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Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Fundación Alfonso Martín Escudero The response of the right ventricle (RV) to the hemodynamic effects of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is unpredictable. We hypothesized if presence of uni- or bi-ventricular failure before implantation and cannulation strategy may influence. We assessed RV performance during VA-ECMO support and identify RV-related predictors of weaning. Methods. Changes of RV size and function during VA-ECMO by echocardiography were retrospectively analyzed in 87 patients. Predictors of weaning were evaluated by logistic regression. Results. RV echocardiographic parameters did not vary significantly during VA-ECMO, neither after stratification by cannulation type or presence of isolated or biventriular failure. Succesful weaning was conditioned by absence of RV dysfunction before implantation (OR 14.7,95%CI 13.3-140.3;p = 0.025) or in the last day of support (OR 9.5; 95%CI 1.6-54;p = 0.011) and was favored by a total or partial recovery of RV function during the assistance (OR 6.2; 95%CI 1.7-22.4;p = 0.005). RV improvement was more often observed in patients with acute RV failure, while VA-ECMO configuration had no effect. Conclusions. Preservation or improvement of RV function during VA-ECMO support is essential for weaning. RV echocardiographic performance does not change significantly during VA-ECMO and is not influenced by cannulation type or presence of uni- or bi-ventricular failure before implantation. Echo parameters evolution during VA-ECMOPre-ECMO< 24h on ECMO> 24h on ECMOpNn = 68n = 68n = 63LV diastolic diameter, mm (mean ± SD)53.34 ± 15.5954.86 ± 13.8956.18 ± 14.620.317LV systolic diameter, mm45.28 ± 11.6745.17 ± 14.5846.07 ± 15.590.963LVEF, n (%)20 (10-38.75)17.5 (10-30)25 (10-40)0.102RV basal diameter, mm (mean ± SD)41.05 ± 9.7938.92± 9.1740.05 ± 9.560.484RV systolic disfunction, n (%)65 (95.6)65 (95.5)43 (68.2)0.073Tricuspid regurgitation, n (%)50 (73.4)37 (54.3)49 (77.8)0.146Pulmonary systolic pressure, mmHg (mean ± SD)41.54 ± 24.1339.09 ± 20.2445.29 ± 25.730.783Aortic regurgitation, n (%)47 (69.1)39 (57.4)35 (55.5)0.775Mitral regurgitation, n (%)64 (94.1)48 (70.5)44 (69.8)0.591Dd diastolic diameter; EF: ejection fraction; LV: left ventricle; LVOT: left ventricle outflow tract; RV: right ventricle; RVOT: right ventricle outflow tract; VTI: velocity time integralAbstract Figure. Right ventricular function predictors

Mechanical complications of acute myocardial infarction are those caused by ruptures or geometrical distortions of cardiac structures. Cardiac ruptures are currently rare complications, less than 1% in the era of reperfusion therapy, but often with catastrophic consequences, and include free wall rupture, the most frequent, interventricular septal rupture, and papillary muscle rupture. The clinical presentation may vary from unusually milder presentations to sudden presentation with severe hypotension, cardiogenic shock or electro-mechanical dissociation. Therefore, immediate diagnosis is key, generally by echocardiography, followed by resuscitation and/or hemodynamic support, pharmacological or mechanical. In the majority of cases, these complications require urgent surgical repair. In some cases percutaneous therapies may be a valid alternative. Mechanical complications due to geometrical distortion include functional ischemic mitral regurgitation, ventricular aneurysms and intraventricular thrombosis. These complications are more frequent than ruptures and, in general, less severe, ranging from accidental findings by imaging techniques in asymptomatic patients to advanced heart failure. Most often these complications can be treated medically and occasionally may need surgical therapy.

Non-ST-segment elevation acute coronary syndromes are potentially life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted according to the patient's risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.

