bluuebunny/crossref_metadata_2025 huggingface dataset:
P4533Duration of heart failure and effect of defibrillator implantation in patients with non-ischemic systolic heart failure
Authors: Elming M B , Thoegersen A M , Videbaek L , Bruun N E , Eiskjaer H , Haarbo J , Egstrup K , Gustafsson F , Svendsen J H , Hoefsten D E , Pehrson S , Nielsen J C , Koeber L V , Thune J J
Published: October 2019

Introduction

Patients with non-ischemic systolic heart failure have increased risk of sudden cardiac death (SCD) and death from progressive pump failure. Whether the risk of SCD changes over time is unknown. We seek to investigate the relationship between duration of heart failure, mode of death, and effect of implantable cardioverter defibrillator (ICD) implantation.

Methods

We examined the risk of all-cause death and SCD according to the duration of heart failure among patients with non-ischemic systolic heart failure enrolled in the Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality (DANISH) trial. Patients were divided according to quartiles of heart failure duration (Q1 ≤8 months, Q2 9 ≤18 months, Q3 19 ≤65 months, Q4 ≥66 months).

Results

A total number of 1116 patients were included. Patients with the longest duration of heart failure were older, more often men, had more comorbidity, and more often received cardiac resynchronizing therapy device. Doubling of heart failure duration was an independent predictor of both all-cause mortality (HR 1.26 95% CI 1.17–1.37, p<0.0001), and SCD (HR 1.29 95% CI 1.11–1.49, p=0.0009). The proportion of deaths caused by SCD was not different between heart failure quartiles (p=0.91), and the effect of ICD implantation on all-cause mortality was not modified by the duration of heart failure (p=0.59).

Duration of heart failure and death

Conclusions

Duration of heart failure predicted both all-cause mortality and risk of SCD independently of other risk indicators. However, the proportion of death caused by SCD did not change with longer duration of heart failure and the effect of ICD was not modified by the duration of heart failure.

Acknowledgement/Funding

The work was sponsored by The Danish Heart Foundation (Hjerteforeningen) and the Lundbeck Foundation (Lundbeckfonden). The DANISH trial was supported
P4546Acute heart failure: speckle tracking echocardiography, a new ally in intensive care unit
Authors: Cameli M , Falciani F , Mandoli G E , Parisella M L , Incampo E , Rizzo C , D'Ascenzi F , Focardi M , Valente S , Mondillo S
Published: October 2019

Background

Acute Heart Failure (AHF) is a life-threatening condition with high mortality rate.

Purpose

The aim of our study was to identify the best predictors of in-hospital mortality and stay, among laboratory blood tests, clinic and echocardiographic (standard and by Speckle Tracking Echocardiography, STE) parameters in patients admitted to our Intensive Care Unit (ICU) for AHF.

Methods

We enrolled 57 patients (age 70±13 y, 70% man) admitted to our ICU with de novo AHF or acute decompensation of Chronic Heart Failure (CHF). Exclusion criteria were: active malignancies, chronic liver disease, absent acoustic echocardiographic window and patient refusal. At ICU admission, all patients were assessed with vital signs (heart rate, HR; systolic blood pressure, SBP), blood laboratory tests, standard echo and STE of left ventricle (LV), right ventricle (RV) and left atrium (LA). These indexes were then related to the length of stay and mortality.

Results

The population was finally composed of 52 patients, due to 5 in-hospital deaths. 56% had an ischemic aetiology, 26% idiopathic dilated cardiomyopathy, 11% valvular diseases, 7% other causes of HF. At admission, average HR was 78±16 bpm, SBP 119±24 mmHg and EF 33±13%. Among all the parameters, the ones that showed significant statistical correlation with the length of hospitalization (15,34±7.03 days) were plasmatic creatinine, SBP, Systolic Pulmonary Artery Pressure, high LV filling pressure (E/E' >12) and Peak Atrial Longitudinal Strain (PALS). The maximal dose of intravenous loop diuretics and inotropic drugs also showed a good correlation. Analysing the two sub-populations with mortality data, we observed that patients who died, had a significantly lower EF (19±9.62% vs 35±12.55%; p=0,01), but not a higher left atrial volume indexed (31.04±14.87 vs 26.36±12.03 ml/m2; p= ns) compared to the survivors; instead PALS was significant worse (10.08±4.62 vs 20.64±13,35%; p<001). Free wall RV Longitudinal Strain (fw-RVLS) values for the patients who died (−9.41±4.66%) were significantly lower than in survivors (−13.67±6.02%; p<0.01). LVGLS (Left Ventricular Global Longitudinal Strain) did not show statistical significant differences between the two populations. Based on the results of ROC analysis (Figure 1), we created a score to predict in-hospital mortality, composed of: EF, PALS and RVLS-free wall. The ideal cut point to predict mortality was >1.5.

Figure 1

Conclusions

AHF represents one of the major challenges in ICU. The use of a combined echocardiographic score, assessed at admission, could help to better predict mortality risk, in addition to commonly used indexes.
P4567Factors associated with poor adherence to medication among hypertensive patients in twelve low and middle income sub-Saharan countries
Authors: Kramoh K E , Macquart De Terline D , Damourou J M F , Kouam Kouam C , Ali Toure I , Mipinda J B , Diop B I , Ferreira B , Houenassi M D , Mfeukeu Kuate L , Limbole E , Jouven X , Azizi M , Antignac M , Kingue S
Published: October 2019

Background

Over the past few decades, the prevalence of hypertension has dramatically increased in Sub-Saharan Africa. Poor adherence has been identified as a major cause of failure to control hypertension. Scarce data are available in Africa.

Purpose

We assessed adherence to medication and identified socioeconomics, clinical and treatment factors associated with low adherence among hypertensive patients in 12 sub-Saharan African countries.

