bluuebunny/crossref_metadata_2025 huggingface dataset:
P1633Age, creatinine, and ejection fraction (ACEF) score continues to predictive prognosis in patients with ischemic cardiomyopathy
Authors: Chen W Z , Ran P , Cai A P
Published: October 2019

Purpose

ACEF (Age, Creatinine, and Ejection Fraction) andACEFMDRD (Modification of Diet in Renal Disease) score have been validated as effective predictors for prognosis in patients undergoing elective cardiac surgery or PCI. However, the predictive value for ICM (Ischemic Cardiomyopathy)was not clear. This study sought to investigate their predictive value in patients with ICM.

Methods

862 ICM patients hospitalized in the Department of Cardiology were prospectively enrolled during November 2014 and December 2017.Inclusion criteria: previous definite diagnosis of myocardial infarction, previous PCI, CABG, or coronary angiographic findings of one or more vessel stenosis >70%; Simpson echocardiography showed LVEF <45%. Exclusion criteria: malignant tumors of any organ or once had a history of malignancies; and other serious diseases with estimated survival time less than one year.The ACEF score was calculated by the formula: age/ejection fraction + 1 (if creatinine >176 μmol/L). As for ACEFMDRD score, estimated glomerular filtration rate (eGFR) was calculated using the MDRD formula. Then using the formula: age/EF +1 point for every 10 mL/min reduction in eGFRMDRD below 60 ml/min per 1.73 m2 (up to a maximum of 6 points). Patients were divided into low, middle and high ACEF, ACEFMDRD tertiles. The median duration of follow-up was 13 months (IQR: 7–23 months). The clinical endpoints were all-cause mortality, cardiac mortality, major adverse cardiovascular and cerebrovascular events (MACCEs) and re-hospitalization for heart failure (HF).

Results

The mean original ACEF and ACEFMDRD score were 1.99±0.63 and 2.53±1.42. Patients in high ACEF and ACEFMDRD tertile were associated with significantly higher all-cause and cardiac mortality, MACCEs and re-hospitalization for HF. Compared with ACEFMDRD score, original ACEF exhibited similar discrimination and predictive ability on all-cause mortality (AUC: 0.739 vs. 0.724, P=0.567), cardiac mortality (AUC: 0.733 vs. 0.717, P=0.525), MACCEs (AUC: 0.635 vs. 0.624, P=0.587) and rehospitalizaiotn (AUC: 0.642 vs. 0.632, P=0.757). In multivariate Cox analysis, the original ACEF or ACEFMDRD score were related with increasing risks of all-cause mortality (HR: 2.00 vs. 1.32, 95% CI: 1.46–2.73 vs. 1.13–1.53, P<0.001), cardiac mortality (HR: 1.97 vs. 1.28, 95% CI: 1.43–2.70 vs. 1.10–1.50, P<0.001 vs. P=0.002), MACCEs and re-hospitalization for HF, respectively.

ROC curves of cardiac mortality

Conclusions

In patients with ICM, the original ACEF and ACEFMDRD score are independent predictors of adverse outcomes during 13-month follow-up, respectively.

Acknowledgement/Funding

None
P1639Prognostic utility of H2FPEF score in heart failure with preserved ejection fraction
Authors: Przewlocka-Kosmala M , Marwick T H , Jankowska E A , Ponikowski P , Kosmala W
Published: October 2019

H2FPEF (obesity, atrial fibrillation, age >60 yrs, ≥2 antihypertensives, E/e' >9, and pulmonary artery systolic pressure by echo >35 mmHg) is a newly-developed score used for establishing the likelihood of heart failure with preserved ejection fraction (HFpEF). Given the clinical significance of its components, it is tempting to speculate that this algorithm might be useful for cardiovascular (CV) risk prediction.

Aim

To investigate the prognostic value of H2FPEF score in a well-characterized HFpEF population.

Methods and results

A group of 205 patients (64±8yrs) with symptomatic HFpEF, underwent clinical and echocardiographic evaluation. At a mean follow-up of 26.2 months, 64 patients (31%) experienced the composite of CV hospitalization or death, and 51 (25%) HF hospitalization. Cox regression analysis revealed that H2FPEF was significantly associated with both study endpoints (HR: 1.30; 95% CI: 1.10 to 1.54; p=0.002 for CV hospitalization or death, and 1.45; 95% CI: 1.21 to 1.75; p<0.001 for HF hospitalization). The prognostic value of H2FPEF was non-inferior to a traditional prognosticator in HF - MAGGIC (Meta-analysis Global Group in Chronic Heart Failure) risk score (area under ROC curve 0.62 for H2FPEF and 0.65 for MAGGIC, p=0.58, for the composite end-point, and 0.66 for both predictors, p=0.96, for HF hospitalization). Using an externally-derived cutpoint for H2FPEF of 5 (considered as the upper limit of the range corresponding to an intermediate probability of HFpEF), we demonstrated that the subset with the score equal to or above this threshold was characterized by a higher risk of both study end-points (Figure).

Figure 1. Kaplan-Meier estimates of survival free of the study outcomes according to H2FPEF score.

Conclusions

H2FPEF score, originally dedicated to discrimination of HFpEF, is a potent prognosticator in this condition, with the ability to identify increased clinical risk comparable to MAGGIC score.
P1649Prognostic significance of serum cholinesterase in patients with acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry
Authors: Seo M , Yamada T , Tamaki S , Yasumura Y , Uematsu M , Abe H , Higuchi Y , Hikoso S , Nakatani D , Fukunami M , Sakata Y
Published: October 2019

Background

Comorbidities strongly influence the prognosis in heart failure with preserved ejection fraction (HFpEF). Malnutrition is one of the most important comorbidities among heart failure patients. Serum cholinesterase (CHE), one of the markers of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. In addition, we previously reported prognostic significance of CHE from a single center registry data of acute decompensated heart failure (ADHF). The aim of this study is to conduct external validation of the prognostic role of CHE using multi-center HFpEF registry.

