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Funding Acknowledgements Type of funding sources: None. Background A rapid and efficient disposition of patients with chest pain and a suspected acute coronary syndrome (ACS) diagnosis represents a clinical challenge in the emergency department (ED). The latest European clinical guidelines recommend the use of diagnostic algorithms at 0/1 and 0/2 hours, but their performance in different patient populations needs to be further investigated. Purpose To evaluate the performance of the 0/1-h and 0/2-h high-sensitivity cardiac troponin T (hs-cTnT) algorithms in a cohort of patients admitted to an ED in an academic center in Spain. Methods We performed a single-center, prospective study in patients admitted with suspected non-ST elevation ACS (NSTEACS). Hs-cTnT (Roche Diagnostics) was measured at admission (t0) and one (t1) and two hours (t2) later; hs-cTnT differences between times were named Delta 0/1h (D-0/1) or Delta 0/2h (D-0/2). Patients were sub-grouped according to the following: "Rule out" when the time of pain-debut was >3 hours and t0 hs-cTnT Results 286 patients were enrolled in the study. Median age was 70 (higher than in previous validation studies of rapid rule-in and rule-out algorithms; see Table 1 for baseline characteristics). The overall prevalence of NSTEACS was 17% (n = 49/286). A hs-cTnT52 ng/L existed in 39 patients, but only 69% were NSTEACS. The 0/1-h algorithm demonstrated an NPV of 97.3% and a PPV of 72% while the 0/2-h algorithm achieved an NPV of 100% and a PPV of 72.9% for the "Rule-out" and "Rule-in" group, respectively (Figure 1). Both algorithms allocated same percentage of patients (~30%) in the "Observe" group. Overall, the algorithms performed well, but in the 0/1-h algorithm, four patients with final diagnosis of NSTEACS were wrongly allocated to the "Rule-out" group. This did not occur in the 0/2-h algorithm where the same patients were allocated to the "Observe" group. Conclusion In our prospective cohort, the performance of the two recommended rapid rule-in and rule-out algorithms were good, but the 0/2-h algorithm achieved a better NPV and allowed for a more precise disposition of patients with respect to the 0/1-h algorithm.

Funding Acknowledgements Type of funding sources: None. Background Current evidence suggests that incremental levels of PEEP generate an increase in right intracavitary pressures, diminishing venous return and consequently lessening left ventricular preload and stroke volume, resulting in a significant decrease of cardiac output. Nonetheless, most studies regarding these interactions have been done in patients requiring mechanical ventilation for non-cardiac disorders or in animals. We studied the effects of incremental levels of PEEP on cardiac intracavitary pressures and hemodynamics in mechanically ventilated patients admitted into the Cardiac Intensive Care Unit. Purpose We aimed to model how increments in PEEP alter cardiac output and other hemodynamic variables in patients with cardiac disfunction. Methods We included 14 mechanically ventilated patients admitted into a Cardiac Intensive Care Unit from 2018 to 2020. Data on intracavitary pressures and hemodynamics were recorded via Swan-Ganz catheterization and echocardiographic imaging. We documented measurements for all variables of interest at three different levels of PEEP: 5cmH2O, 10cmH2O and 15cmH2O. We conducted general descriptive statistics, mean comparison tests for paired data and linear regression models with Stata version 12.0 (StataCorp LP, College Station, TX). Results 7 (50%) patients admitted in the study had cardiogenic shock, 11 (79%) patients were mechanically ventilated in a volume-controlled setting and 3 (21%) were on pressure support ventilation. Seven (50%) patients needed vasoactive drugs during the study. Only 1 (7%) patient required an intra-aortic balloon pump. Seven (50%) patients had a visual left ventricular ejection fraction lesser than 40% and 3 (21%) had a moderate-severe mitral regurgitation. Paired mean testing by groups associated to gains of PEEP revealed statistically significant increments in Mean Pulmonary Artery Pressure (mPAP), Pulmonary Capillary Wedge Pressure (PCWP) and Central Venous Pressure (CVP). Inversely, increments of PEEP were linked to significant decrements in Cardiac Output (CO) [Figure 1 & Table 1]. Conclusions In mechanically ventilated patients admitted into the Cardiac Intensive Care Unit, rises in PEEP are associated to increments in intracavitary cardiac pressures, and inversely, with decrements in cardiac output. Although our findings are statistically significant, we have yet to clarify whether these are clinically meaningful, specifically within PEEP increments of 5 to 10cmH2O, the usual range in clinical practice.

