bluuebunny/crossref_metadata_2025 huggingface dataset:
Increased risk of heart failure is associated with chronic habitual hypohydration that elevates serum sodium above 142 mmol/l suggesting lifelong optimal hydration as preventive measure
Authors: Dmitrieva N.I , Liu D , Boehm M
Published: October 2021

Background

With increasing prevalence of heart failure (HF) owing to the aging population, identification of preventive measures that delay onset of the disease and their implementation become increasingly important. Recent studies demonstrated that chronic subclinical hypohydration accelerates degenerative changes and increases prevalence of many age-dependent degenerative diseases including heart failure (1). Worldwide surveys find wide differences in habitual water intake between and within countries and substantial prevalence of hypohydration in general population (2). Hypohydration elevates extracellular sodium triggering activation of water conservation mechanisms when serum sodium exceeds a threshold around 142 mmol/l. These adaptive responses include secretion of antidiuretic hormone and activation of the renin angiotensin aldosterone system (3), important contributors to pathogenesis of HF.

Purpose

The purpose of this study was to evaluate whether serum sodium concentration at middle age of 44–66 years as a measure of hydration habits is a significant predictor for left ventricular hypertrophy (LVH) and HF events 25 years later at age of 70–90 years.

Methods

Data from Atherosclerosis Risk in Communities (ARIC) study were obtained from the BioLINCC data repository. In ARIC study, 15,792 44–66 year-old participants were evaluated over 5 visits spanning 25 years (Figure 1A). Two separate logistic regression models were used in the study, where the dependent variable is diagnosis of LVH and HF at visit 5 (age:70–90 years), and the predictors are serum sodium concentration measured at visits 1 and 2 (age: 44–66 years), age, gender, total cholesterol, glucose, eGFR, BMI, smoking and hypertension statuses.

Results

Midlife serum sodium is associated with LVH and HF diagnosis 25 years later at visit 5 both with adjustment for age only (LVH: OR=1.24, 95% CI 1.15–1.34, P<0.001; HF: OR=1.06, 95% CI 1.02–1.10, P=0.006) and in fully adjusted model (LVH: OR=1.20, 95% CI 1.11–1.30, P<0.001; HF: OR=1.11, 95% CI 1.01–1.22, P=0.031) (Figure 1B). Cornell voltage criteria used for LVH diagnosis is elevated in participants with higher serum sodium and demonstrates sharper increase with age indicating accelerated hypertrophic LV remodeling (Figure 1C). These associations are reflected in increased prevalence of HF and LVH in 70–90 year-old participants whose middle age serum sodium exceeded 142 mmol/l (Figure 1D).

Conclusions

Habitual life-long hypohydration increases risk to develop LVH and HF. Keeping serum sodium below 142 mmol/l by drinking appropriate amount of liquids may slow down decline in cardiac function and decrease prevalence of HF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): NHLBI Intramural program
Starting Neurohormonal Antagonists in Patients with Acute Heart Failure with Mid-Range and Preserved Ejection Fraction
Authors: Seko Y , Kato T , Morimoto T , Yaku H , Inuzuka Y , Tamaki Y , Ozasa N , Shiba M , Yamamoto E , Yoshikawa Y , Yamashita Y , Kitai T , Kuwahara K , Kimura T
Published: October 2021

Background

The clinical benefits of neurohormonal antagonist in patients with heart failure (HF) with mid-range and preserved ejection fraction (HFmrEF and HFpEF) were uncertain. This study aimed to evaluate the prognostic effect of starting angiotensin-converting enzyme inhibitors (ACE-I) / angiotensin II receptor blockers (ARB) and β-blocker during HF hospitalization in these patients.

Methods

We analyzed 858 consecutive patients with HFmrEF (EF:40–49%) or HFpEF (EF≥50%), who were hospitalized for acute decompensated HF, were discharged alive, and were not taking ACE-I/ARB or β-blockers at admission. The study population was classified into four groups according to the status of prescription of ACE-I/ARB and β-blocker at discharge: no neurohormonal antagonist (N=342, 39.9%), ACE-I/ARB only (N=128, 14.9%), β-blocker only (N=189, 22.0%), and both ACE-I/ARB and β-blocker (N=199, 23.2%) groups. The primary outcome measure was a composite of all-cause death or HF hospitalization.

Results

The cumulative 1-year incidence of the primary outcome measure was 41.2% in the no neurohormonal antagonist group, 34.0% in the ACE-I/ARB only group, 28.6% in the β-blocker only group, and 16.4% in the both ACE-I/ARB and β-blocker group (P<0.001). Compared with the no neurohormonal antagonist group, the both ACE-I/ARB and β-blocker group were associated with a significantly lower risk for a composite of all-cause death or HF hospitalization (HR: 0.59, 95% CI: 0.38–0.91, P=0.02).

Conclusions

In hospitalized patients with HFmrEF and HFpEF, starting both ACE-I/ARB and β-blocker was associated with a reduced risk of a composite of all-cause death or HF hospitalization compared with not starting ACE-I/ARB or β-blocker.

Funding Acknowledgement

Type of funding sources: None.
Assessment of the visceral adipose tissue by magnetic resonance imaging in patients with coronary artery disease: link to metabolism disorders and condition of the abdominal aorta
Authors: Ryumshina N , Koshelskaya O A , Kologrivova I V , Kharitonova O A , Ussov W Y U
Published: October 2021

Aim

MRI-quantification of the visceral and subcutaneous adipose tissue (AT) and investigation of its interconnections with anthropometric parameters of obesity, carbohydrate metabolism and condition of abdominal aorta in patients with chronic coronary artery disease (CAD).

