bluuebunny/crossref_metadata_2025 huggingface dataset:
P3593Improving the performance of high-sensitivity cardiac troponin for the diagnosis of myocardial infarction
Authors: Anand A , Shah A S V , Strachan F E , Lee K K , Chapman A R , Bularga A , Stewart S , Ferry A , Marshall L , Newby D E , Mills N L
Published: October 2019

Background

The Universal Definition of Myocardial Infarction (UDMI) mandates a rise and/or fall in high-sensitivity cardiac troponin (hs-cTn) concentration with at least one measure above the 99th centile of a healthy reference population. However, the 99th centile varies by age, sex, and prevalence of comorbid disease within reference populations, and the application of a single threshold may create diagnostic uncertainty in unselected patients attending the Emergency Department.

Purpose

To compare performance of hs-cTnI at the 99th centile with a model that includes additional clinical variables, for the diagnosis of type 1 myocardial infarction.

Methods

The High-Sensitivity Troponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS trial) was a stepped wedge cluster randomised controlled trial of 48,282 consecutive patients across 10 hospitals in Scotland. We evaluated the positive predictive value (PPV) of a hs-cTnI >99th centile for a diagnosis of type 1 myocardial infarction. Patients with ST-segment elevation myocardial infarction (STEMI) were excluded, and all were adjudicated according to the 4th UDMI. The study population was randomly divided into derivation (80%) and internal validation (20%) cohorts. Using generalised additive modelling, we tested the effect of adding clinically relevant variables to hs-cTnI for the prediction of type 1 myocardial infarction in the derivation cohort, and assessed performance of the final model in the validation cohort.

Results

We included 47,101 consecutive patients (61±17 years, 47% female), of whom 9,057 (19%) had at least one hs-cTnI >99th centile (7,207 in derivation and 1,850 in validation cohorts). There were 4,087 (45%) patients with type 1 myocardial infarction, with 3239 (45%) and 848 (46%) in the derivation and validation cohorts, respectively. Across the study population, PPV for type 1 myocardial infarction reduced markedly with increasing age (Figure). Age, sex, chest pain, ischaemia on the electrocardiogram, creatinine and rate of change of hs-cTnI were included in the model. Comorbidities (ischaemic heart disease, diabetes, stroke and hyperlipidaemia) did not improve model performance. In the validation cohort, the area under the curve (AUC) for type 1 myocardial infarction using the 99th centile alone was 0.72 (95% CI 0.70–0.74), whereas the AUC for the optimised model was 0.84 (95% CI 0.82–0.85) (p<0.001 by DeLong's test for difference, see Figure).

Figure 1

Conclusion

The diagnostic performance of the 99th centile for type 1 myocardial infarction is poor, particularly in older populations. A simple model including readily available clinical features improves diagnostic performance and with further external validation could support more individualised treatment decisions.

Acknowledgement/Funding

British Heart Foundation
P3601Association of cdkn2b rs2891168 polymorphism with wall motion index score and the development of major adverse cardiovascular events within one year following ST elevation myocardial infarction
Authors: Magamedkerimova F A , Magamedkerimova F A , Ivantsov E N , Khasanov N R , Valeeva E V , Ibrahim M
Published: October 2019

Introduction

According to the GRACE registry the largest amount of deaths occurs in the first year after ST elevation myocardial infarction (STEMI).

Purpose

To investigate the incidence of Major Adverse Cardiovascular Events (MACE), which include cardiovascular death, nonfatal myocardial infarction, nonfatal stroke one year after STEMI and Wall Motion Index Score (WMSI) in patients with different genotypes A/G of rs2891116 polymorphism in CDKN2B gene.

Materials and methods

A total of 141 patients, diagnosed with STEMI based on the Third Universal Definition of Myocardial Infarction (ESC, 2013) were included in the study, composed of 52 females and 89 males. The study group mean age was 63.8±11.8 years. Informed consent was obtained. During hospitalization echocardiography was performed and a blood sample was taken for genetic testing. Over the one-year period MACE were recorded. 17 patients were lost to follow up. Data was analysed using Kaplan-Meier estimator; to compare differences between groups log-rank test was applied; continuous data analysis was performed by Mann-Whitney test. The measured genotype frequencies fit the Hardy-Weinberg equilibrium (p>0.05).

Results

Kaplan-Meier survival analysis revealed that in patients with AA genotype the proportion of individuals who experienced MACE over the one year period after STEMI was higher in comparison with AG genotype carriers (log rank p=0.022). Participants with GG genotype did not show significant differences compared to other genotypes carriers (Picture 1). WMSI value in patients with AA genotype was higher (Me = 1.25; Q(0.25) = 1.13; Q(0.75) = 1.56) than in AG genotype carriers (Me = 1.13; Q(0.25) = 1.13; Q(0.75) = 1.25; p=0.037). In participants with GG genotype compared to AA and AG the WMSI value was not significantly different (Me = 1.19; Q(0.25) = 1.13; Q(0.75) = 1.32).

Picture 1

Conclusions

Genotype AA in CDKN2B gene rs2891168 in patients after STEMI is associated with higher probability of the development of MACE over the one year period after the index event, compared to AG genotype carriers. Participants with AA genotype exhibited a higher WMSI value after STEMI compared to patients with AG genotype.
P3611The effect of concomitant AF on in-hospital clinical outcomes of NSTE-ACS related hospitalizations in the United States: an analysis of rates, trends and predictors from 2004 to 2014
Authors: Mohamed M O , Kirchhof P , Vidovich M , Savage M , Rashid M , Kwok C S , Thomas M , El Omar O , Al Ayoubi F , Fischman D , Mamas M A
Published: October 2019

Background

Atrial fibrillation (AF) is the most common arrhythmia in patients presenting with acute coronary syndrome (ACS).

Purpose

We sought to examine the rates, trends, and clinical outcomes of non-ST Elevation acute coronary syndrome (NSTE-ACS) related hospitalisations in the United States in patients with AF compared to those with sinus rhythm (SR).

