bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic implication of sodium nitroprusside vasodilator test in pulmonary hypertension and left heart disease: insights from PUSHON registry
Authors: Boretto P , Bruno F , Bertaina M , Bocchino P , Galluzzo A , Gatti P , Peyracchia M , De Ferrari G.M
Published: November 2020

Background

Definition of combined post and pre-capillary pulmonary hypertension (Cpc-PH) is controversial, despite involving up to 25% of patients with heart failure with reduced ejection fraction (HFrEF). The 2019 World Symposium on PH focused on conflicting results and potential misleading interpretation of mean transpulmonary gradient (TPG) and diastolic transpulmonary gradient (DPG) in predicting outcomes in type 2 PH patients. A new Cpc-PH definition has been proposed, basing on pulmonary arterial wedge pressure (PAWP) >15 mmHg and pulmonary vascular resistance (PVR) >3 WU. In this setting, the role of vasodilator challenge has marginally been explored.

Purpose

This study aims to investigate whether vasodilator test increases prognostic accuracy in PH-LHD comparing to PVR and TPG.

Methods

125 patients with a first diagnosis of PH-LHD were selected within the PUlmonary hypertenSion in rigHt heart catheterization (PUSHON) registry. All patients underwent right heart catheterization and sodium nitroprusside vasodilator infusion. Hemodynamic response was defined as decrease of mean pulmonary arterial pressure (mPAP) <25 mmHg with maintenance of systemic systolic arterial pressure >85 mmHg. Primary endpoint was a composite of cardiac death, heart transplantation and urgent LVAD implant at 2 years.

Results

34 (27%) patients were sodium nitroprusside responders. Normalization of mPAP during acute vasodilator challenge was associated with higher event-free survival at 2 years (HR 2.46, 95% C.I. 1.29–4.69, p=0.006). Responders to nitroprusside showed lower baseline pressure regimens in pulmonary artery (sPAP 56.4±12.9 vs 63.2±12.4 mmHg, p=0.009; mPAP 38.1±6.9 vs 44.7±8.8 mmHg, p=0.001) and lower Wedge Pressure (25.1±6.6 vs 29.8±6.6 mmHg, p=0.001). Also, patients with positive vasodilator test showed better right ventricular function expressed by TAPSE (17.2±4.3 vs 15.4±3.8 mm, p=0.05) and higher EF (34.6±15.3% vs 28.1±13.1%, p=0.023). Interestingly, nitroprusside responders exhibited lower DPG (−0.11±5.30 vs 2.04±5.21 p=0.04). At multivariate analysis PVR and TPG ≥12 mmHg fail to independently predict primary endpoint, while positive vasodilator response was independently associated with better outcome (OR 0.22, 95% C.I. 0.09–0.52, p=0.001). The same results were confirmed in the Cpc-PH subgroup (OR 0.54, 95% C.I. 0.08–0.78, p=0.018).

Conclusions

Nitroprusside vasodilator response was associated with a higher event-free survival at 2 years follow-up in our cohort of patients with PH-LHD. Larger studies with prospective hemodynamic evaluations are needed to support our hypothesis.

Figure 1

Funding Acknowledgement

Type of funding source: None
Effect of macitentan on left ventricular (LV) function in pulmonary arterial hypertension (PAH): results from REPAIR
Authors: Rosenkranz S , Channick R , Cottreel E , Galie N , Kiely D.G , Marcus J.T , Swift A.J , Tawakol A , Torbicki A , Vonk Noordegraaf A , Wetherill G , Peacock A
Published: November 2020

Introduction

PAH impacts right ventricular (RV) structure and function but also leads to changes in the LV due to RV/LV interaction and underfilling. REPAIR, the first PAH study to use a primary endpoint assessed by cardiac MRI (cMRI), reported that RV stroke volume (RVSV) increased by 12 mL and pulmonary vascular resistance (PVR) decreased by 38% from baseline (BL) to Week 26 with macitentan.

Purpose

To assess the effect of macitentan on LV function in patients with PAH.

Methods

REPAIR (NCT02310672) was a 52-week, multicentre, open-label, single-arm, phase 4 study assessing the effect of macitentan primarily on RV structure and function, determined by cMRI and right heart catheterisation. Macitentan 10 mg was initiated in treatment-naïve patients, in patients receiving stable background phosphodiesterase type-5 inhibitor (PDE5i) at BL, or in initial combination with PDE5i. Exploratory LV endpoints were assessed by cMRI at Weeks 26 and 52. Safety was assessed up to end of study treatment +30 days in all patients who received ≥1 dose of macitentan (N=87). Patients with BL and Week 26 assessments for both PVR and RVSV were included in the modified Full Analysis Set (mFAS; N=71).

Results

In the mFAS, 57 (80%) patients were female. At BL, median age was 45 years; median (Q1, Q3) six-minute walk distance was 395 (323, 483) m; 48%/51% of patients were WHO functional class II/III; 59% had idiopathic PAH. Compared to BL, at Weeks 26 and 52 there were significant changes in LV cMRI parameters (table). The most common AEs were peripheral oedema (22%), headache (21%) and dizziness (14%).

Conclusions

Macitentan led to improvements in LV mass, volume and function, including clinically-relevant increases in LV stroke volume, at both 26 and 52 weeks in patients with PAH. Safety was consistent with other macitentan clinical trial data.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Actelion Pharmaceuticals Ltd
The effect of pulmonary arterial hypertension specific treatment on the left ventricle in patients with pulmonary arterial hypertension
Authors: Mouratoglou S.A , Wessels J.N , Marcus J.T , Meijboom L.J , Handoko-De Man F , Vonk Noordegraaf A
Published: November 2020

Background

Pulmonary arterial hypertension (PAH) is characterized by right ventricular (RV) pressure overload, leading to RV dilation, failure and death. In the course of the disease, the left ventricle (LV) is often impaired, due to interventricular interaction. Although the impact of PAH treatment on the RV has been well described, less is known on the LV.

