BACKGROUND AND AIMS:Despite current antithrombotic treatments, the recurrence of ischaemic events remains high in patients with diabetes mellitus (DM) or aspirin resistance after acute coronary syndrome (ACS). Whether twice-daily aspirin dosing reduces major adverse cardiovascular events (MACE) in this population remains unknown. METHODS:In this prospective multicentre, randomized trial, patients with ACS and DM or high-risk of aspirin resistance (HRAR) defined as: (i) an index event occurring while on aspirin; (ii) body mass index ≥27 kg/m2; or (iii) increased waist circumference were assigned to receive enteric-coated aspirin once daily (100 mg/day) or twice daily (100 mg morning and evening). The primary outcome was MACE, a composite of any death, myocardial infarction, stroke, urgent coronary revascularization, stent thrombosis, or acute arterial thrombotic event assessed using a time-to-first-event analysis. The main secondary outcome was major bleeding (Bleeding Academic Research Consortium type 3-5). RESULTS:In total, 2484 participants were enrolled (77.2% with DM, 55.5% with ST-elevation segment myocardial infarction). The median follow-up duration was 18 (interquartile range: 17.6-18.3) months. The primary outcome occurred in 95 of 1228 participants (7.7%) in the twice-daily aspirin group, and 110 of 1256 (8.8%) in the once-daily group (hazard ratio [HR] 0.90; 95% confidence interval [CI] 0.69-1.19; P = .42). Major bleeding rates were similar between the groups (1.9% vs 2.1%; HR 0.88; 95% CI 0.50-1.55). CONCLUSIONS:In patients with ACS and DM or HRAR, twice-daily aspirin did not significantly reduce the risk of MACE compared to once-daily dosing. No significant difference was observed in major bleeding between groups. TRIAL REGISTRATION:NCT02520921/EUDRACT No: 2015-000947-18.

BACKGROUND:Although recent work has shown that recent recreational drug use is associated with in-hospital outcomes in patients admitted to the intensive cardiac care unit (ICCU), its cardiovascular consequences after hospitalization for an acute cardiovascular event are not well established. We aimed to evaluate the prognostic impact of recreational drug use at 1-year follow-up on major adverse cardiovascular and cerebrovascular events (MACCE) in patients admitted to the ICCU. METHODS:The ADDICT-ICCU study (Addiction in Intensive Cardiac Care Units) is a prospective multicentric study including all consecutive patients admitted to the ICCU over 2 weeks in April 2021 at 39 French centers. Patients were excluded in cases of scheduled hospitalization, hospitalization within 24 hours before ICCU admission, or in-hospital death. Screening for recreational drug use was performed by a systematic urinary testing upon admission. The primary composite outcome was 1-year MACCE defined as cardiovascular death, nonfatal myocardial infarction, or stroke. Outcomes were adjudicated by 2 senior cardiologists after patient contact and review of anonymized records. A multivariable Cox regression analysis adjusted for traditional prognostic factors was performed to assess the independent association between overall recreational drug use and clinical outcomes. RESULTS:Of the 1392 patients assessed (63±15 years, 69.9% men), 157 (11.3%) had an initial positive test (cannabis or opioids, cocaine, amphetamines, or 3,4-methylenedioxymethamphetamine). After 1-year of follow-up, 94 (6.7%) patients experienced MACCE, with a higher incidence observed among drug users compared with nonusers (12.7% versus 6.0%; risk difference, 6.7% [95% CI, 1.5%-12.2%]). Cannabis or opioid use alone was also associated with MACCE (hazard ratio, 1.77 [95% CI, 1.02-3.08] for cannabis, and hazard ratio, 3.60 [95% CI, 1.57-8.23], for opioids). After adjustment for traditional prognostic factors, recreational drug use remained independently associated with MACCE (hazard ratio, 2.91 [95% CI, 1.68-5.05]). CONCLUSIONS:Recreational drug use markedly increases the risk of 1-year adverse cardiovascular outcomes in ICCU patients highlighting the need for targeted, tailored interventions. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT05063097.

