bluuebunny/crossref_metadata_2025 huggingface dataset:
P6323Exercise capacity as predictor for anaemia or iron deficiency in patients with chronic heart failure
Authors: Ebner N , Dinopoulos G , Evertz R , Garfias Macedo T , Godoy B , Springer J , Von Haehling S
Published: October 2019

Background

Anaemia and iron deficiency (ID) are important factors for muscle function and exercise capacity in patients with chronic heart failure (HF). Their interaction in HF remains to be defined.

Methods

A total of 280 out-patients with stable chronic HF were enrolled with mean age of 67.0±10.7 years, 21%female, mean left ventricular ejection fraction (LVEF) was 38.9±13.4%, mean Body Mass Index (BMI) 29.3±5.5 kg/m2]. Anaemia was defined according to World Health Organization criteria [Haemoglobin (Hb) <13 g/dL in men and <12 g/dL in women]. ID was defined as ferritin <100 μg/L or ferritin <100 <300 μg/L than with transferrin saturation (TSAT) <20%. Exercise capacity was assessed by spiroergometry (peakVO2), 6 minute walk test (6MWT), short physical performance battery test (SPPB), hang grip strength (HGS) and leg force (LF). All patients were followed up for a mean of 8 month.

Results

A total of 89 (32%) chronic HF patients had anaemia and 142 (51%) had iron deficiency at baseline. Patients with anaemia showed significant lower exercise capacity compared to patients without anaemia (peak VO2: 15.3±4.6 vs. 18.5±4.8 kg/min p<0.0001, 6MWT: 365.2±135.5 vs. 461.6±127.4 m p<0.0001, SPPB: 9.4±2.3 vs. 11.0±1.6 total points p<0.0001, HGS: 32.5±10.0 vs. 38.8±12.4 kg p<0.0001, LF: 31.4±11.0 vs. 41.3±21.6 kg p<0.0001). The same we found in patients with ID compared to patients without ID (peak VO2: 16.3±5.1 vs. 18.6±4.5 kg/min p=0.001, 6MWT: 400.0±140.8 vs. 458.8±128.4 m p=0.0008, SPPB: 10.0±2.1 vs. 10.9±1.7 total points p=0.0003, HGS: 34.5±11.9 vs. 39.3±11.7 kg p=0.001, LF: 35.7±23.4 vs. 40.5±13.6 kg p=0.04). After a Follow up of mean 8 month 53 patients develop a new onset of either anaemia (n=24) or ID (n=29). Logistic regression analysis showed that gender, 6 minute walk distance, SPPB, HGS and presence of diabetes mellitus at baseline are significantly associated with the development of anaemia or ID (all p<0.05). The strongest predictor was lower SPPB (p=0.0008). Interestingly known determinates lower peak VO2, higher age, higher NYHA class, Creatinine, and hsCRP were not predictive in our cohort to develop anaemia or ID after 8 month (all p>0.05).

Conclusion

Both anaemia and ID are strongly associated with reduced exercise capacity in patients with HF. The effect of anaemia and iron deficiency together is stronger than that of anemia and ID alone. Reduced SPPB, 6MWT, and HGS are important risk factors for the development of anaemia or ID.
P6344Volume overload-triggered pathological myocardial remodeling occurs in the absence of calcium/calmodulin-dependent protein kinase type II delta
Authors: Elkenani M , Mohamed B A , Buchholz E , Lbik D , Schnelle M , Hasenfuss G , Toischer K
Published: October 2019

Background

Calcium/calmodulin-dependent protein kinase type II delta (CamKIIδ), the predominant cardiac CaMKII isoform, has been implicated in the progression of myocardial infarction- and pressure overload-induced pathological remodeling and heart failure, but its role in volume overload (VO) has not been defined. We have previously reported an activation of CamKII during transition to HF in VO.

Purpose

Here, we analyzed the impact of CamKIIδ deletion in VO-triggered myocardial remodeling and heart failure development.

Methods

CaMKIIδ knockout (CaMKIIδ-KO) and wild-type (WT) littermates were exposed to aorto-caval shunt-induced VO, and the progression of myocardial remodeling was assessed by serial echocardiography, histological and molecular analyses.

Results

CaMKIIδ-KO and WT littermates exhibited similar mortality pattern in response to VO. Serial echocardiographic measurements showed a comparable eccentric myocardial remodeling, altered left ventricle geometry and perturbed ventricular function after shunt. At 12 weeks post-shunt both CaMKIIδ-KO and WT mice experienced comparable increases in relative heart weight, cardiomyocyte diameter, cardiac apoptosis, and hypertrophic genes expression.

Conclusion

We therefore conclude that CaMKIIδ signaling is dispensable for the progression of pathological cardiac remodeling induced by VO. This should be considered before CaMKII inhibition is approved therapeutically for HF treatment.
P6355The behavior of atrial fibrillation in patients with heart failure hospitalization
Authors: Fukunaga M , Hirose K , Isotani A , Morinaga T , Ando K
Published: October 2019

Background

Relationship between atrial fibrillation (AF) and heart failure (HF) is often compared with proverbial question of which came first, the chicken or the egg. Some patients showing AF at the HF admission result in restoration of sinus rhythm (SR) at discharge. It is not well elucidated that the restoration into SR during hospitalization can render the preventive effect for rehospitalization.

Purpose

To investigate the impact of restoration into SR during hospitalization for readmission rate of the HF patients showing AF.

Methods

We enrolled consecutive 640 HF patients hospitalized from January 2015 to December 2015. Patients data were retrospectively investigated from medical record. Patients showing atrial fibrillation on admission but unrecognized ever were defined as “incident AF”; patients with AF diagnosed before admission were defined as “prevalent AF”. Primary endpoint was a composite of death from cardiovascular disease or hospitalization for worsening heart failure. Secondary endpoints were death from cardiovascular disease, unplanned hospitalization related to heart failure, and any hospitalization.

