bluuebunny/crossref_metadata_2025 huggingface dataset:
P5012Ten-year trends and outcomes in cardiogenic shock related to first-time acute myocardial infarction: a nationwide population-based cohort study
Authors: Dam Lauridsen M , Rorth R , Lindholm M G , Kjaergaard J , Schmidt M , Torp-Pedersen C , Gislason G , Kober L , Fosbol E L
Published: October 2019

Introduction

Despite declining incidence and mortality for acute myocardial infarction, cardiogenic shock remains a severe complication with poor in-hospital prognosis. Little is known about the temporal trends in hospitalization with acute myocardial infarction-related cardiogenic shock (AMI-CS) and the long-term prognosis.

Purpose

We aimed to investigate the hospitalization with first-time AMI-CS and subsequent 1-year mortality.

Methods

In this nationwide Danish cohort study we identified from 2005 through 2015 patients with first-time acute myocardial infarction and compared those with and without cardiogenic shock (defined by either an ICD-10 diagnosis code with cardiogenic shock and/or procedure code with inotropes or vasopressors). Patient characteristics and 1-year mortality were compared between groups using Kaplan-Meier plots and multivariable Cox regression analysis.

Results

We included 96,030 patients with acute myocardial infarction of whom 5.4% had cardiogenic shock. Median age was 69.7 years (IQR 59.0–80.1) and 37.5% were female among those without cardiogenic shock and 70.2 years (IQR 61.4–78.1) and 33.0% were female in those with cardiogenic shock. We observed no change in hospitalization with cardiogenic shock during the study period (5.45% in 2006 vs 5.54% for 2016, P for difference 0.6). One-year mortality was higher among those with cardiogenic shock relative those without (See Figure). Crude 1-year mortality risk associated with AMI decreased over time from 23.4% in 2006 vs 11.5% in 2016 (p for difference <0.0001) and this was consistent for AMI patients without CS (21.4% in 2006 vs 9.4% in 2016, p<0.0001) and patients with AMI-CS (58.1% in 2006 vs 46.2% in 2016, p<0.0001). When comparing patients with AMI-CS to those without in multivariable analysis, AMI-CS was associated with a 1-year mortality hazard ratio of 5.38 (95% CI 5.17–6.61)).

Cumulative 1-year mortality among patien

Conclusion

In a large population-based setting, this study suggests that the hospitalization for first-time AMI-CS was stable from 2005 through 2015, while mortality improved with time. However, the grave outcome related to AMI-CS remains with a 5-times higher mortality compared to AMI patients without CS.

Acknowledgement/Funding

Rigshospitalets Research Fund
P5017Factors associated with a negative D-dimer test in patients diagnosed with acute symptomatic pulmonary embolism
Authors: Barco S , Russo M , Klok F A , Konstantinides S V
Published: October 2019

Background

The recommended diagnostic strategy for suspected acute pulmonary embolism (PE) combines the assessment of pre-test probability, D-dimer level, and -if indicated- computed tomography pulmonary angiography.

Purpose

To evaluate the frequency and potential explanations for negative D-dimer tests in patients diagnosed with acute PE.

Methods

The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. The items of the Simplified revised Geneva Score and the D-dimer levels at diagnosis have been prospectively collected, but they did not necessarily guide management decisions. Quantitative D-dimer was measured on admission either by quantitative latex-based assays or enzyme-linked immunosorbent assays. A negative D-dimer was defined by fixed (0.50 μg/mL) or age-adjusted (age*0.01 μg/mL if age>50) cut-off.

Results

Using the fixed cut-off, a negative D-Dimer was detected in 17 of 773 patients with ultimately diagnosed PE (miss rate 2.2% [95% CI 1.4–3.5]); using the age-adjusted cut-off, the test was discordant with the PE diagnosis in 24 patients (3.1% [2.1–4.6]). In Figure 1, red dots indicate negative D-dimer test by fixed cut-off and blue dots indicate additional negative D-dimer tests by age-adjusted cut-off.

In 448 (59%) patients post-hoc classified as PE-unlikely, 11 (2.5% [1.4–4.3]) and 14 (3.1% [1.9–5.2]) patients had a negative D-dimer using the two different cut-offs, respectively. Haemoptysis on admission, V/Q scan-based diagnosis, and chronic lung disease were associated with a discordant D-dimer, while an inverse association existed for concomitant DVT. In 7 (29%) PE cases with normal D-dimer, PE was verified to be subsegmental also in a post-hoc evaluation. Another seven (29%) patients were receiving anticoagulation at the time of D-dimer assessment.

Figure 1

Conclusions

Our results show that the frequency of discordance between a normal D-dimer test and the diagnosis of acute PE is low, but not negligible. One third of discordant findings were related to subsegmental PE. Physicians should be aware that the risk of obtaining a false-negative D-dimer might be higher in specific subgroups of patients.

Acknowledgement/Funding

The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG
P5020Modified CT-based Bova score may improve the classification of patients with acute pulmonary embolism at risk of adverse events
Authors: Skowronska M Z , Karolak B , Ciurzynski M , Machowski M , Paczynska M , Pacho S , Wyzgal-Chojecka A , Roik M , Kostrubiec M , Kurnicka K , Wisniewska M , Pruszczyk P
Published: October 2019

Background

Whether the Bova score with right ventricle dysfunction (RVD) assessed is computed tomography (CT) may be used for prognosticating adverse events (AE) in normotensive patients with acute pulmonary embolism (PE) is not fully determined.

Aim

To determine: (1)the optimal cut-off for RVD in CT for AE;(2)whether CT-assessed RVD may accurately substitute TTE-assessed RVD and improve the Bova score for risk assessment in PE.

Methods

Post-hoc analysis of a prospective study of 171 consecutive normotensive pts (93F, mean age 64.7 y.o. ±19) with at least segmental APE confirmed in CT. BP, HR, hsTnT and TTE for RVD were assessed within the first 24-hours from admission. CT-RVD was measured from a diagnostic angio-CT using the RV/LV transverse-axis diameter ratio. The Bova score was calculated from patient records. The combined endpoint (PCE) included PE-related death and/or hemodynamic deterioration requiring catecholamines i.v., rescue thrombolysis, cardio-pulmonary resuscitation; the secondary combined endpoint (SCE) included PE and non-PE events as above and hemorrhagic events. Proposed CT-RVD cut-offs and subsequent CT-based Bova vs TTE-based scores were compared using AUROCs and net reclassification improvements (NRI).