AIMS:Although predominant in routine practice, non-ischaemic cardiogenic shock (NICS) remains underrepresented in past studies, mainly focused on ischaemic cardiogenic shock (CS). This study aims to describe the current NICS picture and define its independent correlates of short- and long-term outcomes. METHODS AND RESULTS:FRENSHOCK is a prospective registry including 772 CS patients from 49 centers. One-year mortality was the primary outcome. One-month mortality and the composite of 1-year mortality, heart transplantation (HTx), or ventricular assistance device (VAD) were secondary outcomes. Within 772 patients included, 492 (63.7%) were NICS. One-month and 1-year mortality rates were 25.6% and 45.7%, with a combined endpoint of 1-year mortality, HTx, or VAD of 53.9%. Multivariate analysis showed five independent factors for 1-year mortality: age (per year: aHR 1.03 [1.01-1.05], P < 0.01), chronic kidney disease (CKD) (aHR 1.87 [1.25-2.80], P < 0.01), norepinephrine use (aHR 1.52 [1.02-2.26], P = 0.04), active cancer (aHR 1.91 [1.07-3.42], P = 0.03) and acute renal replacement therapy (aHR 1.57 [1.01-2.46], P = 0.049). Age, CKD and norepinephrine were also predictive of 1-month mortality and 1-year mortality and/or HTx and/or VAD. Additionally, 1-month mortality was associated with septic triggers, and 1-year mortality and/or HTx and/or VAD with acute mechanical circulatory support, NYHA stage ≥ 3 and fluid administration. CONCLUSIONS:In this large study, NICS accounted for almost two-thirds of all CS cases, with substantial rates of short- and long-term mortality. Future studies should evaluate interventions to improve early stratification and management. NCT02703038.

BACKGROUND:Patients in cardiogenic shock (CS) can benefit from temporary mechanical circulatory support (tMCS) but data in heterogeneous populations with diverse CS aetiologies are rare. AIMS:To compare baseline characteristics, management and independent correlates of 30-day and 1-year mortalities between patients managed with and without tMCS for CS. METHODS:The FRENSHOCK registry (NCT02703038) included 772 unselected patients with CS admitted in 49 French critical care units between April and October 2016. RESULTS:Among 770 patients with CS and available data, 135 (17.5%) received tMCS (63 extracorporeal life support, 35 intra-aortic balloon pump, 13 micro-axial flow pump and 24 combination), of whom 69.0% were implanted during the first 24hours. Patients with tMCS were less likely to present with histories of cardiac or peripheral artery diseases or chronic renal failure. An ischaemic or mechanical complication trigger for CS tripled the probability of receiving tMCS, while increased lactate doubled the probability. Thirty-day mortality was higher among patients with versus without tMCS (34.1% vs. 24.3%; P<0.001), but after adjustment for age and CS severity (LVEF and arterial lactates at admission, noradrenaline and invasive mechanical ventilation use), the difference was no longer significant (hazard ratio: 1.37, 95% confidence interval: 0.93-2.01). Among 30-day survivors, mortality was similar regardless of initial receipt of tMCS (P=0.312). CONCLUSION:In real-life practice, tMCS may not be associated with improvements in 30-day or 1-year mortality in an all-comers cohort of patients with CS. However, it should be noted that there were substantial differences in patient characteristics and management between patients who received tMCS and those who did not. Additional targeted studies should help to determine more precise algorithms for granting assistance within the complex and heterogeneous population of patients with CS.

OBJECTIVES:MSSA remains the leading cause of infective endocarditis (IE) and is responsible for significant mortality. While clinical factors tied to mortality are well documented, possible contributing strain-specific characteristics have not been extensively explored. This study investigates MSSA phenotypic and genotypic characteristics and medical-surgical data related to Day-90 mortality in IE. METHODS:We included all patients enrolled in a monocentric prospective cohort (2016-23), with definite or probable MSSA IE. Cefazolin and oxacillin MICs and inoculum effects were determined by broth microdilution. Genotyping analysis and BlaZ typing were obtained from WGS. Phenotypic and genotypic characteristics of strains and clinical risk factors were confronted with Day-90 mortality. RESULTS:Eighty-eight patients with MSSA IE were included. The most frequent clinical presentations were left-sided native valve IE (25/88), left-sided prosthetic valve IE (12/88) and right-sided IE (19/88). Day-90 mortality rate was 39% (34/88). Most patients were treated with antistaphylococcal penicillin as a primary antibiotic (60/88). The main MSSA clonal complexes identified were CC398 (17/88), CC30 (13/88) and CC5 (13/88). Cefazolin inoculum effect was observed in 18/88 strains, and oxacillin inoculum effect in 13/88. Overall, 15/88 isolates exhibited an inoculum effect on primary antibiotic therapy. Factors independently associated with improved outcomes included cardiac surgery [hazard ratio (HR) 0.34, 95% CI (0.13-0.89)] and source control [HR 0.21, 95% CI (0.03-0.53)]. Neither genetic background, blaZ carriage, nor in vitro inoculum effect to the primary antibiotherapy was associated with Day-90 mortality. CONCLUSIONS:This cohort of MSSA IE did not find any microbiological factors correlated with Day-90 mortality. Clinical features and infection management appear to be the main factors in the prognosis of MSSA IE.

