bluuebunny/crossref_metadata_2025 huggingface dataset:
P1257ETNA-AF Europe: First 1-year follow-up snapshot analysis of more than 7,500 AF patients treated with edoxaban in routine clinical practice
Authors: De Caterina R , Kelly P , Monteiro P , Deharo J C , De Asmundis C , Lopez-De-Sa E , Weiss T , Waltenberger J , Steffel J , De Groot J R , Levy P , Bakhai A , Kirchhof P
Published: October 2019

Introduction

Edoxaban has been approved for stroke prevention in patients with atrial fibrillation based on its comparable efficacy and superior safety compared to warfarin in the pivotal ENGAGE AF-TIMI 48 trial. ETNA-AF Europe (NCT02944019) was initiated in agreement with the EMA to evaluate benefits and risks of edoxaban treatment in unselected patients in routine clinical practice.

Methods

13,980 patients from across 825 hospital and office-based physicians from 10 European countries (Austria, Belgium, Germany, Ireland, Italy, The Netherlands, Portugal, Spain, Switzerland and United Kingdom) were enrolled, and will be followed-up for 4 years. This snapshot analysis includes baseline and first outcome data of 7,672 patients (56.3% of all enrolled patients) that have completed their first 1-year follow-up visit (mean follow-up: 343.5 days).

Results

The average age of patients was 73.4 years, the mean weight was 81.9 kg (Table 1). Frequent comorbidities include hypertension (77.2%), valvular heart disease (17.4%), congestive heart failure (5.8%) and history of myocardial infarction (4.2%). Patients receiving the 30 mg dose (22.9%) were older, had a lower creatinine clearance and had a higher risk for both stroke and bleeding as compared to those on the 60 mg dose (77.1%). Overall, the incidence of clinical events was low: all-cause mortality: 3.56%/y, major bleeding 0.95%/y, intracranial haemorrhage 0.28%/y, any stroke or systemic embolic events 0.88%/y.

Patient characteristics at Year 1 Patient characteristics All patients Edoxaban 60 mg Edoxaban 30 mg [7,672] [5,916 (77.1%)] [1,756 (22.9%)] Age [years] mean (SD) 73.4 (9.26) 71.8 (8.98) 79.1 (7.81) Body weight [kg] mean (SD) 81.9 (17.33) 84.1 (16.80) 74.3 (16.93) CrCl (CG) [mL/min] mean (SD) 75.0 (30.29) 82.5 (29.14) 51.2 (19.75) CHA2DS2-VASc mean (SD) 3.1 (1.38) 2.9 (1.34) 3.8 (1.28) HAS-BLED mean (SD) 2.5 (1.10) 2.4 (1.07) 2.9 (1.08) First occurrence of all-cause mortality (n, %/year) 257 (3.56%) 129 (2.31%) 128 (7.90%) First occurrence of intracranial haemorrhage (n, %/year) 20 (0.28%) 16 (0.29%) 4 (0.25%) First occurrence of major bleeding (n, %/year) 68 (0.95%) 49 (0.88%) 19 (1.18%) First occurrence of stroke/SEE (n, %/year) 63 (0.88%) 45 (0.81%) 18 (1.11%) CG, Cockcroft-Gault; CrCl, creatinine clearance; SD, standard deviation; SEE, systemic embolic events.

Conclusions

We found low bleeding and stroke rates in 7,672 unselected, mainly elderly AF patients treated with edoxaban in routine clinical practice. These findings were consistent across edoxaban doses and reinforce the effectiveness and safety of NOACs such as edoxaban in routine clinical care in Europe.

Acknowledgement/Funding

Daiichi Sankyo Europe GmbH, Munich, Germany
P1258Left atrial dimension and risk of cardiovascular outcomes in patients with and without atrial fibrillation: a systematic review and meta-analysis
Authors: Meyre P , Froehlich L , Aeschbacher S , Blum S , Djokic D , Kuehne M , Osswald S , Kaufmann B , Conen D
Published: October 2019

Background

The prognostic value of left atrial (LA) dimensions measured by transthoracic echocardiogram among patients with versus without atrial fibrillation (AF) is uncertain. We aimed to investigate the association of LA echocardiographic parameters with the risk of cardiovascular events in AF patients compared to non-AF patients.

Methods

MEDLINE and EMBASE were searched from inception to July 2018. Records were retained if they studied the association between LA echocardiographic parameters and cardiovascular outcomes in AF patients, and in populations with no or less than 10% of AF patients. Left atrial dimensions had to be measured by transthoracic echocardiography, and parameters of interest were the following: LA diameter (LAD), LA diameter indexed to body surface (LADI), LA volume (LAV) and LA volume indexed to body surface (LAVI). Data were independently abstracted by 2 reviewers and pooled using inverse variance random-effects meta-analysis. The primary outcome was incident stroke and thromboembolic events. Secondary outcomes were heart failure, all-cause mortality and major adverse cardiac events (MACE).

Results

Twenty-three studies of AF patients (14'939 patients) and 69 studies of non-AF patients (52'654 patients) were included. Summary of the meta-analyses for the associations of LA parameters with cardiovascular outcomes is presented in the Figure. Increasing LAD was significantly associated with the risk of stroke and thromboembolic events in non-AF patients (P=0.03), but not among AF patients (P=0.27), and the association did not differ between population (P for difference=0.05) (Figure, A). Greater LADI was associated with risk of stroke and thromboembolic events in AF patients (P<0.001) and in non-AF patients (P=0.04), but the association did not differ between populations (P for difference=0.49). For MACE, increasing LADI was significantly associated with the outcome in AF patients (P<0.001) and in non-AF patients (P<0.001), but the association was stronger in non-AF populations (P for difference<0.001). Increasing LAVI was associated with high risk of MACE in AF patients (P=0.03) and in non-AF populations (P<0.001). Again, the correlation was stronger among non-AF patients (P for difference<0.001). Other associations did not differ between populations, and meta-analysis of LAV was not conducted by the limited number of studies.