Methods

The study included 55 patients (mean age 61.2±7.2 y.o.) with chronic CAD. All patients underwent MRI of the abdominal AT and abdominal aorta segment on a 1.5 T MRI in standard modes. Calculation of the area and volume of abdominal subcutaneous (SAT) and visceral adipose tissue (VAT) was conducted at L4-L5 level; the total volumes of abdominal SAT and VAT were calculated. Parameters of lipid and carbohydrate metabolism as well adipokines' profile were measured in blood serum.

Results

To eliminate gender bias the data in the total group was corrected for the sex, height and body weight. In the course of the multiple linear regression analysis, we detected the independent determinants, which described 95% of the total VAT volume variability and were represented by waist circumference and serum levels of HDL cholesterol and adiponectin. The model was characterized by the significance level p<0,ehab724.116501, the residues of the model were normal. The evaluation of the coefficients in the model was as following: 1,39 for waist circumference, −0.26 for HDL cholesterol and −0,19 for adiponectin. We detected direct correlation between the aorta diameter and total SAT volume (rs=0.30), which was independent from sex; and reverse correlations between the aorta diameter and HbA1c level (rs=−0.40) and postprandial glycemia (rs=−0.40). Patients with dilated aorta when compared to the patients with normal aorta diameter did not differ in the AT accumulation, but demonstrated decreased levels of HbA1c and postprandial glycaemia, which was dependent upon the lower numbers of patients with diabetes mellitus type 2.

Conclusion

We have identified the independent determinants of the total volume of the abdominal visceral AT increase, which appeared to be increment of the waist circumference and decrease of the serum adiponectin and HDL cholesterol. Results of the study indicate the presence of the interconnection between the processes of the abdominal aorta remodeling, accumulation of subcutaneous adipose tissue and carbohydrate metabolism impairments.

Funding Acknowledgement

Type of funding sources: None. MRI of the abdominal tissueMRI of the abdominal aorta
Can we simplify or improve long-term risk stratification for patients with ST-segment elevation myocardial infarction undergoing primary intervention?
Authors: Dias Ferreira Reis J P , Rio P , Timoteo A , Ramos R , Ferreira M L , Cruz Ferreira R
Published: October 2021

Background

Various scores have been developed to predict early to mid-term prognosis after ST-elevation myocardial infarction (STEMI). The aim of this study was to compare the predictive value of 7 popular risks scores for the long-term outcome of STEMI patients undergoing primary intervention, and to find an easy model with similar or superior predictive and discriminative ability.

Methods

Patients who underwent primary PCI from January 2003 through August 2007 in a single tertiary-center were analysed (n=665) using a dedicated prospective registry. Global Registry for Acute Coronary Events (GRACE), GRACE 6 months, Thrombolysis In Myocardial Infarction (TIMI) STEMI, dynamic TIMI, TIMI risk index, Primary Angioplasty in Myocardial Infarction (PAMI) and Zwolle primary percutaneous coronary intervention (PCI) index were calculated for each patient. We assessed, through the C statistic in receiver-operating characteristic analysis, the predictive accuracy of these scores using all-cause mortality at 5 year as an endpoint. With multivariate regression analysis the variables with highest predictive ability were applied to build a model.

Results

All-cause mortality at 5 years after primary PCI was 22.1%. The risk scores showed moderate predictive ability, GRACE (0.759, 95% confidence interval (CI) 0.712–0.805), GRACE 6 months (0.802, 95% CI 0.759–0.845), TIMI STEMI (0.744, 95% CI 0.696–0.791), dynamic TIMI (0.774, 95% CI 0.727–0.820), TIMI risk index (0.757, 95% CI 0.710–0.803), PAMI (0.753, 95% CI 0.707–0.800) and Zwolle index (0.749, 95% CI 0.703–0.795). Six independent predictors of 5-year mortality were identified (age >70 years, history of MI, history of stroke, heart tare above 85 beats per min, 3-vessel disease and in-hospital adverse events) and the model built had similar discriminative performance in estimation of probabilities of death (0.804, 95% CI 0.762–0.846, p=0.953 for difference with GRACE score).

Conclusions

The prediction values of currently recommended risk scores are moderate for long-term perspective (5-year). The simplified risk stratification score for STEMI and primary angioplasty using only six variables demonstrates accuracy similar to the more advanced risk scores.

Funding Acknowledgement

Type of funding sources: None.
Incidence and course of acute coronary syndromes cases following first wave of COVID-19 pandemy
Authors: Jankowska - Sanetra J , Sanetra K , Konopko M , Kutowicz M , Synak M , Kachel M , Kazmierczak P E , Milewski K , Buszman P P
Published: October 2021

Background

SARS-COV-2 virus pandemic is a challenge for healthcare across the globe. Although COVID-19 is a significant cause of mortality and morbidity, the collateral damage caused by this disease might influence patients with cardiovascular disease, especially acute coronary syndromes (ACS) very prone to treatment delay and lack of infrastructure and staff availability. Additionally lock-down causes patients concern and reluctance which further delays the invasive. treatment.

Purpose

In our report we sought to analyse the incidence and course of ACS patients following the first wave of COVID-19 pandemy in Poland.