Aims Although some scores based on traditional statistical methods are available for risk stratification in patients hospitalized in cardiac intensive care units (CICUs), the interest of machine learning (ML) methods for risk stratification in this field is not well established. We aimed to build an ML model to predict in-hospital major adverse events (MAE) in patients hospitalized in CICU. Methods and results In April 2021, a French national prospective multicentre study involving 39 centres included all consecutive patients admitted to CICU. The primary outcome was in-hospital MAE, including death, resuscitated cardiac arrest, or cardiogenic shock. Using 31 randomly assigned centres as an index cohort (divided into training and testing sets), several ML models were evaluated to predict in-hospital MAE. The eight remaining centres were used as an external validation cohort. Among 1499 consecutive patients included (aged 64 +/- 15 years, 70% male), 67 had in-hospital MAE (4.3%). Out of 28 clinical, biological, ECG, and echocardiographic variables, seven were selected to predict MAE in the training set (n = 844). Boosted cost-sensitive C5.0 technique showed the best performance compared with other ML methods [receiver operating characteristic area under the curve (AUROC) = 0.90, precision-recall AUC = 0.57, F1 score = 0.5]. Our ML score showed a better performance than existing scores (AUROC: ML score = 0.90 vs. Thrombolysis In Myocardial Infarction (TIMI) score: 0.56, Global Registry of Acute Coronary Events (GRACE) score: 0.52, Acute Heart Failure (ACUTE-HF) score: 0.65; all P < 0.05). Machine learning score also showed excellent performance in the external cohort (AUROC = 0.88). Conclusion This new ML score is the first to demonstrate improved performance in predicting in-hospital outcomes over existing scores in patients admitted to the intensive care unit based on seven simple and rapid clinical and echocardiographic variables. Trial Registration ClinicalTrials.gov Identifier: NCT05063097.

Background: Although recreational drug use is a strong risk factor for acute cardiovascular events, systematic testing is currently not performed in patients admitted to intensive cardiac care units, with a risk of underdetection. To address this issue, machine learning methods could assist in the detection of recreational drug use.Aims: To investigate the accuracy of a machine learning model using clinical, biological and echocardiographic data for detecting recreational drug use in patients admitted to intensive cardiac care units.Methods: From 07 to 22 April 2021, systematic screening for all traditional recreational drugs (cannabis, opioids, cocaine, amphetamines, 3,4-methylenedioxymethamphetamine) was performed by urinary testing in all consecutive patients admitted to intensive cardiac care units in 39 French centres. The primary outcome was recreational drug detection by urinary testing. The framework involved automated variable selection by eXtreme Gradient Boosting (XGBoost) and model building with multiple algorithms, using 31 centres as the derivation cohort and eight other centres as the validation cohort.Results: Among the 1499 patients undergoing urinary testing for drugs (mean age 63 ± 15 years; 70% male), 161 (11%) tested positive (cannabis: 9.1%; opioids: 2.1%; cocaine: 1.7%; amphetamines: 0.7%; 3,4-methylenedioxymethamphetamine: 0.6%). Of these, only 57% had reported drug use. Using nine variables, the best machine learning model (random forest) showed good performance in the derivation cohort (area under the receiver operating characteristic curve = 0.82) and in the validation cohort (area under the receiver operating characteristic curve = 0.76).Conclusions: In a large intensive cardiac care unit cohort, a comprehensive machine learning model exhibited good performance in detecting recreational drug use, and provided valuable insights into the relationships between clinical variables and drug use through explainable machine learning techniques.

