bluuebunny/crossref_metadata_2025 huggingface dataset:
Heart involvement in type 1 and type 2 myotonic dystrophy. Insights from a 10-year follow-up study
Authors: Fioravanti F , Golzio P.G , Carbone M.L , Panarelli A , Gagliardi M , Mazzilli S , Colopi M , Ferraro I , Castagno D , Giustetto C , De Ferrari G.M
Published: November 2020

Background and aim

Myotonic Dystrophy (MD) is the most common inherited muscular dystrophy of the adult. Cardiac manifestation, including arrhythmias and conduction disorders, contributes significantly to the morbidity and mortality of the disease. The transition from a subclinical form of cardiac involvement to potentially life-threating manifestations is highly variable and not yet entirely understood. Aim of this work is to evaluate whether PQ interval (PQi) prolongation could be a reliable marker to predict left and right ventricle impairment and the necessity of a stricter monitoring.

Methods

In this retrospective cohort study, we selected all consecutive patients with a confirmed diagnosis of MD (type 1 and type 2) referred to our Centre. We performed clinical, laboratoristic and instrumental assessments (every 3, 6 or 12 months), tailored on each patient's features. Every patient was treated according to the latest guidelines for pharmacological and device therapy. ECG (recorded at 25 and 50 mm/sec), 24h ECG Holter and transthoracic echocardiography were performed at least yearly. Cardiac Magnetic Resonance was requested to better stratify intermediate risk patients to implantable device therapy.

Results

A total of 72 patients (age 48±15 years, 39% female) were included in the analysis. Patients with MD type 1 and type 2 were referred to our Centre after a mean period of 12 years (SD ±8 years) from initial diagnosis. After a mean follow-up of 5 years (±4 years), 8 patients died (mean age at death: 60±12.4 years), all of them for respiratory insufficiency. We evaluated PQ interval (PQi) evolution and type I AVB onset. No statistically significant differences emerged when stratifying for type I AVB. Nevertheless, a PQi increase of more than 20 ms during the follow-up (even if PQ <200 ms) is significantly associated with lower values of TAPSE and greater LVEDD, while no differences emerged for LVEF, dyastolic function and other echocardiographic parameters. Moreover, the evolution of PQ interval is associated with an increasing number of supraventricular arrhythmias and a worse prognosis (shorter interval from first cardiac symptom to death, p 0.025), despite optimal medical therapy.

Conclusions

Although relatively rare, MD is a challenge for present Cardiologists. How and when to treat those patients is not codified in guidelines or consensus papers. This study suggests PQi variation as a proxy for critical evolution of MD cardiac involvement. ECG and its modification during lifetime seem pivotal for these patients' care, qualifying as a red flag for stringent follow-up. Further evidences, on larger cohorts, are needed to validate these findings.

Funding Acknowledgement

Type of funding source: None
Genetically rheumatoid arthrits and risk of comorbidities: a Mendelian randomization study
Authors: Fokina A , Fill J , Klappacher G
Published: November 2020

Background

Ample observational evidence indicates that patients with rheumatoid arthritis (RA) are at increased risk of developing comorbid conditions, in particular cardiovascular disease. The pathogenesis of these comorbidities is still largely unknown. For effective preventive measures, it would however be important to discriminate between those that are causally linked with rheumatoid arthritis and those that are the results of concomitant treatments or other confounding factors.

Purpose

Our objective was to explore whether genetically determined manifestation of RA was associated with any comorbidities, in particular cardiovascular disease, by conducting a 2-sample Mendelian randomization (MR) study on publicly available summary statistics from genome-wide association study (GWAS) consortia.

Methods

Genetic instruments for RA were obtained from a GWAS of 14,361 autoantibody-positive individuals with RA and 43,923 controls of European descent (Okada et al. 2014). The CARDIoGRAMplusC4D consortium comprising 60,801 cases with coronary artery disease and 123,504 controls was used to evaluate the associations with cardiovascular outcomes applying inverse variance–weighted meta-analysis, weighted-median analysis, Mendelian randomization–Egger regression, and multivariable Mendelian randomization. Genetic instruments for RA were further tested for association with other etiologically related traits by using publicly available GWAS data.

Results

Genetic predisposition to RA was not associated with higher risk of coronary artery disease (beta coefficient [b] ± standard error [se] = 0.02±0.03; P=0.4913), and myocardial infarction (b ± se = 0.03±0.03; P=0.3338). In contrast, IgA nephropathy (b ± se = 0.47±0.18; P=0.0225) and triglyceride levels were significantly related as outcomes to genetically determined RA as exposure. Other significantly related outcomes were the manifestation of squamous cell lung cancer (b ± se = 0.17±0.08; P=0.0496), serous ovarian cancer (b ± se = 0.13±0.05; P=0.0202), and prostate cancer (b ± se = 0.06±0.02; P=0.0041).

Conclusions

Despite the high prevalence of coronary artery disease and myocardial infarction among RA patients in observational studies, cardiovascular outcomes were not significantly associated with RA by Mendelian randomization. This paradox might partly be explained by the traits such as IgA nephropathy and elevated triglyceride levels that could act as mediators for the increased cardiovascular risk by their causal link with genetically determined RA.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Medical University of Vienna, Austria
Mothers with post-partum hypertension and kidney damage after pre-eclampsia should receive ACE inhibitors rather than methyldopa
Authors: Gaisin I , Iskchakova A.S , Maximov N.I , Valeeva R.M , Shilina L.V , Sava N.P
Published: November 2020

Background

Both hypertension (HT) and pre-eclampsia (PE) have been recognized as an important cause of chronic kidney disease (CKD) in women. There are no uniform recommendations for the treatment of HT with kidney damage after PE yet.

