bluuebunny/crossref_metadata_2025 huggingface dataset:
P1646Do Extracellular Vesicles repair chronic ischemic heart disease by replenishing the cardiomyocyte pool?
Authors: Lima Correa B , El Harane N , Perotto M , Tence N , Pidial L , Desgres M , Barron E , Bellamy V , Perier M C , Renault N K , Gnecchi M , Silvestre J S , Menasche P
Published: October 2019

Introduction

Extracellular Vesicles (EV) seem to mediate the benefits of cell therapy for ischemic heart failure. Although their mechanism of action remains poorly understood, one hypothesis is that they might trigger the generation of new cardiomyocytes.

The doubly transgenic fate-mapping MerCreMer/ZEG mice model was thus used to distinguish whether these putative new cardiomyocytes originated from the division of preexisting ones (GFP+, Troponin T [TnT+], EdU+) or differentiated from endogenous progenitors, in which case they would stain positive for TnT+/EdU+ but negative for GFP.

Methods

Myocardial infarction was induced in 35 MerCreMer/ZEG mice by permanent occlusion of the left anterior descending coronary artery. Three weeks later, the surviving mice (n=18) with a left ventricular ejection fraction (LVEF) ≤45% received transcutaneous echo-guided injections in the peri-infarct myocardium of either EV (from 1.4 million human iPS-derived cardiovascular progenitor cells; 10 billion particles, n=9) or PBS (n=9); osmotic pumps were implanted to deliver EdU for 7 days in order to track the proliferation of new and native cardiomyocytes. Four-6 weeks after treatment all mice were evaluated by echocardiography (n=9 per group) and MRI (7 in each group), and then sacrificed for histological assessment, blindly.

Results

Based on echocardiography (MRI data pending), EV improved LVEF by 16% relative to baseline while a decrease of 4% was observed in the PBS group (p=0.46).

The number of new cardiomyocytes (TnT+/EdU+/GFP+) did not significantly differ between the EV-treated hearts and the controls, and averaged 0.54% of the total heart cell content in infarct, peri-infarct and remote areas. However, EV treatment better preserved preexisting GFP+/WGA+/TnT+ cardiomyocytes in the peri-infarct area as their number was greater by 5.15% compared to PBS (32 sections analyzed for each mouse). Compared to the PBS control group, EV delivery was also associated with a 2.5% decrease in fibrosis, a reduction of infarct size by 14.9%, and an increase in angiogenesis in the peri-infarct area (with a between-group absolute difference of 71 capillaries, on the basis of isolectin staining).

Conclusions

EV secreted by iPS-derived cardiovascular progenitors improve the function of chronically infarcted hearts. Preservation of the existing cardiomyocyte pool and limitation of adverse remodeling and scarred tissue, likely favored by increased neoangiogenesis, are the main mechanisms mediated by the EV, while fate mapping allowed to exclude the generation of new cardiomyocytes.
P1652Limited correlation of calculated plasma volume status with invasive right heart pressures in patients with heart failure
Authors: Campbell R , Barton A , Docherty K F , Kristensen S L , Payne J , Dalzell J R , Gardner R S , McMurray J V , Petrie M C
Published: October 2019

Background

Estimated plasma volume (ePV) can be calculated from haematocrit and body weight, and has been shown to correlate with PV measured using 125Iodine labelled human serum albumin. Comparing a patient's ePV to ideal PV (iPV), an estimate of a patient's relative congestion, called PV status (PVS), is possible. Higher PVS is associated with increased mortality in patients with heart failure (HF), and has been proposed as a simple, cheap, and non-invasive way of assessing congestion.

Purpose

Whether PVS is associated with invasively measured markers of congestion is unknown. We calculated PVS in patients with HF who had right heart catheterisation (RHC), and assessed any correlation between PVS and invasive measures of congestion.

Methods

We calculated PVS in consecutive patients who had RHC performed as part of transplant assessment. iPV was calculated as: iPV = c × weight (kg) where c=39 in males and c=40 in females. ePV was calculated using subjects' haematocrit and weight as follows: ePV = (1 − haematocrit) × [a + (b × weight in kg)], where haematocrit is a fraction, a=1530 in males and a=864 in females, and b=41 in males and b=47.9 in females. PVS was calculated as: PVS = PVS = (ePV − iPV) /iPV × 100%. Correlation between PVS and invasive wedge pressure, mean right atrial (RA) pressure, and NTproBNP were made using Pearson correlation.

Results

PV indices and RHC data were available for 61 patients, 43 (71%) were male. Median age was 55 [IQR 48, 58] years. 20 (33%), 24 (39%), and 15 (25%) were NYHA association class II, III, and IV respectively. The median NTproBNP was 1390 [IQR 512, 3612] pg/ml and median ejection fraction was 29 [IQR 20, 35] %. The median PVS was −5.9% (IQR −12.5, −1.6]. Median wedge and mean-RA pressures were 14 [7, 21] and 4 [1, 8] mmHg, respectively. Correlation between mean RA pressure and PVS is shown in the figure. There was no correlation between PVS and mean RA pressure (r=0.12, p=0.34) or wedge pressure (r=0.01, p=0.92). There was a weak correlation between NTproBNP and PVS (r=0.31, p=0.01)

Correlation mean RA pressure and PVS

Conclusion

PVS did not correlate with the invasive measures of congestion, mean RA and wedge pressure, but was weakly correlated with NTproBNP. Although there were limited number of patients in this study, we question the conclusion that PVS is a marker of congestion, and whether it can be used clinically for this purpose.
P1667Comparison of post-implant anticoagulation agents in left ventricular assist devices
Authors: Bigeh A , Keuth J , Gerkin R , Gopalan R
Published: October 2019

Background

Left ventricular assist devices (LVADs) improve survival in patients with end-stage heart failure. Despite technological advancements, there is still a high risk of bleeding and thromboembolic events. To minimise device clotting, anticoagulation is usually started three days after implant. Unfractionated heparin (UFH) is the standard as a bridge to coumadin, however, current guidelines lack comparative evidence and do not delineate between anticoagulation agents (such as enoxaparin).