OBJECTIVE:Cardiogenic shock (CS) in patients with left ventricular hypertrophy (LVH) due to hypertrophic cardiomyopathy (HCM) or hypertensive heart disease, is underreported in the literature. This study aimed to delineate the characteristics, management strategies, and outcomes of patients experiencing CS with preexisting LVH and HCM. METHODS:FRENSHOCK is a prospective multicenter registry including 772 unselected CS patients from 49 centers. Baseline characteristics, management, and 1-year outcomes were analyzed according to the occurrence on preexisting LVH. RESULTS:Among the 772 included patients with CS, CS occurred in 34 patients with preexisting LVH (4.4%, 1.4% with HCM). Clinical characteristics, medical history, usual medications, and hemodynamic parameters upon inclusion did not differ between the patients with or without LVH. Left ventricular ejection fraction in patients with CS and LVH was 27.3 ± 14.5% indicating a non-obstructive cause of CS. In-hospital management according to the LVH and non-LVH groups indicated no differences between the groups. The 1-month and 1-year mortality did not differ between patients with CS with and without LVH (26.5% vs. 26%, adjusted HR [hazard ratio] [95% CI]: 0.87 [0.44-1.72]) and 55.9% vs. 44.7%, respectively (adjusted HR [95% CI]:0.88 [0.54-1.42]). Subgroup analyses comparing HCM (n = 11) and hypertensive LVH (n = 23) revealed similar clinical characteristics, in-hospital management, and one-year rehospitalization rates in these patients. CONCLUSION:In a large and unselected CS population, the prevalence of patients with LVH was low (4.4%) with less than half having HCM (1.4%). The presentation, management, and outcomes of CS were similar to the broader CS population in our series. However, HCM-CS represents a distinct clinical entity necessitating tailored management approaches.

BACKGROUND:Recent guidelines have proposed dichotomizing acute heart failure and cardiogenic shock phenotypes based on signs/symptoms of hypoperfusion/congestion. AIM:We aimed to assess the prognostic significance of congestion and its early evolution during the first 24hours in a nationwide cardiogenic shock cohort. METHODS:FRENSHOCK was a prospective registry including 772 patients with cardiogenic shock from 49 centres. Patients were classified as cold and wet or cold and dry according to congestive signs. Death at 30days was analysed according to baseline phenotype. RESULTS:Among 593 patients with cardiogenic shock included, 70.7% were male; the median age was 67.0 (58.0-77.0) years, and 521 patients (87.9%) presented with congestion. Congestive patients had higher rates of previous cardiac disease (60.5% vs. 43.1%; P<0.01) and chronic kidney disease (24.2% vs. 12.5%; P=0.04). No differences were found regarding Society for Cardiovascular Angiography and Interventions class distribution and lactate concentrations. Congestion was associated with an increased 30-day all-cause death rate (hazard ratio: 1.99, 95% confidence interval: 1.05-3.78; P=0.04), particularly among patients with persistent congestion beyond 24hours (hazard ratio: 2.29, 95% confidence interval: 1.20-4.36; P=0.01). Conversely, patients with resolved congestion at 24hours had similar outcomes to non-congestive patients (hazard ratio: 0.76, confidence interval: 0.31-1.88; P=0.56). The negative impact of congestion was confirmed in multivariable Cox regression analysis. CONCLUSIONS:Congestion and its persistence beyond 24hours of management are frequent in patients with cardiogenic shock, and are significantly associated with an increased 30-day all-cause death rate, which may reflect either a direct harmful effect of congestion or difficulties in achieving decongestion in sicker patients. Further studies are warranted to clarify optimal decongestion strategies in patients with cardiogenic shock.

