bluuebunny/crossref_metadata_2025 huggingface dataset:
P4580The effect of anesthetic techniques on cardiac troponin-T after non-cardiac surgery
Authors: Oh E , Kwon J , Park J , Min J , Lee J
Published: October 2019

Background

The effects of anesthetics on cardiac protection and clinical outcomes have shown conflicting results in patients undergoing non-cardiac surgery. Unlike cardiac surgeries in which cardio-protective effects of anesthetic techniques have been reported, it lacks evidence and reproducibility in non-cardiac surgery. A current generation high-sensitivity cardiac troponin (hs-cTnI) is known to detect perioperative myocardial injury in non-cardiac surgery which is closely related to clinical outcomes. In this study, we hypothesized that balanced anesthesia using both remifentanil and volatile agents is the most effective in reducing postoperative myocardial injury, and compared the incidence of postoperative myocardial injury among different types of general anesthesia.

Methods

We analyzed the data of 3555 patients who underwent general anesthesia for non-cardiac surgery in our hospital between February 2010 and December 2016. In all patients, hs-cTnI was detected in preoperative period and postoperative period within 48 hours. Major exclusion criteria was troponin elevation before surgery. Patients were stratified into three groups; 661 patients who were received propofol-remifentanil total intravenous anesthesia (TIVA group), 1279 patients who were received volatile anesthesia without remifentanil (Volatile group) and 1622 patients who were received volatile anesthesia with remifentanil (Balanced group). The Primary outcome was troponin elevation [hs-cTnI≥0.04 ng/mL] within post-operative within 48 hours, and the incidence of postoperative complications such as postoperative acute kidney injury, new-onset atrial fibrillation and in-hospital mortality were also compared.

Results

The occurrence of myocaridial injury were significant difference between three groups. The occurrence of myocardial injury was significantly lower in the Balanced group than in Volatile group after adjustment (Odds ratio (OR) = 0.727; 95% confidence interval (CI) = 0.59–0.89; P-value = 0.002). Balanced group and TIVA group showed comparable results in risk of postoperative troponin elevation after adjustment (OR 1.131; 95% CI 0.96–1.33; P-value = 0.133). The incidence of troponin elevation was significantly higher in Volatile group than TIVA group after adjustment (OR 1.6; 95% CI 0.52–0.96; P-value = 0.005). The incidence of AKI was significantly lower in Balanced group than Volatile group after adjustment (OR 0.637; 95% CI 0.49–0.81; P-value <0.001).

Conclusion

The remifentanil combination during general anesthesia may be associated with myocardial protection effect in patients undergoing non-cardiac surgery. Whether this impact leads to adverse long-term outcome remains unclear, and requires further investigation.
P45945-years clinical outcomes of patients underwent percutaneous coronary intervention for calcified lesions with rotational atherectomy and second-generation drug eluting stent
Authors: Ogata K , Koiwaya H , Shinzato K , Goriki Y , Yoshioka G , Shibata Y
Published: October 2019

Background

Percutaneous coronary Intervention (PCI) with rotational atherectomy (RA) was useful for severe calcified lesions. However, the long-term clinical outcomes of PCI with second-generation drug eluting stent (DES) following RA has been still unclear.

Purpose

The purpose of this study was to investigate the long-term clinical outcomes of RA followed by second-generation DES.

Methods

We retrospectively enrolled 254 consecutive patients treated with second-generation DES following RA. The primary outcome was the cumulative 5-year incidence of MACE, defined as cardiac death, myocardial infarction, clinically-driven target lesion revascularization and definite stent thrombosis.

Results

The incidence of MACE was 22.8% at 5-years. Multivariate analysis showed 3 predictors of MACE, hemodialysis, diabetic mellitus and extremely angulated lesions (>90°).Significantly higher MACE was observed in the high-risk (≥2 risk factors) group, compared with the low-risk (2< risk factors) group (68.7% vs. 18.7%, P<0.001, Figure).

Multivariate analysis for MACE at 5 year Hazard ratio (95% Confidence Interval) P-value Diabetic Mellitus 2.58 (1.35–4.91) 0.004 Hemodialysis 4.57 (1.64–12.76) 0.004 extremely angulated (>90°) 3.08 (1.06–8.93) 0.04

Kaplan-Meier curves for 5-years MACE

Conclusions

The long-term clinical outcomes of PCI for severely calcified lesions was acceptable. However, the clinical outcomes of patients classified high risk cohort was unsatisfactory.
P4599Strict versus no fasting prior to cardiac catheterization: a prospective evaluation of safety and clinical outcomes
Authors: Mishra A , Singh M , Kane M , Acker W , Kaluski E , Sattur S , Sethi A , Arora S , Sporn D
Published: October 2019

Background/Methods

No studies have examined safety of a no fasting (NF) strategy as compared to current nil per os (NPO) practice in patients undergoing non emergent cardiac catheterization (CC). We compared these two strategies in this single center, prospective, randomized study. Fasting group was NPO for solids after midnight but could have clear liquids up to 2 hours prior to procedure. NF group had no restriction or oral intake.

Results

A total of 520 patients enrolled till December 2018 were included in this interim analysis. Both groups had similar baseline characteristics (figure 1). As compared to the fasting group (n=274), NF group (n=246) had similar rates of primary outcomes: CIN (0.02% in both groups), peri-procedural hypotension (0.02% vs 0.03%), aspiration pneumonitis (none vs 0.009%), nausea/vomiting (0.05 vs 0.07%), hypoglycemia (0.007% vs 0.008%) respectively [p=not significant for all].Secondary outcomes including patient's satisfaction and 30-day mortality were also similar in both groups. Cost of index hospitalization was significantly lower in NF group (table 1).

