bluuebunny/crossref_metadata_2025 huggingface dataset:
5225Bystander cardiopulmonary resuscitation and survival in out-of-hospital cardiac arrest of non-cardiac origin
Authors: Christensen D M , Rajan S , Kragholm K , Sondergaard K B , Hansen O M , Gerds T A , Torp-Pedersen C , Gislason G H , Lippert F K , Barcella C A
Published: October 2019

Background

Knowledge about the effect of bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) of non-cardiac origin is lacking. We aimed to investigate the association between bystander CPR and survival in OHCA of presumed non-cardiac origin.

Methods

From the Danish Cardiac Arrest Registry and through linkage with national Danish healthcare registries we identified all adult patients with OHCA of presumed non-cardiac origin in Denmark (2001–2014). These were categorized further into OHCA of medical and non-medical cause. We analyzed temporal trends in bystander CPR and 30-day survival during the study period. Multiple logistic regression was used to examine the association between bystander CPR and 30-day survival and reported as standardized 30-day survival chances with versus without bystander CPR standardized to the prehospital OHCA-factors and patient characteristics of all patients in the study population.

Results

We identified 10,761 OHCAs of presumed non-cardiac origin. Bystander CPR was associated with an increased 30-day survival chance of 3.4% (95% confidence interval [CI]: 2.9–3.9) versus 1.8% (95% CI: 1.4–2.2) with no bystander CPR, corresponding to a significant difference of 1.6% (95% CI: 0.9–2.3). During the study period, the overall bystander CPR rates increased from 13.6% (95% CI: 11.2–16.5) to 62.7% (95% CI: 60.2–65.2). 30-day survival increased overall from 1.3% (95% CI: 0.7–2.6) to 4.0% (95% CI: 3.1–5.2). Similar findings were observed in subgroups of medical and non-medical OHCA.

Table 1. Patient and arrest characteristics according to cause of out-of-hospital cardiac arrest Overall Medical OHCA Non-medical OHCA Patient characteristics   Total patients 10761 7625 3136   Median age,y 67 70 50   Male, n (%) 6357 (59.1) 4154 (54.5) 2204 (70.4) OHCA factors   Witnessed arrest, n (%) 4306 (40.0) 3574 (46.9) 732 (23.3)   Public location, n (%) 6979 (64.9) 5494 (72.1) 1485 (47.4) OHCA, out-of-hospital cardiac arrest; CPR, cardiopulmonary resuscitation.

Figure 1. Temporal trends

Conclusion

Bystander CPR was associated with a higher chance of 30-day survival among OHCA of presumed non-cardiac origin regardless of the underlying cause (medical/non-medical). Rates of bystander CPR and 30-day survival improved during the study period.
5227Effects of witness status and time to cardiopulmonary resuscitation by emergency medical services on neurological outcomes in out-of-hospital cardiac arrest patients with non-shockable rhythm
Authors: Funada A , Goto Y , Okada H , Maeda T , Takamura M
Published: October 2019

Background

Data on the effects of witness status and time from an emergency call to initiation of cardiopulmonary resuscitation (CPR) by emergency medical service (EMS) providers on neurological outcome in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm according to the first documented rhythm are limited.

Purpose

We aimed to determine the effects of witness status and time from an emergency call to CPR initiation by EMS providers on neurologically intact survival in OHCA patients according to the type of non-shockable rhythm (pulseless electrical activity [PEA] and asystole).

Methods

We analysed the records of 583,431 adult OHCA patients with non-shockable rhythm (191,905 bystander-witnessed arrest and 391,526 unwitnessed arrest). Data were derived from the prospectively recorded All-Japan OHCA registry between 2011 and 2016. Call to EMS-CPR interval was defined as the time from an emergency call to CPR initiation by EMS providers. The primary outcome was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1–2) and secondary outcome was presence of PEA.

Results

The rates of 1-month CPC 1–2 were 1.21% (2,326/191,905) for bystander-witnessed arrest and 0.24% (959/391,526) for unwitnessed arrest. When divided into 4 groups based on witness status and initial documented rhythm, these rates were 2.42% (1,869/77,190) for bystander-witnessed arrest with PEA (group A), 0.40% (457/114,715) for bystander-witnessed arrest with asystole (group B), 1.51% (679/44,926) for unwitnessed arrest with PEA (group C) and 0.08% (280/346,600) for unwitnessed arrest with asystole (group D). Multivariate logistic regression analysis revealed each 1-min delay of Call to EMS-CPR interval to be significantly associated with decreased chances of 1-month CPC 1–2 for groups A, B and D (adjusted odds ratio [OR]: 0.95, 0.91 and 0.96, respectively; 95% confidence interval [CI]: 0.93–0.96, 0.88–0.94 and 0.93–0.99, respectively). However, for group C, there was no significant relationship between these variables (adjusted OR: 1.00; 95% CI: 0.98–1.02). The proportion of PEA was 40.2% (77,190/191,905) for bystander-witnessed arrest and 11.5% (44,926/391,526) for unwitnessed arrest. Multivariate logistic regression analysis revealed that, as Call to EMS-CPR interval lengthened (per 1-min delay), the number of OHCA patients with PEA decreased for bystander-witnessed arrest (adjusted OR: 0.94; 95% CI: 0.93–0.94) and for unwitnessed arrest (adjusted OR: 0.96; 95% CI: 0.96–0.97).

Conclusions

The 1-month CPC 1–2 rate differed by witness status and initial documented rhythm in OHCA patients with non-shockable rhythm. Shortening of Call to EMS-CPR interval is crucial for improving 1-month CPC 1–2 rate and sustaining PEA, particularly in bystander-witnessed arrest.
5230Association of cardiac output during targeted temperature management with mortality after out-of-hospital cardiac arrest
Authors: Grand J , Kjaergaard J , Bro-Jeppesen J , Wanscher M , Hassager C
Published: October 2019

Purpose

Myocardial dysfunction and low cardiac output are common after out-of-hospital cardiac arrest (OHCA) as part of the post-cardiac arrest syndrome. This study investigates the association of cardiac output during targeted temperature management (TTM) with mortality. We hypothesized that low cardiac output during TTM is associated with mortality.

