bluuebunny/crossref_metadata_2025 huggingface dataset:
789 USEFULNESS OF NEUTROPHIL-TO-LIMPHOCYTE RATIO AS A PROGNOSTIC BIOMARKER FOR IN-HOSPITAL COMPLICATIONS AND LONG-TERM MORTALITY IN OLDEST OLD STEMI PATIENTS
Authors: Donazzan Luca , Ruzzarin Alessandro , Zilio Filippo , Muraglia Simone , Zanon Sofia , Flaim Massimo , Baessato Francesca , Bonmassari Roberto , Oberhollenzer Rainer , Unterhuber Matthias
Published: December 2022

Background

the neutrophil to lymphocyte ratio (NLR) is an indicator of systemic inflammation and a prognostic marker in patients undergoing percutaneous coronary intervention (PCI) that has been demonstrated to be related to in-hospital complications and long-term mortality in patients with ST segment elevation myocardial infarction (STEMI).

Aims

to assess the correlation between NLR and in-hospital complications and mortality, as well as long-term mortality in a population of oldest old (i.e. >85 years old) STEMI patients.

Methods

we enrolled every oldest old patient admitted in two Hub hospitals with a diagnosis of STEMI who underwent an invasive strategy (coronary angiography ± percutaneous coronary intervention) between January 2010 and June 2021. Blood samples were performed at the first medical contact (in the emergency room or in the cath-lab according to presentation). Follow-up data were collected with phone calls or with revision of computer registries. In-hospital MACCE was defined as a composite of death, heart failure, in-stent thrombosis, relapsing angina, stroke, BARC 3 to 5 bleedings during hospital stay.

Results

four hundred fifty-eight patients accessed the Hub hospitals for STEMI during the selected period. Among them, 355 patients were eligible for this analysis. One hundred fifty-five patients (44%) experienced an in-hospital MACCE. Patients with in-hospital MACCE had a significantly higher NLR at baseline (10,2±7,4 vs 7,0±4,7 p<0,001), this was also true when in-hospital mortality was considered per se (11,1±8,3 vs 8,0±5,8 p=0,002).

Conclusions

in our multicentre registry of oldest old STEMI patients, NLR has demonstrated to be an easy access, useful tool to predict in-hospital MACCE and in-hospital mortality.
535 CT SCAN AORTIC VALVE CALCIFICATION PATTERNS AND HEMODYNAMIC PERFORMANCE OF SELF-EXPANDING INTRA-ANNULAR TRANSCATHETER PROSTHESES
Authors: Viscusi Michele Mattia , Nusca Annunziata , Mangiacapra Fabio , Ricottini Elisabetta , Melfi Rosetta , Gallo Paolo , Cocco Nino , Rinaldi Raffalele , Cammalleri Valeria , Grigioni Francesco , Ussia Gian Paolo
Published: December 2022

Introduction

Aortic valve calcification (AVC) represents a negative prognostic factor in patients undergoing transcatheter aortic valve implantation (TAVI). Recent randomized clinical trials comparing commercially available self-expanding (SE) supra-annular and balloon-expandable (BE) devices with second-generation SE intra-annular devices demonstrated the clinical non-inferiority of the latter in terms of procedural success. However, no current data are available in vivo regarding the potential impact of AVC on SE intra-annular device performance and clinical outcomes.

Purpose

to evaluate the potential impact of different AVC patterns on SE intra-annular device performance in a consecutive cohort of patients undergoing TAVI.

Methods

this is an observational, non-randomized, prospective, single-center study preliminarily enrolling 53 consecutive patients who underwent TAVI with a SE intra-annular device (Portico - Abbott Structural Heart, St Paul, MN, USA) between 2019 and 2022 at our department. All patients underwent transthoracic echocardiography, contrast-enhanced multidetector row computed tomography (MDCT) with volumetric calcium score and coronary angiography before TAVI. Patients with bicuspid aortic valve and previous surgical aortic valve replacement eligible for valve-in-valve TAVI were excluded. AVC and left ventricle outflow tract (LVOT) calcification (up to 15 mm below the basal annular plane) were quantified in the contrast images by using a Hounsfield unit threshold of 850.

Results

Patients undergoing post-TAVI pacemaker implantation (19% of the overall study population) had higher AVC levels compared with those that did not show this complication (all three cusps AVA calcium score 270.6±409.6 vs 158.1±137.1, p=0.146; p=0.048, p=0.181 and p=0.346 for left cusp- LCC, right cusp – RCC- and non-coronary cusp-NCC, respectively). Severe LVOT calcification was also associated with a higher incidence of AV conduction abnormalities (37.9±44.5 vs 13.4±39.0 of patients without AV defects, p=0.045). Moreover, post-procedural moderate/severe aortic regurgitation occurred more frequently in patients with LCC calcification (183.7±87.0 vs 64.2±99.6, p=0.018) and RCC calcification (188.7±149.5 vs 58.7±120.8, p=0.019) rather than those with NCC or LVOT calcification.

Conclusion(s)

preliminary results of our observational registry highlight the potential impact of AVC patterns on the occurrence of aortic regurgitation and pacemaker implantation after a SE intra-annular device. A larger sample size is needed to better understand the impact of calcium patterns on each single outcome in order to identify patients at higher risk and to early manage these complications, improving long-term outcomes.
1 ACE-INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS DO NOT IMPACT ON OUTCOME NOR IN LONG TERM CONSEQUENCES OF COVID-19
Authors: Salvotti Francesca , Boari Gianluca , Fusco Maria Elena , Borghi Erika , Volpe Pietro , Tosoni Federico , Turini Daniele , Malerba Paolo , Pasini Giancarlo , Guarinoni Vittoria , Ferrari-toninelli Giulia , Leidi Francesca , Bressa Stefano , Santagiuliana Marzia , Napoli Federico , Geroldi Veronica , Rosei Claudia Agabiti , De Ciuceis Carolina , Rizzoni Damiano
Published: December 2022

Introduction

COVID-19 pandemic still represents a major clinical problem worldwide. Many studies are actively being carried out to better understand prognostic factors of outcome as well as optimal treatment.

