bluuebunny/crossref_metadata_2025 huggingface dataset:
Figuring out complete left ventricular reverse remodeling in tachycardiomyopathy
Authors: Izquierdo Bajo A , Fernandez-Valenzuela I , Arroyo-Monino D F , Cozar-Leon R , Bastos-Amador P , Diaz-Infante E
Published: October 2022

Introduction

Tachycardiomyopathy is a common cause of left ventricular systolic dysfunction (LVSD), whose complete resolution after arrhythmia control is highly variable among patients.

Purpose

To assess the associated factors with complete left ventricular reverse remodeling (CLVRR) in patients with confirmed tachycardiomyopathy.

Methods

Retrospective single-centre, observational study of consecutive patients with diagnosed tachycardiomyopathy between January 2015–2022. CLVRR was defined by a recovered left ventricular ejection fraction (RLVEF) >55% and a left ventricular end-dyastolic diameter (LVEDD) <55 mm assessed by transthoracic echocardiography.

Results

134 patients were gathered in this period. Patients with previous known LVSD or LV dilatation were excluded from the analysis (n=6). Baseline characteristics are displayed in Image 1. Most frequent arrhythmia was atrial fibrillation (73.8%), followed by atrial flutter (25.4%), atrial tachycardia (2.2%) and ventricular extrasystole (5.2%). 99.2% of patients were treated with beta-blockers, 71.6% with ACEI/ARBs, 23.9% with neprilysin inhibitors and 64.2 with aldosterone receptor antagonist. Rhythm control was achieved in 82.1% of patients, of whom 80% underwent an ablation procedure after a mean of 8.2 months. After 10.8 months since LVSD, mean RLVEF was 55.4% (+6.3) and mean LVEDD 52.1 mm (+5.8). CLVRR was observed in 50% of patients. A multivariate analysis was performed in a stepwise fashion to assess associated factors, including baseline information (medical history, echocardiographic information and received treatment, both pharmacological and ablation). CLVRR was associated with female-sex (coefficient 1.18; p=0.009) and severe baseline left ventricular disfunction (coefficient −0.80; p=0.041), corrected by previous alcohol abuse history (coefficient 0.94; p=0.055) and a rhythm-control strategy (coefficient 0.98; p=0.052) which didn't reach complete statistical significance.

Conclusion

Women, patients without severe LV dysfunction at baseline, with history of previous alcohol abuse and receiving a rhythm-control strategy were associated with a complete left ventricular reverse remodeling in patients with tachycardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.
Evaluation of a prescribing pharmacist-led heart failure (HF) up-titration clinic
Authors: Williams R , Donald R , James A , Schiavone E , Hughes D , Wong A
Published: October 2022

Background/Introduction

Pharmacotherapy is considered the cornerstone of treatment for patients with heart failure with reduced ejection fraction (HFrEF). Modulation of the renin-angiotensin-aldosterone (RAAS) and sympathetic nervous system have been shown to improve survival, reduce the risk of heart failure (HF) hospitalisations and improve quality of life. Unless contraindicated or not tolerated, these patients should be prescribed angiotensin-converting enzyme inhibitor (ACEi)/angiotensin-receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 (SGLT2) inhibitor and up-titrated to guideline directed dosages.1 Despite the availability of effective treatments, patients are often sub-optimally dosed and experience a prolonged optimisation process. Pharmacist-led clinics can complement existing services and increase uptake of guideline directed medical therapies (GDMT).

Purpose

To evaluate the effectiveness of pharmacist-led heart failure clinics in the Princess of Wales Hospital, supported by the Heart Failure team, in optimisation of patients with HFrEF.

Methods

Patients who attended HF pharmacist led clinic between November 2020 and November 2021 were included in the analysis. Baseline demographics, left ventricular ejection fraction (LVEF), biomarkers, vital signs and medications were documented at baseline and after optimisation of GDMT. Number of clinics appointments and rate of hospitalisation and mortality were captured during the study period.

Results

76 patients were reviewed over a total of 318 consultations (34% virtual), averaging 4 consultations per patient. The mean age was 71 years, 36% of patients were female, mean LVEF was 32% and NT-proBNP 3078ng/L with 15% of patients on “quadruple therapy” at baseline. 93% of patients were referred by cardiologists and the average time from referral to first appointment was 42 days. Post-optimisation, 67% of patients were receiving “quadruple therapy”, with increased uptake of ACEi/ARB/ARNI, beta-blocker, MRA and SGLT2i from baseline (100%, 77%, 93% and 90% respectively). Mean LVEF increased to 42% and mean NT-proBNP reduced to 1695ng/L. No significant changes in creatinine clearance, blood pressure, heart rate or serum potassium (sK+) were recorded. The hospitalisation rate was 11% for heart failure, 6% for other cardiovascular causes and the mortality rate was 7%.

Conclusions

The pharmacist-led HF clinic demonstrated a high uptake of optimally dosed GDMT and improvements in NT-proBNP and LVEF. Pharmacist-led clinics can enhance the provision of existing heart failure services to improve patient outcomes and heart failure care.

