bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 12265: Evaluation of Aortic Valve Calcification in Patients With Suspected Cardiac Amyloidosis
Authors: Ng Daniel , Moussa Karine , Allinson Francis , Behroozian Adam , Jordan Timothy , Puglisi Leah , Stinis Curtiss , Teirstein Paul , Mohan Rajeev
Published: December 2023

Introduction:
Cardiac amyloidosis (CA) is characterized by the deposition of misfolded proteins within the heart causing a restrictive cardiomyopathy. Transthyretin (TTR) is one of the most common proteins implicated in CA, as well as in aortic stenosis (AS). The mechanism of TTR-CA associated AS is unclear.

Hypothesis:
We propose patients with severe AS being evaluated for transcatheter aortic valve replacement (TAVR) and suspected TTR-CA by echocardiogram will have an increased aortic valve calcium score. Secondary outcomes include post-procedural complications.

Methods:
This was a single-center, retrospective analysis of patients with severe AS referred to the Scripps system for TAVR between January 2017 and November 2022. A total of 496 patients were included and divided into two cohorts. The enriched (Likely CA) cohort consisted of patients with both IVS ≥1.2 cm and average mitral annular systolic s’ ≤ 6 cm/s. The unenriched (Unlikely CA) cohort met only one or none of the above echocardiographic criteria.

Results:
Of the 496 patients analyzed, 145 patients were in the Likely CA cohort and 351 patients were in the Unlikely CA cohort. Baseline demographics (Table 1A) and echocardiographic data (Table 1B) are shown. There was no statistically significant difference in the primary end point of aortic valve calcium score between the Likely CA and Unlikely CA cohort (p = 0.914). The Likely CA cohort had evidence of worse diastolic function and increased left ventricular dimensions. There was a non-significant trend towards an increased rate of post-procedural atrial fibrillation in the Likely CA cohort (p = 0.051). Otherwise, there was no significant difference in post-procedural complications between the two cohorts (Table 1C).

Conclusions:
In our analysis of patients with likely TTR-CA and AS compared to those with lone AS, there was no difference in aortic valve calcium score. This suggests aortic valve leaflet calcification is a process independent of TTR-CA.
Abstract 12276: The Mediating Effects of Insomnia Symptom Severity on the Relationship Between Acculturation Stress and the Prevalence of Hypertension Among Latinx Adults
Authors: Giorgio Luciana , Arias Darwin
Published: December 2023

Introduction:
Hypertension (HTN), a well-known risk factor for cardiovascular morbidity and mortality, affects about 44% of Latinxs in the US. Acculturation stress, a type of sociocultural stress, is associated with poor cardiovascular outcomes (i.e., HTN), in this population yet the mechanisms driving this association are understudied. Insomnia symptom severity(ISI) has been associated with increased acculturation stress and increased risk of HTN. So, ISI may drive the positive association between acculturation stress and HTN among Latinxs. We aim to examine the direct and indirect effects of acculturation stress on the prevalence of HTN via ISI among Latinxs.

Hypothesis:
We hypothesize that increased acculturation stress will be directly and indirectly associated with an increased prevalence of hypertension via increasing ISI.

Methods:
Using a sample of Latinx adults participating in the Hispanic Community Health Survey/Study of Latinos Baseline and Sueño Ancillary studies (n=1464), we conducted weighted unadjusted and adjusted bias corrected bootstrap tests of mediation. Acculturation stress was measured through the Hispanic Stress Index. ISI was measured through the Insomnia Severity Index. Hypertension was categorized as blood pressure >130/80 or antihypertensive medication use. Adjustments for age, sex, nativity status, body mass index, and site were made.

Results:
Participants were
M
age=41.99 (SD=12.96). Most were women (53.76%), immigrants (65.44%), and of Mexican heritage (31.80%). Participants had a
M
ISI=7.38 (SD=6.49). About 39.01% were hypertensive. The total and direct effects of acculturation stress on the prevalence of HTN were statistically significant (PR=1.01, 95% CI: 1.00-1.02; PR=1.01, 95%CI: 1.00-1.02). ISI was a statistically significant mediator in the relationship between increased acculturation stress and increased prevalence of HTN in unadjusted models (Indirect effect=0.002, BCa 95% CI: 0.0002-0.004).

Conclusions:
Results suggest acculturation stress impacts HTN via increasing ISI among Latinxs. These findings should be replicated using longitudinal designs. If replicated, ISI may be an important target of intervention to mitigate the effects of acculturation stress on HTN among Latinxs.
Abstract 12312: UBC9 Protects Against Cardiac Hypertrophy and Heart Failure via Regulating FOXO3-LMCD1 Pathway
Authors: Zhou Ting , Wu Hanlin , Liu Chunying , Jia Xiaodong , Liu Dan , Yan Chenghui , song haixu , Han Yaling
Published: December 2023

Introduction:
Pathological cardiac hypertrophy is a major risk factor for heart failure (HF) and a leading cause of morbidity and mortality worldwide. However, the molecular mechanisms underlying pathological cardiac hypertrophy remain unclear.

Hypothesis:
In the present study, we investigated the possible underlying effects of UBC9 on cardiac hypertrophy and heart failure.

Methods:
UBC9 was upregulated in samples of human hypertrophic hearts compared to normal controls using RNA sequencing analysis from the Gene Expression Omnibus (GEO, https://www.ncbi.nlm.nih.gov/geo). Real-time polymerase chain reaction (RT-PCR) and western blotting were used to analyze the expression of UBC9 in samples of human hypertrophic hearts and normal controls. Mice with cardiac-specific over-expression and low-expression of UBC9 by intravenous injection of adeno-associated virus 9 (AAV9)-encoding UBC9 under the control of cardiac troponin T (cTnT) promoter were subjected to transverse aortic construction (TAC). Co-immunoprecipitation assays were performed to determine the mechanism by which UBC9 regulates the expression of forkhead box O3 (FOXO3).

