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Background Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce. Objectives To externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course. Methods The Simplified Acute Physiology Score (SAPS)-II Score, the CardShock score, the IABP-SHOCK II score and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. Discriminative power was assessed by comparing area under the curves (AUC) in case of continuous scores. Results In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination (AUC=0.74), followed by the CardShock score (AUC=0.69) and the SAPS-II score, giving only moderate discrimination (AUC=0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (stage E), but showed poor discrimination between stages C and D with respect to short-term-mortality. Conclusion Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification or even development of new scores might be necessary to reach higher levels of discrimination. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, German Centre for Cardiovascular Research Survival probabilities continuous scoresSurvival probabilities SCAI

Objectives: To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Background: Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. Methods: This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. Results: Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®, n = 95 extracorporeal membrane oxygenation (ECMO), n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%, p &lt, 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p &lt, 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7–5.9, 0.001). Conclusions: In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.

Background: Women are more likely to suffer and die from cardiogenic shock (CS) as the most severe complication of acute myocardial infarction. Data concerning optimal management for women with CS are scarce. Aim of this study was to better define characteristics of women experiencing CS and to the influence of sex on different treatment strategies. Methods: In the CULPRIT-SHOCK trial (The Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), patients with CS complicating acute myocardial infarction and multivessel coronary artery disease were randomly assigned to one of the following revascularization strategies: either percutaneous coronary intervention of the culprit-lesion-only or immediate multivessel percutaneous coronary intervention. Primary end point was composite of death from any cause or severe renal failure leading to renal replacement therapy within 30 days. We investigated sex-specific differences in general and according to the revascularization strategies. Results: Among all 686 randomized patients included in the analysis, 24% were women. Women were older and had more often diabetes mellitus and renal insufficiency, whereas they had less often history of previous acute myocardial infarction and smoking. After 30 days, the primary clinical end point was not significantly different between groups (56% women versus 49% men; odds ratio, 1.29 [95% CI, 0.91–1.84]; P =0.15). There was no interaction between sex and coronary revascularization strategy regarding mortality and renal failure ( P interaction =0.11). The primary end point occurred in 56% of women treated by the culprit-lesion-only strategy versus 42% men, whereas 55% of women and 55% of men in the multivessel percutaneous coronary intervention group. Conclusions: Although women presented with a different risk profile, mortality and renal replacement were similar to men. Sex did not influence mortality and renal failure according to the different coronary revascularization strategies. Based on these data, women and men presenting with CS complicating acute myocardial infarction and multivessel coronary artery disease should not be treated differently. However, further randomized trials powered to address potential sex-specific differences in CS are still necessary. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01927549.

Objectives This study evaluated the usability and contrast volume savings of the novel DyeVert™ System. Background During coronary diagnostic and interventional procedures, a substantial portion of injected contrast does not contribute to vessel imaging due to reflux into the ascending aorta. Contrast volume is the primary physician modifiable risk factor for prevention of contrast-induced acute kidney injury CI-AKI which is a frequent complication in patients undergoing coronary angiographic procedures and is related to increases in morbidity, mortality, and healthcare costs. Methods In this pilot trial, 44 patients undergoing coronary diagnostic and/or percutaneous coronary intervention (PCI) procedures were enrolled in two centers. All procedures were conducted using a manual manifold injection setup and the DyeVert System, which facilitates the diversion of excess contrast volume prior to injection into the patient. Direct measurements of both the amount of contrast that was attempted to be injected and the actual volume injected into the patient were taken. Results The difference between the two amounts indicated the volume saved. Procedure types included 34 diagnostic studies and 10 PCI. The mean percent volume saved by the DyeVert System was 47%, with a corresponding P value of

