bluuebunny/crossref_metadata_2025 huggingface dataset:
Direct oral anticoagulants versus left atrial appendage closure in elderly patients (>80) with atrial fibrillation: results from a propensity matched analysis in real-life patients
Authors: Caneiro B , Raposeiras-Roubin S , Abu Assi E , Estevez-Loureiro R , Gonzalez-Ferreiro R , Bastos Fernandez G , Diego Nieto A , Cruz Gonzalez I , Rodes Cabau J , Iniguez Romo A
Published: November 2020

Introduction

Information comparing left atrial appendage closure (LAAC) to direct oral anticoagulation therapy (DOAC) is scarce.

Purpose

Our aim is to compare the clinical outcomes between LAAC and DOACs of an elderly population (over 80 years-old).

Methods

We retrospectively collected 1144 patients with atrial fibrillation over 80 years old from three different tertiary hospitals. 970 patients have received DOACs and 174 patients have undergone LAAC. We have performed a propensity score matching analysis (PSM), with a caliper of 0.2. After propensity score with matching analysis, 58 patients received DOACs alone and 58 patients treated with LAAC with similar baseline risk factors, comorbidities and risk scores were selected. Outcomes of DOACs and LAAC were assessed by Cox regression.

Results

Both groups had similar cardiovascular risk factors with more proportion of diabetic and hypertensive patients among LAAC group (37.4% and 90.2%, respectively vs 20.3% and 70.3%). Patients undergoing LAAC had more frequently history of bleeding, anemia or previous cancer. CHA2DS2VASC score was also significantly higher in these patients. During a median follow-up of 2.0 years (range 0.9–3.5) event rate for the combined endpoint of death, bleeding and embolic events was 24.9%. 81 embolic events were recorded (27 patients had transient ischemic attacks and 52 were diagnosed of stroke and only 2 patients with pulmonary embolism and 2 more with peripheral embolic events). 131 bleedings were recorded with 1,5% of intracranial bleeding. After propensity score matching, no differences regarding the primary composite endpoint were found (HR 1.05, 95% CI 0.15–7.51; p=0.955). Bleeding events were more frequent in LAAC group, especially during the first three months, thereafter rates become similar in both groups with no statistically significant differences (HR 1.79, 95% CI 0.73–4.41; p=0.205) (Figure 1). We calculate the time to first bleeding for LAAC 0.9±1.3 vs 1.7±1.3 on DOACs. Mortality was numerically greater in patients on DOACs (31,8%) vs LAAC (26,4%). However, this finding did not reach statistical significance (HR 0.70, 95% CI 0.33–1.47; p=0.343).

Conclusions

LAAC has no differences in terms of embolic events, bleeding events and mortality compared to DOACS in a population of elderly patients over 80 years-old. In our population, LAAC is a strategy as safe and effective as DOACs and represents an alternative to consider in real life patients older than 80 years.

Figure 1

Funding Acknowledgement

Type of funding source: None
Initial and long-term antithrombotic therapy after left atrial appendage closure with the WATCHMAN
Authors: Ledwoch J , Sievert K , Boersma L , Bergmann M , Ince H , Kische S , Pokushalov E , Schmitz T , Schmidt B , Gori T , Meincke F , Protopopov A , Betts T , Mazzone P , Sievert H
Published: November 2020

Background

Evidence regarding post-procedural antithrombotic regimes other than used in randomized trials assessing percutaneous left atrial appendage (LAA) closure is limited.

Purpose

The present work aimed to compare different antithrombotic strategies applied in the real-world EWOLUTION study.

Methods

A total of 998 patients with successful WATCHMAN implantation at 47 centers were available for the present analysis. The composite ischemic endpoint of stroke, TIA, systemic embolism and device thrombus as well as the bleeding endpoint defined as at least major bleeding according to BARC were assessed during an initial period (from implant until first medication change) and long-term period (from first change until up to 2 years).

Results

The antithrombotic medication chosen in the initial phase was dual antiplatelet therapy (DAPT) in 60%, oral anticoagulation (OAC) in 27%, single antiplatelet therapy (SAPT) in 7% and no medication in 6%. In the long-term phase SAPT was used in 65%, DAPT in 23%, no therapy in 8% and OAC in 4%. No significant differences were found between the groups regarding the ischemic endpoint both in the initial period (Kaplan-Meier estimated rate 2.9% for DAPT vs. 4.3% for OAC vs. 3.9% for SAPT or no therapy; p=0.97) and in the second period (4.2% for SAPT vs. 1.8% for DAPT vs. 3.5% for no therapy; p=0.36). With respect to bleeding events the only difference was found in the initial phase with a higher incidence in patients under SAPT or no therapy (1.0% for DAPT vs. 0.8% for OAC vs. 7.4% for SAPT or no therapy; p=0.01). No differences in bleeding complications were observed during the second period (2.6% for SAPT vs. 2.9% for DAPT vs. 2.2% for no therapy; p=0.88).

Conclusions

Tailored antithrombotic treatment using even very reduced strategies such as SAPT or no therapy showed no significant differences regarding ischemic complications after LAA closure.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific
Incidence and predictors of postoperative ischaemic stroke after coronary artery bypass grafting in the United States
Authors: Mohamed W , Hirji S , Mohamed M , Percy E , Braidley P , Chung J , Aranki S , Mamas M.A
Published: November 2020

Background

Postoperative acute ischemic stroke (AIS) is a catastrophic complication of coronary artery bypass grafting (CABG). There is limited data on the incidence and outcomes of AIS complicating CABG in the contemporary era, and whether these have changed over the years.

