bluuebunny/crossref_metadata_2025 huggingface dataset:
P195 A CASE REPORT OF TYPE TWO KOUNIS SYNDROME
Authors: Napoli F , Giannattasio C , Sganzerla P
Published: May 2022

A 81–years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre–existing LBBB. HS–T–Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn’t show any new ischemic abnormalities in the setting of pre–existing LBBB. The peak CK–MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK–MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre–existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm.

Take Home Message

We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.
P203 CHALLENGES IN THE MANAGEMENT OF RECTUS MUSCLE HEMATOMA DURING TRIPLE ANTITHROMBOTIC THERAPY IN RECENT ANTERIOR STEMI COMPLICATED BY LEFT ENDOVENTRICULAR THROMBOSIS
Authors: Caggiari L , Pittau R , Marchetti M , Tuveri F , Maiani S , Perra F , Utzeri E , Fazzini L , Contini F , Montisci R
Published: May 2022

A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.
P206 IMPACT OF AGE, GENDER AND HEART FAILURE ON MORTALITY TRENDS AFTER ACUTE MYOCARDIAL INFARCTION IN ITALY
Authors: De Luca L , Cicala S , D’Errigo P , Cerza F , Mureddu G , Rosato S , Badoni G , Seccareccia F , Baglio G
Published: May 2022

Background

The outcome of patients with acute myocardial infarction (AMI) may vary substantially based on baseline risk. We aimed at analyzing the impact of gender, age and heart failure (HF) on mortality trends, based on a nationwide, comprehensive and universal administrative database of AMI.

Methods

This is a nationwide cohort study of patients admitted with AMI from 2009 to 2018 in all Italian hospitals. In–hospital mortality rate (I–MR) and 1–year post–discharge mortality rate (1–Y–MR) were assessed.

Results

Among the 1,000,965 AMI events included in the analysis, 43.6% occurred in patients aged ≥75 years, 34.7% in females and 21.8% in AMI complicated by HF at the index hospitalization (Figure 1). Both I–MR and 1–Y–MR significantly decreased over time (from 8.87% to 6.72%; mean annual change − 0.23%; confidence intervals (CI): − 0.26% to − 0.20% and from 12.24% to 10.59%; mean annual change − 0.18%; CI: − 0.24% to − 0.13%, respectively). This trend was confirmed in younger and elderly AMI patients, in both sexes (Figure 2). In AMI patients complicated by HF, both I–MR and 1–Y–MR were markedly high, regardless of age and gender.

Conclusions

This contemporary, nationwide study suggests that I–MR and 1–Y–MR are still elevated, albeit decreasing over time. Elderly patients and those with HF at the time of index admission, present a particularly high risk of fatal events, regardless of gender.
P219 IS DISPROPORTIONALITY ENOUGH TO IDENTIFY CANDIDATES FOR PERCUTANEOUS MITRAL VALVE REPAIR? A CLINICAL CASE
Authors: Carassia C , Mennuni M , Degiovanni A , De Vecchi S , Erbetta R , Patti G
Published: May 2022

Functional mitral regurgitation (FMR) is defined as regurgitation with structurally normal leaflets secondary to the distortion of the LV in the context of dilated cardiopathy. The conflicting results emerged from the MITRA–FR and COAPT trials have raised a new interest in the individuation of “primary–like” components of MR. In this scenario, a binary classification in proportionate and disproportionate FMR has been proposed by Garland et al. When the MR is completely due to LV remodeling, they observed a linear relationship between ERO and LVEDV, defining a proportionate FMR; on the other side, when the ERO is superior to the expected one, the FMR is considered as disproportionate, and it may benefit from TEER on top of GMDT. However, the Garland’s model may not explain the full complexity of MV apparatus and FMR. We present the case of a 75–years–old woman diagnosed with dilated cardiopathy of ischemic origin, known since 2008. In 2021 she started receiving multiple hospitalizations for acute decompensation of HF with dyspnoea and symptoms of hypoperfusion, such as AKI on top of CKD and hypotension. The TOE showed a severe LV dysfunction and a moderate dilation of the left ventricle (EF 19%, LVEDVi 90 ml/m2), with a severe FMR secondary to annular dilation and retraction with tethering of the posterior leaflet (MR ERO 0,27 cm2, VC 0,67 cm, RV 45 ml). In order to improve symptoms she underwent TEER with implantation of one Edwards Pascal device at the level of A2–P2, with good results and a mild residual MR. Basing on the Garland’s model our patient would have been classified as proportionate FMR, with no benefit from TEER. However, removing MR component from the heart disease, she improved her stroke volume and her systolic function, allowing a better peripheral perfusion, as showed by an increase in renal function and in arterial pressure during follow–up, which allowed an introduction ad up–titration of Sacubitril/Valsartan, impossible before TEER. At the same time TEER decreased pulmonary pressures improving dyspnoea and functional status (she was NYHA II–III at the 6 month follow–up). In conclusion, the binary model of proportionality has the strength of being easy–to–use and of easily recognizing a primary–like MR that can benefit from TEER; however, proportionate FMR probably includes different pathophysiological mechanisms of disease, requiring an ultra stratification to better identify cases where TEER may increase survival.
P225 RESPIRATORY FAILURE AND BIOELECTRICAL PHASE ANGLE ARE INDEPENDENT PREDICTORS FOR LONG–TERM SURVIVAL IN ACUTE HEART FAILURE
Authors: Scicchitano P , Potenza A , Basile M , Piscopo A , Landriscina R , Sasanelli P , Trotta F , Sanasi M , Paolillo C , Ciccone M , Caldarola P , Massari F
Published: May 2022