Outcome table Outcomes Fasting group (n=274) Non- Fasting group (n=246) p value Length of Stay (days)† 2.13±0.2 1.96±0.19 0.524 SBP post catheterization† 133.31±1.44 133.15±1.39 0.936 Hypotension peri procedurally 6 (2%) 7 (3%) 0.617 Fluid resuscitation required for hypotension 2 (0.7%) 3 (1%) 0.669 Pressor required for hypotension 1 (0.4%) 2 (0.8%) 0.603 Acute Kidney Injury 10 (4%) 9 (4%) 0.981 Contrast induced nephropathy 5 (2%) 6 (2%) 0.612 Hypoglycemia 2 (0.7%) 2 (0.8%) 1 Hyperglycemia 12 (4%) 4 (2%) 0.080 Symptomatic hypotension 1 (0.4%) 2 (0.8%) 0.603 Nausea/vomiting 12 (5%) 15 (7%) 0.344 Aspiration pneumonitis 0 (0%) 2 (0.9%) 0.219 Patient satisfaction score† 4.39±0.06 4.45±0.06 0.438 Alive on discharge 271 (98.9%) 240 (98%) 0.622 30-day mortality 4 (1.5%) 6 (2.4%) 0.417 30-day Cardiac readmission 32 (13%) 26 (11%) 0.557 Total Cost (US Dollars)† 10148.97±985.71 7710.914±648.33 0.040 Results are shown as number (%). †Expressed as mean ± standard error.

Conclusion

NF strategy is safe and cost effective as compared to traditional NPO practice in patients undergoing CC.

Acknowledgement/Funding

A financial grant of USD15,000 from Guthrie Research Foundation
P4601Reduced exercise capacity and clinical outcomes following acute myocardial infarction
Authors: Tashiro H , Tanaka A , Ishii H , Motomura N , Arai K , Adachi T , Okajima T , Hitora Y , Hayashi M , Furusawa K , Imai H , Ogawa Y , Kawaguchi K , Murohara T
Published: October 2019

Background

Reduced exercise capacity is known to be an important predictor of poor prognosis and disability in patients with cardiovascular diseases and chronic heart failure, and even members of the general population. However, data about exercise capacity assessed by cardiopulmonary exercise testing (CPX) in acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) is scarce. The purpose of this study is to assess the associated factors and clinical influence of exercise capacity measured by CPX in AMI patients.

Methods

Among 594 consecutive AMI patients who underwent primary PCI, we examined 136 patients (85.3% men, 64.9±11.9 years) who underwent CPX during hospitalization for AMI. CPX was usually performed five days after the onset of AMI. Reduced exercise capacity was defined as peak oxygen consumption (peak VO2) ≤12. Clinical outcomes including all-cause death, myocardial infarction, and hospitalization due to heart failure were followed.

Results

Among 136 patients, reduced exercise capacity (peak VO2 ≤12) was seen in 38 patients (28%). Patients with reduced exercise capacity were older, more likely to have hypertension, and had lower renal function. In echocardiography, patients with reduced exercise capacity had higher E/e' and larger left atria. Median follow-up term was 12 months (interquartile range: 9–22). The occurrence of composite endpoints of all-cause death, myocardial infarction, and hospitalization due to heart failure was significantly higher in patients with peak VO2≤12 than those with peak VO2>12 (p<0.001). Multivariate logistic analysis showed that E/e' (Odds ratio, 1.19, 95%, confidence interval 1.09 to 1.31, p<0.001) was an independent predictor of reduced exercise capacity (peak VO2≤12).

Cumulative incidence of clinical events

Conclusion

Diastolic dysfunction is associated with reduced exercise capacity following successful primary PCI in AMI patients and may lead to poorer clinical outcomes.
P4605Landiolol, a beta-blocker, optimizes cardiac energetics and peripheral microhemodynamics better than ivabradine while reducing heart rate at hemodynamic resuscitation of experimental septic shock
Authors: Uemura K , Kawada T , Nishikawa T , Zheng C , Meihua L , Sigimachi M
Published: October 2019

Background

Septic shock is associated with sympathetic over-activation characterized by tachycardia, which is associated with poor survival. Though several kinds of drugs are available to reduce heart rate (HR), it is not clear which drug should be used to reduce HR effectively in initial hemodynamic resuscitation in septic shock.

Purpose

The aim of this study was to experimentally investigate comparative effects of landiolol (a β-blocker) and ivabradine (an If-channel inhibitor) on initial hemodynamic resuscitation in a canine model of endotoxin shock.

Methods

We used 19 anesthetized dogs. Seven dogs were allocated to control (CT) group, six dogs to landiolol (BB) group, and six dogs to ivabradine (IVA) group. In all the groups, endotoxin shock was induced by intravenous infusion of Escherichia coli lipopolysaccharide (4 mg/kg) over 1 h. After induction of endotoxin shock, we started hemodynamic resuscitation to restore mean arterial pressure (AP) and cardiac output (CO) by infusing noradrenaline (NA) and Ringer acetate solution (RiA). Dose of NA and RiA were automatically titrated with use of a computer-controlled drug infusion system that we developed previously. Hemodynamic resuscitation was continued for 4 h. During resuscitation, the BB group was given landiolol infusion at a low-dose range (1–10 μg/kg/min, manually titrated), while the IVA group was given ivabradine at 0.25 mg/kg bolus-injected every 2 h.