Methods

We analysed the Nationwide Inpatient Sample (NIS) database from 2004 to 2014 for patients with a primary discharge diagnosis of NSTEMI or UA, and further stratified the cohort on the basis of diagnoses into SR and AF groups. Multivariate analysis was performed to identify the association between AF and MACCE (composite of mortality, stroke and cardiac complications), mortality, stroke, and bleeding.

Results

A total of 4,668,737 NSTE-ACS admissions were included in our analysis. The proportions of SR and AF groups were 82.4% (3,848,202) and 17.6% (820,535), respectively. The incidence of AF increased significantly over time from 16.5% in 2004 to 19.3% in 2014 (p<0.001). The AF group was at a greater risk of adverse outcomes with higher overall rates and adjusted relative risk of MACCE (12.9% vs. 5.3%; RR: 1.74 [1.72, 1.75]), mortality (6.5% vs. 3.3%. RR: 1.12 [1.11, 1.13]), stroke (2.7% vs. 1.5%; RR: 1.32 [1.30, 1.34]) and bleeding (14.7% vs. 8.8%; RR: 1.42 [1.41, 1.43]). The AF group was less likely to receive coronary angiography (47.1% vs. 58%) and PCI (18.7% vs. 32.6%) and more likely to undergo CABG (13.9% vs. 7.6%) in comparison to SR.

Figure 1. Crude rates of adverse events

Conclusion

The prevalence of concomitant Atrial Fibrillation amongst patients presenting with NSTE-ACS has increased over a decade. However, this high-risk group remains less likely to receive invasive coronary management for NSTE-ACS than patients with sinus rhythm, independent of their comorbidities, and are associated with worse clinical outcomes.
P3613J-shaped relationship between cardiac mortality risk and admission systolic blood pressure in patients aged 65 years and over with acute coronary syndrome
Authors: Jiang C Y , Li H W
Published: October 2019

Objective

To observe the effects of different admission systolic blood pressure (SBP) levels on the in-hospital and long-term prognosis of elderly patients with acute coronary syndrome (ACS).

Methods

This retrospective cohort study included 5812 ACS patients aged 65 and over admitted from January, 2013 to September, 2018. Their blood pressure, medical history and laboratory examinations were recorded. The patients were divided into 5 groups according to the level of admission SBP (<100, 100–119, 120–139, 140–159, and ≥160 mmHg). The main endpoint of this study was cardiac death and all-cause death in hospital and during 6-year follow-up.

Results

Among the participants, the number of patients admitted with SBP <100, 100–119, 120–139, 140–159, and ≥160 mmHg were 143 (2.5%), 1014 (17.4%), 2456 (42.3%), 1607 (27.6%), and 592 (10.2%), respectively. The highest in-hospital cardiac mortality and all-cause mortality rate were found in the group with admission SBP <100 mmHg and the lowest were found in the group with SBP 140–159 mmHg (9.1% vs. 3.2% vs. 1.1% vs. 0.8% vs. 1.5%, P=0.000; 9.8% vs. 3.4% vs. 1.1% vs. 0.8% vs. 1.7%, P=0.000). Kaplan-Meier curve showed that patients with SBP 120–139 mmHg at admission had better prognosis (cardiac mortality: 3.9% vs. 10.9%, 5.6%, 5.1%, and 6.7% respectively, P=0.000; all-cause mortality: 7.6% vs. 14.7%, 9.7%, 9.1%, and 11.0%, respectively, P=0.000). Multivariate analysis showed that admission SBP <120 mmHg or ≥160 mmHg was a independent predictors of follow-up cardiac death (HR 1.747, 95% CI 1.066–2.861, P=0.027; HR 1.496, 95% CI 1.092–2.050, P=0.012; HR 1.630, 95% CI 1.120–2.372, P=0.011) compared with patients admitted with SBP 120–139 mmHg.

In-hospital and 6-year follow-up outcomes of ACS patients ≥65y by admission SBP Admission SBP Level <100mmHg ≥100mmHg and <120mmHg ≥120mmHg and <140mmHg ≥140mmHg and <160mmHg ≥160mmHg P In-hospital (n=143) (n=1014) (n=2456) (n=1607) (n=592)   Cardiac mortality, n (%) 13 (9.1) 32 (3.2) 28 (1.1) 13 (0.8) 9 (1.5) 0.000   All-cause mortality, n (%) 14 (9.8) 34 (3.4) 28 (1.1) 13 (0.8) 10 (1.7) 0.000 Follow-up (n=129) (n=980) (n=2428) (n=1594) (n=582)   Cardiac mortality, n (%) 14 (10.9) 55 (5.6) 94 (3.9) 81 (5.1) 39 (6.7) 0.000   All-cause mortality, n (%) 19 (14.7) 95 (9.7) 185 (7.6) 144 (9.1) 64 (11.0) 0.000

Kaplan-Meier analyses

Conclusion

In ACS patients ≥65 y, a “J” relationship between admission SBP and cardiac mortality is observed. For ACS patients aged 65 years and over, admission SBP <120 mmHg or ≥160mmHg is a independent risk factor for long-term cardiac death.

Acknowledgement/Funding

National Natural Science Foundation of China (No. 81300333))
P3619Incidence of progressively reduced LVEF during long-year follow-up after myocardial infarction: impact for mid-term outcomes
Authors: Yoshioka G , Shibata Y , Node K , Watanabe N , Kuriyama N , Koiwaya H , Ogata K , Goriki Y , Shinzato K
Published: October 2019

Background

Severely reduced left ventricular ejection fraction (LVEF≤35%) is commonly seen in approximately 5% of the myocardial infarction (MI) survivors in its acute-phase, which is recognized as a risk factor of post-MI cardiac death. However, clinical impact of the progressively reduced LVEF in the chronic-phase after MI has not been clarified.

Purpose

To evaluate clinical impact of the progressively reduced LVEF in the chronic-phase after MI.

