bluuebunny/crossref_metadata_2025 huggingface dataset:
P3606Impact of diabetes mellitus on the selection of antiplatelet treatment and medium-term prognosis after acute coronary syndrome
Authors: Nunez Martinez L , V-Ibarra N , Marin Ortuno F , Pernias Escrig V , Sandin Rollan M , Carrillo Aleman L , Candela Sanchez E , Lozano Palencia T , Esteve-Pastor M A , Orenes Pinero E , Rivera-Caravaca J M , Morillas Blasco P , Ruiz-Nodar J M
Published: October 2019

Introduction

Patients with diabetes mellitus (DM) have a higher atherothrombotic risk and higher rates of recurrent ischemic events compared with the non-diabetic population. Although current antiplatelet therapy strategies have been shown to be successful in improving outcomes in acute coronary syndrome (ACS), patients with DM continue to experience high rates of adverse cardiovascular events. Today, it is known that diabetic patients are characterized by a deregulation in different intracellular signaling pathways, which leads to an inadequate or suboptimal response to antiplatelets agents. The purpose of this study is to analyze the different therapeutic strategies, the use of new antiplatelet drugs and medium-term prognosis in diabetic patients compared with non-diabetic patients who have suffered an ACS.

Methods

It is an observational, prospective and multicenter registry of patients with ACS. The objective is to analyze the differences in the management of DM patients vs non-DM patients in the acute phase and their evolution during the first year after coronary event. Antiplatelet therapy administered will be evaluated, type of coronary injury and treatment performed, major adverse events as well as cardiovascular complications and mortality at one year of follow-up.

Results

Of a total of 1717 patients, 38% were diabetic. The diabetic population was older, with a higher prevalence of cardiovascular risk factors and higher rate of previous cardiovascular events (cerebrovascular, peripheral arterial disease and coronary disease). Patients with DM received less new antiplatelets drugs at admission (15.5% DM vs 26.5% non DM, p<0.001) and less in-hospital switch to new antiplatelet agents was performed. They were subjected to a lower number of catheterizations and at the time of revascularization, the drug-eluting stent was of choice. During admission, they developed more complications, both ischemic (refractory angina, reinfarction or CVA) and hemorrhagic. Following one year, DM had higher major cardiovascular events (MACE) and higher mortality (7.72% vs 5.14%, p=0.0039). Non-coronary revascularization, renal failure, and reduced ejection fraction were predictive variables of death in diabetic population. Treatment with new antiplatelet drugs was associated with a statistically significant decrease in total mortality an MACE without differences in major bleeding.

Conclusion

More than a third of patients with ACS are diabetic. These patients present with more severe coronary disease associating a greater number of cardiovascular events and a higher mortality rate after one year of ACS. However, despite this, they undergo less invasive tests and they were undertreated with the new antiplatelets therapies.

Acknowledgement/Funding

SEC
P3608Long-term mortality and mode of death among patients with type 1 and 2 myocardial infarction
Authors: Sandoval Y , Smith S W , Schulz K , Sexter A , Apple F S
Published: October 2019

Background

Few studies address long-term outcomes among patients with type 2 myocardial infarction (T2MI). It has been suggested that patients with T2MI with concomitant stable ischemic heart disease are at higher-risk.

Purpose

Our goals were two-fold. First, to examine 5-year mortality rates and mode of death among patients with type 1 (T1MI) and T2MI. Second, to evaluate the prognostic impact of coronary artery disease (CAD) on long-term outcomes among patients with T2MI.

Methods

Post-hoc analysis of UTROPIA (NCT02060760), a prospective, observational cohort study involving 1,640 consecutive emergency department patients with serial cardiac troponin (cTn) I measurements obtained on clinical indication. 5-year death rates, including mode of death, were examined among patients with T1MI and T2MI. CAD was defined as the presence of any of the following: history of CAD, prior MI, prior coronary artery bypass graft surgery, prior percutaneous coronary intervention, prior coronary stenting, or documented CAD (≥50%) on index admission angiography.

Results

Among 1640 patients, acute MI was diagnosed in 217 patients, including 77 (4.7%) classified as T1MI and 140 (8.5%) as T2MI. At 5-years, 23% (n=18) of patients with T1MI had died, with 61% (n=11) categorized as cardiac deaths. For T2MI, 37% (n=52) had died at 5-years, with 36% (n=19) categorized as cardiac deaths. Patients with T2MI had a higher 5-year mortality than T1MI (37% vs 23%, p=0.038) (Figure, Panel A), with T2MI more likely than T1MI to die from non-cardiac causes (64% vs. 39%, p=0.04). CAD was present in 22% (n=31) of patients with T2MI and associated with worse outcomes (p=0.0496) (Figure, Panel B).

Conclusion

T2MI has worse long term outcomes than T1MI. The predominant mode of death among patients with T2MI is non-cardiac. However, approximately 40% of deaths are cardiac. Further, we confirm the presence of CAD identifies a subset of patients with T2MI at high-risk.

Acknowledgement/Funding

Abbott Diagnostics and Hennepin Healthcare Research Institute (formerly MMRF)
P3610Prognostic implication of new-onset atrial fibrillation burden in patients with acute myocardial infarction
Authors: Luo J C , Li H Q , Li Z Q , Liu B X , Gong M M , Shi B B , Qin X M , Wei Y D
Published: October 2019

Background

New-onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI) can be associated with adverse cardiovascular events. The prognostic implication of the burden of atrial fibrillation has been investigated in various settings.

Purpose

We aimed to explore the association of the burden of post-MI NOAF with the risk of adverse cardiovascular events during hospitalization.

