bluuebunny/crossref_metadata_2025 huggingface dataset:
P3752Ablation of the superior left ganglionic plexus is not necessary for effective denervation of the sinoatrial and atrioventricular nodes
Authors: Jansova H , Stiavnicky P , Stojadinovic P , Konecny P , Cihak R , Peichl P , Kautzner J , Wichterle D
Published: October 2019

Background

Cardioneuroablation by targeting of atrial ganglionic plexi (GP) has been proposed as a new therapeutic option in selected patients with reflex syncope. Contribution of individual GPs to cardiac autonomic regulations is not fully established.

Purpose

Because consistent vagal responses have been observed during left superior pulmonary vein isolation in patients undergoing ablation for atrial fibrillation, we investigated whether standalone ablation of the superior left GP modifies the vagal input into the sinoatrial (SAN) and atrioventricular node (AVN).

Methods

Study hypothesis was investigated in otherwise healthy patients undergoing cardioneuroablation for symptomatic bradyarrhythmias. All had preprocedural atropine test suggesting functional disorder. Anatomically-navigated (CARTO-3) radiofrequency (RF) ablation (25–30 W/30 s/20 ml/min) at empirical GP sites was performed in general anaesthesia. Extracardiac high-frequency vagal nerve stimulation (25–60 V/30–50 Hz/0.05–0.1 ms) via right jugular vein was performed at baseline, after initial superior left GP ablation, and after the ablation of remaining septal and inferior GPs. High-frequency vagal nerve stimulation was always done in both sinus rhythm and atrial pacing. The elimination of all stimulation-induced vagal responses was the endpoint of the procedure.

Results

A study included 8 patients (34±8 years; 5 males). Six of them had recurrent syncope with cardioinhibitory response at the SAN (n=4), AVN (n=1) or both nodes (n=1); and 2 patients had symptomatic sinus bradycardia. At baseline, high-frequency vagal nerve stimulation induced long episodes of sinus arrest and advanced AV block in all patients. Cluster ablation at the superior left GP (RF time: 192±28 s) did not change the sinus rate (59±14 vs 60±15, NS), PQ interval (174±37 vs 173±37, NS), and did not induce any tangible change in SAN/AVN response to high-frequency vagal nerve stimulation. Subsequently, anterior right GP was targeted from the aspect of right atrium (n=7), from the anterior antrum of right pulmonary veins (n=6), and inferior GPs were targeted from the aspect of left atrium (n=7). This lesion set finally resulted in complete non-responsiveness of SAN and AVN to high-frequency vagal nerve stimulation in all patients. Ablation procedure overall (duration: 172±15 min; RF time: 988±306 s; radiation dose: 70±34 μGy·m2) led to sinus rate acceleration by a median of 29 (IQR: 18–38) bpm, increase of Wenckebach point by 21 (IQR: 9–28) bpm, and shortening of AVN effective refractory period by 40 (IQR: 15–73) ms.

Conclusions

Cardioneuroablation guided by extracardiac high-frequency vagal nerve stimulation can achieve complete denervation of SAN and AVN by ablation of postero(para)septal and inferior GPs only. Ablation of the superior left GP appears unnecessary and can be eliminated from the lesion set design.
P3760Temporal trends in stroke prevalence and its associations with changing patterns of antithrombotic regimens in patients with atrial fibrillation and a wide spectrum of coronary artery disease
Authors: Hudzik B , Desperak A , Freedman B , Nielsen P B , Larsen T B , Desperak P , Trzeciak P , Gasior M
Published: October 2019

Introduction

Much of the morbidity and mortality associated with atrial fibrillation (AF) is due to cerebrovascular thrombo-embolic complications such as ischemic stroke. Antithrombotic therapy is the fundamental treatment for many cardiovascular conditions, e.g. coronary artery disease (CAD), AF, and stroke to prevent thrombotic complications and death, but many patients have both CAD and AF. Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor has proven most effective in patients with recent myocardial infarction (MI) or after percutaneous coronary intervention (PCI), whereas for AF, oral anticoagulation (OAC) is most effective, with lesser efficacy but similar bleeding using DAPT. We investigated temporal trends in stroke prevalence and its associations with changing patterns of antithrombotic regimens in patients with non-valvular AF and a wide spectrum of co-incident CAD.

Methods

The Silesian TRiplE Antithrombotic Therapy (TREAT) Registry enrolled 14,873 patients with CAD from 2006 to 2014: 9,379 with stable CAD (SCAD), 1,460 with unstable angina (UA), 1,760 with NSTEMI and 2,328 with STEMI. We compared temporal trends in clinical features, an incidence of clinical events and patterns of antithrombotic regimens.

Results

2,194 of 14,873 patients (14.6%) had AF, including 74.1% with SCAD, 7.7% with UA, 10.1% with NSTEMI and 8.1% with STEMI. The AF prevalence increased from 11.2% in 2006 to 17.2% in 2014 which may be attributed to increasing age from 62.7 in 2006 to 67.8 in 2014. Overall, there was an increasing use of OAC therapy alone or with SAPT or DAPT from 46–50% in 2006–7 to 77–86%% in 2013–14. There was a steady increase in utilization of TREAT, and OAC ± SAPT throughout the study period (Panel A): after PCI there was a substantial increase in TREAT with a steady decline in DAPT (Panel B). The stroke rates declined throughout the study period from 3.3% in 2004 through a peak of 4.9% in 2011 to 1.1% in 2014. Conversely, bleeding rates increased from 6.0% to 10.5%.