Methods

In a case-control, open-label 1-year study, 54 post-partum women (aged 25–37 years) with grade 2 (53.7%) or 3 (46.3%) HT and kidney damage [48 patients (88.9%) had moderately increased albuminuria (30–299 mg/g), 6 (11.1%) – severely increased albuminuria (>300 mg/g), 32 (59.3%) – mildly decreased eGFR (60–89 mL/min/1.73 m2 (BSA)) and 3 (5,6%) – mildly to moderately decreased eGFR (45–59 mL/min/1.73 m2)] after early-onset PE (with delivery at <34+0 weeks of gestation) superimposed to HT received either adjusted-dose ACE inhibitors – ACEi (33 non-feeding mothers: 19 – perindopril, 5 – ramipril, 9 – perindopril and indapamide SR combination) or methyldopa (21 nursing women). No significant differences observed between two groups at baseline.

Results

After comprehensive follow-up, blood pressure (BP) was not found to differ between ACEi and methyldopa groups (123.2±2.4/78.5±1.5 mmHg vs. 136.2±4.8/86.2±3.2 mmHg respectively, p>0.05) with more strict BP control on ACEi. There were significant differences in albuminuria reduction, in favour of ACEi (–207.2 mg/24 h vs. –33.7 mg/24 h, p<0.01) and in eGFR increasing (+19.4 mL/min/1.73 m2 (BSA) vs. +6.6 mL/min/1.73 m2 (BSA), p=0.029), as well as in decrease of left ventricular (LV) mass index (−31.2 g/m2 vs. −16.7 g/m2, p=0.038) and increase of LV ejection fraction (+8.2% vs. +1.9%, p=0.022). Treatment with ACEi more improved endothelial function, non-invasively assessed by flow-mediated dilatation of a brachial artery using high-resolution ultrasound (+10% vs. +3.4%, p=0.035) and decreased intima media thickness (−0.33 mm vs. −0.17 mm, p=0.009).

In a year, all methyldopa patients had albuminuria, C1 stage of CKD was in 13 (61.9%) women, CKD C2 in 8 (38.1%). In ACEi group, CKD C1 had 7 (21.2%) mothers (p<0.01), C2 – none (p<0.01).

Conclusion

Non-feeding women with grade 2 or 3 post-partum HT and renal damage after early-onset PE get greater heart, kidney and vessels benefits from 1-year ACEi treatment than nursing mothers from methyldopa.

Funding Acknowledgement

Type of funding source: None
Evidence of platelet dysfunction in congenital cyanotic heart disease: relevance to palliative systemic-pulmonary shunt and haemostatic parameters
Authors: Hassan F , Agha H , Khalil M , Gabr H , Alsoda S
Published: November 2020

Introduction

Platelets in congenital cyanotic heart disease (CCHD) were occasionally characterized by significantly enhanced expression of P-selectin in resting circulating platelets as well as their augmented activation in response to stimulating agents. P-selectin is present in the alpha granule membrane as well as Weibel-Palade body membrane of endothelial cells. It is translocated to platelet membrane after activation; thus, its expression on platelet surface is an indicator of platelet activation in vivo. The occurrence of the prothrombotic variant of GPIIIa in cyanotic children may be associated with enhanced activation of circulating platelets.

Purpose

To study the platelet functions in patients with CCHD by determination of Pselectin expression and the GPIIIa polymorphism and to correlate these findings with other clinical, radiological, and laboratory parameters in these patients.

Methods

This study included 47 patients, with cyanotic congenital heart disease with decreased pulmonary blood flow, attending the Pediatric Cardiology Clinic. They were divided into two groups: Group I: 31 patients with congenital cyanotic heart disease before cardio surgery Group II: 16 patients with congenital cyanotic heart disease 3–6 months after palliative or corrective cardio surgery, Group III: 12 age and sex matched normal children were included in the study as control group. They were subjected to Flow-cytometric evaluation of platelet activation by Pselectin expression: P-selectin expression was estimated using monoclonal antibody.-Typing of GPIIIa gene polymorphism was done.

Results

Statistically significant higher P-selectin levels were found in patients compared with controls being significantly higher in patients <3 years of age. There was significant negative correlation between P-selectin level and O2 in patients. The incidence of prothrombotic variant A2 was described as phenotype positive. Statistically significant higher levels of P-selectine were found in positive phenotype patients than positive phenotype controls

Conclusion

Enhanced platelet activation may be an important contributor in the high thrombotic liability in congenital cyanotic heart disease. This may be attributed in part to genetic factors

Funding Acknowledgement

Type of funding source: None
Prevalence of aortic valve regurgitation in a large population-based study of newborns
Authors: Farooqui A , Bjerrekaer J.K , Boerresen M.F , Voegg R.O , Pihl C.A , Norsk J.B , Bundgaard H , Iversen K.K
Published: November 2020

Background

Congenital aortic valve regurgitation (AVR) has been estimated to be present in 0.25 per 1,000 live births globally. The true prevalence in an unselected large-scale cohort remains unknown. Presence of congenital AVR could indicate a structural valve abnormality and may result in long-term strain on the heart.

Aim

To find the true prevalence of AVR in a large cohort of unselected newborns.

Methods

Between April 2016 and October 2018, 25,752 newborns were consecutively included in a population-based prospective multicenter cohort and examined with transthoracic echocardiography within the first 30 days of life. Examinations with AVR were categorized as trivial AVR by the presence of a trivial diastolic transvalvular flow, or as non-trivial AVR by the presence of a significantly larger and visually observable transvalvular flow. In newborns with non-trivial AVR, the vena contracta, the duration of the transvalvular flow, and the duration of the diastole were measured. The cases were matched 1:4 with newborns with no AVR based on sex, gestational age at birth, birth weight and age at time of examination.