Methods

All consecutive patients admitted forAMI between February 2014 and February 2018 were analyzed by continuous electronic monitoring (CEM) through hospitalization. AF burden was calculated by dividing the total AF duration by the total CEM duration. Patients were divided into 3 groups: sinus rhythm group, low burden (AF burden≤8.5%) group, and high burden (AF burden>8.5%) group. The primary outcome was a composite of in-hospital all-cause death, recurrent MI, acute heart failure, or cardiogenic shock.

Results

Overall, 2405 patients (mean age: 65.8 years; male: 76.6%) were included. NOAF was documented in 11.6% of patients, and the primary outcome was recorded in 288 patients (13.6%) of the sinus rhythm group, 42 (30.0%) in the low burden group, and 71 (50.7%) in the high burden group. Compared with patients with sinus rhythm, a greater burden of NOAF was associated with a higher risk of the primary outcome after multivariable analysis (low burden: hazard ratio, 1.22; 95% confidence interval [CI]: 0.87–1.70; high burden: hazard ratio, 1.90; 95% CI: 1.43–2.51; p for trend<0.001).

In-hospital cardiovascular events MACE Patients/Events, n Unadjusted HR (95% CI) Adjusted HR (95% CI)a Sinus rhythm 2125/288 1.00 (reference) 1.00 (reference) Low burden 140/42 2.05 (1.48–2.84) 1.22 (0.87–1.70) High burden 140/71 3.93 (3.03–5.10) 1.90 (1.43–2.51) P for trend – <0.001 <0.001 All-cause death Patients, n Unadjusted HR (95% CI) Adjusted HR (95% CI)a Sinus rhythm 2125/106 1.00 (reference) 1.00 (reference) Low burden 140/10 1.02 (0.53–1.97) 0.52 (0.27–1.02) High burden 140/32 3.62 (2.41–5.42) 1.37 (0.89–2.09) P for trend – <0.001 0.081 aAdjusted for age, sex, current smoking, hypertension, diabetes mellitus, dyslipidemia, CKD, previous MI, previous stroke, previous heart failure, symptom onset to emergency department duration, STEMI, pre-hospital cardiac arrest, LVEF, and on-admission HR, SBP and CS, peak TnT, reperfusion therapy and GPIIb/IIIa inhibitor.

Kaplan-Meier plots of in-hospital events

Conclusion

A greater burden of NOAF complicatingAMI was associated withan increased risks of in-hospital adverse events.

Acknowledgement/Funding

National Natural Science Foundation of China grant 81270193 and Natural Science Foundation of Shanghai grant 18ZR1429700
P3622Demographic and clinical characteristics of atrial fibrillation patients suffering from an ACS without prior revascularization history
Authors: Coner A , Saracoglu E , Akdeniz A , Ozkan H , Tuluce K , Gul M , Coskun F Y , Kurt D , Karagoz A , Karaarslan O , Gok G , Ozdogan O , Ozpelit E , Ozer S F , Zoghi M
Published: October 2019

Background

The incidence of atrial fibrillation in acute coronary syndromes (ACS) ranges from 3% to 25%. The purpose of the current study was to investigate the demographic and baseline clinical characteristics, cardiovascular risk factors and comorbid conditions between patients (pts) with concomitant atrial fibrillation (AF) to those without AF in patients suffering from ACS without previous coronary artery bypass graft (CABG) and/or percutaneous coronary intervention.

Methods

The MINOCA-TR study has a cross-sectional, multicenter, observational design and was conducted with 32 interventional cardiology centers in our country. Heart rhythm at emergency admission, demographical, clinical and angiographic data was recorded for each patient. Patients with stable coronary artery disease, unstable angina pectoris and with type 4/5 myocardial infarction were excluded from study population.

Results

A total of 1626 patients (male: 70.7%, mean age: 61.4±12.5 years) were classified according to the presence of AF. The rate of AF was 3.1% in study population. This group was older (73.4 vs. 61.0 years, p<0.001) and AF was more common among females (43.1% vs. 28.7%, p=0.027). The frequency of AF was slightly higher (7.8%) in MINOCA group (p=ns).

STEMI presentation was more common in patients without AF (31.3% vs. 46.9%, p=0.028). LVEF was significantly lower in ACS patients with AF (44.1% vs. 49.4%, p=0.039). The frequency of AF was significantly higher (3.7%) in MINOCA group.

AF vs. non-AF ACS pts w/o prior revasc Parameter ACS with AF ACS without AF p value Age (years) 73.4 (±9.4) 61.0 (±12.4) <0.001 Female (%) 43.1 28.7 0.027 cTnT levels (pg/dL) median (IQR) 15.2 (96) 15.3 (428) 0.421 STEMI (%) 31.3 46.9 0.028 LVEF (%) 44.1 (±12.2) 49.4 (±10.4) 0.039 MINOCA (%) 7.8 6.6 0.743 STEMI: ST-segment elevation MI; NSTEMI: Non-ST-segment elevation myocardial infarction; LVEF: left ventricular ejection fraction; MINOCA: Myocardial Infarction with Non-Obstructive Coronary Arteries.

Conclusions

The frequency of AF was relatively lower in patients suffering from an ACS without prior revascularization history. They were older than patients without AF and were common in females. Non-ST-segment elevation myocardial infarction was significantly higher in the AF. The presence of MINOCA was similar between 2 groups.
P3643Junctional Adhesion Molecule-A (JAM-A) polymorphisms influence serum levels of soluble JAM-A and are associated with long term prognosis in coronary artery disease
Authors: Rath D , Altgelt K , Mueller K , Hack L P , Schaeffeler E , Winter S , Schwab M , Chatterjee M , Gawaz M , Geisler T
Published: October 2019

Aims

Junctional adhesion molecule A (JAM-A/F11R) is a cell adhesion molecule. Membrane associated JAM-A mediates platelet aggregation, secretion, adhesion, and spreading. Plasma levels of JAM-A are elevated in hypertension and atherosclerosis. This study was designed to investigate the impact of JAM-A single nucleotide polymorphisms (SNPs) on circulatory JAM-A levels and prognosis in patients with symptomatic coronary artery disease (CAD).

