bluuebunny/crossref_metadata_2025 huggingface dataset:
6076Improvement of exercise capacity over the course of outpatient cardiac rehabilitation is an independent predictor of prognosis after a myocardial infarction
Authors: Novakovic M , Novak T , Vizintin Cuderman T , Krevel B , Tasic J , Rajkovic U , Fras Z , Jug B
Published: October 2019

Background

Cardiac rehabilitation after myocardial infarction improves cardiovascular health and quality of life. However, data on long-term prognostic impact of surrogate rehabilitation parameters–such as exercise capacity improvements–remain scarce.

Purpose

To assess the independent prognostic impact of exercise capacity improvement over the course of outpatient cardiac rehabilitation after myocardial infarction.

Methods

Consecutive patients undergoing outpatient cardiac rehabilitation (3-times weekly for 12 weeks) after a myocardial infarction at a university centre were included. Exercise testing was performed at inclusion and after completion of the rehabilitation programme, with exercise capacity improvement defined as ≥2 MET increase over the course of the programme. Clinical data and risk factors were systematically collected, and patients were followed up for a minimum of 2 years. Kaplan-Meier curves and a multivariate Cox proportional hazard model were constructed for prediction of events (defined as a composite of incident cardiovascular death, re-infarction and coronary revascularsiation), with age, sex, LDL-cholesterol levels and body mass index as co-variates.

Results

A total of 409 patients were included (20% women). Exercise capacity and expected exercise performance were significantly improved after cardiac rehabilitation programme (6.6 to 9.5 METs, p<0.001, and 82 to 117%, p<0.001, respectively). After a median follow-up of 6.5 years, 93 patients experienced an event. Exercise capacity improvement of ≥2 METs was associated with reduced event rates (Figure 1), retaining statistical significance even after adjusting for age, sex, LDL-cholesterol and body mass index (HR 0.485, 95% CI 0.285–0.824).

Kaplan-Meier curve

Conclusion

Improvement of exercise performance over the course of outpatient cardiac rehabilitation is an independent predictor of prognosis after a myocardial infarction, with improvements of ≥2 METs associated with a 50% reduction in events.
6081Efficacy and limitations of quinidine therapy in patients with Brugada Syndrome
Authors: Mazzanti A , Tenuta E , Marino M , Pagan E , Morini M , Memmi M , Curcio A , Monteforte N , Bloise R , Napolitano C , Bagnardi V , Priori S G
Published: October 2019

Background

Quinidine at high-dose is used in patients with Brugada Syndrome (BrS), but its efficacy to prevent life-threatening arrhythmic events (LAE) in BrS is unproven and its use is limited by side effects.

Objective

We assessed whether low-dose quinidine in BrS patients reduces: 1) the occurrence of a first LAE; 2) the arrhythmic burden in the high-risk group of cardiac arrest survivors.

Methods

We first compared the clinical course of 53 BrS patients treated with quinidine to that of 441 untreated controls, matched by sex, age, and symptoms. Furthermore, we calculated the annual incidence of LAEs off- and on-quinidine in 123 BrS patients who had survived a cardiac arrest.

Results

First, we compared the clinical course of 53 BrS patients treated with quinidine (i.e. “cases”: 89% males, median age 40 years) to that of 441 untreated, clinically-matched BrS patients (i.e. “controls”: 91% males, median age 41 years) present in our database of patients with inherited arrhythmias. Cases received quinidine (median dose of 450 mg per day) for 5.0±3.7 years. Quinidine was interrupted in only 3/53 cases (6%) for side effects and it conferred a nonsignificant reduction of the risk of a first LAE in cases versus controls (HR 0.74, 95% CI 0.22–2.48, P=0.62).

Secondly, we calculated the annual recurrence of LAE off- and on-quinidine in 123 BrS cardiac arrest survivors, 27 of whom were treated with quinidine for 7.0±3.5 years. The annual rate of recurrent LAEs decreased significantly from 14.7% while off-quinidine to 3.9% while on-quinidine (P=0.03). Notably, recurrent life-threatening arrhythmic events were recorded in 4/27 (15%) symptomatic patients while on-quinidine.

Conclusion

We demonstrated for the first time in the long-term that low-dose quinidine reduces the recurrence of life-threatening arrhythmias in symptomatic BrS patients, with few side effects. Remarkably, about one-fifth of symptomatic patients experience life-threatening arrhythmias while on-treatment, suggesting that quinidine cannot replace implantable defibrillators in high-risk subjects.
6109A novel parameter for stent expansion is superior to conventional parameters for predicting adverse events after drug-eluting stent implantation
Authors: Katsura A , Minami Y , Kato A , Sato T , Muramatsu Y , Kakizaki R , Nemoto T , Hashimoto T , Fujiyoshi K , Meguro K , Shimohama T , Tojo T , Ako J
Published: October 2019

Background

Among several parameters for stent expansion, which is better for predicting adverse events remains to be elucidated.

Purpose

To assess the predictive significance of several parameters for stent expansion on the incidence of adverse cardiac events.

Methods

A total of 183 consecutive patients with de novo lesion treated with drug-eluting stent (DES) under optical coherence tomography (OCT) guidance were enrolled. The stent expansion was retrospectively assessed on the final OCT images after the stent implantation by both conventional and novel parameters. The conventional parameters included the minimum stent cross-sectional area (MSA) and %stent expansion defined as [MSA/mean reference lumen cross-sectional area × 100]. The novel parameter was the minimum expansion index (MEI) calculated by using a novel algorhythm which yields the ideal lumen area in each frame by taking into account vessel tapering. The expansion index was calculated by [actual lumen area/ideal lumen area × 100] in each frame through the stented segment. The MEI was the minimum value of expansion index through the stented segment. The both conventional and novel parameters were compared between cases with and without device-oriented cardiac events (DoCE). Receiver operating characteristics (ROC) curves were constructed to assess the ability of those parameters to predict DoCE.