Results

The drug infusion system automatically restored AP to 70 mmHg and CO to greater than 90% of baseline level in all the groups. The restored AP and CO were not significantly different among the three groups (Figure A, B). There were no significant differences in the computer-controlled infusion rate of NA and cumulated volume of RiA infused among the three groups (Figure C). During the first 2 h of resuscitation, HR was significantly reduced in the BB and IVA groups in comparison to the CT group (Figure D). However, only in the BB group, cardiac oxygen consumption was significantly lower than that in the CT group (Figure E). Blood lactate level decreased significantly after hemodynamic resuscitation only within the BB group (Figure F).

Figure 1

Conclusions

In the initial hemodynamic resuscitation of septic shock, both low-dose landiolol infusion and ivabradine injection may be used to reduce HR. However, to optimize cardiac energetics and peripheral microhemodynamics, low-dose landiolol infusion may be preferable to ivabradine injection.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant Number 15K01307, 18K12126.
P4612Elevated pentraxin-3 level is associated with impaired post procedural myocardial perfusion assessed by quantitative blush evaluator in patients with acute STEMI undergoing primary PCI
Authors: Parlautan A , Sukmawan R , Dharma S
Published: October 2019

Background

Long Pentraxin-3 (PTX3) has been known as an emerging cardiac biomarker and has potential diagnostic and prognostic value in coronary heart disease. Whether plasma PTX3 level is associated with post procedural myocardial perfusion assessed by quantitative blush evaluator (QuBE) in acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) is unknown.

Purpose

This study sought to evaluate the association between plasma PTX3 level and post procedural myocardial perfusion assessed by QuBE in patients with acute STEMI undergoing primary PCI.

Methods

We enrolled 217 patients with acute STEMI who underwent primary PCI (men=191, women=26). Post procedural myocardial perfusion was evaluated using QuBE. PTX3 level was measured at admission by an ELISA method. We used 0.33 ng/mL for PTX3 level as a cut off point for future worse clinical outcome as shown by previous study. Impairment of myocardial perfusion was defined as QuBE <9 arbitrary unit as also shown by previous studies.

Results

Plasma PTX3 level had an inverse correlation with QuBE score (r=−0.64, p<0.001). Patients in elevated PTX3 group (≥0.33 ng/mL; N=80) had lower median QuBE score compared with lower PTX3 group (<0.33ng/mL; N=137), with QuBE score (8.6 arbitrary unit vs. 15.1 arbitrary unit, P<0.001). Multivariate logistic analysis showed that plasma PTX3 level ≥0.33 ng/mL (OR=7.65, p<0.001) along with Diabetes Mellitus (OR=2.30, p=0.04), and Killip class II-IV (OR=2.57, p=0.04) were independent predictors of impaired myocardial perfusion, as shown by QuBE score <9 arbitrary unit.

Analysis between PTX3 and low QuBE score Variables Multivariate OR (95% CI) P value PTX3 ≥0.33 ng/mL 7.65 (3.37–17.36) <0.001 Diabetes Mellitus 2.30 (1.01–5.23) 0.04 Hypertension 1.15 (0.47–2.82) 0.75 Killip class II-IV 2.57 (1.04–6.35) 0.04 IRA LAD 3.79 (1.64–8.78) 0.002 Thrombus grade 4 & 5 3.36 (1.06–11.98) 0.04 Post PPCI TIMI flow <3 5.29 (2.09–13.36) 0.001 PTX3, pentraxin-3; QuBE, quantitative blush evaluator; IRA, infarct related artery.

Conclusions

Patients with acute STEMI with high plasma PTX3 level were associated with reduced myocardial perfusion after primary PCI shown by low QuBE score. Elevated PTX3 level may be used as a marker for persistent impairment of myocardial perfusion after primary PCI in STEMI
P4626Neuronal nitric oxide sintetase polymorphism increases sympathetic activity and recurrent cardiovascular events after myocardial infarction
Authors: Oliveira E K , Munhoz D B , Carvalho L S F , Moura F A , Machado-Silva W , Figueiredo V N , Nobrega O T , Sposito A C
Published: October 2019

Background

The expression and activity of neuronal nitric oxide sintetase (nNOS) in central and peripheral nervous system attenuate the sympathetic response and promote other cardioprotective effects in animal models. However, in humans those effects are uncertain. Recently, a polymorphism at the sequence rs41279104 G/T has been associated with a reduced expression of nNOS, but its clinical impact has never been studied in the context of ST elevation myocardial infarction (STEMI) in humans.

Purpose

We investigated the impact of the T allele at rs41279104 in sympathetic activation after STEMI and its influence in the incidence of recurrent major cardiovascular events (MACE). We sought to determine a pathway to autonomic nervous system modulation during STEMI and its possible clinical impact.

Methods

297 patients were admitted in the first 24h (D1) after STEMI and followed prospectively. Blood samples and an electrocardiogram were obtained upon D1 and fifth day (D5). We assessed glycosylated hemoglobin, glucose, insulin, C-peptide, lipid profile and nitric oxide (NOx) plasma levels. We genotyped rs41279104 and grouped patients according to carrier status (GT+TT vs. GG). The heart rate variability was obtained with a 15min electrocardiogram recording and processed into spectral analysis variables including low (LF) and high frequencies (HF) and LF/HF ratio. Flow-mediated dilation (FMD) was performed after 30 days. Clinical follow–up was carried over until two years after MI and the endpoint was a composite of major cardiovascular events (MACE) consisting of fatal MI, non-fatal MI, unstable angina with hospitalization and cardiac sudden death.

Results

T-allele carriers showed a decreased parasympathetic activity and an increased sympathetic activity between D1 and D5 (ΔLF −68.43 (median) [IQR −324.76 to −6.29] vs −4.49 [−190.29 to 72.03], p<0.001; ΔHF −19.40 [−185.55 to 6.21] vs −10.73 [−79.53 to 137.53], p=0.004; ΔLF/HF 0.07 [−2.32 to 1.44] vs −0.11 [−1.14 to 0.96], p<0.001). Decreased FMD (6.9±4.7 vs 7.5±4.9, p=0.046) was also detected among T-allele carriers. In the Cox -regression analysis adjusted by sex, age, betablocker use and mean simvastatin dose, T-allele carriers had a relative risk for MACE of 2.112 (95% CI: 1.133–3.938; p=0.019).