Results:
UBC9 expression increased in the hearts of patients with hypertrophic cardiomyopathy (HCM) and pressure overload-induced mice, as well as in the Neonatal Mouse Cardiomyocytes (NMCMs) treated with phenylephrine (PE). Cardiac cell-specific UBC9 over-expression alleviates cardiac hypertrophy and dysfunction. Cardiac cell-specific UBC9 knockout aggravates cardiac hypertrophy and heart failure. Mechanistically, UBC9 inhibits LIM and cysteine-rich domain 1 (LMCD1) expression by directly binding to forkhead box O3 (FOXO3), a transcription factor of LMCD1, and promoting FOXO3 dephosphorylation and nuclear translocation, independent of SUMOylation.

Conclusions:
This study provides a new insight that UBC9, as a potential intervention target in cardiac hypertrophy and HF, may contribute to exploring effective therapeutic strategies for pathological cardiac hypertrophy treatment.
Abstract 12357: Investigating Sex-Specific Factors Influencing Atrial Fibrillation Burden in Patients With Persistent Atrial Fibrillation: A DECAAF II Subanalysis
Authors: Younes Hadi , Feng Han , Sohns Christian , Forkmann Mathias , Mekhael Mario , Noujaim Charbel , Chouman Nour , Assaf Ala' , Lim Chanho , Dagher Lilas , huang chao , El Hajjar Abdel Hadi , donnellan eoin , Kreidieh Omar , Pandey Amitabh C , Marrouche Nassir , mahnkopf christian
Published: December 2023

Background:
Atrial Fibrillation(AF) burden provides insights beyond the common binary classification of AF recurrence after catheter ablation(CA).

Objective:
We sought to investigate the predictors of AF burden in patients with persistent AF(PeAF) at 1 year post-CA, with a focus on sex-based differences. The analysis was conducted separately for both female and male.

Methods:
We examined all PeAF patients in the DECAAF II trial and divided them into 2 groups, women and men. Baseline demographics and late gadolinium enhancement magnetic resonance imaging data were reviewed. Patients were instructed to provide single-lead home ECG strips once daily. AF burden was calculated by dividing the total number of days in AF over the total number of days when strips were sent. Univariate and multivariate analysis were performed to predict AF burden beyond the 3-month blanking period.

Results:
We included 658 patients(20% Female,80% male) who transmitted 215825 ECG strips. The average AF burden across the population was 17%. The mean AF burden was higher in women(21%) than in men(16%)(p<0.01). In women, on univariate analysis, baseline fibrosis(p<0.05), history of stroke(p<0.01) and left atrial(LA) volume(p<0.01) were positively correlated with AF burden. After conducting a multivariate analysis, we found that baseline fibrosis(p<0.05), history of stroke(p<0.05), vascular diseases(p<0.05), and LA volume(p<0.01) were independent predictors of AF burden. In men, on univariate analysis, age(p<0.01), baseline fibrosis(p<0.01), hyperlipidemia(p<0.01) and LA volume(p<0.01) were positively correlated with AF burden. After conducting a multivariate analysis, only LA volume (p<0.01) and age(<0.01) continued to be significantly related(Table 1).

Conclusion:
Sex-specific management strategies are crucial for addressing AF, as our study demonstrates a significant impact of sex on predicting AF burden monitored by a single-lead handheld smartphone ECG device.
Abstract 12359: Does E/e’ Independently Predict Atrial Fibrillation Recurrence Post Catheter Ablation?
Authors: Zimmer Ari , Varrias Dimitrios , Coleman Kristie , Zafeiropoulos Stefanos , Gasparis Christopher , Leavitt Jonas , Wolf Elliot , Epstein Laurence , Goyal Rajat , Mountantonakis Stavros
Published: December 2023

Introduction:
Left atrial size has been traditionally used as a surrogate of atrial fibrillation (AF) chronicity and prognosticator for success post catheter ablation (CA). The importance of other echocardiographic parameters in predicting maintenance of sinus rhythm post CA has not been well studied.

Research Question:
Which echocardiographic parameter best predicts 1 year AF-free survival post CA?

Goal:
Elucidate which parameter best independently predicts AF recurrence and identify which patients may benefit from earlier intervention.

Methods:
We conducted a retrospective cohort study of patients with symptomatic AF. We included patients who were undergoing first-time ablation and had follow-up visits for at least 24 months post CA. Baseline echocardiographic and laboratory data were extracted from common electronic medical records across a large healthcare system. Clinical outcomes were determined after manual review of each 6, 12, and 24-month visit. Echocardiographic measures were used in a stepwise estimation logistic regression model using STATA /IC 16.1.

Results:
Out of a cohort of 1,435 patients (age 67.1 ± 10.4 years, 565 female) who received CA for AF between 2014 and 2022, 402 had AF recurrence at their 12-month follow-up visit (28%). Larger left atrial volumes (p = 0.01), higher mitral valve E/e’ ratios (p = 0.008), and higher degree of aortic regurgitation (p = 0.02) were univariately associated with AF recurrence in 1 year. Stepwise estimation regression model showed that after adjusting for age, sex, BMI, mitral valve E/e’, and left atrial volume, the only independently associated predictor was mitral valve E/e’. The R
2
of our model was 0.31 and its predictive accuracy for recurrence was 85%.

Conclusion:
Among all echocardiographic measures, the diastolic dysfunction parameter of E/e’ was the only independent predictor of 1-year AF recurrence.
Abstract 12389: Predictors of Elevated High-Sensitivity C-reactive Protein in a US Population With Atherosclerotic Cardiovascular Disease: Results From the National Health and Nutrition Examination Survey
Authors: Ray Kausik K , Faurby Mads D , Letnar Gasper , Lophaven Søren , Mortensen Julie T , Nanna Michael G , Reuter Simon B , Sattar Naveed , Mohseni Zonoozi Amir A , Navar Ann Marie
Published: December 2023

Introduction:
Evidence suggests that inflammation is causally related to ASCVD. Elevated levels of high-sensitivity C-reactive protein (hsCRP) may identify individuals most likely to benefit from emerging anti-inflammatory therapies but hsCRP is not measured routinely in clinical practice.

