bluuebunny/crossref_metadata_2025 huggingface dataset:
P1690Lab-on-a-chip based self-monitoring device for dietary intake of potassium and sodium: the LAB-CHIPS study
Authors: Vendeville A C , Kaasjager H A H , Musson R E A , Spiering W
Published: October 2019

Background

Dietary sodium restriction and upholding adequate potassium intake is an important lifestyle modification strategy advocated in guidelines for the management of hypertension and for lowering cardiovascular risk in the general population. The gold standard for estimating sodium and potassium intake, 24-hour urine collection (24hUc), is time consuming and cumbersome, but most importantly not a good indicator of dietary habit due to day-to-day variation. New lab-on-a-chip technology has been developed to measure urinary sodium, potassium and creatinine excretion in a single drop of urine using microcapillary electrophoreses combined with conductivity analyses. Self-monitoring can be done at home over a longer period of time. Results are readily available.

Purpose

To assess agreement between 24hUc and the lab-on-a-chip self-monitoring device for estimating past 24h dietary sodium and potassium intake for single and multiple self-tests by using the Kawasaki, INTERSALT and Tanaka formulae.

Methods

Healthy participants (n=12) were asked to adhere to three different weekly dietary sodium restriction goals. Participants received verbal and written information to aim between 3.3 and 5.0 grams of sodium intake a day during week 1 (“normal”), >3.3<5.0 grams in week 2 (low) and >5.0 grams during week 3 (high). Weekly measurement instructions consisted of one self-test on day 1 through 6 and multiple self-tests (n=3) combined with a 24hUc on day 7. To estimate 24h sodium and potassium intake, Kawasaki, INTERSALT and Tanaka formulas were used. The Bland-Altman method was used to calculate the agreement.

Results

The agreement (mg/day) for sodium between 24hUc and a self-test on first morning urine (fmu) (Kawasaki), was −102±804 (normal), −860±592 (low) and 340±1406 (high). For multiple self-tests (n=3) performed on 24hUc days, using the INTERSALT formula, the agreement was: 577±832 (normal), −701±721 (low) and 1788±911 (high). Any combination of same day single or multiple INTERSALT or Tanaka self-tests and fmu Kawasaki did not result in better agreement. For potassium the agreement between 24hUc and fmu (Kawaksaki) was 1071±966 (normal), 1376±678 (low) and 1654±880 (high). Using the Tanaka formula resulted in further underestimation and thus worse agreement for same day self-tests and fmu.

Conclusion

In this study, agreement between 24hUc and the lab-on-a-chip self-monitoring device for estimating past 24h dietary sodium intake was best for a fmu self-test calculated with the Kawasaki formula. For estimating potassium intake, a fmu self-test with help of the Kawasaki formula overestimated potassium intake considerably. This lab-on-a-chip self-monitoring device has the potential to improve current lifestyle modification strategies.
P1695Incidence and outcomes of unstable angina compared to non-ST elevation myocardial infarction
Authors: Puelacher C , Gugala M , Adamson P D , Shah A S V , Chapmann A R , Anand A , Boeddinghaus J , Nestelberger T , Twerenbold R , Wildi K , Rubini Gimenez M , Osswald S , Mills N L , Mueller C
Published: October 2019

Objective

Assess the incidence and compare characteristics and outcome of unstable angina (UA) and Non-ST-Elevation myocardial infarction (NSTEMI)

Design

Two independent prospective multicenter diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE) and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS)) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30-days and 1-year.

Results

8992 patients were enrolled at 11 centres. UA was adjudicated in 366/4122 (8.9%) and 137/4870 (2.8%) patients in APACE and High-STEACS, respectively, and NSTEMI in 622 (15.1%) and 651 (13.4%). Coronary artery disease was pre-existing in 73% and 76% of patients with unstable angina. At 30-days, all-cause mortality in UA was substantially lower as compared to NSTEMI (0.5% versus 3.7%, p=0.002 in APACE, 0.7% versus 7.4%, p=0.004 in High-STEACS). Similarly, at 1-year in UA all-cause mortality was 3.3% [95% CI 1.2–5.3] vs 10.4% [7.9–12.9] in APACE, and 5.1% [0.7–9.5] vs 22.9% [19.3–26.4] in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, [7.8–14.6] and 7.9%, [5.7–10.2]), and higher than in NCCP (0.6%, [0.2–1.0]).

1-year survival free from future AMI

Conclusions

The incidence and the mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, British Heart Foundation Project Grants, Butler S
P1700Atrial fibrillation with CRBBB highly predict hospital mortality in the AMI patients presenting with out-of-hospital cardiac arrest after return of spontaneous circulation
Authors: Liu Y.-H , Wu Y.-C , Lin J.-L
Published: October 2019

Approximately 70% of survivals of out-of-hospital cardiac arrest (OHCA) have coronary artery disease, with acute vessel occlusion observed in 50%. The use of ECG to predict mortality and neurological outcomes in acute myocardial infarction (AMI) patients successfully resuscitated for OHCA has not been well-determined.

Between May, 2016 and July, 2018, 1428 consecutive patients with OHCA visited the emergency department of Far Eastern Memorial Hospital, New Taipei City, Taiwan. A total number of 117 patients with return-of-spontaneous-circulation (ROSC) were diagnosed of AMI, mostly confirmed by coronary angiography. The mean age was 60.0±13.6 (mean SD) with male gender 105/117. Endpoint was mortality in hospital. The hospital mortality rate was 44.4%.