Results

The MSA and MEI in the DoCE group (n=12) were significantly smaller than the no DoCE group (n=171) (3.29±0.72 vs. 4.45±1.97 mm2, p<0.001, 66.9±10.6 vs. 78.3±14.8%, p=0.01, respectively), although the %stent expansion was not significantly different between the two groups (62.7±11.9 vs. 70.7±16.3%, p=0.094). In ROC analyses, the area under curve of MEI to predict DoCE was the largest among the parameters (Figure).

Conclusion

Among several parameters for stent expansion, a novel MEI was better to predict device-oriented cardiac events after DES implantation.
6113Gender differences in long-term outcomes in patients with deferred revascularization following fractional flow reserve assessment: international collaboration registry of physiologic evaluation
Authors: Hoshino M , Yonetsu T , Kanaji Y , Sugiyama T , Yamaguchi M , Hada M , Ohya H , Sumino Y , Kanno Y , Hirano H , Horie T , Murai T , Koo B K , Escaned J , Kakuta T
Published: October 2019

Background

Studies of sex differences in fractional flow reserve (FFR) measurements have shown that in comparison with men, angiographic lesions of similar visual severity are less likely to be ischemia producing in women. Gender specific differences may influence revascularization decision making and prognosis after deferred revascularization following FFR measurement.

Purpose

This study sought to investigate the gender difference in long-term prognosis of patients of deferred revascularization following FFR assessment.

Methods

A total of 879 patients (879 vessels) with deferred revascularization with FFR >0.75 who underwent FFR and CFR measurements were enrolled from 3 countries (Korea, Japan, and Spain). Long-term outcomes were assessed in 649 men and 230 women by the patient-oriented composite outcome (POCO, a composite of any death, any myocardial infarction [MI], and any revascularization). We applied inverse-probability weighting (IPW) based on propensity scores to account for differences at baseline between women and men (age, hypertension, hyperlipidemia, diabetes mellitus, lesion location, clinical status, FFR, Reference diameter, Diameter stenosis, lesion length). The median follow-up duration was 1855 days (745–1855 days).

Results

Median FFR values were 0.88 (0.83–0.93) in men and 0.89 (0.85–0.94) in women, respectively. The occurrences of POCO were significantly high in men compared with that in women (10.5% vs 4.2%, P=0.007). Kaplan–Meier analysis revealed that women had a significantly lower risk of POCO (χ2=7.2, P=0.007). Multivariate COX regression analysis revealed that age, male, diabetes mellitus, diameter stenosis, lesion length, and coronary flow reserve were independent predictors of POCO. After applying IPW, the hazard ratio of male for POCO was 2.20 (95% confidence interval: 1.12 to 4.33, P=0.023).

Conclusion

This large multinational study reveals that long-term outcome differs between women and men in favour of women after FFR-guided revascularization deferral.

Acknowledgement/Funding

None
6116Thromboembolic risk in infection-related atrial fibrillation: is infection or atrial fibrillation the sinner?
Authors: Gundlund A , Olesen J B , Butt J H , Christensen M A , Gislason G H , Torp-Pedersen C , Koeber L , Kumler T , Fosboel E L
Published: October 2019

Introduction

Infection-related atrial fibrillation (AF) has been associated with similar risk of thromboembolic events as AF without a concurrent infection. However, it is unknown whether the increased thromboembolic risk in this patient group is primarily associated with AF or with the infection.

Purpose

We compared type of infection and 1-year outcomes in patients with AF during an infection and in patients with infection without AF.

Methods

By crosslinking data from Danish nationwide registries, AF naïve patients admitted with an infection from 1996–2016 were identified. Patients with infection-related AF (defined as patients who developed AF during their hospital admission with infection) were matched 1:3 on age, calendar year, sex, and type of infection (gastrointestinal infection, pneumonia, urinary tract infection, sepsis, and other infections) with those who had infection without AF. Cumulative incidences of thromboembolic events were calculated using the Aalen Johansen estimator and adjusted hazard ratios (HR) of thromboembolic events and hospital contacts with AF were assessed by multivariable Cox regression analysis comparing those with infection-related AF with those with infection without AF.

Results

The study population comprised 30,711 patients with infection-related AF and 92,133 patients with infection without AF (median age 79 years [interquartile range 71–86] and 47.6% males in both groups). In general, patients with infection-related AF had more concurrent diseases than patients with infection without AF. During the first week after the hospital admission, 9.8% of the patients with infection-related AF and 0.1% of the patients with infection without AF initiated oral anticoagulation therapy.

During the first year after the infection, 7.6% of patients with infection-related AF and 4.4% of patients with infection without AF had a thromboembolic event, while 36.1% and 1.8% had a new hospital-contact with AF. Cumulative incidences of thromboembolic events are depicted in the Figure. In the multivariable models, infection-related AF was associated with an increased 1-year risk of thromboembolic events and new hospital contacts with AF compared with infection without AF (HR 2.05, 95% confidence interval (CI) 1.94–2.17 for thromboembolic events and HR 26.06, 95% CI 24.72–27.48 for new AF episodes, respectively).

Conclusion

More than one third of patients with infection-related AF had a new hospital contact with AF during the first year after their infection. Further, infection-related AF was associated with a significantly increased 1-year risk of thromboembolic events compared with infection without AF. Consequently, this study suggests that AF begets AF, even if it presents during an infection.

Acknowledgement/Funding

None
6124Aorta and sports. the silent threat
Authors: Diaz Babio G , Vera Janavel G , Carrero C , Garcia Botta T , Masson Juarez G , Mezzadra M , Constantin I , Viguie S , Stutzbach P
Published: October 2019

Background

Thoracic aorta is the less known component of the athlete's heart and current publications shown that may be larger in athletes. It is known that high static training and body collision sports could increase the risk of sudden death, especially in patients with aortic disease (AD). Large scale traditional screening detects underlying cardiovascular diseases which may cause sudden cardiac death (SCD), however AD might be subdiagnosed.