Aim

ACE-2 receptor is highly expressed on the surface of cardiac and pulmonary cells, and it is used by coronaviruses to enter host cells; this makes the role of ACE-inhibitors and Angiotensin Receptor Blockers (ARBs) drugs controversial. Moreover, it is still unclear whether these drugs may have any impact on sequelae.

Methods

In this retrospective study, we analysed a group of 244 hypertensive unvaccinated patients (134 on ACE-inhibitors, 110 on ARBs) admitted for moderate to severe COVID-19 pneumonia. As shown in the table, the two groups where homogeneous.

Of these patients, 46 (20 treated with ACE-I and 26 treated with ARBs) came to a follow-up visit after a mean of 260 days; they underwent a quality-of-life assessment, laboratory and radiologic tests and spirometry (with DLCO).

Results

A total of 20 of 110 (18%) patients under treatment with ARBs and 23 of 134 (17%) died during hospitalization (p=0.8, NS). At discharge, biochemical, radiological and respiratory data were not significantly different. We did not find any significant difference in terms of radiologic alterations, lung fibrosis, spirometry data, DLCO, persisting effort dyspnea. Biochemical data were substantially super-imposable in the two groups.

Conclusions

we could not detect any difference in outcome nor in complications type or number in the two groups undergoing treatment with ACE-inhibitor or ARBs. This result seems to support and to strengthen the idea that ACE-inhibitors and ARBs do not play a significant role in onset, evolution and outcome of moderate to severe COVID-19 pneumoniae. Although the number of follow-up patients is small, we did not find any difference in follow-up sequelae in both groups.
15 THE HEAVY BURDEN OF SARS-COV-2 RELATED PNEUMONIA REQUIRING HIGH-OXYGEN FLOW
Authors: Salvotti Francesca , Scipione Vittorio , Flamminio Gigliola , Pastori Antonella , Geroldi Veronica , Volpe Pietro , Borghi Erika , Tosoni Federico , Fusco Elena Maria , Malerba Paolo , Ferrari-toninelli Giulia , De Ciuceis Carolina , Rosei Claudia Agabiti , Rizzoni Damiano , Boari Gianluca E m
Published: December 2022

Aim

there is evidence of significant clinical sequelae of COVID-19 that may impair both life length and its quality. Aim of this study was to assess the long-term consequences of moderate to severe SARS-CoV-2-related pneumonia in patients requiring high-flow oxygen treatment.

Methods

This prospective follow-up study included 45 patients with confirmed COVID-19 admitted to a medical ward at the Montichiari Hospital, Brescia, Italy from November 2020 to April 2021 Patients had COVID-19 related pneumonia with respiratory failure and needed at least treatment with an inspired fraction of oxygen of 40% (of them, 59% were treated with Venturi mask and 41% needed non-invasive ventilation). Patients underwent a clinical assessment with standard laboratory testing, chest CT scan, lung function tests with DLCO, and evaluation of vital parameters after a mean of 382 days after hospital discharge. A quality-of-life questionnaire was administered to each willing patient.

Results

See table for details. While standard laboratory testing showed a substantial normalization, we found persistence of radiological alterations (i.e. ground-glass opacities, irregular linear/reticular opacities) in 61% of patients; mean Tiffenau index (FEV1/FVC) was reduced, although not clearly pathologic (79%) and 38% of patients showed a mild to moderate reduction in CO lung diffusion (DLCO). Interestingly, 54% of subjects showed concomitant presence of radiologic alterations AND persistence of dyspnea OR reduction in CO lung diffusion, while 21% had all three concomitant conditions, compatible with the diagnosis of lung fibrosis. Overall, a total of 75% patients had some degree of functional or structural alteration of respiratory apparatus. We also evaluated quality of life thorough a structured questionnaire: after more than one year 62% of the patients still lamented fatigue, 62% effort dyspnea, 12% anorexia, 29% dysgeusia or anosmia, 31% insomnia and 43% anxiety.

Conclusions

these data seem to demonstrate that SARS-CoV-2-related pneumonia requiring high flow oxygen has a heavy long-term burden, both in terms of persistence of functional and structural pulmonary damage (which may be progressive and evolve to a more severe degree) and of burden on overall quality daily life.
872 ENDOTHELIAL AND CARDIAC AUTONOMIC FUNCTION IN PATIENTS WITH A RECENT SARS-COV-2 INFECTION
Authors: Tremamunno Saverio , Telesca Alessandro , Felici Tamara , De Vita Antonio , Villano Angelo , Lamendola Priscilla , Tosato Matteo , Landi Francesco , Lanza Gaetano Antonio
Published: December 2022

Background

A significant proportion of patients recovering from SARS-CoV-2 infection (Covid-19) complain a wide variety of bothersome symptoms, including symptoms potentially related to cardiac involvement, that may significantly impair their quality of life (post-Covid or long-Covid syndrome). However, full diagnostic investigation usually does not reveal significant structural or functional cardiac abnormalities. Whether cardiac autonomic dysfunction and/or endothelial dysfunction may play a role in post-COVID-19 symptoms, however, has poorly been investigated.

Methods

We prospectively enrolled 63 young adult patients (age 18-55 years) without any previous cardiovascular disease, referred to our “Post-COVID-19” Day Hospital ward for a clinical follow-up after 3 months from SARS-CoV-2 infection.