Aims:
To identify potential risk factors indicating elevated hsCRP in patients with ASCVD.

Methods:
This cross-sectional study using data from the 1999–2010 and 2015–2018 NHANES cycles included adults (≥ 20 years old) with self-reported ASCVD and available hsCRP levels, plus sex and race/ethnicity data. Elevated hsCRP was defined as hsCRP 2–10 mg/L. Following weighting towards the US population, risk factors were assessed using multivariate logistic regression.

Results:
In total, 3415 individuals with ASCVD were included. In the weighted population (n = 13,008,371), 54.5% had elevated hsCRP. Median hsCRP levels increased with increasing numbers of risk factors (
Figure 1
). Characteristics of groups with and without elevated hsCRP are shown in
Table 1
. Smoking (OR 1.78 [95% CI: 1.11, 2.87];
p
= 0.018) and BMI (OR per unit increase: 1.10 [1.06, 1.15];
p
< 0.001) were associated with higher odds of elevated hsCRP; receipt of metabolic medication (OR 0.55 [0.39–0.77];
p
< 0.001) and male sex (OR 0.60 [0.44–0.83];
p
= 0.002) were associated with lower odds of elevated hsCRP.

Conclusion:
In this analysis of US NHANES data, smoking, BMI and female sex were linked to elevated hsCRP. The greater the number of risk factors, the higher the hsCRP level. Targeted hsCRP screening should be considered to identify those most likely to benefit from emerging anti-inflammatory therapies.
Abstract 12440: Depression and Anxiety Accelerate the Rate of Gain of Cardiovascular Risk Factors: Mechanism Leading to Increased Risk of Cardiac Events
Authors: Civieri Giovanni , Osborne Michael , Abohashem Shady , Grewal Simran , Gharios Charbel , Aldosoky Wesam , Qamar Iqra , Choi Karmel , Smoller Jordan , Tawakol Ahmed A
Published: December 2023

Introduction:
Depression and anxiety are associated with a greater incidence of major adverse cardiovascular events (MACEs).

Hypothesis:
We hypothesized that: 1) depression and anxiety accelerate the development of cardiovascular risk factors (CVDRFs), which in turn significantly heightens MACE risk, and 2) a genetic marker of stress sensitivity (polygenic risk score for neuroticism; nPRS) also associates with accelerated gains of CVDRFs.

Methods:
Subjects enrolled in the Mass General Brigham Biobank were studied. Depression, anxiety, CVDRFs and MACE were defined using ICD codes. Subjects <18 years old, with previous MACE or who developed depression/anxiety after study start date were excluded. CVDRFs were defined as hypertension, hyperlipidemia, and diabetes mellitus. The time between study start date and development of first new CVDRF was measured over 10 years of follow-up. Additionally, nPRS was assessed for subjects who provided genetic data; age of first CVDRF diagnosis was ascertained in this subgroup.

Results:
Data were obtained for 71,262 subjects (age 49.0 ± 15.6 yrs, 44.7% male). 27,048 (38.0%) subjects gained a new CVDRF (mean time 4.8 ± 2.6 yrs). Depression (β=-0.591; p<0.001) and anxiety (β=-0.567; p<0.001) associated with earlier development of a new CVDRF after adjusting for age, sex, and preexisting CVDRFs (
Fig. 1A).
Further, in adjusted analyses, depression and/or anxiety increased the risk of MACE (adjusted odds ratio: 1.353; p<0.001). Mediation analysis shows that 38.9% of the effect of depression and/or anxiety on MACE is explained by the accelerated gains in CVDRFs. Similarly, higher genetic sensitivity to stress (nPRS) associates with an earlier onset of first CVDRF (adjusted β=-0.317; p=0.005,
Fig. 1B)
.

Conclusions:
Depression and anxiety accelerate the acquisition of CVDRFs, which in turn significantly explains the heightened risk of MACE. Genetic risk associated with stress sensitivity also accelerates the development of CVDRFs.
Abstract 12454: Weak Supervision Enables Scalable Post-Market Surveillance on Medical Wearables
Authors: Yoo Richard M , Viggiano Ben T , Pundi Krishna N , Fries Jason A , Zahedivash Aydin , Podchiyska Tanya , Din Natasha , Shah Nigam H
Published: December 2023

Introduction:
With the advent of consumer-facing devices that can render atrial fibrillation (AF) pre-diagnosis, medical wearables now have the potential to affect diagnosis rates and medical care. Post-market surveillance is necessary to understand the impact of wearables on patient outcomes and health care utilization, but is hindered by the lack of codified terms in EHR that capture wearable use.

Research Questions:
Constructing a post-market surveillance system therefore requires a classifier that identifies mentions of AF pre-diagnosis in unstructured EHR data. However, fine-tuning classifiers require large, hand-labeled training sets that can be costly to generate. It is unclear whether a scalable surveillance system could be built for wearables.

Methods:
Two weakly-supervised approaches were evaluated to reduce clinical note labeling overhead: one using programmatic codes, and the other using prompts to large language models (LLMs). Probabilistically labeled notes were then used to fine-tune a classifier, which identified patients with AF pre-diagnosis mentions. A retrospective cohort study was conducted, where the characteristics and care patterns of patients identified by the classifier were compared against those who did not receive pre-diagnosis.

Results:
Label model derived from prompt-based labeling heuristics using LLMs (precision = 0.67, recall = 0.83, F1 = 0.74) nearly achieved the performance of code-based heuristics (precision = 0.84, recall = 0.72, F1 = 0.77), while cutting down the cost to create a labeled training set. The classifier learned on the labeled notes accurately identified patients with AF pre-diagnosis (precision = 0.85, recall = 0.81, F1 = 0.83). Those patients who received pre-diagnosis exhibited different demographic and comorbidity characteristics, and were enriched for anticoagulation and eventual diagnosis of AF. At the index diagnosis, existence of pre-diagnosis did not stratify patients on clinical characteristics, but did correlate with anticoagulant prescription.

