bluuebunny/crossref_metadata_2025 huggingface dataset:
P4127CMR normal reference values of biventricular size and function in male athletes
Authors: D'Ascenzi F , Anselmi F , Piu P , Fiorentini C , Focardi M , Bonifazi M , Mondillo S
Published: October 2019

Background

Exercise-induced enlargement of cardiac chambers is commonly observed in competitive athletes. However, ventricular dilatation is also a common phenotypic expression of life-threatening cardiomyopathies. The use of cardiac magnetic resonance (CMR) for the exclusion of pathology is growing. However, normal reference values have not been established for athletes. The aim of this meta-analysis was to derive normal reference values of biventricular size and function estimated by CMR in competitive athletes.

Methods

We conducted a systematic review of English-language studies in the MEDLINE, Scopus, and Cochrane databases investigating biventricular size and function by CMR in athletes. Athletes were divided into endurance, combined, and mixed groups according to the sport practiced. The potential impact of training volume was also evaluated.

Results

Twenty-seven studies and 983 competitive athletes were included for CMR quantification of biventricular size and function. In this review, normal reference values are presented for biventricular size and function to be applied to male competitive athletes according to the disciplines practiced. A significant impact of training volume was demonstrated for the right ventricle: athletes practicing the largest number of training hours per week were those exhibiting the greatest degree of right ventricular remodeling (Figure 1). Notably, biventricular function was not significantly affected by training volume.

Figure 1

Conclusions

The present meta-analysis defines the normal limits of biventricular size and function estimated by CMR in competitive athletes. The authors suggest using these normal reference values as an alternative to standard upper limits derived from the general population when interpreting CMR images in athletes.
P4133Atrial fibrillation in elderly patients with syncope and dementia: clinical insights from a large multicenter Italian registry
Authors: Ceccofiglio A , Fumagalli S , Mossello E , Mussi C , Bo M , Martone A M , Bellelli G , Nicosia F , Riccio D , Langellotto A , Tava G , Boccardi V , Tonon E , Abete P , Ungar A
Published: October 2019

Background

Syncope and dementia have a high prevalence in elderly individuals. Atrial fibrillation (AF) frequently occurs at advanced age. The coexistence of these conditions can be indicative of a clinically relevant frail status.

Purpose

The aim of this study was to evaluate the characteristics and the long-term outcome of AF patients with dementia and a history of syncope.

Methods

We evaluated the Syncope and Dementia (SYD) Registry. Data were collected by 11 Geriatric Departments between 2012 and 2016. Follow-up was closed at the 12-month evaluation.

Results

During the study period, 522 patients (women – 324, 62.1%; MMSE: 17±6) were enrolled. Of these 138 (26.4%) have or presented a history of AF. Patients with AF were older (85±6 vs. 83±6 years, p=0.012), with a higher heart rate (78±17 vs. 73±14 bpm, p<0.001), had a more complex clinical picture with an increased number (3.9±2.0 vs. 3.0±1.8, p<0.001) and severity (1.8±0.3 vs. 1.6±0.4, p<0.001) of comorbidities, as assessed with the Cumulative Illness Rating Scale. In particular, the prevalence of diabetes (28.3 vs. 20.1%, p=0.047), heart failure (13.8 vs. 7.3%, p=0.023) and stroke/TIA (26.1 vs. 17.7%, p=0.035) was higher in patients with the arrhythmia. Cardiac syncope was more frequently diagnosed at the final evaluation (18.8 vs. 4.9%, p<0.001). Even if the use of antipsychotics (13.0 vs. 27.6%, p=0.001) and cholinesterase inhibitors (6.5 vs. 16.4%, p=0.004) were less used in AF subjects, the total number of prescribed drugs was higher (6.9±2.9 vs. 5.9±2.7, p<0.001). At multivariate analysis (overall predictivity: 75%), AF patients were characterized by advanced age (p=0.041), a higher severity of comorbidities (p<0.001), a greater number of drugs (p=0.020), an increased heart rate (p=0.004) and a more frequent presence of cardiac symptoms (p=0.049).

At one-year follow-up (8 patients lost), the mortality rate in AF patients was 27.7% (N=36/130). Deceased patients presented a greater degree of disability (number of lost activities of daily living: 3.7±2.3 vs. 2.8±1.9, p=0.020) and a higher heart rate at baseline (85±17 vs. 76±15 bpm, p=0.006). Multivariate analysis (overall predictivity: 74%) confirmed the association of disability (p=0.039) and heart rate (p=0.045) with prognosis.

Conclusions

AF is frequently present in patients with dementia and a history of syncope. It is usually associated with a more complex clinical picture and high long-term mortality. Heart rate and a higher degree disability seem to be related to prognosis.

Acknowledgement/Funding

None
P4134Impaired left ventricular systolic function in alcohol abusers expressed by both 3D calculated ejection fraction and longitudinal strain by AFI
Authors: Hamala P , Kasprzak J D , Lipiec P , Wierzbowska-Drabik K
Published: October 2019

Aim

Despite knowledge regarding the existence of alcohol cardiomyopathy the exact impact of alcohol abuse in consecutive subject is poorly examined.

We aimed to evaluate the left ventricle (LV) function in chronic abusers group and compared classical and novel echocardiography parameters in alcohol abusers (ALC) and control group (C).