Purpose

To study the incidence and outcomes of postoperative AIS in a nationally representative cohort of CABG procedures over a 12-year period and examine predictors of AIS in patients undergoing CABG.

Methods

The National Inpatient Sample was used to identify all adult patients (>18 years old) who underwent CABG in the United States between January 2004 and September 2015. Multivariable logistic regression was performed to examine the associations between postoperative AIS and in-hospital mortality and identify predictors of AIS after CABG, expressed as odds ratios (OR) with corresponding 95% confidence intervals (CI).

Results

A total of 2,569,597 CABG operations were analysed. The incidence of postoperative AIS was 1.8% (n=47,279) in the overall cohort increasing from 1.2% in 2004 to 2.3% in 2015 (p<0.001). Significantly higher rates of AIS were observed amongst patients with atrial fibrillation (AF) and those undergoing non-elective or concomitant valve operations over the study period (see Figure). Patient risk profiles increased over time in both AIS and no-AIS cohorts, with higher Charlson comorbidity scores observed amongst AIS patients. AIS was independently associated with increased odds of in-hospital mortality (OR 3.03, 95% CI 2.93, 3.13) and prolonged hospital stay (∼6 more days) and a higher hospitalisation cost (∼$80,000 more) (p<0.001 for all). Several factors were predictors of AIS including age>60 years (61–70 years: OR 1.33, 95% CI 1.29, 1.37; 71–80 years: OR 1.49, 95% CI 1.44, 1.54; >80 years: OR 1.42, 95% CI 1.37, 1.48), female sex (OR 1.33, 95% CI 1.31, 1.36) and AF (OR 1.14 95% CI 1.12, 1.16) (p<0.001 for all). In contrast, on-pump CABG was not an independent predictor of stroke (OR 1.01, 95% CI 0.94, 1.09) (p=0.784).

Conclusion

In this nationally representative study, we have shown that the rates of postoperative stroke following CABG have increased over time in line with complexity of patient risk profiles. The present findings emphasise the need for further work on strategies to reduce the risk of postoperative stroke after CABG.

Trends of postoperative AIS (2004-2015)

Funding Acknowledgement

Type of funding source: None
Perioperative use of renin-angiotensin system inhibitors and short-term outcomes in patients undergoing cardiac surgery
Authors: Vieira De Melo R.M , Azevedo D.C , Danziato L.N , Fernandes M.T.C.F , Alcantara L.F.C , Barbosa M.H.F , Conceicao F.S , Santos Junior S.C.R , Viana T , Figueirero C.S , Passos L.C.P
Published: November 2020

Background

Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) therapy is associated with adverse outcomes after cardiac surgery. Current guidelines stated that it is uncertain about the safety of the preoperative administration of this medications because of the potential deleterious consequences of perioperative hypotension

Purpose

To determine the effect of preoperative therapy with ACEi or ARB on short-term outcome after cardiac surgery.

Methods

Single-center prospective cohort between January 2018 and December 2019. Patients were eligible if they were submitted to elective on-pump cardiac surgery and aged ≥18 years. Patients were divided into two groups according to previous use of ACEi or ARB. All preoperative demographic, clinical, and intraoperative surgical variables were collected prospectively. Outcomes of interests were intensive care unit (ICU) mortality, incidence and duration (hours) of postoperative shock (defined as the need for intravenous vasopressors or inopressors), postoperative acute kidney injury (AKI), defined as a doubling of serum creatinine, duration of mechanical ventilation (hours) and length of stay in the ICU (days). A multivariate regression was performed for categorical outcomes and Kruskal-Wallis test for non-parametric continuous variables.

Results

353 patients were evaluated in the period, 182 (51.6%) of male sex, with a mean age of 54.5 (±14.7) and STS mortality and EURO scores of 1.93 (±1.81) and 1.89 (±1.9), respectively. Coronary artery bypass grafting was the common procedure, 168 (47.6%). After multivariate regression, use of ACEi or ARB preoperatively was associated with postoperative shock: RR: 2.03, CI 1.25–3.30, p=0.004; incidence of AKI: RR: 2.84, CI 1.01–7.98, increased length of ICU stay: 4 (3–6) vs 3 (2–5), p=0.03; and increased duration of shock: 10 (0–39) vs 0 (0–24), p<0.01. There was no association with the duration of mechanical ventilation: 10.5 (6–20) vs 11.0 (5–18), p=0.31 or ICU mortality: 14 (7.3%) vs 16 (10.0%), p=0,44.

Conclusions

The use of preoperative ACEi or ARBs was associated with increased incidence and duration of postoperative shock, incidence of acute kidney injury, and durations of mechanical ventilation and ICU stay.

Funding Acknowledgement

Type of funding source: None
MIDCAB vs OPCAB for severe coronary artery disease: a comparative study
Authors: Tartanus J , Mueller X , Syburra T , Von Wattenwyl R , Cuculi F , Kobza R , Matt P
Published: November 2020

Background/Introduction

MIDCAB (minimally invasive direct coronary artery bypass surgery) ± PCI/DES was compared to classical “off pump” coronary artery bypass surgery (OPCAB) for the treatment of severe coronary artery disease.

Purpose

We hypothesized that MIDCAB is associated with reduced perioperative morbidity and mortality.

Methods

Preoperative and postoperative clinical data were collected prospectively in 329 consecutive patients with severe coronary artery disease undergoing either a MIDCAB procedure ± PCI/DES (MIDCAB group), n=118 patients, or classical OPCAB (OPCAB group), n=211 patients, at our institution from January 2017 to July 2019. A matched analysis using the EuroSCORE II (81 patients per group) was done.

