bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 13094: Association Between Myocardial Strain Using 2d and 3d Speckle-tracking Echocardiography and Diffuse Myocardial Fibrosis in Heart Transplant Recipients
Authors: XIE Mingxing , Wei Sun , Li Zhang , chun Wu , Qing Lv
Published: May 2021

Background:
Myocardial fibrosis (MF) is a well-described histopathologic featurein patients after heart transplant (HT). The two-dimensional speckle-tracking echocardiography (2D-STE) derived strain has been reported as a noninvasive tool to predict myocardial fibrosis (MF). Nevertheless, the relation between three-dimensional (3D)-myocardial strain and MF, and which directions of strain components correlated best with MF in HT recipients have not been reported.

Objective:
The study aimed to 1) explore whether diffuse left ventricular (LV) MF defined by cardiovascular magnetic resonance (CMR)- extracellular volume fraction (ECV) is expanded; 2) evaluate the association between LV MF and LV strain measured by 2D- and 3D-STE, and investigate which strain parameter is the more robust predictor of LV MF in patients after HT.

Methods:
A total of 60 subjects (40 patients after HT and 20 healthy controls) were prospectively enrolled. All subjects underwent the 2D, 3D echocardiography and CMR examination. The LV ejection fraction (EF) was measured by 3D-STE. The LV- global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) were measured by 2D- and 3D-STE. And LV diffuse MF was defined by ECV using the modified Look-Locker inversion recovery (MOLLI) sequence.

Results:
The HT recipients had higher native T1 and ECV than healthy controls (1042.8±35.3ms vs 1006.3±19.6ms, p<0.001; 26.8±3.4% vs 24.6±1.3%, p=0.02). And compared with healthy controls, the 3D-GLS, 3D-GCS, 3D-GRS and 2D-GLS were all lower (p<.005) in the HT recipients. But 3D-LVEF was similar in HT patients and healthy controls. And in the HT group, the increased ECV only correlated with 2D-GLS (r=0.57, p=0.001) and 3D-GLS (r=0.51, p < 0.001), not correlated with 2D- and 3D-GCS, GRS. The separate stepwise multivariate analysis showed that both 2D-GLS (β=0.74, p=0.001) and 3D-GLS (β=0.69, p < 0.001) were independently associated with LVECV.

Conclusions:
Patients after HT have higher LV MF and reduced LV strain compared with control subjects. Moreover, both 2D- and 3D-GLS are the independent predictor of diffuse LV MF. Therefore, the measurement 2D- and 3D-GLS may be provide a noninvasive assessment of LV MF in the transplanted hearts.
Abstract 13103: Nourin-dependent
Mirna-106b
: A Novel Early Inflammatory Diagnostic Biomarker for Cardiac Injury
Authors: Elgebaly Salwa A , Christenson Robert H , Kandil Hossam , Elkhazragy Nashwa , Rashed Laila , Yacoub Beshoy , Sharafieh Roshanak , Klueh Ulrike , Kreutzer Donald L
Published: May 2021

Introduction:
Nourin is an inflammatory mediator rapidly released
by ischemic myocardium “before” necrosis,
and by necrotic cells
. It stimulates leukocyte “
chemotaxis
” and “
activates
” leukocytes and vascular endothelial cells to release several “
cytokine storm
” mediators. Using Nourin amino acid sequence, Bioinformatics analysis indicated that Nourin is likely regulated by
miRNA-106b
; an inflammatory-signaling pathway linked to myocardial ischemia.

Hypothesis:
As an "initial" inflammatory marker, the Nourin-dependent
miR-106b
can early diagnose ischemia-induced injury in UA patients when Troponin levels are below the decision limit, and in STEMI patients. The underlying regulatory mechanism
involves lncR-CTB89H12.4 and mRNA-ANAPC11;
associated with ischemia.

Methods:
Gene expression of
lncR-CTB89H12.4
/
miR-106b
and
mRNA-ANAPC11
were measured in serum samples from UA (n=30 - confirmed by invasive coronary angiography and negative Troponin) and STEMI (n=16) patients at presentation, and healthy volunteers (n=16).

Results:
Gene expression of
miR-106b
was up-regulated by 150-fold in UA compared to healthy, and by 4.6-fold in STEMI compared to UA (Fig. 1). Receiving Operator Characteristics (ROC) analysis revealed a statistically significant difference in
miR-106b
that discriminated UA from healthy controls with a test sensitivity of 87% sensitivity & specificity of 88%. Diagnostic sensitivity was 86% and specificity was 90% for discriminating UA from STEMI. Additionally, Spearman’s correlation analysis revealed a significant association of
miR-106b
with
lncR-CTB89H12.4
and
mRNA-ANAPC11.
The down regulation of
lncR-CTB89H12.4
after ischemia resulted in the up-regulation of
miR-106b
and activation of
mRNA-ANAPC11
.

Conclusions:
The Nourin-dependent miR-106b is a promising early inflammatory biomarker indicating UA patients and discriminating between UA and STEMI. Regulations appears to be from
lncR-CTB89H12.4
and
mRNA-ANAPC11
.
Abstract 13115: Risk Markers for Minimal Coronary Artery Calcification in Persons With Significant Aortic Valve Calcium: The Multi-Ethnic Study of Atherosclerosis
Authors: Razavi Alexander C , Cardoso Rhanderson , Dzaye Omar , Budoff Matthew J , Thanassoulis George , Post Wendy S , Shah Sanjiv J , Berman Daniel S , Nasir Khurram , Blaha Michael J , Whelton Seamus P
Published: May 2021

Introduction:
Calcific aortic valve disease is the most common valve disorder affecting >5 million US adults. The underlying pathobiology for the early stages of aortic valve calcification (AVC) and coronary artery calcium (CAC) includes many shared ASCVD risk factors, but a considerable proportion of individuals with significant AVC have little to no CAC.

Hypothesis:
Among persons with significant AVC (>100 AU), those with a low CAC burden (CAC <100 AU) would be younger and have a lower prevalence of both traditional and novel ASCVD risk factors compared to persons with CAC ≥100.

