bluuebunny/crossref_metadata_2025 huggingface dataset:
P3701Short-term decrease of left atrial size predicts clinical outcome in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement
Authors: De Rosa R , Murray M.-I , Schranz D , Mas-Peiro S , Esmaeili A , Zeiher A M , Fichtlscherer S , Vasa-Nicotera M
Published: October 2019

Background

Increased left atrium (LA) size is a hallmark of severe aortic stenosis (AS) and is associated with adverse patients' cardiovascular outcome. Whether transcatheter aortic valve replacement (TAVR) may lead to a decrease in LA size is not known. Aim: We investigated whether TAVR results in a short-term decrease in LA size and whether such decrease may predict patients' clinical outcome.

Methods

104 consecutive patients with severe symptomatic AS and dilated LA undergoing TAVR were enrolled. LA volume was assessed by echocardiography before and shortly after TAVR (median time: 7 days). Composite rate of death and hospitalization for acutely decompensated heart failure (HF) was recorded and clinical status was assessed through NYHA- class evaluation at 12 months median follow-up.

Results

After TAVR, 49 patients (47%) demonstrated a decrease in LA volume. Despite a similar baseline NYHA class, patients with decrease in LA size had significant better improvement in clinical status respect to patients with unvaried LA size (NYHA post: 1.2±0.6 vs 1.8±1.1, p=0.001; NYHA reduction: −1.6±0.9 vs −0.9±1.0, p=0.002, respectively). Moreover, these patients had a significantly reduced rate of death or HF-hospitalization (4 vs 29%, p=0.001) and a significantly longer event-free-survival from Kaplan-Meier curves (p=0.003). COX regression analysis showed that, among echocardiographic parameters, decrease in LA-size was an independent predictor of clinical outcome (HR: 0.149, CI: 0.034–0.654, p=0.012).

Conclusions

The lack of decrease in LA size shortly after TAVR is associated with significantly higher rates of death and HF-hospitalization, as well as with impaired improvement in clinical status during long-term follow-up.
P3702Aortic stenosis and inappropriate myocardial hypertrophy: is there a difference related to gender?
Authors: Bettega M , Rosa V E E R , Accorsi T A D A , Cordeiro Fernandes J R C F , Spina G S P , Sampaio R O S , Santis A S A L , Tarasoutchi F T
Published: October 2019

Introduction

Degenerative aortic valve presents distinct patterns according to gender. Inappropriate myocardial hypertrophy in response to severe aortic stenosis (AS) and their clinical repercussions is of recent interest.

Purpose

To evaluate the influence of gender on the pattern of ventricular remodelling in patients with AS and inappropriate ventricular hypertrophy.

Methods

Retrospective study, analysing clinical and echocardiographic characteristics of 145 patients, between 2008 and 2018, with severe aortic stenosis and inappropriate ventricular hypertrophy, defined as septal wall thickness greater than 14 mm.

Results

Women were 42% of the patients, with higher mean age compared to men (75.23±12.78 vs 70.01±12.59 years, p=0.01), lower body surface (1.68±0.17 vs 1.94±0.68 m2, p=0.004), lower ventricular volumes (94.33±32.88x3856±23.81 vs 122.68±43.24x50.34±28.10 ml/m2, p<0.001), increased LV wall thickness (0.65±0.19 vs 0.58±0.10, p<0.001). There were no differences in LV mass (163.22±37.92 vs 170.51±39.08g, p=0.26), septal wall thickness (16.08±1.63 vs 15.71±1.02mm, p=0.24), posterior wall thickness (13.35±1.63 vs 13.67±1.58mm, p=0.23), left ventricular ejection fraction (61.31±10.36 vs 58.92±10.33%, p=0.17), indexed aortic valve area (0.41±0.10 x 0.39±0.08 cm/m2, p=0.23), medium transaortic gradient (57.50±16.42 x 55.08±17.11mmHg, p=0.39), BNP (896.28±1432.44 x 591.09±1007.71pg/ml, p=0.365) and troponin I (7.17±26.36 x 1.01±2.64 mcg/L, p=0.29). The difference between the septum and posterior wall indexed to the body surface was significantly higher in women (1.60±1.06 x 1.10±0.83 mm/m2, p=0.02), as well as the septal wall thickness indexed by the body surface (9.60±1.40 x 8.48±1.30 mm/m2, p<0.001).

Conclusions

Septal wall thickness indexed by body surface and difference between septum and the posterior wall in ventricles with smaller volumes suggest that myocardial hypertrophy in response to severe AS is more severe in women than in men. Since inappropriate myocardial hypertrophy is a predictor of outcomes in AS, it is possible that the optimal timing for valve replacement should be earlier in women.
P3703Frequency of undiagnosed atrial fibrillation in patients presenting with acute ischemic cerebrovascular stroke
Authors: Hassan Abdelnabi M , Almaghraby A , Oz T , Saleh Y , Badran H
Published: October 2019

Introduction

Acute ischemic cerebrovascular stroke (CVS) can be the first clinical manifestation of atrial fibrillation (AF), that is why large-scale screening programs for AF are currently implemented especially in individuals more than or equal 65 years old. Yet, to date, cost-effectiveness data have relied on assumptions of stroke rates observed in patients with established AF, while the true incidence rates of undiagnosed AF presenting as a stroke remain unknown.

Purpose

To estimate the incidence of patients with no history of AF who are presented with acute ischemic CVS and are found to be in AF at the time of presentation or developed atrial fibrillation during the hospital stay.

Methods

A retrospective analysis of all patients admitted with acute CVS to a tertiary care stroke specialized center in the period from 01/01/2014 till 31/12/2017.

Ischemic CVS is confirmed by either multislice computed tomography (MSCT) or magnetic resonance imaging (MRI) of the brain.

AF is documented by electrocardiography (ECG) that is made at admission or during hospital stay. Patients with history of AF on rate or rhythm-control therapy were excluded from the study.

Results

Of the 3299 patients admitted by acute ischemic CVS, 707 (21.43%) patients had history of AF and they were on medical rate or rhythm control therapy and thus were excluded from the study.