Method

We evaluated 1659 consecutive patients with acute MI by serial echocardiography. Primary outcome was severely reduced LVEF. And secondary outcome was all cause death and cardiac death.

Result

During follow-up (median: 1097 days), severely reduced LVEF newly developed in 8.6% of AMI survivors. These patients had significantly higher incidence of all cause death (20.7% vs. 4.4%, p<0.01) and cardiac death (10.6% vs. 1.2%, p<0.01) than those with LVEF>35%. Severely reduced LVEF progressed in the chronic-phase associated with all cause death and cardiac death as well as those with severely reduced EF in the acute-phase.

Figure 1

Conclusions

Progressively reduced LVEF during chronic-phase occurred 8.6% per 10-year in MI survivors. Careful long-term follow-up after MI should be needed to identify possible candidate for the implantable cardioverter-defibrillator.
P3621Epidemiology of acute coronary syndrome by subtype in New Zealand 2006–2016: an ANZACS-QI nationwide linkage study of hospitalisation, procedures and case fatality
Authors: Wang T K M , Grey C , Jiang Y , Jackson R , Kerr A
Published: October 2019

Background

Acute coronary syndrome (ACS) is a common manifestation of cardiovascular disease. Inconsistent trends have been reported in the management and outcomes of the three main categories of ACS (ST-elevation myocardial infarction [STEMI], non ST-elevation myocardial infarction [NSTEMI] and unstable angina [UA]). The aims of this study were to evaluate recent trends in the incidence, invasive management and case fatality of these ACS subtypes in New Zealand.

Methods

All ACS hospitalisations between 2006–2016 were identified from routinely collected national data, and categorised into STEMI, NSTEMI, UA, and unspecified myocardial infarction (MI). For each ACS subtype, annual hospitalisation and coronary procedure rates, 28-day and 1-year fatality rates were calculated and trends tested using Poisson regression adjusted for age and sex.

Results

There were 188,264 ACS admissions, of which 16.0% were STEMI, 54.5% NSTEMI, 25.7% UA and 3.8% MI unspecified. During this period, the incidence of all ACS subtypes fell, STEMI by 3.4%/y, NSTEMI by 5.9%/year and UA by 8.5%/year. There was also a rise in the proportion of ACS patients receiving angiography and revascularisation. Rates of percutaneous coronary intervention rose for STEMI, NSTEMI and UA, but rates of coronary artery bypass grafting increased only for NSTEMI and UA. Case fatality at 28 days and 1 year was higher for STEMI than NSTEMI, and lowest for UA. Over the period there was a relative 1.6%/y decline in one-year case fatality for NSTEMI (p<0.001), but no significant change for STEMI and UA.

Conclusions

The observed declines in the incidence of all ACS subtypes is reassuring, as is the increase in the rate of revascularisation among these patients. The finding that case fatality declined in NSTEMI patients but not in STEMI and UA patients, despite an increase in invasive management in all groups, require further investigation.
P3623Integrating depression and acute coronary syndrome care in low-resource hospitals in china: primary results from the I-Care randomised clinical trial
Authors: Wu Y , Yu X , Zhu Y , Shi C , Li X , Jiang R , Gao P , Gao R , Blumenthal J A
Published: October 2019

Background

Depression and acute coronary syndromes (ACS) are significant public health challenges. Patients with ACS often experience depression, which adversely affects prognosis. Low-cost, sustainable, and effective service models that integrate depression care into the management of ACS patients to reduce depression and improve ACS outcomes are critically needed.

Purpose

I-CARE study is a multi-center, randomised clinical trial (RCT) to evaluate the efficacy of an 11-month integrated care (IC) intervention compared to usual care (UC) in the management of ACS patients.

Methods

The I-CARE RCT was conducted between October 2014 and March 2018 in 16 rural Chinese hospitals. A total of 4041 patients with ACS were consecutively enrolled and randomly assigned in a 1:1 ratio to an IC intervention consisting of nurse-led risk factor management, group-based counseling supplemented by individual problem solving therapy and antidepressant medications as needed, or UC. The primary outcome was change in Patient Health Questionnaire-9 (PHQ-9) scores from baseline to 6 and 12 months. Secondary outcomes included incidence of major adverse events (MAEs) after discharge, quality of life (EQ5D), and adherence to ACS secondary prevention medications. Data analysis used a multilevel mixed-effects model with hospital-level and subject-level random-effect intercepts and hospital-level random slope incorporated to adjust for clustering effect. Primary analyses followed the intent-to-treat principle.

Results

The mean age of the patients was 61±10 years and 63% were men; however, only 3.3% were classified as depressed based upon a cutoff of ≥10 on the PHQ-9, and 26.9% had PHQ-9 scores between 5 to 9 at the baseline. There were no significant differences in patients' clinical characteristics between IC and UC groups. Changes in PHQ-9 scores from baseline to 6- and 12-months did not differ between treatment groups (−1.47 in IC group vs −1.40 in UC group; adjusted mean difference, −0.04; 95% CI, −0.17 to 0.08 at 6-months; −1.62 in IC group vs −1.54 in UC group; adjusted mean difference, −0.06; 95% CI: −0.19 to 0.06 at 12-months).The risk of MAEs after discharge between IC and UC groups also did not differ significantly (42.1% vs 43.1%; p=0.307).

Conclusions

Results from the I-CARE trial showed that a nurse-coordinated ACS and depression IC intervention did not reduce depression or improve clinical outcomes among patients with ACS compared to usual care controls. The low prevalence of depression was unexpected and may have minimized the potential added benefits of the IC intervention on depression and clinical outcomes compared to UC.

Acknowledgement/Funding

This study is supported by a grant from the National Institute of Mental Health (R01MH100332).
P3627Characteristics and outcomes following myocardial infarction in patients with schizophrenia
Authors: Attar R , Koul S , Jensen S E , Erlinge D , Andell P
Published: October 2019

Background

Patients with schizophrenia are a high-risk population due to a high prevalence of cardiovascular risk factors that translates into increased cardiovascular morbidity and mortality.