Purpose

To examine effects of advanced PAH treatments on the volumes, function and strain of the left atrium and ventricle.

Methods

This is a retrospective study. All patients underwent CMR and right heart catheterization, both at diagnosis and at 12-months follow up. Ventricular volumes and LV filling rate were calculated from the stack of short axis cine images using Simpsons method while left atrial (LA) volumes from the 4-chamber cine images using the area-length method. Tissue tracking was used for the evaluation of myocardial deformation. The LV endocardial and epicardial borders were manually delineated in all analysed sections with the initial contour set at end-diastole. All analyses were performed offline using dedicated software.

Results

In total, 66 patients (mean age 56.3±17.9 years, 67%women, 77%idiopathic and heritable PAH, 23% connective tissue disease associated PAH) and 29 normal controls were included. The improvement in metrics of right and left heart size and function after the initiation of advanced PAH treatment, are presented in panel A. Of note, LV stroke volume was markedly increased (54.6±19.6ml at baseline vs 70.8±21.7ml at follow up, p<0.0001) to reach controls. LV filling was markedly increased in latter two-thirds of the diastolic phase (panel B), especially at atrial kick point (arrow). Change in LA max volume was associated with changes in diastolic filling (r=0.354, p=0.004), LV end-diastolic and end-systolic volumes and stroke volume. These correlations were more robust in patients that increased LV filling compared to those that failed to increase LV filling (panels C-E). No association between changes in LV circumferential strain and LV volume load was observed. A weak correlation of change of LV peak longitudinal strain with stroke volume (r=−0.345, p=0.006), LV end diastolic volume (r=−0.284, p=0.027), LV ejection fraction (r=−0.337, p=0.008) and LA maximum area (r=−0.447, p<0.0001) was observed. The changes of LV strain showed no correlation with the changes in patients' haemodynamics.

Conclusion

Improvement in stroke volume after the initiation of advanced PAH treatment is associated with an increase in LA size, LV end diastolic volume and normalisation of strain. This reflects the improved filling state of the left ventricle and the potential of the left atrium to monitor treatment effects.

Changes after PAH treatment

Funding Acknowledgement

Type of funding source: None
Are there real differences between the treatment for young and elderly patients with chronic thromboembolic pulmonary hypertension?
Authors: Cristo Ropero M.J , Lopez Gude M.J , Velazquez Martin M , Perez-Olivares Delgado C , Martinez Santos P , Perez Vela J.L , Arribas F , Cortina Romero J.M , Escribano Subias P
Published: November 2020

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable type of pulmonary hypertension, but it is poorly characterized in elderly patients.

Purpose

This study aimed to investigate the clinical characteristics, treatment strategy and survival of elderly patients with CTEPH.

Methods

All CTEPH patients evaluated at our institution between 2000 and 2018 were collected. They were divided into two groups according to 75th percentile of age. Thrombotic lesions were considered proximal when affecting the main pulmonary artery, lobular and proximal segmental arteries. All patients were discussed at a multidisciplinary team meeting. Pulmonary thromboendarterectomy (PTE) was the treatment of choice. Balloon pulmonary angioplasty (BPA) and vasodilator treatment were second-line strategies for those considered inoperable in view of unfavourable pulmonary vascular anatomy or comorbidities. As BPA program was started in our centre in 2013.

Results

484 patients were included. Baseline distinctive features are described in table 1. Medical therapy alone was more frequently considered in elderly patients. However, when adjusted for thrombotic lesions location, there were no differences in treatment strategies (p<0.0005). Mortality was higher in the elderly patients group (p<0.00005), with differences in cumulative survival distribution (p<0.00005). This differences was maintained even after adjusted analysis for thrombotic lesions location (p=0.01) (picture 1).

Conclusion

CTEPH in elderly patients shows more incidence of distal involvement, which limits the number of patients suitable for PTE. After adjusted for the location of the injuries, treatment strategies were similar between both groups. Nevertheless, mortality is still higher in elderly patients.

Picture 1

Funding Acknowledgement

Type of funding source: None
Increased arterial stiffness during acute myocardial infarction results in adverse cardiac remodelling: a two year follow-up study
Authors: Ikonomidis I , Tsilivarakis D , Katsanos S , Vlastos D , Thymis J , Makavos G , Katogiannis K , Kostelli G , Parisis J , Illiodromitis E
Published: November 2020

Increased arterial stiffness is associated with adverse cardiac events. However, it not clear whether increased arterial stiffness at the early phase of acute myocardial infraction (AMI) is associated with adverse left ventricular remodelling.

Methods

We examined 80 patients with STEMI (53±16 years, 80% male, 42% anterior AMI, LVEF=49±15%) after successful revascularisation by echocardiography 48h after admission and 2 years after the index event. We measured a) left-ventricular end-diastolic (LVEDV) and end-systolic volumes (LVESV) using the Simpson Method b) global longitundinal strain (GLS) by speckle tracking imaging c) carotid-femoral pulse wave velocity (PWV, augmentation index and central Aortic pressures by Complior apparatus d) The ratio of PWV/GLS as a marker of ventricular-arterial interaction.