Results

During mean follow up of 19 months, 139 patients (22%) were categorized as incident AF and 145 patients (23%) were categorized as prevalent AF. Among 239 patients showing AF on admission, 44 patients were discharged in SR (39 patients in incident AF and 5 patients in prevalent AF). Among incident AF patients, the primary composite end point occurred in significantly fewer in those who discharged in SR (19% vs. 42% at 1-year; 23% vs. 53% at 2-year follow-up, p=0.005). To compare the risk factors related to readmission due to HF with the cox proportional-hazards model, AF only during hospitalization [Hazard Ratio (HR)=0.37, p<0.01] and prevalent AF (HR=1.67, p=0.04) was significantly associated. There was no significant difference depending on LVEF.

Conclusion

Newly diagnosed AF with restoration to SR during hospitalization was a good marker to forecast future prognosis.
P6362Impact of the 2017 AHA/ACC hypertension guideline on hypertension prevalence and cardiovascular risk factors in a healthy older cohort
Authors: Chowdhury E K , Nelson M R , Ernst M E , Margolis K L , Beilin L J , Johnston C I , Murray A M , Woods R L , Wolfe R , Tonkin A M , Williamson J D , Stocks N P , McNeil J , Reid C
Published: October 2019

Background

The 2017 American Heart Association (AHA)/American College of Cardiology (ACC) hypertension guideline recommends a target blood pressure (BP) of <130/80 mmHg regardless of age, which is lower than previously recommended BP goals.

Purpose

We aimed to determine how much the updated classification for high BP would increase the overall prevalence of “hypertension” in an otherwise healthy elderly population. Additionally, we explored the cardiovascular disease (CVD) risk factor distribution in those newly classified “hypertensives” to determine whether the increased prevalence of hypertension was accompanied by an increase in other modifiable CVD risk factors.

Methods

We used baseline data from 19,114 participants (16,703 in Australia and 2,411 in the USA) aged ≥65 years who were enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) study between 2010 and 2014. Participants were classified as having hypertension using either: (a) pre-2017 thresholds (SBP ≥140 mmHg or mean DBP ≥90 mmHg and/or on anti-hypertensive) or (b) 2017 AHA/ACC guidelines (SBP ≥130 mmHg or DBP ≥80 mmHg and/or on anti-hypertensive). We assessed the presence of cardiovascular disease risk factors such as diabetes, hypercholesterolemia, smoking, obesity, reduced renal function among these hypertensive participants and also estimated their predicted risk over 10 years.

Results

Based on pre-2017 thresholds, 74% of the participants met the criteria for hypertension. Hypertension prevalence increased to 87% when the more stringent 2017 guideline was applied. 29% of this subset of newly classified hypertensive participants did not have any other identifiable traditional CVD risk factors. Further, a significantly lower 10-year predicted cardiovascular risk (22% versus 26%, p<0.001) among those newly classified hypertensive participants was observed in relation to those having hypertension based on pre-2017 guideline (Figure 1).

Figure 1. 10-year predicted CVD risk among hyoertensive and newly classified hypertensive ASPREE participants by presence of CVD risk factor

Conclusion

As expected, the prevalence of hypertension increased among the healthy elderly when applying the new AHA-2017 guideline; however, the increased prevalence occurs despite lack of an accompanying increase in additional CVD risk factors or predicted 10-year risk. Our findings suggest an individualized approach is needed in evaluating high BP among the healthy elderly.

Acknowledgement/Funding

National Institute on Aging and the National Cancer Institute at NIH; NHMRC Australia, Monash University, Victorian Cancer Agency (Australia)
P6368Blood pressure control in a registry of clinical practice, PINNACLE-BRAZIL REGISTRY
Authors: Avezum A , Cordeiro Mattos A , Oliveira G B F , Pinto I M , Rombaldi A R , Fonseca H A R , Bocchese J I , Saback G , Taborga P R C , Silva T O , Campoa R N , Ferreira M H B , Savioli Neto F , Magalhaes C C , Saraiva J F K
Published: October 2019

Introduction

The prevalence of hypertension is estimated to be nearly 50% among Brazilian adults. Achieving an adequate control of this CVD risk factor is challenging but truly relevant on a public health perspective, as this is the top-ranking cause of all deaths globally.

Purpose

We aimed to describe crude and simple metrics of blood pressure management (including its control), as based on current guideline-derived recommendations, after one year of the clinical practice registry

Methods

Patients with documented Hypertension were included by using electronic case report form based on the ACC PINNACLE Registry. The registry has been enrolling patients from general practitioners and specialists. The main goal of the PINNACLE program is to improve the quality of care in “real world” clinical practice. Patients data were evaluated after 01 year of follow-up on regular clinical appointments and the differences on clinical practice were evaluated

Results

Currently, PINNACLE-Brazil has enrolled 7598 patients, with 87% of diagnosed hypertension. Percentage of patients with a diagnosis of hypertension who had a blood pressure measurement <140/90 mmHg was 47.9% (baseline) and 57.3% (follow-up). Percentage of patients who had a blood pressure <140/90 mm Hg, or who had a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications were 67.1% on baseline and 71.2% after 1 year.

Conclusion

The preliminary data of PINNACLE Registry in Brazil shows that a significant proportion of hypertensive patients (nearly half) have not presented with adequate control of blood pressure levels and, moreover, a large proportion have not been treated with recommended combination of 02 or more antihypertensive medications to reach targeted BP levels the quality of care was improving after 01 year of registry.