Purpose

To evaluate the safety of post-implant anticoagulation in LVAD patients using UFH and low molecular weight heparin enoxaparin (LMWH).

Methods

From October 2007 to October 2018, 83 patients underwent LVAD implantation (Heartmate II, III or HVAD) at Banner University Medical Center-Phoenix. Retrospective analysis was performed on 68 patients who received post-implant anticoagulation with a goal INR 1.8–2.5. Patients were bridged with either UFH (n=46) or LMWH (n=22).

Results

Demographics and patient characteristics were comparable between groups. We analysed adverse events, survival, and time to adverse events. The heparin group had a nonsignificant longer event-free period after implant compared with LMWH, median 9.4 and 1.8 months, respectively (p=0.428). The LMWH group had a significantly increased proportion of adverse events across all categories (p=0.021). Bleeding was the most common event for both groups, although substantially more for those receiving LMWH. Most notably 14 heparin patients (30.4%) had no adverse events compared to zero in the LMWH group.

Types of Adverse Events Post-Implant Bleeding Hemorrhagic Stroke Ischemic Stroke Pump Thrombus None Total Bridging Agent Heparin Count 18 3 8 3 14 46 % 39.1% 6.5% 17.4% 6.5% 30.4% 100% Enoxaparin Count 14 2 4 2 0 22 % 63.6% 9.1% 18.2% 9.1% 0% 100% Total Count 32 5 12 5 14 68 % 47.1% 7.4% 17.6% 7.4% 20.6% 100% p=0.021.

Post-Implant Event-Free Survival

Conclusions

Minimising bleeding and clotting are a persistent challenge in LVAD patients. Use of LMWH was associated with significantly more adverse events compared to UFH, with bleeding constituting the majority of events. Establishing institutional protocols and standards are necessary to improve patient outcomes; therefore, larger prospective studies are needed.
P1676De novo aortic insufficiency following long term LVAD support can be successfully treated with TAVI and a pre-stenting technique
Authors: Kofler M , Unbehaun A , Buz S , Klein C , Meyer A , Potapov E , Eggert-Doktor D , Falk V , Kempfert J
Published: October 2019

Background/Introduction

Long-term continuous flow left ventricular assist device (cf-LVAD) can result in the development of relevant aortic regurgitation (AR). Although its impact on survival is still controversial, it causes heart failure related symptoms. Current evidence for less invasive strategies to treat AR in cf-LVAD patients is limited.

Purpose

This study sought to investigate the value of transcatheter aortic valve implantation (TAVI) to treat severe de novo AR in patients on long-term cf-LVAD support. Methods

We performed a retrospective analysis of 13 patients with severe AR following cf-LVAD implantation treated with TAVI between 2010 and 2019. TAVI's were performed via transfemoral (n=11), transapical (n=1) and transaxillary (n=1) access route. CoreValve (n=2), LotusValve (n=1), SapienXT (n=1) and Sapien3 (n=9) were used as transcatheter heart valves. In 4 patients, a new off-label strategy using landing-zone pre-stenting with a Sinus-XL stent was used (Figure 1).

Results

The median time interval from LVAD-implantation to TAVI was 1.7 years [interquartile range (IQR): 1.0 - 3.1]. Median age was 62 years [IQR: 57 - 67]. No procedural mortality or stroke was observed. Overall, device success according to VARC-II criteria was low due to a high rate of second valve necessity (54%). In contrast to the standard implantation technique, device success was 100% when the newly developed pre-stenting technique was applied (Table 1). Aortic regurgitation at discharge was none/trace in all patients. Valve function remained stable in all patients during a median echocardiographic follow-up time of 105 days [IQR: 11 - 298].

Table 1 Overall Sinus-XL prestenting (n=4) NO prestenting (n=9) Device success 7 (54) 4 (100) 3 (33) Procedural mortality 0 (0) 0 (0) 0 (0) Correct positioning of a single valve 7 (54) 4 (100) 3 (33) Intended valve performance 13 (100) 4 (100) 9 (100) Moderate or severe aortic regurgitation 0 (0) 0 (0) 0 (0)

Figure 1

Conclusions

Transcatheter aortic valve implantation is an efficient tool to treat cf-LVAD induced severe AR. The challenging anatomy of the non-calcified device landing zone causes a relatively high rate of primary device failure, which could be overcome with a pre-stenting technique.

Acknowledgement/Funding

None
P1680High density lipoprotein cholesterol (HDL-C) levels and endothelial glycocalyx integrity in treated hypertensive patients
Authors: Triantafyllidi H , Benas D , Schoinas A , Vlachos S , Vlastos D , Pavlidis G , Voutsinos D , Ikonomidis I
Published: October 2019

Background

Endothelial dysfunction indicates target organ damage in hypertensive patients. The integrity of endothelial glycocalyx (EG) plays a vital role in vascular permeability, inflammation and elasticity and finally to cardiovascular disease. We aimed to investigate the role of increased HDL cholesterol levels (HDL-C), which usually are considered protective against cardiovascular disease, in EG integrity in older hypertensive patients.