Methods

We compared 75 adults (mean age 48±12, 60 male) without other overt heart disease, coronary artery disease excluded, but with alcohol abuse history: average alcohol intake 32 alcohol unit per week (AUW) with control group consisted of 40 subjects without history of excessive drinking, abstinents or drinking ≤8 AUW (mean age 50±4, 16 men). One unit was defined as 10 grams of pure etanol. All patients underwent TTE examination including ejection fraction (EF) calculation with 3D and longitudinal strain assessment by AFI method.

Results

ALC group showed LV systolic dysfunction expressed as EF 48±14 vs 60±9%, global longitudinal strain (AFI GLS) −15.6±6.6 vs −18.7±3.4; p<0.0001 and p 0.0064, respectively. On the other hand the LV and left atrial diameters as well as diastolic function were similar in both groups, indicating on relatively low advancement of heart remodeling.

ALC vs Control group comparison ALC N75 C N40 p value Age 48±12 50±4 ns BMI 24±6 28±6 0.0009 LVd 48±13 47±4 ns LVs 34±15 32±4 ns LA 38±9 38±3 ns EF 48±14 60±9 <0.0001 E/A 1.1±0.6 1.1±0.3 ns E' lateral 10.6±3.9 10.6±2.9 ns AFI 2ch −15.9±6.9 −18.8±4.8 0.0143 AFI 3ch −15.9±6.9 −18.9±3.6 0.0116 AFI 4ch −15.2±7.1 −18.6±3.5 0.0053 AFI GLS −15.6±6.6 −18.7±3.4 0.0064

Conclusions

Chronic alcohol abuse revealed harmful effect on LV systolic function which can be assessed quantitatively by both decreased EF and absolute values of myocardial longitudinal strain. This systolic function impairment seems to anticipate the overt remodelling of the heart.
P4142PI3-kinase delta protects against atherosclerosis progression by governing regulatory T-cell biology
Authors: Zierden M , Millarg C , Baldus S , Rosenkranz S , Berghausen E M , Vantler M
Published: October 2019

Introduction and purpose

Atherosclerosis is a chronic inflammatory disease of arteries and represents the main underlying cause of death worldwide. Macrophages are major drivers of atherosclerosis by ingestion of lipoproteins, foam cell formation, and secretion of pro-inflammatory mediators. Although macrophages outnumber other leukocytes in atherosclerotic plaques, T and B lymphocytes can shape the course of disease by promoting or mitigating inflammatory responses. Leukocytes highly express the phosphoinositide 3-kinase isoform delta (PI3Kd), exerting a key role in the regulation of immune responses including the activation, proliferation, differentiation, and effector function of lymphocytes. Since macrophages and lymphocytes are all major effectors of atherosclerosis, we aimed to understand the role of PI3Kd in these leukocytes during atherogenesis.

Methods and results

To investigate the role of haematopoietic PI3Kd in atherosclerosis, bone marrow from PI3Kd−/− or PI3Kd+/+ mice was transplanted into LDLR−/− mice. After 6 weeks of feeding on an atherogenic diet, PI3Kd−/− recipient LDLR−/− mice displayed significantly impaired CD4+ and CD8+ T-cell numbers, CD4+ T-cell activation, CD4+ effector T cells, and proatherogenic CD4+ T helper (Th) 1 responses in para-aortic lymph nodes and spleen compared with PI3Kd+/+ transplanted controls. Surprisingly, the net effect of PI3Kd deficiency was a substantial increase of aortic inflammation and atherosclerosis in LDLR−/− mice. Moreover, haematopoietic PI3Kd deficiency augmented macrophage accumulation in atherosclerotic plaques of LDLR−/− mice, whereas major macrophage functions including foam cell formation, efferocytosis, and cytokine secretion were unaffected by PI3Kd inactivation in these phagocytes. However, haematopoietic PI3Kd deficiency led to depletion of atheroprotective B-1 cells and reduction of proatherogenic B-2 cells in LDLR−/− mice. Moreover, haematopoietic PI3Kd deficiency caused a significant reduction of regulatory CD4+ T cells (Tregs) in plaques, para-aortic lymph nodes, and spleen of LDLR−/− mice. Furthermore, PI3Kd−/− Tregs exhibited reduced secretion of anti-inflammatory cytokines IL-10 and TGF-b as well as impaired suppression of CD4+ T-cell proliferation. Consequently, adoptive transfer of PI3Kd+/+ Tregs fully constrains the atherosclerotic burden in PI3Kd−/− transplanted LDLR−/− mice without affecting B cell numbers.

Conclusions

We demonstrate that PI3Kd plays a crucial role in B lymphocytes, Th1 cells, and Tregs during atherogenesis. Lack of PI3Kd signalling in atheroprotective Treg responses outplays its impact on proatherogenic Th1 responses, thus leading to aggravated atherosclerosis. Hence, PI3Kd is a key regulator of Treg biology and thereby protects against atherosclerosis progression.

Acknowledgement/Funding

Center for Molecular Medicine Cologne (CMMC) and the Marga and Walter Boll-Stiftung
P4150Causes of death in a heart failure clinic in Spain along 17 years
Authors: Moliner P , Lupon J , De Antonio M , Domingo M , Santiago-Vacas E , Zamora E , Santesmases J , Diez-Quevedo C , Troya M I , Boldo M , Altimir S , Alonso N , Gonzalez B , Nunez J , Bayes-Genis A
Published: October 2019

Background

Advances in heart failure (HF) treatment have achieved a reduction of death in HF patients in the last two decades. Indeed, not only mortality has been reduced but also the mode of death might have been modified through these years.

