bluuebunny/crossref_metadata_2025 huggingface dataset:
Echocardiographic evaluation of patients with sickle cell disease. A study based on Etendar Cohort
Authors: d'Humieres T , Savale L , Inamo J , Damy T , Lionnet F , Loko G , Derumeaux G , Humbert M , Bartolucci P
Published: November 2020

Background

Echocardiography is the main non-invasive screening tool for pulmonary hypertension (PH) in Sickle Cell Disease (SCD), but relies mostly on the tricuspid regurgitation velocity (TRV) assessment, without distinction between pre and postcapillary patterns.

Purpose

Using Etendard Cohort data, the aim of this study was to refine echocardiographic assessment of PH in SCD patients.

Methods

The French Etendard Study is a prospective cohort initially designed to assess the prevalence of PH among 398 SCD participants. We analyzed echocardiography data of the 96 Etendard patients who underwent Right Heart Catheterization (RCH), because of a TRV≥2.5m/s, and compared them to invasive haemodynamic measurements. Based on RHC results, patients were classified as follows: Absence of pulmonary hypertension if mean pulmonary arterial pressure (mPAP) was <25mmHg. Precapillary PH if mPAP≥25mmHg and pulmonary-capillary wedge pressure (PCWP) ≤15mmHg. Postcapillary PH if mPAP≥25mmHg and PCWP >15mmHg.

Results

PH was found in 24/96 patients with 11 precapillary and 13 postcapillary. In addition to TRV, multivariate analysis identified indexed left atrial volume (LAVind) and lateral E' wave velocity (E'lat) as independent echocardiographic predictors of PH (OR=1.06 and 0.6 respectively, p<0.01). LAVind and E'lat showed good correlation with mPAP (R=0.51 and R=0.40 respectively and p<10–3 for both) and had good accuracy to predict PH with an optimal cut-off of 48ml/m2 for LAVind (AUC=0.78, Se=81% and Sp=75%) and 12cm/s for E'lat (AUC=0.8, Se=72% and Sp=79). Using the association of a TRV≥3m/s or a TRV [2.5; 2.9] m/s with LAVind>48ml/m2 and E'lat<12cm/s, we could predict PH with a PPV of 68% and NPV of 90%.

Moreover, comparing echocardiography data of pre and post-capillary PH patients, we observed that Pulmonary acceleration time (PAcT) was different in the two groups (104±22ms vs. 160±21ms, p<0.001) with an excellent accuracy for the differentiation of both phenotypes (AUC=0.95, optimal cut-off=115ms, Se=100% and Sp=78%). PAcT correlated with pulmonary vascular resistance (PVR) assessed by RHC (R=0.34, p=0.001) but not with mPAP (R=0.1, p=0.2) and a PAcT>115ms ruled out pre-capillary PH with a NPV of 97%.

Conclusion

Echocardiography can accurately estimates the probability of PH in SCD patients with an integrated approach using TRV, LAVind and E'lat. In addition, among patients with suspected PH, measuring PAcT as a PVR surrogate allows a good differentiation between pre and post-capillary phenotypes. We propose a new echocardiographic algorithm for the diagnosis of PH in SCD that could be a true assistance in referring patients for RHC.

TTE Algorithm for PH in SCD

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Funded by the French Ministry of Health and Assistance Publique–Hôpitaux de Paris
Diabetes mellitus and cardiovascular risk management in patients with rheumatoid arthritis in a large international audit
Authors: Semb A.N.N.E , Rollefstad S , Sexton J , Kitas G , Van Riel P , Crowson C , Graham I , Ikdahl E
Published: November 2020

Background

The cardiovascular disease (CVD) risk in patients with rheumatoid arthritis (RA) is comparable to that of patients with diabetes mellitus (DM). Although several studies have indicated high prevalence's of DM in RA patients, little is known about how this affects their CVD risk.

Objectives

To examine indications for, and use of antihypertensive treatment (a-HT) and lipid-lowering therapy (LLT) in RA patients with DM (RA-DM) and RA patients without DM (RAwoDM). Further, to compare the prevalence of various types of CVD across RA-DM and RAwoDM.

Methods

The cohort was derived from the SUrvey of cardiovascular disease Risk Factor in patients with Rheumatoid Arthritis (SURF-RA), which was performed in 53 centres/17 countries in 5 world regions (West and East Europe; North and Latin America; and Asia) from 2014 - 2019. Indication for a-HT was defined as: 1) systolic/diastolic blood pressure (BP) ≥140/90 mm Hg, 2) self-reported hypertension, and/or 3) current use of a-HT. Indication for LLT was defined according to ESC guidelines. CVD risk estimates (by SCORE) were multiplied by 1.5 according to EULAR recommendations. Target treatment targets for BP and lipids were defined according to ESC guidelines applicable at the time data were recorded.

Results

Presence of comorbid DM was available in 10 602 (73.1%) of the 14 503 RA patients included in SURF-RA, of whom 75 and 1262 patients reported DM type 1 and type 2, respectively (total 1337 patients, 12.6%). Although less often current smokers, RA-DM patients were more often previous smokers, male sex and had higher body mass index compared to RAwoDM (p<0.0001 for all). a-HT (84.7% vs 62.3%) and LLT (100% vs 47.2%) were more frequently indicated in RA-DM than in RAwoDM patients (p<0.0001 for both). RA-DM were more likely than RAwoDM to receive a-HT on indication (60.4% vs 57.6%, p<0.0001), while the difference in LLT use on indication was not significantly different (45.7% vs 42.5%, p=0.06). Moreover, RA-DM compared to RAwoDM patients had more often reached treatment goals when on a-HT (60.7% vs 54.1%, p<0.0001) and LLT (62.8% vs 48.9%, p<0.0001). Finally, the risk of all recorded established CVD (coronary heart disease, stroke, peripheral artery disease and atrial fibrillation) was increased by a factor of 2 to 3 in RA-DM compared to RAwoDM (Figure).