Methods:
After excluding 2 persons with bicuspid aortic valve, 325 participants from the Multi-Ethnic Study of Atherosclerosis without clinical ASCVD and with AVC >100 at Visit 1 (2000-02) were included (34% women, 23% African American). We used Poisson regression to calculate adjusted prevalence ratios for CAC <100 versus CAC >100, using traditional and novel ASCVD risk markers.

Results:
Participants had a mean age of 72.1 years and 133 (41%) had CAC <100 of whom 46/133 had CAC=0. Those with CAC <100 were younger (70 vs. 74 years), had a lower prevalence of both hypertension (74% vs. 87%) and statin use (16% vs. 29%), but otherwise similar risk factor profiles compared to those with CAC ≥100. There were no significant differences in median Lp(a) (19.1 vs. 19.7 mg/dL) or hsCRP values (2.3 vs. 1.9 mg/L). A higher likelihood of CAC <100 was observed per 10 years younger age (PR=1.41, 95% CI: 1.22-1.62), female sex (PR=1.68, 95% CI: 1.28-2.20), and a total cholesterol-HDL cholesterol ratio <3.5 (PR=1.37, 95% CI: 1.02-1.85). There was no significant association between other individual risk factors and CAC <100, but an ASCVD risk of <7.5% had a prevalence ratio of 2.30 (95% CI: 1.85-2.85). Among nontraditional risk factors, only the absence of thoracic calcification was associated with a higher prevalence of CAC <100 (PR=1.71, 95% CI: 1.28-2.28).

Conclusions:
More than 40% of persons with significant AVC had a low burden of CAC, which is incompletely explained through traditional and novel ASCVD risk markers. These results suggest that unmeasured risk markers, genetics, and/or the non-ASCVD pathways of later stage AVC may be more important in understanding the observed discordance between AVC and CAC.
Abstract 13130: Efficacy and Safety of Bempedoic Acid by Sex: Pooled Analyses From Phase 3 Trials
Authors: Goldberg Anne C , Banach Maciej , Catapano Alberico L , Duell P Barton , Leiter Lawrence A , Bloedon LeAnne T , Feng Amy , Mancini G
Published: May 2021

Introduction:
Bempedoic acid (BA), an ATP-citrate lyase inhibitor, lowers low-density lipoprotein cholesterol (LDL-C) in patients with hypercholesterolemia.

Objective:
To report efficacy and safety of BA by sex in patients with elevated LDL-C.

Methods:
Data were pooled from 4 phase 3 randomized (2:1), double-blind studies investigating oral BA (180 mg once daily) vs placebo for 12 weeks to 52 weeks in adults receiving maximally tolerated statins who required additional LDL-C lowering, analyzed by sex. The primary efficacy endpoint was % change in LDL-C from baseline to week 12. Results were analyzed in cohorts with atherosclerotic cardiovascular disease (ASCVD) and/or heterozygous familial hypercholesterolemia (“ASCVD/HeFH on statins pool”, n=3009) or history of statin intolerance (“statin intolerant pool”, n=614). Safety assessments included treatment-emergent adverse events (TEAEs).

Results:
Of all participants, 34.3% were women. Significant LDL-C lowering from baseline with BA vs placebo was demonstrated in both pools and sexes (
P
< 0.001;
Table 1
), with greater lowering in women vs men in the ASCVD/HeFH on statins pool (
P
= 0.04). Rates of TEAEs were similar across groups (
Table 2
). Rates of common TEAEs were similar in both pools and sexes, except urinary tract infection (men: BA, 2.8%; placebo, 3.0%; women: BA, 8.0%; placebo, 10.3%) and pain in extremity (men: BA, 2.5%; placebo, 1.2%; women: BA, 4.2%; placebo, 2.9%), which occurred more frequently in women.

Conclusion:
BA lowered LDL-C significantly in both women and men, with greater effect in women vs men in both pools, and a safety profile generally comparable to placebo in both sexes.
Abstract 13132: Reclassification of CHA
2
DS
2
-VASc Thromboembolic Risk by Coronary Calcifications on Cardiac Computed Tomography in Atrial Fibrillation
Authors: Wang Tom Kai Ming , Chan Nicholas , Cremer Paul C , Kanj Mohammed , Baranowski Bryan , Saliba Walid I , Wazni Oussama M , Jaber Wael A
Published: May 2021

Background:
CHA
2
DS
2
-VASc is the most widely used thromboembolism risk score in patients with atrial fibrillation (AF). Cardiac computed tomography (CCT) routinely performed before or after pulmonary vein isolation (PVI) for AF rhythm control offers the opportunity to detect coronary calcifications (CAC) and this vascular pathology. We evaluated the frequency of CAC and the extent it affects the CHA
2
DS
2
-VASc and decision for anticoagulation for AF patients undergoing PVI.

Methods:
In 2014, 772 consecutive patients underwent PVI at Cleveland clinic, and 621 patients who had CCT within 1-year before or after PVI were studied. Relationships between CAC recorded as a binary variable with clinical characteristics and reclassification of CHA
2
DS
2
-VASc was analyzed.

Results:
Mean age was 63.1±9.8 years, 163 (26.2%) were females, 322 (51.9%) had paroxysmal AF and 264 (42.5%) having prior PVI. CAC was identified on CCT in 388 (62.5%) patients. Age was the only factor independently associated with CAC, odds ratio 1.02 (95% confidence interval 1.01-1.04), P=0.004. CAC increased the CHA
2
DS
2
-VASc in 306 (49.3%) patients, and the mean from 2.0±1.5 to 2.5±1.4 (Table). Using gender-specific cutpoints from the latest guidelines, 71 (11.4%) had CHA
2
DS
2
-VASc going from 0 to 1 in men or 1 to 2 in women (where anticoagulation may be considered), and 113 (18.2%) had CHA
2
DS
2
-VASc going from 1 to 2 in men or to 3 in women (where long-term anticoagulation is indicated).

