bluuebunny/crossref_metadata_2025 huggingface dataset:
P1912Incidence of silent cerebral thromboembolism in catheter ablation for atrial fibrillation under the use of DOAC: Comparison of cryoballoon versus radiofrequency ablation system
Authors: Aso A , Nakamura T , Fukuyama Y , Fukuda S , Sibao K , Araki M , Meno K , Yakebe D , Omura S , Mori T , Takenaka K , Murasato Y
Published: October 2019

Background

Silent cerebral thromboembolism (CE) in catheter ablation for atrial fibrillation (AF) is not rare. Prior our study has reported lower incidence of silent CE in AF radiofrequency (RF) ablation using irrigated-tip catheter than conventional 4 or 8mm-tip catheter. In addition, the incidence of silent CE in AF ablation under direct oral anticoagulant (DOAC) was equivalent to continuous therapeutic warfarin. Recently pulmonary vein isolation (PVI) using cryoballoon (CB) has emerged as an alternative technique to RF ablation because some studies suggested that the efficacy for PVI by CB was equivalent to RF. However, incidence of silent CE in CB ablation under the use of DOAC is unknown.

Objective

We aimed to evaluate the incidence new silent CE in AF ablation using CB system compared with irrigated RF system under the use of DOAC.

Methods

322 consecutive patients with paroxysmal or persistent AF (155 using CB system, 167 using RF system) who underwent the first AF ablation were taking DOAC more than one month prior to the procedure. Throughout AF ablation procedure, heparin was administered to maintain activated clotting time (ACT) between 300 and 400 seconds. Head MRI was performed in all patients within 24 hours after the procedure.

Results

In 14 (9.0%) patients using CB and in 20 (12.0%) patients using RF, head MRI showed new embolic lesions without neurological symptom (P=0.469). Although the amount of heparin during the procedure in group CB was significantly less than in group RF (16134±3125 U vs. 18689±5222 U; P<0.0001), amount of heparin per hour in group CB was more than in group RF (8335±1955 U/h vs. 6143±1918 U/h; P<0.0001) because procedure time in group CB was shorter than in group RF (121.3±34.1 min vs. 189.5±47.4 min; P<0.0001). Mean ACT in both groups was maintained high level (3367±25.3 sec. vs. 338.6±23.5 sec.; P=0.479). In univariate analysis, minimum ACT during procedure, as before puncture of interatrial septum, were significantly correlated with the incidence of silent CE (P=0.027).

Conclusions

The incidence of silent CE in AF ablation using CB system was lower than RF system, although it was not a significant difference between different ablation techniques for AF. In AF ablation, the use of CB may be preferred rather than RF as ablation system in regard to risk reduction of thromboembolic complications.
P1913Implantable Loop Recorder Detected Pattern of Atrial Fibrillation Recurrence Following Cryoballoon Pulmonary Vein Isolation in Patients with Persistent Atrial Fibrillation
Authors: Musat D , Milstein N , Shaw R , Bhatt A , Preminger M , Sichrovsky T , Pistilli C , Mittal S
Published: October 2019

Background

Cryoballoon (CB) pulmonary vein isolation (PVI) is increasingly being used in patients (pts) with persistent atrial fibrillation (AF). However, there are limited data about the pattern of atrial fibrillation (AF) recurrence in these pts.

Objective

To assess, using an implantable loop recorder (ILR), the patterns of AF recurrence following CB PVI in pts with persistent atrial fibrillation.

Methods

We enrolled consecutive pts with persistent AF ablation undergoing their first CB ablation. Other cavotricuspid isthmus ablation when indicated, no other ablation was performed. A Reveal LINQ ILR (Medtronic) was implanted <3 months following ablation; all pts had a minimum of 1-year follow-up. The recurrence of any atrial arrhythmia was determined and adjudicated; 4 distinct AF patterns were characterized (Figure).

Results

We studied 64 pts (66±9 years; 50 [78%] male; CHA2DS2-VASc 2.6±1.9) with persistent AF; 52 (81%) pts were on an antiarrhythmic drug (AAD) peri-ablation. During 803±361 days of follow-up, 33 (52%) pts had their 1st AF recurrence 91–365 days post-ablation and another 17 (27%) pts had their 1st AF recurrence >365 days post-ablation. No AF was seen in 14 (31%) pts. Most pts (33 of 50, 66%) with AF recurrence presented with 1 of 3 distinct patterns of paroxysmal AF (Figure), which ranged from 22 min to 124 hours. In 2/3 of these pts, all AF recurrences lasted <24 hours. Only 17 (34%) pts recurred with persistent AF.

Conclusion

Following single CB PVI, most pts with persistent AF remained free of persistent AF during long-term follow-up. Most pts with recurrent AF have 1 of 3 distinct patterns with episodes commonly last <24 hours. These data suggest that CB PVI ablation may halt AF progression in pts initially presenting with persistent AF.
P1914Relationship between myocardial injury, inflammation and early, late recurrence after pulmonary vein isolation may be different between radiofrequency catheter ablation and cryoballoon ablation
Authors: Yano M , Nishino M , Nakamura H , Matsuhiro Y , Yasumura K , Yasumoto K , Tanaka A , Nakamura D , Matsunaga-Lee Y , Yamato M , Egami Y , Shutta R , Tanouchi J
Published: October 2019

Background

High sensitive cardiac troponin I (hs-TnI), subunit of cardiac troponin complex, is a sensitive and specific marker of myocardium injury as troponin T. Several studies showed hs-TnI was associated with worse cardiovascular outcomes but relationship between serum hs-TnI level in patients with atrial fibrillation (AF) after pulmonary vein isolation (PVI) and AF recurrence remains unclear.