Conclusions

There has been an increase followed by a progressive decline in stroke rate despite increasing age and AF prevalence in patients with both CAD and AF. This phenomenon is associated with a significant increase in the proportion of AF patients receiving guideline-recommended OAC therapy, driven by a steady increase in the utilization of triple antithrombotic therapy in patients following ACS or stent implantation and increase in OAC monotherapy in patients without ACS or stent implantation. This positive effect on stroke incidence is offset by increased bleeding risk, necessitating a closer look at the duration of triple therapy for ACS or PCI, and the long-term requirement for additional antiplatelet treatment in uncomplicated CAD.
P3765Low vascular endothelial growth factor-C was a predictor for cardiovascular events in patients with atrial fibrillation and suspected or known coronary artery disease: a subanalysis of the ANOX study
Authors: Iguchi M , Suzuki M , Matsuda M , Ajiro Y , Shinozaki T , Sakagami S , Yonezawa K , Shimizu M , Funada J , Takenaka T , Morita Y , Abe M , Akao M , Hasegawa K , Wada H
Published: October 2019

Background

Lymphatic system has been considered to play an important role in cardiovascular disease. We recently reported that vascular endothelial growth factor-C (VEGF-C), a central player in lymphangiogenesis, predicted all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, relationship between VEGF-C and atrial fibrillation (AF) remains unclear.

Methods

The ANOX study is a multicenter, prospective cohort study of 2,418 patients with suspected CAD, to determine the predictive value of possible novel biomarkers related to angiogenesis or oxidative stress for major adverse cardiovascular events (MACE) among patients undergoing elective angiography. Blood samples were collected from the arterial catheter sheath at the beginning of coronary angiography. Serum levels of VEGF-C, as well as N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin-I (cTnI), and high-sensitivity C-reactive protein (hsCRP), were measured. The outcome was a MACE defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

Of a total of 2,418 patients, 261 patients had AF at baseline. AF group were older, and had more chronic kidney disease, history of heart failure, and history of stroke, but less diabetes, dyslipidemia, and CAD. The median level of NT-proBNP, cTnI, and hsCRP were higher in AF group [AF vs non-AF: NT-proBNP, 1048 pg/ml vs 162 pg/ml (p<0.0001); cTnI, 0.0003 ng/ml, vs 0.0 ng/ml (p<0.0001); hsCRP, 1.43 ug/ml vs 0.88 ug/ml (p=0.0005)], whereas median level of VEGF-C was lower in AF group [3107 pg/ml vs 3590 pg/ml (p<0.0001)]. AF was associated with lower VEGF-C and higher hsCRP after adjustment for potential confounders. During the 3-year follow-up, 29 (11.1%) patients in AF group and 136 (6.3%) patients in non-AF group developed MACE (p=0.007). Incidence of stroke was higher in AF group (17 (6.5%) vs 52 (2.4%); p<0.0009), despite that the incidence of cardiovascular death and myocardial infarction were similar between the groups. We divided the entire cohort into two groups based on the lowest quartile of VEGF-C or highest quartile of other biomarkers, lowest quartile of VEGF-C (log rank p=0.0004), as well as highest quartile of cTnI (log rank p=0.0009), were significantly associated with MACE in AF group. After adjustment for established risk factors and these biomarkers, both lowest quartile of VEGF-C (HR, 2.73; 95% CI, 1.27–6.06) and highest quartile of cTnI (HR, 2.54; 95% CI, 1.08–6.09) were significantly associated with MACE in AF group.

Conclusions

AF was associated with lower level of VEGF-C, and low VEGF-C as well as high cTnI might serve as an independent predictor of MACE in patients with AF and suspected or known CAD.
P3771Validation of risk scoring system predicting for progression of atrial fibrillation: the Fushimi AF Registry
Authors: Ogawa H , An Y , Ishigami K , Aono Y , Ikeda S , Doi K , Ishii M , Iguchi M , Masunaga N , Esato M , Wada H , Hasegawa K , Abe M , Akao M
Published: October 2019

Background

Atrial fibrillation (AF) increases the risks of thromboembolism and death. Progression from paroxysmal to sustained types (persistent or permanent) of AF is sometimes seen in clinical practice. We recently reported that progression of AF was associated with increased risk of clinical adverse events in Japanese AF patients. However, risk stratification schemes of predicting the progression of AF has not been fully established.

Methods

The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, Kyoto, which is a typical urban district of Japan with a population of 283,000. Follow-up data were available for 4,454 patients. We investigated the risk factors of AF progression and validated the performance of various risk scoring systems predicting for progression of AF, such as APPLE, BASE-AF2, HATCH, and MB-LATER score, using data from 995 paroxysmal AF patients (mean age; 72.6±11.4 years, female; 42.2%, mean CHA2DS2-VASc score; 3.26±1.67) whose echocardiogram data were obtained at baseline.

Results

Of 995 AF patients, during the median follow-up of 1,477 days, progression from paroxysmal to sustained AF occurred in 160 patients (16.1%; 4.0 per 100 person-years). On a multivariate model, we indicated that history of AF ≥2 years (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.28–2.61), left atrial diameter ≥40 mm (OR 1.45; 95% CI 1.02–2.08), daily drinker (OR 1.56; 95% CI 1.24–2.81), and cardiomyopathy (OR 2.58; 95% CI 1.17–5.69) were significantly associated with higher incidence of AF progression. Our model had better predictive potential for AF progression (area under curve [AUC] 0.612; 95% CI 0.566–0.658) than the APPLE (AUC 0.553; 95% CI 0.508–0.598; p=0.06), BASE-AF2 (AUC 0.571; 95% CI 0.526–0.617; p=0.04), CHADS2 (AUC 0.508; 95% CI 0.462–0.554; p<0.01), CHA2DS2-VASc (AUC 0.501; 95% CI 0.453–0.548; p<0.01), HATCH (AUC 0.502; 95% CI 0.456–0.548; p<0.01), and MB-LATER (AUC 0.528; 95% CI 0.483–0.572; p<0.01) score.