Conclusion

The effect of RA and comorbid DM on CVD risk appears to be additive. While CVD preventive medications are more often indicated in RA-DM than in RAwoDM patients, they are also more likely to receive such therapy and to reach CVD preventive treatment goals. The latter finding may be due to more developed CVD preventive care in DM compared to RA patients. Improved CVD preventive systems for patients with RA are warranted.

CVD in RA patients with and without DM

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Lilly
Is female gender associated with worse outcomes after percutaneous coronary intervention of left main coronary artery?
Authors: Skorupski W.J , Grygier M , Grajek S , Pyda M , Mitkowski P , Araszkiewicz A , Skorupski W.A , Siniawski A , Jankiewicz S , Lesiak M , Kaluzna-Oleksy M
Published: November 2020

Introduction

Left main coronary artery (LM) disease is a life-threatening condition, so the invasive treatment is crucial for the survival of the patients. There is still controversy regarding whether female sex is associated with worse outcomes after percutaneous coronary intervention (PCI) of LM.

Purpose

Our aim was to examine gender-based differences in patients after LM PCI.

Methods

Consecutive 459 patients (mean age: 68.4±9.4 years) in whom PCI of LM was performed (between January 2015 and June 2018) were included in the study. The clinical and angiographic data of these patients including short and long-term outcomes has been analyzed.

Results

The whole group consisted of 112 (24.4%) women and 347 (75.6%) men. Compared with men, women were older (69.9±8.9 vs 67.9±9.5; p=0.04), had higher prevalence rates of diabetes (43.8% vs 33.4%; p=0.048) and hypertension (92% vs 79.1%; p<0.01). Renal failure (42% vs 32.3%; p=0.061) was found insignificantly more often in women, frequency of other comorbidities did not differ statistically. Women were more often disqualified from bypass surgery (19.6% vs 11.8%; p=0.036) and more often required complex stenting techniques (29.2% vs 18.7%; p=0.028). SYNTAX Score and Euroscore II did not differ statistically between the genders. All periprocedural complications (8.9% vs 8.4%; p=0.85) and the frequency of periprocedural myocardial infarction (6.3% vs 4%; p=0.330) did not differ among the groups. We observed higher all-cause mortality in men group (19.1% vs 24.3%; p=0.041) at a median follow-up of 808 days (range 367 to 1616 days).

Conclusion

In our real-life cohort of patients, complex LM procedures and comorbidities were more frequent in women. There was no significant difference in short-term results between two genders, although in our real-life study we observed higher long-term all-cause mortality in men. Our results suggest that female gender in LM PCI is not a predictor of adverse outcomes. Further studies are required to determine the optimal revascularization modality in women.

Long-term follow-up

Funding Acknowledgement

Type of funding source: None
Sex differences in the rates of incident and recurrent coronary heart disease and all-cause mortality
Authors: Peters S , Colantonio L , Chen L , Bittner V , Farkouh M , Dluzniewski P , Poudel B , Muntner P , Woodward M
Published: November 2020

Background

Women have lower age-specific rates of incident coronary heart disease (CHD) than men. However, it remains unclear whether women maintain the same advantage once they have had a cardiac event.

Purpose

To assess whether sex differences in the rates of cardiac events and all-cause mortality among individuals without a history of CHD persist following a myocardial infarction (MI).

Methods

We identified 171,897 women and 167,993 men <65 years of age with commercial health insurance and ≥66 years of age with government health insurance through Medicare who had a MI hospitalization between 2015 and 2016 in the US. These beneficiaries were matched to 687,588 women and 671,972 men without a history of CHD based on age and calendar year. Beneficiaries were followed until December 2017 for the occurrence of MI, CHD, heart failure, and all-cause mortality (Medicare only).

Results

The age-standardized rates of MI per 1,000 person-years were 4.5 in women and 5.7 in men without a history of CHD (multivariable-adjusted hazard ratio [HR] [95% confidence interval] of female sex: 0.64 [0.62; 0.67]) and 60.2 in women and 59.8 in men with a history of MI (HR: 0.94 [0.92, 0.96]) (Figure 1). Rates of CHD events in women vs. men were 6.3 vs. 10.7 among those without CHD (HR: 0.53 [0.51, 0.54]) and 84.5 vs. 99.3 among those with MI (HR: 0.87 [0.85, 0.89]). Heart failure hospitalization rates in women vs. men were 9.3 vs. 6.6 for those without CHD (HR: 0.93 [0.90, 0.96]) and 114.9 vs. 97.9 among those with MI (HR: 1.02 [1.00, 1.04]). All-cause mortality rates in women vs. men were 63.7 vs. 59.0 among those without CHD (HR: 0.72 [0.71; 0.73]) and 311.6 vs. 284.5 among those with a MI (HR: 0.90 [0.89, 0.92]).

Conclusion

The women advantage against MI, CHD, heart failure and all-cause mortality is considerably attenuated following a MI, suggesting that a prior MI puts women at almost the same high-risk of subsequent events as men.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This work was funded by an industry/academic collaboration between Amgen Inc. and University of Alabama at Birmingham.
Gender difference in long-term clinical outcomes after percutaneous coronary intervention
Authors: Choi J.H , Lee S.H , Choi J.M , Jang Y.J , Choi K.H , Lee J.M , Park T.K , Yang J.H , Song Y.B , Hahn J.Y , Choi S.H , Gwon H.C , Lee S.H
Published: November 2020

Background

The comparative gender-specific outcome after PCI in real-world practice is limited. We investigated the gender difference in the 5-year outcome after percutaneous coronary intervention (PCI).