Methods

The report represents multiinstitutional registry, with 10 interventional cardiology departments included. The data was gathered from a timeframe separating two waves of the pandemy (June-October), which reflects the situation directly following the first lockdown in Poland (30 March- 31 May 2020) and limitations in planned medical care. The data was compared to same timeframe in year 2019. Patients who were admitted with ACS were included. In hospital outcome was analyzed.

Results

There were 2801 patients hospitalized for acute coronary syndrome in 2019 (Jun-Oct) and 2620 in 2020 (Jun-Oct), which is respectively 52.8% and 57.9% of coronary artery disease admissions (p<0.0001). Patient baseline characteristics and in hospital outcomes are presented in table 1. In 2020 patient presented more often with diabetes, hyperlipidaemia and smoking history when compared to 2019. However, myocardial infarction was more frequent in 2019. There was a visible trend for higher mortality in 2020. More patient were admitted with acute heart failure in 2020.

Conclusions

The COVID-19 pandemic affects both ACS patient profile and course of treatment, which became apparent already after first wave of pandemic. Patient admitted after lockdown has more risk factors, there was a trend toward higher mortality and patient presented more often with acute heart failure, more likely due to delay in treatment or no invasive treatment for MI.

Funding Acknowledgement

Type of funding sources: None. Patients baseline characteristicsHospitalization outcomes
Derivation and validation of a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm
Authors: Lopez Ayala P , Nestelberger T , Boeddinghaus J , Koechlin L , Strebel I , Walter J , Rubini Gimenez M , Miro O , Martin-Sanchez F J , Keller D , Twerenbold R , Giannitsis E , Lindahl B , Mueller C
Published: October 2021

Background

The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed.

Purpose

To derive and internally, as well as externally, validate a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm.

Methods

In an ongoing multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of myocardial infarction (MI). Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial high sensitivity cardiac troponin T (hs-cTnT) sampling and 90-day follow-up information. High sensitivity-cTnT concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. External validation was performed in an independent multicentre international study.

Results

Among 2076 eligible patients, application of the ESC 0/1h-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95% CI 96.0–99.9) and a NPV of 99.3% (95% CI 95.4–99.9). A 0/3h-hs-cTnT absolute change ≥6 ng/L ruled-in 63 patients (11.2%), resulting in a specificity of 98% (95% CI 96.2–98.9) and a PPV of 85.7% (95% CI75.0–92.3). The novel 3h-pathway reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50% (Figure 1). Findings were confirmed in both internal and external validation.

Conclusions

A novel derived pathway combining a 3h hs-cTnT concentration <15 ng/L and a 0/3h absolute change <4 ng/L allowed to very safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-algorithm.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swiss Heart FoundationThe Swiss National Science Foundation Figure 1
Takotsubo syndrome: a way to reach a straightforward diagnosis
Authors: Bonanni A , Pedicino D , Vinci R , D'Aiello A , Ponzo M , Ciampi P , Pisano E , Canonico F , Di Sario M , Conte C , Cribari F , Grimaldi M C , Severino A , Crea F , Liuzzo G
Published: October 2021

Background/Introduction

Acute stress-induced cardiomyopathy, also known as Takotsubo Syndrome (TTS), was originally classified as a benign disease. Nowadays, this assumption has changed, especially in its long-term outcome, due to TTS clinical presentation, that often mirrors the acute myocardial infarction (MI) phenotype. Current knowledge already delineate clinical features distinctive of TTS and MI patients, however, diagnosis requires multiple, expansive, and invasive medical examinations. Moreover, concerning the biological panorama, very slight is known and the lack of a tailored therapy is resented. Therefore, a biological profile for this clinical category could provide easier and less invasive diagnostic tools, leading edge towards novel therapeutic pathways.

Purpose

The aim of the study is to perform a biological profile of the TTS group compared to the ST Segment Elevation Myocardial Infarction (STEMI) in order to explore the molecular peculiarities attendant the pathophysiologic mechanisms.

Methods

We performed a gene expression array on two groups of pooled cDNA from peripheral blood mononuclear cells, from TTS (n=11) and STEMI (n=19) patients. We conducted gene expression validations for each enrolled patient through qPCR.

Results

Our preliminary data displayed several differences in gene expression levels of a grand number of cell adhesion signaling molecule between the two groups. As shown in figure 1, three gene were more expressed in TTS group: Nitric Oxide Synthase 3, also known as endothelial NOS (NOS3; p=0.002), Superoxide dismutase 1 (SOD1; p=0.03) and transferrin receptor (TFRC; p=0.005). Meanwhile, five gene displayed a higher expression in STEMI patients compared to TTS: phospholipase A2 Group 7 (PLA2G7; p=0.04), Galectin 8 (LGALS8; p=0.02), Intercellular Adhesion Molecule 1 (ICAM1; p=0.002), Hyaluronidase 2 (HYAL2; p=0.01) and Hyaluronan Receptor (CD44; p=0.0002).