Acknowledgement/Funding

ACC Foundation
P6372Does modification of activity regimes optimize the effect of high physical activity on hypertensive heart disease?
Authors: Schluter K.-D , Schreckenberg R , Wolf A , Kutsche H , Troidl C , Simsekyilmaz S , Niemann B , Schulz R
Published: October 2019

Aims and background

Spontaneously hypertensive rats (SHR) are a suitable model of essential hypertension and allow analyze the progression of hypertension and hypertension-dependent end-organ damage. In this model, acute improvement of physical activity (free running wheel activity) exerts known beneficial effects (such as lowering oxidative stress). However, these initial beneficial effects are lost during the continuation of high physical activity and translate into mal-adaptive processes, suggesting that not any high physical activity exerts beneficial effects. It has been hypothesized that the skeletal muscle release myokines, that contribute to the beneficial effects of exercise. However, myokines, such as IL-6, are induced by an acute increase in work load not by continuous work load. Therefore, we analyzed whether modification of high physical activity, i.e. intermittent free running wheel activity, modify the long-term impact on long lasting hypertension.

Methods

38 female SHR aged 6 weeks (pre-hypertensive state) were randomly allocated to one of the following groups: Sedentary (S; standard holding condition) imitating the condition of sedentary life style, high activity (HA; life-long free running wheel) imitating the condition of active life style, temporary activity (TA; 6 months free running wheel and 3 months sedentary) imitating the loss of active life style during ageing, and finally intermittent activity (IA; 10 months repetitive access to running wheels every 4 weeks) imitating altered workloads. All rats were sacrificed at the age of 10 months.

Results

IA was the only treatment regime that effectively lowered blood pressure (P syst: 186±11 vs. 165±6 mmHg), improved ejection fraction (EF: 56±5 vs. 63±2%), and displayed clear molecular profile of adaptive myocardial hypertrophy rather than mal-adaptive hypertrophy. Moreover, only IA reduced the number of circulating monocytes (377±102 vs. 220±16 /μl), a cell population that immigrated in the left ventricle. The number of monocytes was directly correlated with the expression of MMP12, BNP, ANP, biglycan, collagen-1, actinin, β-MHC, and somatstatin but inversely related to β-adrenoceptor, Glut-4, and UCP3 expression. Finally, IA increased the skeletal expression of IL-6 and decreased the renal expression of AT1 receptors.

Conclusion

The data confirm the previous findings that not all type of physical activity beneficially affects hypertensive-dependent disease. In contrast, the data support the hypothesis that alterations in work load are required triggering the release of myokines from the skeletal muscle and identify the amount of circulating monocytes as a main trigger of mal-adaptive hypertrophy in these rats. The data are important with respect to optimize life style suggestions for patients with essential hypertension.

Acknowledgement/Funding

DFG (ERAGON and SFB 1213)
P6378Characteristics of hypertensive iron ore miners with oral glucocorticoid induced diabetes mellitus and compromised lung function
Authors: Redkar V , Redkar S , Inamdar M , Inamdar A , Redkar S S , Jagtap M , Rane S , Kulkarni S V , Deshpande J , Gupta S
Published: October 2019

Introduction

Oral glucocorticoids are efficacious agents for treating respiratory diseases, with high risk to induce metabolic diseases including diabetes and hypertension

Purpose

To analyse the hypertensive patient population from the rural setting on ongoing glucocorticoid treatment and diagnosed as diabetic due to the extensive chronic methylprednisolone equivalent glucocorticoid dose of more than 4 mg/day for at least 3 months for treatment of respiratory ailments due to occupational hazard

Methods

We diagnosed the identified and analysed a subset of patients from the Redi iron ore miners (n=25,500), who were newly diagnosed diabetics (n=1100) and with associated systemic hypertension (systolic BP >140 mmHg, diastolic BP > than 90 mmHg). Patients diagnosed as Oral Glucocorticoid Induced Diabetes Mellitus (GIDM) and hypertensives (n=847; 572 males and 275 females) were characterised on metabolic parameters. t-test was utilised for statistical analysis

Results

We observed a high incidence of GIDM (4.31%) with a high rate of hypertension (77%, 847/1100). Mean SBP was 150 mmHg (SD ± 9.9, 95% CI 147–152), mean DBP was 90 mmHg (SD ± 8.9, 95% CI 88–92). BMI in GIDM with hypertension (GIDM-H) group was similar to GIDM group (26 kg/m2) (Table), with relatively older age in GIDM–H (53 vs 51 years). The glycemic parameters were relatively more deranged in GIDM-H group. There was significant correlation for a high propensity of relatively younger <50 years (n=506) and near normal weight people with BMI <26 kg/m2 (n=594) to develop GIDM (p=0.006)

Metabolic Parameters GIDM Vs GIDM-H Mean ±SD, min, max, 95% CI GIDM (n=1100) GIDM with Hypertension (n=847) Age (yrs) 51 (SD ±14, 95% CI 48–54) 53 (SD ±13, 95% CI 50–56) HbA1c (%) 7.1 (SD ±0.62, 95% CI 7–7.3), 7.2 (SD ±0.60, 95% CI 7.1–7.3) BMI (kg/m2) 26 (SD ±3.6, 95% CI 25–27) 26 (SD ±3.4, 95% CI 25–27) Fasting Plasma Glucose (mg/dl) 146 (SD ±49, 95% CI 136–155) 149 (SD ±48, 95% CI 138–160) Post Prandial Glucose (mg/dl) 207 (SD ±74, 95% CI 192 - 221) 212 (SD ±74, 95% CI 195–228)

Conclusions

The high rates of hypertension in patients with GIDM is an alarmingly problem which has pronounced harmful comorbid implications, especially in younger, economically productive population in limited resource setting. The health care professionals need to be educated to limit use of glucocorticoids to inhalational therapy with minimal systemic effects. Specific pathophysiological approach to address the steroid induced insulin resistance, strategies to reduce cardiovascular risk and damage, makes treatment of hypertension and GIDM difficult, which calls for action to limit the mining activities and mitigate risk of chronic complications
P6383Cardiac output during targeted temperature management and renal function after out-of-hospital cardiac arrest
Authors: Grand J , Hassager C , Bro-Jeppesen J , Wanscher M , Kjaergaard J
Published: October 2019

Background

After resuscitation from out-of-hospital cardiac arrest (OHCA), renal injury and hemodynamic instability are common. Low blood pressure during targeted temperature management (TTM) is associated with acute renal injury (AKI). The aim of this study is to test the hypothesis, that low cardiac output during TTM is associated with acute kidney injury after OHCA.