Methods

A retrospective study. nationwide PCI registry. All PCI performed in Korea in year 2011 (N=48,783). Outcomes adjusted with age and propensity for clinical characteristics were compared. Primary outcome was 5-year cumulative incidence of major adverse clinical event (MACE) consisting of all-cause death, revascularization, shock, or stroke.

Results

In unadjusted analysis, women (N=15,710) were older (69.7±9.7 versus 62.0±11.1 year) and had higher frequency of comorbidities including hypertension, hyperlipidemia, and diabetes compared to men (N=33,073) (p<0.001, all). Women had higher 5-year cumulative incidence of MACE than men (41.9% versus 37.2%; hazard ratio [HR] 1.16, 95% confidential interval [CI] 1.12–1.19; p<0.001). In propensity score-matched 14,462 pairs, women had lower 5-year mortality risk (40.7% versus 46.0%, HR 0.85, 95% CI 0.82–0.88, p<0.001). The lower 5-year MACE risk in women was consistent in subgroup analyses of age, risk factors, and clinical diagnosis including angina or acute myocardial infarction (p<0.05, all). The risk of all-cause death, revascularization, and shock were also lower in women than men (p<0.05, all) but the risk of stroke was not different between women and men.

Conclusions

The apparent worse outcome in women can be explained by older age and more common comorbidities in women. After adjusting these disadvantages, women had better outcome after PCI than men. Our result suggests presence of the reversal paradox in the gender-specific outcome following PCI.

Women vs men, 5 year outcome

Funding Acknowledgement

Type of funding source: None
Sex-differences in outcomes after PCI or CABG for left main disease: from the DELTA registries
Authors: Moroni F , Beneduce A , Giustino G , Breite I , Park S.J , Daemen J , Morice M.C , Nakamura S , Meliga E , Cerrato E , Makkar R , Valgimigli M , Mehran R , Colombo A , Chieffo A
Published: November 2020

Background

Women have worse outcomes than men after PCI, with some studies suggesting a lower mortality of CABG vs PCI in females.

Purpose

To assess the outcomes of CABG and PCI according to sex in a large registry population of patients with unprotected left main coronary artery (ULMCA) disease.

Methods

The DELTA and DELTA 2 registries are two multicentric, prospective registries evaluating the outcomes of subjects undergoing coronary revascularization for ULMCA disease.

Results

Total population was 6253 patients, 27% women. Table 1 shows baseline clinical characteristics. Median follow up was of 880 days. Women undergoing CABG had lower incidence of death, myocardial infarction (MI) or cerebrovascular accidentc (CVA) (HR 0.53, 95% CI 0.35–0.79) and a lower risk of death (HR 0.40, 95% CI 0.24–0.67). No significant differences were observed in men (Figure 1A). SIgnificant interaction was observed between sex and revascularization strategy for both outcomes (p<0.01-Figure 1B). CABG was associated with lower risk of target-vessel and target-lesion revascularization consistently inwomen and men (pint=0.49 and pint=0.89, respectively–Figure 1B).

Conclusions

In women undergoing coronary revascularization for ULMCA disease, CABG is associated to lower risk of death, MI or CVA. Further dedicated studies are needed to determine the optimal revascularization strategy in women with ULMCA disease.

Figure 1

Funding Acknowledgement

Type of funding source: None
Comparison between different diagnostic scores for the diagnosis of familial hypercholesterolemia: assessment of their diagnostic accuracy in comparison with genetic testing
Authors: Boccatonda A , Rossi I , D'Ardes D , Cocomello N , Perla F.M , Bucciarelli B , Di Rocco G , Del Ben M , Angelico F , Guagnano M.T , Cipollone F , Bucci M
Published: November 2020

Background

The Dutch Lipid Clinic Network Score (DLCN) is a useful score to guide the physician to the diagnosis of familial hypercholesterolemia (FH). However, some concerns have been pointed out about its diagnostic accuracy in pediatric population; so, other scores such as Simon Broome (SB) and US MedPed Program have been tested and currently used.

Aim

To test the different diagnostic and predictive accuracy between those three scores (DLCN, SM and MedPed) in relation to positivity of genetic test.

Methods

We enrolled 25 pediatric patients aged <18 yo referred to our Chieti and Rome lipid clinics for the clinical suspicion of FH. We performed the genetic analysis for searching pathogenetic mutations for FH (NGS by Lipid in Code, LIPIGEN study). Differently from the others, DLCN provides a numerical data as a diagnostic score; thus, to uniform the three scores, we chose to define subjects with a DLCN score ≥6 as likely FH, while subjects with a lower value were defined as unlikely FH. Furthermore, we calculated the SB and the MedPed score, as previously demonstrated, defining the subjects as likely or unlikely FH. Therefore, we analyzed the diagnostic accuracy of those scores in relation to FH mutation data (positive or negative).

Results

We recruited 25 patients, 13 males (52%), mean age of 11.8 years. Sixteen patients (64%) resulted positive for the genetic mutation The DLCN showed a sensitivity of 43%, specificity of 66%, a positive predictive value (PPV) of 0.7 and a negative predictive value (NPV) of 0.4. SB showed a sensitivity of 68%, specificity of 55%, a PPV of 0.73 and NPV of 0.5. The MedPed score showed a sensitivity of 68%, specificity of 44%, a PPV of 0.68 and NPV of 0.44. Furthermore, we elaborated a ROC curve of low-density lipoprotein cholesterol (LDL-C) values with respect to the positivity of the FH genetic test: the value that showed the best diagnostic accuracy was 190 mg / dL (sensitivity 68.8% and specificity 75%), while the value of 116.5 mg/dL demonstrated a sensitivity of 100% but with a specificity of 11%.