Results

LVEDV and LVESV were decreased while GLS was improved after the 2-year follow-up period (from 103.3±30 to 89.1±37ml, p=0.004, 58.3±25 to 57.6±25, p=0.05, −16.1±4.7 to 17.5±3.2%, p=0.03 respectively). Baseline PWV, GLS and the ratio PWV/GLS were associated with the percent change of LVESV at 2 years (p=0.033, p=0.04 and p=0.035 respectively) after adjustment for type of MI (anterior vs other location), baseline troponin blood pressure and medication.

Patients with PWV >10.6 m/s (upper tercile) had similar baseline LVESV (56.5±18 to 57.2±24 ml, p=0.8) but higher LVESV at 2 years follow-up (74.4±35 to 55.9±24 ml, p=0.03) resulting in a greater percent increase of LVESV compared to patients with baseline PWV <10.6m/s (+26% vs −5% p=0.012).

Conclusion

Increased arterial stiffness in the early phase of AMI impairs ventricular-arterial coupling resulting in adverse LV remodeling despite successful revascularization.

Funding Acknowledgement

Type of funding source: None
Normal and reference values for MRI-based pulse wave velocity in the middle-aged general population
Authors: Van Hout M.J.P , Dekkers I.A , Westenberg J.J.M , Schalij M.J , De Mutsert R , Rosendaal F.R , De Roos A , Jukema J.W , Scholte A.J.H , Lamb H.J
Published: November 2020

Background

Aortic stiffness, assessed through pulse wave velocity (PWV), is an independent predictor for cardiovascular (CV) risk. However, the scarce availability of normal and reference values for magnetic resonance imaging (MRI) based PWV is limiting clinical implementation.

Purpose

The aim of this study was to determine normal and reference values for MRI-PWV in the general population.

Methods

From the 2,484 participants of the NEO study that have available MRI-PWV data, we selected 1,639 participants that were free from CV disease or treatment for diabetes, hypertension or dyslipidaemia (age range 45–65 years, 51% male). Participants were categorized by sex, age and blood pressure (BP) subgroups. Normal values were specified for healthy (<130/80 mmHg) and elevated BP (≥130/80 and <140/90 mmHg) and reference values for high BP (≥140/90 mmHg) subgroups. Differences between groups were tested with either an independent samples t-test or ANOVA.

Results

Overall mean PWV was 6.5 m/s [95% CI 6.4–6.6]. PWV increased significantly with advancing age and BP categories (both p<0.001). There was no difference in PWV between men and women, however a stronger increasing trend for women above 55 years old was observed (figure). The 95% CI's were smaller for participants <55 years old as compared to participants >55, indicating an increasing variability of PWV with age. The elevated PWV upper limits for the higher blood pressure subgroups are particularly evident in participants above 55 years old.

Conclusion

This study provides normal and reference values for MRI-assessed PWV per sex, age and blood pressure category.

PWV percentiles (10, 25, 50, 75 and 90th)

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): The NEO study is supported by the participating departments, the Division and the Board of Directors of the Leiden University Medical Centre, and by the Leiden University, Research Profile Area “Vascular and Regenerative Medicine”
Natural history of the enlarged ascending thoracic aorta: an observational long term study
Authors: Schroeder E , Bihin B , Buche M , Eucher P.H , Felix J , Gabriel L , Gerard M , Guedes A , Hanet C , Seldrum S , Marchandise B
Published: November 2020

To assess the long-term outcome of patients with an enlarged ascending thoracic aorta (ATA), a retrospective study was performed.

Methods

Inclusion criteria: ATA diameter of 38 mm or more by ETT (813 consecutive cases).

Inclusion period: 1.1.2003–31.12.2016.

Results

At baseline, the mean diameter of the ATA was 42±3 mm, the mean Z-score was 2.7±0.8.

In the subgroup of patients with 2 ETT examinations (and no surgical cure of the ATA), the mean diameter was 41.9±4.8 mm, the mean Z-score 2.4±1.1 after a mean follow-up of 6 years.

During the follow-up, 52 patients had an intervention on the ATA, 26 patients were operated within the first 3 months after the diagnostic echocardiogram. 26 patients were operated during FU.

In the 791 remaining patients (without early intervention), the event rate (death, intervention on the ATA) were assessed by the competing risk model.

In the group of patients with a baseline ATA diameter of less than 41 mm (Group A: n=254), the cumulative incidence of death at 5 and 10 y was 34% and 61%; in the group of patients with an ATA diameter of 41–42 mm (Group B: n=238) the incidence was 34% and 61% respectively, in the group of patients with an ATA diameter of 43–44 mm (Group C: n=147), the incidence was 32% and 58%, in the group of patients with a diameter of 45 and more (Group D: n=150), the incidence was 31.1% and 61% (NS).

The cumulative incidence of surgical interventions on the ATA at 5 and 10 years was 0.4% and 1% in group A, 1.3 and 1.8% in group B, 0.7 and 1.4% in group C and 9.8 and 12.9% in group D (p<0.05).

Similar results were observed in patients according to the Z-scores. In the group of patients (221) with a Z-score >3, the incidence of intervention at 5 and 10 y was respectively 7.6% and 10.7% (p=0.01).

Conclusions

– The mean diameter of the enlarged ATA remained nearly unchanged over a period of 6 years.

– No impact of the enlarged ATA on survival was observed.

– Only patients with an ATA diameter of 45 mm and more (or a Z-score of 3 and more) needed an intervention on the ATA at a rate of ± 10% at 10 y after the initial echocardiographic diagnosis.

