 who needed IMV. Data related with the personal history, basal situation and events in the follow-up during the hospitalization were collected. Results A total number of 140 patients were included, being 103 (73,6%) male and with a mean age of 67 years old. In the Abstract Picture 1, we show the most interesting characteristics of the population (previous history, complications during the hospitalization and in-hospital mortality). The most frequent cause of intubation was cardiac arrest (CA) with a 47,9% of the cases (67 patients). Mean stay in the CCCU was 12 days, with a median of 8 days. Only 8 patients (5,7%) needed the performation of a tracheostomy and 53 (37,9%) died during the hospitalization. When comparing sex (Picture 1), we did not find any significative differences according to age of the patients, the cause of their admission (Picture 2) or their previous history but the presence of Chronic Obstructive Pulmonary Disease (COPD), which was significatively more frequent in male (21 vs 2, p = 0,035). There were no differences in the cause of the hospitalization, the intra-hospitalary mortality or the main complications during this hospitalization (shock, sepsis, needing of renal sustitutive therapy). Conclusion In our population of patients admitted to a CCCU who require IMV, we can affirm that we find a very homogeneous population when refering to the sex of the patients admitted, not finding any significative differences according to the personal history and prognosis, only COPD being more frequent in male, which can be relevant as these patients may need to be ventilated in a different way.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The study project was financially supported by a no conditional grant (AstraZeneca) Background/Introduction With the advent of more potent antithrombotic agents, bleeding has emerged as an important safety concern in patients with acute coronary syndrome (ACS). Moreover, hemorrhagic complications have been strongly linked with subsequent mortality in this clinical scenario. Purpose We sought to determine the incidence, types, timing and prognostic relevance of major bleeding events in ACS patients treated with ticagrelor or clopidogrel in contemporary practice. Methods Prospective, observational, multicentre all-comers registry of ACS patients who were intended to receive a 12-month DAPT course with ticagrelor or clopidogrel. Major bleeding was defined as a type 3 or 5 bleed using the Bleeding Academic Research Consortium (BARC) definition. Bleeding was further classified according to the anatomic location. All bleeding episodes were analysed accounting for death as a competing event, using competing risk regression models based on the on-treatment principle (i.e., according to the P2Y12 inhibitor actually received from date of index admission until either time of DAPT cessation plus 14 days or censoring, whichever occurred first). Results Among 2070 patients surviving to hospital discharge (mean age 63 years, 27% women, 62.5% STEMI), 106 (5.3%, 0.6%/year) experienced major bleeding event at a median time of 92 days (interquartile range, 6–187 days) after discharge. Most events (n=59, 55.7%) were BARC type 3a bleeds with 2 fatal bleeds (type 5b). In most cases (53%), the site of bleeding was gastrointestinal, followed by intracranial (n=13, 12%). After adjustments for baseline predictors, ticagrelor was associated with increased but not statistically significant risk of major bleeding compared with clopidogrel (5.6% vs 5.2%, adjusted hazard ratio [aHR] 1.40, 95% CI 0.96 – 2.05; P = .075). Major bleeding was significantly associated with nearly 2-fold higher risk of mortality (aHR 1.94; 95% CI 1.32– 2.86; P = .001), irrespective of P2Y12 inhibitor treatment (P interaction = .159). Conclusion(s) Bleeding was not rare within 1 year after index ACS, with incidence rates peaked at 30 to 60 days post-index admission. The most common bleeding site was gastrointestinal followed by intracranial haemorrhage. Ticagrelor use was not associated with significantly increased risk of major bleeding compared with clopidogrel whereas bleeding led to a nearly 2-fold higher risk of major bleeding.