Funding Acknowledgement

Type of funding sources: None.
Efficacy and safety of sacubitril/valsartan according to frailty in heart failure with preserved ejection fraction: a post hoc analysis of the PARAGON-HF trial
Authors: Butt J H , Dewan P , Kober L , Jhund P S , Solomon S D , McMurray J J V
Published: October 2022

Introduction

Frailty is an increasingly common problem and frail patients are less likely to receive pharmacological therapy because the benefit/risk profile is perceived to be less favorable than in non-frail patients.

Purpose

We investigated the prevalence of frailty, the relationship between frailty status and outcomes, and the efficacy of sacubitril/valsartan, compared with valsartan, according to frailty status in patients with heart failure (HF) with preserved fraction (HFpEF) randomized in PARAGON-HF.

Methods

Patients aged ≥50 years with a left ventricular ejection fraction ≥45%, structural heart disease, and elevated natriuretic peptide were enrolled in PARAGON-HF. Using the Rockwood cumulative deficit approach, a 41-item Frailty Index (FI) was constructed, and a FI score was calculated, with higher scores indicating greater frailty. The primary endpoint was a composite of total HF hospitalizations and cardiovascular death.

Results

Of the 4,796 patients randomized in PARAGON-HF, a FI was calculable in 4,795. Mean FI was 0.227 (standard deviation, 0.091; range, 0.061–0.537). In total, 2,165 (45.2%) patients had class 1 frailty (FI <0.210, i.e., not frail), 2.084 (43.5%) had class 2 (FI 0.211–0.310, i.e. more frail), and 546 (11.4%) were in class 3 frailty (FI >0.311, i.e. most frail). There was a graded relationship between FI class and the primary endpoint, with a significantly higher risk associated with greater frailty (class 1, reference; class 2, rate ratio 2.19 [95% CI, 1.85–2.60]; class 3, 3.29 [95% CI, 2.65–4.09]). The effect of sacubitril/valsartan versus valsartan on the primary endpoint from lowest to highest FI class (as a rate ratio) was: 0.98 [95% CI, 0.76–1.27], 0.92 [95% CI, 0.76–1.12], and 0.69 [95% CI, 0.51–0.95]), respectively (P for interaction=0.23) (Table). When FI was examined as a continuous variable, the interaction with treatment was significant for the primary outcome (P for interaction 0.002) and total HF hospitalizations (P for interaction <0.001) with those most frail deriving greater benefit (Figure). Adverse reactions and discontinuation of trial treatment were not more frequent with sacubitril/valsartan than valsartan, in frailer patients.

Conclusions

Frailty was common in patients with HFpEF in PARAGON-HF and associated with worse outcomes. There was a greater reduction in total HF hospitalizations with sacubitril/valsartan, compared with valsartan, in the frailest patients.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The PARAGON trial was sponsored by Novartis
The clinical relevance of quality of life in patients with acute decompensated heart failure with preserved ejection fraction: insights from the PURSUIT-HFpEF Registry
Authors: Seo M , Watanabe T , Yamada T , Yano M , Hayashi T , Yasumura Y , Hikoso S , Sotomi Y , Sakata Y
Published: October 2022

Background

Improvement of quality of life (QOL) is one of the most important therapeutic goals for patients with heart failure with preserved ejection fraction (HFpEF). It is, therefore, clinically relevant to comprehensively identify aggravating factors among cardiac factors, non-cardiac comorbidities, and social factors. The aim of this study was to elucidate determinant factors of impaired QOL and clarify the association between QOL and prognosis in patients with HFpEF.

Methods and results

Patient data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. EuroQol 5 dimensions 5-level (EQ-5D-5L) data were obtained at discharge to evaluate patients' health-related QOL. A total of 864 patients were enrolled in this study. Multivariable logistic regression analysis revealed that only non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation were significantly associated with low EQ-5D-5L score, whereas cardiac factors showed no significant association after multivariable adjustment. A total of 206 patients died over a mean follow-up period of 2.0±1.2 years. Kaplan–Meier survival curve analysis demonstrated a significant increase in risk of mortality stratified by tertiles of EQ-5D-5L score (p<0.0001). Cox multivariable analysis revealed that patients with low EQ-5D-5L score had a significantly greater risk of mortality than those with high EQ-5D-5L score (adjusted hazard ratio: 2.20 (1.40–3.45), p=0.001).

Conclusion

Among patients with HFpEF, non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation are significantly associated with impaired QOL. The QOL score itself also offers useful prognostic information in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: None.
Impact of type 2 diabetes on the incidence of cardiorenal syndromes and on subsequent clinical outcomes: a propensity-matched nationwide analysis
Authors: Fauchier L , Maisons V , Fauchier G , Herbert J , Angoulvant D , Ducluzeau P H , Halimi J M
Published: October 2022

Background

Type 2 diabetes mellitus (T2DM) is a major risk factor for cardiac diseases and renal dysfunction. Whether T2DM increases the risk of cardiorenal syndromes (CRS) subtypes to a similar extent, and whether the risk of deleterious outcomes after CRS is modified by diabetes are poorly known.

Methods

In a nationwide cohort study including 5,123,193 patients seen in French hospitals in 2012 with at least 5 years of follow-up (or dying earlier), we assessed the incidence of CRS subtypes, and then the impact of T2DM in patients with CRS on the risk of death, cardiovascular death, heart failure (HF), myocardial infarction (MI) and end-stage kidney disease (ESKD) during follow-up (27,735,205 person-years). Patients with history of dialysis, kidney transplantation or type 1 DM were excluded of the analysis. We performed 1:1 propensity matching on baseline characteristics including age, sex, risk factors, cardiovascular and non-cardiovascular comorbidities for patients with T2DM or no T2DM. The model by Fine and Gray was used for analyzing the competing risks for clinical events and all-cause death with sub-distribution hazard ratios (sHR).

