bluuebunny/crossref_metadata_2025 huggingface dataset:
The timing of death in acute pulmonary embolism patients regarding the mortality risk stratification at admission to hospital
Authors: Obradovic S , Dzudovic B , Matijasevic J , Salinger S , Kos L J , Benic M , Mitevska I , Kafedzic S , Kovacevic-Preradovic T , Neskovic A , Bozovic B , Bulatovic N , Miloradovic V
Published: October 2022

Background

The management of patients with acute pulmonary embolism (aPE) depend on the risk stratification at hospital admission. It is unknown when normotensive aPE patients with some other risk factors deteriorate.

Patients and methods

Patients with objectively established acute PE diagnosis enrolled in the regional PE registry from January 2015 to December 2021, were studied in this investigation. According to European Society od Cardiology criteria patients were stratified during admission to hospital in four risk stratums. The timing for death and the main reason for death were recorded. PE-related death was defined if patient has died because of cardiac arrest or obstructive shock if there is no another possible reason for that.

Results

In the REPER registry. Among 1541 patients (514 low risk, 366 intermediate-low risk, 472 intermediate-high risk and 189 high risk) with aPE, 101 (6.6%) have died primary from aPE and 64 (4.2%) have died from other reasons during the 30-day follow-up. PE-related death across the mortality risk groups were 0.8%, 1.1%, 8.5% and 28.5% in low-risk, intermediate-low, intermediate-high and high risk PE, respectively. Median time from hospital admission to PE related death was significantly longer in intermediate-high than in high risk patients 4.5 (2.0–9.0) vs 1.0 (1.0–4.5) days, p=0.001. In the high risk group 50.9% of patients died during the first 24 hours, 9.0% in the next 24 hours and 83.0% of patients died during the first 5 days from admission. In the intermediate-high risk group 17.5% died in the first 24 hours, 12.5% died in the next 24 hours and next 25% died till the fifth day. There was no difference in timing of non PE-related death between intermediate-high and high risk patients 9.5 (6.0–18.5) vs 7.0 (3.0–23.5) days, p=0.631.

Conclusion

There is significant delay in timing of death in intermediate-high compare to high risk PE patients, however, almost 50% of patients who died in the intermediate-high risk PE patients have died inside the first 5 days from hospital admission.

Funding Acknowledgement

Type of funding sources: None.
An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease
Authors: Caravita S , Baratto C , Soranna D , Dewachter C , Bondue A , Zambon A , Badano L P , Parati G
Published: October 2022

Background

Pulmonary hypertension (PH) is associated with a poor prognosis in patients with left heart disease (LHD). Several hemodynamic variables have been shown to predict outcome, including pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and the diastolic pressure gradient (DPG). We sought to provide an updated analysis on the association of these variables with prognosis in PH-LHD.

Methods

We performed a systematic literature review including studies reporting association measurements between DPG and/or PVR and/or PAC and death in PH-LHD patients. These hemodynamic variables were extracted to estimate the pooled hazard ratio (HR) of adverse outcome for each one, and cumulative meta-analysis was performed to investigate temporal trends in the effects reported in the literature as well as the impact of sample size.

Results

17 articles were identified, including 9716 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, we found that PVR (HR, 1.09; 95% CI: 1.06–1.12), DPG (HR, 1.02; 95% CI: 1.01–1.02) and PAC (HR, 0.73; 95% CI: 0.76–0.81) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG (Figure 1). Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD (either heart failure with preserved or reduced left ventricular ejection fraction, or valvular heart disease). Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018 (Figure 2).

Conclusions

Despite the heterogeneity of PH-LHD group and the intrinsic limitations of each variable, PVR, DPG, and PAC have an established prognostic value in PH-LHD. The strongest correlation with PVR and PAC supports their use in defining disease severity and identifying a subgroup of patients at higher risk of adverse outcome. We believe that these results are consistent through the years and unlikely to change with the addition of further studies.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.
Speckle-tracking global longitudinal strain predicts clinical outcomes in patients with systemic sclerosis
Authors: Stronati G , Paolini F , Benfaremo D , Selimi A , Dello Russo A , Moroncini G , Guerra F
Published: October 2022

Introduction

Systemic-sclerosis related cardiomyopathy is frequent and, albeit often asymptomatic, is likely secondary to the underlying pathophysiology of SSc itself and represents a negative prognostic factor. Speckle-tracking derived global longitudinal strain (GLS) has been proven to be a cost-effective tool in the detection of LV and RV dysfunction in patients with SSc and no overt cardiac disease.

Purpose

The aim of our study was to assess whether baseline GLS could predict clinical outcomes in patients with SSc in terms of death, heart failure, hospitalizations, and development of pulmonary hypertension.

Methods

We conducted a prospective observational study on all consecutive patients referred to our clinic between June 2016 and January 2022 with a confirmed diagnosis of SSc and no overt cardiac disease, pulmonary hypertension, or atrial fibrillation at the time of enrollment.

