bluuebunny/crossref_metadata_2025 huggingface dataset:
P6360Prognostic value of polypharmacy in patients with heart failure
Authors: Fujita R , Takabayashi K , Iwatsu K , Matsumura K , Ikeda T , Kitaguchi S , Nohara R
Published: October 2019

Background

Polypharmacy creates an increased patient's burden by drug-drug interactions and poor adherence. However, there are very few studies available evaluating the association of polypharmacy with hospital readmission in patients with heart failure (HF).

Purpose

The aim of this study was to investigate the impact of polypharmacy on hospital readmission for HF.

Methods

We enrolled 1253 patients who were hospitalized with acute heart failure (AHF) or acute exacerbation of chronic heart failure in the Kitakawachi Clinical Background and Outcome of Heart Failure Registry (KICKOFF Registry) from April 2015 to July 2018 (age 78.1±11.5 years, male 51.4%). Our Registry is a prospective multicenter community-based cohort study of HF patients in Japan. The inclusion criteria for the registry was a diagnosis of HF during hospitalization according to the Framingham criteria, and there were no exclusion criteria. From data at discharge, we collected data on clinical characteristics, medication schedule, and social backgrounds. We defined polypharmacy as the use of seven or more medications. The primary end point was HF rehospitalization within 1 year after discharge. Cox proportional hazards regression analysis was used to describe the association between polypharmacy and 1-year HF rehospitalization, controlling for potential confounding factors.

Results

In this study, the prevalence of polypharmacy was 59.7% of all patients. Patients with polypharmacy were more likely to have comorbidities such as hypertension, dyslipidemia, diabetes, chronic kidney disease, coronary artery disease and dementia. They also had lower EF (50.9±0.64 vs 53.6±0.80, p<0.01), compared to patients without polypharmacy. There was no significant difference in age, gender and BMI, compared to patients without polypharmacy. During the follow-up period, a total of 278 patients (24.9%) were readmitted for HF. In Kaplan-Meier analyses, hospital readmission for HF during 1-year follow-up was significantly higher in patients with polypharmacy (p<0.01) (figure). After adjusting for gender, age, EF, and the other co-morbidities, polypharmacy was independently associated with higher risk of rehospitalization for HF (hazard ratio 1.28, 95% confidence interval, 1.07–1.52, p<0.01).

Conclusion

Polypharmacy is an independent predictor of hospital readmission for HF. Our study suggests the need for developing an effective strategy to choose the appropriate drugs in patients with HF.

Acknowledgement/Funding

Nakajima Steel Pipe
P6371Network characteristics of a hypertension referral system in western kenya
Authors: Thakkar A , Valente T , Andesia J , Njuguna B , Miheso J , Mercer T , Mwangi E , Pastakia S D , Pillsbury M M , Pathak S , Kamano J , Naanyu V , Vedanthan R , Bloomfield G S , Akwanalo C
Published: October 2019

Introduction

The Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) trial is creating and testing interventions to improve the effectiveness of referral networks for patients with hypertension in Western Kenya.

Purpose

Network analysis of facility-based healthcare providers was used to understand the existing network of referrals. The ultimate goal was to identify both structural gaps and opportunities for implementation of the planned intervention.

Methods

A network survey was administered to providers who deliver care to patients with hypertension asking individuals to nominate a) individuals to whom, and b) facilities to which they refer patients, both up and down the health system. We analyzed survey data using centrality measures of in-degree and out-degree (number of links each provider received and sent, respectively), as well as fitting a core-periphery (CP) model. A higher CP indicates a strong referral network, while a lower CP indicates a relatively weaker network.

Results

Data were collected from 130 providers across 39 sites within 7 geographically separate network clusters. Each cluster consists of a mix of primary, secondary, and/or tertiary facilities. Compared to a perfect CP referral network model (Correlation Score [CP] = 1.00) and a random referral network model (CP = 0.200), the provider referral networks within each cluster showed a weak tendency for CP structure. There was a large range in CP from 0.334 to 0.639. In contrast, cluster-level facility networks showed a strong tendency for CP structure, with a CP range of 0.857 to 0.949.

Core Periphery Correlation Scores [CP] Network Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 Cluster 7 Provider Referrals 0.433 0.424 0.334 0.639 0.535 0.448 0.407 Facility Referrals 0.949 0.894 0.871 0.949 0.949 0.904 0.857 Each cluster represents a geographically separate referral network. A random referral network would reveal a CP score of 0.200; while a perfect referral network would give a CP of 1.00.

Referral Network Models

Conclusions

The current health system across Western Kenya does not demonstrate a strong network of referrals between providers for patients with hypertension. While facility-to-facility referrals are more in-line with a perfect referral model, there are gaps in communication between the specific providers. These results highlight the need for STRENGTHS to design and test interventions that strengthen provider referral patterns in order to improve blood pressure control and reduce cardiovascular risk.

Acknowledgement/Funding

National Institutes of Health: National Heart Lung and Blood Institute, Doris Duke Charitable Foundation:International Clinical Research Fellowship
P6384Thrombotic-hemorrhagic balance evaluation in STEMI patients with or without associated cardiac arrest: an observational study
Authors: Picard F , Diefenbronn M , Laghlam D , Llitjos J F , Sokoloff A , Varenne O , Dumas F , Cariou A
Published: October 2019

Background

Data is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA).

Purpose

We sought to evaluate the difference in the thrombotic-hemorrhagic balance in STEMI patients with or without associated cardiac arrest.

Methods

This is a monocentric, retrospective study conducted from January 2012 to December 2017. Over the study period, all consecutive patients who were treated for STEMI with our without OHCA were included. Baseline characteristics, treatments, haemorrhagic and thrombotic events were compared between STEMI patients associated or not with OHCA. Univariate and multivariate analysis were performed to identify predictors of 30-day mortality, occurrence of major bleeding, defined by BARC score ≥3 and early stent thrombosis.