Summary of meta-analysis

Conclusions

Left atrial echocardiographic parameters are powerful predictors of adverse cardiovascular events, mainly among individuals without AF.
P1259Right atrial low voltage zone as a novel predictor of sinus node dysfunction in patients with non-paroxysmal atrial fibrillation
Authors: Kondo T , Kimura M , Nakayama M , Matsuda O
Published: October 2019

Background

Although sinus node dysfunction (SND) coexists with atrial fibrillation (AF) in some cases, SND in patients with Non-paroxysmal AF (Non-PAF) could not be estimated in conventional electrophysiological study.

Atrial low voltage zone (LVZ), which may be surrogate for atrial fibrosis, is although reported to present in patients with Non-PAF, the association between SND and right atrial LVZ (RA-LVZ) has not been fully evaluated. The aim of the present study was to assess the relationship between SND and RA-LVZ in patients with Non-PAF.

Method

Eighty-six Non-PAF patients underwent high density voltage mapping of right atrium (RA) during AF before ablation procedure. We defined LVZ as that with electrogram amplitude <0.1 mV in order to delineate strongly damaged area in RA. We evaluated the surface are of the RA-LVZ in Non-PAF patients with and without SND.

Results

Twenty-seven of 86 patients (31.4%) presented with SND after AF termination. There were no significant differences between patients with and without SND in variables such as age, sex, AF duration, left atrial diameter, and left ventricular ejection fraction. The mean value of RA-LVZ of all the patients was 12.1±11.4%, and RA-LVZ was significantly larger in patients with SND than in those without SND (22.8±14.6 vs 7.2±4.2%; P<0.001). In multivariate logistic regression analysis for the incidence of subsequent pacemaker implantation (PMI), only RA-LVZ was a significant predictor of subsequent PMI (odd ratio 1.306; 95% confidence interval 1.159 - 1.473; P<0.001). Receiving-operating characteristic curve for PMI following ablation procedure indicated cut-off value 10.5% for RA-LVZ with 85.2% sensitivity and 88.1% specificity (area under curve = 0.924, P<0.001). Kaplan-Meier analysis of the incidence of PMI after AF termination showed that freedom from pacemaker implantation was significantly better in patients with RA-LVA <10.5% than in those with RA-LVZ ≥10.5% (log-rank test; P<0.001).

Conclusions

Broad RA-LVZ measured during AF was strongly associated with SND and PMI after AF termination in patients with Non-PAF. Evaluation of RA-LVZ during AF could be a potential target in predicting SND requiring PMI in patients with Non-PAF.
P1454A telemonitoring service approved by the ministry of health for a large-scale screening of silent and symptomatic atrial fibrillation
Authors: Lupi L , Glisenti F , Papa I , Piazzani M , Arabia G , Castiello A , Bonelli A , Gensini G , Gabbrielli F , Nodari S
Published: October 2019

Introduction

despite good progress in the management of patients with atrial fibrillation (AF), this disease remains one of the major cause of stroke, heart failure, sudden death and cardiovascular morbidity. Screening for silent AF is recommended in high risk population, especially in elderly, but often it is not applied for the absence of medical prescriptions or long waiting times

Purpose

to evaluate the effectiveness of a remote monitoring through ECG Holter and 12-lead ECG provided by a network of pharmacies across the Country for the screening of AF

Methods

according to a Ministerial Decree, from 2010 authorized pharmacies may provide specialist outpatient care services. Health Telematic Network, in collaboration with our Cardiology University Department and Federfarma (National Association of Pharmacists), has installed in 4,008 authorized pharmacies across the Country a telematic network connected to a single Telemedicine platform where cardiologists were available for tele-consulting. In order to identify silent or symptomatic AF, 12-lead ECG and ECG Holter monitoring were performed in patients with episodes of palpitation, syncope or pre-syncope or with a history of AF. Informations regarding lenght of AF episodes, mean heart rate and anticoagulant therapy were collected

Results

From Jan 2017 to Dec 2018 a total of 31,156 ECG Holter monitoring were performed (46% male, mean age 61 years). Among these records, 2390 (8%) showed paroxysmal or persistent AF (53% male, mean age 77±10 years). The lenght of AF episodes was greater of 6 minutes in 14% cases and mean heart rate was greater of 90 bpm in 406 patients (17%). History of AF was not previously known in 669 patients (28%). None of this subgroup of patients and only 18% of patients with known paroxysmal AF were taking anticoagulant therapy. In the same period 196,349 ECG were performed (mean age 78 years) and 17,088 have been carried out in patients aged 65 years or older. Among these group of patients, 831 records showed unknown AF (5%): 356 (43%) high ventricular rate AF, 385 (46%) medium ventricular rate AF and 90 (11%) low ventricular rate AF. All the patients with unknown AF episodes or with frequent high ventricular rate AF episodes were referred to their General Practitioner or Cardiologist for urgent evaluation and therapeutic management.

Conclusion

our data confirm the important role of a single telematic network in which health care services can be provided timely by authorized pharmacies across all the Country to promote early diagnosis and treatment of AF, then resulting in a likely positive impact on related cardiovascular events
P1459Evaluation of remote monitoring in patients with leadless pacemakers
Authors: Mendez Zurita F , Ramirez De Diego I , Espinosa Viamonte H , Rodriguez Font E , Campos Garcia B , Alonso Martin C , Guerra Ramos J , Elamrani Rami A , Maldonado Chavez J , Paz Jaen E , Velasco Nieves A , Grande Osorio M , Bote Collazo M , Vinolas Prat X
Published: October 2019

Introduction

Remote monitoring (RM) of cardiac devices is a technology established in clinical practice. The early activation of RM is associated with greater survival. The RM of leadless pacemakers consists of a non-automatic remote interrogation (RI), however factors such as age, the monitoring center and the type of device delivered can condition the adequate adherence to the system.