Results

Among the 5,123,193 patients, 4,605,236 (91.2%) had neither HF nor CKD baseline. Among them, 391,186 (8.1%) had T2DM and 380,581 of them were matched 1:1 with 380,581patients with no T2DM. During follow-up, CRS occurred in 42,375 patients (incidence 0.98%/year): acute, i.e. type 1,3 or 5 CRS n=9,438, 22%; type 2 (cardiorenal) CRS n=21,075, 50%; type 4 (renocardiac) CRS n=11,862, 28%). In multivariable analysis, T2DM was the most powerful predictor of incident CRS (any type, HR: 2.182, 95% CI 2.150–2.214) among all baseline characteristics. The incidence of all-type CRS was higher in matched patients with T2DM (1.30%/year, 95% CI 1.29–1.32) than in those with no T2DM (0.65%/year, 95% CI 0.64–0.66): sHR 1.905 (95% CI 1.867–1.943). The risk of CRS associated with diabetes (vs no diabetes) was higher for type 4 (sHR 2.182, 95% CI 2.098–2.269) than for type 2 (sHR 1.834, 95% CI 1.783–1.887) and for acute (sHR 1.707, 95% CI 1.637–1.780) CRS.

Among the 451,942 patients with HF or CKD at baseline, 26,396 patients had CRS at baseline, among whom 11,355 (43.0%) had diabetes: 8,314 of them were matched 1:1 with 8,314 with CRS and no T2DM. Compared to CRS patients with no diabetes, matched patients with CRS and T2DM had a greater incidence of all-cause death (sHR 1.085, 95% CI 1.048–1.123), cardiovascular death (sHR 1.145, 95% CI 1.080–1.214), ESKD (sHR 1.319, 95% CI 1.223–1.422), hospitalization for HF (sHR 1.119, 95% CI 1.078–1.162) and MI (sHR 1.294, 95% CI 1.139–1.470) during follow-up.

Conclusions

T2DM is a major risk factor for all CRS subtypes, may differently affect the incidence of type 2, type 4 and acute CRS and aggravates the risk of deleterious outcomes after CRS.

Funding Acknowledgement

Type of funding sources: None.
Efficacy of empagliflozin in patients with heart failure according to baseline KDIGO risk categories – findings from the EMPEROR-Pooled
Authors: Butler J
Published: October 2022

Background and objective

Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with an incrementally higher risk for mortality and morbidity. EMPEROR-Pooled studied 9,718 HF patients across two trials and showed that empagliflozin reduces the risk for HF hospitalization or cardiovascular (CV) death, slows the progression of estimated glomerular filtration rate (eGFR) decline, and improves health status in patients with HF and reduced ejection fraction (HFrEF) as well as preserved ejection fraction (HFpEF).

Purpose

We explored the effect of empagliflozin on CV and kidney endpoints in patients across KDIGO (Kidney Disease Improving Global Outcomes) risk categories in EMPEROR-Pooled.

Methods

3,730 participants with left ventricular EF ≤40% (EMPEROR-Reduced) and 5,988 with left ventricular EF >40% (EMPEROR-Preserved) were categorized using baseline eGFR and UACR values into 4 categories according to KDIGO classification. The key outcomes were (1) a composite of CV death or hospitalization for HF, (2) first hospitalization for HF, (3) CV death and (4) eGFR slope change/year.

Results

The proportion of participants in low-, moderate-, high-, and very high-risk KDIGO categories was 31.4%, 29.6%, 22.0%, 16.9% for empagliflozin and 32.5%, 28.4%, 21.8%, 17.2% for placebo, respectively. Patients on placebo in higher baseline KDIGO risk categories had a higher risk of CV death or hospitalization for HF (6.78, 11.30, 15.15, and 20.70 events per 100 patient-years for low-, moderate-, high-, and very high-risk patients, respectively) (Figure 1). Similar trends were seen for first HF hospitalization (4.46, 7.68, 11.14, and 15.98 per 100 patients-years at risk) and CV death (2.98, 5.31, 5.69, and 7.60 per 100 patients-years at risk). eGFR slope decreased less in higher baseline KDIGO risk categories (−3.13 in low-, −2.81 in moderate-, −2.17 in high- and −1.61 ml/min/1.73 m2 per year in very high-risk category) (Figure 2).

Empagliflozin reduced the risk of CV death or hospitalizations for HF similarly across KDIGO risk categories (hazard ratio [HR] 0.81; 95% confidence interval [CI] 0.66, 1.01 for low-, HR 0.63; 95% CI 0.52, 0.76 for moderate-, HR 0.82; 95% CI 0.68, 0.98 for high- and HR 0.84; 95% CI 0.71, 1.01 for very high-risk group; P trend=0.299). Similarly, empagliflozin reduced the risk of first HF hospitalization (P trend=0.186), CV death (P trend=0.663) or eGFR slope change (P trend=0.069) across the four groups.