Methods

We enrolled 444 consecutive AF patients who underwent PVI from May 2017 to September 2018. We investigated the difference of relationship between serum hs-TnI, inflammation markers at 48 hours after PVI and early or late recurrence of AF (ERAF, <3 months and LRAF, during 1 year after PVI in patients with AF) between radiofrequency ablation (RFA) group and cryoballoon ablation (CBA) group.

Results

RFA and CBA were performed in 328 and 116 patients, respectively. There were no significant differences in patient characteristics between RFA group and CBA group. Serum hs-TnI in RFA group was significantly lower than in CBA group (1.93 ng/ml±3.28 vs 5.08 ng/ml±4.29, p<0.001), while hs-CRP was significantly higher in RFA group than CB group (1.97±2.38 mg/dl vs 1.10±0.84 mg/dl, p<0.001). The incidence of ERAF was similar between the two groups (RFA group: 26.8% and CBA group: 21.6%, p=0.262). There was no significant difference of hs-TnI and hs-CRP between patients with ERAF and without ERAF (table). In 213 patients who were followed during 1 year (PVIs were performed from May 2017 to January 2018, RFA 149 and CBA 64 patients), there was no significant association between hs-TnI, hs-CRP and incidence of LRAF (table).

TnI and CRP between RFA and CBA RFA (n=328) CBA (n=116) P value hs-TnI 1.93±3.28 5.08±4.29 <0.001 hs-CRP 1.97±2.38 1.10±0.84 <0.001 3 months follow-up RFA (n=328) CBA (n=116) ERAF (+) ERAF (−) P value ERAF (+) ERAF (−) P value hs-TnI 1.68±1.90 2.02±3.66 0.410 5.03±3.17 5.10±4.56 0.943 hs-CRP 2.23±2.65 1.88±2.27 0.238 1.01±0.84 1.13±0.85 0.524 1 year follow-up RFA (n=149) CBA (n=64) LRAF (+) LRAF (−) P value LRAF (+) LRAF(−) P value hs-TnI 1.61±1.77 1.87±2.69 0.570 4.71±2.14 5.60±5.69 0.664 hs-CRP 2.18±2.24 1.92±2.24 0.550 1.12±0.64 1.12±0.98 0.991

Conclusion

CBA may cause more myocardial injury than RFA, on the contrary RFA may cause more inflammation than CBA. These markers did not affect ERAF and LRAF after PVI.
P1922Ablation index-guided ablation versus second-generation cryoballoon for first pulmonary vein isolation in atrial fibrillation
Authors: Felix-Oliveira A , Carmo J , Carmo P , Cavaco D , Fontes A , Rodrigues G , Matos D , Moscoso Costa F , Bello Morgado F , Adragao P , Carvalho S
Published: October 2019

Background

In a recent trial, cryoballoon (CB) ablation was non-inferior to radiofrequency ablation regarding effectiveness in atrial fibrillation (AF). Ablation index (AI) provides a more accurate estimation of ablation quality using three variables: power delivered with time, contact force and catheter stability. The additional benefit of AI-guided ablation versus CB ablation is unknown.

Objective

To compare AI-guided ablation and CB ablation for first pulmonary vein isolation (PVI) in patients with AF.

Methods

We assessed 141 patients (62±12 years old, 76 men and 126 paroxysmal AF) with drug refractory symptomatic AF submitted to AI-guided PVI or second-generation CB catheter. Endpoint was AF/AT/AFL recurrence after a 3-month blanking period with a minimum follow-up of 6 months. Cox regression was used to assess the relationship between type of ablation and AF recurrence.

Results

Fifty-seven patients underwent AI-guided PVI and 84 patients underwent CB ablation. The baseline characteristics are described in table 1. Procedure duration was significantly higher in AI group (150 vs 111 min, P<0.001) although requiring significant less fluoroscopy time (5 min vs 20 min; P<0.001). There was a transient phrenic nerve palsy in CB group and a cardiac tamponade in AI group. During a mean follow-up of 10±3 months there were 23 recurrences (27%) in CB group vs 7 recurrences (12%) in AI group (log rank 0.042) (Fig B). When adjusted for CHA2DS2-VASc score, left atrium diameter (mm) and type of AF (Cox regression), there was lower arrhythmia recurrence in AI group (HR 0.42; 95% CI 0.18–0.99; p=0.047).

Table 1. Baseline characteristics

Conclusion

In this analysis, AI-guided ablation was associated with lower arrhythmia recurrence when compared with CB ablation. This hypothesis should be further evaluated in a prospective randomized trial.
P1925Machine learning versus classic electrocardiographic criteria for left ventricular hypertrophy in a young pre-participation cohort: results from the SAFE protocol study
Authors: Sng G , Lim D Y Z , Sia C H , Lee J S W , Shen X Y , Lee E C Y , Dalakoti M , Wang K J , Kwan C K W , Chow W E , Tan R S , Lam C S P , Chua T , Yeo T J , Chong D T T
Published: October 2019

Background/Introduction

Classic electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH) have been well studied in Western populations, particularly in hypertensive patients. However, their utility in Asian populations is not well studied, and their applicability to young pre-participation cohorts is unclear. We sought to evaluate the performance of classical criteria against that of machine learning models.

Aims

We sought to evaluate the performance of classical criteria against the performance of novel machine learning models in the identification of LVH.

Methodology

Between November 2009 and December 2014, pre-participation screening ECG and subsequent echocardiographic data was collected from 13,954 males aged 16 to 22, who reported for medical screening prior to military conscription.

Final diagnosis of LVH was made on echocardiography, with LVH defined as a left ventricular mass index >115g/m2. The continuous and binary forms of classical criteria were compared against machine learning models using receiver-operating characteristics (ROC) curve analysis. An 80:20 split was used to divide the data into training and test sets for the machine learning models, and three fold cross validation was used in training the models. We also compared the important variables identified by machine learning models with the input variables of classical criteria.

