bluuebunny/crossref_metadata_2025 huggingface dataset:
P1831Prediction of cardiovascular events by atheromatous plaques detected by non-obstructive general angioscopy: two-year results of EAST-NOGA Registry
Authors: Kakuta T , Komatsu S , Kojima K , Fujii H , Kimura S , Dai K , Kawakami H , Matsuoka H , Higuchi Y , Abe H , Inoue T , Okumura Y , Asakura M , Hirayama A , Kodama K
Published: October 2019

Background

Non-obstructive general angioscopy (NOGA) has revealed the intimal damages or atheromatous plaques as well as its spontaneous rupture of the aorta. Recent study revealed that plaque debris or different size of cholesterol crystals were detected in the blood above the spontaneous ruptured aortic plaque observed by NOGA and these plaque materials might cause the peripheral organ damages as the embolic source. These various morphological changes may cause the acute aortic events or atheroembolic events on the peripheral organs, such as brain, kidney, peripheral artery and so on.

Purpose

EAST-NOGA (Evaluation of AtheroSclerotic and rupture events by Non-Obstructive General Angioscopy) is a multi-center prospective observational study to assess the relationship between the findings of NOGA and future cardiovascular events.

Methods

Five hundred and seventy-seven patients with atherosclerotic cardiovascular disease who underwent NOGA study. The major cerebrocardiovascular events including cardiovascular death, non-fatal myocardial infarction, non-fatal cerebral infarction, and acute aortic syndrome were accumulated during the 2-year follow-up after NOGA study.

Results

The median number of aortic atheromatous plaques was 6 [IQR: 3–12]. A total of 514 patients were followed up (89.1%). The mean follow-up duration was 757±120 days. Major adverse cardiovascular events developed in 23 (4.5%) during 2 years follow-up. Patients with MACE and cerebral infarction, had significantly greater number of aortic atheromatous plaques (11 [5–19] vs. 6 [3–11], p<0.001, 12 [4–20] vs. 6 [3–12], p=0.014, respectively). In a univariate analysis, the number of aortic atheromatous plaques and ruptured plaque were significant predictors of MACE (HR: 1.09 95% confidence interval 1.05–1.14, p<0.001) and (HR: 1.12, 95% confidence interval 1.02–1.23, p=0.02). In a multivariate logistic analysis, the number of aortic atheromatous plaques is one of the independent predictors of MACE (HR 1.05, 95% confidence interval 1.00–1.10, p=0.032).

Conclusion

The number of atheromatous plaques identified by NOGA has a significant relation to the onset of cerebral infarction, which suggest the atheromatous plaque were vulnerable and ruptured spontaneously, then cause the aortogenic cerebral infarction. The NOGA study would be useful for predicting the futured atheroembolic events.

Acknowledgement/Funding

None
P1833The c-fos mRNA expression reveals persistent myocardial stretch in the right ventricle during asphyxiated cardiac arrest
Authors: Kadowaki S , Yamazaki S , Kotani Y , Tsuji T , Sakoda N , Kobayashi Y , Horio N , Goto T , Muraoka G , Ozawa S , Suezawa T , Kuroko Y , Tateishi A , Shimizu S , Kasahara S
Published: October 2019

Background

Donation after circulatory death (DCD) heart transplantation has been debated over the past decades because of the shortage of donor. The right ventricular dysfunction is one of the remaining problems for clinical implication of DCD heart transplantation. DCD hearts suffering from the volume overload have a potential to aggravate the right ventricular dysfunction after heart transplantation. The c-fos mRNA is one of the “immediate” response genes to mechanical stresses, such as myocardial cell stretch, without neural and humoral factors. In this study, we assessed myocardial stretch during asphyxiated cardiac arrest using c-fos mRNA expression.

Purpose

The purpose of this study is to reveal the impact of right ventricular volume overload during asphyxiated cardiac arrest.

Methods

Male Wistar rats (8 weeks of age, n=18) were anesthetized with paralyzed ventilation. The trachea was dissected and ligated to initiate asphyxiation. Hearts were harvested at 3 time points: 0, 15 and 30 minutes after termination of the ventilation. Free walls of right and left ventricle were sectioned and immersed in RNA stabilization solution as soon as possible. Total RNA was extracted from these tissues using a guanidine thiocyanate-phenol-chloroform method and cDNA was synthesized using a reverse transcriptase. Next, we measured the quantified expression level by using the droplet digital PCR method with a probe and primers for c-fos gene. Expression of c-fos level was divided by extracted TATA binding protein (TBP) level as a control marker, the ratio of c-fos and TBP was used in analysis.

Results

In the left ventricle, the expression of c-fos rapidly increased by 15 minutes (0.81±0.24 (c-fos/TBP), p<0.05 by one-way ANOVA followed by the Dunnett's test) compared to at 0 minutes (0.21±0.06), but the expression level recovered to the baseline level at 30 minutes after termination of the ventilation (0.19±0.03). On the other hand, in the right ventricle, the c-fos expression was gradually elevated and peaked at 30 minutes (0.88±0.20, p<0.05 by the Dunnett's test) compared to at 0 minutes (0.22±0.05).

Conclusion

These results suggest that the volume overload to the right ventricle during asphyxiated cardiac arrest prolongs compared to that to the left ventricle, which may cause the right ventricular dysfunction after DCD heart transplantation.
P1862Phrenic nerve damage after atrial fibrillation ablation using second generation cryoballoon
Authors: Yorgun H , Oksul M , Sener Y Z , Canpolat U , Evranos B , Ates A H , Aytemir K
Published: October 2019

Background

Cryoballoon (CB) ablation is a safe alternative to radiofrequency ablation in the treatment of atrial fibrillation (AF). However, phrenic nerve damage (PND) is a bothersome complication of the procedure.