Conclusions

Treatment with empagliflozin reduced the risk for CV death or HF hospitalization and slowed the rate of kidney function decline similarly in all KDIGO CKD risk categories.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance
Heterogeneous and overlapping mechanisms of myocardial ischemia in patients with ischemia and non-obstructive coronary arteries. Preliminary results from the MOSAIC-COR Registry
Authors: Szolc P S , Niewiara L , Legutko J , Kleczynski P , Rzeznik D , Tekieli L , Podolec J , Diachyshyn M , Stapor M , Zmudka K , Guzik B
Published: October 2022

Background

Patients with ischemia and non-obstructive coronary arteries (INOCA) account for 30–70% of all patients undergoing elective coronary angiography for angina. In these group of patients various mechanisms may be responsible for myocardial ischemia, including increased microvascular resistance, epicardial spasm or microvascular spasm. There are limited data on the prevalence and coexistence of different mechanisms in patients with INOCA.

Purpose

The primary objective was to assess the occurrence of coronary microcirculatory disease (CMD), epicardial vasospastic angina (EVSA), microvascular vasospastic angina (MVSA) and their coexistance in patients with INOCA. The secondary objective was the analysis of subgroups' clinical characteristics.

Methods

This was a single-center, prospective, observational study. In the absence of significant coronary artery stenosis, a complex functional coronary assessment was performed. Values of fractional flow reserve (FFR), RFR, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were determined. Coronary artery and microvascular vasoreactivity was tested using the provocative acetylcholine test.

Results

We enrolled 90 consecutive patients with INOCA. Overlapping of CMD and CMD/EVSA phenomenon was observed. Accordingly, we distinguished 6 subgroups of INOCA patients in comparison to the CorMicA trial. Mixed pathophysiology (CMD+EVSA and CMD+MVSA) was diagnosed in 33% of patients. In the CMD+EVSA subgroup, 73% of subjects were male, while in the CMD+MVSA only 7.1% were male (p=0.005). Typical cardiovascular risk factors were common in the whole INOCA group.

Conclusions

The INOCA population is a heterogeneous group with various pathophysiology of myocardial ischemia. Overlapping of different pathomechanisms is a frequent phenomenon, which has to be consider for treatment optimization and future research.

Funding Acknowledgement

Type of funding sources: None.
Ethnic disparities in ST-segment myocardial infarction outcomes and processes of care in patients with and without standard modifiable cardiovascular risk factors: a nationwide cohort study
Authors: Weight N , Moledina S , Dafaalla M , Mamas M A
Published: October 2022

Background

There is growing interest in patients presenting with ST-elevation myocardial infarction (STEMI) in the absence of `standard modifiable cardiovascular risk factors' (SMuRFs), which include current smoking, hypertension, diabetes and hypercholesterolaemia. Recent trials have demonstrated how these “SMuRFless” patients can have poorer outcomes after STEMI then those patients with SMuRFs, but these trials have not looked at the role of ethnicity in outcomes (1).

Methods

We analysed 118,177 STEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed using hierarchical logistic regression models according to the presence of ≥1 SMuRF (88,055) and compared to the “SMuRFless” cohort (30,122), with a subgroup analysis comparing the outcomes of white and ethnic minority patients (comprising Black, Asian, Mixed and other) depending on SMuRF status. Our primary outcomes were in-hospital mortality and major adverse cardiovascular events (MACE), and secondary outcomes were in-hospital cardiac mortality and major bleeding.

Results

SMuRFless patients had a higher incidence of MACE (OR 1.09, CI 1.02–1.16), in-hospital mortality (OR 1.09, CI 1.01–1.18), and cardiac-mortality (OR 1.08, CI 1.00–1.17) than those with SMuRFs after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. There were no statistically significant differences in our outcome measures between white and ethnic minority patients. Ethnic minority patients were more likely to undergo revascularisation by PCI or CABG (ethnic minority with SMuRFs 88%, ethnic minority SMuRFless 87%, white with SMuRFs 80%, white SMuRFless 77%).

Conclusion

SMuRFless patients have a higher incidence of MACE, in-hospital mortality, and cardiac-mortality than those with SMuRFs, which persists after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status but did not have poorer outcomes when compared to white patients.

Funding Acknowledgement

Type of funding sources: None.
The association between cardiovascular risk factors and coronary CT angiography findings for predicting obstructive coronary artery disease in Korean patients with stable chest pain
Authors: Kim D , Choi H , Ko D G , Park K T
Published: October 2022

Background/Introduction

The 2019 European Society of Cardiology (ESC) guidelines currently recommend the use of coronary computed tomography angiography (CCTA) as the initial test for diagnosing coronary artery disease (CAD) in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone.

Purpose

The purpose of this study is to identify the prevalence of obstructive CAD in patients with stable chest pain, and the correlation between several clinical cardiovascular disease (CVD) risk factors and CCTA findings presented by Coronary Artery Disease Reporting and Data System (CAD-RADS).

Methods

The present study is a single-center retrospective cross-sectional study. A total of 1,892 patients with stable chest pain who underwent CCTA were enrolled in this study. Diamond-Forrester classification, Framingham risk score (FRS), atherosclerotic CVD (ASCVD) 10-year risk score, coronary artery calcium score (CACS) and CAD-RADS category were obtained from every patient.

