bluuebunny/crossref_metadata_2025 huggingface dataset:
P2636Stage B predictors of non-ischemic heart failure in type 2 diabetes mellitus
Authors: Klabnik A , Murin J
Published: October 2019

Purpose

Stage B heart failure (SBHF), defined as LV hypertrophy (LVH) and impaired ejection fraction (EF), is precursor of reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure in type 2 diabetes mellitus (T2DM).

Left atrial enlargement (LAE) and left ventricular diastolic or systolic dysfunction (assessed with tissue doppler and speckle-tracking echocardiography) are not accepted as HF stage B equivalents.

Methods

396 consecutive community-based elderly (≥65 years) patients (pts) with asymptomatic T2DM (age 76±4 years; 64% women) with preserved EF (≥40%) and no atrial fibrillation, ischemic or valvular heart disease referred to echolab and prospectively followed from January 2015 by regional cardiologist.

Results

Prevalence of SBHF was observed in 6% after 2 years (EF≤40%) and LVH have 13% at baseline and 20% pts after 2 years. Left atrial enlargement (>34 ml/m2) occurs in 31%, resp. 48% pts after 24 months, diastolic dysfunction (E/e' >14) in 42%, resp. 68%. Systolic dysfunction (S' ≤6.0 cm/s) was observed in 20%, resp. 33% pts, and reduced global longitudinal (GLS <16%) in 23%, resp. 40% pts (all p<0.001).

After a mean follow-up of 31±4 months developed new HF 19% pts (1% HFrEF, 6% HFmrEF and 12% HFpEF).

The strongest predictors of incident HFpEF were older age (15%, 45% among men and 20%, 60% among women ages 65–74, and 75–85 years, p<0.001), new-onset atrial fibrillation: hazard ratio (HR) 1.4, p<0.01, and NTproBNP >125 pg/ml (HR 2,8, p<0.001).

Significant (p<0.001) echocardiografic predictors of incident HFpEF were LVH (HR 2.90), systolic dysfunction (S' ≤6.0 cm/s, HR 2.2) and reduced GLS (HR 2.38). But not abnormal E/e' and LAE were associated with incident HF.

Conclusions

New echocardiographic parameters are useful in prediction of incident HF and should be added to standard SBHF criteria in asymptomatic patients with type 2 diabetes mellitus. Additional research is needed to update HF screening guidelines.

Acknowledgement/Funding

Supported by grant from the Slovak Society of Cardiology 2015 Selective screening of heart failure stages in regional settings
P2640The effect of dry-weight reduction guided by lung ultrasound on ambulatory aortic blood pressure and arterial stiffness parameters in hemodialysis patients
Authors: Loutradis C , Papadopoulos C E , Sachpekidis V , Pagourelias E , Ekart R , Krunic B , Toumpourleka M , Theodorakopoulou M , Pateinakis P , Zoccali C , London G , Vassilikos V , Sarafidis P , Papagianni A
Published: October 2019

Introduction and purpose

Arterial stiffness and aortic blood pressure (BP) augmentation are significantly increased in hemodialysis patients. Recent studies suggest that the prognostic significance of ambulatory recordings of arterial stiffness is high in hemodialysis. This study examines for the first time the effect of dry weight reduction with a standardized lung-ultrasound-guided strategy on ambulatory aortic BP and arterial stiffness parameters in hypertensive hemodialysis patients.

Methods

A total 71 hemodialysis patients with hypertension (mean home BP ≥135/85 mmHg), that were clinically euvolemic, were included in this single-blind randomized clinical trial. Patients were randomized in a 1:1 ratio in the active group (n=35), following a strategy for dry-weight reduction guided by the total number of US-B lines (US-B lines score) prior to a mid-week dialysis session and the control group (n=), following standard-of-care treatment. All patients underwent 48-hour ABPM with the Mobil-O-Graph monitor (IEM, Stolberg, Germany) and PWV measurement in office with SphygmoCor (ArtCor, Sydney, Australia) at baseline and after 8-weeks.

Results

Overall, the US-B lines change during follow-up were −5.3±12.5 in active versus +2.2±7.6 in control group (p<0.001), which corresponded to dry-weight changes of −0.71±1.39 versus +0.51±0.98 kg (p<0.001). The change in 48-hour cSBP was significantly greater in the active group (−6.30±8.90 vs −0.50±12.46, p=0.027); the relevant cDBP fall was marginally greater (−3.85±6.61 vs −0.63±8.36, p=0.077) in the active group. 48-hour cPP (41.51±9.63 vs 39.06±9.61 mmHg, p=0.004) and 48-hour PWV (9.30±2.00 vs 9.08±2.04 m/sec, p=0.032) were significantly reduced from baseline to study-end in the active group but remained unchanged in controls. In contrast, 48-hour AIx and AIx(75) did not change between baseline and study-end in both groups; changes in AIx(75) were similar in the two groups (−0.97±3.51 vs −0.36±4.25, p=0.517). PWV measured in office was decreased from baseline to study-end in the active (10.07±2.66 vs 9.79±2.81, p=0.038) but not in the control group.

Conclusions

A lung-ultrasound-guided strategy for dry-weight reduction reduces ambulatory aortic BP and ambulatory or office PWV, but not ambulatory AIx(75). These results suggest that dry-weight reduction can primarily reduce aortic BP levels and large arteries stiffness but not wave reflections from the periphery.
P2645Cardiovascular risk in patients with essential hypertension and nonalcoholic fatty liver disease comorbidity
Authors: Gribenyk O , Kuzminova N V
Published: October 2019

Very often acute myocardial infarction and stroke are recorded among patients with essential hypertension (EH) and non-alcoholic fatty liver disease (NAFLD), including non-alcoholic steatohepatosis (NASP), comorbidity.