Methods

In the TTM-trial, which randomly allocated patients to TTM of 33°C or 36°C for 24 hours, we prospectively and consecutively monitored 171 patients with protocolized measurements from pulmonary artery catheters (PAC). Clinical and hemodynamic variables were registered at pre-specified time points in addition to 30-day survival status. Lactate, heart rate and cardiac index were measured at 3 time-points during TTM and averaged. We defined low cardiac output as a cardiac index during TTM <2.4 l/min/m2 in the TTM36-group and <1.8 l/min/m2 in the TTM33-group, since hypothermia affects cardiac output. We further stratified patients according to serum lactate (above/below 2 mmol/L) and heart rate (above/below median, which was 65 beats/min.).

Results

Of 152 patients with available hemodynamic measurements, 71 (47%) had low cardiac output during TTM (TTM33: 38 (49%), TTM36: 33 (44%)). Low cardiac output was not associated with mortality in univariate analysis (hazard ratio (HR): 1.47 [0.83–2.59], p=0.19) or multivariate analysis adjusted for potential confounders (HRadjusted: 0.74 [0.38–1.44], p=0.37). Low cardiac output combined with HR>65 was associated with increased mortality (HR: 2.69 [1.51–4.79], p=0.0007) in univariate, but not in multivariate analysis (p=0.22) (Figure). Low cardiac output and HR<65 was associated with decreased mortality in multivariate analysis (HRadjusted: 0.36 [0.14–0.93], p=0.03). Low cardiac output and lactate>2mmol/L was associated with increased mortality (HR: 2.73 [1.49–4.99], p=0.001) in univariate, but not in multivariate analysis (p=0.53), whereas patients with low cardiac output and lactate<2mmol/L had low mortality (HRadjusted: 0.58 [0.27–1.24], p=0.16) compared to the rest of the population (Figure).

Figure 1

Conclusion

This study found, that a frequent symptom during TTM is low cardiac output, which was not associated with mortality. However, patients with low cardiac output combined with either increased lactate or heart rate seems to be a population at risk. Whether low cardiac output should be corrected by inotropes or mechanical support to reduce mortality remains to be studied in prospective trials, but the efficacy of goal-directed therapy to increase cardiac output during TTM may be modest, especially if lactate and heart rate are normal.

Acknowledgement/Funding

The research fund Gangstedfonden and the Research fund of Rigshospitalet has supported this study with unrestricted salary in Dr. Grand's PhD project.
5951The impact of regulatory T lymphocytes on long-term survival in patients with ischemic heart failure with reduced ejection fraction
Authors: Sulzgruber P , Koller L , Blum S , Hammer A , Kazem N , Huelsmann M , Wojta J , Hengstenberg C , Niessner A
Published: October 2019

Background

Heart failure with reduce ejection fraction (HFrEF) constitutes a global health issue representing a prevalent clinical syndrome. While pro-inflammatory cytokines proved to have a pivotal role in the development and progression of HFrEF, less attention has been paid to the cellular immunity. Regulatory T lymphocytes (Tregs) seem to have an important role in the induction and maintenance of immune homeostasis especially in patients after acute coronary syndrome and coronary vessel disease. Therefore, we aimed to investigate the impact of Tregs on the outcome of patients presenting with ischemic HFrEF.

Methods

We prospectively enrolled 112 patients with HFrEF defined by New York Heart Association (NYHA) functional class >II and left ventricular ejection fraction (LVEF) <40%. Patients were stratified in ischemic (iHFrEF, n=57) and dilated etiology (dHFrEF, n=55). Cells from fresh heparinized blood were stained and analyzed using BD FACS Canto II flow cytometry. Cox regression hazard analysis was used to assess the influence of Tregs on survival. The multivariate model was adjusted forage and gender.

Results

Comparing patients with iHFrEF to dHFrEF we found a significantly lower fraction of Tregs within lymphocytes in the ischemic subgroup (0.42% vs. 0.56%; p=0.009). After a mean follow-up time of 4.5 years 32 (28.6%) patients died due to cardiovascular causes. We found that Tregs were significantly associated with cardiovascular survival in the entire study cohort with an adjusted HR per one standard deviation (1-SD) of 0.60 (95% CI 0.39–0.92; p=0.017). Interestingly while there was no association with cardiovascular survival independently in the dHFrEFsubgroup (adj. HR per 1-SD of 0.62 (95% CI 0.17–2.31); p=0.486), we found a significant inverse association of Tregs and cardiovascular survival in patients with iHFrEFwith an adj. HR per 1-SD of 0.59 (95% CI 0.36–0.96; p=0.034).

Figure 1. Survival Curves of Cardiovascular Mortality. Kaplan-Meier plots showing survival free of cardiovascular mortality in the total study collective (A) and patients stratified in ischemic CMP (B) as well dilative CMP (C) according to tertiles of frequencies of regulatory T cells. Tertile 1 = high; Tertile 2 = mid; Tertile 3 = low.

Conclusion

Our results indicate a potential influence of Tregs in the pathogenesis and progression of iHFrEF, fostering the implication of cellular immunity in iHFrEF pathophysiology and proving Tregs as a predictor for long-term survival among iHFrEF -patients.
6068Role of the circumferential right ventricle function in the right ventricle to pulmonary circulation coupling and functional capacity
Authors: Bandera F , D'Alesio G , Ghizzardi G , Losito M , Boveri S , Alfonzetti E , Guazzi M
Published: October 2019

Background

Right ventricle to pulmonary circulation (RV-PC) coupling plays a central role during the physical effort. The RV-PC uncoupling can be easily identified by the TAPSE/SPAP ratio, a prognostic marker based on RV longitudinal function and its afterload (SPAP).We sought to explore the relationship between the functional capacity (peak VO2 and VE/VCO2) and the RV-PC coupling, using both a standard and 3D-based echocardiographic assessment of RV.