In all patients endothelium-dependent vasodilator function was assessed non-invasively by measuring the change of brachial artery diameter in response to hyperaemia after 5 minutes of forearm ischemia (flow-mediated dilatation, FMD); furthermore, endothelium-independent vasodilator function was assessed by measuring the change of brachial artery diameter in response to sublingual nitro-glycerine (25 µg) (nitrate-mediated dilatation, NMD). A 24-hour ECG Holter monitoring (HM) was performed to assess cardiac autonomic function by obtaining time-domain and frequency-domain parameters of heart rate variability (HRV).

Results

Symptoms of potential cardiac origin (dyspnoea on exertion, chest pain, arrhythmic symptoms) were referred by 47 patients (74.6%, Group 1), whereas 16 (25.4%, Group 2) were free from any possible cardiac symptom. The two groups did not differ in age, sex and cardiovascular risk factors. FMD was 7.29±3.4% and 7.01±2.3% in Group 1 and 2, respectively (p=0.77), whereas NMD was 11.1±3.8% and 14.2±4.9 in the two groups, respectively (p=0.013). No significant differences were observed for HRV parameters between the two groups (see Table).

Conclusions

Our data do not support a role for both endothelial dysfunction and cardiac autonomic dysfunction in the persistence of symptoms of potential cardiac origin in patients with a recent SARS-CoV-2 infection. The lower endothelium-independent arterial vasodilator found in these patients, however, deserves further investigation.
467 EFFICACY OF TRANSCATHETER INTERATRIAL SHUNT DEVICES IN HEART FAILURE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Basile Christian , Marzano Federica , Dellegrottaglie Sarto , Gargiulo Paola , Abbate Vincenza , Ambrosio Antonio , Carbone Francesca , Dell´aversana Simona , Esposito Immacolata , Fierro Maria Francesca , Perrone-filardi Pasquale , Paolillo Stefania
Published: December 2022

Background

In patients affected by heart failure with reduced ejection fraction (HFrEF), pharmacological treatments have been proven to alleviate symptoms and improve prognosis, while no treatment other than sodium-glucose co-transporter-2 inhibitors have demonstrated significant effects in HF with preserved ejection fraction (HFpEF). Left-to-right interatrial shunt devices are now being investigated for left atrial decompression in patients with HF.

Objectives

To assess the efficacy of left-to-right interatrial shunt devices (IASD) on soft endpoints in HF patients.

Methods

PubMed and Web of Science were searched without restrictions from inception to 28 May 2022 to identify valuable articles. The studies that met the inclusion criteria were analyzed. The prespecified main outcomes were the change from baseline in 6-minute walking distance (6MWD), NYHA class and health-related quality of life (HRQoL). Secondary outcomes were reduction in HF hospitalizations, and echocardiographic and hemodynamic parameters.

Results

Ten studies, with a total of 539 patients were included. IASD significantly improved 6MWD of 44.19 m (95% CI: 29.82–58.56 m), decreased NYHA class by 0.89 (95% CI: 1.10–0.67), and improved HRQoL questionnaire by 20.19 points (95% CI: 12.94–27.44) with better results for all outcomes in younger patients and in patients with lower EFs (Figure).

Conclusion

The present meta-analysis suggests that IASD are favorable in improving 6MWD, NYHA class, and HRQoL in HF across a wide spectrum of ejection fraction, with better outcomes in younger patients and in patients with lower EFs.
143 ESTIMATION OF RIGHT ATRIAL PRESSURE BY ULTRASOUND-ASSESSED JUGULAR VEIN DISTENSIBILITY IN PATIENTS WITH CHRONIC ADVANCED HEART FAILURE
Authors: Colombo Giada , Marchetti Davide , Gentile Piero , D´angelo Luciana , Masciocco Gabriella , Macera Francesca , Occhi Lucia , Musca Francesco , Perna Enrico , Moreo Antonella , Oliva Fabrizio , Garascia Andrea , Metra Marco , Ammirati Enrico
Published: December 2022

Aims

In patients with chronic advanced heart failure (HF) signs of congestion are not always evident on clinical examination. We aim to validate the ultrasound (US)-assessed jugular vein distensibility (JVD), as a non-invasive tool to identify patients with normal right atrial pressure (RAP≤7 mmHg).

Methods and Results

In a single-center prospective study, we assessed chronic HF patients with a left ventricular ejection fraction (LVEF)<50% who underwent a pulmonary artery catheterization in the setting of advanced HF therapies workup. We first identify the JVD threshold (Valsalva/rest ratio of the vein diameter) of 1.6 that allowed the most accurate discrimination between patients with RAP≤7 vs. >7 mmHg (area under the curve [AUC] of 0.74; p<0.0001) in a calibration cohort of 100 patients (mean age 53 years, median LVEF 25%). Based on this JVD threshold, we defined patients with low JVD (≤1.6; n=58; median RAP 8 mmHg) and high JVD (>1.6, n=42; median RAP 4 mmHg). Then, we tested the threshold in 101 patients (validation cohort), where we found comparable results (AUC of 0.82; p<0.0001). The JVD threshold had 0.86 and 0.94 predictive positive values to identify patients with RAP≤7 mmHg in the calibration and validation cohorts. Finally, the low JVD vs. high JVD group had a 42.7% vs. 16.1% incidence of major cardiac events at 2 years (log-rank p=0.006), showing its prognostic value.

Conclusion

US-assessed JVD is an accurate diagnostic tool to identify advanced HF patients with normal RAP. This tool could be tested in the ambulatory setting to modulate diuretic/vasodilator therapies.
733 NT-PROBNP CONCENTRATIONS ACROSS PULMONARY HYPERTENSION GROUPS
Authors: Costa Paolo , Solimano Martina , Crimi Gabriele , Vercellino Matteo , Macchione Andrea , Toma Matteo , Porto Italo , Ameri Pietro
Published: December 2022

Background

Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) are found in both pre-capillary pulmonary hypertension (PH), including pulmonary arterial hypertension, PH associated with hypoxia/lung disease and chronic thromboembolic pulmonary hypertension, and post-capillary PH associated with left heart disease. We asked the question of whether NT-proBNP concentrations differ among these PH subtypes.