Purpose

To assess the causes of death in outpatients attended in a HF Unit since the year 2002 up to the year 2018.

Methods

Causes of death were classified as follows: progression of HF (worsening HF or treatment-resistant HF, in the absence of another cause); sudden death (any unexpected death, witnessed or not, of a previously stable patient with no evidence of worsening HF or any other known cause of death); acute myocardial infarction; stroke; procedural (post-diagnostic or post-therapeutic); other cardiovascular causes (e.g., rupture of an aneurysm, peripheral ischemia, or aortic dissection), and non-cardiovascular. Patients who died of unknown cause were excluded from the analysis. Fatal events were identified from the clinical records of patients with HF, hospital wards, the emergency room, general practitioners, or by contacting the patient's relatives. Furthermore, data were verified from the databases of the Catalan and Spanish Health Systems. Trends on every cause of death were assessed by linear regression.

Results

Since August 2001 to May 2018, 2295 HF patients were admitted to the HF clinic (age 66.4±12.8 years, 71% men, 49% from ischemic aetiology, mean LVEF 35.2% ± 14). During the 17 years of the study, 1201 deaths were recorded. Seventy-eight patients (6.5% of deaths) were excluded due to unknown cause of death. The evolution in the mode of death by years is shown in the figure. Two trends were observed: a decrease in sudden death (p=0.05) and a very significant linear increase in non-cardiovascular causes of death (p<0.001). The decrease of sudden death was mainly driven from changes observed in the first 10 years (p=0.014); thereafter the incidence of sudden death remained stable (p=0.18). Remarkably we did not observe significant changes in HF progression as mode of death (p=0.17).

Conclusions

During the 17 years of the study, a very significant trend towards higher percentage of non-cardiovascular deaths was progressively observed. On the other hand, percentage of sudden death showed a gradual decrease, mainly driven from the changes observed in the first 10 years.
P4158Marked impairment of endothelium-dependent digital vasodilatations in patients with microvascular angina compared with those with vasospastic angina
Authors: Kajitani S , Shiroto T , Godo S , Ito A , Ikumi Y , Sugisawa J , Suda A , Shindo T , Ikeda S , Hao K , Kikuchi Y , Nochioka K , Matsumoto Y , Takahashi J , Shimokawa H
Published: October 2019

Background/Introduction

Nitric oxide (NO) and endothelium-dependent hyperpolarization (EDH) factor are the major endothelium-derived relaxing factors. NO plays an important role in conduit arteries, while the importance of EDH factor increases as the vessel size decrease in patients with microvascular angina (MVA) compared with those with vasospastic angina (VSA) remains to be fully elucidated.

Purpose

We evaluated the roles of NO and EDH factor in conduit (brachial) arteries and resistance (digital) arteries of the patients with MVA, VSA and comorbid MVA+VSA patients.

Methods

We enrolled 39 patients who underwent diagnostic cardiac catheterization and divided them into 3 groups based on acetylcholine (ACh) provocation test, index of microcirculation resistance (IMR), and coronary flow reserve (CFR); MVA (N=9, mean age 59.9±3.5 years), VSA (N=12, mean age 61.3±1.8 years), and comorbid MVA+VSA (N=18, mean age 64.0±2.2 years). Endothelium-dependent brachial and digital vasodilatations in response to intra-arterial infusion of bradykinin (BK, 25, 50, and 100 ng/min for 2 min) were simultaneously measured by ultrasonography and peripheral arterial tonometry, respectively. Measurements were repeated after oral administration of aspirin (486 mg) and intra-arterial infusion of NG-monomethyl-L-arginine (L-NMMA, 8μmol/min for 5 min) in order to inhibit the effects of vasodilator prostaglandins and NO, respectively. Finally, endothelium-independent brachial and digital vasodilatations in response to sublingual nitroglycerin (NTG, 0.3 mg) were measured in the same manner.

Results

In the brachial artery, dose-dependent vasodilatations to BK were comparable among the 3 groups, and L-NMMA equally attenuated the responses to BK (Figure 1). Endothelium-independent brachial vasodilatation in response to NTG was also comparable among the 3 groups. Surprisingly, dose-dependent digital vasodilatations to BK were almost absent in MVA patients compared with VSA or comorbid MVA+VSA group (Figure 2). Furthermore, the digital vasodilatations were unaffected by L-NMMA in VSA group, but were significantly reduced in comorbid MVA+VSA group (VSA, 16.8±15.1% vs. MVA+VSA, −0.23±6.2%, P<0.05), suggesting reduced EDH and compensatory role of NO in the latter group. In contrast, endothelium-independent digital vasodilatation in response to NTG was comparable among the 3 groups.

The main results of this study

Conclusions

These results provide the first evidence that endothelium-dependent digital vasodilatations (both NO and EDH factor) are markedly impaired in MVA patients compared with VSA or comorbid MVA+VSA patients, whereas the responses are comparable in the brachial artery among the 3 groups, suggesting the involvement of severe endothelial dysfunction in the pathogenesis of MVA.
P4170Survival after dispatcher assisted CPR in out of hospital cardiac arrest compared to CPR without dispatcher assistance and no CPR before emergency medical services arrival – a nationwide study
Authors: Riva G , Jonsson M , Ringh M , Claesson A , Djarv T , Nordberg P , Hollenberg J
Published: October 2019

Background

Cardiopulmonary resuscitation (CPR) before arrival of emergency medical services (EMS) is associated with survival in out-of hospital cardiac arrest. Dispatcher assisted CPR (DA-CPR) has been shown to increase CPR rates. However there are several challenges to successful DA-CPR, such as identification of cardiac arrest, time delays to CPR instructions, time delays to start of chest compression and quality of CPR.

