bluuebunny/crossref_metadata_2025 huggingface dataset:
77Infective endocarditis in patients with congenital heart disease: Results of a nationwide study including 1494 endocarditis cases
Authors: Diller G P , Freisinger E , Bronstein L , Koeppe J , Gerss J , Reinecke H , Baumgartner H
Published: October 2019

Background

Infective endocarditis (IE) represents a major complication in patients with congenital heart disease (CHD) and is associated with high morbidity and mortality. The aim of this study was to analyse the frequency and outcome of IE in contemporary CHD patients based on all IE hospital admissions in Germany between 2011 and 2016.

Methods

Based on the German diagnosis related groups data of patients treated between 2011 and 2016, we identified all CHD patients with a diagnosis of IE. The data contains information on patient demographics, primary and secondary diagnoses, interventional or surgical procedures, duration of stay and outcome including mortality. The primary endpoint of the study was endocarditis-associated mortality as well as major adverse events (defined as death or myocardial infarction, stroke, pulmonary embolism, sepsis, resuscitation or intubation).

Results

Overall, 181,924 CHD patients were included in the analysis (55% male; 73% children, mean age 2.3 years; 27% adults, mean age 58.4 years; underlying heart defect of simple complexity 55%, moderate complexity 23% and complex heart defect 22%, respectively). During the study period 1494 cases were treated for IE corresponding to 0.82% of all inpatient treatment cases in CHD patients. Mortality rate was 6.6% (95% CI: 5.0–7.6%) with a major adverse events rate of 44.6% (95% CI: 41.3–48.2%). In total, 682 IE patients (45.7% CI: 42.3%-49–2%) required a surgical intervention. The relative risk of dying due to endocarditis in CHD patients was significantly lower compared to older IE patients without CHD (relative risk 0.39; 95% CI: 0.32–0.47).

Conclusions

Infective endocarditis accounts for a minority of CHD related hospitalizations but remains a deadly disease with a high proportion of patients requiring surgical intervention. In addition, major adverse events are common in this setting, with almost half of the IE population presenting with a major adverse event. Due to different demographic and comorbidity spectrum encountered in CHD patients, these younger patients tend to have significantly better survival prospects compared to non-CHD IE patients in the current era.
94Course of contained annulus ruptures after TAVI: the ENCORE (European contained rupture)-registry
Authors: Breitbart P , Minners J , Pache G , Hansson N C , Norgaard B L , De Backer O , Sondergaard L , Alsanjari O , Hildick-Smith D , Reinoehl J , Abdel-Wahab M , Loebig S , Neumann F.-J , Ruile P
Published: October 2019

Background

An asymptomatic contained rupture (CR) of the aortic annulus is a rare complication of transcatheter aortic valve implantation (TAVI). Their clinical implication is unclear so far.

Purpose

To determine the long-term outcomes in patients with CR.

Methods

The ENCORE-registry is a multicenter registry (6 centers across Europe) of patients with CR diagnosed on post-TAVI computed tomography angiography (CTA) or transesophageal echocardiography (TEE).

Results

A total of 21 patients (mean age 81.9±4.1 years, 81% balloon-expandable TAVI-prostheses) were diagnosed with CR (62% located adjacent to the left coronary cusp, mean size of lesions was 15.3±6.9 x 8.5±3.3 x 8.5±2.3 mm). Seventeen were diagnosed among a total of 1602 consecutive routine post-TAVI CTA (incidence 1.1%), two in TEE and two in post-TAVI CTA (each conducted due to suspicion of periinterventional complications). During a mean follow-up of 2.3±1.7 years nine patients (43%) died from non-cardiac causes. None of the patients exhibited symptoms or underwent interventional treatment related to the CR, no sudden cardiac death occurred. A follow-up CTA, performed in eleven patients 240±176 days post-TAVI, revealed stable CR findings in seven, regression in one, and remission in three patients.

Conclusion

The results of our ENCORE-registry demonstrate a benign course of initially asymptomatic contained ruptures of the aortic annulus after TAVI supporting a watch-and-wait approach in these patients. Thus, no specific treatment seems to be necessary.
102Diagnosis of coronary plaque rupture, plaque erosion, and calcified nodule by using near-infrared spectroscopy intravascular ultrasound
Authors: Terada K , Kubo T , Matsuo Y , Ino Y , Kitabata H , Emori H , Katayama Y , Khalifa A , Shimamura K , Shiono Y , Tanaka A , Hozumi T , Akasaka T
Published: October 2019

Objectives

This study sought to investigate the ability of near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) to differentiate among plaque rupture (PR), plaque erosion (PE), and calcified nodule (CN) in acute myocardial infarction (AMI) using an optical coherence tomography (OCT) diagnosis as a reference standard.

Background

In vivo, precise differentiation among PR, PE and CN is a major challenge for intravascular imaging.