Purpose

To describe the characteristics of patients with schizophrenia experiencing a myocardial infarction (MI) and to analyse the 1-year major adverse cardiac events (MACE: all-cause mortality, reinfarction, stroke and heart failure) and prescriptions of guideline-recommended secondary preventive treatments at hospital discharge.

Methods

All patients with schizophrenia who experienced a MI in the period between 2000–2017 were identified and included from the SWEDEHEART registry and compared to patients without schizophrenia. Uni- and multivariable Cox proportional hazards and Kaplan-Meier survival models were used to compare the populations.

Results

The main results are shown in Table 1. Compared to the general population (n=285,325), patients with schizophrenia (n=1,008) were younger (63 vs 71 years), had a higher smoking burden and prevalence's of diabetes, heart failure, chronic obstructive pulmonary disorder and major bleeding (all p-values <0.05). On the contrary, lower prevalence's of diagnosed hypertension, hyperlipideamia, previous myocardial infarction, renal disease and peripheral artery disease were seen in this population. Lastly, patients with schizophrenia were less likely to be discharged with aspirin, P2Y12 inhibitors, ACE-inhibitors/angiotensin receptor blockers, beta blockers and statins (all p-values <0.005).

Table 1. Clinical endpoints at 5-years for patients with schizophrenia following a MI compared to patients without schizophrenia End-points Unadjusted HR (95% CI) Adjusted HR (95% CI) Model 1 Model 2 Model 3 MACE 1.35 (1.23–1.47)* 2.44 (2.23–2.67)* 2.20 (1.79–2.72)* 2.05 (1.63–2.58)* Mortality 1.44 (1.31–1.59)* 2.99 (2.72–3.29)* 2.53 (2.00–3.21)* 2.38 (1.84–3.09)* Reinfarction 1.00 (0.82–1.24) 1.53 (1.25–1.89)* 1.41 (0.86–2.30) 1.29 (0.77–2.13) Stroke 1.03 (0.80–1.34) 1.67 (1.29–2.17)* 1.72 (1.00–2.97) 1.72 (1.00–2.98) Heart failure 1.25 (1.10–1.42)* 2.14 (1.88–2.42)* 1.49 (1.13–1.98)* 1.39 (1.04–1.86)* *p<0.005. Model 1: adjusted for age and sex; Model 2: adjusted for age and sex, smoking, comorbidities, previous CAG and previous PCI; Model 3: adjusted for age and sex, smoking, comorbidities, previous CAG and previous PCI, discharge medications and treatment with CAG and PCI.

Conclusion

Patients with schizophrenia remain a high-risk population who experience a MI almost 10 years earlier than patients without schizophrenia and have worse outcome. Improved primary and secondary preventive measures are urgently warranted.
P3629Invasive versus medical management of non-ST elevation myocardial infarction in cancer patients: knowledge is bliss
Authors: Balanescu D V , Donisan T , Lee M , Tran P , De Sirkar S , Palaskas N , Lopez-Mattei J , Kim P Y , Iliescu G , Balanescu S M , Marmagkiolis K , Iliescu C
Published: October 2019

Background

Cancer patients with non-ST elevation myocardial infarction (NSTEMI) frequently present with comorbidities (e.g., anaemia, thrombocytopenia) that discourage invasive treatment.

Purpose

To compare outcomes of cancer patients with NSTEMI treated with optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) versus OMT alone and to identify variables associated with overall survival (OS).

Methods

All cancer patients diagnosed with NSTEMI between March 2016 and December 2018 at our institution were included. Patients were classified based on treatment of NSTEMI into 2 groups: invasive strategy or OMT alone. The invasive group was further classified into early (PCI≤72 hours since presentation) or delayed strategy (PCI>72 hours). Clinical and laboratory data, oncologic history, major adverse cardiovascular events, and survival were collected. Univariate Cox proportional hazards regression analyses were conducted to identify variables associated with OS.

Results

We included 201 patients with a mean age of 68±11 years, 136 (68%) of which were women. Median OS was 13 months. Factors influencing OS are presented in Table I. Patients receiving PCI had better OS compared to patients treated with OMT only (Figure 1, p<0.0001). Procedure-related complications were non-fatal and present in 2 (1.85%) cases.

Table I Covariate Hazard Ratio (95% confidence interval) p-value Early invasive treatment (≤72 hours) 0.327 (0.207–0.516) <0.0001 Delayed invasive treatment (>72 hours) 0.496 (0.252–0.977) 0.0426 Presenting symptom: chest pain 0.406 (0.254–0.649) 0.0002 Presenting symptom: others 1.869 (1.223–2.855) 0.0039 Single agent antiplatelet therapy 0.434 (0.263–0.716) 0.0011 Dual agent antiplatelet therapy 0.294 (0.174–0.496) <0.0001 Statins 0.440 (0.276–0.703) 0.0006 Active cancer 4.487 (1.646–12.234) 0.0033 Prior chemotherapy 2.312 (1.328–4.023) 0.0030 Prior chest radiation 1.752 (1.065–2.884) 0.0272 Active chemotherapy 1.931 (1.271–2.934) 0.0021

Figure 1

Conclusions

An invasive management of NSTEMI in cancer patients, especially within 72 hours, appears to be associated with improved OS. Patients presenting with symptoms other than chest pain were less likely to undergo PCI and had worse outcomes. Active cancer, a history of chest radiation, and active or prior chemotherapy were also associated with decreased OS.

Acknowledgement/Funding

None
P3640Association of ceramide and phospholipid levels and cardiovascular events in stable coronary heart disease: findings from the STABILITY Biomarkers substudy
Authors: Laaksonen R , Hilvo M , Kauhanen D , Lakic T G , Lindback J , Held C , Granger C B , Koenig W , Stewart R A H , White H D , Siegbahn A , Wallentin L
Published: October 2019

Background

Both levels of protein and lipid biomarkers have been found associated with cardiovascular outcomes in patients with stable coronary heart disease (CHD). There are few large-scale studies comparing the prognostic value of and interactions between these two groups of biomarkers in CHD.