Purpose

Describe the results of RM in patients with leadless pacemakers in the clinical practice of a tertiary referral hospital.

Methods

All patients with leadless pacemakers were included. Since October 2017, RM was offered to all new patients and to previously implanted patients who had an elevated threshold. Clinical and demographic characteristics were analyzed. The following variables were evaluated: Activation (first RI), early activation (activation occurring before 90 days from the implant or from the medical order), premature activation (activation before 15 days), and adherence to follow-up (patients with almost one RI after 12 months from activation).

Results

A total of 142 patients have been implanted with a leadless pacemaker, of which 56 patients were offered RM, being accepted in 96% of the cases (54 patients, 88±6 years old, 54% males). A 54% patients received a RM using App based technology. During a mean follow-up of 200 days, 7 deaths occurred (13%). 100% of the patients have performed the activation, being in all cases an early activation, and in 50% (26 patients) it has been premature activation. 32 patients have follow-up longer than 12 months and all are adherent to RM. There are no differences in the percentage of activation or adherence depending on the type of monitor.

Conclusions

The implementation of RM program in old patients with a leadless pacemaker has a high acceptance rate, achieving an early activation in all patients. The adherence to this technology remains high despite the limitation of a non automatic transmission. RM using App based technology is possible in spite of the age.
P1460Seismocardiographic measurement of systolic time intervals in left ventricular dysfunction: validation with transthoracic echo
Authors: Padmanabhan D , Bhushan M , Amba R , Joseph P , Sibal S , Vangal R , Venu A , Rao S , Manjunath C N , Vidyasagar K , Reddy S
Published: October 2019

Background

Systolic time intervals (STI) measured using Transthoracic Echo (TTE) have been shown to be sensitive indicators of contractile performance, but TTE is limited to a hospital setting. Recent advances in technology have enabled the simultaneous measurement of Electrocardiograms (ECG) and Seismocardiograms (SCG) using wearable devices. However, the use SCG to measure STIs has not been validated in a mobile setting, or on pathological subjects.

Purpose

To test the validity of an automated algorithm for measuring STIs using a wearable device recording ECG and SCG, in subjects with varying degrees of left ventricular dysfunction.

Methods

179 Patients with suspected left ventricular dysfunction were assessed using TTE performed by a Cardiologist. Patients were simultaneously fitted with a novel wearable device worn on a chest strap, recording SCG and single-lead ECG data, while the cardiologist measured the pre-ejection period (PEP) and left ventricular ejection time (LVET) with the patient in a supine position. Of these subjects 29 (16.2%) were diagnosed with Dilated cardiomyopathy (DCM), and 109 (60.8%) had Ischemic Heart disease.

The SCG and ECG data recorded on the wearable device was then analysed using a peak-detection algorithm, which detected the Q,R,S points on the ECG, and then determined the 4 most prominent peaks in the SCG signal corresponding to each R-peak. Heart rate, patient's age, gender and SCG time intervals were then used in a DecisionTree algorithm to determine the values of PEP and LVET, which were were then compared against those determined by the cardiologist using TTE.

Results

The correlation coefficient (r2) between PEP calculated using TTE, and the values obtained from the algorithm analyzing SCG data was 0.92 while the mean error was 7.47%. The r2 between the LVET calculated using the TTE and the algorithm was 0.75, while the mean error was 8.53% (p-value<0.001 for all cases).

Results All Subjects With IHD Without IHD With DCM Without DCM Number of Subjects 178 109 69 29 149 PEP (r2) 0.92 0.89 0.94 0.88 0.91 PEP (% age error) 7.47 7.50 7.42 6.99 7.56 LVET (r2) 0.75 0.81 0.66 0.55 0.83 LVET (% age error) 8.53 6.69 11.4 20.42 6.16 DCM, Dilate Cardiomyopathy; IHD, Ischemic Heart Disease.

ECG + SCG signals for a DCM patient

Conclusion

The algorithm-derived STIs measured by SCG correlate well with those measured by TTE across most patient groups, including those with Dilated Cardiomyopathy and Ischemic Heart Disease, opening prospects for continuous remote monitoring of STIs in a mobile setting.

Acknowledgement/Funding

Fourth Frontier Technologies
P1466Can physicians trust a machine learning algorithm to diagnose ST elevation myocardial infarction?
Authors: Mehta S , Fernandez F , Villagran C , Frauenfelder A , Matheus C , Vieira D , Torres M A , Mazzini J , Pisana L , Quintero S , Cecilio E , Aboushi H , Acosta M I , Lopez C , Sunkaraneni S
Published: October 2019

Background

For the past years, the medical field has been taking advantage of the endless possibilities that Artificial Intelligence (AI) provides. Using computer-aided devices that can perform and interpret electrocardiograms (EKG) accurately pushes current healthcare boundaries. We present the LUMENGT-AI, this model can handle large datasets, multiclass diagnoses, complex EKG morphology, and still detect ST Elevation MI (STEMI) accurately.

Purpose

To develop an innovative AI-based system for automated STEMI specific EKG analysis.

Methods

An observational, retrospective, case-control study. Sample: 8,511 EKG records, previously diagnosed as “normal”, “abnormal” (over 200 conditions) or “STEMI” (4,255 cases). Records excluded patient and medical information. The sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes by wavelet system, segmentation of each EKG into individual heartbeats (90,592 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, “STEMI” and “Not-STEMI” classes were considered for each heartbeat, individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM.

Results

Ground Truth Score – Accuracy (94.1%), Sensitivity (87.8%), Specificity (98.1%) – see the comparison to published data in Table.

