The ECG is the only rapid, noninvasive diagnostic test that can identify coronary occlusion warranting reperfusion therapy at the bedside. The diagnostic paradigm of STEMI/NSTEMI is based on millimeter ST Elevation (STE) criteria as stated in the 4th Universal Definition of MI. It has identified candidates for emergent reperfusion for decades, but is limited by the low sensitivity and specificity of STE for acute coronary occlusion. A paradigm shift to Occlusion MI/Non-Occlusion MI (OMI/NOMI) has been proposed in response. Although the ECG is not embedded in the OMI/NOMI nomenclature as it is in STEMI/NSTEMI, it remains critical to the initial diagnosis of OMI. This review outlines six principles, dynamicity, acuteness, reciprocity, proportionality, totality, and surrogacy, that organize expert interpretation of the ischemic ECG and are essential to the electrocardiographic diagnosis of OMI. Each is drawn from established scholarship; the contribution here is their integration into one framework linked to coronary pathology.
BACKGROUND:Current risk models for myocardial infarction incidence and post-event mortality primarily rely on clinical parameters and do not account for environmental or socioeconomic factors. We aimed to provide a more comprehensive assessment of determinants of ST-elevation myocardial infarction (STEMI) admission and in-hospital mortality. METHODS:We analyzed nine years of national hospital discharge data of all STEMI admissions in Belgium (2012-2014, 2016-2021). Acute and chronic exposures to PM2.5, NO2, O3, temperature, noise, and greenspace were estimated at residential addresses using high-resolution models. Individual socioeconomic data were linked from administrative records. A time-stratified case-crossover design assessed associations between short-term air pollution exposures and STEMI admission, including delayed associations. Multivariable logistic regression examined clinical, socioeconomic, and environmental determinants of in-hospital mortality. RESULTS:A total of 51,544 STEMI admissions were identified (51.4 per 100,000 inhabitants/year). Interquartile range increases in PM2.5 and NO2 were associated with higher same-day STEMI admission risk (PM2.5: OR 1.022, 95%CI 1.008-1.035; NO2: OR 1.044, 95%CI 1.025-1.063). O3 showed associations over delayed exposure windows (strongest at lag 0-2: OR 1.063, 95% CI 1.034-1.090). In-hospital mortality was 11.8% and was most strongly associated with socioeconomic factors, including lower individual and area-level income and retirement status, alongside clinical characteristics. CONCLUSIONS:Environmental factors through air pollution are associated with STEMI incidence, whereas socioeconomic factors such as financial precarity are related to in-hospital mortality. New risk models integrating socioeconomic and environmental vulnerabilities are needed to ensure an early recognition and reinforced care for patients at risk of adverse outcomes.
AIMS:The benefit of complete revascularization after primary percutaneous coronary intervention (PCI) is well established in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, but the long-term effect in older patients remains uncertain. We aimed to evaluate the 10-year outcome of complete revascularization in older patients (aged ≥75 years) compared with younger patients. METHODS AND RESULTS:Patients with STEMI and multivessel disease were randomized to either culprit-only or fractional flow reserve-guided complete revascularization in the DANAMI-3-PRIMULTI trial. This long-term sub-study stratified the included 627 patients by <75 years (517) and ≥75 years (110). The primary outcome was a composite of all-cause mortality, recurrent myocardial infarction, or any revascularization occurring during a median follow-up of 10.5 years. Of the older patients, 50 underwent complete and 60 culprit-only revascularization, and of the younger patients, 264 were completely revascularized compared to 253 who had culprit-only PCI performed.In the older group, complete revascularization showed no association with the primary outcome (adjusted hazard ratio [HR] 1.29, 95% confidence interval [CI]: 0.82-2.03, P = 0.27). In contrast, complete revascularization was associated with a lower risk of the primary outcome (adjusted HR 0.68, 95% CI: 0.53-0.88, P = 0.003) in younger patients, primarily driven by a reduction in any revascularization (adjusted HR 0.60, 95% CI: 0.44-0.83, P = 0.002. CONCLUSION:In patients aged ≥75 years, clear evidence of a long-term (10 years) benefit of complete revascularization was not demonstrated. However, the elderly subgroup was small with limited events, and the finding should be interpreted as inconclusive. In contrast, complete revascularization was associated with a 32% lower risk of adverse outcomes among younger patients, primarily driven by a reduction in repeat revascularization, without evidence of reduced all-cause death or recurrent myocardial infarction.
