Background This report describes a rare instance of a single coronary artery (SCA) discovered during primary percutaneous coronary intervention (pPCI) for inferior ST-elevation myocardial infarction (STEMI). Case summary A 76-year-old woman with no prior cardiac history presented with inferior STEMI. Acute coronary angiography revealed a SCA originating from the right sinus of Valsalva, bifurcating into the left main coronary artery and a dominant right coronary artery (RCA). The mid-segment RCA occlusion was successfully treated with a drug-eluting stent. Recovery was uneventful, with improvement in left ventricular function and no cardiac events over one-year follow-up. Discussion This case underscores the importance of recognizing coronary artery anomalies in the acute STEMI setting and demonstrates that careful management can yield positive outcomes despite rare anatomical variations.

Recent guidelines recommend centralization of post-resuscitation care in out-of-hospital cardiac arrest (OHCA)-patients. Centralization has been gradually implemented in Denmark since 2009; however, no evaluation of centralization has yet been made. This study assesses the 30-day mortality before and after centralization, and the impact of centralization on survival in Denmark. This nationwide study included consecutive adult OHCA patients with presumed cardiac cause admitted to a hospital. Centralization was introduced in 2009, 2011, and 2012 in four out of five regions. Temporal trends of 30-day mortality were evaluated in patients who were directly transported to CACs and in patients who were transported to non-CACs. A difference-in-difference model with repeated cross-sections was used to estimate the effect of centralization on the 30-day mortality between 2007 and 2020. The model was adjusted for additive effects of known covariates. A total of 14,276 patients were included. The majority of patients were aged between 50 to 75 years (57

INTRODUCTION:Cardiogenic shock (CS) is a main cause of mortality in ST-elevation myocardial infarction (STEMI). The ORBI risk score estimates in-hospital CS risk using pre- and post-procedural angiographic variables. The study aimed to prospectively validate the ORBI risk score for predicting in-hospital CS and to assess its ability to identify post-procedural CS, when all score components are available. METHODS:Consecutive adult STEMI patients without CS at admission were prospectively registered at a tertiary hospital during 2022-2025. Discrimination and calibration were evaluated in all patients and among patients with post-procedural CS after leaving the catheterization laboratory. RESULTS:Among 2,713 adult patients (median age 64 years; 24% female), the median ORBI score was 4 (IQR 2-7), and 103 patients (3.8%) developed in-hospital CS. Among all patients, 80% were low risk (ORBI ≤7) with 1.0% developing in-hospital CS; 13% were low-to-intermediate risk (ORBI 8-10) with 5.6% developing CS; 3.1% were intermediate-to-high risk (ORBI 11-12) with 23% developing CS; and 3.9% were high risk (ORBI ≥13), of whom 40% developed in-hospital CS. The score demonstrated strong discrimination (area under the receiver operating characteristic curve [AUC] 0.89; 95% CI: 0.87-0.94) for in-hospital CS and for post-procedural CS (AUC 0.87; 95% CI: 0.83-0.95). In patients with in-hospital CS, 68% developed peri-procedural CS. Among patients with post-procedural, CS the score substantially overestimated CS risk. CONCLUSIONS:The ORBI risk score performed well at predicting in-hospital CS but markedly overestimated post-procedural CS risk. As post-procedural CS is the clinically relevant endpoint for a model incorporating post-procedural variables, the ORBI score requires recalibration before it can be used to guide post-PCI decisions.

BACKGROUND:Infarct-related cardiogenic shock (CS) is a serious complication. The implementation of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification system facilitates the timely identification and intervention in CS. CASE SUMMARY:A patient presenting with anterior ST-segment elevation myocardial infarction arrived at the catheterization laboratory in SCAI stage B, with rapid progression to stage E. Acute bedside echocardiography revealed an ejection fraction of 10%. The patient was stabilized with norepinephrine and a microaxial flow pump. The device malfunctioned, resulting in replacement. DISCUSSION:SCAI stages need frequent reassessment to guide appropriate interventions. The microaxial flow pump was selected owing to its less invasive nature and its ability to provide left ventricular support. The decision to implant a mechanical circulatory support device is complex and must be made swiftly in response to the patient's clinical condition.

