bluuebunny/crossref_metadata_2025 huggingface dataset:
P805Changes in arterial stiffness independently predict stroke in patients with essential hypertension: Data from a 8-year-follow-up study
Authors: Iliakis P , Tsioufis C , Dimitriadis K , Konstantinidis D , Kasiakogias A , Liatakis I , Asimaki E , Leontsinis I , Kouremeti M , Vogiatzakis N , Karaminas N , Thomopoulos K , Tousoulis D
Published: October 2019

Background/Introduction

Although arterial stiffening is related to atherosclerosis progression, the prognostic role of its alterations in cerebrovascular events in hypertension is not fully elucidated.

Purpose

The aim of the present study was to assess the predictive role of changes inarterial stiffness for the incidence of stroke in a cohort of essential hypertensive patients.

Methods

We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit and underwent blood sampling for assessment of metabolic profile, whilearterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method at the initial and last visit. The distribution of baseline PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by computed tomography and magnetic resonance angiography and/or cerebrovascular angiography findings.

Results

The incidence of stroke over the follow-up period was 2.2%. Hypertensives who had stroke (n=24) compared to those without stroke at follow-up (n=1058) were older at baseline (65±9 vs 56±12 years, p=0.032), had higher office BP levels (155±13 vs 145±15mmHg, p=0.014) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with stroke and those without stroke with respect to baseline renal function and lipid levels (p=NS for all). By univariate Cox regression analysis it was revealed that changes in PWV levels between baseline and last visit predicted stroke (hazard ratio=1.352, p=0.004). Moreover, in multivariate Cox regression model, baseline age (hazard ratio=1.087, p=0.03), changes in PWV (hazard ratio=1.115, p=0.024) but not changes in office BP levels turned out to be independent predictors of stroke.

Conclusions

In essential hypertensive patients, changes in PWV predict future development of stroke, independently of established confounders, including BP. These findings support that PWV constitutes a potent prognosticator of cerebrovascular events and its estimation is essential in order to improve risk stratification in hypertension.
P807Short-term versus visit-to-visit blood pressure variability as predictor of early adverse cardiovascular outcome in hypertension
Authors: Mos L , Mos L , Saladini F , Mazzer A , Vriz O , Azzini V , Palatini P
Published: October 2019

Background

Blood pressure variability (BPV) has emerged as an important predictor of future cardiovascular events among hypertensive patients. However, it is not known whether BPV measured with ambulatory monitoring (short-term BPV) or computed from office visits (visit-to-visit BPV) are related to each other and carry similar prognostic significance.

Purpose

To investigate the association of short-term BPV and visit-to-visit BPVs with cardiovascular and renal events in a young hypertensive cohort untreated at baseline.

Methods

Short-term BPV was measured from 24-hour blood pressure (BP) monitoring at baseline in 1167 participants with stage 1 hypertension from the HARVEST study, aged 33.1±8.5 years. Visit-to-visit BPV was calculated from office BP measured in triplicate at each visit. Visits were made two weeks apart at baseline, and then after 1 month, 2 months, 3 months, 6 months, and 1 year. Only untreated subjects were taken into account for the analysis. Hazard ratios for short-term (weighted 24-hour BP Standard Deviation) and visit-to-visit Standard Deviation were computed, adjusting for the corresponding average BP, age, sex, body mass index, 24h heart rate, smoking, alcohol and coffee consumption, physical activity, parental cardiovascular disease, glucose, total cholesterol, HDL-cholesterol, and nocturnal BP dipping.

Results

Short-term systolic BPV showed a weak correlation with visit-to-visit BPV (p=0.018). No correlation was found for diastolic BPVs. Independent predictors of short-term BPV were average 24h BP, smoking, and nocturnal dipping. Predictors of visit-to-visit BPV were average office BP, parental cardiovascular disease, female gender, and nocturnal dipping. During a 15.4-year follow-up, 95 end-points were observed. In a parsimonious multivariable Cox model, short-term systolic BPV (p=0.03) was an independent predictor of the endpoints with a 7% increase in risk for each 1 mmHg increment in systolic BPV. The hazard ratio for a short-term systolic BPV ≥12.8 mmHg was 2.03 (95% CI, 1.34–3.05, p=0.0007). This threshold value was identified by ROC curve analysis. The association was particularly strong for coronary events (N=41) with a hazard ratio of 3.45 (95% CI, 1.73–6.89, p=0.0004). No independent association with outcome was found for visit-to-visit systolic or diastolic BPV (p>0.66). Similar results were obtained when average real variability was used instead of standard deviation as a metric of visit-to-visit BPV (p>0.15).

Conclusions

These data show that in untreated young hypertensive people short-term BPV and visit-to-visit BPV have a weak relationship and a different clinical significance. Only short-term BPV measured with ambulatory monitoring improved traditional risk prediction models in this setting.

Acknowledgement/Funding

Associazione 18 maggio 1370
P809Effects of air temperature and pollution on Takotsubo cardiomyopathy
Authors: Awada A , Argacha J F , Collart P , Unger P
Published: October 2019

Background

Air temperature and pollution are the main environmental factors influencing cardiovascular mortality and risk of myocardial infarction. Takotsubo cardiomyopathy (TCM) is a transient and reversible myocardial dysfunction whose cause and pathogenesis remain incompletely understood, but which, unlike acute coronary syndrome, does not involve obstructive coronary atherosclerosis or plaque rupture. The potential role of the environment on the risk to develop TCM remains poorly defined.