Conclusions

The earliest results of this study led us to focus on fewer genes related to endothelial and oxidative stress pathways. TTS is habitually triggered by intense emotional or physical stress. Indeed, our results showed how TTS patients present higher expression of NOS3, SOD1 and TFRC, all components involved in the oxidative stress pathways. In STEMI patients, top expressed genes, such as HYAL2, CD44 and ICAM1, are all associated with extracellular matrix turnover, likely due to the presence of a stenotic plaque and the consequent endothelial derangement. The uncovering of diagnostic biomarkers in TTS might improve the early, non-invasive, stratification of this group of patients, thus facilitating novel and personalized therapeutics design.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The present study was supported by the Italian National Project Grant PRIN 2017.
Long-term mortality in patients with myocardial injury after non-cardiac surgery
Authors: Gomes B F O , Silva T M B , Dutra G P , Azevedo A S , Peres L S , Pereira D F P , Nascimento J H P , Homena Junior W S , Petriz J L F , Carmo Junior P R , Pereira B B , Oliveira G M M
Published: October 2021

Background

Myocardial injury that occurs after non-cardiac surgery (MINS) increases mortality in 30 days. However, few studies have assessed the impact of MINS occurrence on long-term mortality.

Methods

Retrospective study including all non-cardiac surgery patients admitted to an postoperative care unit who stayed at least one night in this unit, and had at least one measurement of high-sensitive cardiac troponin. Patients undergoing coronary angiography and patients with an underlying disease with a poor prognosis were excluded. The study period was from January/2011 to December/2019, ensuring a minimum follow-up of 2 years. Clinical characteristics and the occurrence of MINS were assessed between deaths and survivors using the chi-square test and Student's t-test. Variables with p<0.01 in the univariate model were included in the Cox regression model to identify predictor variables.

Results

2532 patients were included, with a mean follow-up of 8.62±2.72 years, mean age = 63.23±16.5 years and 53.6% women. The prevalence of MINS was 12.5% (317 patients). There were 620 deaths (24.5%). In the univariate analysis, the following variables were associated with death: MINS (OR 2.65; p<0.001); previous heart failure (OR 3.87; p<0.001); chronic renal failure (OR 5.0; p<0.001), arterial hypertension (OR 1.83; p<0.001), previous myocardial infarction (OR 2.57; p<0.001), atrial fibrillation (OR 2.59; p<0.001), dementia (OR 8.15; p<0.001) and age (60±16 x 73±13, p<0.001). These variables were included in Cox's regression model and the predictive variables of all-cause death were: MINS (HR 1.76; CI95% 1.44–2.15), previous heart failure (HR 1.85; CI95% 1.18–2.90), previous myocardial infarction (HR 1.46; CI95% 1.17–1.83); dementia (HR 2.85; CI95% 2.18–3.75) and age (HR 1.05; CI95% 1.04–1.06).

Conclusion

In patients undergoing non-cardiac surgery, the increase in high-sensitive troponin increased the risk of death from all causes in the long term.

Funding Acknowledgement

Type of funding sources: None. Survival curve
Comparing outcomes of transcatheter versus surgical aortic valve replacement in patients with atrial arrythmias
Authors: Gill J
Published: October 2021

Introduction

In patients with severe aortic valve stenosis, clinical trials have demonstrated a similar mortality risk with transcatheter aortic valve replacement (TAVR) compared to surgical aortic valve replacement (SAVR) in low to intermediate-risk patients. However, data comparing these procedures in patients with atrial arrhythmias is lacking.

Purpose

This study aimed to evaluate and compare the in-hospital mortality and outcomes of TAVR and SAVR for severe aortic stenosis in patients with atrial fibrillation or atrial flutter.

Methods

We performed a retrospective cross-sectional analysis using the 2018 National Inpatient Sample. Patients aged 50 years and older with TAVR or SAVR related hospitalizations were identified. Patients with endocarditis and those undergoing coronary artery bypass grafting or other valvular procedures were excluded. Propensity score matching was utilized to mitigate selection bias. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, hospital region, hospital teaching status, median household income, and medical comorbidities. Using 8-to-1-digit match, we paired each admission in TAVR group with one admission in SAVR group.

Results

In 2018, a total of 3487 TAVRs and 1466 SAVRs were performed in patients who had atrial fibrillation or atrial flutter. TAVR and SAVR had no statistically significant difference in inpatient mortality (0.9% vs 0.8%, p=0.79). However, SAVR was associated with higher odds of cardiogenic shock (OR 1.82; 95% CI 1.41–2.35, p<0.0001), acute kidney injury (OR 2.29; 95% CI 1.77–2.97, p<0.0001), mechanical ventilation (OR 2.06; 95% CI 1.75–2.43, p<0.0001), pneumonia (OR 1.76; 95% CI 1.37–2.28, p<0.0001), pneumothorax (OR 6.38; 95% CI 4.17–9.76, p<0.0001) and postoperative hemorrhage (OR 3.21; 95% CI 2.13–4.85, p<0.0001). On the contrary, SAVR was associated with decreased likelihood of subsequent cardiac conduction disorders (OR 0.63; 95% CI 0.51–0.79, p<0.0001) and pacemaker implantation (OR 0.69; 95% CI 0.49–0.98, p=0.037). SAVR was associated with an increased length of hospitalization (3.9 vs. 8.4 days, p<0.0001), with no difference in medical costs.

Conclusion

Inpatient mortality for TAVR and SAVR was similar in patients with atrial fibrillation and atrial flutter. TAVR was associated with a lower risk of inpatient complications, indicating greater suitability for high-risk patients. However, clinicians should be cognizant of the increased risk for cardiac conduction disorders after TAVR, necessitating pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None. Characteristics of the matched cohortForest plot comparing outcomes
Double-valve infective endocarditis: clinical features and prognostic impact; a retrospective study in a surgical centre
Authors: Scheggi V , Vanni F , Ceschia N , Merilli I , Sottili E , Alterini B , Stefano P L , Marchionni N
Published: October 2021

Introduction

Most cases of infective endocarditis (IE) involve a single valve, and little is known concerning IE that simultaneously affects two valves. The involvement of more than one valve may imply more severe and extensive cardiac lesions. In these patients, surgery may be challenging.