Methods

In the 15,828 CHD patients included in the STABILITY trial 10,205 provided plasma samples at baseline allowing measurements of distinct ceramide and phospholipid species by mass spectrometry and markers of cardiac dysfunction (N-terminal pro-B-type natriuretic peptide [NT-proBNP]), high sensitivity cardiac troponin-T [cTnT-hs]), renal dysfunction (cystatin-C), oxidative stress (growth differentiation factor 15 [GDF-15]) by electro-immunoassays. During 3.7 years median follow-up, 1291 CVD, MI, and stroke events occurred. A previously developed ceramide and phospholipid species based risk score (CERT) and its associations to outcomes before and after adjustment were evaluated by Cox-regression models.

Results

The CERT model was significantly associated to all cardiovascular outcomes before and after adjustment for clinical characteristics and routine laboratory tests. However, the associations were attenuated after adjustment for other prognostic biomarkers. The data are summarized in Table 1 below.

Table 1. HR per 1 SD increase in CERT HR (95% CI) p-value MACE Model 1 1.30 (1.24–1.37) <0.0001 Model 2 1.23 (1.16–1.31) <0.0001 Model 3 1.08 (1.02–1.15) 0.0120 CVD Death Model 1 1.57 (1.45–1.69) <0.0001 Model 2 1.38 (1.26–1.50) <0.0001 Model 3 1.14 (1.04–1.26) 0.0052 MACE = CVD death, stroke and MI. Model 1 includes score and randomized treatment. Model 2 includes score, randomized treatment, age, gender, and prior (MI, coronary revas., multivessel CHD), B/L diabetes, hypertension, history of smoking, PVD, region, B/L systolic BP, B/L BMI, HB, WBC, CKD-EPI, LDL-C, HDL-C and TG. Model 3 includes the following covariates in addition to Model 2: TnT-hs, proBNP, Cystatin-C, CRP-hs and IL-6.

Conclusion

A ceramide/phospholipids based risk score is associated with the risk of fatal and non-fatal cardiovascular events in patients with stable CHD. The score is attenuated by adjustment for biomarkers indicating cardiorenal dysfunction and inflammatory activity and may be related to underlying mechanisms for adverse outcomes in stable CHD.

Acknowledgement/Funding

The original STABILITY study was funded by GlaxoSmithKline
P3644Plaque progression from normal vessel wall to fibroatheroma: lessons from over 5-year follow-up optical coherence tomography study
Authors: Takeshige R , Otake H , Kawamori H , Toba T , Nagano Y , Tsukiyama Y , Yanaka K , Yamamoto H , Nagasawa A , Onishi H , Sugisaki Y , Nakano S , Matsuoka Y , Tanimura K , Hirata K
Published: October 2019

Background

Progression of atherosclerosis is a non-uniform process characterized by coexistence of normal vessel wall (NVW) and advanced fibroatheroma within the same cross-section (Figure). Plaque progression from NVW to fibroatheroma usually takes years, that has never been investigated in human.

Purpose

To investigate the incidence and related factors associated with atherosclerotic progression from NVW to fibroatheroma using long-term serial optical coherence tomography (OCT) follow-up data over 5 years.

Methods

We enrolled 47 vessels in 30 patients who had undergone serial OCT imaging over 5 years (average: 6.8 years). Baseline and follow-up OCT images were matched for longitudinal and circumferential location and OCT cross-sections that had NVW >30 degrees were enrolled. NVW was defined as vessel wall having OCT-detectable three-layer structure with intimal thickening ≤300μm. Cross-sections were diagnosed as +Progression when NVW in the cross-section reduced by >30 degrees during >5-year follow-up.

Results

In the present study, atherogenic progression from NVW to fibroatheroma was observed only in 37.2% of the enrolled cross-sections. On the other hand, despite an average long-term follow-up period of 6.8 years, the extent of NVW was maintained in 62.8% of cross-sections. The incidence of microchannel in adjacent fibroatheroma within the same cross-section (23.6% vs. 13.1%, p=0.023), eccentric plaque distribution (21.7% vs. 11.4%, p=0.019), and concave shape (6.6% vs. 0%, p=0.001) at baseline was significantly higher in cross-sections with +Progression than those without Progression. Average intimal thickness of NVW (187.2±64.9μm vs. 170.7±68.6μm; p=0.048) at baseline was significantly thicker in cross-sections with +Progression than those without. Multivariate analysis demonstrated that the presence of microchannel, eccentric plaque distribution and thicker average intimal thickness of NVW at baseline were independently associated with plaque progression during the follow-up.

Atheroma progression

Conclusion

The presence of microchannel in adjacent fibroatheroma, eccentric plaque distribution, and thicker intimal thickening of NVW were potentially associated with plaque progression from NVW to fibroatheroma.
P3646A systematic review and meta-analysis on spontaneous coronary artery dissection: epidemiology, risk factors and outcomes
Authors: Franke K , Marshall H , Worthley M , Psaltis P J
Published: October 2019

Background

Spontaneous Coronary Artery Dissection (SCAD) is an elusive but increasingly recognised cause of Acute Coronary Syndrome (ACS). Most knowledge about SCAD has arisen from small to medium sized cohort studies that have been published since 2012.

Purpose

This systematic review and meta-analysis aimed to provide an update on SCAD's association with cardiovascular risk factors, angiographic variants and outcomes.

Methods

The term “Spontaneous Coronary Artery Dissection” was searched in PubMed, EMBASE and SCOPUS on the 2nd of February 2019, yielding a total of 1517 articles. Following exclusion (e.g. of isolated case reports and duplicate cohorts), 31 original studies that reported at least one desired parameter in patients with SCAD were included. Statistical analysis was performed independently for each parameter using random effects models.