Methods

We aimed to study the effects of air temperature, particulate matter (PM) and gaseous pollutants (NO2 and ozone) on hospitalization rate forTCM.

All hospitalizations in Belgian Hospitals for TCM (ICD 9:429.83) from 2009 to 2014 were recorded. National air pollution parameters were extracted from the Belgian Environment Agency database. A time-stratified and temperature-matched (except for air temperature effect) case-crossover analysis of the risk of TCM was performed. The main analysis focused on 0-day lag time (lag 0) between exposure and TCM; a lag structure analysis up to lag 4 was also performed.

Results

1840 patients were included in the study (88% women). More TCM occurred during the warm compared to the cold period (fig.1; chi2p value <0.05). At lag 0, each decrease of 1°C in ambient air temperature increased the odds ratio (OR) of TCM of 1.020 (IC 95%: 1.003–1.035). This effect was more pronounced during the cold period and at lag 4 (RR 1.060; IC 95%: 1.031–1.091). Conversely, during the warm period and between lag 1 and 4, an increase of 1°C in ambient air temperature increased the RR of TCM (OR 1.053 at lag 3; IC 95%: 1.021–1.086). No significant association was found between TCM and PM10, PM2.5, NO2at any lag. During the warm period, each increase in 10μg/m3 in ozone from lag 1 to 3 increased the risk of TCM (OR 1.089 at lag 3, IC 95%: 1.017–1.168).

Conclusions

Air temperature strongly influences the onset of TCM. Both cold spells and heat waves seem to be associated with the development of TCM. Ozone exposure also increases the risk of TCM during the warm period, whereas particulate and NO2 pollution do not seem to play a significant role. These patterns seem to differ from those previously reported with STEMI.
P837Neural networks algorithms improve GRACE Score performance
Authors: Higa C C , Ciambrone M G , Gambarte M J , Novo F , Nogues I , Santillan J , Ginesi A , Giorgini J C , Amrein E , Frederik G , Abud M , Rizzo N , Piccininni R , Marin J , Borracci R A
Published: October 2019

Background

Global Registry of Acute Coronary Events (GRACE) score is a well-known model used to predict the probability of events in acute coronary syndrome (ACS). GRACE model was developed using a logistic regression approach that can only model linear functions, a limitation that could be prevented using artificial neural networks (NN) a recognized tool for nonlinear statistical modeling. The aim of this study was to develop, train and test different NN algorithm-based models to improve the GRACE score performance.

Methods

We analyzed a prospective database including 1,255 patients admitted with diagnosis of ACS in a community hospital, between June 2008 and June 2017. The database included 40 demographic and laboratory admission variables. In the guided approach, only the individual predictors included in the GRACE score were used to train and test three NN algorithm-based models, one- and two-hidden layer multilayer perceptron (MLP), and a radial basis function network. In addition, three extra unguided models were built using the 40 admission variables. Finally, expected mortality according to the GRACE score was calculated using the logistic regression equation.

The database was split into 2 datasets: 70% for model training and 30% for validation. In order to choose the best model, the training process was repeated 50 times. Every time the models were tested on the validation cohort, accuracy, receiver operating characteristic (ROC) area, negative predictive value (NPV), and positive predictive value (PPV) were recorded. Only models showing the best discrimination power were selected for comparison with logistic regression outcomes. The end point was in-hospital all-cause mortality.

Results

In terms of accuracy, ROC area and NPV, almost all NN algorithms outperformed the logistic regression approach (accuracy 97.1, 96.7, 96.2, 97.3 and 94.1%, p<0.001; ROC area 0.89, 0.86, 0.84, 0.84 and 0.75, Hanley-McNeil p≤0.05; for guided and unguided one- and two-hidden layers MLP and GRACE score, respectively). Only radial basis function models obtained a better accuracy level based on NPV improvement (100 vs. 98.8%, p=0.0001), at the expense of PPV reduction (0.0% vs. 13.2%, p<0.0001) (ROC are 0.84 vs. 0.75, p=0.043). Compared with the logistic regression approach, one- and two-hidden layers in guided and unguided MLP models improved PPV from 13.2 to 18.2% (38% increase), 15.4% (17% increase), 27.3% (107% increase), and 25.0% (89% increase), respectively, although these differences were not statistically significant.

Conclusions

NN algorithms improve GRACE score performance in terms of discriminatory power for the prediction of in-hospital mortality. Its application should become a useful tool for the decision making in ACS patients
P838Is multi-biomarker combination approach comparable to the GRACE risk score for short-term mortality prediction in acute myocardial infarction cases?
Authors: Kawamura Y , Yoshimachi F , Nakamura N , Minakawa S , Yamamoto Y , Morita N , Kobayashi Y
Published: October 2019

Introduction

The Global Registry of Acute Coronary Events (GRACE) score is said to be a superior predictor of mortality in acute myocardial infarction (AMI) patients, and same applies to biochemical parameters as N-terminal pro-B-type natriuretic peptide (N-BNP), Troponin-T (TnT) and high-sensitivity C- reactive protein (hs-CRP) levels.

Purpose

We validated that whether each or combination of biochemical parameters are comparable to GRACE score or not for mortality prediction in AMI patients.

Method

We investigated about clinical background including The GRACE score, above parameters and in-hospital mortality in 754 AMI patients (mean age 66±13y/o, 609 ST-elevated AMI cases) received emergency percutaneous coronary intervention (PCI) successfully during 8 years in a single center retrospectively. Combination of biochemical parameters are derived from N-BNP, TnT and hs-CRP by logistic regression analyses. We compared The GRACE score with each or combination of biochemical parameters between survival (SG) and non-survival group (nSG) on receiver operating characteristic (ROC) analysis.