Methods

Single-center substudy of 171 patients included in the prospective, randomized TTM-trial. Hemodynamic evaluation was performed with serial measurements by pulmonary artery catheter. Mean arterial pressure ≥65 mmHg and central venous pressure of 10 to 15 mmHg were hemodynamic treatment goals. Acute kidney injury (AKI) was the primary endpoint and was defined according to the KDIGO-criteria. Differences between groups were tested by repeated measurements mixed models.

Measurements and main results

Of 152 patients with available hemodynamic data, 49 (32%) had AKI and 21 (14%) had AKI with need for renal replacement therapy (RRT) in the first three days. At admission, cardiac index was higher in the AKI-group (mean (confidence interval): 2.6 (2.2–3.0) L/min/m2 versus 2.2 (2.0–2.3) L/min/m2, p=0.003). During 24 hours of targeted temperature management, patients with AKI had increased heart rate (11 beats/min, pgroup<0.0001) and increased lactate (1 mmol/L, pgroup<0.0001) compared to patients without AKI. However, there was no overall difference in cardiac index (pgroup = 0.25) (Figure). In multivariate models, adjusting for potential confounders including targeted temperature, mean arterial pressure (odds ratio: 0.69 (0.50–0.96) per 5 mmHg increase, p=0.03), heart rate (1.04 (1.01–1.08) per beat/min increase, p=0.01) and lactate (1.59 (1.14–2.2) per mmol/L increase, p=0.006) were independently associated with AKI, but cardiac index remained unrelated with AKI.

Figure 1

Conclusions

Blood pressure, heart rate and lactate, but not cardiac output, during 24 hours of targeted temperature management were associated with renal injury in comatose OHCA-patients.

Acknowledgement/Funding

The research fund Gangstedfonden and the Research fund of Rigshospitalet has supported this study with unrestricted salary in Dr. Grand's PhD project.
P6396LDL cholesterol promotes neutrophil extracellular trap formation
Authors: Ondracek A S , Hofbauer T M , Wadowski P P , Mangold A , Gremmel T , Lang I M
Published: October 2019

Background

Pro-protein convertase subtilisin/kexin 9 (PCSK9) is a regulator of low density lipoprotein (LDL) receptor (LDLR) expression and has gained attention in the treatment of hyperlipidemia. Serum levels of LDL are correlated with numbers of activated neutrophils in the circulation of hyperlipidemic patients. Activated neutrophils can form neutrophil extracellular traps (NETs) by expelling their chromatin, and NETs have been recognized as important risk factors for acute myocardial infarction (AMI) and stroke.

Purpose

We analyzed the influence of serum LDL levels on neutrophil activation, their propensity to form NETs, and the correlation of NET surrogate markers with systemic inflammatory responses in AMI.

Methods

We recruited 249 consecutive patients with AMI (mean age 58 years, 20% females) and assessed laboratory parameters, inflammatory markers, and serum lipid profiles 72 h after primary percutaneous coronary intervention. Double-stranded DNA (dsDNA) and citrullinated histone H3 were determined from plasma as markers of in vivo NET formation. In a subset of patients (n=25), ex vivo NET formation in response to PCSK9 and ionomycin was analyzed, neutrophils were stained for CD11b, LDLR, and lectin-like oxidized LDLR (LOX-1) using flow cytometry at baseline and after activation with phorbol myristate acetate. PCSK9 levels were measured by ELISA.

Results

Patients with serum LDL levels above the median [median (IQR) LDL 111 mg/dl (87–141), mean ± SD LDL 115±41 mg/dl] had significantly higher concentrations of circulating dsDNA.

Levels of dsDNA [median 121 ng/ml, IQR 101–156] were linked with levels of the specific NET marker citH3 [median (IQR) 252 ng/ml (655–1600), rs=0.157]. Plasma concentrations of dsDNA and citH3 correlated significantly with CRP (dsDNA rs=0.328; citH3 rs=0.209), proBNP (dsDNA rs=0.286; citH3 rs=0.192), troponin T (dsDNA rs=0.282; citH3 rs=0.197), and IL-6 (dsDNA rs=0.242; citH3 rs=0.216).

In the subset of patients in whom neutrophils were characterized, pre-treatment of neutrophils with PCSK9 could significantly decrease ionomycin induced NET release in a dose-dependent manner. Levels of serum LDL were associated with spontaneous NET formation (r=0.504) ex vivo and activated CD11b on neutrophils (r=0.495).

LOX-1 expression correlated significantly with LDLR expression (rs=0.670) and PCSK9 levels (r=0.520). Patient neutrophil stimulation in whole blood led to a significant decrease of the LDLR positive neutrophil population. This effect was greater when PCSK9 levels were higher.

Conclusion

Our data indicate a role for LDL in boosting neutrophil activation depending on PCSK9.
P6404Myocardial infarction with nonobstructive coronary arteries: does aspirin have a place in the treatment of this entity?
Authors: Ferreira J , Freitas F , Goncalves V , Ferreira C , Milner J , Alves P , Marinho V , Monteiro S , Baptista R , Monteiro P , Goncalves L
Published: October 2019

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is still a clinical enigma that is being increasingly recognised, as the number of coronary angiographies we perform in our centres also increase. However, the treatment for this entity is still a matter of important debate, not only due to the different causative mechanisms of this disease but also because there are no major trials regarding MINOCA treatment.

Purpose

To determine the association between acetylsalicylic acid (ASA) use after discharge and mortality after discharge in MINOCA patients admitted to a coronary care unit (CCU).