Conclusion:
Our work establishes the feasibility of an EHR-based surveillance system for wearable devices that render AF pre-diagnosis. Weakly-supervised approaches can be effective in reducing test set labeling costs.
Abstract 12463: Awareness and Perceptions Towards Inflammatory Risk in Atherosclerotic Cardiovascular Disease: A Multinational Survey Amongst Cardiologists
Authors: Marx Nikolaus , Komuro Issei , Mohseni Zonoozi Amir A , Prasad Preethy , Qian Juying , Saraiva Jose F , Shete Abhijit V , Catapano Alberico L
Published: December 2023

Background:
In patients (pts.) with atherosclerotic cardiovascular disease and chronic kidney disease (ASCVD+CKD), systemic inflammation (SI) contributes to high cardiovascular (CV) risk. Awareness and perception of SI and use of high sensitivity C-reactive protein (hsCRP) amongst cardiologists is less understood.
Aims
FLAME-ASCVD survey assessed the level of awareness and perceptions of cardiologists towards the role of SI (primary objective) and hsCRP as a biomarker in pts. with ASCVD+CKD.

Methods:
This was a non-interventional, cross-sectional, global online survey-based study that collected data from interventional (IC) and/or general cardiologists (GC), treating ≥15 ASCVD+CKD pts./month and practiced for ≥3 years. Survey used an online questionnaire, across 10 countries (Australia, Brazil, China, France, Germany, India, Italy, Japan, Saudi Arabia, UK) during Mar-May 2023. Data were analysed using descriptive statistics.

Results:
Of the 1755 who responded to the survey invitation, 602 eligible cardiologists (IC=247, GC=355) completed the questionnaire (~60/country). Overall, CV risk factors discussed with pts. were hypertension (88%), hyperlipidaemia (82%), hyperglycaemia (78%), and SI ranked tenth at 43%. Overall, 72% agreed that SI was a risk factor for ASCVD, 64% as one of the drivers for CV events and 73% agreed that SI contributed to risk of recurrent CV events. Overall, 64% (n=386) acknowledged intent to test for SI in management, and 41% of these, stated that results influenced decision to initiate anti-inflammatory treatment. 49% of those not measuring for SI (n=216), stated lack of medication for SI as a reason. Overall, 47% used hsCRP as a test for SI and 45% stated the need for guidelines as one of the factors to establish testing in practice.

Conclusion:
In this survey, SI was perceived as a CV risk factor, but not to the same level as traditional CV risk factors. There is a need for better understanding of SI and hsCRP testing in patients with ASCVD+CKD.
Abstract 12465: The Diagnostic Pathway for Patients With Light Chain (AL) Amyloidosis: Analysis of a Large US Claims Database
Authors: Lyons Genevieve , Thompson Jeffrey , Lousada Isabelle , Maurer mathew S , Catini Julia , Manwani Richa
Published: December 2023

Background:
Light-chain amyloidosis (AL) is a rare, multisystem disease with a varied presentation, and significant morbidity and mortality. Diagnostic delay can result in poor survival, particularly in patients with cardiac involvement.
Aim:
To understand the path to diagnosis for patients with AL using US-based claims data.

Methods:
We conducted a retrospective cohort study of adults (age ≥18 years) with AL using IQVIA PharMetrics Plus data (Jan 1, 2016-Sep 30, 2022). Patients with ≥2 AL diagnosis codes (index is date of second diagnosis; ICD-10: E85.81), ≥24 months’ continuous coverage pre-index, and ≥6 months follow-up were included. Results are reported using descriptive statistics.

Results:
A total of 1276 patients (58% male, mean age 62 years, 64% treatment naïve) met inclusion criteria at index. In the 2 years pre-index, patients saw the highest number of cardiologists (mean 4.1) compared with hematologist/oncologists (mean 1.8) and nephrologists (mean 1.7). Cardiovascular (CV) symptoms were experienced by 87% of patients within 2 years prior to index; 55% experienced their first CV symptom >1 year prior to index. 71% of patients with CV symptoms had features suggestive of renal involvement, eg, proteinuria. Almost a quarter (23%) of patients had at least 1 emergency room (ER) visit and a third (31%) had at least one inpatient hospitalization (IP) over the 6-month follow-up period. Over half of the ER visits and IP stays were due to CV-related symptoms. Among patients whose diagnosis of AL was delayed (with early onset of CV symptoms >1 year pre-index) compared with those who did not, the crude unadjusted odds of experiencing a CV related ER visit were 53% higher (OR 1.53, 95% CI: 1.09, 2.14; p=0.01).

Conclusions:
Cardiologists are a key part of the AL diagnostic pathway, as the most visited specialty prior to diagnosis. CV symptoms are the most common experienced by patients with AL and account for the largest proportion of IP stays and ER visits. Patients with delayed AL diagnosis from their first CV symptoms experienced significantly more CV-related ER visits than those without delayed diagnosis. Prompt diagnosis may help prevent a decline and the presence of heart failure symptoms with proteinuria or monoclonal gammopathy should raise suspicion of AL.
Abstract 12472: Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support
Authors: Gregory Vasiliki , Okumura Kenji , Levine Elliot , Isath Ameesh , Khan Shazli , Kai Masashi , Spielvogel David , Ohira Suguru
Published: December 2023

Introduction:
The new heart allocation policy prioritizes veno-arterial extracorporeal membrane oxygenation (ECMO) supported candidates at the highest status. Evidence suggests that left ventricular (LV) unloading during ECMO is beneficial by reducing the LV end-diastolic pressure and increasing support. The impact of LV unloading on outcomes following bridging to heart transplant (HT) with ECMO is uncertain.