Purpose

The aim of this study is to assess survival in out of hospital cardiac arrest after no CPR, DA-CPR and CPR without dispatcher assistance before EMS arrival in a nationwide cardiac arrest register.

Methods

A register based observational study. All consecutive Out of Hospital Cardiac Arrests reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010–2017 were collected. Patients with cardiac arrest witnessed by EMS, who received CPR by off-duty medical professionals, missing data on CPR, DA-CPR or survival were excluded. Exposure was categorized as either; no CPR before EMS arrival (NO-CPR), dispatcher assisted CPR before EMS arrival (DA-CPR) and CPR before EMS arrival without dispatcher assistance, spontaneous CPR (S-CPR). Propensity score matched cohorts were used for comparison between groups. Primary endpoint was 30-day survival.

Results

Out of 36309, a total of 15471 patients were included, 41.6% received NO-CPR 31.0% received DA-CPR and 27.4% received S-CPR. In propensity score matched cohorts survival to 30-days was 9.0% after NO-CPR, 13.6% after DA-CPR and 15.8% after S-CPR. Using DA-CPR as reference, NO-CPR was associated with lower survival (Conditional OR 0.61, 95% CI 0.52–0.72), absolute difference 4.6% (95% CI 3.0%-6.2%) and S-CPR was associated with higher survival (Conditional OR 1.21 (95% CI 1.05–1.39), absolute difference 2.3% (95% CI 0.5%-4.0%).

30-day survival

Conclusion

In this nationwide study spontaneous CPR was associated with the highest survival. When spontaneous CPR is not initiated DA-CPR is a reasonable option.

Acknowledgement/Funding

Swedish Heart and Lung Foundation
P4335The incidence of acute rheumatic fever in indigenous adults in the Northern Territory, South Australia and Western Australia
Authors: De Angelis C , Giles L , Roberts-Thomson R , Brown A
Published: October 2019

Background

Worldwide, knowledge of the contemporary incidence of acute rheumatic fever (ARF) in Indigenous adult populations is limited, with little understanding of patterns of ARF recurrence according to age and geographical location. This has created uncertainty in the development of rheumatic heart disease (RHD) guidelines surrounding the appropriate duration of antibiotic prophylaxis for these patients.

Purpose

This study aimed to describe the incidence rates of ARF in Indigenous Australian adults, analyse patterns of recurrence according to sex, age and geographical location, and assess adherence to secondary prophylaxis.

Methods

ARF episodes in Indigenous adults, aged 18 years and older, recorded within three Australian jurisdictions (Northern Territory, South Australia and Western Australia) ARF registers, diagnosed between 2007 to 2017, were included. Poisson and negative binomial regression were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for first and recurrent episodes according to age, sex and remoteness. Adherence rates to secondary prophylaxis was described in the 12 months preceding recurrent ARF episodes in the Northern Territory.

Results

481 episodes were analysed. The incidence of ARF episodes in these jurisdictions from 2007 to 2017 was relatively constant. The overwhelming burden of disease occurred in remote areas (105 episodes per 100,000 people). An increased rate occurred in females (IRR 2.34, 95% CI 1.81–3.03). The 18–24 year olds had the highest incidence rates (115 episodes per 100,000 people). High rates of recurrence were also observed in those aged 25–34 years (96 episodes per 100,000 people). Adherence to secondary prophylaxis in those having a recurrent episode was only achieved in 10% of cases.

Conclusions

The incidence of ARF remains very high amongst adult Indigenous Australians. Adherence to secondary prophylaxis continues to play a role in recurrent episodes. RHD guidelines should take into account remoteness as a significant risk factor when deciding the duration of secondary prophylaxis.
P4342How burnout affects errors among physicians: meta-analysis
Authors: Olszewski R , Owoc J , Manczak M , Tombarkiewicz M
Published: October 2019

Burnout among physician is a growing and widespread phenomenon that seriously affects various aspects of healthcare delivery. A growing number of studies suggest that it significantly impacts quality of patient care and safety in various ways. This meta-analysis takes a narrowed approach to estimate association of burnout with self-perceived medical errors.

Purpose

To examine and quantify an overall effect of burnout on self-perceived errors among physicians.

Methods

The PubMed, Web of Science, Scopus, MEDLINE and Google Scholar databases were searched using various combinations of key terms: burnout, error, quality of care, patient safety. The inclusion criteria focused on prevalence of burnout among physicians and their self-reported errors in quantitative, observational studies that measured prevalence of self-reported errors in relation to physician burnout. We used Odds Ratio (OR) with 95% CI in the statistical analysis.

Results

The meta-analysis eventually covered 19,932 physicians from 10 studies (Tab. 1). The overall effect of burnout on self-reported errors was 2.72 (OR; 95% CI, 2.19–3.37) for burnout vs non-burnout physicians (Fig. 1). In none of the analysed studies was the effect of overall burnout neutral or negative.