Conclusions

A statistical analysis allowed us to compare STEMI recognition efficiency between physicians and our model. The LUMENGT algorithm results secured its place as a reliable tool to diagnose STEMI faster and more accurately than physicians.
P1468Non-invasive myocardial work indices in ischemic heart disease
Authors: Manganaro R , Cusma' Piccione M , Longobardo L , Carvelli A , Fimiani L , Casile C , Bracco A , Campisi M P , Di Bella G , Costa F , Ando' G , Carerj S , Zito C
Published: October 2019

Background

Myocardial work (MW) is a parameter of myocardial function which takes into account deformation as well as afterload. LV pressure-strain loops (PSLs) are a novel and reliable tool for the non-invasive assessment of MW.

Purpose

To evaluate MW indices in ischemic heart disease and their changes according to ejection fraction (EF) and type of myocardial infarction (MI) namely no-ST-segment elevation MI (NSTEMI) or ST-segment elevation MI (STEMI).

Methods

A total of 61 patients (mean age: 64.4±12 years) since at least 30 days from acute STEMI or NSTEMI treated with primary PTCA and 31 healthy subjects (controls) were enrolled. Patients with MI were divided into three groups according to the EF-based heart failure (HF) classification: a) group 1, HF preserved EF (HFpEF, EF >50%); 2) group 2, HF mid-range EF (HFmrEF, EF 40–49%); 3) group 3, HF reduced EF (HFrEF, EF <40%). Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE), were estimated by LV PSLs using custom software.

Results

As shown in Table 1, GWE was significantly reduced in HFmrEF and HFrEF group (p=0.001) compared to both the controls and HFpEF group, while GWW was significantly higher (p<0.001) in the HFmEF group compared to controls and in the HFrEF group (p<0.001) vs all the other groups. GWI mmHg and GCW mmHg showed significantly compromised values in patients of HFmrEF and HFrEF groups compared to patients in HFpEF group and controls (p=0.001 and p<0.001 respectively). NSTEMI patients showed higher values of GCW compared to STEMI patients (p=0.003), and a trend towards better values of GWI, although not statistical significant. No significant differences were found about GWE and GWW. A strong correlation was found between indices of MW and LV volumes and EF (Table 2)

Conclusions

The non-invasive MW indices show a good correlation with traditional 2D parameters of myocardial systolic function in patients with ischemic heart disease. In addition, STEMI patients have lower constructive work than those with previous NSTEMI.
P1469Comparison prognostic values of coronary flow velocity assessment and ejection fraction during routine echocardiography
Authors: Zagatina A , Zhuravskaya N , Guseva O , Kalinina E , Shmatov D
Published: October 2019

Background

Ejection fraction (EF) is a parameter that has traditionally been used for prognostic aims during echocardiography. However, it is known that its prognostic role is accurate only if EF has clearly decreased. So, in the large group of patients who had no prior myocardial infarction, with normal EF but with severe narrowing of main coronary arteries, it is impossible to predict a high risk of adverse coronary events in the near future with transthoracic echocardiography at rest. The aim of the study was to compare prognostic values of coronary flow velocity assessment and EF during transthoracic echocardiography.

Methods

A prospective cohort study comprises 747 patients (380 males; age 58+13 years) referred for echocardiography. Left side coronary artery (left main - LM, left descending – LAD, and circumflex arteries -LCx) flows were scanned in addition to conventional echocardiography. Cardiac death, nonfatal myocardial infarction (MI), acute coronary syndrome and revascularization were defined as major adverse cardiac events (MACE). The period of follow-up was 3 years.

Results

During a median follow-up of 36 months, 192 patients experienced 224 MACE. Twenty-six deaths, 16 non-fatal MI, 2 acute coronary syndromes, 180 revascularizations were observed. EF and maximal velocity in proximal segments of coronary arteries were independents predictors of death/MI/acute coronary syndromes. The maximal velocity had a significantly higher predictive value (p<0.004) in the whole group (Figure 1A) as well as among the patients with near normal/normal EF (Figure 1B, 1C). The maximal velocity had a significantly higher predictive value (p<0.0001) of MACE (Figure 1D).

Conclusion

Coronary artery scan assessment had the statistically significantly higher predictive accuracy of MACE in comparison with traditional EF in the whole group and in the subgroups with different degrees of decreasing EF.
P1476Global longitudinal strain assessed by 2-D speckle tracking echocardiography identifies myocardial viability and predicts LV function and remodeling after acute MI with systolic dysfunction
Authors: Ben Driss A , Ben Driss Lepage C , Sfaxi A , Hakim M , Tabet J Y , Salhi A , Brandao Carreira V , Hattab M , Elhadad S , Ou P , Quignodon J F , Jondeau G , Laissy J P
Published: October 2019

Aims

To assess whether two-dimensional speckle-tracking echocardiography (2D-STE) could (1) identify myocardial viability in comparison with late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR); (2) predict global left ventricular (LV) functional recovery and remodeling and (3) assess prognosis after acute myocardial infarction (MI) with LV systolic dysfunction.

Methods

Seventy one first STEMI patients with LVEF ≤45%, treated with acute percutaneous coronary intervention, underwent 2D-echocardiography for 2D-STE analysis and LGE CMR between 2 and 45 days after STEMI. Segments were defined as viable when transmural LGE extension was <50% and non viable when transmural LGE extension was ≥50%. At 8-month follow-up, transthoracic echocardiography was repeated to determine global LV functional recovery (increase in LVEF ≥5%) and LV remodeling (increase in end-systolic volume >15%) (n=30) and clinical outcomes were obtained (n=46).

Results

Global longitudinal strain (GLS) was lower in non viable than in viable infarct segments (−6.6±6.1% vs −10.3±5.9%, p<0.0001) and in viable infarct segments than in normal segments (−10.3±5.9% vs −14.5±6.4%, p<0.0001). GLS >−12% had sensitivity of 78% and specificity of 69% to identify non viable segments (area under the curve (AUC), 0.79; 95% confidence interval (CI), 0.77–0.81, p<0.0001). GLS >−11.3% had sensitivity of 53% and specificity of 100% to predict the absence of global functional improvement (AUC=0.73 (CI: 0.55–0.87) p=0.01) at 8-month follow-up. GLS <−12.5% predicted the absence of adverse LV remodeling at 8-month follow-up with a sensitivity of 100% and a specificity of 54% (AUC=0.83 (CI: 0.66–0.94) p<0.0001). GLS >−11.5% was associated with a poor prognosis.