Conclusions

The presence of the T allele at nNOS gene rs41279104 sequence is associated with increased sympathetic tone at acute phase of STEMI and a higher incidence of recurrent MACE.
P4630Prognostic impact of previous Beta-blocker use in STEMI patients
Authors: Faria Da Mota T , Fernandes R , Costa H , Sousa Bispo J , Azevedo P , Guedes J P , Santos W , Mimoso J , Jesus I
Published: October 2019

Introduction

Current guidelines support the use of beta-blockers (βB) in patients with Coronary Artery Disease, especially after a Myocardial Infarction (MI). This use is sustained by their ability to block adrenergic hyperstimulation, reducing the potential for arrythmias, myocardial oxygen consumption and infarct extension. However, questions have been raised regarding the impact βB therapy in patients admitted for ST elevation Myocardial Infarction (STEMI).

Methods

The authors present a retrospective, descriptive and correlational study including all patients admitted for STEMI in a country's Cardiology Departments between the 1st of October 2010 and the 8th of January 2019. A 1-year (1y) follow-up was made through registry consultation and phone call by a Cardiologist. Baseline demographic and clinical characteristics of patients previously medicated with βB (pre- βB) were compared to patients not medicated with βB. The authors performed a univariate and multivariate statistical analysis of in-hospital mortality, as well as 1y mortality and re-admission rate, using SPSS 24,0.

Results

A total of 7818 patients were included, 1931 (24,7%) of which 1931 (24,7%) were female, with a mean age of 64±14 years. In the studied sample, 1109 patients (14,2%) were previously medicated with βB, which was more common in women (18,1 vs. 12,8%) and patients over 65-years old (16,9% vs. 11,4%). βB were also more prescribed in patients with hypertension, diabetes, dyslipidaemia, previous MI, previous stroke or peripheral atherosclerosis, and renal failure. This group of patients was more frequently medicated with anti-platelets, anti-hypertensives, statins and diuretics (p<0,001). Additionally, they presented more frequently with Left Bundle Branch Block, Atrial fibrillation, Killip-Kimball class >1 and BNP >400 (p<0,001), and had significantly higher rates of ventricular systolic disfunction (p=0,003). These patients were also more commonly diagnosed with multivessel disease (p<0,001), but no differences could be identified regarding success of revascularization. During hospital stay, no significant divergences were found regarding incidence of shock, mechanical complications and AV block, but a higher rate of haemorrhage and transfusion was objectified (p<0,001).

Regarding outcomes, on univariate analysis, pre-βB was a strong predictor of higher 1-year mortality (p=0,049) and 1-year readmission (both global and cardiovascular, with p=0,049 and p=0,033, respectively). On multivariate statistical analysis however, pre-βB showed to be a strong independent predictor of lower in-hospital mortality (p=0,023) with differences between groups who suspended and ditn't suspend βB at admission, but had no significant impact on 1-year outcomes.

Conclusion

In the present study, previous βB therapy showed to have an independent positive impact on in-hospital mortality, but not on 1-year outcomes.
P4631Eosinopenia an inflammatory marker of adverse clinical outcomes in patients presenting with acute myocardial infarction
Authors: Alkhalil M , Kearney A K , Hegarty M H , Stewart C S , Devlin P D , Owens C O , Spence M S
Published: October 2019

Background

Inflammation is an indicator of worse clinical outcomes following acute myocardial infarction. Eosinopenia was identified as a surrogate of inflammation in sepsis and obstructive airway disease. Whether this readily-available marker has any impact on long term outcomes following ST-segment elevation myocardial infarction (STEMI) is yet to be determined.

Purpose

We sought to study the incidence and relationship between eosinopenia and infarct severity and whether low eosinophil had impact on clinical outcomes following STEMI.

Methods

606 consecutive STEMI patients undergoing primary PCI from a large volume single centre were enrolled. Low eosinophil count was defined as <40 cells/ml from samples within 2 -hours post reperfusion. Primary endpoint was defined as composite of death, MI, stroke, unplanned revascularisation, re-admission for heart failure over 3.5 years follow up.

Results

65% of patients had eosinopenia. Patients in the low eosinophil group had larger infarct size as measured by troponin value [2934 vs. 1177ng/L, P<0.001] and left ventricle (LV) systolic function on echocardiography [48% vs. 50%, P=0.029]. Thehre was a modest correlation between eosinophil count and both troponin (r=−0.25, P<0.001) and ejection fraction (r=0.10, P=0.017). The primary endpoint was higher in eosinopenic patients (28.8% vs. 20.4%, HR 1.49, 95% CI 1.05 to 2.13, P=0.023) (Figure). The difference was mainly driven from higher percentage of unplanned revascularisations (8.2% versus 2.9%, P=0.012) (Table). Low eosinophil count was an independent predictor of adverse cardiovascular events, beyond infarct severity, in elderly, non-diabetic patients (HR 2.04, 95% CI 1.04 to 4.01, P=0.038).