We performed baseline echocardiogram and GLS calculations for all patients as well as collected clinical and ECG data at baseline and at each follow up.

Results

Out of 164 patients (148 female, 58±14 years), 19 (11.6%) patients died during a median follow-up of 3.2 years for mainly non-cardiovascular deaths (7.3%) while cardiovascular deaths were lower (3% non-sudden, 1.3% sudden).

Left GLS at first visit was associated with all-cause death, with a 1% left GLS worsening associated with a 19% increased risk of death after adjusting for age, gender, and LVEF (adjusted HR 1.19; 95% CI 1.05–1.35; p=0.007).

Similarly, right GLS at first visit was associated with all-cause death, with a 1% right GLS worsening associated with a 12% increased risk of death after adjusting for age, gender, and TAPSE (adjusted HR 1.12; 95% CI 1.03–1.21; p=0.005).

Patients with a left GLS worse (i.e. higher) than −20% had a 3.5-fold increased risk of death when compared to patients with better left GLS (HR 3.55; 95% CI 1.28–9.88; p=0.015; Figure 1a). Similarly, patients with a right GLS worse than −20% had a 4.5-fold increased risk of death when compared to patients with better left GLS (HR 4.47; 95% CI 1.4–13.74; p=0.009; Figure 1b).

Conclusions

Baseline GLS measured is an effective tool to recognize patients with SSc and negative prognosis. It may help us identify early those who need to be followed more closely and start appropriate treatment in order to prevent major cardiovascular and non-cardiovascular events. The close relationship between left and right GLS as risk predictors underlines the role of SSc in promoting overt cardiac disease, not limited to pulmonary hypertension.

Funding Acknowledgement

Type of funding sources: None.
Dyspnea and perfusion defects (V/Q scan) are common after an acute pulmonary embolus whereas chronic thromboembolic pulmonary hypertension (CTEPH) is a rare sequele
Authors: Andersson T , Nilsson L , Larsen F , Carlberg B , Soderberg S
Published: October 2022

Introduction

Acute pulmonary embolism (PE), a common disease with substantial morbidity and mortality. Many previous studies have focused on the short-term consequences after an acute PE, but less attention has been directed to the long-term effects of a PE. The most feared complication is chronic thromboembolic pulmonary hypertension (CTEPH), with reported incidence rates ranging from 0.6 to 4.8%. Even though CTEPH is a rare complication after PE, dyspnea and functional impairment are common complaints, and a syndrome named PPES (post-PE-syndrome) has been suggested. The aim of this study was to follow a large national-wide cohort of post-PE-patients and to gather information regarding long-term symptoms and to determine the prevalence of CTEPH.

Patients and methods

We identified all patients diagnosed with acute PE in 2005 (ICD-10-SE: I26.0 and I26.9) that were registered in the Swedish National Patient Register (NPR), which has nearly 100% coverage.

In 2007, all surviving individuals were invited to participate by letter. They were asked to complete a questionnaire regarding symptoms and risk factors for long-term sequele including CTEPH.

Individuals who reported dyspnea or had known risk factors for CTEPH were invited to a follow-up with blood tests (NT-pro-BNP) and pulmonary scintigraphy. If any perfusion defects were detected, an echocardiography was performed. If signs of pulmonary hypertension, a referral was done to the regional PAH-center.

Results

In 2005, 5793 unique patients were admitted with a PE diagnosis in Sweden. Of those, 3510 were still alive in 2007, and 3226 individuals were contacted and asked to complete the questionnaire. Altogether 2105 (65%) individuals returned the questionnaire, and 53% reported dyspnea and 15% were asymptomatic but had risk factors for CTEPH. Altogether 944 individuals were referred for further follow-up including a recommendation to perform a V/Q-scan. Altogether 530 V/Q-scans were performed and 44% showed perfusion defects, whereof 85% had an echocardiography. Twenty-seven % of them registered a systolic right ventricular pressure of at least 30 mmHg. Referrals resulted in 6 cases with proved CTEPH. In parallel, 10 patients with CTEPH diagnosed before 2005 were detected, and 8 patients were diagnosed after 2005 and outside the study.Altogether 24 patients with CTEPH were thus identified and the cumulative incidence of CTEPH ranged between 0.7 and 1.2%.

Conclusion

Dyspnea is common after an acute PE and over 40% of them have perfusion defects on a V/Q scan, suggesting the presence of a post PE-syndrome (PPES). The incidence of CTEPH is however low. More research is needed to better define PPES.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Actelion PharamceuticalsSwedish Heart and Lung Foundation
Efficacy and safety of balloon pulmonary angioplasty for patients with chronic thromboembolic pulmonary hypertension comorbid to chronic obstructive pulmonary disease
Authors: Fujii H , Taniguchi Y , Yoneda S , Miwa K , Yanaka K , Emoto N , Hirata K
Published: October 2022

Background

Balloon pulmonary angioplasty (BPA) would be promising treatment option for non-operable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for CTEPH with Chronic obstructive pulmonary disease (COPD) might exacerbate ventilation perfusion mismatch. The aim is to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD.