Results

Prevalence of echocardiographic LVH in this population was 0.91% (127 cases). Classical ECG criteria had poor performance in predicting LVH, with the best predictions achieved by the continuous Sokolow-Lyon (AUC = 0.63, 95% CI = 0.58–0.68) and the continuous Modified Cornell (AUC = 0.63, 95% CI = 0.58–0.68). Machine learning methods achieved superior performance – Random Forest (AUC = 0.74, 95% CI = 0.66–0.82), Gradient Boosting Machines (AUC = 0.70, 95% CI = 0.61–0.79), GLMNet (AUC = 0.78, 95% CI = 0.70–0.86). Novel and less recognized ECG parameters identified by the machine learning models as being predictive of LVH included mean QT interval, mean QRS interval, R in V4, and R in I.

ROC curves of models studies

Conclusion

The prevalence of LVH in our population is lower than that previously reported in other similar populations. Classical ECG criteria perform poorly in this context. Machine learning methods show superior predictive performance and demonstrate non-traditional predictors of LVH from ECG data. Further research is required to improve the predictive ability of machine learning models, and to understand the underlying pathology of the novel ECG predictors identified.
P1926Artificial intelligence in echocardiography for standard clinical metrics
Authors: Hewitt W , Curtis L , Spyker A , Howitt L , Walsh H , Gladding P
Published: October 2019

Introduction

A full transthoracic echocardiogram (TTE) study usually takes 40 - 60 mins to perform and report. Our aim was to validate an artificial intelligence (AI) which automatically calculates measurements with manual standard clinical metrics.

Methods

41 patients with heart failure (HF) and 19 controls were enrolled retrospectively. A shortened 5-minute TTE exam was performed. Studies were exported from the hospital database in a DICOM format and fed to an AI pipeline to classify, segment and analyse each image. A convolutional neural network (CNN) was used to label each view into one of 23 classes. Views of interest (Apical 2-, 4-Chamber and Parasternal Short/Long Axis) were individually segmented using a segmentation CNN. View classification was trained on 4,000 labelled studies, segmentation models were trained for each view with 72 manually segmented images for PSAX, 128 for PLAX, 168 for A4C and 198 for A2C. The area-length formula was used to calculate left-ventricular volumes (LVEDV/LVESV), ejection fraction (AI-LVEF). Indexed LA volume (LAVOLI) LV mass (LVMI) were also compared. LVEDV, LVESV, LVEF and LVMI were averaged over multiple videos.

Results

Mean manual LVEF (M-LVEF) in HF patients was 39±10% vs 57±5% in controls. Compute time using was between 4 to 7 mins for classification, segmentation and analysis using a single Graphics Processing Unit (GPU). 11 (18%) non-physiological AI-ESV and associated AI-LVEF were excluded vs 2 (3%) M-LVEF (×2 7 95% CI 3 to 27%, p=0.008). AI generated measurements correlated well with manual measures LVEDV r=0.77, LVESV r=0.8, LVEF r=0.71, LAVOLI r=0.71, LVMI r=0.6, p<0.005. Mean absolute error of M-LVEF vs AI-LVEF was 7.4±6.6%. AI-LVEF, M-LVEF and other HF biomarkers had a similar discrimination for HF (AUC M-LVEF 0.93 vs AI-LVEF 0.88, 95% CI-0.03 to 0.15, p=0.19).

AI vs Manual, Correlation Matrix and ROC

Conclusion

AI with minimal human input is approaching the accuracy required for clinical utility. AI has the ability to distinguish LV systolic dysfunction, and chamber volumes which could be applied to handheld ultrasound in real-time.

Acknowledgement/Funding

Health Research Council of New Zealand, Auckland Bioengineering Institute
P1931Effect of de-escalated switching dual antiplatelet therapy after acute myocardial infarction in patients undergoing percutaneous coronary intervention: real-world data from a nationwide cohort study
Authors: Hsu C.-Y , Yeh J.-S , Huang C.-Y
Published: October 2019

Background

Recently, both unguided (platelet function testing independent) and guided (platelet function testing dependent) DAPT de-escalation strategies have been investigated in different clinical studies but the data is still limited and conflicting. The aim of this study was to examine the effect of switching dual antiplatelet therapy (DAPT) on the major vascular risk after acute myocardial infarction (AMI) in patients undergoing percutaneous coronary intervention (PCI) by using Taiwan National Health Insurance Research Database.

Methods

In total, 1,903 and 4,059 patients defined as switched to aspirin and clopidogrel (switched DAPT) and continuation of aspirin and ticagrelor (unswitched DAPT) cohort, respectively who had received PCI during AMI hospitalization, on aspirin and ticagrelor initially and without occurring adverse events at 3 months were evaluated between 2013 and 2015. An inverse probability treatment of weighted approach was adopted to balance the baseline differences between two groups and Cox proportional hazard regression and competing risk regression were used to evaluated the effect of switching DAPT on death, AMI readmission, major bleeding and non-major clinically relevant bleeding.

Results

The incidence rates (per 100 person-year) of death and AMI readmission were 3.97 (95% confidence interval [CI] = 3.19–4.84) and 3.84 (95% CI = 3.09–4.73) in switched cohort and 1.83 (95% CI = 1.47–2.24) and 2.23 (95% CI = 1.82–2.68) in unswitched cohort, respectively. After adjustment for patients' clinical variables, switched cohort had higher risk of death (adjusted hazard ratio = 2.18, 95% CI = 1.62–2.93, P<0.001), and AMI readmission (adjusted sub-distribution ratio = 1.72, 95% CI = 1.27–2.34, P<0.001) compared to these in unswitched cohort; however, there was no difference in the risk of bleeding. Subgroup analysis showed a similar findings in many specific groups, except the patients who were younger age and had lower comorbidity score.