The aim of the study was to improve cardiovascular risk assessment in patients with combination of second stage EH and NASP, using the metabolism indexes, structural-functional indicators of heart and blood vessels.

According to the study results of 170 patients with second stage of EH (98 (57.6%) were women and 72 (42.4%) - men), mean age 49.3±0.5) it was found that NASP was confirmed in 109 (64.1%) patients (SteatoTest - 0.41 units (S1-S2)). Total cholesterol (TC), triglycerides (TG), high density lipoproteins (HDL); very low (LDL) and low density (LDL) lipoproteins; atherogenic index (IA); lipoprotein (a) (Lp (a)), insulin, HOMA index, tumor necrosis factor α (TNFα)), adiponectin were determined among all patients.

The instrumental examination included electrocardiography, echocardiography, daily blood pressure monitoring (DBPM), carotid arteries ultrasound, calculation of endothelial dysfunction index (EDI) (as the ratio of endothelial-dependent to endothelial-independent vasodilation) and arterial wall stiffness (AS).

Statistical processing of the results was conducted by Microsoft Excel, STATISTICA for Windows 10.0 programs. The proaterogenic lipid spectrum changes (TC (7.7%, p=0.0009), TG (19.8%, p=0.02), LDL (11,8%, p=0.0009), IA (8,8%, p=0.04), increased levels of Lp (a) (58.0%, p=0.0007) TNFα (51.4%, p=0.01), insulin resistance (HOMA index - 3.3 units), decreased adiponectin level (44.3%, p=0.0002) were reported in patients with II stage EH and NASP comorbidity compared to patients with EH without fatty liver infiltration (p<0.05).

Higher systolic (SBP) and pulse arterial pressure (PBP) (both office measurement and DBPM), daily SBP index “nondipper” (63.3% of patients, p<0.05); increased by 2 times the frequency of the registration of atherosclerotic plaques in both carotid arteries (p<0.05), increase in AS (15.7%, p=0.002) and EDI reduction (−12.5%, p=0.01) were determined in patients with II stage EH and concomitant NASP compared with EH patients without NASP.

True (p<0.ehz748.096601) direct correlation bonds were established between the NASP and the level of TC (rs=0.38), TG (rs=0.31), LDL (rs=0.31), Lp (a (rs=0.51), insulin resistance (rs=0.47), TNF-α (rs=0.49), night SBP and PBP (rs=0.33 and rs=0.29), variability night SBP, AS (rs=0.41), reverse – with the level of adiponectin (rs=−0.48) and EDI (rs=−0.58). Thus, in patients with second stage EH NAFLD is associated with negative metabolic changes and structural and functional desorders of heart and blood vessels and can be considered as an additional factor of the overall cardiovascular risk increasing in patients with EH.
P2649Do these data apply to me? Examining the applicability of trials assessing strategies for optimal management of blood pressure to older patients in UK primary care
Authors: Sheppard J , Burt J , Lown M , Temple E , Lowe R , Todd O , Ford G , Hobbs F D R , Little P , Mant J , Mollison J , Payne R , Williams M , Yu L M , McManus R J
Published: October 2019

Background

There is debate as to what extent older patients (≥80 years) should be treated for high blood pressure. Existing trials show that blood pressure lowering in this population is effective at preventing stroke and heart failure but also results in an increased risk of adverse events. However, it has been suggested that these studies enrolled healthier patients, who are less representative of the general population and more likely to benefit from treatment.

Purpose

This study aimed to compare the characteristics of patients eligible for three blood pressure management trials and assess the likelihood of eligibility for each trial based on common characteristics of older patients.

Methods

Cross-sectional study of data extracted from the medical records of 15,376 patients aged ≥80 years, registered to 24 general practices in the south of England. Anonymised patient data relating to the eligibility criteria for two previous medication intensification trials (HYVET, SPRINT) and one medication reduction trial (OPTiMISE) were extracted. Patients eligible for each trial were defined according to criteria specified in each trial protocol. Descriptive statistics were used to define the characteristics of each trial population. A logistic regression model was constructed to estimate predictors of eligibility for each trial, with practice included as a random effect.

Results

Approximately 268 (1.7%), 5,290 (34.4%) and 3,940 (25.6%) patients were eligible for HYVET, SPRINT and OPTiMISE trials respectively. There was little overlap in eligibility for each trial (1.0% were eligible for HYVET and SPRINT; 0% were eligible for HYVET and OPTiMISE; 10.2% were eligible for SPRINT and OPTiMISE). Patients eligible for OPTiMISE were comparable to the general population in terms of frailty (eFI 0.12 [OPTiMISE] vs 0.11 [general population]), but had more morbidities (4 vs 3) and cardiovascular medications prescribed (4 vs 2). Patients in HYVET and SPRINT were less frail, multi-morbid and prescribed less cardiovascular medications. Overall, increasing frailty and a history of cardiovascular disease reduced the likelihood of being eligible for any trial.

Conclusions

Patients eligible for OPTiMISE appear to best represent the population aged ≥80 years attending UK primary care. Increasing frailty and/or multi-morbidity reduce the likelihood of eligibility for all three blood pressure trials. Caution should be exercised when applying the results from randomised controlled trials to management of blood pressure in frail and multi-morbid patients.