OBJECTIVE

To describe AD burden on preparticipation screening and to assess diagnostic precision of traditional screening for AD detection in trained athletes.

Methods

Different sports athletes were recruited to follow current European guidelines (clinical history and cardiac examination, including resting 12-lead ECG) for preparticipation screening program (PSP). Bidimensional transthoracic echocardiography (TTE) was performed in all patients to detect AD: bicuspid aortic valve (BAV), thoracic aorta dilatation by Z score (TAD) and BAV plus TAD (BAD). Athletes were excluded from competition following international criteria. Sensitivity (Sn) and specificity (Sp) were calculated with 95% Clopper-Pearson confidence intervals and results are expressed as percentajes. McNemar paired chi-square test for one sample of individuals was used to compare diagnostic precision (Sn, Sp) of PSP vs gold standard: complete assessment (for sport exclusion, SpE) or TTE (for AD or BAD detection). Significance was set at p<0.05

Results

Included population (n=1123) was 22.3±6.2 y-o and 222 (19.8%) female. Five athletes (0.44% of total) were excluded from competition due to different causes. AD was found on 11 athletes (0.98%) and 4 of them had BAD (0.36%), a high risk condition with poor prognosis. Three patients with BAD were competitive cyclists and close follow up was indicated. The remaining patient with BAD was a rugby player and was excluded from competition (one out of 5 excluded patients, 20%). Diagnostic precision of PSP was better for SpE than for AD or BAD diagnosis. PSP tended to have less Sn for AD [36.4 (10.9–69.2)] and BAD [25 (0.6–80.6)] detection, than for SpE [80 (28.4–99.5); p=NS]. PSP had significant less Sp for AD [91.1 (89.3–92.7)] and BAD [90.9 (89–92.5)] diagnosis, than for SpE [97.2 (96.1–98.1); p<0.05].

Conclusions

AD is subdiagnosed by current PSP and its burden may be overlooked. Despite BAD is less frequent, its finding is determinant in a significant proportion of cases to decide exclusion from competitive (high static or body collision) sports. Although PSP has good sensitivity to detect potential pathologies of SCD, AD cannot be ruled out only by normal ECG and clinical examination. Diagnostic precision of PSP for AD and BAD detection could be enhanced by TTE screening, new studies with a larger number of athletes may answer the question.
P4986Quadruple imaging exercise stress echocardiography in unexplained dyspnoea
Authors: Zagatina A , Ciampi Q , Zhuravskaya N , Carpeggiani C , Picano E
Published: October 2019

Background

Current guidelines recommend the use of exercise stress echocardiography (ESE) in patients with unexplained dyspnoea. The methodological standard of ESE was recently reshaped with the quadruple imaging protocol, mainly tested in patients with chest pain. Aim of this study was to define the ESE pattern of response in patients with dyspnoea as the main symptom

Methods

From the initial population on a 1-year cohort of 604 patients referred in a single center for clinically-driven semi-supine ESE, we selected a subset of 93 consecutive patients (age 63±9 years, 52 females, resting Ejection fraction = 64±7%) with exertional dyspnea (shortness of breath, exertional fatigue or poor exercise capacity). All underwent quadruple imaging ESE: 1- Regional wall motion abnormalities (RWMA, step A) assessment (with wall motion score index, WMSI); 2- B-lines (step B) with simplified 4-site scan, each space scored from 0 = black, to 10= white (positivity criterion: stress score > rest for at least 2 points); 3- Left ventricle contractile reserve (LVCR, step C) assessment with stress/rest ratio of LV force measured as systolic blood pressure/end-systolic volume (positivity criterion:<2.0); 4- Pulsed-wave Doppler coronary flow velocity reserve (CFVR, step D) assessment in mid-distal LAD (positivity criterion: stress/rest diastolic peak flow velocity <2.0). Readers were accredited for each parameter upstream to recruitment via a web-based system.

Results

Feasibility was 100% for steps A, B and C, and 82% for step D. RWMA were present in 56 patients (60%). Of them, 27 underwent coronary angiography verification, showing significant coronary artery disease in 81%. B-lines positivity occurred in 35 patients (38%), an abnormal LVCR in 63 patients (68%), and a reduced CFVR in 44 pts (55%). At least one positivity criterion was observed in 80 patients (86%).

Conclusions

Patients with unexplained dyspnea are a reason of referral to ESE, accounting for 15% of contemporary testing. Quadruple imaging is useful to document the origin of dyspnoea as an ischemic equivalent (A positivity) and/or its cardiogenic origin for acute backward failure with pulmonary congestion (B positivity), myocardial function abnormalities (C positivity), and reduction of CFVR of microvascular-epicardial-myocardial origin (D positivity). Dyspnoea of unexplained origin is a multifactorial problem, and a more comprehensive assessment of these patients during ESE expands the clinical potential of the method.
P4993Tissue sodium concentration emerged as a determinant of hypertrophic vascular remodeling in type 2 diabetes
Authors: Schmieder R , Jung S , Kannenkeril D , Harazny J M , Striepe K , Ott C , Linz P , Nagel A M , Uder M
Published: October 2019

Background

Studies describe a linkage between greater sodium intake and higher incidence of organ damage and cardiovascular end points. Sodium intake is usually assessed by measuring 24-hour urinary sodium excretion, which is prone to high fluctuation. For the assessment of tissue sodium a new technique (23Na-MRI) has been developed. We analyzed whether tissue sodium is linked to vascular remodeling of small resistance vessels in patients with type-2 diabetes.