Results

A total of 549 patients treated for STEMI and 146 patients for STEMI associated with OHCA were included. The incidence of stent thrombosis and major bleeding after coronary angioplasty in patients treated for STEMI was significantly higher when associated with OHCA (2.7% vs. 12.3%, p=0.04 and 3.3% vs. 19.2%, p<0.001, respectively). Independent predictors of major bleeding in OHCA patients were effective anticoagulation (HR=3.11, 95% CI [1.22–7.98], p=0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR=4.16, 95% CI [1.61–10.79], p=0.003). Independent predictors of mortality in STEMI associated with OHCA were age (HR=1.05, 95% CI [1.02–1.09], p=0.004) and stent thrombosis (HR=5.62, 95% CI [1.61–19.65], p=0.007, with a protective effect of new anti-P2Y12 treatments (HR=0.20, 95% CI [0.08–0.46], p<0.001).

Clinical outcomes at 30 days follow-up

Conclusion

Patients treated for STEMI associated with OHCA are at higher-risk of stent thrombosis and bleeding than those who did not experience cardiac arrest. The use of effective anticoagulation and glycoprotein IIb/IIIa inhibitors contributes to increase bleeding complications. In this subset of patients, prospective studies are needed to better evaluate thrombotic and haemorrhagic balance.
P6391Major acute cardiovascular events in patients with inflammatory bowel disease
Authors: Gill G , Fernandez S , Soud M , Mete M , Malhotra N , Garcia-Garcia H M
Published: October 2019

Introduction

Traditional risk factors for coronary heart disease have been reported in around 85% patients who present with myocardial infarction. More recently, inflammation and immune mediated diseases have been associated with ischemic heart disease.

Inflammatory Bowel Disease (IBD) is an immune mediated disorder which comprises of ulcerative colitis and Crohn's disease. Estimated prevalence of IBD in the United States in 2004 was 1.4 million people. These patients have an overall increased risk of thrombotic complications with microvascular thrombosis hypothesized to contribute in disease pathogenesis.

Results from a recent meta-analysis were consistent with increased risk of ischemic heart disease among IBD patients, with risk greater in females and younger patients, although heterogeneity was considerable in overall data. Also, in a recent study, IBD was found to be associated with an increased risk of acute myocardial infarction and heart failure despite lower prevalence of coronary risk factors in IBD patients.

IBD pathogenesis involves sustained activation of immune responses with upregulation of cytokines including but not limited to IL-1 beta, IL-6 and TNF-alpha. Upregulation of these cytokines has also been reported in coronary atherosclerosis.

Based on above information, we explored incidence of MACE (Major Adverse Cardiac Event) in this patient population from our health system data-base.

Methods

Propensity scores were estimated for all 15,292 (0.4%) patients with inflammatory bowel disease from a total patient pool of 3,917,894 patients in our health system to assemble a 1:1 matched cohort balanced for age, gender, race and known cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus and smoking (current and former). ICD-9 and ICD-10 codes were used to identify cardiovascular risk factors and outcomes.

Results

Matched patients (n=30,584) had a mean age of 51 years, with 58% of all being women, and 63% Caucasian. During the median follow up of 4.4 years all-cause mortality was observed in 1.7% and 1.2% of patients from IBD and non-IBD groups respectively (hazard ratio {HR}, 1.31; 95% confidence interval {CI}, 1.08–1.58; p=0.005). Combined outcome for myocardial infarction or all-cause mortality was noted in 4.1% and 3.4% from IBD and non-IBD groups respectively (HR, 1.16; 95% CI, 1.03–1.30; p=0.014) while HRs for cardiovascular mortality, myocardial infarction and unstable angina independently were 1.04 (0.74–1.47; p=0.833), 1.05 (0.89–1.23; p=0.591) and 1.10 (0.83–1.46; p=0.524) respectively.

Conclusion

Inflammatory bowel disease did not show association with myocardial infarction, cardiovascular mortality or unstable angina when matched for known cardiovascular risk factors, but was associated with increased all-cause mortality and combined end-point of all-cause mortality or myocardial infarction.
P6430Does positive family history for premature coronary artery disease increase the cardiovascular risk among elderly?
Authors: Traub Kormann D , Cerci R , Zapparoli M , Antonio Fruet Bettini L , Henrique Ramos Prado P , Vitola J , Morita Fernandes Da Silva M
Published: October 2019

Background

Family history (FH) for premature coronary artery disease (CAD) increases the risk of coronary artery disease and appears to be independently associated with high coronary artery calcium scores (CAC). However, it is uncertain if the positive FH predict high CAC among elderly individuals, as it does among younger individuals.

Objective

We investigated whether the association between family history (FH) for premature coronary artery disease and coronary calcium scores differs according to age.

Methods

We evaluated individuals referred to 128-slice multi-detector computed tomography to measure CAC scores at a single center from 2011 to 2017. Individuals with known CAD or typical angina were excluded. Positive FH was defined as first-degree relatives with early onset CAD (men ≤55 years, women ≤65 years). High CAC scores were defined as above 100 Agatston or higher than the 75th percentile for age and sex. The participants were divided in two age categories: “Younger age” for men ≤55 years old or women ≤65 years old, and “Older age” otherwise.