Funding Acknowledgement

Type of funding source: None
Relationship between aortic distensibility and aortic regurgitation depending on aortic valve anatomy. A CMR study
Authors: La Mura L , Teixido-Tura G , Guala A , Ruiz-Munoz A , Servato M.L , Fassano N , Valente F , Lopez-Sainz A , Galian-Gay L , Gonzalez-Alujas T , Cinque A , Ferreira I , Evangelista A , Galderisi M , Rodriguez-Palomares J.F
Published: November 2020

Background

Aortic regurgitation (AR) can be evaluated by cardiac magnetic resonance (CMR).The most commonly used method to quantify AR is direct measurement using phase contrast (PC) imaging, at the aortic root (as close as possible to the aortic valve), for the calculation of regurgitant fraction (RF). Aortic distensibility (AD) may affect aortic valve dynamics and, as a result, aortic regurgitation grade. However, the impact of aortic distensibility in this evaluation remains unknown.

Purpose

The aim of the study was to evaluate the relationship between AD and AR in patients with different aortic valve anatomy.

Methods

213 patients with different AR severity grades and aortic valve anatomy (tricuspid (TAV) and bicuspid valve (BAV) patients) were enrolled (32.2% female, 74% BAV, 55.5±15.4 years), excluding connective tissue disease. All patients underwent a CMR study with PC sequences for the evaluation of regurgitant fraction at the aortic valve level. AR was considered as mild (<15%), moderate (15–30%) or severe (>30%) depending on RF value. Furthermore we used cine-sequences to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

Results

159 (73.7%) AR were mild, 30 (14.1%) moderate and 24 (11.3%) severe. RF significantly correlated with aortic root diameter (r=0.337, p<0.001) and did not correlate with AD at the level of proximal descending aorta (r=0.121 and p=0.107). Furthermore descendig aorta distensibility correlated with age (r=−0.631, p<0.001) and aortic root diameter (r=−0.224, p=0.002). Dividing population in two different groups, depending on aortic valve anatomy, in TAV patients RF continued to not correlate with AD (r=0.159, p=0.369). In contrast, RF in BAV patients was positively correlated with AD (r=0.223, p=0.007) even after adjustment for aortic diameter and age in a multiple regression model (p<0.001, R2=0.478).

Conclusions

In our study, aortic regurgitation is positively related to descending aorta distensibility in BAV patients, regardless of age and aortic root diameter. Thus, AD may play a role in the evaluation of AR in case of bicuspid valves. In contrast, in TAV patients, distensibility does not seem to influence the assessment of AR severity.

Descending aorta distensibility

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Research grant provided by the Cardiopath PhD program
Risk stratification on admission for predicting death or need for surgery in patients with acute type A intramural hematoma receiving medical therapy – validation cohort
Authors: Kageyama S
Published: November 2020

Background

There has been continuing discussion regarding the treatment strategy for acute type A intramural hematoma (IMH). We previously examined the risk factors of death or need for surgery for acute type A IMH in patients receiving medical treatment using clinical findings on hospital arrival and developed a simple risk score using the factors.

Purpose

We examined the accuracy of the risk score in the validation cohort.

Methods

From 2009 to 2014, 57 consecutive patients diagnosed with acute type A IMH who were receiving initial medical treatment were retrospectively included for derivation cohort. Primary endpoint was a composite of cardiovascular death and operation within 1 year after onset. On admission, the primary endpoint could be predicted with 89.7% sensitivity and 75% specificity if the patient had ulcer-like projection (ULP) and/or ≥2 of the following factors: systolic blood pressure (SBP) <120 mmHg, ascending aorta diameter>45 mm, and pericardial effusion (PE). In the current study, validation cohort study was performed from 2015 to 2020 in 73 consecutive patients who met the same inclusion criteria for derivation cohort to evaluate the risk factors and the accuracy of the risk score.

Result

Mean age of onset was 74 years old. Mean SBP on arrival was 134 mmHg. Computed tomography (CT) on arrival showed a mean ascending aorta diameter of 46 mm. ULP and PE were seen in 27% and 41% of cases, respectively. Thirty-three patients (45.2%) reached the primary endpoint (cardiovascular death, 8 cases [11%]; operation, 25 cases [34.2%]). In univariate analysis of admission values, the primary endpoint group had significantly lower SBP (116±29 vs 147±35 mmHg), higher ascending aorta diameter (49±8 vs 45±9 mm), and higher frequency of ULP (50% vs 10%) and PE (56% vs 29%) than did the event-free group. Multivariate analysis showed that ULP and SBP were significant predictors of the primary endpoint. The total risk score ≥2 could predict the primary endpoint with 87.5% sensitivity and 71.7% specificity (area under the receiver operating characteristic curve, 0.791).

Conclusion

The risk score was useful to predict cardiovascular death and the need for surgery in patients with acute type A IMH receiving medical therapy in the validation cohort study.

ROC curve for the risk score

Funding Acknowledgement

Type of funding source: None
18F-sodium fluoride positron emission tomography-computed tomography in acute aortic syndrome
Authors: Syed M , Fletcher A.J , Dweck M , Forsythe R.O , Tambyraja A.L , Van Beek E , Newby D.E
Published: November 2020

Background

Acute aortic syndrome is characterised by diseases that disrupt the intima and weaken the aorta. This damaged aorta is prone to aneurysmal dilation and ultimately rupture – a catastrophic event. 18F-sodium fluoride positron emission tomography and computed tomography (PET-CT) is a promising multimodality imaging technique that informs on the pathological state of the aorta. In abdominal aortic aneurysms (a chronic aortic disease), 18F-sodium fluoride PET uptake is associated with aortic expansion and requirement for aortic repair.

Purpose

The aim of this study was to describe aortic 18F-sodium fluoride uptake in patients with acute aortic syndrome for the first time.