Methods

Forty-four patients (age 71±10 years; LV EF 54±15%) received rest echocardiography with 3D RV assessment and cardiopulmonary exercise test. RV EF was measured using the 4D RV TomTec software. The 3D mesh of the RV model was post-processed using a custom developed software providing longitudinal (EFlong) and circumferential (EFcirc) components of EF. RV-PC coupling was assessed with the TAPSE/SPAP ratio and with similar parameters obtained using 3D components of RV systolic function over SPAP (EF/SPAP, EFlong/SPAP and EFcirc/SPAP ratio). All variables were correlated with peakVO2 and VE/VCO2.

Results

Correlations between peakVO2 and TAPSE (0.409, p=0.006), SPAP (−0.597, p<0.001), RV EF (0.555, p<0.001), RV EFlong (0.327, p=0.03), RV EFcirc (0.587, p<0.001) were modest, while TAPSE/SPAP (0.641, p<0.001), EF/SPAP (0.751, p<0.001), EFlong/SPAP (0.610, p<0.001) and EFcirc/SPAP (0.775, p<0.001) showed stronger correlations. VE/VCO2 showed a similar relationships although the correlations were weaker [TAPSE (−0.531, p<0.001), SPAP (0.614, p<0.001), RV EF (−0.409, p=0.006), RV EFlong (−0.232, p=0.129), RV EFcirc (−0.454, p=0.002), TAPSE/SPAP (−0.561, p<0.001), EF/SPAP (−0.516, p=0.001), EFlong/SPAP (−0.417, p=0.008) and EFcirc/SPAP (−0.534, p<0.001)].

Conclusions

RV-PC coupling is associated with both peak VO2 and VE/VCO2. The use of 3D-derived markers of RV-PC coupling showed a better correlation with the peak VO2 while there were no differences for VE/VCO2. The circumferential component of RV systolic function seems to emerge as a dominant determinant of RV-PC coupling, as well of functional capacity.
6074Cardiorespiratory fitness, socioeconomic status and mortality in middle-aged men: a population-based prospective cohort study
Authors: Jae S Y , Kurl S , Franklin B A , Choo J , Kim H J , Kunutsor S K , Laukkanen J A
Published: October 2019

Background

Although both low socioeconomic status (SES) and poor cardiorespiratory fitness (CRF) are associated with increased chronic disease and a heightened risk of death, it remains unclear whether moderate-to-high levels of CRF confer survival benefits in low SES populations.

Purpose

The present study evaluated the hypothesis that SES and CRF predict all-cause mortality (ACM), cardiovascular disease (CVD) mortality and sudden cardiac death (SCD), and that moderate-to-high levels of CRF may attenuate the associations between low SES and adverse cardiovascular outcomes.

Methods

This prospective study was based on a population-based sample of 2,368 men aged 42 to 61 years, who were followed in the Kuopio Ischemic Heart Disease cohort. CRF was directly measured by peak oxygen uptake (VO2peak) during progressive exercise testing to volitional fatigue. SES was characterized using self-reported questionnaires via combined measures of income, education, occupation, occupational prestige, material standard of living, and housing conditions. CRF and SES were divided into tertiles, and 4 combined groups (Fit-high SES, Fit-low SES, Unfit-high SES, and Unfit-low SES) based on the median values of CRF and SES.

Results

During a 25 year median follow-up (interquartile ranges: 18–27 years), 1116 ACM, 512 CVD mortality and 221 SCD events occurred. After adjusting for potential confounders (age, smoking, alcohol, body mass index, systolic blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, glucose, diabetes, hypertensive medication, family history of coronary heart disease, and physical activity), the lowest levels of SES were at significantly increased risk for ACM (hazard ratio (HR) 1.49, 95% Confidence Interval (CI): 1.30–1.71), CVD mortality (HR 1.38, 1.13–1.69) and SCD (HR 1.34, 0.97–1.84). In contrast, higher levels of CRF were associated with lower risks of ACM (HR 0.56, 0.46–0.67), CVD mortality (HR 0.53, 0.40–0.71) and SCD (HR 0.53, 0.34–0.83). In combined associations of SES and CRF with mortality, unfit-low SES had significantly higher risks of ACM (HR 2.12, 1.75–2.57), CVD mortality (HR 2.20, 1.64–2.94) and SCD (HR 2.95, 1.79–4.86), but fit-low SES was not associated with a heightened risk of cardiovascular mortality or SCD (CVD mortality, 1.03, 0.73–1.46; SCD, 1.54, 0.87–2.72) as compared with their fit-high SES counterparts (reference).

Conclusion

Our findings indicate that both SES and CRF are independently associated with the risk of death; however, moderate-to-high levels of CRF appear to attenuate the risk of CVD mortality and SCD in low SES men. These unique data have important implications for public health interventions designed to enhance survival in underserved population cohorts.
6082A prospective, multicenter, nationwide, observational study of flecainide controlled release on the quality of life of patients with atrial fibrillation in Greece, the REFLEC-CR study
Authors: Tzeis S , Tsiachris D , Kourouklis S P , Patsourakos F , Karlis D , Kouskos G , Gavriilidou M , Koufaki P , Vatkalis N , Kapetanios K , Papadimitriou G , Taxiarchou E , Giannakoulas G
Published: October 2019

Background/Introduction

Atrial fibrillation (AF) is the most common cardiac arrhythmia with a considerable impact on patients' quality of life (QoL). Flecainide acetate, is a class Ic antiarrhythmic agent, recommended as first line treatment in AF patients without underlying structural heart disease.

Purpose

This prospective, multicenter, nationwide, observational study aimed to evaluate the effect of oral treatment with controlled-release (CR) flecainide administered once daily on AF patients' QoL and treatment compliance during a 12-week period.

Methods

A total of 70 cardiologists participated in the study enrolling consecutive adult patients with paroxysmal or persistent AF, treated with flecainide CR in the context of a rhythm control strategy. The effect on QoL was assessed by the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale (CCS-SAF) measured at baseline and at 12 weeks of treatment.