Result

In-hospital mortality was 6.8%. The GRACE score (106±33 versus 161±32; p<0.005) and N-BNP level (2458±7058 versus 8880±11331pg/ml; p<0.005) were significantly lower in SG than nSG. Area under the ROC curve about in-hospital mortality of The GRACE score were higher (0.868) than N-BNP (0.787; p=0.007), TnT (0.613; p<0.005), hs-CRP levels (0.614; p<0.005) and multi-biomarker combination (0.742; p=0.016) as Figure 1.

Area under the curve of the composite with the GRACE score and multi-biomarker is not increased compared with the GRACE score alone (0.868 versus 0.865; p=n.s.).

Figure 1

Conclusion

The GRACE score is a superior predictor about in-hospital mortality than each or combination of biochemical parameters in AMI patients. Multi-biomarker combination dose not refine the accuracy of the GRACE score.
P841Derivation and validation of novel score system for predicting all-cause death and myocardial infarction in coronary artery ectasia
Authors: Wang Y T , Song W H , Wu Y J , Zhang P
Published: October 2019

Background

Coronary artery ectasia (CAE) bears high risk of death and myocardial infarction. Risk stratification in CAE patients is crucial for their management, but there were no risk score systems intended for risk evaluation of CAE patients so far.

Methods

In a retrospective cohort of 595 patients with CAE, we collected the baseline characteristics (clinical history, biomarkers and quantitative coronary angiography variables). Follow-up were conducted and the end-point event was the composite of all-cause death and non-fatal myocardial infarction. The candidate predictors of end-point event were analyzed using Cox proportional hazards regression models to derive a risk score in the form of nomogram. The predictive performance and discriminative ability of the novel nomogram were determined by concordance index (C-index) and calibration curve, that were validated internally. Risk stratification by nomogram-predicted risk score was further evaluated.

Results

During a median follow-up time of 62.3 months, 26 all-cause deaths and 37 non-fatal myocardial infarctions were identified. The final risk-prediction model named ABCD-CAE score included four items: age (A), Brain natriuretic peptide (B), high sensitivity C-reactive protein (C) and maximum Dilated area of ectatic lesions (D). The nomogram yielded a C-index for end-point event of 0.72 (95% confidence interval, 0.64 - 0.79). The calibration curve demonstrated that there is good agreement between prediction by nomogram and actual observation of end-point events. Compared with the low-risk group (score ≤100), the risk of composite events was significantly increased in the intermediate-risk group (score: 100–130) and high-risk group (score >130) [hazard ratio (95% confidence interval): 2.23 (1.23–4.06), P=0.008 and 7.02 (3.81–12.97), P<0.001 respectively].

ABCD-CAE nomogram for risk prediction

Conclusions

The ABCD-CAE score is a simple four-item risk score, that provides a clinically useful tool for the risk prediction of all-cause death and myocardial infarction in patients with CAE. This user-friendly tool might support clinical decision making for the management of CAE.
P849Comparison of long-term mortality risk assessed with recalculated (maximal) CADILLAC score vs. baseline (admission) CADILLAC score in STEMI patients undergoing primary PCI
Authors: Mehmedbegovic Z , Milasinovic D , Jelic D , Zobenica V , Radomirovic M , Veljic I , Pavlovic A , Dedovic V , Dudic J , Asanin M , Vukcevic V , Stankovic G
Published: October 2019

Background

Since patients with STEMI have high rate of adverse events not only during hospital stay, but also during short and long-term follow–up, appropriate risk stratification is a key part of the management of these patients following hospital discharge. CADILLAC score was derived and subsequently validated as accurate clinical tool for identifying patients with heightened risk following index event.

Purpose

We aimed to compare predictive value of recalculated, maximal, (M-) CADILLAC score vs. baseline (B-) CADILLAC score for long-term mortality in hospital survivors.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5387 consecutive patients STEMI who underwent primary PCI were included in analysis. For each patient B-CADILLAC score was calculated, and for survivors, we recalculated M-CADILLAC score, incorporating changes in three variable score individual contributors (worsening of Killip class, anemia development and renal function deterioration). As in original score derivation, patients with cardiogenic shock were excluded from analysis. Discrimination of the two risk models was evaluated by the C-statistic, Net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) index.

Results

For 111 (2.1%) patients that died in-hospital, B-CADILLAC very well predicted the event (AUC 0.87, 95% CI 0.86–0.88; p<0.0001) (Figure 1A). For hospital survivors, both evaluated scores showed good discriminative ability for long-term mortality (11.7%) but recalculated M-CADILLAC score was statistically better predictor of long-term mortality, as assessed by C-statistics (Table 1 & Figure 1B):

NRI showed that 38% of patients were reclassified with M-CADILLAC with IDI slope 0.8% higher than in first model.

Table 1 4723 pts (follow-up=90% pts, 41±27 months) AUC 95% CI p B-CADILLAC 0.756 0.744–0.768 p=0.018 M-CADILLAC 0.776 0.754–0.779

Figure 1

Conclusions

Baseline CADILLAC score has very good predictive ability for in-hospital mortality, but recalculated, maximal CADILLAC score offers discriminative advantage in hospital survivors for prediction of long-term mortality in STEMI patients undergoing primary PCI.
P851Incidence and prognostic impact of acute infection among patients with type 1 and 2 myocardial infarction
Authors: Sandoval Y , Smith S W , Schulz K , Sexter A , Apple F S
Published: October 2019

Background

The incidence and impact of acute infection among patients with type 1 (T1MI) and 2 myocardial infarction (T2MI) is not well known. Inflammation and increased procoagulant activity can lead to T1MI, whereas cytokine release can cause hemodynamic alterations affecting myocardial oxygen consumption and contribute to T2MI.