Methods

We analyzed data from 370 (11.7% of the global sample) patients admitted with MINOCA in our CCU. Patients with other final diagnoses, missing mortality data, previous acute myocardial infarction, contra-indications to aspirin and known heart failure before admission were excluded. All patients underwent transthoracic echocardiography and coronary angiography at any point during hospitalisation. After adjusting data for relevant comorbidities we then compared mortality after hospital discharge between the ASA group and the no-ASA group.

Results

Of all MINOCA patients admitted in our CCU, 84 (22.7%) were diagnosed with ST-elevation myocardial infarction (STEMI) and 286 (77.3%) with non-ST elevation myocardial infarction (NSTEMI). 296 (80%) patients received ASA after discharge. Both groups were homogeneous as we did not find any significant differences between groups regarding age (p=0.106), left ventricle ejection fraction (p=0.100), GRACE score at hospitalisation (p=0.150), Killip-Kimball class at hospitalisation (p=0.604), incidence of acute kidney injury (p=0.450), maximum c-reactive protein during stay (p=0.804) and low-density lipoprotein levels at hospitalization (p=0.055). There was also no difference in the incidence of diabetes (p=0.350), exposure to daily stress (p=0.767), active smoking (p=0.569), dyslipidemia (p=0.229), hypertension (p=0.057) and type of myocardial infarction (STEMI vs NSTEMI – p=0.215). In this MINOCA cohort (5 years follow-up) a total of 47 patients died (12.7%). ASA vs. no-ASA 1-month (3.1% vs. 0.0%, p=0.214), 6-month (4.5% vs. 1.4%, p=0.317), 1-year (5.9% vs 5.6%, p=0.900), 3-year (10.5% vs. 8.3%, p=0.668) and 5-year (13.3% vs. 12.5%, p=0.860) all-cause mortality was not significantly different. The same non-significant trend towards higher mortality with ASA was obtained when survival curves were taken into account.

Conclusions

MINOCA remains a challenging entity. In our study, the systematic use of ASA in all patients following MINOCA was not associated with better survival after long-term follow-up.
P6408Potential benefit of ticagrelor monotherapy for patients with hypertension undergoing percutaneous coronary intervention: insights from the Global Leaders trial
Authors: Modolo R , Chichareon P , De Faria A P , Steg P G , Hamm C , Vranckx P , Valgimigli M , Windecker S , Onuma Y , Serruys P W
Published: October 2019

Background

Hypertension is one of the most frequent modifiable risk factors for coronary artery disease. Due to the increased risk of bleeding associated with it, hypertensive patients might benefit from an antiplatelet monotherapy following percutaneous coronary intervention.

Purpose

We sought to investigate the effect of 1-month DAPT followed by 23-month ticagrelor monotherapy (ticagrelor monotherapy) compared with the reference arm, 12-month DAPT followed by 12-month aspirin monotherapy (standard DAPT), on clinical outcomes in patients with hypertension undergoing PCI.

Methods

This is a post-hoc analysis of the prospective, multi-center, open-label, all-comers, randomized controlled trial Global Leaders, that tested ticagrelor monotherapy versus standard DAPT in patients receiving PCI with biolimus A9-eluting stent. Patients were stratified by the hypertension status. The primary endpoint for the present analysis was the patient oriented composite endpoint (POCE - defined as composite of all-cause death, any stroke, any MI, or all revascularization) and safety endpoint of BARC type 3 or 5 bleeding, both at 2 years. Event rates are presented as Kaplan-Meier estimates (%).

Results

In Global Leaders 15,991 patients were randomized, 23 (0.14%) requested complete deletion of their data from the database and 54 (0.34%) had no information on hypertension status. Of the 15,914 (99.52%) included in the analysis 11,715 were hypertensive. In the non-hypertensive patients, comparing ticagrelor monotherapy with standard DAPT, no difference was found regarding POCE (12.17% vs. 12.13%, HR 1.004, 95% CI 0.843 to 1.195, p=0.965) nor bleeding (1.71% vs. 1.72%, HR 1.0, 95% CI 0.628 to 1.592, p=1.0, respectively). In hypertensive patients the experimental treatment of ticagrelor monotherapy resulted in less POCE (13.62% vs. 15.04%, HR 0.898, 95% CI 0.816 to 0.988, p=0.028, p for interaction=0.271) with similar bleeding (2.21% vs. 2.26%, HR 0.976, 95% CI 0.765 to 1.246, p=0.846), compared with the standard DAPT at 2 years.

Conclusion

In this sub-group analysis of Global Leaders, in patients with hypertension undergoing PCI the experimental treatment of 1-month DAPT followed by 23-month ticagrelor monotherapy may offer ischemic protection without increasing bleeding. The results must be interpreted cautiously as there was no interaction between treatment strategy and the status of hypertension. Thus, the present results are hypothesis generating.

Acknowledgement/Funding

ECRI - Astra Zeneca - Biosensors - Medicine Company
P6441New continuous glucose monitoring reveals hypoglycemia risk in both diabetic and nondiabetic patients with acute myocardial infarction
Authors: Kuroda M , Kawata M , Matsuura A , Adachi K , Hirayama Y , Matsuura T , Matsumoto A , Kodaira M , Kintsu M , Suzuki Y
Published: October 2019

Background

There has been growing evidence that the glucose fluctuation is an important contributing factor to the development of coronary artery disease. However, whether large glucose fluctuation, especially hypoglycemia, may be associated with acute myocardial infarction (AMI) remains largely unknown.

Aim

As new continuous glucose monitoring (CGM) has recently become available to evaluate glucose fluctuation from immediately after an emergency visit, this study sought to investigate glucose fluctuation and the occurrence of hypoglycemia in patients with AMI.