Results

In total, 679 patients (53.2% females, mean age 65.9±11.7 years, 86.9% paroxysmal AF) were included in the analysis. At least one prior antiarrhythmic treatment was documented in 43.8% of patients. The initial daily dose of flecainide CR was 100mg in 71.7% of the patients, with a titration to 200mg by the end of study achieved in 67%. In 93.6% of patients an excellent compliance score (100%) to treatment was recorded at the end of the study period. Treatment with flecainide CR resulted in a significant improvement in QoL as presented in the table.

Table 1 CCS-SAF score Baseline (Week 0) End of study visit (Week 12) N=679 N=634 Class 1 (minimal effect on QoL) 343 (50.5) 464 (73.2) Class 2 (minor effect on QoL) 253 (37.2) 140 (22.1) Class 3 (moderate effect on QoL) 73 (10.8) 28 (4.4) Class 4 (severely impairs QoL) 10 (1.5) 2 (0.3) CCS-SAF continuous score   Mean ± SD 1.64±0.73 1.32±0.57 Change from baseline‡   Mean (95% CI) −0.325 (−0.379, −0.271)   p-value <0.0001 ‡Paired t-test is used.

Conclusions

This prospective, multicenter, observational study demonstrated that treatment of AF patients with flecainide CR, was associated with a significant improvement of QoL and excellent compliance to treatment.

Acknowledgement/Funding

Sponsored by WinMedica S.A.
6119Correction of transcatheter aortic valve replacement induced left bundle branch block by His bundle pacing
Authors: De Pooter J , Calle S , Coeman M , Philipsen T , Gheeraert P , Jordaens L , Kayaert P , Timmermans F , Vanheuverswyn F
Published: October 2019

Background

Left bundle branch block (LBBB) occurs frequently after transcatheter aortic valve replacement (TAVR) and is associated with increased risk of permanent pacemaker implantation, heart failure hospitalization and sudden cardiac death. This pilot study explored the feasibility of TAVR-induced LBBB correction with His bundle pacing (HBP).

Methods

Patients with TAVR -induced LBBB and postoperative need for permanent pacemaker implant were planned for electrophysiology study and HBP. Patients with persistent high degree AV-block were excluded. HBP was performed using the Select Secure pacing lead, delivered through a fixed curve or a deflectable sheath. Successful HBP was defined as correction of LBBB by selective or non-selective HBP with LBBB correction thresholds less than 3.5V at 1.0ms at implant.

Results

The study enrolled 6 patients (mean age 85±2.5 years, 50% male). Mean QRS duration was 152±10ms, PR-interval 212±12ms AH-interval 166±16ms and HV-interval 62±12ms. Successful HBP was achieved in 5/6 (83%) patients. Mean QRS duration decreased from 153±11ms to 88±14ms (p=0.002). At implantation, mean threshold for LBBB correction was 1.6±1.0V (unipolar) and 2.2±1.3V (bipolar) at 1.0ms. Periprocedural, two complete AV-blocks occurred, both spontaneously resolved by the end of the procedure. Thresholds remained stable at 1 month follow up: 1.8±1.0V (unipolar) and 2.3±1.5V (bipolar) at 1.0ms.

Figure 1

Conclusion

Permanent His bundle pacing can safely correct TAVR-induced LBBB in the majority of patients. Further studies are needed to assess potential benefits of His bundle pacing over conventional right ventricular pacing in this population.
6120Anatomical investigation of the sinus node artery and the radiofrequency application sites for catheter ablation of atrial fibrillation
Authors: Suzuki T , Eguchi S , Ishihara D
Published: October 2019

Background

Circumferential pulmonary vein isolation is an established therapy for selected patients with atrial fibrillation (AF). Three-dimensional imaging modalities can be useful to establish the mechanism of a procedure-related complication.

Purpose

The purpose of this study was to investigate the course of the sinus node artery (SNA) and the coronary arterial injury during catheter ablation of AF.

Methods

In the 254 consecutive patients, the courses of the SNA were recorded using multislice computed tomography.

Results

The visualization rate was 96.9% (246/254). Of 246 patients, 287 SNAs were detected among which 114 (44.9%) originated from the right coronary artery, 91 (35.9%) from the left circumflex (Cx) artery, and 41 (16.1%) from both the right and Cx artery. Only SNAs originated from the Cx artery coursed along the left atrium. Only in 2 patients, SNAs coursed endocardial surface of the left atrium. In one of these 2 patients, sinus node dysfunction developed just after the ablation of the right superior pulmonary vein ostium, requiring a permanent pacemaker implantation. The SNA originated from the distal Cx artery, and precisely coursed endocardial surface at the radiofrequency application site. Coronary angiography revealed the occlusion of the SNA at that site, and the SNA occlusion was presumed the cause of the sinus node dysfunction in this patient.

Conclusion

The recognition of the course of the SNA is important in minimizing the risk of sinus node dysfunction during catheter ablation of AF.
6122Pulmonary vein isolation by different setting of high-power short-duration radiofrequency application: feasibility, short term efficacy and safety in patients with atrial fibrillation
Authors: Castrejon Castrejon S , Martinez Cossiani M , Ortega Molina M , Escobar Cervantes C , Froilan Torres C , Gonzalo Bada N , Diaz De La Torre M , Suarez Parga J M , Batlle M , Gonzalez Davia R , Lopez Sendon J L , Merino J L
Published: October 2019

Aims

Pulmonary vein (PV) isolation (PVI) by point-by-point radiofrequency application (PPRF) results in longer procedures than cryoballoon ablation. In addition, it is associated with more esophageal lesions. The aim of this study was to evaluate the feasibility and safety of PVI by high power short duration (HPSD) PPRF in patients with atrial fibrillation.