Context: The underlying relationship between body mass index (BMI), cardiometabolic disorders, and subclinical atherosclerosis is poorly understood. Objective: To evaluate the association between body size phenotypes and subclinical atherosclerosis. Design: Cross-sectional. Setting: Cardiovascular disease-free cohort. Participants: Middle-aged asymptomatic subjects (n = 3909). A total of 6 cardiometabolic body size phenotypes were defined based on the presence of at least 1 cardiometabolic abnormality (blood pressure, fasting blood glucose, triglycerides, low high-density lipoprotein cholesterol, homeostasis model assessment-insulin resistance index, high-sensitivity C-reactive protein) and based on BMI: normal-weight (NW; BMI 30.0). Main Outcome Measures: Subclinical atherosclerosis was evaluated by 2D vascular ultrasonography and noncontrast cardiac computed tomography. Results: For metabolically healthy subjects, the presence of subclinical atherosclerosis increased across BMI categories (49.6%, 58.0%, and 67.7% for NW, OW, and OB, respectively), whereas fewer differences were observed for metabolically unhealthy subjects (61.1%, 69.7%, and 70.5%, respectively). When BMI and cardiometabolic abnormalities were assessed separately, the association of body size phenotypes with the extent of subclinical atherosclerosis was mostly driven by the coexistence of cardiometabolic risk factors: adjusted OR = 1.04 (95% confidence interval [CI), 0.90-1.19) for OW and OR = 1.07 (95% CI, 0.88-1.30) for OB in comparison with NW, whereas there was an increasing association between the extent of subclinical atherosclerosis and the number of cardiometabolic abnormalities: adjusted OR = 1.21 (95% CI, 1.05-1.40),1.60 (95% Cl, 1.33-1.93), 1.92 (95% CI, 1.48-2.50), and 2.27 (95% Cl, 1.67-3.09) for 1, 2, 3, and >3, respectively, in comparison with noncardiometabolic abnormalities. Conclusions: The prevalence of subclinical atherosclerosis varies across body size phenotypes. Pharmacologic and lifestyle interventions might modify their cardiovascular risk by facilitating the transition from one phenotype to another., The PESA study is cofunded equally by the Centro Nacional de Investigaciones Cardiovasculares (CNIC) and Banco Santander. The study also receives funding from the Instituto de Salud Carlos III (ISCIII, PI15/02019) and the European Regional Development Fund (ERDF) A way to make Europe. The CNIC is supported by the ISCIII, the Ministerio de Ciencia e Innovacion, and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

Background: The European Society of Cardiology established a set of quality indicators for the management of acute myocardial infarction. Our aim was to evaluate their degree of attainment, prognostic value and potential use for centre benchmarking in a large international cohort. Methods: Quality indicators were extracted from the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) (555 hospitals, 20 countries in Europe and Latin America, 2010–2011) and EPICOR Asia (218 hospitals, eight countries, 2011–2012) registries, including non-ST-segment elevation acute myocardial infarction (n=6558) and ST-segment elevation acute myocardial infarction (n=11,559) hospital survivors. The association between implementation rates for each quality indicator and two-year adjusted mortality was evaluated using adjusted Cox models. Composite quality indicators were categorized for benchmarking assessment at different levels. Results: The degree of attainment of the 17 evaluated quality indicators ranged from 13% to 100%. Attainment of most individual quality indicators was associated with two-year survival. A higher compliance with composite quality indicators was associated with lower mortality at centre-, country- and region-level. Moreover, the higher the risk for two-year mortality, the lower the compliance with composite quality indicators. Conclusions: When EPICOR and EPICOR Asia were conducted, the European Society of Cardiology quality indicators would have been attained to a limited extent, suggesting wide room for improvement in the management of acute myocardial infarction patients. After adjustment for confounding, most quality indicators were associated with reduced two-year mortality and their prognostic value should receive further attention. The two composite quality indicators can be used as a tool for benchmarking either at centre-, country- or world region-level.