Of the remaining 2592 patients eligible for the study, 1666 (64.27%) were males with a mean age of 56.06 years (±16.01).

Regarding ECG, 2313 (89.24%) patients were in sinus rhythm and other non-AF rhythms and 211 (8.14%) presented with AF rhythm and 68 (2.62%) developed AF during their hospital stay with a cumulative incidence of (10.76%).

Table 1. Baseline patient characteristics and ECG data (n=2592) Risk factors n=2592 Hypertension 1849 (71.33%) Diabetes Mellitus 925 (35.69%) Smoking 1445 (55.75%) ECG data   Non-AF 2313 (89.24%)   AF on admission 211 (8.14%)   AF in hospital 68 (2.62%)   Total AF 279 (10.76%)

Undiagnosed AF in acute ischemic CVS

Conclusion

The incidence of undiagnosed atrial fibrillation in patients presented with acute cerebrovascular stroke is significantly high. Implementation of good screening programs can significantly reduce the risk of disabilities and morbidities.
P3704Silent ischemic brain lesion detected in patients with subclinical paroxysmal atrial fibrillation
Authors: Kishima H , Mine T , Fukuhara E , Ashida K , Ishihara M
Published: October 2019

Background

Long-lasting atrial fibrillation (AF) has been reported to be associated with an increased risk of dementia, independent of clinical stroke. However, the mechanisms or association in patients with subclinical paroxysmal AF (S-PAF) remain unclear. We evaluated whether S-PAF is associated with silent ischemic brain lesion (S-IBL), one of causes of dementia.

Methods

We studied 46 patients (35 male, 68±15 yrs) without a history of stroke/transient ischemic attack and AF, who implanted insertable cardiac monitoring (ICM) for unexplained syncope (n=33) or embolic stroke of undetermined source (ESUS) (n=13). All patients underwent cerebral magnetic resource imaging (c-MRI), and S-IBL was defined as infarction, lacuna and microbleeds. The lesions in an acute stage were excluded in patients with ESUS.

Results

AF was detected in 15/46 patients (11 with unexplained syncope and 4 with ESUS) during follow-up of 7.0±6.6 months, and S-IBL was observed in 18/46 patients (9 infarction, 8 lacuna, or 8 microbleeds). Univariate analysis revealed that higher prevalence of AF (61% vs. 14%, p=0.0015), elder age (73±10yrs vs. 65±16yrs, p=0.0445), dyslipidemia (67% vs. 25%, p=0.007), structural heart disease (44% vs. 14%, p=0.0383), and larger left atrium diameter (41±6 mm vs. 37±5 mm, p=0.0267) were related to S-IBL. On multivariate analysis, prevalence of AF was independently associated with S-IBL (p=0.0070, OR 13.4, 95% CI 1.945–155.813). When receiver-operating-characteristics (ROC) curve analysis and prevalence of AF were used to detect S-IBL, the area under the ROC curve was 0.7341 (sensitivity: 61.1%, specificity: 85.7%).

Conclusion

Subclinical paroxysmal AF is associated with silent ischemic brain lesion and might cause to dementia.
P3714Cerebral blood flow and cognitive functioning in the heart-brain axis
Authors: Leeuwis A E , Hooghiemstra A M , Bron E E , Brunner-La Rocca H P , Kappelle L J , Van Oostenbrugge R J , Greving J P , Niessen W J , Van Buchem M A , Van Osch M J P , Van Rossum A C , Prins N D , Biessels G J , Barkhof F , Van Der Flier W M
Published: October 2019

Background

Recent studies suggest that cardiovascular disease and dementia are closely related, which led to the concept of a “heart-brain axis”. Dysfunction in any component of the heart-brain axis could be a risk factor for the development of brain damage and consequently to the development of cognitive impairment. In the Heart-Brain study, we focus on vascular cognitive impairment (VCI), symptomatic carotid occlusive disease (COD) and heart failure (HF) as three extreme phenotypes of haemodynamic dysfunction in different components of the heart-brain axis (i.e. heart – carotids – brain). We compared values of cerebral blood flow (CBF), measured with arterial spin labeling (ASL) between patients with HF, COD and VCI and investigated the association between CBF and cognitive functioning.

Methods

We included 442 participants (129 VCI; 75 COD; 124 HF; and 114 controls) from the Heart-Brain Study (67±9 yrs; 38% F; MMSE 28±2). We used 3T pseudo-continuous ASL to estimate whole-brain and regional partial volume-corrected CBF. Using a standardized neuropsychological assessment, we measured global cognitive functioning and four cognitive domains. Compound z-scores were constructed for each cognitive domain. We investigated associations using linear regression analyses, adjusted for age, sex, education, center and diagnosis. Subsequently, we stratified for diagnosis.

Results

Whole-brain and regional CBF values were lowest in patients with COD, followed by VCI and HF, compared to controls. Global cognitive functioning was lowest in patients with VCI, followed by COD and HF, compared to controls. Overall, we found hardly any association between whole-brain or regional CBF values and cognitive functioning (standardized beta [stb] = 0.00–0.10, p>0.05). Subsequent stratification for diagnosis showed no association between whole-brain or regional CBF and cognitive functioning in any participant group.

Conclusions

Our results suggest that reduced CBF is not the major explanatory factor underlying impaired cognitive functioning in patients with disorders along the heart-brain axis. The predisposition of cognitive impairment in these patients is likely to be driven by other (haemodynamic) mechanisms than CBF.

Acknowledgement/Funding

We acknowledge the support of the Netherlands CardioVascular Research Initiative: the Dutch Heart Foundation (CVON 2012-06 Heart Brain Connection), Du
P3716Increased two-year cerebrovascular event rate in patients with bilateral high carotid tempratures
Authors: Benetos G , Toutouzas K , Oikonomou G , Koutagiar I , Karmpalioti M , Barampoutis N , Davlouros P , Siores E , Sfikakis P , Tousoulis D
Published: October 2019

Introduction

The association of carotid plaque inflammation with cerebrovascular events is a matter of rigorous research. Microwave Radiometry (MWR) allows in vivo noninvasive measurement of the internal temperatures of tissues, reflecting inflammation.

