BACKGROUND Long-term trends of the incidence and outcome of cardiogenic shock (CS) patients are scarce. We analyze for the first time trends in the incidence and outcome of CS during a 20-year period in Switzerland. METHODS AND RESULTS The AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry enrolls patients with acute myocardial infarction from 83 hospitals in Switzerland. We analyzed trends in the incidence, treatment, and in-hospital mortality of patients with CS enrolled between 1997 and 2017. The impact of revascularization strategy on outcome was assessed for the time period 2005 to 2017. Among 52 808 patients enrolled, 963 patients were excluded because of missing data and 51 842 (98%) patients remained for the purpose of the present analysis. Overall, 4090 patients (7.9%) with a mean age of 69.6±12.5 years experienced acute myocardial infarction complicated by CS. Overall, rates of CS declined from 8.

Background Patients with transposition of the great arteries corrected by an atrial switch operation experience major clinical events during adulthood, mainly heart failure (HF) and arrhythmias, but data on the emerging risks remain scarce. We assessed the risk for events during the clinical course in adulthood, and provided a novel risk score for event‐free survival. Methods and Results This multicenter study observed 167 patients with transposition of the great arteries corrected by an atrial switch operation (61% Mustard procedure; age, 28 [interquartile range, 24–36] years) for 13 (interquartile range, 9–16) years, during which 16 (10%) patients died, 33 (20%) had HF events, defined as HF hospitalizations, heart transplantation, ventricular assist device implantation, or HF‐related death, and 15 (9%) had symptomatic ventricular arrhythmias. Five‐year risk of mortality, first HF event, and first ventricular arrhythmia increased from 1% each at age 25 years, to 6% (95% CI, 4%–9%), 23% (95% CI, 17%–28%), and 5% (95% CI, 2%–8%), respectively, at age 50 years. Predictors for event‐free survival were examined to construct a prediction model using bootstrapping techniques. A prediction model combining age >30 years, prior ventricular arrhythmia, age >1 year at repair, moderate or greater right ventricular dysfunction, severe tricuspid regurgitation, and mild or greater left ventricular dysfunction discriminated well between patients at low (<5%), intermediate (5%–20%), and high (>20%) 5‐year risk (optimism‐corrected C‐statistic, 0.86 [95% CI, 0.82–0.90]). Observed 5‐ and 10‐year event‐free survival rates in low‐risk patients were 100% and 97%, respectively, compared with only 31% and 8%, respectively, in high‐risk patients. Conclusions The clinical course of patients undergoing atrial switch increasingly consists of major clinical events, especially HF. A novel risk score stratifying patients as low, intermediate, and high risk for event‐free survival provides information on absolute individual risks, which may support decisions for pharmacological and interventional management.

Background: Early treatment with a potent oral platelet P2Y 12 inhibitor is recommended in patients presenting with ST-segment elevation myocardial infarction (STEMI) planned to undergo primary percutaneous coronary intervention (pPCI). The impact on coronary reperfusion of crushed P2Y 12 inhibitor tablets, which lead to more prompt and potent platelet inhibition, is unknown. Methods: We conducted a randomized controlled, multicenter trial in the Netherlands, enrolling STEMI patients planned to undergo pPCI. Patients were randomly allocated to receive in the ambulance, before transfer, a 60 mg loading dose (LD) of prasugrel either as crushed or integral tablets. The independent primary end points were thrombolysis in myocardial infarction (TIMI) 3 flow in the infarct-related artery (IRA) at initial coronary angiography, and complete (≥70%) ST-segment resolution one hour post-pPCI. The safety end points were TIMI major and bleeding academic research consortium (BARC) ≥3 bleedings. Secondary end points included platelet reactivity and ischemic outcomes. Results: A total of 727 patients were assigned to either crushed or integral tablets of prasugrel LD. The median time from study treatment to wire-crossing during pPCI was 57 [47 - 70] minutes. The primary end point TIMI 3 flow in the IRA pre-pPCI occurred in 31.0% in the crushed group vs. 32.7% in the integral group (OR 0.92 [95% CI 0.65 - 1.30], P=0.64). Complete ST-segment resolution one hour post-pPCI was present in 59.9% in the crushed group vs. 57.3% in the integral group (OR 1.11 [95% CI 0.78 - 1.58], P=0.55). Platelet reactivity at the beginning of pPCI, measured as P2Y12 reactivity unit, differed significantly between groups (crushed, 192 [132 - 245] vs. integral, 227 [184 - 254], P=<0.01). TIMI major and BARC ≥3 bleeding occurred in 0% in the crushed group vs. 0.8% in the integral group, and in 0.3% in the crushed group vs. 1.1% in the integral group, respectively. There were no differences observed between groups regarding ischemic events at 30 days. Conclusions: Pre-hospital administration of crushed prasugrel tablets does not improve TIMI 3 flow in the IRA pre-pPCI or complete ST-segment resolution 1h post-pPCI in patients presenting with STEMI planned for pPCI. Clinical Trial Registration: URL: https://www.clincialtrials.gov; Unique identifier: NCT03296540.

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