BACKGROUND:Previous studies show higher mortality for female patients with out-of-hospital cardiac arrest (OHCA) compared to males. The BOX (Blood Pressure and Oxygenation Targets in Post Resuscitation Care) trial investigated the effects of different mean arterial pressure (MAP) targets, oxygenation levels, and durations of fever control, finding no significant differences between groups. OBJECTIVES:The purpose of this study was to explore the association between sex and mortality rates by examining both the individual and possible interactive effects of the interventions in the BOX trial for both sexes. METHODS:This two-center, randomized trial included adult comatose OHCA patients (age ≥18 years) of presumed cardiac cause. Participants were assigned to a blinded MAP target of 63 or 77 mm Hg, open-label arterial oxygen levels of 9-10 or 13-14 kPa, and fever prevention for 36 or 72 hours. The primary outcome was 1-year all-cause mortality. RESULTS:Of 789 comatose OHCA patients, 152 (19%) were females. The median ages of females and males were similar, 64 (51-71) years and 64 (55-73) years, respectively. Comorbidities and characteristics of the cardiac arrest were comparable between sexes except for ischemic heart disease (females: 12%, males 24%). Mortality in females was 42% and 35% in males; HR: 1.27 (95% CI: 0.96-1.69). None of the targeted interventions had a statistically significant impact on mortality for either sex. No mortality difference between sexes was observed across the interventions. CONCLUSIONS:Among comatose patients following OHCA, no differences were observed between sexes in 1-year mortality or the efficacy of the blood pressure, oxygen, or temperature intervention.

BACKGROUND:The Thrombolysis in Myocardial Infarction (TIMI) risk score estimates mortality for patients with ST-elevation myocardial infarction (STEMI). This study aimed to investigate whether biomarkers reflecting the neurohormonal response (pro-atrial natriuretic peptide (proANP), mid-regional pro-adrenomedullin (MR-proADM), and copeptin), inflammation (suppression of tumorigenicity 2 (ST2), C-reactive protein (CRP), and leukocytes), and troponin add prognostic value to the TIMI risk score. METHODS:This sub-study of the prospective PREDICT cohort included 1700 non-comatose and non-cardiogenic shock STEMI patients upon admission. Blood samples were collected before coronary angiography. Biomarker quartiles (Q4vsQ1-3) association with 30-day mortality were examined using Cox proportional hazard models. RESULTS:High levels of all biomarkers were associated with 30-day mortality independently of TIMI risk score, hazard ratio (HR)Q4vsQ1-3 (95%CI), MR-proADM: 8.8 (3.9-20), proANP: 3.5 (1.8-6.7), copeptin: 1.9 (1.1-3.5), ST2: 4.5 (2.3-8.6), CRP: 2.6 (1.3-4.9), and leukocyte: 2.18 (1.2;4.0). TIMI risk score had a high prognostic value, AUC(95%CI): 0.76 (0.69-0.83). Only MR-proADM, proANP, CRP, ST2, and TnT added prognostic value to the risk score, 0.84 (0.77-0.91), 0.80 (0.74-0.87), 0.78 (0.71-0.86), 0.81 (0.73-0.88), and 0.79 (0.71-0.87), respectively. However, MR-proADM demonstrated a higher prognostic value on its own (0.86 (0.80-0.91)). CONCLUSION:TIMI risk score and all the biomarkers added prognostic values of 30-day mortality. The strongest predictor of 30-day mortality was observed for MR-proADM alone.