Results

70 (41%) low-risk patients and 101 (59%) intermediate-risk pts classified according to the ESC algorithm. The PCE occurred in 5 pts, the SCE in 23 pts. TTE-Bova showed AUROC=0.918 (0.806–1.0; p=0.000) for the PCE, and 0.623 (0.545–0.696; p=0.000) for the SCE. The NRIs for the investigated cut-offs for CT-Bova vs TTE-Bova for the PCE are presented in the Table. AUROCs for SCE for CT-Bova vs TTE-Bova are presented in the Figure.

Comparison of CT-Bova and TTE-Bova NRIs for CT-Bova vs TTE-Bova for primary endpoint CT-Bova AUROC (95% CI) RV/LV cut-off No of points NRI (SE) p >0.9 2 0.02 (0.03) 0.58 – >1.0 2 0.17 (0.04) 0.00 0.948 (0.903–0.976)* >1.1 2 0.06 (0.20) 0.75 – when >1.0 and >1.2 1; 2 0.20 (0.04) 0.00 0.927 (0.877–0.961)* AUROC for TTE-Bova 0.918 (0.806–1). AUROC, area under the receiver-operator curve; NRI, net reclassification improvement; SE, standard error. *Denotes no significant differences in AUROCs for CT-based Bova with investigated cut-offs.

AUROC for CT-Bova RV/LV>1.0 and TTE-Bova

Conclusion

CT-based Bova with RV/LV>1.0 for RVD is non-inferior to TTE-based score in the prediction of PE-related in-hospital adverse events in normotensive patients and might improve the stratification of the occurrence of any adverse event. A modified score with a two-step cut-off for RV/LV (1 point for >1.0 and 2 points for >1.2) may more accurately predict PE-related events.
P5237Continued financial benefits of LATIN telemedicine program from avoiding unnecessary transfer of patients
Authors: Mehta S , Botelho R , Niklitschek S , Fernandez F , Cade J , Cavalcanti R , Dusilek C , Estrada A , Lacativa M A , Cardoso R , Frauenfelder A , Matheus C , Vieira D , Torres M A , Vallenilla I
Published: October 2019

Background

Latin America Telemedicine Infarct Network (LATIN) employed telemedicine to construct a population-based AMI program in Brazil, Colombia, Mexico, and Argentina. It increased access, accuracy and guidelines-based care and addressed fiscal issues. Previously, we demonstrated a cost and benefit analysis (CBA) of LATIN based upon avoiding unnecessary transfers and hospitalization. We have performed a scrupulous follow up of this initial observation with a long-term follow up from all expanded LATIN sites.

Purpose

To demonstrate that telemedicine avoids unnecessary transfer of patients.

Methods

784,947 patients at LATIN spokes (small clinics in remote areas) were screened and CBA measured at hubs, spokes and telemedicine centers. Technology, transfer, inpatient, and procedure-related costs were included. A sensitivity analysis was performed for worst and best scenarios of costs, revenues, and savings. A comparison with Avera e-Emergency (Sioux Falls, SD) Telemedicine program, involving 85 rural hospitals in 7 states, is provided (13% transfer avoidance).

Results

Of 784,947 screened patients, 8,448 had STEMI (1.08%); 3,911 (46.3%) were urgently reperfused, 3,049 (78%) with PPCI. Time to Telemedicine Diagnosis was 3 min. With efficient triage, costs for non-AMI patients was controlled. LATIN expenses, including for IT and experts, were $272, and for transfer and indirect care, $1,068. Net savings/patient were $796. Savings, till date, range between $187.4 million and $62.4 million (Best scenario −30% transfer avoidance; Worse scenario −10% transfer avoidance).

Conclusions

Longitudinal analysis firms the trend of enormous cost savings with LATIN. Telemedicine avoids unnecessary transfers and hospitalization and it is a cost-effective strategy for population-based AMI programs.
P5240The cost of pacemaker complications
Authors: Brough C
Published: October 2019

Background

The implantation rate of de novo pacemakers across ESC member countries continues to increase (21,595 per million in 2007 to 28,413 per million in 2016), with an anticipated growth in revision procedures. Revision procedures have a higher rate of complications than de novo implants, all with an associated cost which is infrequently reported in literature.

Purpose

We report the complications/re-operations of standard pacemaker procedures and patient morbidity to 1 year, with all complications micro-costed.

Methods

A retrospective cohort analysis of all pacemaker procedures at a single UK centre was conducted between April 2008–2016. Complications/ re-operations were defined as; 1. Any pneumothorax, 2. Pericardial effusion on transthoracic echocardiogram performed due to clinical concern, 3. Haematoma requiring surgical evacuation, 4. Lead intervention, 5. Device reburial, 6. System explant 7. System re-implant and 8. System upgrade.

Results

6,408 pacemaker procedures were performed; 1,261 single chamber (66.5% primary implant, 27.8% generator replacement, 2.0% lead revision, 1.7% generator and lead, 1.9% reburial); 3,465 dual chamber (61.8% primary implant, 29.7% generator replacement, 3.0% lead revision, 3.3% generator and lead, 0.5% upgrade, 1.7% reburial) and 1,682 CRTP (66.7% primary implant, 8.1% generator replacement, 5.2% lead revision, 1.2% generator and lead, 17.1% upgrade, 1.7% reburial). Table 1 demonstrates the rate of complications according to index procedure and 12 month morbidity.

The total cost of rectifying complications was €1,280,285; primary implants €454,860, generator replacements €298,394, system reburials €217,785, lead revisions €61,818, upgrades €99,140 and generator and lead procedures €148,288.