Methods:
Under the new policy (Oct 18, 2018 to Jun 30, 2022), 596 patients on ECMO at the time of HT were identified in United Network for Organ Sharing database and divided into two groups: ECMO alone (N=387) vs. ECMO with LV unloading (N=209). Sub-analysis was performed in LV unloading group: Impella (N=73) vs. intra-aortic balloon pump (IABP) (N=136).

Results:
The median duration on the waitlist was 5 days for both groups. The ECMO alone group had younger recipients (ECMO alone, 48 vs. LV unloading, 53 years, P=0.018) and younger donors (ECMO alone, 29 vs. LV unloading, 32 years, P=0.041). Other characteristics were similar. In LV unloading group, recipient characteristics were comparable between Impella and IABP patients. Kaplan-Meier survival analysis showed comparable 1-year survival rates between the groups (ECMO alone, 88.1±1.8% vs. LV unloading, 89.8±2.3%, P=0.96, Figure 1A). Multivariable Cox hazard model revealed no association between LV unloading and post-HT mortality (hazard ratio, 0.95, 95% confidence interval, 0.59, 1.54, P=0.80). In the different LV unloading methods, 1-year survival was similar: Impella, 90.6±3.7% vs. IABP, 88.9±2.9%, P=0.65, (Figure 1B). There was a trend toward a higher stroke rate with Impella (12%) compared to IABP (5.2%) (P=0.061).

Conclusions:
LV unloading did not impact survival in patients bridging to HT with ECMO under the new allocation policy, regardless of the specific mode of LV unloading. Individualized approaches are crucial for patients on ECMO undergoing HT, as LV unloading might not always be necessary.
Abstract 12481: Comparative Outcomes of Catheter Directed Thrombolysis Plus Systemic Anticoagulation versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis
Authors: Machanahalli Balakrishna Akshay , Mathew Kalathil Ruth Ann , PUSAPATI SUMA , Atreya Auras R , Mehta Aryan , Bansal Mridul , Aggarwal Vikas , Basir Mir B , Kochar Ajar , Truesdell Alexander G , Vallabhajosyula Saraschandra
Published: December 2023

Introduction:
There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE).

Hypothesis:
This study sought to compare outcomes of catheter directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone.

Methods:
A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing outcomes of CDT+SA versus SA alone in intermediate-risk PE. The major outcomes were in-hospital, 30-day, 90-day, and 1 year mortality, minor and major bleeding, and blood transfusion, right ventricular (RV) recovery, and length of stay (LOS). We used random-effects models to aggregate data and to calculate pooled incidence and risk ratios (RR) with 95% confidence intervals (CIs).

Results:
A total of 15 (two randomized, 13 observational) studies with 10,549 (2,310 CDT+SA and 8,239 SA alone) patients were included. Compared with SA, CDT+SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p =0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p =0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p =0.04). There were no significant differences between the two cohorts in rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p =0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p =0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p =0.08).

Conclusions:
CDT+SA is associated with significantly lower short-term and long-term all-cause mortality without any differences in major/minor bleeding, in patients with intermediate-risk PE.
Abstract 12496: Prognostic Value of Glasgow Prognostic Score and Its Modified Scores on 5-Year Outcome in Patients With Percutaneous Coronary Intervention
Authors: Li Jiawen , Li Yulong , Yan Kailun , Yang Yuejin , Yuan Jinqing , Zhao Xueyan
Published: December 2023

Background:
Glasgow Prognostic Score (GPS) is an inflammatory score commonly used in clinical practice. In recent years, its modified scores have emerged, including modified GPS (mGPS) and hs-CRP-modified GPS (hs-mGPS). However, the long-term predictive values of these three scores (GPS, mGPS, and hs-mGPS) in coronary heart disease (CHD) remains unclear.

Aim:
To assess the predictive values of GPS, mGPS, and hs-mGPS on long-term survival in patients following percutaneous coronary intervention (PCI).

Methods:
Consecutive 10,724 patients with PCI were enrolled in the year of 2013. The primary endpoint was 5-year all-cause death.

Results:
Finally, 8909 patients with complete clinical data and no loss of follow-up were included. According to the original scores, the risk of all-cause death in patients with a high score of GPS, mGPS, and hs-mGPS was significantly higher than that in patients with a low score. All GPS, mGPS, and hs-mGPS had predictive values for all-cause death with relatively lower AUC of 0.534, 0.522, and 0.545, respectively. In further analysis, we improved hs-mGPS by using hs-CRP 2 mg/L and albumin 40 g/L, and established the CHD-hs-mGPS. The AUC of CHD-hs-mGPS was 0.554 which was significantly higher than mGPS (P = 0.017) and was numerically higher than GPS and hs-mGPS in the total population. Of these four scores (GPS, mGPS, hs-mGPS, and CHD-hs-mGPS), only the CHD-hs-mGPS had a predictive value for both ACS and non-ACS subgroups.

Conclusion:
For CHD patients, GPS, mGPS, and hs-mGPS had significant long-term predictive value for all-cause death. The score we modified, CHD-hs-mGPS, simultaneously had a predictive value in the total population, ACS and non-ACS subgroups. These inflammatory scores can help early identification of high-risk patients in the patients with established CHD following PCI.
Abstract 12634: Amplified P2x
3
Pathway Activity in IB4 Positive Muscle DRG Neurons and Exercise Pressor Reflex Regulation in Hindlimb Ischemia-Reperfusion
Authors: Qin Lu , Li Qin , Li Jianhua
Published: December 2023

Background:
Hindlimb ischemia-reperfusion (IR) represents one of the most prominent pathological conditions observed in peripheral artery disease (PAD). Arterial blood pressure response (BP) during exercise, partly driven by the exaggerated exercise pressor reflex (EPR), is associated with an elevated risk of cardiovascular events in PAD patients. However, the precise underlying mechanisms leading to this exaggerated BP response are poorly elucidated. The purinergic P2X
3
signaling pathway, which plays a key role in modifying the EPR, was the focus of the present study.