Conclusion:
Almost two-thirds of patients undergoing PVI have CAC detectable on CCT, and after incorporating this information, long-term anticoagulation may or would be indicated in an additional 30% of the cohort. By assessing vascular pathology, CCT can play an important screening role for thromboembolic risk in AF patients incremental to clinical risk factors.
Abstract 13135: Starting Beta-blockers in Hypertension is Followed by Excess Loop Diuretic Use: Beta-blocker Induced Heart Failure?
Authors: Silverman Daniel N , de Lavallaz Jeanne d , Plante Timothy B , Infeld Margaret M , Meyer Markus
Published: May 2021

Introduction:
Recent investigation has identified that discontinuation of beta-blockers in subjects with normal left ventricular ejection fraction (LVEF) leads to a reduction in natriuretic peptide levels. We investigated whether a similar trend would be seen in a hypertension clinical trial cohort.

Methods:
In 9,012 subjects hypertensive subjects without a history of symptomatic heart failure, known LVEF <35% or recent heart failure hospitalization enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT), we compared incidence of loop diuretic initiation and time to initiation following start of a new anti-hypertensive medication. The categorical relationship (new antihypertensive class followed by loop-diuretic use) and temporal relationship (time to loop diuretic initiation) were each analyzed. The categorical relationship was assessed using a Pearson’s chi-squared test and the temporal relationship using a Wilcoxon rank sum test. Bonferroni-corrected p-values were utilized for all comparisons.

Results:
Among the 9,012 subjects analyzed, the incidence of anti-hypertensive initiation and loop diuretic initiation was greatest following start of a beta-blocker (16.6%) compared with other antihypertensive medication classes (calcium channel blocker 13.8%, angiotensin converting enzyme-inhibitor/angiotensin receptor blocker 12.9% and thiazide diuretic 10.2%; p<0.001). In addition, the median time between starting a new antihypertensive medication and loop diuretic was the shortest for beta-blockers and longest for thiazides (both p <0.01). No significant differences in renal function were identified between groups.

Conclusion:
Compared to other major classes of hypertensive agents, starting beta-blockers was associated with more common and earlier initiation of a loop diuretics in a population without heart failure at baseline. This finding may suggest beta-blocker induced heart failure in a population with a predominantly normal ejection fraction.
Abstract 13136: Left Atrial Appendage Structural Characteristics Predict Thrombus Formation
Authors: Kim Hyun , Ning John , Lu Kaiwei , Thompson Colton , Tyagi Sudhi , Berger Marcie
Published: May 2021

Introduction:
Atrial fibrillation remains highly prevalent in the US with over 6 million diagnosed individuals. Discordant atrial contraction inherent to atrial fibrillation results in stagnant blood flow and increases the risk for thrombus formation particularly within the left atrial appendage (LAA). Anticoagulation is the mainstay of intracardiac thrombus prevention and is initiated based on the CHAD
2
S
2
-VASc risk score that does not account for LAA morphology. The relationship between LAA structural characteristics and thrombus development remains poorly understood.

Hypothesis:
We hypothesized that in patients with atrial fibrillation, LAA structural characteristics correlate with the presence of thrombus.

Methods:
We performed a retrospective case-control study of 151 subjects with a history of atrial fibrillation who underwent transesophageal echocardiogram (TEE) to evaluate the LAA for pre-cardioversion indication or Watchman screening evaluation. Subjects discovered to have LAA thrombus on TEE defined the study case group (n = 74) while control subjects did not have LAA thrombus (n = 77). Baseline demographics and echocardiographic characteristics were collected for all subjects.

Results:
Subjects without thrombus were older than those with thrombus (thrombus: 68.6 ± 13.1 years, no thrombus: 74.7 ± 9.2 years,
p = 0.001
). LAA ostial cross-sectional area was smaller in subjects with thrombus than those without thrombus (thrombus: 251.1 ± 117.4 mm
2
, no thrombus: 332.9 ± 171.2 mm
2
,
p < 0.001
). This finding remained significant in both unadjusted and adjusted logistic regression models (
Table 1
). CHA
2
DS
2
-VASc score did not significantly differ in those with or without thrombus (thrombus: 4.4 ± 1.8, no thrombus: 4.3 ± 1.7, p = 0.822).

Conclusions:
Smaller LAA ostial cross-sectional area correlates with thrombus formation. Consideration of LAA structural characteristics may improve precision of anticoagulation management.
Abstract 13144: Epsilon Waves on Electrocardiograms in Pulmonary Hypertensive Patients With and Without Right Ventricular Hypertrophy or Fibrosis: Comparison With Arrhythmogenic Right Ventricular Cardiomyopathy
Authors: FUNABASHI Nobusada , Kobayashi Yoshio
Published: May 2021

Introduction:
Epsilon waves on V1-3 leads are one of the specific ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) that suggest the presence of RV conduction delay.

Hypothesis:
In patients with pulmonary hypertension (PH) due to RV pressure load, RV hypertrophy and fibrosis are frequently observed that may lead to RV conduction delay and epsilon waves.

Methods:
We retrospectively analyzed 43 PH patients (33 females, 55 ± 15 years, 31 chronic thromboembolic PH, seven idiopathic pulmonary arterial hypertension), with proven PH by right heart catheterization. On CT, RV fibrosis was defined as a contrast defect in the early phase and a conversely abnormal enhancement in the late phase. We also retrospectively analyzed 17 patients (11 males, 57 ± 17 years) with suspected ARVC who underwent cardiac CT. Of these, nine met 2010 ARVC task force criteria on cardiac CT.