Purpose

To investigate whether increased carotid temperatures in patients with documented coronary artery disease (CAD) are associated with cerebrovascular events.

Methods

Consecutive patients with significant CAD from three tertiary centers were included in the study. Maximum carotid plaque thickness was assessed in all carotids by ultrasound. ΔT by MWR was assigned as the temperature difference (maximal minus minimum) along the carotid artery. ΔT ≥0.90°C was assigned as high ΔT. All patients were followed-up clinically for two years and all strokes were adjudicated by an independent committee. Transient ischemic attacks were excluded.

Results

In total 300 patients were included in the study. High ΔT temperatures bilaterally were measured in 47 patients (15.7%). Three patients (1.0%) suffered a stroke, including one fatal. Stoke rate was 4.3% in the group with bilateral high ΔT and 0.4% in non-high ΔT group (p=0.02). In Kaplan-Meier plot patients with bilateral high ΔT showed higher stroke rate (log-rank p=0.004, figure)

Conclusions

Bilateral high carotid temperatures are associated with increased two-year stroke rate. The potential value of the present finding in risk stratification of intermediate carotid stenosis mandates further investigation.
P3732Proportion of acute ischaemic strokes attributable to cardiac causes in an all-comer population of young patients
Authors: Bahl R , Kubiak M , Yusoff S , Van Wyk A , Nagaratnam K , Ruparelia N
Published: October 2019

Introduction

The incidence of stroke in young patients is increasing and is associated with significant morbidity, mortality and socioeconomic cost. Identifying potential underlying causes is central to their overall management to reduce recurrence and improve long-term outcomes. A proportion of these patients are found to have an underlying cardiac cause including atrial fibrillation (AF), patent foramen ovale (PFO) or an intracardiac source of embolus. This area has recently gained greater interest with evidence demonstrating a significant reduction in recurrent ischaemic events following PFO closure. The identification of these patients however, requires extensive investigation and has implications relating to cardiology resources. Outside of clinical trials the true incidence of these patients in a “real-world” population is poorly defined.

Purpose

The aim of this study was to determine the proportion of strokes attributable to cardiac causes in young patients presenting with ischaemic stroke.

Methods

The Sentinel Stroke National Audit Programme (SSNAP) database of a large UK stroke service was used to identify patients ≤55 years old presenting with stroke between 1/1/15 and 31/12/17. Clinical letters, imaging reports and laboratory reports were reviewed. Patients were then categorised by cause of stroke using the Trial of Acute Stroke Treatment (TOAST) criteria. Cardiac causes of stroke were defined as: AF, PFO and intracardiac source of embolus. Patients presenting with a haemorrhagic stroke or where an alternate diagnosis to stroke was more likely were excluded.

Results

During the study period, 206 patients were identified as having suffered a stroke. 35 patients were excluded resulting in a final study population of 171 patients (Figure). 24% (41/171) were identified as having a cardiac cause of stroke including 9.4% (16/171) PFO, 8.8% (15/171) intracardiac source of embolus and 5.8% (10/171) atrial fibrillation. 50.3% (86/171) were thought to have other causes: 24.6% (42/171) small vessel disease; 9.4% (16/171) large artery atherosclerosis; and 16.4% (28/171) other determined aetiology including 5.1% (8.8/171) with arterial dissection. 25.7% (44/171) presented with a stroke but with no clear underlying cause found.

Causes of stroke in young patients

Conclusion

A high proportion (24%) of strokes in young patients were found to be likely secondary to a cardiac cause. With the significant benefit of intervention (medical or procedural) in this patient group, the resource provision allocated to this population does appear to be warranted and further demonstrates the importance of close interdisciplinary links between cardiologists and stroke physicians.
P3738Clinical outcomes after early vs new generation TAVR device deployment
Authors: Kalinczuk L , Chmielak Z , Zielinski K , Mintz G S , Dabrowski M , Kumor M , Jastrzebski J , Skowronski J , Motyl D , Siodmiak A , Pregowski J , Michalowski I , Demkow M , Hryniewiecki T , Witkowski A
Published: October 2019

Background

Whether newer generation devices influence early and long-term outcomes post-TAVR in a real life setting is unknown.

Aim

To assess impact of an early vs a new generation transcatheter heart valves (THV) on clinical outcomes (30-day and -years) in a real life scenario.

Methods

Out of 445 consecutive pts treated between 8/2009 and 10/2017 within the single-center, prospective TAVR Registry, there were 432 [median 83.0 years of age, 63.4% female] with device success (97.1%) as per VARC-2. Early generation THV included: CoreValve; Edwards SAPIEN or SAPIEN XT. Newer generation devices included: Evolut-R/-Pro; Acurate neo; Engager, SAPIEN 3; or Lotus Edge Aortic Valve System.

Results

Median follow-up was 29.3 (15.8–53.1) months with 100% 1-year follow-up. Early generation devices were deployed in 60.6% (n=262) and new devices in 39.4% (n=170). Pts treated with newer devices had more peripheral arterial disease (PAD) and more frequent PCI history (17.1% vs 8.8%, p=0.015, and 35.3% vs 26.7%, p=0.068 respectively); other demographic and clinical data were alike. Baseline aortic valve area and LV ejection fraction were similar between early and newer devices. Pre-dilation was less frequent with newer devices (41.8% vs 70.6%, p<0.001), whereas THV size, contrast volume, fluoroscopy time, radiation dose, and post-procedure aortic valve gradients were similar. Moderate PVL assessed early post-TAVR was recognized with same frequency between earlier vs newer devices (28.2% vs 28.6%). An VARC-2 safety endpoint was recognized more often among pts treated with early vs new devices (30.5% vs 21.8%, p=0.028, respectively), with more frequent: 30-day death (3.8% vs 1.8%, p=0.177), life-threatening or disabling bleeding (8.4% vs 5.3%, p=0.181), major vascular complications (20.2% vs 15.3%, p=0.121), and new permanent pacemaker implantation (22.9% vs 10.0%, p=0.001) with early devices, but similar frequencies of stroke and acute kidney injury (1.9% vs 1.8% and 3.8% vs 5.9%, respectively). The 1-year mortality rates were similar (13.4% vs 13.5%, respectively), with similar estimated midterm (1–2 years) prognosis, but worse estimated very long-term follow-up for newer THV devices (fig 1).