Objectives:
To examine the regulatory role of P2X
3
on the EPR in a rat model of hindlimb IR, which was induced by 6 hours’ ischemia followed by 18 hours’ reperfusion (referred to as IR rats).

Results:
We found that, in IR rats, there were: 1) upregulation of P2X
3
protein expression in the L4-6 dorsal root ganglion (DRG) (1.48±0.16 in IR rats/n=8 vs. 1.00±0.41 in sham rats/n=9; P<0.05), which was localized in IB4 positive DRG neurons by the method of immunohistochemistry, 2) amplified P2X currents in isolated muscle DRG neurons (P2X transient currents: 1281.64±776.74 pA in IR rats/n=25, vs. 717.91±556.2 pA in sham rats/n=9, P<0.05; and sustain currents: 466.94±168.68 pA in IR rats/n=11, vs. 271.49±200.90 pA in sham rats/n=8, P<0.05); 3) amplification of P2X-mediated BP response (29±8 mmHg in IR rats/n=12 vs. 21±4 mmHg in sham rats/n=7; P<0.05); and 4) alleviation of the exaggerated BP response induced by static muscle contraction (18±8 mmHg in IR +A317491/n=8, vs. 29±11 mmHg in IR/n=7, P<0.05) and P2X-mediated BP response by α, β-me-ATP injection (15±4 mmHg in IR+A317491 /n=6 vs. 23±7 mmHg in IR/n=4, P<0.05) following the inhibition of muscle afferents’ P2X
3
receptor by A-317491. We further verified that both A-317491 and siRNA knockdown of P2X
3
significantly decreased the activity of P2X currents in the isolated muscle DRG neurons (all P<0.05 vs. their respective controls).

Conclusion:
With the above evidence from multiple approaches, we concluded that the P2X
3
signaling pathway activity is amplified following hindlimb IR via the enhancing expression and activity of P2X
3
receptors in IB4 positive muscle DRG afferents. This contributes to the exacerbated EPR responses in PAD.
Abstract 12686: Serious Complications Occur in Patients With Transcatheter Aortic Valve Replacement Who Develop In-Hospital Infective Endocarditis
Authors: Quintero Martinez Juan A , Vasquez Moises , Mintz Joel , Iskander Mina , Luna-Alvarez-Amezquita Jose , mustafa mohammed , Noy Jose , Uribe Juan , Espinoza Joaquin , Lecompte Paola , Alfonso Carlos , de Marchena Eduardo , Baddour Larry M
Published: December 2023

Introduction:
Transcatheter aortic valve replacement (TAVR) is a well-recognized treatment for severe aortic stenosis. One potentially life-threatening complication of TAVR is infective endocarditis (IE). There is limited contemporary data on the clinical characteristics and outcomes of patients undergoing TAVR who develop in-hospital IE.

Aim:
Describe the clinical characteristics and outcomes of patients undergoing TAVR who develop in-hospital IE.

Methods:
The National Inpatient Sample Database was queried from 2016 to 2020 for relevant ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes of adult (≥18 years) patients undergoing TAVR who developed in-hospital IE were compared to that of patients who did not develop IE. Multivariate logistic-regression analyses adjusting for age, race, gender, and statistically significant comorbidities between cohort's were performed. A p-value <0.05 was considered significant.

Results:
A total of 314,250 hospitalizations for patients undergoing TAVR were identified. Of them, 1065 (0.3%) developed in-hospital IE. Overall, mean age of IE patients was 70.3 ± 15.0. Patients were predominantly (62%) males and white (79.5%) (
Table 1)
. IE patients had a higher risk of in-hospital all-cause mortality (adjusted odds ratio [95% CI]: 2.07 [1.50-2.86]), septic shock (3.73 [2.71-5.13]), acute respiratory failure (2.59 [2.19-3.06]), ischemic stroke (4.4 [3.48-5.51]), acute kidney injury (3.05 [2.61-3.57]), cardiac arrest (2.82 [1.83-4.37] and cardiogenic shock 3.70 [2.98-4.57]). All p values were <0.01.

Conclusion:
Patients undergoing TAVR who develop in-hospital IE had higher in-hospital complications when compared to those of patients who did not develop IE. Although the rate of in-hospital IE was low, the number of patients identified in the NIS database was sizable and the syndrome deserves investigation due to its associated complications.
Abstract 12693: Invasive Derivation, Validation, and Prognostic Association of a Quantitative Echocardiographic Estimate of Pulmonary Artery Wedge Pressure
Authors: Lindow Thomas , Aristomenis Manouras , Lindqvist Per , Manna Daniel , Wieslander Björn , Kozor Rebecca , Strange Geoff , Playford David , Ugander Martin
Published: December 2023

Background:
Grading of diastolic dysfunction (DD) commonly leads to indeterminate classifications and provides little information on treatment effect or disease progression. A quantitative non-invasive estimate of LV filling pressures would have clinical utility.

Aim:
To invasively derive and validate a quantitative echocardiographic estimation of pulmonary artery wedge pressure (PAWP), and to compare its prognostic performance with diastolic dysfunction grading.

Methods:
Echocardiographic measures were used to estimate PAWP (ePAWP) using multivariable linear regression in patients undergoing right heart catheterization (RHC). Prognostic associations were analyzed in the National Echocardiography Database of Australia (NEDA).

Results:
In patients who underwent both RHC and echocardiography within two hours (n=90), ePAWP was derived using left atrial volume index (LAVi), mitral peak early velocity (E), and pulmonary vein peak systolic velocity (PVs). In an external validation cohort (n=53), ePAWP showed good agreement with invasive PAWP (mean±SD difference 0.5±5.0 mmHg) and good diagnostic accuracy for estimating PAWP >15mmHg (area under the curve [95% confidence interval] 0.94 [0.88-1.00]). Among patients in NEDA (n=38,856, median [interquartile range] follow-up 4.8 [2.3-8.0] years, 2,756 cardiovascular deaths), ePAWP associated with cardiovascular death even after adjustment for age, sex, and diastolic dysfunction grading (hazard ratio (HR) 1.08 [1.07-1.09]) and provided incremental prognostic information to diastolic dysfunction grading (C-statistic: 0.68 vs. 0.65, p<0.001). Increased ePAWP associated with worse prognosis across all grades of diastolic function (HR normal: 1.07 [1.06-1.09]; indeterminate: 1.08 [1.07-1.09]; abnormal: 1.08 [1.07-1.09].