Purpose

In this study, we aimed to establish the incidence of PND during CB and define the characteristics of affected patients.

Methods

In this retrospective analysis, all patients with AF that underwent CB ablation between 2013 and 2018 were included into the study. Characteristics and outcomes of patients complicated with PND were evaluated. PND was detected by palpation of diaphragma contractions or observation of reduced diaphragma motility by fluoroscopy during the procedure.

Results

Totally 653 patients were included in the study. PND was detected in 3.5% (23/653) of the patients. Median age of the patients with PNP was 56 (25–78) years and 10 patients (43.4%) were male. The most common ablation site related with PND was right superior pulmonary vein (RSPV) (18 patients, 78%). Transient PND was observed in 16 patients (69%) of the patients which resolved within 24 hours after the procedure. In the remaining 5 patients (21%) diaphragmatic contraction was recovered at the 6th month control visit. In 2 patients (10%), phrenic nerve paralysis was still present >1 year visit.

Table 1. Baseline characteristics of patients with PND Age (years), median (min–max) 56 (25–78) Gender, n (male %) 10 (43.4%) Hypertension, n (%) 9 (39.1%) LA (mm), (mean ± sd) 38.5±5.8 EF (%), (mean ± sd) 60.8±6.5 Structrual heart disease, n (%) 3 (0.13%) – HCMP 2 (0.087%) – DCMP 1 (0.043%) DCMP: Dilated cardiomyopathy; HCMP: Hypertrophic cardiomyopathy; EF: Ejection fraction; LA: Left atrium; PND: Phrenic nerve damage.

Conclusion

PND is not a rare complication of CB ablation despite all the preventive maneuvers during the procedure and technological developments. However, most of the PND recovered during the follow-up.
P1865Incidence and predictors of invasively-treated pericardial effusion during catheter ablation of atrial fibrillation in Japan
Authors: Murakawa Y , Yamane T , Goya M , Inoue K , Naito S , Miyauchi Y , Morita N , Nogami A , Shoda M , Okumura K , Hirao K
Published: October 2019

Purpose and method

Japanese Heart Rhythm Society requested electrophysiology centers to register the data of patients who underwent catheter ablation for atrial fibrillation (AF) in designated eight months from 2011 to 2017. We assessed the incidence and predictors of pericardial effusion (PE) as an early complication of AF ablation.

Results

More than two hundred EP centers reported the data of 13,233 AF ablation cases (age; 64.2±10.7 years, male; 72.6%, paroxysmal AF; 63.4%). Clinically significant complications occurred in 601 subjects (4.5%). Critical PE occurred in 116 patients (0.8%), while six of them required open-chest surgery. Overall complication rate did not show significant changes. In contrast, incidence of PE declined over time (2012:1.2%, 2017:0.5%, p=0.003). Multiple logistic regression analysis showed that seven factors were related with higher incidence of PE. Among these factors, primary extra-PV ablation and hypertrophic cardiomyopathy (HCM) were more remarkably associated with higher rate of PE (PVI[−] vs. PVI[+]= 9.0% vs. 0.8%, OR 12.3, p<0.001; HCM: [+] vs. [−] = 2.6% vs. 0.8%, OR 3.26, p=0.001). Comorbidity of coronary artery disease (CAD) and use of CARTO system were related with lower PE rate (CAD: [+] vs [−] = 0.2% vs. 0.9%, OR 0.22 [p=0.034], CARTO: [+] vs [−] = 0.7% vs. 1.2%, OR 0.52 [p=0.001]). None of cryobaloon ablation, gender, type of AF, center volume, periprocedural oral anticoagulant, or left atrial diameter was significantly related with the occurrence of PE.

Conclusions

Incidence of critical PE decreased recently. HCM and primary extra-PV ablation were outstanding predictors of critical PE.
P1866Catheter-ablation of paroxysmal atrial fibrillation is associated with improvement of maximal cardiopulmonary exercise capacity
Authors: Mujovic N , Marinkovic M , Nedeljkovic I , Banovic M , Markovic N , Potpara T
Published: October 2019

Background and purpose

Catheter-ablation (CA) of paroxysmal atrial fibrillation (AF) is associated with improvement in symptoms and quality of life (QoL), whilst the effects on functional capacity are underreported. We studied the change in cardiopulmonary exercise testing (CPET) indices of functional capacity from baseline to follow-up in patients undergoing their first CA for paroxysmal AF.

Methods

Consecutive patients who underwent their first CA for paroxysmal AF in our center during 2015, with a >12-month post-procedural follow-up were included. All patients completed the CPET and SF-36 (Short Form Health Survey) questionnaire to evaluate maximal functional capacity and QoL, respectively, at baseline (prior to CA) and 1 year post-CA. The follow-up 24h-Holter-monitoring was performed at 1, 3, 6 and 12 months after CA; finding of any atrial tachyarrhythmia lasting >30 sec was considered the arrhythmia recurrence.