Figure 1

Conclusions

Newer TAVR devices with smaller delivery system size, although deployed in pts with more PAD and PCI history, are associated with less frequent occurrence of an VARC-2 safety endpoint and less frequent permanent pacemaker implantation. The 1-year and midterm (1–2 years) prognosis are similar for early and newer devices, whereas the longer follow-up could have been influenced by intrinsic pt characteristics (more frequent PAD and history of PCI).
P3745Differences in short-term outcome between early- and new-generation TAVR devices
Authors: Veulemans V , Klein K , Maier O , Wolff G , Polzin A , Westenfeld R , Jung C , Blehm A , Lichtenberg A , Kelm M , Zeus T
Published: October 2019

Background

For transcatheter aortic valve replacement (TAVR) morbidity- and outcome relevant factors like paravalvular aortic regurgitation, vascular access complications and the need for permanent pacemaker implantation remain key challenges. New-generation devices for TAVR have been optimized to improve clinical outcome.

Purpose

We aimed to address safety and effectiveness of new-generation TAVR devices compared with earlier generations in a single centre study.

Methods

We compared 30 days outcome of the new-generation repositionable MER (n=614) and MEP (n=90) and the balloon-expandable ES3 (n=414) valve with the last-generation self-expandable MCV (n=270) and the balloon-expandable SXT (n=103) in patients treated with TAVR between 2009 and 2018. TAVR endpoints and adverse events were defined according to the Valve Academic Research Consortium-2.

Results

Logistic EuroSCORE I as predictor for risk stratification and 30-day mortality was comparable between both cohorts (27.3%±2.9 new vs 23.0%±1.4 early; p=n.s.). Compared to early-generation devices (MCV/SXT), new-generation devices (MER/MEP/ES3) had significantly higher primary device success (98.9% new vs 96.8% early; p=0.0089), lower incidence of new renal replacement therapy (2.6% new vs 6.2% early; p=0.0028), new permanent pacemaker therapy for conduction disturbances (12.8% new vs 17.0% early; p=0.0394), and disabling bleeding (1.4% new vs 4.0% early; p=0.0040). No difference could be observed concerning incidence of moderate-to-severe paravalvular leakage (4.2% new vs 5.0% early; p=n.s.), stroke (3.3% new vs 2.1% early; p=n.s.), major vascular complications (2.8% new vs 3.5% early; p=n.s.) and 30-day mortality (2.7% new vs 4.4% early; p=n.s).

Conclusion

Data from the retrospective analysis indicate higher primary device success and lower incidence of renal replacement, pacemaker therapy and disabling bleeding events in new-generation devices, although praised “hot-item” advantages like paravalvular leackage/aortic regurgitation, vascular complications and mortality remain unacknowledged.
P3764Morphological mechanisms of atrial functional mitral regurgitation in patients with atrial fibrillation
Authors: Nagaoka K , Mukai Y , Kawai S , Takase S , Sakamoto K , Inoue S , Yakabe D , Ikeda S , Chishaki A , Tsutsui H
Published: October 2019

Background

Atrial functional mitral regurgitation (AFMR) occurs in patients with atrial fibrillation. However, morphological mechanisms of AFMR are poorly understood.

Purpose

The purpose of this study was to examine the morphological characteristics in patients with AFMR.

Methods

Among consecutive 795 patients undergoing initial radiofrequency catheter ablation (RFCA) at our hospital, twenty-five patients with persistent AF accompanied by AFMR (≥ moderate) before RFCA (AFMR group) were studied. Age-matched 25 patients with persistent AF without MR were defined as a control group.

Results

Left ventricular ejection fraction (LVEF) was lower and left atrium volume index was larger in the AFMR group (Table). Mitral valve annulus diameter and length of anterior mitral leaflet (AML) were similar between groups, whereas length of posterior mitral leaflet (PML) was significantly shorter in the AFMR group. Smaller tethering angle of AML (γ in the figure) and shorter tethering height were significantly associated with the occurrence of AFMR, which were different from morphology of functional mitral regurgitation in patients with dilated LV. Multiple regression analysis revealed that less tenting height (p<0.05) and LA dilatation toward the posterior (p<0.01) were significantly related to AFMR.

Echocardiographic parameters AFMR (n=25) Control (n=25) P value Age, y 69±8 66±10 NS Male, n (%) 9 (36) 20 (80) P=0.001 LVEF,% 60±9 67±6 P=0.004 LAD, mm 44±5 41±7 NS LAVI, ml/m2 56±17 41±13 P<0.001 MV diameter, mm 3.9±0.4 3.8±0.5 NS α angle, ° 34±9 35±7 NS β angle, ° 48±9 50±8 NS γ angle, ° 32±5 37±5 P=0.0005 AML length, mm 3.0±0.5 3.0±0.5 NS PML length, mm 2.1±0.1 2.4±0.1 P=0.03 Tenting height, mm 1.5±0.1 1.8±0.1 P=0.02 D, mm 0.8±0.3 0.5±0.3 P=0.001 LVEF: left ventricular ejection fraction; LAD: left atrial diameter; LAVI: left atrial volume index; AML: anterior mitral leaflet; PML: posterior mitral leaftlet.