AIMS:Recent Guidelines of the European Society of Cardiology have introduced the concept of Inflammatory Myocardial and Pericardial Syndrome (IMPS), a unified entity encompassing both myocarditis and pericarditis. This framework reflects the continuum between these conditions in term of anatomy, shared aetiologies, and a common diagnostic approach. This study sought (i) to describe factors associated with pericardial involvement; (ii) to compare the outcomes of patients hospitalized for proven acute myocarditis (AM) with or without pericardial effusion; (iii) to identify the independent correlates of clinical outcome. METHODS AND RESULTS:This is an observational ambispective cohort study based on the AMPHIBIA registry (Assistance Publique-Hôpitaux de Paris/ACTION Study Group), including patients hospitalized for proven AM between August 2008 and December 2024 at La Pitié Salpêtrière Hospital, Paris, France. Patients were stratified into two groups based on the presence of pericardial effusion on admission transthoracic echocardiography, ranging from minimal effusions to tamponade. The main composite outcome was defined as the occurrence of all-cause death, temporary mechanical circulatory support, severe ventricular arrhythmia, and heart transplantation, at the longest follow-up, up to 7 years. A total of 581 patients with AM were included [follow-up 3.7 (1.3-7.3) years]. Among them, 134 (23%) patients presented with pericardial effusion and 447 (77%) patients without. Four independent variables were associated with pericardial effusion at admission: left ventricular (LV) dysfunction, immunological myocarditis, elevated CRP, and fever. The occurrence of the composite event was significantly higher in patients with pericardial effusion compared to those without [38.1% vs. 15.7%, hazard ratio (HR) 2.69, 95% confidence interval (CI) (1.88-3.86), P < 0.001]. This difference was observed regardless of pericardial effusion size. After multivariable analysis, pericardial effusion was independently associated with the main composite outcome [HR 1.99 (1.32-3.00), P < 0.001. CONCLUSION:This study characterizes the phenotypes and outcomes of patients hospitalized for an AM, with and without pericardial effusion. Pericardial involvement was associated with LV dysfunction, immunological myocarditis, elevated CRP, and fever and was linked to a markedly higher risk of the composite outcome, remaining an independent predictor of adverse events. Differentiating these two phenotypes may provide physicians with valuable guidance for managing therapy in these patients.
Cardiogenic shock is a complex clinical syndrome with a high mortality risk. As heterogeneity of patient presentation is high and diagnosis not standardized, a timely diagnosis and thus initiation of treatment are oftentimes not achieved, further worsening the prognosis of affected patients. We therefore propose standardized criteria for the diagnosis of cardiogenic shock, based on three essential pillars: (i) an evidence of end-organ hypoperfusion at rest, (ii) which is primarily caused by haemodynamic abnormalities and a direct consequence of (iii) an underlying cardiac dysfunction commensurate with the state of shock.