Methods

We studied 120 treated hypertensive patients older than 50 years were divided regarding HDL-C tertiles in group HDLH, (HDL-C >71 mg/dl, upper HDL-C tertile) and group HDLL, (HDL-C <71 mg/dl, two lower HDL-C tertiles). Increased perfusion boundary region (PBR) of the sublingual arterial microvessels (ranged from 5–9 micrometers) using Sideview Darkfield imaging was measured as a non-invasive accurate index of reduced EG thickness.

Results

PBR 5–9 was significantly decreased in group HDLH (p=0.04). In the whole population, HDL-C was inversely but moderately related with PBR 5–9 (r=−0.22, p=0.01). In a multiple linear regression analysis model, using age, BMI, smoking habit, HDL-C, LDL-C and office SBP, as independent variables, we found that BMI (β=0.25, p=0.006) independently predicted PBR 5–9 in the whole population.

Differences in PBR5-9 between HDL groups

Conclusions

In older hypertensive patients, HDL-C ranged between 71–101 mg/dl might moderately protect EG and subsequently endothelial function. Future studies in several groups of low or high risk hypertensives are needed in order to evaluate the beneficial role of extremely elevated HDL-C regarding cardiovascular risk evaluation as well as endothelial glycocalyx as a novel index of target organ damage in essential hypertension.
P1681Clinical profile of patients initiating evolocumab in Spanish Cardiology Units: A RETrospective, Observational Study of Real-World Clinical Practice (RETOSS-Cardio)
Authors: Barrios V , Antorrena Miranda M I , Bonanad Lozano C , Cosin Sales J , Diaz De Castro O , Fernandez Del Olmo M R , Garcia Del Egido A , Garcia Fuertes D , Garcia Izquierdo E , Mera Romero M , Otero Chulian E , Rincon Diaz L M , Vazquez Garcia R , Roldan Suarez C , Arrarte Esteban V
Published: October 2019

Background/Introduction

Cardiovascular (CV) disease represents the leading cause of death and disability in developed countries with elevated LDL-C among the main risk factors for CV events.

Purpose

We conducted a study to describe the clinical profile of patients initiating evolocumab in real-world clinical practice, specifically hospital cardiology units in Spain.

Methods

Retrospective, observational, serial chart review of consecutive hyperlipidemic patients (≥18 years) who initiated evolocumab in 31 Spanish hospital cardiology units from February-2016 to May-2017. Relevant patients characteristics and clinical data were collected from medical records at 12 weeks pre- and 12±4 weeks post-evolocumab initiation. Baseline values correspond to data collected up to 12 weeks prior to initiation of evolocumab.

Results

186 patients were enrolled: 72.0% men, mean (SD) age 60.3 (9.8) years, mean (SD) body mass index 28.5 (4.3) kg/m2. CV history and CV risk factors at evolocumab initiation are summarised below (Figure). Half of all patients were statin intolerant and almost all (94.1%) were secondary prevention. At baseline, half (51.1%) of all patients were receiving ezetimibe and 44.1% were receiving high-intensity statins. At baseline, mean (SD) LDL-C was 144.0 (49.0) mg/dL; 38.7% of patients had LDL-C 100-<130 mg/dL, 28.0% had LDL-C 130-<160 mg/dl, 12.4% had LDL-C ≥160 mg/dL, 12.9% had LDL-C ≥190 mg/dL. Mean (SD) baseline HDL-C was 47.7 (13.0) mg/dL. After 12 weeks of evolocumab treatment, mean (SD) LDL-C was reduced by 57.6% (21.6) to 62.2% (44.1) mg/dL (p<0.0001; LDL-C reductions of 57.5% [23.2]/57.6% [21.6] in patients with/without FH and 46.0% [21.5]/58.5% [22.1] in primary/secondary prevention patients, respectively). At week 12, 64.9% patients reached LDL-C levels <70 mg/dL, and 49.1% <50 mg/dL, while statin use remained stable (data not shown). Only 3.2% (n=6) patients discontinued evolocumab (voluntary withdrawal, mostly).

Baseline CV history and CV risk factors

Conclusions

In Spanish Cardiology Units, evolocumab was typically prescribed in patients with FH and/or atherosclerotic cardiovascular disease, aligned with 2016 ESC/EAS guidelines recommendation on PCSK9i usage. Patients tended to have LDL-C levels above the recommended thresholds with LDL- levels markedly reduced after 12 (± 4) weeks of evolocumab treatment.

Acknowledgement/Funding

This work was supported by Amgen.
P1684Elevated serum uric acid associated with hypertension in healthy individuals
Authors: Liu C W , Wu Y W , Hwang J J
Published: October 2019

Background

Elevated serum uric acid (SUA) induces endothelial dysfunction and is associated with hypertension according to the traditional definition of hypertension. The impact of a divergent definition of hypertension between contemporary guidelines is unclear.

Purpose

We conducted the present study to investigate the association between SUA and new-onset hypertension according to contemporary blood pressure guidelines.

Methods

We enrolled 10,537 healthy individuals aged more than 30 years, who routinely underwent an annual health exam with office blood pressure records at our hospital in 2016; of them, 7,349 individuals repeated the exam in 2017. The individuals with hypertension at baseline were excluded, and the rest of the study population were divided into the European Society of Cardiology (ESC) cohort and the American College of Cardiology (ACC) cohort. According to the ESC guideline, hypertension was defined as office BP ≥140/90 mm Hg, whereas ACC guidelines defined hypertension as blood pressure ≥130/80 mm Hg. Hyperuricemia (HUA) is defined as an SUA level of ≥7 mg/dl in men and ≥6 mg/dl in women.