Conclusion:
Echocardiographic ePAWP is an easily acquired continuous variable with good accuracy that associates with prognosis beyond diastolic dysfunction grading.
Abstract 12699: Impact of Mode of Delivery on Maternal and Fetal Outcomes in Pregnant Patients With Heart Failure or Pulmonary Hypertension
Authors: Patel Kunal N , Majmundar Monil , Zala Harshvardhan , Khawaja Tasveer , Doshi Rajkumar P , Kalra Ankur , Lippmann Mathew , Gulati Martha
Published: December 2023

Introduction:
Despite the existing guidelines, data on maternal, fetal, and obstetric outcomes associated with various modes of delivery in pregnant patients with heart failure (HF) or severe pulmonary hypertension (pHTN) is limited.

Methods:
This retrospective population based cohort study used Nationwide Readmission Database to identify all hospitalized pregnant patients who were primarily admitted for vaginal or cesarean delivery from 2011 to 2019. Pregnant patients with HF or pHTN were identified. Primary outcomes were inhospital maternal and fetal mortality.

Result:
23,359 hospitalized pregnant patients with HF or pHTN were identified. Cesarean deliveries were performed more than vaginal deliveries (66.2% vs. 33.8%). Patients undergoing cesarean delivery had lower odds of fetal mortality [OR: 0.18 (0.07-0.45), p<0.001] and postpartum hemorrhage than vaginal delivery. However, the odds of in-hospital maternal mortality [OR: 2.0 (1.07-3.77), p=0.03], ACS, and puerperal sepsis were higher in cesarean group than in vaginal delivery group. There were no differences in the odds of in-hospital stroke and DVT/PE between two groups. We found that 167 pregnant women would have to undergo cesarean delivery to have one inhospital maternal mortality (NNH=167), and 164 pregnant women would have to undergo cesarean delivery to prevent one fetal mortality (NNT=164). There were increased odds of all-cause readmissions within 6 months in patients who had cesarean delivery compared with those who had vaginal deliveries. There was no difference in risk of acute exacerbation of HF, readmission mortality, ACS, stroke, and DVT/PE between two groups at 6 months.

Conclusion:
In this retrospective multicentric cohort study, cesarean delivery was associated with lower fetal mortality but higher inhospital maternal mortality. Thus, unique features of each patient case should be considered via a multidisciplinary discussion before determining a preferred delivery method.
Abstract 12729: Leadless Pacemaker Insertion is Safe in Nonagenarians
Authors: Harb Ahmad , Harb Amjad , Salah Abdelraouf , Al Kalaji Bilal , Khabsa Mariam , Dwaram Amulya Reddy , Battikh Naim , Muhyieddeen Amer , Orji Richard , Gill Jashan
Published: December 2023

Introduction:
Increased age is associated with increased frailty and often worse postoperative outcomes. We aim to assess the safety of leadless pacemaker (LPM) insertion in the very elderly population.

Methods:
We queried the National Readmission Database years 2017-2020 for patients who underwent LPM insertion with the ICD10 code 02HK3NZ. Patients with age 90 or more were included in the nonagenarians group. Patient comorbidities were queried through the appropriate ICD 10 codes. We compared outcomes using multivariate logistic and linear regression, adjusting for patient comorbidities.

Results:
At baseline, nonagenarians had a higher prevalence of hypertension, history of stroke, A fib./A. flutter, dementia and hypothyroidism. The control group had more of diabetes, coronary disease, chronic kidney disease, chronic pulmonary disease, oxygen use, coagulopathy, anemia, obesity, substance abuse and chronic liver disease (Table 1).

Compared to controls, nonagenarians were found to have shorter length of stay (-2.486 days, p <0.001), lower rate of mortality (aOR 0.696, p 0.0187), lower rates of postprocedural cardiac arrest (aOR 0.301, p 0.0267), mechanical ventilation (aOR 0.378, p <0.001), and vasopressor use (aOR 0.583, p 0.001).

Nonagenarians were only found to have increased risk of pericardial complications (tamponade, pericardiocentesis, hemopericardium) (aOR 1.596, p 0.0151).

There was no significant difference in 30-day readmissions (aOR 0.97, p 0.696), postoperative bleed (aOR 0.84, p 0.072), or stroke (aOR 0.586, p 0.112).

Conclusions:
Our study demonstrates LPM insertion is safe in the very elderly population. However this is likely a demonstration of survivorship bias as patients in the nonagenarians group had overall less comorbidities. Even though our analysis adjusted for comorbidities, there are always unknown confounders which cannot be accounted for. Age itself does not seem to be a risk factor for worse outcomes in this population.
Abstract 12764: Reduced EF With Mavacamten Initiation in a Patient With Atrial Fibrillation: A Case Report
Authors: Patel Nidhi , Williams B Robinson
Published: December 2023

Description of Case:
A 55-year-old male with a history of paroxysmal atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM) diagnosed three years prior at an outside institution presented to clinic with exertional dyspnea. Baseline TTE confirmed HCM demonstrating an EF of 69%, mitral systolic anterior motion (SAM), left ventricular outflow tract (LVOT) obstruction, and a peak gradient exceeding 100 mmHg. Initiation of mavacamten 5mg resulted in symptom improvement and a one-month follow-up TTE demonstrating a reduced peak gradient of 74 mmHg and normal EF. However, two months after initiation the patient returned with AF with rapid ventricular response (RVR) and TTE showed a newly reduced EF of 21%. Mavacamten was stopped while home metoprolol XL was increased from 100 to 150 mg daily for rate optimization. Holter monitoring showed a 100% Afib burden with an average heart rate of 108 beats per minute. Stopping mavacamten for four weeks resulted in worsening exertional dyspnea but restoration of EF to 52% on TTE. Mavacamten was reinstated at a lower dose of 2.5 mg, resulting in symptom improvement. Monthly TTE exams over four months consistently demonstrated a normal EF without LVOT obstruction at rest.