Methods and results

JAM-A SNP analysis (JAM-A F11R rs2774276 and rs790056) was performed in 943 patients with symptomatic CAD. All patients were tracked for all-cause death (ACD), myocardial infarction (MI), and ischemic stroke (IS) for 1080 days. The primary combined endpoint (CE) was defined as a composite of ACD and/or MI and/or IS. Secondary endpoints were defined as the single events of ACD and MI. Homozygote carriers of the minor allele (F11R rs2774276 and rs790056) showed significantly worse event-free survival for MI when compared with major allele carriers (Log rank = 0.011 and log rank = 0.031, respectively). No significant differences could be shown for the CE and ACD. Of note, in multivariate analysis, both SNPs were significantly and independently associated with MI. Furthermore, serum levels of soluble JAM-A were elevated in homozygote carriers of minor allele when compared to major allele carriers. Finally, serum levels of soluble JAM-A were significantly elevated in patients with MI when compared to stable CAD (p=0.036).

Figure 1

Conclusion

JAM-A SNPs are associated with prognosis in patients with symptomatic coronary artery disease. Furthermore, JAM-A SNPs might influence serum concentration of soluble JAM-A. Finally, serum concentration of soluble JAM-A is higher in patients with myocardial infarction when compared to stable coronary artery disease. These findings suggest JAM-A as a valuable biomarker for risk stratification and tailoring therapies in patients with coronary artery disease.

Acknowledgement/Funding

DFG-KFO274, CRC/Transregio 240
P3662Relationships between bacteria and echocardiographic manifestations in infective endocarditis - data from the Swedish endocarditis registry
Authors: Damlin A , Westling K , Maret E , Caidahl K , Eriksson M J
Published: October 2019

Introduction

Echocardiography (ECHO) is a method of choice for direct visualization of infective endocarditis (IE) - induced cardiac manifestations.

Purpose

To investigate the correlations between certain bacteria causing the IE and specific IE manifestations diagnosed by ECHO in the population from the Swedish Endocarditis Registry.

Methods

A cohort study based on selected data from the Swedish Endocarditis Registry including patients aged 18 and above, admitted between 2008 and 2017 with positive culture result from blood or surgical material, in total 570 patients (mean age 58±18 years, 33% female, 67% male patients). For numeric variables, Student's t-test was used. Correlations between the variables were estimated using odds ratio (OR) and 95% confidence intervals (CI). P<0.05 was considered significant.

Results

Of 570 patients 165 (29%) had a history of drug abuse; 21 (4%) had a bicuspid aortic valve and 110 (19%) had prosthetic valves. Significant correlations were seen between patients with aortic valve IE and coagulase negative staphylococci (OR 2.88, p=0.01, CI 1.26–6.88) and enterococcus spp (OR 2.31, p<0.01, CI 1.30–4.16), specifically enterococcus faecalis (2.45, p<0.01, CI 1.34–4.54), mitral valve IE and streptococcus spp (OR 1.92, p<0.01, CI 1.31–2.83), specifically group B streptococci (OR 8.16, p<0.01, CI 1.71–77.03), tricuspid valve IE (OR 6.55, p<0.01, CI 3.93–11.23) and pulmonic valve IE (OR 7.53, p=0.03, CI 1.0–335.25), and staphylococcus spp, specifically staphylococcus aureus (tricuspid valve: OR 6.55, p<0.01, CI 3.93–11.23 and pulmonic valve: OR 9.26, p=0.01, CI 1.22–412.22), abscess and coagulase negative staphylococci (OR 4.13, p<0.01, CI 1.13–12.25), pacemaker or ICD-associated IE and HACEK (OR 7.60, p=0.01, CI 1.66–27.06).

Conclusions

Significant correlations were found between certain bacteria and specific IE manifestations detected by ECHO, i.e. on aortic valve, mitral valve, tricuspid valve or pulmonic valve, abscess and pacemaker or ICD-associated IE.
P3664Infective endocarditis after transcatheter aortic valve implantation, a comparison with endocarditis occurring in surgical aortic prosthesis and native aortic valve patients
Authors: Flouriot C , Avinee G , Joulakian M , Alarcon C , Marchand C , Savoure A , Durand E , Tron C , Frebourg N , Litzler P Y , Chapuzet C , Eltchaninoff H
Published: October 2019

Background

Infective endocarditis is rare but serious. Epidemiology is well known in standard population and surgical valve patients (Pts). The recent development of Transcatheter Aortic Valve Implantation (TAVI) raises new questions about endocarditis in this population.

Purpose

The aim of this study was to assess outcomes of endocarditis in TAVI Pts and to compare the results to surgical aortic valve (SV) owners and native aortic valve (NV) patients.

Methods

We included all patients hospitalized in our institution and presenting with endocarditis after TAVI between 2012 and 2018. We compared these patients to those discussed within the “endocarditis team” and presenting with endocarditis located on SV or on NV.