Cardiovascular diseases cause approximately one-third of all deaths in the world, of which 7.5 million deaths are estimated to be due to ischaemic heart disease (IHD). Acute coronary syndromes (ACS) and sudden death cause most IHD-related deaths, which represent 1.8 million deaths per year. The incidence of IHD in general, and of ACS, increases with age although, on average, this occurs 7–10 years earlier in men compared with women. ACS occurs far more often in men than in women below the age of 60 years but women represent the majority of patients over 75 years of age. The risk of acute coronary events in life is related to the exposure to traditional cardiovascular risk factors. This can be estimated using risk scores, such as the European Society of Cardiology SCORE system. Huge differences within European and world regions can be found in the incidence and prevalence of IHD and ACS as well as in case fatality rates. However, information on the incidence of ACS is still limited for Europe. While the incidence of non ST-segment elevation ACS has remained relatively stable, the incidence of ST-segment elevation myocardial infarction has suffered a significant decrease in recent years. Furthermore, the majority of European countries experienced substantial decreases in age-standardized death rates for cardiovascular diseases and IHD in the last decades, particularly for myocardial infarction. This is the consequence of the improvement in cardiovascular prevention and ACS treatment but this trend may be reverting due to population ageing and the increase in some risk factors.

Acute heart failure (AHF) is a potentially life-threatening medical condition requiring emergency hospital evaluation. This chapter highlights aspects of early diagnosis, risk stratification, and treatment. The high-risk patient with AHF is characterized by the presence of severe respiratory failure and haemodynamic instability with or without systemic hypoperfusion, and the presence of potentially life-threatening AHF causes CHAMP (acute Coronary syndrome, Hypertensive emergency, Arrhythmias, acute Mechanical cause, and acute Pulmonary embolism). This high-risk patient is a potential candidate for respiratory and circulatory support, invasive monitoring with an arterial line, and the treatment of CHAMP. After ruling out a high-risk situation, AHF diagnosis must be confirmed with clinical evaluation and additional investigations, including 12-lead electrocardiography, chest X-ray, and laboratory assessment with natriuretic peptide levels. This non-high-risk patient requires non-invasive monitoring and early initiation of appropriate therapy guided by systolic blood pressure.

Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.

In acute heart failure (AHF) syndromes significant respiratory failure (RF) is essentially seen in patients with acute cardiogenic pulmonary oedema (ACPE) or cardiogenic shock (CS). Non-invasive ventilation (NIV), the application of positive intrathoracic pressure through an interface, has shown to be useful in the treatment of moderate to severe RF in several scenarios. There are two main modalities of NIV: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV) with positive end expiratory pressure. Appropriate equipment and experience is needed for NIPSV, whereas CPAP may be administered without a ventilator, not requiring special training. Both modalities have shown to be effective in ACPE, by a reduction of respiratory distress and the endotracheal intubation rate compared to conventional oxygen therapy, but the impact on mortality is less conclusive. Non-invasive ventilation is also indicated in patients with AHF associated to pulmonary disease and may be considered, after haemodynamic stabilization, in some patients with CS. There are no differences in the outcomes in the studies comparing both techniques, but CPAP is a simpler technique that may be preferred in low-equipped areas like the pre-hospital setting, while NIPSV may be preferable in patients with significant hypercapnia. The new modality 'high-flow nasal cannula' seems promising in cases of AHF with less severe RF. The correct selection of patients and interfaces, early application of the technique, the achievement of a good synchrony between patients and the ventilator avoiding excessive leakage, close monitoring, proactive management, and in some cases mild sedation, may warrant the success of the technique.

Aims To determine the relationship between admission systolic blood pressure (SBP) and mortality in older patients hospitalized for heart failure (HF) and among various subgroups. Methods and results We evaluated the independent association between initial SBP and 30-day and 1-year mortality, and potential interactions by age, gender, race, previous hypertension, and left ventricular dysfunction using multivariable logistic regression in the National Heart Failure Project, a database of Medicare patients >65 years old recruited from 1998 through 2001. Among 56 942 patients, mean admission SBP was 147.0 ± 92.3 mmHg, 15% presenting with SBP >180 mmHg. Systolic blood pressure showed an inverse relationship with 30-day and 1-year mortality rates in all subgroups analysed. Using admission SBP of 120–149 mmHg as the reference, the adjusted odds ratios (95% confidence intervals) for 1-year mortality were 2.18 (1.77–2.69) for SBP

Holger Thiele was the PI of the CULPRIT-SHOCK trial, which was funded the European Union 7th Framework Program (FP7/2007-2013) and by the German Heart Research Foundation and the German Cardiac Society. Sí