Background

The assessment of long term mortality in acute decompensated heart failure (ADHF) is challenging. Respiratory failure and congestion play a fundamental role in risk stratification of ADHF patients. The aim of this study was to investigate the impact of arterial blood gases (ABG) and congestion on long–term mortality in patients with ADHF.

Methods and Results

We enrolled 252 patients with ADHF. Brain natriuretic peptide (BNP), blood urea nitrogen (BUN), phase angle as assessed by means of bioimpedance vector analysis (BIVA), and ABG analysis were collected at admission. The endpoint was all–cause mortality. At a median follow–up of 447 days, (IQR: 248–667), 72 patients died 1–840 days (median 106, IQR: 29–233) after discharge. Respiratory failure types I and II was observed in 78 (19%) and 53 (20%) patients, respectively. The ROC analyses revealed that the cut–off points for predicting death were: >441 pg/mL for BNP, >30 mg/dL for BUN, ≤ 69.7 mmHg for partial pressure in Oxygen (PaO2), and ≤4.9° for Phase Angle. Taken together, these four variables proved to be good predictors for long–term mortality in ADHF (AUC 0.78, 95% CI 0.72–0.78), thus explaining 60% of all deaths. A multiparametric score based on these variables was determined: each single–unit increase promoted a 2.2–fold augmentation of the risk for death (HR 2.2, 95% CI 1.8–2.8, P < 0.0001).

Conclusions

A multiparametric approach based on measurements of BNP, BUN, PaO2, and phase angle is a reliable approach for long–term prediction of mortality risk in patients with ADHF.
P226 LONGITUDINAL EVALUATION OF CONGESTION AND RENAL FUNCTION IN ADVANCED HEART FAILURE PATIENTS TREATED WITH A LEFT VENTRICULAR ASSIST DEVICE
Authors: Zucchetti O , Iacovoni A , Vittori C , Abete R , Terzi A , Campo G , Senni M
Published: May 2022

Introduction

In patients affected by advanced heart failure (advHF) long term mechanical support with left ventricular assist devices (LVADs) is a established therapeutic option. Congestion and renal function in pts treated with a LVAD require expert management.

Aim

Describe the longitudinal trend of congestion and renal function during a 12th follow–up in advHF pts treated with a LVAD, examine the correlation between congestion and renal function, study predictors of sustained improvement of congestion and renal function.

Methods

retrospective single–centre analysis of 39 pts treated with a LVAD and followed in ASST–PG23 Hospital for at least 12 months. Biochemical, echocardiographic and clinical parameters were collected at specific time points from baseline to 12 months after hospitalization during which a LVAD was implanted. Congestion was studied with BNP, bilirubin, haematocrit and daily diuretics dosage. Renal function was studied with absolute changes of eGFR (Cockcroft–Gault). Primary endpoint was sustained improvement of congestion and renal function, derived after comparing baseline pre–LVAD and 12th month parameters.

Results

congestion improved early after LVAD implantation, with steep and high reduction of BNP, bilirubin and daily diuretics dosage. The improvement was higher in those pts with a baseline BNP>median. Bilirubin, haematocrit and daily diuretics dosage showed statistically significant correlations with BNP. Sustained improvement of congestion was present in 59% pts, in particular in those with higher baseline BNP (p = 0.04 after χ²–test). Renal function showed an early steep improvement from baseline pre–LVAD to discharge, more significant in those pts with baseline CKD; during the following months renal function did not show significant changes. Sustained improvement of renal function was present in 54% pts, in particular in those with baseline CKD (p = 0.002 after χ²–test). No significant correlations were found after comparing the trend of congestion and renal function. At multivariable logistic regression, no significant predictors were found for sustained improvement of congestion or renal function.

Conclusions

A multiparametric evaluation of congestion in pts with a LVAD is feasible. The benefit derived from LVAD support appears to be higher in those pts with a baseline higher risk, both in term of congestion and renal function. No significant correlation between the trend of congestion and renal function was found.
P227 DOES NITROPRUSSIDE TEST BEHAVE AD AN INCREMENTAL PROGNOSTIC FACTOR IN SELECTION OF PATIENTS CANDIDATE TO LVAD IMPLANTATION?
Authors: Cusenza V , Pidello S , Frea S , De Ferrari GM
Published: May 2022

Background

Left ventricular assist device in the last two decades has been used to improve survival and quality of life of patients suffering from heart failure, regardless presence of concomitant pulmonary hypertension. Most patients showed improvement in pulmonary pressure. Current clinical practice lacks a reliable method for prediction of reverse remodelling and prognosis.