Purpose

We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of double-valve IE (DVIE).

Method

We retrospectively included in the analysis 380 consecutive patients with definite active IE in a single surgical centre. The univariate and multivariate long-term survival was analysed by the Kaplan-Meier method and by stepwise Cox proportional hazards models, respectively. We repeated the mortality analysis using the propensity score matching technique, to adjust for baseline differences between SVIE and DVIE groups.

Results

DVIE occurred in 60 of the total enrolled 380 patients (15.8%) and involved mostly the combination of mitral and aortic valves (N=52, 87%). Most patients had double-native IE (N=38, 63%). Staphylococci were significantly less frequent in patients with double-valve than single-valve IE (SVIE). The proportion of patients undergoing valve repair among those treated surgically was higher for patients with DVIE than for SVIE (p<0.001). Valve repair of at least one valve was associated with non-significant better survival than double replacement. DVIE was associated with higher all-cause mortality than SVIE (p<0.001). DVIE was not associated with a higher risk of relapse or non-fatal adverse events.

Conclusions

DVIE represents a considerable proportion of overall cases of IE, mainly involving aortic and mitral valves, with a jet lesion on the mitral valve; Staphylococcus is significantly less frequent than in SVIE; DVIE is independently associated with higher mortality; finally, mitral valve repair is feasible in a considerable proportion of surgical cases.

Funding Acknowledgement

Type of funding sources: None. Propensity score matchingKaplan-Meier analysis: survival of DVIE
Left ventricular noncompaction: the importance of identifying high-risk patients within the scope of left ventricular hypertrabeculation
Authors: Viegas J M , Rosa S A , Bras P , Castelo A , Ferreira V , Gameiro F , Rio P , Abreu J , Timoteo A T , Galrinho A , Branco L M , Ferreira R C
Published: October 2021

Introduction

Prominent left ventricular (LV) trabeculation is frequently encountered, however LV noncompaction (LVNC) criteria are not always fulfilled. The clinical and prognostic significance of these findings remains unclear.

Objectives

To characterize the patients (P) with echocardiographic suspicion of LVNC and to assess clinical outcomes.

Methods

Retrospective single-centre study that included all echocardiograms between January 2018 and June 2020 perceiving LV hypertrabeculation. The cohort underwent diagnostic assessment for LVNC by Chin and Jenni criteria. Baseline characteristics were evaluated. Composite endpoint of cardiovascular death, heart failure (HF) hospitalization, ventricular arrythmias (VA) and nonfatal stroke was considered.

Results

51P, 75% male, mean age 50±18 years. 35P (69%) had associated heart conditions, of which 57% had other known cardiomyopathy (mainly dilated cardiomyopathy), 14% congenital, 26% ischemic and 3% valvular heart disease. 2P were in postpartum period and 1P was an athlete. Family history of cardiomyopathy was present in 8P (16%). 12P underwent genetic testing, with TTN and MYH7 mutations being the most frequently detected. Prior clinical HF was reported in 53%, previous stroke in 14%, and non-sustained and sustained VA in 24% and 4%, respectively. Mean NYHA classification was 1.8±0.7, with 31% being asymptomatic.

The prevalence of LVNC by Chin criteria was 31% and by Jenni criteria was 55%. 32P (63%) met at least one LVNC criteria. This group was younger (45±18 vs 59±15, p=0.004), had higher NT-proBNP levels (3644±2819 vs 389±640, p=0.048) and QRS fragmentation (59% vs 21%, p=0.027). Significantly higher LV end-diastolic volume (84 (41) vs 64 (28)ml/m2, p=0.008) and end-systolic volume (51 (37) vs 35 (20)ml/m2, p=0.004), along with lower LV ejection fraction (39±12 vs 49±13%, p=0.009) and global longitudinal strain (−11±5 vs −17±4%, p=0.003) were noticed. P who met LVNC criteria also had higher number of affected LV segments (6.4±1.8 vs 4.2±1.6, p<0.001).

Over a mean follow-up of 18±9 months, the incidence of composite endpoint was 35%. Univariate Cox analysis showed a significant association between the presence of LVNC criteria and adverse outcomes (HR: 5.108, 95% CI: 1.682–11.236, p=0.030) (Fig. 1).

Conclusion

LV hypertrabeculation can be encountered in a variety of clinical scenarios and often overlaps with other heart diseases. P satisfying criteria for LVNC had more impairment in LV performance and worse clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Persistent hypertension and left ventricular hypertrophy after repair of native coarctation of aorta in adults
Authors: Shaik L , Katta R , Iftikhar M , Goda A , Devara J , Egbe A , Connolly H
Published: October 2021

Background

There are limited data about outcomes after repair of native coarctation of aorta (COA) in adulthood. The purpose of this study was to describe the procedural outcomes, hemodynamic improvement, regression of LV hypertrophy and cardiovascular events in adults undergoing repair of native COA.

Methods

The primary outcomes were procedural complications, re-interventions, and hemodynamic improvement (residual COA gradient <20 mmHg) after COA repair. The secondary outcomes were improvement in the severity of hypertension, regression of left ventricular mass index (LVMI), and incidence of cardiovascular events (atrial fibrillation, heart failure hospitalization, and cardiovascular death) after COA repair. Clinical and imaging indices were assessed pre-intervention, and at 1-year (Y1) and 3-years (Y3) post-intervention.