Results

We evaluated 3187 individuals ageing from 18 to 92 years, 54% (n=1721) being categorized as “Younger age”. Overall, participants with positive FH (n=759) were younger (56±12 vs 60±13) and more frequently women (54% vs 48%) than those with negative FH. Positive FH was independently associated with high CAC, after adjustment for age, sex, body mass index, smoking status, hypertension, diabetes mellitus, dyslipidemia and sedentary lifestyle. This association was similar between individuals at “Younger age” [Odds Ratio 1.46 (95% Confidence Interval 1.15 - 1.86)] and individuals at “Older Age” [OR 1.65 (95% IC 1.23 - 2.20), p for interaction = 0.79, Figure]

Conclusion

Positive FH for premature CAD was associated with higher CAC scores, independently of other cardiovascular risk factors, and this association was similar between younger and older individuals.
P6469Predictive value of currently available echocardiographic work-up algorithm for previous and updated pulmonary hypertension definitions
Authors: Tanyeri S , Akbal O Y , Keskin B , Hakgor A , Karagoz A , Tokgoz H C , Kulahcioglu S , Erdogan E , Tanboga I H , Dogan C , Acar R D , Ozdemir N , Kaymaz C
Published: October 2019

Background and aim

In this study we evaluated the predictive value of currently available European Society of Cardiology 2015 Pulmonary Hypertension (PH) Guidelines two-step echocardiographic (Echo) work-up algorithm for two PH definitions as invasively evaluated pulmonary arterial mean pressures (PAMP) ≥25 mmHg and >20 mmHg.

Methods

Study group comprised the retrospectively evaluated 1299 patients (pts) (53.1±18.8 years, female 807, 62.1%) who underwent right heart catheterisation (RHC) with different indications between 2006 and 2018. Echo data obtained from same day and pre-RHC evaluation were available in all pts. Chemla method was used for Doppler estimation of PAMP from tricuspid regurgitant jet. For two PH definitions as PAMP ≥25 mmHg (definition-A) and PAMP >20 mmHg (definition-B) predictive value of the ESC Echo algorithm was tested with two logistic regression models based on only PAMP-Echo (Model-1) and PAMP-Echo and Echo findings supportive for PH (Model-2).

Results

RHC revealed that criteria for PH definitions A and B were met in 891 (68.6%) and 1051 (80.9%) of overall pts. Pre-RHC Echo findings supportive for PH were noted in 529 (40.7%) of pts. Because pulmonary regurgitant velocity data were imprecise, other 6 supportive Echo findings were utilised. The % of the supportive Echo measures were as follows; 1 (11%), 2 (10%),3 (8.1%), 4 (7.2%), 5 (2.5%) and 6 (1.8%). In Model-1, for definitions A and B, odds ratio (OR) of PAMP-Echo were (1.07; 0.99–1.19, p=0.058, LRX2:139, c: 0.72) and (1.05; 0.98–1.12, p=0.102, LRX2:129, c: 0.71), respectively.

In Model-2, for definition-A, OR of PAMP-Echo and number of supportive findings were (1.05; 0.98–1.12, p=0.162) and (1.58; 1.42–1.75, p<0.001) (LRX2:217, c: 0.77), respectively. Using the same model for definition-B, OR of PAMP-Echo and number of supportive findings were (1.04; 0.97–1.11, p=0.264) and (1.56; 1.40–1.73, p<0.001),(LRX2:203, c: 0.76), respectively. Receiver operating curve (ROC) analysis yielded that PAMP-Echo >39.8 mmHg had a sensitivity of 80% and a specificity of 54% for definition-A, and a sensitivity of 81% and a specificity of 52% for definition-B, respectively. Regardless of the definition tresholds for PH on RHC, number of supportive Echo findings were responsible for nearly 70% of the overall variance in the PH diagnosis.

Conclusions

Irrespective of the RHC definition criteria as PAMP ≥25 mmHg or >20 mmHg, number of supportive Echo findings but not PAMP-Echo only approach seems to be reliable in the diagnostic work-up for PH.
P6534Prognostic implication of serum cystatin C and creatinine-based glomerular filtration rate ratio in coronary disease patients receiving PCI: a surrogate of low muscle mass and a predictor of mortality
Authors: Rhee T.-M , Park K W , Kim C.-H , Kang J , Han J.-K , Yang H.-M , Kang H.-J , Koo B.-K , Kim H.-S
Published: October 2019

Background

Low muscle mass results in impaired exercise capacity and is related with poor prognosis in chronic diseases. Although the ratio of serum creatinine (Scr) to cystatin C (Scys) is known as a surrogate marker of body muscle mass, the value of this marker is unclear in the patients with coronary artery disease (CAD).

Purpose

We assessed the clinical significance of two markers representing body muscle mass, the ratio of Scr to Scys (Scr/Scys), and ratio of estimated glomerular filtration rate by Scys to Scr (eGFRcys/eGFRcr).

Methods

We analyzed patients enrolled in a single tertiary center prospective percutaneous coronary intervention (PCI) registry that had Scr and Scys levels simultaneously measured before PCI. Optimal cut-off values of Scr/Scys and eGFRcys/eGFRcr, and their prognostic impact on 3-year mortality after PCI were analyzed. Subgroup analysis according to various demographics and risk factors was performed.

Results

A total of 1,928 patients who underwent PCI for significant CAD were analyzed (age 65.2±9.9 years, 70.8% men). Both Scr/Scys and eGFRcys/eGFRcr showed strong correlation with estimated proportion of muscle mass. Cut-off values of Scr/Scys discriminating 3-year death were 1.0 for men and 0.8 for women, while those of eGFRcys/eGFRcr were 1.1 for men and 1.0 for women. Both Scr/Scys- and eGFRcys/eGFRcr-based low muscle mass groups showed significantly higher risk of death, after adjusting for 7 selected covariates including age. The additional discriminative power of low muscle mass group on the predictive model was greater in the group determined by eGFRcys/eGFRcr than Scr/Scys. Low eGFRcys/eGFRcr values showed additional prognostic impact especially in patients older than 65 years, non-obese, men, chronic kidney disease, and current smokers.