Results

Study group consisted of 50 patients (the mean age 57±12 years, males 76%). The mean left ventricular ejection fraction and left atrial diameter were 61±8% and 41±6 mm, respectively. All patients were free of heart failure; the commonest comorbidities were hypertension (65%) and diabetes mellitus (21%). The follow-up CPET 1 year post CA demonstrated an improvement in maximal functional capacity compared to baseline values, with significant increase in maximal load (123±38 vs. 134±33 W, p=0.012), peak oxygen consumption (VO2max, 18±5 vs. 20±4 mL kg–1 min–1, p=0.001) and peak breathing equivalent (EQ-O2, 28±4 vs. 29±4, p=0.020). The AF-free patients (n=40) had a greater 1-year improvement in work time (22±129 vs. −71±123 sec, p=0.008) and maximal load (15±24 vs. −6±26 W, p=0.005) compared with those expiriencing AF recurrence post-CA (n=10). There was a significant correlation between the 1-year change in SF-36 score and the increase in maximal load (ρ=0.26, p=0.018) and between the 1-year change in SF-36 score and the prolongation of work time (ρ=0.27, p=0.017).

Conclusion

Our study suggests that CA of paroxysmal AF favourably affects the maximal functional capacity, especially in patients with stable sinus rhythm following the procedure. The increase in functional capacity is followed by QoL improvement. This should be considered in treatment decision-making.
P1870Predicting mortality and mode of death by clinical score systems for patients with atrial fibrillation
Authors: Fauchier L , Bisson A , Bodin A , Clementy N , Pierre B , Angoulvant D , Babuty D , Hanon O , Lip G
Published: October 2019

Atrial fibrillation (AF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to measure comorbid disease status and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict mortality and the different modes of death in AF.

Methods

All patients with AF seen in an academic institution were identified and followed up for mortality. CHA2DS2VASc score, CCI and CFI were calculated for each patient. Predictive abilities of the scores were compared using the c-statistic.

Results

Among 8962 consecutive patients with AF, 1294 patients died during a follow-up of 929±1082 days (median 456), (yearly rate 5.5%) and 97% of causes of death were identified (54% cardiovascular and 43% non-cardiovascular). Death occurred more often in patients with higher CHA2DS2VASc scores, CCI and CFI. CFI was a better predictor of total mortality than CCI and CHA2DS2VASc score (table). CFI was also a better predictor of cardiovascular mortality than CCI and CHA2DS2VASc score. Finally, CFI was also a better predictor of non-cardiovascular mortality than CCI and CHA2DS2VASc score. The predictive performances of the 3 tools were better for cardiovascular death than for non-cardiovascular death.

Prediction of mode of death ROC area (95% C) p vs CHA2DS2VASc/Charlson Total mortality CHA2DS2VASc 0.651 (0.636–0.665) – / 0.0001 CHARLSON (CCI) 0.687 (0.672–0.702) 0.0001 / – Frailty index (CFI) 0.714 (0.700–0.729) <0.0001 / <0.0001 Cardiovascular death CHA2DS2VASc 0.673 (0.654–0.692) – / 0.004 CHARLSON (CCI) 0.707 (0.688–0.726) 0.004 / – Frailty index (CFI) 0.737 (0.719–0.756) <0.0001 / <0.0001 Non cardiovascular death CHA2DS2VASc 0.590 (0.567–0.612) – / 0.0008 CHARLSON (CCI) 0.637 (0.614–0.659) 0.0008 / – Frailty index (CFI) 0.650 (0.628–0.672) <0.0001 / 0.008

Conclusion

Frailty assessed with CFI demonstrated better performances in predicting total mortality, cardiovascular mortality and non-cardiovascular mortality than CHA2DS2VASc score and Charlson comorbidity index in AF patients. Identifying the risk of non-cardiovascular death with simple tools remains a more difficult challenge in these patients.
P1871Bodyweight variability and atrial fibrillation development
Authors: Lee H , Choi E K , Han K D , Oh S
Published: October 2019

Background

Bodyweight fluctuation is a risk factor for cardiovascular events and death. We investigated whether bodyweight variability is also a risk factor for atrial fibrillation (AF) development.

Methods

A nationwide population-based cohort of 8,091,401 adults from the Korean National Health Insurance Service database without previous history of AF and with at least 3 measurements of bodyweight over a 5-year period was followed up for incident AF. Intra-individual bodyweight variability was calculated using variability independent of mean, and high bodyweight variability was defined as the quartile with highest bodyweight variability (Q4) with Q1–3 as reference.

Results

During median 8.1 years of follow-up, AF was newly diagnosed in 158,347 (2.0%). Increasing bodyweight variability was associated with AF development after adjustment for baseline bodyweight, height, age, sex, lifestyle factors and comorbidities: each increase of 1-SD in bodyweight variability was associated with 5% increased risk of AF development (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.04–1.05), and subjects with highest bodyweight variability (Q4) showed 14% increased risk of AF development compared to those in the quartile with lowest bodyweight variability (HR 1.14, 95% CI 1.12–1.15).

When the cohort was grouped by body mass index (BMI) into underweight, normal weight, overweight, obese (Figure 1A), subjects with high bodyweight variability showed a shallow U-shaped relationship of BMI with AF incidence, with the highest incidence rate of AF in the underweight group. On the other hand, subjects with reference bodyweight variability showed a proportional increase of AF incidence with BMI, with the highest AF incidence in the obese group. High bodyweight variability was significantly associated with AF development in all BMI groups except in the very obese (BMI≥30) in multivariable analysis, and this association was stronger in subjects with lower bodyweight. In underweight subjects, high bodyweight variability was associated with 16% increased risk of AF development (HR 1.16, 95% CI 1.08–1.24). Obese subjects with high bodyweight variability compared to those with reference variability showed lower crude AF incidence rates, but after multivariable analysis, AF risk was increased (obese stage I) or comparable (obese stage II).