Conclusions

AFMR occurs in patients with unique morphological features, such as less tethering height and LA dilatation toward the posterior.
P3773Thromboembolic risk of heart failure with preserved, mid-range, and reduced ejection fraction in atrial fibrillation: results from the CODE-AF registry
Authors: Chung S , Kim T H , Uhm J S , Cha M J , Lee J M , Park J N M B , Park J K , Kang K W , Shim J , Kim J , Park H W , Choi E K , Kim J B , Lee Y S , Joung B
Published: October 2019

Purpose

Thromboembolic risk of atrial fibrillation (AF) in heart failure with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF) is not well identified. This study assessed the thromboembolic risk of AF in patients with HFpEF, HFmrEF and HFrEF.

Materials and methods

Within the CODE-AF prospective, outpatient registry (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation), a total of 10476 patients with non-valvular AF including 929 (8.8%) patients with HF was analyzed. Multivariable cox regression was used to evaluate the risk of thromboembolic event, including stroke, systemic embolism and transient ischemic attack. Hazard ratio (HR) was adjusted by each component of CHA2DS2-VASc risk score and the use of oral anticoagulant (OAC).

Results

The median age of the overall population was 68.0 (interquartile range, 60.0–75.0); 63.9% were male. The proportion of HFpEF, HFmrEF and HFrEF was 43.6%, 26.7% and 29.7%, respectively. CHA2DS2-VASc risk score was higher in HF group than no-HF group. OAC was more commonly used in HF group than no-HF group (85.2% vs. 68.9%, p<0.001). The rate of OAC usage was 85.1%, 86.6%, and 84.0% in HFpEF, HFmrEF, and HFrEF group, respectively. During follow-up period of median 14.3 months, 15 patients experienced thromboembolic event in HF group with incidence rate of 1.39 events per 100 person-years, while 94 patients did in no-HF group with 0.87 events per 100 person-years. In patients without OAC, incidence rate of thromboembolic event was 1.31, 2.77, and 6.24 events per 100 person-years in HFpEF, HFmrEF, and HFrEF, respectively. Compared with no-HF group, HF was associated with increased risk of thromboembolic event with clinical variable adjusted HR of 3.04 (95% CI, 1.12–8.26, p=0.03). Among 3 types of HF, HFrEF increased the risk of thromboembolic event (adjusted HR 7.39, 95% CI 2.15–25.44, P=0.002), while HFmrEF or HFpEF did not. Finally, in patients with optimal OAC, risk of thromboembolic event was not increased by HF or HFrEF.

Conclusion

In OAC-naïve non-valvular AF, HF was associated with increased risk of thromboembolic event. Among 3 types of HF, HFrEF increased the risk of thromboembolic event, while HFmrEF or HFpEF did not. However, in patients with optimal OAC, even HFrEF was not associated with increased risk of thromboembolic event. These results support current OAC strategy in HF patients, especially emphasizing optimal OAC in HFrEF population.

Acknowledgement/Funding

The National Research Foundation of Korea
P3778Long-term outcome of non-pharmacologial treatment of atrial fibrillation in hypertrophic cardiomyopathy: a large single-centre experience
Authors: Dinshaw L , Lemoine M , Hartmann J , Schaeffer B , Klatt N , Jularic M , Gunarwadene M , Muenkler P , Tam A , Eickholt C , Willems S , Patten M , Meyer C
Published: October 2019

Introduction

Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM) and is generally associated with a significant deterioration of clinical status. Non-pharmacological treatment such as surgical and catheter ablation has become an established therapy for symptomatic AF but in patients with HCM often having a chronically increased left atrial pressure and extensive atrial cardiomyopathy the long-term outcome is uncertain.

Purpose

The present study aimed to analyse the long-term outcome of AF ablation in HCM and the mechanism of recurrent atrial arrhythmias using high-density mapping systems.

Methods

A total of 65 patients (age 64.5±9.9 years, 42 (64.6%) male) with HCM undergoing AF ablation for symptomatic AF were included in our study. The ablation strategy for catheter ablation included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines if appropriate. In patients with suspected atrial tachycardia (AT) high-density activation and substrate mapping were performed. A surgical ablation at the time of an operative myectomy for left ventricular outflow tract obstruction was performed in 8 (12.3%) patients. The outcome was analysed using clinical assessment, Holter ECG and continuous rhythm monitoring of cardiac implantable electric devices.

Results

Paroxysmal AF was present in 27 (41.6%), persistent AF in 37 (56.9%) and primary AT in 1 (1.5%) patients. The mean left atrial diameter was 54.1±12.5 ml. In 11 (16.9%) patients with AT high-density mapping was used to characterize the mechanism of the ongoing tachycardia. After 1.9±1.2 ablation procedures and a follow-up of 48.5±37.2 months, ablation success was demonstrated in 58.9% of patients. The success rate for paroxysmal and persistent AF was 70.0% and 55.8%, respectively (p=0.023). Of those patients with AT high-density mapping guided ablation was successful in 44.4% of patients. The LA diameter of patients with a successful ablation was smaller (52.2 vs. 58.1 mm; p=0.003).

Conclusion

Non-pharmacological treatment of AF in HCM is effective during long-term follow-up. Paroxysmal AF and a smaller LA diameter are favourable for successful ablation. In patients with complex AT the use of high-density mapping can guide ablation resulting in further ablation success in a reasonable number of patients.
P3784Impact of progressively impaired renal function on major adverse outcomes in European patients with atrial fibrillation: a report from the ESC EORP-AF long-term general registry
Authors: Boriani G , Proietti M , Laroche C , Diemberger I , Kalarus Z , Potpara T , Fauchier L , Crijns H J G M , Maggioni A , Lip G Y H
Published: October 2019

Background

Renal function is an important predictor of major adverse outcomes in the general population. In the setting of atrial fibrillation (AF), renal dysfunction may act both as a risk factor and a proxy of vascular risk factors and comorbidities.

Methods

We analyzed the association of renal function, as estimated glomerular filtration rate (eGFR) using the CKD-EPI formula, with 1-year outcomes in a “real-world” cohort of European AF patients from the EORP-AF Long-Term General Registry.