Results

A total of 34 TAVI Pts were included and compared to a population of 45 SV and 68 NV Pts. TAVI Pts were older (83.1±1.1 yrs, vs 73.3±1.7 and 66.0±1.7, respectively; p<0.001) and had a higher Charlson score (6.2±0.4, vs 5.6±0.4 and 4.1±0.3; p<0.001). TAVI Pts underwent more frequently invasive procedures during the 6 months prior to the diagnosis of endocarditis (38.2%, vs 11.4 and 8.8%; p<0.001). They had less incidence of a new valvular murmur (0%, vs 28.9 and 33.8%; p=0.001) and less heart failure symptoms (26.5%, vs 28.9 and 33.8%; p=0.007). Clinical complications were similar between the 3 groups and mortality was high and comparable at 1 year (29.2%, vs 36.4 and 29.7% p=0.730). However, TAVI Pts were more frequently re-hospitalized (41.2% vs 26.7% and 16.2%, p=0.02) and were treated less invasively (surgery or pacemaker extraction in 14.7% vs 35.6% and 42.6%, p=0.019). Only one TAVI Pt needed surgical aortic valve replacement.

Conclusion

Despite more frequent comorbidities, TAVI patients affected by infective endocarditis have the same mortality during the first year after diagnosis compared to SV and NV patients but are more often rehospitalized.
P3676Hemodynamic phenotypes in systemic sclerosis patients screened for pulmonary hypertension (PH): impact of the new definition of PH
Authors: Xanthouli P , Milde N , Marra A M , Benjamin N , Nagel C , Eichstaedt C , Blank N , Egenlauf B , Harutyunova S , Lorenz H M , Grunig E
Published: October 2019

Background

Patients with systemic sclerosis (SSc) are at high risk of developing concomitant pulmonary hypertension (PH) which has a crucial impact on the patients' symptoms, quality of life and prognosis.

Purpose

The aim of this study was to analyse the impact of the new hemodynamic definition of precapillary PH as proposed at the 2018 World Symposium on PH in Nice in patients with SSc. Although recent data suggest that PVR >2 WU could be considered as abnormal in the new definition a conservative cut-off value of PVR ≥3 WU has been used.

Methods

SSc-patients were screened for PH using clinical assessments as WHO-functional class, 6 minute walking distance and right heart catheterisation. Patients were divided into hemodynamic subgroups according to their mean pulmonary arterial pressure (mPAP) values with mPAP ≤20 mmHg, 21–24 mmHg and ≥25 mmHg. These subgroups were further divided according to their pulmonary vascular resistance (PVR) with PVR <3 WU or ≥3 WU.

Results

One-hundred-twenty-two patients (79% female, age 57.6±12.7 years, 6MWD 439.5±98.1 meters, 70% diffuse cutaneous SSc, 30% limited cutaneous SSc, 53% WHO-FC II, 25% WHO-FC III) who were prospectively screened for PH were included in the analysis (Figure 1). Among them 26 had a symptomatic manifest PH using the cut-off value of mPAP ≥25 mmHg. Only half of this group presented with PVR ≥3 WU, the others had PVR <3 WU. Eight of these 26 PH-patients presented with PH due to left heart disease. Out of 21 patients with mildly elevated mPAP 21–24 mmHg, two (10%) met the new definition criteria of PH (pulmonary arterial wedge pressure <15 mmHg, mPAP 23 and 24 mmHg, PVR 3.0 and 3.2 WU, CI 2.2 L/min/m2 both, WHO-FC II both, respectively). Out of 75 patients with mPAP <21 mmHg, three presented with PVR ≥3 WU.

Overview of systemic sclerosis patients

Conclusions

The new definition of precapillary pulmonary hypertension may on the one hand allow detecting an additional 10% of PH patients with mild elevated mPAP. On the other hand, eight of 13 patients (62%), who met the former definition of pulmonary arterial hypertension, would be classified as “normal” due to a lack of increase in PVR according to the new definition. The data of this study suggest that for SSc-patients the cut-off value of mPAP >20 mmHg is useful, but the criteria of PVR ≥3 WU may be too strict.

Further studies with larger sample sizes will be needed to better characterise these hemodynamic subgroups and to define the extent of pulmonary vascular disease and treatability.
P3700Left trial appendage thrombosis in patients with severe aortic stenosis treated by transfemoral transcatheter aortic valve implantation
Authors: Mangner N , Stachel G , Woitek F , Crusius L , Haussig S , Kiefer P , Leontyev S , Schlotter F , Spindler A , Hoellriegel R , Hommel J , Borger M , Thiele H , Holzhey D , Linke A
Published: October 2019

Introduction

Data about the impact of left atrial appendage thrombosis (LAAT) on early safety and midterm mortality in patients undergoing transfemoral (TF) transcatheter aortic valve implantation (TAVI) are scarce.

Purpose

To investigate the incidence and predictors of LAAT as well as the outcome associated with this condition in a large cohort of patients treated by TF-TAVI.

Methods

Patients receiving TF-TAVI for native aortic valve stenosis or failed aortic bioprostheses were stratified according to the presence of LAAT diagnosed by transoesophageal echocardiography. Early safety at 30-days according to Valve Academic Research Consortium-2 (VARC-2) and 2-year all-cause mortality were the primary outcome measures.

Results

From 02/2006 to 06/2016, 2.527 patients (88.5%) out of 2.854 patients treated by TF-TAVI had an available transesophageal echocardiography (TEE) at baseline and formed the analysis cohort. LAAT was found in 7.6% of the whole cohort and in 16.6% in those patients with known pre-existing atrial fibrillation (AF cohort). Patients with LAAT appeared to be sicker compared to controls indicated by a higher STS-Score and burden of comorbidities. Neither VARC-2 defined early safety at 30-days nor the rate of stroke was different between LAAT and controls in both the whole (early safety: 24.2% vs. 29.2%, p=0.123; stroke: 4.7% vs. 5.9%, p=0.495) and AF cohort (early safety: 22.9% vs. 29.1%, p=0.072; stroke: 3.3% vs. 5.6%, p=0.142). Evaluating the whole cohort in a univariate analysis, the 2-year mortality was significantly higher in LAAT compared to controls (HR 1.41 [95% CI 1.07–1.86], p=0.014). However, a multivariate analysis of the whole cohort and a separate examination of the AF cohort revealed no association between LAAT and 2-year mortality.

