bluuebunny/crossref_metadata_2025 huggingface dataset:
P5506Proprotein convertase subtilisin/kexin 9 (PCSK9) and lipopolysaccharide (LPS) in patients with atrial fibrillation. A biomarker post-hoc analysis from the ATHERO-AF cohort
Authors: Pignatelli Spinazzola P , Farcomeni A , Pastori D , Violi F
Published: October 2019

Background

Proprotein convertase subtilisin/kexin 9 (PCSK9) and lipopolysaccharides (LPS) are emerging as novel risk factors for cardiovascular events (CVEs). In vitro evidence suggested that PCSK9 production may be elicited by LPS via oxidative stress, However, their relationship in patients with atrial fibrillation (AF) has not been investigated.

Methods

Post-hoc analysis of a prospective, single centre cohort study of 907 patients with non-valvular AF. At baseline, PCSK9, LPS and NADPH oxidase (sNOX2-dp) were measured. We also assessed adherence to Mediterranean Diet (Med-Diet). PCSK9 and LPS were correlated to incidence of CVEs.

Results

At multivariate analysis, with PCSK9 above the median as dependent variable we found that high adherence to Med-Diet and antiplatelet drugs were inversely correlated to PCSK9 (odds ratio [OR] 0.737 95% Confidence interval [CI] 0.643–0.845 p=0.001 and OR 0.437 95% CI 0.219–0.871 p=0.017 respectively), while sNOX2-dp and LPS concentrations (OR 1.759 C.I. 95% 1.167–2.650, p=0.007 and OR 1.727 C.I. 95% 1.147–2.600 p=0.009 respectively) were directly correlated. In particular use of oil and wine were negatively associated to high PCSK9 levels (OR 0.376 95% CI 0.185–0.763, p=0.001 and OR 0.460 95% CI 0.289–0.733 p=0.007, respectively). Patients with concomitant high PCSK9 and LPS (highest tertile for both) had and increased risk of CVEs as compared to those with low levels (lowest tertile for both) with 48 and 29 CVEs in each group respectively (Log-Rank test, p=0.022)

Conclusion

This study demonstrated for the first time in vivo that circulating levels of PCSK9 are associated with high LPS concentration and NADPH oxidase activation. Concomitant increase of PCSK9 and LPS increased the risk of CVEs.
P5507Growth differentiation factor-15 and mortality in suspected or known coronary heart disease patients with chronic kidney disease: a subanalysis of the ANOX study
Authors: Takagi D , Suzuki M , Matsuda M , Ajiro Y , Shinozaki T , Sakagami S , Yonezawa K , Shimizu M , Funada J , Takenaka T , Morita Y , Abe M , Akao M , Hasegawa K , Wada H
Published: October 2019

Background

Chronic kidney disease (CKD) is an independent risk factor for the development and progression of coronary heart disease (CHD). Growth differentiation factor-15 (GDF-15), a distant member of the transforming growth factor-β cytokine superfamily, plays a role in the initiation of inflammation in atherosclerotic lesions. Elevated GDF-15 was found in various diseases including CKD and stable CHD, and was reported to predict mortality and cardiovascular events in general or established CHD population. However, the prognostic value of GDF-15 in suspected or known CHD patients with CKD is unknown.

Methods

Serum GDF-15 levels were measured in 999 suspected or known CHD patients with CKD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 154 patients died from any cause, 61 died from cardiovascular disease, and 96 developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.78; 95% confidence interval [CI], 1.57–2.00), cardiovascular death (HR, 1.88; 95% CI, 1.58–2.25), and MACE (HR, 1.54; 95% CI, 1.32–1.79). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.401; 95% CI, 0.231–0.571; P<0.001; integrated discrimination improvement [IDI], 0.041; 95% CI, 0.021–0.062; P<0.001) and cardiovascular death (NRI, 0.297; 95% CI, 0.039–0.555; P=0.024; IDI, 0.032; 95% CI, 0.010–0.055; P=0.005), but not that of MACE (NRI, 0.138; 95% CI, v0.070–0.347; P=0.194; IDI, 0.012; 95% CI, −0.000–0.024; P=0.053).

Conclusions

In suspected or known CHD patients with CKD undergoing elective coronary angiography, elevated GDF-15 levels may predict all-cause and cardiovascular mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.
P5513Relation of thyroid hormones level to the extent of myocardial injury in patients with acute coronary syndrome
Authors: Badran H , Soltan G , Belal A
Published: October 2019

Objective

Previous studies have identified that abnormal thyroid hormonal status is associated with worse prognosis especially in coronary artery disease (CAD). The present study further explores whether thyroid hormones associated with size of myocardial injury and extent of CAD in patients with acute coronary syndrome (ACS).

Methods

In this study, we enrolled 120 consecutive patients (52% male, mean age 54.2±6.4 years) who were admitted to ICU with ACS and having coronary angiography.

All patients underwent testing for thyroid function status [thyroid stimulating hormone (TSH), free triiodothyronine (FT3) and free thyroxine (FT4)], cardiac troponin I (cTnI), cardiac enzymes, C-reactive protein (CRP). Risk profile, clinical characteristics and angiographic results (Gensini score) were also analyzed.