Methods

Based on right heart catheterization (RHC) data collected at our institution between Jan. 2019 and Dec. 2021, 146 patients were classified as no PH, pre-capillary PH, isolated post-capillary PH (iPC-PH) or combined pre- and post-capillary PH (cPC-PH) according to the 2022 ESC/ERS guidelines (GL). NT-proBNP values were compared across PH groups by Kruskal-Wallis test with Bonferroni correction. The characteristics of subjects with pre-capillary PH and NT-proBNP ≤ or >1.100 pg/mL, a cut-off for severity proposed by the 2022 GL, were compared by chi-square test, T-test, or Mann-Whitney test, as appropriate. We also applied the hemodynamic definitions of the 2018 6th World Symposium on PH (6WSPH) and of the 2015 GL, examined the differences in the distribution of PH groups with the McNemar test, and reassessed NT-proBNP concentrations.

Results

44 (30%) of patients did not have PH, 38 (26%) had pre-capillary PH, 18 (12%) had iPC-PH, and 46 (32%) had cPC-PH. NT-proBNP levels were progressively higher from pre-capillary PH to iPC-PH to cPC-PH (Figure). Interestingly, the 25th percentile of the cPC-PH group was 1.138 pg/mL, close to the 1.100 pg/mL cut-off. Compared with patients with pre-capillary PH and NT-proBNP ≤1.100 pg/mL, those with >1.100 pg/mL NT-proBNP had larger right ventricle basal diameter [50 (43-53) vs 43 (36-45) mm; p=0.02], lower TAPSE/sPAP ratio [0.21 (0.15-0.25) vs 0.35 (0.25-0.43), p=0.01], more often massive tricuspid regurgitation (83% vs 20%, p<0.001), higher pulmonary vascular resistance [9.5 (7.6-15.1) vs 5.7 (2.7-7.8) WU; p=0.004], and lower stroke volume index [28 (17-32) vs 36 (32-50) mL/m2; p=0.002]. The proportion of no PH decreased and the one of cPC-PH increased when the 6WSPH or the 2015 GL criteria were used (p for trend <0.001). Nonetheless, the trend of NT-proBNP remained similar to that observed with the 2022 GL definitions (Figure).

Conclusions

A gradient of NT-proBNP exists across PH groups, with the highest values being in cPC-PH. The concentrations of NT-proBNP in severe pre-capillary PH overlap with those in cPC-PH, indirectly confirming the validity of this biomarker to discriminate the severity of pre-capillary PH.
306 HEART FAILURE AS THE CANCER FOR THE HEART: THE PROGNOSTIC ROLE OF THE HLM SCORE
Authors: Severino Paolo , Mancone Massimo , D´amato Andrea , Mariani Marco Valerio , Prosperi Silvia , Fegatelli Danilo Alunni , Birtolo Lucia Ilaria , Angotti Danilo , Costi Bettina , Cestiè Claudia , Francia Aurora Labbro , Tomarelli Elisa , Myftari Vincenzo , Germanò Rosanna , Milanese Alberto , Cerrato Enrico , Maestrini Viviana , Pizzi Carmine , Foà Alberto , Vestri Annarita , Palazzuoli Alberto , Vizza Carmine Dario , Casale Paul , Mather Paul , Fedele Francesco
Published: December 2022

Background

The multiorgan involvement of heart failure is similar to the spread observed in cancer. We proposed a new score, named HLM, analogous to TNM classification used in oncology. HLM refers to (i) H: heart damage, instead of “T” for tumor; (ii) L: lung involvement, instead of “N” for lymph nodes; (iii) M: systemic multiorgan involvement, instead of “M” for metastasis.

Objectives

to compare HLM score to NYHA class, ACC/AHA stages and left ventricular ejection fraction (LVEF) classification, to assess the most accurate prognostic tool for HF patients.

Methods

We performed a multicentric, observational, prospective study of consecutive patients admitted for HF, or at risk for HF. Parameters for heart, lungs and organs’ function were collected. Each patient was classified according to HLM, NYHA, ACC/AHA stages and LVEF classification. Patients were followed up for 12 months. The primary composite endpoint was all-cause death and rehospitalization due to HF.

Results

We enrolled 1720 patients who completed the 12-month follow-up. As shown by Kaplan Meier curves, HLM was the most accurate score to predict primary endpoint at 12- month. The area under the ROC curve (AUC) was greater for HLM score than NYHA, ACC/AHA stages and LVEF classification, regarding the composite endpoint (HLM=0.645; NYHA=0.580; ACC/AHA=0.589; LVEF=0.572) (Figure 1). HLM score related AUC showed statistically significant differences compared to LVEF (p=0.002), ACC/AHA (p=0.029) and NYHA (p=0.009).

Conclusions

HLM score has a greater prognostic power compared to other nosologies, in terms of the composite endpoint of all-cause death and rehospitalization due to HF, at 12-month follow-up.

Key words: heart failure; HLM score; prognosis; mortality; rehospitalization.