Results

Among 1,892 patients (mean age, 60.5±8.6 years; men, 59.3%), 356 (18.8%) had obstructive CAD according to CCTA. Patients with high and intermediate ASCVD 10-year risk score had 2.59 times (aOR 2.59, 95% CI; 1.58 to 4.23) and 1.66 times (aOR 1.66, 95% CI; 1.04 to 2.65) higher odds of having obstructive CAD than patients with low ASCVD 10-year risk score, respectively (adjusted for Diamond-Forrester classification and CACS group). Higher ASCVD risk scores were significantly associated with higher CAD-RADS category (p<0.001), and patients with CAD-RADS category 3 had ASCVD 10-year risk score of 20.1±12.7. CACS showed the highest discrimination in presence of obstructive CAD, followed by ASCVD 10-year risk score, FRS, and Diamond-Forrester classification (AUC: 0.821 [95% CI; 0.797–0.845]; 0.711 [95% CI; 0.683–0.740]; 0.675 [95% CI; 0.646–0.704]; 0.600 [95% CI; 0.569–0.632], respectively).

Conclusion

This is the first study of CCTA findings in stable chest pain patients in Korea. The prevalence of obstructive CAD in patients with stable chest pain was 18.8%. Higher ASCVD score is significantly associated with presence of obstructive CAD and higher CAD-RADS category. As coronary stenosis of 50%-69% had a mean ASCVD score of 20.1, we should consider CCTA for identifying obstructive CAD in patients with ASCVD score over 20 with stable chest pain.

Funding Acknowledgement

Type of funding sources: None.
Absolute flow and resistance have a lower variability in repeated testing as compared to CFR and IMR: an EDIT-CMD substudy
Authors: Jansen T P J , De Vos A , Damman P , Paradies V , Konst R E , Teerenstra S , Van Den Oord S C H , Dimitriu-Leen A , Maas A H E M , Smits P C , Elias-Smale S E , Van Royen N
Published: October 2022

Background

Invasive coronary function testing (CFT), including both acetylcholine (ACH) spasm provocation testing and assessment of coronary flow and resistance, is recommended to assess coronary vasomotor dysfunction (CVDys) in patients with angina and non-obstructive coronary artery disease (ANOCA).

Objectives

To determine repeat testing reliability of invasive measurements of CVDys.

Methods

In the EDIT-CMD trial, 73 patients underwent both baseline and follow-up CFT after six weeks. Repeat testing reliability for CVDys assessment, including coronary flow reserve (CFR), index of microvascular resistance (IMR), absolute flow (Q) and microvascular resistance (R) was assessed by 1.) comparing continuous values between baseline and follow-up measurement, including difference and correlation between the two measurements 2.) classification agreement (CCA) for the presence of CMD according to cut-offs, which was also assessed for ACH spasm provocation test and 3.) Bland-Altman plots. Fisher-Z scores were used to compare correlations.

Results

Mean CFR was 3.1±1.5 at baseline and 4.1±1.5 at follow-up (P=0.03), with no significant correlation (ρ=0.285, P=0.10). Mean IMR was 27±12 at baseline and 27±19 at follow-up (P=0.94), with a trend to a significant correlation (ρ=0.312, P=0.07). The CCA between the baseline and follow-up was 74% for CFR and 57% for IMR.

Mean Q was 183±72 at baseline and 192±78 at follow-up (P=0.49), with a significant correlation (ρ=0.579, P<0.001). Mean R was 527±233 at baseline and 506±228 at follow-up (P=0.67), with a significant correlation (ρ=0.51, p=0.03). The CCA between R at baseline and 6 weeks follow-up was 72% and for Q this was 82%.

The correlation coefficient (ρ) of Q was significantly better than the ρ of CFR (P=0.006). The ρ of R and IMR did not differ.

For the ACH spasm provocation test we found a CCA of 79% between both measurements.

Conclusion

This is the first study to assess re-test reliability of the invasive CFT. Measurements of Q and R show higher agreement and correlation than their surrogates CFR and IMR in assessing microvascular function. ACH provocation spasm test also demonstrated good re-test reliability.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott
Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories
Authors: Ishii M , Kaikita K , Yasuda S , Akao M , Ako J , Matoba T , Nakamura M , Miyauchi K , Hagiwara N , Kimura K , Hirayama A , Matsui K , Ogawa H , Tsujita K
Published: October 2022

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose

The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods

Patients were categorized into groups 1 (underweight: BMI of <18.5 kg/m2), 2 (normal: BMI of 18.5 to <25 kg/m2), 3 (overweight: BMI of 25 to <30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions

Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd
Prognostic implication of residual inflammatory risk according to disease status in patients treated with percutaneous coronary intervention
Authors: Song H G , Ahn J H , Koh J S , Bae J S , Park Y W , Hwang S J , Hwang J Y , Jeong Y H
Published: October 2022

Background

Compared with stable angina, acute myocardial infarction (AMI) phenotype is related with the elevated inflammatory activity. However, time-dependent change of inflammatory level and its prognostic implication has not been fully understood according to the disease entity.

Methods

We enrolled total 4,263 patients who underwent percutaneous coronary intervention (PCI) with serial measurement of high-sensitivity C-reactive protein (hsCRP) at on-admission and 1-month post-PCI. The risks of MACE (a composite of death, MI or stroke), and major bleeding were evaluated up to 4 years after procedure.