Results

43.3% of patients presented with STEMI, 33.3% with NSTEMI and 23.3% unstable angina. CK-MB, troponin and CRP were significantly higher in STEMI compared with NSTEMI group (P<0.0001). Abnormal thyroid status was prevalent in 13.4% of total population; Low FT3 syndrome in 6.7%, subclinical hypothyroidism in 5% and clinical hypothyroidism in 1.7%. Lower thyroid hormone levels showed significantly lower HDL (P<0.02), higher triglyceride level& CRP and cTnI (P<0.007), higher rate of in hospital complications including recurrent angina, CHF and cardiogenic shock (P<0.001) and more severe CAD using Gensini score (P<0.0001). However, there was no significant difference in abnormal thyroid status between STEMI and NSTEMI. After adjusting for conventional risk factors, FT3 showed direct correlation to LV EF% (r=0.62, P<0.000) and inverse correlation to LV internal dimension (r=−0.57, P<0.0001), troponin (r=−0.27, P<0.03), CRP (r=−0.39, P<0.003), Gensini score (r=−0.48, P<0.0001) and number of in hospital complications (r=−0.62, P<0.0001). From a linear stepwise regression analysis low EF% (β: 0.032, 95% CI: 0.009–0.055, P<0.007) and presence of complications (β: 0.625, 95% CI: 1.194–0.056, P<0.03) are independent predictors of low FT3.

Conclusions

In ACS, the lower thyroid hormones levels are associated with larger myocardial injury, more severe CAD and higher rate of complications especially during their hospital course.
P5514Impact of pro-inflammatory conditions on myocardial infarction with non-obstructive coronary arteries
Authors: Lopez Pais J , Espinosa Pascual M J , Izquierdo Coronel B , Galan Gil D , Alcon Duran B , Moreno Vinues C , Awamleh Garcia P , Martinez Peredo C G , Alvarez Rodriguez L , Nunez Rodriguez A , Gorriz Magana J , Mata Caballero R , Oteo Dominguez J F , Gonzalez Juanatey J R , Alonso Martin J J
Published: October 2019

Background

Despite all the recent publications, including new guidelines, myocardial infarction with non-obstructive coronary arteries (MINOCA) is still a controversy “working diagnosis”. MINOCA patients have a characteristic risk profile, with a lower prevalence of classical risk factors (CVRF). The aim of this study is to analyze the relationship between known proinflammatory conditions and MINOCA.

Methods

Analytical and observational study developed in a University Hospital, which covers 220.000 individuals. We analyzed data of 109 consecutive MINOCA patients admitted to our center during a 3 years period (2016–2018). We used the definitions and the clinical management of the 2016 European Society of Cardiology Working Group Position Paper on MINOCA.

The composite of proinflammatory conditions (PIC) includes vasculitis and other autoimmune pathologies; connective tissue diseases, the presence of active cancer and the fact of presenting the myocardial infarction as a complication during admission for a non-cardiovascular pathology. Follow up analysis included death from any cause and major adverse cardiovascular events (MACE). Survival analysis is based on Cox regression and represented by Kaplan Meier curves. Median follow up was 17 months.

Results

Around one-third of the MINOCA patients had PIC (34.8%). They tended to be older (67.9±14 vs 62.8±15, p 0.08), with no differences in rate of female sex (55.3 vs 49.3%, p 0.55) neither in traditional CVRF: Tobacco (40.5 vs 42.6%), diabetes (18.4 vs 26.8%), dyslipidaemia (39.5 vs 48.6%) or hypertension (55.3 vs 64.8%). Patients with PIC had a higher proportion of ischemic ECG at presentation (75.7 vs 53.5%, p 0.03), a tendency to worse ejection fraction (45.9 vs 28.2%, p 0.07) and higher in-hospital mortality (2.6 vs 0.0%, p 0.17). Levels of troponin were similar (4.0±6.0 vs 6.6±10.4, p 0.2)

During follow-up (Figure 1), PIC was related to a higher all-cause-mortality (16.2 vs 1.5%, Hazard Ratio (HR) 10.7 (95% Confidence Interval [CI]: 1.3–89.0, p 0.03). Patients with PIC also showed a non-significant higher cardiovascular mortality (5.3 vs 1.4%, HR 3.5 [CI: 0.3–38.5], p 0.3) and higher rate of MACE (13.5 vs 9.2%, HR 1.6 [CI: 0.5–5.1], p 0.4).

Conclusion

In this study, MINOCA patients had a high prevalence of PIC, being present in more than one-third of them. They are linked to worse prognosis, with higher all-cause mortality and a non-significant increase in cardiovascular mortality and MACE, which could be significant with the appropriate number of patients.
P5519Effects of crowding in the emergency department on time dependent processes and outcomes using fast diagnostic protocols in patients with suspected acute coronary syndrome
Authors: Giannitsis E , Biener M , Hund H , Mueller-Hennessen M , Vafaie M , Katus H A , Stoyanov K M
Published: October 2019

Background

Accelerated diagnostic algorithms using high-sensitivity troponin (hsTn) assays in suspected acute coronary syndrome (ACS) are regarded as particularly beneficial to expedite diagnosis and safe discharge of low risk patients in crowded emergency departments (ED). However, little is known about potential negative effects of crowding on implementation and efficacy of fast diagnostic protocols. We studied the effects of crowding on outcomes and process times in patients admitted with suspected ACS using fast diagnostic protocols.

Methods

A total of 2,525 consecutive patients were evaluated during 12 months using 2015 ESC guideline recommended fast protocols. Crowding was defined as mismatch between patient visits and monitoring capacities as well as effective physician time per case. Electronic time-stamps were available for length of ED stay, timing of hsTnT measurements, time intervals between measurements, and laboratory turn-around-times (TAT). Patients were followed up for all-cause mortality at 30 days and 1 year.

Results

Crowding was associated with increasing intervals between blood samples from 98 to 107 minutes (p=0.008), increasing median TAT from 53 to 57 minutes (p<0.001), significantly higher numbers of additional hsTnT measurements after diagnosis (p<0.001 for trend), and a trend for more frequent hospital discharge (58.9 vs. 62.8%, p=0.08) across crowding levels. There were indirect findings for additional negative effects on time dependent care processes. However, there was no significant effect of crowding on 30-day (1.8 vs. 1.9%) or 1-year all-cause mortality (5.4 vs. 5.9%).