Aim

of this study is to investigate the possible role of nitroprusside test as prognostic factor in candidates to LVAD implantation.

Methods

We conducted a monocentric prospective observational study analysing 31 consecutive patients implanted with LVAD between July 2013 and October 2021 that underwent right heart catheterization and nitroprusside test before implantation. Basal and nitroprusside–obtained hemodynamic parameters were subsequently correlated with the primary outcome, defined as the composite of death and episodes of right ventricular failure.

Results

Mean age of study population was 58,6 ± 7,97 years, 12,9% were female. Most prevalent INTERMACS class was 3 and mean EF was 18 ± 4,92 %. Mean follow–up was 31,3 ± 20,4 months, during which 11 death and 14 episodes of RVF occurred. At basal hemodynamic assessment, patients with pulmonary vascular resistance above 3 WU had a significant higher rate of events (50% vs 9%, Likelihood ratio 5.7, p = 0.029). No hemodynamic parameter measured after nitroprusside infusion was found to predict survival or episode of RVF.

Conclusion

In this exploratory study we have shown that nitroprusside infusion does not add further prognostic information when compared with basal hemodynamic parameters.
P231 PULMONARY ARTERY WEDGE PRESSURE VS LEFT VENTRICULAR END–DIASTOLIC PRESSURE DURING EXERCISE IN PATIENTS WITH UNEXPLAINED DYSPNEA
Authors: Caravita S , Baratto C , Gallone G , Faini A , Céline D , Sganzerla P , Perego G , Muraru D , Iacovoni A , Senni M , Badano L , Vachiéry J , Parati G
Published: May 2022

Background

Left ventricular end–diastolic pressure (LVEDP) approximates LV stiffness. Pulmonary artery wedge pressure (PAWP) reflects the hemodynamic load imposed by the left heart on the pulmonary circulation, with the interposition of the left atrium (LA). PAWP is frequently seen as a surrogate measure for LVEDP, but the two measures may not coincide. The imprecision of PAWP estimates for LVEDP and the disagreement between the two measures have been widely described for cardiac catheterization at rest. PAWP measurement during exercise has been advocated to discriminate heart failure with preserved ejection fraction (HFpEF) from non–cardiac dyspnea (NCD), with an end–expiratory pathologic threshold ≥25 mmHg. However, a formal comparison of PAWP vs LVEDP during exercise has never been performed. Aim. We sought to compare LVEDP and PAWP during exercise.

Methods

We retrospectively analyzed consecutive patients with unexplained dyspnea and a normal LV ejection fraction, who performed right and left heart catheterization at rest and during exercise.

Results

Forty–six consecutive patients were included in the analysis (80% with a peak PAWP ≥25 mmHg). We found a good correlation between both end–diastolic and mean PAWP on one side, and LVEDP on the other side (R2>0.55). End–expiratory, end–diastolic (mid–A) peak PAWP had no bias as compared with LVEDP, while mean PAWP slightly overestimated LVEDP by 1–2 mmHg. However, confidence intervals were quite large (Figure 1), suggesting imprecision of PAWP estimates for LVEDP. A disagreement between PAWP and LVEDP, using a threshold of ≥ 25 mmHg for both variables at peak exercise, was found in 11% of patients. In 4%, PAWP was ≥25 but LVEDP <25 mmHg, due to the appearance of tall V waves in the PAWP position (increased LA stiffness), increasing PAWP above LVEDP. In 7%, LVEDP was ≥25 but PAWP <25 mmHg. Those patients would have not been diagnosed as HFpEF based on peak PAWP alone. However, they had a PAWP increase during exercise relative to cardiac output changes (PAWP/CO slope) >2 mmHg/L/min, as an alternative parameter confirming HFpEF.

Conclusions

PAWP estimates for LVEDP during exercise bear a good correlation and a minimal bias, albeit being burdened by a relevant imprecision. In patients with unexplained exertional dyspnea and peak PAWP <25 mmHg, additional measures (including LVEDP or PAWP/CO slope) may be indicated in order to maximize the diagnostic yield of exercise cardiac catheterization.
P232 EXERTIONAL BREATHLESSNESS IN HYPERTROPHIC CARDIOMYOPATHY: OBSTRUCTION–INDEPENDENT SYMPTOMS IN A “PARADOXICAL” RESPONSE TO EXERCISE
Authors: Baratto C , Caravita S , Crotti L , Villella F , Rella V , Cecchi F , Badano L , Parati G , Perego G
Published: May 2022