Methods

PPRF around the PVs was done in 125 consecutive patients distributed in two chronologically successive groups. Conventional PPRF with 30W for ≤30 s under luminal esophageal temperature monitoring was performed in the first 47 patients (Group 1). 68 patients were enrolled in the HPSD (Group 2). Power was set to 50 W and delivered to reach a predefined lesion index value (LSI ≥5 or Abl-I ≥350) in the first 18 patients (Group 2A). 30 patients underwent PPRF with 60W for 7–10 s (Group 2B) and the last 30 patients underwent PPRF with 70W for 9 s (Group 2C). Esophageal endoscopy was performed after ablation in all patients.

Results

PVI of all targeted veins was achieved in 96% and 100% of patients of groups 1 and 2 respectively (p=0.6). Total RF time was 30 [27–43], 25 [20–29], 16 [14–20] and 14 [11–16] min in groups 1, 2A and 2B and 2C respectively (p<0.001). RF was delivered for 12 [9–17] s vs 9 [8–9]s vs 9 [8–9] per application in groups 2 A, 2B and 2C respectively (p<0.001). Total number of RFa to completely isolate all PV was 105 [90–126] in group 2A, 113 [90–135] in group 2B and 94 [79–112] in group 2C (p=0.12).

First-pass PVI was achieved in 56%, 57% and 85% of left PV (p=0.038) and in 56%, 60% and 82% of right PV (p=0.13) in groups 50W, 60W and 70W respectively. The carina was the most frequent location of persistent conduction when first-pass failed. Reconnections occurred in 6%, 3% and 11% of left PV (p=0.6) and in 6%, 7% and 4% (p=0.63) of right PV in groups 50W, 60W and 70W respectively. Adenosine test was systematically used in groups 60W and 70W: the incidence of dormant conduction was 23% and 22% (p=0.9) in left PV and 20% and 22% (p=0.8) in right PV respectively.

The incidence of esophageal lesions was 28% in Group 1, 2% in Group 2A, and 0% in groups 2B and 2C (p<0.001). No other intraprocedural complications occurred in the high-power group.

Total RF time

Conclusions

PVI is feasible with HPSD PPRF in most patients using shorter total RF times. This approach appears associated with very low incidence esophageal damage than the conventional one, especially when 60W/70W and shorter application time are used.

Acknowledgement/Funding

Grant of the Spanish Society of Cardiology
6129Temporal trends and patterns in cause-specific mortality and hospitalisations after incident heart failure: a longitudinal analysis of 86,000 individuals
Authors: Conrad N , Judge A , Canoy D , Cleland J G , McMurray J J V , Rahimi K
Published: October 2019

Background

The past two decades have brought considerable improvements in heart failure care. Clinical trials have demonstrated effectiveness of several different treatments in reducing mortality and hospitalisations, and observational studies have shown that these treatments are increasingly being used in many countries. Little is known about whether these changes have been reflected in patient outcomes in routine clinical settings.

Methods

We used anonymised electronic health records that link information from primary care, secondary care, and the national death registry to investigate 86,000 individuals with newly diagnosed heart failure between 2002 and 2013 in the UK. We computed all-cause and cause-specific mortality rates and number of hospitalisations in the first year following diagnosis. We used Poisson regression models to calculate category-specific rate ratios and 95% confidence intervals, adjusting for patients' age, sex, region, socioeconomic status and 17 major comorbidities.

Findings

One year after initial heart failure diagnosis, all-cause mortality rates were high (32%) and did not change significantly over the period of study (adjusted rate ratio (RR) 2013 vs 2002: 0.94 [0.88, 1]). Overall rates masked diverging trends in cause-specific outcomes: a decline in cardiovascular mortality (RR: 0.74 [0.68, 0.81]) was offset by an increase in non-cardiovascular mortality (RR: 1.28 [1.17, 1.39]), largely due to infections and chronic respiratory conditions. Sub-group analyses further showed that overall mortality declined among patients under 80 years of age (RR 2013 vs 2002: 0.79 [0.71, 0.88]), although not in older age groups (RR 2013 vs 2002: 0.97 [0.9, 1.06]). After cardiovascular causes (43%), the major causes of death identified in 2013 were neoplasms (15%), respiratory conditions (12%), and infections (11%). Hospital admissions within a year of heart failure diagnosis were common (1.15 hospitalisations per patient-year at risk), changed little over time (RR: 0.96 [0.92, 0.99]), and were largely (60%) due to non-cardiovascular causes.

Interpretation

Despite increased use of life-saving interventions, overall mortality and hospitalisations following a new diagnosis of heart failure have changed little over the past decade. Improved prognosis among young and middle-aged patients marks an important achievement and attests of complex barriers to progress in elderly patients. The shift from cardiovascular to non-cardiovascular causes of death suggest that management of associated comorbidities might offer additional opportunities to improve patients' prognosis.

Acknowledgement/Funding

British Heart Foundation, National Institute for Health Research, UK Research and Innovation.
6131Association between hospital care quality and readmission among Japanese patients with heart failure. From JROAD-DPC study
Authors: Nakao K , Yasuda S , Noguchi T , Nakai M , Sumita Y , Nakao Y M , Nishimura K , Miyamoto Y , Ogawa H
Published: October 2019

Background

Measuring the process of care has become a widely used practice to improve a quality of care. Recently, some studies have demonstrated poor to no correlation between 30-day readmission rates and quality of care for heart failure (HF) among hospitalized HF patients. However the investigation about relationships of care quality for HF and 1 year outcome is limited.

Purpose

To investigate the relationship between quality of care in each hospitals and readmission among HF patients in Japan.

Methods

From Japanese Registry of All cardiac and vascular diseases (JROAD-DPC) database in 2014, 84,325 HF patients hospitalized to 741 certificated hospitals by Japanese Circulation Society were analyzed. A primary endpoint was readmission for HF in one year. Five performance measures were defined as prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), prescription rate of beta blocker and prescription rate of spironolactone, measurement rate of echocardiography and measurement rate of B-type natriuretic peptide (BNP) during hospitalization. For each of the five measures, a composite score was created by giving points ranging from 1 to 4 from the lower quartile of rates, with the score ranging from 5 to 20 points. Hazard ratios (HR) indicating the effects of the performance measures were estimated using Cox proportional hazard models. Covariates included age, gender, Charson score, and NYHA class.