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This project received a Scholarship for Training and Research from the Association of Ischemic Heart Disease and Cardiological Critical Care of the Spanish Society of Cardiology and an Original Research Projects Grant from the Catalan Society of Cardiology. Background Heart failure (HF) is an important prognostic factor in ST-segment elevation myocardial infarction (STEMI). Although most STEMI patients are Killip-Kimball class I (KK-I) at admission, there is a risk of developing HF during hospitalization and follow-up. Lung ultrasound (LUS) is an easy, fast, and accurate technique that allows pulmonary congestion to be diagnosed even in pre-clinical stages. Several risk scores have been developed to identify low-risk STEMI patients, nonetheless any of these scores include LUS assessment. Purpose We evaluated the prognostic value of subclinical congestion assessed by LUS at hospital admission in patients with KK-I STEMI. Primary endpoint was a composite of readmission for HF or new acute coronary syndrome or death during 30-day follow-up. Methods This was a multicenter study prospectively enrolling 300 patients admitted for KK-I STEMI. LUS was performed during the first 24 hours after revascularization by and independent operator and B-lines were counted off-line differentiating between patients with wet lung (≥ 3 B-lines in at least one lung field) or dry lung. To assess whether LUS could improve the predictive capacity of current risk scales, a model with categorical result of LUS (dry/wet lung) and categorical result of Zwolle score (low/higher risk) was compared to the isolated result of Zwolle score and net reclassification index (NRI) was calculated. Results Wet lung patients had a higher risk of developing the follow-up composite endpoint (hazard ratio [HR] 10.8, 95% CI 2.6-45.2, p=0.001). After adjusting by a propensity score including age, sex, hypertension, chronic kidney disease (glomerular filtration rate CONCLUSIONS Early subclinical pulmonary congestion identified by LUS in KK-I STEMI patients at hospital admission is a strong predictor of adverse outcomes at 30-day follow-up. Patients without subclinical congestion have a very low risk of adverse outcomes and can potentially benefit from an early discharge. LUS improves the predictive ability of the Zwolle risk score, allowing a more accurate identification of low-risk patients.

The harvesting is one of the most expensive stages during Colombian coffee production since the selectivity of ripe fruits (from the trees) is carried manually nowadays. However, the scarcity of workforce has become a new challenge for developing technologies that can be used in situations that traditional mechanized harvesters cannot be implemented. The classification of coffee fruits through the ripeness could help create selective harvesting methods from the different engineering fields (robotic, artificial vision, vibratory systems, etc.). This study describes a methodology to characterize the coffee fruit ripeness (Coffea arabica var. Castillo) using color maps obtained from digital image processing and colorimetry. Ninety-two samples were measured, and for each sample, a digital image was processed to extract the most representative color with an algorithm (RGB space), and parallel to this, the chromaticity was measured with a colorimeter (CIELab space). Both color spaces were related through linear transformations computed from the data. Results show that the ripeness classification is well defined in both color spaces; however, RGB space was divided into four ripening since the ripeness timeline was linearly represented. Through the transformations, the image data were contrasted with those measured with the colorimeter, which demonstrated that it could be converted in a colorimeter under certain specific conditions.

