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Background: Type I myocardial infarction (T1MI) or type II myocardial infarction (T2MI) have different underlying mechanisms; however, in the setting of cardiogenic shock (CS), it is not understood if patients experience resultantly different outcomes. The objective of this study was to determine clinical features, biomarker patterns, and outcomes in these subgroups. Methods: Patients from the CAPITAL-DOREMI trial presenting with acute myocardial infarction-associated CS (n = 103) were classified as T1MI (n = 61) or T2MI (n = 42). The primary endpoint was a composite of all-cause in-hospital mortality, cardiac arrest, the need for mechanical circulatory support, or initiation of renal replacement therapy at 30 days. Secondary endpoints were evaluated as individual components of the primary endpoint. Results: Patients with T1MI CS did not have a higher incidence of the primary composite endpoint compared with T2MI CS (adjusted hazard ratio [HR], 1.63; 95% confidence interval [CI], 0.96-2.77; P = 0.07). Cardiac biomarkers including troponin I (P < 0.001), and creatine kinase levels (P = 0.001) were elevated in patients with T1MI CS compared with T2MI. Furthermore, patients with T1MI CS presented with decreased urine output (P = 0.01) compared with T2MI. Predictors of T2MI CS included nonischemic ventricular dysfunction (P = 0.002), atrial fibrillation (P = 0.02), and chronic obstructive pulmonary disease (P = 0.002). Conclusions: There were no differences in adverse clinical outcomes between patients with T1MI and T2MI CS, although the events were numerically increased, and the sample size was small. Overall, this study provides a hypothesis-generating analysis regarding the clinical and biochemical outcomes in T1MI vs T2MI CS. Résumé: Introduction: L’infarctus du myocarde de type 1 (IMT1) et l’infarctus du myocarde de type 2 (IMT2) ont des mécanismes sous-jacents différents. Toutefois, dans le contexte du choc cardiogénique (CC), nous ignorons si les patients ont donc des résultats cliniques différents. Les objectifs de la présente étude étaient de déterminer les caractéristiques cliniques, les profils des biomarqueurs et les résultats cliniques dans ces sous-groupes. Méthodes: Les patients de l’essai CAPITAL-DOREMI qui présentaient un CC associé à un infarctus aigu du myocarde (n = 103) étaient classifiés dans le sous-groupe IMT1 (n = 61) ou dans le sous-groupe IMT2 (n = 42). Le critère de jugement principal était un critère composite qui regroupait la mortalité à l’hôpital toutes causes confondues, l’arrêt cardiaque, la nécessité d’une assistance circulatoire mécanique ou l’amorce d’une thérapie de remplacement rénal dans les 30 jours. Les critères secondaires étaient évalués en fonction des composantes individuelles du critère de jugement principal. Résultats: Les patients qui avaient un CC-IMT1 n’avaient pas une plus grande fréquence de survenue du critère de jugement principal composite que les patients qui avaient un CC-IMT2 (rapport de risque [RR] ajusté, 1,63 ; intervalle de confiance [IC] à 95 %, 0,96-2,77 ; P = 0,07). Les biomarqueurs cardiaques dont les concentrations de la troponine I (P < 0,001) et de la créatine kinase (P = 0,001) étaient élevées chez les patients qui avaient un CC-IMT1, mais non chez les patients qui avaient un CC-IMT2. De plus, les patients qui avaient eu un CC-IMT1 avaient une diurèse réduite (P = 0,01), mais non les patients qui avaient un CC-IMT2. Les prédicteurs du CC-IMT2 étaient la dysfonction ventriculaire non ischémique (P = 0,002), la fibrillation auriculaire (P = 0,02) et la maladie pulmonaire obstructive chronique (P = 0,002). Conclusions: Il n’y avait aucune différence dans les résultats cliniques défavorables entre les patients qui avaient un CC-IMT1 et les patients qui avaient un CC-IMT2, bien que les événements aient augmenté en nombre, et que la taille de l’échantillon était petite. Dans l’ensemble, cette étude fournit une analyse de génération d’hypothèses quant aux résultats cliniques et biochimiques du CC-IMT1 vs du CC-IMT2.