Conclusion

Switching DAPT might increase the risk of death and AMI readmission among patients with AMI undergoing PCI.
P1935Pharmacokinetic and pharmacodynamic assessment of a lipid-based aspirin formulation: results of a prospective, randomised, crossover study
Authors: Angiolillo D J , Bhatt D L , Lanza F , Cryer B , Dong J , Jeske W , Von Chong E , Prats J , Deliargyris E , Marathi U
Published: October 2019

Objectives

Aspirin, or acetylsalicylic acid (ASA), can lead to gastrointestinal mucosal injury through disruption of its protective phospholipid bilayer, underscoring the need for ASA formulations with a more favorable safety profile while maintaining an effective pharmacologic profile. A liquid formulation using a novel pharmaceutical lipid aspirin complex (PL-ASA) has been designed to prevent the disruption of the protective mucosal bilayer. We sought to determine the pharmacokinetic (PK)/pharmacodynamic (PD) characteristics of PL-ASA compared with traditional, immediate release aspirin (IR-ASA).

Methods

In this active-control crossover study, 16 healthy volunteers were randomized to receive a single dose of either IR-ASA 325 mg or PL-ASA 325 mg in a sequential fashion with a 2-week washout period between treatment assignments. The primary objectives of the study were to assess PK (i.e., plasma salicylic acid levels) and PD (i.e., serum thromboxane B2 levels) bioequivalence over a 24–hour period after drug administration, of PL-ASA and IR-ASA using established criteria.

Results

The PK parameter values were similar for PL-ASA and IR-ASA, with median AUC 0-t and Cmax values nominally higher for PL-ASA. Log-transformed PK parameters meeting FDA-criteria for bioequivalence (80% to 125%) are provided in the Table. Serum thromboxane B2 levels were similar for PL-ASA and IR-ASA, with Cmin values below 3.1 ng/mL (cut-off associated with decreased cardiovascular events) for both drugs. Both drugs also showed >99% inhibition of serum thromboxane B2 levels (≥95% inhibition represents the cut-off to define aspirin responders). Several secondary PK/PD parameters showed similarities between the two drugs (data not shown). Overall, these findings support functional and clinical equivalence between PL-ASA and IR-ASA.

PK Results Parameter Ratio (PL-ASA/IR-ASA) 90% Confidence Interval AUC0-t 96.51 89.24, 104.37 Cmax 103.73 92.06, 116.89

Conclusions

PL-ASA's novel liquid formulation has similar PK and PD performance compared with IR-ASA. The improved endoscopic safety profile of PL-ASA coupled with its pharmacologic efficacy equivalent to IR-ASA may result in an improved benefit-risk performance, warranting evaluation in future trials.

Acknowledgement/Funding

PLx Pharma, Inc.
P1940Reciprocal regulation of Endothelial-Mesenchymal Transition by MAPK7 and EZH2 activity in Intimal Hyperplasia and Coronary Artery Disease
Authors: Vanchin B , Sol M , Gjaltema R A F , Van Der Pol B , Brinker M G L , Kiers B , Pereira A C , Harmsen M C , Moonen J A J , Krenning G
Published: October 2019

Introduction

Endothelial cells play a pivotal role in the formation of neointimal lesions by the acquisition of a fibro-proliferative phenotype through endothelial-to-mesenchymal transition (EndMT). Uniform laminar shear stress activates the mitogen-activated protein kinase 7 (MAPK7) which suppresses EndMT. It is elusive how MAPK7 activity is regulated in fibroproliferative disease. We recently found in intimal hyperplasia the signaling activity of MAPK7 is rapidly lost through the activation microRNA-374b.

The histone methyltransferase Enhancer of Zeste Homolog 2 (EZH2), which is the catalytic subunit of the Polycomb Repressive Complex 2, plays a pivotal role in endothelial dysfunction. EZH2 trimethylates lysine 27 on histone 3, which silences gene expression and is elevated in endothelial cells in atherosclerotic lesions. Here, we found the reciprocity that exists between MAPK7 and EZH2 in the regulation of EndMT and in human coronary artery stenosis.

Materials and results

In endothelial cells, activation of MAPK7 increases the expression of microRNA-101, which represses the expression of EZH2. Reciprocally, the loss of EZH2 coincides with a decreased expression of the Dual Specificity Phosphatase (DUSP)-1 and DUSP-6 – the phosphatases responsible for the dephosphorylation of MAPK7 - which facilitates the activation of MAPK7.

H3K27Me3, the repressive histone mark placed by EZH2, is abundantly present in the promoter regions of the miR-200b/a/429 and miR-200c/141 gene clusters, which are responsible for the loss of DUSP-1 and DUSP-6 expression. Endothelial cells deficient in EZH2 have reduced levels of H3K27Me3 at these gene promoters, which associates with the increased expression of miR-200b and miR-200c and concurrent increased MAPK7 activation. In endothelial cells with constitutively active MAPK7 signaling (MEK5D), the enrichment of H3K27Me3 at the promoter regions of miR-200b/a/429 (1.6-fold, p=0.034) and miR-200c/141 (1.9-fold, p=0.035) is decreased, suggesting that MAPK7 activation results in a decreased EZH2 activity. Disbalances in this reciprocal signaling circuit culminate in the induction of EndMT and associate to the severity of human coronary artery stenosis.