Method

Data from 149 CTEPH patients were collected retrospectively who underwent BPA from March 2011 to June 2021. Patients were divided according to the comorbidity of COPD: a COPD group (defined as forced expiratory volume in one second (FEV1.0) / forced vital capacity (FVC)<70% and FEV1.0<80% predicted [n=32]) or a non-COPD group [n=101]. Mild COPD patients (n=16) were excluded. Hemodynamics and respiratory parameters were compared.

Results

Hemodynamics improved similarly in both group (percent decrease of pulmonary vascular resistance; −61.1±12.3% in a COPD group, −65.8±11.1% in a non-COPD group, p=N.S). Patients in a COPD group showed improved respiratory function and oxygenation with FEV1.0% from 61.8±7.0% to 66.5±10.2% (p=0.02), and partial pressure of arterial oxygen from 60.9±10.6mmHg to 69.3±13.6mmHg (p<0.01). Higher vital capacity (r2=0.123, p=0.024), higher diffusing capacity for lung carbon monoxide (r2=0.308, p=0.028) at baseline were correlated with larger improvement of oxygenation after BPA in multivariate linear analyses. Lung injury per session was 1.6% in a COPD group.

Conclusion

The efficacy and safety of BPA for non-operable CTEPH with COPD were equivalent to those of patients without COPD. Oxygenation and FEV1.0% also improved in COPD patients. BPA might be considered even though patients comorbid COPD.

Funding Acknowledgement

Type of funding sources: None.
Increased B-type natriuretic peptide is a better predictor of hospital mortality then increased troponin in patients with acute pulmonary embolism
Authors: Dzudovic B , Matijasevic J , Salinger S , Obradovic S
Published: October 2022

Background

Both elevated troponin (Tn) and B-type natriuretic peptide (BNP) or N-terminal pro BNP (NT-proBNP) are recognized as markers of increased right ventricular overload in acute PE. However, among these biomarkers, only elevated Tn is suggested in the current guideline for estimation of early mortality risk in acute PE.

Purpose

To compare the values of the increase above the upper limit of normal (ULN) for both Tn and BNP markers in terms of their predictive value for hospital mortality in acute PE patients.

Patients and methods

This is a multi-centric retrospective cross-sectional study of consecutive PE patients during the 6 years (2015–2021). BNP and Tn were measured on admission to the hospital. BNP or Tn values were then divided with ULN provided by the laboratory for each biomarker, and the results thus obtained were used in ROC curve comparison analysis to compare the prediction values for all-cause hospital mortality in PE patients.

Results

Overall 758 patients were included in the study, and among them, 72 (9.5%) died. The cut-off value for the increase of BNP was 2.3 times ULN and had 81.2% sensitivity and 55.5% specificity. Positive predictive value (PPV) and negative predictive value (NPV) were 15.3% and 96.8%, respectively. The cut-off value for the increase of Tn was 1.5 times ULN, with 77.3% and 45.6% of sensitivity and specificity, respectively (NPV 95.3% and PPV 12.3%). in the comparison of ROC curves, AUC for BNP increase was 0.716 and the AUC for Tn increase was 0.625, p=0.03 (Fig. 1).

Conclusion

The increase of BNP above the upper limit of normal is a better predictor of early mortality among acute PE patients than the increase of Tn in the same patients.

Funding Acknowledgement

Type of funding sources: None.
Trends in management and outcomes of pulmonary embolism with a multidisciplinary response team
Authors: Chopard R , Campia U , Morin L , Jering K S , Almarzook Z I , Snyder J E , Rizzo S , Waxman A B , Goldhaber S Z , Piazza G
Published: October 2022

Background

Multidisciplinary pulmonary embolism (PE) response teams have garnered widespread adoption given the complexities of managing acute PE and provide a platform for assessment of trends in therapy and outcomes. We aimed to describe temporal trends in PE management and outcomes following the deployment of such a team.

Methods

All consecutive patients managed by our multidisciplinary PE response team activated by the Emergency Department were included over a 5-year calendar period. We examined temporal trends in management and rates of a composite primary endpoint (all-cause-death, major bleeding, recurrent venous thromboembolism, and readmission) at 30 days and 6 months.

Results

We assessed 425 patients between 2015 and 2019. We observed an increase in PE acuity and use of systemic thrombolysis. The primary endpoint at 30 days decreased from 16.3% in 2015 to 7.1% in 2019 (adjusted rate ratio per period, 0.63; 95% CI, 0.47–0.84), driven by a decrease in the adjusted rate of major bleeding. Among 406 patients with complete follow-up, the adjusted rate ratio per year for the primary outcome at 6 months was 0.37 (95% CI, 0.19–0.71), driven by a decrease in all-cause mortality.

Conclusions

We observed evidence of temporal changes in clinical presentation therapeutic strategies, and outcomes for acute PE, in parallel to, but not necessarily because of, the implementation of a multidisciplinary response team. Over time, major bleeding, mortality and readmission rates decreased, despite an increase in PE risk category.