Table 1. Characteristics of studies in the meta-analysis Study Year No. of physicians OR (95% CI) p weight % Shanafelt 1 2002 115 5.37 (1.71–16.81) 0.0039 3,02% Fahrenkopf 2008 123 3.68 (1.03–13.15) 0.0452 3,42% Toral-Villanueva 2009 312 8.90 (3.97–19.95) <0.001 5,26% Klein 2010 1,311 2.07 (1.50–2.86) <0.001 14,02% Tawfik 2018 6,695 3.25 (2.70–3.92) <0.001 17.73% O'Connor 2017 168 2.16 (1.08–4.30) 0.029 6.58% Baer 2017 258 7.32 (2.03–26.42) 0.002 2.47% Shanafelt 2 2010 7,905 2.34 (2.00–2.73) <0.001 18.42% Oliveira 2013 1,508 1.92 (1.44–2.56) <0.001 14.97% Wen 2016 1,537 2.79 (2.03–3.83) <0.001 14.11% Overall 19932 2.72 (2.19–3.37) 0.ehz745.0750 100.00%

Figure 1. Associations between burnout and errors.

Conclusions

This study provides evidence that burnout among physicians increases the likelihood of errors and thus may seriously affect patient safety at hospitals. The results suggest that it may be one of the key aspects in terms of patient safety and quality of care and should be considered a priority in patient safety improvement programs and policies.
P4353Global longitudinal strain is a measure of subclinical left ventricular dysfunction in chronic inflammatory autoimmune conditions
Authors: Khanna S , Newman J M , Gan G , Bhat A , Chen H , Tan T
Published: October 2019

Background

Myocardial deformation indices are proposed to be a more sensitive marker of subclinical dysfunction compared to standard measures of left ventricular (LV) systolic function. We hypothesize that subclinical myocardial dysfunction is present in chronic inflammatory autoimmune diseases such as Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA), despite both conditions being mediated by different pro-inflammatory modulators.

Purpose

Identify subclinical myocardial dysfunction through assessment of global longitudinal strain in two different chronic autoimmune conditions, SLE and RA.

Methods

Consecutive patients admitted to our institution with known history of SLE or RA (>1 year disease activity) were examined. Patients with preexisting cardiac disease, LVEF <50% and those without comprehensive transthoracic echocardiograms (TTE) were excluded. Mean longitudinal LV strain was performed offline using vendor-independent software (TomTec v4.6) and compared to age- and gender-matched controls with normal LV function and no history of cardiac disease.

Results

Of the 86 patients examined (mean age 53.01±21.74, 85.4% female), 51 (59.3%) had SLE and 35 (40.7%) had RA. No significant difference in BMI, hypertension, hypercholesterolemia, diabetes, obesity, obstructive sleep apnea and stroke was observed between controls and patients with SLE or RA. While there was no significant difference in LVEF between RA patients and matched controls, there was a significantly lower GLS in the RA cohort. Conversely, patients with SLE had significantly lower LVEF and GLS when compared to matched controls, despite LVEF being in the normal range. See Table 1. Receiver operator curve analysis revealed that mean GLS is a better discriminator for autoimmune disease with an area under the curve of 0.829 (95% CI, 0.77 to 0.89; p<0.01) compared to LVEF with an area under the curve of 0.632 (95% CI, 0.55 to 0.72; p<0.01).

Echocardiographic Parameters SLE (n=51) Controls (n=51) Sig (p value) RA (n=35) Controls (n=35) Sig (p value) LVEDV (mls) 102±30 85±20 <0.01 84±28 89±30 0.43 LVESV (mls) 36±17 29±9 0.02 26±14 30±12 0.24 Biplane LVEF % 59±6 63±4 <0.01 62±6 62±5 0.81 LV Mass (grams/m2) 96±34 72±20 <0.01 79±26 82±23 0.67 LV Mean GLS % 16.7±2.8 21.3±2 <0.01 17.8±1.7 19.1±2.5 0.02

Conclusions

Our results suggest that chronic inflammatory conditions (SLE and RA) are associated with subclinical cardiac dysfunction. Impaired GLS may reflect early myocardial damage and be used as a tool for screening of patients with inflammatory conditions.

Acknowledgement/Funding

None
P4354Regional Strain Pattern Index - A novel technique to predict CRT response
Authors: Orszulak M , Mizia-Stec K , Wrobel W , Berger-Kucza A , Orszulak W , Filipecki A , Urbanczyk-Swic D , Kwasniewski W
Published: October 2019

Background

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in heart failure individuals. Despite many efforts 30–40% patients with CRT still do not respond to therapy.

Purpose

The purpose was to propose and evaluate a novel dyssynchrony scoring system – Regional Strain Pattern Index (RSPI) in prediction of response to CRT.

Methods

Forty-nine HF patients (age: 66.5±10 years, LV ejection fraction: 24.9±6.4%, QRS: 173.1±19.1 ms, NYHA class II/III: 34.7%/63.3%, ischemic aetiology: 57.1%) underwent CRT implantation. Transthoracic echocardiography was performed before and 15±7 months after CRT implantation. Baseline dyssynchrony was studied by standard indices, strain pattern analysis and novel, author's index- RSPI. RSPI constitutes a method of quantification of LBBB-related strain curve pattern analysis. RSPI was calculated using longitudinal strain by 2D speckle tracking as the sum of dyssynchronous components across 12 segments from all three apical views. In one view, four components were assessed: 1) the contraction of the early-activated wall, 2) the prestretching of the late activated wall, 3) the contraction of the early-activated wall in the first 70% of the systolic ejection phase and 4) the peak contraction of the late-activated wall after aortic valve closure. One point was attributed to each component, thus the maximum was 12 points. RSPI was prospectively evaluated in predicting response to CRT. The response to CRT was defined as ≥15% reduction in the left ventricular end-systolic volume after 15 month follow-up.