Conclusion

In summary, we show that in endothelial cells there is reciprocity between MAPK7 signaling and EZH2 expression and that disturbances in this reciprocal signaling circuit associate with the induction of EndMT and severity of human coronary artery stenosis. The reciprocity between MAPK7 and EZH2 is governed by a complex mechanism involving microRNAs and the phosphatases DUSP-1 and DUSP-6. Our study contributes to a better understanding of the molecular and epigenetic cascades that underlie EndMT during coronary artery stenosis and might identify novel targets for therapy.

Acknowledgement/Funding

Mongolian Government Scholarship #621
P1944Relationship between the duration of hypertension and cerebral and cardiovascular disease in the adult Korean population
Authors: Rha S W , Choi B G , Choi S Y , Byun J K , Cha J A
Published: October 2019

Background

Although advances in medical technology and health care have led to increased life expectancy, the prevalence of chronic diseases such as hypertension, diabetes, stroke and cardiovascular events has increased.

Purpose

This study evaluated the prevalence of hypertension, treatment, and the impact of hypertension on cardiovascular disease (CVD) and stroke risk in Koreans.

Methods

The Korean National Health and Nutritional Examination Survey (KNHANES) database, which is a stratified random sampling to assess the health and nutritional status of Koreans (https://knhanes.cdc.go.kr), was analyzed for this study. The subjects of the survey were sampled to represent the entire population of the Republic of Korea. The endpoints of the study are the risk of CVD and stroke due to the prevalence of hypertension. We also examined the relationship between the control of hypertension and the risk of CVD and stroke.

Results

The prevalence of hypertension has increased rapidly as with longer life expectancy of the population. As the duration of hypertension increases, CVD and stroke risks are increased. Achieving a target goal blood pressure below 140/90 mmHg can reduce the risk of all CVD and stroke by nearly half.

Korea-HTN

Conclusion

The risk of CVD and stroke in hypertensive patients can be significantly reduced by achieving optimal blood pressure control.
P1957Impact of fraility on the super elderly patients with peripheral artery disease
Authors: Nishigawa K , Nagae A , Miura T , Katoh T , Hirabayashi M , Miyashita Y , Kashiwagi D , Mochidome T , Sakai T , Senda K , Saigusa T , Ebisawa S , Okada A , Motoki H , Kuwahara K
Published: October 2019

Background

The current consensus is that frail patients have high risks of mortality. However, it remains unclear whether frailty is associated with mortality risks in super-elderly patients with peripheral artery disease (PAD).

Methods

The I-PAD registry was a prospective multicenter observational study involving 12 institutions in Nagano prefecture in Japan. From July 2015 to July 2016, the I-PAD registry enrolled 371 consecutive PAD patients who had undergone endovascular therapy (EVT). Among them, we selected and analysed 109 PAD patients who were >80 years old when they had undergone EVT and divided them into two groups: those with frailty (Clinical Frailty Scale≥5, n=47) and those without frailty (Clinical Frailty Scale≤4, n=62). The primary endpoints were overall survival and major adverse limb events (MALE), defined as a composite of all-cause death, major amputation and revascularization.

Results

The median follow-up period was 1.58±0.3 years. Overall, 109 patients with a mean age of 84.8±4.0 years, of whom 63.3% were men, were included. Overall survival and freedom from MALE were significantly lower among patients with frailty than among those without frailty (60.5% vs. 91.6%, P<0.001; 51.4% vs. 87.5%, P<0.001; respectively).

Conclusion

The prognosis of super-elderly patients with frailty is worse than that of patients without frailty.
P1958Baseline glycated hemoglobin level was differently associated with long-term prognosis in peripheral artery disease patients with and without hemodialysis
Authors: Shirotani S , Jujo K , Mizobuchi K , Ishida I , Minami Y , Haruki S , Akashi M , Nakao M , Hagiwara N
Published: October 2019

Introduction

Diabetes (DM) is the leading cause of induction of hemodialysis (HD), and both are major prognostic factors in patients with peripheral artery disease (PAD). However, the prognostic importance of baseline glycated hemoglobin (HbA1c) levels in PAD patients with and without HD is yet to be elucidated.

Purpose

We hypothesized that baseline HbA1c levels had different prognostic impacts after endovascular therapy (EVT) in between PAD patients with and those without regular HD.

Methods

This observational study included 643 consecutive patients who received EVT between 2013 and 2017. Each of 313 HD patients and 330 Non-HD patients was respectively divided into 2 groups by the comorbidity of diabetes, and DM patients were further divided into 3 subgroups depending on HbA1c level at the time of EVT; DM-Low (HbA1c: <6.0%), DM-Mid (6.1–7.0%), and DM-High (>7.1%) groups. The primary endpoint of this study was major amputation-free survival (AFS).

Results

HD group included significantly more patients presenting critical limb ischemia than Non-HD group (46.6% vs. 30.0%, p<0.001). During the observation period after EVT, there were 81 events (25.9%), including 55 death and 26 major amputations in HD group, and 45 events (13.6%), including 30 death and 15 major amputations in Non-HD group. Kaplan-Meier analysis revealed that DM patients had a significantly higher AFS rate in HD group (Log-rank: p=0.003, Figure A). In contrast, in Non-HD group, there was no statistical difference in AFS between DM and Non-DM patients (p=0.36). In Cox regression analysis in HD group, the higher HbA1c-DM group showed the higher hazard ratio (HR) for AFS (p=0.039, Figure B), and DM patients with HbA1c >6.0% had significantly higher HR than Non-DM patients. Whereas, in Non-HD group, HbA1c-DM class adversely associated with HR for AFS (p=0.003), even any classes did not reach statistical differences from Non-DM patients.