Conclusions

Our work demonstrates that none of the three scores tested has an optimal diagnostic accuracy with respect to the diagnosis of FH in the pediatric population. By comparison, SB demonstrates the best sensitivity and the best specificity. In addition, the LDL-C value of 190 mg / dL provides the best diagnostic accuracy against the diagnosis of FH in the pediatric population. Further data and studies will be needed to improve the diagnostic performance of these scores, in order to refer pediatric patients to the genetic test, for an early confirmation in order to refer pediatric patients to the genetic test, for an early FH diagnosis confirmation.

Funding Acknowledgement

Type of funding source: None
Coronary artery diseases after right ventricular outflow tract reconstruction surgery
Authors: Kwon H , Bae E.J , Kim G.B , Lee S.Y , Song M.K , Lee J.R , Kim W.H , Kwak J.G , Cho S.K
Published: November 2020

Background

The occurrence of coronary artery disease (CAD) is unknown to date in patients who have undergone the right ventricular outflow tract (RVOT) reconstruction surgery for congenital heart disease using a bioprosthetic valve or conduit.

Purpose

We present the incidence and outcomes of CAD in patients who underwent RVOT reconstruction surgery in a single tertiary center.

Method

From April 1986 to February 2019, 544 patients underwent Rastelli operation or pulmonary valve replacement for conotruncal anomalies at the Seoul National University Children's Hospital in Korea. The patient's medical records and imaging findings were analyzed retrospectively.

Results

Significant coronary stenosis or occlusion were observed in 19 patients (3.5%) after RVOT reconstruction surgery. Their underlying diseases were pulmonary atresia in 8, tetralogy of Fallot in 3, double outlet right ventricle with pulmonary stenosis in 3, truncus arteriosus in 2, congenitally corrective transposition of great artery in 2, and congenital aortic stenosis in 1. Mechanism of CAD was compression of coronary artery by artificial conduit or valve in 10, intraoperative coronary injury in 7, and intramural course of coronary artery in 2 patients. The median number of RVOT reconstruction surgery before the diagnosis of CAD was 2 times (interquartile range: 2–3 times). The median age at diagnosis of CAD was 15 years (interquartile range: 9.5 - 25 years). The median time to detection of the CAD from the last RVOT reconstruction surgery was 9 years (interquartile range: 3.5–12.5 years). Involved coronary artery was right coronary artery (RCA) in 10, left anterior descending coronary artery (LAD) in 7, and left main coronary artery in 2 patients. Seven (36.8%) patients had underlying congenital coronary anomalies, such as single coronary artery, intramural course of the coronary artery, and anomalous origin of the coronary artery from an abnormal sinus. One patient died due to brain injury on extracorporeal membrane oxygenator after intraoperative coronary injury. Two patients with intramural course of coronary artery and one patient with high take-off of RCA which was compressed by adjacent calcified conduit underwent surgical repair of the CAD. One patient with recurrent ventricular tachycardia needed an implantable cardioverter-defibrillator. Nine patients are on medication for heart failure. Three patients with total occlusion of RCA or LAD showed well-developed collaterals from another normal coronary artery.

Conclusion

CAD after RVOT reconstruction surgery are not common but can be fatal. Because the clinical significance of CAD and long-term prognosis are not known yet, we need to closely track the patient after RVOT reconstruction surgery. Indications for the management of the CAD should be prepared to prevent sudden cardiac death, arrhythmia, and ventricular dysfunction in these patients.

Funding Acknowledgement

Type of funding source: None
Influence of Nuss surgical operation for pectus excavatum on electrocardiogram abnormality considering anatomical severity as indicated by Haller index acquired by computed tomography and age
Authors: Funabashi N , Kobayashi Y
Published: November 2020

Background

Pectus excavatum (PEX) is a depression of the sternum relative to costal cartilages and sometimes depress heart anatomically which cause abnormal ECG change. Nuss operation is minimal invasive technique for PEX repair.

Purpose

We speculated this Nuss operation would improve these ECG abnormalities. We also considered the Haller index (HI) and age to these influences. HI is an anatomical severity indicator of PEX calculated from CT.

Methods

A total of 17 patients (14 male, 12±6 years), who underwent Nuss operation for PEX, underwent unenhanced CT and ECG before and after the Nuss operation.

Results

All Nuss operation was successfully performed. On CT, HI was significantly improved from 5.62±2.29 to 3.29±0.65 (P=0.0002). A P wave with a negative portion >1 mm deep and >40 ms duration in V1 lead, incomplete right bundle branch block (RBBB), sinus arrhythmia, and right-axis deviation of a QRS wave were diagnosed in 15, 6, 12, and 5 patients, respectively. Comparing before with after Nuss operation, there were no significant differences of the degree of electrical axis of QRS waves, the degree of electrical axis of P waves, or the PQ interval, respectively (All P=NS). Absolute values of voltage of a negative portion of the P wave in V1 lead was significantly improved after the operation (1.55±1.25 vs 0.76±0.91mm, P<0.001). Among 12 patients with sinus arrhythmia, only one patient improved to that without. Among 6 patients with incomplete RBBB, only one patient improved to that without. The correlation coefficient (CC) between “values of the improvement of negative portion of the P wave in V1 lead after the operation” and “HI before operation” was 0.305 (P<0.05). The CC between “absolute values of the improvement of negative portion of the P wave in V1 lead after the operation” and “age at the operation” was −0.216 (P<0.05).