Table 1. Complication and Re-Operation Rates According to Index Procedure and 12 Month Morbidity Index Procedure 12 Month Morbidity Complication/ Re-operation rate (%) (%) Single chamber Dual chamber CRTP Single chamber Dual chamber CRTP Primary 1.8 3.9 4.8 2.5 5.0 5.1 Generator replacement 2.8 3.2 5.9 3.1 3.9 5.9 Generator and lead 18.2 13.0 14.3 22.7 13.9 14.3 Upgrade – 11.1 7.6 – 11.1 8.0 Lead only 4.0 11.7 9.2 4.0 14.6 9.2 Reburial 16.7 16.9 32.1 16.7 18.6 32.1

Conclusion

Complication and re-operation rates are dependent upon the procedure performed and the complexity of device. Expenditure on rectifying complications is significant (€2,560,570 over 8 years).
P5252Can functional MR imaging supersede angiography? An audit of stress cardiac MRI outcomes compared those seen in the CE-MARC trials
Authors: Brown A , Thomas H , Matthews I , Runnett C , Lee A , Ripley D
Published: October 2019

Background

Recent studies have compared the performance of cardiac MRI (CMR) with coronary angiography. The CE-MARC trial established CMR's high diagnostic accuracy for coronary artery disease (CAD). Following these results, and those of CE-MARC 2, which showed reduced unnecessary angiography rates with CMR-guided care, we increased our adoption of CMR as an investigation of choice for CAD at our centre.

Purpose

In patients who have a CMR for stable angina, what is the outcome after detection of CAD, how do findings compare with angiography, and do those without CAD identified go on to have a major adverse cardiovascular event (MACE)?

Method

We performed a retrospective audit of all stress CMR performed from August 2016 to March 2017 at our hospital in North England. All patients were followed up for a minimum of 12 months.

NICE guideline care was used during the study period. The CE-MARC trial was used for quality standards and to compare results.

Results

91 stress CMRs were performed. 13 were excluded as they were performed on out-of-area patients. Median follow up was 14.5 months.

Of the remaining 78 patients, 34 (43%) had a positive CMR. 20/34 (59%) proceeded to angiogram. In 16/20 of patients, CMR findings correlated with angiogram findings. A PPV of 80%. The PPV in CE-MARC was 77.2% (72.1–81.6).

Of those who did not proceed to angiography, 8/14 had non-viable myocardium, 3 continued with medical management, in two it was unclear. 3/34 (8.8%) with positive CMR had a MACE.

44 patients had a negative CMR. Three had an angiogram during follow up. All were negative. There was a MACE in 1/44 (2.3%).

Conclusion

The audit population has a similar PPV to that of CE-MARC.

MACE rates at 12 months were similar to CE-MARC which suggests that the trial results are reproducible in our setting. The wider use of CMR can therefore improve investigation and management for patients with stable angina.

The audit is limited by the small number of patients proceeding to angiogram and the ability to confirm negative CMR results.
P5255Culprit vessel related myocardial mechanics and prognostic implications following acute myocardial infarction
Authors: Backhaus S J , Kowallick J T , Stiermaier T , Lange T , Koschalka A , Navarra J L , Lotz J , Kutty S , Bigalke B , Gutberlet M , Feistritzer H J , Hasenfuss G , Thiele H , Eitel I , Schuster A
Published: October 2019

Background

Prognosis in acute myocardial infarction (AMI) depends on the amount of infarct related artery (IRA) subtended myocardium and associated damage but has not been described in great detail. Consequently, we sought to describe IRA associated pathophysiological consequences using cardiac magnetic resonance (CMR).

Methods

1235 AMI patients (n=795 ST-elevation (STEMI) and 440 non-STEMI) underwent CMR following percutaneous coronary intervention. Blinded core-laboratory data were compared according to left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA) regarding major adverse clinical events (MACE) within 12 months. Left ventricular (LV) global longitudinal/circumferential/radial (GLS/GCS/GRS) as well as left atrial (LA) total (εs), passive (εe) and active (εa) strains were determined using CMR-feature tracking. Tissue characterisation included infarct size (IS) and microvascular obstruction.

Results

LAD and LCx were associated with higher mortality compared to RCA lesions (4.6% and 4.4% vs 1.6%). LAD lesions showed largest IS (16.8%), largest ventricular (LV ejection fraction (EF) 47.4%, GLS −13.2%, GCS −20.8%) and atrial (εs 20.2%) impairment. There was less impairment in LCx (IS 11.8%, LVEF 50.8%, GLS −17.4%, GCS −25.0%, εs 20.7%) followed by RCA lesions (IS 11.3%, LVEF 50.8%, GLS −19.1%, GCS −26.6%, εs 21.7%). In AUC analyses εs (LAD, RCA) and GLS (LCx) best predicted MACE (AUC>0.69). Multivariate analyses identified εs (p=0.017) in LAD and GLS (p=0.034) in LCx infarcts as independent predictors of MACE.

Conclusions

CMR allows IRA specific phenotyping and characterisation of morphologic and functional changes. These alterations carry infarct specific prognostic implications and may represent novel diagnostic and therapeutic targets following AMI.

Acknowledgement/Funding

DZHK - German Centre for Cardiovascular Research
P5257Prediction of 12-month cardiovascular event-free survival with regadenoson perfusion cardiovascular magnetic resonance
Authors: Weiss H , Behm P , Gastl M , Kelm M , Boenner F
Published: October 2019

Background

To identify and stratify coronary artery disease (CAD) non-invasively, cardiovascular magnetic resonance (CMR) derived perfusion imaging holds a class Ia recommendation.

As Gold standard, hyperemia is induced by an intravenous application of adenosine in a body weight adapted dosage over a constant time. However, adenosin has two disadvantages: 1.) efficacy of adenosine to induce maximal hyperemia via peripheral line is imperfect and 2.) additional adenosine specific effects exclude patients having comorbidities (e.g. AV-blocks and obstructive lung disease). Fortunately, regadenoson as aselective A2A-receptor agonist has the main advantages of being easier to handle (bolus application) and to be not restricted to patients without specific comorbidities. However, there is a lack of comprehensive data on the prognostic value of regadenoson perfusion CMR to predict clinical endpoints. To assess the predictive value of regadenoson perfusion CMR, our hypothesis was, that a “negative” ischemia test result by regadenoson-CMR predicted freedom from MACE at 12 month.