Objectives The aim of the present study was to assess the outcome of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) receiving drug-eluting stents (DES) compared with bare-metal stents (BMS). Data comparing these two stent technologies in AMI with CS were limited. Methods A total of 783 patients with AMI and CS undergoing early revascularisation were included in the randomised Intra-aortic Balloon Pump in Cardiogenic Shock II trial (n=600) and the associated registry (n=183). Patients receiving no stent or both, DES and BMS, were excluded. Primary end point was the composite of 1-year mortality or re-AMI. Results Of the total cohort, 652 (83%) patients received either solely DES or BMS and were included in the present analysis. Of these, 276 (42%) patients received DES and 376 (58%) received BMS. After adjustment for baseline characteristics, there was no significant difference between DES and BMS regarding the primary end point (HR 0.83 (CI 0.64 to 1.06); p=0.14). There was an independent association of BMS use with older age, atrial fibrillation and coronary single-vessel disease. DES use was associated with prior known dyslipidaemia, baseline haemoglobin level, anterior AMI and treatment at frequently enrolling centres. Conclusions Despite the frequent use of DES nowadays, a substantial number of patients were treated by BMS in AMI complicated by CS. After adjustment for risk factors, the 1-year outcome of patients treated by DES compared with BMS was similar. Trial registrationnumber www.clinicaltrials.gov: NCT00491036.

This study evaluated the usability and contrast volume savings of the novel DyeVert™ System.During coronary diagnostic and interventional procedures, a substantial portion of injected contrast does not contribute to vessel imaging due to reflux into the ascending aorta. Contrast volume is the primary physician modifiable risk factor for prevention of contrast-induced acute kidney injury CI-AKI which is a frequent complication in patients undergoing coronary angiographic procedures and is related to increases in morbidity, mortality, and healthcare costs.In this pilot trial, 44 patients undergoing coronary diagnostic and/or percutaneous coronary intervention (PCI) procedures were enrolled in two centers. All procedures were conducted using a manual manifold injection setup and the DyeVert System, which facilitates the diversion of excess contrast volume prior to injection into the patient. Direct measurements of both the amount of contrast that was attempted to be injected and the actual volume injected into the patient were taken.The difference between the two amounts indicated the volume saved. Procedure types included 34 diagnostic studies and 10 PCI. The mean percent volume saved by the DyeVert System was 47%, with a corresponding P value of0.0001 achieving the pre-specified level of greater than 15% of contrast media being saved. Mean volume savings were similar for both diagnostic (47 ± 9%) and PCI (50 ± 9%) procedures. Image quality was good in 43/44 (98%) patients.The DyeVert System substantially decreases contrast delivered to patients during diagnostic or interventional coronary procedures while maintaining adequate image quality. © 2017 Wiley Periodicals, Inc.

It is unknown whether the occurrence of ST-elevation myocardial infarction (STEMI) at a younger age is associated with differences in myocardial damage compared with older patients. We aimed to compare the infarct characteristics (area at risk [AAR], myocardial salvage index [MSI], infarct size [IS], microvascular obstruction [MVO]) and clinical outcome in patients aged ≤45 years and45 years. We analyzed 795 patients with STEMI treated with primary percutaneous coronary intervention. All patients completed 12-month follow-up for the assessment of major adverse cardiac events (MACE). Left ventricular ejection fraction, AAR, MSI, IS, and MVO were determined by cardiac magnetic resonance imaging. Seventy-eight patients (9.8%) were aged 45 years or younger. Young patients were more likely to be male (p = 0.01), to be current smokers (p0.001), and to have a family history of coronary artery disease (p = 0.05). Contrary, they had significantly lower prevalence of hypertension (p0.001), diabetes (p0.01), and 3-vessel disease (p0.01). There were no significant differences in left ventricular ejection fraction (p = 0.36), AAR (p = 0.30), MSI (p = 0.34), IS (p = 0.29), or MVO (p = 0.58) between both groups. MACE rate was significantly lower in patients aged ≤45 years compared with patients aged45 years (1.3% vs 7.5%, p = 0.04). After multivariate adjustment for clinical risk factors and cardiac magnetic resonance findings, age remained an independent predictor of MACE (hazard ratio 1.04, 95% CI 1.01 to 1.07, p = 0.03). In conclusion, infarct characteristics are not dependent on age in patients undergoing primary percutaneous coronary intervention for STEMI.