Figure 1.
61 LEFT ATRIAL RESERVOIR AND STIFFNESS IN PATIENTS WITH WILD-TYPE TRANSTHYRETIN AMYLOID VS HYPERTROPHIC CARDIOMYOPATHY
Authors: Campisi Mariapaola , Trimarchi Giancarlo , De Sarro Rosalba , Poleggi Cristina , Luongo Alfredo , Teresi Lucio , Lofrumento Francesca , Restelli Davide , Recupero Antonino , Zito Concetta , Di Bella Gianluca , De Gregorio Cesare
Published: December 2022

Objectives

Left atrial (LA) function can be investigated by advanced ultrasound speckle tracking modality, much better than in the past. Modern ultrasound technology allows attaining myocardial deformation profiles from both ventricular and atrial chambers. Each of the 3 components of LA function [reservoir, also known as peak longitudinal strain (PALS); conduit and pump] can be impaired in various chronic diseases. We previously demonstrated that PALS (reservoir) and pump function weaken in patients with cardiac transthyretin amyloidosis (ATTR) and hypertrophic cardiomyopathy (HCM). In the present study we sought to recognize LA stiffness (LAst), a relatively novel marker of atrial dysfunction, in the same clinical settings.

Methods

17 patients, 9 with ATTR wild-type (wt) and 8 with non-obstructive HCM, mean aged 67±12 years, were investigated by using transthoracic color-Doppler and strain ultrasound equipment. LV mass index (LVMI), LA area index (LAAI), LV ejection fraction (LVEF), E/E’ ratio, LV global longitudinal strain (GLS), PALS and LAst were assessed in both groups. LAst was calculated by PALS/E/E’ ratio, as suggested by studies.

Results

LVMI and LAAI were similar in the 2 groups: 171±40 vs 161±51 g/m2.7 and 14±3 vs 16±4 cm/m2.7 in ATTRwt vs HCM, respectively (p=NS). However, patients in the former group showed poorer LV diastolic and systolic function (LVEF was 47±9 vs 58±5%, respectively, p<0.01), as well as GLS (9.5±2.2 vs 12.6±2.8, respectively, p=0.02). PALS and LAst were more impaired in ATTRwt compared to HCM patients (Figure), despite similar LA chamber size. Considering that LAst value >0.65 has been reported as a predictor of adverse LA morphofunctional remodeling, both groups were considered at risk for atrial dysfunction, but mainly the former one.

Conclusions

Although present findings were achieved by a small patient population, LA reservoir and stiffness were impaired in patients with ATTRwt more than in those with HCM. Left atrial dysfunction may not be strictly related with LVMI or LA size, but with LV-GLS, confirming an atrio-ventricular functional interplay in cardiac amyloidosis. Further larger study is needed to corroborate present results.
542 USE OF ANGIOTENSIN RECEPTOR/NEPRYLISIN INHIBITORS (ARNI) IN WILD TYPE TTR CARDIAC AMYLOIDOSIS (WTATTR) AND HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF) : IS IT WORTH A TRY?
Authors: Fowler Bianca , Vincenzi Antonella , Massa Paolo , Massabo Didi , Vullo Eleonora , Lettino Maddalena
Published: December 2022

Background

wtATTR is a therapeutic challenge. Although the majority of patients with wtATTR presents with HFpEF, some evolve to systolic disfunction. According to international guidelines, Tafamidis is the only recommended disease modifiyng agent in wtTTRCA. Therapies for neurohormonal antagonism have no established role and concerns have been raised about their safety. Observational studies have focused on beta blockers (bb), angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers. The role of ARNI has not been directly explored. We report results of the use of ARNI in three male patients with HFrEF in wtATTR who were not eligible to Tafamidis, due to advanced HF (NYHA III-IV).

Cases

wtATTR was diasgnosed in all three patients in 2019 when no drugs were yet available. Baseline median LVEF was 57%. At two years follow up (FU), at average age of 83 years old, patients developed systolic disfunction (median LVEF 21%). They were all symptomatic for dyspnoea (NYHA III-IV), median systolic blood pressure (SBP) was 103mmHg (95-120), median N-terminal fraction of pro-B-type natriuretic peptide (NTproBNP) levels were 11.500 pg/ml (10.263-13.000) and estimated glomerular filtration marked CKD between stages III-IV. Two out of three patients were in anticoagulant treatment for atrial fibrillation and all three were on low dose of bb. S/V 24/26 mg was introduced (T1) in all patients according to eGFR. At 8 months (T2) downgrade of NYHA class was observed in all three patients, none of them developed symptomatic hypotension. Average NTproBNP levels were reduced (average 6853 ng/l), despite of mild worsening of renal function, and reverse remodelling of LV with improvement of contractile function (EF 21% > 45%) was showen at ecocardiography (Tab 1).

Conclusions

A very remarkable clinical, laboratoristic and echographic improvement was observed after 8-months therapy with S/V. The result may be purely due to natriuretic effect of ARNI in patients so strictly reliant on volemic state because of severe dyastolic disfunction, or more complicated effects may be mediated by neprilisin on amiloyd protein. Further research and clinical studies are certanly warranted to guarantee patients with wtATTR HFrEF best possible care.
118 SHORT-TERM EFFECTS OF DAPAGLIFLOZIN ON CARDIAC BIOMARKERS, FLUID RETENTION, RENAL AND PULMONARY FUNCTION IN HFREF PATIENTS: NOT AS GOOD AS EXPECTED
Authors: Mapelli Massimo , Capovilla Maria Teresa , Marongiu Alessandro , Maranzano Gaspare , Salvioni Elisabetta , Mattavelli Irene , Vignati Carlo , Gugliandolo Paola , Mantegazza Valentina , Garlasché Anna , Agostoni Piergiuseppe
Published: December 2022

Background

Sodium-glucose co-transporter-2 inhibitors (SGLT2-i) are currently a standard therapy for patients with heart failure with reduced ejection fraction (HFrEF). Still, their potential benefits on biomarkers, respiratory function parameters and fluid retention have not been extensively studied. Bioimpedance vector analysis (BIVA) has emerged as a new tool capable of assessing congestion, providing an estimate of the total body water and hydration index (HI). BIVA is more accurate than NT-proBNP in detecting peripheral congestion in chronic heart failure and can be used to evaluate the effects of the treatment. This study aims to assess the short-term effects of Dapagliflozin on spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), cardiac biomarkers, and BIVA.