Conclusion

In patients with PEX, successful Nuss operation could achieve improvement of negative portion of the P wave in V1 lead positively correlated with “HI before operation” and negatively correlated with “age”. Nuss procedure would be more effective to abnormal ECG change, when anatomical severity is severer or age is younger.

Improvement of negative P wave

Funding Acknowledgement

Type of funding source: None
Direct comparison of the accuracy of preoperative high-sensitivity cardiac troponin T to predict mortality, acute heart failure and perioperative myocardial infarction/injury after non-cardiac surgery
Authors: Gualandro D , Puelacher C , Liffert M , Arslani K , Meister R , Glarner N , Luratibuse G , Cardozo F.A , Bolliger D , Steiner L , Caramelli B , Osswald S , Mueller C
Published: November 2020

Background

Death, acute heart failure (AHF) and perioperative myocardial infarction/injury (PMI) are the most relevant cardiovascular complications following non-cardiac surgery. Unfortunately, the incidence of these complications are higher than expected. Currently available tools to predict these complications have only modest accuracy.

Purpose

To determine the accuracy of preoperative high-sensitivity cardiac troponin T (hs-cTnT) concentrations for prediction of mortality, AHF and PMI after non-cardiac surgery.

Methods

We prospectively included 4,709 patients at high cardiovascular risk undergoing non-cardiac surgery. Hs-cTnT concentrations were measured before surgery and, daily after surgery, for two days. PMI was defined as an absolute increase of 14ng/L (the 99th percentile of the assay used) from hs-cTnT baseline values. The primary endpoint was the diagnostic accuracy of preoperative hs-cTnT concentration to predict death, AHF and PMI within 30 days, as quantified by the area under the receiving-operating curve (AUC). Multivariate logistic regression analysis was performed to test the association between preoperative hs-cTnT and each endpoint.

Results

All-cause mortality occurred in 133 (3%), AHF in 84 (2%) and PMI in 742 (16%) patients. Preoperative hs-cTnT concentrations had good accuracy for prediction of death, AHF and PMI (AUC = 0.75 [95% CI, 0.71–0.79], 0.72 [95% CI, 0.67–0.77] and 0.73 [95% CI, 0.71–0.75], respectively). After adjusting for confounders, hs-cTnT remained an independent predictor for death with an adjusted odds ratio (aOR) of 2.1 (95% CI, 1.7–2.7, P<0.001) and for PMI (aOR 2.2, 95% CI, 1.9–2.4, P<0.001), but not for AHF (aOR 1.0, 95% CI, 0.7–1.4, P=0.99). An hs-cTnT concentration below 5ng/L was found in 526 (11%) patients, and this cut-off yielded a negative predictive value of 99.6% for the occurrence of death, 99.2% for AHF and 95.6% for PMI.

Conclusion

The preoperative hs-cTnT concentration has a good accuracy to predict mortality, AHF and PMI after non-cardiac surgery, but is an independent predictor only for mortality and PMI. A cut-off value of 5ng/L identifies a subgroup of patients at low risk for these complications.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Foundation, Swiss Herat Foundation
Differential effect of anticoagulation therapy in patients older versus younger than 80 years with atrial fibrillation and severe chronic kidney disease
Authors: Fortuny Frau E , Raposeiras-Roubin S , Andreu-Cayuelas J.M , Garcia-Egido A , Ortiz-Cortes C , Camacho-Freire S.J , Alonso P , Jorge-Perez P , Lopez-Pais J , Bravo-Marques R , Palacios-Rubio J , Benezet-Mazuecos J , Cosin-Sales J
Published: November 2020

Introduction

In non-valvular atrial fibrillation (NVAF) patients, advanced age and chronic kidney disease (CKD) raise the thrombotic and bleeding rates, making the decision of antithrombotic therapy a challenge. Therefore, we conducted an analysis to explore the efficacy and safety of anticoagulation therapy in this population (AF patients ≥80 years) in comparison with younger AF patients (<80 years).

Methods

For these results we have analyzed data from FIBRA, a multicentric Spanish retrospective registry on patients with CKD-EPI <30 ml/min/1.73 m2 and newly diagnosed NVAF. For death, multivariable Cox regression analysis was developed. For embolic and bleeding events, competing-risks regression based on Fine and Gray's proportional subhazards model was performed, being death the competing event

Results

We analyzed 405 patients with CKD-EPI <30 ml/min/1.73 m2. 232 were ≥80 years-old (57.3%). Median of CHA2DS2-VASC and HASBLED scores were 5 and 3 in patients ≥80 years, respectively, and 3 and 2 in patients <80 years, respectively. The prescription of antithrombotic therapies in elderly versus younger patients is shown in Figure 1. During a follow-up of 4.6±2.5 years, 205 died (50.6%), 34 had embolic events (8.4%) and 85 had bleeding outcomes (21.0%). After multivariate analysis, no benefit of anticoagulation therapy was found for mortality in both, older and younger patients. In patients ≥80, anticoagulation was associated with higher rates of bleeding events without a decrease in embolic outcomes.