Conclusion

We identified 4 risk factors which may be useful to predict for progression of AF in Japanese patients. External validation of our model in other cohorts is needed.

Acknowledgement/Funding

Boehringer, Bayer, Pfizer, Bristol-Myers, Astellas, AstraZeneca, Daiichi Sankyo, Novartis, MSD, Sanofi and Takeda. Japan Agency for Medical Research
P3776Blood pressure variability and incidence of new-onset atrial fibrillation
Authors: Choi E.-K , Lee S R , Han K D , Oh S
Published: October 2019

Background

Visit-to-visit blood pressure (BP) variability is a known risk factor for stroke, but the association between BP variability and atrial fibrillation (AF) incidence is uncertain. We sought to evaluate the association between BP variability and incident AF.

Methods

We identified 8,063,922 subjects (mean age 48 years; 59% men) who had ≥3 health checkups provided by the Korean National Health Insurance Corporation between 2004 and 2010. Systolic and diastolic BP variability was defined as variability independence of the mean (VIM). VIM was divided into four groups and high variability of BP was defined as the highest quartile values. The primary end point was new-onset atrial fibrillation.

Results

During a mean 7 years of follow-up, 140,086 subjects were newly diagnosed with AF (2.53 per 1000 person-years). High variation in BP was associated with an increase in the risk of AF (SBP: hazard ratio [HR], 1.060; 95% confidence interval [CI], 1.044–1.075, DBP: HR, 1.066; 95% CI, 1.050–1.082) compared with subjects with lowest quartile of BP. Among subjects with high variation both in SBP and DBP, the risk of AF was 7.6% higher than subjects without high variation in SBP and DBP. The risk of high BP variation on new-onset AF was more obvious in high-risk patients. The association of high BP variability with AF was being stronger for high-risk subjects who were older (≥65 years), with diabetes, or with CKD compared with subjects who were younger, without diabetes, or without CKD.

Conclusions

Fluctuation in SBP and DBP was associated with higher incidence of AF, especially in high-risk subjects, independent of traditional AF risk factors.
P3795Should we also screen for obstructive sleep apnea in patients presenting with excessive supraventricular ectopic activity?
Authors: Marinheiro R , Parreira L , Amador P , Mesquita D , Farinha J , Fonseca M , Esteves A , Pinheiro A , Sousa S , Silva M , Lopes C , Chambel D , Santos B , Carradas C , Caria R
Published: October 2019

Background

It is recommended to consider obstructive sleep apnoea (OSA) screening in atrial fibrillation (AF) patients with risk factors, due to the strong evidence of an association between these two entities. Excessive supraventricular ectopic activity (ESVEA) has been proposed to be a risk factor for AF. However, strong evidence between ESVEA and OSA has not been established.

Objective

We aimed to determine if ESVEA is associated with moderate to severe OSA since its treatment may prevent AF.

Methods

We studied patients who performed polysomnography and 24-hour Holter monitoring. Patients with atrial fibrillation were excluded. ESVEA was defined as more than 30 PACs per hour (frequent PACs) or runs of >4 consecutive PACs. The circadian pattern of PACs was also evaluated. Sleeping hours were used to define “nocturnal”. Moderate to severe OSA was defined when polyssonography demonstrated a apnoea/hypopnoea index (AHI) >15. We examined the association between ESVEA and moderate to severe OSA during wakefulness and sleep.

Results

We studied 290 patients [median age 65 (55–72) years, 62% males, body mass index (BMI) 30 (27–34)]. 112 (38%) had moderate to severe OSA. Median AHI was 11 (5–24) and mean oxygen saturation was 94% (92–95). Median PACs was 35 (9–117) and 29 patients (10%) had frequent PACs. Runs of >4PACs occurred in 114 patients (39%). Forty-three patients (15%) had predominant nocturnal PACs and 42 (14%) had nocturnal runs of PACs. Multivariate logistic regression analysis demonstrated only nocturnal PACs were associated with moderate to severe OSA (p=0.027) (table 1).

Multivariate logistic regression Odds Ratio 95% Confidence Interval p-value Male gender 4.49 2.48–8.17 <0.001 Body mass index (kg/m2) 1.09 1.03–1.15 0.002 Nocturnal PACs 4.12 1.17–14.46 0.027 Variables not included in the model: age, number of PACs/h, frequent PACs (>30 PAcs/hour), runs of PACs (>4 consecutive PACs), nocturnal frequent PACs and nocturnal runs of PACs.

Conclusion

OSA screening in patients presenting with nocturnal PACs should be routinely considered, especially in male and obese. Treating moderate to severe OSA patients with CPAP has a potential benefit in preventing ESVEA and consequently AF.
P3798High levels of C-reactive protein after coronary artery bypass graft surgery is associated with postoperative atrial fibrillation
Authors: Olesen O J , Vinding N E , Oestergaard L , Butt J H , Gislason G H , Torp-Pedersen C , Koeber L , Fosboel E L
Published: October 2019

Background

Postoperative atrial fibrillation (POAF), a common complication following coronary artery bypass graft (CABG) surgery, is associated with increased morbidity and mortality. Inflammation seems to be an important pathogenic factor and elevated preoperative levels of C-reactive protein (CRP) are associated with POAF. However, the association between postoperative CRP and POAF is less established.

Purpose

To examine the association between postoperative levels of CRP and POAF after CABG.

Methods

Patients undergoing first-time isolated CABG (Jan 01, 2000 to Dec 31, 2016) were identified using Danish nationwide administrative registries. Patients with CRP measurements from the fourth postoperative day and no history of atrial fibrillation were included. POAF was defined as a postoperative atrial fibrillation rhythm that required medical therapy or cardioversion, with patients being followed for POAF until discharge. The study population was divided into quartiles based on CRP levels. A Cochran-Armitage trend test was used to examine the trend of increased levels of CRP and the associated risk of POAF. The association between CRP levels and POAF was investigated using a multivariable logistic regression analysis adjusted for other patient characteristics.