Injectable antiplatelet agents can provide immediate and effective platelet inhibition in patients with acute coronary syndromes (ACS). These agents are able to overcome many of the limitations of oral antiplatelet agents, and maybe of particular benefit in patients with ST-elevation myocardial infarction (STEMI), especially those presenting with cardiogenic shock or rescuscitated cardiac arrest. In these patients, factors such as vomiting, altered physiology, sedation, mechanical ventilation or therapeutic hypothermia can impair drug absorption, reducing the intended antiplatelet effect and increasing ischaemic risk. Intravenous aspirin is used widely in patients with ACS, while the absorption of oral P2Y12 inhibitors is often delayed, and the intravenous P2Y12 inhibitor cangrelor can achieve almost complete platelet inhibition within minutes. While use of the glycoprotein IIb/IIIa inhibitors (GPI) eptifibatide and tirofiban is decreasing, typically reserved for thrombotic complications or no reflow following PCI, recently zalunfiban, a novel subcutaneously administered GPI has been shown to improve reperfusion before revascularisation in patients with STEMI when given at first medical contact. In this review, we dicuss the rationale and potential benefits of injectable antiplatelet medications, including currently available agents and those in development or being tested in clinical trials. While the benefit of injectable medications on hard clinical endpoints such as major adverse cardiac events remains unclear for an allcomers ACS population, there is emerging data that these agents achieve rapid platelet inhibition, improve coronary flow and clinical outcomes particular in high risk ACS patients, such as those with cardiogenic shock.
AIMS:Guidelines recommend immediate invasive management for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients meeting very high-risk (VHR) criteria. Whether these criteria identify occlusion myocardial infarction (OMI) and expedite reperfusion is uncertain. METHODS AND RESULTS:This post-hoc analysis included 2979 NSTE-ACS patients undergoing percutaneous coronary intervention (PCI) in the MATRIX programme with available culprit-lesion flow. OMI was defined as culprit-vessel TIMI flow 0-1. We evaluated European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) VHR criteria for OMI detection and time from first medical contact (FMC) to PCI. OMI occurred in 592 patients (19.9%). At least one VHR criterion was present in 52.9% according to ESC and 14.1% according to ACC/AHA definitions. Among patients with OMI, only 58.1% fulfilled ESC and 24.1% ACC/AHA criteria. Median FMC-to-PCI time was shorter in patients fulfilling ESC criteria (27.0 vs. 40.5 h) or ACC/AHA VHR criteria (12.2 vs. 69.9 h; both P < 0.001). Nevertheless, PCI within 2 h occurred in only 2.6% and 7.7% of patients meeting ESC and ACC/AHA criteria, respectively, and in 3.6% of patients with OMI. Even among OMI patients fulfilling VHR criteria, timely reperfusion within 2 h occurred only 4.7% and 9.9%. CONCLUSION:Guideline-directed VHR criteria had limited sensitivity for OMI and rarely translated into guideline-recommended immediate PCI. Current NSTE-ACS classification and triage strategies require reconsideration to improve recognition and timely reperfusion of acute coronary occlusion.
BACKGROUND:Frailty may increase the risk of major adverse cardiovascular events (MACE) after non-cardiac surgery. We aimed to assess the association between frailty and MACE after non-cardiac surgery and potential improvements in the performance of the Revised Cardiac Risk Index (RCRI) with the addition of frailty status. METHODS:We conducted a retrospective cohort study of older US adults aged ≥65 insured through Medicare undergoing non-cardiac surgery between 1/2015 and 9/2021. Frailty was assessed with the Hospital Frailty Risk Score, categorized as low(<5), intermediate(5-14), and high(≥15). The primary outcome was 30-day major adverse cardiovascular events (MACE; mortality, myocardial infarction, stroke, or heart failure). Patients with intermediate/high frailty were propensity-matched 1:1 with low-frailty patients with exact match on age, sex, race, surgical procedure, and RCRI. The incremental utility of adding categorical frailty to RCRI was assessed by comparing concordance statistics and receiver-operating characteristics. RESULTS:Among 6,399,535 patients (mean age 73y, 43% male), 22.4% had intermediate/high frailty, and 2.97% experienced 30-day MACE. In the propensity-matched cohort, frailty was associated with higher odds of 30-day MACE (OR[95%CI]: 1.19[1.17-1.21], P<0.001) and mortality (OR[95%CI]: 1.53[1.49-1.58], P<0.001). The association of frailty with MACE was stronger in patients with low baseline cardiac risk (RCRI 0-1: OR[95%CI] 1.28[1.25-1.31]) versus high risk (RCRI 2-4: OR[95% CI]:1.06[1.03-1.09]; Pinteraction<0.001). Adding frailty to RCRI improved predictive performance for 30-day MACE (C-index: 0.773 vs. 0.758, P<0.001; Brier score: 0.0277 vs. 0.0290). CONCLUSION:Frailty before non-cardiac surgery was associated with increased 30-day MACE. Incorporating frailty into RCRI improves risk prediction, particularly for patients with low baseline cardiac risk.