BACKGROUND:Tricuspid regurgitation (TR) leads to right heart congestion and increased mortality risk. Unlike secondary TR, primary TR results from leaflet degeneration. Transcatheter edge-to-edge repair (TEER) is widely used for TR. However, its feasibility primary TR remains uncertain. OBJECTIVES:The aim of this study was to assess the safety and feasibility of TEER in patients with primary TR. METHODS:The primary TR registry is a multicenter cohort study of patients with primary TR undergoing TEER. Echocardiographic assessment classified leaflet pathology into type 1 (flail), type 2 (billowing prolapse), type 3 (perforation), and type 4 (restricted mobility). The primary endpoint was TR reduction to moderate or less at discharge. RESULTS:From December 2016 to April 2023, 114 patients (mean age 79.9 years, 53.5% men) were included. Most patients were in NYHA functional class III or IV (83.3%), with a median TRI-SCORE of 5.0. The TR pathologies were type 1 (28.1%), type 2 (61.4%), and type 4 (10.5%), with no type 3 cases. Device deployment was achieved in 95.6%, and 83.3% showed TR reduction to moderate or less. In-hospital mortality was 1.8%, and single-leaflet device attachment occurred in 3.5%. At 1 year, 79.7% of patients had TR moderate or less, with significant reductions in vena contracta (-5.0 mm; P < 0.001), annular diameter (-2.0 mm; P = 0.003), and mid right ventricular diameter (-3.0 mm; P < 0.001). NYHA functional class also improved significantly (NYHA functional class I or II: 17.1% at baseline vs 66.5% at follow-up; P < 0.001). CONCLUSIONS:TEER is a safe and effective option for primary TR, promoting right heart reverse remodeling and symptomatic relief, offering a vital alternative to surgery in selected patients.

BACKGROUND:Patients with diabetes mellitus (DM) or aspirin resistance are exposed to recurrent atherothrombotic events after acute coronary syndrome (ACS). Aspirin once-daily can allow the recovery of platelet cyclooxygenase activity before the next intake in these patients. Twice-daily administration provides more stable inhibition of platelet aggregation and may improve prognosis in these patients. AIM:To demonstrate the superiority of twice-daily aspirin compared to once daily in reducing major adverse cardiovascular events (MACE) in patients with DM or aspirin resistance after ACS. METHODS:The ANDAMAN trial is a randomized, multicenter study including patients (aged ≥18 years) with DM or with aspirin resistance defined as: (1) index event occurring under aspirin; (2) body mass index ≥27 kg/m2); (3) increased waist circumference (≥88 cm for women or ≥ 102 cm for men). The patients will be recruited in 39 centers after an ACS (with or without ST elevation) with at least one significant coronary stenosis and will be randomized before hospital discharge between twice-daily vs once daily low-dose aspirin (100 mg bid vs od). The primary composite endpoint will be the occurrence of MACE including all-cause death, myocardial infarction, stroke, urgent coronary revascularization or acute arterial thrombotic event during a follow-up of 18 months. To achieve a 20% reduction in the relative risk of MACE in the twice-daily aspirin group, a total of 2,574 patients will be included in the trial. The main secondary endpoint will be major bleeding (type 3-5 following BARC classification). CONCLUSIONS:The trial will evaluate the prognostic impact of twice-daily aspirin for ACS patients with DM or aspirin resistance and may change the way aspirin is administered to these patients. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT02520921.

BACKGROUND:The United Nations has recently highlighted a global epidemic of psychoactive substance use among elderly people. Although several studies have established the important prognostic impact of psychoactive substance use in terms of cardiovascular events, the epidemiological characteristics of this consumption in elderly patients hospitalized in intensive cardiac care units (ICCUs) are not well established. AIM:To assess the prevalence of psychoactive substance use in all consecutive elderly patients hospitalized in ICCUs from the Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) trial. We described the epidemiological characteristics of this consumption to identify the consumption pattern in elderly and younger patients. METHODS:Systematic prospective screening for psychoactive substances was performed by a urine test (NarcoCheck®) in all patients admitted to an ICCU in 39 French centres from 7th to 22nd April 2021. The primary outcome was the prevalence of psychoactive substances, including recreational drugs (cannabis, cocaine, ecstasy, amphetamine, opioids) and psychoactive medications (benzodiazepines, methadone, buprenorphine, barbiturates, tricyclic antidepressants). RESULTS:Among the 1499 patients included in the study, 760 (51%) were elderly (≥ 65 years). Among the elderly patients, 157 (21%) tested positive for at least one psychoactive substance, 38 of whom (5%) tested positive for a recreational drug. The psychoactive substances most frequently detected were benzodiazepines (44%), followed by opioid substitution medications (42%) (methadone [24%] and buprenorphine [18%]), cannabis (18%), tricyclic antidepressants (9%), cocaine (7%) and opioids (3.2%). Multiple psychoactive substance detection was frequent (22% of positive patients). Compared with younger patients, elderly patients had a 3-fold lower cannabis consumption (18 vs. 53%; P<0.001), but a 2-fold higher benzodiazepine consumption (44 vs. 22%; P<0.001). CONCLUSIONS:This study highlights the significant prevalence of psychoactive substance use among a large cohort of elderly patients hospitalized in ICCUs. Differential patterns of substance use were observed in elderly and younger patients.