Conclusions

In patients with recent first acute MI with LV systolic dysfunction, GLS assessed by 2D-STE: (1) is able to identify non viable segments in comparison with LGE CMR, (2) allows prediction of LV global functional recovery and LV remodeling at 8-month follow-up and (3) provides strong prognostic information, independently of LVEF.
P1477Right atrial and ventricular function assessed by speckle tracking in patients with inferior wall myocardial infarction
Authors: Gonzalez-Velasquez P , Gopar-Nieto R , Flores-Garcia A , Alexanderson-Rosas E , Espinola-Zavaleta N
Published: October 2019

Background

Right chambers involvement in left ventricular inferior wall myocardial infarction (LVIWMI) has a prognostic impact.

Purpose

To evaluate the influence of LVIWMI in right atrium (RA) and right ventricular (RV) mechanics.

Methods

We included 60 consecutive patients who underwent myocardial perfusion (MP) gated-SPECT for chest pain. We identify 30 patients with LVIWMI and 30 control individuals with normal MP. Comprehensive echocardiography was performed in all patients. RV free wall longitudinal strain (RVFWLS) and RA reservoir (RAr), contraction (RAct) and conduit (RAcd) phase strain were analyzed by 2D speckle tracking echocardiography (STE).

Results

RVFWLS (−26.1 vs 30.3, p<0.01), RAr (peak strain) (31.5 vs 56.2, p<0.01) and RAcd strain (12.5 vs 35, p=0.01) were significantly lower in the LVIWMI patients vs control individuals. In a logistic regression model, LVIWMI, reduced 3D LV and RV ejection fraction, mitral regurgitation and pulmonary hypertension were associated with reduction in RV an RA strain.

Echocardiographic parameters LV inferior wall MI patients (n=30) Control subjects (n=30) p value 3D LV EDV (ml) (median, IQR) 121 (99.7–150) 89.5 (73–99) <0.01 3D LV EF (%) (median, IQR) 46 (37–53) 60 (58–63) <0.01 Mitral E/A (median, IQR) 0.82 (0.7–1.2) 1.21 (0.97–1.44) <0.01 Medial E/e' (median, IQR) 9.59 (7.9–13) 7.7 (6.9–10.5) 0.01 RV EDD (mm) (mean, SD) 36.7±7.4 34.7±4.39 0.12 TAPSE (mm) (mean, SD) 18.6±5.05 21.7±4.1 <0.01 RV FAC (%) (mean, SD) 37±9 46.8±7.24 <0.01 RV S' (cm/s) (mean, SD) 9.9±2.7 11.8±1.85 <0.01 3D RV EF (%) (median, IQR) 47.5 (42–52) 54 (49–57) <0.01 RIMP (mean, SD) 0.49±0.2 0.46±0.12 0.60 SPAP (mmHg) (median, IQR) 31.5 (27–37) 29.5 (26–33) 0.07 Peak global LV LS (%) (median IQR) −13.35 (−17.6–9.3) −22 (−23.2–20.4) <0.01 RV free wall LS (%) (median, IQR) −26.1 (−32.1–17.8) −30.3 (−36.6–27.5) <0.01 RA peak strain (reservoir phase) (%) (median, IQR) 31.5 (25.2–43) 56.2 (47–66.4) <0.01 RA contraction phase strain (%) (mean, SD) 20.17±10.4 24.4±10.36 0.07 RA conduit phase strain (%) (median, IQR) 12.5 (5.9–15.6) 35 (21–47.6) 0.01

Normal RVFW (A) and RA strain (B)

Conclusion

STE is a feasible technique for assessment of RVFW and RA deformation. Subclinical extension to RV in LVIWMI and its influence in RA mechanics could be assess by 2D-STE.
P1478Pilot study to predict future cardio-vascular events by novel 3D-echocardiography global area strain in STEMI patients managed by primary PCI
Authors: Al Ashry A , Esmail Y , Fahim M , Adel W , Fiky A
Published: October 2019

Background

Three-dimensional speckle tracking echocardiography (STE) is an ideal modality for accurate assessment of myocardial deformation, the Novel 4D-Global Area strain (GAS) is a very sensitive parameter in detection of subtle changes involving the myocardium as it encompasses both global longitudinal and global circumferential strains.

Objectives

To investigate the predictive value of four dimensional (4D) strain echocardiography for major adverse cardio-vascular events (MACE) in ST-elevation acute myocardial infarction (STEMI) after successful reperfusion by primary PCI.

Methods

One hundred seventy one patients who underwent successful primary PCI were enrolled and properly examined by 2D and 4D echocardiography with 4D strain parameters evaluation then followed up all-over a year for the occurrence of Major adverse Cardiovascular Events (MACE).

Results

Thirty two MACE were recorded in 170 patients who completed the follow-up period for one year, compared with those without MACE, patients with MACE had PTCA done during the index Primary PCI intervention, had multi-vessel CAD affection, higher LVEDD, higher LVESD, lower 2D- LVEF, higher WMSI, higher baseline HR, higher EDV and ESV, lower 3D- LVEF, higher 3D-GLS, 3D-GCS and 3D-GAS with lower 3D-GRS, all with p-values <0.005. Multi-variant logistic regression analysis showed that GAS was the most powerful predictor for MACE among our study population with the best cut-off value of 3D-GAS >−17, with p-value of (0.008) OR (20.668), CI (2.227–191.827) with relative risk of adverse events of 18.205 (95% CI 6.976–47.506, P value <0.001).