Methods

676 patients, with known or suspected CAD with intermediate risk were retrospectively analyzed from May 2015 till December 2016. Cardiovascular risk factors (CVRF) like age, sex, arterial hypertension, dis-/hyperlipidemia, cigarette smoking status and diabetes were documented. All included patients received perfusion CMR (Philips 1.5 Tesla) with regadenoson (0.4 mg) and a positive ischemia test was defined as perfusion defects in ≥1,5 cardiac segments (using the 17-segment model). Major cardiovascular events (MACE) were defined as cardiovascular death, rehospitalisation due to myocardial infarction and rehospitalisation due to revascularization. The follow-up time was 12 month.

Results

80,3% (n=543) of all analyzed patients showed negative ischemia testing in CMR and were thus followed up for 12 month. From these patients, 284 (52,3%) had a pre-existing coronary artery disease. The mean age regarding only the patients with negative ischemia was 66 years (65% male and 35% female) with 1,35±1,03 CVRF. The primary endpoint (MACE) occurred in 6 patients (1,1%): 3 (0,6%) died due to cardiovascular events, 1 (0,2%) suffered from a myocardial infarction and 2 (0,4%) received coronary revascularization. Consequently, an event-free survival was correctly predicted in 98,9% of all patients. No undesirable adverse reactions have appeared.

Conclusion

Regadenoson-CMR predicts a very low MACE-rate and an event-free survival in 98,9% in over 500 patients. In our study, Regadenoson was well tolerated and no side effects were reported.
P5270Impaired myocardial deformation assessed by cardiac magnetic resonance is associated with increased arrhythmic risk in hypertrophic cardiomyopathy
Authors: Barbosa A R , O'neill C M , Ruivo C , Cruz I , Sousa O , Dias Ferreira N , Braga P , Rocha Lopes L
Published: October 2019

Background

Strain techniques, such as feature tracking cardiac magnetic resonance (FT-CMR), have emerged as a promise for more accurate evaluation of cardiac function compared to ejection fraction. In hypertrophic cardiomyopathy (HCM) patients, impaired myocardial deformation measured by FT-CMR has been associated with severity of hypertrophy and presence of late gadolinium enhancement (LGE) but associations with clinical severity and prognosis are scarce.

Purpose

To analyse the association between left ventricular strain measured by FT-CMR, morphologic features and prognostic markers in patients with HCM.

Methods

Retrospective analysis of clinical, echocardiography, Holter and CMR data of HCM patients aged ≥16 years followed at two referral centres. Ventricular arrhythmias (VA) were defined as non-sustained or sustained ventricular tachycardia or sudden cardiac arrest. Sudden cardiac death (SCD) risk was evaluated using the score proposed by the European Society of Cardiology. LGE extension was evaluated using the American Heart Association 17-segment model. FT-CMR was used to evaluate global peak systolic longitudinal (GLS), radial (GRS) and circumferential (GCS) strains - GLS was averaged from three standard longitudinal views while GRS and GCS were averaged from the basal, mid and apical LV short-axis planes.

Results

A total of 109 HCM patients (59.2±16.2 years old; 60.6% males) were included; mean follow-up was 39±25 months. Mean LV mass was 170.6±70.3g, LVEF was 63.7±10.0% and the number of segments with LGE was 3.14±3.32. Mean GLS, GRS and GCS were −14.8±4.0%, 34.4±13.3% and −17.5±4.8%, respectively. Impaired strain was associated with higher LV mass (GLS: r=0.46, GRS: r=−0.46, GCS: r=0.47, p<0.001 for all), reduced LVEF (GLS: r=−0,33, GRS: r=0,44, GCS: r=−0.41, p<0.003 for all) and LGE extension (GLS: r=0.26, GRS: r=−0.38, GCS: r=0.38, p<0.01 for all).

SCD risk score was 3.12%±2.98 (8 patients scored as high risk) and VA were documented in 26 patients (26%). Patients with VA had worse strain values than those without (GLS −13.2±4.12 vs −15.5±3.71, p=0.011; GCS −15,8±5.22 vs −18.3±4.24, p=0.017). Patients with high estimated risk of SCD also had worse strain values than those at low/intermediate risk (GLS −12.2±3.57 vs −15.1±3.83, p=0.048; GCS −14.5±4.26 vs −17.9±4.54, p=0.047). A correlation between SCD risk and GLS and GCS was observed (r=0.32, p=0.004; r=0.23, p=0.03, respectively).

Conclusions

In our population, worse strain measurements were associated with a more severe HCM phenotype, presence of VA and a higher estimated risk of SCD. Strain assessed by FT-CMR may improve risk stratification in HCM patients.
P5277Head to head comparison of MOLLI sequences against hs-troponin in patients with biopsy proven myocarditis
Authors: Vasquez M , Zainal H , Zhou H , Arcari L , Sokalskis V , Vasa-Nicotera M , Zeiher A , Nagel E , Puntmann V
Published: October 2019

Introduction

Increase in native T1 mapping values provides insight into presence of disease and its evolution. Despite the surge of evidence, the immediate clinical application of these techniques is complicated by several variants of T1 mapping sequences, whose diagnostic bioequivalence is not known.

Methods

We undertook an intra-individual comparison of two native T1 measurements based on modified Look-Locker (MOLLI) schemes, MOLLI 3(2)3(2)5 (flip angle, FA 50°, T1-FFM) and MOLLI 5(3)3 (FA 35°, T1 Long) in 30 patients with myocarditis proven by left ventricular endomyocardial biopsy. We examined their agreement with high-sensitive troponin T (hs-TnT) levels, as the reference standard for myocyte injury. All patients underwent a routine cardiovascular magnetic resonance (CMR) scan using a 3-Tesla clinical scanner. Native T1 values were estimated using a septal region of interest (ROI) in a single mid ventricular short axis (SAX) slice. Areas of late gadolinium enhancement (LGE) were excluded from ROIs. Venous blood was sampled at the time of the CMR study and hs-TnT analyzed using standardized commercially available test kits. A p value <0.05 was considered statistically significant.