Results

Of the k=31 studies (n=77,025 patients), only 3 were published before 2012 (n=68). Mean age was 62.4 years and 85.1% [78.9%-89.8%, I2=91.7, k=28] were female. Prevalence of associated conditions and traditional cardiovascular risk factors are outlined in the table. Importantly, only 37.4% [30.0%-45.4%, I2=77.0, k=10] were associated with a traditional Type 1 angiographic appearance. Yearly incidence was 3.4% [2.4%-4.4%, I2=73.4, k=16] for SCAD recurrence and 5.8% [4.1%-7.5%, I2=85.7, k=16] for MACE. Incidence of MACE at follow-up was 4.1% [1.7%-9.9%, I2=74.0, k=3] for conservative treatment and 7.2% [5.1%-10.3%, I2=43.7, k=4] for PCI (p=0.14).

Estimated prevalence of traditional cardiovascular risk factors, associated conditions and angiographic variants in cohorts of patients with SCAD Associated Patient Factor Number of Studies Prevalence (%, [95% CI]) Heterogeneity (I2) Hypertension 29 36.0 [29.9–42.6] 97.9% Dyslipidemia 27 28.7 [17.4–43.5] 99.7% Smoking 29 23.3 [14.5–35.3] 99.6% Depression/Anxiety 6 28.1 [19.3–38.9] 94.3% Fibromuscular Dysplasia 9 50.7 [40.0–61.3] 91.9% Type 1 Angiographic Appearance 11 37.4 [30.0–45.4] 77.0% Type 2 Angiographic Appearance 11 62.4 [50.0–73.3] 93.3% Type 3 Angiographic Appearance 6 10.2 [6.2–16.4] 78.3%

Incidence of Recurrence in SCAD Cohorts

Conclusions

This meta-analysis confirms associations of SCAD with fibromuscular dysplasia, anxiety and depression, and reveals a small but important risk of recurrence and MACE. Furthermore, a majority of SCAD cases present with non-traditional angiographic appearances highlighting the need for increased familiarity with this condition among treating physicians.
P3654Location of the coronary origins in transposition patients following anatomical repair: Implications for invasive coronary angiography and intervention
Authors: Constantine A H , Segura T , Nicol E , Kempny A H , Rafiq I , Barradas Pires A , Barracano R , Gatzoulis M A , Rubens M , Semple T , Dimopoulos K
Published: October 2019

Background

Surgical repair of transposition of the great arteries (TGA) is most commonly via the arterial switch operation (ASO). This involves translocation of the aorta and pulmonary trunk, typically with anastomosis of the branch pulmonary arteries anteriorly (LeCompte manoeuvre) and re-implantation of the coronary arteries onto the posterior neo-aorta. As such, the position of the coronary ostia may differ from their expected locations.

Purpose

To use ECG-gated CT angiography to describe the anatomic position of coronary ostia in post-switch TGA patients guiding potential catheter interventions in this population.

Methods

All post ASO patients who underwent CT imaging between 2008–2018 were identified. Patients with complex anatomy such as double outlet right ventricle were excluded. The positions of the coronary ostia were measured in degrees from vertical on a double-oblique reconstruction in the aortic valve plane. Ostium positions were compared to those of patients with no congenital heart disease via Watson's two-sample test of homogeneity for circular data. Angular dispersion was compared between groups via the Wallraff test. P<0.05 indicated statistical significance.

Results

Of 206 adult patients with TGA and ASO followed in our adult congenital heart disease centre, 38 (18.4%) had CT imaging available for analysis during the study period (mean age 24±6.8, 75% male).

The control group consisted of 15 patients investigated for chest pain (mean age 54±15.1, 73% male). In the control group, the right and left coronary ostia arose at a mean angle of −19 and +125 degrees from vertical (figure 1a). This was significantly different to the mean ASO coronary ostia clustered at mean angles of −70 and +29 degrees from vertical (Watson p<0.001) (figure 1b, with stenosis at the left coronary anastomosis).

There was no significant difference in spread of left ostia (Rho 0.9 vs 0.99, p=0.12), but right ostia were significantly more variable in ASO patients than controls (0.71 vs 0.96, p=0.003).

Figure 1

Conclusions

Coronary ostial positions in the neo-aorta of post-ASO patients differ significantly from those of normal controls, with considerable variability, especially in right coronary position. CT can demonstrate coronary ostia in 3D space and derive appropriate tube angles to guide catheterisation in post-operative congenital cardiac patients, optimise catheter selection, reduce catheterisation tome, radiation and contrast dose.
P3663Prevalence of infective endocarditis in patients with a left-sided heart valve prosthesis: a nationwide study
Authors: Ostergaard L , Voldstedlund M , Andersen C O , Schonheyder H C , Lemming L , Valeur N , Sogaard P , Andersen P S , Skov R , Gill S , Torp-Pedersen C , Mortensen R N , Lauridsen T K , Dahl A , Kober L
Published: October 2019

Background

Increasing attention has been given to patients with blood stream infection (BSI) and the concurrent prevalence of infective endocarditis (IE). However, there exist a gap in knowledge on the prevalence of IE among patients with a left-sided heart valve prosthesis and BSI.

Purpose

To examine the prevalence between different BSI and IE in patients with a left-sided heart valve prosthesis.

Methods

By linking Danish nationwide registries, we were able to identify patients with a left-sided prosthetic heart valve and first-time BSI of interest (Enterococcus faecalis, Staphylococcsus aureus, streptococci species (spp.), and coagulase negative staphylococci [CoNS]) in the period of 2010–2016. Concurrent admission for IE was identified from the Danish National Patient Registry in a period of up to 14 days after the BSI.

Results

A total of 1,465 patients with BSI were included (1,319 patients with an aortic valve prosthesis [82.6% bioprosthetic] and 146 patients with a mitral valve prosthesis [48.6% bioprosthetic]). Among the included patients, 244 had E. faecalis (median age: 78.3 years, 77.0% male), 301 had S. aureus (median age: 76.9 years, 69.1% male), 401 had streptococci spp. (median age: 78.0 years, 69.1% male) and 519 had CoNS (median age: 76.4 years, 64.2% male). The percentage of patients with a diagnosis of IE in relation to the BSI was 44.3%, 33.6%, 34.4%, and 7.9% for E. faecalis, S. aureus, streptococci spp., and CoNS, respectively. No difference in the overall results was seen by type of valve prosthesis, sex, or age group.