Conclusion

LAAT was frequent in patients undergoing TF-TAVI, in particular in patients with a history of AF, but it was not associated with an increase in periprocedural complications. The fact that LAAT was no independent predictor of mortality indicates that it should be interpreted as a marker of an advanced disease stage rather than a prognostic factor.
P3737Predictors, feasibility and outcomes of coronary interventions up to 3 years after TAVI with a balloon-expandable valve. Results from a large European multicenter registry
Authors: Tarantini G , Nai Fovino L , Leprince P , Darremont O , Urena M , Bartorelli A L , Vincent F , Hovorka T , Dumonteil N , Ohlmann P , Wendler O
Published: October 2019

Background/Introduction

Coronary artery disease (CAD) and aortic stenosis often coexist. Transcatheter aortic valve implantation (TAVI) is emerging as a favorable treatment for younger and lower surgical risk patients. The need for coronary angiography (CA) and percutaneous coronary intervention (PCI) after TAVI will thus increase.

Purpose

We retrospectively evaluated the outcome of PCI performed after TAVI with the balloon-expandable SAPIEN 3 transcatheter heart valve in the SOURCE 3 European registry.

Methods

Cardiovascular (CV) mortality was computed at 3 years for patients with PCI and for those without. Univariate and Cox multivariate models were developed to assess the potential impact of PCI on CV mortality.

Results

Out of 1939 TAVI patients, 44 (2.3%) underwent PCI within 3 years after TAVI (mean interval from TAVI: 428±341 days). Patients with PCI were 80.9 years old and 63.6% were male. They had higher baseline logistic EuroSCORE (22.6% vs. 18.3%, p=0.007), higher rate of prior CAD diagnosis (72.7% vs. 51.0%, p=0.005), prior PCI (45.5% vs. 33.6%, p=0.108) and previous CABG (25.0% vs. 11.0%, p=0.013) than other patients of the cohort. Coronary access (ability to cannulate selectively the coronaries) was feasible in 100% of patients; PCI was successful in all but one case. The univariate model showed that CV mortality was slightly higher in patients undergoing PCI compared with those without PCI (Hazard Ratio: 1.86 [0.96–3.59], p=0.07); CV mortality rate was even lower with the multivariate model (HR: 1.39, p=0.52).

Conclusions

Interventions of CA and PCI after TAVI with a balloon-expandable valve was feasible and successful in all but one case in this large European registry. There was a trend towards a worse CV mortality at 3 years in patients needing PCI, which did not reach statistical significance likely because of the low incidence of PCI in our TAVI population.

Acknowledgement/Funding

The SOURCE 3 registry is sponsored by Edwards Lifesciences
P3739Differences in short-term outcome between balloon- and self-expandable TAVR devices relating to more than one generation
Authors: Veulemans V V , Klein K , Maier O , Wolff G , Polzin A , Westenfeld R , Jung C , Blehm A , Lichtenberg A , Kelm M , Zeus T
Published: October 2019

Background

Transcatheter aortic valve replacement (TAVR) is the treatment option of choice in inoperable and high-risk patients and only recently even revealed favorable outcome in an intermediate risk cohort. Morbidity- and outcome relevant factors like paravalvular aortic regurgitation, vascular access complications and the need for permanent pacemaker implantation remain key challenges during balloon- and self-expandable valve-improvement.

Purpose

We aimed to address safety and effectiveness between balloon- and self-expandable TAVR devices relating to more than one generation.

Methods

Patients treated with TAVR between 2009 and 2018 were categorized into either balloon-expandable (BAVR, n=516) or self-expandable (SAVR, n=974) groups. TAVR endpoints and adverse events were defined according to the Valve Academic Research Consortium-2. Primary endpoint was 30-day mortality.

Results

Logistic EuroSCORE I as predictor for risk stratification and 30-day mortality was comparable between both cohorts (BAVR/SAVR: 25.7%±5.2 vs 25.5%±2.5; p=n.s). Compared to SAVR devices, BAVR devices had significantly higher periprocedural gradients (BAVR/SAVR: 11.7mmHg±0.1 vs 8.3mmHg±0.8; p=0.0175), lower incidence of new renal replacement therapy (BAVR/SAVR: 1.8% vs 4.6%; p=0.0025), and new permanent pacemaker therapy for conduction disturbances (BAVR/SAVR: 8.3% vs 17.3%; p<0.0001), but more frequently disabling bleeding (BAVR/SAVR: 3.9% vs 1.0%; p=0.0003) complications. 30-day mortality was significantly reduced in SAVR-patients (BAVR/SAVR: 4.4% vs 2.4%; p=0.0395). No difference could be observed concerning primary device success (BAVR/SAVR: 1.0%vs 2.0%; p=n.s.), incidence of moderate-to-severe paravalvular leakage (BAVR/SAVR: 3.2% vs 5.0%; p=n.s.), stroke (BAVR/SAVR: 3.3% vs 2.6%; p=n.s.), and major vascular complications (BAVR/SAVR: 2.7% vs 3.5%; p=n.s.).