Methods

Patients with intramural haematomas, aortic dissections or penetrating aortic ulcers, along with healthy control subjects, underwent contrast-enhanced 18F-sodium fluoride PET-CT. 18F-Sodium fluoride uptake was assessed using standardised uptake values and corrected for background blood pool activity to obtain tissue-to-background ratios (TBR).

Results

Forty-six patients and twenty healthy control subjects were matched for age, gender, body mass index, ischaemic heart disease and diabetes mellitus. Participants with acute aortic syndrome had widespread aortic 18F-sodium fluoride uptake. Radiotracer binding in patients with acute aortic syndrome was substantially greater than healthy subjects (TBR 2.00±0.45 vs 1.36±0.39, p<0.001). Subgroup analysis in patients with untreated type B acute aortic dissection revealed peak radiotracer binding at the site of intimal disruption compared to the proximal reference aorta (TBR [inter-quartile range] 1.61 [1.38–1.88] vs 1.18 [1.08–1.39] respectively; p<0.001).

Radiotracer uptake was highest in patients with penetrating aortic ulcers, followed by aortic dissection and intramural haematomas (TBR (±SD) 2.19±0.55 vs 1.99±0.43 vs 1.71±0.27 respectively; p=0.046). No difference in radiotracer uptake was observed between patients with sub-acute and chronic disease (TBR (±SD) 1.94±0.37 vs 2.04±0.51, p=0.497). 18F-sodium fluoride uptake was similar between Stanford Type A and Type B dissections (TBR (±SD) 1.98±0.49, 2.00±0.44, p=0.851). 18F-Sodium fluoride binding was independent of maximum aortic diameter (R2 = 0.036, p=0.21).

Conclusion

Our preliminary findings suggest that aortic 18F-sodium fluoride uptake is increased in patients with acute aortic syndrome, especially around the site of intimal disruption or penetrating aortic ulcers. This technique appears to identify disease activity that may have clinical applications for assessing prognosis and guiding therapeutic interventions.

18F-NaF PET/CT in Acute Aortic Syndrome

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation
Impact of endovascular repair on the outcomes of octogenarians with ruptured abdominal aortic aneurysms: a nationwide Japanese study
Authors: Yamaguchi T , Nakai M , Sumita Y , Kodama T , Ogino H
Published: November 2020

Objective

This study aimed to clarify the impact of endovascular aneurysm repair (EVAR) on clinical outcomes in Japanese patients of advanced age with ruptured abdominal aortic aneurysm (rAAA).

Methods

This was a national registry based retrospective comparative study, using data from the Japanese Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination (JROAD-DPC), a nationwide claim based database from more than 600 hospitals. Patients admitted with rAAA between April 1, 2012, and March 31, 2015 were included in the study. Patient characteristics, management, and outcomes were compared between the elderly (aged ≥80 y) and the less old. The primary endpoint was in hospital mortality; the secondary endpoint was the functional status at discharge.

Results

Of 3 969 eligible patients, 49.9% were categorised as elderly. Elderly patients had a higher prevalence of female gender (41.8% vs. 17.0%, p<0.001) and disturbance of consciousness on admission (28.6% vs. 20.7%, p<0.001). They were less likely to undergo open surgical repair (31.6% vs. 56.7%, p<0.001), although EVAR was performed similarly in both groups (13.7% vs. 14.8%, p<0.33). The unadjusted mortality rate (61.8% vs. 37.6%, p<0.001) and mean Barthel index at discharge (73.0 vs. 91.8, p<0.001) were statistically significantly worse in the elderly. Multilevel mixed effect logistic regression analyses showed that old age was detected as an independent predictor of in hospital death (odds ratio 2.75; 95% confidence interval, 2.39–3.17; p<0.001). However, for patients who received EVAR, old age was not statistically significant (odds ratio 1.13; 95% confidence interval, 0.77–1.66; p<0.53).

Conclusion

Elderly patients with rAAA were less likely to be offered open surgical repair, and the mortality among those who received surgery was high. However, for the small subgroup of elderly patients currently selected for EVAR there was a favourable outcome. The further implementation of EVAR for rAAA in Japan, especially for elderly patients with suitable anatomy, may be justified.

Funding Acknowledgement

Type of funding source: None
Geriatric nutritional risk index (GNRI) predicts long-term survival and limb events in patients with peripheral artery disease
Authors: Horiguchi M , Yamagishi H , Unno K , Takamura T , Tone K , Sakabe S , Maeno K , Izumi D , Seko T , Kasai A
Published: November 2020

Background

Geriatric nutritional risk index (GNRI) was developed as a “nutrition-related” risk index and was reported in different populations as associated with the risk of all-cause and cardiovascular morbidity and mortality.

Purpose

The purpose of this study was to assess the associations of GNRI with mortality and amputation free survival in patients with peripheral artery disease (PAD).

Methods

From January 2011 to June 2016, 295 consecutive patients (73.3±9.2 years; 75.6% male) with PAD undergoing endovascular treatment (EVT) in our hospital were retrospectively examined. The GNRI on admission was calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × body mass index (BMI)/22. Characteristics and mortality were compared between 2 groups: low GNRI (<92, n=110) with moderate or severe nutritional risk; and high GNRI (≥92, n=185) with no or low nutritional risk.

Results

The median follow up period was 39.4±26.4months. There were 85 deaths (28.8%) and 13 major amputation (4.4%) during the follow-up. Patients in the low-GNRI group were more often higher age, non-ambulatory state, hemodialysis and critical limb ischemia. BMI, serum hemoglobin, albumin, low-density lipoprotein were significantly lower, whereas serum C-reactive protein was significantly higher in the low-GNRI group than the high-GNRI group (P<0.05, respectively). Kaplan–Meier analysis revealed that patients in the low-GNRI group had a significantly lower amputation free survival, compared to those in the high-GNRI group (log-rank test, P<0.001).