Results

7725 were available for this analysis. Of these, 1294 (16.7%) had normal renal function (≥90 mL/min/1.73 m2), 3848 (49.8%) mildly reduced renal function (60–89 mL/min/1.73 m2), 2311 (29.9%) moderately reduced renal function (30–59 mL/min/1.73 m2) and 272 (3.5%) severely reduced renal function (<30 mL/min/1.73 m2). CHA2DS2-VASc and HAS-BLED scores values increased across eGFR strata (p<0.0001). Among patients qualifying for oral anticoagulant (OAC) therapy, those with severely impaired renal function were less often prescribed with any OAC (79.8%, p<0.0001), more likely with vitamin K antagonist (62.9%) than non-vitamin K antagonist oral anticoagulants (16.9%) (p<0.0001). At 1-year follow-up the rates of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death progressively increased with worsening renal function, up to 20.7% in patients with severe dysfunction (p<0.0001). Rates of CV death and all-cause death were higher in severe renal dysfunction (16.9% and 21.3%; p<0.0001). Cox regression analysis (adjusted for known predictors) showed that eGFR <30 mL/min/1.73 m2, compared to normal renal function was associated with an increased risk of all the adverse outcomes (Table). eGFR decrease by 10 mL/min/1.73 m2 was associated with increased risks (Table).

Any TE/ACS/CV Death CV Death All-Cause Death mL/min/1.73 m2 HR (95% CI) HR (95% CI) HR (95% CI) eGFR ≥90 (ref.) – – – eGFR 60–89 0.99 (0.67–1.46) 0.81 (0.44–1.51) 0.74 (0.47–1.19) eGFR 30–50 1.12 (0.74–1.69) 1.00 (0.53–1.89) 0.95 (0.59–1.54) eGFR <30 2.47 (1.52–3.99) 2.73 (1.36–5.49) 2.16 (1.25–3.72) eGFR (by 10 mL/min/1.73 m2 decrease) 1.11 (1.05–1.17) 1.18 (1.10–1.27) 1.11 (1.03–1.18) ACS = Acute coronary syndrome; CI = Confidence interval; CV = Cardiovascular; eGFR = estimated Glomerular Filtration Rate; HR = Hazard ratio; TE = Thromboembolic event.

Conclusions

In AF patients, impaired renal function at baseline is associated with a progressive increase in the risk of major adverse outcomes during follow up. Severe renal dysfunction is an independent predictor of all the adverse outcomes.
P3797Increased risk of cardiovascular events and stroke among patients with atrial fibrillation and obstructive sleep apnea
Authors: Dalgaard F , North R , Pieper K , Steinberg B A , Mahaffey K W , Fonarow G , Kowey P R , Gersh B J , Pokorney S , Peterson E D , Piccini J
Published: October 2019

Background

Obstructive sleep apnea (OSA) is common in patients with atrial fibrillation (AF). It is not well understood if OSA impacts cardiovascular outcomes in patients with AF.

Purpose

To investigate patient characteristics and major adverse cardiovascular and neurological events (MACNE) in patients with AF and OSA.

Methods

Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) and ORBIT-AF II we compared the adjusted risk of the composite of cardiovascular death, myocardial infarction, stroke/transient ischemic attack/non-CNS embolism (stroke/SE), and new-onset heart failure (MACNE) according to the presence or absence of OSA, using multivariable adjusted Cox proportional hazard models. Secondary outcomes were the individual components of MACNE.

Results

Among 22,760 patients with AF, there were 4,045 (17.8%) with OSA at baseline. Median follow-up time was 1.5 (IQR: 1–2.2) years. OSA patients were younger (median [IQR] 68 [61–75] years vs. 74 [66–81] years, were more likely to be male (70.7% vs. 55.3%), and had markedly increased body mass index (BMI) (median 34.6 kg/m2 [29.8–40.2] vs. 28.7 kg/m2 [25.2–33.0]). Those with OSA had a higher prevalence of diabetes (39.2% vs. 25.2%), chronic obstructive pulmonary disease (COPD) (20% vs. 12%), heart failure (32.2% vs. 25.1%), and hyperlipidemia (73.2% vs. 66.7%). After adjustment, the presence of OSA was significantly associated with MACNE (HR: 1.16 [95% CI: 1.03–1.31], p=0.011) [Figure]. Stroke/SE was higher in patients with OSA (HR: 1.38 [95% CI 1.12–1.70], p=0.003). Addition of OSA to a model containing the CHA2DS2-VASc risk factors slightly improved discrimination for stroke/SE: CHA2DS2-VASc risk factors alone C-index (Standard Error) was 0.6867 (0.0125) vs. CHA2DS2-VASc risk factors plus OSA 0.6876 (0.0124), p=0.022.

Figure 1. Hazard ratios with 95% confidence intervals and event rates for the association between obstructive sleep apnea and major adverse cardiovascular and neurological events combined and separately. Abbreviations: OSA; obstructive sleep apnea MACNE; major adverse cardiovascular and neurological events, CV; cardiovascular, TIA; transient ischemic attack.

Conclusion

One in five patients with AF in community practice had OSA. The presence of OSA was associated with higher risk of MACNE and stroke/SE. Addition of OSA to CHA2DS2-VASc risk factors only slightly improved discrimination for the occurrence of stroke.

Acknowledgement/Funding

The Danish Heart Foundation, T32 NIH Grant HL079896. The ORBIT-AF registry is sponsored by Janssen.
P3813The economic cost heterogeneity of patients with heart failure - a retrospective nationwide study
Authors: Bundgaard J S , Mogensen U M , Christensen S , Ploug U , Roerth R , Ibsen R , Kjellberg J , Koeber L
Published: October 2019

Background

Heart failure (HF) imposes a major economic burden, however the individual management for patients vary potentially leading to large cost heterogeneity. The aim of this study was to investigate the total direct health cost stratified across the spectrum of cost groups.

Methods

Using Danish nationwide registries from 2012 to 2015 we identified all patients >18 years with a first-time diagnosis of HF. Total health costs were investigated using two perspectives; at index and after 3 years (including index). We investigated the cost of patients in the highest cost group (highest 10%) vs. the lowest cost group (lowest 10%). A multivariable logistic regression was used to identify variables associated with being in the highest cost decile compared to the rest (90%).