Percentage of patients with endocarditis

Conclusion

In patients with a left-sided heart valve prosthesis, IE was diagnosed in almost half of the patients with E. faecalis, in 1/3 with S. aureus or streptococci spp. and in 1 in 12 with CoNS BSI. Future studies may try to explain why some microbes are more likely to cause prosthetic heart valve endocarditis, than others are.
P3673Electroanatomical mapping of right atrium in patients with pulmonary hypertension
Authors: Fingrova Z , Havranek S , Ambroz D , Jansa P , Linhart A
Published: October 2019

Introduction

Atrial fibrillation (AF) and related atrial tachycardia (AT), including cavotricuspid isthmus dependent atrial flutter (AFL), are a known complication of pulmonary hypertension (PH). Catheter ablation is an established method of treatment of selected patients with heart rhythm disorders. The aim of the work was to evaluate arrhythmogenic substrate in the right atrium (RA) of the group of patients who underwent catheter ablation with electroanatomical mapping.

Methods

The findings in electroanatomical mapping with contact force of RA were evaluated in a group of 22 patients (16 men, median and scattering age 73, range 45–87 years) indicated for catheterization ablation for AFL or other right-sided AT. During electroanatomical mapping, 8 patients had sinus rhythm and 14 patients had AF or AT (all AT with cycle length under 350 ms). Areas with reduced atrial electrogram voltages (AEGM) <0.1 mV in sinus rhythm or <0.04 in AF or AT, existence of double and fragmented potentials were identified.

Results

Out of the 22 patients, 3 patients had hypoxic PH, 13 individuals had chronic thromboembolic PH (7 undergoing surgical treatment) 4 patients had idiopathic PH and 2 patients had combined PH. The median mean pulmonary arterial pressure was 44 (range 22 - 72) mmHg. The median RA CARTO volume was 225 (range 151–383) ml. Out of all patients, 2 subjects manifested scattering of the surface proportion RA with a defined reduced voltage over 10% (maximum 15%).

Six subjects had surface proportion with defined reduced voltage in interval 1–9% and 14 subjects had scattering below 1% of total surface area of RA. The predominant localizations of pathological AEGMs was the area adjacent to the vena cava superior and posterior portion of RA between caval veins. Regular finding in patients following surgical treatment of thromboembolic PH was a scar after atriotomy.

Arrhythmogenic substrate in right atrium

Conclusion

Dilatation of RA is present in all PH patients. However, the proportion of tissue with reduced AEGM voltage in RA does not appear to be extensively high in this population.
P3682Myocardial structural abnormalities in nonischemic patients presenting with ventricular arrhythmias
Authors: Dello Russo A , Della Rocca D , Gasperetti A , Casella M , Basso C , Bianchini L , Fassini G , Riva S , Moltrasio M , Ribatti V , Tundo F , Zucchetti M , Carbucicchio C , Natale A , Tondo C
Published: October 2019

Background

The diagnosis of concealed cardiomyopathies in patients with ventricular arrhythmias (VAs) is one of the major challenging issues faced by physicians.

Purpose

We aimed at reporting the cardiomyopathic substrate in patients with recurrent arrhythmias of ventricular origin.

Methods

Consecutive patients with unexplained VAs underwent a complete diagnostic work-out, including endomyocardial biopsy (EMB).

Results

Ninety-seven patients were enrolled (76.3% male, age 39.7±13.3 yrs). The presenting arrhythmic manifestation was aborted cardiac arrest in 30 (30.9%) patients, sustained ventricular tachycardia (VT) in 9 (9.3%), nonsustained VT in 15 (15.5%) and frequent premature ventricular complexes in 43 (44.3%). Overall, 350 biopsies were collected (3.6/patient). The incidence of procedure-related complications was 5.1% (n=5): 4 major complications (1 rupture of a tricuspid chorda tendinea w/o hemodynamic impairment, 1 dissection of right external iliac artery treated with stent, 1 thrombotic occlusion of left superficial femoral artery which required surgical treatment, 1 TIA) and 1 minor complication (groin hematoma) occurred. The final diagnosis was arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) (n=41; 42.3%), followed by myocarditis (n=20; 20.6%), dilated cardiomyopathy (n=6; 6.2%), cardiac sarcoidosis (n=6; 6.2%), and myocarditis in ARVD/C (n=5; 5.1%). Among the 25 patients whose final diagnosis was consistent with myocarditis, an acute stage of the disease was documented in 7 (7.2%), while a chronic myocarditis in 18 (18.5%). Additionally, according to medical history and diagnostic workout, in 2 of the 6 patients the dilated cardiomyopathy had a likely post-inflammatory etiology. Absence of myocardial abnormalities was documented in 15 (15.5%) patients: this group included 1 case of methadone-induced torsade de pointes. The remaining 4 (4.1%) patients were diagnosed with a cardiac hypertrophy (n=2, 2.1%, secondary to exercise or Fabry disease), a dilated mitochondrial cardiomyopathy (n=1, 1.0%), a dilated cardiomyopathy in Emery-Dreifuss muscular dystrophy (n=1; 1.0%).

Conclusion

In our series, approximately 45% of patients with unexplained VAs had a final diagnosis of ARVD/C.
P3694Discordant criteria in moderate aortic stenosis patients: prognostic implications
Authors: Pio S M , Amanullah M R , Sin K Y , Ajmone Marsan N , Ding Z P , Ewe S H , Delgado V , Bax J J
Published: October 2019

Background

The frequency of discordant mean valve gradient (MG) and aortic valve area (AVA) in patients with moderate aortic stenosis (AS) has not been investigated.

Objectives

Determine the occurrence of discordant gradient in patients with moderate AS (defined by MG <20 mmHg), and how these patients compare with concordant gradient moderate AS (MG >20 mmHg) in terms of patients' characteristics and the impact on long term prognosis.