Conclusions

Low muscle mass was an independent prognostic indicator in the patients who underwent coronary stenting. eGFRcys/eGFRcr was identified as a useful surrogate of muscle mass, which may be used to detect vulnerable patients with low muscle mass at high risk for future events.

Acknowledgement/Funding

None
P6535Atrial fibrillation and its impact in hospitalised cancer patients
Authors: Malik A H , Siddiqui N , Shetty S , Godara A , Khan Z , El Accaoui R
Published: October 2019

Background

Atrial fibrillation (AF) is associated with increased morbidity and mortality. However, its impact on outcomes of cancer patients is largely unknown. We sought to determine the prevalence and effect of AF on in-hospital outcomes of patients admitted with AF in the United States.

Methods

We obtained and analyzed data from Nationwide Inpatient Sample (NIS 2002- 2014). The study population included all adults (>18 years old) with the discharge diagnosis of cancer and the associated secondary diagnosis of AF. The associations of AF with in-hospital complications, procedures, discharge outcomes, and mortality, were analyzed after adjusting for potential confounders using logistic regression analyses.

Results

During the study period, 12,410,290 patients were admitted with cancer; of which, 1,013,735 (8.2%) had AF. Patients with AF were likely to be male (51.1% vs 42.7%), white (86.3% vs 73.6%), and had significantly higher rates comorbidities including hypertension (59.6% vs 44.6%), diabetes (20.9% vs 15.8%), heart failure (23.8% vs 4.5%), and stroke (1.3% vs 0.7%). Similarly, in-hospital complications (including infections, venous thromboembolism, gastrointestinal bleeding, myocardial infarction) and hospital procedures (including cardiac catheterization, intubation, blood transfusion, percutaneous coronary intervention) were found at a significantly higher rate in cancer patients with AF compared to without AF (p-value for all <0.0001). After adjusting for all confounding factors, cancer patients in the AF group had higher odds of in-hospital death (odds ratio, 1.26; 95% confidence interval, 1.23–1.28; P<0.0001). The presence of AF conferred on average three days of extra inpatient stay in patients with cancer. Mortality in the cancer patients admitted with a concomitant diagnosis of AF has gradually increased from 7.2% to 9.7% over the 13-year study period.

Table 1. Multivariate model showing Atrial fibrillation as an independent risk factor of inpatient mortality in cancer patients Unadjusted univariate model Multivariate model adjusted for age, sex, race and potential confounders* Odds ratio (95% confidence interval P-value Odds ratio (95% confidence interval P-value Discharged alive Reference Reference In-hospital mortality 2.08 (2.07, 2.10) <0.0001 1.26 (1.23, 1.28) <0.0001 *Confounders adjusted for include all clinical comorbidities and in-hospital complications and procedures.

Conclusions

In patients with cancer, AF confers significant in-hospital burden by increasing the hospital stay by 3 days. AF is also associated with significantly higher rates of in-hospital procedures and complications in cancer patients and is an independent risk factor of in-hospital mortality.

Acknowledgement/Funding

None
P6546Canadian Registry of Electronic Device Outcomes (CREDO): remote monitoring outcomes in the abbott battery performance alert, a multicentre cohort
Authors: Davis S , Thibault B , Mangat I , Coutu B , Bennett M , Philippon F , Sandhu R , Sterns L , Essebad V , Nery P , Wells G , Yee R , Exner D , Krahn A , Parkash R
Published: October 2019

Background

Cardiac implantable electronic devices have been known to have lead and device malfunctions leading to advisories. Increased use of remote monitoring of devices has been suggested to allow the identification of abnormal device performance and allow early intervention. We sought to describe the outcomes of patients with and without remote monitoring of in devices in the Abbott Premature Battery Depletion advisory with data from a Canadian registry

Methods

Patients with an Abbott device subject to the Battery Performance Alert Advisory from nine ICD implanting centres in Canada were included in the registry. The use of remote monitoring was identified from baseline and followup data in the registry. The primary outcome was detection of premature battery depletion and all cause mortality.

Results

2679 patents were identified with a device subject to the advisory. Devices were implanted between 2010 and 2017. 1716 patients (64%) had remote monitoring at baseline with this increasing to 83.7% at followup at 12 months. Premature battery depletion occurred in 43 patients (1.6%). Discovery of premature battery depletion was detected by remote monitoring in 70% of patients. There were 492 deaths during the follow up. Mortality was higher in those without a remote monitor compared to those with a remote monitor at follow-up and remote monitor at baseline and follow-up (11.3%, 2.6% versus 6.1% respectively; p=0.0186). There were no deaths attributed to premature battery depletion

Conclusion

The use of remote monitoring in patients with ICD and CRT under advisory reliably detected device failure and was associated with a reduction in all-cause mortality.
P6551Evaluation of a new ultra low-dose radiation protocol during electrophysiological device implantation
Authors: Eichenlaub M , Astheimer K , Restle C , Maring C , Blum T , Minners J , Schweitzer S , Thiel U , Neumann F.-J , Arentz T , Lehrmann H
Published: October 2019

Objectives

The aim of this study was to evaluate the impact of a new ultra low-dose radiation protocol on radiation doses, feasibility and safety during electrophysiological device implantation.

Background

Radiation is one of the main hazards during electrophysiological procedures. Shielding is especially difficult during device implantation and particularly implantation of cardiac resynchronisation therapy devices (CRT) is associated with high radiation doses.

Methods

From January 2005 to January 2019, 8612 patients underwent de novo device implantation at our University Heart Center.