Incidence rate of major clinical Clinical characteristics Low eosinophil Normal eosinophil P value Long term clinical events 28.8% (112) 20.4% (42) 0.026 Long term mortality 14.1% (55) 11.1% (23) 0.31 Long term MI 6.9% (27) 4.9% (10) 0.32 Long term unplanned revascularisation 8.2% (32) 2.9% (6) 0.012 Long term re-admission CCF 6.7% (26) 4.9% (10) 0.37 Long term stroke 2.6% (10) 1% (2) 0.19

Conclusions

Eosinopenia is a readily-available marker which was associated with a larger infarcts and worse clinical outcomes over long term follow up.
P4635Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy
Authors: Holm A C , Henriksson M , Alfredsson J , Janzon M , Johansson T , Swahn E , Vial D , Sederholm Lavesson S
Published: October 2019

Background

Triple antithrombotic therapy (TAT) is known to increase bleeds and its relevance is questioned. No study has observed the long-term risk of bleeding and health care costs from a sex perspective, in a total TAT population. We investigated the rate of all bleeds in patients receiving TAT at index hospitalization and within one year. We explored early discontinuation of TAT and potential sex disparities. We also assessed health care costs related to bleeding complications.

Methods

All patients discharged with TAT registered in SWEDEHEART in the County of Östergötland 2009–2015 were included. Information about bleeds during one-year follow-up were retrieved from the medical records. All bleeds receiving medical attention were included. Resource use associated with bleeds were assigned unit cost to estimate the health care costs associated with bleeding episodes.

Results

Among 272 identified patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p=0.01) and bled more (48.6 vs. 37.1%, p=0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively.

Conclusion

The very high bleeding incidence in patients with TAT is a cause of concern, especially in women. There is a need for an adequately sized randomized, controlled trial to determine a safe but still effective treatment for these patients.
P4638Impact of a prior history of stroke on long-term cardiac mortality in patients with acute coronary syndrome treated with percutaneous coronary intervention
Authors: Takeuchi M , Ogita M , Tsuboi S , Yasuda K , Nishio R , Takahashi N , Iso T , Sonoda T , Yatsu S , Wada H , Dohi T , Suwa S , Daida H
Published: October 2019

Background and objective

A prior history of stroke is associated with increased adverse cardiovascular outcomes in patients with acute coronary syndrome (ACS), however the prognostic impact on long-term outcomes remains unclear.

Methods

We conducted an observational cohort study of ACS patients underwent primary percutaneous coronary intervention (PCI) between January 1999 and May 2015 at our hospital. The aim of the present study is to evaluate the overall prevalence and clinical impact of a history of stroke. The primary outcome was cardiac death during the median follow-up period of 5yrs.

Results

Among 2562 ACS patients of the current cohort, 268 patients (10.5%) had a history of stroke at the onset of ACS. The cumulative incidence of cardiac death was higher in patients with a history of stroke (11.4% vs. 19.7%, log-rank p<0.0001). Multivariate Cox regression analysis showed a history of stroke was significantly associated with higher cardiac mortality. (adjusted HR 1.47, 95% CI 1.03–1.92, p=0.0309).

Kaplan-Meier curve

Conclusion

Among ACS patients treated with primary PCI, a history of stroke was not rare and was associated with increased long term cardiac mortality.
P4646Prospective study for antenatal diagnosis of coarctation of the aorta
Authors: Meysonnier Marechal C , Di Filippo S , Pangaud N , Galoin Bertail C , Joly H , Massardier J , Martin Bonnet C , Massoud M
Published: October 2019

The objective of this study was to define echocardiographic (ECHO) parameters during fetal life, to predict postnatal aortic coarctation (COA).

Material and methods

This prospective single-center study from 2010 to 2018 included all fetus diagnosed with isolated ventricular and/ or great vessels asymetry (right heart dominance). Complex CHD were excluded. The cohort was divided in patients with coarctation after birth (COA) and those free from coarctation (noCOA). Left heart, aortic and ductus measurements were collected serially at second trimester (T2), third trimester (T3) ad Z-scores were assessed. COA and noCOA were compared, sensitivity (Se) and specificity (Spec) and ROC curves (cut-off values) were assessed for each parameter.

Results

67 cases were included: 34 (50.7%) ranged in group COA and 33 (49.3%) in noCOA. Coarctation occurred more frequently if suspected at T2 (70.6% in COA vs 30.3% in noCOA, p=0.001). Mitral annulus (T3) was 8.6mm in COA vs 10.3mm in noCOA (p=0.002) with cut-off <7.3mm (Se= 50%, Spec= 93.6%, OR= 14.5). Aortic annulus diameter (T3) was 4.8mm in COA vs 6mm in noCOA (p=0.005), with cut-off <5.4mm (Se= 65%, Spec= 77%, OR= 6.3). Aortic isthmus diameter (T3) was 1.4mm in COA vs 2.8mm in noCOA (p=0.003), with cut-off <3mm (Se= 91%, Spec= 65%, OR= 18.9). Ductus arteriosus/ aortic isthmus ratio (T3) was 2.5 in COA vs 1.8 in noCOA (p=0.01) with cut-off >1.57mm (Se= 90.5%, Spec= 62%, OR= 15.4).

Conclusion

Mitral annulus <7.3mm, aortic annulus <5.4mm, aortic isthmus <3mm and ductus/isthmus ratio >1.57 assessed during 3rd trimester of fetal life may help to predict postnatal coractation of the aorta. These results have to be confirmed by larger prospective studies.
P4648Retrograde flow in aortic isthmus in fetuses with congenital heart defects and computer flow dynamic modeling
Authors: Chen Z , Lin S H , Amy T , Han J C , Yang X , Ge S H P , He Y H
Published: October 2019

Background and objectives

Retrograde flow (RF) in the aortic isthmus is frequently observed in fetuses in various hemodynamic states including congenital heart defects (CHD). This study sought to: 1) establish the association between this observation and variables of CHD by fetal echocardiography (FE); and 2) to computer flow dynamic (CFD) model to probe the causes and mechanisms underlying this observation.