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals in Osaka recorded clinical, echocardiographic, and outcome data of patients with ADHF and preserved ejection fraction. Between June 2016 and January 2018, 381 patients were enrolled and we excluded patients without sufficient laboratory data and in-hospital death. Finally, we analyzed 204 patients with survival discharge. Laboratory data including CHE and echocardiography were obtained just before discharge. The endpoint of this study is the composite of all-cause death and worsening heart failure re-admission (cardiac event). During a follow up period of 0.92±0.37 years, 49 patients had cardiac event. CHE was significantly lower in patients with than without cardiac event (183±67 vs 223±71 U/L, p<0.0001). At multivariate Cox analysis, CHE (p=0.0020) was significantly associated with cardiac event, independently of NT-pro BNP after adjustment of age, sex, eGFR and hemoglobin. ROC curve analysis showed that AUC of CHE for the prediction of cardiac event was 0.706 (95% CI 0.638–0.768). Kaplan-Meier analysis showed that patients with low CHE (<211U/L defined by median) had a significantly greater risk of cardiac event (35% vs 13% p=0.0002).

Figure 1

Conclusion

Serum cholinesterase level is the useful prognostic marker for the prediction of cardiac event in patients with ADHF with preserved ejection fraction.

Acknowledgement/Funding

Roche diagnostics, FUJIFILM Toyama Chemical
P1650Clinical significance of uNGAL, uKIM-1, and uL-FABP in patients with acute pulmonary edema
Authors: Kuragaichi T , Hotta K , Miyata A , Nakayama H , Nishimoto Y , Kobayashi T , Saga S , Fukuhara R , Yoshitani K , Taniguchi R , Toma M , Miyamoto T , Sato Y
Published: October 2019

Introduction

Novel urinary biomarkers such as urinary neutrophil gelatinase-associated lipocalin (u-NGAL),urinary kidney injury molecule-1 (u-KIM-1), and urinary liver-type fatty acid-binding protein (uL-FABP) are proposed to be reliable markers for acute heart failure (AHF). Acute pulmonary edema (APE) is one of the vascular phenotypes of AHF, such as `vascular failure”, often with high blood pressure at admission. We aimed to investigate the differences in the clinical impact and prognostic utility of urinary biomarkers in AHF patients with and without APE.

Methods and results

This prospective observational study included 203 AHF patients (mean age: 77 years, 52% male). uL-FABP, u-NGAL, and u-KIM-1 were measured at admission and before discharge, with correction for urinary creatinine. APE was defined as acute-onset dyspnea and radiographic alveolar edema requiring non-invasive positive pressure ventilation. The primary outcome was a composite of all-cause death and AHF rehospitalization for 1 year. The median uL-FABP levels at admission were higher in APE (n=42) than in non-APE patients (n=161; 10.8 [4.5–23.7] vs. 20.7 [5.9–63.5] μg/gCr, p=0.017), whereas u-KIM-1, u-NGAL, and serum creatinine did not significantly differ between AHF patients with and without APE. The primary outcome did not differ between patients with and without APE. However, among patients with APE, Kaplan–Meier analysis showed that higher uL-FABP (≥median: 20.7 μg/gCr) was associated with adverse events (log-rank: p=0.019). After adjusting for age, sex, serum creatinine, and brain natriuretic peptide, multivariable Cox hazard analysis showed that higher uL-FABP is an independent predictor of adverse events (HR: 4.0 [1.2–18.2], p=0.023).

Conclusion

Unlike u-NGAL and u-KIM-1, uL-FABP was higher in APE patients than in non-APE patients. Further, among patients with APE, higher uL-FABP was predictive for poor prognosis.

Acknowledgement/Funding

None
P1653Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure
Authors: Aimo A , Januzzi J , Mueller C , Miro' O , Pascual-Figal D A , Jacob J , Herrero-Puente P , Llorens P , Wussler D , Kozhuharov N , Sabti Z , Breidthardt T , Vergaro G , Passino C , Emdin M
Published: October 2019

Background

High-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage and holds independent prognostic significance in chronic heart failure (HF). In acute HF (AHF), its additive prognostic value over natriuretic peptides is unclear.

Methods

Individual data of 1571 AHF patients with admission hs-TnT were collected from 3 cohorts.

Results

Patients were aged 78±10 years, and 51% were men. Median hs-TnT and N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) concentrations were 43 ng/L (interquartile interval 26–69) and 5660 (2693–12466), respectively. Patients experiencing in-hospital death (n=187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p<0.001). The risk of in-hospital death increased by 45% per each doubling of hs-TnT (HR 1.45, 95% confidence interval - CI 1.31–1.59, p<0.001), and by 32% per each doubling of NT-proBNP (HR 1.32, 95% CI 1.17–1.50, p<0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% CI 1.7–4.5). Among the 1262 patients discharged, 1024 deaths occurred over a median 11-month follow-up (4–22). In a model including NT-proBNP, hs-TnT ≥43 ng/L was a strong, independent predictor of all-cause death at 6, 12 and 24 months, and the composite of cardiovascular death or HF hospitalization at 6 and 24 months. hs-TnT ≥43 ng/L also improved risk reclassification.

Conclusions

The risk of in-hospital death is almost 3 folds higher with admission hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L, and hs-TnT ≥43 ng/L holds strong independent prognostic significance for post-discharge outcome.
P1657Hyperuricaemia treatment in acute heart failure patients does not improve their long-term prognosis: a propensity score matched analysis from the AHEAD registry
Authors: Miklikova M , Jarkovsky J , Benesova K , Miklik R , Felsoci M , Spinar J , Dusek L , Parenica J
Published: October 2019

Background

Hyperuricaemia is associated with a poorer prognosis in heart failure (HF) patients. Benefits of hyperuricaemia treatment with allopurinol have not yet been confirmed in clinical practice. The aim of our work was to assess the benefit of allopurinol treatment in a large cohort of HF patients.