During 2018, we established a new ultra low-dose radiation protocol and compared 661 patients who were treated during 2017 utilizing the conventional low-dose protocol with 512 patients after the application of the new program (11.5% one-chamber devices, 68.5% two-chamber devices and 19.9% CRT).

Results

After establishment of the radiation reduction protocol, dose area products could be reduced by 62% and the effective doses by 59% (113 (47–292) vs. 43 (14–130) cGycm2, p<0.0001 and 0.25 (0.11–0.63) vs. 0.10 (0.03–0.28) mSv, p<0.0001). These results could be achieved without prolonging procedure time, increasing complication and decreasing success rate.

Male gender, higher BMI, longer procedure and fluoroscopy duration and the use of the conventional radiation protocol were statistically significant factors for the need of higher radiation doses in multivariate regression analysis.

Clinical and procedural characteristics All (n=1173) Group pre (n=661) Group post (n=512) P Age, years 77 (69–82) 77 (69–82) 77 (69–83) 0.6 Male, n (%) 726 (62) 403 (61) 323 (63) 0.5 Body mass index, kg/m2 26.6 (24–29.8) 26.6 (24–29.8) 26.4 (24–29.4) 0.5 Procedure time, minutes 35 (25–50) 37 (26–50) 35 (25–54.5) 0.5 Fluoroscopy time, minutes 3.7 (2–7.8) 4 (2–7.8) 3.4 (1.9–7.7) 0.07 Dose area product, cGy cm2 80 (28–228) 113 (47–292) 43 (14–130) <0.0001 Effective dose, mSv 0.18 (0.06–0.51) 0.25 (0.11–0.63) 0.1 (0.03–0.28) <0.0001 Complications, n (%) 11 (0.9) 7 (1.1) 4 (0.8) 0.8

Conclusions

Radiation exposure during electrophysiological device implantation has been continuously reduced over the last years. By establishing a new ultra low-dose radiation protocol, we could further decrease the radiation dose significantly and reach the lowest radiation values published so far. This protocol can easily be implemented in the workflow of other hospitals and should become standard during implantation procedures.
P6559Long-term follow-up and outcomes of patients with discontinuation of oral anticoagulant therapy after successful ablation procedures for atrial fibrillation
Authors: Fujino T , Yuzawa H , Kinoshita T , Shinohara M , Koike H , Akitsu K , Yano K , Wada R , Suzuki T , Ikeda T
Published: October 2019

Background

Oral anticoagulant therapy (OAT) is effective for preventing strokes in atrial fibrillation (AF) patients. Currently, there is controversy regarding the discontinuation of OATs in patients with ablation procedures to eliminate AF.

Aim

We investigated the incidence of major bleeding and ischemic strokes/systemic embolisms in low-risk patients that discontinued OATs after successful AF ablation procedures.

Methods

Of 330 consecutive patients that underwent AF ablation procedures and were prescribed one of the direct oral anticoagulants or warfarin, 207 AF patients (158 men, mean age 61±11 years) who discontinued OATs three months after the procedure were enrolled. The average CHADS2 and HAS-BLED scores were 1.0±0.9 and 1.2±1.0, respectively, which meant that most patients had a low risk for strokes.

Results

During follow-up, 31 patients (15%) had recurrences of AF. Those patients underwent a re-ablation procedure and then re-discontinued their OATs three months after the session. During a 60±13 months follow-up, major bleeding was observed in five patients (2.4%) and was associated with a higher HAS-BLED score (2.2±0.4 vs. 1.1±1.0, P=0.027). In contrast, none of the patients experienced ischemic strokes/systemic embolisms.

Conclusions

This prospective study demonstrated that in patients with successful ablation procedures and low risk scores for AF management, OATs could be discontinued three months after the procedure. Unnecessary continuation of OATs may increase the incidence of major bleeding during the follow-up.
P6585Number of ECG leads and prognosis of spontaneous type 1 Brugada syndrome
Authors: Probst V , Arnaud M , Behar N , Mabo P , Guyomarch B , Tixier R , Briand J , Berthome P , Mansourati J , Babuty D , Maury P , Clerici G , Thollet A , Sacher F , Gourraud J B
Published: October 2019

Introduction

Brugada syndrome (BrS) is an inherited arrhythmia syndrome with an increased risk of sudden cardiac death (SCD). The recent single lead-based diagnosis of Brugada syndrome recommended criterion may lead to overdiagnosis of Brugada syndrome and overestimation of the risk of SCD.

Objective

We aim to investigate the value of a single lead diagnosis in spontaneous type 1 ECG Brugada patient and to investigate the association between the number of ECG leads with a spontaneous type 1 ST elevation and the arrhythmic risk.

Methods

Consecutive patients affected with BrS were recruited in a multicentric prospective registry in France (15 centers) between 1994 and 2016. A total of 1613 patients affected by the Brugada syndrome were enrolled. For this specific study, only patient with a spontaneous type 1 BrS were enrolled (n=505). Data were prospectively collected with an average follow-up of 6.5±4.7 years. ECGs were reviewed by 2 physicians blinded to clinical status. Type 1 ST elevation was defined by ≥2 mm J-point elevation with coved ST segment and negative T wave.

Results

A total of 505 patients with a spontaneous type 1 BrS (mean age 46±15 years, 398 males, 79%) were enrolled. 117 patients (23%) were symptomatic at baseline (32 (6%) aborted SCD, 85 (17%) syncope). Implantable cardiac defibrillator (ICD) was implanted in 191 patients (38%).