Results

A total of 11,170 patients with HF were included and those in the highest cost decile (n=1,117, 10%) were younger (69 vs. 75 years), more males (43 vs. 34%), and more inpatients (83 vs. 70%) compared to the rest of the patients (n=10,053, 90%). Patients in the highest cost decile (10%) incurred a 30 times higher cost with a mean total health cost in index year of €86,607 compared to €2,893 for patients in lowest cost decile (10%) (Figure 1A). Results were similar for 3 years aggregated (€139,473 vs. €4,086), corresponding to a 34 times higher cost. At index year, variables associated with being in the highest cost decile included young age, male sex, inpatient admittance, renal disease, and several other comorbidities (Figure 1B).

Conclusion

Among patients with HF a large total direct health cost heterogeneity exists with younger age, inpatient admittance, male sex, and comorbidities being associated with a higher likelihood of belonging to the highest cost group.

Acknowledgement/Funding

Novartis
P3834PULSE-COR REGISTRY: non invasive LV stiffness assessment in subjects with essential hypertension
Authors: Torbas O , Sirenko Y U , Rekovets O , Kushnir S
Published: October 2019

Background

Left ventricle (LV) diastolic dysfunction for a long time had been associated with its hypertrophy. But recent studies have demonstrated that it is more associated with LV fibrosis which is also the cause of poor prognosis. Unfortunately, there is no proven tool for its clinicall assessment. The aim of the study was to demonstrate which of LV stiffness parameters are associated with arterial stiffness which we can measure using validated techniques.

Methods

PULSE-COR is one center registry started in 2011 and still running. We included 779 subjects with AH. Final analysis included 320 patients that underwent all necessary diagnostic procedures from whom we have identified a separate cohort of patients (n=283) with essential AH without any significant comorbidities. We used SphygmoCor device (AtCor, Australia) for the determination carotid-femoral pulse wave velocity (cfPWV). Also we measured CAVI and ankle-brachial index (ABI) with the mean of VaSera 1500 (Fukuda Denshi, Japan). Ultrasound diagnostics included vascular ultrasound with intima-media thickness (IMT) measurement. Echocardiography was done according ASE standardized protocol, LV diastolic function was evaluated according to ASE 2016 guidelines. Ventricle-arterial coupling (VAC) was evaluated using standardized formula. In order to find associations we used Spearman correlation analysis.

Results

Mean age was 53,6±2,0 years, 17 men and 30 women. Mean body mass index 29,8±1,0 m/kg2, mean systolic blood pressure (SBP) was 159,8±4,5 mmHg, diastolic BP (DBP) was 97,9±2,6 mmHg, pulse BP (PBP) was 62,0±3,5 mmHg and heart rate (HR) was 76,6±2,2 bits per min. VAC was significantly associated with both (left and right) CAVI (R=0,698; P=0,012 and R=0,683; P=0,014, respectively). ABI was significantly associated with both E/A and E/e' (R=0,716; P=0,006 and R=0,764; P=0,002, respectively). Ea was significantly associated with IMT (R=0,491; P=0,24), total cholesterol (R=0,499; P=0,07), low-density lipoproteins (R=0,687; P=0,001), cfPWV was associated with almost the same factors (R=0,248; P=0,001 for correlation with IMT, R=0,382; P=0,01 for correlation with low-density lipoproteins). Ees was significantly associated with E/A (R=0,159; P=0,007); E/e' (R=-0,130; P=0,029), end diastolic volume (R=0,644; P<0,001) and with blood lymphocytes (R=-0,678; P=0,001).

Conclusions

We have found that VAC was significantly associated with arterial elasticity (CAVI), but we have not any correlation with CAVI for none of its component (Ea or Ees). Arterial elastance (Ea) was associated with similar factors as large arteries stiffness (cfPWV). Ventricle elastance instead was associated with diastolic dysfunction. All these components play role in clinical LV stiffness assessment.
P3835Improvement of myocardial energetic efficiency during treatment in hypertensive patients: the life study
Authors: Losi M A , Mancusi C , Gerdts E , Wachtell K , Kjeldsen S E , Greve A M , Devereux R B , De Simone G
Published: October 2019

Background

Myocardial energetic efficiency (MEE) per unit of left ventricular (LV) mass significantly predicts composite of cardiovascular (CV) events in treated hypertensive patients and specifically heart failure in an event-free population-based cohort with normal ejection fraction, independently of LV hypertrophy (LVH).

Purpose

To investigate whether MEEi changes over time in treated hypertensive patients, and whether different treatments have different effects.

Methods

From the Losartan Intervention For Endpoint study (LIFE Echo Sub-study) we selected 744 hypertensive patients (age 66±7 years; 45% women) with LVH at ECG, without atrial fibrillation, previous or incident myocardial infarction and with normal echocardiographic ejection fraction (>50%). MEE was estimated as the ratio of stroke work to the “double” product of heart rate times systolic blood pressure (BP), simplified as the ratio of stroke volume to heart rate, as previously reported. MEE was normalized for LVM (MEEi) and analyzed in quartiles at baseline and at the end treatment, according to an “intention-to-treat” protocol.

Results

Age and proportion of women were not significantly different from the highest to the lowest quartiles (from 65±7 to 66±7 years, p for trend=0.352; from 45% to 42%, p=0.946, respectively), whereas diastolic blood pressure (from 97±8 to 100±9 mmHg, p=0.006), prevalence of obesity (from 14 to 31%, p=0.001) and diabetes (from 4 to 14%, 0.004) progressively increased. Prevalence of concentric LV geometry and echocardiographic LVH also progressively increased from the highest to the lowest quartile (from 14 to 70%, and 61 to 90%, both p<0.0001). MEEi increased over time (p<0.007), independently of initial diastolic BP, diabetes and obesity, significantly more in patients treated with atenolol than with losartan (p<0.0001) (Figure), due to both increased stroke volume and decreased heart rate (both p<0.0001).