Results

The study included 6,711 patients with mean CRP values from the lowest to the highest CRP groups being 66, 109, 150 and 228 mg/L, respectively. Patients in the highest CRP group were older and more likely to be male compared with the lowest CRP group (median age 67 years [P25-P75: 61–73] and 84.7% men vs. median age 64 years [P25-P75: 56–70] and 77.9% men). In the highest CRP group, 35% of patients developed POAF vs. 25% in the lowest CRP group. A dose-response relationship was seen between increasing levels of CRP and the associated risk of POAF (p<0.0001 for trend). An adjusted analysis showed a statistically significant association between the highest CPR group and POAF (OR: 1.44; 95% CI: 1.24–1.69) compared with the lowest CRP group (figure 1).

Conclusion

High postoperative CRP levels after CABG were associated with POAF development. Future studies may examine whether CRP also predicts worse outcomes and whether these factors could be modified in the development of POAF.

Acknowledgement/Funding

Internal grant from Copenhagen University Hospital
P3801The impact of the type of response to cardiac resynchronization therapy in the survival of patients with advanced heart failure
Authors: Camanho L , Slater C , Oliveira Jr L A , Carvalho Dias L , Saad E B , Mourilhe-Rocha R
Published: October 2019

Fundamental

Cardiac resynchronization therapy (CRT) reduces total mortality in patients (pt) with advanced heart failure (HF). However, the impact of this reduction is unknown in the different types of response.

Objective

To describe the survival of responders and super responders pt to CRT in a retrospective cohort.

Methods

250 pt who underwent a CRT were retrospectively evaluated. All presented in functional class (FC) III/ IV (NYHA). The criteria of response to CRT were: improvement of FC (>1); increase in ejection fraction (EF) >10% and decrease in left ventricular end-systolic diameter (LVESD) – >15%. They were divided into three groups: Group I – 73/250 pt (33%): responder only by the criterion of FC improvement. Group II - 57/250 pt (24%): responder was defined by three criteria (clinical and echocardiographic). Grupo III - super responder – 48/250 pt (20%): decrease >30% in LVESD and/or EF >45%. The survival and clinical outcomes were analyzed in the 3 groups.

Results

In group I, the mean age was 68.7 years; 75% were male; left bundle branch block (LBBB) was observed in 93% and average QRS duration was 164 ms; EF: 26%; average LVESD and left ventricular end-diastolic diameter (LVEDD): 46 and 57.7 mm, respectively. BIV-ICD was observed in 72% of pt. The mean post-implant survival was 30.8 months (CI95%: 25.06–36.54). In group II, the mean age was 70 years; 82% were male; left bundle branch block (LBBB) was observed in 98% and average QRS duration was 166 ms; EF: 27.5%; average LVESD and LVEDD: 52 and 67 mm, respectively. BIV-ICD was observed in 75% of pt. The mean post-implant survival was 45.4 months (CI95%: 38.96–51.84). In group III, the mean age was 71 years; 65% were male; left bundle branch block (LBBB) was observed in all pt (100%) and average QRS duration was 176 ms; EF: 29.2%; average LVESD and LVEDD: 54 and 68 mm, respectively. BIV-ICD was observed in 70% of pt. The mean post-implant survival was 53 months (CI95%: 45.96–60.04). The total mortality observed was 11%, 17% and 6.25%, respectively (48%: neoplasia; 24%: stroke; 19%: terminal HF; 9%: sepsis).

Conclusion

In the present study, the survival of responders pt to CRT varied according to the type of response, being significantly higher in the super responders and in those who presented echocardiographic criteria of response to CRT. These findings present significant clinical relevance and should be evaluated in future studies.
P3803New predictive score for clinical prognosis in non-ischemic cardiomyopathy patients with cardiac resynchronization therapy
Authors: Yang S , Hua W
Published: October 2019

Objective

To derive and validate a prediction score for clinical prognosis in non-ischemic cardiomyopathy (NICM) patients receiving cardiac resynchronization therapy (CRT).

Methods

A cohort of 422 consecutive NICM patients with CRT were retrospectively enrolled from January 2010 to December 2017, randomly categorized into the derivation group (n=338) and the validation group (n=84). Primary endpoint defined as all-cause death and heart transplantation. A new score was established based on the β coefficients of each risk factor.

Results

High sensitive C-response protein [hazard ratio (HR):1.081, 95% confidence interval (CI): 1.029–1.134 P=0.002], left atrial diameter (HR: 1.056, 95% CI: 1.020–1.093, P=0.002), non-LBBB (HR: 1.793, 95% CI: 1.131–2.844, P=0.013), N-terminal pro-B-type natriuretic peptide per 100 pg/ml (HR: 1.018, 95% CI: 1.007–1.030, P=0.002), were independent predictors for primary endpoint. A new prediction score, HALP score, showed significant difference of primary endpoint among different risk groups (log-rank test, all P<0.01) by Kaplan-Meier curve; Compared with three prior models, HALP scores had adequate discrimination [AUC: 0.738 (95% CI: 0.680–0.794)] and good calibration for all caused death and heart transplantation.