Brugada ECG pattern was found in 1 lead in 250 patients (50%, group 1), in 2 leads in 227 patients (45%, group 2) and in 3 leads in 28 patients (5%, group 3). Groups were comparable in term of clinical presentation except for group 3 who presented more frequently an early repolarization pattern (n=19 (8%) in group 1, n=15 in group 2 (6%) and n=7 (25%) in group 3, p=0.02) and more frequently QRS fragmentation (n=6 (2%) in group 1, n=3 in group 2 (1%) and n=3 (11%) in group 3, p=0.03).

During follow-up, 46 (9%) patients presented an arrhythmic event: 22 (9%) in group 1 (4 SCD, 14 appropriate ICD therapy, 4 ventricular arrhythmias), 22 (10%) in group 2 (6 SCD, 11 appropriate ICD therapy, 5 ventricular arrhythmias) and 2 (7%) in group 3 (1 SCD, 1 appropriate ICD therapy). Patients with type 1 BrS pattern in 2 or 3 ECG leads had not a significantly higher rate of arrhythmic events than patients with type 1 BrS pattern in only 1 ECG lead (HR: 1.1; 95% CI: 0.6–1.9 for group 2 and HR: 0.7; 95% CI: 0.2–3 for group 2; p=0,087).

Conclusion

In the largest cohort of BrS patients ever described, the prognosis of Brugada syndrome with a spontaneous ECG pattern does not appear to be affected by the number of leads required for diagnostic.
P6602Plasma signature of apoptotic microparticles in acute coronary syndromes is associated with endothelial dysfunction and plaque rupture
Authors: Zacharia E , Papageorgiou A , Antonopoulos A S , Pallantza Z , Oikonomou E , Miliou A , Mistakidi C V , Kriebardis A , Orologas N , Valasiadi E , Papaioannou S , Tousoulis D
Published: October 2019

Background

Circulating microparticles (MP) are surrogate biomarkers of atherosclerosis and are elevated in acute coronary syndromes (ACS) but its exact biological role remains unknown.

Purpose

To explore the diagnostic and biological significance of circulating apoptotic MP signature in patients with ACS.

Methods

We enrolled 122 ACS patients: n=38 with unstable angina (UA), n=49 with STEMI, 35 with NSTEMI. Flow cytometry analysis was used to quantify circulating apoptotic (annexin+) endothelial cell (EMP), red blood cell (RMP) and platelet (PMP) derived microparticles. Endothelial function was estimated with flow mediated dilation (FMD), and inflammatory status with C-reactive protein (hsCRP).

Results

The association between EMP, RMP and PMP is shown on a cloud plot (A). Using an unbiased approach, we performed hierarchical clustering (A) of the total population of patients with ACS by using the circulating levels of EMP, RMP and PMP (B). Hierachical clustering identified two discreet clusters of patients (Cluster A and B) without any differences in the presence of traditional risk factors (not shown), but significant differences in the distribution of ACS type (C). STEMI subtype (a surrogate for definite plaque rupture) was significantly increased in Cluster B, which also had significantly decreased FMD (D), but not hsCRP (p=NS).

Conclusions

Apoptotic MP are involved in the pathogenesis of acute coronary syndromes via promotion of endothelial dysfunction and plaque rupture. The diagnostic and/or predictive value of microparticles' profiling for plaque vulnerability should be explored in future studies.
88Oxygen therapy in myocardial infarction patients with or without diabetes mellitus - A predefined subgroup analysis from the DETO2X-AMI trial
Authors: Hofmann R , Jernberg T , Lindahl B , Ostlund O , Erlinge D , Herlitz J , Svensson L , Witt N , James S K , Nystrom T
Published: October 2019

Background

In diabetes, there is an interaction between hyperglycaemia and cellular hypoxia, which may induce oxidative stress. Oxygen therapy in patients with diabetes and myocardial infarction (MI) has not been studied.

Purpose

Our aim was to determine the effects of supplemental oxygen in MI patients with or without diabetes.

Methods

The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial randomised 6629 patients with suspected myocardial infarction (MI) to receive oxygen at 6 L/min for 6–12 hours or ambient air. In this prespecified analysis involving 5010 patients with confirmed MI, 934 had known diabetes (19%). The main composite endpoint was the effect of supplemental oxygen on all-cause death, rehospitalisation with MI, or heart failure at one year in patients with diabetes. Key secondary endpoint was the comparison between patients with or without diabetes.

Results

In patients with diabetes, the main composite endpoint occurred in 16.2% (72 of 445) of patients allocated to oxygen compared to 16.6% (81 of 489) allocated to ambient air (hazard ratio [HR] 0.93; 95% confidence interval [CI], 0.67–1.27, P=0.81) at one year (figure). There was no statistically significant difference for the individual components of the main composite endpoint, or the rate of cardiovascular death up to one year. In comparison, corresponding endpoints in patients without diabetes were similar between the treatment groups.

However, when comparing patients according to diabetes status, event rates were significantly higher in the diabetic population (main composite endpoint: HR 1.60; 95% CI, 1.32–1.93, P<0.01).

Kaplan-Meier curves for main endpoint

Conclusions

Oxygen therapy in normoxemic MI patients did not significantly affect 1-year all-cause death, cardiovascular death, rehospitalisation with MI or heart failure, irrespective of underlying diabetes. Noteworthy, despite that the incidence of cardiovascular outcomes has declined substantially in patients with diabetes over the last decades, we still observed markedly increased event rates in patients with diabetes.

Acknowledgement/Funding

Swedish Heart-Lung Foundation; Swedish Research Council; Stockholm County Council
99Non-ruptured plaque and platelet-rich thrombi in ST-segment elevation myocardial infarction: new insight into early spontaneous reperfusion
Authors: Chen J , Wang G Z , Liu Z , Zhang Y H , Guo J C , Li J
Published: October 2019

Objectives

To detect the potential mechanism of early spontaneous reperfusion (ESR) in STEMI.