Methods

A total of 256 (gestational age (GA) 26.3±9.8 weeks) fetuses with CHD and 168 (GA: 25.8±10.3weeks) with normal FE were examined from January, 2011 to May, 2016. The study group was divided into: 1) no RF, 2) end systolic RF, end diastolic RF, systolic RF, diastolic RF, and systolic and diastolic RF sub-groups (Figure upper). GA, cerebroplacental ratio (CPR) of pulsatility index (PI) in middle cerebral and umbilical arteries, cardiothoracic area ratio (CTR), left and right atrial dimensions (LA/RA), left and right ventricular dimensions (LV/RV), aortic and pulmonary artery dimensions (AO/PA), and aortic isthmus and ductal arch dimensions (AI/DA), velocity ratio of aorta and pulmonary artery (AO/PAv), aortic isthmus and ductal arch in systolic (AI/DAvs) and diastolic (AI/DAvd). Using principal component analysis (PCA), the component score coefficient matrix and optional variance percent (OVP) was calculated by PCA and the RF pattern was simulated by CFD (Figure lower).

Results

RF modeling by CFD was feasible (Figure B). Component analysis by PCA showed that four types of variables were associated with RF: 1) Structural variables contribute 23.7% OVP, including LV/RV, LA/ RA, AO/PA, and IS/DA; 2) Resistance variables 16.8% OVP, i.e. CPR; 3) Growth variables 12.2% OVP, i,e, GA and CTR; and 4) Velocity variables 10.9% OVP, i.e. AO/PAv, AI/DAvd.

Retrograde flow by fetal echo and CFD

Conclusions

Retrograde flow in the aortic isthmus is associated with structural, resistance, growth, and velocity variables in fetal circulation in various CHD and normal 3rd trimester pregnancies. Simulation and modeling by CFD is feasible and may be useful to understand the causes and mechanisms of retrograde flow and its utility in diagnosis and prognosis in CHD.

Acknowledgement/Funding

Research on prevention and control of reproductive health and major birth defects
P4667Loss of function in PCSK9, atherogenic lipoprotein concentrations, and calcific aortic valve stenosis
Authors: Perrot N , Moschetta D , Boekholdt S M , Valerio V , Martinsson A , Capoulade R , Mass E , Mathieu P , Bosse Y , Pibarot P , Smith J G , Camera M , Theriault Y , Poggio P , Arsenault B
Published: October 2019

Background

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition reduces plasma concentrations of most atherogenic lipoproteins such as low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (apoB) and lipoprotein(a) [Lp(a)]. Atherogenic lipoprotein concentrations have also been linked with calcific aortic valve stenosis (CAVS).

Purpose

1) To determine the association between genetic variants in PCSK9 and lipoprotein-lipid levels, 2) to determine whether loss of function (LOF) in PCSK9 is associated with CAVS and 3) to evaluate if PCSK9 could be implicated in aortic valve interstitial cells (VICs) calcification.

Methods

We built a weighted genetic risk score (wGRS) using 10 single nucleotide polymorphisms at the PCSK9 locus associated with LDL-C in the Global Lipids Genetics Consortium. We determined the association between the wGRS and LDL-C, apoB and Lp(a)] in 9692 participants of the EPIC-Norfolk study using linear regression. We investigated the association between the LOF PCSK9 R46L variant and CAVS risk in a meta-analysis of published (three Copenhagen studies, 1463 cases and 101,620 controls) and unpublished studies (UK Biobank, 1350 cases and 349,043 controls, Malmö Diet and Cancer study, 682 cases and 5963 controls and EPIC-Norfolk, 508 cases and 20,421 controls) prospective, population-based studies using logistic regression adjusted for age and sex. We evaluated PCSK9 expression and localization in explanted aortic valves by capillary Western blot and immunohistochemistry in patients with and without CAVS. Von Kossa staining was used to visualize aortic leaflet calcium deposits. We also assessed VICs calcification potential under oxidative stress condition.

Results

In EPIC-Norfolk, the wGRS was significantly associated with TC, LDL-C, and apoB (all p<0.0001), but not with VLDL-C, HDL-C, triglycerides apoA-I, or Lp(a). Carriers of the R46L variant were at lower CAVS risk (odds ratio=0.71 (95% CI, 0.57–0.88, p<0.001)). Aortic valves of patients with aortic sclerosis (n=12) and CAVS (n=8) presented elevated PCSK9 levels (log2 fold change [FC]=+28.6±5.1, p=0.008 and FC=+39.3±15.2, p=0.02, respectively) compared to controls (n=4).In calcified leaflets, PCSK9 expression co-localized with calcium deposits. PCSK9 expression in VICs was induced by oxidative stress (FC=+2.3±0.4, p=0.02), and subsequent increment in calcification potential was observed.

Conclusion

PCSK9LOF variants are associated with lifelong reductions in non-Lp(a) apoB-containing lipoprotein levels and a lower risk of coronary artery disease and CAVS. PCSK9 is abundant in fibrotic and calcified aortic leaflets. Oxidative stress increases PCSK9 expression in VICs. These results support randomized clinical trials of PCSK9 inhibition in the prevention of CAVS.
P4668Risk of valvular heart disease in bromocriptine-treated women with hyperprolactinaemic disorders
Authors: Clausen M , Roerth R , Torp-Pedersen C , Gislason G H , Koeber L , Fosboel E , Kristensen S L
Published: October 2019

Background

Systematic echocardiographic screening is currently recommended for patients with hyperprolactinemic disorders treated with dopamine agonists, due to a perceived risk of cardiac valve regurgitation as observed in patients with Parkinson's disease. The dopamine agonist bromocriptine is used frequently in hyperprolactinemia patients, but its relation to cardiac valve disease remain uncertain.