Table 1. Predictors of all-cause mortality and heart transplantation risk by uni- and multivariate Cox proportional hazards models in deviation datasets Variables Univariate Multivariate HR (95% CI) P-value HR (95% CI) P-value Age 0.992 (0.972–1.012) 0.423 Sex (male) 1.821 (1.091–3.041) 0.022 Non-LBBB 2.260 (1.438–3.552) <0.001 1.793 (1.131–2.844 0.013 Type of device (CRT-D) 1.592 (1.009–2.512) 0.046 Atrial Fibrillation 1.797 (1.055–3.062) 0.031 NYHA function class IV 1.878 (1.105–3.191) 0.020 AST 1.014 (1.000–1.027) 0.045 HS-CRP 1.106 (1.055–1.160) <0.001 1.081 (1.029–1.134) 0.002 NT-proBNP per100 1.029 (1.020–1.039) <0.001 1.018 (1.007–1.030) 0.002 Big Endothelin-1 1.973 (1.350–2.882) <0.001 Creatinine 1.007 (1.001–1.013) 0.015 Uric acid 1.001 (1.000–1.003) 0.144 LA 1.084 (1.051–1.117) <0.001 1.056 (1.020–1.093) 0.002 LVFE 0.975 (0.950–1.000) 0.054 LVEDD 1.032 (1.011–1.053) 0.003

Figure 1. Comparison of different scores

Conclusion

HALP score system may be an effective model for clinical prognostics in NICM patients with CRT.

Acknowledgement/Funding

None
P3806Very long-term and late response to CRT: is left ventricular ejection fraction a powerful indicator of sustained and late response?
Authors: Kahr P C , Kaufmann P , Kuster J , Tonko J , Breitenstein A , Flammer A , Ruschitzka F , Steffel J , Winnik S
Published: October 2019

Background

Cardiac-resynchronization therapy (CRT) reduces morbidity and mortality in selected symptomatic patients with reduced left ventricular ejection fraction (LVEF) and wide QRS complex. While many patients demonstrate a response to CRT within the first year of follow-up, sustained or late response to CRT is highly relevant but poorly characterized.

Purpose

To characterize the patient population that demonstrates improvements of LVEF late after CRT implantation, irrespective of the primary response, and to identify factors associated with beneficial long-term outcome.

Methods

All patients undergoing CRT implantation at our institution between Nov 2000 and Jan 2015 with at least two follow-up echocardiographic studies were included. Primary follow-up (FU1) was performed within one year after CRT implantation (median 6.1 months [IQR: 3.5–10.7]). The most recent echocardiography at a median follow-up time of 3.9 years [27.3–70.4] was considered as long-term follow-up (FU2). LVEF-based response to CRT was stratified into 4 categories: non-response (ΔLVEF <−5%), non-progression (−5% to +5%), response (+6 to +15%) and super-response (>+15%). Primary study endpoint was the composite of all-cause death, heart transplantation or implantation of a ventricular assist device.

Results

Out of 362 patients (median age 65.9 years, 23% female, 41% with ischemic cardiomyopathy), 99 (27.3%) demonstrated LVEF improvements beyond their primary response to CRT (blue bars in figure). At baseline, late responders demonstrated lower LVEF (23.4% [19.0–30.0] vs. 27.0 [22.0–32.0], p=0.005) and an increased prevalence of non-ischemic cardiomyopathy (67.8% vs. 55.9%, p=0.042) compared to the remaining patients. Reduction in LVEDV(I) at FU1 correlated positively with late response (ΔLVEDV −28.5 ml [−71.8; −3.25] vs. 18.0 [−46.0; 3.0], p=0.033). Importantly, late responders were seen amongst all types of primary response, including patients demonstrating a negative response with substantially worsened LVEF at first follow-up after CRT implantation. Finally, patients with late response demonstrated significantly better survival compared to patients with late progression of heart failure or continued non-progression (median survival 7.8 [7.1–8.5] vs. 7.0 [6.6–7.5] years, aHR 0.54 [0.33–0.88] p=0.013 on multivariate cox regression analysis).

Conclusions

A significant proportion of patients achieves LVEF improvements beyond the initial phase after CRT implantation indicating a substantial limitation in categorizing patients into “responders” and “non-responders” based on the initial response to CRT. Further prospective studies are required to validate these findings and optimize treatment strategies for CRT patients.
P3818Association between e-cigarette use and myocardial infarction: analysis of two large population-representative studies in USA
Authors: Farsalinos K , Voudris V , Niaura R
Published: October 2019

Background

Smoking is a major risk factor for cardiovascular disease. E-cigarettes are an emerging and controversial public health issue. It is unknown how e-cigarette use affects cardiovascular disease.

Purpose

In this study, we examine the association between e-cigarette use and myocardial infarction (MI) in two large population-representative studies in USA.

Methods

The study analyzed the 2016 and 2017 (pooled) National Health Interview Survey (NHIS, N=59,770) and the 2017 Behavioral Risk Factor Surveillance System survey (BRFSS, N=450,016). Proportions (95% CI) were calculated and logistic regression analyses were performed to identify the association between e-cigarette use and MI. Independent variables in the models were demographics, e-cigarette use (daily, some days, former, never), smoking status (daily, some days, former, never) and risk factors for MI (hyperlipidemia, hypertension, diabetes, BMI). Exercise was also introduced as an independent variable, where available (BRFSS only).

Results

In NHIS, 90.9% (88.8–93.0%) of daily e-cigarette users were current or former smokers. The respective proportion in BRFSS was 86.3% (85.3–87.3%). The majority of some days and former e-cigarette users (≥70%) were also current or former smokers in both surveys. MI was reported by 4.2% (2.7–5.7%) of daily vs. 3.2% (3.0–3.4%) of never e-cigarette users in NHIS (P=NS), and 4.2% (3.5–6.1%) vs. 4.4% (4.2–4.5%) in BRFSS (P=NS), respectively.