Results

Native T1 by T1-FFM was moderately associated with MOLLI 5(3)3 (FA 35°) (Pearsons r=0.877, p<0.0001), however the Bland Altman analysis showed a poor agreement with a fixed bias of 46ms (p 0.001) and evidence of proportional bias (p 0.008). There was a significant correlation between native T1-FFM and hs-TnT (rho=0,500, p 0.018), whereas T1 Long showed no association (rho=0,374, p 0,086).

Conclusions

Although native T1 by T1 Long showed a moderate correlation with the native T1 FFM in patients with biopsy proven myocarditis, only T1 FFM had a significant correlation with hsTnT suggesting a greater sensitivity for myocardial injury.
P5283The prognostic value of contouring papillary muscles vs. simplified contouring in CMR volumetry of the left ventricle
Authors: Haney A , Riffel J , Katus H A , Friedrich M G , Ochs M
Published: October 2019

Background

Cardiovascular magnetic resonance (CMR) has evolved as a gold standard for the quantitative assessment of functional parameters. While only inclusion of trabecles and papillary muscles (TPM) accurately reflects anatomy, a simplified approach is frequently used, that “cuts off” this tissue when contouring. Current recommendations favour their inclusion yet also allow for a simplified method. No data exist on any impact of the selection of methods on the prognostic value of the CMR findings.

Purpose

We aimed to assess the prognostic value of left ventricular (LV) volumetry in non-ischemic dilated cardiomyopathy (NIDCM) assessed by CMR with (1) the exclusion method (accounting TPM to LV cavity volume) or (2) the inclusion method (accounting TPM to LV mass). Furthermore, the predictive value of measuring myocardial mass in end-systole compared with end-diastole was evaluated.

Methods

Three-hundred forty-six patients with NIDCM who had undergone CMR examination between 2005 and 2013 were enrolled for retrospective analysis. Left ventricular endo- and epicardial contours were acquired by semi-automatic threshold detection in end-diastole and in end-systole, both with the inclusion and the exclusion method. The combined endpoint was cardiac death, heart transplantation, cardiac decompensation, ventricular tachycardia or ventricular fibrillation. Cox regression analysis was performed to evaluate prognostic impact.

Results

Primary endpoint occurred in 76 patients during a median follow-up of 4.5 years. A significant absolute difference between the two measurement methods was shown for ejection fraction (EF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV) and myocardial mass both in end-systole and end-diastole (p<0.05). Correlation analyses showed significant direct correlation between the two measurement methods. However, in multivariate Cox regression, there was no significant difference in prediction of the combined endpoint between using the inclusion or the exclusion method for EF, LVESV, LVEDV and myocardial mass. Similarly, there was no significant difference in analysis of myocardial mass in end-diastole compared with end-systole.

Conclusion

In patients with non-ischemic dilated cardiomyopathy, there is no impact of the contouring method (inclusion vs. exclusion of trabecular tissue an papillary muscles from myocardial tissue) on the prognostic value of a CMR volumetry. Although there is a significant absolute difference in measurements, the prediction of adverse events is not influenced.
P5285Pressure-volume relationship by cardiovascular magnetic resonance: feasibility and clinical implications
Authors: De Luca A , Meloni A , Nugara C , Cappelletto C , Aquaro G , Grigoratos C , Todiere G , Barison A , Novo G , Sinagra G , Pepe A
Published: October 2019

Background

The variation between rest and peak stress end-systolic pressure-volume relation (ESPVR; the Suga index) is easily obtained during routine stress echocardiography and has been established as a reasonably load-independent index of myocardial contractile performance that provides prognostic information above and beyond regional wall motion.

Purpose

This is the first study assessing the delta rest-stress ESPVR (DESPVR) by stress Cardiovascular Magnetic Resonance (CMR).

Methods

Eighty-five consecutive patients (19 females, main age 62.99±9.26 years) who underwent dipyridamole stress-CMR in a high volume CMR Laboratory were considered. The ESPVR was evaluated at rest and peak stress from raw measurement of systolic arterial pressure by cuff sphygmomanometer and end-systolic volume by biplane Simpson method.

Results

Mean ESPVR index at rest and peak stress was, respectively, 4.52±2.26 mmHg/mL/m2 and 4.62±2.32 mmHg/mL/m2 and mean DESPVR was 0.11±1.19 mmHg/mL/m2.

DESPVR was not associated to age or sex.

An inverse relationship between rest left ventricular end-diastolic volume index (LVEDVI) and both rest and peak ESPVR was present (R=-0.805 P<0.0001 and R=-0.795 P<0.0001, respectively), but it was absent when the DESPVR was considered (R=0.170 P=0.121).

An abnormal stress CMR was found in 22 patients and the DESPVR was comparable between patients with normal and abnormal stress exam.

During a median follow-up of 60.62 months (IQ range 36.78 months), 27 cardiovascular events occurred: 3 deaths, 1 ventricular arrhythmias, 9 coronary syndromes, 14 heart failure hospitalization. At receiver-operating characteristic (ROC) curve analysis, a DESPVR<0.009 predicted the presence of future cardiac events with a sensitivity of 0.70 and a specificity of 0.64 (P=0.049).

Conclusions

We showed for the first time that dipyridamole stress CMR can be used for the assessment of DESPVR. DESPVR was shown to be independent from chamber size and, as a consequence, can be used for a comparative assessment of patients with different diseases. DESPVR by CMR can provide a prognostic stratification and the optimal cutoff for relevant events was 0.009.
P5294Metabolically healthy obese is associated with better left atrial function and lower risk of adverse cardiovascular events including atrial fibrillation
Authors: Lai Y H , Liu Y M , Liu M E , Su C H , Yeh H I , Hung C L
Published: October 2019

Purpose

Metabolic syndrome (MetS) and obesity are both crucial risk factors for heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF). However, the prognostic value of utilizing left atrial (LA) deformation imaging in metabolically healthy obese (MHO) or metabolically unhealthy normal weight (MUNW) subjects remains largely unexplored.