Conclusion

In our registry, anticoagulation has not shown benefit in NVAF patients ≥80 years with glomerular filtrate rate <30 ml/min/1.73 m2, increasing the risk of bleeding events without reducing embolic outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer alliance unconditional grant
Long-term outcomes after transcatheter aortic valve implantation. An analysis of 5-year survival and beyond
Authors: Stathogiannis K , Drakopoulou M , Oikonomou G , Soulaidopoulos S , Toskas P , Xanthopoulou M , Synetos A , Latsios G , Kosmas E , Voudris V , Tousoulis D , Toutouzas K
Published: November 2020

Background

Transcatheter aortic valve implantation (TAVI) has seen an unprecedented rise in the past decade and has become the gold-standard therapy for inoperable, high- and intermediate-risk patients with aortic valve stenosis.

Purpose

To investigate the long-term clinical outcomes (5-year survival and beyond) of patients undergoing TAVI.

Methods

Consecutive patients who underwent TAVI with a self-expanding valve between 2012 - 2015 were included in the study. Patients with bicuspid valves and valve-in-valve procedures were excluded. Clinical follow-up was performed at specified time intervals (30-day post TAVI and yearly thereafter). The primary endpoint of this study was to evaluate survival rates in the long-term (≥5 years). Secondary endpoints were echocardiographic findings and clinical status at 5 years. All endpoints were considered as per the VARC-2 criteria and the latest consensus documents.

Results

In total, 267 patients were included in the study. Complete follow-up was complete in 189 (70%) patients. The mean age at implantation was 80.71±6.81 years, 129 (48%) were female, mean logistic EuroSCORE was 24.28±8.64% and 73% of patients were at NYHA Class III. The median follow-up was 4.0±1.5 years.

Before the procedure, ejection fraction (EF) was 49.92±9.37%, mean gradient was 48.83±14.68mmHg, pulmonary artery systolic pressure (PASP) was 44.31±12.72mmHg and aortic valve area was 0.98±5.02cm2.

All patients received the self-expanding valve (mean valve size was 27.60±2.12mm), with the majority of them undergoing transfemoral TAVI (71%). Predilation was performed in 77% of the population and post TAVI dilation was performed in 20%.

Compared to pre TAVI values, EF was higher at 50.66±9.37% (p=0.041), mean gradient was lower at 9.41±4.65mmHg (p<0.001), PASP was lower at 41.55±9.93mmHg (p=0.005) and aortic valve area was higher at 1.69±0.81cm2 (p<0.001) post TAVI.

At the end of the fifth year, 160 (60%) patients were alive. Mean survival post TAVI was 32 months (median: 32.2 months, range: 0–91.2 months) and the majority of deaths were non-cardiac in nature (78%). Also, 43% patients of patients were at NYHA Class I, 50% were at NYHA Class II and 7% were at NYHA Class III. At multivariate analysis, sole independent predictor of death at 5 years was baseline PASP levels (OR 1.027, 95% CI: 1–1.054, p=0.049).

Conclusion

Transcatheter aortic valve implantation offers a viable solution for aortic stenosis patients and long-term results beyond 5 years are reassuring. Further studies are necessary in order to shed a light for very long-term outcomes.

Funding Acknowledgement

Type of funding source: None
Early revascularization in elderly with nstemi
Authors: Gonzalez Ferrero T , Alvarez Alvarez B.A.A , Cacho Antonio C.C.A , Perez Dominguez M.P.D , Abou Jokh C.A.J.C , Rigueiro Veloso P.R.V , Agra Bermejo R.A.B , Garcia Acuna J.M.G.A , Gonzalez Juanatey J.R.G.J
Published: November 2020

Objective

This study sought to analyse the association of early coronary intervention with poor outcomes in patients ≥75 years with NSTEMI.

Methods

This retrospective observational study included 7811 NSTEMI patients between the years 2005 and 2017; 2451 were older than 75 years old. We compared baseline characteristics according to GRACE risk score.

Results

We found that 1486 patients (60.6%) underwent early invasive coronary intervention. The long-term all-cause mortality, cardiovascular mortality and MACE differed significantly according to early coronary intervention (HR 0.67, 95% CI: 0.59–0.76; HR 0.64, 95% CI: 0.54–0.74; and HR 0.70, 95% CI: 0.63–0.78, respectively).

Conclusion

In elderly high-risk NSTEMI patients, early revascularization was associated with reduced all-cause and cardiovascular mortality and MACE.

Funding Acknowledgement

Type of funding source: None
Spontaneous coronary artery dissection in the elderly: clinical features, angiographic findings, management and outcomes
Authors: Diez Villanueva P , Garcia-Guimaraes M , Vera A , Moreu J , Ojeda S , Nogales J.M , Salamanca J , Veiga G , Masotti M , Camacho-Freire S.J , Jimenez-Valero S , Jimenez-Kockar M , Lozano I , Bastante T , Alfonso F
Published: November 2020

Background

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Clinical features, angiographic findings, management and outcomes of SCAD in elderly patients remain unknown.

Methods

The Spanish multicenter prospective SCAD registry included 318 consecutive patients with SCAD diagnosis. Patients were classified according to age in two groups: <65 and ≥65 years old.

Results

A total of 55 patients (17%) were 65 or older (Table). Elderly patients had more often hypertension (29% vs 76%, p<0.01) and dyslipidemia (30% vs 56%, p<0.01), and less smoking history (51% vs 7%, p<0.01). Previous history of coronary artery disease was also more frequent in older patients (4% vs 11%, p=0.044). Interestingly, an identifiable trigger was more often found among patients under 65. Coronary artery tortuosity (1±0.99 vs 1.4±1, p=0.027) and coronary artery ectasia (9% vs 24%, p<0.01) were both more frequent in elderly patients, who were more often managed conservatively (75% vs 89%, p=0.025). A trend toward a higher mortality rate was found among patients ≥65, with no differences in terms of in hospital stay, new acute myocardial infarction, unplanned coronariography or heart failure.