Results

The study population consisted of 6,378 individuals in the ESC cohort and 4,330 individuals in the ACC cohort. The HUA group was predominantly male and older than the normouricemic group and had a greater ratio of alcohol intake and histories of gout, and greater values of laboratory cardiometabolic biomarker values. The incidence of hypertension was 5.8% in the ESC cohort and 19% in the ACC cohort. Incident hypertension was significantly greater in the HUA vs. normouricemic group (8.6% vs. 4.7%, P<0.001 for ESC and 25.5% vs. 16.9%, P<0.001 for ACC). In multivariate logistic regression analyses, each increment of SUA was associated with increased risks of incident hypertension after age, gender, body mass index, blood pressure at baseline, fasting glucose were adjusted (OR: 1.160, 95% CI: 1.056–1.274, P=0.002 for ESC and OR: 1.120, 95% CI: 1.040–1.207, P=0.031 for ACC).

Incidence of hypertension

Conclusion

Elevated SUA was associated with incident hypertension in healthy individuals from Taiwan regarding various contemporary blood pressure guidelines. Future studies might investigate the effect of urate-lowering therapy on lowering blood pressure.

Acknowledgement/Funding

TSGH 108-14
P1688Behavior of indices of sympathetic activity in relation to sleep time duration in untreated hypertensives
Authors: Seravalle G , Quarti Trevano F , Dell'oro R , Bertoli G , Mancia G , Grassi G
Published: October 2019

Background

Short sleep duration and poor sleep quality has been reported to be associated with increased cardiovascular risk and increased incidence of cardiovascular events.

Purpose

Whether and what extent the pathophysiology of this association includes sympathetic abnormalities has never been examined via microneurography.

Methods

In 28 untreated mild-to moderate essential hypertensives aged 66.4±3.1 (mean±SEM) without other cardiovascular or non-cardiovascular disease (including obstructive sleep apnea) recruited from the outpatient clinic and referred for short sleep duration, we directly assessed at patients home via actigraphy (actiwatch spectrum activity monitor, Phillips) time sleep duration and efficiency. Measurements, performed during a day preceding or following the 7 day actigraphy evaluation, included microneurographic recording of efferent postganglionic sympathetic nerve traffic (MSNA), venous plasma norepinephrine (HPLC), clinic, 24 hour and beat to beat blood pressure and heart rate values. Sleep diary and a sleep questionnaire were also administered.

Results

Nine patients slept less than 6 hours per night (LSD), while the remaining ones between 6 to 7 (MSD, n=8) or more than 7 hours (GSD,N=11). The 3 groups showed similar age and gender distribution and a body mass index amounting to 28.1±0.8, 28.6±0.5 and 27.3±0.5 kg/m2 (P=NS). For similar mean blood pressure values LSD showed MSNA values significantly greater than GSD (53.4±4.9 vs 40.1±3.8bs/100hb, P<0.03), this being the case also for MSD (49.7±4.4, P<0.05 vs GSD but not SLD). HR was significantly elevated only in LSD group when compared to GSD, while no significant difference was found in plasma NE between the 3 groups.

Conclusions

The present study provides the first microneurographic direct evidence that short sleep duration is linked to a marked sympathetic activation, which may participate at the high cardiovascular risk of these subjects. The sympathetic overdrive affects both the cardiac and peripheral district but is not reflected by NE, which thus does not represent in this condition a valuable adrenergic marker.
P1689Nighttime blood pressure and dipping patterns relate to sodium sensitivity of blood pressure
Authors: Xing X , Liu F , Yang X , Huang J
Published: October 2019

Background

Attenuated nighttime blood pressure (BP) fall during a high-sodium diet is associated with higher sodium sensitivity of BP. However, the prognostic value for sodium sensitivity of nighttime BP profile during a habitual diet is not fully understood.

Purpose

To elucidate the usefulness of nighttime BP and dipping patterns under a habitual diet in assessing sodium sensitivity.

Methods

We conducted a dietary intervention study among 250 resident aged 18–60 years with high-normal or stage I hypertension in rural areas of northern China. The 24-hour ambulatory BP monitoring and baseline survey were performed for each participant under a habitual diet during the first 3 days. Then participants underwent a 7-day low-sodium intervention (51.3mmol sodium per day), followed by a 7-day high-sodium intervention (307.8mmol sodium per day). Three clinic BP measurements were obtained in every morning of the 3-day baseline observation and days 5, 6, and 7 of each intervention period.

Results

Among 250 participants, 86 (34.4%) had daytime hypertension (DH) and 149 (59.6%) had nighttime hypertension (NH). The systolic BP (SBP) responses to low-sodium and high-sodium intervention were significantly higher in those with NH than those without irrespective of DH status [−8.1 (−9.3, −7.0) vs. −5.5 (−7.0, −4.1) mmHg, P=0.001; and 13.0 (11.6, 14.3) vs. 11.0 (9.3, 12.7) mmHg, P=0.038, respectively]. Compared with dippers, extreme dippers had significantly higher SBP responses to low-sodium and high sodium intervention independently of 24-hour SBP. Moreover, the quadratic curve between nighttime SBP fall and SBP responses to low-sodium (β=−105.5 for quadratic term, P=0.015) and high-sodium (β=108.9 for quadratic term, P=0.035) intervention suggested both non-dipping and extreme dipping might indicate higher sodium sensitivity.