Methods

In patients with type 2 diabetes we assessed tissue sodium content and vascular structural parameters of the retinal arterioles, since structural changes of resistance vessels (150–300 μm) can be non-invasively and reliably assessed in the retinal circulation by Scanning Laser Doppler Flowmetry (SLDF). Patients with antidiabetic medication were off the therapy (antihypertensives were kept constant) for 4 weeks. The structural parameters of retinal arterioles assessed were outer- and inner diameter (OD & ID), wall thickness (WT), wall-to-lumen ratio (WLR) and wall cross sectional area (WCSA). Tissue sodium content was assessed non-invasively with a 3.0 T clinical MRI system in each patient. Subject placed their lower legs in the center of a 23Na knee coil and sodium content in skin and muscle (musculus triceps surae) were measured.

Results

In patients with type 2 diabetes (N=52) we observed a significant correlation between tissue sodium content (muscle and skin) and OD, WT and WCSA and a trend has been noticed between muscle sodium content and ID and WLR. Multiple linear regression analysis demonstrated that tissue sodium content is a significant determinant of hypertrophic vascular remodeling as indicated by increased WT and WCSA, independent of age, gender and 24-hour ambulatory diastolic blood pressure.

Correlation coefficients Muscle sodium content (mmol/l) Skin sodium content (mmol/l) OD (μmol) r=0.402, p=0.003 r=0.299, p=0.033 ID (μmol) r=0.265, p=0.058 r=0.202, p=0.154 WT (μm) r=0.402, p=0.003 r=0.313, p=0.026 WLR r=0.247, p=0.078 r=0.171, p=0.230 WCSA (μm2) r=0.417, p=0.002 r=0.322, p=0.021

Conclusion

With the novel 23Na-MRI technology, we could demonstrate that high tissue sodium concentration is linked to with hypertrophic vascular remodeling of retinal arterioles. Thus, the reduction of tissue sodium content may emerge as a therapeutic target.
P5002The impact of diabetes mellitus on global longitudinal strain of patients with acute heart failure
Authors: Kwak S , Hwang I.-C , Park J.-J , Park J.-H , Cho G.-Y , Park J.-B
Published: October 2019

Introduction

Diabetes mellitus (DM) aggravates the clinical features and the prognosis of heart failure (HF) patients. However, the impact of DM on the ventricular systolic function of HF patients is not well delineated.

Purpose

The present study aimed to investigate the impact of DM on HF, regarding the systolic function presented by the global longitudinal strain (GLS).

Methods

In 4312 patients with acute HF, left ventricle (LV) and right ventricle (RV) GLS were acquired by speckle-tracking echocardiography. HF patients with DM were compared to those without DM from the entire cohort (n=4312), as well as the propensity-score matched cohort (n=3034).

Results

Our cohort consisted of 1750 DM patients (40.6%). Both LV-GLS and LVEF were significantly lower within the patients with DM (10.1±4.8% vs. 11.3±5.1%, p<0.001 for LV-GLS; 39.1±15.5% vs. 41.7±15.6%, p<0.001 for LVEF) in the entire cohort. In the propensity-score matched cohort, LV-GLS was significantly reduced in the patients with DM compared to those without DM (10.2±4.9% vs. 10.9±5.0%, p<0.001), even with the matched LVEF (Table 1). Decreased LV-GLS in the DM patients was consistently identified in both subgroups of preserved EF and reduced EF (Table 1). Although RV-GLS was slightly lower in the patients with DM from the matched cohort, it was not significant in neither the preserved EF nor the reduced EF subgroup. When comparing the adverse outcome in the propensity-score matched cohort, the survival of patients with DM was significantly lower (Figure 1-A, 1-B), except for the preserved EF group (Figure 1-C).

Comparison between heart failure patients with and without diabetes in the matched cohort Matched cohort p-value HFrEF (matched) p-value HFpEF (matched) p-value No-DM (n=1517) DM (n=1517) No-DM (n=823) DM (n=801) No-DM (n=652) DM (n=669) Age, years 71±14 71±11 0.962 69±14 70±11 0.305 75±11 74±10 0.061 Ischemic heart disease, n (%) 545 (35) 575 (37) 0.275 375 (36) 402 (39) 0.238 150 (34) 147 (34) 0.945 GFR, mL/min/1.73m2 56±27 55±27 0.282 58±28 56±27 0.253 54±27 54±26 1.000 HbA1C, % 5.7±0.4 7.3±1.4 <0.001 5.7±0.4 7.3±1.4 <0.001 5.7±0.4 7.2±1.4 <0.001 LV ejection fraction, % 39±15 39±15 0.871 31±9 31±10 0.99 59±5 59±6 0.279 LV-GLS, % 10.9±5.0 10.2±4.9 <0.001 9.1±3.8 8.3±3.6 <0.001 15.5±4.5 14.9±4.5 0.036 RV-GLS, % 13.1±6.5 12.7±6.2 0.045 12.1±6.2 11.8±5.9 0.188 15.6±6.5 15.0±6.4 0.157

Figure 1. Outcome by DM status

Conclusions

DM is associated with the impaired LV systolic function presented by GLS in HF patients, even with the adjustment of LVEF. The result indicates that GLS is a more sensitive marker of systolic function than LVEF, in terms of the DM status among the HF patients.
P5007Acute natriuretic activity of sodium-glucose cotransporter 2 inhibitor in heart failure patients with type 2 diabetes mellitus
Authors: Fukuoka S , Dohi K , Ishiyama M , Takeuchi T , Fujimoto N , Ito M
Published: October 2019

Background

Sodium-glucose cotransporter 2 (SGLT2) inhibitor promotes diuresis and reduces the risk of hospitalization for heart failure (HF). However, the mechanisms of diuretic effects of SGLT2 inhibitor in HF patients with type 2 diabetes mellitus (T2DM) remain under investigation.

Purpose

The purpose of this study was to investigate the mechanisms of acute diuretic effects of SGLT2 inhibitor and to identify its predictor in HF patients with T2DM.