Conclusion

Data from the retrospective analysis indicate lower incidence of renal replacement and pacemaker therapy, but higher periprocedural gradients, disabling bleeding complications, and enhanced 30-day mortality for the BAVR device as compared to SAVR. Other issues like paravalvular leackage/aortic regurgitation and stroke still remain unacknowledged.
P3750Efficiency of electrocardiographic algorithms in management of idiopathic outflow tract ventricular arrhythmias in children
Authors: Ludwik B , Styczkiewicz K , Baszko A , Szydlowski L , Chodorowski L , Morka A , Chrabaszcz M , Szafran B , Mazij M , Sledz J , Stec S M
Published: October 2019

Introduction

Ablation of idiopathic ventricular arrhythmias (IVA) originating in left ventricle outflow tract (LVOT) are more challenging as compared to right ventricle outflow tract (RVOT). In recent years, several ECG algorithms predicting the site of origin (SOO) of arrhythmia for adult population have been published. There is a sparse information on their diagnostic performance in children.

Purpose

The aim of this study was to validate two algorithms: 1) Novel TZ index, 2) V2S/V3R and their combined application in children for predicting the appropriate SOO of IVA.

Methods

Two groups of children without structural heart disease, thorax anomalies and normal QRS complexes during sinus rhythm were included in the study: 1) patients with IVA with inferior axis who underwent successful RFCA using the 3D-electroanatomical system, 2) patients with paced or mechanically-induced QRS complexes from LVOT or RVOT during other procedures. ECGs were analyzed in a specially developed software for analyzing the amplitude of the QRS complex waves. Semi-automated measurements of amplitudes of QRS complexes and calculations were carried out for 2 published algorithms: 1) Novel TZ index, 2) V2S/V3R. The results of their separate and combined use were compared with SOO of acute successful RFCA and mapping or spot of pacing.

Results

108 PVC morphologies (68 from the RVOT and 40 from LVOT) from 74 pediatric patients (age: 14.0±2.9, 39 female) were included into the study. The algorithm V2S/V3R predicted left-sided SOO with a sensitivity and specificity of 94%. Novel TZ-index showed sensitivity of 89% and specificity of 84%. Combined use of Novel TZ-index+V2S/V3R showed high sensitivity (92%) and very height specificity (97%) of the LVOT SOO prediction

Conclusion

Both algorithms allowed accurate, simple and precise identification of SOO of RVOT/LVOT IVA in children. The combined use of those algorithms may facilitate additional pharmacologic treatment, omitting RVOT mapping with direct mapping LVOT, performance of the procedure by experienced operator.
P3754Comparison of the transdermal bisoprolol patch with the oral bisoprolol fumarate administration as a therapeutic agent for idiopathic frequent premature ventricular contractions
Authors: Shinohara M , Wada R , Akitsu K , Kinoshita T , Yuzawa H , Fujino T , Ikeda T
Published: October 2019

Background

The transdermal bisoprolol patch (TB) was designed to maintain a sustained concentration of bisoprolol in plasma by higher trough concentration than the oral bisoporolol fumarate administration (OB). It is unclear whether the TB is as effective in treating idiopathic premature ventricular contractions (PVCs) as the OB.

Purpose

We compared the efficacy between the TB and OB in treating idiopathic PVCs while considering their duration of action.

Methods

Among 198 patients with a PVC count of ≥3,000 beats/24 hours, 84 patients were divided into groups treated with TB 4mg (n=50) or OB 2.5mg (n=34). The PVCs were divided into positive heart rate (HR)-dependent PVCs (P-PVCs) and non-positive HR-dependent PVCs (NP-PVCs) based on the relationship between the hourly PVCs density and hourly mean HR. To evaluate the efficacy, PVC counts by 24-hour Holter electrocardiograms were measured at baseline and at 1 month after the initiation of the therapy.

Results

There were no significant between-group differences for the mean HR, PVC count, or type of PVCs. Both the TB (from 16,692±9,737 to 10,442±10,711 beats/24 hours, P<0.001) and OB (from 19,633±16,298 to 9,235±12,124 beats/24 hours, P<0.001) significantly decreased the total PVC count after the initiation of therapy, and a comparison between the two drugs showed no significant difference (P=0.46). In the P-PVC group, both the TB and OB significantly decreased the total PVC count (P<0.001, P=0.022 respectively), PVC count during the day-time (P<0.001, P=0.030 respectively), and PVC count during the night-time (P=0.0038, P=0.022 respectively). In contrast, in the NP-PVC group, neither the TB nor OB made any significantly change in the total PVC count (P=0.079, P=0.10 respectively), PVC count during the day-time (P=0.35, P=0.12 respectively), or PVC count during the night-time (P=0.11, P=0.12 respectively). The TB exhibited a significant reduction during each time period regarding the changes within 24-hours in the P-PVC count from baseline, while the OB did not significantly reduce the P-PVC count from baseline during each time period between 0 and 5 o'clock.

Conclusions

Compared with the OB, the TB could be used with the same efficacy for reducing the PVC count. The TB could be a more useful therapeutic agent for idiopathic P-PVCs during a 24-hour period than the OB.
P3755Left atrial enlargement as an independent risk factor for ischemic stroke in Japanese atrial fibrillation patients: pooled analysis of five major Japanese atrial fibrillation registries
Authors: Akao M , Ogawa H , Suzuki S , Yamashita T , Kodani E , Tsuda T , Hayashi K , Furusho H , Sawano M , Fukuda K , Nakai M , Miyamoto Y , Tomita H , Okumura K
Published: October 2019

Background

Atrial fibrillation (AF) increases the risk of ischemic stroke. It remains unknown whether left atrial diameter determined by routine trans-thoracic echocardiography is a risk factor for ischemic stroke in non-valvular AF (NVAF) patients.