Methods and results

The prospective acute heart failure registry (AHEAD) was used to select 3,160 hospitalized patients with a known level of uric acid (UA) who were discharged in a stable condition. Hyperuricaemia was defined as UA ≥500μmol/l and/or allopurinol treatment at admission. The patients were classified into three groups: without hyperuricaemia, with treated hyperuricaemia and with untreated hyperuricaemia at discharge. Two- and five-year all-cause mortality were defined as endpoints. Patients without hyperuricaemia, unlike those with hyperuricaemia, had a higher left ventricular ejection fraction, a better renal function and higher haemoglobin levels, had less frequently diabetes mellitus and atrial fibrillation, and showed better tolerance to treatment with ACEIs/ARBs and/or beta-blockers. In a primary analysis, the patients without hyperuricaemia had the highest survival rate. After using the propensity score to set up comparable groups, the patients without hyperuricaemia had a similar five-year survival rate as those with untreated hyperuricaemia (42.0% vs 39.7%, p=0.362) whereas those with treated hyperuricaemia had a poorer prognosis (32.4% survival rate; p=0.006 vs non-hyperuricaemia group and p=0.073 vs untreated group).

Conclusion

Hyperuricaemia was associated with an unfavourable cardiovascular risk profile in HF patients. Treatment of hyperuricaemia with low doses of allopurinol did not improve the longterm prognosis of HF patients.

Acknowledgement/Funding

Ministry of Health CZ 65269705 and MUNI/A/1250/2017
P1686Natriuretic peptides personifying role in patients with arterial hypertension and chronic heart failure
Authors: Gubareva I , Gubareva E
Published: October 2019

Aim

The aim of research was to study NT-proBNP in patients with arterial hypertension (AH) and chronic heart failure (CHF).

Object and methods of research

420 male patients in age from 30 to 60 years old were examined: group 1 (n=180) – patients with AH without CHF, group 2 (n=86) – patients with AH and CHF, group 3 (n=74) – patients with CHF without AH and the group of control (n=80). NT-proBNP, fmol/ml, was measured.

Results

NT-proBNP had the highest levels in patients of group 3 in comparison with the group of control (p=0.046), group 1 (p=0.037) and group 2 (p=0.046). The duration of AH didn't affect the level of NT-proBNP (r=0.186; p=0.537). In the group with AH, the plasma level of NT-proBNP was lower in patients with 2 and 3 degrees of AH compared with patients with 1 degree of AH (p<0.05). In the group of patients with AH and CHF this pattern wasn't observed (p>0.05). NT-proBNP was interrelated with AH degree in group 1 (r=−0.624; p=0.023). Such a relationship wasn't established in group 2 (r=0.151; p=0.294), NT-proBNP was interrelated with NYHA functional class of CHF (r=0.215; p=0.049).

The diagnostic value of changes in the level of NT-proBNP in the diagnosis of grade 1 AH relative to 2–3 degrees of AH in patients without CHF: at the point of separation (cut off) 3.85 fmol/ml, sensitivity 83% and specificity of 71%. ROC-area under curve = 0.81. The quality of the model was very good. NT-proBNP determining diagnostic value analysis to predict the enhancement in NYHA functional class of CHF in patients with AH and CHF: at a separation point of 3.4 fmol/ml specificity of 71%, sensitivity – 76%. ROC-area under curve = 0.74.

We investigated the level of NT-proBNP in patients of groups 1 and 2 with different types of circadian blood pressure (BP) profiles. NT-proBNP levels were the highest in patients with “non-dipper”, “night-peaker” circadian blood pressure profile and differed significantly from patients profiles “dipper” and “over-dipper” as for systolic BP and for diastolic BP.

Data correlation analysis revealed the inverse relationship between NT-proBNP and SBP (r=−0.498; p=0.035). Since there were no patients with circadian profiles “night-peaker” and “over-dipper” in group 1, and the results of the study reflected the level of NT-proBNP in group 2, we studied the level of these hormones in patients with the same type of circadian profiles in group 1 and group 2. The level of NT-proBNP in patients of group 1 with “non-dipper” profile was reduced in comparison with patients of group 2 and “dipper” circadian profile.

Conclusion

Determination of natriuretic peptides in patients with AH and CHF personifies the diagnosis and prognosis of cardiovascular complications. Natriuretic peptides are involved in circadian blood pressure profile.
P1692Cardiac fibrosis in competitive triathletes is associated with arterial hypertension
Authors: Muench J , Knappe D , Witzel K , Von Stritzky A , Tahir E , Lund G , Patten M
Published: October 2019

Background

Myocardial fibrosis is an occasional finding in asymptomatic athletes.

Purpose

Evaluation of clinical conditions with possible impact on cardiac fibrosis in competitive triathletes.

Methods

Cardiac fibrosis in 61 male competitive triathletes (>10 hrs of training per week, mean 45 yrs) and 19 controls (mean 38 yrs), was quantified using late gadolinium enhancement (LGE) in cardiac magnet-resonance imaging (CMR). Physical examination, past medical history, and routine lab diagnosis were performed and baseline characteristics like blood pressure at rest (BP), body mass index (BMI), and echocardiographic parameters were measured. Triathletes were sub-divided into LGE positives vs. negatives.

Results

All individuals appeared healthy with no drug history of note and a normal cardiac function according to echocardiography. Focal non-ischaemic LGE was detected in 18 triathletes (5.2±4.5 g; 3.5±2.8 g/m2) and none of the controls. Compared to LGE negative triathletes, LGE positives showed significantly higher systolic BP and BMI (see Table). 67% of the LGE positives and only 14% of the LGE negative athletes showed first degree arterial hypertension and 56% of the LGE positives vs. 21% of the LGE negatives were formally overweight (BMI≥25 kg/m2). Controls had smaller left atrial volume indices than the triathletes, in line with characteristics of the athlete's heart. The triathletes were older than the controls (see Table below), but had a normal diastolic function. 38% of the controls and 31% of all triathletes were overweight. Equally to the LGE negatives, 14% of the controls were hypertensive.