OBJECTIVES:. Inotropic support is commonly used in patients with cardiogenic shock (CS). High-quality data guiding the use of dobutamine or milrinone among this patient population is limited. We compared the efficacy and safety of these two inotropes among patients with low cardiac output states (LCOS) or CS. DATA SOURCES:. MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched up to February 1, 2023, using key terms and index headings related to LCOS or CS and inotropes. DATA EXTRACTION:. Two independent reviewers included studies that compared dobutamine to milrinone on all-cause in-hospital mortality, length of ICU stay, length of hospital stay, and significant arrhythmias in hospitalized patients. DATA SYNTHESIS:. A total of eleven studies with 21,084 patients were included in the meta-analysis. Only two randomized controlled trials were identified. The primary outcome, all-cause mortality, favored milrinone in observational studies only (odds ratio [OR] 1.19 (95% CI, 1.02–1.39; p = 0.02). In-hospital length of stay (LOS) was reduced with dobutamine in observational studies only (mean difference –1.85 d; 95% CI –3.62 to –0.09; p = 0.04). There was no difference in the prevalence of significant arrhythmias or in ICU LOS. CONCLUSIONS:. Only limited data exists supporting the use of one inotropic agent over another exists. Dobutamine may be associated with a shorter hospital LOS; however, there is also a potential for increased all-cause mortality. Larger randomized studies sufficiently powered to detect a difference in these outcomes are required to confirm these findings.

Objective: To ensure compliance with optimal secondary prevention strategies and document the residual risk of patients following revascularization, we established a postrevascularization clinic for risk-factor optimization at 1 year, with outcomes recorded in a web-based registry. Although coronary revascularization can reduce ischemia, medical treatment of coronary artery disease (CAD) remains the cornerstone of ongoing risk reduction. While standardized referral pathways and protocols for revascularization are prevalent and well studied, post-revascularization care is often less formalized. Patients and Methods: The University of Ottawa Heart Institute is a tertiary-care center providing coronary revascularization services. From 2015 to 2019, data were prospectively recorded in the CAPITAL revascularization registry, and patient-level procedural, clinical, and outcome data are collected in the year following revascularization. Major adverse cardiovascular event (MACE) was defined as death, myocardial infarction, unplanned revascularization, or cerebrovascular accident. Kaplan-Meier curves were generated to evaluate time-to-event data for clinical outcomes by risk-factor management, and comparisons were performed using log-rank tests and reported by hazard ratio (HR) and 95% confidence intervals (CIs). Results: A cohort of 4147 patients completed 1-year follow-up after revascularization procedure that included 3462 undergoing percutaneous coronary intervention (PCI), 589 undergoing coronary artery bypass graft (CABG), and 96 undergoing both PCI and CABG. In the year following revascularization (median follow-up 13.3 months—interquartile range [IQR]: 11.9-16.5) 11% of patients experienced MACE, with female patients being disproportionately at risk. Moreover, 47.7% of patients had ≥2 risk factors (diabetes, dyslipidemia, overweight, active smoker) at the time of follow-up, with 45.0% of patients with diabetes failing to achieve target hemoglobin (Hb) A1c, 54.8% of smokers continuing to smoke, and 27.1% of patients failing to achieve guideline-directed lipid targets. Conclusion: Patients who have undergone revascularization procedures remain at elevated risk for MACE, and inadequately controlled risk factors are prevalent in follow-up. This highlights the need for aggressive secondary prevention strategies and implementation of programs to optimize postrevascularization care.