Results

Compared with the non-AMI group (n=1,887), the AMI group (n=2,376) showed the significant decrease of hs-CRP during 1 month (∇0.5 vs. ∇0.1 mg/L; P<0.001). However, 1-month hs-CRP value still was higher in the AMI group than in the non-AMI group (median: 1.0 vs. 0.9 mg/L; P=0.001). During 1-month follow-up, high vs. low inflammatory risk (upper vs. lower tertile of hs-CRP) was significantly associated with increased rate of MACE in the AMI group (HR: 7.66; 95% CI: 2.29–25.59; P<0.001), but not in the non-AMI group (HR: 0.74; 95% CI: 0.12–4.40; P=0.736). From 1-month to 4-years, patients with high inflammatory risk showed the greater rate of MACE compared to those with low inflammatory risk, in both the AMI (HR: 2.40; 95% CI: 1.73–3.45; P<0.001) and non-AMI (HR: 2.67; 95% CI: 1.80–3.94; P<0.001) groups.

Conclusion

In PCI-treated patients, patients presented with AMI showed the greater values of inflammatory activity and its prognostic implication during the early phase, but combined inflammatory risk appeared similar across the disease entity during the late phase. This result may support that clinical benefit of post-PCI anti-inflammatory treatment would be constant regardless of the disease entity during the stabilized phase.

Funding Acknowledgement

Type of funding sources: None.
Impact of recent 2021 ESC guideline changes on postoperative survival of patients with severe aortic regurgitation: insights from the AVIATOR registry
Authors: Hanet V , De Azevedo D , Krug P , Schafers H J , Lansac E , De Kerchove L , El-Hamamsy I , Vojacek J , Contino M , Pouleur A C , Beauloye C , Pasquet A , Vanoverschelde J L , Vancraeynest D , Gerber B
Published: October 2022

Background

Until 2021, the strongest guidelines on surgical correction of severe aortic regurgitation (AR) focused on the left ventricular systolic function (LVEF) and the presence of symptoms. However, those situations lead to an outcome penalty, even after surgical correction. Left ventricle end-systolic diameter (LVESD) gained in strength in 2021 European guidelines. Moreover, more inclusive cut-off values are now recommended (class IIb) in patients at low surgical risk, reflecting the will to recommend surgery before developing heart failure and its consequences on post-operative outcome.

Purpose

We sought to evaluate the impact of guidelines triggers and their recent changes on postoperative survival of patients with severe AR from a large multicentric international registry.

Method and results

Postoperative overall survival of 1899 patients operated for severe and chronic AR (mean age 49±15 years, 85% male) in the international multicenter surgery registry for aortic valve surgery, AVIATOR, was evaluated over a median of 37 months. Twelve patients (0.6%) died postoperatively, and 68 within 10 years. By multivariable Cox analysis, presence of heart failure symptoms (HR 2.60; 95% CI [1.20–5.66]; p=0; 016), and either LVESD >50 mm or >25 mm/m2 (HR 1.64; 95% CI [1.05–2.55]; p=0.029) predicted survival independently over and above age (HR 2.25 per SD, 95% CI [1.67–3.03], p<0.001), female gender and bicuspid phenotype. Therefore, patients operated on when meeting either old or new 2021 class I triggers had worse adjusted survival (respectively 86±2% and 87±2%) than patients operated on without meeting triggers (97±2%, p<0.01). However asymptomatic patients operated on while meeting new 2021 ESC class IIb triggers (ie LVESD >20 mm/m2 or LVEF between 50–55%, 10-year survival 97±3%). Moreover, the sub-group of patients having a dilated LVESD >50 mm or >25 mm/m2 but a preserved LVEF >50% had excellent survival (10-year survival 95±3%).

Conclusions

In severe AR, patients operated on when meeting any class I trigger have postoperative survival penalty. Asymptomatic patients operated on earlier have better survival. This supports early surgery in AR as encouraged by the recent ESC/EACTS guidelines.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fondation Nationale de la Recherche Scientifique of the Belgian Government
Cardiopulmonary arrest and in-hospital outcomes in young patients with acute myocardial infarction: insights from the Japanese nationwide registry
Authors: Ando H , Yamaji K , Kohsaka S , Ishii H , Sakakura K , Goto R , Nakano Y , Takashima H , Ikari Y , Amano T
Published: October 2022

Background

Cardiopulmonary arrest (CPA) is the most serious presentation of acute myocardial infarction (AMI). However, the frequency and prognostic impact of CPA in young patients with AMI have been still unclear.

Objectives

This study aimed to characterize AMI in young patients who underwent primary percutaneous coronary intervention using large-scale nationwide all-comer registry data in Japan (J-PCI registry).

Methods

Data on risk factor profiles, clinical features, post-procedural complications, and in-hospital outcomes were reviewed within the J-PCI registry between 2014 and 2018.

Results

Among 213,297 patients with AMI, 23,985 (11.2%) were young (age, 20–49 years). Compared with the older group (age, 50–79 years; n=189,312), the young group included a higher number of men, smokers, patients with dyslipidemia, and patients with single-vessel disease, and a lower number of patients with hypertension and diabetes. Despite favorable clinical profiles, younger age was associated with a higher rate of presentation with CPA (Figure 1). Further, concomitant CPA was strongly associated with in-hospital mortality in the young group (Table 1).