Results

A total of 172 patients (age 38 [27–48]) underwent COA repair (surgical 161; transcatheter 11). There were no procedural deaths, and all patients had residual COA gradient <20 mmHg. One patients that received transcatheter stent therapy required re-dilation of stent at 12 months post-intervention. There as a reduction in the prevalence of patients requiring anti-hypertensive therapy from 73% (pre-intervention) to 59% and 64% at Y1 and Y3 respectively. However, 72% and 69% of the patients still had systolic blood pressure >130 mmHg (stage 1 and 2 hypertension) at Y1 and Y3 respectively. As compared to patients without hypertension at Y1, patients with stage 1 and stage 2 hypertension had less robust LVMI regression (% change in LVMI 12±5% vs 9±6% vs 5±3%, p<0.001). Hypertension (HR 1.16, 1.05–1.27) and LVMI regression (HR 0.86, 0.81–0.90) were independently associated with cardiovascular events.

Conclusions

Persistent hypertension was common after repair of native COA in adults. Hypertension (including stage 1 hypertension) was associated with suboptimal regression of LVMI and cardiovascular events. These results are concerning, and highlight the importance of early COA diagnosis and repair, and optimal medical therapy for hypertension after COA repair.

Funding Acknowledgement

Type of funding sources: None.
Role of heparin prophylaxis at different doses in patients with COVID-19 and respiratory failure: a systematic review and meta-analysis
Authors: Vedovati M C , Graziani M , Becattini C
Published: October 2021

Background

Venous thromboembolism (VTE) is common in patients with coronavirus disease-2019 (COVID-19). The use of heparin at higher doses than prophylactic is advocated, but the optimal regimens remain unknown due to the balance between prevention of thromboembolic events and bleeding risks.

Objective

To systematically review and perform a meta-analysis aimed at evaluating the risk of VTE and of major bleeding (MB) in patients with respiratory failure due to COVID-19 according to heparin doses.

Methods

We performed a systematic search in MEDLINE up until 22 March 2021. Studies on patients with respiratory failure due to COVID-19 were included if reported on study outcomes according to standard prophylactic and to higher heparin doses and included more than 10 patients. Study primary outcome was VTE; secondary outcomes were MB, all-cause death, fatal bleeding and fatal pulmonary embolism (PE).

Results

Overall, 2 randomized and 16 observational studies were selected (3458 patients). In 13 studies (2492 patients) VTE events were similar in patients receiving standard prophylaxis or higher heparin doses (RR 1.06, 95% CI 0.58–1.95, I2 87%; only randomized studies RR 1.72, 95% CI 0.78–3.81, I2 54%). 16 studies (3174) reporting on MB and showed a significant reduction in favor of standard heparin prophylaxis (RR 0.39, 95% CI 0.28–0.53, I2 8%). No differences were observed for overall mortality according to heparin doses (RR 1.11, 95% CI 0.88–1.40, I2 68%; in 8 studies, 2448 patients). Similarly, no differences were observed for fatal bleedings and fatal PEs.

In the subanalysis of studies reporting only on intensive care unit patients (ICU) an increase in the risk of VTE (RR 1.86, 95% CI 1.28–2.72, I2 18%) and a reduction on the risk of MB (RR 0.60, 95% CI 0.40–0.90, I2 0%) were observed in patients receiving standard heparin doses compared to higher doses. Overall mortality was similar (RR 1.09, 95% CI 0.86–1.39, I2 64%).

Conclusion

Different doses of heparin prophylaxis seem to not affect the risk of VTE in the overall patients with COVID-19 and respiratory failure. In studies reporting only on ICU patients the risk of VTE was lower when higher heparin doses were used compared to standard doses, but with no advantage in overall death and with an increase of MBs.

Funding Acknowledgement

Type of funding sources: None.
Clinical outcomes up-to 10 years of asymptomatic incidental aortic dissections and large aortic aneurysms detected on computer tomography aortography (CTA) prior to transcatheter aortic valve implantation (TAVI)
Authors: Tan J H , Teoh T K , Fong J , Amirthalingam A , Baig K
Published: October 2021

Background/Introduction

Computer tomography aortography (CTA) is performed routinely to aid planning of transcatheter aortic valve implantation (TAVI). Incidental findings are common, and may influence the decision to proceed with TAVI. The safety and long term outcomes of performing TAVI in patients with previously undiagnosed incidental CT findings of aortic dissections and large aortic aneurysms is currently unknown.

Purpose

To establish the frequency of incidental aortic dissections and large aortic aneurysms prior to TAVI, and subsequent clinical outcomes of patients. We hypothesize that transfemoral access is safe in patients with incidental finding of aortic dissection and large aortic aneurysms.

Methods

This was a retrospective study of 628 sequential TAVI patients in a large, UK tertiary centre between January 2010 and September 2020. Patients were evaluated in 3 groups as per pre-TAVI CTA: incidental aortic dissections, aortic aneurysm >4cm and all others (control group). Endpoints were procedural success, peri-procedural major bleeding and/or vascular complications and/or CVA, length of hospital stay, 30-day and 1-year mortality.

