Ferran Rueda

Background: Mechanical complications (MC) give a poor prognosis for ST elevation myocardial infarction (STEMI). Its prevalence had decreased in the era of primary angioplasty, at the expense of free wall rupture (FWR). Purpose: To analyse the prevalence of post-STEMI MC for two periods, before and after the COVID-19 pandemic. Methods: Unicentric prospective registration of patients with STEMI admitted between January-2018 and December-2021. They are classified into two groups according to the onset of the pandemic by COVID-19: Pre-COVID: January-2018 to December-2019, and Post-COVID: January-2020 to December-2021. The prevalence of post-STEMI MC is analysed, including ventricular septal rupture (VSR), papillary muscle rupture (PMR) and FWR, and 30-day mortality. Results: 1507 consecutive patients with STEMI (Pre-COVID n=775, Post-COVID n=732) are included. Age 62.9 years vs 63.3 years (p=0.5097). Men 78.1% Vs 79.5% (p=0.493). No differences in cardiovascular risk factors, previous heart infarction or anterior wall STEMI. Primary angioplasty was similar in both groups (92%). The Post-COVID group has a higher prevalence of Killip>I (21.7% vs 17.2% p=0.025) and LVEF ≤40% (27.2% vs 20% p=0.001), and longer symptom onset to balloon dilatation interval (316 min vs 257 min p=0.0004). MC are most developed in Post-COVID (2.6% vs 1.2% p=0.039), at the expense of FWR (1.91% vs 0.3% p=0.001). No significant changes in VSR and PMR prevalence or 30-day mortality. Multivariate analysis identifies the independent predictors of FWR: Age (OR 1.05, p=0.024), Primary angioplasty (OR 0.09, p<0.001), and Post-COVID (OR 6.8, p=0.013). Conclusions: The COVID-19 pandemic is independently associated with a higher prevalence of FWR, probably due to delayed reperfusion. Funding Acknowledgement: Type of funding sources: None.

Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI). In AMI-CS, the ST segment deviation on ECG may be elevated (STEMI-CS) or non-elevated (NSTEMI-CS), which may influence prognosis. Our aim was to analyze the clinical profile, acute-phase prognosis, and long-term outcomes of CS relative to the ST pattern on admission. In a prospective registry of 4647 AMI patients admitted to the intensive cardiac care unit of a university hospital between 2010 and 2019, we compared the clinical characteristics, 30-days case fatality, and long-term outcomes of AMI-CS, based on the presence of ST-segment deviation. AMI-CS developed in 239 (5.1%) patients (26.4% women): 190 (79.5%) STEMI-CS and 49 (20.5%) NSTEMI-CS. The mean age was 69.7 years. The STEMI-CS patients had larger infarcts and more mechanical complications than the NSTEMI-CS patients. The NSTEMI-CS patients had a greater prevalence of hypertension, diabetes, peripheral vascular disease, previous cardiovascular comorbidities, three-vessel disease, and left main disease than the STEMI-CS patients. The STEMI-CS patients had higher 30-day mortality than the NSTEMI-CS (59.5% vs. 36.7%; p = 0.004), even after multivariable adjustment (HR 1.91; 95% CI 1.16–3.14), but no differences in mortality were observed at 3 years. In conclusion, the 30-day case-fatality is higher in STEMI-CS, but the long-term outcome is similar in both groups.

Funding Acknowledgements: Type of funding sources: None. OnBehalf: Codi IAM investigators Background: Long revascularization times have been associated with worse prognosis in PCI-treated STEMI patients. Thus, efforts have been focused in optimizing revascularization times. In Catalonia, the different first medical contact (FMC) points with the regional STEMI network CODI IAM have been associated with different degrees of delay in reperfusion. Purpose: we aim to determine if our regional STEMI network achieves better mortality rates in the fastest circuits than in slower ones by optimizing revascularization times. Methods: since CODI IAM network was launched in June 2009, a prospective registry of all attended cases is conducted. We included in the study all patients with final STEMI diagnosis treated with primary PCI from January 2010 to December 2016. Patients were divided in 4 different groups regarding FMC point: primary care center (PCC), community hospital (CH), PCI-hospital (PCI-H), emergency medical services (EMS)). Clinical data, reperfusion times and 30-day and 1-year mortality were analyzed. Results: a total of 14,483 patients (PCC 19%, CH 35,7%, PCI-H 12,5%; EMS 32,7%) were included in the analysis. Women proportion was higher in hospital-attended cases (p < 0,001), and so was diabetes (p < 0,001). Previous history of MI, PCI and CABG were more frequent in both EMS and PCI-H groups (p < 0,001). Killip-Kimball Classes III-IV were more frequent in PCI-H and EMS groups (EMS 12,5%, PCI-H 10,4%, CH 7%, PCC 4,6%; p < 0,001). All complications (intubation, ventricular fibrillation, ventricular tachycardia, atrial fibrillation, AV block) in first medical assistance were more frequent in EMS group (p < 0,001). Median time from ECG to reperfusion was shorter in the PCI-H group (74 min (IQR 56-110), p < 0,001) but the shortest median ischaemic time was achieved by EMS group (155 min (IQR 120-215), p < 0,001). Global 30-day and 1-year mortality were 5,8% and 9,4% respectively, significantly higher in PCI-H and EMS groups than in CH and PCC groups (30-day m. CH 4,9%, PCC 3,3%, PCI-H 7%, EMS 7,8%), p < 0,001). After Cox regression adjusted analysis including sex, age, diabetes, anterior STEMI, Killip-Kimball Class and primary VF, 30-day and 1-year mortality remained higher in PCI-H and EMS groups compared to CH group, both without adjusting by time (HR 1,31 (1,01-1,69), p = 0,04 for PCI-H 30-day mortality; HR 1,25 (1,03-1,51), p = 0,025 for EMS 30-day mortality), and after adjusting by time ECG-reperfusion >120 min (HR 1,56 (1,20-2,03), p = 0,001 for PCI-H 30-day mortality and HR 1,48 (1,21-1,82), p < 0,001 for EMS 30-day mortality). Conclusions: considering that reperfusion time intervals favour EMS and PCI-H groups, crude between-groups mortality differences might be justified by a selection bias rather than by the pathway itself. Despite this probable selection bias, the STEMI network achieves a reduction of these differences by shortening reperfusion times in EMS and PCI-H groups. Abstract Figure. 1-year mortality curves