ST-elevation myocardial infarction (STEMI) is frequently associated with reciprocal ST-segment depression in contralateral ECG leads. However, the relationship of the resolution of ST-segment depression (STD-R) with myocardial damage is unknown and the potential prognostic value incompletely understood. We sought to evaluate the association between STD-R and markers of myocardial injury as well as to determine the prognostic impact of STD-R in patients with acute reperfused STEMI.We enrolled 611 patients with STEMI in this multicentre cardiac magnetic resonance (CMR) study. STD-R, defined as either worsened (0%), incomplete (0-50%) or complete (≥50%), was determined 90 min after primary percutaneous coronary intervention (PCI). Patients underwent CMR in median 3 (2-4) days after infarction. Major adverse cardiac events (MACE) were defined as a composite of death, reinfarction and new congestive heart failure within 12 months after enrollment.Patients with worsened or incomplete STD-R (n=148 (24.2%)) had a significantly larger area at risk (42 (31-50) vs 37 (29-52) vs 34 (24-46) %LV, p=0.001), larger infarct size (20 (13-30) vs 17(10-26) vs 16 (8-24) %LV, p=0.003), larger extent of microvascular obstruction (0.6(0-3.4) vs 0.4 (0-2.4) vs 0.0 (0-1.4) %LV, p=0.003), and a lower LVEF (46 (39-54) vs 48 (40-56) vs 52 (45-58) %, p0.001). MACE rate (n=37 (6%)) was significantly higher in patients with worsened (n=10 (19%)) or incomplete STD-R (n=7 (7%)) than in patients with complete STD-R (n=20 (4%), p0.001). In multivariate Cox regression analysis, categorised STD-R emerged as an independent predictor of MACE at 12 months after adjusting for clinical variables (p=0.007).Patients with acute STEMI and worsened or incomplete STD-R after PCI show a more pronounced myocardial as well as microvascular damage as detected by CMR with subsequent independent prognostic information on MACE over a 12-month follow-up period.

Data on the exact incidence and predictors of left ventricular (LV) thrombus formation after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) are scarce. Moreover, data on the prognostic significance of LV thrombi on hard clinical outcome measures are

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is associated with high mortality. Previous studies regarding gender-specific differences in CS are conflicting and there are insufficient data for the presence of gender-associated differences in the contemporary percutaneous coronary intervention era. Aim of this study was therefore to investigate gender-specific differences in a large cohort of AMI patients with CS undergoing contemporary treatment. In the randomized Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial, 600 patients with CS complicating AMI undergoing early revascularization were assigned to therapy with or without intra-aortic balloon pump. We compared sex-specific differences in these patients with regard to baseline and procedural characteristics as well as short- and long-term clinical outcome. Of 600 patients 187 (31 %) were female. Women were significantly older than men and had a significantly lower systolic and diastolic blood pressure at presentation (p

This research was performed to provide data on the specific needs and expectations of junior cardiologists across Europe from a professional medical organization characterized by the European Society of Cardiology (ESC).The study was carried out using telephone interviews. The target respondents were based in a wide range of different locations within Europe and were identified by national groups of young cardiologists and trainees. A questionnaire was employed asking about information sources, membership of professional societies and related benefits.A total of 120 interviews were conducted. Websites and journals proved the most popular sources for professional information, consulted by .71 and 68% of respondents, respectively.With regard to the up to date best practice recommendations, guidelines documents were most common, mentioned by 63%. Overall, the ESC resources appeared within highest priority. The two main important tangible benefits expected from membership of professional societies were access to medical information, mostly journals and guidelines, and reduced financial congress requirements. Also, the most significant intangible benefit was networking.The ESC is widely respected by the junior cardiologists and trainees. Its congresses and guidelines are central to respondents’ image of it as a large, well arranged, important, and impressive organization. The ESC is a competently placed institution to further develop its relationship with young cardiologists.