Background

Early spontaneous reperfusion occurs in around 20% of STEMI and is associated with favorable outcomes. Optical coherence tomography (OCT) is more accurate in detecting subtle morphological details of the culprit lesion.

Methods

In this prospective study, a total of 107 consecutive patients with STEMI were enrolled from July 2016 to May 2017. Of that total, 21 (19.6%) met the criteria of angiographic ESR (TIMI-3 flow in the initial angiogram). Among those without ESR (TIMI-0 flow in the initial angiogram), 21 patients were assigned into the control group according to propensity score matching with the ESR group. The OCT findings and one-year clinical outcomes were compared between the two groups.

Results

Although baseline characteristics were comparable, plaque features significantly differed between the ESR and control group (P<0.001), including plaque rupture (23.8% vs. 66.7%), plaque erosion (47.6% vs. 33.3%), calcified nodule (9.5% vs. 0%) and vasospasm (19.1% vs. 0%). Red thrombus (19.1% vs. 85.7%) was far less found whereas white thrombus (61.9% vs. 14.3%) was more common in the ESR group. In addition, despite of less stent placement (0.6±0.5 vs. 1.3±0.9, P<0.001), patients in the ESR group had a non-statistically lower rate of cardiac adverse events (4.8% vs. 14.3%, P=0.269) during one-year follow up.

The OCT finding Variables ESR group (n=21) Control group (n=21) P value The OCT imaging <0.001   Plaque erosion 10 (47.6) 7 (33.3)   Plaque rupture 5 (23.8) 14 (66.7)   Calcified nodule 2 (9.5) 0 (0)   Vasospasm 4 (19.1) 0 (0) The Type of Thrombus <0.001   Red thrombus 4 (19.1) 18 (85.7)   White thrombus 13 (61.9) 3 (14.3)   No thrombus (vasospasm) 4 (19.1) 0 (0)   MLA (mm2) 2.7±2.2 2.3±2.4 0.534 Values are n (%), mean ± SD. ESR = early spontaneous reperfusion; MLA = Minimum lumen area; OCT = optical coherence tomography.

ESR and control group

Conclusions

Relief of coronary occlusion induced by non-ruptured plaque and platelet-rich thrombi may be one of the main mechanism underlying early spontaneous reperfusion in STEMI.

Acknowledgement/Funding

No.81470491 from the National Natural Science Foundation of China and No.7192078 from Beijing Municipal Natural Science Foundation to Dr. Li.
106Plasma trimethylamine N-oxide is associated with culprit plaque characterization as assessed by optical coherence tomography in patients with acute myocardial infarction
Authors: Sheng Z , Tan Y , Yan H
Published: October 2019

Background

Previous study have demonstrated that plasma trimethylamine N-oxide (TMAO) is associated with vulnerable plaque characteristics as assessed by optical coherence tomography (OCT) in patients with coronary artery disease. However, the relation between TMAO and the culprit plaque characteristics as assessed by OCT in patients with acute myocardial infarction (AMI) exhibiting plaque rupture at the site of the culprit stenosis is unknown.

Objective

To explore the relation between plasma TMAO and coronary culprit plaque characterization assessed by OCT in AMI patients exhibiting plaque rupture.

Method

We prospectively enrolled 90 AMI patients with plaque rupture identified by OCT and collected demographic data, risk factors, coronary angiography and OCT data, medical history and laboratory findings of all patients. Plasma TMAO levels were detected by stable isotope dilution liquid chromatography tandem mass spectrometry. Macrophage presence in coronary culprit plaque was quantified by normalized standard deviation (NSD).

Result

All patients were divided into two groups (high TMAO group and low TMAO group) according to the median plasma TMAO level (3.22uM). The culprit plaques in the high TMAO group exhibited a thinner fibrous cap thickness (60um [60–100um] versus 90um [70–110um], P=0.013]), higher frequency of thin-cap fibroatheroma (TCFA) (15.6% versus 55.6%, P<0.001), microvessel (24.4% versus 4.4%, P=0.014) and macrophage infiltration (66.7% versus 26.7%, P<0.001) compared with the low TMAO group. Moreover, the level of TMAO was significantly positively associated with NSD (Pearson's correlation coefficient: r=0.766, P<0.001).

Conclusion

Plasma TMAO levels are associated with coronary plaque vulnerability and inflammation in patients with AMI exhibiting plaque rupture.

Acknowledgement/Funding

Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2016-I2M-1-009)
125Incidence and outcomes of bailout stenting following use of drug coated balloon
Authors: Basavarajaiah S , Handi S , Foley L , Watkin R , Freestone B , Pitt M , Lee K , Bhatia G , Ment G , Pulikal G
Published: October 2019

Background

The incidence of bailout stenting post-drug coated balloon use (DCB) in the literature has been more than 10%; ranging up-to 21% in Bello trial and this variation could be due to the different criteria used to consider bailout stenting and may also reflect aggressive pre-dilatation. Our eyes are trained to expect stent like result and anything less is considered sub-optimal and this could be one of the reasons for high incidence of bailout stenting. The current recommendation is to use drug eluting stent (DES) for bailout stenting and hence raising in the possibility of drug toxicity or maybe even synergistic effect from combination of Paclitaxel (DCB) and limus (DES).

Aim

We have evaluated the incidence and outcomes of patients needing bailout stenting in our centre.

Methods and results

We evaluated all patients who were treated with DCB between January 2016-August 2017. Bailout stenting per lesion were identified and studied for endpoints which included cardiac death, target vessel MI, stent thrombosis, target lesion revascularization and target vessel revascularisation.