Funding Acknowledgement

Type of funding sources: None.
Pulmonary embolism response team implementation and its clinical value across countries: a scoping review and meta-analysis
Authors: Farmakis I , Keller K , Scibior B , Mavromanoli A C , Sagoschen I , Munzel T , Ahrens I , Konstantinides S , Hobohm L
Published: October 2022

Background

Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has been developed to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE), but data on the use and the benefit of PERT are sparse.

Purpose

We aimed to systematically investigate the composition of PERT and its clinical value in clinical routine across different countries.

Methods

We searched PubMed, CENTRAL and Web of Science until January 2022 for full-text, prospective and retrospective observational studies, which included patients with acute PE who were evaluated by a PERT. Eligible articles were designed to either describe the structure and function of PERTs and/or to investigate outcomes related to the implementation of PERT. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and use of advanced therapies.

Results

We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In total, PERT involved a median of 6 (range 2–10) specialties for guiding further diagnostic and treatment modalities. Patients evaluated by a PERT had a mean age of 60 years; of them, 48.7% were females, and 23.5% suffered from malignancy. Right ventricular dysfunction was present in 55% of the patients. In total, 74.5% were classified as intermediate-risk PE and 16% as high-risk PE. In eleven single-arm studies, 1,532 patients with intermediate- and high-risk PE were evaluated by PERT with a mortality rate of 10% and a bleeding rate of 9%. The mean length of stay was 7.3 days and the use of advanced therapy was reported in 30% of all cases. From these, catheter-directed treatment (CDT) was performed in 22% and inferior vena cava filter was inserted in 15%, while systemic thrombolysis was administered in only 6%, surgical thrombectomy in 2% and ECMO in 3% of all cases. When comparing PERT and pre-PERT era no difference in mortality (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.67–1.19, I2=63%) was observed based on nine controlled studies, while mortality tended to be lower when including only intermediate and high-risk patients in the analysis (RR 0.71, 95% CI 045–1.12) (Figure 1). The use of advanced therapies was more common (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay as well as the duration of treatment in intensive care unit was shorter (mean difference −1.6 days and −1.8 days, respectively) in the PERT era.

Conclusion

PERT implementation tended to reduce the mortality rate in patients with intermediate- and high-risk PE and resulted in a shorter in-hospital stay. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.
Exercise-induced pulmonary hypertension assessed by echocardiography in patients with chronic thromboembolic pulmonary disease
Authors: Dhayyat A , Mykland Hilde J , Jervan O , Stavem K , Ghanima W , Melsom M N , Steine K
Published: October 2022

Background

Many patients with chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension (PH) at rest suffer from exercise intolerance. Exercise echocardiography, which is a noninvasive examination, may have potential to discover exercise-induced PH in these patients, however, its role is scarcely explored in this population.

Purpose

To determine the occurrence of abnormal pulmonary pressure during rest and by exercise echocardiography in patients with CTEPD.

Methods

In total, 24 patients with CTEPD, all diagnosed after pulmonary embolism, underwent exercise echocardiography with dynamic supine leg exercise using a cycle ergometer. In addition, all participants underwent a modified incremental shuttle walk test (mISWT), pulmonary function tests and measurement of NT pro-BNP. Systolic pulmonary arterial pressure (sPAP) >50 mmHg by echocardiography during exercise was chosen as cutoff to define exercise-induced pulmonary hypertension (EIPH). Left ventricular diastolic dysfunction during stress was defined according to the American Society of Cardiology guidelines from 2016. Mean pulmonary artery pressure was estimated by sPAP measurements using the Chemla formula (0.61 x sPAP + 2 mmHg), and pulmonary vascular resistance (PVR) by the Doppler method (5.19 x TRV2/TVI RVOT − 0.4) proposed by Abbas et al. [1]. Subjects with heart failure with reduced or preserved ejection fraction, significant valvular heart disease, chronic pulmonary disease and chronic thromboembolic pulmonary hypertension were excluded.

Results

11 (46%) of the patients had EIPH at peak exercise (range 50 to 89 mmHg). PVR at peak exercise ranged from 2.6 to 5.9 WU, whereas 10 had PVR >3.0 WU. None had unmasked left ventricular diastolic dysfunction during exercise, resting tricuspid regurgitation peak velocity (TR V max) >3.4m/s, or a high probability of PH at rest. Three patients had TR V max between 2.9 and 3.4m/s or intermediate probability of PH. All patients had normal biventricular systolic function at rest and during exercise (Table 2).