A 66–y.o. man with hypertrophic cardiomyopathy presented with residual exertional dyspnea NYHA III a few years after surgical myectomy, mitral valve repair and ICD implantation. Echocardiography showed residual mild septal hypertrophy and mitral regurgitation (MR), and a variable obstruction of left ventricular outflow tract (LVOT), witnessed by a pressure gradient ranging from 15 to 50–70 mmHg (Figure 1). Exercise echocardiography did not suggest exercise–induced LVOT obstruction (LVOTO) or functional MR. We thus performed a thorough invasive hemodynamic evaluation at rest and during exercise. LVOTO was present at rest, with a maximum pressure gradient of 90–100 mmHg and typical “spike–and–dome” configuration of the aortic pulse contour (Figure 2), with LV end–diastolic pressure (LVEDP) at the upper limit of normal (15 mmHg) and normal pulmonary hemodynamics. During exercise, we observed a paradoxical reduction of the LVOTO (30–40 mmHg at peak, Figure 2). Pulmonary hypertension developed during exercise, due to LV diastolic dysfunction, witnessed by a marked increase in pulmonary artery wedge pressure and LVEDP (up to 25 mmHg and 30 mmHg at peak, respectively). Cardiac output (CO) reserve was at the lower limits of normal, mainly due to chronotropic incompetence, responsible for a mildly reduced exercise capacity (peak oxygen consumption was 20 mL/Kg/min, 75% of predicted). Thus, cardiac catheterization confirmed the presence of a relevant LVOTO at rest, that was not directly related to exertional symptoms. These latter were mainly attributable to LV diastolic dysfunction and reduced CO reserve. These findings helped us driving treatment decision in a tailored way: beta–blockers were not uptitrated, because of their negative inotropic effect, and high–risk septal reduction therapies were excluded, since exertional symptoms were unrelated to LVOTO. However, an attempt to reduce LVOTO was done by DDD sequential pacing through the ICD. Pacing could induce mechanical dyssynchrony and reduce LVOTO by increasing the end–systolic LVOT diameter. The simultaneous echocardiographic monitoring highlighted an acute reduction of LVOT gradient from 50–70 mmHg to 20–30 mmHg (Figure 3).

This case suggests that, in well–selected cases, patients’ management based on pathophysiological reasoning may help to define the etiopathogenetic mechanism underlying symptoms, and to drive treatment decision in a patient–centered way.
P237 INFLUENCE OF HEART RATE ON LEFT AND RIGHT VENTRICULAR LONGITUDINAL STRAIN IN PATIENTS WITH CHRONIC HEART FAILURE
Authors: Di Terlizzi V , Barone R , Manuppelli V , Correale M , Casavecchia G , Goffredo G , Pellegrino P , Puteo A , Ieva R , Di Biase M , Brunetti N , Iacoviello M
Published: May 2022

Background

Myocardial deformation evaluated by two–dimensional speckle tracking echocardiography (STE) is a useful tool to evaluate both left and right ventricular function. However, there are no conclusive data about the relationship between strain measures and heart rate (HR).

Aim of the Study

To analyse changes in left (LV) and right ventricular (RV) longitudinal strain associated with variations of HR in patients with and without chronic heart failure (CHF). Methods. We enrolled 45 patients. Of the 38 patients diagnosed with CHF, 21 were carrying an ICD (Group 1), and 17 an ICD with CRT (Group 2). Group 3 included 7 participants without CHF with sinus node dysfunction that were carrying a pacemaker. The frequency of atrial stimulation was increased to 90 beats/min and an echocardiogram was performed at each increase of 10 beats/min. Global LV and RV longitudinal strain (LVGLS and RVGLS, respectively) and RV free wall longitudinal strain (RVfwLS) were calculated at each HR, together with other echocardiographic parameters. Worsening or improvement of strain measures was defined as a relative change from baseline of 10%.

Results

The reproducibility of strain measurements was assessed in all the images obtained at the different HRs for 19 of the study participants. A high degree of reproducibility was observed for LVGLS (ICC = 0.96; 95% CI, 0.93 – 0.97) as well as for RVGLS (ICC = 0.91; 95%CI, 0.86 – 0.94) and RVfwLS (ICC = 0.91; 95%CI, 0.85 – 0.94). When analysed as continuous variables, significant reductions in LVGLS were detected at higher HRs, whereas improvements in both RVGLS and RVfwLS were observed (left panels of the figure). Patients with worsening of LVGLS (76% overall) were more likely to present lower baseline LV function and maximum relative changes of LVGLS correlated significantly with the E/e’ ratios (r = –0.56; p < 0.001). Only few patients (18% for RVGLS and 16% for RVfwLS) exhibited HR–related worsening of RV strain measures, which was associated with lower levels of baseline RV function and higher pulmonary systolic pressures. Finally, 21 (47%) and 25 (56%) of the participants responded with improvements in RVGLS and RVfwLS, respectively. Right panels of the figure show the trend of left and right measures in the different groups.