Results

Thirty-six (73.5%) patients were responders. There were no significant differences in the baseline demographics, clinical, echocardiographic parameters between responders and non-responders. The mean RSPI in the overall population was 5.39±2.9 and higher RSPI values were observed in responders (5.86±2.9) than in non-responders (4.08±2.4, p=0.044). The ROC curve indicated that RSPI significantly predicted CRT response (area under curve, AUC=0.691, p=0.014) with the cut-off value at 7 points. Therefore, study population was divided into two groups according to RSPI score: ≥7 points (19 patients, 38.8% of population) and <7 points (30 patients, 61.2%). In univariate logistic regression analysis, among all of the dyssynchrony indices only RSPI≥7 points predicted the positive response to CRT (OR: 12; 95% CI=1.33–108.17; p=0.0036) with specificity of 92.3%, sensitivity of 50%, positive of 64.7% and negative of 40% predictive value for CRT response.

ROC curve for RSPI

Conclusion

RSPI constitutes a novel, valuable predictor for CRT response.

Acknowledgement/Funding

Grant for scientific research in the field of CRT efficacy funded by Medical University of Silesia.
P4365Role of 3D speckle-tracking echocardiography system, using comparison with cardiac magnetic resonance imaging and to assess the contribution of regional RV function to global function in COPD patients
Authors: Sen N , Tanwar S , Jain A , Kalra B , Bansal M , Mehta A , Gokhroo R K
Published: October 2019

Background

Chronic obstructive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In COPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging.

Purpose

The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function.

Methods

In a retrospective, cross-sectional study setting, RV volumetric data were studied in 302 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments.

Results

208 patients (69%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.88; RV end-systolic volume, R2=0.81; RV ejection fraction [RVEF], R2=0.69; P<0.004 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −2.8% and −7.8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.29, P=0.003). Among segmental 3D strain variables, inlet area strain (r=−0.48, P<0.002) and outflow circumferential strain (r=−0.37, P<0.003) were independent factors associated with CMR-derived RVEF.

Conclusions

Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements. Severity of COPD influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters.
P4368Estimation of pulmonary artery pressure from right atrial strain and tricuspid regurgitation velocity
Authors: Inoue K , Remme E W , Khan F H , Andersen O S , Gude E , Skulstad H , Smiseth O A
Published: October 2019

Background

Systolic pulmonary artery pressure (SPAP) can be estimated non-invasively as the sum of indices for right atrial (RA) pressure and tricuspid regurgitation (TR) pressure gradient. Although echocardiographic evaluation of inferior vena cava diameter and collapsibility is currently being used to estimate RA pressure (IVC method), RA strain may be an alternative since atrial strain is related to atrial pressure.

Objective

We tested if RA strain by speckle tracking echocardiography can be used as a surrogate of mean RA pressure (RA strain method), and by adding the TR pressure gradient, be used to estimate SPAP.

Methods

We retrospectively analyzed 91 patients (mean age, 58 years) referred to right heart catheterization due to unexplained dyspnea or suspected pulmonary hypertension. Echocardiography was performed within 24 hours of the invasive procedure. RA reservoir strain was calculated from apical four-chamber view. SPAP was calculated as the sum of peak TR pressure gradient and estimated RA pressure by the IVC or RA strain methods.

Results

Right heart catheterization showed SPAP and mean RA pressures of 51±20 mmHg and 9±6 mmHg, respectively. RA reservoir strain was inversely correlated with mean RA pressure (r=−0.61, p<0.01). Thus, we set mean RA pressure as 5, 10 and 15 mmHg depending on high (≥25%), middle (10–25%) and low (≤10%) values of RA reservoir strain. As shown in the figure, both the RA strain and IVC methods when combined with peak TR velocity, provided good estimates of invasively measured SPAP.

Conclusions

RA strain provides a semiquantitative measure of RA pressure, which can be used in combination with peak TR velocity to estimate SPAP. This approach can be used as an alternative when the IVC method is not available in cases with poor subcostal window.
P4374Biventricular systolic function analysis in patients with Marfan Syndrome using speckle-tracking 2D ecocardiography
Authors: Torres Sanabria M , Monivas Palomero V , Garcia Izquierdo Jaen E , Forteza Gil A , Gonzalez Mirelis J , Martin Lopez C E , Navarro Rico S , Aguilera Agudo C , Baena Herrera J , Mitroi C , Mingo Santos S
Published: October 2019

Background

Left Ventricular systolic disfunction has already been described in Marfan Syndrome (MS) in patients without valvular dysfunction using 2D and 3D speckle tracking echocardiography (STE). This dysfunction has been related to a more severe causal genetic mutation, which suggest the presence of a primary cardiomiopathy in these patients. Right ventricular function has been less studied so far. We sought to evaluate biventricular function in our cohort of MS patients with 2D-STE.

Methods

95 unoperated adult patients with MS and 32 healthy controls were prospectively enrolled. Patients with more than mild mitral or aortic regurgitation were excluded. Using STE we obtanied left ventricular global longitudinal strain (LVGLS) from the average of 16 segments from 4,2 and 3-chamber views and RVGLS values were obtained from the average of 6 segments from the apical 4-chamber view. We also measured classic parameters of systolic biventricular function (LVEF and TAPSE).