Clinical parameters Athletes LGE+ LGE− Controls p-value (athletes vs. controls) p-value (LGE+ vs. LGE−) p-value (LGE− vs. controls) n 61 18 43 19 Age (yrs) 44.6±9.80 48.2±9.04 42.2±9.96 38.4±11.12 0.0371* 0.1222 0.0016* BMI (kg/m2) 24.1±2.57 25.3±2.75 23.8±2.4 24.5±2.74 0.2564 0.0315* 0.1228 Sys. BP (mmHg) 132±15.80 144±17.52 128±12.99 124±15.93 0.0145* 0.0020* 0.2426 LAVI (ml/m2) 29.13±6.79 31.45±8.02 26.68±6.26 24.25±5.48 0.0014* 0.4389 0.0053* All values shown as mean values with standard deviation, if not otherwise indicated, BMI = body mass index, LAVI = left atrial volume index, athletes = all triathletes; LGE+ = triathletes with cardiac LGE visualised by CMR, LGE− = triathletes without LGE in CMR. *Significant p-value, vs. = versus, Sys. BP = systolic blood pressure.

Conclusion

In competitive triathletes, there is a significant correlation between cardiac fibrosis and arterial hypertension at rest as well as overweight. We therefore recommend, that individuals with these characteristics should undergo cardiac consultation before starting endurance-training in competitive disciplines.
P1699Non-ST segment elevation miocardial infarction (NSTEMI) vs. Unstable angina (UA) in young women aged < 45 years - differences in symptomatology, clinical course, treatment and prognosis
Authors: Beckowski M , Gierlotka M , Polonski L , Gasior M , Dabrowski R , Zdrojewski T , Kowalik I , Drygas W , Szwed H
Published: October 2019

Background

Almost 50% of all ACS in young women are NSTEMI and UA. Due to the type of ACS we observed differences in the symptomatology, treatment and outcomes. The aim was to evaluate the differences in the clinical course and prognosis in young women aged ≤45 years with NSTEMI vs. UA.

Methods

We compared 1143 women aged ≤45y.o. with acute cardiac syndromes: 51% NSTEMI, 49% UA from the PL-ACS registry between 2007 - 2014.

Results

Chest pain was predominant in both group, with a higher incidence in NSTEMI group (91.7% vs. 84.7, p=0.0002). UA group was older (42y.o. vs. 41y.o p=0.003), more often presents atypical symptoms (8.0% vs. 1.5%, p<0,0001) mostly with dyspnea (3.9%vs. 1.7%, p=0.025). During NSTEMI more often occurred pre-hospital cardiac arrest (2.9% vs. 0.8%, p=0.0031). There was no difference between groups in general condition at admission expressed by Killip class. Onset-to-intervention time was longer in UA group (41.8 vs. 30.3 hour p=0.0053) resulted from longer door-to-intervention time only (3.3 vs. 1.5 hour, p<0.0001). In NSTEMI group more often the culprit artery was circumflex (17.1% vs. 9.3% p=0.0004) and diagonal branch (4.4% vs. 1.5%, p=0.0095) with a higher number of total occlusions (pre-procedural TIMI 0: 27.8% vs. 15.6% p=0,0023). Number of PCI was also higher in this group (50.9% vs. 36.1%, p<0.0001) without differences in completed revascularizations. In UA group in stent restenosis was found more often (2.8% vs. 1.5%, p=0.026). Drug eluting stents (DES) were often used in UA group (60.2% vs. 49.6% p=0.027). There were no difference in the incidence of PCI complications. We observed a lower usage of clopidogrel, GP IIb/IIIa inhibitors and parenteral anticoagulant in UA group during hospitalization (for all p<0.0001). Ejection fraction LVEF was higher in UA group (56% vs. 54% p=0.0026) at discharge. The 30-day and 1 year prognosis in both group was low with no statistical difference (Table 1).

Table 1. Mortality rate in studied group NSTEMI group (N=580) UA group (N=563) P 30-day mortality 1.60% 0.70% 0.1799 6-month mortality 2.20% 0.90% 0.0662 One year mortality 3.10% 1.60% 0.0940

Conclusions

Clinical course of ACS in young women is different regardless of the type of ACS (NSTEMI/UA) however with no difference in mortality rate. Typical symptoms increases the probability of unstable angina (UA) 2.8 times (p=0.0003). In the UA group, ACS was rarely related to circumflex and diagonal branch with more frequent in-stent restenosis. PCI delay in patients with UA results from a longer door-to-ballon time.
P1708Therapeutic hypothermia in cardiac arrest survivors with pre-existing heart failure is nephroprotective
Authors: Dutta A , Hari K , Qureshi W
Published: October 2019

Introduction

The impact of therapeutic hypothermia on kidneys in cardiac arrest survivors with known congestive heart failure (CHF) is not known. Weak evidence suggests higher risk of acute kidney injury with hypothermia.

Purpose

The effect of hypothermia on organ function in cardiac arrest patients with preexisting CHF

Methods

This analysis includes 1417 comatose cardiac arrest survivors that achieved achieved return of spontaneous circulation on hospitalization and had a previous left ventricular ejection fraction (LVEF) assessment within last 1 year. Detailed chart review of these patients was performed. CHF was defined as either prior episode of congestive heart failure or presence of LVEF <50%. Odds ratio (OR) and 95% confidence intervals (CI) for association of hypothermia and acute kidney injury as well as hemodialysis at discharge among patients with and without CHF were computed using multivariable adjusted logistic regression.