BACKGROUND:Acute kidney injury (AKI) is common in patients treated with microaxial flow pumps (mAFP). Plasma-free haemoglobin (PFHb) due to haemolysis is known to increase kidney injury in a dose-dependent manner. Therefore, we aimed to identify the association between flow pump level, cumulative PFHb exposure, and AKI. METHODS:In this retrospective observational study, we analysed consecutive patients aged ≥18 years with cardiogenic shock who underwent mAFP between December 2019 and March 2025 at Saiseikai Kumamoto Hospital, Japan. The primary outcome was AKI. RESULTS:A total of 160 patients were analysed separately: mAFP alone (n = 49) and veno-arterial extracorporeal membrane oxygenation (V-A ECMO) plus mAFP (n = 111). Among patients treated with mAFP alone, higher mAFP pump levels were significantly associated with higher PFHb levels (Adjusted P for spline <0.001). Higher cumulative PFHb exposure was significantly associated with an increased risk of AKI in the mAFP-alone subgroup (adjusted P for spline = 0.03). In contrast, these associations were not observed in patients treated with V-A ECMO plus mAFP. Multivariable analysis demonstrated that a high flow pump level ≥ P8 for 24 h or longer (adjusted RR 3.31; 95% CI 1.67-6.58; P < 0.001), as well as higher peak PFHb, longer duration of mAFP support, higher serum creatinine levels at mAFP initiation, and more severe shock status were significantly associated with an increased risk of AKI occurrence. CONCLUSIONS:Higher mAFP levels are significantly associated with higher PFHb levels, which may increase the risk of AKI in patients treated with mAFP alone. Keywords: microaxial flow pump, cardiogenic shock, acute kidney injury, plasma-free haemoglobin.
AIMS:Patients at high bleeding risk (HBR) and acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) are at high risk of adverse outcomes. We investigated the clinical outcomes and their consistency after biodegradable polymer sirolimus-eluting (BP-SES) or durable polymer zotarolimus-eluting stent (DP-ZES) implantation in HBR patients with or without ACS. METHODS AND RESULTS:The per-protocol population of the BIOFLOW-DAPT randomized control trial (RCT) consisted of HBR patients with (n = 541) or without ACS (n = 1245) who were randomized to BP-SES or DP-ZES and underwent 1 month dual antiplatelet therapy (DAPT). The primary efficacy and safety endpoints were target lesion failure (TLF), defined as the composite endpoint of cardiac death, target vessel myocardial infarction (TV-MI), or clinically driven target lesion revascularization (cd-TLR) as well as major bleeding defined as BARC 3 or 5 (according to Bleeding Academic Research Consortium classification) and definite/probable stent thrombosis (ST). At 1 year, patients with ACS suffered from higher cardiac death rates (3.4 vs. 1.3%, log-rank P = 0.004) but similar TLF (6.8 vs. 6.7%, P = 0.992), TV-MI (2.8 vs. 4.5%, P = 0.100), cd-TLR (1.4 vs. 2.1%, P = 0.300), major bleeding (4.2 vs. 3.1%, P = 0.266), and ST (0.2 vs. 0.9%, P = 0.098) compared with no ACS patients. The rate of TLF and of all secondary endpoints was consistent with BP-SES or DP-ZES across ACS strata. CONCLUSION:HBR patients with ACS are at higher risk of cardiac death than those without ACS and experience a consistent outcome with BP-SES or DP-ZES followed by 1 month DAPT at 1 year follow-up. CLINICAL TRIAL REGISTRATION:NCT04137510.