Results

Compared to controls, patients with MFS had significantly lower LVGLS and RVGLS (table 1). Values obtanied for LVGLS in MS patients were at the lower limit of normality stablished in the latest cuantification guidelines, while RVGLS and RV free wall LS were slightly above the limit of normality. LVEF and TAPSE were also slightly diminished in MS patients, though the differences found were clinically not relevant.

Results of statistical analysis MS (n=93) Controls (n=32) p Age (years) 32.84±12.4 32.41±7.98 0.85 Aortic Root Diameter Valsalva Sinuses (mm) 38.82±5.35 30.91±5.3 <0.001 LVGLS (%) −18.93±2.62 −21.52±2.26 <0.001 RVGLS (%) −21.25±3.54 −24.68±3.08 <0.001 RV free wall LS (%) −22.09±3.92 −25.56±3.63 <0.001 LVEF (%) 59.5±5.34 63.27±4.19 0.001 TAPSE (mm) 23.97±4.57 25.82±3.32 0.03 MS = Marfan Syndrome; LVGLS = Left ventricular global longitudinal strain; RVGLS = right ventricular global longitudinal strain.

Conclusions

Our study suggests that patients with MFS show lower biventricular strain compared with healthy controls. 2D-STE imaging may be useful to detect subclinical changes in cardiac function in patients with MFS and should be added to routine ecocardiographic evaluation in order to improve the follow-up and treatment of these patients.
P4382O2-pulse measure obtained by gas exchange analysis is an accurate esteeme of stroke volume?
Authors: Evangelista M , Alfonzetti E , Bandera F , Guazzi M
Published: October 2019

Background

It is axiomatic that exercise performances depends on cardiac output increase. Among several methods for noninvasively estimating stroke volume, O2 pulse (i.e. the ratio of VO2/HR) is generally used during gas exchange analysis, but its accuracy has never been well investigated.

Purpose

To test the validity and the accuracy of O2 pulse as a measure of stroke volume (SV) in comparison with the echocardiographic methods.

Methods

From 22nd of August 2016 to 30th of April 2018 our laboratory performed 259 cardiopulmonary exercise tests (CPET) combined with echo. The group of patients was characterized by a heterogeneous spectrum of diseases: 70 coronary artery disease, 10 heart failure with preserved ejection fraction, 13 heart failure with middle ejection fraction, 26 heart failure with reduced ejection fraction, 29 Fabry disease, 7 hypertrophic cardiomyopathy, 10 dilated cardiomyopathy, 30 aortic stenosis, 16 aortic regurgitation, 8 mitral stenosis, 76 mitral regurgitation, 6 tricuspid regurgitation, 7 congenital heart diseases. The median age was 65 yr (52,5; 74,5) and 61,5% of patients was male. In our group are present 20 healthy subjects with normal heart. O2 pulse was measured at rest, at 2 minutes, 4 minutes, 6 minutes and at maximum of stress. In some cases the maximum of stress correspond to 4- or 6-minutes of stress. All the echocardiographic images were taken with Epiq7C, Philips. The left ventricle SV was measured as SV = LVOT area x LVOT VTI, all the measures and the images where acquired by the same operator to reduce at minimum the external error introduce by the operator.

Results

As first step we analysed the absolute value of O2-pulse and SV at rest and during the different steps of exercise to see if and how they behave. In the figure attached is possible to see that both the values increased during the exercise with a small reduction at the maximum that may be explained by a premature interruption of the exercise. Secondly we analysed the correlation between O2 pulse and LVOT-SV at rest and during 2-, 4-, 6- minutes of exercise and at maximum which was respectively: r=0,23 (p<0,0001), r=0,36 (p<0,0001), r=0,30 (p<0,0001), r=0,25 (p<0,0001) and r=0,51 (p<0,0001) (see figure 2).

The analysis has been possible in 259 patients at rest, in 246 at 2-minutes of stress, in 221 at 4-minutes of stress and in 149 patients at 6-minutes of stress. At maximum of exercise, the analysis has been carried out in 229 patients, but we need to keep in mind that maximum of stress includes both 4- and 6-minutes of exercises according to the capability of each patients.

Conclusion

In our analysis we show an incremental trend during exercise of O2-Pulse value and of LVOT-SV. At rest and during exercise it is present a good correlation between O2-pulse and LVOT-SV. These data reinforce the concept that O2 pulse reflects an estimation of SV and may explain its reported prognostic validity in prospective studies.
P4389Effect of cigarette smoking on carotid artery atherosclerosis: a community-based cohort study
Authors: Kiriyama H , Kaneko H , Itoh H , Yoshida Y , Nakanishi K , Mizuno Y , Daimon M , Morita H , Yatomi Y , Yamamichi N , Komuro I
Published: October 2019

Background

Cigarette smoking is closely associated with the development of cardiovascular diseases (CVD), and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines recommend smoking bans.On the other hand, the relationship between cigarette smoking and subclinical atherosclerosis has not been fully studied. Carotid intima-media thickness (cIMT) is commonly used as a subclinical atherosclerosis marker, and a carotid plaque feature is also known to be an important predictor of cardiovascular diseases.

Purpose

We sought to clarify the association between cigarette smoking and subclinical atherosclerosis by evaluating carotid plaque including cIMT and carotid plaque features in general population.