Methods

The study enrolled 156 AMI patients who had a de novo culprit lesion in a native coronary artery. The culprit lesions were assessed by both NIRS-IVUS and OCT.

Results

OCT identified 112 PR, 29 PE, and 15 CN. IVUS-detected plaque ulceration showed a high specificity (100%) to identify OCT-PR although the sensitivity (62%) was intermediate. IVUS-detected convex calcium showed a high sensitivity (93%) and specificity (100%) to identify OCT-CN. In NIRS, the maximum lipid core burden index in 4 mm (maxLCBI4mm) was greatest in OCT-PR (values are median [interquartile range]) (671 [530 to 853]), followed by OCT-CN (355 [303 to 432]) and OCT-PE (283 [89 to 357]) (p<0.001). MaxLCBI4mm of <422 was the best cut-off to discriminate OCT-PE from OCT-PR and OCT-CN. The NIRS-IVUS classification algorithm using plaque ulceration, convex calcium, and maxLCBI4mm <422 showed a sensitivity and specificity of 96% and 95% for identifying OCT-PR, 93% and 95% for OCT-PE, and 93% and 100% for OCT-CN, respectively.

NIRS-IVUS classification algorism

Conclusion

Lipid component assessed by NIRS-IVUS was different among OCT-PR, OCT-PE and OCT-CN. The NIRS-IVUS classification algorism was highly sensitive and specific for differentiating these unstable lesion types in AMI.

Acknowledgement/Funding

None
103Maximum calcium thickness is a useful predictor for under expansion after post dilatation in calcified lesions: optical coherence tomographic study
Authors: Matsuhiro Y , Nishino M , Nakamura H , Yasumoto K , Tanaka A , Nakamura D , Matsunaga Y , Yano M , Yamato M , Egami Y , Shutta R , Tanouti J
Published: October 2019

Background

Several reports have revealed that stent under expansion is associated with target lesion failure and calcified lesions usually induced inadequate stent expansion. Contemporary debulking devices such as rotational/orbital atherectomy can modify severe calcified lesions before stenting. However, it is uclear which calcium parameter is most useful predictor for stent expansion in the calcified lesions. Thus, we investigated useful calcium parameters correlating with stent expansion in the calcified lesions.

Methods

We enrolled 43 consecutive calcified lesions (43 patients) who underwent optical coherence tomography (OCT) guided percutaneous coronary intervention (PCI) between September 2016 and January 2019. We evaluated the lesions treated with post dilatation by non-compliant balloon due to stent under expansion after stenting. Exclusion criteria included acute coronary syndrome, in-stent restenosis and lesions without any calcium or treated with rotational atherectomy. If there were several calcium lesions in one patient, we selected maximum calcium angle lesion. Stent expansion defined as post-PCI lumen area divided by the values predicted by the manufactures compliance charts. We compared mean reference area, pre lesion area stenosis, calcium parameters including calcium arc, maximum thickness, area and longitudinal length in pre-PCI OCT evaluations with post-PCI stent expansion at that site.

Results

Maximum calcium thickness showed significant correlation with stent expansion, while the others did not show a significant correlation with stent expansion (table). The optimal thresholds of maximum calcium thickness for the prediction of acceptable stent expansion defined by 80% of the values predicted by the manufactures compliance charts was 870mm (area under curve (AUC): 0.65) (figure).

Results of OCT parameters Univariate analysis P value Mean reference area 0.41 Pre % area stenosis 0.16 Calcium parameters   Calcium arc 0.37   Calcium maximum thickness 0.04   Calcium area 0.20   Calcium longitudinal length 0.43

Conclusion

A maximum calcium thickness<870mm is a useful predictor for acceptable stent expansion after post dilatation in calcified lesions.
123Effects of scoring or cutting balloon use on severely calcified lesions treated by percutaneous coronary intervention
Authors: Ikuta A , Kuwayama A , Tada T , Kadota K
Published: October 2019

Background

Whether preparation techniques during percutaneous coronary intervention (PCI) are associated with restenosis in severely calcified lesions is not well studied.

Purpose

We aimed to clarify the effects of the preparation techniques during PCI on mid-term outcomes of severely calcified lesions.

Methods

We examined 2688 consecutive severely calcified lesions (1854 patients) treated by PCI between January 2008 and December 2017, and identified 1789 lesions (66.6%) undergoing routine follow-up angiography within one year postprocedure. The angiographic outcome measure was defined as in-stent restenosis (ISR); ISR was defined as stenosis of ≥50%. We divided the 1789 lesions into two groups on the basis of the presence or absence of ISR: ISR and non-ISR groups.