Conclusion

Time-dependent processes are prolonged in a crowded ED diminishing some positive effects of fast diagnostic protocols for evaluation of suspected ACS.

Acknowledgement/Funding

Roche Diagnostics International Ltd.
P5531A systematic follow-up strategy after percutaneous coronary intervention based on patient risk profile: the prospective POST-PCI registry
Authors: Ferlini M , Rossini R , Musumeci G , Grieco N , Trabattoni D , Cornara S , Cardile A , Calchera I , Russo F , Ielasi A , Faggiano P , Castiglioni B , Lettieri C , Klersy C , Oltrona Visconti L
Published: October 2019

Background

Redundant clinical and non-invasive examinations after percutaneous coronary intervention (PCI) increase the cost of medical care with no outcome improve. A multidisciplinary consensus document (MCD) providing a follow-up (FU) strategy based on 3 clinical and angiographic risk profile (A high, B intermediate, and C low) has been recently proposed.

Aim

To evaluate the potential reduction of cardiologic consults (CC), stress tests (ST), and echocardiograms (EC) with the application of the MCD after PCI.

Methods

The Post-PCI registry is a multicenter, observational, prospective data collection carried out during a four-week period that included consecutive patients undergoing PCI at 31 Italian Hospitals both for acute coronary syndromes (ACS) or stable coronary artery disease (SCAD). FU strategies were left at investigator's discretion. A comparison between the CC, ST and EC performed in the first 12-months with the potential suggested by the MCD was evaluated.

Results

A total of 1113 patients were included; 12-months follow up was available in 90% of the cases (mean age 68±11 years old, 58% ACS). Based on MCD risk profile 17% were in A, 74% in B and 9% in C strategy. On average observed CC and ST were significantly lower compared to the expected based on MCD (respectively 1.63±1.07 vs 1.91±0.28, and 0.41±0.59 vs 0.61±0.84; on the contrary EC were significantly higher (0.64±0.73 vs 0.34±0.75, all: p<0.001). The excess rate for CC, ST and EC as compared to MCD was respectively 25%, 14% and 8% for the strategy A, 14%, 25% and 50% for the strategy B and 26%, 54% and 40% for the strategy C. At multivariable logistic analysis the MCD strategy was an independent predictor (in a model with age, sex, consulting physician, public or private hospital) of an increased number of cardiac examination in patients at intermediated and low risk [B group OR 2.56 (95% CI 1.38–4.75), C group 27.00 (95% CI 8.13–89.62)]. The other independent predictor was age, with a reduced number of examination for elderly (>75 years old) patients [OR 0.59 (CI 95% 0.43–0.80)].

Conclusion

Our data suggest that in a real word population of patients undergoing PCI, a follow-up strategy based on clinical and anatomical risk profile would allow to a reduction of cardiac tests and consultations, particularly in patients at intermediated and low risk leading to an increase of appropriateness of prescription and to a cost reduction of medical care.

Acknowledgement/Funding

The Post-PCI registry was supported by the Italian Society of Interventional Cardiology (SICI-GISE) receiving an unrestricted grant from Astra Zeneca
P5538Safety and efficacy of acetylcholine provocation test for diagnosis of vasospastic angina in young patients
Authors: Tateishi K , Kitahara H , Nakayama T , Fujimoto Y , Kobayashi Y
Published: October 2019

Background

Vasospastic angina (VSA) is considered as a cause of myocardial infarction with nonobstructive coronary arteries. Given the previous reports of higher incidence of cardiovascular events in young VSA patients, early diagnosis and optimal treatment are important for these patients. While acetylcholine provocation test (ACh test) for VSA diagnosis is well reported, ACh test among young patients is not as commonly performed, therefore its safety and usefulness for this patient subset have not been fully evaluated.

Purpose

The purpose of this study was to evaluate the safety and the proportion of positive results of ACh test for young patients.

Methods

Data from patients who underwent ACh test in our institution from May 2012 to September 2018 were retrospectively analyzed. A total of 669 patients were enrolled and divided into 2 groups according to age: Young group (Age≤50, n=106); and Senior group (Age>50, n=563).

Results

The senior group had a higher incidence of hypertension, dyslipidemia, diabetes mellitus, and coronary artery disease. On the other hand, the young group had a significantly higher incidence of current smoker and tendency of daily alcohol. The rate of positive ACh test was similar, and there were no significant differences in major or minor complications between the 2 groups.

Patient characteristics and outcome Young group Senior group p (n=106) (n=563) Age (years) 42.8±7.3 68.0±9.0 <0.001 Male (%) 56.6 52.2 0.407 Current smoker (%) 34.9 15.4 <0.001 Daily alcohol (%) 31.1 22.9 0.070 Hypertension (%) 33.0 66.6 <0.001 Dyslipidemia (%) 50.0 68.4 <0.001 Diabetes (%) 12.3 20.8 0.047 ACh positive (%) 52.8 49.9 0.581 Minor adverse event (%) 4.7 5.9 0.820 Major adverse event (%) 0.9 1.4 1.000 Major adverse event: composite of death, ventricular fibrillation, sustained ventricular tachycardia (VT), myocardial infarction and stroke. Minor adverse event: non-sustained VT and paroxysmal atrial fibrillation.

Conclusion

ACh provocation test for young patients can be safely performed, and the rate of positive results was similar to that of senior patients. In young patients suspected of having VSA, ACh test should be actively performed to identify optimal medical therapy for prevention of cardiovascular events.

Acknowledgement/Funding

None
P5544Antiplatelet effects of intraoperative administration of ticagrelor versus clopidogrel in patients undergoing one-stop hybrid coronary revascularization: a single-center randomized controlled trial
Authors: Zhang Q , Xu H Y , Wu Y J
Published: October 2019

Background

“One-stop” hybrid coronary revascularization (HCR) has emerged to be a reliable and attractive alternative for selected patients with multivessel coronary artery disease. However, the optimal antiplatelet regimen of this procedure still remains controversial. Therefore, we conducted a randomized controlled trial to compare antiplatelet effect between ticagrelor and clopidogrel during this hybrid procedure.