Methods

Stable HF patients (EF <40%, NYHA class II or III) eligible for SGLT2-I therapy according to guidelines underwent standard spirometry, DLCO, BIVA and venous blood sampling at baseline (V0) and after 2-4 weeks of therapy (V1).

Results

Patients characteristics (N=32) at baseline are shown in Table 1. None of the patients interrupted the treatment and/or experienced adverse events. After 26±6 days, we observed worsening of renal function (eGFR from 73.1±28.5 mL/min/1.73m2 to 67.4±27.0 mL/min/1.73m2, p<0.001) and potassium levels (4.36±0.36 mEq/l vs 4.58±0.57 mEq/l, p= 0.017). There were no significant changes in NT-proBNP levels (1378 [615-2542] ng/l vs 1034 [554-2552] ng/l, p= 0.538). HI, total body water, DLCO and spirometry values did not change. On the contrary, a mild reduction in hsTnI was observed (13.88 [9.24-26.8] ng/l vs 11.58 [7.7-24.2] ng/l).

Conclusions

Our study did not detect short-term effects of Dapagliflozin on spirometry values, DLCO, fluid retention and NT-proBNP. As revealed in DAPA-HF trial, a mild worsening of potassium and serum creatinine levels was observed. Taken together, these results suggest that the favourable effects of Dapagliflozin could unfold over a longer period of time. A more extended follow-up and a larger population are needed to confirm these preliminary data.
695 PRESCRIBING A COMPREHENSIVE THERAPY WITH THE FOUR FOUNDATIONAL TREATMENTS OF HEART FAILURE WITH REDUCED EJECTION FRACTION AMONG IN-PATIENTS AT DISCHARGE
Authors: Rodolico Daniele , Delvinioti Agni , Iacomini Chiara , Masciocchi Carlotta , Restivo Attilio , Lenkowicz Jacopo , Patarnello Stefano , Crea Filippo , D´amario Domenico
Published: December 2022

Background

Current guidelines recommend that patients with heart failure and a reduced ejection fraction (HFrEF) should receive four foundational treatments, i.e. renin-angiotensin system inhibitor (RASi) or angiotensin-receptor neprilysin inhibitor (ARNi), β-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter 2 inhibitor (SGLT2i). There is emerging consensus that simultaneous initiation or rapid sequencing provide greater benefit, enhancing tolerability of these therapies and improving outcomes. However, implementation of a comprehensive approach is limited by common underuse and underdosing, and paucity of data exists on initiating the four pharmacological pillars of HFrEF during hospitalization or at discharge.

Aim

To investigate the feasibility of a comprehensive pharmacological approach in patients with HFrEF at discharge after an episode of heart failure (HF) hospitalization in a tertiary referral center.

Methods

In-patients with HFrEF and a first HF hospitalization (2019-2021) were categorized according to the number/type of treatments prescribed at discharge. Prevalence of contraindications and cautions for HFrEF treatments – as defined by current European Society of Cardiology (ESC) guidelines on HF – was as assessed. Logistic regression models were fitted to assess predictors of number of treatments prescribed and risk of re-hospitalization.

Results

Among 305 patients with HFrEF, 49.2% received at least two current recommended drugs. A β-blocker was prescribed in 93.4% of patients, and a RASi/ARNi in 68.2%. Based on current recommendations, 46.2% of patients could receive four foundational drugs. An MRA was prescribed in 32.5% of patients and 100% of patients did not show contraindications to MRA use. Renal dysfunction was present in 13.1% of patients, while hypotension in 11.8%. Bradycardia and renal dysfunction were associated with lower number of drugs prescribed [adjusted OR (95% CI) 0.18 (0.06-0.50), and 0.50 (0.39-0.64), respectively]. A higher number of drugs used was associated with no rehospitalization during the 30 days after discharge [OR (95% CI) 0.22 (0.10-0.49) per number of pillars increase].

Conclusions

Based on the presence/absence of contraindications, a quadruple therapy could be implementable in a contemporary cohort of HFrEF in-patients at discharge. Renal dysfunction and bradycardia were the main prevalent conditions limiting the achievement of a more comprehensive therapeutic approach. Use of a higher number of drugs was associated with lower risk of re-hospitalization within 30 days after discharge.
348 PROGNOSTIC EVALUATION OF HEART FAILURE IN WOMEN: INSIGHT FROM THE MECKI SCORE DATABASE
Authors: Salvioni Elisabetta , Moscucci Federica , Bonomi Alice , Mapelli Massimo , Paolillo Stefania , Corrà Ugo , Vignati Carlo , Magrì Damiano , Sciomer Susanna , Agostoni Piergiuseppe
Published: December 2022

Background

Heart failure (HF) in women often assumes extremely peculiar characteristics. The risk stratification and prognostic evaluation of HF in women is a challenge for clinicians. The actual prognostic scores are, in fact, lacking a specific sex-oriented assessment. In HF women show better survival despite a comparatively low peak oxygen consumption (VO2) at cardiopulmonary exercise testing: this raises doubt about the accuracy of risk assessment in women. Previous studies on MECKI score database have demonstrated that female prognostic advantage is lost when sex-specific differences are correctly considered. The present analysis has the aim to identify parameters which could be differently associated to prognosis in men and women and to re-calibrate the MECKI score according to these differences.

Methods

The new weights of the MECKI score variables according to gender, were calculated using the means of the 200 repetitions obtained to cross-validation procedure. The primary outcome of the study was the composite of all-cause mortality, urgent heart transplant and LVAD implant. The difference in predictive ability between the native and gender re-calibrated MECKI was calculated with the ROC curve at 2 years follow-up and calibration plot.