Acknowledgement/Funding

This study was funded by the National Institute for Health Research (NIHR) SPCR and Oxford CLAHRC
P2653Seasonal variations of myocardial infarction and sex-specific differences in Germany
Authors: Keller K , Hobohm L , Munzel T , Ostad M A
Published: October 2019

Background

Ischemic heart disease (IHD) is the most common cause of death with an increasing frequency worldwide. It accounts for approximately 20% of all deaths in Europe and the United States of America. Approximately 1/3 of the IHD patients present with sudden cardiac death. The acute presentation of IHD myocardial infarction (MI) is a life-threatening, serious health problem, which causes substantially morbidity and mortality. It is well established that the onset of MI follows a circadian and seasonal periodicity. Seasonal variation regarding the incidence and the short-term mortality of acute MI was frequently reported, but data about sex-specific differences are sparse.

Purpose

Thus, our objectives were to investigate seasonal variations of myocardial infarction.

Methods

We analyzed the impact of seasons on incidence and in-hospital mortality of patients with acute MI in Germany from 2005 to 2015. We included all MI patients (ICD code I21) with an acute MI (, but not those MI patients with a recurrent event in the first 28 days after a previous MI (ICD code I22)), who were hospitalized in Germany between 2005 and 2015, in this analysis (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2015, own calculations).

Results

The nationwide sample comprised 3,008,188 hospitalizations of patients with MI (2005–2015). The annual incidence was 334.7 per 100.000 population. Incidence inclined from 316.3 to 341.6 per 100.000 population per year (β 0.17 [0.10 to 0.24], P<0.001), while in-hospital mortality rate decreased from 14.1% to 11.3% (β −0.29 [−0.30 to −0.28, P<0.001). Overall, 377,028 (12.5%) patients died in-hospital.

Seasonal variation of both incidence and in-hospital mortality were of substantial magnitude. Seasonal incidence (86.1 vs. 79.0 per 100.000 population per year, P<0.001) and in-hospital mortality (13.2% vs. 12.1%, P<0.001) were higher in the winter than in the summer saeson. Risk to die in winter was elevated (OR 1.080 (95% CI 1.069–1.091), P<0.001) compared to summer season independently of sex, age and comorbidities. Reperfusion treatment with drug eluting stents and coronary artery bypass graft were more often used in summer.

We observed sex-specific differences regarding the seasonal variation of in-hospital mortality: males showed lowest mortality in summer, while females during fall. Low temperature dependency of mortality seems more pronounced in males.

Conclusions

Incidence of acute MI increased 2005–2015, while in-hospital mortality rate decreased. Seasonal variations of incidence and in-hospital mortality were of substantial magnitude with lowest incidence and lowest mortality in the summer season. Additionally, we observed sex-specific differences regarding the seasonal variation of the in-hospital mortality.

Acknowledgement/Funding

This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503)
P2660Definition of clinically relevant thresholds of acute kidney injury in patients with ST-elevation myocardial infarctions undergoing primary percutaneous coronary interventions
Authors: Schmucker J , Fach A , Osteresch R , Retzlaff T , Michel S , Garstka D , Wettwer T , Hambrecht R , Wienbergen H
Published: October 2019

Background

Although the clinical importance of deteriorating kidney function in patients with ST-elevation-myocardial infarctions (STEMI) on overall prognosis is generally accepted, there is conflicting evidence on the importance of small changes in renal function. Aim of the present study was to calculate clincially relevant thresholds for deterioration of renal function after STEMI.

Methods

From a large registry of patients with STEMI renal function was estimated calculating the glomerular filtration rate (GFR in ml/min/1.73 m2) with the CKD-EPI-equation. To assess acute kidney injury the ratio GFR (at peak creatinine))/ GFR (at admission) was calculated for each patient (with 1 representing no change). Patients were graded by GFR-reduction and assigned to 11 groups (G1 to G11) each representing 5% intervals.

Results

Of 6583 patients admitted with STEMI between 2006–2017 3518 (53%) had no change or a change <5% during hospital stay (G1) while 161 (3%) showed a decrease in GFR of ≥50% (G11). The rest of the patients could be attributed to G2- G10 (table). There was a pronounced correlation between extent of GFR-reduction and peak creatine kinase (indicating size of STEMI, r2=0.785; G1: 1521±1684 U/l vs. G11: 2885±2943 U/l, p<0.01) as well as left-ventricular ejection fraction (LVEF) (r2=0.79; G1: 50.9±9% vs. G11: 41.4±10%, p<0.01). However, no such correlation could be detected between GFR-reduction and amount of contrast media (CM) applied (r2=0.05, G1: 141±60 ml vs. G11: 139±61 ml, p=0.5). Analysis of outcome-data (1-year-mortality and major adverse cardiovascular and cerebrovascular events (MACCE: death, stroke, re-infarction)) revealed, that beneath a threshold of 25% deterioration of renal function did not significantly impact prognosis, while higher degrees of deterioration led to a 7-fold increase in mortality and a 5-fold increase in MACCE-rates (table).

Impact of GFR-reduction on outcome Group G1 G2 G3 G4 G5 G6 G7 G8 G9 G10 G11 GFR-reduction (in %) 0–4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 ≥50 Patients, n (%) 3518 (53) 881 (13) 717 (11) 492 (7) 327 (5) 196 (3) 119 (2) 88 (1) 48 (1) 36 (1) 161 (3) 1 year mortality (%) 7 4 5 8 7 15 20 22 39 43 50 1-year-MACCE (%) 12 8 8 12 10 19 27 27 49 49 52

Conclusions

These data from a large STEMI-registry show that small changes (less than 25%) in GFR did not significantly impact long-term outcome, while the impact was pronounced for all patients beyond that threshold. The degree of renal deterioration furthermore correlated with size of STEMI as well as reduction of LV-function after STEMI while no correlation to amount of contrast media could be found.
P2661Ventricular fibrillation during acute STEMI is not associated with early repolarization pattern on ECG recorded prior to the index ischemic episode
Authors: Demidova M M , Carlson J , Erlinge D , Platonov P G
Published: October 2019

Background

Generally considered as benign, ECG early repolarization (ER) pattern was recently claimed to be an indicator of increased susceptibility to fatal arrhythmias during acute ischemia. The victims of sudden cardiac death have been reported to have high prevalence of ER comparing with survivors of acute coronary event.