Purpose

The study objective was to evaluate the onset of platelet inhibition between ticagrelor and clopidogrel in patients during “one-stop” HCR.

Methods

In a single-center, randomized, open-label study, 60 patients receiving one-stop HCR were randomized equally to received either clopidogrel (300 mg loading dose, 75 mg once per day), or ticagrelor (90 mg loading dose, 90 mg twice daily) after confirmation of LIMA-LAD graft patency. All patients treated with aspirin 100mg once daily during the treatment period. Platelet reaction units (PRU) was assessed by Verify Now™ P2Y12 assay before surgery; after confirmation of LIMA-LAD graft patency before administration study drugs; and at 30 minutes, 1 hour, 2 hours, 6 hours, 12 hours, 24 hours after loading dose. Major adverse cardiac events and bleeding events within a year follow-up were recorded.

Results

Ticagrelor produced further suppression of platelet aggregation in patients undergoing “one-stop” HCR from 2 hours after loading dose (PRU 271.0±51.6 vs 313.2±61.2, P=0.008). The average PRU value was still better at 24 hours after loading dose in the ticagrelor group than in the clopidogrel group (121.1±75.5 vs 284.3±67.0, P<0.001). There were no differences of bleeding or major adverse cardiac events between two groups.

PRU value at various time points T C T vs C, P BS 272.7±48.5 275.5±60.4 0.842 BA 321.4±50.0 324.6±60.2 0.823 0.5 h 335.5±50.7 334.47±58.9 0.940 1 h 309.9±45.3 319.6±64.6 0.503 2 h 271.2±57.6 313.2±61.2 0.008 6 h 215.9±57.5 291.5±56.2 <0.001 12 h 196.9±80.1 295.4±62.8 <0.001 24 h 121.1±75.5 284.3±67.0 <0.001 PRU = platelet reation units; T = ticagrelor; C = clopidogrel; BS = before surgery; BA = before administration (after confrimation of left internal mammal artery graft patency).

The trial flow diagram

Conclusions

In patients receiving “one-stop” HCR, the onset of action was fater and higher with ticagrelor than with clopidogrel.

Acknowledgement/Funding

This study was funded by AstraZeneca (China) Co, Ltd.
P5550The prognostic and therapeutic characteristics of heart failure among elderly patients with hypertrophic cardiomyopathy
Authors: Ghersin I , Bahouth F , Farah J , Azzam Z S
Published: October 2019

Introduction

Symptomatic heart failure is frequent among patients with hypertrophic cardiomyopathy. Once regarded a disease of mostly young adults, recently, hypertrophic cardiomyopathy has been increasingly diagnosed in older patients. There is scarce medical literature specifically dedicated to hypertrophic cardiomyopathy in elderly patients. As a result, their natural history with respect to risk of adverse events such as heart failure, stroke, and sudden cardiac death remains relatively unknown.

Purpose

We aimed to determine the prognostic and therapeutic implications of heart failure in hypertrophic cardiomyopathy patients older than 65 years old.

Methods

In this retrospective observational study, we searched our hospital's database for hypertrophic cardiomyopathy patients who were admitted due to acute decompensated heart failure between 1/1/2000 and 31/12/2016. Patients were stratified into two age groups: over 65 years old and under 65 years old (our control group).

Our primary outcomes were overall mortality and re-admissions due to acute decompensated heart failure.

Results

Our cohort included 86 patients. 54 patients were older than 65 years and 32 were younger than 65. There were significantly more women in the over 65 group. In the elderly group, significantly less patients had a history of smoking (26% vs. 47%, p=0.047), whereas more patients had known coronary artery disease (48% vs. 19%, p=0.006). The echocardiographic features of the two groups were similar.

The survival rate was not significantly different between the two age groups (10 year survival rate 41% under 65, 37% over 65, p=0.68). There were also no significant differences in the risk of re-admission due to acute decompensated heart failure between the two age groups.

Conclusion

No differences were seen in overall mortality or in re-admission due to acute decompensated heart failure between older (over 65) and younger (under 65) patients. Hence, it appears prudent to adhere to ESC guidelines for hypertrophic cardiomyopathy management in older hypertrophic cardiomyopathy patients.
P5556Impact of viral genome detection in endo-myocardial biopsy of arrhythmogenic cardiomyopathy substrate
Authors: Gasperetti A , Dello Russo A , Casella M , Basso C , Della Rocca D , Catto V , Zanchi S , Fassini G , Moltrasio M , Vettor G , Andreini D , Natale A , Tondo C
Published: October 2019

Background

Arrhythmogenic cardiomyopathy (ACM) is a genetically inherited cardiomyopathy characterized by myocardial fibro-fatty replacement. A pathogenetic role of viral myocardial infections in ACM natural history has been proposed over the years, although no definitive conclusion has been reached yet.

Purpose

To describe viral genome presence into a cohort of ACM biopsy proven patients (pts) and its impact on clinical features and outcome.

Methods

A cohort of all ACM pts undergoing an invasive third level evaluation at our institution was enrolled. All pts underwent a cardiac magnetic resonance (MR), an invasive electrophysiological study (EPS) with endo-cavitary electro-anatomical mapping (EAM), and a EAM guided endo-myocardial biopsy (EMB). Viral genome research through molecular biology techniques was performed on all biopsied samples.

According to arrhythmic risk evaluation, a trans-catheter ablation (TCA) and/or an internal cardioverter device (ICD) implant was performed. Clinical arrhythmic presentation, MR data, arrhythmia inducibility at EPS, EAM and EMB characteristic, and arrhythmic events at a 12-month follow up visit were retrieved in all pts and compared between the viral genome positive (v+ACM) and negative group (v-ACM).

