The ACVC certification programme: gaining competencies in Acute CardioVascular Care.

As cardiovascular care evolves at a rapid pace, so too does our understanding of the intricacies surrounding the diagnosis, treatment, and prognosis of patients with acute cardiovascular conditions. In the March issue of the European Heart Journal-Acute Cardiovascular Care, we delve into a collection of pivotal studies and expert perspectives that may help reshape our approach to managing acute myocardial in-farction (AMI), myocardial injury, and chronic coronary syndromes. Boeddinghaus et al. 1 present a groundbreaking prospective cohort study, offering a new classification system for Type 2 myocardial infarc-tion (MI) based on cardiac imaging with coronary angiography and cardiac magnetic resonance imaging (MRI). This classification challenges traditional diagnostic thresholds, separating out those without obstructive coronary disease or myocardial abnormality and seeking to provide clearer pathways to understanding the underlying pathology, with crucial implications for patient outcomes and preventive therapies. The study's findings emphasize the value of imaging in refining diagnoses and risk assessment in suspected Type 2 MI. In a different vein, Restan et al. 2 offer an important validation study on the Siemens Atellica IM high-sensitivity cardiac troponin I assay. This study provides compelling evidence for the assay's potential to optimize cardiac evaluations in emergency departments globally, bringing clarity to the decision-making process for patients presenting with non-ST-elevation MI (NSTEMI). Their findings underscore the potential of rapid, high-sensitivity assays to transform acute care settings and improve patient outcomes. Alaoui-Ismaili et al. 3 investigates a niche but important intersection between post-cardiac neuroprognostication in AMICS (Acute myocar-dial infarction complicated by cardiogenic shock) patients supported by the Impella micro-axial flow pump, revealing the confounding impact of haemolysis on neuron-specific enolase (NSE) levels. The study calls for caution in interpreting NSE levels, highlighting the complexity of prognostic markers in this patient population. These findings have significant implications for patient management and the interpretation of biomarkers in acute cardiovascular care. Additionally, our Perspectives section explores the 2024 European Society of Cardiology guidelines for chronic coronary syndromes, with an in-depth focus on ischaemia with non-obstructive coronary arteries (INOCAs) 4 and antithrombotic therapy, providing expert insights into these complex conditions. 5 Furthermore, Hickman et al.'s 6 educational paper critiques the evolving role of the 99th per-centile in cardiac troponin assays, stressing the importance of context and understanding the limitations of this threshold in clinical decision-making. Finally, Verbeeck et al. 7 present a timely examination of the shift towards patient-centric outcomes in clinical trial design, advocating for the increasing importance of superiority trials over non-inferiority designs. This shift is exemplified by the REC-CAGEFREEI trial, which provides critical insights into how we assess and improve therapies aimed at enhancing patient safety and well-being. Finally, we like to take this opportunity and warmly invite you to explore the latest advancements in acute cardiovascular and intensive care at this year's Annual Conference in Florence. This event promises to be an extraordinary gathering of experts, where cutting-edge research, transforma-tive treatment approaches, and practical solutions to the most pressing challenges in cardiovascular care will be shared. Join us for an inspiring experience that will enhance your knowledge, broaden your perspective, and strengthen your network. Whether you are a clinician, researcher, or healthcare professional, this conference is an opportunity to stay at the forefront of your field and engage with peers who share your passion for improving patient outcomes. Do not miss out on the chance to be part of this pivotal event-discover more, connect with the best, and shape the future of acute cardiovascular and intensive care!

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/ critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Acute cardiovascular care consists in a large range of well-defined pathologies and expertise. They are needed to manage these most critically ill cardiovascular patients with evidence suggesting this is associated with improved outcomes. This chapter presents the different levels of training and available curricula in acute cardiovascular care especially the ESC-ACCA certification process.

Patient and public involvement is a fundamental part of research design and is increasingly required by research funders and regulators. In addition to the moral and ethical arguments in its favour, it has the potential to improve the accessibility and transparency of research, and to optimise study recruitment and retention. While clinical trials in acute cardiovascular care have traditionally focussed on "hard" outcomes, such as mortality or major adverse cardiovascular events, there is increasing recognition that these fail to capture the full breadth of patient experience. Patient-centred outcomes aim to measure things of greater value to patients, using validated tools to quantify symptoms, patient self-reports, or novel outcomes such as days alive and outside hospital. This In Perspective commentary explores the rationale behind patient and public involvement, the background to and evidence supporting the use of patient-centred outcomes, and discusses potential challenges and how they can be mitigated.

Vranckx, P (corresponding author), Jessa Ziekenhuis, Dept Cardiol & Crit Care Med, Stadsomvaart 11, B-3500 Hasselt, Belgium.; Vranckx, P (corresponding author), Hasselt Univ, Fac Med & Life Sci, Martelarenlaan 42, B-3500 Hasselt, Belgium.