We aimed to test the association between the ER pattern on resting ECG recorded prior to ST-elevation myocardial infarction (STEMI) and the risk of ventricular fibrillation (VF) during acute phase of STEMI in non-selected population of STEMI patients.

Methods

For STEMI patients admitted to a tertiary care hospital for primary PCI during 2007–2010 (n=2286), all ECGs recorded prior to the date of admission with STEMI were extracted from a digital archive. The latest ECG recorded prior to the index STEMI was used for analysis.

After excluding ECGs with paced rhythm and intraventricular blocks with QRS duration ≥120ms, the remaining ECGs were processed using the Glasgow algorithm allowing automatic ER detection. The association between ER-pattern on historical ECG and VF during the first 48 hours of STEMI was tested using logistic regression.

Results

Historical ECGs were available for 1584 patients; 124 of them were excluded due to a paced rhythm or wide QRS, leaving 1460 patients available for analysis (age 68±12 years, 67% male). The time from historical ECG to STEMI was 16 (IQR 4–49) months. ER pattern was present on historical ECG in 272 of 1460 (18.6%) (ER+ group), among them in 90 (33%) – in inferior leads, in 116 (43%) – in lateral leads, in 66 (24%) – both in inferior and lateral leads.

ER+ patients were younger both at the time of historical ECG (64±13 vs 66±19; p=0.041) and at the time of STEMI (67±12 vs 68±12; p=0.033), and had lower heart rate on historical ECG (68±12 vs 73±15; p<0.001) than ER- patients. ER+ and ER- groups did not differ regarding clinical characteristics and conventional ECG measurements. The course of STEMI was complicated by VF in 106 patients (17 of them from ER+ group). The occurrence of VF during STEMI was not associated with ER-pattern on historical ECG (OR 0.875 95% CI 0.518–1.479; p=0.618). There was no association of ER pattern with VF before reperfusion (OR 0.54 95% CI 0.25–1.21; p=0.135) or reperfusion VF (OR 1.28 95% CI 0.55–3.01; p=0.569). No association was observed with regard to localization (inferior or lateral) of ER-pattern either.

Conclusion

In a non-selected population of STEMI patients the presence of ER-pattern on ECG recorded prior to the acute coronary event was not associated with VF during the first 48 hours of STEMI.
P2664Long-term follow-up in a large cohort of survivors after out-of-hospital cardiac arrest: global mortality and comparison with age-specific mortality rate in the general population
Authors: Caro Codon J , Rodriguez Sotelo L , Rey Blas J R , Rosillo Rodriguez S O , Gonzalez Fernandez O , Iniesta Manjavacas A , Armada Romero E , Fernandez De Bobadilla J , Ruiz Cantador J , Casas Sanchez B , Rivas Perez A , Martinez Marin L A , Garcia De Veas J M , Lopez-Sendon J L , Lopez-De-Sa E
Published: October 2019

Background

Data regarding long-term clinical outcomes after out-of-hospital cardiac arrest (OHCA) are scarce.

Purpose

To assess long-term mortality rate in OHCA patients, compare it with the general population age-specific mortality rate and identify relevant predictive factors.

Methods

All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA from August 2007 to January 2019 and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Stepwise regression techniques and Cox proportional hazards models were used to investigate clinical variables related to long-term survival. The study population was divided into four quartiles according to their age and their mortality rate was compared with age-specific data from the Spanish National Statistics Institute.

Results

The final analysis included 201 patients. Mean age was 57.6±14.2 years and 168 (83.6%) were male. The majority of patients experienced witnessed arrests related to shockable rhythms (176, 87.6%). Median time to ROSC was 18 (IQR 12–27) minutes and 14 patients (7.0%) were discharged in a poor neurological condition (CPC 3–4). Thirty-six patients (17.9%) died after a median follow-up of 40.3 months (18.9–69.1). A prognostic multivariate Cox model was developed and is shown in Table 1. Mortality was mainly driven by neurologic (33.%), cardiovascular (30.6%) and oncologic (30.6%) causes. Annual mortality rate per 1000 patients was statistically superior to that in the general population among the first three age quartiles: 18.08 (6.78–48.16) vs 0.64; 29.62 (12.33–71.16) vs 3.30; 63.07 (33.94–117.22) vs 7.77. Nevertheless, no significant differences were observed among the oldest patients, ranging from 68.6 to 90.7 years: 70.93 (43.45–115.78) vs 54.95.

Table 1. Cox proportional hazard model Variable Hazard Ratio Std. Err. p value 95% Confidence Interval Time from CA to CPR (per minute) 1.06 0.03 0.06 1.00–1.13 Non-shockable rhythm 2.93 1.11 0.01 1.39–6.16 Poor LVEF at discharge (per %) 1.03 0.01 0.01 1.01–1.06 Age at time of CA (per year) 1.04 0.01 0.01 1.01–1.06 CPC 3–4 at hospital discharge 3.50 1.43 <0.01 1.58–7.78

Figure 1

Conclusions

OHCA survivors face significant mortality during follow-up, and its long term prognostic impact may be higher among younger patients. Age at the time of CA, time from CA to CPR, non-shockable rhythm, poor LVEF and poor neurological condition at discharge are independent predictors of long term mortality.
P2679Normal high sensitive troponin I and suspected myocardial infarction, is the rapid rule out algorythm for all?
Authors: Marcusohn E , Epstein D , Roguin A , Zukermann R
Published: October 2019

Introduction

Since the introduction of High sensitive troponin assays, many studies showed that patients presenting to the ED with cardiac chest pain and HsTnI under 5 ng/dl have very good prognosis and extremely low risk for major cardiovascular events at follow up. These studies led to a few rapid rule out algorythms for MI according to undetectable HsTnI in first hours following admission.