Methods

We prospectively enrolled 40 hospitalized HF patients with T2DM (68±13 years, 63% male, and hemoglobin A1c 7.1±0.9%) between July 2014 and June 2018. All patients received ipragliflozin at a dose of 50 mg once daily after breakfast. They underwent 24-hour urine test and first-morning blood and urine tests before and after ipragliflozin therapy.

Results

Urine volume significantly increased from 1,365±511 ml/day on day 0 to 1,698±595 ml/day on day 3 (p<0.001). Multivariate linear regression analyses showed that the increase of 24-hour urine sodium but not urine sugarwas significantlyand independently associated with the increase of 24-hour urine volume (β-Coefficient=0.80; P<0.001). Univariate and multivariate logistic regression analyses showed that higher dosage of furosemide-equivalent loop diuretics and lower level of first-morning urine sodium concentration (per 1 mEq/L) at baseline were significantly associated with the diuretic effect of ipragliflozin therapy, and the latter independently predicted increase of 24-hour urine volume (Table).

Predictors for increase of urine volume Univariate Multivariate Odds ratio (95% CI) P value Odds ratio (95% CI) P value Dosage of furosemide, mg 1.09 (1.01–1.18) 0.04 – – HbA1c, % 1.45 (0.56–3.78) 0.44 Fasting blood glucose, mg/dL 1.02 (0.99–1.04) 0.24 eGFR, mL/min/1.73m2 1.01 (0.97–1.05) 0.65 Plasma BNP, pg/mL 1.00 (0.99–1.01) 0.12 Left ventricular ejection fraction, % 0.98 (0.94–1.02) 0.24 First-morning urine sugar, mg/dL 1.20 (0.96–1.50) 0.12 First-morning urine sodium, mEq/L 0.96 (0.93–0.99) 0.02 0.96 (0.93–0.99) 0.02 24-hour urine sugar, g/day 3.49 (0.13–93.40) 0.46 24-hour urine sodium, mEq/day 0.98 (0.96–1.01) 0.20 eGFR, estimated glomerular filtration rate; BNP, brain natriuretic peptide.

Conclusion

SGLT2 inhibitor has acute natriuretic activity and may restore loop-diuretic resistance in HF patients with T2DM.

Acknowledgement/Funding

None
P5021Hypoperfusion markers identify patients with acute pulmonary embolism at highest risk for an adverse outcome
Authors: Ebner M , Sentler C , Harjola V P , Bueno H , Keller K , Lerchbaumer M , Hobohm L , Hasenfuss G , Eckardt K U , Konstantinides S , Lankeit M
Published: October 2019

Background/Introduction

According to the European Society of Cardiology (ESC) 2014 guideline, systemic hypotension (HT) is the critical variable defining high-risk in patients with pulmonary embolism (PE). However, signs of organ hypoperfusion might more adequately identify PE patients with cardiogenic shock due to right ventricular (RV) failure.

Purpose

We investigated whether hypoperfusion markers provide superior prognostic information for identifying PE patients at highest risk of early adverse outcomes.

Methods

Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were included. We analysed the predictive value of symptoms and findings suggesting hypoperfusion for in-hospital adverse outcome (catecholamine treatment, resuscitation or PE-related death) and in-hospital all-cause mortality.

Results

We analysed 814 patients, including 83 (10.2%) ESC 2014 high-risk patients. Patients presenting with cardiac arrest (CA, 4.5%) were a priori defined as high risk. Markers suggesting hypoperfusion of the brain (altered metal status, odds ratio [OR] 8.2 [95% CI, 4.2–16.0]), lung (respiratory insufficiency, 25.0 [9.4–66.7]) and tissue (venous lactate ≥2.2 mmol/l, 6.4 [3.2–12.9]) as well as HT (13.5 [6.7–27.2]) predicted an adverse outcome. The risk for an adverse outcome increased with the number of positive markers (AUC 0.86 [0.80–0.93]). Patients with ≥3 positive hypoperfusion markers had an OR of 42.9 (11.0–167.3) and patients defined as high-risk by the ESC 2014 an OR of 17.2 (8.8–33.3) with regard to an adverse outcome (Figure 1; Table 1).

A new definition of high-risk (CA or ≥3 hypoperfusion markers) was associated with an OR of 73.2 (31.3–171.1) for an in-hospital adverse outcome and 26.2 (12.1–56.7) for in-hospital mortality.

Table 1. Prognostic performance of hypoperfusion markers Adverse outcome (if negative) Adverse outcome (if positive) Sensitivity Specificity LR+ OR (95% CI) ≥1 hypoperfusion marker 1.1% 21.0% 91.9% 68.2% 2.9 24.4 (7.3–80.8) ≥2 hypoperfusion markers 4.7% 50.0% 48.6% 95.5% 10.9 20.3 (9.1–45.1) ≥3 hypoperfusion markers 6.5% 75.0% 24.3% 99.3% 32.7 42.9 (11.0–167.3) ESC 2014 high-risk 5.7% 51.1% 35.0% 96.9% 11.4 17.2 (8.8–33.3) Cardiac arrest 8.4% 86.5% 33.0% 99.3% 47.3 70.1 (26.4–186.1) Abbreviations: LR+, positive likelihood ratio; OR, odds ratio; CI, confidence interval.

Figure 1. Frequency of adverse outcome

Conclusions

Markers of organ hypoperfusion have high predictive value for early adverse outcomes in acute PE. Risk increases with the number of positive markers and is critically elevated in patients presenting with CA or ≥3 markers.