Abstract Inflammation plays a key role in the pathophysiology of acute ST-elevation myocardial infarction (STEMI) and subsequent left ventricular (LV) remodeling. Rapid neutrophil mobilization, followed by monocyte and lymphocyte recruitment, may contribute to adverse remodeling and LV dysfunction, increasing the risk of heart failure. Early identification of patients at risk of LV dysfunction post-STEMI could optimize therapeutic strategies and improve outcomes. This study evaluates the impact of early inflammatory responses on LV remodeling after STEMI. Specifically, it assesses whether inflammatory biomarkers, including leukocyte dynamics, predict LV dysfunction in the acute phase, enhancing early risk stratification. Methods: A prospective, descriptive, analytical, longitudinal study was conducted on patients with STEMI without prior cardiovascular disease between January 2023 and January 2025. Blood samples were collected at primary percutaneous coronary intervention and 12 hours later. Advanced echocardiography was performed prior to discharge. Leukocyte dynamics and inflammatory parameters were analyzed in relation to adverse LV remodeling, defined as reduced left ventricular ejection fraction (LVEF) or impaired global longitudinal strain (GLS), using IBM SPSS Statistic. Results: The study included 52 patients (median age 56,6 years, IQR 52-61), with 84,6%male. Cardiovascular risk factors included smoking (84%), hypertension (49%), diabetes (25%), and dyslipidemia (50%). Most patients (92%) were Killip- Kimball class I, the rest were class II. The culprit vessel was the RCA (50%),followed by LAD (38.5%) and LCx (11.5%). Revascularization involved drug- eluting stents in 42 patients (80.7%), 1 bioresorbable stent (1.9%), and 2 balloon angioplasties (3.8%). All patients received AAS and P2Y12 inhibitors, primarily Prasugrel (46%) and Ticagrelor (44%). Median LVEF was 49.6% (IQR 45-55%), with a mean GLS of -13% ± -3.3% in the acute phase. At 12 hours, the inflammatory response was characterized by leukocytosis (12,707 ± 3,741 cells/μL), predominantly neutrophils (median 9,230, IQR 6,940-11,560). Lymphocytes averaged 2,227 ± 803 cells/μL, and monocytes 985 (IQR 767-1,307). The median neutrophil-to-lymphocyte ratio (NLR) at 12 hours was 3.7 (IQR 2.8-4.5). Peak C-reactive protein was 61 ± 57 mg/dl. NRL at 12 hours was the principal predictor of both LVEF and GLS, with significant negative correlation coefficients (-0.369, p=0.012; -0.377, p=0.012, respectively). Higher NLR was associated with reduced GLS (<-16%) with a statistically significant difference of -1.04 (-2.05 to -0.02, p=0.045). Conclusion: A higher neutrophil-to-lymphocyte ratio at 12 hours post-STEMI was associated with lower LVEF and GLS, suggesting its potential as an early predictor of adverse LV remodeling. This biomarker may aid in early risk stratification. Further studies are needed to validate these findings and explore their clinical implications.