Conclusion

Our data supports the superiority of 4D strain echocardiography parameters specially GAS for prediction of adverse clinical events among patients managed by successful primary PCI.
P1484Exploring the grey zone of E/e' ratio: does left atrial strain help?
Authors: Cerrito L F , Inciardi R M , Benfari G , Bergamini C , Ribichini F L , Rossi A
Published: October 2019

Background

The combination of early trans-mitral inflow and mitral annular tissue Doppler velocities (E/e' ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However E/e' ratio has a significant gray zone that restrict its accuracy and left atrial (LA) deformation analysis by speckle tracking echocardiography (STE) was recently proposed as an alternative approach to estimate LV filling pressures, but the clinical application of LA strain in the subgroup of patients with E/E' between 8 and 14 has been under-investigated.

Aims

This study aimed to analyze the role of LA longitudinal function by STE (PALS) to estimate intra-cardiac pressures as assessed by systolic pulmonary artery pressure (sPAP), measured by Doppler, specifically in patients with an E/e' ratio >8 and ≤14.

Methods

We enrolled 142 consecutive, non-selected patients, referred to our echocardiography laboratory for a comprehensive transthoracic echocardiography. Exclusion criteria were: organic mitral valve disease or prosthesis and presence of disease possibly associated with pre-capillary pulmonary hypertension. Particular care was used for accurate measurement of maximal tricuspid regurgitation velocity and of right atrial pressure and consequently sPAP estimation. PALS values were obtained by averaging all segments, and by separately averaging segments measured in the 4-chamber and 2-chamber views.

Results

Seventy-four patients (52% of total) showed an E/e' ratio >8 and ≤14, with the following characteristics: mean age 65.5±11.9 years, LVEF 54.5±11.2, E/e' 11.2±1.9, sPAP 33±7 mmHg, PALS 31.6±11.7%. A negative correlation between PALS and sPAP was found (r=−0.55, p<0.0001). From receiver operating characteristic (ROC) curves, PALS demonstrated a high diagnostic accuracy (AUC 0.78 (95% CI: 66%–90%)); the cutoff value of 23% showed an excellent specificity of 90% with a sensibility of 60%, to predict sPAP higher than 35 mmHg.

Correlation between sPAP and PALS

Conclusions

LA function measured by STE is a simple parameter able to predict increased intra-cardiac pressure even in the intermediate E/E' group. This parameters might help in improving the diagnostic algorithm of diastolic function.
P1500Effects of empagliflozin on cardiac function in patients with type 2 diabetes mellitus: echocardiographic substudy of the EMPA-HEART cardiolink-6 trial
Authors: Bami K , Gandhi S , Leong-Poi H , Yan A , Ho E , Zahrani M , Garg V , Teoh H , Quan A , Mazer D , Verma S , Ong G , Connelly K
Published: October 2019

Background

The EMPA-HEART trial showed a reduction in left ventricular (LV) mass index by cardiac MRI at 6 months in patients treated with Empagliflozin vs placebo. A secondary analysis of key echocardiographic parameters was performed to provide further insight into the mechanism of LV remodeling.

Methods

All patients enrolled prospectively underwent transthoracic echocardiography (TTE) at baseline and at 6 months. Measurements were performed according to the American Society of Echocardiography guidelines. Key outcomes of interest included changes in diastolic function and right ventricle parameters at 6 months in patients treated with Empagliflozin vs placebo.

Results

A total of 97 patients were enrolled (49 treated with Empagliflozin and 48 in the placebo group). There was no significant difference in the change in average E/E' at 6-months in the Empagliflozin group vs placebo (−0.4 vs +0.2, adjusted difference −0.2, 95% CI [−1.3 to 0.82], p=0.7) Similarly, there was no difference between the groups in secondary TTE parameters (Table 1). Subgroup analyses showed no benefit among patients with baseline LVEF >50% vs. ≤50%, and baseline LV mass index ≥60 g/m2 vs <60 g/m2.

Echocardiographic Parameter Placebo (n=48) Empagliflozin (n=49) Adjusted Difference Between Groups 95% CI P-Value Baseline 6 months Change Baseline 6 months Change LVEF (%)* 55.5 (8.7) 54.3 (8.9) −1.0 (6.5) 58.0 (7.5) 59.1 (8.57) 0.72 (5.1) 2.2 (−0.2, 4.7) 0.1 Diastolic Parameters:   Average E/e' 10.1 (3.1) 10.3 (2.5) 0.2 (3.0) 10.6 (3.0) 10.5 (3.6) −0.4 (2.5) −0.2 (−1.3, 0.8) 0.7   Medial E/e' 12.3 (3.9) 12.5 (3.6) 0.1 (3.7) 12.6 (4.2) 12.6 (5.2) −0.3 (3.3) −0.3 (−1.7, 1.1) 0.7   Lateral E/e' 8.0 (2.8) 8.2 (2.2) 0.2 (2.7) 8.7 (2.6) 8.4 (2.5) −0.4 (2.7) −0.1 (−1.0, 0.8) 0.8   E velocity (cm/sec) 68.6 (15.2) 70.6 (14.7) 1.8 (15.4) 74.4 (18.2) 71.2 (16.8) −3.2 (15.1) −2.3 (−7.9, 3.3) 0.4   A velocity (cm/sec) 74.7 (17.9) 77.9 (18.8) 2.9 (15.9) 76.2 (16.5) 75.8 (14.5) −1.4 (11.7) −3.5 (−8.9, 1.6) 0.2   LA volume index (mL/m2) 32.7 (7.9) 30.8 (8.1) −2.0 (6.7) 30.2 (6.7) 28.7 (5.5) −1.6 (6.5) −0.9 (−3.4, 1.6) 0.5 RV Parameters:   TAPSE (cm) 1.8 (0.5) 1.8 (0.4) 0.1 (0.4) 2.0 (1.2) 1.8 (0.4) −0.3 (1.4) −0.1 (−0.3, 0.1) 0.3   RV S' TDI (cm/sec) 10.9 (2.9) 10.6 (2.5) −0.1 (2.2) 10.4 (2.7) 10.2 (2.6) −0.4 (2.0) −0.3 (−1.2, 0.5) 0.4 *Measured by cardiac MRI. LA, left atrium; LVEF, left ventricular ejection fraction; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue Doppler imaging. Data expressed as mean (standard deviation).