Wide QRS duration (>120ms; 48.1%), complete right bundle branch block (33.3%) and atrial fibrillation (59.3%) occurred frequently in the first ECG of post-rescuscitation patients. Patient with wide QRS duration (correlation coefficient, CC: 0.350; p=0.074) and atrial fibrillation (CC: 0.287; p=0.147) had a trend towards higher mortality rate.

Complete right bundle branch block (CRBBB) on the first ECG post resuscitation (CC: 0.632; p<0.001) and ST depression on first ECG post resuscitation (CC: 0.481; p=0.011) were associated with worse outcome (Mortality). Shockable rhythm (Ventricular tachycardia or fibrillation) during CPR (CC: −0.635; p<0.001), and sinus rhythm on first ECG (CC: −0.474; p=0.012) were associated better outcome (survival and neurological recovery).

The combination two ECG characteristics of atrial fibrillation and CRBBB on the first ECG post resuscitation was highly associated with in-hospital mortality (CC: 0.725; p<0.001). It had a 66.7% sensitivity, 93.3% specificity, 88.9% positive predictive value, and 78.9% negative predictive value for predicting mortality. In conclusion, atrial fibrillation with CRBBB on the first ECG post resuscitation is the best predictors for unfavorable neurological outcome and mortality.
P1710Risk of Mortality associated with use of mechanical support devices among comatose cardiac arrest patients
Authors: Dutta A , Hari K , Qureshi W
Published: October 2019

Background

The impact of mechanical circulatory assist devices (MCS) has not been well studied in cardiac arrest survivors. We examined that association of MCS with risk of mortality among comatose cardiac arrest survivors

Purpose

Compare the survival between different MCS and non MCS groups

Methods

This is a retrospective cohort study of 1417 comatose adult cardiac arrest survivors that survived for at least 1 day post cardiopulmonary resuscitation. Cox proportional hazard models adjusted for demographics, resuscitation parameters, comorbidities and medications were used to compute hazard ratios for extracorporeal membrane oxygenation (ECMO), ECMO + Impella/intraaortic balloon pump (IABP), IABP and Impella associated with risk of short term 60 day mortality. Kaplan meier's curves were used to demonstrate cumulative survival rate.

Results

Among 1417 cardiac arrest survivors, MCS was used among 553 (39.1%) patients. After 60 days of follow up, mortality rate was 49.4% in non MCS group, 58.6% in IABP group, 22.9% in Impella group, 40.0% in ECMO only group, 50.0% in ECMO + Impella/IABP group. When compared with no MCS use, only Impella use was associated with decrease risk of short term mortality (HR 0.37; 95% CI 0.16–0.83, p=0.02) while there was no significant association of other forms of MCS with short term mortality. There was no significant association of any MCS with long term mortality. Kaplan-Meier curves demonstrate early benefit of Impella and very early benefit of ECMO (figure 1).

Conclusions

This is the first large study to report various types of MCS use among comatose cardiac arrest survivors and has shown an indication of benefit with Impella use only in first 60 days post cardiac arrest. Future prospective study may be needed to validate this association

Acknowledgement/Funding

None
P1715Management and outcome in patients with non-ischemic cardiogenic shock and Impella CP use
Authors: Maniuc O , Salinger T , Anders F , Muentze J , Liu D , Hu K , Lengenfelder B , Voelker W , Frantz S , Nordbeck P
Published: October 2019

Background and purpose

From the various mechanical cardiac assist devices and indications available, use of the percutaneous intraventricular Impella CP pump is usually restricted to acute ischemic shock or prophylactic indications in high-risk interventions. In the present study, we investigated clinical usefulness of the Impella CP device in patients with non-ischemic cardiogenic shock as compared to acute ischemia.

Methods

In this retrospective single-center analysis, patients who received an Impella CP between 2013 and 2017 due to non-ischemic cardiogenic shock were age-matched 2:1 with patients receiving the device due to ischemic cardiogenic shock. Inclusion criteria were therapy refractory hemodynamic instability with severe left ventricular systolic dysfunction and serum lactate >2.0 mmol/l at implantation. Basic clinical data, indications for mechanical ventricular support, and outcome were obtained in all patients with non-ischemic as well as ischemic shock and compared between both groups. Continuous variables are expressed as mean ± standard deviation or median (quartiles). Categorical variables are presented as count and percent.

Results

25 patients had cardiogenic shock due to non-ischemic reasons, and were compared to 50 patients with cardiogenic shock due to acute myocardial infarction. Resuscitation rates before implantation of Impella CP were high (32 vs 42%; P=0.402). At implantation, patients with non-ischemic cardiogenic shock had lower levels of HsTNT (110.65 [57.87–322.1] vs 1610 [450.8–3861.5] pg/ml; P=0.001) and LDH (377 [279–608] vs 616 [371.3–1109] U/I; P=0.007), while age (59±16 vs 61.7±11; P=0.401), GFR (43.5 [33.2–59.7] vs 48 [35.75–69] ml/min; P=0.290), CRP (5.17 [3.27–10.26] vs 10.97 [3.23–17.2] mg/dl; P=0.195), catecholamine-index (30.6 [10.6–116.9] vs 47.6 [11.7–90] μg/kg/min; P=0.663), and serum lactate (2.6 [2.2–5.8] vs 2.9 [1.3–6.6] mg/dl; P=0.424) were comparable between both groups. There was a trend for longer duration of Impella support in the non-ischemic groups (5 [2–7.5] vs 3 [2–5.25] days, P=0.211). Rates of hemodialysis (52 vs 47%; P=0.680) and transition to ECMO (13.6 vs 22.2%; P=0.521) were comparable. No significant difference was found regarding both 30-days survival (48 vs 30%; P=0.126, Figure 1) as well in-hospital mortality (66.7 vs 74%; P=0.512) although there was a trend for better survival in the non-ischemic group.