Aims Women continue to have a worse prognosis following ST-elevation myocardial infarction (STEMI) compared to men, despite advancements in treatment. This study investigates whether neurohormonal biomarker differences contribute to sex-related disparities in mortality. Methods and results A total of 1892 consecutive STEMI patients from two tertiary heart centres were included. Admission neurohormonal activation defined as pro-atrial natriuretic peptide (proANP) and mid-regional pro-adrenomedullin (MR-proADM) was measured in blood drawn prior to acute coronary angiography (CAG). The primary endpoint was 1-year mortality stratified according to sex and biomarker level. Of 1782 (94%) with biomarkers available, 476 (27%) of patients were women. They were older (68 vs. 62 years), had longer symptom-to-angiography delay (211 vs. 181 min), and displayed a higher one-year mortality rate (12% vs. 7.4%, P < 0.001) compared to men. The neurohormonal response was higher in women compared to men [median (interquartile range) proANP 1050 (671-1591) vs. 772 (492-1294) pmol/L, P < 0.001); MR-proADM 0.80 (0.63-1.03) vs. 0.70 (0.58-0.89) nmol/L, P < 0.001]. In women, a level at or above the median was independently associated with a significantly higher mortality risk when adjusting for age, left ventricular ejection fraction, diabetes, heart failure, symptom onset to CAG, left-sided culprit lesion, obesity, renal dysfunction, primary percutaneous intervention, admission systolic blood pressure, and multivessel disease (HR proANP 6.05, 95% CI 1.81-20.3, P = 0.004; HR MR-proADM 3.49, 95% CI 1.42-8.62, P = 0.007). In men, there was an independent prognostic association for proANP but not for MR-proADM (HR proANP 2.38, 95% CI 1.18-4.81, P = 0.015; HR MR-proADM 1.74, 95% CI 0.89-3.40, P = 0.11). Conclusion Increased neurohormonal activation (MR-proADM and proANP) is associated with higher mortality in women compared to men. Neurohormonal activation may contribute to the observed sex-related differences in mortality.

Abstract Background Cardiogenic shock (CS) occurs in 5–10% of patients with acute myocardial infarction (AMI), and the condition is associated with a 30-day mortality rate of up to 50%. Most of the AMI patients are in SCAI SHOCK stage B upon hospital arrival, but some of these patients will progression through the stages to overt shock (SCAI C-E). Around one third of patients who develop CS are not in shock at the time of hospital admission. Pro-B-type natriuretic peptide (proband) is a biomarker closely related to CS development. The aim of this study is to investigate the potential for preventing progression of hemodynamic instability by early inotropic support with low-dose dobutamine infusion administrated after revascularization in AMI patients with intermediate to high risk of in-hospital CS development. Methods This investigator-initiated, double-blinded, placebo-controlled, randomized, single-center, clinical trial will include 100 AMI patients (≥ 18 years) without CS at hospital admission and at intermediate-high risk of in-hospital CS development (ORBI risk score ≥ 10). Patients will be randomized in a 1:1 ratio to a 24 h intravenous (IV) infusion of dobutamine (5 μg/kg/min) or placebo (NaCl) administrated after acute percutaneous coronary intervention (PCI) (< 24 h from symptom onset). Blood samples are drawn at time points from study inclusion (before infusion, 12, 24, 36, and 48 h). The primary outcome is peak plasma proBNP within 48 h after infusion as a surrogate-measure for the hemodynamic status. Hemodynamic function will be assessed pulse rate, blood pressure, and lactate within 48 h after infusion and by transthoracic echocardiography (TTE) performed after 24–48 h and at follow-up after 3 months. Markers of cardiac injury (troponin T and creatine kinase MB (CK-MB)) will be assessed. Discussion Early inotropic support with low-dose dobutamine infusion in patients with AMI, treated with acute PCI, and at intermediate-high risk of in-hospital CS may serve as an intervention promoting hemodynamic stability and facilitating patient recovery. The effect will be assessed using proBNP as a surrogate marker of CS development, hemodynamic measurements, and TTE within the initial 48 h and repeated at a 3-month follow-up. Trial registration The Regional Ethics Committee : H-21045751. EudraCT: 2021–002028-19. ClinicalTrials.gov: NCT05350592, Registration date: 2022-03-08. WHO Universal Trial Number: U1111-1277–8523.