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Virgen Macarena Introduction The time to diagnostic coronary angiography in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) is considered one of the main prognostic factors in patients at higher risk. Purpose Our aim is to know whether early coronary angiography modifies the prognosis of high-risk patients with NSTEACS and to compare it with performing this procedure later. Methods We include patients admitted to the coronary unit of a 3rd level hospital from January-2015 to December-2021 due to NSTEACS. We plan to examine whether the clinical characteristics of patients in whom early coronary angiography (ECA) is performed, the one performed in the first 24 hours from the onset of symptoms, differ from those in whom it is performed later. Likewise, we analyze the clinical results obtained according to the strategy. Results 811 patients were included (73.4% men and 26.6% women), with an average age of 65, in which 229 (28.2%) of them underwent early coronary angiography. Initially, we found more smokers (44.5% vs 32.8, p = 0.006), a higher frequency of risk electrocardiographic changes (ST decrease> 2 mm in 2 contiguous leads, transient ST segment elevation, left main stem pattern) (p = 0.000), greater need for inotropic drugs (14.5% vs 9.6%, p = 0.045), worse Killip-Kimball (KK) during hospital stay (p = 0.002), as well as higher frequency of cardiogenic shock (p = 0.005) among the patients in whom ECA was performed. Although in-hospital mortality was higher in patients who underwent ECA, no statistically significant difference was found. No differences were obtained in the other cardiovascular risk factors, previous history of acute myocardial infarction, heart failure, stroke, coronary revascularization, initial KK presentation, or post-catheterization LVEF. Conclusions In our study, we observed that in patients admitted for NSTEACS, we performed ECA more frequently in patients with a worse prognosis (pathological alterations in the initial ECG, greater frequency of support with inotropics and worse KK during hospital admission), without observing significant differences in in-hospital mortality or in post-catheterization LVEF. The results suggest that ECA improves the prognosis in the group with the worst clinical profile.

Background: Anaplastic thyroid carcinoma represents 2% of all thyroid carcinomas. The most common metastatic sites are lung and neck lymph nodes. Cardiac metastasis is extremely rare. Autopsy studies of patients with thyroid cancer have documented a frequency of metastatic cardiac involvement of 0%–2%. Clinical Case: A 57- year- old woman was admitted to the emergency room with a rapidly expanding neck mass of 3 months duration. She complained of pain in the anterior neck, dysphagia, dyspnea, palpitations and hemoptoic sputum. She further reported history of weight loss. She denied medical history of cancer in the family. Prior medical history was described as non- significant. On clinical examination, vital signs were normal. General swelling around the thyroid region was noted. A hard, tender, immobile mass was palpated. A superficial lymph node of about 5 cm in diameter was palpated in level II A and IIB. The patient was admitted to the hospital for further workup. Laboratory work up revealed, hemoglobin 7.6 g/dL, hematocrit 22.5%, white blood cells 15,000/mm3, fasting plasma glucose 135 mg/dL and urea 59 mg/dL. Thyroid function tests revealed TSH 2.46 mUI/ml (normal range: 0.38-5.33 mUI/ ml), fT3 1.69 pg/ml (normal range: 2.39-6.79 pg/ml), fT4 0.57 ng/dl (normal range: 0.58-1.64 ng/dl). A fine needle aspiration cytology from the thyroid lesion described a poorly differentiated thyroid carcinoma. CT scan of the neck and chest revealed a large heterogeneous mass with hypointense areas involving the thyroid gland of 9 x 8 x 7 cm that surrounded the vertebral bodies and displaced and infiltrated the neck vessels, trachea and esophagus. In the right atrium and right ventricle three well- circumscribed ovoid masses were observed, the largest one measured approximately 21 x 17 mm, suggestive of cardiac metastases. Bilateral adrenal masses were also observed the largest one measuring 69 x 51 mm. Diagnosis of anaplastic thyroid cancer stage IVC was established with a large thyroid mass, widespread metastasis and poorly differentiated metastatic carcinoma on fine needle aspiration biopsy. During her hospitalization she presented both atrial tachycardia and atrial fibrillation and was started on amiodarone. A week later, the patient′s condition deteriorated and she died of respiratory arrest without having any further treatment for the tumor. Conclusion: In patients with established thyroid malignancy who develop cardiac arrhythmias, cardiac metastasis should be considered.