Methods

We conducted a cross-sectional survey in urban clinics of both low and middle income countries. Data were collected by physicians on demographics, treatment and clinical data among hypertensive patients attending the clinics. Adherence was assessed by questionnaires completed by the patients. Factors associated with low adherence were investigated using logistic regression with a random effect on countries.

Results

There were 2198 individuals from 12 countries enrolled in the study. Overall, 678 (30.8%), 738 (33.6%), 782 (35.6%) participants had respectively low, medium and high adherence to antihypertensive medication. Multivariate analysis showed that the use of traditional medicine (OR: 2.28, 95% CI [1.79–2.90]) and individual wealth index (low vs. high wealth: OR: 1.86, 95% CI [1.35–2.56] and middle vs. high wealth: OR: 1.42, 95% CI [1.11–1.81]) were significantly and independently associated with poor adherence to medication. In stratified analysis, these differences in adherence to medication according to individual wealth index were observed in low-income countries (p<0.001) but not in middle-income countries (p=0.17). In addition, 26.5% of the patients admitted having stopped their treatment due to financial reasons and this proportion was 4 fold higher in the lowest than highest wealth group (47.8% vs 11.4%) (p<0.001).

Conclusion

This study revealed the high frequency of poor adherence in African patients and the associated factors. These findings should be useful for tailoring future programs to tackle hypertension in low income countries that are better adapted to patients, with a potential associated enhancement of their effectiveness.

Figure 1. Percentage of patients according to their adherence level by patient wealth index stratified by country-level income.
P4570Prognostic interest of HbA1c and plasma glucose assessment on one-year mortality in non-diabetic patients after acute myocardial infarction
Authors: Gueniat-Ratheau E , Mouhat B , Verges B , Chague F , Beer J.-C , Maza M , Zeller M , Cottin Y
Published: October 2019

Background

The usefulness of the combined assessment of HbA1c and plasma glucose (PG) in acute myocardial infarction (AMI) in nondiabetic patients remains unclear.

Purpose

In a large observational study, we aimed to identify the prognostic values of these biomarkers regarding one-year all-cause mortality in nondiabetic patients after AMI.

Methods

From the “obseRvatoire des Infarctus de Côte d'Or” (RICO) survey database, we included all consecutive nondiabetic patients with AMI (n=6617) from May 2001 to December 2016. Exclusion criteria were: admission known or unknown diabetes, in-hospital death. The primary endpoint was all-cause one-year mortality. The secondary endpoints were: MACE, infarct size, LVEF<40% and GRACE risk score. Cut off levels (high/low) were determined by ROC curve analysis for the prediction of one-year death (HbA1c 5.9% and PG 7.3mmol/L) to set up 4 groups: low HbA1c/low glucose (n=3158), low HbA1c/high glucose (n=1264), high HbA1c/low glucose (n=1378) and high HbA1c/high glucose (n=817).

Results

Elevation of PG was associated with elevated rate of LVEF<40%, STEMI, anterior wall location, DFG<60mL/min/m2 and higher troponin Ic pic (all p<0.001); HbA1c>5.9% was associated with elevated rate of CRP>3mg/L (p<0.001); High HbA1C and high PG together were associated with higher rate of MACE (p<0.001). By multivariate logistic regression analysis, elevated admission PG remained a strong predictor of one-year all-cause (OR (95% CI): 1.64 (1.31–2.05)) mortality and cardiovascular mortality (OR (95% CI): 1.75 (1.33–2.31)), beyond GRACE score (OR (95% CI): 1.03 (1.03–1.04)), as well as elevated HbA1c (OR (95% CI): 1.43 (1.15–1.78) and OR (95% CI): 1.83 (1.39–2.41) respectively).

Conclusions

Admission PG and HbA1c had strong independent predictive value regarding one-year all-cause mortality in our nondiabetic patients with AMI. These biomarkers could be useful to identify the most-at-risk patients after AMI in order to reduce residual risk in this target population.

Acknowledgement/Funding

University Hospital Center Dijon Bourgogne, France
P4572Lipoprotein(a) is not associated with survival after acute coronary syndromes
Authors: Roth C , Dalos D , Gangl C , Krychtiuk K , Schrutka L , Distelmaier K , Wojta J , Hengstenberg C , Berger R , Speidl W
Published: October 2019

Aims

Lipoprotein(a) [Lp(a)] is associated with coronary artery disease in population studies, however studies on its predictive value in patients with established cardiovascular disease, in particular after acute coronary syndromes (ACS), are conflicting. The aim of this study was to investigate whether Lp(a) is associated with survival after ACS.

Methods and results

We analyzed 4469 consecutive patients that underwent coronary angiography for ACS. Lp(a) measurement at time of ACS was available in 1245 patients and median follow-up for cardiovascular and total mortality was 5.0 (IQR 3.2–8.0) years. 655 (52.6%) presented with ST-segment elevation myocardial infarction (STEMI), 424 (34.1%) with Non-ST-segment elevation myocardial infarction (NSTEMI) and 166 (13.3%) underwent coronary angiography for unstable angina. Cardiovascular mortality was 9.1% and total mortality was 15.7%. Patients were stratified into four groups to their Lp(a) levels. (≤15 mg/dL, >15–30 mg/dL, >30–60 mg/dL, and >60 mg/dL). Multivessel disease was significantly more common in patients with Lp(a) >60 mg/dL (p<0.05). Increased levels of Lp(a) were not associated with cardiovascular mortality (HR compared with Lp(a) ≤15 mg/dL were 1.2, 1.2, and 1.0, respectively; p=0.69) and not with total mortality (HR compared with Lp(a) ≤15 mg/dL were 1.2, 1.2, and 1.2, respectively; p=0.46).