Figure 1

Conclusions

Comorbidity of diabetes at the time of EVT worsened long-term prognosis in PAD patients receiving regular HD, but not in those without HD. Additionally, baseline HbA1c levels oppositely affected prognosis in PAD patients with and without HD.
P2247Pregnancies and childbirth in women with arrhythmogenic right ventricular cardiomyopathy are associated with low risk of ventricular arrhythmias
Authors: Platonov P G , Carlson J , Castrini I , Svensson A , Christiansen M K , Gilljam T , Madsen T , Hansen J , Astrom M A , Haagua K , Jensen H K , Edvardsen T , Svendsen J H
Published: October 2019

Background

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with a risk of ventricular arrhythmias (VA) and sudden cardiac death (SCD). Even though female patients with ARVC are considered to be at lower risk of VA, the impact of pregnancy and child birth on the arrhythmic risk and development of arrhythmic substrate in the context of ARVC remains insufficiently studied.

Objective

To assess the risk of VA in relation to childbirth in women with ARVC and the impact of multiple pregnancies on progression of arrhythmic manifestations of the disease.

Methods

The study included 186 females with definite ARVC (n=107, 70 probands) or unaffected mutation-carriers (n=79) with median age at the end of follow up of 48 (IQR 34–60) years. Seventeen women had 1, 59 had 2 and 29 had ≥3 child births by the age of 40 years. VA was defined as ventricular tachycardia, appropriate ICD therapy, aborted cardiac arrest or SCD. Proportions of patients who experienced VA by the age of 40 years were compared between nulliparous women (n=81) and those with reported child births (n=105). VA-free survival after accomplished pregnancies was assessed for women ≥40 years of age (n=119). Cumulative probability of VA for each pregnancy (n=230) was assessed from conception through 2 years after child birth and compared between those that occurred before ARVC diagnosis (Pre-Ds, n=164), after it (Post-Ds, n=11) and in unaffected mutation carriers (No-Ds, n=55).

Results

The nulliparous women had lower age at ARVC diagnosis (37 vs 44, p=0.023) and more often had VA before the age of 40 (31% vs 13%, p=0.003) while the number of child births was not related to the prevalence of VA (18% among women with 1 childbirth, 12% in those with 2 and 14% in those with 3 or more, ns). Three women suffered SCD before the age of 40. VA-free survival after 40 years did not differ between nulliparous and those who gave birth (Figure A). Only four pregnancy-related events were documented (Figure B): 1 in the Post-Ds group and three in the Pre-Ds group. No pregnancy-related events were reported in the unaffected mutation carriers.

Conclusion

In this Scandinavian cohort of women with ARVC we observed no indication of an increased VA risk either associated with pregnancies or during long-term follow up after the last child birth.
P2257Self-care abilities and depression symptoms linked to brain injury in heart failure
Authors: Woo M A , Roy B , Kumar R
Published: October 2019

Heart failure (HF) patients show brain damage in regions controlling mood, autonomic, and cognitive functions. HF patient's exhibit symptoms related to depression, anxiety, poor sleep quality, daytime sleepiness, impaired cognition, and poor self-care, however, the relationship between brain damage and disease related symptoms is unclear. Therefore, our aim was to correlate gray matter density in prefrontal cortices, hippocampus, and insular lobe with disease symptoms using T1-weight voxel based morphometry procedure and evaluate the measure that predicts the brain damage.

Methods

Two high-resolution T1-weighted data were collected from each 42 HF subjects (age, 55.65±7.61; 30 male; LVEF 27.74±9.40%; NYHA class II/III) using a 3.0-Tesla MRI scanner. Depression, anxiety, sleep quality, daytime sleepiness, cognition, and self-care issues were examined with Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Montreal Cognitive Assessment (MoCA), and Self-Care of Heart Failure Inventory (SCHFI) respectively. Both T1-weighted scans were realigned, averaged, and segmented into gray matter (GM), white matter, and cerebrospinal fluid tissue type. GM maps were normalized (unmodulated) to a common space and smoothed to obtain GM density maps. The smoothed GM density maps were used to examine the association of brain damage with disease symptoms (SPM 12; partial correlation; covariates, age and gender; p<0.005). Region of interest analyses were performed in prefrontal cortices, insular lobe and hippocampus to evaluate the correlation using partial correlation (SPSS, covariates, age and gender, p<0.05).

Results

The average scores for BAI 9.55±9.90, BDI 8.69±7.05, ESS 7.00±3.72, MoCA 24.64±3.48, PSQI 6.62±3.90, maintenance 73.12±13.78, management 70.28±13.98, and confidence 73.77±15.96 were calculated. Significant negative correlations was observed between GM density values and BAI (prefrontal cortices, r=−0.532, p<0.001), BDI (prefrontal cortices, r=−0.60, p<0.001; insula, r=−0.528, p<0.001, hippocampus, r=−0.432, p<0.005), ESS (prefrontal cortices, r=−0.419, p=0.007; insula, r=−0.443, p=0.004), and PSQI (prefrontal cortices, r=−0.517, p=0.001) scores, and positive correlation between GM density values, MoCA (prefrontal cortices, r=0.462, p=0.003) and SCHFI scores (maintenance: prefrontal cortices, r=0.422, p=0.007; insula, r=0.412, p=0.009, hippocampus, r=0.455, p=0.004; management: prefrontal cortices, r=0.728, p=0.001; insula, r=0.707, p=0.001, hippocampus, r=0.775, p<0.001) (Figure 1).

Figure 1

Conclusions

HF subjects show more wide-spread and significant correlations between regional GM density values and BDI as well as SCHFI management scores compared to the other disease symptom measures. The findings suggest that damage in mood, autonomic, and cognitive functions sites better correlate with BDI and SCHFI over other measures.

