2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

At high concentrations, free radicals and radical-derived, nonradical reactive species are hazardous for living organisms and damage all major cellular constituents. At moderate concentrations, how...

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Free Radicals in the Physiological Control of Cell Function

ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation

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2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

WRITING GROUP MEMBERS Emelia J. Benjamin, MD, SCM, FAHA Michael J. Blaha, MD, MPH Stephanie E. Chiuve, ScD Mary Cushman, MD, MSc, FAHA Sandeep R. Das, MD, MPH, FAHA Rajat Deo, MD, MTR Sarah D. de Ferranti, MD, MPH James Floyd, MD, MS Myriam Fornage, PhD, FAHA Cathleen Gillespie, MS Carmen R. Isasi, MD, PhD, FAHA Monik C. Jiménez, ScD, SM Lori Chaffin Jordan, MD, PhD Suzanne E. Judd, PhD Daniel Lackland, DrPH, FAHA Judith H. Lichtman, PhD, MPH, FAHA Lynda Lisabeth, PhD, MPH, FAHA Simin Liu, MD, ScD, FAHA Chris T. Longenecker, MD Rachel H. Mackey, PhD, MPH, FAHA Kunihiro Matsushita, MD, PhD, FAHA Dariush Mozaffarian, MD, DrPH, FAHA Michael E. Mussolino, PhD, FAHA Khurram Nasir, MD, MPH, FAHA Robert W. Neumar, MD, PhD, FAHA Latha Palaniappan, MD, MS, FAHA Dilip K. Pandey, MBBS, MS, PhD, FAHA Ravi R. Thiagarajan, MD, MPH Mathew J. Reeves, PhD Matthew Ritchey, PT, DPT, OCS, MPH Carlos J. Rodriguez, MD, MPH, FAHA Gregory A. Roth, MD, MPH Wayne D. Rosamond, PhD, FAHA Comilla Sasson, MD, PhD, FAHA Amytis Towfighi, MD Connie W. Tsao, MD, MPH Melanie B. Turner, MPH Salim S. Virani, MD, PhD, FAHA Jenifer H. Voeks, PhD Joshua Z. Willey, MD, MS John T. Wilkins, MD Jason HY. Wu, MSc, PhD, FAHA Heather M. Alger, PhD Sally S. Wong, PhD, RD, CDN, FAHA Paul Muntner, PhD, MHSc On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart Disease and Stroke Statistics—2017 Update

Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association

/pdf/2016-esc-guidelines-for-the-diagnosis-and-treatment-of-acute-53v7yllhiz.pdf


 Introduction:
 Studies evaluating trends in the incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease admitted to the intensive care unit (ICU) are rare. Additionally, there is limited information on factors associated with IHCA and mortality.
 
 
 Hypothesis:
 We hypothesized that the incidence of IHCA and the mortality rate in cardiac children admitted to the ICU has significantly decreased over time.
 
 
 Methods:
 We conducted a systematic review of PubMed, Web of Science, EMBASE, and CINAHL from inception to Sept 2021. Random effects meta-analysis was used to compute pooled-proportions and pooled-ORs. Meta-regression adjusted for type of study (registry vs cohort) and diagnostic category (surgical vs general cardiac) was used to evaluate trends in incidence and mortality.
 
 
 Results:
 Of the 2,574 studies identified, 25 were included in the systematic review (126,087 patients), 18 in the meta-analysis. Five percent (95% CI: 4-7%) of ICU children experienced IHCA and 35% (95% CI: 27-44%) did not achieve ROSC. In centers with ECMO, 21% (95% CI: 15-28%) underwent ECPR. The pooled in-hospital mortality was 54% (95% CI: 47-62%). Both incidence of IHCA and in-hospital mortality decreased significantly in the last 20 y (p<0.001, Figure 1, and p=0.020, respectively), while the proportion of patients achieving ROSC did not change (p=0.572). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, pre-arrest mechanical ventilation, ECMO, and higher surgical complexity increased IHCA and mortality odds.
 
 
 Conclusions:
 A significant proportion (5%) of cardiac children in the ICU experience IHCA. Decreasing trends in IHCA and in-hospital mortality suggests that education on preventive measures and post-arrest care have been effective. However, unchanged proportion of patients not achieving ROSC illustrates the crucial need for developing resuscitation strategies specific to children with cardiac disease.
 
 
 


Abstract 13952: Incidence of In-Hospital Cardiac Arrest and Associated In-Hospital Mortality in Pediatric Critically Ill Patients With Cardiac Disease Significantly Decreased Over Time: Results From a Systematic Review and Meta-Analysis