Central Figure

Conclusion

Lp(a) levels at time of ACS were neither associated with cardiovascular nor with total mortality. Although Lp(a) has been shown to be associated with incidence of coronary artery disease, this study does not support any role of Lp(a) as a risk factor after ACS. This should be taken into account for development of outcome studies for agents targeting Lp(a) plasma levels.
P4583Effect of permanent right internal mammary artery occlusion on right coronary artery collateral function. a randomized controlled trial
Authors: Bigler M R , Stoller M , Tschannen C , Grossenbacher R , Seiler C
Published: October 2019

Background

Extracardiac coronary artery supply via the pericardiophrenic branch of the internal mammary arteries (IMA) has been well documented anatomically. Recently, a proof-of-concept study has found functional relevance of these anastomoses in patients with coronary artery disease (CAD) during a brief right coronary artery (RCA) occlusion.

Purpose

The aim of the present randomized controlled, single-blind trial was to investigate the effect of permanent right IMA (RIMA) occlusion on RCA collateral flow index (CFI) and on the occurrence of angina pectoris. We hypothesized that the change in RCA CFI from baseline to follow-up examination is higher in the group of patients with than without permanent RIMA occlusion.

Methods

One hundred patients with CAD were randomly allocated (1:1) to permanent RIMA device occlusion at baseline or to no RIMA occlusion (sham control group). The primary study endpoint was CFI change in the RCA from baseline to the 6-week follow-up examination. CFI is the ratio between mean coronary occlusive and aortic pressure both subtracted by central venous pressure as obtained during a 1-minute proximal RCA balloon occlusion. RCA CFI was measured at baseline before RIMA occlusion or the sham procedure and at the follow-up invasive exam. At the end of the same occlusion, occurrence of angina pectoris was assessed. Percutaneous coronary intervention (PCI) of the RCA was deferred until after follow-up RCA CFI measurement.

Results

There were 51 patients in the RIMA occlusion (verum) group and 49 patients in the sham control group. PCI in the left coronary territory was performed at baseline for clinical reasons in 27 patients of the verum group and in 25 patients of the sham control group. There were no differences in clinical characteristics at baseline between the groups (age 68±12 years, 88 men). RCA CFI change during the 6 weeks of follow-up was equal to +0.028±0.077 in the verum group and −0.026±0.079 in the sham control group (p=0.0017). Angina pectoris during CFI measurement had disappeared at follow-up exam in 30% of the verum group and in 2% of the sham control group (p=0.0013).

Conclusions

Right coronary collateral function is augmented 6 weeks after permanent RIMA occlusion when compared to sham treatment. This manifests as less frequent angina pectoris during myocardial ischemia among patients with RIMA occlusion.

Acknowledgement/Funding

This study was supported by a grant from the Swiss National Science Foundation for Research (grant #32003B_163256/1 to CS).
P4586Bilateral internal thoracic artery grafting neutralizes detrimental effect of diabetes on survival in patients with ischemic cardiomyopathy
Authors: Kainuma S , Taniguchi K T , Toda K T , Miyagawa S M , Yoshikawa Y Y , Hata H H , Yoshioka D Y , Ueno T U , Kuratani T K , Sakaguchi T S , Funatsu T F , Kondoh H K , Masai T M , Daimon T D , Sawa Y S
Published: October 2019

Background

In ischemic cardiomyopathy patients requiring coronary artery bypass grafting (CABG), the association of diabetic status with outcomes after surgery as well as survival benefit with bilateral internal thoracic artery (ITA) grafting remain largely unknown.

Purpose

We evaluated the associations of diabetic status with postoperative LV reverse remodeling, change in renal function, and late outcome following surgical revascularization, with focus on cases with severely impaired LV function. We also attempted to determine the survival benefit of bilateral ITA grafting over single ITA grafting according to diabetic status.

Methods

We classified 188 patients (mean age 67±9 years) with left ventricular (LV) ejection fraction ≤40% who underwent isolated initial CABG into non-diabetic (n=64), non-insulin-dependent DM (NIDM, n=74), and insulin-dependent DM (IDM, n=50) groups.

Results

At baseline, there were no differences between the diabetic and non-diabetic patients in terms of age, LV function parameters and degree of coronary artery disease, while the diabetic patients were more likely to present chronic kidney disease and peripheral vascular disease. During follow-up (68±47 months), the 5-year survival rate was 84% and 65% in the non-diabetic and diabetic patients respectively (p=0.034). After adjusting for all covariates, both NIDM and IDM were independently associated with increased mortality (NIDM: adjusted hazard ratio 1.9, 95% confident interval 1.0–3.7, p=0.049; IDM: adjusted hazard ratio 2.4, 95% confident interval 1.2–4.8, p=0.016) and composite adverse events defined as mortality and/or heart failure readmission (NIDM: hazard ratio 1.7, 95% confident interval 1.0–2.8, p=0.038; IDM: hazard ratio 3.0, 95% confident interval 1.7–5.1, p<0.001). Diabetic patients showed less improvements in LV dimensions and ejection fraction (interaction effect p<0.05 for all), and steady decrease in the estimated glomerular filtration rate over time after surgery (group effect p<0.05). Among non-diabetic patients, there was no difference in survival rate between single ITA and bilateral ITA grafting (5-year: 86% vs. 80%, p=0.95), whereas among diabetic patients, survival of those who received the latter was better (57% vs. 81%, p=0.004). Multivariate analysis revealed that use of bilateral ITA was significantly associated with decreased risk of mortality (hazard ratio 0.3, 95% confident interval 0.1–0.8, p=0.024).

Conclusion

Non-insulin- and insulin-dependent diabetes was significantly associated with worse long-term clinical outcome after CABG for ischemic cardiomyopathy. Bilateral ITA grafting has potential to improve survival in diabetic patients with ischemic cardiomyopathy.
P4589The prognostic impact of the Medina classification in bifurcation lesion percutaneous coronary intervention
Authors: Perl L , Witberg G , Vaknin-Assa H , Kornowski R , Assali A
Published: October 2019

Background/Introduction

The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding the prognostic impact of the classification.

Purpose

To assess the prognostic significance of the Medina classification following percutaneous coronary intervention (PCI).