Results

We retrospectively analyzed 7900 HF patients with reduced ejection fraction included in the MECKI score registry (61±13 years, 6456 M/ 1444 F, LVEF 33±10%, VO2 /kg 14.9±4.9 mL/min Kg). Patients follow up was: 4.05 years [1.72-7.47]. Table 1 presents the weights of the individual MECKI variables for males and females. The main differences have been detected for the intercept value, hemoglobin and Na+. We used these variables to recalibrate the algorithm of MECKI score. We obtained higher AUC for MECKI re-calibrated by gender than for Native MECKI (0.7893 vs. 0.7799, p=0.0194, Fig. 1 left panel). Moreover, the gender MECKI was better calibrated (Fig. 1, right panels).

Conclusions

The calibration of MECKI Score according to gender specific differences improves the prognostic power and accuracy of mortality prediction at two years follow up.
135 ASSOCIATION OF TRICUSPID REGURGITATION WITH OUTCOME IN ACUTE HEART FAILURE
Authors: Cocianni Daniele , Stolfo Davide , Perotto Maria , Contessi Stefano , Barbisan Davide , Savonitto Giulio , Rizzi Jacopo Giulio , Barbati Giulia , Merlo Marco , Altinier Alessandro , Sinagra Gianfranco
Published: December 2022

Background

Tricuspid regurgitation (TR) is common in chronic heart failure (HF) and is associated with negative prognosis. However, evidence on prognostic implications of TR in acute HF (AHF) is lacking.

Objectives

We sought to investigate the association between TR and mortality and the interaction with pulmonary hypertension (PH) in patients admitted for AHF.

Methods

We enrolled 1176 consecutive patients with a primary diagnosis of AHF and with available non-invasive estimation of TR and pulmonary arterial systolic pressure (PASP).

Results

Moderate-severe TR was present in 352 patients (29.9%) and was associated with older age and more comorbidities. The prevalence of PH (i.e., PASP>40mmHg), right ventricular dysfunction (RVD) and mitral regurgitation (MR) was higher in moderate-severe TR. At 1 year, 184 (15.6%) patients died. Moderate-severe TR was associated with higher 1-year mortality risk after adjustment for other echocardiographic parameters (PASP, left ventricle ejection fraction – LVEF, RVD and MR; HR=1.623, p=0.004) and the association with outcome was maintained when clinical variables were added to the multivariable model (HR=1.515, p=0.035). The association between moderate-severe TR and outcome was consistent in patients with vs without PH, with vs without RVD, and with vs without LVEF<50%. Patients with coexistent moderate-severe TR and PH had 3-fold higher 1-year mortality risk compared to patients with no TR or PH (HR=2.920, p<0.001).

Conclusions

In patients hospitalized for AHF, the severity of TR is associated with 1-year survival, regardless of the presence of PH. However, the combination of moderate-severe TR and PH conferred a further incremental mortality risk.
589 THE EFFECT OF DAPAGLIFLOZIN ON SYMPTOMS, QUALITY OF LIFE AND ECHOCARDIOGRAPHIC PARAMETERS IN A REAL-WORLD POPULATION OF HFREF PATIENTS
Authors: Visco Valeria , Rispoli Antonella , Di Fonzo Rosanna , Di Pietro Paola , Izzo Carmine , Melfi Americo , Carrizzo Albino , Galasso Gennaro , Vecchione Carmine , Ciccarelli Michele
Published: December 2022

Background

Large cardiovascular (CV) trials enrolling patients with type 2 diabetes showed that sodium glucose co-transporter-2 inhibitors (SGLT2i) significantly decreased heart failure (HF) hospitalization, both in patients with or without a history of HF.

Accordingly, DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure)

demonstrated the efficacy of dapagliflozin, for the reduction of CV death/HF hospitalization in patients with HF with reduced ejection fraction (HFrEF) regardless of type 2 diabetes status. However, there are still few real-word data and it is still not well known how early the clinical benefits are after the introduction of the drug into therapy; consequently, we aimed to evaluate the effect of dapagliflozin three months after its introduction in therapy in our real-world population.

Methods

From February 2022 to September 2022 we introduced Dapagliflozin in 23 HFrEF patients’ therapy and we collected data of 11 patients (66.78±3.96 years; 89% men) at 3-months-FU. Specifically, on the first visit we collected the clinical, laboratory and echocardiographic parameters and dapagliflozin was added to optimal medical therapy of patients; then, the patients were evaluated after 3 months (follow-up).

Results

At follow-up, all patients were free from side effects and we did not record statistically significant differences in laboratory parameters and/or blood pressure values.

As regards the echocardiographic parameters, there was an improvement in FE (28.11±2.95 vs 37.00±5.71%, p0.17), PAPS (46.89±3.94 vs 37.63±5.27mmHg, p0.17), and LVEDVind (75.34±10.58 vs 57.20±13.55 ml/m2, p0.30), although not statistically significant. Moreover, we observed a statistically significant reduction in the diameter of the inferior vena cava (18.89±1.78 vs 11.5±1.15 mm, p<0.01), in NYHA class (2.78±0.15 vs 2±0, p<0.001), in basal SO2 (95.67±0.78 vs 97.67±0.47%, p0.04) and an improvement of quality of life (EQ5Dtot 73.33±4.71 vs 86.67±4.41, p0.05; pain/discomfort 3.67±0.29 vs 4.78±0.22, p<0.01; anxiety/depression 3.67±0.29 vs 4.67±0.24, p0.0163). Finally, we recorded a not statistically significant reduction in the amount of mineralocorticoid receptor antagonists (MRAs) at follow-up (62.5±12.5 vs 37.5±5.59 mg of eplerenone, p0.09).