Purpose

Determine the incidence and prognostic impact of acute infection among patients with T1MI and T2MI.

Methods

Post-hoc analysis of UTROPIA (NCT02060760), a prospective, observational cohort study involving 1,640 consecutive emergency department patients with serial cardiac troponin (cTn) I measurements obtained on clinical indication. The incidence of acute infection, antibiotic use, and/or laboratory evidence of infection were examined among patients with T1MI and T2MI. 5-year cumulative survival curves were plotted using the Kaplan-Meier method, frequencies were compared via Chi-Square, and a multivariate cox-proportional hazards model was used to assess the impact of infection on mortality.

Results

Among 217 patients with acute MI (T1MI, n=77 and T2MI, n=140), acute infection occurred in 63 (29%) of patients. Acute infection was more common in patients with T2MI than T1MI (35% vs. 18%, p=0.009). The predominant source of infection was pneumonia (59%), followed by urinary tract infections (11%). Patients with T2MI were also more likely than T1MI to have sepsis (11% vs. 1%, p=0.012), bacteremia (30% vs. 18%, p=0.057), and antibiotic use (35% vs. 17%, p=0.005). At 5-years, patients with acute MI and acute infection had a higher mortality rate than patients without infection (49% vs. 25%, p=0.0006) (Figure). Among the 31 deaths in MI patients with acute infection, most deaths were non-cardiac (65%) and occurred in those with T2MI (77%). Following adjustment for age, sex, and comorbidities in a Cox proportional hazards model, acute infection was an independent predictor of death (hazard ratio: 2.2, 95% CI: 1.3–3.5, p=0.0016).

Conclusion

Acute infection occurs in almost a third of patients that are diagnosed with acute MI during the index hospitalization. Most infections are due to pneumonia and occur most often in patients classified as having T2MI. Acute infection is an independent risk factor for 5-year mortality, with nearly half of all patients with acute MI in whom concomitant acute infection is present during the index hospitalization dead at 5-years. Most deaths are non-cardiac and the vast majority occur in patients with T2MI.

Acknowledgement/Funding

Abbott Diagnostics and Hennepin Healthcare Research Institute (formerly MMRF)e
P852Frequency and prognosis of type 2 myocardial infarction vs non ischemic myocardial injury: large observational study from an emergency department
Authors: Putot A , Buet-Derrida S , Avondo A , Ray P , Maza M , Zeller M , Cottin Y
Published: October 2019

Background

Type 2 Myocardial Infarction (T2MI), due to myocardial oxygen supply-demand mismatch in the absence of atherothrombosis and non-ischemic myocardial injury (NIMI), corresponding to troponin elevation without overt ischemia, are emerging concepts which are suspected to be common in patients hospitalized. However, their respective frequencies, risk profiles and short term prognosis in current routine clinical practice of emergency unit remains to be investigated.

Methods

Among the medical records of all the patients admitted from January 2014 to December 2016 in a university hospital emergency unit (n=82 543), patients with elevated troponin Ic (≥0.10μg/L) (n=4568) were systematically adjudicated as T2MI in the presence of symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes), or as NIMI without such signs. Patients with missing biological data on admission (n=112) or T1MI diagnosis (n=2467) were excluded.

Results

Among the 1989 patients included, 539 (27%) were classified as T2MI and 1450 (73%) as NIMI. When compared with patients with NIMI, T2MI had higher troponin levels (0.27 (0.14–0.71) vs 0.22 (0.13–0.54) μg/L, p=0.008, respectively). NIMI and T2MI had similar risk factors (age (84 (74–90) vs 84 (75–91) y, p=0.3), male sex (43 vs 48%, p=0.07), hypertension (67 vs 71%, p=0.133), diabetes (25 vs 25%, p=0.9), prior CAD (24 vs 26%, p=0.342), systemic inflammatory response syndrome (SIRS, 47 vs 49%, p=0.3), and systolic blood pressure (SBP) (130 (111–153) vs 132 (112–153) mmHg, p=0.545). Biological data on admission were also similar (hyperglycemia (glucose ≥11 mmol/L), 14 vs 13%, p=0.37, creatinine (96 (72–148) vs 94 (72–141) μmole/L, p=0.598), anemia (Hemoglobin rate ≤10g/dL, 13 vs 14%, p=0.5), C-reactive protein elevation (CRP ≥3 mg/L, 88 vs 89%, p=0.7)). Moreover, in-hospital mortality was high and similar for both groups (15 vs 18%, p=0.2). In multivariate analysis, age, troponin rate, SIRS, anemia, SBP, hyperglycemia, creatinine and CRP elevation were independent factors associated with hospital mortality, but not T2MI (vs NIMI) (OR: 0.88 (0.66–1.17)). Older age and hyperglycemia were specific covariates associated with increased risk of mortality in T2MI, but not in NIMI.

Conclusions

This large real-life study of non-T1MI inpatients with elevated troponins from emergency department shows that myocardial injury without necrosis and T2MI share the same risk factors, characterized by a high rate of infections and anemia and a high risk of hospital mortality.