Methods

The study included 738 consecutive patients from a prospective bifurcation registry. There were 609 patients (82.5%) with “true bifurcation” (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 129 (17.5%) in all other categories (“non-true bifurcation” = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12 months and 3 years.

Results

Patients with TB had lower rates of previous bypass surgery (9.4% vs. 12.2%, p=0.03) and hyperlipidemia (75.2% vs. 79.0%, p=0.04). TB lesions were more likely to be calcified (33.8% vs. 28.2%, p=0.03) and ulcerated (8.9% vs. 3.4%, p<0.01). At 12 months, mortality was numerically higher for TB PCI (4.1% vs. 2.0%m p=0.052) and MACE rates were higher (13.2% vs. 5.2%, p<0.001). At 3 years, both all cause death (10.1% vs. 4.9%, p=0.002), as well as rates of MACE (27.2% vs. 11.6%, p<0.001) were higher for TB PCI (Figure 1). After performing regression analysis, TB remained an independent predictor for poor outcomes (OR- 3.93 at 12 months, CI 1.45–10.66, p=0.007, OR-3.26 at 3 years, CI 1.47–7.25, p=0.004 for MACE).

Conclusions

TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision making in treatment.
P4590Temporal trends of the characteristics, management, and clinical outcomes of patients with acute coronary syndrome and multi-vessel disease - the ACSIS registry
Authors: Shiyovich A , Shlomo N , Iakobishvili Z , Kornowski R , Eisen A
Published: October 2019

Introduction

Multi-vessel coronary artery disease (MVD) is common among patients with acute coronary syndrome (ACS) and is associated with worse outcomes compared with single-vessel disease. Multiple studies focused particularly on patients with ACS and MVD and their results were incorporated into guidelines' recommendations.

Objectives

To examine temporal trends in clinical characteristics, treatment and outcomes of patients presenting with ACS and MVD.

Methods

Time- dependent analysis of patients enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2016 according to three time periods: early (2004–2006; n=2,111), mid (2008–2010; n=2,049), and late (2013–2016; n=2,010). MVD was defined as >50% stenosis in ≥2 separate major coronary territories at the index ACS. Clinical outcomes were 30-day MACE (death, unstable angina, myocardial infarction, stroke, stent thrombosis, urgent revascularization) and 30-days and 1-year mortality.

Results

Overall 6,170/15,000 patients (41.1%) had MVD (age 64.5±12.1, males 80%). Patients admitted in the later periods were older with a higher prevalence of cardiovascular risk factors and their treatment (i.e. statins, and hypoglycemic drugs) prior to admission. The rate of CABG has decreased and of MV percutaneous coronary intervention and guideline recommended medical treatment has increased with time. At 30 days, the rates of mortality, MACE and re-infarction have decreased (Figure). A trend of reduction in 1-year mortality was observed with time, yet it did not reach statistical significance (early=9.3%, mid=7.8%, late=7.7%, P=0.13). A multivariate adjusted analysis demonstrated that the mid and late periods were associated with significantly reduced risk for 30-day MACE (OR=0.65 [0.54–0.77] and 0.54 [0.45–0.65], respectively).

Figure 1. Temporal trends in 30-day outcomes of patients with ACS and MVD

Conclusions

During the last decade, the burden of cardiovascular risk factors among ACS patients with MVD has increased, more extensive invasive and medical treatments were provided and significant improvements in 30-day outcomes were observed.

Acknowledgement/Funding

None
P4606Comparing biomarker profiles in patients with stable atherosclerosis treated with anacetrapib versus placebo: a nested proteomic study from HPS3/TIMI 55-REVEAL
Authors: Berg D , Morrow D , Braunwald E
Published: October 2019

Background

The cholesteryl ester transfer protein (CETP) inhibitor anacetrapib improves cardiovascular outcomes in patients with stable atherosclerosis; however, the potential interaction of HDL-C-, LDL-C-, and non-lipid-mediated effects remains incompletely understood.

Purpose

The aim of this study was to identify biological pathways that are influenced by treatment with anacetrapib.

Methods

HPS3/TIMI 55-REVEAL was a randomized, double-blind, placebo-controlled trial of anacetrapib in patients with stable atherosclerotic cardiovascular disease. We performed a nested prospective biomarker study in 500 patients, analyzing 274 candidate biomarkers. We compared changes in biomarker levels between randomization and mid-study (∼2 years) in patients treated with anacetrapib vs. placebo using a stringent threshold for statistical significance. We evaluated associations between changes in selected biomarkers and changes in HDL-C and LDL-C from baseline to mid-study in each treatment group.

Results

Eleven biomarkers were significantly modified by anacetrapib vs. placebo (Figure). These proteins represent pathways implicated in inflammation, lipid metabolism, and hematopoiesis. Among anacetrapib-treated patients, changes in 5/11 biomarkers were not significantly correlated with changes in either serum HDL-C or serum LDL-C.

Conclusion(s)

In patients with stable atherosclerosis, treatment with anacetrapib results in changes in protein expression extending beyond lipid metabolism. Some of these changes appear to be independent of anacetrapib-mediated effects on HDL-C and LDL-C.

Acknowledgement/Funding

HPS3/TIMI 55-REVEAL was sponsored by Merck.
P4609The use of stellate ganglion block in the management of electrical storm reduces VA burden by 92% and completely excludes the need for general anesthesia
Authors: Jiravsky O , Spacek R , Chovancik J , Szmek B , Neuwirth R , Hrosova M , Palowski M , Sknouril L
Published: October 2019

Background

The electrical ventricular storm (ES) is a life-threatening condition. The treatment is based on addressing the triggering cause, influencing reversible factors, patient sedation, and antiarrhythmics. Suppressing the massive sympathetic surge is a keystone in the emergent management. Stellate ganglion block (SGB) might serve this purpose.

Purpose

To show the efficacy of ultrasound-guided SGB in the management of ES.