Results

Overall, 1417 cardiac arrest patients (mean age 62.5±14.6 years, 60.2% males, 67.2% white and 29.7% black) were included in this analysis, out of which 467 (33.0%) were treated with therapeutic hypothermia and known CHF was present in 624 (44%). AKI developed in 25.2% of CHF patients that were not treated with hypothermia while, only in 18.0% among CHF patients treated with hypothermia (OR 0.56; 95% CI 0.32–0.96, p=0.03). There was an decrease in trend of requiring hemodialysis at discharge among CHF patients treated with hypothermia compared with CHF patients that were not treated with hypothermia (8.1% vs. 19.62%, p=0.019) among CHF patients not treated with hypothermia. However, there was no significant result.

Conclusions

Hypothermia is associated with nephroprotective effects among patients with cardiac survivors with pre-existing CHF. Future research is needed to identify subgroups that derive benefit from therapeutic hypothermia after cardiac arrest.
P1709A comprehensive meta-analysis on the impact of cardiopulmonary resuscitation guideline changes on outcomes after in- and out-of-hospital cardiac arrest
Authors: Nas J , Te Grotenhuis R , Bonnes J L , Thannhauser J , Furlaneto J , Smeets J L R M , De Boer M J , Van Royen N , Navarese E P , Brouwer M A
Published: October 2019

Background

Studies on international registries report improved outcomes after in- and out-of-hospital cardiac arrest over the last decade. The 2015 resuscitation guidelines incorporate initiatives derived from both guidelines 2005 and 2010, respectively.

Purpose

In order to assess the impact of these respective updates, we aim to provide the most comprehensive quantitative summary of comparative studies that specifically focused on outcomes before and after guideline updates.

Methods

PubMed, Web-of-Science, Embase and The Cochrane Libraries were searched for studies that compared clinical outcomes of patients resuscitated in the period before and after introduction of guidelines 2010 and 2005, respectively.

Results

For studies on guidelines 2010 vs. 2005 (n=6; 1,002 patients), the pooled estimate did not indicate a difference [OR 1.29 (95% CI 0.74–2.25) p=0.372] in return of spontaneous circulation (ROSC). For survival to discharge a significant benefit [OR 1.70 (1.01–2.84) p=0.045] was observed for patients resuscitated according to guideline 2010. As for guidelines 2005 vs. 2000 (n=23; 40,859 patients), the pooled estimates for ROSC, survival to admission, to discharge and favourable neurologic outcome consistently indicated benefit for guideline 2005 [OR 1.21 (1.04–1.42) p=0.014; OR 1.34 (1.09–1.65) p=0.005; OR 1.46 (1.25–1.70) p<0.001; OR 1.35 (1.01–1.81) p=0.040].

Conclusions

This comprehensive meta-analysis quantifies the positive impact of resuscitation guideline updates on outcomes and supports the current way of guideline development. While there is robust evidence for improved overall outcomes after guidelines 2005, the 2010 guideline benefit was restricted to improved survival to discharge. In terms of quality control, our findings call for continued initiatives to monitor outcomes after guideline updates.

Acknowledgement/Funding

None
P1739Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry
Authors: Hakim R , Revue E , Saint Etienne C , Marcollet P , Chassaing S , Decomis M P , Yafi W , Laure C , Gautier S , Godillon L , Akkoyun-Farinez J , Koning R , Motreff P , Grammatico-Guillon L , Range G
Published: October 2019

Background

Whether helicopter transportation for ST-Elevation Myocardial Infarction (STEMI) patients in France is the faster alternative is not known. Data from United States and Europe are controversial and studies have been limited to small series of patients

Purpose

The aim of this study was to analyse delays in emergency medical system (EMS) transfer of STEMI patients from home to the nearest percutaneous coronary intervention (PCI) centre (primary transfer) or from non-PCI centres to PCI centres (secondary transfer) according to transport modalityin a rural French region.

Methods and results

Data from the prospective multicentre CRAC France PCI registrywere analysed for 1911 STEMI patients: 410 transferred by helicopter (HEMS) and 1501 by ground transport (GEMS). The primary endpoint was the percentage of transfers with first medical contact (FMC) to primary PCI (PPCI) within the 90-min recommended in guidelines. The secondary endpoint was time FMC–PPCI. With HEMS,FMC-PPCI <90 min was less frequently achieved than with GEMS (9.8% vs 37.2%; odds ratio 5.49; 95% confidence interval [3.90; 7.73]; p<0.0001). Differences were greatest for transfers <50 km (13.7% vs 44.7%; p<0.0001) and for primary transfers (22.4% vs 49.6%; p<0.0001). Median time from FMC to PPCI and from symptom onset to PPCI (total ischemic time) were significantly higher in HEMS group than in GEMS group (respectively 137 min vs 103 min; p<0.0001 and 261min vs 195 min; p<0,0001). There was no significant difference in in-hospital mortality between the HEMS and GEMS groups (6.9% vs 6.6%; p=0.88).

STEMI patients FMC-PPCI < 90 min

Conclusion

Helicopter transport of STEMI patients was 5 times less effective than ground transport in maintaining the 90-min FMC-PPCI time recommended in guidelines, particularly for transfer distances <50 km.

Acknowledgement/Funding

Regional health agency of CVL, Medtronic, Boston Scientific, Abbot, Biosensor, Terumo, Biotronik, Lilly Daichii Sankyo, Hexacath and Braun.
P1760Incidence and effects of stroke, MI and bleeding on mortality among patients with ACS undergoing PCI: a comparative analysis from the PROMETHEUS registry
Authors: Chandiramani R , Chen H , Cao D , Claessen B , Blum M , Goel R , Sartori S , Aquino M , Guedeney P , Effron M , Keller S , Baker B , Pocock S , Baber U , Mehran R
Published: October 2019

Background

Stroke represents a potentially calamitous complication among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) even though its rates are relatively low. Data on the distribution of stroke occurrence over time and its overlap with myocardial infarction (MI) and bleeding after PCI is scarce.