Conclusion

This study showed no significant change in key echocardiographic parameters in patients treated with Empagliflozin, suggesting that changes in loading conditions induced by empagliflozin (i.e. preload) do not mediate the reduction in LV mass.
P1502Age- and gender-specific prognostic cutoff values of coronary flow velocity reserve in vasodilator stress echocardiography
Authors: Lombardo A , Cortigiani L , Ciampi Q , Rigo F , Bovenzi F , Picano E
Published: October 2019

Background

Coronary flow velocity reserve (CFVR) of left anterior descending artery is useful for risk stratification during stress echocardiography (SE) as an add-on to regional wall motion abnormalities (RWMA), but the age-and sex-dependence of prognostic cutoff values remains unclear.

Purpose

To provide sex and age-specific prognostic cut-off values which may be needed to account for the physiologic decline of CFVR with age, and sex-related differences in resting flow.

Methods

In an observational, prospective, multicenter, registry study design, we enrolled from August 2003 to August 2017 in 4 Italian cardiology referral centers with accredited, quality-controlled stress echo laboratory a consecutive sample of 5,577 patients (of them, 2,284 women and 110 aged ≥85 years) referred to the SE lab for known or suspected coronary artery disease, after exclusion of patients with inadequate acoustic window (n=295), premature test interruption (n=105), and lost to follow-up (n=173).All underwent dual imaging (RWMA and CFVR) dipyridamole SE (0.84 mg/kg over 6') and were followed-up. All-cause death and non-fatal myocardial infarction were the main outcome measures. Median follow-up of 20 months (1st quartile 8, 3rd quartile 43 months),

Results

There were 649 hard events (236 deaths and 413 non-fatal myocardial infarctions), 288 of which occurred in women and 38 in patients ≥85 years. With a ROC analysis, the best prognostic cut-off value for CFVR was almost the same for men (2.03) and women (2.02) and consistent across all age strata (<45 years: 2.03; 45–54 years: 2.04; 45–64 years: 2.03; 65–74 and 75–84 years: 2.0) except for the very elderly (>85 years) who showed an optimal value of 1.90. Independent prognostic indicators were RWMA (HR=5.42, 95% CI=2.42–12.15; p<0.0001) and reduced CFVR (HR=3.26, 95% CI 2.27–3.90; p<0.0001) in patients aged <85 years, and RWMA (HR=5.42, 95% CI=2.42–12.15; p<0.0001) in patients aged >85 years.

Best prognostic cut-off value of CFVR

Conclusion

A sex-independent cut-off value of CFVR ≤2.0 provides the optimal risk stratification across all age groups, except those >85 years in whom a lower cut-off <1.90 is needed. Risk stratification is more effective for all age groups when CFVR is combined with RWMA.
P1504Impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block
Authors: Stoickov V , Deljanin Ilic M , Tasic I , Nikolic L J , Marinkovic D , Stoickov M , Simonovic D , Saric S , Stoickov I
Published: October 2019

Background/Introduction

ECG has always provided very useful information that can be used to diagnosis, treatment and prevention of cardiovascular events, but ECG changes is not useful to the detection of myocardial ischemia in patients with left bundle branch block (LBBB). QT dispersion (QTd) is a measure of inhomogeneous repolarization of myocardium. Abnormally high QTd has been correlated with risk of cardiac death in coronary patients.

Purpose

The aim of this study was to establish the impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block.

Methods

The study involved 123 patients with LBBB, average age 52.7 years. In all subjects clinical examination, standard ECG and exercise stress echocardiography, were performed. The criterion for myocardial ischemia was the appearance of transient segmental wall motion abnormality. The first ECG was done before the exercise stress echocardiography and the second one was done immediately after exercise, with calculation of corrected QT dispersion (QTdc).

Results

During exercise stress echocardiography, in 45 (36.6%) subjects wall motion abnormality occurred (group with myocardial ischemia: MI), and 78 (63.4%) subjects were without ischemia (group without myocardial ischemia: NMI). Before starting the exercise stress echocardiography, MI group patients had significantly higher values of QTdc (61.2±17.6 vs 43.6±15.4 ms; p<0.001) in comparison to NMI group patients. During the exercise stress echocardiography, the QTdc significantly increased in MI group from 61.2±17.6 to 87.4±20.3 ms (p<0.001). In the NMI group there were no significant changes in the values QTdc during exercise stress echocardiography (from 43.6±15.4 to 46.5±19.8 ms (p - NS).

Conclusions

Significant increase of QT dispersion is associated with the occurrence of myocardial ischemia during exercise stress echocardiography in patients with LBBB. This new diagnostic approach, of using QT dispersion, significantly improves the clinical usefulness of exercise stress echocardiography in detecting myocardial ischemia in patients with LBBB.
P1508The Coronary Arteriogenesis with combined Heparin and Exercise therapy in chronic refractory Angina (CARHEXA) trial: a double-blind randomized placebo-controlled stress echocardiographic study
Authors: Petrovic M T , Djordjevic-Dikic A , Stepanovic J , Giga V , Boskovic N , Vukcevic V , Cvetic V , Mladenovic A , Radmili O , Markovic Z , Kalimanovska-Ostric D , Aleksadric S , Ostojic M C , Beleslin B , Picano E
Published: October 2019

Background

Coronary collateral circulation exerts protective effects on myocardial ischemia due to coronary artery disease (CAD) and can be promoted by exercise (E) with heparin (H) co-administration. Whether this arteriogenetic effects is accompanied by functional improvement of left ventricle (LV) during stress remains unknown.