AIMS:The study aims to assess the in-hospital and 1 year incremental prognostic value of recent drug abuse use, detected by a systematic urinary screening, in a consecutive cohort of patients hospitalized for acute heart failure (AHF). METHODS:All patients admitted for AHF with a drug abuse screening using a urinary assay were included in this prospective multicentric study (39 French centres). The outcomes were (i) in-hospital major adverse cardiovascular events (MACEs) defined as all-cause death, resuscitated cardiac arrest or cardiogenic shock; and (ii) 1 year MACEs defined as cardiovascular death or hospitalization for AHF. Incremental prognostic value was assessed using the C-index, the global χ2 and likelihood-ratio (LR) test, the net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS:In total, 458 patients with AHF were included (mean age 68 ± 14 years, 67% male, 79% of new heart failure onset). In-hospital and 1 year MACEs occurred, respectively, in 65 (14.2%) and 129 (28.2%) patients. Drug abuse detection was independently associated with in-hospital MACEs [model 1-known comorbidities: odds ratio (OR) = 4.46, 95% confidence interval (CI) (1.88-10.3), P < 0.001; model 2-clinical severity: OR = 3.64, 95% CI (1.56-8.26), P = 0.002], even after propensity-matched population analysis [OR = 3.34, 95% CI (1.32-8.70), P = 0.011], with a significant incremental prognostic value over and above traditional risk factors (C-statistic improvement 0.04 with LR test P < 0.001 for both models). Patients with drug abuse detection had worse 1 year survival: HR = 1.82, 95% CI (1.13-2.92), P = 0.012. Drug abuse detection was independently associated with 1 year MACEs after adjustment with traditional prognosticators [OR = 2.54, 95% CI (1.28-4.98), P = 0.008] and propensity-matched population analysis [OR = 2.77, 95% CI (1.98-5.21), P = 0.001], with an incremental prognostic value as well (C-statistic improvement 0.02, LR test P < 0.001, positive NRI and IDI). CONCLUSIONS:Drug abuse use was independently associated with a higher occurrence of both in-hospital and 1 year MACEs with an incremental prognostic value. These results suggest a potential interest of a systematic illicit drug screening in these patients. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT05063097.

Aim:Differences between cardiogenic shock (CS) with and without prior resuscitated cardiac arrest (CA) remain largely unexplored. We hypothesized that patients who experience shockable CA followed by CS are likely to have worse outcomes compared to CS without prior CA. Methods:FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units in 2016, which included CS from various etiologies. Patients admitted after resuscitation of a CA were included if they fulfilled previously defined CS criteria. Non-shockable rhythms at the time of medical intervention were considered exclusion criteria and were not recorded in the registry. Results:Among the 771 enrolled patients (mean age 65.7 ± 14.9 years; 71.5 % male), 79 (10.2 %) had a resuscitated shockable cardiac arrest just before inclusion. Shockable CA patients had more respiratory support (78.5 % vs. 33.2 %, p < 0.001), more mechanical circulatory support (35.4 % vs. 16.5 %, p < 0.001), more coronary angiography performed (76 % vs. 48.8 %, p < 0.001), finding more mono-troncular lesions (39 % vs. 16.9 %, p < 0.001). Thirty-day and one-year survival were similar between groups. Among 30-day survivors, CS with an initial shockable CA exhibited significantly improved long-term survival compared to CS without prior resuscitated CA. Conclusion:In a cohort of patients with cardiogenic shock from various etiologies, approximately 10% had experienced prior resuscitation following a cardiac arrest with shockable rhythms. Our findings suggest that selected cardiac arrest with a shockable rhythm leading to cardiogenic shock does not inherently confer a worse prognosis compared to other causes of cardiogenic shock.