Acknowledgement/Funding

NIH/NINR 1R01 NR014669
P2263Prognostic impact of perceived social isolation in patients with heart failure
Authors: Ikeda T , Iwatsu K , Matsumura K , Ashikawa H , Takabayashi K , Fujita R , Kitaguchi S , Nohara R
Published: October 2019

Background

Perceived social isolation (SI), the subjective sense of feelings of loneliness or isolation, has a negative impact on health outcomes, particularly in older adults. Although SI may also contribute to poor prognosis in patients with HF, evidence on the relationship between SI and outcomes in patients with HF is limited.

Purpose

The aim of this study was to investigate the relationship between SI and hospital readmission in patients with HF.

Methods

This study was a single center prospective cohort study. We consecutively enrolled 203 patients (mean age 72.9±11.7) who admitted for acute HF or exacerbation of chronic HF. At hospital discharge, we assessed perceived SI by using Lubben Social Network Scale - 6 (LSNS-6). Lower scores in LSNS-6 represents greater SI. Study outcome was rehospitalization for worsening HF within 180 days after discharge. We selected the optimal cutoff point of LSNS-6 that predict a worse outcome by the receiver operating characteristic (ROC) curve analysis. We investigate the association between SI and 180-days HF rehospitalization by using Cox proportional-hazard models, controlling for potential confounding factors.

Results

During follow up, A total of 40events (19.7%) were observed. The optimal cut-off point of LSNS-6 score was 17 points (the area under the ROC curve: 0.62, p<0.05, sensitivity: 82.5%, specificity 42.4%). Kaplan-Meier survival curves showed that those patients with greater SI (LSNS-6≤17) presented significantly higher HF rehospitalization rate (Figure). After adjusting for several pre-existing prognostic factors, LSNS-6≤17 was independently associated with HF rehospitalization (hazard ratio2.15,95% confidence interval 1.00–4.89).

Conclusion

The present study shows that SI is a independent predictor of HF rehospitalization in patients with HF. Assessing SI in the clinical practice with a brief screening tool may help identify patients with heart failure at greater risk of rehospitalization.
P2266The predictor of mortality and neurological outcome in out-of-hospital cardiac arrest patients with non-ST-segment elevation
Authors: Matsuda J , Nitta G , Kato S , Kono T , Ikenouchi T , Murata K , Kanoh M , Takamiya T , Inamura Y , Negi K , Inaba S , Sato A , Yamato T , Matsumura Y
Published: October 2019

Background

The prognosis of patients with out-of-hospital cardiac arrest (OHCA) remains poor. Coronary artery disease (CAD) is the most frequent cause of OHCA. The prompt evaluation and revascularization for coronary artery in OHCA patients with ST-segment elevation are recommended because they often have CAD. However, OHCA patients without ST-segment elevation also have any coronary stenosis in the non-negligible proportion. The predictor of mortality and neurological outcome in OHCA patients with no ST-segment elevation has not been sufficiently elucidated.

Purpose

We sought to investigate the predictor of mortality and neurological outcome at 30 days in OHCA patients without ST-segment elevation.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, 183 patients' electrocardiogram after ROSC were without ST-segment elevation. We performed coronary angiography (CAG) for 103 patients, who were eligible for final analysis. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, post-hospital care.

Results

Any coronary stenosis was founded in 50 patients (48.5%). Male (P=0.007), older age (P<0.001), past history of coronary artery disease (CAD) (P=0.037) and diabetes mellitus (P=0.087) were associated with coronary artery stenosis on CAG findings. Age (OR 1.05; 95% confidence interval (CI) 1.02–1.08; P<0.001), male (OR 5.33; 95% CI 1.37–20.7; P<0.001) were independent predictors of coronary artery stenosis. Among those who had stenosis, 34 patients (68.0%) survived and 27 patients (54.0%) achieved good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. Successful revascularization by percutaneous coronary intervention (PCI) was not associated with low mortality (P=0.77). Past history of CAD (P=0.014) and high Syntax score (P=0.030) were associated with mortality. Bystander cardiopulmonary resuscitation (CPR) (P-0.021), pre-hospital ROSC (P<0.001) was more frequent in patients with good neurological outcome. Pre-hospital ROSC (OR 14.7; 95% CI 3.1–69.3; P<0.001) was independently predictive for good neurological outcome.

Conclusions

Successful PCI for OHCA patients with no ST-segment elevation was not a predictor of mortality. CAD past history and complex CAD was associated with mortality. Pre-hospital information such as pre-hospital ROSC was important to achieve good neurological outcome.
P2267CTEPH patients long term follow-up: results from a single center
Authors: Mladoniczky S , Szegedi M , Piroth Z S , Nemeth J , Ablonczy L , Andreka P , Temesvari A , Balint O H
Published: October 2019

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is a thrombotic pulmonary disease associated with pulmonary vasculopathy. Pulmonary endarterectomy (opus, PEA) is the first treatment choice in CTEPH, and specific PAH medication when there is a contraindication for surgery or residual pulmonary arterial hypertension (rPAH) occurs. In the presence of PAH balloon pulmonary angioplasty (BPA) might be also recommended if available.

Objective

We investigated the long term outcome of our CTEPH patients.

Methods

CTEPH from our institution retrospectively analyzed (data between 2003 and 2018). Baseline, treatment and outcome data were documented. We compared the outcome, together with mortality in those with and without surgery (PEA vs. non PEA group). NYHA class, 6 minutes walking distance (6MWD) and NT-proBNP were also reported during follow-up.

Results

Of 29 CTEPH patients (mean age was 62±19 years, 52% male) 16 (55%) were accepted for PEA, and further 12 of them had a long term follow-up post surgery (n=3 periop exit, n=1 waiting for surgery). Half of the PEA patients were cured (n=6) and the other half (n=6) required specific PAH treatment (n=1, in combination with BPA) for rPAH. All patients from the non-PEA group (n=13) were started on specific PAH treatment (n=1 in combination with BPA). Patients with or without PEA did not differ hemodynamically. At the late follow-up there was a significant improvement in PEA group for NYHA class and NT-proBNP (p<0,001, and p=0,046), and in non PEA group for NYHA class and the 6MWD (p=0,012, and 0,006). We found significant difference in mortality at 1,3,5 year (Kaplan-Meier survival analysis) follow-up, for PEA group 100%-100%-100% and non PEA group 100%-85%-78% (p=0,013), respectively.