Purpose

The aim of this study is to investigate the impact of left atrial enlargement (LAE) on the incidence of ischemic stroke in a large-scale cohort of Japanese NVAF patients.

Methods

We combined the data of 5 major AF registries in Japan, J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and Hokuriku AF Registry. After excluding patients without echocardiographic data, 7,672 NVAF patients were analyzed in the present study (mean age, 69.3±12.3 years; mean CHADS2 score, 1.6±1.3). We compared clinical characteristics and the incidence of ischemic stroke between NVAF patients with LAE (left atrial diameter >45 mm; LAE group) and those without (non-LAE group).

Results

The mean left atrial diameter was 43.1±8.6 mm, and the LAE group accounted for 40.0% (n=3,066) of the entire cohort. Compared with non-LAE group (60.0%, n=4,606), the LAE group was older (LAE vs. non-LAE; 70.3±12.0 vs. 68.0±12.5, p<0.01), more often non-paroxysmal type (73.7% vs. 32.1%, p<0.01), had higher CHADS2 (1.86±1.34 vs. 1.46±1.29, p<0.01) and CHA2DS2-VASc (3.02±1.83 vs. 2.53±1.78, p<0.01) scores, and more frequently received oral anticoagulant (72.9% vs. 55.0%, p<0.01).

During the median follow-up period of 774.5 days (interquartile range: 567–1466 days), ischemic stroke occurred in 241 patients (131 vs. 110 patients; 1.52 vs. 0.82 per 100 person-years). In Kaplan Meier analysis, LAE was associated with a higher incidence of ischemic stroke (unadjusted hazard ratio (HR): 1.83, 95% confidence interval (CI): 1.42–2.36; log rank p<0.01) (Figure). LAE was independently associated with increased risk of ischemic stroke (adjusted HR: 1.63, 95% CI: 1.25–2.11; p<0.01) after adjustment by the components of CHADS2 score and the use of oral anticoagulant, on multivariate Cox proportional hazard analysis.

Conclusion

In this large-scale cohort of Japanese patients with AF, LAE was an independent predictor of ischemic stroke, suggesting that this simple echocardiographic parameter could refine thromboembolic risk stratification of NVAF patients.

Acknowledgement/Funding

Japan Agency for Medical Research and Development, AMED
P3790Left ventricular stiffness assessed by diastolic wall strain predicts infrequent atrial fibrillation
Authors: Kishima H , Mine T , Fukuhara E , Ashida K , Ishihara M
Published: October 2019

Background

Left ventricular (LV) stiffness as the passive LV filling property in the LV diastolic function has been reported to be related with the prevalence of atrial fibrillation (AF). On the other hand, a novel insertable monitoring (ICM) system is a powerful tool to detect AF with rare appearance in patients with embolic stroke of undetermined source (ESUS). We investigated whether the LV stiffness assessed by diastolic wall strain (DWS) predicts infrequent atrial fibrillation.

Methods

Fifty-five patients (41 males, 68±14 years) who underwent ICM implantation for ESUS (n=19) or unexplained syncope (n=36) were studied. DWS, left atrial (LA) stiffness and other measurements were assessed using transthoracic echocardiography before the ICM implantation. DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd) during sinus rhythm, and DWS was defined as PWd/PWs. LA stiffness index was defined as the ratio of E/e' to LA peak strain.

Results

AF was detected in 20 patients (36%) during the follow-up periods (280±243 days). Patients with AF showed reduced DWS (0.30±0.07 vs. 0.41±0.08, p<0.0001), larger LA volume index (39.0±10.9 vs. 32.3±9.0, p=0.0174), and higher age (74.6±10.4 vs. 64.6±14.9, p=0.0105). On the other hand, LA stiffness index, LA function (reservoir, booster, and conduit function estimated by LA volume), and LV relaxation function (E wave, E/A ratio, deceleration time) were not associated with detection of AF. There was no difference on AF detection rate between ESUS and unexplained syncope (26% vs. 42%, p=0.2604). On multivariate analysis, DWS was only independently associated with detection of AF (p<0.0001, OR 5.647 for each 0.1 decrease in DWS, 95% CI 1.084–1.338). Moreover, patients with reduced DWS (<0.38) had a higher risk of incidences of AF than patients with preserved DWS (figure).

Figure 1

Conclusions

LV stiffness assessed by DWS predicts infrequent AF. Reduced LV stiffness rather than LA dysfunction or LV relaxation dysfunction may be the main cause of AF in the early stages.
P3814An analysis of Medicare reimbursement rates in cardiology from 2000 to 2018
Authors: Bhatt S , Haglin J , Tseng A S , Mishark K
Published: October 2019

Background

There is a paucity of data regarding financial trends for procedural reimbursement in the field of cardiology. A comprehensive understanding of such trends is important as continued progress is made to advance agreeable reimbursement models in cardiology while maintaining quality of care.

Purpose

To evaluate monetary trends in Medicare reimbursement rates for 10 commonly utilized cardiology procedures from 2000 to 2018.

Methods

Reimbursement data was extracted using The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services of the 10 included Current Procedural Terminology (CPT) codes in cardiology. The utilized CPT codes included each of the top two most frequently billed codes in the echocardiology, catheterization, pacemaker, electrophysiology, and device integrations divisions of our local cardiology department during the 2017 calendar year. All monetary data for each code was adjusted for inflation to 2018 US dollars (USD) utilizing changes to the United States consumer price index (CPI). If the code was redefined throughout the study period, the correct replacement code was utilized for each year as defined by the procedure. The R-squared and both the average annual and the total percentage change in reimbursement were calculated based on these adjusted trends for all included procedures.