Results

The median of EuroSCORE II was 1.05 in both groups, p=1. All MIDCAB patients underwent a left-sided mini-thoracotomy and received a single LIMA-LAD graft, OPCAB patients received median 3 distal anastomoses, p<0.001. Operative time was shorter in MIDCAB patients, 160min vs. 240min, p<0.001. Maximum postoperative Troponin levels were lower in MIDCAB compared to OPCAB, 105 μg/l vs. 260 μg/l, p<0.001. Intubation time was shorter in MIDCAB, 7.0 h vs. 9.3 h, p=0.04, as was ICU time, p=0.02. Chest tube drainage after 24 hours was lower in MIDCAB patients, 405 mL vs. 555 mL, p<0.001. Transfusions of blood, platelets and fresh frozen plasma were rarely needed. Transfusion of erythrocytes were more common in OPCAB, 19%, vs. MIDCAB, 2.5%, p=0.001. A transient neurological deficit showed one (1.2%) patient in the OPCAB group, non in MIDCAB, p=0.3. A hybrid procedure was performed in 18 MIDCAB patients (22%) and 5 OPCAB patients (6.2%). In-hospital mortality was 0% in the MIDCAB group, and 1.2% in OPCAB patients, p=0.3.

Conclusions

MIDCAB is a good and safe option to treat severe coronary artery disease. MIDCAB is not only less invasive, but associated with reduced perioperative risk compared to standard OPCAB surgery even if a hybrid procedure is needed.

Funding Acknowledgement

Type of funding source: None
Valve repair in patients with infective endocarditis
Authors: Scheggi V , Olivotto I , Alterini B , Merilli I , Starnazzi F , Ceschia N , Andrei V , Stefano P.L
Published: November 2020

Background

Valve repair is considered the treatment of choice for native mitral and tricuspid valve regurgitation but the rate of feasibility when the defect is caused by acute infective endocarditis (IE) is debated. We report the experience of valve repair versus replacement following IE in a high-volume surgical center.

Methods

We retrospectively analyzed 351 consecutive patients (123 women) admitted to our department with definite diagnosis of IE. IE occurred on native valves in 219 patients (62%) and on prosthetic valves in 132 (38%). Among native valves, IE involved the aortic valve in 105 cases (48%), mitral valve in 97 cases (44%) and tricuspid valve in 17 (8%). Since only native mitral and tricuspid valves are elegible for surgical repair, we limited the analysis to this subset (114 patients); of them, 92 (80.7%) underwent surgery (the final cohort) and 22 were treated conservatively, 13 due to absence of surgical indication and 9 due to prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence).

Results

Mean age at surgery was 61.9 years (SD 14.5). Mean vegetation length was 11.6 mm (SD 8.8). Endocarditis was left-sided in 80 (87%). Among the 92 surgical patients, 58 (63%) underwent valve replacement and 34 valve repair (37%). Mortality was similar between valve repair and replacement (15 vs 12%). Adverse events rate (19% vs 16%) and relapse were not statistically different between repair and replacement procedures.

Conclusions

The present study shows that a sizeable subgroup of consecutive patients with native mitral or tricuspid IE are amenable to valve repair in expert hands. Outcome of repair in IE is comparable to valve replacement mid-term, and should be considered whenever possible, as in degenerative valve disease.

Funding Acknowledgement

Type of funding source: None
Anticoagulation and outcomes after surgical aortic valve replacement with a biological prosthesis
Authors: Angleitner P , Zinggl M , Werner P , Coti I , Mach M , Kocher A , Laufer G , Andreas M
Published: November 2020

Background

No strong recommendation exists regarding the use of short-term anticoagulation after surgical aortic valve replacement (SAVR) with a biological prosthesis.

Purpose

Our aim was to analyze outcomes of patients receiving warfarin versus low-molecular weight heparin (LMWH) after isolated SAVR.

Methods

We retrospectively analyzed all adult patients who underwent surgery between 2009 and 2017 at our department (n=598). Exclusion criteria included pre-operative anticoagulation, atrial fibrillation, dialysis, previous aortic valve replacement, or active endocarditis. Patients who were discharged alive were stratified according to the type of anticoagulation (warfarin, n=332, 55.5%; LMWH, n=266, 44.5%). Long-term survival during the follow-up period was analyzed (median follow-up, 5.6 years).

Results

Patients who received warfarin had significantly lower logistic EuroSCORE and were younger (Table 1). Warfarin was more frequently utilized between 2009 and 2014, whereas LMWH was more commonly used between 2015 and 2017. Kaplan-Meier curves in Figure 1 show that patients who received warfarin had significantly superior long-term survival (log-rank test: p=0.002). Multivariable Cox proportional hazards regression analysis confirmed that the use of warfarin was associated with significantly lower risk of long-term mortality when compared with LMWH (hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.34–0.74, p=0.001). Covariables in this model included logistic EuroSCORE, era, and duration of cardiopulmonary bypass.

Conclusions

The present analysis suggests that the use of warfarin is associated with significantly superior survival after SAVR with a biological prosthesis. Our findings require validation in a prospective randomized controlled trial.

Figure 1. Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None
Carotid wall sublayers and their association with atherosclerosis in hypertensive subjects
Authors: Carvalho-Romano L.F.R , Bonafe R.P , Paim L.R , Marques E.R , Vegian C.F.L , Schreiber R.P , Sposito A.C , Matos-Souza J.R , Nadruz W
Published: November 2020

Introduction

Intimal thickening is a characteristic and initial step of atherosclerosis. Carotid intima-media thickness (IMT) is considered a measure of subclinical atherosclerosis, but it can be influenced by increases not only of intima layer thickness (IT), but also of media layer thickness (MT). Hypertension is a risk factor for atherosclerosis, but may also stimulate media layer hypertrophy by increasing artery wall tension. However, little is known regarding the measures of carotid wall sublayers and their association with atherosclerosis in hypertensive subjects.