Results

Forty-five pts were enrolled in our study (48±13 years; 66% male); the EMB samples of 7 (15%) pts presented a lymphocytic infiltrate and tested positive for viral genome (n=3 B19 Parvovirus; n=2 for Citomegalovirus; n=2 for Ebstein-Bar Virus) [Figure1].

At arrhythmic presentation, complex ventricular arrhythmias (NSVT, SVT and FV) were more frequent in the v+ACM group (86% vs 50%; p=0.039). Both left and right ventricular ejection fraction at MR resulted more depressed in the v+ACM group (44±7 vs 52±2 and 47±2 vs 52±2; p=0.047 and p=0.041). Complex ventricular arrhythmia inducibility at EPS was more frequent in v+ACM (72% vs 34%; p=0.032), while no differences in pathological potentials rate and extension at unipolar and bipolar EAM were found. TCA was performed in 55% and 57% and an ICD was implanted in 29% and 42% in the v+ACM and v-ACM group respectively. No differences in 12-months arrhythmic event rates (39% vs 42%) between the two groups were described.

EBM at different magnifications/stains

Conclusion

In our cohort a viral infection super-imposed to the fibrofatty infiltration was found in 15% of the patients. ACM pts testing positive for viral genome at the EMB had a more severe arrhythmic disease presentation, a more impaired heart function, and a higher rate of complex ventricular arrhythmias at disease presentation, but seemed to respond as well as viral genome negative ACM to ablative and pharmacological treatment
P5558Conditions associated with eosinophilic myocarditis: a national population-based cross sectional study
Authors: Li W , Wu L
Published: October 2019

Background

Eosinophilic Myocarditis (EM) is a rare but potentially fatal form of myocardial inflammation, characterized by eosinophilic infiltration of the myocardium. Due to its rare occurrence, there has been no descriptive study of EM on the population level.

Purpose

Our study aims to use a large national database to describe the prevalence, associated clinical conditions and hospital outcomes of EM.

Methods

We analyzed the 2016 National Inpatient Sample Database (NIS) for all hospitalizations with a diagnosis of EM. Prevalence and baseline characteristics of EM were described and compared with non-EM admissions, as well as associated clinical conditions.

Results

In 2016, there were 170 admissions with a diagnosis of EM. Among those, White represented the major ethnic group, followed by African American, Asian/Pacific Islander/Native American, and Hispanic (Fig. 1). There was no significant gender predisposition to EM, but EM patients presented at an older age compared with the general population. The prevalence of Systemic Lupus Erythematosus, Myeloproliferative disorders, Acute Coronary Syndrome, Heart Failure, Arrhythmia, Heart Transplant, Eosinophilic Granulomatosis with Polyangiitis, Eosinophilia was significantly higher in EM patients. Also, EM patients had higher mortality. (Table 1)

Table 1. A comparison of EM and Non-EM EM (n=170) Non-EM (n=35,675,421) P-value Demographic   Age, years 61.53±2.93 49.00±0.19 P=0.007   Female, % 50.00±7.80 56.72±0.10 P=0.38 Clinical Conditions   Systemic Lupus Erythematosus, % 2.94±2.74 0.50±0.01 P=0.03   Myeloproliferative Disorder, % 8.82±4.33 0.52±0.01 P<0.001   Acute Coronary Syndrome, % 20.59±6.07 6.55±0.06 P<0.001   Heart Failure, % 61.76±9.42 13.29±0.10 P<0.001   Arrhythmia, % 14.71±7.25 2.44±0.03 P<0.001   Heart Transplant, % 2.94±2.84 0.06±0.005 P<0.001   EGPA, % 2.94±2.92 0.00±0.00 P<0.001   Eosinophilia, % 5.88±3.95 0.07±0.002 P<0.001 Outcome   Mortality, % 8.82±4.83 1.91±0.02 P=0.003 Data is presented in the format of the mean ± standard error.

Figure 1. Racial distribution of EM patients

Conclusion(s)

Eosinophilic Myocarditis is rare, and it's associated with autoimmune diseases, cardiac complications, and worse hospital outcomes.
P5566Prognostic value of quantitative assessment of tricuspid regurgitation. Correlation between echocardiography and cardiac magnetic resonance
Authors: Hinojar Baydes R , Garcia Martin A , Gonzalez-Gomez A , Alonso-Salinas G , Plaza-Martin M , Pascual-Izco M , Lorente A , Hernandez-Jimenez S , Fernandez-Mendez M A , Esteban Peris A , Jimenez-Nacher J J , Zamorano J , Fernandez Golfin C
Published: October 2019

Background

Significant tricuspid regurgitation (TR) is related to poor prognosis independently of the etiology. TR severity and right ventricular (RV) size and function are determinant in the evaluation of patients with RT and are independently related to outcomes. While TR severity is commonly evaluated with echocardiography (echo), cardiac magnetic resonance (CMR) is the gold standard to study the RV. The association between CMR and echocardiographic measures of quantitative TR is unknown.

Purpose

Our aim was to evaluate the association between the most commonly used methods in both techniques: biplane vena contracta (VC) and effective regurgitant orifice (ERO) parameters evaluated by echo and TR volume (TRV) and TR regurgitant fraction (TRF) by CMR; secondly we aimed to evaluate the prognostic value of each parameter.