Funding Acknowledgements Type of funding sources: None. Background Post-cardiac arrest myocardial dysfunction contributes to morbidity in survivors of cardiac arrest (CA) and, in case of refractory shock, some patients will benefit from aggressive mechanical support. In this scenario, a non-invasive, reliable and real-time estimation of potential neurological recovery is required to establish personalized treatment escalation plans. Methods We prospectively collected data of bispectral index (BIS) and suppression ratio (SR) monitoring of adult comatose survivors of CA consecutively admitted to an acute cardiac care unit and managed with targeted temperature management (TTM). Neurological status was assessed according to the Cerebral Performance Category (CPC) scale. Results We included 340 patients, 72.1% had an initial shockable rhythm, 72 (21.2%) were females and their mean age was 61.7 ± 14.3 years. Throughout 3-month follow-up, 210 patients (61.8%) achieved a CPC of 1-2 and 130 (38.2%) a CPC of 3-5. Mean BIS values were significantly higher and median SR lower in patients with CPC 1-2 (Figure 1). An average BIS value >26 during first 12 hours of TTM predicted good outcome with 89.3% sensitivity and 75.2% specificity (AUC of 0.86), while average SR values >24 during first 12 hours of TTM predicted poor outcome (CPC 3-5) with 83.6% of sensitivity and 91.8% of specificity (AUC of 0.92). Hourly BIS and SR values exhibited a good predictive performance (AUC > 0.85), starting as soon as hour 2 for SR and 4 for BIS. Conclusions BIS and SR real-time monitoring correlates with patient´s potential of neurological recovery after CA. This finding could help establish personalized treatment escalation plans that reduce consequences of inappropriate interventions, economic costs and uncertainty burden of the patient´s family.

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Societat Catalana de Cardiologia (SCC) Sociedad Española de Cardiología (SEC) Introduction About 80-90% of patients admitted for ST-segment elevation myocardial infarction (STEMI) present with no signs of heart failure at admission. Heart failure at admission is one of the most relevant prognostic factors in STEMI, whereas incidence and prognostic significance of HF developed during hospitalization is unclear. B-lines in lung ultrasound (LUS) provide useful diagnostic and prognostic information in heart failure patients with the potential to stratify the risk of complications in patients presenting with STEMI KKI. Purpose To assess the capacity of the lung ultrasound to predict heart failure developing or death during hospitalization in patients admitted for STEMI KKI Methods This is a prospective observational multicenter study. Consecutive patients admitted for STEMI KKI in four tertiary hospitals were included, exclusion criteria were patients with cardiac arrest at presentation, severe lung disease or hemodialysis. The LUS was carried out by an independent operator blinded to clinical data in the first 24 hours after admission. We counted B-lines using 8-scan site LUS protocol and divided patients in two groups : wet lung group (3 or more B-lines in at least one zone) and dry lung (no positive zone). The primary endpoint was a composite of clinical congestive heart failure, cardiogenic shock, or mortality during the index hospitalization. Results From June 2020 to November 2021, 221 patients STEMI KKI patients were included. Fifty-four patients (25,4%) had a wet lung according to the LUS. Seventeen patients (7,7%) presented the primary outcome (all of them developed congestive heart failure, 1 of them cardiogenic shock and 2 of them died during hospitalization). Fourteen in 54 wet-lung patients (25,9%) presented the primary outcome whereas only 3 in 167 (1,7%) of the dry-lung patients [relative risk of 14,4 (IC 95% 4,3-48,3)]. Patients who develop the primary outcome had no differences in NTproBNP at admission but had higher NTproBNP peak, higher troponin T peak, lower left ventricular ejection fraction and longer length of stay. Conclusions In patients admitted with STEMI KKI, presenting 3 or more B-lines at least at one lung zone in the LUS at first 24 hours after admission was strongly associated with worse prognosis during hospitalization. LUS allows a better risk classification of patients and may potentially discriminate those with potential risk of complications during hospitalization from those with an excellent prognosis who can benefit from early discharge.