Purpose

To measure carotid IMT, MT and IT and evaluate their relationship with carotid atherosclerotic plaques in hypertensive subjects.

Methods

This cross-sectional study evaluated clinical and carotid characteristics of 186 hypertensive patients (age = 61±11 years, 43% men, BMI = 30.6±6.2 kg/m2) followed at a university outpatient clinic. High-resolution images of common carotid arteries wall and plaques were obtained by ultrasonography equipped with 10MHz-13MHz transducers. IMT, MT and IT were measured using an image processing software.

Results

Mean IT, MT and IMT values were 0.267±0.060, 0.475±0.107 and 0.742±0.142 mm, respectively. IMT showed stronger correlation with MT (r=0.92; p<0.001) than with IT (r=0.72; p<0.001). Patients with carotid plaques (n=100; 58% of the sample) had higher age (p<0.001) and carotid diastolic diameter (p=0.002) and a trend toward higher diabetes prevalence (p=0.06) than those without plaques. In logistic regression analysis adjusted for these variables, plaques showed stronger association with IT than with MT and IMT (Figure 1). In addition, IT showed greater area under the ROC curve (0.92; 95% CI 0.88–0.96) than IMT (0.79; 95% CI 0.72–0.85) and MT (0.64; 95% CI 0,56–0,72) to identify plaques.

Conclusions

MT is the main determinant of carotid IMT in hypertensive subjects. Conversely, IT showed stronger correlation and greater discriminatory value to identify atherosclerotic plaques than MT and IMT. These findings suggest that carotid IT may be a more accurate marker of atherosclerosis that MT or IMT in hypertensive subjects.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CNPq
CMR fast-SENC segmental intramyocardial LV strain monitors decline in heart function before ejection fraction in patient with arterial hypertension
Authors: Montenbruck M , Kelle S , Esch S , Schwarz A.K , Giusca S , Korosoglou G , Steen H
Published: November 2020

Background

Left ventricular ejection fraction (LVEF) is commonly used to assess cardiac function for patients with chronic cardiac diseases. LVEF, like most systemic function assessments, detects dysfunction once enough damage has occurred to prevent common compensatory mechanisms from maintaining cardiac output. More sensitive metrics are being evaluated to more accurately identify subclinical regional dysfunction before cardiac remodeling results in changes in LVEF and global longitudinal strain (GLS). Fast-SENC intramyocardial strain (fSENC) is a unique cardiac magnetic resonance imaging (CMR) modality that measures intramyocardial contraction in 1 heartbeat per image plane. This prospective registry compares segmental fSENC to standard CMR calculations (e.g. LVEF, volumes, mass, etc.) for patients with arterial hypertension in the absence of non-ischemic cardiomyopathy.

Methods

A single center, prospective registry of CMR scans acquired with a 1.5T scanner were evaluated for standard CMR calculations as well as fSENC scans. Intramyocardial LV & RV strain was quantified with MyoStrain software. Three short axis scans (basal, midventricular, & apical) were used to calculate peak strain in 16 LV & 6 RV longitudinal segments while three long axis scans (2-, 3-, & 4-chamber) were used to calculate 21 LV & 5 RV circumferential segments.

Results

A total of 773 scans in 650 patients with arterial hypertension but without non-ischemic cardiomyopathies were included in the study. Patients had an average (± stdev) age of 64 (13) yrs and BMI of 28 (5) kg/m2; 24% diabetes mellitus, 10% atrial fibrillation, 15% pulmonary disease, and 39% coronary artery disease. Figure 1 shows a Box & Whisker's plot demonstrating the non-linear relationship between segmental fSENC strain (% of normal LV segments ≤−17%) versus LVEF. The progression of hypertensive heart disease was associated with reduction in septal circumferential contraction despite normal LVEF.

Conclusion

Segmental fSENC detects subclinical LV dysfunction in patients with early hypertensive heart disease before changes in LVEF. Evaluating segmental longitudinal and circumferential fSENC peak strain provides an alternative metric that shows consistent changes in cardiac function in patients with arterial hypertension.

Figure 1

Funding Acknowledgement

Type of funding source: None
Efficacy of radiofrequency RDN may be significantly improved if the procedure is guided by impedance drop during the treatment
Authors: Pekarskiy S , Baev A , Tarasov M , Mordovin V , Falkovskaya A , Zubanova I
Published: November 2020

Background

Experimental studies of radiofrequency renal denervation (RDN) have shown a strong relation of the depth of structural lesions and completeness of renal nerve injury to the relative drop in impedance during the treatment caused by the increased permeability of the cell membranes. Thus, the otherwise successful treatments but with low impedance drop may be, in fact, totally ineffective.

Objective

We assessed the relation between impedance drop during single radiofrequency treatments and local structural changes of vascular wall at the electrode positions using optical coherence tomography.

Methods

Optical coherence tomography of the treated segments was performed during radiofrequency RDN in 14 patients with resistant hypertension. The parameters of contrast injection depended on the position of the guiding catheter: for selective branch imaging 15 ml volume was injected at 8 ml/sec speed; otherwise 30 ml of contrast was injected at the speed 15 ml/sec to flush the whole renal artery. Automatic pullback of the sensor was done with the standard speed 20 mm/sec. In total, 423 mm of treated segments in 22 renal vessels (mostly distal branches) had sufficient quality of imaging and were studied for structural changes.