In NHIS, daily e-cigarette use was not associated with MI (OR: 1.59, 95% CI: 0.97–2.61, P=0.067). Some days and former e-cigarette use were also not associated with MI. In the BRFSS, daily e-cigarette use was not associated with MI (OR: 1.40, 95% CI: 0.96–2.04, P=0.077), but some days (OR: 1.51, 95% CI: 1.09–2.11, P=0.014) and former e-cigarette use (OR: 1.14, 95% CI: 1.02–1.28, P=0.021) were associated with MI. In both surveys, all patterns of smoking (daily, some days and former smoking) and established risk factors (hypertension, hyperlipidemia, diabetes) were consistently and strongly associated with MI.

ORs for MI

Conclusion

E-cigarettes are predominantly used by current and former smokers. Daily e-cigarette use was not associated with having had an MI, while inconsistent and seemingly paradoxical associations are observed for some days and former e-cigarette use. Long-term epidemiological studies are needed to examine how e-cigarette use affects the risk of MI, considering the complex interactions between smoking and e-cigarette use.

Acknowledgement/Funding

None
P3825Long-term prognostic value of growth differentiation factor-15 in acute coronary syndrome
Authors: Peiro Ibanez O M , Ordonez J , Garcia A , Bonet G , Quintern V , Rojas S , Bardaji A
Published: October 2019

Introduction

Biomarkers plays a critical role in diagnostic, prognostication, and decision-making in cardiovascular medicine. Growth differentiation factor-15 (GDF-15) has been reported as a potential biomarker in acute coronary syndrome (ACS). However, there is limited data on the long-term prognostic value after an ACS.

Purpose

To study the long-term prognostic value of GDF-15 in ACS.

Methods

We included patients with ACS who underwent coronary angiography. During angiography an arterial blood sample was collected. Plasma GDF-15 were measured and clinical data and long-term events were obtained. As previously reported, risk categories were defined as low risk (<1200ng/L), intermediate (1200–1800ng/L) and high risk (>1800ng/L). Incremental prognostic value of GDF-15 for all-cause death was assessed on top of a clinical model (GRACE score, LVEF<40% and age).

Results

A total of 358 patients were included; 157 as a low risk, 85 as an intermediate and 116 as a high risk. The median (IQR) age was 65 (56–74) years and 27.4% were female. Of all patients, 61.5% were admitted with non-ST-elevation myocardial infarction, 24.0% with ST-elevation myocardial infarction and 14.5% with unstable angina. Higher values of GDF-15 were consistently associated with an increased prevalence of cardiovascular risk factors. During 6 years of follow-up 54 patients died. Of those patients, 7 (4.5%) had values of GDF-15 below 1200ng/L, 6 (7.1%) between 1200–1800ng/L and 41 (35.3%) above 1800ng/L. After adjustment for a multivariate Cox regression model, GDF-15 >1800ng/L were independently associated with all-cause death (HR 4.5; 95% CI 1.8–11.6; p=0.002) and the composite of major adverse cardiovascular events (MACE) which were identified as all-cause death, nonfatal MI and heart failure (HR 2.5; 95% CI 1.4–4.4; p=0.001). For long-term all-cause death a significant increase of the c-statistic was seen after addition of GDF-15 to the clinical model 0.871 (95% CI 0.817–0.924; p=0.019) as well as net reclassification improvement (0.769; 95% CI 0.487–1.051; p<0.001) and integrated discrimination improvement (0.117; 95% CI 0.062–0.172; p<0.001). Of 18 events of heart failure, 17 occurred in patients with GDF>1800ng/L. A multivariate competing risk model showed a significant association between GDF-15>1800ng/L and incidence of heart failure (adjusted HR 30.8; 95% CI 4.1–231.5; p=0.001) but non-significant association were found for myocardial infarction.

KM figures and all-cause death ROC curve

Conclusions

In the setting of ACS GDF-15 can predict long-term all-cause death, MACE and heart failure and provides incremental prognostic value beyond traditional risks factors in the long-term all-cause death.
P3856Timing and associated predictors of onset of new conduction disturbances requiring permanent pacemaker implantation after transcatheter aortic valve implantation
Authors: Kooistra N H M , Van Mourik M S , Rodriguez-Olivares R , Maass A H , Nijenhuis V J , Van De Werf H , Ten Berg J M , Kraaijeveld A O , Baan Jr J , Voskuil M , Vis M M , Stella P R
Published: October 2019

Objectives

This study aimed to investigate the onset and the associated predictors of new conduction disturbances (CDs) requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI).

Background

The onset and associated predictors of onset of new CDs leading to PPI are still unknown. However, these are essential for safe and early discharge. Currently, these CDs lead to prolonged post-procedural monitoring after TAVI, limiting early discharge possibilities.

Methods

We retrospectively analyzed data from five centers in Europe. Post-TAVI electrocardiograms and telemetry data were evaluated to identify the onset of new CD in all patients who required a PPI within 30 days after TAVI. Early onset CDs were defined as within 48 hours after procedure, and late onset CDs as after 48 hours.

Results

A total of 2,804 patients were included for analysis. The PPI rate was 11%, of which 18% was due to late onset (>48h) CDs. Independent predictors for late onset CDs requiring PPI were pre-existing non-specific intraventricular conduction delay (IVCD), pre-existing right bundle branch block (RBBB), self-expandable valves, and predilation (Figure). Patients with a balloon-expandable valve without predilation did not develop CDs requiring PPI after 48 hours.

Figure 1

Conclusions

Associated predictors of late onset conduction disturbances leading to PPI after TAVI were pre-existing IVCD, pre-existing RBBB, the use of self-expandable valves, and predilation. Patients without CDs in the first 48 hours after TAVI and without risk factors for late onset CDs requiring PPI are possible candidates for early discharge after 48 hours.
P4128The right heart in patients undergoing transcatheter aortic valve replacement: insights from cardiac magnetic resonance imaging
Authors: Koschutnik M , Nitsche C , Kammerlander A A , Aschauer S , Goliasch G , Siller-Matula J , Winter M P , Andreas M , Loewe C , Hengstenberg C , Mascherbauer J
Published: October 2019

Background

Cardiac magnetic resonance (CMR) provides the gold standard for the assessment of ventricular volumes and mass. However, data on right ventricular systolic dysfunction (RVSD) and its prognostic significance on outcome in patients undergoing transcatheter aortic valve replacement (TAVR) are lacking.