Conclusions

NH as well as non-dipping and extreme dipping determined during a habitual diet might indicate higher sodium sensitivity, which highlights the potential usefulness of nighttime BP profile in assessing sodium sensitivity.

Acknowledgement/Funding

This study is supported by the National Natural Science Foundation of China (grant no. 81570386)
P1691Impact of dose and duration of dietary salt reduction on blood pressure levels: systematic review and meta-analysis of randomised trials
Authors: Huang L , Trieu K , Yoshimura S , Woodward M , Campbell N , Lackland D , Leung A , Anderson C A M , MacGregor G , Neal B , He F
Published: October 2019

Background

Authoritative medical and public health agencies in most countries advise to reduce population dietary salt intake to under 5–6 g/day as a strategy for preventing high blood pressure and cardiovascular disease. However, there is still dispute about whether salt reduction should be adopted by all populations. In addition, the effect of duration of dietary salt reduction has not been sufficiently investigated.

Purpose

To understand the effect of dietary salt reduction on blood pressure and the impact of intervention duration.

Methods

A systematic review and meta-analysis was conducted. Randomized controlled trials that allocated participants to low and high salt intake, without confounding from unequal concomitant interventions, were included. We excluded studies done in individuals younger than 18 years, pregnant women, individuals with renal disease or heart failure, and studies with sodium excretion estimated from spot urine. Random effect meta-analysis was used to generate pooled estimates of the effect on 24-hour urinary sodium excretion, systolic and diastolic blood pressure. Multivariate meta-regression was used to quantify the dose response effect of dietary salt on blood pressure change and to understand the impact of the intervention duration.

Results

125 studies were included with 162 data points extracted. Ninety-nine data points (61%) had interventions under 4 weeks. Overall, 24-hour urinary sodium excretion changed by −141 mmol (95% CI: −156; −126), systolic blood pressure changed by −4.4 mm Hg (95% CI: −5.2; −3.7) and diastolic blood pressure changed by −2.4 mm Hg (95% CI: −2.9; −1.9). Sodium reduction resulted in a significant decrease of systolic blood pressure in all subgroups except in participants with low baseline sodium intake (<109 mmol) (Figure 1). Each 100 mmol reduction of sodium was associated with 2.7 mm Hg (95% CI: 1.0; 4.4; p=0.002) reduction of systolic blood pressure and 1.2 mm Hg (95% CI: 0.0; 2.4; p=0.046) reduction of diastolic blood pressure after adjusting for intervention duration, age, sex, race, baseline blood pressure, baseline sodium intake and interaction between age and baseline blood pressure. For the same amount of salt reduction, a 10 mm Hg higher baseline systolic blood pressure would result in 2.5 mm Hg greater reduction of systolic blood pressure. There is not enough evidence to show the impact of intervention duration.

Figure 1

Conclusions

Our meta-analysis showed that sodium reduction could reduce blood pressure in all adult populations regardless of age, sex and race. The effect of salt reduction on systolic blood pressure increases with higher baseline blood pressure. Further studies, designed to investigate the impact of intervention duration, are needed to understand the significance of the duration.

Acknowledgement/Funding

None
P1697Determinants and prognostic value of cardiac magnetic resonance imaging derived infarct characteristics in Non-ST-Elevation Myocardial Infarction
Authors: Feistritzer H.-J , Eitel I , Jobs A , De Waha-Thiele S , Meyer-Saraei R , Freund A , Stiermaier T , Abdel-Wahab M , Lurz P , Reinstadler S J , Reindl M , Klug G , Metzler B , Desch S , Thiele H
Published: October 2019

Background

The prognostic significance of cardiac magnetic resonance (CMR) derived infarct characteristics has been demonstrated in ST-elevation myocardial infarction (STEMI) cohorts but is undefined in non-ST-elevation myocardial infarction (NSTEMI) patients.

Purpose

To investigate determinants and the long-term prognostic impact of CMR imaging derived infarct characteristics in patients with NSTEMI.

Methods

Infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) were assessed using CMR imaging in 311 consecutive NSTEMI patients undergoing percutaneous coronary intervention (PCI) in three centers. CMR imaging was performed 3 [interquartile range (IQR) 2–4] days after admission. The clinical endpoint was defined as major adverse cardiac events (MACE) during a median follow-up of 4.4 (IQR 3.6–4.9) years.

Results

Median IS was 7.0% (IQR 2.3–13.5) of LV myocardial mass (%LV) and MSI was 65.2 (IQR 36.7–82.9). Age (p=0.003), heart rate (p=0.002) and TIMI flow grade before PCI (p<0.001) were independent predictors of IS. Independent predictors of the MSI were age (p=0.001), heart rate (p=0.01), the number of diseased coronary arteries (p=0.001) and the TIMI flow grade before PCI (p<0.001). MACE occurred in 75 (24.1%) patients. CMR-derived infarct characteristics had no additional prognostic value over and above LV ejection fraction in multivariable analysis.

Conclusions

In this prospective, multicenter NSTEMI cohort reperfused by PCI, age, heart rate, the number of diseased coronary arteries and TIMI flow grade before PCI were independent predictors of IS and MSI assessed by CMR. However, in contrast to STEMI patients there was no additional long-term prognostic value of CMR-derived infarct characteristics above and beyond traditional risk markers.
P1703Impact of prehospital epinephrine administration and quality of cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest patients with non-shockable rhythm
Authors: Funada A , Goto Y , Okada H , Maeda T , Takamura M
Published: October 2019

Background

The effects of prehospital epinephrine administration in combination with the quality of cardiopulmonary resuscitation (CPR) on neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm remains unclear.