Results

There was almost no local structural changes of the arterial wall after the treatments with low impedance drop <10% reflecting a rather weak heating of even superficial tissue layers. No effect on the deeper tissue layers is expected in this case because these layers are heated almost exclusively by the heat transfer from superficial layer. In contrast, the treatments with the impedance drop 10% or greater were able to significantly affect the arterial structure causing local edema, small dissections, and local thrombi formation as a result of significant resistive heating of the superficial tissue, and, therefore, high potential for heating of the deep layers containing the renal nerves. Only approximately 40% of the point treatments had the impedance drop 10% or greater suggesting adequate lesion depth and sufficient completeness of renal nerve injury. This may indicate a rather low procedural efficacy of the current mode of radiofrequency RDN due to a large proportion of small-depth treatments marked by only a few percent decrease in impedance yet considered fully “successful”. Also, it means a potential for significant increase in the efficacy of radiofrequency RDN through controlling/guiding the treatment by the impedance drop.

Conclusion

Our study shows that variable efficacy of radiofrequency RDN may be explained by a significant proportion of the small-depth point treatments ineffective in terms of renal nerve injury, and, thereby, may be significantly improved if the procedure is guided by the impedance drop during the treatment.

Funding Acknowledgement

Type of funding source: None
Stroke, systemic embolism and bleeding rate in non-valvular atrial fibrillation patients without anticoagulation on the real world data in Japan
Authors: Tanizawa K , Nishimura Y , Okada A , Nishikawa M , Tamaru S , Nagai N
Published: November 2020

Background

Anticoagulant therapy is recommended in patients with non-valvular atrial fibrillation (NVAF) for those with CHADS2 ≥2. However, there have been significant number of subjects with CHADS2 ≥2 who receive no anticoagulation. Most of reported real world data have been collected mainly before wide spread use of DOAC. This study evaluated the clinical outcome of no anticoagulant drug therapy in NVAF.

Methods

This study is a non-interventional, observational, retrospective cohort study of NVAF patients in Mie-LIP Database, which is a regional clinical database joining 1 university hospital and 8 general hospitals in Mie prefecture in Japan. Patient enrolment was conducted from 1st Jan. 2016 to 31st Dec. 2018. The primary outcome events are ischemic stroke, systemic embolism, and bleeding events (bleeding to need a blood transfusion, intracranial bleeding, intraocular bleeding, and gastrointestinal bleeding).

Results

7001 patients were included in the current analysis, 2550 patients, 36.4% were treated without any anticoagulant drug therapy. Table 1 shows patients with no anticoagulant drug therapy, mean age was 75.4 years and 42.2% of patients were female. The most frequent comorbidities included hypertension (50.0%), diabetes mellitus (28.2%), heart failure (14.0%), ischemic stroke (12.7%), vascular disease (14.4%) respectively. The annual incidence of ischemic stroke, systemic embolism per 100 person-years is 3.7, and that in each CHADS2 group is 0: 1.4, 1: 1.4, 2: 3.2, 3–6: 8, respectively in Figure 1. The annual incidence of bleeding events is 1.5, and that in each CHADS2 group is 0: 0.7, 1: 1.0, 2: 1.2, 3–6: 2.9, respectively.

Conclusions

Approximately one-thirds of subjects have not received any anticoagulation in the modern DOAC in daily clinical practice in Japan. The rate of ischemic stroke and systemic embolism increased by CHADS2. Stroke or SEE rate was very low in subjects with CHADS2 ≤1, supporting no indication of anticoagulation in current guidelines. Regarding subjects with CHADS2>2, considering the higher risk of stroke, use of anticoagulant drug therapy is recommended.

Funding Acknowledgement

Type of funding source: None
10 years observation study of low and moderate cardiovascular risk hypertensive patients: the impact of anxiety and depression level in development of cardiovascular complications
Authors: Smirnova M.D , Blankova Z.N , Barinova I.V , Fofanova T.V , Svirida O.N , Ageev F.T
Published: November 2020

Not only “classic” risk factors such as age, sex, smoking status, blood pressure (BP) and cholesterol (HS) levels, but also additional factors, one of which is the psychological status of the patient, need to be considered to improve the prediction of cardiovascular complications. This is especially true for low/moderate risk patients on the SCORE scale, whose risk of cardiovascular complications (CVC) is often underestimated.

Aim

To assess the contribution of psychological status of hypertensive patients and SCORE<5% to increase the risk of development of cardiovascular complications for a period of 10 years of observation.

Materials and methods

In 2009, 142 hypertensive patients with SCORE risk <5% (37 men and 105 women) in addition to the clinical examination, were interviewed on the HADS scale to assess the level of anxiety and depression. In 2019, these patients were interviewed by phone for CVC suffered over the past 10 years: all-cause mortality, cardiovascular death (CVD), fatal and nonfatal myocardial infarction (MI), stroke, revascularization, hospitalization for cardiac events.

Results

At the time of inclusion in the study, the age of the patients was 50, 9±8.2 years. At the first visit systolic BP (SBP) level was 130.0 (128.4; 133.7) mm Hg and diastolic BP (DBP) 80.0 (81.3; 84.5) mm Hg. The HS level was 6.1 (5.9; 6.3) mmol/L, triglycirides 1.4 (1.5:1.8) mmol/L, low dencity lipoproteins 3.8 (3.6; 4.0) mmol/L, high density lipoproteins 1.3 (1.4; 1.5) mmol/L. Level of anxiety (A) was 7.0 (7.0; 8.2) points, depression (D) – 5.7 (5.2; 6.2) points. The patients without the expressed symptom of D (0–7 points) – 76.8% (n=109), A (0–7 points) – 52% (n=74). The patients with clinically significant D (>11 points) – 8.5% (n=12), A (>11 points) – 18.3% (n=26). 2 CVD occurred in the observed group in 10 years (1.4%), 6 MI, 12 percutaneous coronary intervention (8 acute coronary syndrome), 4 strokes, 34 cardiovascular hospitalizations. 14 new onset cases of coronary artery disease (9.6%). Thus 31.7% of observed patients had CVC.