Results:
All 9 ARVC patients (100%) had epsilon waves on ECG. In PH patients, 32 and 9 patients had RV hypertrophy and fibrosis, respectively. Of these, 4 patients had both. Among 32 PH patients with RV hypertrophy, 2 had complete right bundle branch block (RBBB) and 8 had incomplete RBBB. Of 22 PH patients with RV hypertrophy but without any RBBB, two (9%, P < 0.01, compared with ARVC) had waves with abnormal small upward spikes after the QRS wave. These were more marked in lead II and aVF leads than in V1 and 2 leads, and were not typical epsilon waves, suggesting RV conduction delay shown in ARVC. Fourteen patients had a negative T wave in V1-3 leads (5 had only a V1 lead, one had only V1 and 2 leads, four had only V1-3 leads, and four only had V1-4 leads, respectively). Of nine PH patients with RV hypertrophy, one had complete RBBB and one had incomplete RBBB. Of seven PH patients with RV fibrosis but without any RBBB, none (0%, P < 0.01, compared with ARVC) had epsilon waves in V1-3 leads; all seven had a negative T wave in V1-3 leads (three only had a V1 lead, one had only V1 and 2 leads, two had only V1-3 leads, and one had V1-4 leads).

Conclusions:
In PH patients with an organized RV myocardial change, such as RV hypertrophy and/or fibrosis, the frequency of epsilon waves was significantly less than those in ARVC. Epsilon waves seem not only to be caused by an organized RV myocardium but also by other factors.
Abstract 13155: Differences in Cardiovascular Prescription Drug Utilization Among Medicaid Beneficiaries in Early Expander vs. Non-expander States From 2011 to 2018
Authors: Sumarsono Andrew , Lalani Hussain , Segar Matthew W , Pandey Ambarish
Published: May 2021

Introduction:
Cardiovascular disease remains the leading cause of death in the United States. In 2014, the Affordable Care Act expanded Medicaid eligibility allowing low-income adults to access healthcare. It remains unclear how Medicaid expansion affected access to cardiovascular prescription drugs.

Methods:
We used the publicly available Medicaid State Drug Utilization dataset to evaluate the utilization of statins, P2Y12 receptor blockers (P2Y12-RB), and seven classes of oral antihypertensives. We used a difference-in-differences analysis to compare quarterly prescriptions per 1,000 Medicaid beneficiaries for each drug class among Medicaid expansion states versus non-expansion states during the three years before and five years after the 2014 Medicaid expansion.

Results:
Between 2011 and 2018, the number of annual prescriptions of statins, P2Y12-RB, and antihypertensives increased by 89.7% (11.0 to 20.8 million), 37% (1.7 to 2.3 million), and 76% (35.3 to 62.2 million). Medicaid expansion states had higher quarterly prescriptions per 1000 Medicaid beneficiaries compared to non-expansion states for statins (22.54 [CI 95%: 15.5 to 28.58], p<0.001), antiplatelets (1.68 [CI 95%: 1.15 to 2.21], p<0.001), and antihypertensives (63.21 [CI 95%: 47.31 to 79.11], p<0.001).

Conclusion:
National Medicaid use of statins, P2Y12-RB, and antihypertensives increased between 2011 to 2018. The Medicaid expansion was associated significant increases in per-capita utilization of all cardiovascular prescription drugs. These gains in utilization are likely providing long-term cardiovascular benefits to lower-income and previously underinsured populations.

Figure 1:
Trends in Quarterly Prescriptions/1000 Beneficiaries of statins, anti-platelets, and antihypertensives between 2011 to 2018 between expander and non-expander states. 1A: statins. 1B: P2Y12 inhibitors. 1C: Antihypertensives
Abstract 13170: Bicuspid Aortic Valve Exacerbates the Ascending Aorta Aortopathy but Not Hypertension in Repaired Coarctation of the Aorta
Authors: Saengsin Kwannapas , Gauvreau Kimberly , Prakash Ashwin
Published: May 2021

Introduction:
Coarctation of the aorta (COA) is a generalized vascular disease, associated with reduced aortic distensibility and a higher prevalence of systemic hypertension. 60-85% of COA patients have a bicuspid aortic valve (BAV). BAV is independently associated with lower aortic distensibility, but not hypertension (HTN). It is not known if the presence of a BAV accentuates the aortopathy and hypertension in CoA patients.

Hypothesis:
COA patients with a BAV have a stiffer aorta than those with a tricuspid aortic valve (TAV).

Methods:
We retrospectively identified COA patients with and without BAV in whom the cardiac MRI (CMR) data was available from 2005-2019 and calculated aortic distensibility at the ascending (AAO) and descending aorta (DAO). Patients with residual COA were excluded.

Results:
Among 215 COA patients (median age 25.3 years, 56% male), 67% of patients had a BAV. BAV and TAV groups were similar to the current age, gender, and modality of COA treatment. As expected, BAV patients had larger AAO size (median diameter
z
-score 1.4 versus 0.1, p<0.001). Median AAO distensibility z-score was significantly lower in the BAV group (-1.2 versus -0.7; p=0.014) but DAO distensibility was similar in BAV and TAV patients. The prevalence of HTN was not different between BAV (32%) and TAV groups (36%, p = 0.56). On multivariable analysis, HTN was not associated with BAV or AAO distensibility but was associated with lower DAO distensibility (p=0.01).

Conclusions:
In young adults with adequately treated COA, the BAV group had lower AAO distensibility and a larger AAO compared with the TAV group. However, DAO distensibility and the prevalence of hypertension were similar in BAV and TAV patients. These results suggest that although the presence of a BAV in COA exacerbates the AAO aortopathy in a localized fashion, it does not exacerbate the more generalized vascular dysfunction and associated HTN.
Abstract 13178: Attainment of LDL-C Goals is Associated With Measures of Patient Engagement With Their Healthcare Providers
Authors: Shiffman Dov , Louie Judy Z , Devlin James J , Knowles Joshua W , McPhaul Michael
Published: May 2021

Introduction:
Achieving optimal levels of low density lipoprotein cholesterol (LDL-C) reduces risk of cardiovascular events. We have found substantial gaps in LDL-C goal attainment in employees and spouses with an employer-sponsored medical plan. Understanding how patients’ engagement with healthcare providers affects LDL-C goal attainment may inform gap-closure programs.

Methods:
The study was drawn from 35,276 participants in an annual health assessment program offered by nation-wide clinical diagnostic provider to employees and spouses between September 2017 and June 2018. We excluded those with <1 consecutive year of employer- sponsored health plan and those younger than 40 or older than 75. The analysis was further limited to 7,363 participants who would benefit from LDL-C management according to the AHA/ACC definition of patient-management groups. The association between attaining LDL-C goal and education, socioeconomic status, and self-reported measures of engagement with healthcare providers was assessed in age, sex, and ethnicity adjusted logistic regression models.