Methods

In this prospective study, 93 consecutive patients with AMI from April 2017 to November 2018 were enrolled. Subcutaneous interstitial glucose levels were monitored from emergency room to discharge using the CGM System. Based on the CGM data, 24-h mean glucose levels, the time in hyperglycemia and hypoglycemia and the occurrence of hypoglycemia, defined as less than 70 mg/dL, were measured, and the mean amplitude of glycemic excursions (MAGE) were calculated.

Results

The majority of patients [n=57, 61% (non-DM)] did not have diabetes and 36 patients had diabetes (DM). The occurrence of hypoglycemia within 24 hours after admission was observed in 49 patients [DM: n=11 (30.6%), non-DM: n=38 (66.7%)]. MAGE within 24 hours after admission were 100±47 in DM patients and 67±20 in non-DM patients. The mean time in hypoglycemia within 24 hours after admission was 148 minutes [DM: 100±260 minutes, non-DM: 178±287 minutes]. The occurrence of hypoglycemia during a hospital stay (mean 11.5 days) was detected in 76 patients [DM: n=28 (77.8%), non-DM: n=48 (84.2%)].

Representative case of hypoglycemia

Conclusion

Not only in DM patients but also in non-DM patients with AMI, large glucose fluctuation and high incidence of hypoglycemia were observed using new CGM system. Further investigations should address the rationale for the early detection and control of glucose fluctuation for AMI patients.
P6445Stress hyperglycemia and in-hospital mortality in patients with ST-segment elevation myocardial infarction
Authors: Kong M G , Park H W , Choi H O , Seo H S , Suh J , Cho Y H , Lee N H
Published: October 2019

Introduction

Stress hyperglycemia is common in acute ill patients and associated with poor clinical outcomes. Some studies demonstrated the association of stress hyperglycemia and poor outcomes in acute MI. However, current results for the impact of stress hyperglycemia on mortality in acute MI who underwent PCI are insufficient.

Purpose

We aimed to evaluate the impact of stress hyperglycemia on clinical outcomes of patients with STEMI underwent primary PCI in large scale multi-center registry.

Methods

From 2007 to 2014, in 1,538 patients of the INTERSTELLAR (Incheon-Bucheon Cohort of Patients Undergoing Primary PCI for Acute ST-Elevation Myocardial Infarction) cohort, 997 patients without diabetes who underwent primary PCI for STEMI were retrospectively analyzed. We defined random glucose more than 200mg/dl at admission without diabetic history or results of HbA1C more than 6.5% as stress hyperglycemia. The primary endpoint was in-hospital all-cause death and the secondary endpoint was all-cause death within 1 year after index PCI.

Results

From 997 nondiabetic cohort population, 117 patients with stress hyperglycemia and 880 patients without stress hyperglycemia were enrolled. Baseline characteristics including age, sex, hypertension, hyperlipidemia, atrial fibrillation, left main disease, and multivessel disease were not significantly different between two groups. However, systolic blood pressure was lower (111.2±39.2 vs. 125.5±28.1, p<0.001) and hypoxic liver injury was frequent (31.0% vs. 20.1%, p=0.007) in stress hyperglycemia. In-hospital and 1-year all-cause mortality were higher in stress hyperglycemia (13.7% vs. 2.7%, p<0.001; 15.4% vs. 3.8%, p<0.001, respectively). However, there is no significant difference in post-discharge mortality rate. Stress hyperglycemia was a significant independent predictor of in-hospital death (adjusted OR: 5.67, 95% CI: 2.40–13.39; p<0.001). Hypotension (defined less than 90mmHg) and left ventricular dysfunction (defined less than 40% of LVEF on echocardiography) were significantly associated with stress hyperglycemia (adjusted OR: 5.72, 95% CI: 3.33–9.82; p<0.001; adjusted OR: 2.38, 95% CI: 1.49–3.82; p<0.001, respectively).

Landmark analysis of all-cause death

Conclusions

In nondiabetic patients who underwent primary PCI for STEMI, stress hyperglycemia is significantly associated with an increased in-hospital all-cause mortality but did not increase post-discharge mortality within 1 year.
P6466Novel index with combined echocardiographic parameter and CT parameter (pPAT) is useful for screening pulmonary hypertension in Systemic Sclerosis Patients
Authors: Orihara Y , Asakura M , Okuhara Y , Matsumoto Y , Masai K , Goda A , Masuyama T , Ishihara M
Published: October 2019

Background

Systemic sclerosis (SSc) patients with pulmonary arterial hypertension (PAH) had poor survival rate. Usual index of estimating PH is tricuspid regurgitate jet pressure gradient (TRPG). Accurate assessment of PAH is important for the management of SSc patients. However, estimated mean pulmonary arterial pressure (mPAP) using TRPG by echocardiography does not always reflect actual mPAP by right heart catheterization (RHC) in SSc patients. On the other hand, recent reports have shown that rPA, a ratio of diameter of pulmonary artery to ascending aorta (PA/Ao) calculated by computed tomography (CT), was associated with mPAP. However, both index are not sufficient for evaluation of PH. We hypothesized that the product of TRPG and rPA (pPAT) could estimate mPAP of SSc patients more accurately than TRPG or rPA.

Purpose

We investigated the usefulness of the product of TRPG and rPA for detecting actual mPAP in SSc patients.

Methods

Thirty-six SSc patients who suspected PH were enrolled retrospectively. We defined PH as resting mPAP from RHC of >25 mmHg. We measured both a widest pulmonary artery diameter and an adjacent ascending aorta diameter at the same level of the bifurcation of the main pulmonary artery using CT images.

Results

The average age was 67 years old and average mPAP by RHC was 24.7 mmHg. Mean TRPG and mean rPA were 35.1 mmHg and 1.06, respectively. Furthermore, mean pPAT was 37.9. We found pPAT had a stronger correlation with actual mPAP (r=0.848, p<0.001) than TRPG (r=0.754, p<0.001) or rPA (r=0.584, p<0.001). On ROC analysis, pPAT predicted PH with high accuracy for a cut-off of 33.1. In order to evaluate the usefulness of pPAT, we compared false-negative patients between two cutoff values of TRPG 34 mmHg described in ESC guideline and pPAT 33.1. Among the patients with TRPG <34mmHg, 4 patients (18%) had PH. In contrast, when screening PH using pPAT, the diagnosis of PH was missed in only one patient.