30-days survival

Conclusions

The current results position short-time use of the Impella CP as an alternative in the treatment of patients with cardiogenic shock due to underlying non-ischemic cardiomyopathy and/or complicating additional factors. However, additional studies are needed to test whether these findings can be confirmed in larger patient populations and which subgroups might benefit most from Impella therapy.
P1716Dual antiplatelet therapy on veno arterial ECMO to bleed or not to bleed?
Authors: Vandenbriele C , Azzu A , Gambaro A , Morosin M , Arachchillage D , Trimlett R , Rosenberg A , Ledot S , Patel B , Price S
Published: October 2019

Background

Patients presenting with INTERMACS-1 cardiogenic shock and necessitating VA-ECMO, often undergo coronary angiography and percutaneous coronary intervention (PCI). Therefore, a substantial subset of VA-ECMO patients will have an indication for dual antiplatelet therapy (DAPT) plus unfractionated heparin (UFH). According to atrial fibrillation registry data, bleeding incidence on DAPT combined with oral anticoagulation is significantly higher as compared to anticoagulation alone. Although it has been reported that the addition of low dose aspirin to UFH did not increase bleeding or transfusion in VenoVenous (VV)-ECMO patients, it remains to be elucidated whether the addition of DAPT to UFH on VA-ECMO-therapy enhances bleeding.

Methods

We report single center data for 100 VA-ECMO patients between 2011 and 2019. VA-ECMO-patients post-surgery were excluded. Patient demographics, blood product transfusions and reported/radiographically diagnosed bleeding or thrombotic complications were analysed. All VA-ECMO patients received UFH, aiming for an anti-Xa levels of at least 0,3 U/ml. Targets were hemoglobin 7 g/dl, fibrinogen 100 mg/dl (or 150 mg/dl when active bleeding) and platelet counts above 50/fL. DAPT-patients were on a low dose aspirin plus a P2Y12-inhibitor (clopidogrel or ticagrelor).

Results

51% Of the VA-ECMO-group received DAPT (59% clopidogrel and 41% ticagrelor). UFH-levels were comparable between both groups. Patients on DAPT were significantly older (DAPT 52.8 vs. Control 41.3; p<0.001) and predominantly male (DAPT 76% vs. Control 63%). Total bleedings (DAPT 52% vs. Control 55%; p=0,68) and major bleedings (BARC score of 3 or more; DAPT 41% vs. Control 45%; p=0,71) did not differ significantly. We observed a significant lower number of clinically or radiographically overt arterial/venous thromboses (DAPT 13.7% vs. Control 36.2%; p=0,02) in the DAPT-group. When comparing fresh frozen plasma (FFP), red blood cell and platelet pool transfusions between both groups, only FFP-tranfusion (DAPT 0.47 units/day vs. Control 1.18 units/day; p=0,047) intends to be lower for the DAPT-group.

DAPT (plus UFH) vs control (plus UFH)

Conclusions

Haemorrhage is frequent during extracorporeal support. However, in our cohort, DAPT on top of UFH in the treatment of VA-ECMO-supported ischemic cardiogenic shock does not increase the risk of major bleeding. Therefore, DAPT should not necessarily be witheld in the setting of VA-ECMO. Interestingly, our data support a lower incidence of overt thromboses and a trend towards less FFP-transfusion. These findings suggest DAPT-induced platelet inhibition being protective against both thrombotic events and posibly consumptive coagulopathy without paying a price for major bleeding.
P1717The clinical impact of intra-aortic balloon pumping for acute coronary syndrome from Mie ACS registry
Authors: Takasaki A , Kurita T , Masuda J , Dohi K , Hoshino K , Tanigawa T , Saito Y , Kitamura T , Kakimoto H , Setsuda M , Makino K , Ichikawa T , Ito M
Published: October 2019

Background

Intra-Aortic Balloon Pumping (IABP) was widespread used in cases of Acute Coronary Syndrome (ACS) at daily clinical situation in Japan, even though the efficacy of IABP in AMI patients with cardiogenic shock was not proved. The aim of this study was to investigate the efficacy of IABP use in ACS patients in Japan.

Methods

We investigated 2-year all-cause-mortality of 2,660 enrolled ACS patients including 358 patients with IABP and 2,302 patients without IABP from Mie ACS registry.

Results

We compared a 1:1 propensity score-matched cohort of 426 ACS patients with or without IABP (n=213, respectively). 2-year mortality was significantly higher in patients with IABP than without IABP (p=0.02, Figure A). In addition, IABP usage was independent predictor of mortality with hazard ratio of 1.6 by multivariate analysis. However, 2-year mortality was not statistically different between 2 groups only when analyzed patients with shock (p=0.60, Figure B).

Figure 1

Conclusion

IABP was not commonly recommended in ACS patients. However, IABP was might as well used in some situation especially in shock.
P1724Prognostic impact of atrial fibrillation in acute myocardial infarction and cardiogenic shock: results from the CULPRIT-SHOCK trial
Authors: Feistritzer H.-J , Desch S , Zeymer U , Fuernau G , De Waha-Thiele S , Dudek D , Huber K , Stepinska J , Schneider S , Ouarrak T , Thiele H
Published: October 2019

Background

It is unclear whether atrial fibrillation (AF) influences prognosis in patients with cardiogenic shock (CS) and multivessel disease.

Purpose

To investigate the prognostic impact of AF in patients with CS complicating acute myocardial infarction (AMI).