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 discordant or concordant gradients, MG <20 mmHg or >20 mmHg, respectively. The clinical endpoint was all-cause mortality.

Results

Of 522 patients with moderate AS, 95 (18.2%) had discordant gradient moderate AS (MG <20 mmHg). Patients with discordant mean gradient were older, had higher prevalence of previous myocardial infarct, larger left ventricular (LV) end-diastolic volume index, lower LV ejection fraction (EF), stroke volume index and higher LV filling pressure. Compared to patients with concordant gradients, these patients had higher mortality rates (57.9% vs 46.6%, p=0.05) and lower aortic valve replacement rates (33.7% vs 54.9%, p<0.001) during a median follow-up of 6.2 [IQR 3.2–9.0] years. The results of Cox regression analysis are shown on the table.

Cox proportional hazard analysis All-cause mortality Univariate analysis Multivariate analysis Hazard ratio (95% CI) P value Hazard ratio (95% CI) P value Age (per 1 year increase) 1.05 (1.03–1.06) <0.001 1.04 (1.02–1.06) <0.001 Diabetes (yes/no) 1.34 (1.03–1.74) 0.031 1.33 (0.97–1.82) 0.072 Previous myocardial infarction (yes/no) 1.73 (1.29–2.34) <0.001 1.01 (0.70–1.46) 0.980 eGFR <60 ml/min/1.73m2 (yes/no) 2.15 (1.68–2.76) <0.001 1.71 (1.25–2.33) 0.001 Left ventricular hypertrophy (yes/no) 1.74 (1.31–2.30) <0.001 1.50 (1.07–2.09) 0.018 Indexed LA volume (per 1 mL/m2 increase) 1.005 (1.001–1.009) 0.008 1.006 (1.001–1.012) 0.040 Tricuspid regurgitation >moderate (yes/no) 2.02 (1.29–3.16) 0.002 1.36 (0.73–2.54) 0.337 Discordant moderate AS (yes/no) 1.81 (1.34–2.45) <0.001 1.42 (1.01–2.01) 0.049 AS, aortic stenosis; CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; LA, Left atrial.

Conclusion

Discrepant aortic mean gradient in moderate AS is not uncommon and occurs more often in older patients, with higher LV filling pressure and lower EF and stroke volume index. The lower gradient values lead to underestimation of AS severity, and is associated with greater cardiac extra-valvular damage and higher mortality.
P3696Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: an echocardiographic and computed tomography study
Authors: Altes A , Sochala M , Attias D , Dreyfus J , Toledano M , Macron L , Renard C , Truffier A , Guerbaai R A , Ennezat P V , Graux P , Tribouilloy C , Marechaux S
Published: October 2019

Background

Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS).

Purpose

To identify the determinants associated with increased AT/ET.

Methods

The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were studied in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography – Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients.

Results

In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r=0.57, p<0.0001), mean pressure gradient (MPG, r=0.60, p<0.0001), aortic valve area (AVA, r=−0.50, p<0.0001) and CT-AVC score (r=0.24, p<0.0001). An AT/ET ratio had a good accuracy to predict an aortic peak velocity ≥4 m/s, a MPG≥40 mmHg, or an AVA≤1.0 cm2, with an optimal cut-off value of 0.34. By multivariate linear regression analysis, presence of AS-related symptoms, decreased LV stroke volume index, LVEF, systolic blood pressure (SBP), absence of diabetes mellitus, and increased LV mass index, relative wall thickness, and Vmax were independently associated with increased AT/ET ratio (all P<0.05). In the subgroup of patients who underwent CT-AVC, CT-AVC score was independently associated with increased AT/ET ratio (P<0.05).

Conclusion

AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF.

Acknowledgement/Funding

Local funding
P3697A reappraisal of bioprosthetic aortic valve failure related to structural valve degeneration
Authors: Le Tourneau T , Cueff C , Guerma L , Guimbretiere G , Piriou N , Warin-Fresse K , Capoulade R , Serfaty J M , Veziers J , Senage T , Roussel J C
Published: October 2019

Background

Structural valve degeneration (SVD) remains a major complication of aortic bioprostheses.

Purpose

We aimed to assess the mode of SVD leading to bioprosthetic aortic valve failure (BVF) in a large series of patients.

Methods

Between 2010 and 2017, we prospectively enrolled 261 consecutive patients with BVF related to SVD. All patients underwent a clinical work-up. Explanted bioprostheses were analysed for assessing the mechanism of SVD.

Results

The delay from surgery to SVD diagnosis was 8.5±3.3 (1.7 to 21.4) years, 10 years after exclusion of a specific type of bioprosthesis. Of the 261 SVD patients, 150 (57%) had mainly a stenotic type, and 111 (43%) a regurgitant type. In regurgitant SVD bioprosthesis was more frequently porcine (19 vs 7%, P=0.002), prosthesis diameter was larger (23.2±2.5 vs 21.6±1.9 mm; P<0.0001), severe mismatch was less frequent (6 vs 17%, P=0.005), cardiovascular risk factors and especially diabetes, obesity and hypertension were less frequent, patients were more often in NYHA class 3–4 (64 vs 49%; p=0.015), Nt-pro BNP was significantly higher (P<0.0001), and diuretic treatment was more frequent (73 vs 61%, P=0.04). Bioprostheses were explanted during redo surgery in 112 (43%) patients. Of these 112 bioprostheses, moderate to severe calcifications were present in 94 (83.9%) and was the main cause of either stenotic (n=64, 57.1%) or regurgitant SVD. A cusp tear (n=46) accounted for 41.1% of the explanted SVD. A perforation, a recent thrombus or a delamination process were occasionally identified. Structural degeneration developed with minimal calcification in 18 (16.1%) bioprostheses.

Conclusion

Structural valve degeneration remains a matter of concern in current practice with a mean delay of 8 to 10 years after surgery. Beside classical SVD with extensive calcification process other types of SVD can be observed with minimal calcification.