Purpose

We sought to compare the occurrence and impacts of stroke, MI and bleeding on subsequent mortality in ACS patients undergoing PCI in contemporary clinical practice.

Methods

A total of 19,914 ACS patients who underwent PCI in the PROMETHEUS multi-center observational study were analyzed. We calculated the cumulative stroke incidence at 30 days and 1 year using Kaplan Meier (KM) method. We also compared the distribution of stroke, myocardial infarction (MI) and bleeding across time and evaluated the overlap between their occurrences. Predictors of 1 year stroke occurrence were identified through multivariable Cox-regression and stroke, MI and bleeding were entered as time-updated covariates to estimate their individual effects on subsequent mortality.

Results

Of the total number of patients, 244 patients (1.5%) had a stroke within 1 year. 48 of these patients also experienced an MI while another 48 patients experienced a bleeding event. Furthermore, 14 of these overlapping patients experienced a stroke, MI and bleeding event, all within the 1-year follow-up. Patients who sustained a stroke were more likely to have a prior history of cerebrovascular disease, peripheral artery disease, MI and heart failure compared to those who did not have a stroke. Mortality risk was significantly higher among those with stroke versus those without stroke (adjusted HR 4.84, p<0.0001). However, the association attenuated over time with a much larger effect in the first 30 days of its occurrence (adjusted HR 17.7, p<0.0001) versus beyond 30 days (adjusted HR 1.22; 95% CI: 0.6–2.46, p=0.58). Although the effects of MI and bleeding on subsequent mortality within 30 days of occurrence were significantly lower than stroke (adjusted HR 6.22, p<0.0001; adjusted HR 7.30, p<0.0001, respectively), their effects were more sustained on mortality beyond 30 days (adjusted HR 2.89, p<0.0001; adjusted HR 3.05, p<0.0001, respectively).

Conclusion

When compared with MI and bleeding, stroke had a substantially stronger impact on mortality that attenuated rapidly over time among ACS patients undergoing PCI. Optimization of modifiable risk factors and medication adherence are essential parts of management of stroke following PCI for ACS.
P1771Right ventricular mechanical changes after septal myectomy for obstructive hypertrophic cardiomyopathy. Vector velocity imaging study
Authors: Badran H , Soltan G , Faheem N , Ezzat M , Yacoub M H
Published: October 2019

Objectives

The impairment of right ventricular (RV) myocardial mechanics is evident in hypertrophic cardiomyopathy (HCM). It is independently influenced by LV mechanics and correlated to the severity of LV phenotype. We investigated the changes in RV global and regional deformation following surgical septal myectomy using vector velocity imaging (VVI).

Methods

25 HCM patients, 68% males with mean age (34.5±12 years) were examined before and within two months after surgical myectomy using VVI. In addition to conventional echocardiographic parameters, peak systolic strain (εsys), strain rate (SR) and time to peak εsys (TTP) of regional RV free wall (RVFW) & septal walls were analyzed in longitudinal (long) directions from apical four chamber view and their (Δ)changes were calculated. Similar parameters were quantified in LV from apical 2 & 4 CH views. Intra-V-delay was defined as SD of TTP and inter-V dyssynchrony was estimated from TTP difference between the most delayed LV segment & RVFW.

Results

All study patients showed improvement of their functional class from NYHA class III to class I and reduction of LVOT gradient to below 20 mmHg except one patient who had 30 mmHg gradients at rest. There was significant reduction of septal thickness, left atrial diameter& volume, LVOT gradient, LVMI, severity of mitral regurgitation, tricuspid annular velocities (P<0.0001), RV diameter (P<0.02) and increase in LV internal dimensions (P<0.001) post myectomy. However, there was significant reduction of RV and LV systolic mechanics; RV global εsys % (from −16.1±4.4 to −12.9±2.9, P<0.0001) and LV global εsys %: from −11.6±2.8 to −9.4±2.2%, P<0.0001) respectively. The magnitude of reduction of RV strain (Δ RV εsys%, Δ SRsys) was directly correlated LV maximal wall thickness (r=0.46, P<0.01) and ΔRV dyssynchrony (TTP-SD), (r=0.4, P<0.05) and negatively correlated to age (r=−0.46, P<0.02), pre-op RV SRsys (r=−0.52, P<0.01) and pre-op LV EF% (r=−0.43, P<0.03). Meanwhile the reduction in RV diastolic mechanics: Δ RV SRe & SRa were directly correlated to PAP and LVOT gradient before surgery (r=0.62, P<0.002).

Conclusion

Despite improvement of patient functional status and reduction LVOT gradient, RV mechanics shows further deterioration after surgical myectomy. The magnitude of reduction is modestly related to cardiac phenotype and pre-op mechanical function.
P1797Prevalence of coronary anomalies in tetralogy of Fallot and its clinical implications, a meta-analysis
Authors: Koppel C , Jongbloed M R M , Kies P , Hazekamp M G , Schalij M J , Vliegen H W
Published: October 2019

Background

In literature, anomalous coronary arteries from the opposite sinus of Valsalva or opposite coronary artery (ACAOS) are reported between 2% to 39% of patients with Tetralogy of Fallot (TOF). Knowledge of coronary anatomy prior to corrective surgery is vital to avoid damage to vessels crossing the right ventricular outflow tract (RVOT). The current range of reported prevalences is broad and a general overview comparing current knowledge on anomalous coronary arteries in TOF is lacking to date.

Purpose

In this meta-analysis, we aim to provide a detailed overview of current knowledge on prevalence of coronary anomalies in TOF and discuss the implications for patient management.

Methods

PubMed, Embase and Web of Science were searched for articles on TOF and coronary anomalies. Analysis was done using Revman 5.3 (Cochrane Community, London). The primary analysis focused on the origin and proximal course of the right and left coronary arteries. Also, the prevalences of large conus arteries and coronary arteriovenous fistulas were calculated.