Conclusion

The low GNRI is associated with an increased risk of mortality and limb events in patients with PAD.

Amputation-free survival (Kaplan-Meier)

Funding Acknowledgement

Type of funding source: None
Prevalence, clinical characteristics and prognosis of intracranial artery atherosclerosis in heterozygous familial hypercholesterolemia: insights from magnetic resonance angiography imaging analysis
Authors: Funabashi S , Kataoka Y , Hori M , Ogura M , Matsuki K , Doi T , Noguchi T , Harada-Shiba M
Published: November 2020

Introduction

Heterozygous familial hypercholesterolemia (HeFH) exhibits substantially atherogenic substrate which involves coronary and peripheral arteries. Whether atherosclerosis in HeFH propagates to intracranial arteries causing stroke remains to be determined.

Purpose

To characterize intracranial artery stenosis (IAS) in subjects with HeFH.

Methods

148 HeFH subjects who underwent MRI/MRA imaging to evaluate intracranial arteries were analyzed. IAS was defined as the presence of stenosis with its % diameter stenosis ≥25%. Clinical demographics and cardiovascular events (all-cause death, ACS, stroke and PAD) were compared in those with and without IAS.

Results

IAS was observed in 24.3% (=36/148) of study subjects. It was more frequently located at middle cerebral artery (30.6%=11/36), followed by internal carotid artery (25.0%=9/36). 47.2% of IAS exhibited % diameter stenosis ≥75%. Furthermore, 58.3% of HeFH patients with IAS exhibited concomitance of CAD, PAD or carotid stenosis. They were more likely to be older (Table). While there was no significant difference in LDL-C level, an elevated triglyceride level was observed in those with IAS (Table). Of note, during the observational period (median=14.1 years), IAS was associated with a greater likelihood of experiencing not only stroke but other cardiovascular events (all-cause death + ACS + PAD) (picture). Multivariate analysis demonstrated triglyceride level ≥1.7mmol/l as an independent predictor of IAS in HeFH patients (HR=5.53, 95% CI: 1.85–16.5, p=0.002).

Conclusions

Around one-fourth of HeFH patients harboured IAS, which was associated with concomitance of atherosclerosis in other vascular beds and the occurrence of stroke and other cardiovascular events. Given the relationship of IAS with hypertriglyceridemia, this lipid feature may be an important contributor to atherosclerotic formation which involves intracranial artery in HeFH patients.

Clinical outcome

Funding Acknowledgement

Type of funding source: None
Atrial fibrillation in a cohort of patients with peripheral arterial disease. A retrospective study of a healthcare database in UK
Authors: Vitalis A.V , Shantsila A.S , Thayakaran R.T , Nirantharakumar K.N , Lip G.Y.L
Published: November 2020

Atrial fibrillation in a cohort of patients with peripheral arterial disease. A retrospective study of a healthcare database in UK.

Background

There is strong evidence that peripheral arterial disease (PAD) is linked with worse outcomes in patients with atrial fibrillation (AF), which has led vascular disease to be included as one of the components of CHA2DS2-VASc score for risk stratification in AF. On the other hand, very limited evidence exists on the prognostic implication of AF in patients with PAD.

Purpose

The aim of this study is to identify the prevalence of AF in a cohort of PAD patients and demonstrate its association with adverse cardiovascular outcomes, limb loss and mortality.

Methods

This is a retrospective study of The Health Improvement Network (THIN) database, which contains computerized records from primary care physicians, covering more than 11 million patients from over 600 general practices in the UK. During the studied period from 1995 to 2017, 55540 patients with newly diagnosed PAD have been detected in the database and baseline characteristics, coexisting medical diagnoses (including AF), relevant medication and subsequent outcomes have been recorded using appropriately selected clinical codes (READ codes). A comparison of baseline characteristics was made between patients with PAD and AF and those without AF using descriptive statistics. Multivariate cox regression analysis was then performed and hazard rations for mortality, stroke or transient ischaemic attack (TIA), ischaemic heart disease (IHD), heart failure (HF) and major lower limb amputation at presence of AF were calculated, after adjustment for age, sex, ethnicity, BMI, smoking, Townsend comorbidity index, diabetes, hypertension, kidney function, and medication (lipid- lowering, antiplatelets, anticoagulants).

Results

From the 55540 patients with new diagnosis of PAD during the study period, 5685 (10.2%) had coexisting AF. Patients with AF were older, had higher prevalence of diabetes, hypertension and renal failure, were more likely to be on anticoagulants, antiplatelets and lipid lowering agents, were more likely to be ex-smokers but less likely to be active smokers. Mean follow up period was 5.1 (SD= 4) years. After adjustment for confounders, AF patients were at higher risk for death (HR: 1.30, 95% CI 1.24- 1.37, p<0.01) for stroke or TIA (HR: 1.46, 95% CI 1.29- 1.65, p<0.01) and for HF (HR: 1.85, 95% CI 1.65- 2.08, p<0.01). There was no significant association between AF and development of IHD (p=0.34) and limb loss (p=0.14) in this cohort.

Conclusion

AF is a predictor of worse prognosis in patients with PAD. Close monitoring and medical optimization of these patients is warranted.

Funding Acknowledgement

Type of funding source: None
PAD patients present with poorer lipid target attainment than polyvascular patients – a call for intensified treatment
Authors: Dopheide J.F , Adam L , Khorrami Borozadi M , Kaspar M , Baumgartner I , Drexel H
Published: November 2020

Background

Due to the very high risk of future cardiovascular events, strict lipid lowering therapy is recommended in patients with peripheral artery disease (PAD). However, data on target level attainment and statin adherence is scarce, especially when the atherosclerotic burden is extended to other vascular beds, i.e. coronary artery disease (CAD) and/ or cerebrovascular disease (CeVD).