Methods

In a subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial, patients were grouped according to the presence of AF during index hospital stay. The primary endpoint was all-cause death at 30 days and the key secondary endpoint was all-cause death at 1 year.

Results

AF was documented in 142 (21%) of 686 patients. AF was not a significant predictor of 30-day (adjusted OR 1.01, 95% CI 0.66–1.56, p=0.95) and 1-year (adjusted OR 0.89, 95% CI 0.58–1.37, p=0.59) all-cause mortality. Patients with AF already on admission showed higher all-cause mortality at 30 days (52 of 90, 58% vs. 19 of 52, 37%; p=0.02) and 1 year (57 of 90, 63% vs. 20 of 52, 39%; p=0.004) compared to patients with newly detected AF during hospital stay. AF was significantly associated with the need for renal replacement therapy (adjusted OR 1.76, 95% CI 1.05–2.94, p=0.03) and longer time to hemodynamic stabilization (4, IQR 1–8 days vs. 3, IQR 1–6 days; p=0.04) at 30 days.

Conclusions

In CS complicating AMI all-cause mortality is similar in patients with and without AF. Adverse outcome was detected in the subgroup of patients showing AF already on hospital admission.
P1741Hitting the wall in converting diagnosed ST-elevation myocardial infarction patients to treating them: a humbling analysis from LATIN telemedicine
Authors: Mehta S , Botelho R , Niklitschek S , Fernandez F , Cade J , Cavalcanti R , Dusilek C , Estrada A , Lacativa M , Cardoso R , Torres M A , Vieira D , Nola F , Munguia A , Cecilio E
Published: October 2019

Background

The behemoth telemedicine program, Latin America Telemedicine Infarct Network (LATIN) has exponentially grown in 4 countries in Central and South America. It has provided AMI coverage to >100 million patients and it has contributed to transforming AMI care in the continent by its “halo” effect. We continue our meticulous search in evaluating the impact of LATIN and in doing so, we have confronted a sobering reality.

Purpose

To make continued improvements in population-based AMI management, the continued success of the initiative requires participation from healthcare policy makers, health economists, and payers.

Methods

LATIN was created as a hub and spoke model to hugely increase access (>100 million population coverage) to quality AMI treatment primarily with short door to balloon time (D2B) PCI. Innovative telemedicine platforms were created and networked at all 350 centers that were located in small clinics and primary health centers in poor sections of the countries (spokes) and at 24/7 PCI capable institutions (hubs). Remote cardiologists, located in 3 central locations, provided immediate EKG diagnosis (time to telemedicine diagnosis, TTD <3.5 minutes) and they provided expert guidance for the entire STEMI process, Door in Door Out (DIDO), and transport times (TT). LATIN performance metrics, under its strict control, and including process metrics at the hubs, spokes, and at the command telemedicine sites, were measured and plotted. The macroeconomic variables of insurance approvals, ambulance structure, and availability of ICU beds were determined and incorporated into performance variables of the LATIN program.

Results

784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Over 4 years of operation, the proportion of reperfused STEMI patients has ranged between 41–48% - the major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation.

Conclusions

Sustained improvements, as a result of stringent QA processes and continuous education, have resulted in reduced D2B, TTD, DIDO, TT, and in overall mortality. However, LATIN remains constrained with a large proportion of patients that are diagnosed but not treated, largely because of payer denials. Although this metric is showing improvement from broad dissemination of LATIN benefits, further gains from LATIN will result mainly from improved reimbursements.
P1742Is time to telemedicine diagnosis (TTD) analogous to door to balloon time?
Authors: Mehta S , Botelho R , Fernandez F , Cade J , Prudente M , Cavalcanti R , Dusilek C , Bojanini F , De Los Rios O , Alcocer Gamba M , Frauenfelder A , Matheus C , Torres M A , Pisana L , Mazzini J
Published: October 2019

Background

Telemedicine is a powerful, cost-efficient, and scalable tool for population-based AMI management. Traditional metrics of D2N, D2B do not gauge telemedicine effectiveness. We explored the utility of TTD in 784,947-screened patients within the Latin America Telemedicine Infarct Network (LATIN).

Purpose

To evaluate the competence of TTD as an efficiency indicator in telemedicine.

Methods

LATIN employed a spoke-hub strategy to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics (spokes) in remote areas were strategically connected to PCI-capable facilities (hubs). Experts at 4 remote locations provided urgent EKG diagnosis via tele-consultation, additionally, they triggered ambulance dispatch and implementation of guidelines-based protocols. Investing in updated telemedicine technology provided a system-wide TTD reduction.

Results

714,450 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). Within our territories 8,448 (1.08%) patients were diagnosed as STEMI; 3,911 (46.3%) were urgently reperfused, of those 3,049 (78%) underwent Primary PCI. TTD was 3 min, demonstrating 98.9% tele-accuracy. D2B was 51 min; in-hospital mortality 5.2%. We encountered a linear correlation between D2B and TTD. The latter was, also, inversely related to the number of screened patients - both associations are favorable for LATIN.

Conclusions

TTD is an important indicator of telemedicine efficiency. LATIN will continue to explore this value's strength and other important associations.
P1753Novel biomarker algorithmic panel measuring permutations of immune response to cardiac endothelial injury and global risk factors identifies patients at risk of acute coronary syndrome (ACS)
Authors: Harrington D S , Zhao Y , Simonini A , Wong N
Published: October 2019

Background

Global cardiovascular risk scores frequently underestimate risk in persons with underlying asymptomatic cardiac lesions who eventually experience cardiovascular events. The Get-With-The-Guidelines Initiative analysis revealed that over 70% of patients with a first cardiac event were well within guideline targets for lipid values. Most artery flow-disrupting events occur at locations with less than 50% lumen narrowing. From clinical studies published in the late 1990s using IVUS (in-the-artery-ultrasound) to visualize disease status, the typical heart attack occurs at locations with about 20% stenosis (narrowing), prior to sudden lumen closure and resulting ACS. This sudden lumen closure is caused by rupture of an unstable cardiac lesion causing a blood clot and occlusion in up to 75% of heart attacks. The role of multi-biomarker algorithms to identify vulnerable patients with these lesions at risk of short-term ACS events is of great interest.