Acknowledgement/Funding

University Hospital Center Dijon Bourgogne, France
P855Evaluation of epicardial coronary resistance using computed tomography angiography
Authors: Mizukami T , Tanaka K , Sonck J , Vandeloo B , Roosens B , Lochy S , Argacha J F , Schoors D , Suzuki H , De Mey J , De Bruyne B , Cosyns B , Collet C
Published: October 2019

Background

A Fractional flow reserve (FFR) pullback allows assessing the distribution of pressure loss along the vessel. FFR derived from CT (FFRCT) provides a virtual pullback curve that may also aid in the assessment of epicardial coronary resistance in the non-invasive setting.

Purpose

The present study aims to determine the accuracy of the virtual FFRCT pullback curve using a motorized invasive FFR pullback as reference in patients with stable coronary artery disease.

Methods

This is a single centre, prospective study of patients with stable coronary artery disease in whom FFRCT was performed as standard of care for non-invasive assessment. Patients referred to coronary angiography with clinically indicated invasive FFR measurement were included. FFRCT and invasive FFR values were extracted from coronary vessels every 1 mm to generate pullback curves. Invasive FFR pullbacks were acquired using a dedicated device at a speed of 1 mm/s. The area under the pullback curve (AUPC), defined as the sum of areas under the FFR pullback curve, was compared between FFRCT and invasive FFR pullbacks. Lesions were defined based on invasive angiography. FFR gradients in lesions and non-obstructive segments were defined as the difference between FFR values at the proximal and distal edge of the segments. FFR vessel gradient was defined as the difference between the most distal FFR value and the FFR at the ostium of the vessel. Mixed effect model was used to account for the correlation of FFR values within vessels. The agreement between FFRCT and FFR gradients was assessed using the Passing Bablok regression analysis and Bland-Altman methods at the vessel, lesion and non-obstructive level.

Results

A total of 3172 matched FFRCT and FFR values were obtained in 24 vessels. The correlation coefficient between FFRCT and FFR was 0.76 (95% CI 0.75 to 0.78; p<0.001). The mean difference between the FFRCT and invasive FFR pullback values was 0.07 (LOA −0.11 to 0.24). AUPC was similar between FFRCT and invasive FFR (79.0±16.1 vs. 85.3±16.4, p=0.097); the mean slope of FFRCT pullback curve was steeper compared to invasive FFR (p<0.001). The mean difference in lesion gradient was −0.07 (LOA −0.26 to 0.13) and −0.01 (LOA −0.06 to 0.05) in non-obstructive segments. There were no systematic or proportional differences between FFRCT and FFR gradients either in lesion or non-obstructive segments); however, vessel gradients were overestimated by FFRCT with a bias of −0.12 (LOA −0.35 to 0.12) driven by a higher mean difference in lesion gradients (−0.07; 95% CI −0.26 to 0.13).

Conclusions

The evaluation of epicardial coronary resistance using coronary CT angiography with FFRCT was feasible. FFRCT pullbacks were accurate in the assessment of lesion and non-obstructive gradients. FFRCT can identify the physiological pattern of coronary artery disease in the non-invasive setting.
P861A quantitative CCTA evaluation in non-obstructive coronary artery disease for the diagnosis of vessel-specific ischemia: results from the prospective, multicenter, international CREDENCE trial
Authors: Gianni U , Van Rosendael A R , Van Den Hoogen I J , Al Hussein Alawamlh O , Stuijfzand W , Al'aref S J , Pena J M , Lu Y , Chang H J , Berman D S , Shaw L J , Min J K , Lin F Y
Published: October 2019

Aim

To improve the diagnosis of coronary vessel-specific ischemia in non-obstructive coronary artery disease (CAD) using a quantitative whole-heart coronary computed tomography angiography (CCTA) evaluation. To date, predictors of ischemia in non-obstructive CAD remain underexplored.

Methods

Within the CREDENCE trial, 612 patients with suspected CAD at 13 sites (64±10 years, 70% men) underwent coronary computed tomography angiography (CCTA) and invasive coronary angiography with 3-vessel fractional flow reserve (FFR) measurements. For this specific analysis, only vessels with non-obstructive plaque (1–49% maximal diameter stenosis) by CCTA were included. The primary endpoint was coronary vessel-specific ischemia which was defined as FFR ≤0.80 (or ≥90% stenosis). Multivariable logistic regression modeling was performed to evaluate the effect of quantitative CCTA features beyond coronary stenosis on the prevalence of vessel-specific ischemia.

Results

FFR ≤0.80 (or ≥90% stenosis) was prevalent in 22.8% of 1,102 vessels with non-obstructive plaque. Using a step-wise approach, in addition to diameter stenosis (χ2=72), non-calcified PAV (χ2=126, P<0.001), lumen volume (χ2=175, P<0.001) and number of lesions with >30% stenosis (χ2=187, P=0.001) were independent CCTA-predictors of coronary vessel-specific ischemia (Figure 1). In the final model, diameter stenosis was no longer significantly associated with ischemia (P=0.236).

Figure 1

Conclusion

In vessels with non-obstructive plaque on CCTA, ischemia was present in approximately 20%. Measures of overall non-calcified plaque burden and smaller lumen volume were more important determinants of vessel-specific ischemia than maximal diameter stenosis.