Conclusions

Our findings revealed heterogeneous RV and LV responses to increases in HR. These findings might ultimately be used to optimize cardiac functionality at rest in patients diagnosed with CHF.
P239 TOLERABILITY OF SACUBITRIL/VALSARTAN TREATMENT IN OLDER PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION: PRELIMINARY DATA FROM THE REAL–WORLD AGING–HF REGISTRY
Authors: Herbst A , Orso F , Camartini V , Virciglio S , D‘Errico G , Salucci C , Verga F , Fattirolli F , Marchionni N , Di Bari M , Ungar A , Baldasseroni S
Published: May 2022

Background

Although older patients with heart failure (HF) with reduced ejection fraction enrolled in PARADIGM–HF showed a good tolerance to sacubitril/valsartan (Sa/Va), more real–word data are needed to define their tolerability in this population. Aim: To describe the Sa/Va tolerability and titration in older HFrEF patients followed by our HF outpatient.

Methods

HFrEF patients aged ≥65 years and treated with Sa/Va from November 2016 to June 2021 were enrolled, assessing Sa/Va tolerability at six months and its clinical and hemodynamic effects.

Results

We enrolled 101 patients with a mean age of 78 years (⁓20% female). The aetiology was ischemic in 59% of cases while the mean ejection fraction was 31%. Sa/Va was prescribed at the starting dose (24/26mg) and intermediate dose (49/51mg) in 91% and 9% of cases, respectively. After six months, 9 of the 100 patients still alive had discontinued treatment with Sa/Va (4 for symptomatic hypotension, 3 for suspected allergic reaction and 2 for worsening renal function). Of the 91 patients still on therapy, only 17 had reached the target dose (97/103mg) while 28 were at the intermediate dose (Figure 1). Symptomatic hypotension (62%), hyperkalaemia (15%) and worsening of renal function (4%) were the main causes of maintaining Sa/Va therapy at the starting dose; note, in 15% of cases a specific cause of non–titration was not identified. Comparing HF treatment between starting dose vs higher–dose patients, after six months in low–dose patients there was a slight improvement in mineralcorticosteroid receptor antagonist (MRA) prescription and in combination therapy (Sa/Va, beta–blocker and MRA) while in patients at higher–doses there was a significant decrease (Figure 2). In patients still receiving Sa/Va, significant clinical improvement was observed while renal function, K+ levels and systolic blood pressure remained stable (Figure 3).

Conclusions

After six months of treatment, Sa/Va was well tolerated in most of our older patients and used in combination with a beta–blocker and an MRA in a high percentage of cases, although a reduction in MRA prescription is observed in patients taking higher dosages of Sa/Va. In addition, there was a marked improvement in the clinical variables.
P250 PROTOCOL FOR TELEHEALTH EVALUATION AND FOLLOW–UP OF PATIENTS WITH CHRONIC HEART FAILURE DURING THE COVID–19 PANDEMIC
Authors: D‘Errico G , Herbst A , Orso F , Baldasseroni S , Fattirolli F , Virciglio S , Camartini V , Di Bari M , Marchionni N , Ungar A , Salucci C , Verga F
Published: May 2022

Background

After the lockdown imposed by the COVID19 pandemic, physicians had to limite ambulatory visits to exceptional cases to reduce interpersonal contact. We structured a telephone follow–up developing a standardized 23 item questionnaire to administrate to our HF outpatient clinic and from whom we obtained the Covid–19–HFscore.

Methods

The patients were identified by a numeric code, date of birth and gender. The questionnaire was designed for rapid administration during telephone interview (on average 6 minutes) and was administered directly by physicians to patients and/or to their caregiver. It was built to reproduce our usual clinical evaluation.

Results

As shown in Figure 1, we investigated seven domains: 1) social and functional condition 2) mood 3) adherence to pharmacological and non–pharmacological recommendations (blood pressure, heart rate, weight monitoring and fluid intake control) 4) clinical and hemodynamic status 5) recording of laboratory tests 6) current pharmacological treatment 7) recent evaluation by family physician or need to contact emergency services followed or not by hospitalisation. General and pharmacological recommendations as well as the following telephone contact were finally recorded. To determine the timing of the next telephonic evaluation, we decided to weight questions regarding clinical and hemodynamic status, adherence to pharmacological and non–pharmacological recommendations, therapeutic changes and need for hospitalisation by scoring the answers (from 1 to 3) to build a score. The sum of individual scores represented the novel TeleHFCovid19–score, ranging from 0 to 29. Based on such score, three groups of patients were identified by arbitrary cut–off levels: the green (score <4), the yellow (score 4–8) and the red (score ≥9) group, for which next telephonic evaluation was planned respectively after four, two and one week respectively. Alternatively, the red group could receive recommendation for urgent hospital evaluation.

Conclusion

During this emergency situation this questionnaire could be a useful clinical tool to help physicians maintaining a regular FU of their patients and identifying patients at greatest risk of imminent instability. Furthermore, this instrument could also represent a useful resource in the management of low–risk HF patients.
P251 PERIODIC BREATHING (EOV) ON CARDIORESPIRATORY STRESS TESTING: ARE THERE PROGNOSTIC DIFFERENCES BETWEEN PATIENTS WITH PERIODIC BREATHING THAT PERSISTS THROUGHOUT THE TEST AND PATIENTS TO WHOM IT DISAPPEARS?
Authors: Palermo P , Apostolo A , Contini M , Mapelli M , Alessandra M , De Martino F , Salvioni E , Agostoni P
Published: May 2022

Introduction

Oscillatory exercise ventilation (EOV) is frequently seen in patients with severe heart failure (HF) and has a ne:gative prognostic value in both patients with reduced HF and those with average ejection fraction. Two types of EOV have been described one that lasts throughout exercise and one that disappears before the end of exercise, Figure 1

Aim of the Study

It is currently unknown whether there are differences in prognosis and functional capacity between HF patients with EOV that persists or disappears during exercise.

