Rapid Classification and Treatment Algorithm of Cardiogenic Shock Complicating Acute Coronary Syndromes: The SAVE ACS Classification

Introduction. We aimed to identify the independent “frontline” predictors of 30-day mortality in patients with acute coronary syndromes (ACS) and propose a rapid cardiogenic shock (CS) classification and management pathway. Materials and Methods. From 2011 to 2019, a total of 11439 incident ACS patients were treated in our institution. Forward conditional logistic regression analysis was performed to determine the “frontline” predictors of 30 day mortality. The C-statistic assessed the discriminatory power of the model. As a validation cohort, we used 431 incident ACS patients admitted from January 1, 2020, to July 20, 2020. Results. Independent predictors of 30-day mortality included age (OR 1.05; 95% CI 1.04 to 1.07, p < 0.001 ), intubation (OR 7.4; 95% CI 4.3 to 12.74, p < 0.001 ), LV systolic impairment (OR severe_vs_normal 1.98; 95% CI 1.14 to 3.42, p = 0.015 , OR moderate_vs_normal 1.84; 95% CI 1.09 to 3.1, p = 0.022 ), serum lactate (OR 1.25; 95% CI 1.12 to 1.41, p < 0.001 ), base excess (OR 1.1; 95% CI 1.04 to 1.07, p < 0.001 ), and systolic blood pressure (OR 0.99; 95% CI 0.982 to 0.999, p = 0.024 ). The model discrimination was excellent with an area under the curve (AUC) of 0.879 (0.851 to 0.908) ( p < 0.001 ). Based on these predictors, we created the SAVE (SBP, Arterial blood gas, and left Ventricular Ejection fraction) ACS classification, which showed good discrimination for 30-day AUC 0.814 (0.782 to 0.845) and long-term mortality p log − rank < 0.001 . A similar AUC was demonstrated in the validation cohort (AUC 0.815). Conclusions. In the current study, we introduce a rapid way of classifying CS using frontline parameters. The SAVE ACS classification could allow for future randomized studies to explore the benefit of mechanical circulatory support in different CS stages in ACS patients.

Intestinal Flora and Inflammation in Acute Coronary Syndromes

Background: Acute coronary syndromes (ACS) is closely associated with chronic low-grade inflammation and gut microbiome composition. However, the composition and functional capacity of the gut microbiome in relation to ACS have not been systematically examined. Results: we perform a metagenome-wide association study on stools and plasma from 66 individuals with ACS and 46 healthy controls (HC). We then compared gut microbial composition using 16S ribosomal RNA gene sequencing in fecal samples to detect species with differential abundance between 2 groups. We reported that the altered composition of gut microbiota was associated with ACS and exacerbated inflammatory status. Moreover, parameters in ACS including body weights (BWs), low-density lipoprotein (LDL), triglyceride (TG), total cholesterol (TC), C-reactive protein (CRP) and high homocysteine (HCY) were elevated; whereas high-density lipoprotein (HDL) was decreased. pro-inflammatory interleukin (IL)-1β, IL-6, IL-10, tumor necrosis factor (TNF)-α, monocyte chemoattractant protein-1(MCP-1) and lipopolysaccaride (LPS) in ACS were increased respectively. The results of 16S rRNA sequencing and analysis displayed that the overall community of gut microbiota in ACS was notably changed mainly through increasing the abundance of Bacteroidetes, Verrucomicrobia, Proteobacteria Parabacteroide, Unidentified_Enterobacteriaceae, Subdoligranulum, Akkermansia, Alistipes, Streptococcus, Paraprevotella as well as decreasing Subdoligranulum, Roseburia, Faecalibacterium, Blautia, Agathobacter, Anaerostipes, Bifidobacterium. Further analysis showed that there was a significant correlation between the above differences in gut microbiota and inflammatory factors. Conclusions: Our data represent a comprehensive resource for further investigations on the role of the gut microbiome in promoting or preventing ACS.

Genetic Variation of Migration Inhibitory Factor Gene rs2070766 Is Associated With Acute Coronary Syndromes in Chinese Population

Genetic variation of macrophage migration inhibitory factor (MIF) gene has been linked to coronary artery disease. We investigated an association between the polymorphism of MIF gene rs2070766 and acute coronary syndromes (ACS) and the predictive value of MIF gene variation in clinical outcomes. This study involved in 963 ACS patients and 932 control subjects from a Chinese population. All participants were genotyped for the single nucleotide polymorphism (SNP) of MIF gene rs2070766 using SNPscan™. A nomogram model using MIF genetic variation and clinical variables was established to predict risk of ACS. Major adverse cardiovascular events (MACE) were monitored during a follow-up period. The frequency of rs2070766 GG genotype was higher in ACS patients than in control subjects (6.2 vs 3.8%, p = 0.034). Multivariate logistic regression analysis revealed that individuals with mutant GG genotype had a 1.7-fold higher risk of ACS compared with individuals with CC or CG genotypes. Using MIF rs2070766 genotypes and clinical factors, we developed a nomogram model to predict risk of ACS. The nomogram model had a good discrimination with an area under the curve of 0.781 (95% CI: 0.759–0.804), concordance index of 0.784 (95% CI: 0.762–0.806) and well-fitted calibration. During the follow-up period of 25 months, Kaplan-Meier curves demonstrated that ACS patients carrying GG phenotype developed more MACE compared to CC or CG carriers (p &lt; 0.05). GG genotype of MIF gene rs2070766 was associated with a higher risk of ACS in a Chinese population. The GG genotype carriers in ACS patients had worse clinical outcomes compared with those carrying CC or CG genotype. Together with rs2070766 genetic variant of MIF gene, we established a novel nomogram model that can provide individualized prediction for ACS.

Cardiovascular Presentation in Pheochromocytoma: What We Should be Aware

Pheochromocytoma is a catecholamine-producing tumor that although being a rare disease, it poses diagnostic problems because its clinical presentation often mimics certain diseases, including cardiovascular disorders. The effects of excessive catecholamine secretion cause a variety of cardiovascular presentations ranging from hypertension to life-threatening cases such as hypertensive emergency, shock, supraventricular or ventricular arrhythmias, pulmonary edema, and acute coronary syndromes. The principal medical treatment for pheochromocytoma is a blockade of adrenergic receptors. However, surgical or tumor resection often provides complete resolution of abnormal myocardial dysfunction or arrhythmias, so this approach remains the mainstay of treatment that should be performed as soon as the diagnosis of pheochromocytoma is established. As clinicians, we must be aware of the characteristics of the cardiovascular manifestations of pheochromocytoma to make an earlier diagnosis and more appropriate management.