Acknowledgement/Funding

NIH R01-HLL118019; Dalio Foundation and Michael J. Wolk Foundation
P8833-year prognosis of patients with acute coronary syndromes with non-obstructive coronary arteries
Authors: Zandecki L , Sadowski M , Siudak Z
Published: October 2019

Background

More than 10% of patients presenting with symptoms suggestive of acute myocardial ischaemia have no significant atherosclerotic plaques in coronary angiography. The management and longer term prognosis of these patients has been a subject of debate.

Material and methods

The aim of the study was to assess the 3-year prognosis of patients with the diagnosis ACS (acute coronary syndrome) in Swietokrzyskie region of Poland based on data from the Polish National ORPKI Registry. Between 2014–2015, 9771 patients with ACS who underwent coronary angiography entered the registry and were included in the study. Of them, 2141 had no evidence of atherosclerosis or no significant stenosis on coronary angiography. Data on death, myocardial infarction, stroke, heart failure and cardiac hospitalization were compared between ACS patients with and without significant atherosclerotic plaques in coronary angiography.

Results

The results are presented in the table.

Death and cardiovascular events at 3-year follow-up ACS with significant stenosis ACS without significant stenosis p-value Death 14.4% 7.8% <0.001 Myocardial infarction 16.8% 11.6% 0.04 Stroke 6.8% 2.5% 0.01 Heart failure 38.0% 34.0% 0.19 Cardiac hospitalization 50.3% 22.7% <0.001

Conclusion

Patients who have presented with ACS and had no significant stenosis on angiography have had generally better 3-year prognosis that patients with ACS with significant stenosis. However, cardiovascular events, especially heart failure have not been uncommon in this group of patients.
P895Apical sparing in patients without cardiac amyloidosis
Authors: Binder C B , Duca F , Aschauer S , Rettl R , Camuz Ligios L , Dusik F D , Capelle C , Agis H , Hengstenberg C B , Bonderman D
Published: October 2019

Background

Apical sparing describes a reduced longitudinal strain in the basal segments and preserved or supranormal longitudinal strain in the apical segments of the left ventricular (LV) myocardium. This pattern has been described as a typical finding in patients with cardiac amyloidosis (CA) and restrictive cardiomyopathy. However, apical sparing is not a quantitative parameter and is fairly subjective to the echocardiographer's judgement. It is not known, if a certain degree of apical sparing is also present in patients with only mild LV hypertrophy and diastolic dysfunction such as it is present in heart failure with preserved ejection fraction (HFpEF).

Methods

Patients with cardiac transthyretin and light chain amyloidosis and patients with HFpEF were included in a clinical registry at our outpatient clinic. CA was diagnosed according to current guidelines. All patients underwent a comprehensive transthoracic echocardiography (TTE) exam at the time of study inclusion. The TTE protocol included standard and speckle-tracking imaging to assess the presence of apical sparing as well as the basal to apical strain gradient. Patients with known coronary artery disease were excluded.

Results

In total 115 patients were included in this study. Of these, 87 (75.7%) were diagnosed with CA and 28 (24.3%) with HFpEF. Not surprisingly, apical sparing was found in a majority (86.2%) of patients with CA, however mild forms of this phenomenon were also present in 67.9% of patients with HFpEF (p=0.029, Figure 1). Median basal longitudinal strain was significantly more impaired in patients with CA (p<0.001) but there was no difference between longitudinal strain in the apical segments when comparing CA to HFpEF (p=0.443). This resulted in a higher median apical to basal strain gradient in patients with CA (2.3 (IQR 1.7–3.83) versus 1.13 (IQR 1.5–1.8), p<0.001).

Figure 1

Conclusion

Mild forms of apical sparing can be found in patients without CA. Gradual reduction in strain from base to apex could be an unspecific pathophysiologic mechanism which is remarkably pronounced in patients with CA.
P897Diagnostic utility of tissue biopsy in transthyretin cardiac amyloidosis diagnosed by non-invasive diagnostic criteria
Authors: Nishi M , Yamada T , Takashio S , Tsujita K
Published: October 2019

Background

In the recent past, transthyretin cardiac amyloidosis (TTR-CA) is recognized as an important cause of heart failure with preserved ejection fraction, and diagnostic utility of 99mTc-pyrophosphate (99mTc-PYP) scintigraphy in TTR-CA has been established. However, pathological evaluation is still the basis to confirm diagnosis. Subcutaneous tissue and gastrointestinal tract biopsy are useful examinations alternative to endomyocardial biopsy. Nevertheless, the positive ratio of amyloid deposition in these organs is not fully evaluated based on recent non-invasive diagnostic criteria.

Purpose

Our aim was to evaluate the diagnostic sensitivity of tissue biopsy in TTR-CA patients diagnosed by 99mTc-PYP scintigraphy.

Methods

We retrospectively evaluated 124 consecutive TTR-CA patients [wild-type (ATTRwt): 90, hereditary (hATTR): 34] who were diagnosed by positive findings of 99mTc-PYP scintigraphy (visual score 2 or 3) between June 2002 and January 2019 at our institute.

Results

A total of 114 patients underwent tissue biopsy at least one organ. Amyloid was detected on Congo red staining of subcutaneous tissue (43/97: 44%), gastrointestinal tract (52/78: 67%) and heart (78/79: 99%), respectively. Among 70 patients who underwent both subcutaneous tissue and gastrointestinal tract biopsy, amyloid was detected at least one specimen in 57/70 (81%). Compared to hATTR CA patients, ATTRwt CA patients had lower positive ratio of subcutaneous tissue (81% vs. 27%) and gastrointestinal tract (73% vs. 63%) biopsy.