Acknowledgement/Funding

This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).
P5029Inducibility of ventricular tachyarrhythmias by up to two extrastimuli does not predict future cardiac events in asymptomatic Brugada patients: results from long-term follow-up
Authors: Takagi M , Kamakura T , Shinohara T , Sekiguchi Y , Yokoyama Y , Aihara N , Hiraoka M , Aonuma K
Published: October 2019

Background

Most recent consensus conference report recommends Implantable Cardioverter Defibrillator (ICD) implantation for asymptomatic Brugada patients with spontaneous or fever-induced type-1 ECG (A-BrS) and inducible ventricular tachyarrhythmias (VTs) by up to two extrastimuli as class IIb indication. However, the validity of the inducible VTs by up to two extrastimuli in A-BrS is still unknown.

Purpose

To evaluate the validity of the inducibility by up to two extrastimuli in A-BrS in a large Japanese cohort of BrS (The Japan Idiopathic Ventricular Fibrillation Study [J-IVFS]).

Methods

A total of 193 consecutive A-BrS patients performed programmed electrical stimulation (PES) with non-aggressive uniform protocol (mean age 50±13 years, 180 males) were enrolled. PES protocol was using 2 basic pacing cycles and the order of introduction of up to 2 ventricular extra-stimuli from right ventricular apex [RVA] first, then right ventricular outflow tract [RVOT], 3 ventricular extra-stimuli from RVA then RVOT down to the minimum of 200ms. Clinical outcomes during the follow-up period were compared between A-BrS patients with and without inducible VTs by up to two extrastimuli.

Results

Thirty-five A-BrS (18%) had inducible VTs by up to two extrastimuli. During a mean follow-up period of 101±48 months, 7 A-BrS experienced cardiac events (sudden cardiac death [SCD] or VTs, 0.4%/yr). None of the 7 A-BrS had inducible VTs by up to two extrastimuli. The incidences of cardiac events tended to be higher in A-BrS without inducible VTs by up to two extrastimuli than in those with inducible VTs (p=0.10), as determined by the Kaplan-Meier method. In the A-BrS, the annual incidences of cardiac events in A-BrS with family history of SCD, inferolateral J wave, wide QRS duration >90msec in lead V2, or inducible VT/VF by 3 extrastimuli were 0.7, 0.7, 0.6, and 0.3%/yr, respectively.

Conclusions

Our large-scaled multicentre study with long-term follow-up revealed the inducibility of ventricular tachyarrhythmias by up to two extrastimuli does not predict future cardiac events in A-BrS, even using non-aggressive uniform protocol. Rather, other parameters such as family history of SCD or inferolateral J wave might be helpful for risk assessment in A-BrS.
P5242Gender equality in acute coronary syndrome: modern times, old habits?
Authors: Craveiro N , Saraiva M , Moura A R , Vieira M J , Domingues K , Peres M , Martins V
Published: October 2019

Introduction

Historically, women with acute coronary syndrome (ACS) have worse outcomes compared with men. Differences in clinical, demographic characteristics and treatment may explain this result. In recent times with new diagnostic capabilities and revascularization therapies this panorama may be changing.

Methods

Single-center retrospective study comparing gender differences in ACS patients from 2012 to 2017. Two groups were formed comparing women and men: Group A: years 2012 to 2014 and group B: years 2015 to 2017.

Results

From 2012 to 2017 we identified 1091 patients with ACS. Of them 356 (32,6%) were women and NSTEMI (60%) was the most frequent type of ACS in this group. Women with ACS were older than men (73 vs 66 years) had more arterial hypertension (83,4% vs 68,3% p<0,001), diabetes mellitus (46,3% vs 30,9% p<0,001) and were less frequently smokers (6,5% vs 25,3% p<0,01). Dyspnea as the predominant symptom was more frequent in women (10,4% vs 5,2% p=0,002) who were less submitted to invasive strategy (63,2% vs 74,7% p<0,001) where non obstructive disease was more prevalent compared to men (9,8% vs 3,3% p<0,001). In-hospital mortality was greater in the women group (7,9% vs 3,7% p=0.005). There were no differences between groups in hospitalization or cardiovascular mortality over 1-year follow-up. When comparing Group A with Group B there were differences in hospitalization at 1 year (Group A 15,4% vs 9,3% p=0,029, Group B 11% vs 12,4% p=0,766), in-hospital women mortality (Group A 9,5% vs 3,6 p=0,005, Group B 5,8 vs 3,8% p=0,346) and coronary invasive angiography (Group A 61,2% vs 80,2% p<0,001 vs Group B 65,8 vs 68,5%, p=0,606).

Conclusion

Different demographic and clinical presentation as well as in-hospital and 1-year outcomes were present in our study population: while in Group A threre were significant gender differences regarding hospitalization and in-hospital mortality, those differences faded away in Group B. Efforts should be made to lessen gender differences in treatment and assistance knowing the different demographical and clinical patient profile.
P5243Indirect costs of acute myocardial infarction in Portugal
Authors: Timoteo A T , Gouveia M , Soares C , Ferreira R C
Published: October 2019

Introduction

Cardiovascular diseases are the main cause of death in Portugal. The high incidence of acute myocardial infarction (AMI) is also a major problem, particularly due to the economic burden caused by productivity losses (indirect costs) associated with temporary absence from work, not yet sufficiently studied in Portugal. Our objective was to quantify the indirect costs of AMI in the first year after admission.

Methods

All consecutive patients admitted in a single center with <66 years (official retirement age) during one year that survived to discharge were included in the present study. Employment status on admission was assessed in every patient. For each employed patient, working at the time of admission, the monthly wage was estimated from market wage rates from national public sources (grossed up by social security contributions) according to gender and age. A day-cost was calculated to assess the cost of temporary absence from work. A half-day absence was considered for Cardiology medical appointments and exams. The duration of temporary absence from work was assessed by a first follow-up contact at 30-day and a second follow-up evaluation up to one-year after admission. The cost of temporary absence from work per episode was calculated in this sample and results were applied to the total number of MI in Portugal during the year 2016 (last available national data) and separately according to ST-elevation AMI (STEAMI) or non-ST-elevation acute coronary syndrome (NSTACS).