Results

Twenty-nine studies, comprising 6977 patients all together, were included for primary meta-analysis of ACAOS. 6% of TOF patients have an ACAOS. Of these anomalous vessels, 72% crosses the RVOT. 6% of patients have a large conus artery and 4% a coronary arteriovenous fistula. Other incidentally reported coronary anomalies in TOF include a left or right coronary artery originating from the pulmonary artery, an accessory left anterior descending artery, hypoplasia of the entire coronary tree and anastomoses between coronary and bronchial arteries. CT-angiography is the imaging modality of preference because of its high spatial resolution. Transthoracic echocardiography can be used in younger children as well for discerning the coronary anatomy. Most surgical approaches can be adapted to an anomalous coronary artery coursing over the RVOT.

Overall prevalence of ACAOS in TOF

Conclusions

Coronary anomalies have a high prevalence in TOF. An ACAOS occurs in 6%, large conus arteries exist in 6% and coronary arteriovenous fistulas in 4% of cases. A substantial part crosses the RVOT. This has to be taken into account during surgery.
P1801Multiple members with an isolated atrial septal defect phenomenon presented in a family with Holt-Oram syndrome
Authors: Si K , Liu H N , Sun C , Zheng Z
Published: October 2019

Background

Holt-Oram syndrome (HOS), characterized by upper limb malformations, congenital heart diseases (CHD) and/or cardiac conduction abnormalities, is an autosomal dominant disease. Almost all the HOS patients suffer from cardiac and limb abnormalities at the same time. Among them, atrial septal defect (ASD) is the most common cardiac anomaly. The unusual phenotype in a pedigree including multiple members with isolated ASD and a few with isolated limb deformity attracted attention.

Aim

To detect mutant genes of ASD in this pedigree and make a definitive diagnosis. To investigate the mutant type of the gene and illustrate the possible mechanism of heterogeneous phenotype.

Methods

Echocardiography, electrocardiography and physical examination were given to a four-generation Chinese HOS family. Of all 11 patients in this pedigree, eight patients had isolated ASD and one patient had isolated finger deformity. In addition, two patients suffered from both diseases (Figure. 1). Whole Exome Sequencing was performed on the proband and his relatives including three with ASD only, one with finger deformity only and one normal person. Sanger sequencing was performed on biological relatives in this pedigree to valid rare variants. Single nucleotide polymorphisms and insertions/deletions were identified using the GATK program. Pathogenicity was predicted in software like SIFT, Ployphen-2, MutationTaster and CADD_phred.

Results

An exon site mutation (c.100dupG:p.Ala34fs) of TBX5 was detected in all the patients of this pedigree. This mutation site is located in front of T-box and most probably leads to haploinsufficiency of TBX5 protein. In addition, only 42 variants (1 splicing single nucleotide variants (SNV), 15 insertions/deletions, 24 nonsynonymous SNVs, 1 stopgain SNVs and 1 unknown) were found in 29 genes, which are related to cardiac disease.

Figure 1

Conclusions

Our study revealed a mutation (c.100dupG:p.Ala34fs) of TBX5 and further demonstrated the possibility of HOS-related TBX5 mutation in patients with congenital ASD only. This study clarified the diagnosis of this pedigree, provided genetic counseling and promoted the prevention and treatment of HOS. Further research is needed on mechanisms that may lead to phenotypic variation between and within families, such as random monoallelic expression.

Acknowledgement/Funding

None
P1812Speckle tracking echocardiography for early detection of left ventricular systolic dysfunction in patients with Chagas disease
Authors: C P Nunes M , Ribeiro A L P , R S Junior O , Olivera C D L , Cardoso C S , Ariela A M , Maia M A , Oliveira L C , Moreira C H V , Bierrenbach A L , Haikal D S A , Sabino E S
Published: October 2019

Introduction

Longitudinal strain by speckle tracking echocardiography (STE) imaging is a reliable tool for quantitative measurement of myocardial contractility. Assessment of left ventricular (LV) systolic function has a central role in the evaluation of patients with Chagas disease, particularly for identification of subtle changes that could predict disease progression.

Purpose

We aimed to detect early LV dysfunction using LV global longitudinal strain (GLS) in patients with Chagas disease and its relationship to other echocardiographic and laboratory parameters.

Methods

Eight-hundred and fifty patients with Chagas disease (mean age of 60±12 years, 70% female) who live in remote areas in Brazil were enrolled. Clinical evaluation, ECG, N-terminal pro-brain natriuretic peptide (NT-ProBNP), and echocardiogram were performed. LV GLS was assessed offline on the four-, three- and two-chamber views. Patients were divided into tertiles according to the LV strain. Data were analyzed using One-way ANOVA.

Results

The ECG was normal in 19%, whereas typical ECG abnormalities related to Chagas cardiomyopathy were found in 58% of the patients. Overall mean LV ejection fraction (LVEF) was 59±11%, and LV GLS was - 14.1±4.4%. Apical aneurysm was detected in 34 patients (4%).The prevalence of LV systolic dysfunction, defined as LVEF <54% and GLS ≤ |16|%, was 19% and 66%, respectively. Abnormal GLS was observed in 408 (48%) patients despite a normal LVEF. Stratified according to tertiles of LV GLS, patients in the first tertile (strain <|10.7|%), had a significantly decreased in LVEF (Fig 1, A), increased E/e' ratio (Fig 2,B), left atrial volume (Fig 1,C), and NT-proBNP levels (Fig 1,D), indicating severity of LV dysfunction (n=215). Similarly, the patients in the third tertile (strain >|17|%), had normal standard echo parameters and NT-proBNP levels (n=210). However, patients in the second tertile (|10.7|% to |17|%; n=425), the strain was abnormal while other parameters were normal, showing LV impairment that was not evidenced by conventional exams.