Conclusion

Non-invasive diagnostic criteria of TTR-CA had excellent sensitivity of amyloid deposition in heart. The diagnostic sensitivity of subcutaneous tissue and gastrointestinal tract biopsy was lower in ATTRwt CA compared to hATTR CA. Combination of subcutaneous tissue and gastrointestinal tract biopsy was useful for pathological confirmation of amyloid deposition without endomyocardial biopsy.
P912Outcomes of aortic valve surgery in non-stenotic valves: mechanical replacement versus repair
Authors: Moreira S , Quintal J , Cerqueira R J , Saraiva F A , Ferreira A F , Moreira R , Raimundo R , Amorim M J , Almeida J , Pinho P , Lourenco A P , Leite-Moreira A
Published: October 2019

Background

Considering selected patients and the expertise of the surgical team, aortic valve repair (REPAIR) has been recognized as an alternative to aortic valve replacement.

Aim

To compare mid-term survival, need of reoperation and hemodynamic results after mechanical replacement (MECH) or REPAIR in non-stenotic aortic valve disease.

Methods

Retrospective single-center cohort study including consecutive patients younger than 70 years-old, with non-stenotic aortic valve disease, who underwent 1st aortic valve surgery with MECH or REPAIR (2 experienced surgeons), during a 6-year period. Concomitant procedures were not excluded. First follow-up echocardiogram was performed within 3 months after surgery (median). Mean follow-up time was 4 years, maximum 7. According to the data distribution appropriate statistical tests to compare independent samples were used. Mid-term survival and need of reoperation were studied through Kaplan-Meier curves and Cox regression.

Results

MECH was performed in 94 (56.6%) and REPAIR in 72 patients. Individuals in MECH group were older and presented higher NYHA functional class than REPAIR group (51±11 vs 47±13 years, p=0.048; 30 vs 4%, p<0.001). MECH group presented higher prevalence of rheumatic etiology (17 vs 3%, p<0.001). Although aortic root intervention was more frequent in MECH group (41 vs 17%, p<0.001), there were no differences in cardiopulmonary bypass and cross clamping aortic times (166 vs 148 minutes, p=0.16; and 121 vs 108 minutes, p=0.15 in MECH and REPAIR group, respectively). Left ventricle mass regression was similar (18 vs 21%, p=0.450, in MECH and REPAIR group, respectively). Mid-term survival (REPAIR cumulative survival 97% and MECH 93%, Log-Rank test p=0.752) and reoperation rates were similar between the two groups. REPAIR procedure failed in 3 patients: 2 months (new aortic regurgitation, AR), 7 months (infective endocarditis, IE) and 4 years (AR). MECH failed in 2 patients: 6 months (IE) and 2 months after surgery (prosthesis thrombosis) (Figure 1).

Conclusion

Aortic valve repair seems to be safe and effective in this single-center study showing similar results comparing with mechanical aortic valve replacement. We should reinforce the need of judiciously select patients for this complex surgical technique and the specialized training of the surgical team. Further studies are needed to provide reliable recommendations on this theme.
P923Feasibility of the transcatheter mitral valve repair as the rescue therapy for patients with severe mitral regurgitation and endangered heart failure
Authors: Huang W M , Lee C W , Sung S H , Chang H C
Published: October 2019

Background

For those who carry high or prohibitive surgical risk, the transcatheter edge-to edge mitral valve repair using MitraClip has been a safe and effective treatment for severe mitral regurgitation (MR). In patients with severe MR and cardiogenic shock under hemodynamic supporting devices, emergent surgical mitral valve interventions carry extremely high risk for peri-operative morbidities and mortalities. The feasibility and efficacy of emergent MitraClip to rescue patients in critical conditions remains elucidate.

Methods

Patients with severe MR were evaluated by the heart team and those with high or prohibitive surgical risks were referred to receive MitraClip procedures. Emergent MitraClip were conducted in patients with unstable hemodynamics and under mechanical or inotropic support. The hemodynamic measures, transthoracic echocardiography, transesophageal echocardiography, and blood tests were performed before MitraClip procedures. Procedural success was defined as having mild mitral regurgitation immediately after MitraClip, and patients were free from in-hospital mortality. Clinical and echocardiographic outcomes were followed by telephones and clinics.

Results

Among 50 consecutive patients (74.7±11.2 years, 74% male), 8 emergent MitraClip procedures were conducted to rescue patients with cardiogenic shock. Extracorporeal membrane oxygenation were used in 2 patients and intra-aortic balloon pump were applied in 4 patients (50%). The rest of 4 patients received continuous inotropic agent administration. Compare to those who underwent elective procedures, patients underwent emergent MitraClip had higher surgical risk profile (Euroscore II 34.8% vs 5.1% and STS score 19.7% vs 5.1%), poorer renal function and higher right atrial pressure. There was no peri-procedural death, myocardial infarction, stroke or any adverse events requiring emergent cardiac surgery in both groups. Mild mitral regurgitation was achieved in 87.5% patients from the emergent group and 95.2% patients in the elective group (P=0.514). In follow up, there were 5 deaths (three in the emergent group), including 2 non-cardiovascular deaths. The Kaplan-Meier analysis showed patients who underwent emergent procedures have poorer long-term survival rate as compare to those who received elective procedures. (P value = 0.008).