Results

After adjusting for inflation, the average reimbursement for all procedures decreased by 38.2% from 2000 to 2018. The greatest mean decrease was observed in transthoracic echocardiogram (−64.4%). The only procedure with an increased adjusted reimbursement rate throughout the study period was biopsy of heart lining (+60.4%). From 2000 to 2018, the adjusted reimbursement rate for all included procedures decreased by an average of 2.8% each year, with an average R-squared value of 0.81, indicating a stable decline throughout the study period.

Conclusion

This is the first study to evaluate trends in procedural Medicare reimbursement for cardiology. When adjusted for inflation, Medicare reimbursement for included procedures has steadily decreased from 2000 to 2018. Increased awareness and consideration of these trends will be important for policy-makers, hospitals, and surgeons in order to assure continued access to meaningful cardiology care both at the local and global level.
P3817Predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in a rural South African setting
Authors: Ameh S , Klipstein-Grobusch K , Kahn K , Tollman S , Gomez-Olive F X
Published: October 2019

Background

South Africa is undergoing an epidemiological transition with a dual burden of chronic communicable and non-communicable diseases. A pilot integrated chronic disease management (ICDM) model was initiated in 2011 by the National Department of Health in selected primary health care (PHC) facilities. The aim of the ICDM model is to leverage an established HIV treatment programme for non-communicable diseases (NCDs) for better health outcomes of patients with chronic diseases.

Purpose

This study determined predictors of controlled CD4 count and blood pressure (BP) in hypertension and HIV patients receiving antihypertension medication and antiretroviral drugs, respectively in PHC facilities in the Bushbuckridge sub-district of Mpumalanga province, South Africa.

Methods

This was a panel study to assess the effectiveness of the ICDM model in controlling patients' CD4 count and BP. Patients ≥18 years were recruited through a three-step sampling process into the ICDM model facilities (n=435) and comparison facilities (n=443) in the Bushbuckridge sub-district. Health outcome data (BP and CD4 counts) for each patient were retrieved from health facility records over 30 months (January 2011 to June 2013). Control of BP and CD4 counts were defined as BP <140/90 mmHg and CD4 counts >350 cells/mm3, respectively. Multilevel logistic regression analyses were conducted to determine predictors of controlled CD4 count and controlled hypertension. Data were analysed using Stata 14 statistical software.

Results

The odds of controlling CD4 count were increased by reception of care at the ICDM model facilities (OR=4.05, 95% CI: 2.77–5.92), but decreased by male gender (OR=0.52, 95% CI: 0.34–0.80). The odds of controlling hypertension were higher with increasing age: 40–49 years (OR=6.02, 95% CI: 2.07–17.57); 50–59 years (OR=23.17, 95% CI: 7.46–72.16); ≥60 years (OR=77.48, 95% CI: 25.03–82.26), but decreased by male gender (OR=0.38, 95% CI: 0.21–0.69).

Conclusion

Application of the ICDM model appeared effective in controlling patients' CD4 counts, but not their BP; hence, the HIV programme should be more extensively leveraged for hypertension treatment in health facilities in the study setting. Health education programmes to improve HIV treatment outcomes should focus on males. Hypertension educational programmes should target younger males in the study setting.

Acknowledgement/Funding

Fogarty International Centre of the National Institutes of Health under the Award number D43 TW008330
P3819Machine learning for predicting early left ventricular abnormalities in the general population
Authors: Kuznetsova T , Cauwenberghs N , Haddad F , Alonso-Betanzos A , Vens C
Published: October 2019

Background

Current heart failure guidelines emphasize the importance of timely detection of subclinical left ventricular (LV) remodelling and dysfunction for more precise risk stratification of asymptomatic subjects. Both LV diastolic dysfunction (LVDD) and LV hypertrophy (LVH) as assessed by echocardiography are known independent prognostic markers of future cardiovascular events in the community. However, selective screening strategies of individuals at risk who would benefit most from in-depth cardiac phenotyping are lacking.

Purpose

We assess the utility of several Machine Learning (ML) classifiers built on clinical and biochemical features for detecting subclinical LV abnormalities.

Methods

We included 1407 participants (mean age, 51 years, 51% women) randomly recruited from the general population. We used echocardiographic parameters reflecting LV diastolic function and structure to define LV abnormalities (LVDD, n=239; LVH, n=135). After that four supervised ML algorithms (Random Forest (RF), Gradient Boosting (GD), Stochastic Gradient Descent (SGD) and Support Vector Machines (SV)) were built based on routine clinical, hemodynamic and laboratory data (features; n=61) to categorize LVDD and LVH (two prediction tasks). We applied a 10-fold stratified cross-validation set-up.

Results

ML classifiers exhibited a high area under the ROC (AUC) for predicting LVDD with values between 88.5% and 93.1% (Figure, left panel). Age, BMI, different components of blood pressure, antihypertensive treatment, routine biomarkers such as serum electrolytes, creatinine, blood sugar, leptin, uric acid, lipid profile, as well as blood cell counts were the top selected features for predicting LVDD. Prediction AUC of ML algorithms for detection of LVH was somewhat lower than for LVDD and ranged from 72.5% to 78.7% (Figure, right panel). The top selected features for LVH classifier were similar to those of LVDD, but also included social class, serum gamma-glutamyl transferase, fasting insulin, plasma renin activity and cortisol.

ROC curves (sensitivity-1-specificity)

Conclusions

ML algorithms combining routinely measured clinical and laboratory data have shown high accuracy of LVDD and LVH prediction. These ML classifiers might be useful to preselect individuals at risk for further in depth echocardiographic examination, monitoring and implementation of preventive strategies in order to delay transition to disease symptoms.