Methods

We consecutively enrolled patients with severe aortic stenosis scheduled for TAVR who underwent preprocedural CMR. Kaplan-Meier estimates and multivariate Cox-regression analysis were used to identify factors associated with outcome, including RVSD. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint.

Results

145 consecutive patients (80.5±7.6 years; 51.7% female) were prospectively included, 25 (17.2%) of which had RVSD defined as RV ejection fraction (RVEF) <40%. RVSD was significantly associated with male sex, atrial fibrillation, reduced left ventricular (LV) EF (<50%) and RV endsystolic volume on CMR (all p<0.05). Serum NT-proBNP (14065±12042 vs. 3203±4615 ng/ml; p<0.001) and creatinine levels (1.59±0.96 vs. 1.29±1.03 mg/dl; p=0.201) were elevated in patients with RVSD. A total of 27 events occurred during follow-up (29±13 weeks). While LVSD was not significantly associated with outcome (p=0.654), RVSD showed a strong and independent association with event-free survival in the multivariate Cox-regression analysis [hazard ratio 3.836 (95% confidence interval 1.670–8.810); p=0.002], which included all relevant CMR parameters, cardiovascular risk factors and routine biomarkers.

Conclusions

RVSD rather than LVSD, as determined by CMR, is an important predictor of outcome in patients undergoing TAVR. RV function might thus add useful prognostic information on top of established risk factors.
P4136Neurogenic stunned myoacardium in multiple sclerosis patients
Authors: Gialafos E , Tsougos E , Andreadou E , Tzanetakos D , Tzartos I , Vakrakou A , Evangelopoulos E M , Koutsis G , Dimitrakopoulos A , Anagnostouli M , Stefanis L , Kilidireas K
Published: October 2019

A wide spectrum of topics regarding Multiple Sclerosis (MS) have been thoroughly studied, like immunology, nature of demyelinating lesions (DL's), therapeutics, etc. However, little is known about the influence of MS DL's on the cardiovascular system and especially in the coronary vasculature although few reports mention coronary vasospasm due to autonomic nervous system (ANS) abnormalities. Aim of this study was the detection the presence of Neurogenic Stunned Myocardium (NSM) through perfusion test.

Method

We enrolled 50 asymptomatic fulfilling the criteria MS patients, aged 45±7 years old and disease in our study duration of 6±13 years with EDSS= 2,5. After echocardiography and clinical examination as primary screening, pharmacologic stress thallium 201 scintigraphy and/or coronary angiography were performed to identify the incidence of NSM. Clinical characteristics of MS, type of disease, treatments as well as localization of demyelinating plaques (DP) were noted.

Results

13 patients (26%) had abnormal scintigraphy test although clinical profile was not indicative. Cardiac ultrasound showed that 2 patients from this group had a critical ejection fraction (around 50%). All positive patients that underwent for coronary angiogram were negative implying coronary artery spasm as a potential mechanism for the stress positive result. A common finding of all positive patients was the localization of DP which was in the lateral horn of the lower cervical part (C5–7) and upper thoracic part (Th1–4). No correlation seems to have the presence of CAD with disease duration, EDSS and treatment approaches.

Discussion

Our study shows a high incidence of NSM. This finding due to the location of the DP seems to correlate with ANS disturbance and might help to distinguish patients at higher risk.
P4167Non-shockable rhythm related sudden cardiac arrest in the community
Authors: Sharifzadehgan A , Rischard J , Bougouin W , Dumas F , Waldmann V , Beganton F , Aissaoui N , Geri G , Jost D , Lamhaut L , Cariou A , Jouven X , Marijon E
Published: October 2019

Introduction

A significant increase in the prevalence of sudden cardiac arrest (SCA) with non-shockable rhythm has been reported, related to asystole and pulseless electrical activity (PEA). Factors associated with non-shockable rhythm and the mode to the return of spontaneous circulation (ROSC) may help for a better understanding.

Purpose

We aimed to describe the frequency, characteristics and outcome of SCA related to non-shockable versus shockable rhythm in the community.

Methods

In this prospective ongoing, multicentre population-based registry (6.7 million inhabitants), data from all SCA over a 5-year period were analyzed. Initial rhythm was obtained from the EMS report and the initial recorded rhythm strip when available. Medical records for each SCA were reviewed by cardiologists to identify underlying aetiology and associated conditions.

Results

Among the 3,028 SCAs admitted alive out of a total of 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 2,904 patients had available information regarding initial rhythm at the time of EMS arrival. Among them, 1,314 patients (45.3%) presented with non-shockable rhythm: 1,109 (38.2%) cases with asystole, 197 (6.8%) with PEA and 8 (0.3%) with high degree atrioventricular block.

Cases with non-shockable rhythm were older (60.6 vs. 57.4 years, P<0.001), with greater proportion of females (34.9 vs. 19.2%, P<0.001) and less proportion of family history of coronary artery disease or SCA. Proportion of warning symptoms prior to the SCA was higher among patients with non-shockable rhythm (74.3 vs. 64.9%, P<0.001) but the proportion of chest pain was lower (24.0 vs. 43.3%, P<0.001). Survival rate was much lower in non-shockable rhythm cases (7.2 vs. 42.3%, P<0.001).