Purpose

To establish the stress-induced functional effects on LV regional and global function of 2-week cycle of H+E in patients with “no-option” CAD.

Methods

In a prospective, single-center, double-blind, randomized, parallel-group study we recruited 32 “no-option” patients (27 males; mean age of 61±8 years), with stable angina and CTO, refractory to OMT, not suitable for revascularization and with E-induced ischemia. All underwent 2-week cycle of E (2 E test per day, 5 days a week) and were pre-treated with i.v. 0.9% saline or unfractionated H (100 IU/kg up to maximum of 5.000IU, 10 min prior to E). Canadian Class Score (CCS) and 12-lead E-ECG for time-to-1 mm ST-segment depression were assessed at entry and after treatment. LV function was evaluated during treadmill exercise with conventional and advanced imaging indices: Wall Motion Score Index (WMSI); Ejection Fraction (EF); Force (systolic blood pressure/end-systolic volume); Global Longitudinal Strain (GLS).

Results

Post-treatment exercise-time and CCS improved in both groups. In H+E patients exercise-time improved from 369.8±107.8 sec to 475.3±114.6 sec (p=0.001) while in E patients improved from 384±152.7 sec to 464.8±134.1 sec (p=0.019). CCS score changed in H+E from 2.6±0.7 to 1.9±0.7 (p=0.000), and in E group from 2.4±0.7 to 2.1±0.9 (p=0.046). At peak exercise, H+E was different from E group for EF and GLS (see Table).

Effects of H+E on SE parameters H+E p P+E p *H+E vs P+E STRESS Time 0 vs Time 1 Time 0 vs Time 1 Time 0 Time 1 WMSI 1.377 vs 1.279 0.005 1.404 vs 1.376 0.290 0.626 0.255 EF (%) 60.9 vs 64.8 0.016 61.2 vs 57.8 0.284 0.943 0.016 Force (mmHg/mL) 6.36 vs 6.5 0.158 5.82 vs 4.68 0.209 0.760 0.098 GLS (%) −16.96 vs −18.50 0.001 −15.79 vs −15.60 0.380 0.325 0.027 SE = stress echocardiography; H+E = heparin+exercise; P+E = placebo+exercise; Time 0 = before randomization; Time 1 = after 2-week therapy cycle. *p values.

Conclusion

A 2-week, H+E cycle is associated with improvement in regional and global LV function during exercise, concordantly shown by conventional (WMSI, EF) and advanced (GLS) echocardiographic indices of LV function. This integrates and supplements the classical objective index based on ST-segment depression, unable to localize and quantify the functional consequences of therapy on myocardial ischemia.
P1512The selected stress testing protocol is independently associated with mortality irrespective of exercise capacity and comorbidities
Authors: Harb S , Menon V M , Wu Y W , Cremer P C , Cho L C , Gulati M G , Jaber W A J
Published: October 2019

Background

A variety of exercise stress testing protocols with various workloads are available. The test protocol is typically selected according to patient's expected exercise performance.

Purpose

We sought to assess whether the choice of the protocol is by itself independently associated with mortality even after adjusting for clinical variables and estimated workload achieved in metabolic equivalents of task (METS).

Methods

In a 25-year stress testing registry spanning from 1991 to 2015, we identified 120,705 patients who underwent 7 different standardized exercise protocols: Bruce, Modified Bruce, Cornell 0%, 5%, and 10%, Naughton, and modified Naughton. The choice of the protocol was dependent on the supervising exercise physiologist, mainly according to patient's expected exercise performance. The primary outcome was all-cause mortality.

Results

Mean age was 53.3±12.5 years and 59% were male. There were 74953 Bruce, 8368 modified Bruce, 2648 Cornell 0%, 9972 Cornell 5%, 20425 Cornell 10% 1226 Naughton, and 3113 modified Naughton protocols. A total of 8426 death occurred over 8.7 years of mean follow-up duration. Table 1 presents the baseline characteristics by protocol. After adjusting for the number of METs, age, gender, hypertension, diabetes, coronary disease, end-stage renal disease, smoking, and statin use, the protocol selected remained predictive of mortality. Figure 1 shows the adjusted HR for death by protocol selected when compared to Bruce.

Baseline characteristics by protocol Variable Bruce (n=74953) Modified Bruce (n=8368) Cornell 0% (n=2648) Cornell 5% (n=9972) Cornell 10% (n=20425) Naughton (n=1226) Modified Naughton (n=3113) Age, mean ± SD 49.4±11.3 61.3±10.3 66.4±11.7 62.5±11.8 57.2±11.5 67.5±9.8 55.5±11.9 Male, % 64.6 51.8 37.8 42.3 51.7 49 66.7 Coronary disease, % 8.7 32.5 31.7 26.7 21.1 49.7 45.6 Diabetes mellitus, % 7.6 16.5 25.3 20 14.2 27.2 26.2 Hypertension, % 41.7 64 85.4 77.9 67.1 82.5 97.5 Smoker, % 40.9 55 50.7 50.9 50.8 56.9 60.6 ESRD, % 0.7 1 3.7 2.4 1.6 2.7 8.1 Mets, mean ± SD 10.3±2.4 7.2±1.7 5.2±1.6 6.7±1.5 8.3±1.9 4.8±1.5 4.6±1.5 Statin use, % 22.4 15.2 41.8 38.3 35.1 19 40.1 ESRD = end-stage renal disease; METS = metabolic equivalents of task.

Adjusted HR by protocol selected

Conclusion

The choice of the stress testing protocol, which is in large part dependent on patient's expected exercise performance is in itself independently associated with mortality even after adjustment for METs achieved and patients' demographics and comorbidities. The choice of the modified-Naughton is associated with the greatest risk of mortality, likely chosen based on limited functional capacity