Funding Acknowledgements Type of funding sources: None. Background Takotsubo syndrome (TKS) is characterized by the appearance of apical reversible dyskinesia in its typical form. Electrocardiogram (ECG) in the acute phase ( Purpose To compare ECG in the acute phase of typical TKS versus mid-ventricular TKS, as it was the more frequent form of atypical TKS in our registry. Methods Patients included in the prospective TKS registry of our center according to the Mayo Clinic diagnostic criteria, with the first ECG performed less than 12 hours from the symptoms onset were reviewed. All cardiac left ventriculographies were reviewed to ensure a correct classification of the different types of TKS. Results A total of 297 patients were included in our local registry. 80 patients met our study inclusion criteria. 56 ECGs of typical apical TKS were compared to 24 ECGs of atypical midventricular TKS. There were no differences between the baseline characteristics in both groups, except for mid-ventricular TKS, that was more frequently triggered by physical stressor. Regarding the ECG analysis, the main difference found in our serie was related to ST-segment deviation (Table 1). While ST-segment elevation was more common in typical TKS than in atypical TKS (73% vs 50%), ST-segment depression (generally in inferior leads) was observed in 54% of patients with atypical TKS and in no patient with typical TKS (figure 1). Conclusion The different location of dyskinesia between typical TKS and mid-ventricular TKS is associated to significant differences in the ECG obtained in the first hours after the onset of the clinical symptoms. The presence of ST-segment depression is highly suggestive of mid-ventricular TKS. ECG characteristicsTypical (n = 56)Midventricular (n = 24)pSTe > 1mm, no (%)41 (73)12 (50)0,044STd >0,5 mm, no (%)013 (54)< 0,001T wave inversion, no (%)12 (21)4 (17)0,626Q wave, no (%)22 ( 39)12 (50)0,374cQT, mean (SD)445 (54)438 (37)0,578QRS low voltages*, n (%)9 ( 16)1 (4)0,328STe ST-segment elevation, STd: ST-segment depression, cQT: corrected QT interval *Voltages

Background Cardiopulmonary resuscitation (CPR) Guidelines are updated every five years in the light of new evidence. Recent major changes emphasized the importance of quality chest compressions during CPR and simplified recommendations for lay providers, but it is unknown whether these changes improved neurological outcomes. Purpose To analyse whether changes in CPR guidelines had an impact on the prognosis of comatose survivors after cardiac arrest (CA). Methods Prospective database of consecutive patients (pts) admitted to the acute cardiac care unit of a tertiary hospital after in-hospital and out-of-hospital CA (IHCA and OHCA) treated with targeted temperature management (32–34°) from August 2006 to January 2020. Patients were divided into three groups, each one representing the 5-year time frame of publication/implementation of CPR Guidelines: G1 (2006–2010); G2 (2011–2015); G3 (2016–2020). Results A total of 510 pts were included: G1 94 (18.4%), G2 243 (47.6%), G3 173 (33.9%). Mean age was 62.6±14.5 and 413 (81.0%) were men. Demographic characteristics and cardiovascular risk factors did not differ significantly among groups. Changes in CA features among the three analysed periods are shown in Table 1. On regards of prehospital care, CPR provided by lay bystanders (G1 51.6%; G2 63.3%, G3 69.8%) and the use of automated external defibrillators (AED) (G1 11.0%; G2 14.9%; G3 18.9%) progressively increased (p=0.01 and p=0.04, respectively) (Figure 1, A and B). After 2010, there was a higher proportion of CPR-related injuries: G1 12.7%, G2 23.5%, G3 22.7% (p=0.02). Global survival at discharge was 51.6% (263/510). Cerebral Performance Category (CPC) of 1–2 within a 3-month follow-up period significantly increased over time when comparing G1, G2, G3 groups (p=0.04) (Figure 1, D). Among all pts, those with CPR related injuries had a higher proportion of CPC 1–2 (71/109, 65.1% vs 168/389, 43.2%, p Conclusions We found a progressive increase of lay bystander CPR and use of AED over the three time periods. Moreover, a higher proportion of CPR-related injuries was observed after publication of 2010 CPR Guidelines which recommended greater depth and higher rate of chest compressions. Survival and neurological outcomes improved significantly over time. Figure 1 Funding Acknowledgement Type of funding source: None

Background Cardiopulmonary resuscitation (CPR) manoeuvres involve vigorous compressions with the proper depth and rate in order to keep sufficient perfusion to organs, especially the brain. Accordingly, high incidences of CPR-related injuries (CPR-RI) have been observed in survivors after cardiac arrest (CA). Purpose To analyse whether CPR-related injuries have an impact on the survival and neurological outcomes of comatose survivors after CA. Methods Observational prospective database of consecutive patients (pts) admitted to the acute cardiac care unit of a tertiary university hospital after in-hospital and out-of-hospital CA (IHCA and OHCA) treated with targeted temperature management (TTM 32–34°) from August 2006 to December 2019. CPR-RI were diagnosed by reviewing medical records and analysing image studies during hospitalization. Results A total of 498 pts were included; mean age was 62.7±14.5 years and 393 (78.9%) were men. We found a total of 145 CPR-RI in 109 (21.9%) pts: 79 rib fractures, 20 sternal fractures, 5 hepatic, 5 gastrointestinal, 3 spleen, 1 kidney, 26 lung and 6 heart injuries. Demographic characteristics and cardiovascular risk factors did not differ between the non-CPR-RI group and CPR-RI group. Also, we did not find differences in CA features (Table 1). Survival at discharge was higher in the CPR-RI group [74 (67.8%) vs 188 (48.3%); p Conclusions In our cohort, the presence of CPR-RI was associated with higher survival at discharge and better neurological outcomes during follow-up. Figure 1 Funding Acknowledgement Type of funding source: None