Among the 1,314 non-shockable cases eventually admitted alive to hospital, 1,022 (77.8%) did not require external defibrillation prior to ROSC, and a majority (91.7%) received adrenaline during resuscitation. In this subgroup, the main identified cardiac cause was acute coronary syndrome (45.3%), followed by chronic CAD (27.1%), structural non-ischemic heart disease (22.4%), and non-structural heart disease (5.2%).

Conclusions

Initial non-shockable rhythm is encountered in almost half of SCA cases admitted alive; mostly occurs in older patients with higher proportion of females. Over three quarters of these cases did not require external defibrillation prior to ROSC.
P4339Reference values for cardiorespiratory fitness in healthy Koreans: compared to western nations and nomogram
Authors: Jang W Y , Kim W , Kang D O , Park Y , Park E J , Na J O , Choi C U , Rha S W , Park C G , Seo H S , Park S , Kim E J
Published: October 2019

Introduction

Cardiorespiratory Fitness (CRF), defined as the integrated ability to properly oxygenate skeletal muscles during physical activity, is associated with a high risk of cardiovascular disease and all-cause mortality. The reference range for CRF may differ among nations, with Asians under-represented in previous data.

Purpose

In this study, we sought to establish reference values of CRF for Asians using a recent Korean cohort.

Methods

We analyzed 2646 healthy Korean adults recently enrolled in the Korea Institute of Sports Science Fitness Standards (KISS FitS) project with estimated maximal oxygen uptake (VO2max) values during treadmill test. Patients with cardiovascular or renal disease, systemic infection, pregnant women and those with orthopedic injuries unable to measure physical fitness were excluded. Age-specific mean VO2max values were compared with those from recent American, Norwegian, Danish cohorts and old Korean data.

Results

Age-specific reference values for healthy Korean adults in this cohort were as shown (Table). We were able to draw a nomogram to predict exercise capacity for a given age and MET value (Figure). When compared to other countries, less CRF reduction by aging was seen in Asians than in other Westerners. When compared to old Korean data from the 1980s, values were similar after adjustment for difference in methods, except for those under 30 years old which were decreased.

Exercise capacity of healthy Korean Men Women Age VO2max (ml/kg/min) N P-value for trend Age VO2max (ml/kg/min) N P-value for trend 19–29 42.3±6.3± 209 <0.01 19–29 34.3±4.3± 110 <0.01 30–39 42.0±5.0± 170 39–39 32.2±4.5± 211 40–49 41.4±5.6± 238 40–49 30.8±4.6± 284 50–59 38.0±5.7± 274 50–59 28.3±4.6± 367 60–69 32.4±6.2± 134 60–69 26.0±5.7± 336 70–79 27.2±5.6± 83 70–79 23.9±4.4± 195 >80 24.1±4.0± 11 >80 21.0±3.7± 24 Total 38.6±7.4± 1119 Total 28.5±5.8 1527 Data are presented as mean ± standard deviation. VO2max, maximal oxygen uptake; N, number.

Nomogram of exercise capacity in Koreans

Conclusions

While there was no significant change in CRF over time in the same ethnic group, there was a clear inter-ethnic difference. CRF should be assessed according to ethnic or national standards, and it is necessary to establish a reference for each nation or ethnicity with periodic updates.

Acknowledgement/Funding

National Sports Promotion Fund of the Korea Sports Promotion Foundation in 2015
P4349Simple and rapid estimation of left ventricular longitudinal deformation by tissue-tracking mitral annular displacement in single apical view
Authors: Nishi T , Hozumi T , Takemoto K , Wada T , Maniwa N , Kashiwagi M , Shimamura K , Shiono Y , Kuroi A , Matsuo Y , Kitabata H , Ino Y , Kubo T , Tanaka A , Akasaka T
Published: October 2019

Background

Noninvasive assessment of left ventricular (LV) deformation using global longitudinal strain (GLS) has prognostic value in patients with and without preserved ejection fraction (EF). Application of speckle-tracking technology to the mitral annulus provides rapid and easy assessment of displacement of septal and lateral mitral annulus and mid-point of mitral annular line in single apical view (TMAD) even in poor echo-image quality. TMAD may be used as a simple index of LV longitudinal deformation in patients with and without preserved EF (Figure).

Purpose

The purpose of this study was to examine whether TMAD can be used as a simple index of LV longitudinal deformation in patients with and without preserved EF.

Methods

The study population consists of 95 patients without segmental wall motion abnormality, significant valvular diseases, and atrial fibrillation in whom both TMAD and GLS measurements were applied by QLAB software (Philips). We estimated GLS from apical 4- and 2-chamber views and apical longitudinal views, and TMAD from apical 4-chamber view. TMAD was automatically and quickly evaluated as the base-to-apex displacement of septal (TMADsep), lateral (TMADlat), and mid-point of annular line (TMADmid) (Figure). The percentage of M-TMAD to LV length from the mid-point of mitral annuls to the apex at end-diastole (%TMADmid) was also calculated. We compared each TMAD values with GLS values by linear regression analysis, and evluated TMAD values by a receiver operating characteristic (ROC) analysis to detect impaired LV longitudinal deformation (|GLS|<12.0%).

Results

TMAD was successfully assessed in 94 of 95 patients (99%) while GLS was measured in 84 of 95 patients (87%, p=0.0082 vs TMAD). There were good correlations between each TMAD index and |GLS| (TMADsep:r=0.77, TMADlat:r=0.81, TMADmid:r=0.82, %TMADmid:r=0.87). According to ROC curve, the best cut-off values for TMADsep, TMADlat, TMADmid, and %TMADmid in determining LV longitudinal deformation were 6.8mm, 8.0mm, 7.8mm, and 9.5% respectively (Table).

Conclusions

The present results suggest that rapid and easy assessment of TMAD in single apical view may be used as a simple index of LV longitudinal deformation.