Results

AVR was identified in 329 newborns (1.3%). Of these, 260 were classified as trivial AVR, 69 (0.27%) were non-trivial AVR. Non-trivial AVR had significantly larger aortic roots at all points of measurement compared to controls (mean±SD): aortic valve annulus (7.3 (0.73) vs. 7.0 (0.63) mm), Sinus of Valsalva (10.3 (1.0) vs. 9.7 (1.0) mm), sino-tubular junction (8.4 (0.8) vs. 8 (0.8) mm), and ascending aorta (10 (0.9) vs. 9.4 (1.1) mm) (p<0.01 for all). Left ventricular dimensions and function did not significantly differ between the cases and controls. The presence of a non-trivial AVR was highly associated with a bicuspid aortic valve (9 (13.0%) vs. 3 (1.1%), p<0.001).

Conclusions

We found a prevalence of congenital AVR of 1.3% in a large cohort of unselected newborns, which is higher than previously reported. One in five of all AVR found were classified as non-trivial. Newborns with non-trivial AVR presented with larger aortic root and ascending aorta dimensions. Newborns with non-trivial AVR also had a ten-fold higher occurrence of bicuspid aortic valve compared to controls.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Hjerteforeningen
The Peguero-Lo Presti criteria has the highest diagnostic accuracy for the diagnosis of left ventricular hypertrophy in the elderly
Authors: Tavares C.A.M , Samesima N , Hajjar L.A , Godoy L.C , Hirano E.M.P , Facin M , Jacob Filho W , Farkouh M.E , Pastore C.A
Published: November 2020

Background

Left Ventricular Hypertrophy (LVH) is an independent predictor of mortality and cardiovascular morbidity and the 12-lead ECG is recommended as a universal screening for patients with hypertension. However, the ECG has low sensitivity and there is limited data in patients 70 years or older. The recently published Peguero-Lo Presti (PLP) criteria had improved accuracy compared with other ECG criteria but with very few patients with age ≥70 years included.

Purpose

To compare the accuracy of the PLP criteria versus the traditional ECG criteria for detecting LVH in patients ≥70 years.

Methods

Retrospective single-center study. Patients were included if they were 70 years or older and underwent an ECG and echocardiogram (gold standard) less than 180 days apart from jan/2017 to mar/2018. Patients with left or right bundle branch block, non-sinus rhythm or ventricular paced rhythm were excluded. All tracings were independently reviewed by two cardiologists, blinded to the echocardiogram. The PLP criteria was compared against Cornell voltage (CV), Sokolow-Lyon voltage (SL), and Romhilt-Estes 4 and 5 (RE) criteria. LVH was defined as a left ventricular mass index >115 g/m2 in males and >95 g/m2 in females, according to the echocardiogram. McNemar's test, F1 score, and the area under the Receiver Operating Characteristic curves (AUC) were used to compare the diagnostic performance of the tests

Results

A total of 592 patients were included (mean age 77.5 years, SD: 5.9; 50.8% were women). The PLP criteria had increased sensitivity compared with both the SL and CV criteria (p<0.0001 for both comparisons) and RE5 (p=0.042). PLP also had better specificity than the RE4 criteria (p<0.0001) and the highest F1 accuracy score (Table 1). The AUC of the PLP was significantly higher than the AUC of the CV and RE criteria (0.70 vs 0.66 vs 0.64, respectively, p<0.05) and numerically higher than the SL criteria (AUC=0.67, p=0.311, Figure 1).

Conclusion

Compared to the traditional ECG criteria for LVH, the PLP criteria had the highest diagnostic accuracy in elderly patients.

Figure 1. AUC of the ECG criteira

Funding Acknowledgement

Type of funding source: None
Cardiovascular effects of chimeric antigen receptor t-cell therapy for refractory or relapsed non-hodgkin lymphoma
Authors: Ganatra S , Redd R , Hayek S , Parikh R , Azam T , Yanik G , Spendley L , Nikiforow S , Jacobson C , Nohria A
Published: November 2020

Purpose

Cardiovascular complications of chimeric antigen receptor T-cell (CAR T-cell) therapy are poorly understood. We examined the incidence, predictors and impact of new or worsening cardiomyopathy in patients undergoing CAR T-cell therapy.

Methods

All patients with refractory or relapsed non-Hodgkin's lymphoma, undergoing CAR T-cell therapy at collaborative institutes underwent serial echocardiograms at baseline and within 7 days after developing high-grade cytokine release syndrome (CRS), and were followed for all-cause mortality. New or worsening cardiomyopathy was defined as a reduction in left ventricular ejection fraction (LVEF) >10% from baseline to <50% during the index hospitalization.

Results

Among 187 consecutive CAR T-cell therapy patients, 116 (50 Grade ≤1 CRS, 66 Grade ≥2 CRS) had >1 echocardiogram performed and were included in this analysis. The median age was 63 (range 19–80) years, 42% were women, 91% were Caucasian. A total of 12 (10.3%) patients developed new or worsening cardiomyopathy with a decline in LVEF from 58±6% to 36±7% within a median of 12.5 (range 2–24) days of CAR T-cell infusion. In multivariable analyses, older age, prior stem cell transplantation, baseline angiotensin-converting enzyme inhibitor use and CRS grade ≥2 were associated with the development of cardiomyopathy. Patients who developed cardiomyopathy were more likely to require vasopressor support (p=0.004) and mechanical ventilation (p=0.014). LVEF improved in 9/12 (75%) patients. CAR T-cell associated cardiomyopathy did not impact overall mortality or cancer response to CAR-T cell therapy.

Conclusions

Patients undergoing CAR T-cell therapy are at risk of developing cardiomyopathy and hemodynamic instability. Pre-CAR T-cell therapy cardiovascular risk stratification and echocardiogram surveillance during therapy should be considered for prompt identification and mitigation of cardiac complications.