Purpose

To determine the incidence of valvular heart disease in bromocriptine-treated women with hyperprolactinaemic disorders compared with matched controls from background population.

Methods

In nationwide Danish registries, we identified patients with hyperprolactinaemic disorders treated with bromocriptine between 1995–2017. Patients were matched 1:5 with population controls based on age and sex using incidence density sampling. We estimated the risk of valvular heart disease defined as admission and/or outpatient clinic visits. Incidence rates, cumulative incidence curve and adjusted cox-proportional hazard models were used to assess outcomes.

Results

A total of 23883 female bromocriptine users and 119415 controls were included. Median age was 29.9 years (Q1-Q3 26.4–33.8). Both groups had few comorbidities, 218 (0.9%) patients and 787 (0.7%) controls with hypertension, 160 (0.7%) patients and 629 (0.5%) controls with diabetes, 408 (1.7%) patients and 1305 (1.1%) controls were beta-blocker users. During a mean follow-up of 19 years 106 (0.44%) patients and 416 (0.35%) controls were diagnosed with valvular heart disease. Incidence rates were 0.254 per 1000 patient years (PY) in bromocriptine users (95% CI 0.21–0.31) and 0.198 per 1000 PY in the control cohort (95% CI 0.18–0.22). Overall, the cumulative incidence of valvular heart disease was 0.6% (95% CI 0.48–0.73) among patients and 0.5% (95% CI 0.4–0.51) among controls; P=0.03 (figure 1a). In adjusted analysis bromocriptine users still had a significant higher risk of valvular heart disease (hazard ratio=1.32, 95% CI 1.06–1.64, P=0.01).

Incidence of valvular heart disease

Conclusion

The use of bromocriptine in younger and otherwise healthy women with hyperprolactinaemic disorders, were associated with a low absolute risk of cardiac valve disease. Still risk was approximately 30% higher compared with age- and sex matched controls. Our study suggests a low clinical yield of echocardiographic screening in this patient population.

Acknowledgement/Funding

Internal grant, Copenhagen University Hospital Rigshospitalet
P4670Long-term changes of exercise haemodynamics and physical capacity in chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy
Authors: Waziri F , Mellemkjaer S , Clemmensen T S , Hjortdal V E , Ilkjaer L B , Nielsen S L , Poulsen S H
Published: October 2019

Background

A substantial number of chronic thromboembolic pulmonary hypertension (CTEPH) patients experience dyspnoea on exertion and limited exercise capacity despite surgically successful pulmonary endarterectomy (PEA).

Purpose

We sought to prospectively evaluate resting and peak exercise haemodynamics before, 3 and 12 months after PEA in consecutive CTEPH patients and correlate it to physical functional capacity.

Methods

Twenty CTEPH patients who underwent PEA treatment were examined between December 2014 and January 2017. The patients were examined pre-operatively and 3 and 12 months post-operatively with right heart catheterisation at rest and during a maximal symptom-limited, semi-supine cardiopulmonary exercise test. Finally, the data were compared with 15 healthy controls who had previously undergone the same protocol.

Results

Twelve months after PEA, 75% of patients with severely increased pre-PEA mean pulmonary arterial pressure (mPAP) at rest had normal or mildly increased mPAP. However, mPAP reduction was less pronounced during exercise where only 45% had normal or mildly increased mPAP at 12 months. Cardiac output (CO) reserve (CO increase from rest to peak exercise) was increased (5.7±2.9 L/min) 12 months after PEA compared with pre-PEA (2.5±1.8 L/min), p<0.0001. However, 12 months after PEA, the CO reserve was only 49% of that of healthy controls, p<0.0001. Changes in cardiac output (ΔCO), calculated as the difference between CO before PEA and 12 months later, were significantly correlated with six-minute-walk-test and peak oxygen uptake (VO2), both at rest and peak exercise.

Figure 1

Conclusion

Invasive exercise haemodynamic examination in CTEPH patients demonstrates that after otherwise successful PEA surgery, more than 50% of patients have a significant increase in exercise mPAP, and the CO reserve remains compromised 12 months after PEA. Improvement in physical capacity is correlated with ΔCO.

Acknowledgement/Funding

Danish Heart Foundation, Aarhus University, Arvid Nilssons Fond, Eva & Henry Frænkels Mindefond, and Snedkermester Sophus Hustru Astrid Jacobsens Fond
P4672Current outcome of chronic thromboembolic pulmonary hypertension in Spain
Authors: Martinez Santos P , Aurtenetxe Perez A , Lopez Gude M J , Barbera J A , Lopez Meseguer M , Lopez Reyes R , Martinez Menaca A , Lara Padron A , Domingo Morera J A , Blanco I , Escribano Subias P
Published: October 2019

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) treatment has evolved over the last decade. Increasing evidence regarding new therapeutic developments has shown clinical benefit among these patients in different scenarios. However, there is scarce information about the long-term impact of these achievements in a real-life population on a national scale. We aimed to analyze the impact of current CTEPH therapies on survival in Spain.

Methods

We prospectively collected epidemiological, clinical and prognostic data from CTEPH patients consecutively included in the Spanish REHAP registry from January 1, 2007, to December 31, 2017. All-cause mortality data were gathered during this period.

Results

Eight hundred thirteen patients were included. The mean age was 61 (15) years and 58.1% were women. Out of the 813 patients, 537 (66%) were referred to an expert PH-center. Overall, 245 (30.1%) patients were selected for surgery and 52 (6.4%) for percutaneous treatment and 452 (60.5%) received medical treatment exclusively with specific PH drugs. Survival rates of patients who underwent an invasive procedure (pulmonary thrombendarterectomy or balloon pulmonary angioplasty) were remarkably high.