Primary ventricular fibrillation is an ominous complication of ST-segment elevation myocardial infarction, and proper biomarkers for risk prediction are lacking. Growth differentiation factor-15 is a marker of inflammation, oxidative stress and hypoxia with well-established prognostic value in ST-segment elevation myocardial infarction patients. We explored the predictive value of growth differentiation factor-15 in a subgroup of ST-segment elevation myocardial infarction patients with primary ventricular fibrillation. Prospective registry of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention from February 2011–August 2015. Growth differentiation factor-15 concentrations were measured on admission. Logistic regression and Cox proportional regression analyses were used. A total of 1165 ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention (men 78.5%, age 62.3±13.1 years) and 72 patients with primary ventricular fibrillation (6.2%) were included. Compared to patients without primary ventricular fibrillation, median growth differentiation factor-15 concentration was two-fold higher in ST-segment elevation myocardial infarction patients with primary ventricular fibrillation (2655 vs 1367 pg/ml, pppp=0.012) and 1.72 (95% confidence interval 1.23–2.40) in patients without primary ventricular fibrillation (p=0.001). Growth differentiation factor-15 is a robust independent predictor of 30-day mortality in ST-segment elevation myocardial infarction patients with primary ventricular fibrillation.

Background: Coronary artery disease remains a major cause of death despite better outcomes of ST‐segment–elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti‐STEMI registry of in‐hospital, 28‐day, and 1‐year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results: Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28‐day and 1‐year STEMI mortality and in‐hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28‐day all‐cause mortality declined from period 1 to period 5 (10.4% versus 6.0%; P P P =0.001), with a 24% reduction after multivariable adjustment (HR, 0.76; 95% CI, 0.60–0.98; P =0.036). A significant temporal reduction was observed for in‐hospital complications including postinfarct angina (−78%), ventricular tachycardia (−57%), right ventricular dysfunction (−48%), atrioventricular block (−45%), pericarditis (−63%), and free wall rupture (−53%). Primary ventricular fibrillation showed no significant downslope trend. Conclusions: In‐hospital STEMI complications and 28‐day and 1‐year mortality rates have dropped markedly in the past 30 years. Reducing ischemia‐driven primary ventricular fibrillation remains a major challenge.

Aims: Cardiogenic shock (CS) is an ominous complication of ST-elevation myocardial infarction (STEMI), despite the recent widespread use of reperfusion and invasive management. The Ruti-STEMI-Shock registry analysed the prevalence of and 30-day and 1-year mortality rates in ST-elevation myocardial infarction (STEMI) complicated by CS (STEMI-CS) over the last three decades. Methods and Results: From February 1989 to December 2018, 493 STEMI-CS patients were consecutively admitted in a well-defined geographical area of ~850,000 inhabitants. Patients were classified into six five-year periods based on their year of admission. STEMI-CS mortality trends were analysed at 30 days and 1 year across the six strata. Cox regression analyses were performed for comparisons. Mean age was 67.5 ± 11.7 years; 69.4% were men. STEMI-CS prevalence did not decline from period 1 to 6 (7.1 vs. 6.2%, p = 0.218). Reperfusion therapy increased from 22.5% in 1989–1993 to 85.4% in 2014–2018. Thirty-day all-cause mortality declined from period 1 to 6 (65% vs. 50.5%, p < 0.001), with a 9% reduction after multivariable adjustment (HR: 0.91; 95% CI: 0.84–0.99; p = 0.024). One-year all-cause mortality declined from period 1 to 6 (67.5% vs. 57.3%, p = 0.001), with an 8% reduction after multivariable adjustment (HR: 0.92; 95% CI: 0.85–0.99; p = 0.030). Short- and long-term mortality trends in patients aged ≥ 75 years remained ~75%. Conclusions: Short- and long-term STEMI-CS-related mortality declined over the last 30 years, to ~50% of all patients. We have failed to achieve any mortality benefit in STEMI-CS patients over 75 years of age.

The incidence of cardiogenic shock (CS) has increased remarkably over the past decade and remains a challenging condition with mortality rates of ∼50%. Cardiogenic shock encompasses cardiac contractile dysfunction; however, it is also a multiorgan dysfunction syndrome, often complicated by a systemic inflammatory response with severe cellular and metabolic dysregulations. Here, we review the evidence on the biochemical manifestations of CS, elaborating on current gold standard biomarkers and novel candidates from molecular signatures of CS. Glucose and lactate, both identified over a century ago, remain the only clinically used biomarkers in current predictive risk scores. Novel genomic, transcriptomic, and proteomic data are discussed, and a recently reported molecular score derived from unbiased proteomic discovery, the CS4P, which includes liver fatty acid-binding protein, beta-2-microglobulin, fructose-bisphosphate aldolase B, and SerpinG1 is comprehensively described. Recent advances in -omics technologies provide new insight into a more holistic molecular signature of CS. Thus, we need to open new diagnostic and therapeutic avenues if we aim to improve outcomes.