Results:
Attaining LDL-C goal was more likely in those with a personal physician than in those without (OR =2.25, 95%CI, 1.70 to 2.99,
P
<0.0001). Similarly, greater confidence in selecting a physician, talking with a physician, or understanding medical benefits, as well as a more recent physical exam and a greater number of medications were associated with greater odds of attaining LDL-C goal (
Figure,
all
P
values <0.0001). Socioeconomic status and education levels were not associated with attaining LDL-C goals (
P
>0.05).

Conclusion:
Confidence in interaction with healthcare providers (understanding benefits, selecting a physician, and talking with a physician) was associated with LDL-C goal attainment in those with an employer-sponsored health plan. Improving patients’ confidence in their ability to interact with healthcare providers may improve LDL-C goal attainment.
Abstract 13180: Ultrasound Jugular Venous Pressure Collapse Point Predicts Elevated Right Atrial Pressure on Right Heart Catheterization in Obese and Nonobese Patients
Authors: Wang Libo , Harrison Jonathan , Dranow Elizabeth , Khor Lillian
Published: May 2021

Introduction:
Accurate intravascular volume status assessment is central to heart failure management, but current non-invasive bedside techniques remain a challenge. Visual inspection of jugular venous pulsation (JVP) is used as a surrogate for central venous pressure (CVP). Studies have shown variability and inaccuracy of the JVP exam in estimating CVP or right atrial pressure (RAP). Published methods of RAP estimation through internal jugular vein (IJV) ultrasonography are either complex or require offline analysis. We validated a simplified approach to ultrasonography of the JVP (uJVP) as a method to predict RAP.

Methods:
Adult patients undergoing right heart catheterization (RHC) were enrolled prior for IJV imaging with point of care ultrasound (POCUS) device, Butterfly iQ™. The IJV was identified on ultrasound with the patient reclined (head of bed between 30-45°) and followed cranially until tapering smaller than the adjacent carotid artery throughout the entirety of the respiratory cycle. The height of this collapse point from the sternal angle added to 5 centimeters was defined as ultrasound JVP (uJVP).

Results:
77 participants underwent uJVP assessment on the same day prior to RHC. Average BMI was 33 kg/m
2
. The area under the curve (AUC) of uJVP and RAP greater than 10mmHg on RHC was 0.879 (95% CI 0.759-0.931, p<0.001), with AUC of 0.972 and 0.818 for non-obese and obese subgroups respectively, and AUC of 0.876 for elevated RAP and pulmonary capillary wedge pressure (PCWP). A uJVP cutoff of 9 or higher was 85% sensitive and 72% specific at identifying RAP greater than 10mmHg.

Conclusion:
We developed and validated a novel technique identifying the uJVP using POCUS which correlates with invasive RAP regardless of obesity. This technique predicted combined elevated left and right sided intracardiac pressures. The uJVP’s potential to enhance the diagnostic value of the bed-side examination in an increasingly obese heart failure population warrants further research.
Abstract 13198: Immunohematologic Failure Identifies Fibrotic Phenotype in Heart Failure With Preserved Ejection Fraction
Authors: Rana Mariam N , Bevan Graham , Albar Zainab , Zidar David A , Al-Kindi Sadeer
Published: May 2021

Background:
We have shown that immunohematologic failure (IHF: lymphopenia (absolute lymphocyte count (ALC)<1.5 x10
3
/μL) and anisocytosis (red cell distribution width, RDW > 14.5%)) is associated with risk of heart failure. Lymphopenic patients have elevated numbers of regulatory T cells with profibrotic phenotype.

Hypothesis:
We hypothesized that IHF is associated with fibrosis in HFpEF.

Methods:
We investigated the association between ALC, RDW, and IHF with markers of fibrosis (galectin-3 and Corboxy-Terminal Telopeptide of Collagen Type I [CITP]) in patients enrolled in RELAX trial of HFpEF (Clinicaltrials.gov NCT00763867) using linear regression, and adjusting for age, sex, race, eGFR, BMI and diabetes status.

Results:
A total of 122 patients with both ALC and RDW were included. There was a modest correlation between ALC and RDW (Spearman’s rho=-0.22, P=0.017). Both ALC and RDW were significantly associated with galectin 3 and CITP (figure). A total of 33 (27%) patients had IHF. Patients with IHF had lower GFR (62±25 vs 53 ± 21 ml/min/1.73 m
2
, P<0.001), lower peak VO2 (12.5±2.8 vs 11.0 ± 3.0 ml/kg/min, P=0.007), lower exercise capacity (78 ± 26 vs 64 ± 35 watts, P=0.018), higher NT-proBNP (900±1152 vs 1615 ± 1247 pg/mL, P=0.004), galectin-3 (13.3 ± 4.1 vs 17.7 ± 5.8, P<0.001 ng/mL) and CITP (6.1 ± 3.5 vs 11.0 ± 5.7 μg/L, P<0.001) but no difference in age, sex, race, CRP or diabetes status. After multiple adjustments, IHF was associated with higher galectin-3 levels (P=0.01) and CITP (P<0.001).

Conclusions:
Immunohematologic failure is common in HFpEF and is associated with fibrotic phenotype. The mechanisms linking IHF and fibrosis need to be elucidated in future studies.
Abstract 13309: Soluble Fibrin Monomer Complex is Associated With Cardio- and Cerebro-vascular Events in Patients With Heart Failure
Authors: KIMISHIMA Yusuke , YOSHIHISA Akiomi , Ichijo Yasuhiro , Watanabe Koichiro , Hotuki Yu , Yokokawa Tetsuro , Misaka Tomofumi , Sato Takamasa , Oikawa Masayoshi , KOBAYASHI ATSUSHI , Takeishi Yasuchika
Published: May 2021

Background:
The soluble fibrin monomer complex (SFMC) is a biomarker of fibrin formation, and has been shown to be abnormally elevated in various clinical situations of hypercoagulability. However, the association between SFMC and cardiovascular events in patients with heart failure (HF) remains uncertain. We aimed to examine the prognostic impact of SFMC concerning increased risk of major cardio- and cerebro-vascular events (MACCE) and all-cause mortality in patients with HF.