PurposeDespite extracorporeal membrane oxygenation (ECMO) utilization in up to 20% of cases, there are limited outcome data in pediatric patients with acute fulminant myocarditis (AFM) requiring mechanical circulatory support.MethodsRetrospective cohort of patients <18 years with AFM admitted to a single center cardiac ICU and supported with ECMO from 1997-2021. Patients had ≤14 days of symptoms, rapid cardiogenic shock, and normal LV size. We compared clinical variables in patients who survived to discharge without heart transplant (HT) to those who did not. In addition, we assessed long-term LV function in survivors.ResultsAmong 29 patients (median age 9 years; IQR 3,14), 22 (76%) survived to discharge without HT. Patients were supported on ECMO for a median of 6 days (IQR 5,8). Three patients were bridged to HT with durable ventricular assist devices (VAD). Four patients died, 2 of whom were supported with VAD. At presentation, 7 patients (24%) had high grade or complete atrioventricular block and 8 (28%) had ventricular tachycardia. CPR prior to ECMO occurred in 22 (76%) including all patients in the death/HT group. The death/HT group had higher peak troponin levels (12.5 vs 0.9 ng/mL, p=0.01). All patients underwent cardiac catheterization. Initial LA pressure was higher in the death/HT group (27 vs 18 mmHg, p=0.02) and LA decompression was performed in 23 patients (79%). Twenty-two (76%) had biopsy findings consistent with AFM. Among transplant-free survivors, 19 (86%) had normalization in LV function (median 16 days from presentation, IQR 9,449); the remaining 3 patients had persistent mild LV dysfunction at last follow up. Nine patients underwent cardiac MRI (median 752 days post-diagnosis), among whom 4 exhibited late gadolinium enhancement.ConclusionTransplant-free survival of pediatric patients with AFM supported on ECMO was 76% and associated with lower initial LA pressure. Recovery of ventricular function among survivors was rapid and durable. Despite extracorporeal membrane oxygenation (ECMO) utilization in up to 20% of cases, there are limited outcome data in pediatric patients with acute fulminant myocarditis (AFM) requiring mechanical circulatory support. Retrospective cohort of patients <18 years with AFM admitted to a single center cardiac ICU and supported with ECMO from 1997-2021. Patients had ≤14 days of symptoms, rapid cardiogenic shock, and normal LV size. We compared clinical variables in patients who survived to discharge without heart transplant (HT) to those who did not. In addition, we assessed long-term LV function in survivors. Among 29 patients (median age 9 years; IQR 3,14), 22 (76%) survived to discharge without HT. Patients were supported on ECMO for a median of 6 days (IQR 5,8). Three patients were bridged to HT with durable ventricular assist devices (VAD). Four patients died, 2 of whom were supported with VAD. At presentation, 7 patients (24%) had high grade or complete atrioventricular block and 8 (28%) had ventricular tachycardia. CPR prior to ECMO occurred in 22 (76%) including all patients in the death/HT group. The death/HT group had higher peak troponin levels (12.5 vs 0.9 ng/mL, p=0.01). All patients underwent cardiac catheterization. Initial LA pressure was higher in the death/HT group (27 vs 18 mmHg, p=0.02) and LA decompression was performed in 23 patients (79%). Twenty-two (76%) had biopsy findings consistent with AFM. Among transplant-free survivors, 19 (86%) had normalization in LV function (median 16 days from presentation, IQR 9,449); the remaining 3 patients had persistent mild LV dysfunction at last follow up. Nine patients underwent cardiac MRI (median 752 days post-diagnosis), among whom 4 exhibited late gadolinium enhancement. Transplant-free survival of pediatric patients with AFM supported on ECMO was 76% and associated with lower initial LA pressure. Recovery of ventricular function among survivors was rapid and durable. 

http://www.jhltonline.org/article/S1053249822013006/pdf

Contemporary Outcomes of Pediatric Patients with Acute Fulminant Myocarditis Supported with Extracorporeal Membrane Oxygenation


 Introduction:
 Clinical data within the electronic health record (EHR) combined with artificial intelligence (AI) and machine learning (ML) offer the promise of rapid advancement of knowledge at the point of care.
 
 
 Hypothesis:
 We hypothesized that aggregating clinical data with preservation of relational elements will yield a more precise and less biased representation of patient data for predictive analytics. We leveraged these data to predict clinically significant bleeding in the ECMO-supported population.
 
 
 Methods:
 The data of children 0-19 years managed on ECMO for first run cardiac indications in a single center between 1/2010-12/2020 were analyzed. Bleeding Day was defined as any 24-hour period which included pulmonary, gastrointestinal, intracranial or surgical wound hemorrhage, and/or surgical intervention or Factor VIIa administration for hemorrhage control. EHR data documenting the ECMO episode and embedding relational elements were used to inform 1) a multivariable logistic regression model matching a previously- performed analysis using manually extracted data [1], and 2) a feature-limited graph neural network (GNN) model of bleeding.
 
 
 Results:
 There were 272 patients supported with ECMO for total 2,012 days which informed the analysis, with median age 0.4 [IQR 0.03, 3.30] years, 56% male and 14% of days including a bleeding event. Direct comparison of the EHR-derived logistic regression model with previously published manual results are presented in Table 1. Inclusion of the EHR-derived covariates in a GNN model achieved similar operating characteristics.
 
 
 Conclusions:
 EHR-derived AI-prediction models of bleeding in this complex patient population are at least as accurate as models with manual data and traditional statistical analysis, but with a known pathway to potentially more accurate predictions. This methodology can be replicated to other conditions, allowing rapid insights towards a learning healthcare system.
 
 
 


Ravi R. Thiagarajan

Papers

Abstract 13952: Incidence of In-Hospital Cardiac Arrest and Associated In-Hospital Mortality in Pediatric Critically Ill Patients With Cardiac Disease Significantly Decreased Over Time: Results From a Systematic Review and Meta-Analysis

Contemporary Outcomes of Pediatric Patients with Acute Fulminant Myocarditis Supported with Extracorporeal Membrane Oxygenation

Abstract 15673: AI-Enabled Prediction of Bleeding in Patients Supported on Extracorporeal Membrane Oxygenation