Comparison of the initial data of the group with CVC with the group without CVC revealed a difference only in the level of D: 7.0 (5.6; 7.3) points in patients with CVC vs 5.0 (4.7; 5.8) p=0.04) – Fig. 1. The patients were comparable in sex and age. BP, lipid profile, glucose, heart rate, smoking status, levels of A did not differ significantly. Multi-factor regression analysis has demonstrated that depression levels D is an independent predictor of the development of complications in a model involving age, sex, BP, HS and A (β=0,218, p=0,03).

Conclusion

Level D is an independent risk factor development of CVC in hypertensive patients low/moderate risk on SCORE.

Funding Acknowledgement

Type of funding source: None
Depression and risk of atrial fibrillation: a nationwide population-based study
Authors: Choi J , Lee K.N , Kim Y.G , Jeong J.H , Choi H.Y , Choi Y.Y , Shim J , Na J.O , Choi C.U , Han K.D , Kim Y.H
Published: November 2020

Background

Although treatments of atrial fibrillation (AF) based on the biological mechanisms for initiation and maintenance of AF improve cardiovascular outcomes, psychosocial factors have been also implicated in the etiology and progression of cardiovascular disease.

Objective

We aimed to evaluate the association between depression and incident AF using nationwide database from the National Health Insurance Service in South Korea.

Methods

A total of 9,075,224 participants with data of national health checkup in 2009 were included, and participants who were diagnosed with AF before the examination were excluded. Exposure to depression is determined by the precedence of depression diagnosed within 2 years.

Results

Depression was diagnosed in 1.37% (124,709) of participants at baseline. Compared to the non-depression group, depression group was likely to be female and had higher comorbidities. After adjusting covariates, depression group had a higher risk of incident AF compared with non-depression group (hazard ratio, 1.30; 95% confidence interval, 1.26–1.34). Repeated exposure to depression increased a risk of incident AF (Figure 1).

Conclusion

Depression was associated with an increased risk of new-onset AF. This association was stronger for patients who had more burden of depression. Future studies should investigate whether early treatment of depression can prevent incident AF.

Figure 1

Funding Acknowledgement

Type of funding source: None
The effect of physical activity enlargement on anthropometric parameters and blood lipids depending on genetic polymorphisms of beta-2 and beta-3 adrenoreceptors
Authors: Isayeva G.S , Shalimova A , Vovchenko M , Buriakovska O , Galchinska V
Published: November 2020

Background

Assessment of genetic factors, which determine the effect of physical exercise, allows to identify individuals that are not susceptible to positive effects of enlargement of physical activity.

The aim of the study was to assess the effect of enlargement of physical activity on anthropometric parameters and blood lipids in individuals without cardiovascular diseases.

Methods

One hundred ten persons, mean age 41.1±8.1 y.o. were included in the study. Blood pressure, body mass index, fat to muscular ratio (bioimpedance method), blood lipids and glucose levels, eating habits were assessed before and after 6 month of physical activity enlargement. Patients were instructed how to increase physical activity and their activity was monitored monthly with the pedometer and with “International Questionnaire on Physical Activity”. Genotyping of polymorphic sites of ADRB2 (C531G, rs1042714 and A46G, rs1042713) and ADRB3 (T190C, rs4994) genes was done with real-time polymerase chain reaction. Statistical analysis was performed in SPSS 17 (IBM).

Results

It was found out that carries of AA+AG genotypes of A46G polymorphism of ADRB2 gene and TT genotype of T190C polymorphism of ADRB3 gene had significant reduction of fat tissue and rise of muscular tissue proportion as well as a rise of muscular strength. Higher level of physical activity was associated with reduction of low-density cholesterol in carries of TT genotype of T190C polymorphism of ADRB3 gene and carries of AA+AG genotypes of A46G polymorphism of ADRB2 gene (Table 1).

Conclusion

Carrying of AA+AG genotypes of A46G polymorphism of ADRB2 gene and TT genotype of T190C polymorphism of ADRB3 gene is associated with significant decline of proportion of fat tissue and decrease of low-density cholesterol after physical activity enlargement.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): L.T. Mala National Institute of Therapy
Serum copeptin is a new biomarker of continuous-positive-airway-pressure treatment in severe obstructive sleep apnea
Authors: Sekiguchi H , Ishida I , Suzuki M , Hagiwara M
Published: November 2020

Introduction

Copeptin, the C-terminal fragment of antidiuretic hormone (ADH), is a biomarker which has been reported to be increased in cardiovascular and cerebrovascular diseases, thus playing a role in predicting their prognosis. Patients with obstructive sleep apnea syndrome (OSA) have been demonstrated to have a high risk for developing these vascular diseases. However, there have been no authentic reports concerning the effect of continuous positive airway pressure (CPAP) on serum copeptin levels in OSA patients.

Purpose

We hypothesis that CPAP treatment substantially modifies copeptin levels in OSA patients.

Methods

A total of 60 OSA patients confirmed by polysomnographic examinations was divided into two groups: a mild-moderate OSA (apnea-hypopnea index: AHI <30/h) group and a severe OSA (AHI ≥30/h) group. Blood samples were collected early in the morning after overnight fasting, and serum copeptin and ADH levels were measured with an enzyme immunoassay method. In patients initiated with CPAP, hormone levels were measured before and after CPAP treatment.