Conclusions

When open-heart surgery is not feasible and deferred due to excessive risk, trans-catheter mitral valve repair is an alternative way to rescue patients in cardiogenic shock status. The emergent MitraClip procedure may provide comparable safety and efficacy in treating patients with severe MR and unstable hemodynamics.
P924Prognostic significance of moderate primary mitral regurgitation and atrial fibrillation
Authors: Hayashi H , Abe Y , Kuriyama T , Mu X , Hamaguchi T , Inoko M
Published: October 2019

Background

Severe primary mitral regurgitation [degenerativeMR (DMR)] is associated with poor outcome, including cardiac death and admission due to worsening heart failure. Whereas little information is available regarding the characteristics of moderate DMR and their impact on prognostic outcome.

The aim of the present study was to investigate the prognosis and its determinant in patients with moderate DMR.

Methods

From 13,700 consecutive patients who underwent transthoracic echocardiography. We selected moderate DMR but without other underlying cardiac diseases. Characteristics and event free rate as compared with age- and gender-matched patients with none to mild MR.

Results

Of a total of our cohort, 185 (1%) patients had moderate DMR, and we compared with 185 age- and gender-matched patients with none to mild MR. During the follow-up period of 1372±655 days, 30 patients (8%) met the composite endpoint defined as cardiac death and admission due to worsening heart failure. Kaplan-Meier analysis showed patients with moderate DMR was significantly associated with a poor outcome compared to patients with none to mild MR (log-ranktest P<0.0001). Cox proportional hazard ratio revealed thatmoderate MR and atrial fibrillation (AF) were the independent predictors of the composite endpoint.

Prgnostic outcome: AF and moderate DMR

Conclusions

Patients withmoderate DMR and concomitant AF had a significant poor outcome. An activesurveillance and some intervention for AF and moderate MR may be required.
P927Long-term mortality in patients with paradoxical low-flow low-gradient versus normal-flow high-gradient aortic stenosis undergoing transcatheter aortic valve implantation
Authors: Fusini L , Muratori M , Tamborini G , Ghulam Ali S , Gripari P , Salvi L , Roberto M , Trabattoni P , Agrifoglio M , Bartorelli A L , Alamanni F , Pepi M
Published: October 2019

Background

Controversial data exist on clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG) undergoing valve replacement. This entity is a combination of a small aortic valve area (AVA<1cm2), a preserved left ventricular ejection fraction (LVEF≥50%), and a “paradoxical” low mean gradient due to the presence of low LV stroke volume (≤35 mL/m2). The low flow state is explained by the presence of a high afterload and pronounced LV concentric remodeling, with impaired LV filling. Currently, poorer outcomes have been reported after surgical aortic valve replacement in patients with PLF-LG AS compared with the normal-flow high-gradient (NF-HG) AS.

Purpose

The aim of this study was to determine the clinical outcomes in patients with PLF-LG AS undergoing transcatheter aortic valve implantation (TAVI) compare to NF-HG patients.

Methods

A total of 609 patients (age 81±6 years) with symptomatic severe AS and preserved LVEF who underwent TAVI, was enrolled and divided in two groups: group A included patients with NF-HG (542 patients) and group B including those with PLF-LG (66 patients). At 1-year follow-up, death and clinical events were reported.

Results

TAVI was feasible in all patients. A significant reduction in mean aortic pressure gradient was observed after TAVI both in PLF-LG (baseline, 30±5 mmHg; 1-year, 11±4 mmHg; p<0.001) and in NF-HG (baseline, 53±11 mmHg; 1-year, 12±4 mmHg; p<0.001) together with an increase in AVA (PLF-LG: baseline, 0.74±0.16 cm2, 1-year: 1.83±0.41 cm2, p<0.001; NF-HG: baseline, 0.65±0.16 cm2, 1-year: 1.84±0.35cm2, p<0.001). Perioperative mortality at 30-days was similar in group A (17/542, 3%) and in group B (2/66, 3%). Figure shows the survival curves up to 5 years follow-up according to the two groups. PLF-LG and HG-AS had similar survival rate throughout the long-term follow-up. Similarly, rehospitalization rate was not different in the two groups (PLF-LG: 12% vs NF-HG: 7%, p=0.121).

Kaplan-Meier analysis

Conclusions

Differently from surgical series, TAVI patients with PLF-LG AS had showed similar mortality and rehospitalization rates compared to NF-HG.
P942Impact of left ventricular ejection fraction in patients with critical limb ischemia: from I-PAD registry
Authors: Fujimori K , Nagae A , Miura T , Katoh T , Hirabayashi M , Kashiwagi D , Yokota D , Yanagisawa T , Sakai T , Senda K , Saigusa T , Ebisawa S , Okada A , Motoki H , Kuwahara K
Published: October 2019

Introduction

In patients with critical limb ischemia (CLI) it is known that malnutrition, low BMI, inflammation and so on are prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of CLI patients. So we investigated that LVEF affects prognosis of CLI patients.

Methods

From July 2015 to July 2016, 371 consecutive peripheral artery disease patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. 179 of them were patients with CLI. We could conduct follow up survey about 126 (age 75.5±11.1, men 63.5%) and divided two groups according to their LVEF (group with LVEF≤40%, n=13, group without LVEF≤40%, n=113). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 11.5±6.7 months. The 18 months MALE rate was significant higher in the group with low LVEF than group without low LVEF (76.9% vs 37.2% p<0.05). The 18months all-cause death tended to be higher in the group with low LVEF, however there was not statistical significance in the two groups (53.8% vs 24.8% p=0.09).

Conclusion

LVEF was associated with MALE in patients with CLI.