Population

Male and female patients, aged≥18 years, diagnosed with HF and LVEF<45% were enrolled.

Methods

The retrospective study enrolled patients who performed a cardiopulmonary exercise test (CPET) and presented with EOV during exercise (Monzino Heart Center Laboratory and patients included in the MECKI score registry, identified a total of 255 patients). A subset of 100 patients underwent measurement of maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after exercise (Table 2). All patients were treated at the top of therapy for HF. CPETs were performed and analyzed with a standard approach using a customized ramp protocol. The main parameters obtained are reported and compared in Table 1. EOV was defined according to as a cyclic fluctuation in ventilation as proposed by Corrà et al. Statistical analysis:Data are reported as mean ± standard deviation or median and interquartile range as appropriate. The two groups of patients were compared by t test for unpaired data in the case of data with normal distribution. Mortality was analyzed by Kaplan Meier curves and Log Rank test. Survival was considered using the composite end–point of cardiovascular death, urgent cardiac transplantation, or implantation of a left ventricular assist device. The median MECKI score of the total population was 5.5% (2.5–13.7) with no significant differences between the 2 groups. Figure 1 shows the Kaplan Meyer describing the 5–year survival analysis in both groups.

Conclusions

Patients with disappearing EOV demonstrated better exercise performance but no significant difference in survival and major prognostic parameters.
P252 PROTOCOL FOR TELEHEALTH MANAGEMENT AND STRATIFICATION RISK OF ELDERLY PATIENTS WITH CHRONIC HEART FAILURE DURING THE COVID–19 PANDEMIC: A MID–TERM PROGNOSTIC EVALUTATION BY TELEHFCOVID–19 SCORE
Authors: Verga F , Orso F , Herbst A , Camartini V , Virciglio S , D‘Errico G , Salucci C , Di Bari M , Marchionni N , Ungar A , Fattirolli F , Baldasseroni S
Published: May 2022

Introduction

The Coronavirus Disease (COVID–19) pandemic and its consequences has forced physicians to develop telematic methods in order to follow up patients with cronic diseases, such as heart failure (HF).

Objectives

To evaluate TeleHFCovid–19 score as a mid–term (six months) prognostic score in terms of prediction of hospitalitazion and cardiovascular mortality in patients with chronic HF during Covid–19 pandemic.

Methods

During COVID–19 pandemic (from March 2020 to May 2020), we were forced to cancel nearly all follow–up checks in our HF outpatient clinic. We hence standardized a telephone follow–up by developing a questionnaire (Fig. 1) from which we then obtained a score, later called the “TeleHFCovid–19 score” (0–29). This score stratified patients in three risk score groups: green (0–3), yellow (4–8), and red (≥9), for which the next telefonic evaluation was planned after 4, 2 and 1 weeks, respectively.

Results

146 patients were enrolled: 112 were classified as green, 21 as yellow and 13 as red. Mean age was 81 years, females were 40%. Approximately one third had EF < 40%. At six months, compared to red (69.2%) and yellow patients (33.3%), green patients (8.9%) presented a significantly lower rate of the composite outcome of cardiovascular death and/or HF hospitalization, (p < 0.001, Fig 2). Multivariate analysis showed that high levels of creatinine (OR 5.960, 95% CI 1.627–21.837, p = 0.007), dyspnea at rest or for basic activities (OR 2.469, 95% CI 1.216–5.013, p = 0.012) and a high loop–diuretic dosage (OR 6.224, 95% CI 1.504–25.753, p = 0.012) were indipendently associated with the outcome. Moreover, ROC analysis showed a high sensibility and specificity for our score at six months (AUC =0.789, 95% CI 0.682–0.896, p < 0.001), with a score < 4.5 (very close to the green group cut–off) that identified lower–risk subjects (Fig 3).

Conclusions

The TeleHFCovid–19 score was able to correctly identify patients with good outcomes at six months. Furthermore, it has the ability to stratify the adverse event risk and this could represent a useful tool to appropriately schedule the reevaluation timing of these patients and to identify those who may need urgent hospital evaluation.
P253 INDEPENDENT PREDICTORS OF 1–YEAR MORTALITY IN OLDEST OLD PATIENTS MANAGED BY A GERIATRIC–CARDIOLOGY HF UNIT OF AOU CAREGGI
Authors: Virciglio S , Orso F , Herbst A , Camartini V , Girardi E , Ghiara C , Perfetti G , Pratesi A , Di Bari M , Ungar A , Fattirolli F , Marchionni N , Baldasseroni S
Published: May 2022

Background

A multidisciplinary heart team and continuum care approach seems to be the most appropriate clinical strategy in order to reduce mortality, functional decline and disability of frail and clinical complex oldest old patients affected by heart failure (HF). We analysed the independent predictors of 1 year–total mortality in our cohort of oldest old HF patients.