Methods

We studied 725 adults (≥18 yrs) from Cardiology practices who received a 5-year modified Framingham Risk Score (mFRS), and a coronary artery disease predictive algorithm (CADPA) multi-biomarker score. CADPA incorporates 9 biomarkers (CTACK, Eotaxin, Fas Ligand, HGF, IL-16, MCP-3, sFas, HDL, and HbA1c) with age, sex, diabetes, and family history of myocardial infarction, previously shown to more accurately reclassify risk of cardiovascular events (cNRI=43%). Patients were classified into low (<3.5%), intermediate (3.5% - <7.5%), and high (≥7.5%) 5-year risk categories with both mFRS and CADPA. Patients low or intermediate risk by mFRS, but reclassified high by CADPA are reported and compared.

Results

Persons at low, intermediate, and high global risk categories were successively more likely to demonstrate high-risk scores with CADPA (Figure). However, 349 (65%) in the low mFRS risk group were reclassified into higher CADPA risk groups and 104 (70%) intermediate risk patients were reclassified into the high-risk group (p<0.0001 for CADPA vs. mFRS). Analysis demonstrated that 89% (309) of the low or intermediate mFRS [125 females (99%); 184 males (83%); p<0.0001] and, 86 below 65 years (93%) and 223 above 65 years (88%); p=0.26)] were classified as high-risk by CADPA, indicating that many persons who may be at high risk are not identified as such by global risk assessment.

CADPA Risk Reclassification

Conclusions

We conclude that this novel multi-biomarker panel (CADPA) identifies many persons at increased risk of cardiac events due to asymptomatic cardiac lesions missed by traditional global risk methods. Further investigation of the value of such a test for prediction of near-term CVD events is required.
P1759Elevated NT-pro BNP predicts Heart Failure re-hospitalizations after an acute coronary syndrome
Authors: Martinez Rey-Ranal E , Cordero A , Moreno M J , Bertomeu Gonzalez V , Moreno Arribas J , Pomares A , Torroba G , Bertomeu Martinez V
Published: October 2019

Background

NT pro-BNP is a well-established biomarker of tissue congestion and has prognostic value in patients with heart failure (HF) and, also, with acute coronary syndrome (ACS). Nonetheless, there is scarce evidence on the predictive capacity of NT pro-BNP for HF re-admission after an ACS.

Objective

To test whether elevated values of NT pro-BNP can predict subsequent hospitalizations for HF in patients discharged after an ACS.

Methods

We performed a prospective study of all patients discharged after an ACS in a single center. HF re-admission was analysed by competing risk regression, taking all-cause mortality as a competing event, and results are presented as sub-Hazard Ratio (sHR); recurrent hospitalizations were tested by negative binomial regression and results are presented as incidence risk ratio (IRR).

Results

We included 1,679 patients, mean age 70.1 (29.7) year, 71.9% males, 41.4% STEMI and mean GRACE score 151.7 (44.4). Median NT pro-BNP was 948.2 pg/ml (IQ range 274.5–2923) and patients were divided in <300U (27.0%), 300–600 pg/ml (13.4%), 600–1000 pg/ml (10.8%) and >1000 pg/ml (46.7%) A total of 132 (5.9%) died within hospitalization and follow-up was available 98% of the patients, with a median follow-up of 33 months (IQ range 16–59). A total of 220 patients (13.1%) had at least one hospital re-admission of HF and 126 (7.5%) had more than one re-hospitalization for HF. Patients with NT pro-BNP had higher un-adjusted HF re-admissions (22.2% vs. 4.4%; p<0.01). Cardiovascular mortality increased significantly in each category of NT pro-BNP (3.8%; 8.0%; 7.7%; 18.5%) as well as all-cause mortality (0.1%; 12.4%; 11.6%; 25.3%), first HF readmission (2.7%; 7.1%; 5.5%; 23.5%); patients with NT pro-BNP had higher rates of recurrent HF readmissions: 11.6/1000 vs. 2.4/1000 patients/years (p<0.01). Multivariate analyses, adjusted by age, gender, GRACE score, left ventricle ejection fraction, revascularization and medical treatments at discharge, identified that NT pro-BNP >1000 pg/ml was associated to HF re-hospitalization (sHR: 2.60 95% CI 1.12–5.95) and recurrent hospitalizations (IRR: 1.10 95% CI 1.04–1.14).

Conclusions

NT pro-BNP >1000 pg/ml is an accurate risk factor for first and recurrent HF rehospitalisations after an ACS.
P1774Genetic heterogeneity and clinical outcomes of non-compaction cardiomyopathy
Authors: Vaikhanskaya T , Kurushka T V , Sivitskaya L N , Liaudanski A , Danilenko N G
Published: October 2019

The clinical outcomes of non-compaction cardiomyopathy (NCM) range from mild-symptomatic to progressive HF, arrhythmias, thromboembolism, and SCD.

Objective

The genetic spectrum and clinical outcomes of verified NCM were investigated.