A 70-year-old woman was admitted to the emergency department because of cardiogenic syncope and acute heart failure. She had a mechanical mitral prosthesis (MMP) (ATS Open Pivot 25 mm) implanted in August 2018, due to degenerative rupture of posterior leaflet. One month before admission anticoagulation was temporally interrupted due to humerus surgery. At admission, a transthoracic echocardiogram demonstrated a significant increase in MMP gradient with preserved ejection fraction and a pulmonary artery pressure of 50mmHg. To improve the assessment of MMP a transesophageal echocardiogram (TEE) was performed showing a restricted mobility of the mitral anterior prosthetic lens and a complete block of the mitral posterior lens leading to a severe mitral stenosis (mean pressure gradient 21 mmHg, peak pressure gradient 34 mmHg and peak velocity 2.9 meters/second) with a CW pattern that simulate an aortic morphology (Image 1A). MMP three-dimensional (3D) images were processed using a dedicated transillumination technology that uses a freely movable virtual light to enhance image details and depth (Image 1B and 1C). This rendering tool allows us to characterize tissue consistency and boundary delimitation, confirming the presence of a large thrombus that surrounded the entire posterior region of the prosthetic ring leading to a MMP 3D effective area of 0.49 cm2. After discussing the case with the valvular Heart Team an urgent surgery was performed to replace MMP. This case shows how the transillumination rendering tools enhance specific image features in prosthetic cardiac valves in critical clinical scenarios as symptomatic MMP thrombosis. Abstract P1463 Figure. Image 1

Background Data regarding incidence of ventricular (VA) and atrial arrhythmias (AA) in survivors after out-of-hospital cardiac arrest (OHCA) are scarce. Purpose To assess incidence of VA and AA in OHCA patients during long-term follow-up and to identify relevant predictive factors during the index hospital admission. Methods All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA from August 2007 to January 2019 and surviving until hospital discharge were included. Cox proportional hazard models and logistic regression analysis were used to investigate clinical variables related to the incidence of VA and AA. Results The final analysis included 201 patients. Mean age was 57.6±14.2 years and 168 (83.6%) were male. The majority of patients experienced witnessed arrests related to shockable rhythms (176, 87.6%). Thirty-six patients (17.9%) died after a median follow-up of 40.3 months (18.9–69.1), but only 4 presented another cardiac arrest. Eighteen patients (9.0%) suffered new VA and 37 (18.4%) developed atrial fibrillation/atrial flutter. History of coronary heart disease [HR 3.59 (1.37–9.42), p=0.010] and non-acute coronary syndrome-related arrhythmia [HR 5.17 (1.18–22.60), p=0.029] were independent predictors of VA during follow-up. The optimal predictive model for atrial arrhythmias included age at the time of OHCA, LVEF at hospital discharge and non-acute coronary syndrome-related arrhythmias (p Table 1 Variable Without VA With VA p value Age, mean ± DS, years 57.4±14.2 60.8±14.7 0.336 Male sex, n (%) 150 (83.3) 15 (83.3) 1.000 Coronary heart disease, n (%) 36 (20.0) 11 (61.1) Figure 1 Conclusions Despite low incidence of recurrent cardiac arrest, OHCA survivors face a high incidence of VA and AA. Several clinical characteristics during index hospital admission may be useful to identify patients at high risk.