Results

In Japanese HF patients (age; 78.1 years old, man 52%), the HF readmission rate in one year was 14,520 (17.2%). The readmission rate decreased with higher quartiles of prescription rate in each medications and performance rates. The highest quartile of each measurements was significantly lower risk for readmission compared to the lowest quartile (ACE/ARB, adjusted HR 0.87 [95% CI, 0.83–0.91], p<0.001; beta-blocker, 0.83 [0.79–0.88], p<0.001; spironolactone, 0.88 [0.83–0.92], p<0.001; echocardiography, 0.90 [0.86–0.94], p<0.001; BNP, 0.92 [0.87–0.96], p<0.001). Kaplan-Meier curves showed that readmission rates were better among higher composite score, compared to lower composite score (Log-rank test=p<0.001). (Figure) Higher composite scores were associated with statistically significant risk reduction of 23% for HF readmission (HR 0.77, 95% CI [0.73–0.81], p<0.001).

Figure 1

Conclusion

The hospital performance measures were associated with a significant risk reduction of readmission in Japanese patients with HF.
6133Profile of cardiomyopathy patients in Cape Town - pilot phase the IMHOTEP Study
Authors: Kraus S M , Samuels P , Laing N , Ntsekhe M , Chin A , Moosa S M , Sliwa K , Ntusi N
Published: October 2019

Background

Cardiomyopathies pose a great challenge because of poor prognosis and high prevalence in LMIC with limited access to specialised care. Little is known about the clinical profile of cardiomyopathy in Africa.

Purpose

Delineation of clinical presentation and cardiovascular magnetic resonance (CMR) phenotypes of cardiomyopathy.

Method

The African Cardiomyopathy and Myocarditis Registry Program (IMHOTEP) is a prospective multi-centre, hospital-based study and aims to investigate the clinical characteristics, aetiology, genetics, management and outcomes of cardiomyopathies in Africans.

Results

Assessment of the first 99 adult cases showed that dilated cardiomyopathy (DCM; n=67) was commonest, followed by hypertrophic (HCM; n=13), left ventricular noncompaction (LVNC; n=11), restrictive (RCM; n=4) and arrhythmogenic (ARVC; n=4) cardiomyopathies. Idiopathic DCM (22%) and peripartum cardiomyopathy (16%) accounted for the majority (Figure). A family history of cardiomyopathy or SCD was reported in 20% of cases. Mean age of presentation was 37±12 years. Most patients (96%) were symptomatic at presentation. NYHA class III/IV was more frequently seen in DCM (61%), RCM (50%) and LVNC (64%), whereas syncope was more common in ARVC (50%) and HCM (23%). VT and aborted cardiac arrest were reported in 7% and 3%, respectively. Onset of symptoms in the peripartum period was observed in 47% of women. Beta-blockers and ACE-inhibitors were prescribed in 77% and 78%, respectively, however optimal dosing was achieved in ≤14% of patients at a median time of 5.4 months after symptom onset. CMR was performed in 67 (68%) cases (Table) and contributed diagnostically in a third of cases. Late gadolinium enhancement (LGE) was observed in 92%. In DCM, linear mid-wall and subendocardial patterns of LGE were seen in 95% and 8% of patients respectively – a much higher percentage than previously reported in the literature.

CMR volumetric and functional assessment DCM, n=38 HCM, n=11 ARVC, n=3 RCM, n=4 LVNC, n=11 LVEF (%) 27±15 78±7 55±5 52±7 32±17 LVEDV/BSA (ml/m2) 150±40 80±17 98±12 59±13 155±52 LV mass/BSA (g/m2) 82±23 102±35 74±3 71±14 88±31 RVEF (%) 34±15 68±10 22±15 49±18 33±15 RVEDV/BSA (ml/m2) 104±37 68±15 189±27 56±8 106±51 All continuous variables presented as mean ± standard deviation.

Cardiomyopathy diagnosis (n=99)

Conclusion

IMHOTEP is the first multi-centre registry for cardiomyopathy in Africa. Preliminary data suggests an earlier age of onset with female predominance compared to other cohorts, and DCM is the predominant form of cardiomyopathy in Africa.

Acknowledgement/Funding

NEWTON FUND NON-COMMUNICABLE DISEASE - South African Medical Research Council (SAMRC/GSK)
P4982Blunted heart rate reserve as an imaging-independent prognostic predictor during dipyridamole-echocardiography test
Authors: Torres M A R , Cortigiani L , Bovenzi F , Carpeggiani C , Picano E
Published: October 2019

Background

A blunted heart rate (HR) response during dipyridamole myocardial perfusion imaging have been associated with a poor outcome.

Aim

To assess the value of HR response in patients undergoing high dose dipyridamole stress echocardiography (SE).

Methods

We retrospectively selected a consecutive sample of 1,622 patients (none with pacemakers or atrial fibrillation), mean age 66±12 years, 431 (27%) on beta-blockers. All underwent high dose (0.84 mg/kg) dipyridamole SE for known or suspected coronary artery disease and/or heart failure from January 1988 to January 2018 in our Cardiology Division. HR (with 12-lead ECG) was obtained each minute and recorded at rest and peak stress. HR reserve (HRR) was calculated as the peak/rest HR ratio. All patients were followed-up. The composite end-point was made of all cause-death, non-fatal myocardial infarction and late (>3 months) symptoms-driven myocardial revascularizations.

Results

SE was positive for regional wall motion abnormalities (RWMA) in 192 patients (12%). HR increased (rest=70±11 beats/min vs stress= 92±17 beats/min, p<0.0001). During a median follow-up time of 904 days, 462 events occurred: 73 deaths, 57 non-fatal myocardial infarctions, 332 myocardial revascularizations. Receiver operating curve analysis identified a HRR ≤1.27 as the best cutoff. At multivariate analysis a reduced HRR was a significant predictor of hard events (Hazard Ratio, HR=2.02, 95% Confidence Intervals, CI, 1.38–2.95, P<0.0001), additive to ischemic regional wall motion abnormalities (HR=2.11, 95% CI 1.28–3.48, P=0.004), resting RWMA (HR =1.88, 95% CI 1.31–2.72, P<0.001), age (HR =1.06, 95% CI 1.04–1.08, P<0.001) and beta-blockers at the time of testing (HR =1.55, 95% CI 1.06–2.29, P=0.03). Five-year hard event-free survival increased from 6% to 26% from the highest to the lowest HRR quartile: see figure.