Purpose

The aim of the study was to examine whether a maximal HsTnI under 5 ng/dl, in a hemodynamicaly stable patient, is sufficient to discharge a patient without further testing.

Methods

Retrospective analysis of patients admitted to the emergency depatment due to suspected myocardial infarction between February 2016 and December 2018. All patients had a HsTnI under 5 ng/dl and were either discharged home or admitted for further observation and testing. The collection of data was performed by the MDCLONE software from the electronic medical records in our medical center.

Results

Between February 2016 and December 2018, 10,936 patients were admitted to the emergency department due to chest pain or suspected MI. In 7925 (72%) the maximal HsTnI value was under 5 ng/dl. Group 1 included 6699 (85%) patients who did not undergo any further test and group 2 included 1226 (15%) who were admitted for further testing. Further testing included Coronary CT in 999 (81%) and Stress myocardial perfusion imaging (MPI) in 227 (19%). 11 patients underwent both tests. Out of the 999 patients examined with coronary CT, 114 (11%) needed further evaluation with coronary angiogiography and 41 required angioplasty and stening. 18 (7%) patients that were evaluated using stress MPI needed angio and 7 (3%) required stenting.

Comparing the group 1 and 2, patients who went through further testing were more likely to be older, with higher prevalence of diabetes, hypertenstion, smoking history and after CABG in the past. Group 1 had 0.07%, 0.16% and 0.33% all cause mortality in 30, 90 and 360 days respectivly. Group 2 had no mortality in 30 and 90 days, and 0.25% all cause mortality in 360 days. No statistical significance was reached in all time points.

There was no difference in re-admissions in the first 90 days after discharge between the groups.

Conclusions

Based on our data, patients admitted to the emergency department due to suspected myocardial infarction and known cardiovascular risk factors but with HsTnI under the 5 ng/dl, the use of rapid rule out algorithms may be questionable.

Acknowledgement/Funding

None
P2693Late catch-up phenomenon and late-term target lesion revascularization of two-stenting for coronary bifurcation lesions between first and second generation drug-eluting stents
Authors: Okabe K , Ohya M , Matsushita K , Kuwayama A , Murai R , Miura K , Shimada T , Amano H , Kubo S , Habara S , Tada T , Tanaka H , Fuku Y , Goto T , Kadota K
Published: October 2019

Background

The second generation drug-eluting stent (G2-DES) has been reported as superior to the first generation drug-eluting stent (G1-DES) in mid-term outcomes. However, the late-term outcomes between G1-DES and G2-DES in two-stenting for coronary bifurcation lesions are not well studied.

Purpose

To evaluate the late catch-up phenomenon and late-term target lesion revascularization (TLR) of two-stenting for coronary bifurcation lesions between G1-DES and G2-DES.

Methods

This study included 1133 lesions in 1089 patients undergoing drug eluting stent implantation with two stenting from 2004 to 2016. These consisted of 496 G1-DES implanted lesions and 637 G2-DES implanted lesions. Late-term follow-up angiography was performed without in-stent restenosis (ISR) and TLR at mid-term follow-up in 582 lesions (242 G1-DES lesions and 340 G2-DES lesions). ISR was defined as more than 50% restenosis. Late catch-up phenomenon was defined as ISR without ISR within 1 year following index stent implantation. Late-term TLR was defined as from 1 to 5 year TLR. Bifurcation lesions were defined as the main branch ranging from the proximal stem to the distal main branch with boundaries defined by 5 mm proximal and distal to the stent-implanted area, and the side branch ranging from the bifurcation carina to the distal side branch with boundaries defined by the carina and 5 mm distal to the stent-implanted area.

Results

The median follow-up duration was 5.1 years (the first and third quarters, 3.2 and 7.1 years). The late-catch up phenomenon rate significantly differed between the G1-DES and G2-DES groups (16.9% vs 8.4%, p=0.001). A significant difference in late catch-up between the same two groups was also observed in bifurcation lesions of the main branch (5.0% vs 0.6%, p=0.001) and side branch (10.3% vs 5.6%, p=0.033), respectively. The 5-year cumulative rates also differed between the two groups in TLR (8.2% vs 3.7% log-rank p=0.001), and late-term TLR (7.0% vs 3.6% log-rank p=0.001).

Conclusion

Two-stenting using G2-DES, compared with G1-DES, significantly reduced late-term restenosis and TLR. The restenosis rate in bifurcation area may be associated with differences between two groups in late-term outcome.
P2698Is stent thrombosis caused by patient-related factors or by operator-related factors?
Authors: Kamenik M , Widimsky P
Published: October 2019

Background/Introduction

Stent thrombosis (ST) is the most feared complication of percutaneous coronary intervention (PCI).

Purpose

To analyze the patient-, lesion- and operator-related risk factors of ST.

Methods

Coronary angiograms of 1764 consecutive patients admitted between 2014–16 with an acute coronary syndrome (ACS) to a large tertiary center have been analyzed retrospectively for the presence of ST. ST was found in 29 of them (1,6% of all ACS patients). Paired angiograms (initial PCI from the time of stent implantation and second angiography done at the time of ST) from these 29 ST patients were analyzed by two independent observers with focus on lesion characteristics and procedure techniques. Clinical and laboratory data were included in the analysis.