Purpose

We hypothesized that patients with PAD alone have poorer lipid target attainment than polyvascular patients (+ CAD and/ or CeVD) and that an intensified statin therapy improves attainment of lipid targets and thus survival of patients with PAD only.

Methods

Single center longitudinal observational study with 1380 symptomatic PAD patients over a mean follow-up period of 60±32 months. We related statin adherence and LDL-C target attainment to all-cause mortality.

Results

Initially, 58% of the PAD only patients were on statins in contrast to PAD patients with one (+1V (79%)) or two (+2V (80%)) further vascular regions. At follow up we observed an increase to 87% statin use (p<0.0001) in PAD only patients. Statin use in +1V and +2V patients increased as well (+1V: 92%; +2V: 87%). Lipid target attainment in PAD only (<55 mg/dl) was observed in only 10%, but increased to 19%. Statin dosage in PAD only patients, normalized to simvastatin 40 mg, increased from 46 to 52 mg/ day (p<0.01), and was paralleled by a mean decrease of LDL-C from 103 to 84 mg/ dL (p<0.0001).

PAD only patients had a significant lower mortality rate (13%) than +1V (22%) or +2V patients (35%) (p<0.0001). Survival of PAD only patients significantly improved when having newly received a statin (11%), similar to those continuously on statins (10%). Moreover, patients on a high intensity statin medication had a low mortality of 10%. Those who terminated statin medication or never received a statin had a higher mortality (26%; p<0.01).

Conclusion

Patients with a PAD only have a lower mortality than PAD patients where progression to one or two vascular beds occurred. Our data suggest that for PAD only patients an intensified statin therapy is then associated with reduced mortality. A strategy of intensive and sustained statin therapy as early as possible is recommended.

PAD only Statin Therapy outcomes

Funding Acknowledgement

Type of funding source: None
TRIACCESS study: randomized comparison between radial, femoral and transpedal access for for percutanous supertfitial femoral artery angioplasty
Authors: Ruzsa Z , Csavajda A , Deak M , Sotonyi P , Bertrand O.F , Kwan T.W , Nemes B , Becker D , Hizoh I , Merkely B
Published: November 2020

Background

Traditional access for the treatment of femoral artery lesions is the femoral artery (FA) approach, but radial (RA) and pedal access (PA) is an alternative access site. The aim of the study was to compare the success rate, complication rate of different access sites for the treatment of superfitial artery stenosis in a randomized study

Methods

180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral stenosis, via RA, FA and PA. Primary endpoint: technical success, rate of major and minor access site complications. Secondary endpoints: major adverse events (MAE), procedural factors, cross-over rate, and duration of hospitalization.

Results

Technical success was achieved in 96.6%, 100% and 100% patients in RA, FA and PA group (p=ns). Secondary access site was used in 30%, 3.3% and 30% in the RA, FA and PA access group (p<0.01). Stent implantation was done in the femoral artery in 26.6%, 58.3% and 71.6% cases in RA, FA and PA group (p<0.01). CTO recanalization was performed in 34/36 (100%), 30/30 (100%) and 45/45 (100%) cases successfully in RA, FA and PA group (p=ns). Contrast consumption, fluoroscopy and procedure time was not statistically different, but the X Ray dose was significantly lower in PA than in the RA and FA access group (63.1 vs 162 vs 153 Dyn). The cumulative rate of access site complications in the RA, FA and PA group was 3.3% (0% major and 3.3% minor), 15% (3.3% major and 11.6% minor) and 3.3% (0% major and 3.3% minor) (p<0.01), respectively. The cumulative incidence of MAE's at 6 months in the RA, FA and PA group was 8.3% vs 13.3% and 18.3%. (p<0.05)

Conclusion

Femoral artery intervention can be safely and effectively performed using radial, femoral and pedal access, but radial and pedal access is associated with less access site complication rate. Pedal access is associated with less X Ray dose than radial and femoral access.

Funding Acknowledgement

Type of funding source: None
Applicability of the VOYAGER trial criteria: a cohort study on patients in the nationwide Danish Vascular Registry
Authors: Soegaard M , Nielsen P.B , Skjoeth F , Larsen T.B , Eldrup N
Published: November 2020

Introduction

Peripheral artery disease (PAD) carries a high risk of debilitating stroke, myocardial infarction, and death. The VOYAGER PAD trial investigates whether rivaroxaban 2.5 mg plus aspirin vs aspirin alone leads to a reduction in major adverse cardiovascular events (MACE) in patients with symptomatic PAD undergoing revascularization. However, it is unclear whether patients enrolled in VOYAGER PAD reflect those undergoing lower extremity revascularization in daily clinical practice.

Purpose

To describe the proportion of patients eligible for the VOYAGER PAD trial within the nationwide Danish Vascular Registry (DVR), the reasons for ineligibility, and rates of cardiovascular outcomes in VOYAGER-eligible and VOYAGER-ineligible patients.

Methods

We identified and characterized all patients from 2000–2016 undergoing open surgical or endovascular revascularization for symptomatic PAD in the DVR and applied the VOYAGER inclusion and exclusion criteria. We computed one-year rates per 100 person-years of VOYAGER PAD trial endpoints of MACE, myocardial infarction, ischemic stroke, major amputation, major bleeding, cardiovascular (CV) death, and all cause death.