Frailty is a health condition leading to many adverse clinical outcomes. The relationship between frailty and advanced age, multimorbidity and disability has a significant impact on healthcare systems. Frailty increases cardiovascular (CV) morbidity and mortality both in patients with or without known CV disease. Though the recognition of this additional risk factor has become increasingly clinically relevant in CV diseases, uncertainty remains about operative definitions, screening, assessment, and management of frailty. Since the burdens of frailty components and domains may vary in the various CV diseases and clinical settings, the relevance of specific frailty-related aspects may be different. Understanding these issues may allow general cardiologists a clearer focus on frailty in CV diseases and thereby make more tailored clinical decisions and therapeutic choices in outpatients. Guidance on identification and management of frailty are sparse and an international consensus document on frailty in general cardiology is lacking. Moreover, new options linked with eHealth are going to better define and manage frailty. This consensus document on definition, assessment, clinical implications, and management of frailty provides an input to integrate strategies pre- and post-acute CV events with a comprehensive view including out of hospital, office-based diagnostic and therapeutic choices, and based on a multidisciplinary team approach (general cardiologists, nurses, and general practitioners).

Out-of-hospital cardiac arrest (OHCA) represents a major public health challenge, with high mortality and significant neurological impairments among survivors. Haemodynamic instability, particularly hypotension (a mean arterial blood pressure <65 mmHg), may be a key contributor to post-resuscitation morbidity and mortality. After return of spontaneous circulation, hypotension can result from various causes, including arrhythmias, mechanical complications, thromboembolism, or different types of shock, as well as sedation, temperature control and positive pressure ventilation. Differentiating between hypotension with vs. without hypoperfusion is critical to avoid unnecessary interventions while ensuring adequate cerebral and myocardial perfusion. Clinical assessment and repeated echocardiography should be routine in all patients. Therapeutic targets should include evidence of preserved end-organ function, including urine output, and normal or decreasing lactate. In selected cases, advanced haemodynamic monitoring with pulmonary artery catheters may be necessary to diagnose the shock-type and monitor treatment effects. Causal treatment of the precipitating cause of hypotension is crucial as well as symptomatic treatment with fluids, vasopressors and inotropes if needed. Mechanical circulatory support may be employed for refractory shock unresponsive to other treatment. This clinical consensus statement by the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology (ESC) provides clinical guidance for the haemodynamic monitoring and management of hypotension in OHCA patients in intensive care. The document advocates for a multidisciplinary approach that integrates clinical assessment, imaging, and haemodynamic parameters to guide treatment, with the overarching goal of improving survival rates and neurological outcomes.

Catheter-directed interventions in acute pulmonary embolism. Position statement of SEC-Interventional Cardiology Association/SEC-Ischemic Heart Disease and Acute Cardiovascular Care Association/SEC-GT Pulmonary Hypertension Working Group

Imaging plays an integral role in all aspects of managing heart disease and cardiac imaging is a core competency of cardiologists. The adequate delivery of cardiac imaging services requires expertise in both imaging methodology-with specific adaptations to imaging of the heart-as well as intricate knowledge of heart disease. The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging have developed and implemented a successful education and certification programme for all cardiac imaging modalities. This programme equips cardiologists to provide high quality competency-based cardiac imaging services ensuring they are adequately trained and competent in the entire process of cardiac imaging, from the clinical indication via selecting the best imaging test to answer the clinical question, to image acquisition, analysis, interpretation, storage, repository, and results dissemination. This statement emphasizes the need for competency-based cardiac imaging delivery which is key to optimal, effective and efficient, patient care.

Background Hemodynamic profiling in acute cardiovascular care has been essential in acute heart failure (AHF) for prognosis and decision-making. Traditional, invasive, methods have limitations, while non-invasive imaging, like echocardiography and lung ultrasound, offers a promising alternative, highlighting the need for an improved classification system. Purpose This study aims to reclassify the Nohria profile using VExUS protocol and VTI LVOT to assess major adverse cardiovascular events (MACE) in acute heart failure (AHF) patients and evaluate its prognostic value. Methods A retrospective single-centre study was conducted with adult AHF patients who underwent bedside echocardiography within 24 hours of admission. The VExUS protocol and VTI LVOT measurements were used to reclassify the Nohria profiles into four categories based on congestion and hypoperfusion. The primary endpoint was the occurrence of MACE within 30 days. The secondary endpoint compared the prognostic accuracy of VTI/VExUS index with traditional clinical assessment using ROC curve analysis. Results A total of 167 patients were included, with a mean age of 58.2 years, and 72.4% were male. Distribution across the Nohria profiles was as follows: 46.7% in Profile 0, 15.6% in Profile 1, 22.1% in Profile 2, and 15.6% in Profile 3. The VTI/VExUS-based classification showed an AUC of 0.74 (95%) for predicting MACE, compared to 0.58 (95%) for the adapted Nohria classification. During the 30-day follow-up, 48 patients (28.5%) experienced MACE, including 13 deaths (7.7%), 23 cases of cardiogenic shock (13.8%), 43 requiring mechanical ventilation (25.9%), 13 requiring a ventricular assist device (7.7%), and 71 requiring inotropes (42.7%). Kaplan-Meier survival curves indicated significantly poorer outcomes for Profile 3, with a higher incidence of MACE. Log-rank test showed a significant prognostic difference between VTI/VExUS profiles (HR 1.93, 1.49–2.49, P &amp;lt;0.001). Conclusion The VTI/VExUS index demonstrated that it redefines Nohria’s profiles, improving prognostic accuracy compared to traditional methods. This non-invasive tool has the potential to enhance clinical decision-making and patient outcomes. However, further research is needed to confirm its validity and broader applicability in clinical practice.Flow chart KM for each new classification profile