Results

2.9% of patients (n=18) had incidental aortic dissection, of which 66.7% (n=12) were male, with a mean age of 86.7±4.4. 3.8% of patients (n=24) had aortic aneurysms >4 cm. 83.3% (n=20) of them were male and the mean age was 82.8±5.4. Transfemoral approach was favoured in 77.8% of patients in the dissection group and 83.3% of patients in the aneurysm group versus 93.3% in the control group. Procedural characteristics are summarised in Table 1. Vascular access complications, stroke, bleeding and length of hospital stay were comparable between all 3 groups (Table 1). Patients with dissection and large aneurysm had similar success rate of valve implantation compared to the control group (88.9% and 87.5% vs 97.1%, p=0.452). 30-day mortality in the dissection group was higher than the other 2 groups (21.1% vs 0% and 5.6%, p=0.004). Log-rank analysis revealed a higher incidence of MACE in the dissection group over 24 months compared to the other two groups (Figure 1).

Conclusion

A transfemoral approach appears to be a safe choice in patients with incidental findings of aortic dissection or aortic aneurysms >4cm, given no significant difference in terms of valve implant success, vascular injury, major bleeding or unplanned surgical repair. However, patients with stable previous aortic dissections have a significantly higher 30-day mortality and overall lower survival rate over 24 months. This important observation needs to be further investigated in a larger-scale, long-term follow up study, and may in future influence TAVI treatment planning.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Survival curve
Impact of significant preprocedural mitral regurgitation on mortality after transcatheter aortic valve implantation
Authors: Karmpalioti M , Drakopoulou M , Oikonomou G , Simopoulou C , Soulaidopoulos S , Apostolos A , Toskas P , Stathogiannis K , Synetos A , Latsios G , Tsioufis C , Toutouzas K
Published: October 2021

Background

Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation (TAVI). The presence of significant pre-procedural MR, however, has not been accounted in pivotal trials of TAVI and data regarding its independent impact on outcome are contradictory.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were stratified into two groups according to MR severity: ≤ grade 1 were defined as non-significant and ≥ grade 2 as significant. Change in MR was determined by comparison between baseline and 30-day echocardiogram. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 331 consecutive patients were enrolled in the study: 247 (74.6%) had non-significant MR and 84 (25.4%) patients had significant MR at baseline. Patients with significant pre-procedural MR had lower baseline ejection fraction (47.7±10.4% versus 51.2±8.4%, p=0.002), higher pulmonary artery systolic pressure (52±14.3mmHg versus 42.5±11.1mmHg, p<0.0001) and higher rates of moderate or severe tricuspid regurgitation (TR) (50% versus 19.4%) compared to patients with non-significant MR. Of all patients, mitral regurgitation improved in 9.5%, remained the same in 83.9%, and worsened in 6.6% 30 days after TAVR. In a multivariable analysis, pre-procedural TR severity was predictor of improved mitral regurgitation [OR 3.003,(95% CI 1.216–7.417, p=0.017)].

The primary clinical end point occurred in 44.7% of all patients during a follow-up period of 36.6.±25.9 months. Patients with significant pre-procedural MR had significantly higher rates of all-cause mortality compared to patients with non-significant (54.7% and 41.3%, respectively; log rank p=0.015). Performing a multivariable analysis demonstrated that preprocedural MR severity could independently predict cumulative mortality [OR 0.480, (95% CI 0.247–0.932, p=0.03)].

Conclusion

Significant pre-procedural MR is common in patients undergoing TAVI and is associated with increased all-cause mortality. TAVI is associated with a significant improvement in MR, especially in severe types. These data provide new insights in the crucial role of mitral regurgitation in the risk assessment of TAVI candidates.

Funding Acknowledgement

Type of funding sources: None.
Predictors of in-hospital mortality, 20-year survival and reflection on risk scoring in patients with impaired left ventricular function undergoing isolated coronary artery bypass grafting
Authors: Di Tommaso E , Bruno V D , Sankanahalli Annaiah A , Dixon L K , Ascione R
Published: October 2021

Background

Impaired left ventricular ejection fraction (LVEF) is a risk factor for mortality in patients undergoing coronary artery bypass grafting (CABG). Limited data is available on survival after 5 years and sensitivity of preoperative risk scoring systems in this high-risk population.

Purpose

To investigate in-hospital mortality, 20-year survival, predictors of early and late mortality and sensitivity of available risk-scoring systems in a large population with moderate to poor baseline LVEF and undergoing isolated CABG.

Methods

Patients presenting with moderate to poor LVEF and undergoing isolated CABG between 1996 and 2015 were selected for the purpose of this study. LVEF was defined moderate if between 30–39% and poor if <30%. Data collection was prospective and retrospectively analysed. Early and long-term mortality was derived from the NHS National Mortality Tracking system. Exclusion criteria included reoperations and combined procedures only. Patients undergoing urgent and emergency CABG procedures were included. Key outcome measures included 30-day health outcome, long-term survival, impact of incomplete revascularization (IC) and off-pump coronary artery bypass (OPCAB) surgery, independent predictors of poor in-hospital outcome and long-term mortality and reliability of Euroscore in predicting mortality in this high-risk population. Comparative analysis was conducted with Student t-test or Mann-whithney test fro numerical variable and Chi-Square for categorical variables. Survival were compared and reported using Log rank test and Kaplan Meier methods. A Cox Proportional Hazard model was developed to identify risk factors for long term mortality.