Methods

Consecutive patients in stable clinical status with significant TR evaluated in the Heart Valve Clinic between 2015–2018 with a contemporaneous echo and CMR were included. TR severity was evaluated by VC and ERO method, using EPIQ system and by VRF and TRF using a 1.5 Tesla CMR Philips scanner. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 36 patients were included (mean age was 72±7 years, 72% females, 94% functional TR). Both VC and ERO showed moderate to strong and significant correlations with VRF and TRF (table). During a median follow up of 20 months [IQR: 10–29], 38% of the patients reached the combined end point (n=7 developed right heart failure, n=11 underwent tricuspid valve surgery, and n=2 died). Patients with events showed a larger ERO and higher VRF and TRF (p<0.01 for all) and a tendency to larger VC (p=0.06). PISA, VRF and TRF were prognostic factors of the combined endpoint (PISA per 0.1 cm2, HR: 282 [3.9–20362], p=0.01; VC per 1 mm, HR 1.27 [0.98–1.64] p=0.06; VRF per 1ml: HR: 1.02 [1.005–1.025], p=0.003; FRT per 1%, HR: 219.5 [4.8–9897], p=0.06). A value of PISA of 0.42, of VRF of 46 ml and FRV of 43% reached the best accuracy to predicted poor outcomes (p<0.01 for all).

Table 1. Bivariate correlations ERO VC Regurgitant volume by CMR R=0.57, p=0.004 R=0.55, p=0.003 Regurgitant fraction by CMR R=0.61, p<0.001 R=0.56, p=0.01

Conclusion

Validated echocardiographic parameters of TR are significantly correlated with quantitative measures by CMR. PISA by echo, and VRF and FRV by CMR are predictive of impaired prognosis. Further studies confirming our CMR cut-off values of poor outcomes are needed for clinical implementation.
P5582Predicting the clinical outcomes in moderate aortic stenosis: implementation of the newly proposed staging classification
Authors: Amanullah M R , Pio S M , Sin K Y , Ajmone Marsan N , Ding Z P , Delgado V , Ewe S H , Bax J J
Published: October 2019

Background

While symptomatic severe aortic stenosis (AS) carries a worse prognosis and early intervention is favoured, it is always assumed that patients with moderate AS are more stable and their disease progression can be monitored yearly. However, it is known that patients with moderate AS have a higher risk of cardiovascular events but is unclear if other factors may also affect the overall prognosis.

Purpose

In this multicentre registry of patients with moderate AS, the prognostic value of a new staging classification on the extent of cardiac damage was examined.

Methods

Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into five stages depending on the extra-aortic valvular cardiac damage: no signs of cardiac damage (Stage 0), left ventricular (LV) damage [LV ejection fraction <50%, LV mass index >95 g/m2 for women or >115 g/m2 for men or E/e' >14] (Stage 1), mitral valve or left atrial (LA) damage [LA volume index >34 ml/m2 or mitral regurgitation ≥grade 3 or presence of atrial fibrillation] (Stage 2), tricuspid valve or pulmonary artery vasculature damage [systolic pulmonary arterial pressure ≥60 mmHg or tricuspid regurgitation ≥grade 3] (Stage 3), or right ventricular damage [tricuspid annular plane systolic excursion <17 mm] (Stage 4). The clinical endpoint was all-cause mortality. The association between the extent of cardiac damage and all-cause mortality was assessed by the Kaplan Meier method using log-rank test.

Results

Of the included 522 patients with moderate AS (age 71±11 years, 54% males), 12% (63) of patients were re-classified as Stage 0, 30% (157) in Stage 1, 47% (245) in Stage 2, 6% (31) in Stage 3 and 5% (26) in Stage 4. During follow-up, 43% (226) of patients underwent surgical or transcatheter aortic valve replacement. Over a median follow-up of 6.2 [interquartile range 3.2–9.0] years, 254 (49%) patients died. The cumulative event rates for all-cause mortality increased with increasing stage, particularly for Stages ≥2: 39% for Stage 0, 55% for Stage 1, 67% for Stage 2, 68% for Stage 3 and 57% for Stage 4, respectively (Figure, log-rank test p=0.001).

Cumulative death rates after re-staging

Conclusion

In a real-world registry of patients with moderate AS patients, worsening extra-aortic valvular cardiac damage portends a worse long-term prognosis.
P5585Determinants of the use of direct oral anticoagulants in acute pulmonary thromboembolism in argentina
Authors: Bernal M I , Scatularo C E , Cigalini I M , Jauregui J C C , Ortego J I , Cornejo D , Aboy J M , Burgos L M , Gamarra A L , Visconti M , Garcia Zamora S , Igolnikof D B , Bonorino J M , Zaidel E J , Thierer J
Published: October 2019

Background

In the last decade, direct oral anticoagulants (DOACs) were incorporated as an alternative for anticoagulation in patients with venous thromboembolism. Although they have a better pharmacologic profile than vitamin K antagonists (VKAs), the use of these drugs is not massive.

Purpose

Assess the rate of use of DOACs in acute pulmonary embolism (PE) patients (P) in Argentina and analyze the determinants of their use.

Methods

Based on a registry of 684 P admitted for acute PE in 75 academic centers between October 2016 and November 2017, we performed an analysis of DOACs prescription at discharge. A conventional statistical analysis was performed, to assess the differences between the P that received DOACs or other anticoagulants using univariate and multivariate models.

Results

579 of 601 P who survived were discharged with anticoagulant treatment: 348 (60%) received VKA; 108 (19%) received DOACs (49% Rivaroxaban, 34% Apixaban, 17% Dabigatran) and 123 (21%) received low molecular weight heparins.

Patients who received DOACs had lower severity of PE and less risk of bleeding. The main baseline characteristics are described in table 1. Also, those patients who received DOACs at discharge had fewer in-hospital complications (heart failure, infections or bleeding; all p<0.05).

In the multivariate analysis, health insurance (OR 7.45, 95% CI: 1.74–31.9, p<0.01) was an independent predictor of DOACs prescription at discharge. The history of previous heart failure (OR 0.19, 95% CI: 0.04–0.84, p=0.03) or oncologic disease (OR 0.49; 95% CI: 0.27–0.89; p=0.02) were inversely and independent predictors for DOACs prescription.