Predictors of Cardiomyopathy Development

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Anju Nohria, MD is supported by the Gelb Master Clinician Award at Brigham and Women's Hospital.
Sacubitril/valsartan improves heart failure functional class, left ventricular systolic and diastolic function and neurohumoral status in patients with anthracycline-induced cardiomyopathy
Authors: Vitsenya M , Potekhina A , Gavryushina S , Ibragimova N , Masenko V , Ageev F
Published: November 2020

Anthracycline-induced cardiomyopathy (AC-CMP) is more resistant or even refractory to conventional heart failure (HF) treatments and has a higher mortality rate as compared to HF associated with other diseases. Sacubitril/valsartan (S/V) significantly reduces cardiovascular mortality and hospitalization rate in HF patients with reduced left ventricular ejection fraction (HFrEF). There is lack of evidence of S/V efficacy and safety in patients with AC-CMP.

We aimed to assess the efficacy and tolerability of S/V in patients with AC-CMP.

Methods

We enrolled 20 patients with anthracycline-induced HFrEF who met the indication criteria for S/V. Median age was 61 [51.5; 67], 100% women, 8 (40%) hypertensive, 1 (5%) diabetic. Seventeen (85%) patients had breast and 3 (15%) hematological cancers. Median time from anthracycline therapy was 3 [1; 11] years. Surgery due to cancer and radiation therapy were performed in 15 (75%) cases. All patients had been receiving ACE inhibitors or angiotensin II receptor blockers and were switched to S/V. 85% of patients were treated with beta-blockers, 60% – mineralocorticoid antagonists, 50% – loop diuretics. The exam (at admission and after 6 months) included 6-MWT, echo/speckle tracking, creatinine, potassium and NTproBNP level.

Results

Eleven (55%) patients achieved the target dose of S/V. The mean S/V dose was 289±149.1 mg. Symptomatic hypotension, hyperpotassemia or creatinine level elevation were the reasons for S/V dose reduction in 8, 1 and 2 patients, respectively. S/V wasn't withdrawn in any patient. No hospitalization due to HF or need for loop diuretics increase occurred during the follow-up. After 6 months 6-MWD increased from 416 [347.5; 477.5] to 465 [395; 513.5] m, p=0.0004. NYHA functional class improved in 50% of patients. We revealed LVEDVI decrease (61.7 [55.9; 71.6] to 57.1 [53.4; 60.1] ml/m2 p=0.002), LVEF and GLS increase (39 [34.7; 41] to 45 [39; 47]%, p=0.001 and 11 [8.7; 13.9] to 13.4 [11.9; 15.5]%, p=0.002, respectively), LAVI decrease (40.7 [32; 43.9] to 31.3 [28.6; 37.4] ml/m2, p=0.003), E/A and E/e ratios decrease (1.37 [0.7; 2.23] to 0.69 [0.64; 0.83], p=0.04, and 13 [11.3; 17.8] to 10.7 [6.9; 13.6], p=0.01, respectively). NTproBNP blood level declined from 1659 [1090; 2316] to 377 [206.8; 920] pg/ml, p<0.001. There was change in serum creatinine level but in normal ranges (from 70.3 [66.8; 80; 6] to 77 [68.6; 96.3] micromol/l, p=0.02). No significant changes in potassium level were observed.

Conclusions

In this pilot study S/V was well tolerated in patients with AC-CMP, but cardiologic assessment was needed for accurate dose adjustment. Therapy with S/V was associated with improvement in HF functional class and LV systolic and diastolic function as well as neurohumoral status in patients with AC-CMP.

Funding Acknowledgement

Type of funding source: None
Regional cardiac dysfunction determined by radiation dose in patients with breast cancer
Authors: Trivedi S , Tang S , Otton J , Delaney G , Holloway L , Liney G , Koh E , Thomas L
Published: November 2020

Background

Subclinical left ventricular (LV) dysfunction by 2D global longitudinal strain (GLS) immediately following radiotherapy (RT) and persisting at 12 months has been described in breast cancer (BC) patients. We hypothesised that persistent LV dysfunction may be regional and correlate with segmental RT.

Methods

Transthoracic echocardiograms were performed at baseline, 6 weeks and 12 months post-RT on 61 chemotherapy-naïve women with left sided BC.

Results

Anterior and anteroseptal regions received the highest radiation dose, and posterior and inferior segments the lowest radiation dose (Figure 1). Within each region, there was a progressive increase in the radiation dose received from base to apex. At 6 weeks, the greatest reduction in strain was observed in the anterior and anteroseptal regions, with the most significant reduction in strain in the apical segments. At 12 months, despite improvement in strain, the percentage reduction in strain was similar. There was a significant interaction between both region and segment, on the percentage change in strain at 6 weeks (p<0.001) and at 12 months (p=0.007). Pairwise comparisons of apical to basal percentage change in strain demonstrated the most significant reductions in the anterior region at 6 weeks and 12 months (Table 1).

Conclusions

RT causes segmental myocardial dysfunction, with areas receiving the highest RT demonstrating the largest impairment in strain, with these changes persisting at 12 months. Long term correlation with adverse events is required.

Figure 1. Radiation dose by region and segment

Funding Acknowledgement

Type of funding source: None
Carcinoid heart disease: the role of echocardiography in predicting post-surgical outcomes
Authors: Brooke A , Ahmed R , Hodson J , Rooney S , Oelofse T , Singh H , Shah T , Steeds R.P
Published: November 2020

Background

Carcinoid heart disease (CHD) often complicates neuroendocrine tumours (NET). The prognosis of CHD without intervention is poor; 3 year survival is estimated at 31%. Surgical valve replacement is the only treatment for CHD, but is associated with high 30-day mortality (10–15%).