Purpose

This study aimed to elucidate the effects of prehospital epinephrine administration in combination with the quality of CPR on neurologically intact survival in OHCA patients with non-shockable rhythm.

Methods

We analysed 118,732 adult OHCA patients with non-shockable rhythm from the All-Japan OHCA registry between 2011 and 2016 (29,989 emergency medical service [EMS]-witnessed arrests with EMS-initiated CPR [high-quality CPR] and 88,743 bystander-witnessed arrests with bystander-initiated CPR continued by EMS providers [low-quality CPR]). Patients who achieved prehospital return of spontaneous circulation without prehospital epinephrine administration were excluded. The primary outcome measure was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1–2). Time from collapse to prehospital epinephrine administration for patients with prehospital epinephrine administration, or to hospital arrival for patients without prehospital epinephrine administration was calculated and adjusted collectively in multivariate logistic regression analysis for 1-month CPC 1–2.

Results

Multivariate logistic regression analysis revealed that the time from collapse to prehospital epinephrine administration or to hospital arrival was negatively associated with 1-month CPC 1–2 (adjusted odds ratio [OR] 0.95 per 1-minute increment, 95% confidence interval [CI] 0.94–0.96). Compared with bystander-witnessed arrests without prehospital epinephrine administration, EMS-witnessed arrests with or without prehospital epinephrine administration were significantly associated with increased chances of 1-month CPC 1–2 (adjusted OR 2.04, 95% CI 1.50–2.75 and adjusted OR 1.97, 95% CI 1.57–2.48, respectively). Prehospital epinephrine administration was significantly associated with an increased chance of 1-month CPC 1–2 among bystander-witnessed arrests (adjusted OR 1.57, 95% CI 1.24–1.98), but not among EMS-witnessed arrests. EMS-witnessed arrests without prehospital epinephrine administration were significantly associated with an increased chance of 1-month CPC 1–2 compared with bystander-witnessed arrests with prehospital epinephrine administration (adjusted OR 1.26, 95% CI 1.01–1.56).

Conclusions

High-quality CPR is crucial for increasing neurologically intact survival in OHCA patients with non-shockable rhythm. The additional beneficial effects of prehospital epinephrine administration were observed only among OHCA patients with low-quality CPR.
P1705The association between pre-shock ventricular fibrillation duration and shock success during out-of-hospital cardiac arrest
Authors: Nas J , Thannhauser J , Van Grunsven P M , Meinsma G , Van Royen N , De Boer M J , Bonnes J L , Brouwer M A
Published: October 2019

Background

After the first shock, most ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) patients require subsequent shocks before organized rhythm is restored. Currently, all those shocks are given after a fixed 2 or 3-minute chest compression interval, resulting in many unsuccessful shocks. However, recently new defibrillators have been developed that can recognize VF during chest compressions, and enable earlier shocks immediately upon detection of VF. This prompts the question whether VF of shorter duration is associated with higher shock success.

Purpose

To study the association between pre-shock VF-duration and shock success in all subsequent shocks during OHCA.

Methods

Detailed VF-study on a subset of our prospective, real-world cardiac arrest-registry, focusing on patients with ≥2 shocks for VF and available ECG-tracings. These were scrutinized to determine VF-duration (time from VF-onset until shock) and shock success (return of organized rhythm within 1 min. after the shock). All first shocks were excluded.

Results

We studied 397 shocks from 101 patients. Of these, 77% were male and median age was 64 (interquartile range [IQR] 54–76) years. Overall shock success was 51% and survival to discharge was 19%. Overall median pre-shock VF-duration was 221s (IQR 125–433). The median pre-shock VF-duration was shorter before a successful (171s [IQR 75–295]) than before an unsuccessful shock (334s [IQR 174–740]), p<0.001. Shock success decreased from 75% in the quartile with the shortest to 21% in the quartile with the longest pre-shock VF-duration, p for trend<0.001 (Figure 1).

Figure 1

Conclusion

In shocks following the first defibrillation attempt, VF of shorter duration is associated with higher proportions of shock success. In an era of defibrillators that are able to recognize VF during chest compressions, our findings prompt the question whether shock upon detection of VF may improve the dismal outcomes of VF cardiac arrest.

Acknowledgement/Funding

None
P1706Neurological outcome in patients with out-of-hospital cardiac arrest undergoing a standardised protocol including therapeutic hypothermia and routine coronary angiography
Authors: Akin M , Garcheva V , Sieweke J T , Tongers J , Napp L C , Flierl U , Bauersachs J , Schaefer A
Published: October 2019

Purpose

To establish cut-offs for neuromarkers such as neuron-specific enolase (NSE) and S-100 predicting good neurological outcome for patients treated with therapeutic hypothermia with out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC) as current cut-offs had been derived from normothermic cohorts.

Methods

Consecutive data of all patients with OHCA admitted to our institution between 01/2011 and 12/2016 were collected in a database. Patient received standard intensive care according to the Hannover Cardiac Resuscitation Algorithm (HaCRA) including mandatory hypothermia. Neurological markers such as neuron-specific enolase (NSE) and S-100 have been used to assess neurological damage following OHCA.