Results

We included 219 patients (54±7 years, 83% males), from which, 66.2% were working, 16.4% early-retired, 11.9% unemployed and 5.5% in long-term exit from work due to non-cardiac disease. During the one-year follow-up there were no changes in employment status. In our sample, mean monthly labor cost was 1802 euros (69 euros/day). Median number of days absent from work were 34 days (31 days in men and 52 days in women) and a median of 2 half-days were also obtained for Cardiology appointments / exams. We obtained a total cost of 760.521,55 euros. We used available data from 2016 to estimate indirect costs at a national level. There were 4133 patients with <66 years admitted in Portugal due to AMI that survived to discharge. We performed an analysis, using the proportions of 41% of cases with STEAMI and 59% with NSTACS that came out of the Portuguese Registry on Acute Coronary Syndromes and the working patient's proportions in each group. Costs were higher in patients with STEAMI. We estimate an indirect total cost in Portugal of € 10.12 million in the first year after MI.

Conclusions

In Portugal, the costs to society of disability generated losses of productivity are over ten million euros during the first year after AMI. Strategies to improve time of return to work are very important to lower these costs.
P5245Cost-saving diagnosis approach by artificial intelligence tool in patients with suspected coronary artery disease. The co-operative ARTICA registry database
Authors: Mazzanti M , Shirka E , Gjergo H , Pugliese F , Goda A
Published: October 2019

Background

Although coronary tomographic angiography (CTA) has shown promise as a “gatekeeper” to invasive coronary angiography (ICA) in longitudinal cohort studies, it remains unknown whether the strategy of direct initial performance of CTA is cost-effective when compared with selected exercise treadmill testing (ETT) +/− functional cardiac imaging strategies in patients with suspected coronary artery disease (CAD). An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has been used at point of care for evaluating subjects with stable chest pain (SCP).

Purpose

The objective was to verify the cost-saving effect of the robotic AI DSS vs direct CTA by human standard care (SD) for diagnosing CAD in subjects presenting with SCP.

Methods

From October 2016 over three hospitals, 1017 subjects, 620 males, age 62±11 years, with clinically SCP being referred for CTA by SD received also a same day pre-scan AI DSS administration. All patients did not demonstrate significant CAD at CTA. CTA/ICA, or exercise treadmill test (ETT)/ stress echocardiography (SE), gated myocardial perfusion scintigraphy (gMPS) or Follow up/No tests (FNT) strategies by AI DSS were analyzed and compared to direct CTA SD. Pre-test likelihood (pt-lk) of CAD consider clinical risk factors into the model. Sensitivity and specificity of non-invasive diagnostic tests within our model were based upon a bivariate analysis of data from published multicenter trials. Costs of procedures were calculated by the sum of technical and professional components. Probabilistic sensitivity analysis was conducted to assess the impact of uncertainty in model parameters.

Results

The direct approach used performing direct CTA strategy by SD in all subjects costed 406.800 €. Costs of each procedure and distribution of AI DSS outputs are shown in the Table. Across the range of pt-lk of CAD, total costs of AI DSS strategy resulted 146.030€ with −65% vs SD approach.

AI DSS tests distribution and costs pt-lk (pt/%) FNT (0€) ETT (90€) SE (350€) Stress gated MPS (750€) CCTA (400€) ICA (3.000€) High (29/2.8) 0 0 1 2 0 26 Int (371/36.5) 259 5 51 48 7 1 Low (612/60.7) 595 2 2 0 13 0 Total costs (€) 0 630 18,900.00 37,500.00 8,000.00 81,000.00

Conclusion

These results from ARTICA registry seem to demonstrate that AI DSS is extremely cost-saving in subjects with stable chest pain across the whole range of pt-lk of CAD.
P5250Diastolic strain rate ratio as determined on MRI on detecting left ventricle stiffness and predict heart failure in post-STEMI patients
Authors: Diao K Y , Huang S , Gao Y , He S , Yang Z G , He Y
Published: October 2019

Background

ST-elevation myocardial infarction (STEMI) Patients suffered from progressive heart failure, for which progressive and aggravated Left ventricle stiffness was one of the major culprit. Myocardial deformation in the early diastole is largely affected by the left ventricle compliance which could partly reflect chamber stiffness and potentially predict left ventricular remodeling for post-STEMI patients.

Purpose

To determine the value of diastolic strain rate in detecting left ventricle stiffness and early heart failure in post-STEMI patients.

Methods

A number of 52 (M/F: 46/6, age: 54.27 [46.8–62.3]yrs) patients with STEMI three months ago were prospectively recruited from 2016 to 2017. Follow-up was done until 2018. The primary end points were the symptoms of heart failure (NYHA II-IV). Consent was acquired from each patient and 3.0 T MRI was arranged. Imaging analysis was performed on Cvi 42 (V5.9.3 Canada). Peak radial strain (PS) and strain rate (SR) were extracted both from 2D short- and long-axis cine images, while peak circumferential parameters only from the short axis slices and longitudinal the long axis slices. The diastolic strain rate ratios (DSRRs) were calculated as the peak early diastolic SR divided by the peak late diastolic SR, which were derived from the two peak points on the corresponding curve of time-to-SR curve in the diastole (Figure 1a). Receiver-operating characteristics curve analysis and Logistic regression test were done for statistical analysis on R project and P<0.05 was considered as significant.

Results

Three patients were excluded due to unsatisfied cine images. Among the 52 patients, none of the patients died or had congestive heart failure. 23/52 (44.2%) patients complained of heart failure symptoms at the one-year follow-up. No significant difference was found in LVEF and three directional peak strain values or systolic peak strain rates between the patients with and without heart failure. Patients with symptoms had lower Longitudinal PS (P=0.049), early diastolic radial SR (P=0.01798), longitudinal SR (P=0.0042), and decreased DSRR in all directions (Figure 1b). Multivariate Logistic regression test showed that only DSRR in the radial direction on the short axis (DSRR-SR) was the independent predictor of the heart failure symptoms (6.59; range, 6.71–3.68; P=0.026). ROC analysis demonstrated that the DSRR-SR of 2.35 had sensitivity 91.3% and specificity 58.6% for the prediction of heart failure (Figure 1c).