Conclusions

Dapagliflozin improved symptoms, and quality of life in patients with HFrEF of our real world population already after 12 weeks, accordingly with previous data of DEFINE-HF trial. Moreover, already after 3 months was possible to record improvements in the echocardiographic parameters, even if they are not statistically significant. Certainly, it will be necessary to continue with the study to evaluate these results on a larger sample.
681 RIGHT ARM PAIN WITH RIGHT BUNDLE BRANCH BLOCK: SHOULD WE PERFORM TROPONIN ASSAY?
Authors: Acone Lorenzo , Foti Marco , Tarantini Roberto , Sorropago Antonio , Toscano Evelina , Mortara Andrea
Published: December 2022

We present the case report of a 67 year old man with no previous cardiovascular history, who was admitted to our emergency department (ED) for two days onset of right arm pain which was not responsive to painkillers. On admission, he was asymptomatic for typical angina. His BP was 190/100 mmHg, HR 80 bpm, SpO2 99% and apyretic. The clinical examination was unremarkable. The ECG showed sinus rhythm, complete right-bundle-branch-block (RBBB) and left-axis deviation, negative T-waves in V1-V2 and positive T-waves in V3 > V6 (figure 1A) (no previous ECGs were available). The blood samples showed normal renal function and blood count. Surprisingly, there was a progressive rise in troponin I levels 0.023 > 0.061 > 0.38 ng/ml (ULN 0.010 ng/ml). Echocardiography revealed preserved LVEF without major regional wall motion abnormalities (RWMA), nor any valvulopathy.

Despite the atypical presentation and ECG, the troponin rise was strongly suggestive for an acute coronary syndrome (ACS), so the patient was sent to the Cath lab to undergo coronary angiography (CAG). At the time of the CAG he was asymptomatic. The exam revealed thrombotic occlusion of mid-segment left anterior descending artery (LAD). Primary PCI with DES implantation was performed obtaining TIMI 3 flow (figure2). The remaining hospital stay was uneventful, the patient was discharged asymptomatic after 4 days. Pre-discharge echocardiography reported normal LVEF with no RWMA. Discharge ECG showed persistency of the RBBB with negative T-waves from V1 to V4 (figure 1B). On 3 months follow up visit the patient is asymptomatic with preserved LVEF. On ECG there is persistency of RBBB and normalization of the T-waves in the precordial leads (figure 1C).

Discussion

This case report is an atypical presentation of acute thrombotic occlusion of an epicardial coronary artery, without the typical ST segment elevation (STEMI equivalent) and without the typical angina. RBBB may represent an uncommon ECG presentation of acute myocardial ischemia, with an incidence from 2 to 6% overall, with TIMI 0 flow in the infarct-related artery only in half of the cases. RBBB (especially new or presumably new onset RBBB) is also associated with increased mortality and morbidity, possibly due to delay in diagnosis and primary reperfusion strategies. Troponin dosage was fundamental to understand that we were facing an acute coronary syndrome, however we were not expecting complete occlusion of the LAD.

In conclusion, the presence of RBBB on admission may delay primary reperfusion strategies, especially when symptoms are atypical. However, in case of unresponsive pain and presumably new-onset conduction disturbances on ECG it is mandatory to perform troponin assay and therefore drive the correct timing of coronary revascularization.
219 ISOLATED CORONARY OSTIAL STENOSIS DUE TO RECURRENT AORTIC WALL THROMBOSIS
Authors: De Gaspari Monica , Rizzo Stefania , Cassaro Mauro , Facchin Michela , Verlato Roberto , Basso Cristina , Buja Paolo
Published: December 2022

Background

Coronary ostial lesions are a rare entity and isolated coronary ostial stenosis is even less frequent. Diffuse coronary artery atherosclerosis is the main cause for the non-isolated stenosis, based on old post-mortem series and histological analysis of tissue removed during atherectomies.

Case presentation

A 49-year-old woman suffering from mild non-familial hypercholesterolemia reported to her family physician repeated episodes of chest pain related to exercise. During a cardiological outpatient evaluation, 12 lead electrocardiogram (ECG) and echocardiography turned out normal. During a stress test she had recurrent chest pain coupled with ECG ischemic changes (diffuse ST segment elevation). She was immediately referred to the emergency department where the ECG was back to normal and the troponin dosage within normal range. Coronary angiography was performed: non-selective cannulation revealed some irregularities of the aortic wall profile at the level of the right coronary ostium, with inability to visualize the right coronary artery. The selective cannulation of the left main coronary artery (LMCA), left anterior descending (LAD) and left circumflex branches showed a critical ostial stenosis at the origin of the LMCA without any other relevant lumen restriction, in a left-dominant pattern of coronary circulation. A suspicion of LAD dissection was raised when a laminar flux was observed at its origin. At the end of the procedure, the patient suddenly collapsed. The recorded rhythm was initially bradycardia, evolving to episodes of ventricular tachycardia for which multiple shocks were applied. Despite the resuscitation efforts, the patient never recovered. Autopsy was performed at the local hospital. At gross analysis, a non-uniform pale-tan thickening at the level of the sino-tubular junction was evident with involvement of both the right and left coronary ostia. Histological examination allowed to ascribe the thickening to recurrent thrombosis, without any underlying inflammatory process at the level of the aortic wall and with only minimal atherosclerotic plaques. No coronary artery dissection nor significant stenosis was present in all the coronary tree. Regarding the ventricular myocardium, one focus of replacement-type fibrosis was identified at subendocardial level in the infero-septal wall coupled with a small spot of loose connective tissue rich in hemosiderin-laden macrophages in the same region, consistent with an area of subacute ischemic damage.

Conclusion

Several series reported a higher frequency of isolated coronary ostial stenosis in women versus men. In fact, female sex along with hypertriglyceridemia have been recognized as independent risk factors for ostial lesions. The case herein reported highlights the diagnostic relevance of the autopsy investigation together with clinicopathological correlation, particularly in cases where the definite diagnosis can't be achieved in vivo.