Methods

Retrospective analysis of case series. All ES patients in whom SGB was used. SGB was performed after the initial failure of reversible factors modification + sedation + antiarrhythmics. We compared the mean VA burden 2 days before vs. 7 days after SGB (to show the long effect of SGB).

31 patients (5 females). Procedure date between 01.03.2017 and 21.11.2018. Mean LVEF 27±9%. Etiology: 74% ischemic vs. 26% non-ischemic cardiomyopathy. Antiarrhythmic treatment: amiodarone 27 pt. (87%), trimecaine 3pt (10%), digoxin 2 pt. (6%), beta-blocker 28 pt. (90%).

Results

The ES management including SGB resulted in a significant decrease (92%) in VA burden (mean 26,0 episodes/day vs. 0,6 episodes/day; p<0.001). Separately, ATP episodes were reduced by 99%, external or ICD shocks by 76%. There was no need for general anesthesia as a last resort in refractory ES. 30-days mortality 12,9%. No significant adverse events have been noticed, 10 pt. (32,3%) have developed Horner syndrome, which always disappeared in 24 hours.

Conclusion

Ultrasound-guided SGB in the management of ES is safe and very effective. Randomized prospective studies are required to precisely determine the effect of SGB.
P4614Predictor factors of microvascular obstruction in early presenters of ST-segment elevation myocardial infarction
Authors: Rivero Monteagudo A L , Arroyo Rivera B , Garcia Talavera C , Cortes Garcia M , Franco Pelaez J A , Navarro Del Amo F , Tunon Fernandez J
Published: October 2019

Background

Microvascular obstruction (MVO) is a phenomenon that occurs frequently even after primary coronary intervention with recanalization of the infarct-related artery (IRA) and it has been shown to increase the risk of adverse cardiovascular events in ST-segment elevation myocardial infarction (STEMI) patients. The most important clinical predictor of MVO is ischemia duration, but there is a lack of information regarding predictor factors in promptly revascularized patients.

Methods

From January 2007 to October 2017, 1022 patients with STEMI that underwent urgent coronary angiography were retrospectively enlisted. We included 760 patients that were revascularized in ≤6 hours from symptom onset. Clinical, echocardiographic and angiographic data were taken from hospital records. A multivariate Cox regression analysis was made to assess the relationship between MVO (defined as final TIMI <3 in IRA) and potential predictors.

Results

From the 760 patients included, 73.7% were male and the mean age was 64.8±14.2 years. LVEF at admission was 46.1±12% and Killip class at admission was III-IV in 12.8% of the cases. The mean time between symptom onset and wire crossing was 3.3±1.3 hours. MVO was found in 130 cases (17.2%). After the multivariate Cox regression analysis, Killip class III-IV at admission was associated with MVO (OR 2.87 [1.31–6.31]). No other clinical variables were independently associated with the occurrence of MVO. The angiographic and interventional variables with a significant association with MVO were: predilatation (OR 1.87 [1.003–3.49]), postdilatation (OR 0.49 [0.27–0.89]), stent length (OR 1.04 [1.001–1.08]), stent diameter (OR 1.89 [1.11–3.23]), thrombus burden of the culprit lesion (OR 2.69 [1.26–5.71]) and distal embolization (OR 5.52 [2.79–10.89]).

Conclusions

In early presenters of STEMI, angiographic and interventional variables were more important as predictors of MVO than clinical variables. Killip class III-IV at admission was a clinical predictor factor for MVO in this population. Prospective studies are needed to confirm these results.
P4615Dyslipidemia as a predictor of no-reflow after primary PCI in STEMI pts
Authors: Stepura A O , Parkhomenko A N , Lutay Y M , Irkin O I , Kushnir S P , Bilyi D O , Sokolov Y N , Sokolov M Y
Published: October 2019

According to current guidelines all pts with ACS should be treated by intensive statin therapy, independently of baseline cholesterol level. However, the significance of baseline lipid profile for the results of treatment in STEMI pts has been insufficiently studied.

The aim of the study was to evaluate baseline lipids level in STEMI patients with different degrees of tissue blood flow recovery after primary PCI.

Methods

110 pts with STEMI admitted within 24 hrs (4.5±1.2 h) from symptoms onset and treated by primary PCI were included. Patients were treated according to current guidelines, and intensive statin therapy was initiated before any intervention. Blood lipids were tested at admission. Myocardial Blush Grade (MBG) was used for angiographic assessment of myocardial reperfusion. Dyslipidemia was assessed by total cholesterol (TC)/high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) / HDL-C ratios.

Results

Good restoration of microvascular perfusion (MBG3) was found in 44 (40%) pts, MBG2 was achieved in 32 (29%) pts, while poor microvascular flow was seen 34 (31%) pts (MBG1 in 17 (15,5%) pts and MBG0 in 17 (15,5%) pts). Pts with MBG0 tended to have higher TC and triglycerides (TG) levels and lower HDL-C levels at baseline. TC/ HDL-C and LDL-C/HDL-C ratios that usually used to predict ischemic heart disease risk were also significantly higher in pts with no-reflow phenomenon (MBG0) (table 1)

Table 1 MBG 0 MBG 1 MBG 2 MBG 3 p N=17 (15.5%) N=17 (15.5%) N=32 (29%) N=44 (40%) TC, mmol/l 6.42±0.23 5.9±0.21 6.1±0.25 6.1±0.26 nd LDL-C, mmol/l 4.22±0.21 3.89±0.18 3.95±0.22 3.97±0.2 nd HDL-C, mmol/l 1.24±0.03 1.34±0.02 1.36±0.021 1.39±0.022 nd TG, mmol/l 2.53±0.12 1.8±0.11 1.9±0.11 1.9±0.1 nd nonHDL-C, mmol/l 4.84±0.18 4.69±0.17 4.55±0.19 4.59±0.18 nd LDL-C/HDL-C 3.45±0.17 2.98±0.18 3.02±0.16 2.76±0.15 0.016 TC/HDL-C 5.23±0.21 4.59±0.2 4.71±0.18 4.29±0.19 0.011

Conclusion

TC/HDL-C and LDL-C/HDL-C ratios can be used to predict the development of no-reflow after pPCI in STEMI pts.
P4628A multiple biomarker approach for risk assessment after ST-segment elevation myocardial infarction
Authors: Rasmussen S , Olsen F , Pedersen S , Lindberg S , Nochioka K , Magnusson N , Bjerre M , Iversen K , Pareek M , Gislason G , Biering-Soerensen T
Published: October 2019

Background

Several biomarkers independently predict outcome following ST-segment elevation myocardial infarction (STEMI). We hypothesized that combining information from multiple circulating biomarkers with numerous pathophysiological pathways may improve biomarker risk stratification following a STEMI.