Background: The vasoprotective effects of physical exercise are only partially understood on the molecular level. Telomere-associated proteins affect cellular senescence and survival. We studied the molecular effects of physical exercise in aortic tissue of running and sedentary mice. Methods: C57/Bl6 wildtype, endothelial nitric oxide synthase (ENOS) deficient and telomerase reverse transcriptase (TERT) deficient mice were randomized to voluntary running or no running wheel conditions (n=8 –10 per group). Results: Physical exercise for 3 weeks upregulated aortic telomerase activity to 303 ± 32% (p Conclusions: Voluntary physical activity upregulates aortic telomere regulating proteins which induces anti-senescent and anti-apoptotic effects mediated by ENOS and TERT independent of telomere length.

Cardiogenic shock (CS) complicating acute myocardial infarction is strongly associated with mortality. Even though there has been previous research regarding gender specific differences in these patients, the results so far are conflicting and, moreover, there is insufficient data for the

Background: Endothelial progenitor cells (EPC) improve endothelial function and promote vascular repair. Aleglitazar combines lipid-modifying effects of PPAR-α agonists (fibrates) and insulin-sensitizing effects of PPAR-γ agonists (thiazolidinediones). We studied the effects of the novel dual peroxisome proliferator-activated receptor (PPAR)-α/γ agonist aleglitazar on glucose tolerance, EPC, endothelial function, neoangiogenesis and atherosclerosis in mice. Methods and results: C57Bl/6 wild-type (WT, normal chow), ApoE-/- mice (Western-type diet) and eNOS-/- mice were treated with aleglitazar (10 mg/kg/d, i.p.) or vehicle. Aleglitazar enhanced the expression of both the PPAR-α and PPAR-γ target genes and normalized glucose tolerance in cholesterol-fed ApoE-/- mice. In WT mice, aleglitazar treatment upregulated sca-1/VEGFR-2-positive EPC in the blood (153±10%) and bone marrow (197±22%), and upregulated spleen-derived diLDL/lectin-positive EPC (182±8%). Furthermore, aleglitazar augmented EPC migration (186±6% vs. controls) and enhanced neoangiogenesis (vascularized disk area 178±18% vs. controls). The effects of the dual PPAR-α/γ agonist on EPC number and function were abolished in eNOS knock-out mice. In ApoE-/- mice, aleglitazar upregulated EPC number and function, potently improved endothelium-dependent vasodilation and markedly reduced the formation of atherosclerotic plaques (plaque area/total lumen area 2.3±0.8% vs. 10.1±1.9% after 6 weeks and 22±2.2% vs. 36±2.1% after 8 weeks treatment). OilRed staining of hepatic sections showed a profound reduction of liver steatosis in ApoE-/- mice. In cultured human EPC, aleglitazar increased migration and colony forming units in a concentration-dependent manner. Furthermore, oxidative stress-induced EPC apoptosis and protein expression of p53 were reduced, while telomerase activity and expression of phospho-eNOS (S1177) and phospho-Akt were elevated. Comparative and inhibitor experiments revealed that aleglitazar's effects on EPC migration and colony forming units (CFU) were mediated by both PPAR-α and -γ signaling. E.g., aleglitazar treatment (10nM/l) induced EPC migration (304±21% vs. controls) and CFU (300±67% vs. controls) comparably to a co-stimulation of EPC with pioglitazone 10μM/l+fenofibric acid (150μM/l) (Migration: 332±28%; CFU: 289±72%). Conclusions: The dual PPAR-α/γ agonist aleglitazar augments number, function and survival of endothelial progenitor cells in an Akt- and eNOS-dependent fashion. The effects on EPC correlate with improved neoangiogenesis, restored endothelial function and prevention of atherosclerosis.