Results

The following risk factors for ST were found: renal insufficiency (OR 4,30; p<0,001), type 2. diabetes (OR 2.24, p=0,03), stent implantation for STEMI (OR 1,75; p=0,009), left main or left anterior descending artery as culprit lesion (OR 2,80; p<0,001), absolute platelet count (p=0,005) and absence of antiplatelet therapy prior to ST (OR 1,87; p=0,01). The rates of lesion-/operator-related factors among ST patients were: bifurcation lesion (n=7; 24%), heavy coronary calcifications (n=13; 44%), wrong stent size selection (diameter undersizing or incomplete lesion coverage) (n=6, 20%). A combination of at least one clinical/laboratory and one lesion/operator risk factor was identified in 28 patients out of 29 with confirmed ST (96%).

Conclusion

Stent thrombosis usually occurs when clinical, laboratory, lesion and/or operator-related risk factors combine together. While clinical, laboratory and lesion-related factors are well described in the literature, operator-related factors need more detailed research.
P2699Comparison of fractional myocardial mass, a vessel-specific myocardial mass-at-risk, with coronary angiographic scoring systems for predicting myocardial ischemia
Authors: Kim H.-Y , Choi J.-H , Doh J.-H , Lim H.-S , Shin E.-S , Koo B.-K , Lee J.-M , Kim S.-M
Published: October 2019

Aims

The burden of coronary artery disease has been assessed by various semi-quantitative angiographic scores, which are frequently different each other. A non-invasive and quantitative modality may substitute angiographic sores for prognostic implication and decision of revascularization strategy. We compared fractional myocardial mass (FMM) with angiographic scores for predicting myocardial ischemia.

Methods

In this multicenter registry, 411 patients who underwent coronary computed tomography angiography (CCTA) were followed by invasive coronary angiography and FFR measurement. CCTA–derived %FMM with diameter stenosis ≥70% (%FMM-70) or ≥50% (%FMM-50) were compared with 9 angiographic scores (APPROACH, Duke Jeopardy, BARI, CASS, SYNTAX, Jenkins, BCIS-1, Leaman, Modified Duke) and were tested regarding their performance for predicting FFR ≤0.80. Predictive performance of %FMM or angiographic scores for FFR ≤0.80 established in derivation cohort (N=250) and tested in validation cohort (N=161).

Results

The performance of %FMM-70 and %FMM-50 were similar to most angiographic scores (%FMM-70, c-statistics=0.76; %FMM-50, 0.71; angiographic scores, 0.68–0.79). The frequency of FFR ≤0.80 increased consistently according to %FMM-70, %FMM-50, and all angiographic scores (p<0.001, all). The optimal cutoff of %FMM-50 and %FMM-70 for FFR ≤0.80 were ≥34.5% and ≥9.8%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of %FMM-50 were 83%, 56%, 73%, 70%, 72%, and of %FMM-70 were 72%, 78%, 75%, 75%, and 75% using these cutoffs. Validation cohort showed consistent results.

Conclusion

%FMM correlated well with angiographic scores and had a potential to be used as a non-invasive alternative to the angiographic scores. The integration of the severity of stenosis and the amount of subtended myocardium may improve the detection of clinically significant coronary artery stenosis.
P2706Persistent impairment of coronary endothelial vasomotor responses is related to atheroma plaque progression in the infarct-related coronary artery of AMI survivors
Authors: Horikoshi T , Kugiyama K , Nakamura T , Obata J E , Yoshizaki T , Saito Y
Published: October 2019

Background

Although coronary endothelial vasomotor dysfunction predicts future coronary events, there are few human studies showing the relationship between endothelial vasomotor dysfunction and atheroma plaque progression in the same coronary artery.

Purpose

This study examined whether endothelial vasomotor dysfunction is related with atheroma plaque progression in the infarct-related coronary artery of ST-segment elevation myocardial infarction (STEMI) survivors using serial assessment of coronary plaque size with intravascular ultrasound (IVUS) and coronary vasomotor responses to acetylcholine (ACh).

Methods

This study included 50 patients with a first acute STEMI due to occlusion of left anterior descending coronary artery (LAD) and successful reperfusion therapy with percutaneous coronary intervention (PCI). IVUS and vasomotor response to ACh in the LAD were measured within 2 weeks after AMI (1st test) and repeated 6 months (2nd test) after AMI under optimal anti-atherosclerotic therapies. The impairment of vasomotor response to ACh was defined as <10% of the responses to ACh in 25 control subjects.

Results

Percent atheroma volume (PAV) and total atheroma volume (TAV) in the LAD progressed over 6 months of follow-up in 18 and 14 patients, respectively. Epicardial coronary artery dilation and coronary blood flow increase in response to ACh were persistently impaired at both the 1st and 2nd tests in 18 and 19 patients. In logistic regression analysis, the progression of PAV and TAV was significantly associated with patients with the persistent impairment of epicardial coronary diameter and blood flow response to ACh (PAV, OR, 6.2 [95% CI, 1.4–28], P=0.02 and 4.3 [1.2–16], P=0.03, respectively. TAV, 6.0 [1.4–26], P=0.02 and 5.5 [1.4–21], P=0.01, respectively). The progression of PAV and TAV had no significant association with the coronary vasomotor responses to ACh at the 1st test, traditional risk factors, PCI-related variables, medications, and the coronary vasomotor responses to sodium nitroprusside, an endothelium-independent vasodilator.

Conclusions

Persistent impairment of endothelial vasomotor function in the conduit arterial segment and the resistance arteriole was related to atheromatous plaque progression in the infarct-related coronary arteries of STEMI survivors despite optimized anti-atherosclerotic therapies.