Conclusion

Patients with CTEPD had normal pulmonary pressures at rest. However, approximately half of the patients showed abnormal rise in pulmonary pressure during exercise, which may explain or contribute to the exercise intolerance in these patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Ostfold Hospital Trust
Predictors of acute pulmonary embolism-related hospitalizations – an artificial neural network analysis using a nationwide cohort in the United States
Authors: Desai R , Singh S , Dyutima D R , Verma J , Raina J , Itare V , Rizvi B , Gandhi Z , Vyas A , Jain A
Published: October 2022

Background

Considering a paucity of large-scale data on predictors of pulmonary embolism (PE) and its higher association with complications and worse outcomes, we aimed to determine the predictors of PE in this United States population-based analysis using Artificial Neural Network (ANN) Model in a nationally representative cohort.

Methods

We identified PE-related hospitalizations using 2018's National Inpatient Sample database. The relevant predictive factors for ANN were selected for this cohort. Of all admissions (unweighted n=7,105,498, weighted n=35,527,481), PE cohort (weighted n=387805) consisted of 1.1% of all admissions in 2018. The 2018 cohort was randomly split into training data (unweighted n=4716132, 70.0%) which were used to calibrate ANN and testing data (unweighted n=2019290, 30%) which were used to assess the accurateness of the algorithm. We equated the rate of incorrect prediction between training and testing data and measured the Area under Receiver Operator Curve (AUC) to determine ANN's efficacy in predicting PE hospitalizations.

Results

Patients hospitalized with PE often consisted of older (mean age 62.5±17.1 years), female (51.3%), white (70.5%) patients, and patients from lower-income quartile (0–25% income quartile: 28.8%%), often admitted non-electively (93.7%) with higher rates of cardiovascular disease risk factors. PE admissions revealed significantly higher (6.5% vs. 1.9%, p<0.001) in-hospital mortality, less frequent routine discharges (51.4% vs. 68.1%) and more frequent other facility transfers and requirement of home health care. Normalized Predictors of PE admissions are displayed in Fig. 1. Our ANN model had AUC 0.873 which correlates with an excellent prediction model. Our data demonstrated low levels (0.8%) error in both testing and training models.

Conclusion

Our ANN model showed high performance to predict risk factors for PE admissions in the US population. It will enable clinicians to screen patients at high-risk for PE admissions, curtail complication rate, improve survival and lower the healthcare cost.

Funding Acknowledgement

Type of funding sources: None.
Body fluid status in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension
Authors: Yogeswaran A , Husain-Seyed F , Tello K , Sommer N , Rako Z A , Ghofrani H A , Seeger W , Richter M J , Gall H
Published: October 2022

Introduction

Body fluid status can be determined by plasma volume status and extracellular water to total body water (ECW/TBW) ratio and is a well-known parameter associated with survival in patients with chronic heart failure (1–3). However, its prognostic impact in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) is not fully understood.

Methods

409 patients with PAH and CTEPH who entered the Giessen PH registry were included in this study (4). Plasma volume status was estimated using Duarte formula (ePVS = (1 − hematocrit) / hemoglobin × 100). ECW was calculated via Peters formula ((−2.47 × 0.842 + 8.76 × body surface area) for men and (−1.96 × 0.572 + 8.05 × body surface area) for women) and TBW via Watson formula ((2.447 − [0.09516 × age] + [0.1073 × height] + [0.3362 × body weight]) for men and (−2.097 + [0.1069 × height] + [0.2466 × body weight]) for women). Statistical analyzes were performed with R (The R Foundation).

Results

Median age of the included patients was 65 [53, 74] years. Median ePVS and ECW/TBW ratio were 4.5 [3.9, 5.5] and 0.39 [0.37, 0.40]. Correlation analyses revealed that ePVS correlates with pulmonary artery wedge pressure (PAWP), pulmonary vascular resistance (PVR), cardiac index, and mixed venous oxygen saturation (SvO2), whereas ECW/TBW ratio did not correlate with pulmonary hemodynamics. Accordingly, univariate Cox regression revealed that ePVS but not ECW/TBW ratio was associated with mortality (HR: 1.18 [1.02, 1.37]). ePVS remained as an independent prognostic parameter in multivariate Cox regression analysis. Patients with high ePVS showed significantly decreased survival rates (log-rank p<0.001).

Conclusion

ePVS but not ECW/TBW ratio is associated with prognostic parameters such as PVR, cardiac index and SvO2. Thus, ePVS may be an independent prognostic parameter in patients with PAH and CTEPH.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)
Predictive value of neutrophil-to-lymphocyte ratio for atrial fibrillation and stroke in type 2 diabetes mellitus: a population-based cohort study
Authors: Chou O H I , Chang C , Zhou J , Chan J , Leung K S K , Lee T T L , Wong W T , Liu T , Zhang Q , Lee S , Wai A K C , Tse G
Published: October 2022

Introduction

Neutrophil-to-lymphocyte ratio (NLR) is a routinely available biomarker that reflects systemic inflammation. The study evaluated the predictive value of NLR for ischemic stroke and atrial fibrillation (AF) in patients with type 2 diabetes mellitus.

Methods

This was a population-based cohort study of patients with type 2 diabetes mellitus and complete blood count tests at baseline between January 1st, 2009 to December 31st, 2009 at government-funded hospitals/clinics in Hong Kong. Follow-up was until December 31st, 2019 or death.