Method

This was a prospective study of 735 patients with STEMI treated with primary percutaneous coronary intervention. Seventeen biomarkers were drawn before revascularization, including adrenalin, noradrenalin, C-reactive protein (CRP), neutrophil gelatinase-associated lipocalin (NGAL), pro-atrial natriuretic peptide (pro-ANP), alfa-defensin, adiponectin, troponin I, hemoglobin, thrombocyte, and total leukocyte count. The primary outcome was a composite of cardiovascular death or heart failure (CVD/HF) identified by national registries. In the effort to identify the best model, the population was randomly split into two equally sized groups, a derivation cohort and a validation cohort. We used classification and regression tree (CART) analysis to develop a risk model. The identified risk model was hereafter applied to the whole cohort.

Results

Mean age was 63 years, 74% were male and 33% had hypertension. During a median follow-up time of 5.0 years (3.2; 5.0), we observed 185 primary events. After including all biomarkers in the initial model, the CART analysis created a risk model including pro-ANP, NGAL, and CRP (Figure 1a). The risk of CVD/HF increased incrementally with increasing risk group (Figure 1b). The risk remained significantly higher in groups 3 and 4 after multivariable adjustments (hazard ratio (HR)=3.38 [95% confidence interval (CI): 1.60; 7.16] p=0.001 and HR=6.55 [95% CI: 2.73; 15.76] p<0.001, respectively) when compared with group 1.

Figure 1

Conclusion

We developed a risk model based on multiple biomarkers (NGAL, CRP, and pro-ANP) determined from a CART analysis which may ease risk stratification after STEMI.

Acknowledgement/Funding

Sif Rasmussen received a scholarship grant from Herlev & Gentofte Hospital and the P. Carl Petersens Fond during preparation of this manuscript.
P4629Long-term outcomes in patients with ST-segment elevation myocardial infarction according to modalities of reperfusion therapy: data from china acute myocardial infarction (CAMI) registry
Authors: Gao X J , Yang J G , Yang Y J , Wu C , Qiao S B , Hu F H , Li S D , Xu H Y
Published: October 2019

Background

Although primary percutaneous coronary intervention (pPCI) is the optimal reperfusion method for ST-segment elevation myocardial infarction (STEMI), it remains difficult to implement in many areas. Some STEMI patients have to accept fibrinolytic therapy and no reperfusion therapy instead.

Purpose

The aim of this study was to describe the impact of reperfusion therapy on the long-term outcomes of STEMI patients in China.

Methods

Using data from the China Acute Myocardial Infarction (CAMI) registry, we analyzed the 2-year outcomes of 18,075 STEMI patients symptom onset within 7 days from January 2013 to September 2014 according to the type of reperfusion therapy. The primary endpoint was a composite of major adverse cardiovascular event (MACE), defined as all-cause mortality, myocardial infarction or stroke.

Results

7798 (43%) were treated with pPCI and 1798 (10%) underwent fibrinolysis; 8479 (47%) did not receive any reperfusion. The 2-year MACE was 9.6% following pPCI, 15.7% following fibrinolysis, and 21.5% for patients without reperfusion therapy (P<0.0001). Adjusted hazard ratios for 2-year MACE were 0.71 (95% confidence interval [CI] 0.65–0.78, P<0.0001) for pPCI versus no reperfusion and 0.92 (95% CI 0.82–1.03, P=0.16) for fibrinolysis versus no reperfusion. Compared with patients without reperfusion, fibrinolysis only showed benefit in patients presented within 3 hours of symptom onset (HR 0.70, 95% CI 0.57–0.85, P=0.0005), whereas pPCI was associated with significantly decreased 2-year MACE rate in patients presented within 3 hours (HR 0.53, 95% CI 0.44–0.64, P<0.0001), 3–6 hours (HR 0.60, 95% CI 0.51–0.71, P<0.0001) and >6 hours (HR 0.86, 95% CI 0.76–0.97, P=0.01) of symptom onset.

Adjusted cumulative MACE rate

Conclusions

In a real-world setting, early reperfusion is the optimal strategy for STEMI. Fibrinolysis was not associated with better outcome in STEMI patients admitted >3 hours of symptom onset in Chinese real world setting.

Acknowledgement/Funding

Ministry of Science and Technology of China (Grant No. 2011BAI11B02)
P4641Are coronary artery abnormalities in Kawasaki disease associated with iron deficiency anemia?
Authors: Eun L , Kim S K , Kim J K
Published: October 2019

Purpose

Coronary artery abnormalities (CAA) are the most important complication of Kawasaki disease (KD). Iron deficiency anemia (IDA) is prevalent micronutrient deficiencies and its association with KD remains unknown. We hypothesized the presence of IDA could be a predictor of CAA.

Methods

This retrospective study included 173 KD patients, divided into two groups by absence (Group 1) and presence (Group 2) of CAA. The odds ratio (OR) with 95% confidence interval (CI) was calculated using a logistic regression model to estimate the association between CAA and other indicators. Due to the collinearity between the IDA indicators, each indicator was paired with anemia in 3 models.