Methods

Speckle-tracking echocardiography was used to evaluate LA strain and strain rate among 3,915 subjects free from clinical heart failure (mean age: 50.0±10.6 years, 66.2% male) undergoing annual cardiovascular health survey. Metabolically unhealthy was defined by the presence of at least one MetS component or history of cardiovascular disease. Participants were categorized as: metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy overweight/obese (MHO), metabolically unhealthy overweight/obese (MUO).

Results

Markedly decreased LA strain, early-diastolic LA strain rate and increased LA stiffness were observed with metabolic disorders (all trend p: <0.05). During a median follow-up period of 3.68 years, significantly higher risk of primary endpoints (death, heart failure, major cardiovascular events) was observed in MUO vs. MHO (HR=1.87, p=0.005) and MUNW vs. MHNW (HR=2.82, p=0.004). Similar patterns with incident AF (MUO vs MHO: HR=3.05, p=0.001, MUNW vs MHNW: HR=4.04, p=0.002) were also observed. After multivariate adjustment, risk of AF remained associated with low LA strain (β=−0.07, p<0.001), systolic LA strain rate (β:−0.05, p=0.007) and high LA stiffness (β=0.18, p<0.001).

Comparison between metabolic groups MHNW (N=1107) MUNW (N=255) p (MUNW vs MHNW) MHO (N=1859) MUO (N=694) p (MUO vs MHO) Age 48±10.57 54.29±11.52 <0.001 49±10.02 54.21±10.49 <0.001 LA GLS (%) 40.6±7.68 37.16±7.5 <0.001 36.77±7.66* 33.58±8.01‡ <0.001 LA SRs 1.79±0.41 1.76±0.48 NS 1.63±0.39* 1.55±0.41‡ <0.001 LA SRe 2.11±0.62 1.8±0.63 <0.001 1.68±0.55* 1.48±0.52‡ <0.001 LA stiffness 0.17±0.08 0.22±0.12 <0.001 0.21±0.11* 0.25±0.13‡ <0.001 *p<0.001 for MHO vs MHNW, ‡p<0.001 for MUO vs MUNW. LA GLS = left atrial global longitudinal strain, LA SRs = left atrial systolic strain rate, LA SRe = left atrial early-diastolic strain rate, NS = non-significant.

Kaplan-Meier curves of adverse events

Conclusion

Metabolic abnormality may contribute to certain aspects of mechanistic LA dysfunction tightly linked to clinical events, even with normal lean body mass. Our observations may be insightful for targeted interventions in higher-risk patients with subclinical atrial dysfunction.
P5297Body weight in adolescent men in Sweden and risk of an early acute coronary event
Authors: Aberg M , Robertson J , Waern M , Schaufelberger M , Kuhn H G , Aberg N D , Schioler L , Toren K , Rosengren A
Published: October 2019

Background

To improve cardiovascular disease (CVD) prevention, knowledge of early key risk factors, especially those that are modifiable such as overweight and obesity, is essential.

Purpose

We aimed to determine whether body mass index (BMI) at age 18 predicted early acute coronary events among men in Sweden.

Methods

Population-based Swedish cohort study of conscripts (n=1,668,921; mean age at baseline, 18.3 years) who enlisted during 1968–2005. Follow-up was done through linkage to the nationwide Swedish patient- and death registries. Risk of an acute coronary event (hospitalization for acute myocardial infarction or coronary death) during follow-up (5–46 years) was calculated with Cox proportional hazards models. Objective baseline measures of fitness and cognition were included in the models in a second set of analyses.

Results

During follow-up there were 22,412 acute coronary events (mean age at diagnosis, 50.2 (SD 7.4) years, maximum 64 years). Compared with men with BMI of 18.5 to 20.0 kg/m2, men with BMI 20 to <22.5 and 22.5 to <25.0 kg/m2 had hazard ratios (HR) of 1.17 (1.12–1.43) and 1.51 (1.44–1.59), respectively, for an acute coronary event, after adjustment for age, year of conscription, comorbidities at baseline, parental education, blood pressure, IQ, muscle strength, and fitness. Those with a BMI of ≥35 kg/m2 had an HR of 3.47 (2.75–4.39) for an event before the age of 65. The multiple-adjusted risk per 1-unit increase in BMI was 1.10 (95% CI, 1.09–1.10).

Conclusion

We found a rise in risk of an early acute coronary event detectable already at normal levels of body weight at age 18, and rising to more than 3-fold in the highest weight category. Given increasing levels of body weight, and prevalence of overweight and obesity in young adults, the current decrease in coronary heart disease incidence in Sweden may flatten or even reverse in the near future.

Acknowledgement/Funding

The Swedish Heart and Lung Foundation [2015-0438]; the Swedish Research Council [2013-5187,2013-4236]
P5314Albumin is a prognostic marker of long-term outcomes in patients with triple-vessel coronary artery Disease: a large data from China
Authors: Zhao X Y , Jiang L , Xu L J , Zhao Y Y , Xu B O , Gao R L , Song L , Yuan J Q
Published: October 2019

Background

Hypoalbuminemia was reported to be associated with poor prognosis in severe diseases. Triple-vessel coronary artery disease (TVD) has high risk of death. We aimed to evaluate the predictive value of hypoalbuminemia in TVD patients.

Methods

A total of 8,943 consecutive TVD patients were enrolled from April 2004 to February 2011. The primary endpoint was all-cause death and the secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE; a composite of all-cause death, myocardial infarction or stroke). Patients were divided into two groups according to normal serum albumin level (<4.0 g/dL and ≥4.0 g/dL).