Results

A total of 85351 patients (age=67.6±13.2 years old, male=48.8%, follow-up=3101±1441 days) were included. Univariable Cox regression found that increased NLR at quartiles 2, 3 and 4 was significantly associated with higher risks of new onset ischemic stroke (HR: 1.28 [1.20–1.37], P<0.001, HR: 1.41 [1.32–1.51], P<0.001 and HR: 1.38 [1.29–1.47], P<0.001) and AF (hazard ratio [HR]: 1.09 [1.02–1.17], P<0.015; HR: 1.28 [1.20–1.37], P<0.001; HR: 1.39 [1.31–1.49], P<0.001) compared to quartile 1. On multivariable analysis, NLR remained a significant predictor of ischemic stroke risk for quartiles 2 and 3 (quartile 2: HR: 1.14 [1.05, 1.22], p=0.001; quartile 3: HR: 1.14 [1.06, 1.23], p<0.001) but not quartile 4 (HR: 1.08 [0.994, 1.17], p=0.070). By contrast, NLR was not predictive of AF after adjusting for confounders (quartile 2: HR: 0.966 [0.874, 1.07], p=0.499; quartile 3: HR: 0.978 [0.884, 1.08], p=0.661; quartile 4: HR: 1.05 [0.935, 1.16], p=0.462).

Conclusion

NLR is a significant predictor of new onset ischaemic stroke but not AF after adjusting for significant confounders.

Funding Acknowledgement

Type of funding sources: None.
Four-month treatment with long-acting glucagon-like peptide-1 receptor agonists (GLP-1) or sodium-glucose co-trasporter-2 inhibitors (SGLT-2i) improves vascular function in type 2 diabetes mellitus
Authors: Ikonomidis I , Prentza V , Kountouri A , Pavlidis G , Katogiannis K , Thymis J , Pliouta L , Korakas E , Kostelli G , Mixalopoulou E , Balampanis K , Palaiodimou L , Zompola C , Tsivgoulis G , Lambadiari V
Published: October 2022

Background/Introduction

Patients with type 2 diabetes mellitus (T2DM) and ischemic stroke present impaired markers of vascular and endothelial function. Glucagon-like peptide-1 receptor agonists (GLP-1) and sodium-glucose contrasporter-2 inhibitors (SGLT-2) are novel antidiabetic agents reducing the risk of cardiovascular complications.

Purpose

The aim of the study is to investigate the effect of treatment with GLP-1 or SGLT2 on arterial stiffness and endothelial glycocalyx in patients with T2DM and ischemic stroke.

Methods

We recruited in total 81 patients with T2DM and ischemic stroke who received dulaglutide (n=27), dapagliflozin (n=27) or insulin (n=27). We measured at baseline and at four months post-treatment the: a) Carotid-femoral pulse wave velocity (PWV-Complior; ALAM Medical), b) Augmentation index (Aix), c) Central systolic blood pressure (cSBP), and d) Perfused boundary region (PBR) of the sublingual arterial microvessels(marker of endothelial glycocalyx thickness), e) Left ventricular global longitudinal strain (GLS) using speckle-tracking echocardiography.

Results

At baseline, patients among the three groups had similar age, sex, HbA1c and markers of endothelial and cardiovascular function (p>0.05). Dapagliflozin and dulaglutide showed a greater reduction of PBR, PWV and central SBP than insulin, despite a similar HbA1c reduction (p<0.05). After four months treatment, patients on dapagliflozin and on dulaglutide displayed a greater reduction of PWV (−10% and −8% vs −1%), of cSBP (−9% and −8% vs +1%), of Aix (−65% and −13% vs −3%) and of GLS (+11% and +7% vs +5%) compared to patients on insulin (p<0.05 for all comparisons) (Table 1). PBR values were improved only in patients who received dulaglutide (−4% vs dapagliflozin: −2% vs insulin +1%).

Conclusions

Dulaglutide and dapagliflozin improve cardiovascular function, but only dulaglutide improves endothelial glycocalyx in patients with T2DM and ischemic stroke after four months treatment.

Funding Acknowledgement

Type of funding sources: None.
Aortic flow patterns by 4D flow CMR in Marfan and Loeys-Dietz patients before and after valve sparing aortic root replacement: a comparison with healthy volunteers
Authors: Ruiz Munoz A , Guala A , Dux-Santoy L , Rodriguez-Palomares J F , Garcia-Duran A , Garrido-Oliver J , Galian-Gay L , Valente F , Casas G , Fernandez-Galera R , Johnson K , Wieben O , Ferreira-Gonzalez I , Evangelista A , Teixido-Tura G
Published: October 2022

Introduction

Abnormal aortic flow patterns in patients with a connective tissue disorder (CTD), such as Marfan or Loeys-Dietz syndrome, may contribute to aortic root dilation [1,2]. Valve sparing aortic root replacement, which is effective in reducing the risk of aortic dissection in case of severe dilation, may also normalize flow patterns beyond the replaced aorta and potentially slow its progressive aortic dilation.