Results

The 3 indicators of IDA, serum iron, iron saturation and ferritin, were all significantly higher in Group 1 than in Group 2. Three sets of models including anemia with iron indicators produced the odd ratio (OR) of CAA of 3.513, 3.171, and 2.256, respectively. The 3 indicators of IDA were negatively associated with CAA, by OR of 0.965, 0.914, and 0.944, respectively. The Area under the curve (AUC) of ferritin, iron saturation, serum iron, anemia, and Kobayashi score was 0.907 (95% CI, 0.851–0.963), 0.729 (95% CI, 0.648–0.810), 0.711 (95% CI, 0.629–0.793), 0.638 (95% CI, 0.545–0.731), and 0.563 (95% CI, 0.489–0.636) respectively.

Figure 1 & 3

Conclusion

The indicators of IDA, especially ferritin, were highly associated with CAA, so that they were stronger predictors compared to the Kobayashi score. The IDA indicators can be used to predict CAA development and suggest the need for early intervention.

Acknowledgement/Funding

None
P4655The incidence and risk factors of post-cardiac injury syndrome after heart rhythm device implantation
Authors: Sedaghat-Hamedani F , Filbey K , Kayvanpour E , Katus H A , Meder B , Zitron E
Published: October 2019

Background

Post cardiac injury syndrome (PCIS) is an inflammatory process, which occurs in the setting of injury to the pericardium, epicardium or myocardium. It may follow cardiac surgery, myocardial infarction, trauma, intracardiac ablation, percutaneous coronary intervention, and implantation of heart rhythm devices (HRD). In this study we aimed to assess the incidence of PCIS after HRD implantation and its possible risk factors.

Material and methods

All patients who received HRD implantation at our University Hospital between the years 2000 to 2014 were evaluated (n=4,989 patients) for developing PCIS. Clinical data including age, sex, underlying cardiac disease, type of implanted HRD, location of electrode implantation, clinical symptoms, time of symptom onset of PCIS, therapy, and outcome were extracted and analysed.

Results

19 cases of PCIS were identified in altogether 4,989 patients resulting in an incidence of 0.38%. The age in patients with PCIS ranged from 39 to 86 years. Dilated cardiomyopathy (DCM) as underlying cardiac disease and right atrial (RA) lead implantation showed significant association to occurrence of PCIS (p=0.045 in DCM and p<0.001 in RA lead implantation). Dyspnea, chest pain, dry cough and fever were the most frequently reported symptoms in patients with PCIS. Pericardial and pleura effusion, as well as elevated C-reactive protein (CRP), increased erythrocyte sedimentation rate (ESR), and leukocytosis were the most common findings.

Conclusion

To the best of our knowledge, this is the thus far largest cohort evaluating the incidence of PCIS after HRD implantation. PCIS remains a rare, but potentially lethal complication of heart rhythm device implantation. It should be considered particularly in patients with right atrial lead active fixation and DCM as underlying cardiac disease.
P4658Left ventricular non-compaction, trait or cardiomyopathy
Authors: Kayvanpour E , Sedaghat-Hamedani F , Gi W T , Tugrul O F , Amr A , Haas J , Ehlermann P H , Uhlmann L , Katus H A , Meder B
Published: October 2019

Background

The diagnosis of cardiac hypertrabecularization has increased considerably in recent years. Whether or not the non-compaction is a pathological condition or a physiological trait is still highly debated. We performed a meta-analysis and systematic review on more than 7,000 adult individuals with left ventricular non-compaction to provide a comprehensive overview on its clinical outcome as well as its genetic background.

Methods

We first retrieved PubMed/Medline literatures in English language between 2000 to 2018 on clinical outcome and genotype of patients with non-compaction. Altogether, 35 studies with non-compaction cardiomyopathy patients passed the selection criteria and were extensively reviewed and meta-analyzed. Furthermore, we summarized the results of 8 major studies, which investigated the non-compaction in athletes, pregnant women, patients with sickle cell disease, or in individuals from population-based cohorts.

Results

About 60% of the patients with left-ventricular non-compaction cardiomyopathy were male. The diagnosis was mostly made in the mid of patients' 5th decade. Seven percent of patients had congenital heart diseases (CHD) including atrial/ventricular septum defect or Ebstein anomaly. Around 25% of the patients had positive family history for cardiomyopathy. Frequent phenotypic manifestations were heart rhythm abnormalities including conduction disease (26%), supraventricular tachycardia (17%), and sustained or non-sustained ventricular tachycardia (18%). Neuromuscular disease was a reported comorbidity with a mean frequency of 5%. Three important outcome measures including systemic thromboembolic events (9%), heart transplantation (4%), and adequate ICD therapy (15%) were reported. The genetics of non-compaction cardiomyopathy showed TTN to be the most frequently mutated gene (11%), followed by MYH7 (9%), MYBPC3 (5%), and CASQ2, LDB3 (3% each). TPM1, MIB1, ACTC1, and LMNA mutations had an average frequency of 2% each followed by PLN, HCN4, TAZ, DTNA, TNNT2, and RBM20 (1% each). Eight studies that investigated the occurrence of non-compacted myocardial regions in apparently heart healthy individuals applied different, established imaging-based diagnostic criteria for non-compaction and could confirm its presence in a wide range of 1.3% to 37%.

Conclusion

This meta-analysis summarizes the clinical presentation of left ventricular non-compaction in a large dataset and indicates that its presence often leads to unfavourable outcome, but can also be observed in heart healthy individuals. Multimodal diagnostic workflows are needed for comprehensive understanding of these individuals and for distinguishing between benign morphological trait and manifest cardiomyopathy.
P4681Early findings in patients with noncompaction cardiomyopathy and normal ejection fraction: a cardiopulmonary exercise test, echocardiographic and biomarkers study
Authors: Aoki A F , Dos Santos M R , Andretta C R L , Yeu S P , Tavares De Melo M D , Jordao C P , Guimaraes G V , Strunz C M C , Bocchi E A , Salemi V M C
Published: October 2019

Background

Noncompaction cardiomyopathy (NCC) is a cardiomyopathy with controversial diagnostic criteria. Furthermore, it has been discussed whether asymptomatic individuals with normal left ventricular (LV) ejection fraction (EF) and diagnostic criteria for this disease could be classified as NCC. Therefore, the objective of this study was to evaluate the functional capacity of patients with NCC and the relation with echocardiographic and biomarkers indices.