Results

During the median of follow-up 7.5 years, 1365 deaths and 2354 MACCE occurred. Multivariate Cox regression indicated that hypoalbuminaemia (<4.0 g/dL) was an independent predictor of all-cause death (HR 1.30, 95% CI 1.14–1.50, P<0.001) and MACCE (HR 1.19, 95% CI 1.07–1.32, P<0.001). Adjustment of the all-cause death risk estimated by albumin improved the predictive value of SYNTAX score (AUC from 0.585 to 0.602, P=0.002; IDI=0.005, P<0.001; NRI=0.205, P<0.001). For SYNTAX II score, improvement was shown for NRI and IDI but not for AUC (SYNTAX II for PCI: IDI=0.003, P<0.001; NRI=0.205, P<0.001; AUC from 0.711 to 0.713, P=0.257; SYNTAX II for CABG: IDI=0.002, P<0.001; NRI=0.205, P<0.001; AUC from 0.696 to 0.698, P=0.120).

Predictive value for all-cause death using the AUC, NRI and IDI AUC (95% CI) P value NRI (95% CI) P value IDI (95% CI) P value SYNTAX 0.585 (0.568–0.602) Ref. Ref. – Ref. – SYNTAX + albumin 0.602 (0.586–0.619) 0.002 0.205 (0.145–0.264) <0.001 0.005 (0.004–0.007) <0.001 SYNTAX II (for PCI) 0.711 (0.696–0.726) Ref. Ref. – Ref. – SYNTAX II (for PCI) + albumin 0.713 (0.698–0.728) 0.257 0.205 (0.145–0.264) <0.001 0.003 (0.001–0.004) <0.001 SYNTAX II (for CABG) 0.696 (0.680–0.711) Ref. Ref. – Ref. – SYNTAX II (for CABG) + albumin 0.698 (0.683–0.714) 0.120 0.205 (0.145–0.264) <0.001 0.002 (0.001–0.004) <0.001

Multi-factor adjusted KM analysis in TVD

Conclusions

For TVD patients, hypoalbuminaemia was a strong independent prognostic factor for long-term outcomes of death and MACCE. Albumin improved the prediction of death with the SYNTAX score and the SYNTAX II score.

Acknowledgement/Funding

CAMS Innovation Fund for Medical Sciences (2016-I2M-1-002), Beijing Natural Science Foundation (7181008)
P5322Oxidized phospholipids on apolipoprotein B-100 among black US adults with and without PCSK9 loss-of-function variants
Authors: Mefford M , Marcovina S , Bittner V , Cushman M , Brown T , Farkouh M , Tsimikas S , Monda K , Lopez J , Muntner P , Rosenson R
Published: October 2019

Background

High oxidized phospholipid-apolipoprotein B-100 (OxPL-apoB) levels are associated with an increased risk for coronary heart disease (CHD). Genetic PCSK9 loss-of-function (LOF) variants result in life-long lower levels of LDL-C and lipoprotein(a) and reduced CHD risk, but the association with OxPL-apoB is unknown.

Purpose

To estimate the association between PCSK9 LOF variants and OxPL-apoB levels among black adults.

Methods

Genotyping for LOF variants (Y142X and C679X) was conducted for 10,196 black Reasons for Geographic And Racial Differences in Stroke study participants. OxPL-apoB was measured using antibody E06 for all participants with LOF variants (n=241) and randomly selected participants, matched at a 1:3 ratio, without LOF variants (n=723). Low OxPL-apoB was defined as the bottom quartile of the population distribution (<1.6 nM). Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated for the association between PCSK9 LOF variants and low OxPL-apoB levels adjusting for age, sex, and estimated glomerular filtration rate.

Results

Adults with versus without PCSK9 LOF variants had lower LDL-C and lipoprotein(a) and were less likely to be taking a statin. (Table) A higher proportion of adults with versus without PCSK9 LOF variants had low OxPL-apoB levels (30.3 vs 23.4, p=0.03). After adjustment for covariates, the PR of low OxPL-apoB was increased for participants with compared to without LOF variants (PR 1.31, 95% CI 1.00, 1.72).

Characteristics of REGARDS participants PCSK9 loss-of-function variant p-value Yes (n=241) No (n=723) Age, years, mean (SD) 63.7 (9.2) 63.8 (8.6) 0.81 Female, % 61.4 60.6 0.82 Diabetes, % 34.4 27.4 0.04 LDL-C, mg/dL, mean (SD) 85 (32) 118 (37) <0.001 Lp(a), nmol/L, median (25th, 75th percentile) 63.2 (30.4, 119.6) 80.4 (39.7, 138.4) 0.02 Statin use, % 13.3 30.4 <0.001 OxPL-apoB <1.6 nM, % 30.3 23.4 0.03 Abbreviations: LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein(a); LOF, loss-of-function; nM, nanomolar; OxPL-apoB, oxidized phospholipids on apolipoprotein B-100; PCSK9, proprotein convertase subtilisin/kexin type-9; REGARDS, REasons for Geographic And Racial Differences in Stroke; SD, standard deviation.

Conclusion

Among black adults, PCSK9 LOF variants were associated with lower OxPL-apoB levels.

Acknowledgement/Funding

Industry/academic collaboration between Amgen Inc., University of Alabama at Birmingham and the Icahn School of Medicine at Mt. Sinai; and U01NS041588
P5324Children with familial hypercholesterolemia: lipid profile, treatment and evaluation of different formulas for calculating low-density lipoprotein cholesterol: an analysis from the HELLAS-FH registry
Authors: Liberopoulos E , Rizos C , Garoufi A , Kolovou G , Athyros V , Skoumas I , Kotsis V , Rallidis L , Tziomalos K , Skalides E , Attilakos A , Katsiki N , Koutagiar I , Antza C , Elisaf M
Published: October 2019

Introduction

There is limited data on cardiometabolic characteristics and treatment of underage patients with familial hypercholesterolemia (FH). Accurate estimation of low-density lipoprotein cholesterol is essential to tailor hypolipidemic treatment.

Purpose

To report lipid profile and current treatment of underage patients with FH in Greece as recorded in the HELLAS-FH registry. Also, to compare the Friedewald with the Martin/Hopkins equation, (which provides a customized estimation of VLDL-C) and the Dahlen's formula [(which adjusts the LDL-C measurements for the amount of cholesterol in Lp(a)].

Methods

Underage patients with FH were evaluated. Lipid profile, current treatment regimen as well as LDL-C levels as assessed with different formulas were evaluated.