Purpose

The aim is to identify pre-operative transthoracic echocardiogram (PTTE) findings that could determine which patients have a high likelihood of post-surgical mortality at 1 year.

Methods

This retrospective observational cohort study recruited 88 patients with a confirmed diagnosis of CHD between 2005–19 at University Hospital Birmingham; 49 (56%) of these were treated surgically. Indications for surgery: stable NET, symptomatic severe valvular dysfunction, progressive RV dilatation or RV dysfunction, no significant comorbidities. All patients underwent a standard PTTE. PTTE parameters assessed: right ventricular (RV) size, RV function (qualitative), TAPSE, RV fractional area change, RV S wave velocity, left ventricular (LV) size, LV ejection fraction and valve velocities. Surgery was performed by a single surgical team with bioprosthetic valve replacements.

Results

Patients were followed up for a median of 15 months (IQR: 6–59) after surgery, during which time there were 33 deaths, giving a median survival time of 30 months (IQR: 7–85). Increasingly severe RV dilatation was significantly associated with shorter survival (p=0.032). The estimated survival rate at three years was 67% in those with normal RV size, compared to 24% in the severe RV group (Figure 1). RV basal diameter was assessed used ROC curve analysis for the outcome of one year survival and returned an area under the curve of 0.66 (SE=0.10). Youden's index identified RV diameter >4.8cm to be the optimal cut-off for identifying high-risk patients. One year mortality rates were 26% (7/27) vs. 75% (9/12) in those with RV basal diameter of ≤4.8 vs. >4.8cm (p=0.006).

Conclusion

A pre-operative right ventricular basal diameter >4.8cm is associated with a near three-fold increase in post-operative mortality at one year. These findings highlight the importance of regular imaging in order to optimise the timing of surgery in patients with CHD.

Figure 1. Kaplan-Meier curve of post-op survival

Funding Acknowledgement

Type of funding source: None
Patient characteristics and in-hospital outcomes of Takotsubo Cardiomyopathy in pregnancy: a retrospective analysis
Authors: Joshi S , Patil S.P , Rojulpote C , Gonuguntla K
Published: November 2020

Introduction

Takotsubo Cardiomyopathy (TCM) is characterized by reversible left ventricular dysfunction and predominantly affects post-menopausal women. However, it is rarely identified as a cause of acute heart failure in pregnancy.

Objective

We aimed to determine patient characteristics and in-hospital outcomes of TCM occurring in pregnancy.

Methods

We retrospectively analyzed the United States - National Inpatient Sample (NIS) Database from 2010–2014 to assess TCM in pregnant women ≥18 years using international classification of diseases 9th revision clinical modification (ICD-9-CM) codes. We compared patient demographics, co-morbidities and in-hospital outcomes between pregnant and non-pregnant women with TCM aged 18–49 years. Patients with a diagnosis of peripartum cardiomyopathy were excluded. Chi-square test and Student-t test or Mann- Whitney U test were used for categorical and continuous variables with normal and skewed distribution, respectively.

Results

TCM occurred at a younger age in pregnant women compared to non-pregnant women (Age [Mean ±SD]: 31.2±7.2 years vs. 41.8±7.1 years; p<0.001). Rates of TCM were higher during pregnancy in African American (19% vs. 11.5%; p=0.008), Hispanic (27.3% vs. 9.6%; p<0.001) and Asian women (11.3% vs. 2.6%; p<0.001) compared to non-pregnant women of similar race. However, among Caucasian women rates of TCM were higher in non-pregnant women (42.4% vs. 72.7%; p<0.001). There were no in-hospital deaths among pregnant women with TCM (0% vs. 5.2%; p=0.005), however they had higher rates of cardiogenic shock (13.8% vs. 5.8; p<0.001) and respiratory failure requiring mechanical ventilation (51.7% vs. 20.9%; p<0.001). The average length of hospitalization was also longer among pregnant women with TCM (Days [Mean±SD]: 5.8±4 vs. 5.5±7.5; p<0.001). Pregnant women had lower rates of diagnostic angiography (24.1% vs. 55.6%; p<0.001). Pregnant women with TCM had higher rates of ventricular fibrillation (6.9% vs. 2.9%; p=0.02), but had no atrial fibrillation (0% vs. 2.6%; p=0.05), atrial flutter (0% vs. 0.4%; p=0.43), paroxysmal supraventricular tachycardia (0% vs. 0.5%; p=0.4) and ventricular tachycardia (0% vs. 4.8%; p=0.07). Pregnant women with TCM had lower rates of psychiatric and certain medical co-morbidities: anxiety (6.9% vs. 20.4%; p<0.001), depression (0% vs. 2.6%; p=0.05), bipolar disorder (0% vs. 0.8%; p=0.3), hypertension (27.6% vs. 40.3%; p=0.002), hyperlipidemia (3.4% vs. 25.7%; p<0.001) and smoking (6.9% vs. 40.2%; p<0.001). The rates of diabetes (13.8% vs. 15.9%; p=0.5) and obesity (10.3% vs. 8.2%; p=0.37) were similar between the two groups.

Conclusion

There was no in-hospital mortality observed in pregnant women who developed TCM, however, they had increased rates of cardiogenic shock, mechanical ventilation, ventricular fibrillation and had longer hospitalizations.

Funding Acknowledgement

Type of funding source: None
Feasibility and safety of early initiation of a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor in patients with acute myocardial infarction undergoing primary PCI
Authors: Okada T , Tsushima R , Taya S , Saito E , Takagi W , Sogo M , Ugawa S , Nosaka K , Takahashi M , Okawa K , Sakane K , Miyoshi T , Ito H , Doi M
Published: November 2020

Background

Recent ESC/EAS Guidelines for the management of dyslipidemia stated that the treatment goal of LDL cholesterol (LDL-C) in very high-risk patients is less than 55mg/dl. PCSK9 inhibitors in addition to strong statins could be a useful strategy for rapid and aggressive lowering of LDL-C. However, the feasibility and safety of early initiation of a PCSK9 inhibitor for AMI patients undergoing primary PCI remain unclear.