Survival curve

Conclusion

A blunted HRR is a useful non-imaging predictor of adverse events during high dose dipyridamole-SE. It is additive over resting or inducible regional wall motion abnormalities, and unmasks a prognostically meaningful autonomic unbalance. Chronotropic incompetence during dipyridamole SE is a negative prognostic finding, equally important than RWMA.
P4983Safety of dobutamine stress contrast echocardiography; a single-center experience of 15 years
Authors: Dimitroglou Y , Aggeli C , Tsiampalis T , Oikonomou E , Zisimos K , Raftopoulos L , Polytarchou K , Verveniotis A , Angelis A , Kastellanos S , Savvalas D , Roussakis G , Tousoulis D
Published: October 2019

Introduction

Dobutamine stress contrast echo (DSCE) is an accurate method for the diagnosis of coronary artery disease (CAD). Scarcity of serious adverse events has led to its establishment as a popular method for the diagnosis of CAD and to its increased use beyond CAD. However, data regarding the safety of single-line dobutamine and contrast infusion are limited. The aim of our study was to assess the safety of a DSCE protocol using a single line of intravenous access.

Methods

Over a 15-year period (2004–2018), 34,675 patients underwent DSCE in our department, which was performed using 10–20–30–40–50 μg/kg/h of dobutamine with dosage increase every three minutes, while atropine up to 1mg could also be administered. Two commercially available contrast agents were used at rest and at peak in all patients and a single intravenous line was used for infusion of dobutamine, atropine and contrast agents. Demographic data, risk factors and information concerning the most common cardiovascular or allergic adverse events were available for all patients. Finally, the adverse events of DSCE were compared with respective events reported by relevant studies in order to determine the safety of our method.

Results

Mean age of patient population was 63.9 (SD: 11.4 years), while 67.9% of patients (n=23,544) were males. There were 22,731 hypertensive patients (65.6%), 9,256 diabetics (26.7%), 21,683 patients (62.5%) had dyslipidemia, 11,760 (33.9%) were smokers and 10,437 (30.1%) had a positive family history of CAD. Adverse events were reported in 876 patients (2.5%). Allergic reaction was reported in 69 patients (0.2%). We recorded 643 patients (1.85%) with non-sustained VT or frequent premature ventricular ectopic beats and 154 patients (0.44%) with AF or SVT episodes leading to protocol termination. In 24 patients (0.07%) with sustained VT, antiarrhythmic drugs were given intravascularly, while in 10 patients (0.03%) with VT or VF, resuscitation was needed. No death was reported. Frequency of life threatening adverse events reported by relevant studies did not differ significantly when compared to the present results.

Conclusion

DSCE protocols involving single line infusion of dobutamine, atropine and ultrasound enhancing agents are safe, since adverse event rates are low and do not differ significantly to rates reported for unenhanced DSE by other relevant studies. Implementation of such protocols in clinical practice may increase patient comfort and cost-effectiveness and should therefore be encouraged.
P4985Blunted heart rate reserve as an imaging-independent predictor of abnormal left ventricular contractile reserve
Authors: Zagatina A , Bombardini T , Djordjevic-Dikic A , Rodriguez-Zanella H , Ciampi Q , Gaibazzi N , Wierzbowska-Drabik K , Simova I , Lattanzi F , Cortigiani L , Haberka M , Ostojic M , Kovacevic Preradovic T , Carpeggiani C , Picano E
Published: October 2019

Background

Stress echocardiography (SE) relies on regional wall motion and left ventricular contractile reserve (LVCR) based on force (systolic blood pressure/end-systolic volume). An additional non-imaging parameter based on EKG is the blunted heart rate reserve (HRR) which is a simple marker of altered autonomic balance and is associated with worse prognosis independently of ischemia.

Aim

To assess the relationship between HRR and LVCR in patients undergoing SE.

Methods

We enrolled 4707 patients (age 63.6±11.3 yrs, 2800 males) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. The employed stress was exercise (n=2062), dipyridamole (n=2007) or dobutamine (n=638). We assessed LVCR (stress/rest ratio of force=systolic blood pressure/end-systolic volume, ESV). Stress-specific abnormal cutoff value of LVCR were <2.0 for exercise and dobutamine and <1.1 for dipyridamole. All readers had passed the upstream quality control reading for wall motion abnormalities and ESV. HR (with 12-lead ECG) was obtained each minute and recorded at rest and peak stress. HR reserve (HRR) was calculated as the peak/rest HR ratio.

Results

HRR was related to LVCR at cumulative (n=4707; r=0.351; p<0.001: see figure) and stress-specific analysis for exercise (r=0.351; p<0.001), dipyridamole (r=0.241; p<0.001) and dobutamine (r=0.214; p<0.001). At multivariate logistic regression analysis, blunted HRR (optimal cutoff: 1.73 for exercise, 1.306 for dipyridamole, 1.932 for dobutamine) was a significant predictor of abnormal LVCR at stress-specific analysis for exercise (Odds ratio = 0.285, 95% Confidence Intervals: 0.149–0.546, p=0.0001), dobutamine (Odds ratio = 0.187, 95% Confidence Intervals: 0.057–0.617, p=0.0001) and dipyridamole (Odds ratio = 0.263, 95% Confidence Intervals: 0.115–0.602, p=0.002).