Figure 1

Conclusion

The product of TRPG and PA/Ao (pPAT) could be a novel and useful noninvasive index for identifying PH in SSc patients.
P6473Impact of prosthesis choice on mortality after transfemoral transcatheter aortic valve implantation in patients with reduced versus preserved left-ventricular ejection fraction
Authors: El Chilali K , Kahlert H A , Riebisch M , Mincu R I , Al-Rashid F , Totzeck M , Lind A , Janosi R A , Rassaf T , Kahlert P
Published: October 2019

Background

Outcomes of transfemoral transcatheter aortic valve implantation (TF-TAVI) with a self-expanding (SEP) and a balloon-expandable prosthesis (BEP) seem to be comparable, though head-to-head comparisons, especially in certain patient subsets, are sparse. In addition, patients with a reduced left-ventricular ejection fraction (rEF, ≤40%) appear to be at higher risk for an increased mortality after TF-TAVI than patients with a preserved left-ventricular ejection fraction (pEF). As it remains unclear, whether outcomes of patients with rEF differ between TF-TAVI using SEP and BEP, we sought to compare all-cause mortality of patients with rEF using a SEP or a BEP.

Methods

We retrospectively analyzed data of 679 single-center TF-TAVI patients, which were stratified by baseline ejection fraction (rEF versus pEF) and type of implanted prosthesis (SEP versus BEP). Patients were censored at death or completion of 1-year follow-up, whichever occurred first.

Results

Twenty-one percent of patients had rEF, and these patients had a higher 1-year mortality compared to patients with pEF (28% vs. 19%, p=0.007). SEP were implanted in 149 patients (49 patients with rEF), while BEP were implanted in 538 patients (92 patients with rEF). All-cause 1-year mortality was similar after SEP- and BEP-implantation (16% vs 19%, p=0.516) in patients with pEF. In patients with rEF, however, 1-year mortality was higher after SEP- than after BEP-implantation (43% vs. 21%, p=0.004, see figure). Patients with rEF had a higher incidence of new permanent pacemaker implantation (26.5% vs. 13%, p=0.046) and paravalvular leak ≥2 (21% vs. 10%, p=0.07) after SEP- than after BEP-implantation, but both factors could not explain the excess mortality after SEP-implantation in multivariate analysis.

Conclusion

Patients with rEF had a higher 30-day and 1-year mortality after TF-TAVI when a SEP instead of a BEP was used. Further studies are needed to confirm and explain this finding.
P6488Prognostic value of right ventricular systolic function by speckle tracking echocardiography beyond conventional echocardiography in significant tricuspid regurgitation
Authors: Hinojar Baydes R , Garcia Martin A , Gonzalez-Gomez A , Martin-Plaza M , Sanroman-Guerrero M , Pascual-Izco M , Alonso-Salinas G , Lorente A , Jimenez-Nacher J J , Zamorano J , Fernandez Golfin C
Published: October 2019

Background

Right ventricular (RV) systolic function is determinant in the evaluation of patients with significant tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is limited by the geometry of the RV. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function that can allow detection of subclinical RV dysfunction

Purpose

This study was aimed to evaluate the prognostic value of RV strain in stable patients with significant TR, in comparison with conventional parameters of RV systolic function.

Methods

Consecutive patients in stable clinical status with significant TR evaluated in the Heart Valve Clinic between 2015–2018 were included. RV systolic function was measured with conventional echocardiographic parameters (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE]), DTI S wave (`S) and with STE derived peak global and free wall longitudinal strain (GLS, FW-LS respectively) using the EPIQ system. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure

Results

A total of 70 patients were included (mean age was 74±8 years, 71% females). 5 patients were excluded due to poor acoustic window. According to ethyology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). Mean values of RV function parameters are shown in the table. During a median follow up of 18 months [IQR: 4–28], 37% of the patients reached the combined end point (n=15 developed right heart failure, n=17 underwent tricuspid valve surgery, and n=3 died). Patients with events showed impaired RV-GLS and FW-LS. Both parameters were predictive of the combined endpoint (table 1). Conventional parameters of RV systolic function were not associated with outcomes.

Mean ± SD Mean ± SD Mean ± SD HR (95% confidence interval) P value in Cox regression analysis in all patients in patients with events in patients without events TAPSE 20±5 20±7 21±5 0.97 (0.9–1.06) 0.56 DTI S wave 10.5±2 11±3 10±2 1.08 (0.87–1.35) 0.49 FAC 44±7 43±6 45±8 1.04 (0.97–1.1) 0.22 FW longitudinal strain (FW-LS) 18±5 −16±5* −20±5 0.91 (0.84–0.98) 0.02 Global longitudinal strain (GLS) 19±4 −16±4* −21±4 0.87 (0.81–0.95) 0.001

Conclusion

In patients with asymptomatic TR, RV strain values are superior to conventional parameters to detect RV dysfunction. Among different measurements of RV function, RV GLS and FW-LS were the only predictors of poor prognosis. These parameters may be included in the serial evaluation of these patients.
P6490Paradoxycal restricted motion in diastole is a frequent finding in mitral valve prolapse/dystrophy patients
Authors: Le Tourneau T , Cueff C , Piriou N , Capoulade R , Le Scouarnec S , Merot J , Schott J J
Published: October 2019

Background

Filamin-A mitral valve prolapse/dystrophy (FLNA-MVP) phenotype associates MVP and a paradoxical restricted motion in diastole.