Background: Multiple studies have examined the prevalence of left atrial appendage thrombus (LAAT) in patients anticoagulated with direct oral anticoagulants (DOACs) and have reported conflicting results. Methods: Studies reporting the prevalence of LAAT on transesophageal echocardiography (TEE) after 3 or more weeks of DOAC therapy were identified. The proportions of anticoagulated patients diagnosed with LAAT were pooled using random-effects models. Prespecified subgroup analyses by the indication of TEE (pre–atrial fibrillation [AF] ablation vs cardioversion) and TEE strategy (routine use vs selective) were conducted via stratification. Results: Forty studies were identified: 22 full manuscripts and 18 abstracts. Only 11 studies performed TEE routinely. Most studies included patients with paroxysmal AF and low thromboembolic risk. The pooled prevalence of LAAT was 2.5% (95% confidence interval [1.6%-3.4%]). The prevalence of LAAT is lower in the pre-AF ablation group compared with pre-cardioversion (1.1% vs 4.0%, P = 0.033). Routine TEE strategy yielded a lower LAAT prevalence in both groups (0.1% vs 2.3%, P = 0.002 and 3.2% vs 5.8%, P = 0.432, respectively). Conclusion: The reported prevalence of LAAT on TEE in patients treated with DOACs is highly variable. Factors associated with a high LAAT prevalence were pre-cardioversion indication and selective TEE strategy. Routine use of TEE before AF ablation may not be warranted. Résumé: Introduction: De nombreuses études ont porté sur la prévalence des thrombi se formant dans l’appendice auriculaire gauche (TAAG) chez les patients qui reçoivent des anticoagulants oraux directs (AOD) et ont révélé des résultats contradictoires. Méthodes: Nous avons recensé les études qui ont fait état de la prévalence des TAAG à l’échocardiographie transœsophagienne (ETO) trois semaines ou plus après le traitement par AOD. Les modèles à effets aléatoires ont permis de regrouper les patients qui prenaient des anticoagulants et avaient reçu un diagnostic de TAAG. Nous avons réalisé les analyses de sous-groupes prédéterminés par l’indication d’ETO (fibrillation auriculaire [FA] avant l’ablation vs FA avant la cardioversion) et la stratégie d’utilisation de l’ETO (systématique vs sélective) grâce à la stratification. Résultats: Nous avons recensé 40 études : 22 manuscrits complets et 18 résumés. Seules 11 études portaient sur l’utilisation systématique de l’ETO. La plupart des études portaient sur des patients qui étaient atteints de FA paroxystique et exposés à un faible risque thromboembolique. La prévalence groupée de TAAG était de 2,5 % (intervalle de confiance à 95 % [1,6 %-3,4 %]). La prévalence de TAAG était plus faible dans le groupe de FA avant l’ablation que dans le groupe de FA avant la cardioversion (1,1 % vs 4,0 %, P = 0,033). La stratégie d’utilisation systématique de l’ETO a permis d’obtenir une prévalence plus faible de TAAG dans les deux groupes (0,1 % vs 2,3 %, P = 0,002 et 3,2 % vs 5,8 %, P = 0,432, respectivement). Conclusion: La prévalence de TAAG à l’ETO chez les patients traités par AOD varie beaucoup. Les facteurs associés à une prévalence élevée de TAAG étaient l’indication avant la cardioversion et la stratégie d’utilisation sélective de l’ETO. L’utilisation systématique de l’ETO avant l’ablation peut ne pas être justifiée.

Background: High-power short-duration (HPSD) ablation has been explored for pulmonary vein isolation. Early data suggest similar efficacy with shorter procedure times and perhaps greater safety. Data are lacking on the use of this ablation strategy for other arrhythmias. Objective: The purpose of this study was to evaluate the safety, efficacy, and clinical outcomes of HPSD ablation in patients with typical atrial flutter compared to those undergoing ablation with conventional settings. Methods: Consecutive patients undergoing cavotricuspid isthmus (CTI) ablation using standard power settings were compared to those performed after transitioning to HPSD ablation. Demographics, procedural details, and ablation outcomes were prospectively collected. The primary endpoint was duration of radiofrequency energy delivery. Secondary endpoints were radiation duration and analgesia requirements. Results: A total of 114 consecutive subjects undergoing CTI ablation (57 standard power, 57 HPSD) were included. HPSD ablation and electroanatomic mapping/contact force (EAM/CF) use were associated with 66% (95% confidence interval [CI] 58%–73%) and 50% (95% CI 37%–60%) shorter ablation times compared to standard power and not using EAM/CF, respectively. Patients in the HPSD group required 50 mcg less fentanyl relative to the standard ablation arm after adjusting for sex, age, and comorbidities (P = .048). At a median follow-up of 6 months, 4 patients (7%) in the standard arm had recurrence of atrial flutter, compared to none in HPSD group (P = .057). Conclusion: HPSD is a safe and effective approach to CTI ablation. This strategy may reduce ablation time and analgesia requirements. Larger studies and longer follow-up are needed to further evaluate this strategy.