AIMS:Acute myocarditis (AM) is a rare but severe disease affecting patients of all ages. Large multicentric studies comparing children and adults are currently lacking. We aimed to elucidate differences in presentation, management, and outcomes of AM across age groups. METHODS:We analysed a comprehensive French national cohort study, encompassing 53 paediatric and adult units from March 2020 to November 2021, collecting data on baseline characteristics, evolution, management and in-hospital complications. Myocarditis-related events (MRE) within 30 days included all-cause death, cardiogenic shock, cardiac arrest, ventricular arrhythmias or complete AV block. RESULTS:We included 745 AM patients (328 children and 417 adults), mainly male (73.4%) with a median age of 10.9 years [Q1-Q3 (7.3-14.6)] for children and 28.7 years [22.6-41.2] for adults. Multisystem inflammatory syndrome (MIS) was more prevalent among children (69.8%), and infectious aetiologies dominated in adults (13.4 vs. 52.4%). Children exhibited more severe clinical presentation (15.9 vs. 7.2%, P < 0.001, with heart failure and 14.4 vs. 6.9%, P < 0.001, with cardiogenic shock), requiring higher use of inotropes (25.0 vs. 9.4%, P < 0.001), vasopressors (12.0 vs. 6.2%, P < 0.001), and ventilatory support (13.7% vs. 7.9%, P = 0.01). Cardiac treatments were used less frequently in children, and corticosteroids (68.3 vs, 14.3, P < 0.001) and immunomodulators (65.1 vs. 4.5%, P < 0.001) were more common. MRE occurrence was substantial but not significantly different between children and adults (18.1 vs. 13.4%, P = 0.09). Extra-cardiac manifestations at admission were significant predictors of MRE [adjusted odds ratio 2.40 (1.43-4.38)], regardless of MIS status. CONCLUSIONS:AM exhibits variations in presentation, aetiologies and management but has a comparable 30 day prognosis in children and adults. These findings underscore the importance of tailored management strategies in AM across different age groups.

Abstract Background Acute myocarditis (AM) usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favorable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders and is considered the leading cause of sudden cardiac death in young apparently healthy adults. There is no recommendation for AM, only expert consensus, given the lack of important databases for a strong level of confidence. Methods We performed a multicenter prospective observational study of patients admitted for AM acknowledged by cardiac MRI to describe baseline characteristics, management, in-hospital and long-term outcomes of AM patients in France. Secondary objectives were to investigate determinants of prognosis, modalities of treatment and follow-up, and to identify gaps between expert consensus and real-life management. Results We enrolled 805 consecutive patients hospitalized for AM in 49 participating centers between May 2016 and February 2019. Median age was 31 (IQR 23-41) with 19% of female. Chest pain was the most frequent symptom (93%) and 112 (14%) had severity criteria upon admission (LVEF<50% or severe ventricular arrythmia or high-grade AV block or cardiogenic shock). ST elevation was observed in 49% of patients. One 26-years old patient died during initial hospital stay. Overall, 62 patients (8%) experienced intra-hospital complication of their AM, defined as a combined endpoint of death, LVEF<40% (MRI), sustained ventricular or supraventricular arrythmia, acute renal failure, cardiogenic shock, need for ventricular assistance device, need for inotropic drugs, temporary cardiac pacing, pace-maker or cardiac defibrillator implantation. Patients with initial severity criteria were 10 times more likely to present intra-hospital complication (33% vs 3.6%, p<0.001). Conclusion This prospective cohort represents the largest database on AM worldwide. Here we report baseline characteristics and in hospital events. Most patients had typical presentation with favorable outcomes but as much as 8% of patients did exhibit intra-hospital complication. The prospective follow up will provide valuable data to better identify subset of patients with poor prognosis that may be of interest to develop new therapeutic strategies.Acute myocarditis on cardiac MRI

Background The effects of pharmacological therapy on cardiogenic shock (CS) survivors have not been extensively studied. Thus, this study investigated the association between guideline‐directed heart failure (HF) medical therapy (GDMT) and one‐year survival rate in patients who are post‐CS. Methods and Results FRENSHOCK (French Observatory on the Management of Cardiogenic Shock in 2016) registry was a prospective multicenter observational survey, conducted in metropolitan French intensive care units and intensive cardiac care units. Of 772 patients, 535 patients were enrolled in the present analysis following the exclusion of 217 in‐hospital deaths and 20 patients with missing medical records. Patients with triple GDMT (beta‐blockers, renin‐angiotensin system inhibitors, and mineralocorticoid receptor antagonists) at discharge (n=112) were likely to have lower left ventricular ejection fraction on admission and at discharge compared with those without triple GDMT (n=423) (22% versus 28%, P<0.001 and 29% versus 37%, P<0.001, respectively). In the overall cohort, the one‐year mortality rate was 23%. Triple GDMT prescription was significantly associated with a lower one‐year all‐cause mortality compared with non‐triple GDMT (adjusted hazard ratio 0.44 [95% CI, 0.19–0.80]; P=0.007). Similarly, 2:1 propensity score matching and inverse probability treatment weighting based on the propensity score demonstrated a lower incidence of one‐year mortality in the triple GDMT group. As the number of HF drugs increased, a stepwise decrease in mortality was observed (log rank; P<0.001). Conclusions In survivors of CS, the one‐year mortality rate was significantly lower in those with triple GDMT. Therefore, this study suggests that intensive HF therapy should be considered in patients following CS.