Results

Twenty-one patients (age: 54.7±12.4 y, male: 17, NT-proBNP: 45.3±44.2 pg/mL) were diagnosed as having mild-moderate OSA (AHI: 16.5±8.4/h), while 39 patients (age: 57.8±11.4y, male: 29, NT-proBNP: 73.7±87.3 pg/mL) were diagnosed as severe OSA (AHI: 49.5±21.1/h). As a whole, there were no significant differences in copeptin and ADH levels between mild-moderate OSA and severe OSA groups (copeptin: 2.1±1.4 pmol/L vs. 1.9±1.4, ADH: 2.3±2.6 pg/dL vs. 2.0±0.7). In 26 severe OSA patients (age: 55.9±12.9y, male: 23, NT-proBNP: 63.3±85.2 pg/mL), these hormones were again evaluated after CPAP initiation. AHI was significantly improved after CPAP treatment (45.5±20.8/h vs. 5.0±5.0, P<0.01). Although the ADH level was changed from 1.85±0.77 pg/dL to 1.68±0.99, the difference did not reach the statistical significance. The copeptin level was certainly decreased after CPAP by 26% (2.29±2.63 pmol/L vs. 1.69±1.68, P<0.01) (Figure 1).

Conclusions

Serum copeptin levels decreased after CPAP treatment in patients with severe OSA. Copeptin, but not ADH, can be considered as a new biomarker for predicting cardio/cerebrovascular events in severe OSA patients.

Figure 1

Funding Acknowledgement

Type of funding source: None
Validation and comparison of six risk scores for post acute myocardial infarction infection
Authors: Liu Y.H , Wang L.T , Dai Y.N , Zeng L.H , Fan H.L , Duan C.Y , Tan N , Chen J.Y , He P.C
Published: November 2020

Background

Various risk scores have been proven to predict outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, few of them were validated and compared the difference of the prediction of infection during hospitalization in such patients.

Aim

We aimed to validate and compare the discriminatory value of different risk scores for predicting infection.

Methods

Patients who were diagnosed with STEMI treated with PCI were enrolled from January 2010 to May 2018. The six risk scores included the Age, Serum Creatinine (SCr), or Glomerular Filtration Rate, and Ejection Fraction (ACEF or AGEF) score, Canada Acute Coronary Syndrome Risk Score (CACS score), CHADS2 score, Global Registry for Acute Coronary Events (GRACE) score and Mehran score. The primary end point was infection during hospitalization. The secondary endpoint was major adverse clinical events including all cause death, stroke and any bleeding. The prognostic accuracy of the six scores was assessed using the c statistic for discrimination and the Hosmer-Lemeshow test for calibration.

Results

A total of 2260 eligible patients were enrolled (62.32±12.36 year, 81.3% of males). A significant gradient of risk with respect to infection and in hospital major adverse clinical events (MACE) was observed with increasing all six risk scores. Other than the CHADS2 score (AUC: 0.682; 95% CI, 0.652–0.712), other five risk scores showed the good discrimination for predicting infection, with the GRACE score being the best (AUC: 0.791; 95% CI, 0.765–0.817). In addition, all risk scores showed best calibration for infection, but good calibration for CACS risk score (calibration slope: 0.77, 95% CI: 0.18–1.35) (Figure 1). Furthermore, each score showed a best discrimination for in hospital MACE, with AUCs ranging from 0.761 to 0.786, other than CACS risk score and CHADS2 risk score with AUC of 0.700 and 0.696, respectively. All risk scores showed best calibration for in hospital MACE.

Conclusions

In patients with STEMI undergoing PCI, these risk scores (ACEF, AGEF, CACS, GRACE and Mehran) showed good discrimination and calibration to predict infection and MACE. The CACS score was recommended for clinical use as its clinical variables were simple and practical.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): National Science Foundation for Young Scientists of China
Evaluating the sensitivity of the ACC/AHA pooled cohort risk calculator to predict atherosclerotic cardiovascular events within 10 years: how many events are we failing to predict?
Authors: Medina-Inojosa J , Somers V.K , Hayes S , Mankad R , Lopez-Jimenez F
Published: November 2020

Background

The ACC/AHA Pooled Cohort Equation (PCE) for atherosclerotic cardiovascular disease (ASCVD) has been recommended as the initial step in cardiovascular risk assessment. The sensitivity of this tool to detect those who will develop ASCVD within 10-years, while considering age and sex groups, has not been extensively studied.

Methods

Using the Rochester Epidemiology Project (REP) we evaluated a community-based cohort of consecutive patients that sought primary care in Olmsted County, MN, between the years 1998–2000 and were followed up through March 1st 2016. Inclusion criteria were ages 40–79 and complete data to calculate the PCE. We excluded those with known ASCVD, atrial fibrillation or heart failure. Criteria were similar to those used to derive the PCE. Events were validated in duplicate and included fatal and non-fatal myocardial infarction and ischemic stroke. Patient information was ascertained using the record linkage system of the REP. Follow-up was truncated at 10 years. We assessed the ASCVD predicted risk (categorized as low <5%, intermediate 5–9.9%, high 10–19.9%, and very high ≥20% risk) at baseline, in subjects having an ASCVD event within 10-years in the community across age (<65 years) and sex categories. We also categorized ideal cardiovascular health as ≥4 metrics [non-smoker, body mass index <25 kg/m2, and not having of elevated blood pressure (≥130/80 mmHg), LDL cholesterol (>100 mg/dL), or fasting blood glucose (>100 mg/dL), in the absence of a medical diagnosis or treatment].