Methods and results

Among 1,209 participants with no prior coronary artery disease who received a medical check-up with cardiovascular examination at our institution, 450 participants (37.2%) were smokers (including both past and current smokers). We defined carotid plaque as cIMT ≥1.1 mm and high-risk plaque as carotid plaque with hypoechoic dominant and/or plaque ulceration. The value of cIMT and the rate of carotid plaque were not different between smokers and never smokers (Figure A & B). However, the rate of carotid high-risk plaque was significantly higher in participants with smokers than those with never smokers (29.7%, vs 23.5%, p=0.011) (Figure C). Even after adjustment with covariates including age, gender and traditional cardiovascular risk factors, cigarette smoking was independently associated with high-risk plaque formation (odds ratio 1.384, 95% CI 1.020–1.877; p=0.037). According to the subgroup analysis classified by age, cigarette smoking was associated with not only the development of high-risk plaque but also the increased value of cIMT in the subgroup over 60 years old, whereas only the rate of high-risk plaque was higher in smokers than never smokers in the subgroup under 60 years old.

Carotid plaque and smoking

Conclusion

The development of high-risk carotid artery plaque may precede thickening of cIMT in cigarette smokers, suggesting that the novel insight for the pathological mechanism underlying cardiovascular events and cigarette smoking.
P4394Two-year therapeutic effectiveness of pharmacotherapy versus electronic cigarettes for smoking cessation: A single-center experience
Authors: Ioakeimidis N , Vlachopoulos C , Georgakopoulos C , Dima I , Gardikioti V , Solomou E , Gardikioti V , Oikonomou E , Tousoulis D
Published: October 2019

Purpose

Aim of this study is to compare the long-term (2-year) effectiveness of e-cigarettes (EC) vs pharmacotherapy for smoking cessation.

Methods

We analyzed data from 173 smokers visiting our unit from January 2012 to December 2016 followed for two years. Of them, 128 were treated with varenicline for 3 months and 45 used EC for 3 months to quit smoking.

Results

There were not significant differences in severity of nicotine dependence and cigarette consumption (pack-years) between the two groups. Compared to smokers under varenicline therapy, EC users were younger (38±7 vs 49±12 years, P<0.01). The two groups had no gender difference and similar prevalence of traditional risk factors and coronary artery disease. Figure shows the smoking abstinence rates at the end of treatment period (3 months) and the continuous abstinence rates at 2 years. At the end of treatment period, 79 (62%) of subjects under therapy with varenicline were abstinent from smoking while 31 (69%) of individuals using EC did not smoke combustile cigarettes 3 months after the initiation of vaping. The continuous abstinence rates at 2 years was significantly higher among individuals treated with varenicline compared to EC (41% vs 24%, P<0.05). Interestingly, at 2 years, 12 EC users (27%) continued vaping alone and 21 (47%) were dual (EC and tobacco cigarette) users.

EC vs varenicline and smoking abstinence

Conclusions

Our preliminary data indicate that smokers who received varenicline had significantly higher continuous abstinence rates compared to individuals who used EC at a 2-year follow-up. Furthermore, almost half of the later group maintained dual use.
P4402Effect of carnitine supplementation on progression of carotid plaque in the metabolic syndrome: the ECoM study
Authors: Johri A , Hetu M F , Heyland D K , Herr J E , Norman P , Matangi M F , Lahaye A , Saunders F W , Spence J D
Published: October 2019

Background/Introduction

L-carnitine (L-C) has been investigated as a potential therapy for cardiovascular (CV) disease, but its direct effects on human atherosclerosis are unknown. Epidemiological studies suggest a possible reduction of CV risk factors following treatment, whereas animal studies have shown that L-C may increase pro-atherogenic metabolites.

Purpose

The purpose of this study was to determine whether L-C therapy led to atherosclerosis progression or regression by direct quantification of carotid atherosclerotic lesions in patients with metabolic syndrome (MetS).

Methods

This study was a Phase 2, prospective, parallel, double blinded, randomized, placebo-controlled, two-center trial. MetS was defined according to the International Diabetes Federation harmonized definition, where presence of any 3 of the 5 following risk factors constituted a diagnosis: elevated waist circumference; elevated triglycerides; reduced HDL or treated; elevated blood pressure or treated; elevated glucose or HbA1c or treated. Participants with a baseline carotid total plaque volume (TPV) ≥50 mm3 were randomized to placebo or 2 g L-C daily for 6 months. Plaque progression was quantified by 3D carotid ultrasound for change in TPV and reduction in vessel lumen area (% area stenosis, Fig. 1). Absolute differences were assessed on the raw scale, while percent change on the log scale. Analysis of covariance (ANCOVA) was used to assess within- and between-arm differences.

Results

Of the 177 participants randomized, 157 completed the study (L-C n=76, placebo n=81). No statistically significant difference between arms was found in the primary outcome (TPV). However, there was progression of plaque stenosis in the treatment arm: the L-C group had an increase in stenosis of 9.8% (p=0.01) higher than the placebo arm, and a 2.7% (p=0.03) greater absolute change. Total cholesterol and LDL levels (0.10 mmol/L and 0.05 mmol/L, respectively) were higher in the intervention arm compared to the placebo arm (−0.06 mmol/L and −0.07 mmol/L).

Figure 1

Conclusions

We observed progression of atherosclerosis with L-C therapy compared to placebo in patients with MetS. The clear lack of benefit of L-C therapy in this population raises serious concerns for its further use as a potential therapy. Given its association with pro-atherogenic metabolites our study offers further understanding of the atherosclerotic process.

Acknowledgement/Funding

Heart and Stroke Foundation of Canada