Abstract Background Pericardiocentesis is the standard procedure for diagnosing and treating pericardial effusion. Although the subxiphoid approach is the traditional access site, the widespread use of ultrasound guidance for invasive procedures allows alternative windows tailored to effusion location and patient anatomy. Despite its increasing use, there is a scarcity of published data detailing the apical approach. Purpose We present our institutional experience with pericardiocentesis, comparing the effectiveness, safety and outcomes of the apical and the subxiphoid aproaches. Methods Retrospective analysis of patients undergoing pericardiocentesis for pericardial effusion between 2022 and 2025, at a tertiary cardiac care center. Patients were categorized according to access site: apical or subxiphoid. Data was collected from electronic health records. Statistical comparisons were performed using two-sided Fisher’s exact test. Procedural details: Bedside echocardiographic imaging of the effusion was performed to select the safest approach, favoring the largest effusion window with the lowest risk of perforating adjacent structures. For the apical approach, the entry site was typically located 1–2 cm lateral to the apex beat, between the 5th and 7th intercostal spaces. The chosen site was either marked on the skin or continuously monitored with ultrasound. A needle was advanced above the corresponding rib’s upper border, to avoid injury to the intercostal neurovascular bundle. Aspiration of pericardial fluid confirmed entry into the pericardial space and ultrasound assessed correct needle placement. Drainage was maintained as clinically indicated. Results A total of 45 patients underwent pericardiocentesis, 14 (31%) performed via the apical and 31 (69%) via the subxiphoid approach. There was a higher proportion of women in the apical group but body mass index was comparable. Post-procedural iatrogenic pericardial effusion (32% vs 14%) and hemodynamic instability (68% vs 36%) were more common in the subxiphoid group. The overall success rate was 91% and severe complications occurred in four patients (8%), with no statistically significant difference between the two techniques. No pneumothorax occurred. In the apical group, one case (7%) was complicated with left ventricular puncture. In the subxiphoid group, three patients (10%) had immediate complications: one right and two left ventricular punctures, with one patient going into cardiac arrest and requiring emergent sternotomy with subsequent death at 16 days, attributed to the procedure. Patient outcomes, including overall (p-value 0.519) and in-hospital survival (p-value 1), showed no statistically significant differences (median follow-up: 260 [75-121] days). Conclusions Our institutional experience supports the apical approach as a safe and effective alternative for the traditional subxiphoid technique, enabling tailored treatment to each patient’s effusion and anatomy.Apical aproach
Abstract Background Infective endocarditis (IE) remains a serious condition with adverse clinical outcomes, influenced by the causative pathogen. This study evaluates the impact of specific pathogens on complications and in-hospital mortality in IE. Methods A retrospective cohort of 90 patients diagnosed with IE at a secondary care center over six years was analyzed. Pathogens were categorized into Staphylococcus spp., Streptococcus spp., Enterococcus spp., other agents, culture-negative cases, and multiple pathogens. Outcomes included sepsis, acute kidney injury (AKI), in-hospital mortality, and other clinical events. Results Patients with Enterococcus spp. were older than the cohort average (75.6 vs. 69.9 years, p=0.023), while patients with Other agents were younger (60.3 vs. 69.9 years, p=0.008). No significant diferences were noted for gender, hypertension, diabetes, atrial fibrilation, HIV, or immunosuppression. Native valve, prosthetic valve, or device infections did not show significant statistical diferences. Similarly, vegetation size >10 mm, local complications, embolic events, significant functional impact of IE (e.g., regurgitation/stenosis), vasopressor use, atrioventricular block, de novo heart failure, stroke, and surgical indication also showed no significant variation between groups. Sepsis occurred in 46.7% of patients, with significant diferences between pathogens (p=0.002). Staphylococcus spp. (66.7%, p=0.039) and multiple pathogens (100%, p=0.048) were associated with higher sepsis rates, while Streptococcus spp. showed lower rates (25.0%, p=0.005). Other pathogen groups showed no significant diferences. AKI occurred in 71.3% of patients, with rates higher in Staphylococcus spp. (90.5%, p=0.036) and lower in Streptococcus spp. (54.2%, p=0.008). In-hospital mortality was 32.5%, varying significantly by pathogen (p=0.014). Staphylococcus spp. (57.1%, p=0.017) and multiple pathogens (100%, p=0.011) were associated with increased mortality. Streptococcus spp. exhibited a trend toward reduced mortality (16.7%, p=0.07), while other groups showed no significant diferences. Conclusion This study highlights the significant impact of pathogen type on outcomes in infective endocarditis (IE), particularly regarding sepsis, AKI and mortality. However, further research is needed to understand the underlying mechanisms driving these diferences. Given the complexity of IE, including multi-pathogen infections, the establishment of dedicated IE teams could enhance early diagnosis and improve management. These teams are essential for implementing pathogen specific strategies, which may ultimately lead to be ter patient outcomes and reduced mortality.