Results

We included 30,042 adults, mean ± SD age 48.5±12.2 years, 54% women, with a median follow-up of 16.5±5.3 years. There were 1,555 ASCVD events (5.2%) at 10 years of follow-up. The performance of the PCE was similar to what was described in the original report (0.78 vs 0.79). Overall, among those who suffered an ASCVD, 54% of women and 41% of men were not high risk as predicted by PCE (Figure 1A). Most women (73%) <65 years of age would had been considered low risk within 10-years before the event, and only 10% would have been considered to be high risks (Figure 1B). Nonetheless, women <65 years who had an ASCVD event and low 10-year predicted ASCVD risk by PCE were less likely to have ideal cardiovascular health [55 (0.40%) vs 3884 (28.39%), p-value<0.0001], when compared to women in the low risk category without an event.

Conclusion

The PCE fails to identify most women who will develop an ASCVD event, particularly women <65 years of age. These results underscore the importance of using additional information when estimating ASCVD risk among women and the need for better cardiovascular risk prediction tools.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Mayo Clinic
Utilization of Guidelines-recommended secondary cardiovascular preventive medications in a decade or more survivors after coronary revascularization in the Middle East; analysis form the DECADE PLUS S
Authors: Hammoudeh A , Qabbaa L , Alhaddad I.A , Izraiq M , Jarrah M , Shami D , Hattar M , Dahabreh Z , Al-Jarrah M , Othman A , Al-Kouz M , Shahwan Y , Alfawara M
Published: November 2020

Background

There is scarcity of studies from the Middle East had address the use of guideline-recommended secondary cardiovascular prevention medications among individuals who survived at least one decade after coronary revascularization (CR) by percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG).

Purpose

An objective of the DECADE-PLUS study was to evaluate the use of antiplatelet agents (APA), statins, beta blockers (BB) and renin-angiotensin system inhibitors (RASI) in such patients.

Methods

We enrolled consecutive patients seen at ambulatory or in-patient settings with the following inclusion criteria: patient had PCI or CABG >10 years ago, age >18 years at the time of the index CR, and availability of data of currently used medications.

Results

Of 892 patients enrolled, 600 (67.3%) had PCI and 292 (32.7%) had CABG. Patients had CR >20 years ago (100; 11.2%), 11–19 years ago (536; 60.1%) or 10 years ago (256; 28.7%). Women comprised 13.8% of the whole cohort, and mean age at index CR was 53.4+9.4 years. Hypertension, diabetes mellitus, and dyslipidemia were present in 398 (44.6%), 351 (39.3%) and 290 (32.5%), respectively at the time of CR. Overall, aspirin was used in 745 (83.5%), and a second APA in 329 (36.9%). Statins, BB and RASI were used in 83.7%, 71.7% and 54.3%, respectively. Univariate analysis of predictors of lower rates of use of these medications showed that survival time (10 years vs. >20 years), and revascularization type (PCI vs. CABG) had no impact on use of these medications. However, nondiabetics were less often prescribed second APA (odds ratio (OR) 0.78, p=0.005) and RASI (OR 0.85, p=0.007) compared with diabetics. Furthermore, compared with men, women were less often prescribed aspirin (OR 0.66, p<0.0001), statin (OR 0.67, p<0.0001), BB (OR 0.71, p=0.005), and RASI (OR 0.79, p=0.005).

Conclusion

Middle East patients surviving at least one decade after coronary revascularization have a high rate of utilization of secondary cardiovascular medications compared with western data. However, women and non-diabetic individuals have lower rate of use of these medications compared with diabetics and men, respectively. Larger studies are warranted to explore the reasons behind these discrepancies and thus represent potential targets for positive intervention.

Funding Acknowledgement

Type of funding source: None
Hospital variation in downstream secondary preventive medication uptake: implications for quality and outcomes
Authors: Jug B , Dosenovic Bonca P , Fras Z
Published: November 2020

Background

Adherence to guideline recommended therapy improves outcomes in patients with myocardial infarction. We sought to appraise between-hospital variation in downstream adherence to secondary preventive medication and hypothesised that discharge from high-adherence hospitals was associated with improved long-term outcomes.

Methods

We included 7,624 patients hospitalised because of myocardial infarction in 14 hospitals between 2015 and 2017 in Slovenia (nation-wide sample). Using indirect identifiers, we linked routinely collected data on patients from the i) Hospital Discharge Statistics Database, ii) the National Mortality Registry and iii) the Medication Reimbursement Database. We used random intercept logistic regression modelling for prediction of secondary prevention medication uptake 30 to 90 days after discharge, adjusting for case-mix, hospital size and percutaneous coronary intervention (PCI) availability. We classified hospitals into high- and low adherence (i.e., above and below the national median adjusted odds) and assessed the association between hospital performance, and death or re-infarction with multivariate Cox proportional hazards modelling.

Results

Secondary preventive medication uptake ranged from 30.7% to 87.3% in high- and low-performing hospitals, respectively. Discharge from high-adherence hospitals were associated with significantly lower all-cause mortality and re-infarction rates (hazard ratio 0.82; 95% confidence interval 0.69–0.98) when compared to hospitals with secondary preventive medication uptake below the national median, after adjusting for case-mix and hospital characteristics.

Conclusions

Downstream secondary preventive medication uptake vary across hospitals. Although case-mix and hospital characteristics explain some of the variation, discharge from a hospital with good downstream secondary preventive medication uptake is associated with lower risk of death or re-infarction.

Event rates, low- vs. high-adhererence

Funding Acknowledgement

Type of funding source: None