Purpose

To assess aortic flow dynamics in patients with a CTD by 4D flow cardiovascular magnetic resonance (CMR) before and after valve sparing aortic root replacement, and to compare the results with those of healthy volunteers (HV).

Methods

Patients with Marfan or Loeys-Dietz syndrome underwent two non-contrast enhanced 4D flow CMR, one before and another after undergoing valve sparing aortic root replacement. Healthy volunteers matched for age, sex and BSA were also included for comparison. Maximum velocity, in-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and wall shear stress (WSS) magnitude and its axial and circumferential components were obtained at 24 planes covering the thoracic aorta from the sinotubular junction to the descending aorta at the diaphragmatic level [3–5].

Results

Sixteen patients and 21 healthy volunteers were included. Demographic and clinical data is presented in Table. The mean time between the CMR prior and posterior to surgery was 15 months. Compared to HV, patients with CTD before intervention presented lower maximum velocity at the proximal ascending aorta (Fig. 1A), lower IRF and circumferential WSS at the arch and the proximal descending aorta (Fig. 1B and F), lower magnitude and axial WSS at the proximal ascending and descending aorta (Fig. 1E and D), and increased SFRR at the proximal descending aorta (Fig. 1C). The intervention completely restored maximum velocity and partially-restored physiological helical flow and circumferential WSS, but barely improved axial WSS and SFRR.

Conclusion

Valve sparing aortic root replacement in patients with Marfan or Loeys-Dietz syndrome partially restore to physiological level both in-plane rotational flow and circumferential wall shear stress in the descending aorta. This flow normalization may contribute to prevent progressive dilation after the surgery.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III (Spain) (PI17/00381)Spanish Society of Cardiology (SEC/FEC-INV-CLI 20/015)
Clinical outcomes in patients with bicuspid aortic valves and ascending aorta dilatation equal or above 50mm
Authors: Ye Z , Lane C , Beachey J , Medina-Inojosa J , Galian L , Dentamaro I , Calvo-Iglesias F , Alegret J , Sanchez V , Moral S , Bellino M , Enriquez-Sarano M , Bagnati R , Evangelista A , Michelena H
Published: October 2022

Background

Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins.

Purpose

To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation.

Methods

Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation.

Results

We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (>6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was >90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or >1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001).

Conclusions

Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients.

Funding Acknowledgement

Type of funding sources: None.
COVID-19 and cardiovascular system: not only heart but also vascular. The effects of the infection on arterial stiffness
Authors: Maloberti A , Gualini E , Scarpellini S , Algeri M , Biolcati M , Grasso E , Tognola C , Moreo A
Published: October 2022

Background

SARS-CoV-2 determines a framework of multi-organ dysfunction that can involve the cardiovascular system creating damages of different nature. Among these, endothelial damage could play a key role in increasing arterial stiffness and thus the cardiovascular risk of infected patients. The aim of this study is to evaluate the Pulse Wave Velocity (PWV) of a population of patients after recovery from infection and to compare them with those of a group affected by arterial hypertension.

Methods

This prospective observational monocentric study involved 143 patients with previous diagnosis of Covid-19 who undergone PWV measurement during the follow-up at a median time of 3.8 months after the infection. These patients were compared to a population of 143 patients with hypertension matched by age, sex, Systolic Blood Pressure values and Body Mass Index.

Results

PWV values were higher in Covid-19 group comparing to hypertension group (10.5±3.0 m/s VS 8.9±2.5 m/s). Furthermore, there is a correlation between higher PWV values and lower values of SpO2% at time of admission at the Emergency Department. (R=−0.302; p<0.001).

Conclusions

SARS-CoV-2 infection seems related to increased PWV values. Moreover, higher arterial stiffness seems correlated to a worse oxygen saturation in Emergency Department. More studies with longer follow-up time are necessary to establish whether the vascular damage is reversible and whether it correlates with an increase of long-term cardiovascular risk.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Niguarda Hospital, Milan, Italy
The role of cardiometabolic risk factors and endothelial dysfunction in serum albumin levels and capillary leak syndrome of patients with COVID-19
Authors: Oikonomou E , Lampsas S , Lampadiari V , Korakas E , Bletsa E , Souvaliotis N , Theofilis P , Tsatsaragkou A , Poulakou G , Tsoukalas D , Pantelidis P , Kyvelou S M , Siasos G , Tousoulis D , Vavuranakis M
Published: October 2022

Background

Growing evidence focuses on the role of hypoalbuminemia in the COVID-19 course and the role of vascular inflammation in the progression to Capillary Leak Syndrome (CLS). CLS may be mediated by a derangement of endothelial barrier following vascular endothelial dysfunction. We investigated the role of cardiometabolic risk factors in the association of hypoalbuminemia with endothelial dysfunction of hospitalized COVID-19 patients.