Results

In the DVR, 32,911 patients underwent lower extremity revascularization for symptomatic PAD and were evaluated for eligibility. Among these, 32.2% had at least one exclusion criteria and an additional 40.6% without exclusion criteria did not fulfil inclusion criteria. The “VOYAGER-eligible” population therefore comprised 27.2% of the identified patients (Figure 1A). Main reasons for exclusion were atrial fibrillation (30.7%), poorly regulated hypertension (19.6%), PCI or ACS within 12 months before (16.0%), treatment with strong inhibitors or inducers of cytochrome P450 (9.2%), active cancer (8.8%), and severe renal failure (8.3%). Main reasons for non-inclusion were aorto-iliac procedures (79.0%), non-successful revascularization (13.1%), and age<50 years (7.1%). Compared with “VOYAGER-eligible” patients, event rates were slightly lower among patients in the DVR not fulfilling inclusion criteria and markedly higher for “VOYAGER excluded” patients (Figure 1B).

Conclusion

In this nationwide cohort of symptomatic PAD patients undergoing lower extremity revascularization, 27.2% full filled the inclusion and exclusion criteria for dual pathway therapy in the VOYAGER PAD trial. Non-inclusion predominantly related to aorto-iliac procedures and were associated with lower event rates. Future studies are needed to clarify if these patients could also benefit from dual pathway therapy.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bayer AG, Berlin, Germany
Lymphocyte-to-monocyte ratio is an independent predictor of 90-day mortality after endovascular therapy in the patients with critical limb ischemia
Authors: Ukita K
Published: November 2020

Background

Critical limb ischemia (CLI), the most severe form of peripheral artery disease (PAD), is associated with a high risk of mortality. We usually perform endovascular therapy (EVT) for CLI, but not a few patients with CLI die in the early period after EVT. There is some research on the relationship between inflammatory responses and mortality after EVT for CLI, but little has been reported on the association of mortality after EVT and lymphocyte-to-monocyte ratio (LMR), which has recently been considered to be a novel inflammatory marker.

Purpose

The purpose of this study was to investigate the relationship between LMR and 90-day mortality after EVT in the patients with CLI.

Methods

We enrolled the consecutive patients with CLI undergoing EVT between September 2014 and September 2019 in our hospital. We compared pretreatment LMR between D group who died within 90 days after EVT and S group who survived more than 90 days.

Results

A total of 281 patients were enrolled in this study. D group consisted of 33 patients and S group consisted of 248 patients. The univariate analysis showed that pretreatment LMR was significantly lower in D group compared with S group (4.04±1.56 vs 4.86±1.45, P=0.002), and this result remained significant in the multivariate analysis (hazard ratio [HR]: 0.415, 95% confidence interval [CI]: 0.214–0.789; P=0.013).

Conclusions

LMR is an independent predictive factor of 90-day mortality after EVT in the patients with CLI.

Funding Acknowledgement

Type of funding source: None
Extremely elevated lipoprotein (a) as an independent risk factor for peripheral arterial disease in large patient cohort
Authors: Poudel M.R , Kirana S , Stoyanova D , Mellwig K.P , Hinse D , Knabbe C , Sauzet O , Gottfried R , Rudolph V , Rudolph T.K , Van Buuren F
Published: November 2020

Background

Elevated lipoprotein (a) [LP (a)] levels are an independent, genetic, and causal factor for cardiovascular disease and associated with myocardial infarction (MI). Although the association between circulating levels of lipoprotein(a) [Lp(a)] and risk of coronary artery disease (CAD) is well established, its role in risk of peripheral arterial disease (PAD) remains unclear. PAD affects over 236 million individuals and follows ischaemic heart disease (IHD) and cerebrovascular disease (CVD) as the third leading cause of atherosclerotic cardiovascular morbidity worldwide. LP (a) is genetically determined, stable throughout life and yet refractory to drug therapy. While 30 mg/dl is considered the upper normal value for LP (a) in central Europe, extremely high LP (a) levels (>150mg/dl) are rare in the general population.

The aim of our study was to analyse the correlation between lipoprotein (a) [LP (a)] levels and an incidence of PAD in high-risk patients.

Patients and methods

We reviewed the LP (a) concentrations of 52.898 consecutive patients admitted to our cardiovascular center between January 2004 and December 2014. Of these, 579 patients had LP (a) levels above 150 mg/dl (mean 181.45±33.1mg/dl). In the control collective LP (a) was <30mg/dl (n=350). Other atherogenic risk factors in this group were HbA1c 6.58±1.65%, low density lipoprotein (LDL) 141.99±43.76 mg/dl, and body mass index 27.81±5.61. 54.40% were male, 26.07% were smokers, 93.2% had hypertension, and 24% had a family history of cardiovascular diseases. More than 82.6% were under statins. The mean glomerular filtration rate (GFR) was 69.13±24.8 ml/min [MDRD (Modification of Diet in Renal Disease)].

Results

45.00% (n=261) of the patients with LP (a) >150mg/dl had PAD. The prevalence of PAD in patients with LP (a) <30mg/dl in our control collective was 15.8%. (P- Value 0.001). Patients with LP (a) >150mg/dl had a significantly increased risk for PAD (Odds ratio 4.36, 95% CI 2.94–6.72, p: 0.001).

19.1% of patients were re-vascularized by percutaneous angioplasty (PTA) and 7.09% of patients had to undergo peripheral vascular bypass (PVB). Mean LP (a) level in patients with PAD was 182.6±31.61.

Conclusion

Elevated LP (a) levels above 150 mg/dl are associated with a significantly increased risk of PAD in our collective and it confirms our hypothesis. Over one fourth of these patients had severe PAD and requiring revascularization therapy. We need more prospective studies to confirm our findings.

Funding Acknowledgement

Type of funding source: None