Results

Mean age of overall patient population (n=302) was 63±14 [54–74] years with a male predominance (77%). Cardiac arrest was witnessed in 81% and bystander cardiopulmonal resuscitation (CPR) was performed in 67%. Initial rhythm was ventricular fibrillation in 69%. ROSC had been achieved after 24±17 minutes. Hypothermia was applied in all patients. In 95% percutaneous coronary angiography and in 57% of them coronary intervention was performed. After ROSC, STEMI was present in 44%. Mechanical support was required in 19%. 30 day mortality was 44% in the total cohort. Mean NSE was 27±69 μg/l, mean NSE with good neurological outcome was 20±8.7 μg/l, highest NSE with good neurological outcome was 46 μg/l. Mean S-100 was 0.114±2.037μg/l, mean S-100 with good neurological outcome was 0.068±0.067 μg/l, highest S-100 with good neurological outcome was 0.360 μg/l.

Conclusion

Even when using a strict protocol for OHCA patients and routinely applying therapeutic hypothermia, the cut-offs for NSE and S-100 regarding good neurological outcome are similar to those reported before without therapeutic hypothermia, but they must not be used solitary to withdraw life support as even very high markers can be associated with goof neurological outcome in individual patients.
P1711The association of multidisciplinary team approach with clinical outcomes in patients with acute myocardial infarction underwent veno-arterial extracorporeal membrane oxygenation
Authors: Hong D , Choi K H , Youn T , Lee S Y , Bak M , M K M , Cho Y H , Yang J H
Published: October 2019

Background

Multidisciplinary team approach is necessary for the management of critically-ill patients. However, limited data are available on the impact of specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock.

Objectives

This study aimed to identify whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients underwent venoarterial ECMO.

Methods

A total of 255 AMI patients underwent venoarterial ECMO from May 2004 to July 2018 were enrolled. In January 2014, multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into pre-ECMO team group (n=131) and post-ECMO team group (n=124). The primary outcome was in-hospital mortality.

Results

In-hospital mortality (54.2% vs. 33.9%, p=0.002) and cardiac intensive care unit mortality (45.0% vs. 25.0%, p=0.001) were significantly lower after the implantation of multidisciplinary ECMO team (pre ECMO team vs. post-ECMO team). On binary logistic regression model, the multidisciplinary ECMO team approach was associated with lower risk of in-hospital mortality (odds ratio 0.36, 95% confidence interval 0.19–0.67, p=0.001). Incidence of all-cause mortality (58.3% vs. 35.2%, p<0.001) and rehospitalization due to heart failure (28.2% vs. 6.4%, p=0.001) at 6-months follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group.

Clinical outcomes Variables Total (N=255) Pre-ECMO team (N=131) Post-ECMO team (N=124) P value In-hospital mortality 113 (44.3) 71 (54.2) 42 (33.9) 0.002 Cardiovascular death 90 (35.3) 59 (45.0) 31 (25.0) 0.001 Noncardiovascular death 23 (9.0) 12 (9.2) 11 (8.9) >0.99 Cardiac intensive care unit mortality 106 (41.6) 68 (51.9) 38 (30.6) 0.001 Successful weaning of ECMO 169 (66.3) 75 (57.3) 94 (75.8) 0.002 Data are presented as n (%). Abbreviations: ECMO, extracorporeal membrane oxygenation.

Incidence of death, readmission for HF

Conclusions

The multidisciplinary ECMO team approach was associated with improved clinical outcomes in AMI patients complicated by cardiogenic shock. Our data support that specialized ECMO team is indispensable to improve outcomes in patients with AMI with refractory cardiogenic shock.
P1713Predictors of mortality following extracorporeal membrane oxygenation support in a large unselected critically ill patient population
Authors: Nemeth B T , Edes I F , Hartyanszky I , Szilveszter B , Fazekas L , Polos M , Nemeth E , Becker D , Merkely B
Published: October 2019

Background

Mechanical circulatory support (MCS) has been established as a means of augmenting circulation in critically ill patients due to a variety of underlying clinical reasons. Different methods of MCS may be applied with the venous-arterial extracorporeal membrane oxygenation (VA-ECMO) system being one of the most utilized in everyday care.

Objectives

Our aim was to determine independent predictors of mortality following VA-ECMO therapy in a large, unselected, adult, critically ill patient population requiring MCS.

Methods

Data on 181 consecutive, real-world VA-ECMO treatments have been assessed. Analysis was conducted for all subjects requiring MCS with the VA-ECMO as first instalment, regardless of underlying cause or eventual upgrade. All potential clinical factors influencing mortality were examined and evaluated.

Results

Overall mortality amounted to ≈65% at a median follow-up of 28 days and depended upon: glomerular filtration rate of <60 ml/min/1.73 m2 (HR: 1.53; p=0.03) and age ≥65 years (HR: 1.65; p=0.02) based on multivariate Cox regression analysis. However, prolonged ECMO time, conversion of the ECMO to longer duration MCS, diabetes, prior ACS or revascularization, reduced left ventricular ejection fraction (EF) had no effect on adverse mortality outcomes (all p>0.05). Surprisingly, neither the need for resuscitation during MCS nor any ECMO implantation indication influenced mortality by itself (p>0.05).