Methods and Results:
We conducted a prospective observational study. We analyzed data on 723 hospitalized patients with HF who discharged alive and measured SFMC at stable condition in prior to discharge. Patients were divided into tertiles based on levels of SFMC: 1
st
(SFMC <1.7 μg/ml, n = 250), 2
nd
(1.8
≤
SFMC <2.9 μg/ml, n = 233), and 3
rd
(3.0 μg/ml
≤
SFMC, n = 240) tertiles. We compared baseline patients’ characteristics and their post-discharge MACCE and mortality. Prevalence of chronic kidney disease (CKD) and anemia was significantly higher in the 3
rd
tertile than in the 1
st
and 2
nd
tertiles. In contrast, age, sex, CHADS
2
-Vasc score, left ventricular ejection fraction, and prevalence of hypertension, diabetes and atrial fibrillation did not differ among the tertiles. During the median follow-up period of 422 days, 61 patients experienced MACCE, and 82 patients died. In the Kaplan-Meier analysis (
Figure
), accumulated event rates of both MACCE and all-cause mortality progressively increased from the 1
st
to the 3
rd
tertiles (MACCE, 4.8%, 8.6% and 12.1%, log-rank P=0.014; all-cause mortality, 6.4%, 9.4% and 18.3%, log-rank P<0.001). In the multivariable Cox proportional hazard analysis, the 3
rd
tertile was found to be an independent predictor of MACCE (HR 2.608, 95%CI 1.331-5.113, P=0.005) and all-cause mortality (HR 2.938, 95%CI 1.657-5.207, P<0.001).

Conclusion:
SFMC is an independent predictor of adverse prognosis in patients with HF.
Abstract 13314: Effect of Eicosapentaenoic Acid and Docosahexaenoic Acid on Epicardial Fat Volume; Results From a Randomized Controlled Trial
Authors: Asbeutah Abdul Aziz , Amangurbanova Maral , Waseem Smaha , Mirza Hasan , Welty Francine K
Published: May 2021

Introduction:
Epicardial adipose tissue is an ectopic fat depot that may be associated with coronary artery atherosclerosis. Reduction in weight has been associated with a reduction in epicardial fat volume in several studies. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are known to lower triglyceride level. Whether the reduction in triglyceride level is associated with a reduction in epicardial fat volume is unknown.

Hypothesis:
We hypothesize that EPA and DHA reduce triglyceride levels and possibly can cause regression of epicardial fat volume after 30 months of therapy.

Methods:
A total of 139 patients with stable coronary artery disease on statins were randomized to EPA and DHA versus none for 30 months. Epicardial fat volume was measured with coronary computed tomographic angiography at baseline and 30 months. Change in epicardial fat volume was calculated.

Results:
No difference in baseline characteristics was observed (Table). At 30-month follow-up, those on EPA and DHA had a significant 6.7% reduction in triglyceride level compared to a 12.6% increase in controls (p=0.02). However, there was no difference in percent change in epicardial fat volume between control and EPA/DHA groups at 30 months (-3.1% [-16.7, 4.9] vs. -5.0% [-13.1,7.3], p-value=0.80, respectively). There was no significant change in body mass index in either group at 30-month follow-up.

Conclusions:
EPA and DHA led to a significant reduction of triglyceride level; however, there was no corresponding significant reduction in epicardial fat volume. This finding suggests that lowering triglyceride level does not affect epicardial fat volume.
Abstract 13318: Omega-3 Ethyl Esters and Atrial Fibrillation or Flutter in Patients With Coronary Artery Disease: Results From a Randomized Trial
Authors: Asbeutah Abdul Aziz , Mirza Hasan , Waseem Smaha , Amangurbanova Maral , Welty Francine K
Published: May 2021

Introduction:
Statins have led to significant reductions in cardiovascular disease (CVD) events; however, a high level of residual cardiovascular risk remains. The REDUCE-IT trial showed additional benefit with icosapent ethyl to statins in reducing CVD morbidity and mortality. However, the safety of omega-3 ethyl esters with regards to atrial fibrillation (Afib) in patients with coronary artery disease (CAD) remains unclear.

Hypothesis:
We hypothesize that omega-3 ethyl esters may influence the risk of Afib or flutter in patients with CAD.

Methods:
In total, 285 CAD patients on statins were randomized to high dose omega-3 ethyl esters (1.86 g of Eicosapentaenoic acid [EPA] and 1.5 g of Docosahexaenoic acid [DHA]) or no omega-3 for 30 months. The incidence and recurrence of Afib or flutter was compared in those on EPA/DHA plus statin to statin alone (control).

Results:
A total of 240 patients were included in the analysis and no difference in baseline characteristics was observed (Table A). In total, 19 patients were in Afib or flutter during the trial: 12 in EPA/DHA and 7 in control (9.5% vs. 6.1%, respectively, p=0.33). The incidence of new onset Afib or flutter within 30 months was 7.2% and 4.9% in patients receiving omega-3 ethyl esters compared to controls, respectively (p=0.48). No significant difference in recurrence of Afib occurred among patients with a history of paroxysmal Afib receiving omega-3 ethyl esters compared to control (26.7% vs. 16.7%, respectively, p=0.53) (Table B).