Objectives

We examined the effects of early initiation of a PCSK9 inhibitor, evolocumab, on lipid profile and inflammatory markers and its safety in AMI patients undergoing primary PCI.

Methods

This study is a single center, randomized, controlled trial involving 102 patients hospitalized for AMI. The patients were randomly assigned 1:1 to the evolocumab group and the control group. Evolocumab (140 mg) was subcutaneously injected within 24 hours after PCI and then every two weeks. All patients received pitavastatin (2mg/day) in addition to the allocated treatment. The primary endpoints were changes in lipid profile and inflammatory markers from baseline to 4 weeks.

Results

102 patients were enrolled between October 2017 and December 2019. 89 patients were ST-segment elevation myocardial infarction (STEMI), 13 patients were non-STEMI. Primary PCI was successfully performed in all patients. 76 patients were statin-naïve. 2 patients were excluded from analyses because they died severe heart failure in acute phase. Finally, 100 patients (evolocumab; n=51 and control; n=49) were analyzed. Baseline LDL-C was 121.6±30.3 mg/dl in the evolocumab group and 124.7±33.6 mg in the control group. Change in LDL-C from the baseline to 4 weeks was −92.4±32.4 mg/dl (−75%) in the evolocumab group and −44.8±32.1 mg/dl (−33.1%) in the control group (mean difference; 47.6mg/dl, 95% CI; 34.8 to 60.4 mg/dl, p<0.001). LDL-C <70mg/dl at 4 weeks was achieved in 96.0% of the evolocumab group as compared with 26.5% of the control group. Further, in the evolocumab group. LDL <55mg/dl was achieved in 92.1% at 2 weeks and 92.1% at 4 weeks. Regarding inflammatory markers, there were no significant difference in change in high-sensitivity C-reactive protein (p=0.49) and tumor necrosis factor-alpha (p=0.63) between two groups even after adjustment of baseline value. No adverse event associated with evolocumab was observed during this study.

Conclusion

In patients with AMI undergoing primary PCI, early initiation of evolocumab rapidly reduced LDL-C without no adverse event, and achieved LDL-C<55mg/dl in most patients within 2 weeks. Early administration of a PCSK9 inhibitor combined with a strong statin could be a feasible and safe treatment for AMI patients undergoing PCI.

Funding Acknowledgement

Type of funding source: None
The effects of empagliflozin on arterial stiffness, endothelial function and ventriculoarterial coupling in type 2 diabetes mellitus: 1 year follow up
Authors: Ikonomidis I , Thymis J , Pavlidis G , Birba D , Kalogeris A , Kousathana F , Kostelli G , Triantafyllou C , Katogiannis K , Lampadiari V , Iliodromitis E.K
Published: November 2020

Introduction

Sodium glucose cotransporters inhibitors (SGLT2i) are currently used in the treatment of patients with type 2 diabetes mellitus (T2DM) who pose high cardiovascular risk. However their effects on arterial stiffness, endothelial function and ventriculoarterial coupling have not been described.

Methods

We recruited 120 patients with T2DM. They received either the SGLT2i empagliflozin (n=60) or insulin (n=60). We measured at baseline and after 1 year of treatment: 1) Perfused Boundary Region (PBR 5–25μm) to evaluate endothelial glycocalyx integrity via Glycocheck, 2) Pulse wave Velocity (PWVc-f), 3)central systolic blood pressure (cSBP), 4) central Pulse Pressure (cPP) via Complior,5) the ratio PWV/GLS by echocardiography to assess ventriculoarterial coupling (VA coupling).

Results

The patients were matched for age, gender, smoking, hypertension and hyperlipidemia (p=NS). Hemoglobin A1c was deteriorated in both groups (8.1% vs 8.2%, p=NS). The baseline measurements of aforementioned markers did not differ between the 2 groups (p=NS). PWV was correlated with cSBP (r=0.4.p<0.05) and cPP (r=0.35, p<0.05) for all participants at baseline. After 1 year of treatment both groups achieved significant reduction of HbA1c. Patients treated with insulin showed an increase of PWV in contrary with empagliflogin group (11.4±0.5 to 12.6±0.4 vs 11.7±0.5 to 10.9±0.4, correspondingly, p<0.05). cSBP declined considerably in empagliflozin group (135±10 to 129±10 vs 134±9 to 136±9 respectively, p<0.05) and cPP remained approximately steady (47±8 to 48±8 vs 49±6 to 55±6 respectively, p<0.05) compared with insulin group. PBR dropped in SGLT2i group (2.20±0.2 to 1.98±0.2, p<0.05) whereas PBR fluctuated at the same level in insulin group (2.18±0.2 to 2.15±0.3, p=NS).PWV/GLS fell in both groups but the reduction was more prominent in empagliflozin group (−0.72±0.1 to −0.67±0.1 vs −0.72±0.1 to −0.60±0.1 respectively, p<0.05).

Conclusion

1 year treatment with empagliflozin resulted in improved markers of arterial stiffness, ventriculoarterial coupling and endothelial function, independently of glycemic control.

Funding Acknowledgement

Type of funding source: None
Effects of candesartan on left ventricular hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy
Authors: Maqsood H , Shakeel H.A , Shoukat H.F , Khan M.D , Shah S.A.Y , Gulraiz A
Published: November 2020

Introduction

Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular (LV) hypertrophy in the absence of pressure overload. Manifestations of the disease include heart failure associated with diastolic dysfunction and atrial and ventricular tachyarrhythmias. Pathological features of HCM include myocyte hypertrophy, interstitial fibrosis, and myocyte disarray and are mediated by angiotensin II.