Conclusions

Elderly patients with SCAD show different clinical and angiographic characteristics and they receive distinct management. Short-term outcomes do not significantly differ from those seen in younger patients.

Funding Acknowledgement

Type of funding source: None
Clinical outcomes of chemotherapy-induced subclinical left ventricular systolic dysfunction among breast cancer patients detected using echocardiographic global longitudinal strain
Authors: Manaloto J.G.G , Cruz-Tan M.K , Tiongco R.H , Jimenez R.M , Cornelio G.H
Published: November 2020

Background

Echocardiographic global longitudinal strain (GLS) detects early subclinical left ventricular (LV) systolic dysfunction, before the occurrence of a decreased LV ejection fraction. However, our local data is lacking to determine its impact to clinical outcomes.

Purpose

The study aimed to determine the clinical outcomes of breast cancer patients who developed subclinical LV systolic dysfunction as determined by an abnormal GLS post-chemotherapy.

Methods

This retrospective cohort study included 99 breast cancer patients who underwent anthracycline and/or HER-2 receptor inhibitor chemotherapy from January 1, 2016 to December 31, 2018 in a single tertiary hospital.

Clinical outcomes of all-cause mortality and overt heart failure were compared between those with normal and abnormal GLS post-chemotherapy.

Results

The prevalence of subclinical LV systolic dysfunction was 18%, wherein 28% of them had subsequent overt heart failure, and 33% expired. Abnormal GLS occurred at a mean 3.5 months (range 1–8 months) after initiation of chemotherapy and at 8 months (range 6–10 months) after the entire chemotherapy sessions. Development into heart failure was observed at a mean of 6.7 months (range 4–12 months) after occurrence of abnormal GLS.

Hypertension and age >56 years were determined to be risk factors. Beta-blockers, ACE inhibitors and statins seemed to be non-protective in our cohort. Abnormalities in GLS were observed at a mean dose of 260 mg/m2 of epirubicin, lower than the dose described as high risk in the literature (600 mg/m2 for epirubicin). In trastuzumab, abnormal GLS occurred as early as 1 month after initiation.

LVEF had no significant change within 2 months (p=0.56), but was significantly lower within 12 months post-chemotherapy (p=0.005). All-cause mortality was 3-fold higher (RR=3.00; p=0.02), and the risk to develop heart failure was 4 times higher (RR=4.74; p=0.008) in those with abnormal GLS.

Conclusion

The development of abnormal GLS post-chemotherapy was associated with subsequent development of overt heart failure and increased all-cause mortality. Abnormal GLS occurred at lower doses of epirubicin and as early as 1 month after initiating trastuzumab. We recommend echo surveillance with GLS monitoring beginning >250 mg/m2 with anthracycline (and after 1–2 months of Trastuzumab), and to repeat at 1–2 months and 9–12 months post-chemotherapy.

Funding Acknowledgement

Type of funding source: None
Different risk of atrial fibrillation according to the type of cancer: a nationwide population-based study
Authors: Yun J.P , Choi E.K , Han K.D , Lee S.R , Lim J.H , Ahn H.J , Lee E.J , Cha M.J , Oh S.I
Published: November 2020

Introduction

Patients with malignancies are known to have an increased risk of atrial fibrillation (AF). However, there is a paucity of information regarding the cancer type and the risk of AF. We aimed to evaluate the risk of AF according to the type of cancer.

Methods

We enrolled 816,811 patients who were diagnosed with cancer from the Korean National Health Insurance Service database between 2009 and 2014. Age and sex-matched non-cancer control subjects (1:2, n=1,633,663) were selected and compared with patients with malignancy. Newly diagnosed nonvalvular AF was identified using the claims data. Besides, we performed a sensitivity analysis using lag periods from cancer diagnosis to AF for more than 1 year and more than 5 year.

Results

During a mean follow up of 4.7 years, AF was newly diagnosed in 25,356 patients with cancer (6.6 per 1000 person-years) whereas 31,801 patients in the control group (3.6 per 1000 person-years). In multivariate Cox regression analysis, cancer was an independent risk factor for incident AF (HR 1.97; 95% CI 1.94–2.00).

Hematologic malignancies show higher correlation with incident AF (multiple myeloma, the hazard ratio (HR) 4.57; 95% confidence interval (CI) 4.08–5.12; leukemia, HR 4.15; 95% CI 3.75–4.59).

Malignancies of the nervous system, esophagus, lung, and pancreatic cancer show higher risks of AF more than 3 times than control, whereas prostate cancer shows the lowest association with AF risk (HR 1.36; 95% CI 1.29–1.44).

In subgroup analysis, the effect of cancer on AF development was more prominent in patients with younger age (<65 years) and fewer comorbidities (hypertension, diabetes mellitus, chronic kidney disease, dyslipidemia, and obesity).

In sensitivity analysis using lag periods, the strength of risks of AF decline with time from cancer diagnosis but remain significant (“>1yr” HR 1.77; 95% CI 1.74–1.81; “>5yrs” HR 1.12; 95% CI 1.07–1.16). However, AF risk was more diverse according to the types of cancers in patients surviving above five years. Multiple myeloma, leukemia, lymphoma, ovarian, liver, and lung cancer show higher risks of AF than control while other types of cancer show no significant association with AF incidence after five years from a cancer diagnosis.

Conclusion

Although patients with cancer showed a higher risk of AF, but the impact on AF development was diverse among cancer types. Hematologic malignancies showed the highest risk of AF, and the risk was maintained up to 5 year after diagnosis of cancer. Therefore it would be reasonable to screen AF especially in those malignancies with high-risk for AF.