Background The 2023 Duke-International Society for Cardiovascular Diseases (ISCVID) criteria for infective endocarditis (IE) were proposed as an updated diagnostic classification of IE. Using an open prospective multicenter cohort of patients treated for IE, we compared the performance of these new criteria to that of the 2000 Modified Duke and 2015 European Society of Cardiology (ESC) criteria. Methods Cases of patients treated for IE between January 2017 and October 2022 were adjudicated as certain IE or not. Each case was also categorized as either definite or possible/rejected within each classification. Sensitivity, specificity, and accuracy were estimated with 95% confidence intervals. Results Of the 1194 patients analyzed (mean age, 66.1 years; 71.2% males), 414 (34.7%) had a prosthetic valve and 284 (23.8%) had a cardiac implanted electronic device (CIED); 946 (79.2%) were adjudicated as certain IE; 978 (81.9%), 997 (83.5%), and 1057 (88.5%) were classified as definite IE in the 2000 modified Duke, 2015 ESC, and 2023 Duke-ISCVID criteria, respectively. The sensitivity of each set of criteria was 93.2% (95% confidence interval [CI], 91.6-94.8), 95.0% (95% CI, 93.7-96.4), and 97.6% (95% CI, 96.6-98.6), respectively (P < .001 for all 2-by-2 comparisons). Corresponding specificity rates were 61.3% (95% CI, 55.2-67.4), 60.5% (95% CI, 54.4-66.6), and 46.0% (95% CI, 39.8-52.2), respectively. In patients without CIED, sensitivity rates were 94.8% (95% CI, 93.2-96.4), 96.5% (95% CI, 95.1-97.8), and 97.7% (95% CI, 96.6-98.8); specificity rates were 59.0% (95% CI, 51.6-66.3), 56.6% (95% CI, 49.3-64.0), and 53.8% (95% CI, 46.3-61.2), respectively. Conclusions Overall, the 2023 Duke-ISCVID criteria had a significantly higher sensitivity but a significantly lower specificity compared with older criteria. This decreased specificity was mainly attributable to patients with CIED.

Background: Chronic kidney disease (CKD) is one of the leading causes of death worldwide, closely interrelated with cardiovascular diseases, ultimately leading to the failure of both organs − the so-called “cardiorenal syndrome‿. Despite this burden, data related to cardiogenic shock outcomes in CKD patients are scarce.Methods: FRENSHOCK (NCT02703038) was a prospective registry involving 772 patients with cardiogenic shock from 49 centres. One-year outcomes (rehospitalization, death, heart transplantation, ventricular assist device) were analysed according to history of CKD at admission and were adjusted on independent predictive factors.Results: CKD was present in 164 of 771 patients (21.3%) with cardiogenic shock; these patients were older (72.7 vs 63.9 years) and had more comorbidities than those without CKD. CKD was associated with a higher rate of all-cause mortality at 1 month (36.6% vs 23.2%; hazard ratio 1.39, 95% confidence interval 1.01–1.9; P = 0.04) and 1 year (62.8% vs 40.5%, hazard ratio 1.39, 95% confidence interval 1.09–1.77; P < 0.01). Patients with CKD were less likely to be treated with norepinephrine/epinephrine or undergo invasive ventilation or receive mechanical circulatory support, but were more likely to receive renal replacement therapy (RRT). RRT was associated with a higher risk of all-cause death at 1 month and 1 year regardless of baseline CKD status.Conclusions: Cardiogenic shock and CKD are frequent “cross-talking‿ conditions with limited therapeutic options, resulting in higher rates of death at 1 month and 1 year. RRT is a strong predictor of death, regardless of pre-existing CKD. Multidisciplinary teams involving cardiac and kidney physicians are required to provide integrated care for patients with failure of both organs.