Background Data regarding long-term clinical outcomes after out-of-hospital cardiac arrest (OHCA) are scarce. Purpose To assess long-term mortality rate in OHCA patients, compare it with the general population age-specific mortality rate and identify relevant predictive factors. Methods All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA from August 2007 to January 2019 and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Stepwise regression techniques and Cox proportional hazards models were used to investigate clinical variables related to long-term survival. The study population was divided into four quartiles according to their age and their mortality rate was compared with age-specific data from the Spanish National Statistics Institute. Results The final analysis included 201 patients. Mean age was 57.6±14.2 years and 168 (83.6%) were male. The majority of patients experienced witnessed arrests related to shockable rhythms (176, 87.6%). Median time to ROSC was 18 (IQR 12–27) minutes and 14 patients (7.0%) were discharged in a poor neurological condition (CPC 3–4). Thirty-six patients (17.9%) died after a median follow-up of 40.3 months (18.9–69.1). A prognostic multivariate Cox model was developed and is shown in Table 1. Mortality was mainly driven by neurologic (33.%), cardiovascular (30.6%) and oncologic (30.6%) causes. Annual mortality rate per 1000 patients was statistically superior to that in the general population among the first three age quartiles: 18.08 (6.78–48.16) vs 0.64; 29.62 (12.33–71.16) vs 3.30; 63.07 (33.94–117.22) vs 7.77. Nevertheless, no significant differences were observed among the oldest patients, ranging from 68.6 to 90.7 years: 70.93 (43.45–115.78) vs 54.95. Table 1. Cox proportional hazard model Variable Hazard Ratio Std. Err. p value 95% Confidence Interval Time from CA to CPR (per minute) 1.06 0.03 0.06 1.00–1.13 Non-shockable rhythm 2.93 1.11 0.01 1.39–6.16 Poor LVEF at discharge (per %) 1.03 0.01 0.01 1.01–1.06 Age at time of CA (per year) 1.04 0.01 0.01 1.01–1.06 CPC 3–4 at hospital discharge 3.50 1.43 Figure 1 Conclusions OHCA survivors face significant mortality during follow-up, and its long term prognostic impact may be higher among younger patients. Age at the time of CA, time from CA to CPR, non-shockable rhythm, poor LVEF and poor neurological condition at discharge are independent predictors of long term mortality.

Background Poor adherence is a barrier to optimal secondary cardiovascular prevention. The need for a polymedication, the cost of some drug therapies and the silent evolution of some cardiovascular conditions are often related to poor adherence. A fixed-dose polypill strategy (AAS, ACEi and statin) has emerged as a possibility to improve adherence in cardiovascular prevention and therefore improve outcomes. Nevertheless, the complexity of cardiovascular disease patients' drug therapy regimes and the need for titration of doses in order to reach the goals, makes it difficult to introduce a fix-dose polypill. Methods We performed a prospective study of consecutive patients attending a secondary prevention consultancy. In order to find out whether they were amenable to a polypill regime, we analyzed their drug therapy scheme and the level of control of blood pressure and LDL cholesterol. Results We included 302 patients, and their treatment is shown in table 1. Of the total of patients, we found that only 25 patients (8.3%) were optimal candidates for receiving a fixed-dose polypill. The reasons for not being eligible are summarized in figure 1, highlighting the need for higher statin dose or statin intolerance as the most frequent cause (79.5%), or the need for titration or combination of drugs according to the blood pressure levels. Patients' characteristics and therapy Patients (n=392) Sex (male) 252 (83.4%) Age (mean ± SD) 60.82 (±11,33) Event (STEMI, NSTEMI, angina) 155 (51.3%), 123 (40,7%), 24 (7.9%) ACEi/ARBs 279 (72.5%) ASA 279 (92.4%) Statins (Atorvastatin 80mg, atorvastatin 40mg, rosuvastatin, other statin) 221 (73.2%), 37 (12.3%), 25 (8.3%), 17 (5.6%) Anti-arterial hypertensive combination pill 51 (16.9%) Number of drugs (mean±SD) 6.61 (±2.47) Optimal blood pressure control ( Causes of non-eligibility for polypill Conclusion Despite the fact that polypill could bring the opportunity to improve cardiovascular drug therapy adherence, the complexity of secondary prevention patients and the common need for a high dose statin makes it difficult to implement a polypill scheme in the real practice.