Methods

The study enrolled 72 unrelated pts (aged 39.2±14.1 years; 43/59.7% male; LVEF 44.7±13.2%) with morphological signs of non-compaction myocardium, confirmed by any three accepted criteria: Echo (Jenni and Stöllberger), MRI (Petersen and Jacquier). During the follow-up 59,7±16,2 months, diagnosis of NCM has been revised by supporting diagnostic elements based on clinical evidence: a family history of cardiomyopathy, coexisting neuromuscular disorders, abnormal 12-lead ECG findings, presence of arrhythmias, heart failure or thromboembolic events. After exclusion 19 cases with isolated asymptomatic and reversible (athletic/peripartum) LVNC, a group (53 persons) for NGS (174 genes) was formed. All variants considered as pathogenic and likely pathogenic were confirmed by a Sanger sequencing.

Results

Forty-nine (likely) pathogenic variants were identified in 38/71,7% carriers (gene positive pts), including 27/50,9% pts with single variant and 11/20,8% pts with complex genotypes. The most prevalent mutations involved genes were TTNtv (11), MYBPC3 (8), LMNA (4), then MYH7 (3), and two each ILK, HCN4, LAMP2, RAF1, SDHA, RYR2. One mutation is found in the genes TAZ, HADHA, ACTC1, ACTN2, MYH6, DSP, SLC25A4, FBN1, BAG3, SCN5A, TBX20. Clinical features and adverse outcomes during follow-up were compared between groups of the gene-positive and gene-negative pts.

Combined adverse clinical outcomes were taken as composite endpoints: death due to HF, SCD, HTx, life-threatening VTA (VT/VF, successful resuscitation, ICD discharges). To analyze composite endpoints, a multivariate regression analysis was performed with step-by-step exclusion. As a result, a prognostic model was constructed (R=0.89; R2=0.78; F=32.9; p<0.ehz748.05261) and independent predictors of adverse outcomes were identified: gene-positivity (β=0.45; p=0.ehz748.05261), 6MWT (β=−0.30; p=0.0002), PQ interval (β=0.23; p=0.0008), syncope history (β=0.29; p=0.ehz748.05263), mTWA (β=0.23; p=0.0005), LVDD (β=0.27; p=0.0001) and RVEF (β=−0.40; p=0.ehz748.05261). As a strongest factor of adverse outcome was gene-positivity, Kaplan-Meier survival curves were constructed. According to the Cox F-criterion (F=24.9) a high level of significance of differences to achieving combined endpoints in the groups (p=0.0001) was determined.

Conclusions

These results show that NCM is basically a genetic disease with significant heterogeneity and predominant TTNtv mutations; the patients with (likely) pathogenic variants have a worse prognosis with an increased risk for the composite end point of death, transplantation, and defibrillator implantation. Genetic evaluation is an important for prediction and subsequent management NCM pts considering genetic status.
P1784Dismal outcomes and high societal burden of mitral valve regurgitation in France in the recent era
Authors: Messika Zeitoun D , Vahanian A V , Candolfi P C , Gilard M G , Iung B I , Mesana T M , Enriquez-Sarano M E S
Published: October 2019

Background

Mitral regurgitation (MR) is the most common heart valve disorder worldwide. The contrast between the large burden of MR and the overall low number of performed mitral valve surgery suggest a marked undertreatment of MR patients. Large and comprehensive contemporary data assessing the management and outcome of patients with MR as well as the societal burden of the disease at the Nationwide level are currently lacking.

Methods

Based on a French mandatory administrative hospital-discharge database, we collected all admissions in France both in public and private hospitals in 2014 and 2015 with MR as primary or secondary code. Patients with infective endocarditis, congenital or rheumatic disease were excluded. Cost were calculated for patients admitted in public hospitals.

Results

In 2014–2015, 107,412 patients with MR were admitted in France in 1238 public and private hospitals; 74,098 patients (69%) presented with primary MR (PMR) and 33,314 patients (31%) with secondary MR (SMR). Overall 8,676 patients (8%) were operated on (81% PMR) within 1 year and 98,736 (92%) were conservatively managed and constituted our study population. Mean age was 77±15 years (50% were ≥80 years and 12% ≥90 years) and 53% were female. Most of the patients presented with comorbidities and Charlson Index was ≥2 in 53% of the population. In-hospital and one-year mortality were 4.1% and 14.3% respectively. Readmission were very common and one-year mortality/readmission all cause, and one-year mortality / CHF readmission rates were 67% and 34% respectively and increased with age, Charlson Index, CHF at presentation and SMR etiology but events rate remained notably high in the PMR subset (64% and 28% respectively). The total annual cost in public hospitals (initial hospitalisation and readmissions) was 325,716,311 euros. When only readmissions for heart failure were considered (43% of all readmissions), total annual cost was 202,904,869 euros.

Conclusion

In this large administrative contemporary nationwide database, 1) MR was a common reason for admission and affected an elderly population with frequent comorbidities, 2) less than 10% of patients were offered any intervention, 3) MR was associated with high mortality and readmissions rates in all subsets; 4) MR represented a major societal burden with an extrapolated annual cost between 250 and 400 million euros. These finding highlight the critical need to develop strategies to improve the overall management and outcomes of patients with both primary and secondary MR.

Acknowledgement/Funding

Edwards Lifesciences
P1785Whole exome sequencing unravels new genes associated with mitral valve prolapse
Authors: Van Wijngaarden A , Hiemstra Y L , Koopmann T T , Ruivenkamp C A L , Aten E , Bax J J , Delgado V , Barge-Schaapveld D Q C M , Ajmone Marsan N
Published: October 2019

Background

Several studies have suggested a familial clustering of mitral valve prolapse (MVP), especially for Barlow disease (BD), which is regarded as the effect of genetic or developmental errors. However, the genetic etiology of MVP, in particular BD, is largely unknown. So far only three genes have been identified: FLNA, DCHS1 and PLD1.