Conclusions

Young patients with AMI presented a higher risk of CPA than older patients, which was strongly associated with in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI
Age-related difference in the impact of diabetes mellitus on all-cause mortality after acute myocardial infarction
Authors: An S Y , Um R B , Park J H , Jeong J O , Song P S
Published: October 2022

Background

Diabetes mellitus (DM) is highly prevalent among individuals hospitalized with acute myocardial infarction (AMI) and is associated with increased risk for cardiovascular complications and short-term and long-term mortality. However, most existing data are from older patients. Little is known about the incidence of diabetes in individuals who experience AMI at a young age. Whether the presence of DM is associated with worse outcomes in these patients is not clear.

Purpose

To test the hypothesis that the impact of DM on clinical outcomes after AMI can vary by age.

Methods

A total of 12,600 AMI patients from the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) between November 2011 and December 2015 was classified into young (n=3,590 [28.5%]) and elderly (n=9,010 [71.5%]). Those less than 55 years of age were considered young. We performed comparisons of baseline characteristics, in-hospital treatments, and long-term clinical outcomes between patients with and without diabetes after stratification according to age group.

Results

The prevalence of diabetes mellitus was 26.5% in the young AMI group. In the multivariable-adjusted model of the entire cohort, diabetes mellitus was associated strongly with 3-year all-cause mortality (12.6% vs. 6.8%; adjusted hazard ratio [HR], 1.318; 95% confidence interval [CI], 1.138–1.526; P<0.001). When the entire cohort was subdivided into two age groups, young diabetic patients showed a 107.0% higher mortality rate than those without diabetes (adjusted HR, 2.070; 95% CI, 1.150–3.724; P=0.015). Meanwhile, elderly diabetic patients had a 25.3% higher risk of mortality than non-diabetic patients (adjusted HR, 1.253; 95% CI, 1.076–1.459; P=0.004). The interaction of diabetes with age was significant (adjusted P for interaction = 0.008).

Conclusion

DM is not uncommon in younger AMI patients, and the relative risk of long-term mortality is significantly higher in young patients than in older counterparts. More aggressive treatments are needed to prevent future cardiovascular events in younger patients after AMI.

Funding Acknowledgement

Type of funding sources: None.
1-year mortality after myocardial injury in COVID-19 patients
Authors: Gomes B F O , Silva T M B , Dutra G P , Peres L S , Camisao N D , Menezes I R R , Goudar H C , Butter A , Petriz J L F , Carmo Junior P R , Pereira B B , Oliveira G M M
Published: October 2022

Background

Myocardial injury is a known complication of COVID-19 and is related to a worse prognosis on admission. However, its impact on 1-year mortality is unknown.

Methods

Retrospective cohort study with patients admitted to intensive care and confirmed diagnosis of COVID-19 by RT-PCR and with at least one measurement of troponin during hospitalization. The study period was from March/2020 to June/2021. Clinical characteristics and the occurrence of myocardial were assessed between deaths and survivors using the chi-square test and Student's t-test. Variables with p<0.01 in the univariate analysis were included in the Cox regression model to identify predictor variables of 1-year mortality.

Results

1037 patients were included, with a mean follow-up of 1.06±0.58 years, mean age = 59.9±16.2 years, and 62.7% men. The prevalence of myocardial injury was 42.8% and occurred 204 deaths (19.7%). In the univariate analysis, the variables associated with 1-year mortality were: myocardial injury (OR 7.5; CI95% 5.2–10.9), age >60 years (OR 5.65; CI95% 3.9–8.2), arterial hypertension (OR 2.8; CI95% 2.0–3.9), diabetes (OR 2.3; CI95% 1.6–3.1), chronic kidney failure (OR 3.9; CI95% 2.2–6.8), dementia (OR 1.8; CI95% 1.2–2.6) and mechanical ventilation (OR 50.5; CI95% 33.9–77.3). In Cox regression, the predictor variables were: myocardial injury (HR 2.4; CI95% 1.7–3.5), age >60 years (HR 2.5; CI95% 1.8–3.6), chronic kidney disease (HR 1.9; CI95% 1.2–2.9), dementia (HR 3.2; CI95% 2.1–5.0) and mechanical ventilation (HR 17.5; CI95% 12.2–25.2).

Conclusion

In patients admitted to intensive care by COVID-19, the detection of myocardial injury more than doubled the risk of death in 1 year.

Funding Acknowledgement

Type of funding sources: None.
High-sensitivity troponin is a biomarker of medium term mortality in 20,000 consecutive hospital patients undergoing a blood test for any reason
Authors: Hinton J , Mariathas M , Gabara L , Allan R , Nicholas Z , Kwok C S , Ramamoorthy S , Martin G , Cook P , Mamas M A , Curzen N
Published: October 2022

Introduction

High sensitivity troponin (hs-cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in patients without a clinical presentation consistent with type 1 myocardial infarction. There is increasing evidence that these concentrations may act as a marker of prognosis in a range of conditions. However, previous studies have been limited because they have only included patients in whom the clinician has requested the test. The aim of this study was to assess the relationship between medium term mortality and hs-cTn concentration in a large consecutive hospital population undergoing a blood test, regardless of whether there was a clinical indication for performing the hs-cTn.