Conclusions

LV longitudinal strain assessed by STE in a general population of Chagas disease provided diagnostic information beyond conventionally measured LVEF. Early detection of ventricular impairment may help to identify Chagas disease patients at risk for development of heart failure.
P1820New parameters for the evaluation of mechanic and elastic properties of the aortic root in Marfan Syndrome
Authors: Torres Sanabria M , Garcia Izquierdo Jaen E , Monivas Palomero V , Forteza Gil A , Navarro Rico S , Mitroi C , Gonzalez Mirelis J , Martin Lopez C E , Aguilera Agudo C , Baena Herrera J , Mingo Santos S
Published: October 2019

Background

Elastic properties of the thoracic aorta in patients with Marfan Syndrome (MS) have already been evaluated with classic echocardiographic parameters. In the latest years the use of Speckle-Tracking (STE) ecocardiography has been widely extended. Our aim is to describe and provide new parameters of aortic deformation measured by STE in patients with MS.

Methods

95 unoperated adult patients with MS and 32 healthy controls were prospectively enrolled. We measured classic parameters of the aortic root using 2D echocardiography. We calculated the posterior aortic wall systolic excursion at the sinuses of Valsalva and ascending aorta using M Mode in TDI colour; with ST 2D ecocardiography we measured the aortic strain at the sinuses of Valsalva (SV) and the anterior and posterior aortic wall displacement at the SV. Aortic distensibility was calculated using the formula: 1000 * (Ds − Dd)/Dd * 1/(Ps − Pd) in mmHg–1 (Ds: systolic and Dd: diastolic diameters, Ps systolic and Pd diastolic blood pressure). Aortic stiffness index was calculated as Ln((Ps/Pd)/(Ds-Dd)/Dd)).

Results

As shown in the table bellow, patients with MS had lower aortic strain, aortic anterior and posterior wall displacement and impaired aortic distensibility and stiffness index compared to healthy controls. We found a strong negative linear correlation between aortic root diameter at the SV and aortic root strain (r=−0.56, figure 1).

Results of statistical analysis MS (n=95) Controls (n=32) p Age (years) 32.84±12.35 32.41±7.98 0.85 Aortic root diameter at the sinuses of Valsalva (mm) 38.82±5.35 30.92±3.65 <0.001 Aortic root strain (%) 4.66±2.45 9.19±2.49 <0.001 Anterior aortic wall displacement STE (mm) 10.39±3.64 13.10±2.26 <0.001 Posterior aortic wall displacement STE (mm) 9.02±2.87 11.04±1.82 <0.001 Aortic distensibility 0.98±0.46 1.37±0.72 0.01 Aortic stiffness index 3.74±0.43 3.47±0.51 0.01 MS = Marfan Syndrome; STE = Speckle Tracking Ecocardiography.

Figure 1. Dispersion plot

Conclusions

Our results suggest that aortic deformation and displacement obtained by STE echocardiography is impaired in MS, showing a reduced distensibility and an increased stiffness of the aortic wall, with a strong negative correlation between aortic root dilation and aortic strain. All these parameters may be useful as additional tools for the diagnosis and follow-up of Marfan patients, and could be useful to to improve the echocardiographic evaluation of the aortic root.
P1821Proximal aorta longitudinal but not circumferential strain predicts aortic events and aortic root dilation rate in marfan syndrome patients
Authors: Guala A , Teixido Tura G , Rodriguez-Palomares J F , Ruiz Munoz A , Granato C , Galian L , Valente F , Servato L , Villalva N , Gutierrez L , Lopez Sainz A , Gonzalez-Alujas T , Sanchez V , Forteza A , Evangelista A
Published: October 2019

Background

The most common cardiovascular complications in Marfan syndrome (MFS) are aortic root dilation and type A aortic dissections. Elective aortic root surgery is indicated when maximum aortic diameter is larger than a defined threshold or in the case of fast-progressing dilation. However, maximum aortic diameter is limited for the prediction of aortic events. Indeed, a large international registry of acute aortic syndromes reported that as much as 40% of aortic dissections happen with maximum aortic diameter lower than 50 mm. Consequently, there is a need for new, non-invasive biomarkers to improve the prediction of aortic complications.

Purpose

The aim of the present study was to assess if proximal aorta circumferential and longitudinal strain and ascending aorta distensibility were associated with progressive aortic dilation and incidence of aortic events in Marfan syndrome patients.

Methods

Eighty seven Marfan syndrome patients free from previous cardiac/aortic surgery or dissection, were prospectively included in a multicenter follow-up. Patients were diagnosed by original Ghent criteria. Proximal aorta longitudinal and circumferential strain and distensibility were computed from baseline cine CMR images by means of feature-tracking. The predictive capacity of each stiffness biomarkers was separately tested with multivariable linear regression analysis (aortic growth) and with Cox logistic regression analysis (aortic events), both corrected for clinical and demographic variables, including baseline maximum aortic diameter.

Results

During a follow-up of 81.6±17 months, mean diameter growth-rate was 0.65±0.67 mm/year and z-score growth rate was 0.07±0.13 / year. Elective aortic root replacement was performed in 11 patients while two patients presented type A aortic dissection.Baseline proximal aorta longitudinal strain was independently related to diameter growth-rate (p=0.001), z-score growth-rate (p=0.018) and aortic events (p=0.018). Conversely, neither circumferential strain nor distensibility were independent predictors of diameter growth-rate (p=0.385 and p=0.381, respectively), z-score growth-rate (p=0.515 and p=0.484, respectively) and aortic events (p=0.064 and p=0.205, respectively).

Conclusions

Proximal aorta longitudinal strain predicts aortic root dilation and major aortic events in Marfan syndrome patients beyond aortic root diameter and clinical and demographic characteristics.

Acknowledgement/Funding

ISCIII PI14/0106, La Maratό de TV3 (20151330) and CIBERCV. Guala A. FP7/People n° 267128