When the cohort was grouped by total bodyweight change (Figure 1B), subjects with high bodyweight variability showed higher AF incidence and elevated AF risk on multivariable analysis in all weight change groups. Subjects with overall weight loss (≥-5%) and high bodyweight variability showed the highest AF incidence and AF risk (HR 1.12, 95% CI 1.09–1.15).

Figure 1

Conclusions

Fluctuation in bodyweight was independently associated with higher risk of AF development. The association of high bodyweight variability with AF development was especially stronger in subjects with lower bodyweight, and in subjects with overall weight loss (≥-5%)
P1878Long-term effect of atrial fibrillation on the evolution of mitral and tricuspid valve regurgitation
Authors: Pype L , Embrechts L , Cornez B , Van Paesschen C , Sarkozy A , Miljoen H , Heuten H , Saenen J , Van Herck P , Van De Heyning C , Heidbuchel H , Claeys M
Published: October 2019

Background

While severe mitral regurgitation is a well-established risk factor for atrial fibrillation (AF), it is less known whether atrial fibrillation induces mitral/tricuspid valve regurgitation (MR/TR). The present study aims to identify the long-term effects of permanent or non-permanent AF on atrial remodelling and on the progression of MR/TR.

Methods

The severity of MR/TR was assessed at baseline and after a period of 65±10 months in 37 patients with permanent AF, in 80 patients with non-permanent AF (of whom 43 were treated with ablation) and in 53 control patients with persistent sinus rhythm. MR/TR was qualitatively assessed by the multi-integrative approach, and quantitatively by measurement of the colour jet area.

Results

At baseline, AF patients had larger MR jet areas than control patients. At follow up, progression of MR, expressed as delta MR jet area, was 0.05±1.3 cm2 in the control group, 0.73±2.1 cm2 in the non-permanent AF group and 1.95±3.6 cm2 in the permanent AF group (p=0.001). Severe MR at follow up was observed in 0%, 2.5%, 8%, respectively. After adjustment for baseline clinical and echocardiographic parameters, permanent AF remained independently associated with the progression of MR. There was a significant positive correlation between a progression of MR and an increase in left atrial volume index (r=0.31, p<0.001). Although rhythm control in non-permanent AF patients was better with AF ablation than with medical treatment only, the MR evolution was similar (delta MR jet area: 0.85±2.05 cm2 vs 0.61±2.12 cm2, p=0.6). Comparable findings, albeit less pronounced, were observed for the association between of AF and TR progression.

MR jet area

Conclusions

The presence of longstanding AF is associated with a significant progression of MR/TR mainly due to atrial remodelling. Our data showed a beneficial effect of sustained rhythm control, either medically or by ablation, on MR/TR progression.
P1879Characterization of cardiac diagnostic care pathways by indication and physician specialty in a real-world dataset of 314,554 patients
Authors: Landman S , Sarkar S
Published: October 2019

Background

A variety of modalities exist for diagnosing cardiac arrhythmias via ambulatory ECG recording. These can range from short-term (i.e. ≤48 hours) holter monitoring, medium-term external monitoring for up to 30 days, and long-term monitoring via an implantable cardiovascular monitor (ICM).

Purpose

To quantify the prevalence of different diagnostic care pathways for cardiac arrhythmias in a large, real-world dataset.

Methods

A de-identified database of aggregated EHR data from 2015–2017 was used to identify patients with any procedure or service received for an ambulatory cardiac diagnostic monitor. Three categories of diagnostic monitoring technologies were identified: (1) Holter monitoring for up to 48 hours, (2) External ECG and event monitoring for up to 30 days via external loop recorder, mobile cardiac telemetry (MCT), or other external ECG recording device, and (3) ICMs. Patients with their first monitor in 2015 or later were selected. The number of patients that had their initial monitor in each of the different categories were quantified, as well as the number that followed a care pathway progression from shorter-term to longer-term monitoring. Patients were grouped by clinical history (syncope or ischemic stroke diagnosis codes in the 6 months prior) as well as by whether they had a clinical interaction with an electrophysiologist (EP) at any point in their care pathway.

Results

A total of 314,554 patients were identified with a mean follow-up duration of 340.1±232.5 days. The initial monitor type used across all patients was 68.8% holter, 27.7% extended holter/MCT/external loop recorder, and 3.5% ICMs. 5.1% of all patients received multiple categories of monitoring. 50,812 patients had a prior history of syncope, 46.4% of which were seen by an EP. 28,374 patients had a prior history of ischemic stroke, with 50.9% seen by an EP. The figure shows that patients seen by an EP are more likely to receive ICMs than those not seen by an EP (20.6% vs. 3.8% for syncope; 25.3% vs. 5.7% for stroke; both p<0.001). Patients seen by an EP are also more likely to receive multiple categories of progressively-longer monitoring than those not seen by an EP (10.4% vs. 4.6% for syncope; 8.3% vs. 4.0% for stroke; both p<0.001).

Conclusion

Cardiac diagnostic care pathways for syncope and ischemic stroke are significantly different between those patients that are seen by an EP versus those that are not. Relatively few patients overall received multiple types of cardiac diagnostic monitoring.

Acknowledgement/Funding

Medtronic
P1905Propofol suppresses atrial fibrillation in an experimental whole-heart model
Authors: Ellermann C , Koenemann H , Wolfes J , Eckardt L , Frommeyer G
Published: October 2019

Background

Many clinical studies suggest an impact of propofol on the occurrence of atrial arrhythmias.

Purpose

Since experimental data is sparse, purpose of this study was to investigate the influence of propofol on atrial electrophysiology and the vulnerability to atrial fibrillation in a sensitive whole-heart model of atrial fibrillation.