Between the study period; 468 lesions (in 364 patients) were treated with paclitaxel DCB (Sequent Please, B Braun, Germany). Bailout stenting was required in 23 lesions (4.9%) and of which 12 (52%) was for flow limiting dissections (type C or more) and the remaining 11 was for recoil of more than 50%. Majority of the lesions were de novo (18; 78%). All bailout stenting was performed with third generation limus eluting stents. During a median follow-up of 18.14 months; range; 7–33 months, there was no cardiac death and target vessel MI occurred in 1 patient (4.3%), TLR and TVR were in 3 lesions (13%). MACE rate (combination of cardiac death, target vessel MI and TVR) was 13%. There were no cases of stent thrombosis as per the ARC definition.

Conclusion

One of the highlighting features of our study is very low-rates of bailout stenting. This may be due to our criteria of not stenting mild dissections (unless they are flow limiting) and also to accepting recoil of up-to 50% post-DCB use. The outcome in bailout stenting group is acceptable especially with hard endpoints (cardiac death, target vessel MI and stent thrombosis) although TLR and TVR rates were higher indicating synergistic effect of paclitaxel and limus may not offer additional benefits.
127Prevalence of coronary artery disease and coronary microvascular dysfunction in heart failure with preserved ejection fraction
Authors: Rush C , Berry C , Oldroyd K , Rocchiccioli P , Lindsay M , Campbell R , Ford T , Sidik N , Murphy C , Touyz R , Petrie M , McMurray J
Published: October 2019

Background/Introduction

The prevalence of epicardial coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) have not been studied systematically in an unselected cohort of patients with heart failure and preserved ejection fraction (HFpEF). Both types of coronary disease may play an important role in the pathophysiology and prognosis of HFpEF.

Methods

This prospective multi-centre observational study enrolled near-consecutive patients hospitalized with HFpEF. Patients underwent invasive coronary angiography. Where possible, patients also had guidewire-based assessment of fractional flow reserve, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) performed, followed by vasoreactivity testing with intracoronary acetylcholine.

Results

A total of 75 patients underwent invasive coronary angiography. Guidewire-based assessment of FFR/CFR/IMR was performed in 62 patients, and vasoreactivity testing was possible in 41 patients. Obstructive epicardial CAD was identified in 38 patients (51%). CMD (defined as a CFR <2.0 and/or IMR ≥25) was present in 66% of patients assessed and was similarly prevalent in those with and without obstructive epicardial disease (62% vs. 69%, p 0.52). During vasoreactivity testing, 24% of those assessed had evidence of coronary microvascular endothelial dysfunction. Patients with obstructive CAD were more often male (63% vs. 38%, p 0.028), and had a history of CAD (50% vs. 19%, p 0.005), diabetes mellitus (63% vs. 41%, p 0.05), and a higher E/e' on echocardiography (median 14.4 vs. 12.3, p 0.044) than those without obstructive coronary disease. Patients with CMD had higher B-type natriuretic peptide levels (median 569 vs. 197 pg/ml, p 0.036) than those without microvascular dysfunction.

Selected baseline characteristics No obstructive CAD (n=37) Obstructive CAD (n=38) p-value No CMD (n=21) CMD (n=41) p-value Age (mean, years) 72 73 0.4 74 72 0.41 Female, n (%) 23 (62%) 14 (37%) 0.028 11 (52%) 22 (54%) 0.92 CAD history, n (%) 7 (19%) 19 (50%) 0.005 7 (33%) 12 (29%) 0.74 Diabetes mellitus, n (%) 15 (41%) 24 (63%) 0.05 11 (52%) 22 (54%) 0.92 BNP (median, pg/ml) 323 315 0.9 197 569 0.036 Ejection fraction (median, %) 59 58 0.35 60 56 0.064 E/e' (median) 12.3 14.4 0.044 14.2 12.4 0.74

Study flow diagram

Conclusion

Both epicardial CAD and CMD are common in HFpEF and each may be a therapeutic target in this condition. Although it has been hypothesized that CMD may be due to endothelial dysfunction, our findings suggest that CMD is predominantly due to structural abnormalities in HFpEF.

Acknowledgement/Funding

Chief Scientist Office
227A novel risk prediction model for sudden cardiac death in childhood hypertrophic cardiomyopathy (HCM Risk-Kids)
Authors: Norrish G , Ding T , Field E , O'mahony C , Elliott P M , Omar R Z , Kaski J P
Published: October 2019

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM) but there is no validated algorithm to identify those at highest risk. This study sought to develop and validate a SCD risk prediction model that provides individualized risk estimates.

Methods

A prognostic model was derived from an international, retrospective, multi-center longitudinal cohort study of 1024 consecutively evaluated patients aged ≤16 years. The model was developed using pre-selected predictor variables [unexplained syncope, maximal left ventricular (LV) wall thickness (MWT), left atrial diameter (LAD), LV outflow tract (LVOT) gradient and non-sustained ventricular tachycardia (NSVT)] identified from the literature and internally validated using bootstrapping.

Results

Over a median follow up of 5.3 years (IQR 2.6, 8.2, total patient years 5984), 89 (8.7%) patients died suddenly or had an equivalent event [annual event rate 1.49 (95% CI 1.15–1.92)]. The pediatric model was developed using pre-selected variables to predict the risk of SCD. The model's ability to predict risk at 5 years was validated; C-statistic was 0.69 (95% CI 0.66–0.72) and the calibration slope was 0.98 (95% CI 0.58–1.38). For every 10 ICDs implanted in patients with ≥6% 5-year SCD risk, potentially 1 patient will be saved from SCD at 5 years.

Conclusions

This new validated risk stratification model for SCD in childhood HCM provides accurate individualized estimates of risk at 5 years using readily obtained clinical risk factors.

Acknowledgement/Funding

British Heart Foundation