Nitroglycerine (glyceryl trinitrate) remains one of the most extensively utilized vasodilators in cardiovascular medicine, with a therapeutic legacy spanning over 150 years. Despite the emergence of novel anti-anginal and heart failure therapies, nitroglycerine continues to serve as a cornerstone agent for rapid symptomatic relief in angina pectoris and acute coronary syndromes. This review provides a comprehensive and mechanistically integrated analysis of nitroglycerine, encompassing its chemical characteristics, pharmacokinetic profile, nitric oxide–mediated signaling pathways, hemodynamic effects, clinical indications, adverse effects, drug interactions, and the phenomenon of nitrate tolerance. Particular emphasis is placed on mitochondrial aldehyde dehydrogenase (ALDH2)- dependent bioactivation, cyclic guanosine monophosphate (cGMP) signaling, and emerging insights into pharmacogenomic variability influencing therapeutic response. Contemporary clinical applications in acute coronary syndromes, hypertensive emergencies, pulmonary edema, perioperative blood pressure control, and special populations are critically examined alongside limitations related to tachyphylaxis and long-term efficacy. Furthermore, evolving research directions, including nanoformulations, sustained-release delivery systems, and comparative effectiveness against newer anti-anginal agents, are discussed to contextualize the modern relevance of this classical therapy. While nitroglycerine does not confer demonstrated mortality benefit in chronic coronary disease, its rapid onset of action and predictable hemodynamic profile sustain its indispensable role in acute cardiovascular care. Ongoing translational research aimed at optimizing delivery strategies and overcoming tolerance mechanisms may further refine its clinical utility in contemporary cardiovascular therapeutics.

Background: Sex disparities exist in acute cardiovascular care. Despite sex-specific cardiac arrest (CA) research being identified as a priority by professional societies, there are limited studies on this topic. Objectives: To assess sex disparities in management and outcomes of CA complicating acute myocardial infarction (AMI) in a contemporary United States population. Methods: Adult admissions with a primary diagnosis of AMI and concomitant diagnosis of CA were identified using the National Inpatient Sample. Outcomes of interest included sex disparities in in-hospital mortality, coronary angiography (CAG), percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS) use. Results: Between January 1, 2000 and December 31, 2017, 11,622,528 admissions for AMI were identified, of which 584,216 (5.0%) were complicated by CA. Men had higher prevalence of CA compared to women (5.4% vs 4.4%, p&lt; 0.001) in both STEMI and NSTEMI (2017 vs 2000, STEMI-men: 12.3% vs 7.8%, STEMI-women: 10.4% vs 7.5%, NSTEMI-men: 3.1% vs 2.7%, NSTEMI-women: 2.4% vs 2.5%). Women with AMI-CA were on average older (70.4 vs 65.0, p&lt;0.001), of black race (12.6% vs 7.9%, p&lt;0.001) and had higher comorbidity. Women were more likely to present with NSTEMI (36.4% vs 32.3%, p&lt;0.001) and a non-shockable rhythm (47.6% vs 33.3%, p&lt;0.001). Women less frequently received CAG (56.0% vs 66.2 %), early CAG (32.0% vs 40.2%), PCI (40.4% vs 49.7%), MCS (17.6% vs 22.0%), and CABG (all p&lt;0.001). Women had significantly higher unadjusted in-hospital mortality (52.6% vs 40.6%, p &lt; 0.001). In a multivariable logistic regression analysis, female sex was associated with higher in-hospital mortality (OR 1.13 [95% CI 1.11-1.14]; p&lt; 0.001). When stratified by type of rhythm, type of AMI, presence of cardiogenic shock and location of CA, women consistently received less frequent CAG and experienced higher in-hospital mortality. Conclusion: In the largest 18-year study evaluating management and outcomes of CA in AMI, we identified the presence of significant sex disparities. Women with AMI-CA were older, with higher rates of non-shockable rhythm, were less likely to undergo therapeutic procedures including CAG, PCI, and MCS. Women had higher unadjusted and adjusted in-hospital mortality.

D-dimer testing is important to aid in the exclusion of venous thromboembolic events (VTEs), including deep venous thrombosis and pulmonary embolism, and it may be used to evaluate suspected aortic dissection. D-dimer is produced upon activation of the coagulation system with the generation and subsequent degradation of cross-linked fibrin by plasmin. Many different assays for D-dimer testing are currently used in routine care. However, these tests are neither standardized nor harmonized. Consequently, only clinically validated assays and assay specific decision limits should be used for routine testing. For the exclusion of pulmonary embolism/deep vein thrombosis, age-adjusted cut-offs are recommend. Clinicians must be aware of the validated use of their hospital's D-dimer assay to avoid inappropriate use of this biomarker in routine care.

An interview with Dr