Methods

11 hearts of New Zealand white rabbits were isolated and Langendorff-perfused. Two catheters were placed on both atria to record atrial monophasic action potentials. Hearts were stimulated at three different cycle lengths (350ms, 250ms, 150ms), thereby obtaining cycle-length dependent atrial action potential durations (aAPD90) and effective refractory periods (aERP). Atrial post-repolarization (aPRR) refractoriness was defined as the difference between aERP and aAPD90.

To increase the occurrence of atrial fibrillation, hearts were perfused with a combination of acetylcholine (ACh, 1μM) and isoproterenol (Iso, 1μM) after obtaining baseline data. Vulnerability to atrial fibrillation was tested by a standardized protocol consisting of several trains of burst pacing.

Results

Acetylcholine/isoproterenol infusion reduced aAPD90 (−3ms), aERP (−16ms) and aPRR (−14ms). Additional treatment with propofol prolonged aAPD90 (+5ms), aERP (+24ms) and aPRR (+20ms).

Under baseline conditions, 13 episodes of atrial fibrillation lasting longer than 1s occurred. Additional treatment with acetylcholine/isoproterenol provoked more episodes of atrial fibrillation (33 episodes, p<0.05). Infusion of propofol on top of acetylcholine/isoproterenol significantly suppressed atrial fibrillation (2 episodes, p<0.05).

Conclusion

In this study, propofol prolonged aAPD90 and significantly reduced the occurrence of atrial fibrillation. Prolongation of effective refractory periods and especially of post-repolarization refractoriness protects the atrial myocardium against premature excitation and thereby prevents arrhythmias.
P1916A novel echo-guided approach of cryoballoon ablation without using contrast medium
Authors: Kanda T , Masuda M , Asai M , Iida O , Okamoto S , Ishihara T , Nanto K , Tsujimura T , Matsuda Y , Okuno S , Mano T
Published: October 2019

Background

Pulmonary vein isolation (PVI) using cryoballoon requires contrast medium injection for the confirmation of appropriate venous occlusion. However, some patients have contra-indications against contrast use such as allergy for contrast medium, bronchial asthma or renal dysfunction. We hypothesized that intra-cardiac echocardiographic observation of microbubble leakage after saline injection from the cryoballoon lumen can be used as a maker of incomplete venous occlusion.

Purpose

The aim of this study was to assess the effect of echo-guided approach using saline injection on the acute clinical outcomes as well as the amount of contrast medium.

Methods

Twenty consecutive patients with paroxysmal atrial fibrillation (AF) were studied. They had any reason to avoid using contrast medium. Plain CT scan was performed in all cases to understand the anatomical features. Intra-cardiac echocardiography was used in all cases to guide transseptal puncture and to confirm pulmonary-vein occlusion. Procedural results and clinical outcomes were compared with patients who were performed by the conventional method (n=279).

Results

In all study patients, we could perform PVI without using contrast medium. A total of 2 patients required touch-up ablation using radiofrequency ablation catheter. The procedure time (85±23 vs 86±27 min, P=0.84), the dose of radiation exposure (108±78 vs. 140±133 mmGy/m2, P=0.29), and ratio of requiring touch-up ablation (5% vs 4%, P=0.81) were similar between the study group and the reference group. There was no significant difference in the AF-free survival rate (73% vs. 76%, P=0.79) during a follow-up period of 14±6 months.

Images of ICE

Conclusion

Echo-guided approach using saline infusion was effective and less invasive in terms of reduction of contrast use.
P1927A European randomised controlled trial for m-health guided cardiac rehabilitation in the elderly; results of the EU-CaRE RCT study
Authors: De Kluiver E P , Van Der Velde A E , Meindersma E P , Prins L F , Wilhelm M , Iliou M C , Pena Gil C , Gonzalez-Juanatey J R , Snoek J A , Kolkman E , Van't Hof A W J , Prescott E
Published: October 2019

Introduction

Knowledge about effectiveness of cardiac rehabilitation (CR) in the elderly is limited. Participation rates in supervised CR are consistently lower in the elderly and innovative interventions are needed. The EU has granted a CR study project; a randomised controlled trial conducted in 5 European countries, investigating the effectiveness of mobile telemonitoring guided CR (mCR) in elderly cardiac patients who declined regular CR.

Methods

Patients ≥65 years with indication for CR who declined regular CR were eligible for inclusion. Patients were randomised between regular care (without CR) and a 6-month mCR programme: dedicated programmed smartphone, heartrate monitoring (target HR zones) and coaching. The primary endpoint is the difference in VO2peak between 6-months follow-up and baseline.

Results

Between 2015 and 2018 179 patients were included. Baseline characteristics between groups (table 1) did not differ significantly, except for hypertension. The difference in VO2peak was significantly better in the mCR group (table 1). After correction (mixed linear model) for baseline VO2 peak (fixed factor) and centre (random factor) this difference remained significant. Mean number of registered activity sessions was 4.79 (95% CI; 4.07–5.50) per patient per week.