Method

This single centre study included 20,000 consecutive patients undergoing a blood test for any reason, in whom hs-cTnI was added, regardless of the clinical indication (CHARIOT population). Mortality data up to 2.25 years was obtained via NHS Digital. The association between hs-cTnI concentration and one year mortality was evaluated using Kaplan-Meier plots (with log-rank test) and Cox proportional hazards analyses. After the cohort was considered as a whole, each of the clinical areas (inpatient (IPD), outpatient (OPD), emergency department (ED)) were considered separately. Furthermore, in the IPD and ED populations, a landmark analysis was performed excluding those patients who died within 30 days to assess whether any longer term relationship was driven by short term mortality.

Results

Overall, 2825 (14.1%) patients had died at 2.25 years. The mortality at 2.25 years was significantly higher if the hs-cTnI concentration was above the ULN (45.3% versus 12.3%, p<0.001 (log rank) in the entire cohort (Figure 1). Multivariable Cox regression analysis demonstrated that the log10hs-cTnI concentration was independently associated with 2.25 year mortality (hazard ratio (HR) 1.69 (95% confidence interval (CI): 1.59–1.80)). This relationship was demonstrated for patients in each of the clinical areas (IPD HR 1.46 (95% CI: 1.33–1.60), OPD HR 2.19 (95% CI: 1.84–2.60), ED HR 1.87 (95% CI: 1.68–2.07)). Further analysis by excluding those patients that died within 30 days demonstrated that the relationship between hs-cTnI concentration and mortality persisted and it was not driven by short term mortality.

Conclusion

In a large, unselected hospital population of both in- and out-patients, the majority of whom there was no clinical indication for testing, hs-cTnI concentration was independently associated with medium term mortality. These data suggest that hs-cTnI may have a role as a biomarker of future risk.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Beckman Coulter
Educational Differences in Life Expectancies With and Without Pain
Authors: Sun Feinuo , Zimmer Zachary , Zajacova Anna
Published: October 2022

Objectives

This study computes years and proportion of life that older adults living in the United States can expect to live pain-free and in different pain states, by age, sex, and level of education. The analysis addresses challenges related to dynamics and mortality selection when studying associations between education and pain in older populations.

Methods

Data are from National Health and Aging Trends Study, 2011–2020. The sample contains 10,180 respondents who are age 65 and older. Pain expectancy estimates are computed using the Interpolated Markov Chain software that applies probability transitions to multistate life tables.

Results

Those with higher educational levels expect not only a longer life but also a higher proportion of life without pain. For example, a 65-year-old female with less than high school education expects 18.1 years in total and 5.8 years, or 32% of life, without pain compared with 23.7 years in total with 10.7 years, or 45% of life without pain if she completed college. The education gradient in pain expectancies is more salient for females than males and narrows at the oldest ages. There is no educational disparity in the percent of life with nonlimiting pain.

Discussion

Education promotes longer life and more pain-free years, but the specific degree of improvement by education varies across demographic groups. More research is needed to explain associations between education and more and less severe and limiting aspects of pain.
Performance effectiveness of vital parameter combinations for early warning of sepsis—an exhaustive study using machine learning
Authors: Rangan Ekanath Srihari , Pathinarupothi Rahul Krishnan , Anand Kanwaljeet J S , Snyder Michael P
Published: October 2022

Objective

To carry out exhaustive data-driven computations for the performance of noninvasive vital signs heart rate (HR), respiratory rate (RR), peripheral oxygen saturation (SpO2), and temperature (Temp), considered both independently and in all possible combinations, for early detection of sepsis.

Materials and methods

By extracting features interpretable by clinicians, we applied Gradient Boosted Decision Tree machine learning on a dataset of 2630 patients to build 240 models. Validation was performed on a geographically distinct dataset. Relative to onset, predictions were clocked as per 16 pairs of monitoring intervals and prediction times, and the outcomes were ranked.

Results

The combination of HR and Temp was found to be a minimal feature set yielding maximal predictability with area under receiver operating curve 0.94, sensitivity of 0.85, and specificity of 0.90. Whereas HR and RR each directly enhance prediction, the effects of SpO2 and Temp are significant only when combined with HR or RR. In benchmarking relative to standard methods Systemic Inflammatory Response Syndrome (SIRS), National Early Warning Score (NEWS), and quick-Sequential Organ Failure Assessment (qSOFA), Vital-SEP outperformed all 3 of them.

Conclusion

It can be concluded that using intensive care unit data even 2 vital signs are adequate to predict sepsis upto 6 h in advance with promising accuracy comparable to standard scoring methods and other sepsis predictive tools reported in literature. Vital-SEP can be used for fast-track prediction especially in limited resource hospital settings where laboratory based hematologic or biochemical assays may be unavailable, inaccurate, or entail clinically inordinate delays. A prospective study is essential to determine the clinical impact of the proposed sepsis prediction model and evaluate other outcomes such as mortality and duration of hospital stay.
Paraconsistentization and many-valued logics
Authors: de Souza Edelcio G , Costa-Leite Alexandre , Dias Diogo H B
Published: October 2022

This paper shows how to transform explosive many-valued systems into paraconsistent logics. We investigate mainly the case of three-valued systems exhibiting how non-explosive three-valued logics can be obtained from them.