Purpose

We aim to assess the association of mitral valve prolapse to restricted motion in diastole in MVP patients (restricted MVP).

Methods

We prospectively enrolled 475 MVP probands (64±13 years) and controls relatives. Patients underwent a clinical examination and a comprehensive echocardiographic analysis of mitral valve apparatus.

Results

Among 475 consecutive probands, 48 (10.1%, 95% CI 7.7–13.3) had both a MVP and a doming aspect in diastole. Patients with restricted MVP exhibited shorted chordae tendinaes, and a shorter distance between papillary muscle tip and mitral annulus. Compared with controls, mitral valve leaflets were lenghtened, thickened and mitral valve annulus was enlarged. The prevalence of polyvalvular disease and bicuspid aortic valve was not increased in restricted MVP patients compared with conventional MVP. Familial form of restricted MVP was identified even in the absence of Filamin-A mutation.

Conclusion

Restricted MVP is a quite frequent finding in MVP patients and is associated with unique features of the MV apparatus. Restricted MVP can be regarded as a third type of MVP beside myxomatous Barlow disease and fibro-elastic deficiency MVP.

Acknowledgement/Funding

PHRC I Mitral, Fédération Française de Cardiologie, Fondation Coeur et recherche
P6496Endovascular reconstruction from aortic valve to aortic arch by one-piece valved-fenestrated-bifurcated endografting in animal experiments
Authors: Jing Z P , Feng J X , Bao X H , Li T , Zhao Y , Li Y , Li Z J , Liu J , Wu M W , Zhao Z Q , Lu Q S , Bao J M , Feng R , Zhou J
Published: October 2019

Aims

The possibility of endovascular reconstruction of aortic valve, sinus of Valsalva, and ascending aorta by a minimal-invasive single endograft has not been proven in vivo. Combining our own long-term experiences from transcatheter aortic valve replacement (TAVR) and Thoracic Endovascular Repair (TEVAR) for ascending and arch dissection, we designed the special endo-graft: a novel one-piece valved-fenestrated-bifurcated endografting, and tried to endovascularly reconstruct the area from Left ventricular outflow tract to aortic arch in animal experiments.

Methods and results

For 20 healthy adult female pigs weighed between 62.3±2.2 kilograms, we did aortic compute tomography angiography (CTA) examinations and measured morphologic parameters of aortic root. Then we accordingly customized the valved-fenestrated-bifurcated endograft. The endograft was delivered through transapical access and endovascularly reconstructed the segment from aortic valve to proximal part of aortic arch. The overall technical success rate was 95% because of one case of delivery system failure. Instant transesophageal echography (TEE) and aortic CTA confirmed ideal position of the endograft, satisfactory function of aortic valve, and the patency of coronary arteries in all subjects. During follow-up, 12 subjects were sacrificed according to the plan and seven were followed up for 8.1±3.6 months. There was one unplanned death of cardiac infection (unplanned mortality: 5.3%). Follow-up re-examinations (aortic CTA, cardiac ultrasound, and electrocardiogram) found no adverse events. Among 12 sacrificed subjects, there was no evidence of fenestrations alignment lost and no myocardial ischemia according to the pathological analysis.

Conclusion

The novel one-piece valved-fenestrated-bifurcated endografting might be feasible for minimal-invasive reconstruction of aortic root in animal models, thus provided a prospect to simultaneously treat pathologies involving aortic valve and aortic root in endovascular way.
P6512Prognosis of patients with chronic coronary artery disease undergoing to percutaneous coronary intervention (5 years follow-up)
Authors: Shugushev Z , Maximkin D A , Chepurnoy A , Safonova O , Mambetov A , Faibushevich A , Baranovich V , Veretnik G , Sturov N
Published: October 2019

Aim

To evaluate the prognosis of patients with chronic ischemic heart disease, who underwent percutaneous coronary interventions (PCI) and were only on optimal medical therapy (OMT).

Methods

Measurement of the fractional flow reserve (FFR) was performed for 432 patients. According to the measurement results, all patients were randomized in 2 groups (1:2): Group I (n=168) – included patients, who had a FFR <0.8 and were followed by PCI; Group II (n=264) – included patients with FFR >0.8 - received OMT and were under monitoring for to 5 years. Inclusion criteria: stable angina II-III FK, post-MI, silent myocardial ischemia. Concomitant diseases: diabetes mellitus (19.2%), multifocal atherosclerosis (21%), hypertension (27%), post-MI (24%), PCI in previously (15%). According to angiography, 44% had a one-vessel disease, 35% had two-vessel diseases, and 21% had a three-vessel disease. Primary endpoints: MACE (death, MI, repeated interventions). Observation periods: 6, 12, 24, 36, 48, 60 months. Long-term results were evaluated by repeated coronary angiography and measurement of FFR.

Results

During 6 and 12 months there were not a single case of MACE in both groups. By the 18th month, 7% of cases conversion from the OMT to the PCI group on the basis of FFR measurements was recorded. By the 24th and 36th months in the OMT, PCI group was performed in 12 and 21% of patients, respectively. By the 48th and 60th month, the number of such patients was 24 and 31%, respectively. Among the total number of performed PCI in Group II, 20% of them were due to unstable angina. Thus, over the entire observation period, 149 patients from group II (56%) had PCI performed. The frequency of MACE in group I to 36 months was 2.4%, and in group II - 18%, respectively (p<0.001). By the end of the observation period, the frequency of MACE in groups I and II was 4.2 and 31%, respectively (p<0.001). Multifactor analysis showed that with SYNTAX score>28, multifocal atherosclerosis, diabetes mellitus, MACE was significantly more frequent and there was a need to perform PCI in the long-term period.

Conclusions

The prognosis of patients with chronic coronary artery disease undergoing percutaneous coronary intervention, performed using measurement of FFR, is significantly better than in patients who were only on optimal medical therapy.

Acknowledgement/Funding

Russian Academic Excellence Project 5-100