Methods

All patients aged > 85 years referred to our Heart Failure Unit of a Tertiary teaching hospital were consecutively enrolled in the study and were evaluated at first visit with a comprehensive assessment recording cardiological, geriatric and bio–humoral variables. Then we assessed with a multivariable Cox regression analysis the independent predictors of 1–year all–cause mortality.

Results

87 patients were enrolled (mean age 89 ± 2.7 years, range 86–96 years); 48.9% were females, 57.9% were in NYHA class III or IV, 43.2% had HFpEF, 36.4% had an ischemic aethiology, 69.3% had a history of atrial fibrillation, 19.3% were living alone, the mean number of prescribed drugs was 8.8 ± 2.2, EVEREST congestion score was 5.2 ± 2.6, mean NT–proBNP was 8187 ± 11170 pg/ml. In the year after enrolment, 25 patients (34.1%) had more than one HF hospitalisation and 17 patients (19%) died. Among all clinical variables, living alone, having had one or more HF hospitalisation and HF–type (HFpEF, HFmrEF, HFrEF), EVEREST congestion score, trans–tricuspid gradient and tricuspid annular plane systolic excursion were significantly (p < 0.05) associated with 1–year mortality. At multivariable Cox–regression model only living alone (HR 3.34; 95% CI: 1.16–9.64) and EVEREST congestion score (HR 1.24; 95% CI: 1.04–1.46) resulted significantly associated with 1–year mortality. In the Figure we report the Kaplan–Meier curves according to the EVEREST congestion score (dichotomized according to a median value of 4) and living alone (yes vs not).

Conclusions

In a cohort of HF oldest old patients tightly managed in a dedicated cardiologic and geriatric Heart Failure Unit, 1–year all–cause mortality was independently predicted by a clinical score of congestion and by living alone status.
P262 ULTRASOUND–ASSISTED THROMBOLYSIS OF HIGH RISK AND INTERMEDIATE–HIGH RISK PULMONARY EMBOLISM: A MULTICENTRE REAL WORLD EXPERIENCE IN LOMBARDY REGION
Authors: Russo F , Cianfanelli L , Galli M , Chizzola G , Bossi I , Chieffo A , Montorfano M
Published: May 2022

Introduction

Acute pulmonary embolism (PE) is associated with high morbidity and mortality rate. Catheter–directed treatments (CDTs) seem a therapeutical option in case of sistemic thrombolysis (ST) contraindication or failure. Ultrasound–assisted thrombolysis (USAT) allows low–dose thrombolytic loco–regional infusion facilitated by ultrasounds.

Methods and Results

A multicentre retrospective observational cohort study was conducted among 4 Cardiovascular Interventional Centres in Lombardy Region to evaluate safety and efficacy of USAT in high risk and intermediate–high risk PE patients presenting with contraindications to ST. Patients at high risk were included in case of USAT because of ST contraindications. Patients at intermediate–high risk were included in case of rescue USAT. Loco–regional thrombolysis was performed using rTPA. Procedural success was defined as successful catheters‘ deployment in pulmonary arteries and patient survival during the procedure. Bleeding were defined according to BARC criteria. Echocardiographic evaluation to determine the prevalence of right ventricular (RV) dysfunction and pulmonary hypertension was performed at presentation, discharge and follow–up. Between 2011 and 2021, 109 patients were included. 21.1% presented with high risk PE, the remaining 78.9% with intermediate–high risk. Procedural success was obtained in 99.1% of the cases; major bleedings occurred in 9.2%, minor bleedings in 11.9% and vascular complications in 7.3% of the patients. 91.7% of patients were alive at discharge. In–hospital all–cause mortality was higher in high risk patients (26.1% vs 3.5%; p = 0.003) that showed a steep decline in survival as compared to intermediate–high risk patients that constantly maintained a high survival rate throughout the observation period. At six–months follow–up 3 patients in intermediate–high risk group died so that the overall mortality remains higher in high risk patients (26.1% vs 7%; p = 0.018). No re–hospitalization for recurrent PE at six–months occurred. Prevalence of RV dysfunction and pulmonary hypertension significantly decreased from hospital admission to discharge and to six–months follow–up (p–value <0.0001 for all comparisons).