Figure 1

Conclusions

In a randomized clinical study, MEEi improves with anti-hypertensive therapy. Improvement is more evident in patients with atenolol than with losartan-based treatment, possibly providing pathophysiologic explanation of the comparable performance in prevention of ischemic heart disease previously reported in the LIFE study.
P3838Evaluation of echocardiographic determinants of interatrial block in patients with essential hypertension
Authors: Kalcik M , Bekar L , Celik O , Yetim M , Dogan T , Karaarslan O , Ekinozu I , Yilmaz M M , Gokdeniz T , Karavelioglu Y
Published: October 2019

Introduction

Interatrial block (IAB), defined as a conduction delay between the right and left atrium, is manifested on the electrocardiogram as a prolonged P-wave duration. Large number of studies recently have been published regarding the prevalence of IAB and its associations with cardiovascular events. It has been previously reported that myocardial fibrosis may cause conduction delays in hypertensive patients. In this study, we aimed to investigate the echocardiographic determinants of IAB in patients with hypertension.

Methods

This study enrolled a total of 220 patients [male: 93 (42.3%), mean age: 61.8±7.8 years] with hypertension. Patients with atrial fibrillation were excluded. IAB was defined as P wave duration of ≥120 ms with or without presence of notching. Routinely obtained 12-lead electrocardiography recordings were examined, and patients were divided into two groups as those with and without IAB. All patients were evaluated by transthoracic echocardiography.

Results

Electrocardiography revealed IAB in 70 patients. The baseline demographic characteristics of the patients with and without IAB were similar in both groups. Left atrial diameter (LAD), interventricular septal thickness, posterior wall thickness, left ventricular mass, left ventricular mass index, and the prevalence of left ventricular hypertrophy (LVH) were found to be significantly increased in hypertensive patients with IAB. Increased LAD (OR=1.082; 95% CI: 1.006–1.164; p=0.034) and LVH (OR=3.051; 95% CI: 1.164–7.994; p=0.023) were found to be independent predictors of IAB. In the receiver operating characteristic curve analyses, LAD values above 38 mm predicted IAB with a sensitivity of 68%, and a specificity of 58% (AUC= 0.678; 95% CI: 0.601–0.754; p<0.001).

Conclusion

A significant association exists between the presence of IAB and echocardiographic parameters related to left ventricular hypertrophy and left atrial dilatation in patients with essential hypertension. The presence of IAB may be used as an electrocardiographic marker of cardiac remodelling and myocardial fibrosis in hypertensive patients.
P3850Impact of sex and risk factors for venous thromboembolism on the clinical course of first acute venous thromboembolism. Insights from the PREFER in VTE
Authors: Giustozzi M , Barco S , Valerio L , Klok F A , Vedovati M C , Becattini C , Konstantinides S V , Agnelli G
Published: October 2019

Introduction

The interaction between sex and specific provoking risk factors for venous thromboembolism (VTE) may influence initial presentation and prognosis.

Purpose

We investigated the impact of sex on the risk of recurrence across subgroups of patients with first VTE classified according to baseline risk factors.

Methods

PREFER in VTE was an international, non-interventional registry (2013–2015) including patients with a first episode of acute symptomatic objectively diagnosed VTE. We studied the risk of recurrence in patients classified according to baseline provoking risk factors for VTE consisted of i) major transient (major surgery/trauma, >5 days in bed), ii) minor transient (pregnancy or puerperium, estroprogestinic therapy, prolonged immobilization, current infection or bone fracture/soft tissue trauma); iii) unprovoked events, iv) active cancer-associated VTE.

Results

A total of 3,455 patients diagnosed with first acute VTE were identified, of whom 1,623 (47%) were women. The percentage of patients with a major transient risk factor was 22.2% among women and 19.7% among men. Minor transient risk factors were present in 21.3% and 12.4%, unprovoked VTE in 51.6% and 61.6%, cancer-associated VTE in 4.9% of women and 6.3% of men, respectively. The proportions of cases treated with Vitamin-K antagonists (VKAs) and direct oral anticoagulants (DOACs) were similar between sexes. Median length of treatment of VKAs was 181.5 and 182.0 days and of DOACs was 113.0 and 155.0 days in women and men, respectively. At 12-months of follow-up, VTE recurrence was reported in 74 (4.8%) women and 80 (4.5%) men. Table 1 shows the sex-specific proportion of recurrences by VTE risk factor categories.

Table 1 Major Transient (n=722) Minor transient (n=573) Cancer-associated (n=195) Unprovoked (1965) Women (361) Men (361) OR (95% CI) Women (346) Men (227) OR (95% CI) Women (79) Men (116) OR (95% CI) Women (837) Men (1128) OR (95% CI) One-year follow-up, n (N%)   Recurrent VTE, 21 (6.2) 10 (2.9) 0.46 (0.2; 0.9) 9 (2.7) 12 (5.4) 2.09 (0.9; 5.0) 6 (8.0) 5 (4.5) 0.54 (0.2; 1.9) 38 (4.7) 53 (4.7) 1.03 (0.7; 1.6)   Major bleeding, 6 (1.8) 5 (1.5) 0.83 (0.3; 2.7) 5 (1.5) 1 (0.5) 0.30 (0.1; 2.6) 1 (1.3) 3 (2.7) 2.07 (0.2; 20) 10 (1.2) 15 (1.4) 1.11 (0.6; 2.4)   All-cause death, 37 (10.2) 31 (8.5) 0.82 (0.5; 1.4) 10 (2.9) 14 (6.2) 2.21 (0.9; 5.1) 26 (32.9) 49 (42.2) 1.49 (0.8; 2.7) 33 (3.9) 30 (2.7) 0.66 (0.4; 1.1)

Conclusions

The proportion of patients with recurrent VTE events after first acute symptomatic VTE provoked by transient risk factors was not negligible during the first year of follow-up during in both women and men. These results may have implications on the decision whether to consider extended anticoagulant therapy in selected patients with provoked events.

Acknowledgement/Funding

This study was funded by Daiichi Sankyo.