Conclusions

55% of CTEPH patients were suitable for PEA, and those who survived the surgery 50% were cured. Non PEA patients improved functionally on the long term, but had worse survival.
P2269IABP-SHOCK II risk score validation for cardiogenic shock after myocardial infarction in a cohort treated with pharmaco-invasive therapy
Authors: Moraes P I M , Alves C M R , Souza M T , Kawakami S E , Galhardo A , Kanhouche G , Cardoso J P , Santos L P M , Arero J R B , Ramon C H , Goncalves Jr I , Moreno A C , Barbosa A H P , Caixeta A , Carvalho A C C
Published: October 2019

Background

Risk stratification using scores is a valuable tool in cardiogenic shock after ST elevation myocardial infarction (STEMI). During pharmacoinvasive therapy (PIT) their use is unexplored in the literature. Objective: To validate the IABP-SHOCK II (Intra-aortic Balloon Pump in Cardiogenic Shock) score in patients treated with PIT and to analyze the influence of ischemia time on the different risk strata.

Methods and results

Of 2,143 STEMI patients seen between May 2010 and April 2017, 212 (9.9%) developed cardiogenic shock. Thirty-one patients (14.6%) with incomplete data were excluded from the analysis and the validation cohort included the remaining 181. Mortality rates were similar between the analyzed and excluded patients (42.5% and 45.1% respectively, p=0.77). The 30-day mortality using the IABP-SHOCK II score was 26.6% for low-risk (n=94), 53.2% for moderate-risk (n=62), and 76% for high-risk (n=25) (p<0.001). The validation of the score showed good discrimination for death, with an area under the curve of 0.73 (95% confidence interval 0.66 to 0.81 p<0.001). Although pain-to-needle time was significantly longer in patients who died within 30 days (251 min, interquartile range 140–528 vs. 210 min, interquartile range 130–343, p=0.032), the median intervals of pain-to-needle and fibrinolytic-catheterization showed no association with the group stratification (220 vs 251 vs 200 min; p=0.22 and 390 vs 435 vs 315 min; p=0.18, respectively). This finding may be explained by the potential of these variables to be more closely associated with the development of cardiogenic shock in STEMI patients treated with PIT, and to be less associated with progression to death when the patient is already in shock.

30-day mortality in scored strata

Conclusion

In patients with cardiogenic shock after STEMI treated with PIT, risk stratification using the IABP-SHOCK II score was adequate. There was no influence of pain-to-needle and fibrinolytic-catheterization times on the ability to the score model stratification.
P2277Utility of cardiovascular implantable electronic device (CIED)-derived patient activity, a novel digital biomarker, to predict inappropriate therapy
Authors: Rosero S , Jones P , Goldenberg I , Zareba W , Stein K , McNitt S , Brown M , Polonsky B , Kutyifa V
Published: October 2019

Background

The role of cardiovascular implantable electronic device (CIED)-derived activity to predict inappropriate implantable cardioverter-defibrillator (ICD) therapy is not known. The Multicenter Automatic Defibrillator Implantation Trial – Reduce Inappropriate Therapy (MADIT-RIT) enrolled 1500 patients with contemporary indication for an ICD or a CRT-D. We aimed to identify whether activity, as a digital biomarker, predicted inappropriate therapy.

Methods

In 1500 patients enrolled in MADIT-RIT, CIED-derived patient activity was acquired daily. CIED-derived activity was averaged for the first 30 days following randomization and utilized in this study to predict inappropriate therapy post- 30-day. Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression models were used to evaluate first inappropriate therapy by 30-day CIED-derived patient activity quintiles, and by 30-day device derived patient activity as a continuous measurement.

Results

There were a total of 1463 patients with activity data available (90%), 135 patients received at least one inappropriate therapy during the post-30 day follow-up period. Patients in the highest quintile (Q5) of CIED-derived activity (more active) were younger, more often males and more likely to have had a prior ablation of an atrial arrhythmia. Patients in the highest quintile of 30-day CIED-derived median activity had the highest risk of receiving inappropriate therapy, 21% at 2 years as compared 7–11% in the other four quintiles (Figure, p<0.001 for the overall duration). Patients with the highest level of 30-day median patient activity (Q5) had 1.75 times higher risk of any inappropriate therapy as compared with lower levels of activity, Q1-Q4 (HR=1.75, 95% CI: 1.23–2.50, p<0.002). Each 10% increase in CIED-derived 30-day median patient activity was associated with a significant, 73% increase in risk of receiving inappropriate therapy (HR=1.73, 95% CI: 1.17–2.54, p=0.005). Patients in the highest quintile for activity had a 68% increase in the risk of SVT excluding atrial fibrillation, atrial flutter or atrial tachycardia (HR=1.69, 95% CI: 1.26–2.25, p=0.004), despite 96% receiving beta-blocker medications.

Inappropriate ICD Therapies by Activity

Conclusions

CIED-derived 30-day median patient activity predicted subsequent inappropriate therapy in ICD and CRT-D patients enrolled in MADIT-RIT. Patients with high levels of 30-day CIED-derived median patient activity were at a significantly higher risk of receiving inappropriate therapy. Activity, as a digital biomarker, may have utility in predicting and managing the risk of inappropriate therapy in this population.

Acknowledgement/Funding

Boston Scientific