Purpose

This study aimed to evaluate the effects of candesartan on left ventricular (LV) hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy (HCM).

Methods

In double-blind fashion, 30 patients (6 women, 24 men; age: 55±11 years) with HCM were randomly assigned to receive placebo (n=13) or candesartan 50 mg twice a day (n=17) for 1 year. To measure LV mass and extent of fibrosis, cardiac magnetic resonance imaging was performed at baseline and 1 year as assessed by late gadolinium enhancement.

Results

There was a trend toward a significant difference in the percent change in LV mass (median: +5% with placebo vs. −5% with candesartan; p=0.06). There was a significant difference in the percent change in the extent of late gadolinium enhancement, with the placebo group experiencing a larger increase (+30±27% with placebo vs. −22±44% with candesartan; p=0.03).

Conclusion

Our study concludes reduction of the progression of myocardial hypertrophy and fibrosis with candesartan in patients with hypertrophic cardiomyopathy. Our study population was limited so we warrant larger trials to confirm a place for angiotensin receptor blockers in the management of patients with hypertrophic cardiomyopathy.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Self funding
Impact of direct oral anticoagulants compared with warfarin in patients on dialysis: a meta-analysis
Authors: Sakurai R
Published: November 2020

Background

Direct oral anticoagulants have been demonstrated to have advantages in several patient populations compared with warfarin. However, the safety and efficacy are controversial between direct oral anticoagulants and warfarin in patients with chronic kidney disease, especially on dialysis, who have been excluded from randomised controlled trials.

Purpose

The purpose of this study was to investigate the safety and the efficacy of direct oral anticoagulants as compared to warfarin in patients on dialysis.

Methods

A meta-analysis was conducted on clinical studies in patients requiring oral anticoagulation and dialysis. PubMed, the Cochrane Library, and Web of Science were queried for the terms “dialysis”, “warfarin”, and “apixaban OR dabigatran OR rivaroxaban OR edoxaban”. The same terms or relevant studies were also queried on the website of the U.S. National Institute of Health and relevant reviews. The clinical endpoints were stroke/systemic embolism and major bleeding. Pooled estimates were calculated using a random-effects model.

Results

Six observational studies (18487 patients) were included in this study. The risk of major bleeding (odds ratio (OR) 0.45; 95% confidence interval (CI) 0.31–0.65; p<0.01) was lower in patients on direct oral anticoagulants compared to those on warfarin, whereas the risk of stroke/systemic embolism (OR0.63; 95% CI 0.30–1.33; p=0.23) was similar between the two types of anticoagulant.

Conclusions

Direct oral anticoagulants are associated with a lower risk of major bleeding and a similar risk of stroke/systemic embolism compared to warfarin in patients on dialysis. To validate these findings, randomised controlled trials are warranted.

Funding Acknowledgement

Type of funding source: None
Genetic polymorphisms and cardiovascular outcomes in Chinese patients undergoing PCI and treated with clopidogrel and aspirin
Authors: Xu K , Ying L , Chen J , Xu L , Li J , Zhu H , Wang F , Yang L , Zhang J , Fan Y , Zhu T , Kong D , Chan N , Li C
Published: November 2020

Background

Genetic polymorphisms of key proteins involved in clopidogrel absorption, metabolism, and action may contribute to variability in platelet inhibition in patients undergoing percutaneous coronary intervention (PCI), but their impacts on cardiovascular outcomes remain unclear.

Purpose

To examine the associations between genetic polymorphisms and cardiovascular outcomes in Chinese patients undergoing PCI and treated with clopidogrel and aspirin.

Methods

This prospective cohort study consecutively enrolled 2,453 post-PCI patients treated with clopidogrel and aspirin. Adenosine diphosphate-induced platelet aggregation was measured by light transmission aggregometry. A total of 40 single nucleotide polymorphisms (SNPs) of 18 genes selected according to published studies were investigated using an improved multiplex ligation detection reaction technique. The primary outcome was major adverse cardiovascular event (MACE), the composite of cardiovascular death, non-fatal myocardial infarction (MI), and ischemic stroke within one year after PCI.

Results

We restricted the analyses to the first 1,452 patients who had finished one-year follow-up and complete data on genotyping and platelet aggregation. 44 (3.03%) patients suffered MACE. Among the 40 SNPs, only the A-allele carriers of CYP2C19*2 had a significant higher risk of MACE (adjusted HR 2.05; 95% CI, 1.01–4.19; p=0.048) and platelet aggregation than non-A-carriers after adjusting age, sex, MI presentation, and left ventricular ejection fraction. CYP2C19*3, CYP2B6 rs3745274, and PEAR1 rs12041331 variants were also significantly associated with platelet aggregation (all p<0.05) but not with MACE at 1 year.

Conclusion

About 54.2% of Chinese patients with PCI were A-allele carriers of CYP2C19*2, who face a two-fold higher risk of MACE than non-A-allele carriers in Chinese patients after PCI. It would help identify low clopidogrel responders and optimize antiplatelet therapy before drug administration.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Natural Science Funding of China
Being married/having an intimate partner/being has protective effects for mild cognitive impairment in acute coronary syndrome patients
Authors: Gallagher R , Zhao E , Naismith S , Tofler G , Bauman A
Published: November 2020

Background

Cardiovascular disease (CVD) is a leading cause of mortality and morbidity and is known to contribute to cognitive impairment, a condition common in CVD patients. Cognitive impairment (CI) is important to detect, manage and accommodate because it limits the capacity of CVD patients to learn about secondary prevention and engage in appropriate self-care including lifestyle change.

Purpose

Therefore this study aimed to determine the prevalence and predictors of cognitive impairment in acute coronary syndrome (ACS) patients during hospital admission.