Figure 1. Cumulative survival from date

Conclusions

Patients who underwent pulmonary thrombendarterectomy or balloon pulmonary angioplasty associated a better outcome.

Acknowledgement/Funding

We gratefully acknowledge all investigators of the REHAP Registry. We express our gratitude to Actelion, Ferrer, GlaxoSmithKline (GSK) and Merck Sharp
P4675The utility of additional balloon pulmonary angioplasty for residual hypoxemia in normohemodynamic chronic thromboembolic pulmonary hypertension patients after invasive treatments
Authors: Shimokawahara H , Matsubara H , Hayashi K , Tsuji M , Nishihara T , Naito T , Shigetoshi M , Tabuchi I , Munemasa M
Published: October 2019

Background

Balloon pulmonary angioplasty (BPA) improves hemodynamics, symptoms and exercise capacity in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are ineligible for pulmonary endarterectomy (PEA). However, certain patients still have hypoxemia after BPA or PEA despite normalization of hemodynamics. In CTEPH, hypoxemia is related increased dead space ventilation caused by vascular obstruction.

Purpose

This study was aimed to clarify whether additional BPA can improve hypoxemia of CTEPH patients after normalization of hemodynamics.

Methods

A total of 335 patients who underwent initial series of BPA in our institute were followed up. Sixty-four patients with mean pulmonary artery pressure (mPAP) <30mmHg and percutaneous oxygen saturation (SpO2) <95% without oxygen inhalation at more than 6 months after the initial series of BPA and of patients who could reevaluate hemodynamics and oxygenation after additional BPA were enrolled. These patients were divided into two groups with or without additional BPA procedures. Change of hemodynamics and SpO2 were retrospectively investigated.

Results

Thirty-three of 64 patients underwent additional BPA procedures. Patients' age was older in BPA group than those in non-BPA group (71.3±10.4 vs. 66.5±9.4 years old, p=0.02). mPAP and pulmonary vascular resistance (PVR) was significantly higher in BPA group (mPAP: 23.9±3.2 vs. 20.7±3.8 mmHg, p=0.001, PVR: 4.2±1.2 vs. 3.5±1.4 wood unit, p=0.03, respectively). Among the 1.8±1.4 BPA procedures per person, total 6.6±3.8 segmental pulmonary arteries per person were treated. While no obvious improvements were observed in non-BPA group, PVR and SpO2 in BPA group were significantly improved (4.2±1.2 to 3.7±1.3 wood unit, p=0.002, 90.7±3.1% to 94.1±3.6%, p<0.001, respectively). In the multivariate logistic regression analysis, additional BPA procedures were associated with further improvement of SpO2 (hazard ratio, 3.7; 95% confidence interval, 1.2–11.5; P=0.02).

Conclusions

Additional BPA procedure was associated with improvement of hypoxemia in CTEPH patients after normalization of hemodynamics. Treating as many lesions as possible in BPA might relieve the patients' residual dyspnea.
P4689How is the impact of updated hemodynamic definitions on frequencies of overall pulmonary hypertension and pre-capillary pulmonary hypertension as compared to those with previous criteria
Authors: Tanyeri S , Keskin B , Akbal O Y , Hakgor A , Karagoz A , Tokgoz H C , Dogan C , Acar R D , Bayram Z , Kulahcioglu S , Erdogan E , Tanboga I H , Ozdemir N , Kaymaz C
Published: October 2019

Background and aim

In this study we evaluated the impact of the updated pulmonary hypertension (PH) definitive criteria proposed in 6th World PH Symposium (WSPH) on numbers and frequencies of and pre- versus post-capillary PH as compared to those in European Society of Cardiology (ESC) 2015 PH Guidelines.

Methods

Study group comprised the retrospectively evaluated 1299 patients (pts) (age 53.1±18.8 years, female 807, 62.1%) who underwent right heart catheterisation (RHC) with different indications between 2006 and 2018. For ESC and WSPH PH definitions, pulmonary arterial mean pressure (PAMP) ≥25 mmHg (definition-A) and PAMP >20 mmHg (definition-B) RHC criteria were used, respectively. For pre-capillary PH definitions, pulmonary artery wedge pressure (PAWP) ≤15 mmHg and pulmonary vascular resistance (PVR) ≥3 Wood units criteria were included in the both definitions.

Results

In RHC assessments, PAMP ≥25 mmHg and >20 mmHg were noted in 891 (68.6%) and 1051 (80.9%) of overall pts, respectively. Moreover, pre-capillary PH was diagnosed in 284 (21.8%) and 298 (22.9%) with definition-A and B, respectively. Although updated WSPH definition was associated with a net 12.3% and a relative 18% increase in the overall PH diagnosis, net and relative changes in the frequency of the pre-capillary PH were only 1% and 4.9%. Increase in the overall PH with updated WSPH criterias compared to previous ESC definitions was associated with increase in the number of pre-capillary PH (n=298, 22.9%) but not in the overall frequency of post-capillary PH (688, 52.9%). Because PVR was the product of the transpulmonary gradient (PAMP minus PAWP) divided by cardiac output, this measure was found to keep specificity for distinction between pre- versus post-capillary PH even after lowering thetreshold diagnostic for PAMP from 25 to 20 mmHg.

Conclusions

Although updated WSPH definition was associated with net 12.3% and relative 18% increase in the overall PH diagnosis, its impact on frequencies of pre- versus post-capillary PH within overall PH population was negligible.These seem to be due to critical role of PVR ensuring specificity in pre-capillary PH diagnosis even after lowering the definitive PAMP treshold to 20 mmHg.