Conclusions

Our experience shows good short and mid–term outcomes in USAT in high risk and intermediate–high risk PE patients with contraindications to ST, suggesting that it might be considered in a neglected subset of patients with no alternative therapeutical options.
P266 D–DIMERO: AN OLD NEGLECTED TEST THAT GOES BEYOND EXPECTATIONS D–DIMER ANALYSIS IN THE STRATIFICATION OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM: EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM
Authors: Savioli G , Ceresa I , Maggioni P , Novelli V , Lava M , Fumoso F , Lapia F , Brattoli M , Bressan M
Published: May 2022

Purpose

To see if D–Dimer correlates, in the real life of an Emergency Department, with more severe forms of pulmonary embolism (massive pulmonary embolism, presence of organ damage), with the need and duration of hospitalization in resuscitation or the length of hospital stay. We then analyzed correlations with sPESI index, shock indices and blood gas parameters.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Anni), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood chemistry and blood gas tests performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We also analyzed vital parameters and the various shock indexes from these derivatives. We then analyzed whether patients had massive pulmonary embolism or the presence of organ damage (right ventricular dilation, pulmonary artery dilation and presence of pulmonary infarction).

Results

We enrolled 247 patients, all in need of hospitalization for acute pulmonary embolism. The average age of 83 with female prevalence (62%). High values of D–Dimer show a strong correlation with the presence of massive pulmonary embolism (p < 0.001) and a correlation, albeit to a lesser degree, with the presence of organ damage (p < 0.01). D–Dimer values show a strong correlation (p < 0.005) even with patients at high risk of short–term mortality (presenting right cardiac ventricular dilation and myocardiospecific enzyme elevation). However, the AUC of the ROC curve is not optimal (0.63; with specificity 63% and sensitivity 62%). They also showed a correlation with the need for hospitalization in the ICU (p < 0.01) and a slight correlation with the length of stay in resuscitation (rho = 0.25; p = 0.05) and hospital stay (rho = 0.20; p < 0.01).

Conclusions

D–Dimer values appear to be useful in the severity stratification of patients with pulmonary embolism.
P278 WHEN HARRY MET SALLY. DESCRIPTION OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM ARRIVING IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM
Authors: Savioli G , Ceresa I , Preda L , Manzoni F , Maggioni P , Fumoso F , Lapia F , Brattoli M , Bressan M
Published: May 2022

Premises

Pulmonary embolism represents one of the major causes of mortality linked to cardiovascular events. The range of symptoms is extremely wide and its recognition difficult. The patients who therefore come to the emergency room are a diverse population.

Purpose

to describe the population that refers to the emergency room and finds there a diagnosis of acute pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes, severity scores.

Results

We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Among those subjected to blood gas analysis 11% showed alteration of pH, 16% showed alteration of pCO2, 8% showed alteration of pO2, 5% of BE, 2% of lactate. 34% showed massive PE, 32% showed organ damage. In particular, 21% showed pulmonary artery dilation, 16% pulmonary infarction and 19% right ventricular dilation. 40% showed elevation of myocardiospecific enzymes. 41% were considered to be at high risk of long–term mortality according to European guidelines, 41% at intermediate risk and 18% at low risk of mortality. 1.4% underwent thrombolysis, 2.4% required intubation. 2.8% needed an operating room for mechanical thrombolysis; 8% of hospitalization in the intensive ward during hospitalization. In–hospital mortality was 7.7%. 5% experienced bleeding during hospitalization following anticoagulation therapy.

Conclusions

The population that arrives in ED for pulmonary embolism presents extremely varied symptomatological pictures, but an overall high degree of clinical risk and assistance and therapeutic complexity.
P295 EXERCISE OXYGEN KINETIC IN HYPERTROPHIC CARDIOMYOPATHY: RESULTS FROM A MULTICENTER CARDIOPULMONARY EXERCISE TESTING STUDY
Authors: Mapelli M , Romani S , Magrì D , Merlo M , Cittar M , Masè M , Muratori M , Gallo G , Sclafani M , Carriere C , Zaffalon D , Salvioni E , Mattavelli I , Vignati C , De Martino F , Rovai S , Autore C , Sinagra G , Agostoni P
Published: May 2022

Aims

Reduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). We evaluated the cardiopulmonary exercise testing (CPET) response in HCM focusing on parameters strongly associated with stroke volume (SV) and cardiac output (CO), such as oxygen uptake (VO2) and O2–pulse, considering both their absolute values and temporal behavior during physical exercise.

Methods and Results

We enrolled 312 non–end stage HCM patients, divided according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva maneuver (72% with LVOTO<30; 10% between 30 and 49 and 18% ≥ 50mmHg). Peak VO2 (percent of predicted), O2–pulse and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety–six (31%) HCM patients presented an abnormal O2–pulse temporal behavior, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106±45 vs. 130±49W), VO2 (74±17 vs. 80±20%) and O2–pulse (12 [9–14] vs. 14 [11–17]ml/beat), with higher VE/VCO2 slope (28 [25–31] vs. 27 [24–31]) (p < 0.005 for all). Only 2 patients had an abnormal VO2/work slope.

Conclusion

None of CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal O2–pulse exercise behavior, which is strongly related to inadequate SV during exercise, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, helping identifying more advanced disease irrespectively of LVOTO. Adding O2–pulse kinetics evaluation to standard CPET could lead to a potential incremental benefit in terms of HCM prognostic stratification and, then, therapeutic management.