Methods

ACS (myocardial infarction, unstable angina) inpatients (n=81) who did not have a neurocognitive diagnosis were recruited to a prospective descriptive study in 2019. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) and the Hopkins Verbal Learning Test (HVLT).

Results

The sample had an age mean of 63.49±10.86 (range 40–89) years, was mostly male (82.7%) and 50.6% were university educated. MI occurred in 56.8%, equally STEMI (28.4%) and nSTEMI (28.4%) with 70.4% treated by coronary intervention.

The mean education adjusted MOCA score was 25.73±3.05 (range 18–31) and 48.1% were classified as having mild CI (18–26). The domain with the worst performance was delayed recall/memory domain at mean 2.58±1.77 (of potential 0–5 points). The mean unadjusted recall score on HVLT was 19.56±6.18 (range 0–32), the mean z-score −0.69±1.21 (range −4.59–1.87) and 40.7% were classified as having mild CI (age and education adjusted Z-score ≥−1). Mild CI was classified by both MOCA and HVLT (both adjusted) in 24.7%.

Patients classified as having mild CI (MOCA) were significantly older (66.87 versus 60.36 years, p=0.006) and less likely and to be married or have an intimate partner (21% versus 32% p=0.039). When all factors were taken into account using multiple linear regression, higher MOCA scores in patients who were married/partnered (B=1.6) and lower scores with advancing age (B=−0.08).

Conclusions

Mild CI and decreased delayed recall is prevalent in ACS patients and patient education strategies need to be accommodate this. Being married/partnered may have protective effects, therefore additional support may need to be directed to single patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart Foundation of Australia Vanguard Award
Introduction of a nurse led implantable loop recorder service
Authors: Van Der Heijden M
Published: November 2020

Introduction

An Implantable Loop Recorder (ILR) continuously records the patient's electrical cardiac activity and is used to diagnose cardiac causes of unexplained syncope that have not been diagnosed with other tools.

Method

Previously loop recorders were implanted in a dedicated pacing theatre by a consultant cardiologist. The patient was kept nil by mouth and the wound from the device was around 4 cm and was closed with sutures. The typical time in theatre was around 30 min. With the next generation of loop recorders, this device has become injectable and it is now becoming commonplace in various centers around the world, for nurses or allied health professionals to insert the ILR.

In our center we have recently set up an ILR service run by senior cardiac nurses without the need for medical staff to be present. A process was started, and a pathway/protocol developed, to set out the conditions under which a registered nurse can be credentialed to safely manage the care of patients for an ILR insertion, from admission to discharge.

A training program has been set up for nurses to be trained in obtaining informed consent, the use of a local anaesthetic and the technical/surgical skills for device implantation. The first 10 implants are done under direct supervision of the consultant, followed by a further 10 indirectly supervised before being signed off to perform this procedure independently. They are required to keep a log of their insertions for the first year and submit an audit of their practice after the first year of insertion practice. They will perform an annual audit for quality and complication monitoring and to assure continuing competency.

Most of these patients will be day-stay patients, cared for in the Cardiac cath lab holding area. Patients no longer require fasting and the incision, no longer than 1cm is closed with Steristrips and a waterproof dressing. The average procedure time is 10min. After wards the patients and their family are educated on wound care, use of the device and then discharged home.

The waiting time for this procedure has significantly reduced with cases now generally done within 2 weeks. Previously the waiting time for a consultant to implant a loop recorder was around 2 months.

Conclusion

Our experience so far is consistent with various publications worldwide and has demonstrated that non-medical, non Cath-lab ILR implantations are both safe and effective practice.

Funding Acknowledgement

Type of funding source: None
ECG Holter analysis to detect induced deconditioning on cardiac activity in bedridden volunteers
Authors: Solbiati S , Paglialonga A , Costantini L , Caiani E.G
Published: November 2020

Introduction

Prolonged bed rest (BR) is an unnatural state, often related to hospitalization, chronic diseases and ageing, inducing reduced functional capacity in multiple body systems, possibly leading to cardiovascular deconditioning. We hypothesized that measuring this decline over time could represent the first step for the formulation of appropriate countermeasures or rehabilitation programs while in the hospital. Accordingly, our aim was to assess the effects of 10-day horizontal BR on cardiac electrical activity.

Methods

Ten healthy male volunteers (23±5 years) were enrolled in an hospital, after ethical approval and signed consent, to participate to a 10-day strict horizontal BR campaign, preceded and followed by 2 days in the facility, respectively as acclimatization and recovery. The 12-leads 24-hours Holter ECG (1000 Hz, H12+, Mortara Instrument Inc.) was acquired 1 day before BR (PRE), the 5th (BR5) and 10th day (BR10) of bedridden immobilization. From each recording, beat-to-beat RR and QTend interval series, as well as T wave amplitude (Tamp) and upslope (Tslope) were computed. Statistical analysis was applied to test changes induced by BR (ANOVA with Tukey test, p<0.05), separately for day (7:00–23:00) and night (23:00–7:00) periods.

Results

Daily RR and QTend duration increased during BR, with peak changes at BR5 compared to PRE (+13.3% and +3% respectively), and were still prolonged at BR10 (+12.6% and +2.6%). During the night, while RR increased (BR5:+5.3%; BR10:+1.3%), QTend was found progressively shortened (BR5: −1.6%; BR10: −2.9%). Also, day and night Tamp (BR10: −19.5%) and Tslope (BR10 day: −17.1%; night: −7.8%) were found progressively reduced with the duration of BR.

Conclusion

During BR, cardiac electrical activity is affected by 10-days bedridden immobilization. Noticeably, a mismatch in RR-QTend relation was visible at night, where vagal autonomic system activity is prevailing.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Agenzia Spaziale Italiana (ASI)