Conclusions:
EPA/DHA did not increase the incidence of Afib or flutter in patients with established CAD. Further studies are warranted to better understand the effects of omega-3 ethyl esters on the cardiac conduction system.
Abstract 13324: TRACP5b, a Marker of Osteoporosis, is Associated With Adverse Cardiac Events in Hospitalized Patients With Heart Failure
Authors: KIMISHIMA Yusuke , YOSHIHISA Akiomi , Abe Satoshi , Ichijo Yasuhiro , Watanabe Koichiro , Hotuki Yu , Yokokawa Tetsuro , Misaka Tomofumi , Sato Takamasa , Oikawa Masayoshi , KOBAYASHI ATSUSHI , Takeishi Yasuchika
Published: May 2021

Introduction:
Tarterate-resistant acid phosphatase type 5b (TRACP5b) is derived from osteoclast, and has been used as a maker of osteoporosis. Although heart failure (HF) is associated with catabolic bone remodeling, serum TRACP5b levels have not been rigorously examined in patients with HF.

Methods and Results:
We conducted a prospective observational study of 688 decompensated HF patients, and patients were divided into tertiles based on serum TRACP5b levels: 1
st
(TRACP5b <316 mU/dL, n = 229), 2
nd
(316
≤
TRACP5b <490 mU/dL, n = 229), and 3
rd
(490 mU/dL
≤
TRACP5b, n = 230) tertiles. We compared baseline patients’ characteristics and their post-discharge prognosis including cardiac mortality and cardiac events such as cardiac death and worsening HF. Age was significantly higher, and prevalence of female and anemia was significantly higher in the 3
rd
tertile than in the 1
st
and 2
nd
tertiles (age, 71.9 vs. 64.2 and 67.3 years, P<0.001; female, 50.4% vs. 35.4% and 43.2%, P=0.005; anemia, 54.8% vs. 41.9% and 46.7%, P=0.021). In contrast, left ventricular ejection fraction, prevalence of hypertension, diabetes, chronic kidney disease and atrial fibrillation did not differ among the tertiles. In the Kaplan-Meier analysis (
Figure
, mean follow up of 426 days), cardiac mortality and cardiac event rates progressively increased from the 1
st
to the 3
rd
tertiles (cardiac mortality, 3.1%, 5.2% and 8.7%, log-rank P =0.024; cardiac event rates, 10.9%, 14.0% and 20.4%, log-rank P=0.010). In the multivariable Cox proportional hazard analysis, the 3
rd
tertile was found to be an independent predictor of cardiac mortality and cardiac events (cardiac mortality, hazard ratio 1.381, P=0.035; cardiac events, hazard ratio 1.664, P=0.044).

Conclusion:
High serum levels of TRACP5b, a marker of osteoporosis, is associated with adverse prognosis in HF patients.
Abstract 13325: Complication Rates Between Same-day and Next-day Discharge of Left Atrial Ablation Procedures: A Parallel, Intra-institutional Comparison
Authors: Brown Matthew T , Pelling Mary M , Kiani Soroosh , Wise Donna , Shah Anand D , Westerman Stacy , Leon Angel R , Merchant Faisal M , El-Chami Mikhael F , Lloyd Michael S
Published: May 2021

Introduction:
Over a two-year period, two high-volume electrophysiology centers simultaneously performed left atrial ablation with differing post-procedure discharge strategies. We sought to investigate complication rates between patients undergoing same-day (SD) or next-day (ND) discharges.

Methods:
We identified all patients who underwent transseptal ablation from August 2017 to August 2019 (n = 409) at two high-volume centers practicing either SD (n = 210) or ND (n = 199) discharge protocols. Atrial fibrillation, left atrial flutter and left atrial tachycardia ablations were included in the study while left atrial accessory pathway ablations were not. Complications were defined as any clinical event that resulted in procedural abortion, extended stay for either center, or readmission within 72 hours. The primary endpoint included a composite of major and minor complications ranging in clinical significance from cerebrovascular accident and cardiac tamponade to significant laboratory derangements.

Results:
Among this cohort, average age was 63.9 +/-11 years and 32.3% of patients were female. 93.9% of procedures were for atrial fibrillation, the remainder were for left atrial flutter or left atrial tachycardia. The composite endpoint of overall complication rate was similar between SD and ND discharge (14.3% vs 12.6%, p = 0.665). Rates of complications categorized as major (2.4% vs 3.0%, p = 0. 776) and minor (11.9% vs 9.5%, p = 0.524) were also similar. Multivariable regression modeling revealed no significant correlation between discharge strategy and complication occurrence (OR 1.565 [0.754 - 3.248], p = 0.23), but a positive association of hypertension and procedure duration with complications (OR 3.428 [1.436 - 8.184], p = 0.006) and (OR 1.01 [1 - 1.019], p = 0.046) respectively.

Conclusions:
Left atrial ablation complication rates were similar between SD and ND discharge practices while hypertension and procedural duration were positively correlated with complications. These data, which represent the first side-by-side comparison of discharge strategy, suggest same-day discharge is safe and feasible for left atrial ablation procedures.
Abstract 13340: 10-Year Risk Prediction Equations for Heart Failure in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort Study
Authors: Mehta Rupal , Ning Hongyan , Bansal Nisha , Cohen Jordana , Srivastava Anand , Dobre Mirela A , Rahman Mahboob , Townsend Raymond R , Seliger Stephen L , Lash James , Isakova Tamara , Lloyd-jones Donald M , Khan Sadiya S ,   CRIC Study Investigators
Published: May 2021

Introduction:
Heart failure (HF) is a leading contributor of cardiovascular morbidity and mortality in the chronic kidney disease (CKD) population. While risk equations such as the pooled cohort equations to prevent HF (PCP-HF) have been validated in the general population, no such tools have been evaluated in CKD-specific cohorts. Strategies for identification of individuals with CKD at higher risk of HF are needed.

Methods:
Among black and white participants with CKD stages 2-4 enrolled in the CRIC Study, we included individuals between the ages of 30-79 without baseline cardiovascular disease. We assessed model performance of the PCP-HF to predict incident HF and recalibrated the PCP-HF in the CKD population (PCP-HF
CKD
). Given that indices of kidney function are associated with HF, we examined the contribution of estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) to PCP-HF
CKD
by change in C-statistic, net reclassification index (NRI) and integrated discrimination index (IDI).