Conclusion

A blunted HRR is a useful non-imaging predictor of abnormal LVCR response during exercise or pharmacological SE. HRR is a simple biomarker of autonomic unbalance of physiologic and potentially prognostic meaning. A “slow heart” during stress (with blunted HRR) is more often a “weak heart”, with blunted increase in force.
P4991Effects of the glucagon like peptide-1 receptor analogue, sodium-glucose co-transporter 2 and their combination on myocardial work index and vascular function in diabetes after 3-month treatment
Authors: Ikonomidis I , Birba D , Thymis J , Kalogeris A , Balampanis K , Trantafyllou C , Karamichalakis N , Kountouri A , Makavos G , Pavlidis G , Katogiannis K , Kousathana F , Dimitriadis G , Iliodromitis E , Lambadiari V
Published: October 2019

Glucagon like peptide-1 analogues (GLP-1A) and sodium-glucose co-transporter 2 (SGLT2) are used in the treatment of type 2 diabetes mellitus (T2DM) We investigated whether the effects of treatment with GLP-1A and SGLT2 and their combination on vascular and cardiac function.

Methods

A hundred twenty, patients with type 2 diabetes were randomized to receive the insulin +/− metformin (n=30), GLP-1A, liraglutide (n=30), the SGLT-2, empagliflozin (n=30) or their combination (GLP-1R+SGLT-2) for 3 months (n=30). We measured at baseline and after treatment a) pulse wave velocity (PWV), central systolic blood pressure (cSBP) b) the perfusion boundary region (PBR-micrometers) of the sublingual arterial microvessels, as a marker of endothelial glycocalyx thickness. c) global LV longitundinal strain (GLS), peak LV untwisting velocity and global myocardial work index (GWI) derived by pressure–myocardial strain loops using speckle tracking imaging and PWV to GLS ratio, as a marker of ventricular-arterial coupling

Results

All treatment groups had similar vascular and cardiac markers, glucose levels and HbA1 at inclusion (p>0.05). After treatment, all patients had improved GLS, PWV and increased LV twisting-untwisting velocities (p<0.05). Patients under GLP-1R, SGLT-2 and their combination achieved a significant reduction of PBR, PWV, central SBP and a greater increase of GWI (30%, 25% and 50% respectively) and LV untwisting velocities (p<0.05) than those under insulin (15% reduction of GWI), despite a similar reduction of HbA1 (p<0.05). The combination of GLP-1A and SGLT-2 showed a greater improvement of the measured markers than each treatment alone (table, p<0.05). The reduction of PBR (indicating improvement of glycocalyx thickness) was related with the changes in central SBP (r=0.40) and PWV (r=0.35) (p<0.05).

N=120 Insulin GLP-1A SGLT-2 GLP-1A + SGLT-2 P 3-months N=30 N=30 N=30 N=30 PBR, μm 2.27±0.3 2.17±0.3 2.17±0.3 1.99±0.2 <0.05 Central SBP, mmHg 136±20 127±16 126±11 124±10 <0.05 PWV, m/sec 11.7±0.5 9.5±0.5 9.3±0.5 9.2±0.5 <0.05 HbA1 7.1±1.5 6.6±0.3 6.7±0.6 6.2±0.6 0.8 Myocardial work index (GWI), mmHg% 1343±394 1579±245 1364±431 1784±593 <0.05 LV untwisting velocity, deg/sec −116±36 −123±36 −122±36 −130±36 <0.05 PWV/GLS ratio −0.77±0.2 −0.57±0.2 −0.66±0.3 −0.55±0.3 <0.05

Conclusion

Three-month treatment with GLP-1A, SGLT-2 and their combination showed a greater improvement of vascular markers, ventricular-arterial coupling and effective cardiac work than insulin treatment in type 2 diabetes.
P5009The major bleeding event is the stronger predictor of long term mortality rather than the coronary event in the secondary prevention of ischemic heart disease in Japan
Authors: Kageyama S
Published: October 2019

Background/Introduction

Secondary prevention for ischemic heart disease (IHD) is important part in health care. To improve the risk factor control with general practitioners, we decided to set up a unique referral system to connect the hospital and outpatient clinics.

Purpose

Long term prognosis of IHD patients is unknown. The aims of this study are introducing our unique audit referral system and showing the long term prognosis of IHD patients with optimal second prevention therapy.

Methods

IHD patient registry was established in 2009 to connect cardiologists in the core hospitals and more than 200 general practitioners in Shizuoka city. To audit the treatment of general practitioners, we adopted a circulation type cooperative form. Target values of risk factors are as follows; low-density-lipoprotein cholesterol (LDL-C) concentration less than 100 mg/dl, HbA1c in diabetic patients less than 7%, systolic blood pressure (SBP) less than 130mmHg, and diastolic blood pressure (DBP) less than 80mmHg. General practitioners are required to introduce registered patients at least once a year even there is no event. Mean follow-up interval was 2001±794 days.

Results

We could follow 1240 patients who were registered from May 2009 to December 2013 and followed by at least one visit to the hospital in the prescribed manner until September 2018. Mean age was 77.3±10.6 years old, and 39.6% of them had old myocardial infarction. Latest risk factor controls are as follows; LDL-C 88.0±21.3mg/dl, HbA1c control in diabetic patients 7.0±1.1%, SBP and DBP 133.7±16.5 and 75.0±11.8mmHg respectively.

Cumulative incidence of all-cause death was 10.8%, cardiac death was 1.5%, and coronary event (combination of cardiac death, myocardial infarction, angina pectoris which need hospitalization, and any lesion revascularization) was 15.8%. Cumulative incidence of major bleeding was 2.6%. The patients were divided into three groups without overlapping; major bleeding group (n=34), coronary event group (n=195), and event-free group (n=1049). The nonparametric test showed significant differences between three groups concerning age (p=0.026), the rate of using antithrombotic drugs (p<0.001) and mortality (p=0.017). Kaplan-Meier method concerning all-cause death showed a significant difference between event-free group and major bleeding group (log rank p=0.002), and coronary event group and major bleeding group (p=0.026), while no statistical difference between event-free group and coronary event group.

Cumulative survival rate

Conclusions

Our unique referral system revealed long term events in the stable IHD patients in Japan. The major bleeding event is a strong predictor of long term mortality in IHD patients rather than the coronary event.