Variable DOACs Other anticoagulants P OR CI (95%) Male sex 51 (47.2%) 196 (41.6%) 0.29 – – Age 64.3±17.6 63.3±16.6 0.61 – – Health insurance 106 (98.1%) 402 (85.4%) 0.01 9.1 (2.2–37.7) CKD without dialysis 2 (1.9%) 34 (7.3%) 0.06 0.24 (0.06–1.03) Heart failure 2 (1.9%) 55 (11.7%) 0.01 0.14 (0.03–0.59) Oncology disease 16 (14.8%) 127 (27%) 0.01 0.47 (0.27–0.83) Previous anticoagulation 3 (2.8%) 44 (9.3%) 0.03 0.28 (0.08–0.91) sPESI 1±1.12 1.28±1.11 0.02 0.78 (0.64–0.96) RIETE 1.71±1.17 2.05±1.33 0.02 0.81 (0.68–0.97) CKD: Chronic kidney disease; TIA: Transient ischemic attack.

Conclusions

The rate of use of DOACs in survivors of an acute PE in Argentina was 19%, and this P present lower clinical risk, fewer co-morbidities and greater access to health coverage.
P5590Temporal trends in first-line anticoagulation therapy for cancer-associated venous thromboembolism
Authors: King J M , Delate T , Charlu M , Zhu S , Pai A , Clark N P , Witt D M , King J B
Published: October 2019

Background

Knowledge of the comparative safety and efficacy of anticoagulant classes for the treatment of cancer-associated venous thromboembolism (VTE) has evolved over the past 20 years with recent evidence from randomized trials suggesting that direct oral anticoagulants (DOACs) may be a safe and effective oral alternative therapy to low-molecular-weight heparin (LMWH).

Purpose

To characterize the temporal trends in first-line outpatient anticoagulation therapy for cancer-associated VTE.

Methods

We conducted a retrospective cohort study of patients who were hospitalized for a cancer-associated VTE between 2000 and 2017. Patients were identified from the cancer registries of two regions of a large, integrated healthcare system in the United States. The primary outcome was the age- and sex-adjusted incidence rates of first-line anticoagulant therapy according to the year in which the VTE occurred. We determined each patient's anticoagulant regimen according to her/his outpatient pharmacy dispensing records during the first 30 days post-hospital discharge. Regimens were categorized as 1) LMWH, 2) warfarin ± an injectable anticoagulant, 3) fondaparinux, or 4) DOAC ± an injectable anticoagulant. Patients were excluded if they had history of VTE prior to cancer diagnosis, used an anticoagulant during the 6-months pre-hospitalization, did not initiate an anticoagulant after hospital discharge, or had a skin carcinoma.

Results

Overall, 9,816 patients were included with a mean age of 66±13 years and 5,238 (54%) were female. From 2000 to 2003, prior to publication of the first randomized controlled trial demonstrating LMWHs were superior to vitamin K antagonists for cancer-associated VTE, warfarin was first-line anticoagulant in ≈90% of cases (Figure). After 2003, there was a slow, steady decline in warfarin use corresponding with an increased use in LMWH: from 11% in 2003 to 55% in 2017. Since 2012, fondaparinux has accounted for <1% of first-line anticoagulant therapies. DOACs, which first became commercially available in the United States in 2010, have seen exponential growth since 2014, accounting for 20% of first-line anticoagulant therapies in 2017.

First-line anticoagulant use in cancer

Conclusion

From 2000 to 2017, first-line anticoagulant therapy for cancer-associated VTE has seen significant changes characterized by an increase in LMWH and DOAC use, and a decline in warfarin use.

Acknowledgement/Funding

Kaiser Permanente Northern California Community Benefit Grant, Agency for Health Research and Quality R18HS026156
P5610Inflammatory response after ExoVasc personalized external aortic root support (PEARS) procedure in patients with Marfan syndrome or non-Marfan genetic aortopathy
Authors: Kockova R , Maly J , Krebsova A , Labos M , Pirk J
Published: October 2019

Background

External aortic root support (PEARS) is a novel prophylactic aortic root surgery.

Purpose

The study aimed to determine the severity of inflammatory response after the personalized external aortic root support (PEARS) procedure in comparison to after the standard prophylactic aortic root surgery (SPARS).

Materials and methods

The study was a single-centre, retrospective, based on hospital record analysis of patients who underwent the PEARS procedure (PEARS group) or SPARS (SPARS group) during 1998–2017. C-reactive protein (CRP), white blood count (WBC), and echocardiography were routinely obtained. Fever was defined as body temperature ≥38°C. Diagnosis of pericarditis included a minimum of three signs from chest pain, pericardial effusion, ST elevation, elevated CRP, and body temperature.

Results

PEARS and SPARS groups consisted of 13 and 14 patients, respectively, scheduled for prophylactic aortic root surgery. A majority of patients in both groups had Marfan syndrome with causal mutation in the fibrillin 1 (FBN1) gene (62% vs 79%). Patient baseline characteristics were similar in the two groups, except aortic root was significantly larger in the SPARS group than in the PEARS group (60±12 mm vs 48±5 mm; P=0.003). All surgical procedures were successful and without major complications. The peak values of CRP and WBC were significantly higher in the PEARS group (264.5±84.4 mg/L vs 184.6±89.6 mg/L; P=0.034 and 15.2±3.8 109/L vs 11.9±3.3 109/L; P=0.029). Early and recurrent fever requiring hospital readmission was significantly more frequent in the PEARS group (77% vs 36%; P=0.032 and 46% vs 7%; P=0.020). Early and recurrent pericarditis requiring hospital readmission was also more frequent in the PEARS group (31% vs 0%; P=0.024 and 31% vs 0%; P=0.024).