Acknowledgement/Funding

None
P2723Diagnosis of acute myocardial infarction in the presence of left bundle-branch block
Authors: Nestelberger T , Cullen L , Lindahl B , Reichlin T , Greenslade J , Giannitsis E , Morawiec B , Koechlin L , Twerenbold R , Boeddinghaus J , Rubini M , Osswald S , Pickering J , Than M , Mueller C
Published: October 2019

Objective

Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician.

Methods

We prospectively evaluated incidence of AMI, and diagnostic performance of specific electrocardiographic (ECG) and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. Presence of LBBB, ECG criteria, and final diagnoses were centrally adjudicated by two independent cardiologists using the fourth universal definition of myocardial infarction.

Results

Among 8830 patients, LBBB was present in 247 patients (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1–12%), but high specificity (95–100%). The diagnostic accuracy as quantified by the receiver-operating-characteristics curve of hs-cTnT and hs-cTnI concentrations at presentation (AUC 0.91; 95% CI 0.85–0.96 and 0.89; 95% CI 0.83–0.95) as well as that of their 0/1h and 0/2h changes was very high. A diagnostic algorithm (Figure 1) combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1h or 2h derived in cohort 1 (45 of 45 (100%) of patients with AMI correctly identified), showed high efficacy and accuracy when externally validated in cohort 2 & 3 (28 of 29 patients, 97%).

Figure 1

Conclusion

Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with Hs-cTn testing at 0/1h or 0/2h allows early and accurate diagnosis of AMI in LBBB.

Acknowledgement/Funding

European Union, Swiss National Foundation, University Hospital Basel, University Basel
P2738Prognosis of the systemic right ventricle further refined: a role for myocardial strain analysis
Authors: Woudstra O I , Van Dissel A C , Van Der Bom T , De Bruin - Bon H A C M , Van Melle J P , Vliegen H W , Van Dijk A P J , Mulder B J M , Meijboom F J , Bouma B J
Published: October 2019

Background

Predicting heart failure in patients a with systemic right ventricle (sRV) due to transposition of the great arteries (TGA) is difficult. Strain parameters are easily available and detect early myocardial damage.

Purpose

To determine the value of strain parameters compared to cardiovascular magnetic resonance (CMR) derived parameters as predictors for heart failure-free survival in patients with an sRV.

Methods

In participants of a multicenter prospective trial, global longitudinal strain (GLS) was assessed on echocardiography using speckle tracking. Cox regression was used to determine the association of sRV GLS and postsystolic shortening, defined as >20% of myocardial contraction appearing after aortic valve closure, with the combined endpoint of progression of heart failure and death, compared to CMR derived parameters.

Results

Echocardiograms of 61/88 participants could be analyzed (age 34±11 years, 66% male, 34% congenitally corrected TGA). Mean GLS was −13.5±2.9% and 13 (21%) patients had postsystolic shortening. During 8 [7–9] years, 15 (23%) patients met the composite endpoint. sRV ejection fraction (mean 39±9%, HR=0.93/% [95% CI 0.87–0.99]), sRV end systolic volume (mean 80±31 ml/m2, HR=1.19 per 10ml/m2 [95% CI 1.01–1.40]), GLS (HR=1.25/% [95% CI 1.01–1.54]) and postsystolic shortening (HR=4.10 [95% CI 1.48–11.37]) were all associated with heart failure-free survival in univariable analysis. Optimal cut-offs for sRV ejection fraction and GLS were 30% and −10.5%, respectively, with comparable predictive value for heart failure-free survival (iAUC=0.66 and iAUC=0.68). Patients with both decreased strain (>−10.5%) and decreased RVEF (<30%) were at highest risk for heart failure and death (HR=19.83 [95% CI 4.92–80.01], iAUC=0.73).

Predicted heart failure-free survival

Conclusion

The predictive value of global longitudinal strain is comparable to CMR derived ejection fraction. Patients with both low ejection fraction and low myocardial strain are at highest risk of heart failure and death. These easily available parameters should be integrated in future risk prediction scores and can be used in the clinic to guide follow-up intensity.

Acknowledgement/Funding

This work was supported by the Dutch Heart Foundation [CVON 2014-18 project CONCOR-genes]
P2750Why should cardiopulmonary exercise testing be routinely used for assessing patients with valvular heart disease?
Authors: Cortina C , Sarrion M , Beltran C , Suberviola V , Briongos S , Sanchez A , Ponz I , Estevez A , Jimenez S , Cano J M , Munoz R
Published: October 2019

Introduction

The role of cardiopulmonary exercise testing (CPET) is unquestionable to assess prognosis in heart failure. In patients with valvular heart disease (VHD), the functional capacity (FC) is crucial to aid in the right timing of surgery. The aim of this study was to compare the assessment of the FC by CPET and NYHA and the correlation between ventilatory efficiency parameters and resting systolic pulmonary artery pressure (SPAP).

Methods

We studied 100 VHD patients (57% female) who underwent a CPET. We calculated the real METS (RM) as indexed peak VO2/3.5 (1 MET=3.5 ml O2/kg/min) and compared to estimated METS (EM) derived by the time of exercise. An agreement analysis between RM, EM and NYHA was calculated. The correlation among VE/Vslope CO2, EqCO2at anaerobic threshold (AT), PETCO2, partial pressure end-tidal CO2 at AT and SPAP was analyzed.

Results

The results are shown in Table and Figure. The RM and the EM were 4.7±1.7 and 5.5±3, respectively (p<0.01) with a low agreement (ICC=0.6, p<0.01). The agreement between NYHA and the classification obtained from peak % of predicted peak VO2 was very low (weighted kappa =0.06, p=0.28). In patients with severe mitral VHD, the ventilatory efficiency parameters were correlated with SPAP (PETCO2 (AT), r=−0.7, p=0.002; EqCO2 (AT), r=0.5, p=0.04:VE/Vslope CO2, r=0.3, p 0.2), whereas in those with severe aortic VHD, these correlations were much lower (PETCO2 (AT), r=−0.3, p=0.13; EqCO2 (AT), r=0.2, p=0.15; VE/Vslope CO2, r=0.18, p 0.31).