Methods

In this cross-sectional study, patients hospitalized for COVID-19 at the medical ward or Intensive Care Unit (ICU) were enrolled. Medical history and laboratory examinations were collected while the endothelial function was assessed by brachial artery flow-mediated dilation (FMD) between the first 24–72 hours of their admission to the hospital. According to the body mass index, history of hypertension, dyslipidemia, and diabetes mellitus, COVID-19 patients were categorized in those with Cardiometabolic Risk Factors (CRFact) or without CRFact (no-CRFact). From the study population, we excluded subjects with established cardiovascular disease.

Results

Sixty-six patients with COVID-19 (37% admitted in ICU) were recruited. From the study population, 41 were in the group of CRFact and 25 in the no-CRFact. Patients with CFRact were older (65±9 years vs. 53±14 years, p<0.001), had more impaired FMD (1.16±2.13% vs. 2.60±2.44%, p=0.01), and lower serum albumin levels (3.10±0.68 g/dL vs. 3.52±0.26 g/dL, p=0.006) compared to the no-CRFact group. Between CRFact and no-CRFact, there was no difference in CRP and IL-6 levels. Interestingly, serum albumin in patients with CRFact was significantly lower than the lower reference limit (LRL) (=3.5 g/dl) of albumin (p=0.001), while no such finding was noted in subjects with no CRFact (p=0.64). Furthermore, regression analysis revealed that, even after adjustment for age, the presence of CRFact was associated with decreased serum albumin levels by 0.31mg/dl (95% CI 0.08 to 0.63, p=0.04). In the CRFact population, there was a correlation of albumin with FMD (R=0.29, p=0.05) and an inverse correlation with CRP (rho=−0.48, p=0.02) and IL-6 (rho=−0.66, p<0.001), while in the no-CRFact group no such correlation were observed (p=NS for all).

Conclusion

COVID-19 patients with cardiometabolic risk factors present with low serum albumin levels early at the course of the disease, which may be driven by endothelial dysfunction and vascular inflammation. This data gives insights into the potential association of a dysfunctional endothelial layer and the progression to capillary leak syndrome.

Funding Acknowledgement

Type of funding sources: None.
Nationwide trends and projections of peripheral arterial disease among Danish adults
Authors: Soegaard M , Nielsen P B , Eldrup N , Behrendt C A , Lip G Y H , Larsen T B , Skjoeth F
Published: October 2022

Background

Peripheral arterial disease (PAD) is a critical clinical and public health issue with a prevalence of >10% worldwide among adults ≥50 years. Whether this occurrence has been increasing, decreasing or stable over time remains a matter of debate as contemporary population data are sparse and conflicting.

Purpose

To quantify changes in PAD incidence, prevalence, and mortality and provide projections for future prevalence development through 2050.

Methods

We conducted nationwide analyses of the entire Danish population aged ≥40 years from 2000 through 2018 to assess national trends in diagnosed PAD incidence, prevalence, and all-cause mortality, overall and by sex and age-groups. PAD was identified by primary or secondary in-hospital or outpatient clinic diagnoses, and incident cases comprised individuals whose preceding complete hospital history, potentially back to 1977, lacked a PAD diagnosis. Based on observed trends in incidence and PAD mortality between 2000–2018, and the projected future annual age distribution and population mortality obtained from Statistics Denmark, we projected the future prevalence of PAD through 2050.

Results

The population of Denmark aged 40–99 years between 2000 and 2018 included 4,508,932 individuals, among whom we identified 123,479 incident diagnoses of PAD during 51,4 million person-years of follow-up. The age- and sex-standardized incidence of PAD decreased from 2.70 per 1,000 person-years in 2000 to 1.79 in 2018 (incidence rate ratio 0.67, 95% confidence interval (CI) 0.65–0.70) (Figure 1). The incidence was approximately 20% higher in men than in women but the accentuation was similarly in both sexes. Concurrently, the overall prevalence of PAD in the Danish adult population increased from 0.8% to 1.7% (prevalence ratio 2.12, 95% CI 2.09–2.15). The prevalence rose considerably in the oldest age groups; in 2018 the prevalence was 5.8% in women and 8.0% in men aged ≥80 years. The age- and sex-standardized annual mortality among patients with PAD decreased from 9.9% in 2000 to 7.0% in 2018, representing a mortality ratio of 0.82 (95% CI 0.75–0.91). Projections of PAD prevalence demonstrated that the rise in the national prevalence of PAD will continue until around 2030 followed by a decline towards 2050 (Figure 2). Among individuals aged ≥80 years, the prevalence was projected to reach a maximum of 8.9% for men vs. 6.5% for women before beginning to decline.

Conclusion

Within an unselected nationwide population, the incidence and all-cause mortality of PAD has declined over the last two decades. Concurrently, the prevalence increased, and this increasing trend was projected continue over the coming decade before reaching a breaking point around 2030, underscoring the continued need for health service to manage PAD and its complications in years to come.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Karen Elise Jensen's Foundation