Purpose

The aim of this study was to identify genes associated with MVP using whole exome sequencing (WES).

Methods

Patients with MVP, who were classified as BD and/or had a positive family history for MVP, were referred for genetic counseling and WES. In total, 106 unrelated probands were included to identify potentially pathogenic variants in a set of 551 genes associated with cardiovascular development and/or diseases. The population databases Genome Aggregation and WES data from 110 parents of children with mental retardation were used as controls. Variants were analyzed using prediction programs, frequency in the population database and literature search. Variants were divided into the following categories: likely benign, variant of unknown significance or likely pathogenic.

Results

Thirteen percent (14/106) of the probands had a likely pathogenic variant in seven different genes: DCHS1 (1x), DSP (1x), HCN4 (2x), MYH6 (1x), TMEM67 (1x), TRPS1 (1x) and TTN (7x); the DSP, MYH6 and HCN4 variants cosegregated in affected relatives. None of the 110 parents of children with mental retardation had a likely pathogenic variant in these seven genes. In addition, 31% (33/106) of the probands harbored a variant of unknown significance in 23 different genes, including the genes DSP, FLNA, MYH6 and TTN (Fig). Remarkable, one variant of unknown significance in the FBN2 gene was shared among three unrelated probands and did not occur in population databases.

Conclusion

WES analysis conducted in probands with MVP using a large panel of genes associated with cardiac development and/or disease confirmed previously known causative genes (DCHS1) and expanded the cardiac phenotype of genes originally associated with cardiomyopathy (DSP, HCN4, MYH6 and TTN). This study is the first study that described the association between MVP and the genes DSP, MYH6 and TTN although the pathogenesis is still unknown. This high yield of likely pathogenic variants emphasizes the importance of genetic screening in MVP patients.
P1790TAVI is associated with less patient-prosthesis-mismatch than surgical aortic valve repair of severe aortic stenosis: A systematic review and meta-analysis
Authors: Abi Khalil C , Ignatiuk B , Erdem G , Chemaitely H , Barilli F , Al Suwaidi J , Kofler M , Stastny L , Jneid H , Bonaros N
Published: October 2019

Background

TAVI has shown to be non-inferior to surgical aortic valve replacement (sAVR) in terms of mortality for the treatment of intermediate and high-risk patients with severe aortic stenosis (AS).

Purpose

We sought to assess whether there is a difference on echocardiographic parameters up to 2 years after TAVI and sAVR

Methods

We conducted a systematic review and a random-effect model meta-analysis of randomized controlled trials that compared TAVI and sAVR. The primary outcome was post-proceduralpatient-prosthesis-mismatch (PPM). Secondary outcomes were post-procedural and 2-year effective orifice area (EOA), paravalvular gradient (PVG) and moderate/severe paravalvular leak (PVL).

Results

We identified 5 trials with a total of 5552 participants with AS, including 2777 patients randomized to TAVI and 2775 randomized to sAVR (Figure 1). TAVI was associated with a significant 35% relative risk reduction (95% CI [0.50–0.8), p=0.005) in moderate/severe post-procedural PPM. The effect was more evident in self- than balloon-expandable valves (p=0.029). Similar results were found in terms of post procedural EOA (RR=0.53, 95% CI [0.43–0.62]), and residual gradients (RR=0.54, 95% CI [0.32–0.76]). As expected, TAVI demonstrated higher rates of moderate/severe PVL (RR=9.41, 95% CI [5.22–16.96]). The results were sustainable at 2 years as seen in pooled increased EOA (pooled mean difference 0.48, 95% CI [0.24–0.72]), and the pooled decreased residual gradients of 0.58 (95% CI [0.77–0.25]) in favor of TAVI. The incidence of moderate/severe PVL remained also lower in sAVR patients (RR=10.39, 95% CI [4.80–22.46]).

Figure 1. PRISMA flow diagram

Conclusions

Our meta-analysis suggests that TAVI is associated with a lower risk of PPM, as well as higher EOA and lower residual gradients through 2 years of follow-up. This was accompanied by a higher incidence of moderate/severe PVL compared to sAVR. Future research should focus on the effect of these echocardiographic differences on clinical outcomes.
P1791Conduction abnormalities following aortic valve intervention in patients with transthyretin cardiac amyloidosis
Authors: Zikry Deitch M , Haberman D , Lifshitz S , Tshori S , Fabricant Y , Voldarsky I , Meladin V , Gandelman G , Goland S , Swissa M , George J , Shimoni S
Published: October 2019

Introduction

Aortic Stenosis (AS) is the most common valvular heart disease in the Western world. Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement in medium and high-risk patients. One of the most common complications after TAVI is conduction system disturbances including bundle branch block, complete heart block and need for permanent pacemaker implantation. Transthyretin cardiac amyloidosis (TTR–CA) is an increasingly recognized cause of heart failure that almost exclusively affects older adults. Diagnosis of TTR-CA in patients undergoing valvular intervention is relevant to understand their clinical outcomes and to discuss specific management.

Objectives

Occult amyloid may account for the frequent need for pacemakers among TAVR patients. We aimed to assess the correlation between intervention induced conduction abnormalities and the need for a pacemaker insertion and the presence of TTR-CA.