Figure 1

Conclusion

DSRR especially DSRR-SR was more sensitive to left ventricle stiffness change and help predict the progression of heart failure for Post-STEMI patients. Further studies were needed to verify the its association with other cardiovascular clinical events.

Acknowledgement/Funding

the National Natural Science Foundation of China (81600299,81471721, 81471722, 81771887, and 81771897,);
P5261Feature tracking by CMR: left ventricular dysfunction predicts outcome in heart failure with preserved ejection fraction
Authors: Kammerlander A , Kraiger J , Nitsche C , Dona C , Duca F , Zotter-Tufaro C , Binder C , Koschutnik M , Aschauer S , Loewe C , Hengstenberg C , Bonderman D , Mascherbauer J
Published: October 2019

Objectives

To investigate the association between global longitudinal strain (GLS) using feature tracking (FT) cardiovascular magnetic resonance imaging (CMR) and prognosis in patients with heart failure and preserved ejection fraction (HFpEF).

Background

Echocardiography-based studies have demonstrated that in HFpEF left ventricular (LV) strain analyses can detect impaired systolic function despite preserved ejection fraction and might also predict outcome. CMR also allows strain analysis using FT and is furthermore the gold standard for assessment of ventricular volumes and ejection fractions. In addition, T1-mapping allows non-invasive tissue characterization. However, the prognostic relevance of FT-CMR is unknown. In addition right ventricular (RV) FT-CMR is poorly investigated.

Methods

Consecutive patients with confirmed diagnosis of HFpEF underwent CMR on a 1.5T scanner. We used dedicated software (cvi42, Circle Cardiovascular Imaging Inc.) for global longitudinal left ventricular strain (LV-GLS) in a 3D and global longitudinal RV strain (RV-GLS) in a 2D model using feature tracking (FT). In addition, we performed uni- and multivariable Cox regression using a combined endpoint of heart failure hospitalizations, and cardiovascular death to determine the prognostic relevance of FT-CMR.

Results

We included a total of 131 HFpEF patients (70.4±8.6 years old, 70.2% female). Median LV-GLS by FT-CMR was −8% [IQR: −10% to 5%] and median RV-GLS was −11.9% [IQR: −16.57% to −12.23%]. LV and RV GLS values were significantly correlated with LV and RV ejection fractions (r=−0.463, p<0.001 for LV, and r=−0.306, p=0.001 and RV, respectively). 77 (58.8%) events were recorded during a follow-up of 42.0±31.4 months. Patients with an LV-GLS worse than the median (−8%) showed a significantly reduced event-free survival rate (log-rank, p=0.009).In a multivariable Cox-regression model correcting for the strongest clinical variables, including age (HR 1.018 [0.985–1.052], p=0.290), GFR (HR 0.987 [0.975–1.000], p=0.055), diabetes (HR 1.696 [1.028–2.799], p=0.039), and 6-min-walking distance (HR 0.997 [0.995–0.999)], p=0.014), LV-GLS remained significantly associated with outcome (HR 1.093 [1.039–1.150], p=0.001) while RV-GLS had no effect on outcome (p>0.05).

Conclusions

In patients with HFpEF, LV-GLS but not RV-GLS by FT-CMR is significantly associated with cardiovascular events.
P5266Renal denervation improves diastolic dysfunction in patients with HFpEF - initial results of a multicenter CMR study
Authors: Zamani S , Mahfoud F , Stoiber L , Boehm M , Pieske B , Gebker R , Stawowy P , Kelle S
Published: October 2019

Introduction

Renal denervation (RDN) significantly reduces blood pressure (BP) and improves myocardial function in patients with resistant hypertension.

Purpose

This multicenter study aimed to investigate the intermediate term effect of RDN on left ventricular global longitudinal strain (GLS), a surrogate for diastolic myocardial function in RDN patients with proven heart failure with preserved ejection fraction (HFpEF), assessed by cardiac magnetic resonance imaging (CMR).

Methods

We analyzed data from 22 patients with resistant hypertension (mean age 68±6 years). 16 patients underwent renal denervation (RDN) and 6 matched control patients received optimal medical therapy (OMT). Both groups had diastolic dysfunction defined by preserved ejection fraction (EF ≥50%) and pathologically elevated GLS at baseline (GLS >−18%) quantified by cardiac magnetic resonance (CMR). A standardized CMR protocol was performed at baseline (BL) and 6 months follow-up (FU). Left ventricular mass index (LVMI) was quantified in end-diastolic and end-systolic endo- and epicardial contouring in short axis cine-MRI images. GLS was measured by end-diastolic and end-systolic endocardial contouring in 2-, 3- and 4-chamber view cine-MRI images. MRI-Images have been analyzed with Medis, Netherlands.

Results

GLS following RDN patients significantly improved after 6 months by 21% (−14.21% ±3.19 vs. −17.17%± 3.1; p=0.007). In control patients with OMT, no significant change in GLS was detected (−14.77% ±3.05 vs. −17.39% ± 4.49; p=0.327). LVMI was numerically reduced in the RDN group at follow-up but did not reach statistical significance (58.55 g/m2±11.37 vs. 55.46 g/m2±12.76; p=0.085). There was no such effect in control patients with OMT (49.25 g/m2±8.2 vs. 50.18 g/m2±7.27; p=0.665). (See also: Figure A and B).

Conclusions

We found significantly improved diastolic function (GLS) in patients with HFpEF and resistant hypertension undergoing RDN. Future studies are needed to determine whether RDN represents a treatment option in patients with HFpEF.