AIM:Extracorporeal cardiopulmonary resuscitation (ECPR) can be considered in selected patients with refractory cardiac arrest. Given the risk of patient futility and high resource utilisation, identifying ECPR candidates, who would benefit from this therapy, is crucial. Previous ECPR studies investigating lactate as a potential prognostic marker have been small and inconclusive. In this study, it was hypothesised that the lactate level (immediately prior to initiation of ECPR) and lactate clearance (within 24 hours after ECPR initiation) are predictors of one-year survival in a large, multicentre study cohort of ECPR patients. METHODS:Adult patients with refractory cardiac arrest at three German and four Danish tertiary cardiac care centres between 2011 and 2021 were included. Pre-ECPR lactate and 24-hour lactate clearance were divided into three equally sized tertiles. Multivariable logistic regression analyses and Kaplan-Meier analyses were used to analyse survival outcomes. RESULTS:297 adult patients with refractory cardiac arrest were included in this study, of which 65 (22%) survived within one year. The pre-ECPR lactate level and 24-hour lactate clearance were level-dependently associated with one-year survival: OR 5.40 [95% CI 2.30-13.60] for lowest versus highest pre-ECPR lactate level and OR 0.25 [95% CI 0.09-0.68] for lowest versus highest 24-hour lactate clearance. Results were confirmed in Kaplan-Meier analyses (each p log rank < 0.001) and subgroup analyses. CONCLUSION:Pre-ECPR lactate levels and 24 hour-lactate clearance after ECPR initiation in patients with refractory cardiac arrest were level-dependently associated with one-year survival. Lactate is an easily accessible and quickly available point-of-care measurement which might be considered as an early prognostic marker when considering initiation or continuation of ECPR treatment.

Heart failure with reduced ejection fraction is a syndrome consisting of symptoms (dyspnoea, fatigue, swelling) and/or signs of congestion (pulmonary crackles, oedema). It is caused by structural and/or functional pathologies, most commonly ischaemic heart disease, entailing elevated cardiac filling pressures and can result in low cardiac output. Medical treatment has evolved during the recent decades as outlined in this review, and a 4-pillar treatment strategy is recommended including a renin-angiotensin-aldosterone system blocker or sacubitril/valsartan, a betablocker, a mineralocorticoid antagonist, and an SGLT2 inhibitor.

Background Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used for refractory out‐of‐hospital cardiac arrest (OHCA). However, survivors managed with ECPR are at risk of poor functional status. The purpose of this study was to investigate return to work (RTW) after refractory OHCA. Methods and Results Of 44 360 patients with OHCA in the period of 2011 to 2020, this nationwide registry‐based study included 805 patients with refractory OHCA in the working age (18–65 years) who were employed before OHCA (2% of the total OHCA cohort). Demographics, prehospital characteristics, status at hospital arrival, employment status, and survival were retrieved through the Danish national registries. Sustainable RTW was defined as RTW for ≥6 months without any long sick leave relapses. Median follow‐up time was 4.1 years. ECPR and standard advanced cardiovascular life support were applied in 136 and 669 patients, respectively. RTW 1 year after OHCA was similar (39% versus 54%; P =0.2) and sustainable RTW was high in both survivors managed with ECPR and survivors managed with standard advanced cardiovascular life support (83% versus 85%; P >0.9). Younger age and shorter length of hospitalization were associated with RTW in multivariable Cox analysis, whereas ECPR was not. Conclusions In refractory OHCA‐patients employed prior to OHCA, approximately 1 out of 2 patients were employed after 1 year with no difference between patients treated with ECPR or standard advanced cardiovascular life support. Younger age and shorter length of hospitalization were associated with RTW while ECPR was not.