Results:
Among 2328 participants, mean (SD) baseline eGFR was 46 (15) ml/min/1.73m2 and median (IQR) UACR was 37 (7, 381) mg/g. Over 9.5 years of follow-up, 336 incident HF events occurred. The PCP-HF equations systematically under-predicted HF risk in participants with CKD (C-statistic <0.71 for all sex-race groups). The recalibrated PCP-HF
CKD
had good discrimination and calibration (C-statistic 0.75-0.78), except in black women (0.61). Addition of UACR, but not eGFR, to the PCP-HF
CKD
improved model calibration (Figure) and performance in all race-sex groups (delta C-statistic 0.03-0.11, NRI and IDI values p<0.001).

Conclusions:
Routinely available clinical data in patients with CKD can reliably predict incident HF. Further study is needed to examine whether implementation of the modified PCP-HF
CKD
risk prediction equation into clinical practice can improve HF prevention and patient outcomes.
Abstract 13341: Systolic Time Intervals and Alternative Echocardiographic Parameters to Evaluate Bioprosthetic Aortic Valve Function
Authors: Caron Charles , Pibarot Philippe , Zenses Anne-sophie
Published: May 2021

Background:
Bioprosthesis (BP) used for aortic valve replacement (AVR) in aortic valve disease are subject to structural valve deterioration (SVD) after 20 years or less which leads to reintervention. The diagnostic of SVD can be challenging in the presence of patient-prosthesis mismatch (PPM) which occurs when the effective orifice area (EOA) of the BP is too small for the metabolic needs of a patient. Both SVD and PPM are mainly diagnosed with echocardiography and are characterized by high transprosthetic mean and peak pressure gradients (MG and PG) and maximal velocity (Vmax) as well as reduced EOA. Easily accessible parameters are needed to distinguish SVD from PPM. Acceleration time (AT), ejection time (ET) and AT/ET have been proposed as accurate to identify SVD in presence of PPM. However, these parameters need to be validated.

Objectives:
The main goal of the present study is to determine the accuracy of AT and AT/ET and to validate new echocardiographic parameters that can distinguish SVD from PPM. New parameters proposed for this study are MG/EOA and PG over mean flow rate (PG/MFR).

Methods:
In a retrospective study, we analyzed echocardiographic data of 653 patients who underwent AVR. PPM was defined as a projected EOA to body surface area inferior to 0.85 cm
2
/m
2
. SVD was defined using a multiparametric integrative approach including morphological (fibrocalcific remodeling, thickening and stiffening of valve leaflets) criteria and hemodynamic changes according to American Society of Echocardiography/European Association for Cardiovascular Imaging recommendations.

Results:
EOA was lower and MG higher for patients with SVD compared to those with pure PPM. PG/Q and MG/EOA were significantly higher in patients with SVD compared to patients presenting pure PPM (PG/MFR: 0.22 mm Hg/ml/s ± 0.01 vs 0.15 mm Hg/ml/s ± 0.01; MG/EOA: 31 mm Hg/cm
2
±2 vs 16 mm Hg/cm
2
±2, p<0.001) respectively. ROC analysis showed that PG/Q and MG/EOA were the best echocardiographic parameters to distinguish pure PPM from SVD with AUC of 0.872 and 0.876 respectively. AT and AT/ET achieved AUC of 0.682 and 0.663.

Conclusion:
AT and AT/ET are not accurate parameters to identify SVD in presence of PPM. MG/EOA and PG/MFR represent interesting alternatives to conventional parameters.
Abstract 13343: Is the Early Invasive Strategy Really the Optimal Time for Patients at High-risk of Acute Coronary Syndromes Without ST-segment Elevation?
Authors: Campos Isabel , Oliveira Cátia , Marques Pires Carla , Medeiros Paulo , Flores Rui , Mané Guilherme , Braga Carlos , Gaspar António
Published: May 2021

Introduction:
An early invasive strategy has become the standard of care for pts at high-risk of NSTE-ACS in the latest guidelines, however the optimal timing of coronary intervention in this pts is still a matter of debate.

Hypothesis:
To compare the prognosis between pts at high-risk of NSTE-ACS submitted an early (<24h) versus a delayed invasive strategy (24-72h).

Methods:
A retrospective multicenter observational study including 6722 pts at high-risk NSTE-ACS (established diagnosis of NSTE-ACS based on cardiac troponins OR dynamic ST/T-changes OR GRACE score>140). Low, intermediate and very high-risk of NSTE-ACS pts were excluded, such as pts with an invasive strategy >72h. Pts were divided into two groups: group 1 - pts at high-risk of NSTE-ACS submitted an early invasive strategy (<24h) (n=3351,49.9%); group 2 - pts at high-risk of NSTE-ACS submitted a delayed invasive strategy (24-72h) (n=3371,50.1%). Primary endpoint was the occurrence of death at 1 year.

Results:
The sample was formed by 74.5% men and 25.5% women, with mean age of 65±12 years. Group 2 pts had a higher prevalence of hypertension (69.4% vs 73.0%,p=0.001), dyslipidaemia (63.1% vs 66.7%,p=0.002), CKD (3.2% vs 4.9%,p<0.001), previous MI (19.9% vs 24.3%, p<0.001) and HF (2.4% vs 3.4%, p=0.012). On admission, group 1 pts had more chest pain (96.9% vs 95.7%, p=0.010) compared to group 2 pts that had more dyspnea (1.1% vs 1.9%,p=0.007) and presented more to a non-PCI center (36.0% vs 46.3%,p<0.001). During hospitalization, group 2 had more often HF (3.3% vs 4.5%,p=0.013) and LVEF≤40% (5.9% vs 7.6%,p=0.042). Group 1 pts were more likely to have coronary revascularization (78.9% vs 74.6%,p<0.001), with the culprit artery being less identified in group 2 (20.8% vs 25.2%,p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts at high-risk of NSTE-ACS submitted an early strategy had the same risk of 1-year mortality compared to those submitted a delayed invasive strategy [OR0.76,p=0.280].

Conclusion:
In Portugal, only half of patients at high risk of NSTE-ACS undergo an early invasive strategy. However the early invasive coronary evaluation did not improve overall long-term clinical outcome compared with delayed invasive strategy.