Results

5016 patients with reduced LVEF were identifiedL1024 (20.4%) with poor and 3992 (79.6%) with moderate LVEF. After excluding reoperations and combined procedures, the final sample consisted of 3867 patients. Average age was68 years, 83% were male, 40% had NYHA IV; 12.5% of patients received IC and 44% underwent OPCAB surgery. 30-day mortality was 4.4%, stroke 1.4% and renal failure requiring dialysis of 2.9%. Survival at 1, 5, 10 and 20 years was 91.1%, 76.7%, 55.1% and 22.1% respectively (Figure). OPCAB surgery was not associated with long-term mortality. Independent predictors of late mortality as shown in Table. Additive Euroscore and Logistic Euroscore appeared to overestimate mortality in this patient population (AUC 0.78).

Conclusions

In patients with reduced LVEF the use of CABG is associated with low rates of in-hospital mortality, key post-operative complications and excellent long-term survival. Incomplete revascularization but not OPCAB surgery are surgical predictors of long-term mortality. Euroscore appears to overestimate the risk of mortality in this population.

Funding Acknowledgement

Type of funding sources: None. Cox Hazard Ratio Table
Relationship between year-to-year blood pressure variability and target organ damage in the general population
Authors: Takase H , Hayashi K , Ohno K , Takayama S , Machii M , Sugiura T , Ohte N , Dohi Y
Published: October 2021

Background/Introduction

Visit-to-visit blood pressure variability (BPV) is a strong predictor of cardiovascular events as well as target organ damage (TOD) in hypertension. However, effects of year-to-year BPV on the development of TOD have not been investigated in the general population.

Purpose

The present study was designed to investigate a possible relationship between year-to-year BPV and TOD in the general population.

Methods

Consecutive 5542 subjects (male=3771, 58.6±10.7 yea-old) who visited our hospital for an annual physical check-up for 5 years in a row during 2008 and 2013 were enrolled. The average, standard deviation (SD), coefficient of variation (CV), and average real variability (ARV) of systolic blood pressure (SBP) were calculated using data during the period. Other baseline data were obtained in 2013; left ventricular hypertrophy (LVH; Sokolow-Lyon voltage >3.8 mV and/or Cornell product >2440 mm ms) and kidney impairment (estimated glomerular filtration rate; eGFR<60) were taken as TOD. Then, subjects without TOD at baseline (2013) (n=3801, male=2584, 57.4±10.4 yea-old) were followed up until 2019 (median = 5 years) and the impact of BPV on the development of TOD was investigated.

Results

The average, SD, CV and ARV of SBP were 123.8 mmHg, 8.04 mmHg, 6.50%, and 9.19 mmHg, respectively. At baseline, these parameters were higher in subjects with TOD than those without TOD (Table 1-A). During the follow-up of subjects without TOD at baseline, LVH and kidney impairment developed in 425 and 623 subjects (24.7 and 35.8 per 1000 person-year), respectively. In retrospective analysis, the average, SD, and ARV were higher in subjects with than without future TOD (Table 1-B). Although some indices of year-to-year BPV predicted future development of TOD in univariate Cox-hazard analysis, only the average of SBP predicted incident TOD after adjustment.

Conclusions

Year-to-year BPV is a marker of the incident TOD in the general population. However, these indices do not independently predict the onset of TOD and, thus, there may be unknown pathway that links TOD and BPV.

Funding Acknowledgement

Type of funding sources: None. Table 1. BP variability and TODTable 2. Cox-hazard analyses
Association of common carotid artery measurements with the incidence of hypertension: a retrospective cohort study
Authors: Sasaki N , Maeda R , Ozono R , Nakano Y , Higashi Y
Published: October 2021

Background

Diameter, intima–media thickness (IMT), and flow parameters, including resistance index (RI) and pulsatility index (PI), in the common carotid artery (CCA) are markers of arterial remodeling, atherosclerosis, and vascular resistance, respectively. These CCA parameters have usually been evaluated as markers of target organ damage. Little is known about whether these parameters predict a new onset of hypertension.

Purpose

In this study, we investigated the association of CCA parameters including IMT, diameter, RI, and PI with the incidence of hypertension.

Methods

This is an observational study involving 1249 participants (656 women, mean age 69.6 years) without hypertension, who underwent carotid artery ultrasonography at baseline. The participants were divided into elderly group (defined as age ≥70 years) and a middle-aged group. We defined obesity as BMI ≥25 kg/m2. CCA diameter was defined as the distance between the adventitia–media interface on the near wall and the media–adventitia interface on the far wall. IMT was defined as the distance between the lumen–intima and media–adventitia interfaces. RI was calculated as [peak systolic velocity (PSV)- end-diastolic velocity (EDV)]/PSV. PI was calculated as (PSV-EDV)/Vmean. Larger CCA diameter, increased IMT, high RI, and high PI were determined based on the optimal cutoff values from ROC curve analysis.

Results

Over a mean 5.1-year follow-up period, 524 participants developed hypertension. Multivariate logistic regression analyses showed that larger CCA diameter and increased IMT were significant predicators for incident hypertension in elderly group, but not in middle-aged group. High RI, and high PI were significant predicators for incident hypertension in both the two groups. CCA diameter, IMT, and RI predicted the incidence of hypertension only in nonobesity group, whereas PI predicted it in both obesity and nonobesity groups (Table).

Conclusion

CCA parameters assessed by ultrasonography are useful markers to estimate the risk of hypertension. In particular, PI is a better predictor for the incidence of hypertension.

Funding Acknowledgement

Type of funding sources: None.