Methods

Fifty-nine patients with NCC were prospectively divided into three groups: ejection fraction (EF)>50% (G1), EF between 40 - 50% (G2) and EF <40% (G3). In addition, 11 normal healthy volunteers were selected for control group (CG). All subjects underwent 2D echocardiography with tissue Doppler and myocardial deformation indices, cardiopulmonary exercise test (CPET), troponin I and BNP measurements.

Results

There was a decrease in VO2 peak (ml/km/min) in all NCC groups compared to CG (GC= 34.5±5.3, G1= 25.56±5.6, G2= 25.12±7.7 and G3= 21.86±6.3 ml/kg/min, p<0.001), but no difference was shown among NCC patients (p=0.37). In addition, the VO2 at anaerobic threshold (AT) was lower in all NCC groups compared to CG (GC= 22.88±3.3, G1= 17.30±4.7, G2= 18.58±5.2, e G3= 15.65±3.7 ml/kg/min, p<0.001). There was an increase in indexed ventricular mass in all NCC groups when compared to CG (p<0.001), but it was similar among NCC groups (p=0.72). Regarding to diastolic function, G2 and G3 presented a reduction in the peak velocity of the septal E' when compared to the control group (GC= 14.0±2.4, G2= 8.92±3.0 e G3= 6.86±3.9 cm/s, p<0,001), while E/E' was increased in G3 compared to all groups (p<0.001). G2 and G3 presented a decrease in global longitudinal strain (GLS) when compared to CG and G1 (p<0.001). The BNP levels were higher in G3 compared to the other groups (p<0.05), but no difference was found in troponin I levels. There was a positive correlation between VO2 peak and E' (r=0.56, p<0.001) and a negative correlation between VO2 peak and E/E' (r=−0.53, p<0.001). In addition, there was an inverse correlation between VO2 peak and BNP (r=−0.50, p<0.001).

Conclusion

Our results show that NCC patients present alterations in functional capacity, echocardiographic indices and biomarkers values according to LV dysfunction. Moreover, patients with preserved LV function already present predominant alterations in CPET suggesting subclinical myocardial dysfunction. For this reason, clinical treatment could be considered in this initial stage of this disease.
P4690Effects of pulmonary artery wedge pressure on right ventricular pulsatile loading in pulmonary hypertension: a reappraisal based on pulmonary arterial isobaric stiffness
Authors: Chemla D , Berthelot E , Weatherald J , Lau E , Attal P , Boulate D , Montani D , Jourdain P , Humbert M , Assayag P , Herve P
Published: October 2019

Background

Pulmonary hypertension (PH) is associated with stiffening of pulmonary arteries. Previous studies have suggested that high pulmonary artery wedge pressure (PAWP) in postcapillary PH (Pc-PH) further augments PA stiffness at a given level of pulmonary vascular resistance as compared to pulmonary arterial hypertension (PAH). However, these studies do not take into account differences in distending pressure (mean PA pressure, mPAP), which has an effect on stiffness due to non-linear stress-strain behavior of arteries.

Purpose

To compare total PA stiffness between Pc-PH and idiopathic PAH (iPAH) studied at similar mPAP (isobaric stiffness).

Methods

This was an analysis of right heart catheterization results obtained in 112 Pc-PH and 112 iPAH patients extracted from the French PAH network registry and matched for mPAP (median 38 vs 39 mmHg, P=NS), age (70.5 years each) and sex (64% female each). Total PA stiffness was calculated as the ratio of PA pulse pressure to indexed stroke volume.

Results

Total PA stiffness (n=224) increased with mPAP (Spearman's rho = 0.66) and decreased with PAWP (rho = - 0.17) (each P<0.01). The isobaric stiffness was lower in Pc-PH (median (IQR) = 0.91 (0.64–1.39) mmHg/mL/m2) than in iPAH (1.18 (0.83–1.62) mmHg/mL/m2, P<0.01). The patients were then stratified according to their mPAP (25–35 mmHg, n=74 (37/37); 36–43 mmHg, n=75 (34/41); and 44–66 mmHg, n=75 (41/34)). The isobaric stiffness was lower in Pc-PH than iPAH in the 1st mPAP tertile (0.62 vs 0.83 mmHg/mL/m2, P=0.06), in the 2nd mPAP tertile (0.76 vs 1.22 mmHg/mL/m2, P<0.01) and in the 3rd mPAP tertile (1.41 vs 1.77 mmHg/mL/m2, P<0.01). The pulmonary vascular resistance was lower in Pc-PH than iPAH in every mPAP tertile (each P<0.01). Finally, Pc-PH had a higher indexed stroke volume than iPAH (37 (29–48) vs 32 (27–40) mL/m2, P<0.01) while systolic PA pressure and PA pulse pressure were similar.

Conclusion

Unexpectedly, the isobaric pulmonary arterial stiffness was lower in Pc-PH than iPAH patients. It is proposed that PAWP attenuates the increase in RV pulsatile loading in PH when the natural high-strain-induced stiffening was accounted for. This may contribute to a less impaired right ventricular-PA coupling leading to higher indexed stroke volume in Pc-PH than iPAH despite similar PA pressure. At every mPAP level, both the lower PA stiffness and lower pulmonary vascular resistance in Pc-PH than in iPAH may contribute to explain differences in the pressure overload-induced right ventricular adaptation between the two diseased groups, a point that deserves to be confirmed by further studies.

Acknowledgement/Funding

University regular funds