Different AF risk in cancer patients

Funding Acknowledgement

Type of funding source: None
Association between global longitudinal strain and cardiopulmonary fitness in patients with breast cancer
Authors: Bonsignore A , Amir E , Marwick T.H , Thampinathan B , Brezden-Masley C , Yared K , Thevakumaran Y , Wintersperger B.J , Thavendiranathan P
Published: November 2020

Background

Anthracycline and trastuzumab therapies improve survival in the cancer population, but are limited by treatment induced cardiotoxicity. Echocardiography derived global longitudinal strain (GLS) permits more sensitive detection of cardiotoxicity than left ventricular ejection fraction (LVEF). However, the clinical implication of a reduction in GLS in cancer survivors is unknown.

Purpose

To define the association between GLS and cardiopulmonary fitness in women with breast cancer immediately post cancer therapy.

Methods

Women with HER2+ early stage breast cancer (EBC, Stage I-III) receiving anthracyclines followed by trastuzumab were recruited prospectively and followed between January 2015 and December 2019 with echocardiography during therapy. Left ventricular peak systolic GLS (GE EchoPAC, 3 apical views) and 3D-LVEF were measured prior to anthracyclines, and after completion of trastuzumab at 12 months. Exercise capacity was measured using a supine bicycle cardiopulmonary exercise test. Results of exercise testing at end of treatment were compared between patients with and without reduced GLS (absolute value ≤18% vs >18%) at the end of therapy.

Results

Amongst 128 women, 43 (34%) had a GLS ≤18% at the end of trastuzumab therapy. Baseline patient demographics including tumor characteristics and cardiac risk factors were similar between those with normal and abnormal GLS. During treatment 33 (25.8%) participants developed cardiotoxicity defined by the CREC criteria based on 3D-LVEF. Significant baseline (pre-cancer treatment) differences were found between groups for GLS (GLS 21.2±1.8 vs 19.6±2.2, p<0.001) and 3D LVEF (61.8±3.5 vs 60.2±3.7%, p=0.02) for those with GLS >18% and GLS ≤18% respectively at the completion of trastuzumab. Compared to those with GLS >18% those with GLS ≤18% had lower VO2peak (17.4±3.8 mL.kg-1.min-1 versus 20.2±4.9 mL.kg-1.min-1, p=0.001) despite similar effort (respiratory exchange ratio 1.14 versus 1.12, p=0.30). GLS following therapy (β coefficient: −0.596, SE 0.255; p=0.02) and age (β coefficient: −0.115, SE 0.057; p=0.047) were the only parameters associated with VO2peak after adjusting for relevant confounding factors.

Conclusion

A significant proportion of women receiving cancer therapy for HER2+ EBC had reduced GLS at end of treatment. Abnormal GLS at the end of cancer treatment was associated with lower VO2peak. Reduced VO2peak is strongly associated with late-occurring cardiovascular events and should prompt closer cardiac monitoring, cardiac risk factor management, and referral to exercise rehabilitation programs.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institute of Health Research
The broad spectrum of cardiovascular adverse events related to immune check point inhibitors
Authors: Andres M.S , Baksi J , Khattar R , Rosen S.D , Lyon A.R
Published: November 2020

Background

Immunotherapy is one of the latest and most exciting developments in cancer treatment. Immune checkpoint inhibitors (ICI) have shown to have impressive positive results on several tumours such as melanoma, renal cancer and lung cancer, among others. Along with its benefits come the adverse effects which, concerning the heart, myocarditis is the most well-known and feared event. Yet, the spectrum of cardiovascular adverse events (CVAE) is much broader, ranging from heart failure to arrhythmias, but this has not been well documented until know.

Objective

Describe the broad spectrum of CVAE related to ICI

Methods

Observational retrospective, single centre study. We evaluated all the patients that have been referred to the cardio oncology (CO) unit and were under ICI treatment. The referred patients underwent a day case assessment with cardiovascular tests (blood tests, ECG, resting echocardiogram in all cases and MRI, stress echo or CT coronary angiogram if needed). The results were discussed in the multidisciplinary team meeting and the patients were then reviewed by one of the doctors in the team. The conclusions of the assessment were then communicated to the oncology team.

Results

From the year 2011 until December 2019, 71 patients receiving immunotherapy were referred to the CO unit. Three patients were excluded because they were referred for having an intracardiac tumour, leaving 68 for analysis. The first patient was referred in 2014 and during the first 3 years only 7 patients were reviewed in the CO unit. The frequency increased dramatically in 2017 to 17, 19 in 2018 and 25 in 2019. 21 patients were receiving Nivolumab, 24 on Ipilimumab, and 23 (34%) on combined therapy. The most frequent tumour was Melanoma (26/68, 38%). Regarding the CVAE: 22 patients (32%) were referred for investigtion of myocarditis. 6 had a diagnosis of definite myocarditis, 5 probable and 4 possible. Other CVAE (20/68, 29%) were the supraventricular arrhythmias including atrial fibrilation (20/68, 29%). 8 patients presented with non-inflammatory heart failure with new LVEF drop, 4 with chest pain, and 4 others with syncope. 1 patient developed pulmonary hypertension.

Conclusions

Myocarditis still remains the most frequent CVAE related to ICI, but the spectrum is broader than initially described. Supraventricular arrhythmias and non-inflammatory LVEF disfunction were very frequent in this series and we suspect that the incidence will increase as cardiologist and oncologists start considering them as probable adverse effects of this treatment.

Funding Acknowledgement

Type of funding source: None