Table 1. Baseline and primary outcome parameters Baseline Control Programme (n=90) mCR Programme (n=89) P-value Gender (m/f) 76/14 69/20 0.238 Age (mean±SD) 73.57±5.46 72.38±5.37 0.121 Diabetes 15 (16.7%) 23 (25.8%) 0.133 Hypertension 60 (66.7%) 73 (82.0%) 0.019* Hypercholesteremia 71 (78.3%) 74 (83.1%) 0.468 Normal LV-function 48/89 (53.9%) 53/89 (59.6%) 0.497 Index event (CABG/Valve/PCI/none) 0.735   Cardiac history prior to index event 48/89 (53.9%) 53/89 (59.6%) 0.702   Non cardiac comorbidity 40 (44.4%) 44 (49.4%) 0.503 Results   Baseline VO2peak (ml/kg/min) (95% CI) 19.83 (18.65–21.01) 18.78 (18.67–19.89) 0.191   Delta VO2peak at 6 months (ml/kg/min) (95% CI) 0.20 4 (−0.34–0.83) 1.62 (0.86–2.39) 0.005*   Corrected delta VO2peak at 6 months (ml/kg/min) 0.50 (−1.04–2.04) 1.65 (0.11–3.2) 0.015* *Significant.

Conclusions

The application of mCR in elderly patients who declined regular CR results in a better physical condition after 6 months. Compliance to mCR was excellent.

Acknowledgement/Funding

European Union's Horizon 2020 research and innovation programme under grant agreement number 634439, and funding from the Swiss Government.
P1941The nuclear receptor corepressor 1 blocks CD36-mediated foam cell formation in atherogenesis
Authors: Oppi S , Stein S , Marzolla V , Osto E , Rancic Z , Luscher T F , Oosterveer M , Stein S
Published: October 2019

Background

Nuclear receptors and their cofactors regulate the expression of various target genes in different tissue and organs to orchestrate downstream (patho)physiological processes. Although the function of several nuclear receptors in atherosclerosis has been studied, very little is known about the role of nuclear receptor cofactors in atherosclerosis. Given its important role to suppress inflammatory processes, we speculated that macrophage nuclear receptor corepressor 1 (NCOR1) plays a protective function in atherosclerosis development.

Purpose

To evaluate the contribution of macrophage NCOR1 in atherosclerosis we used myeloid cell-specific Ncor1 knockout mice on an atherosclerosis-prone background.

Methods and results

8-week-old male and female mice were exposed to a high high-cholesterol diet for 12 weeks. Our findings demonstrate that the lack of macrophage Ncor1 leads to a severe atherosclerotic phenotype in both sexes. These mice show a higher content of plaques along the thoraco-abdominal aortae as well as at the aortic sinus, which were characterized by larger necrotic cores and thinner fibrous caps, a typical signature of unstable plaques. Moreover, we found that the pro-atherogenic effects of the Ncor1 deletion are mediated via derepression of peroxisome proliferator-activated receptor gamma (PPARγ) target genes in mouse and human macrophages, especially the enhanced expression of the CD36 scavenger receptor and the subsequent rise in oxLDL uptake. Interestingly, while the expression of NCOR1 is reduced, the PPARγ signature is increased in human atherosclerotic plaques, and this signature is further pronounced in ruptured compared to stable carotid plaques.

Conclusion

Our findings suggest that macrophage NCOR1 blocks the pro-atherogenic functions of PPARγ in atherosclerosis and prevents the disease development.

Acknowledgement/Funding

The Swiss National Science Foundation, the Novartis Foundation, Olga-Mayenfisch Foundation, the OPO foundation
P1945High levels of unawareness and suboptimal management of hypertension in India: data from a large community based study
Authors: Mohan S , Jarhyan P , Ganesh S , Nikhil S V , Khatkar R , Rao B M , Reddy K S , Tandon N , Prabhakaran D
Published: October 2019

Background

Hypertension is the most common cause of the rising cardiovascular disease (CVD) epidemic in India. However, despite availability of proven therapies management remains sub-optimal.

Purpose

To determine the hypertension control rates and associated factors among adults with known hypertension in urban and rural India.

Methods

We conducted a representative population based cross-sectional survey among 12243 participants aged ≥30 years residing in rural and urban North and South India. Participants were selected using a multistage cluster random sampling technique. Trained personnel collected the data using an interviewer administered questionnaire, measured blood pressure, conducted anthropometry and collected bio-samples. Hypertension was defined as known hypertension (self-report of physician diagnosis) or systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Control was defined as SBP <140 mmHg and DBP <90 mmHg among those with known hypertension. The associations were measured using logistic regression.

Results

The mean (±SD) age of participants was 47.7 (±12.5) years, women comprised 54%. The age-standardized prevalence of hypertension was 29.0% (95% CI: 28.2- 29.8) and known hypertension was 14.0% (13.4- 14.6). Among all hypertensives 38.6% (37.0–40.2) were on treatment and 26.2% (24.6–28.0) had their blood pressure controlled, while among known hypertensives 79.8% (77.8–81.7) were on treatment and 55.7% (53.3–58.1) had their blood pressure controlled. In multivariate analysis, participants from North Indian site [OR: 1.9 (1.6–2.3)], urban residents [1.3 (1.1–1.6)], younger participants [1.5 (1.2–1.8)], men [2.0 (1.5–2.6)], those with low socio-economic status [1.6 (1.1–2.3)], without comorbidities and those without a family history hypertension were more likely to be unaware about their hypertensive status and less likely to take treatment. Hypertension control was significantly higher in participants from South Indian site [1.5 (1.2–1.0)], the highly educated [1.6 (1.1–2.4)], those without heart diseases [1.8 (1.1–3.1)], those without central obesity [1.4 (1.1–1.9)], physically active individuals [1.5 (1.1–2.0)] and current non-alcohol users [1.9 (1.3–2.6)].

Conclusions

Many individuals with hypertension remain unaware and sub-optimally managed. This warrants the implementation of tailored public education to raise awareness, complemented by active screening for the early detection and effective management of hypertension, in order to stem the rising tide of preventable CVD in India.