Methods

The study population included patients who had aortic valve intervention between 2011–2018. The patients underwent Tc99m-PYP scan using SPECT technology which has been shown to be valid for the diagnosis of TTR-CA. We examined the rate of conduction disorders and the need for a permanent pacemaker from patient files at the time of hospitalization and during a 24-month follow-up.

Results

The study population included 86 patients, mean age 78±6 years, 55% women. Twenty-nine (33%) of the participants were diagnosed as positive (VAS 2 and 3) for transthyretin cardiac amyloidosis. There were no differences in baseline characteristics with regard to age, gender, risk factors, hemoglobin and renal function between patients positive and negative for TTR CA. Conduction disorders were seen in 35 (40%) patients. Patients with TTR CA had a statistically higher prevalence of conduction disorders. Forty-two percent of TTR CA positive patients underwent peri-procedural permanent pacemaker implantation compared to 28% peri-procedural pacemaker implantations in the negative group (p=0.043). Development of a new left bundle branch block during the follow-up period was observed in 14.1% of all patients. There was a statistically significant higher rate in the positive group compared to TTR CA negative group (39.1% vs 10.9% p=0.03).

Conclusions

We observed a high prevalence of occult TTR-CA in older adults with aortic stenosis who underwent TAVI. We also found a high prevalence of conduction abnormalities following TAVI in patients with TTR CA. These findings suggest a need for more careful observation for possible conduction abnormalities and requirement for pacemaker insertion in these patients.

Acknowledgement/Funding

None
P1792Delirium after transcatheter aortic valve implantation (TAVI) under general anaesthesia: incidence, predictors and relation to long-term survival
Authors: Van Der Wulp K , Van Wely M H , Van Heijningen L , Van Bakel B M A , Schoon Y , Verkroost M W A , Gehlmann H R , Van Garsse L A F M , Vart P , Olde Rikkert M G M , Kievit P C , Morshuis W J , Van Royen N
Published: October 2019

Background

Patients undergoing Transcatheter Aortic Valve Implantation (TAVI) are at risk of postoperative delirium (POD). Prospectively collected data on delirium after TAVI are scarce.

Purpose

Aim of this study is to report the incidence and risk factors of POD after TAVI under general anaesthesia. Also we assessed the relation of POD with clinical outcome and short- and long-term survival.

Methods

POD was assessed prospectively in all consecutive patients treated with TAVI in our centre between 2008 and 2017, according to the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV criteria. TAVI was performed under general anaesthesia in all patients. Outcome was reported according to the updated VARC2-criteria. Survival status was checked by consulting the Municipal Civil Registries.

Results

POD was observed in 16.5% (116/703) of all patients. Stroke and new onset of atrial fibrillation were more often observed in patients with POD (6.9% vs. 1.9%, p=0.007 and 12.1% vs. 5.1%, p=0.005, respectively). Independent preoperative predictors of POD were prior delirium (OR 2.56 [95% CI: 1.52–4.31], p<0.001), aortic valve area (AVA)<0.75 cm2 (OR 2.39 [1.53–3.74], p<0.001), age (1.08 [1.04–1.12], p<0.001) and BMI (0.94 [0.90–0.99], p=0.018). POD was the strongest independent predictor of long-term mortality (HR 1.91 [1.36–2.70], p<0.001) and was associated with impaired 30-day survival (92.2% vs. 96.8%, p=0.034) as well as 5-year survival (40.0% vs. 50.0%, p<0.001).

Survival: Delirium vs No Delirium

Conclusion

One-in-six patients suffered from POD after TAVI under general anaesthesia. Prior delirium and more calcified aortic valve were the strongest independent predictors of POD. POD was the strongest predictor of long-term mortality and was associated with impaired short- as well as long-term survival.
P1796Adults with congenital heart disease have impaired calf muscle oxygenation compared to control subjects
Authors: Sandberg C , Crenshaw A G , Elcadi G H , Christersson C , Hlebowicz J , Thilen U , Johansson B
Published: October 2019

Background

Peripheral muscle factors are presumed to be important contributors to the reduced exercise capacity in congenital heart disease (CHD), but the mechanisms are poorly understood.

Purpose

To investigate if muscle oxygenation in the calf muscle is impaired in adults with complex CHD in comparison to controls.

Method

Seventy-four adults with complex CHD (35.6±14.3 years, females n=22) were recruited from centers specialized in adult CHD. Seventy-four age and gender matched subjects were recruited as controls. Muscle oxygenation was successfully determined using near-infrared spectroscopy on the medial portion of m. gastrocnemiusin 63 patients and 67 controls. Measurements were made at rest, during venous occlusion to estimate blood flow (BF – indicated by the slope increase of total haemoglobin, HbT), at the start of isotonic unilateral heel-lifts to exhaustion, and immediately after exercise.

Results

In comparison to controls, patients had a lower muscle saturation (StO2) at rest, albeit not statistically significant, (66±17% vs. 60±19%, p=0.07), and a lower BF (0.38±0.21 vs. 0.31±0.21 HbTx3.5sec–1, p=0.07). For exercise, compared to the controls, patients had a slower desaturation rate at exercise onset (−11.7±5.8% vs. −7.7±4.3%. StO2x3.5sec–1, p<0.001), and both a slower resaturation rate (6.1±3.8% vs. 3.9±3.7% StO2x3.5sec–1, p=0.002) and a slower half recovery time (16.8±11.1 vs. 28.6±21.2 sec, p<0.001) post exercise.

Conclusion

The lower muscle oxygenation and blood flow at rest, and the slower oxygenation kinetics during exercise may give insight to the mechanism for the reduced exercise capacity commonly found in adults with complex CHD. This finding may also provide implications for design of rehabilitation programs for these patients.