Results

A total of 191 children were included (51.0% boys, 11.0±3.5 years old). Children at baseline had mean LDL-C as calculated by the Friedewald equation (LDL-CF) 233±65 mg/dL and median Lp(a) 15.3 (IQR 8–51) mg/dL. A total of 59.2% of subjects were receiving hypolipidemic treatment, mainly statins (29.4%) and sterols/stanols (25.5%). Children on hypolipidemic therapy had mean LDL-CF 183±98 mg/dL with 22.1% achieving an LDL-C≤130 mg/dL. When LDL-C was calculated based on the Martin-Hopkins equation (LDL-CM/H) respective values were 180±58 mg/dL and 24.8%. When LDL-C was corrected for Lp(a) [= LDL-CM/H − (Lp(a) * 0.30)], LDL-C was 174±105 mg/dL with 33.3% of patients within the LDL-C target.

Conclusions

Nearly two-thirds of children were receiving some kind of hypolipidemic treatment at the time of registration. For those on treatment, LDL-C goal is achieved by one in five, which rises to 1 in 3 when LDL-C is corrected for Lp(a) levels.
P5325A possible paradoxical association between LDL-cholesterol in myocardial infarction patients and relation to major adverse outcomes - a 10-year nationwide cohort study
Authors: Schubert J , Lindahl B , Melhus H , Renlund H , Leosdottir M , Allahyari A , Ueda P , Jernberg T , Hagstrom E
Published: October 2019

Background

Cardiovascular disease (CVD) risk increases with the level of LDL-cholesterol (LDL-C), and LDL-C lowering treatment improves prognosis. Less is known about LDL-C levels at myocardial infarction (MI) admission and long-term prognosis.

Purpose

To investigate admission LDL-C levels in relation to mortality, recurrent MI and baseline characteristics.

Methods

Patients admitted with an MI in Sweden and recorded in the MI-registry (SWEDEHEART) 2006–2016 were included and followed until 2018. Associations between baseline LDL-C, mortality and MI were assessed with Cox regression analysis, adjusting for risk factors (eg. age, diabetes, prior CV events) and lipid lowering therapy.

Results

Of 126,669 patients (median age: 70) admitted with MI, 26.2% (n=32,883) had ongoing statin therapy, and the median LDL-C was 2.96 (interquartile range 2.23, 3.74) mmol/L. During median follow-up of 4.2 years, 31,024 died and 17,896 had an MI (table). Patients with higher LDL-C were younger, had substantially fewer comorbidities such as diabetes and prior CVD (p<0.001). In this analysis there was an interaction with ongoing statin-use (p=0.0025). When dividing patients by LDL-C into quartiles, statin naive in the highest LDL-C quartile (3.95 mmol/L) had a lower risk of death compared to patients in the lowest quartile (2.62 mmol/L) HR 0.86 (95% CI 0.83–0.90). For patients with ongoing statin, the risk was also lower with higher LDL-C (2.84 mmol/L) compared to lower LDL-C (1.72 mmol/L) HR 0.88 (95% CI 0.81–0.96). No association was observed between LDL-C and recurrent MI.

Table 1. Event rate for mortality and myocardial infarction (MI) by LDL quartile groups Q1 Q2 Q3 Q4 LDL-C (mmol/L) Statin naive <2.62 2.62–3.26 3.26–3.95 >3.95 Ongoing <1.72 1.72–2.21 2.21–2.84 >2.84 Mortality Statin naive 0.074 (6553) 0.049 (4596) 0.037 (3706) 0.030 (2949) Ongoing 0.10 (3297) 0.075 (2769) 0.062 (2462) 0.055 (2157) MI Statin naive 0.034 (2808) 0.026 (2292) 0.024 (2269) 0.023 (2094) Ongoing 0.064 (1796) 0.055 (1792) 0.048 (1694) 0.044 (1557) Event/year (n of events) stratified by statin treatment at index event.

Conclusions

In this real-world population with over 126,000 patients and 10 years of follow-up, higher LDL-C at the time of the MI was associated with a markedly better prognosis in patients with and without prior statin therapy. This paradox may, despite adjustment, be caused by a substantially lower CVD baseline risk in patients with higher LDL-C pertaining to a lower burden of risk factors, younger age, and fewer prior CVD events as well as a highly treatable risk factor.
P5351In-Flight Stroke in Korea
Authors: Park H
Published: October 2019

Background

During flight, atmospheric pressure drop, low humidity and restricted motion occur. The environmental change can evoke the stroke occurrence. However, description of in-flight stroke case series has been limited until now. We investigated the clinical and flight trip characteristics of in-flight stroke cases in Korea.

Method

Since the opening of Incheon international airport, which is used by about 50 million people a year, in 2001, our hospital branch has been located at the airport and all the emergency stroke patients have been referred to our hospital. We performed retrospective review of the prospectively collected stroke registry and the information about the flight from January 2001 to December 2018.

Results

During the study period, 31 in-flight stroke cases were identified among total 1,452 ischemic stroke patients (17 men, 62±15 years old). Twenty-six patients had cerebral infarction, and four patients had transient ischemic attack. On etiological classification of cerebral infarction, 19 large artery atherothrombosis (61.3%), 1 septic embolism, 3 cryptogenic stroke, 3 cardioembolism (9.7%) and 1 cerebral venous thrombosis were identified. Six patients had Patent Foramen Ovale. Twenty-two patients reported to experience symptom around landing. Fourteen patients had flight for six hours or longer. Compared to the patients with long flight time (≥6 hrs), those with short flight time had the higher incidence of stroke occurrence around landings (32 vs 68%) and low incidence of unclear stroke onset. Poor outcome, defined as mRS 4 or higher, was associated with old age, unclear stroke onset, and early neurologic deterioration.

Conclusion

In-flight stroke is uncommon, and can easily be neglected during flight, which result in poor outcome. The stroke risk seems to be relatively high around landing, especially in the travelers with short flight time. The possibility of paradoxical embolism related to motion restriction seems low for stroke occurrence. Old age and unclear stroke onset are associated with poor outcomes.