Discussion:
Mavacamten, a promising drug used to treat obstructive HCM, modulates myosin to reduce myosin-actin cross-bridging. Reduction in contractility improves mitral SAM, LVOT obstruction, and symptoms. However, because mavacamten is a negative inotrope it can also precipitate reductions in EF. Generally, patients have a mild drop in EF (~5 points) after initiation. However, our patient had a significant EF drop of over 25 points likely due to both mavacamten initiation and new AF with RVR reducing systolic function. Discontinuation of mavacamten for four weeks and rate optimization likely restored EF. Dose reduced re-initiation of mavacamten resulted in long-term normal EF and improvement in symptoms. This case highlights the need for close monitoring and individualized mavacamten treatment plans. Further research is warranted to understand the interplay and long term outcomes of tachyarrhythmias and mavacamten use.
Abstract 12776: Sustained Impact of Peripartum Cardiomyopathy on Mental Health Disorders and Quality of Life
Authors: Thordsen Sarah , Smith Madeline , Matloub Sara , Briller Joan , Arany Zoltan , Lewey Jennifer
Published: December 2023

Introduction:
Mental health diagnoses such as depression, post-traumatic stress disorder (PTSD), and anxiety are common after acute cardiovascular events. Peripartum cardiomyopathy (PPCM) affects women near the end of pregnancy or in the near post-partum period and occurs during a period of heightened psychosocial stress. There is limited data on the prevalence of mental health diagnoses after the acute PPCM event.

Methods:
Patients with self-identified PPCM enrolled in the online PPCM Registry (PPCM-R at ppcmr.org) and completed validated surveys for depression (Patient Health Questionnaire - 9, PHQ-9), anxiety (Generalized Anxiety Disorder -7, GAD-7), PTSD ( Posttraumatic Stress Disorder Checklist- Civilian, PCL-C) and quality of life (Rand SF-36). Patients were recruited on PPCM support groups, social media, and physician referral.

Results:
After 4 months, 103 patients enrolled and 55 (54%) completed the mental health and QOL surveys. Mean age was 32.3 (SD 4.7) and median time since diagnosis was 4.2 years (IQR 1.7, 10.4 years). Mean (SD) PHQ-9 score was 8.1 (7.3) and 27% had a score (≥10) indicating moderate or severe depressive symptoms. Mean (SD) GAD-7 score was 7.3 (6.7) and 36% of participants had scores (≥10) consistent with moderate or severe anxiety symptoms. Mean (SD) PCL-C score was 20.7 (19.3) and 33% screened positive for PTSD. Overall, 30% of participants reported that QOL was ‘fair’ or ‘poor’ with lower domain scores for physical function, emotional function, energy/fatigue and general health compared to the general population. Characteristics of participants stratified by mental health symptom severity and QOL scores are presented in the Table.

Conclusions:
Half (51%) of participants had at least one mental health screening tool which indicated current moderate or severe symptoms of depression, anxiety or PTSD. These findings confirm a significant burden of mental health symptoms in this PPCM survivor cohort.
Abstract 12787: Efficacy and Safety of Apixaban versus Low Molecular Weight Heparin for the Treatment of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis
Authors: Shrestha Abhigan Babu B , Mainali Nischal , Shrestha Shubham , Jaiswal Vikash , Shrestha Sajina , Adhikari Ashok , Chapagain Sanskriti , SHRESTHA SHUMNEVA , Sedhai Yub Raj , Rijal Rishikesh , Karki Dr. Bikash , Bhattarai Suju , Nuruzzaman Md.
Published: December 2023

Introduction:
Current guidelines recommend the use of low molecular weight heparin (LMWH) for the management of venous thromboembolism (VTE) in cancer patients. However, direct oral anticoagulants (DOACs) have emerged as promising alternative for reducing VTE events. Moreover, apixaban shows a higher safety profile among DOACs.

Hypothesis:
This study aims to compare the efficacy and safety of apixaban versus LMWH (Enoxaparin or Dalteparin) in the treatment of venous thromboembolism in cancer patients.

Methods:
A systematic search was conducted in electronic databases (Pubmed, Embase, Scopus, and Cochrane libraries) from inception until June 2023, using appropriate Mesh terms for ‘apixaban’, ‘LMWH’, and ‘VTE’. Pooled risk ratios (RR) with their corresponding 95% confidence intervals (CI) were calculated using random effects models. A p-value of <0.005 was considered statistically significant.

Results:
Five randomized trials involving 2311 patients (apixaban: 1088 and LMWH: 1223) with mean ages of 64.5±11.45 and 64.2±10.8, respectively, were included in the analysis. At a median follow-up of six months, the occurrence of clinically relevant non-major bleeding (CRNMB) (OR, 1.04, 95% CI: 0.66 - 1.64, I2=37.72%, p=0.87), composite of major and CRNMB (OR, 1.11, 95% CI: 0.84 - 1.46, I2=0.00%, p=0.47), were higher with apixaban treatment. However, the rates of recurrent VTE (OR, 0.72, 95% CI: 0.50 - 1.04, I2=3.91%, p=0.08), major bleeding (OR, 0.83, 95% CI: 0.55 - 1.25, I2=0.00%, p=0.38), and mortality (OR, 0.91, 95% CI: 0.79 - 1.05, I2=0.00%, p=0.19) were lower with apixaban compared to LMWH treatment. However, none of the observed differences reached statistical significance.

Conclusions:
In cancer patients with VTE, apixaban demonstrates non-inferior efficacy and a comparable safety profile to LMWH. Further randomized trials are warranted to confirm these findings.