Acknowledgement/Funding

Unrestricted educational grant from Eli Lilly under the Lilly NCD Partnership
P1948Socioeconomic inequalities in the prevalence and management of hypertension: analyses of the Chilean National Health Surveys 2003, 2010 and 2017
Authors: Passi A , Margozzini P , Mindell J , Ruiz M , Scholes S
Published: October 2019

Hypertension is the highest attributable risk of death worldwide, causing 7.1million deaths annually, and it is the primary cause of cardiovascular morbidity and mortality. In Chile, around one-in-three adults are living with this chronic health condition. Chilean evidence has shown inequalities in hypertension prevalence by various measures of socioeconomic position (SEP). However, information on SEP inequalities in the three key aspects of hypertension management (awareness, treatment, and control of high blood pressure), is only partially known.

Purpose

To assess SEP inequalities in hypertension prevalence and management in Chilean adults.

Methods

Data came from the Chilean National Health Surveys (ENS) 2003, 2010 and 2017. Years of formal education was used as the SEP measure. Age-and gender-specific Slope and Relative Indices of Inequalities (SII and RII) were calculated for the prevalence of hypertension (mean SBP ≥140mmHg, DBP ≥90mmHg, or current medication use to lower blood pressure) and for each management outcome.

Results

Analytical sample comprised 3,426; 4,838 and 5,373 participants aged ≥17y with blood pressure measurements for years 2003, 2010 and 2017, respectively. Prevalence of hypertension was 32.4%, 32.2% and 30.8% for the years 2003, 2010 and 2017, respectively. According to the SII and RII, males and females aged <65y showed higher hypertension prevalence among those with fewer years of education in 2003, 2010 and 2017. Among those classed as hypertensive, levels of awareness increased from 59.4% in 2003 to 65.9% in 2017. Over the same time period, levels of treatment increased from 39.0% to 65.2%, and levels of control increased from 14.1% to 23.9%. SEP inequalities in hypertension management – with better outcomes for the most educated – were highest among females aged ≥65y.

Conclusion

Introduction of universal access to care for hypertension in Chile in 2005 accounted partly for the rise of hypertension management levels since 2003. According to local and international strategies for the prevention and control of noncommunicable diseases, there is room for improvement. However, improvements should have a specific focus on SEP inequalities.

Acknowledgement/Funding

Chilean Ministry of Health
P1950How to improve early prediction of heart failure development after STEMI in clinical arena-is there a place for myocardial deformation imaging?
Authors: Trifunovic D , Krljanac G , Asanin M , Savic-Spasic L , Aleksandric S , Dudic J , Cucic L , Sulovic V , Mrdovic I
Published: October 2019

Heart failure (HF) development after myocardial infarction with ST segment elevation (STEMI) in the modern era varies greatly (between 4% and 28%), with the highest incidence in the first year. Since, HF still carries substantial morbidity and mortality, accurate and early identification of high-risk patients for HF development after pPCI allows for targeted use of intensive therapy.

Aim

The current study is a sub-study of PREDICT-VT study (NCT03263949). Its aim is to define multi-parametric model for early HF prediction in STEMI patients treated by pPCI, based on three data sets: clinical data, conventional echocardiographic data and data from myocardial deformation analysis obtained by early speckle tracking echocardiography.

Methods

In 264 consecutive pts enrolled in PREDICT-VT study early echocardiography (5±2 days after pPCI) was done and included LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec). LV index of post systolic shortening for longitudinal strain (PSS LS) and for circumferential strain (PSS CS) were calculated for the purpose of this study as average of PSS over 18 LV segments.

Results

From 195 patients who completed 1-year follow-up, 17 (8.7%) develop HF NYHA class 3 or 4, 60 (30.8%) NYHA class 2 and remaining 118 patients (60.5%) were in NYHA class I. Significant univariate predictors of NYHA were: from clinical parameters – female gender (β=0.169, p=0018), Killip class on admission (β=0.253, p<0.001) and previous atrial fibrillation (β=0.205, p=0.004); from conventional echocardiographic parameters – LV WMSI (β=0.223, p=0.0072), LVEF (β=−0.256, p<0.001), LAVI (β=0.174, p=0.020) and TAPSE (β=−0.263, p=0.001); from parameters of longitudinal LV deformation – LS at the epicardial level (β=0.242, p=0.001) and PSS LS (β=0.360, p<0.001); from parameters of LV circumferential deformation – CS at epicardial level (β=0.225, p=0.001) and PSS CS at epicardial level (β=0.124, p=0.004); from left atrial mechanics – LA strain (β=−0.199, p=0.007). In multivariable stepwise regression model 5 variables were further identified as independent predictors that significantly increased model power to predict HF development (R square from 0.134 to 0.270, p<0.001). They are: PSS LS (β=0.255, p=0.002), previous atrial fibrilation (β=0.205, p=0.008), TAPSE (β=−0.176, p=0.031), female gender (β=0.165, p=0.032) and PSS CS (β=0.155, p=0.047).

Conclusion

Independently from and above classical clinical and echocardiographic parameters, amount of left ventricular post-systolic deformation in longitudinal and circumferential direction, expressed as LV indexes of post-systolic shortening, significantly improved early prediction of HF development after pPCI.
P1961Clopidogrel compared to aspirin in symptomatic peripheral arterial disease, a nationwide cohort study
Authors: Eldrup N , Toegersen F A T , Soegaard M S , Nielsen P B N , Larsen T B L
Published: October 2019

Background

Aspirin and clopidogrel is currently recommended as equivalent choices for antithrombotic therapy for peripheral arterial disease (PAD) in both European and US guidelines. A recent meta-analysis quested the efficacy of aspirin in prevention of myocardial infarction and cardiovascular mortality and found it protective only against non-fatal stroke. Clopidogrel, however, was effective against non-fatal myocardial infarction and the composite endpoint of death, non-fatal stroke, and myocardial infarction.