Conclusions

We have found that mortality in critically ill patients requiring VA-ECMO use remains very high. Decreased renal function and advanced age were found to influence mortality in our all-comers patient population, while traditional predictors of cardiovascular mortality did not have a significant effect on survival.
P1728Cardiogenic shock patients: those with and those without out-of-hospital cardiac arrest are different clinical entities
Authors: Josiassen J , Helgestad O K L , Moeller J E , Kjaergaard J , Schmidt H , Jensen L O , Holmvang L , Ravn H B , Hassager C
Published: October 2019

Introduction

Cardiogenic shock (CS) due to myocardial infarction (MI) carries 30-day mortality rates as high as 50%. The vast majority of study cohorts assessing mortality in CS comprise both patients presenting with and without out-of-hospital cardiac arrest (OHCA). Patients with and without OHCA are likely to represent two distinctive entities, which may be problematic to combine in an intervention trial.

Purpose

The aim of the study was to compare CS due to MI patients presenting with and without OHCA in terms of patient characteristics and outcome.

Methods

In the period from 2010–2017 all patients admitted at two tertiary heart centres in Denmark with CS following MI were individually identified and validated through patient records. The two centres have a catchment area of 3.9 million citizens corresponding to two-thirds of the Danish population.

Results

A total of 1716 CS patients were identified, of which 42% presented with OHCA. OHCA patients were younger (mean 63 vs 67 years), more frequently male (85 vs 67%), had higher lactate concentration (median 6.2 vs 5.0 mmol/L) on admission and higher left ventricular ejection fraction (median 30 vs 25%) compared to patients without OHCA (p<0.0001 for all). Patients presenting with OHCA had lower 30-day mortality compared to patients without OHCA (49% vs. 57%, respectively, plogrank<0.0001, Figure). Cause of in hospital death differed markedly between the two groups. Not surprisingly, anoxic brain damage was the leading cause of in hospital death in the OHCA group (56%) and only seen in 4% of patients without OHCA. In contrast, cardiac failure was the main cause of death in hospital death among patients without OHCA (60%), compared to 27% in patients with OHCA (p<0.0001).

Figure 1

Conclusion

Among patients with CS due to MI, overall 30-day mortality was significantly lower in patients presenting with OHCA. Anoxic brain damage was the main cause of in hospital death among OHCA patients, whereas fatal heart failure prevailed in patients without OHCA. Combining these two groups in a single trial with one specific intervention seems inappropriate and likely to cause an imbalance in the signal-to-noise ratio.

Acknowledgement/Funding

The Danish Heart Foundation and a research grant from Abiomed
P1729Cardiogenic shock in ST elevation myocardial infarction: prevalence, management and acute phase and one-year mortality over the last three decades
Authors: Garcia-Garcia C , Rueda F , Vila J , De Diego O , Oliveras T , Labata C , Serra J , Ferrer M , El Ouaddi N , Cediel G , Elosua R , Lupon J , Bayes-Genis A
Published: October 2019

Background

Cardiogenic shock (CS) is an ominous complication of ST elevation myocardial infarction (STEMI). However, the widespread use of reperfusion therapies and invasive management could have reduced the prevalence of CS and improved the prognosis of these patients in the last decades.

Purpose

The aim is to analyze the changes over last three decades in the prevalence, management and acute phase prognosis and 1-year mortality of STEMI patients complicated with CS.

Method

Between February 1989 and December 2017, 7,589 STEMI patients were consecutively admitted in the Coronary Care Unit of a University Hospital and were included in a prospective registry. Depending on the year of admission, patients were classified in five groups: 1989–1994: n=1,337, period 1; 1995–1999: n=960, period 2; 2000–2004: n=1,059, period 3; 2005–2009: n=1,535, period 4 and 2010–2015: n=2,698, period 5). We analyze the trend in prevalence of CS, management and 28-day and 1-year mortality over these five periods.

Results

The global prevalence of CS was 6.1% (466 patients), mean age was 67.7 (SD 11.7) years and 68.7% were men. Prevalence of CS in STEMI decreased from period 1 to 5 (7.3%, 6.4%, 5.5%, 5.8%, 6.0%, p<0.001), although it has been reduced more in women (10.1% in period 1 vs 8.3%, period 5, p<0.001) than in men (6.5% vs 5.4%, period 1 vs 5, respectively (p<0.001). Reperfusion therapy increased from 25.8% in period 1 (all with thrombolysis) vs 83.8% in period 5 (all with primary angioplasty). Intra-aortic balloon contrapulsation was only available from period 3 to 5, and it's used were firstly increased (20.7%, 36% and 37.9%, respectively, p<0.001). Ventricular assistance device (Impella CP) it was only available in 2017 and it was implanted in 10.5% of CS due to STEMI. Although 28-day case fatality is very high (60.7%, 283 patients), it has been reduced from period 1 to 5 (69.6%, 77.3%, 64.7%, 55.9% and 57.8%, respectively, p=0.012). This reduction in 28-day case fatality was higher in women (75.5% in period 1 vs 58.6% in period 5, p=0.12) than in men (66.8% vs 57.3, period 1–5, p=0.019). One-year mortality has been reduced between periods 1–5 (73.7% vs 61.8%, p=0.012). After multivariate adjustment, both 28-day (HR 0.63, 95% CI: 0.45–0.89, p=0.008) and 1-year mortality (HR 0.64, 95% CI: 0.45–0.90, p=0.010) have declined in the last period.

Kaplan-Meier curves, 1-year mortality

Conclusions

Cardiogenic shock development in STEMI patients has been reduced from 7.3% to 6.1% in the last three decades. The whole improvement in management of these patients achieves a 37% of reduction in 28-day case fatality and 1-year all-cause mortality. Despite this improvement, acute phase (28-day) case fatality of STEMI complicated with CS remains over 57% in the primary angioplasty era.