Total (n=100) Mitral regurgitation (n=35) Aortic regurgitation (n=23) Age 65 (29–86) 66 (30–84) 65 (11–87) LVEF (%) 62±6 63±6 61±7 SPAP (mmHg) 40±11 39±11 36±8 NYHA I (60%), II (33%), III (7%) I (63%), II (29%), III (9%) I (63%), II (33%), III (4%) Indexed peak VO2 (ml/min/kg) 16±6 17±6 19±8 Peak % predicted VO2 73±18 74±17 79±18 Predicted VO2 AT (%) 58±19 54±19 61±22 Eq CO2 AT 33±6 32±7 32±5 VE/VSlope CO2 33±6 32±7 33±8 PetCO2 AT 34±4 36±4 36±5

Type and degree of VHD

Conclusions

NYHA scale and estimation of METS derived from the time of exercise clearly overestimated the FC of our population. In our series, the ventilatory inefficiency in patients with mitral VHD could be a surrogate marker of advanced disease and could lead to an earlier intervention.
P2756Risk of stroke subsequent to infective endocarditis: a nationwide study
Authors: Ostergaard L , Andersson N W , Kristensen S L , Dahl A , Bundgaard H , Iversen K , Bruun N E , Gislason G , Pedersen C T , Valeur N , Kober L , Fosbol E L
Published: October 2019

Background

Patients with infective endocarditis (IE) are at high risk of cerebral embolization, however little is known about the risk of stroke subsequent to IE in patients with stroke during IE admission.

Purpose

To investigate the risk of stroke after discharge of IE in patients with stroke during IE admission compared with patients without stroke during IE admission.

Methods

Using Danish nationwide registries we identified non-surgically treated patients with IE discharged alive, in the period 1996–2016. The study population was grouped in 1) patients with stroke during IE admission and 2) patients without stroke during IE admission. Crude cumulative risk of stoke were calculated using the Aalen-Johansen estimator accounting for death as a competing risk. Multivariable adjusted Cox proportional hazard analysis was used to compare the associated risk of stroke between groups. We identified differentials in the associated risk of stroke during follow-up between groups (p=0.006 for interaction with time), and follow-up was split into 0–1 year and 1–5 years time periods.

Results

We identified 4,284 patients with IE, 239 patients (5.6%) with stroke during IE admission (median age: 71.9 years, 58.2% males), and 4,045 patients (94.4%) without stroke during IE admission (median age 69.7 years, 64.8% males). The crude cumulative risk of stroke within 1 year of follow-up is shown in Figure Panel A, and with 1 to 5 years of follow-up in Figure Panel B. In multivariable adjusted analyses, the associated risk of stroke was higher in patients with stroke during IE admission within a follow-up period of 1 year, HR 3.21 (95% CI: 1.66–6.20) compared with patients without stroke during IE admission. From 1 to 5 years of follow-up, we identified no difference in the associated risk of stroke between groups, HR 0.91 (95% CI: 0.33–2.50).

Cumulative incidence of stroke

Conclusion

Non-surgically treated patients with IE who had a stroke during IE admission were at significantly higher associated risk of subsequent stroke – although not significant beyond 1 year after discharge from IE. These findings underline the need for identification of causes and mechanisms of recurrent strokes after IE to develop preventive means.
P2763Clinical prognosis of pure right-sided infective endocarditis without association to cardiac devices or intravenous drug abuse
Authors: Vilardell P , Moral S , Bosch D , Morales M , Frigola J M , Albert X , Robles R , Aboal J , Ballesteros E , Brugada R
Published: October 2019

Background

Pure right-sided infective endocarditis (RSIE) without association with cardiac devices or intravenous drug users (IVDUs) is an entity with unclear predisposing factors and prognosis.

Purpose

To evaluate predisposing factors and prognosis of pure RSIE compared tothose associated to cardiac devices or IVDUs.

Methods

280 consecutive patients with endocarditis were included retrospectively in a protocol of clinical and imaging follow-up. Endocarditis-related event was defined as endocarditis mortality or open-surgery requirement. Besides, a review and meta-analysis of the literature between january 2000 and december 2018 were performed.

Results

Fifty-two (19%) patients presented RSIE: 20 of them (39%) were pure RSIE. Intravascular catheters carriers (25% vs 3%; p=0.026) and congenital heart diseases (20% vs 0%; p=0.018) were associated to pure RSIE. These patients demonstrated the worst clinical prognosis, with the highest in-hospital mortality (25% vs 3%; p=0.026) and endocarditis-related event rate (45% vs 6%; p=0.001), being pure RSIE independently associated with in-hospital endocarditis-related events (OR=8.40; 95% CI, 1.13–62.68; p=0.038). Four studies, including ours, with 315 participants diagnosed of RSIE were evaluated in meta-analysis: 94 individuals (30%) presented pure RSIE.This group demonstrated a higher in-hospital mortality than those with cardiac devices or IVDUs (RR=2.854; 95% CI, 1.640–4.965; P<0.001; I2=0.0%; Figure 1).

Figure 1. RSIE and in-hospital mortality based on groups: cases with pure RSIE versus those with cardiac devices or IVDUs.

Conclusions

Pure RSIE is the worst prognosis group among RSIE with the highest endocarditis-related event rate and in-hospital mortality. This growing group should stake out the benign impression and recommendations given to RSIE among IE patients.