Purpose

To investigate if clopidogrel provide clinical benefits over aspirin in a national cohort of revascularized patients with PAD.

Methods

Comparative cohort study including all Danish patients recorded in the Danish Vascular Registry undergoing surgical or endovascular revascularization due to symptomatic PAD in Danish hospital settings from 2000 through 2016. We used multiple national population-based registries to collect individual-level data on comorbidity, medical treatment, and life status. We emulated the principles of a pragmatic randomized controlled trial, i.e. eligibility criteria, exclusion criteria, treatment assignment, and follow-up period, and used inverse probability of treatment weighting to account for treatment confounding.

Results

33,381 patients were considered for inclusion, and 15,737 was excluded according to prespecified criteria, leaving 13,653 taking aspirin and 1,312 clopidogrel. There were baseline differences between the two groups, which mitigated after applying treatment weights. Over a mean follow-up of 5.7 years, there were no treatment differences between aspirin (reference) and clopidogrel for outcomes of myocardial infarction, weighted hazard ratio (HR) 0.84 (95% CI; 0.64–1.10); stroke HR 1.09 (0.83–1.41); amputation HR 0.86 (0.66–1.13); and limb revascularisation HR 0.95 (0.73–1.124). For combined cardiovascular endpoints myocardial infarction, stroke or death we found HR 0.89 (0.75–1.05) and combined limb outcome, amputation and revascularisation HR 0.92 (0.75–1.13), Figure 1. Hazard ratios for risk of all bleedings were similar, also when divided on intracranial, gastrointestinal and others.

Figure 1

Conclusion

In this nationwide cohort of revascularized patients with PAD, clopidogrel in comparison with aspirin showed no difference for cardiovascular outcomes or limb protection.

Acknowledgement/Funding

None
P1964Impact of successful coronary intervention for chronic total occlusion on long-term clinical outcome of patients with impaired and preserved left ventricular ejection fraction
Authors: Tanaka H , Tada T , Fuku Y , Goto T , Kadota K
Published: October 2019

Background

Successful recanalisation of percutaneous coronary intervention for chronic total occlusion lesions has been associated with improved survival.

Purpose

This study aimed to assess the impact of successful percutaneous coronary intervention for chronic total occlusion lesions on the long-term outcome of patients with impaired and preserved left ventricular ejection fraction (LVEF).

Methods

The study sample consisted of 842 consecutive patients (928 chronic total occlusion lesions) undergoing percutaneous coronary intervention at our institution between October 2005 and December 2009. We divided them into 3 groups by the degree of LVEF: less than 40% (severely reduced LVEF, n=140), 40% to 59% (moderately reduced LVEF, n=470), and 60% and above (normal LVEF, n=232). We evaluated mortality during the 10-year follow-up period the basis of procedural success and failure.

Results

The overall procedural success rate was 89.1%. Median follow-up duration was 7.9 years. The 10-year cumulative incidences of cardiac death in each degree of LVEF are shown in the Figure.

Conclusions

Successful recanalisation for chronic total occlusion lesions in patients with impaired LVEF may be associated with reduced cardiac mortality.
P1966Impact of coronary artery calcification on long-term outcomes after implantation of first and second-generation drug-eluting stents: a patient-level analysis of 18 randomized trials
Authors: Guedeney P , Claessen B , Mehran R , Mintz G , Liu M , Sorrentino S , Farhan S , Leon M B , Serruys P , Smits P C , Von Birgelen C , Redfors B , Madhavan M V , Ben-Yehuda O , Stone G W
Published: October 2019

Background

Available data on the long-term impact of coronary artery calcification (CAC) after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) are limited.

Purpose

We evaluated the long-term impact of CAC on outcomes after PCI and the respective performance of first- and second-generation DES.

Methods

We pooled patient-level data from 18 randomized trials evaluating DES categorized according to the presence of angiographic core lab-confirmed moderate or severe CAC in any target lesion. Outcome measures of interest were the patient-oriented composite endpoint (POCE; death, myocardial infarction [MI], or any revascularization), the device-oriented composite endpoint of target lesion failure (TLF; cardiac death, target vessel MI or ischemia-driven target lesion revascularization), and definite or probable stent thrombosis (ST). Multivariable Cox proportional regression with study as a random effect was used to assess 5-year outcomes.

Results

A total of 19,833 patients were included. Moderate or severe CAC was present in 6211 (31.3%) patients and associated with increased 5-year risk of the POCE (adjHR 1.12, 95% CI 1.05–1.20, p<0.001), TLF (adjHR 1.21, 95% CI 1.09–1.35, p<0.001), and a trend for greater ST (adjHR 1.24, 95% CI 0.99–1.54, p=0.06). In patients with CAC, second-generation DES were associated with a reduction in the 5-year risk of TLF and ST, and a trend for reduced POCE compared with first-generation DES (Table).

Conclusion

In this large-scale study, target lesion moderate or severe CAC was associated with adverse patient- and device-related outcomes at 5 years, risks that were reduced but not eliminated with second-generation DES.

Acknowledgement/Funding

This investigator-sponsored study was funded by Abbott Vascular.