BACKGROUND:Extracorporeal cardiopulmonary resuscitation (ECPR) for selected refractory out-of-hospital cardiac arrest (OHCA) is increasingly used. Detailed knowledge of health-related quality of life (HRQoL) and long-term cognitive function is limited. HRQoL and cognitive function were assessed in ECPR-survivors and OHCA-survivors with prehospital return of spontaneous circulation after standard advanced cardiac life support (sACLS). METHODS:Fifteen ECPR-survivors and 22 age-matched sACLS-survivors agreed to participate in this follow-up study. Participants were examined with echocardiography, 6-minute walk test, and neuropsychological testing, and answered HRQoL (EQ-5D-5L and Short Form 36 (SF-36)), and mental health questionnaires. RESULTS:Most patients were male (73 % and 82 %) and median age at follow-up was similar between groups (55 years and 60 years). Low flow time was significantly longer for ECPR-survivors (86 min vs. 15 min) and lactate levels were significantly higher (14.1 mmol/l vs. 3.9 mmol/l). No between-group difference was found in physical function nor in cognitive function with scores corresponding to the 23rd worst percentile of the general population. SACLS-survivors had HRQoL on level with the Danish general population while ECPR-survivors scored lower in both EQ-5D-5L (index score 0.73 vs. 0.86, p = 0.03, visual analog scale: 70 vs. 84, p = 0.04) and in multiple SF-36 health domains (role physical, bodily pain, general health, and mental health). CONCLUSIONS:Despite substantially longer low flow times with thrice as high lactate levels, ECPR-survivors were similar in cognitive and physical function compared to sACLS-survivors. Nonetheless, ECPR-survivors reported lower HRQoL overall and related to mental health, pain management, and the perception of limitations in physical role.

Abstract Background Inflammation and neurohormonal activation play a significant role in the adverse outcome seen in acute myocardial infarction (AMI) and the development of cardiogenic shock (CS), which is associated with a mortality rate up to 50%. Treatment with anti-inflammatory drugs such as tocilizumab, an interleukin-6 receptor antagonist, has been shown to reduce troponin release and reduce the myocardial infarct size in AMI patients and it may therefore have cardioprotective properties. Methods This is a double-blind, placebo-controlled, single-center randomized clinical trial, including adult AMI patients without CS at hospital arrival, undergoing percutaneous coronary intervention (PCI) within 24 h from symptom onset, and at intermediate to high risk of developing CS (ORBI risk score ≥ 10). A total of 100 participants will be randomized to receive a single intravenous dose of tocilizumab (280 mg) or placebo (normal saline). The primary outcome is peak plasma pro-B-type natriuretic peptide (proBNP) within 48 h, assessed using serial measurements at intervals: before infusion, 12, 24, 36, and 48 h after infusion. Secondary endpoints include the following: (1) cardiac magnetic resonance imaging (CMR) during 24–48 h after admission and at follow-up after 3 months with assessment of left ventricular area at risk, final infarct size, and the derived salvage index and (2) biochemical markers of inflammation (C-reactive protein and leukocyte counts) and cardiac injury (troponin T and creatinine kinase MB). Discussion Modulation of interleukin-6-mediated inflammation in patients with AMI, treated with acute PCI, and at intermediate to high risk of in-hospital CS may lead to increased hemodynamic stability and reduced left ventricular infarct size, which will be assessed using blood biomarkers with proBNP as the primary outcome and inflammatory markers, troponin T, and CMR with myocardial salvage index as the secondary endpoints. Trial registration Registered with the Regional Ethics Committee (H-21045751), EudraCT (2021–002028-19), ClinicalTrials.gov (NCT05350592). Study registration date: 2022-03-08, Universal Trial Number U1111-1277–8523.