Inflammatory characteristics Postprocedural inflammatory characteristics PEARS group SPARS group P value (N=13) (N=14) Peak level of CRP (mg/L) 264.5±84.4 184.6±89.6 0.034 Peak WBC (109/L) 15.2±3.8 11.9±3.3 0.029 ST elevation (N) 11 (85) 6 (43) 0.024 Early fever (N) 10 (77) 5 (36) 0.032 Recurrent fever (N) 6 (46) 1 (7) 0.020 Early pericarditis (N) 4 (31) 0 (0) 0.024 Recurrent pericarditis (N) 4 (31) 0 (0) 0.024 CRP, C-reactive protein; WBC, white blood count.

Echocardiography-signs of inflammation

Conclusions

The PEARS procedure is an extremely promising surgical technique, but the postoperative inflammatory response occurs frequently and more severely in comparison to SPARS. Clearly, these findings warrant further investigation.
P5612In vivo histological and clinical evaluation of layered culprit plaque by optical coherence tomography in stable angina patients
Authors: Okamoto H , Kume T , Yamada R , Neishi Y , Uemura S
Published: October 2019

Background

In patients with stable angina pectoris (SAP), exact mechanism of plaque progression overtime is still unclear due to lack of histological evaluation. Directional coronary atherectomy (DCA) allows for the differential cutting of atherosclerotic lesions and for the histological examination.

Purpose

The aims of this study were to compare the histological features obtained by DCA and layered pattern (LP) by OCT, and to establish the prevalence and clinical characteristics of LP in culprit lesion form SAP patients.

Methods

SAP patients who underwent OCT imaging guide PCI in our medical school hospital between June 2016 and June 2018 were included into this study. This was two-fold histological and clinical studies. In a histological study, we evaluated histological features of 42 specimens from 18 patients who underwent DCA and compare OCT findings. Lesions were classified into the following categories based on the OCT finding before DCA cutting; homogeneous or heterogeneous group. Furthermore, lesions in heterogeneous group were classified into 2 categories; LP or non-LP group. In a clinical study, 205 target lesions form 205 patients were categorized as shown above at minimum lumen area (MLA) sites. Plaque characteristics were compared among these groups.

Results

In the histological study, 9 (21.4%) specimens were classified in homogeneous group and 33 (78.6%) in heterogeneous group. In 33 heterogeneous group, LP group were observed in 12 specimens (36.3%). Of 12 LP group, 10 LP group consisted of intramural thrombosis. In clinical study, 39 (19.0%) lesion were classified in homogeneous group and 166 (81.0%) in heterogeneous group. In 166 heterogeneous group, LP group were observed in 75 lesions (45.2%). Of heterogeneous group, LP group had significantly smaller MLA (1.5±0.9 mm2 vs 1.9±1.0 mm2, p<0.05) and higher rate of microchannels (57.3% vs 15.4%, p<0.05) than non-LP group.

A representative layered pattern case

Conclusions

LP in culprit lesion with SAP was significantly associated with intramural thrombosis. MLA sites in LP was significantly smaller than in non-LP group. These data suggest that thrombus formation and subsequent their organization overtime might contribute to the plaque progression even in SAP patients.
P5613Proportional relationship between early mobilization of bone marrow progenitor cells and the extent of vascular injury during coronary stenting: insights on the role of systemic mechanisms of vascular
Authors: Jimenez-Quevedo P , Bernardo E , Del Trigo M , Otsuki S , Nombela Franco L , Brugaletta S , Ortega Pozi A , Salinas P , Nunez Gil I , Megia Renteria H , Fernandez Ortiz A , Macaya C , Escaned J , Sabate M , Gonzalo N
Published: October 2019

Background

The role of circulating progenitor cells (CPCs) on vascular repair after everolimus-eluting stent (EES) implantation is largely unknown.

Objectives

The aim of the study was to investigate the quantitative and temporal variations of CPCs levels after EES implantation, and its relationship with the degree of peri-procedural vascular damage, stent healing and neointimal hyperplasia, as measured by optical coherence tomography (OCT).

Methods

In a consecutive series of patients with stable coronary artery disease undergoing stent implantation CPC subpopulations (CD34+/CD45low, CD133+/CD45low, CD34/KDR/CD45low, CD133/KDR/CD45low) were evaluated using a flow cytometry technique at baseline, 1 and 4 weeks. OCT evaluation was performed immediately after stent implantation to quantify stenting-related injury, and at 9-month follow-up to assess mid-term vascular response.

Results

Twenty patients (mean age 66±9 years; 80%male) with 24 stenoses treated with EES were included in the study. Vascular injury score was associated with the increase of CD133+/KDR/CD45 low at 1-week (β0.28 [95% CI0.15; 0.41], p<0.001) and with the maximum neointimal thickness at 9-month follow-up (β0.008 [95% CI-0.0004; 0.002]:p=0.04). Mean neointimal area at 9-month was associated with the increase in the number of CD34+/CD45low at 1 week (β0.029 [95% CI0.025;-0.033]; p<0.0001). Inverse relationships between the number of uncoated and apposed struts at 9-month and the 1-week delta values of CD34/KDR/CD45low and CD133/KDR/CD45low (β-4.49 [95% CI-8.17;-0.82]; p=0.017 and β −12.53 [95% CI: −22.17; −2.90]; p=0.011, respectively) were also found.

Conclusion

Long-term vascular healing after EES implantation is modulated by early changes in levels of CPC subpopulations. This systemic response is proportional to the extent of vessel wall injury. Early mobilization of CPCs influences mid-term strut coverage and the development of neointimal hyperplasia.

Acknowledgement/Funding

Dr Jimenez-Quevedo is a recipient of the ISCIII (Instituto de Salud Carlos III) grant “Fondo de Investigaciόn Sanitaria” (PI11/00299) to perform this