Result

ISR was detected in 337 of the 1789 lesions (18.8%). The ISR group, in comparison with the non-ISR group, had more chronic total occlusion lesions (17.9% vs. 12%, p<0.01), less bifurcation lesions (41.9% vs. 48.5%, p=0.03), less reference diameter (2.85±0.64 mm2 vs. 2.96±0.54 mm2, p<0.01), lower use rate of scoring or cutting balloon (13.9% vs. 23.1%, p<0.01), and lower postprocedural percent stenosis (25.9±20.7% vs. 16.9±9.3%, p<0.01). After adjusting chronic total occlusion lesions, target lesions, and other factors in multiple logistic regression models, the use of scoring or cutting balloon was independently associated with ISR (hazard ratio, 0.62; 95% confidence interval, 0.44 to 0.89; p<0.01).

Conclusion

Using scoring or cutting balloon is associated with good midterm results of severely calcified lesions treated by PCI.
208Effect of hypertension duration and systolic blood pressure on dementia in patients with atrial fibrillation
Authors: Kim D , Yang P S , Jang E , Yu H T , Kim T H , Uhm J S , Kim J Y , Sung J H , Pak H N , Lee M H , Lip G Y H , Joung B
Published: October 2019

Background

Atrial fibrillation (AF) is associated with a higher risk for cognitive impairment and dementia, with or without a history of clinical stroke. There are a paucity of data on the associations of hypertension duration and blood pressure (BP) level with risk of dementia in patients with AF.

Purpose

We examined associations of duration of hypertension and secondly, systolic blood pressure (SBP) levels with incidence of dementia among patients with AF.

Methods

We enrolled a total 196,388 patients aged ≥50 years who were newly diagnosed as AF and undergoing hypertension treatment from the Korean National Health Insurance Service database (2005–2016). Starting from AF diagnosis, participants were followed up until the date of dementia, death, or December 31, 2016. To incorporate the effect of BP level and hypertension duration changes over time on dementia incidence, we constructed time-updated multivariable Cox models in which BP levels and hypertension duration were updated at each participants' regular national health examination visits (at 0–7 years of follow-up). Similarly, age, BP medications, and health-related behaviors were included as time-varying covariates in these models.

Results

During 1,016,744 person-years of follow-up, there were 32,692 dementia events. A cubic spline curve using continuous hypertension duration measures suggested a linear association between increase of hypertension duration and dementia risk. One-year increase of hypertension duration increased the adjusted risk of dementia with a hazard ratio (HR) of 1.17 [95% confidence interval (CI) 1.13–1.22]. In patients with hypertension duration <6 years, SBP of ≥140 mmHg was significantly associated with higher dementia risk, compared to SBP of <130 mmHg (in patients with hypertension duration <3 years: adjusted HR 1.08, 95% CI 1.01–1.16; and in those with 3 ≤ hypertension duration <6 years: adjusted HR 1.13, 95% CI 1.07–1.20), whereas no significant association between SBP and dementia risk in those with hypertension duration ≥6 years.

SBP and dementia in different duration

Conclusion

In patients with AF, the increase of hypertension duration was strongly associated with increased risk of dementia. Uncontrolled SBP was also associated with higher dementia risk. But, this effect of SBP might be attenuated in patients with longer hypertension duration. These findings suggest more emphasis needed on BP control in AF patients with earlier phase of hypertension (duration <6 years).

Acknowledgement/Funding

The Korean Ministry of Education, Science and Technology (NRF-2017R1A2B3003303) and the Korean Ministry of Health & Welfare (HI16C0058, HI15C1200)
218Different impact of muscle, fat, and bone mass in heart failure with reduced and preserved ejection fraction
Authors: Konishi M , Akiyama E , Matsuzawa Y , Sato R , Kikuchi S , Nakahashi H , Maejima N , Iwahashi N , Hibi K , Kosuge M , Tamura K , Kimura K
Published: October 2019

Background

Low muscle mass with or without fat mass is a main component of cachexia in heart failure (HF) and associated with poor prognosis. There is a paucity of data, however, regarding prognostic impact of each component of body composition (i.e., muscle, fat, and bone mass).

Purpose

We hypothesized that muscle, fat, and bone mass have different impact on prognosis in HF.

Methods

We retrospectively analyzed 418 patients admitted with a diagnosis of HF (71±13 years, 59% male, 46 and 54% with preserved/mid-range (left ventricular ejection fraction (LVEF) ≥40%) and reduced (<40%) LVEF), respectively). Dual-energy X-ray absorptiometry was performed at stable state after decongestion therapy.

Results

Mean appendicular skeletal mass index (ASMI) was 6.9±1.2 kg/m2 in men and 5.6±0.9 in women, so that 55% of patients had low muscle mass categorized by the Asian Working Group of Sarcopenia. During median follow-up of 502 days, 163 (39.0%) patients experienced primary outcome defined as death or heart failure hospitalization. Using optimal cut-off of each body component chosen on the basis of a receiver operating characteristic curve and the Youden method, we demonstrated that lower ASMI defined by the cut-off of 6.5 kg/m2 in male and 5.2 in female (adjusted hazard ratio (HR): 1.768, 95% CI: 1.210–2.581, p=0.003) and bone mass (adjusted HR: 1.498, 95% CI: 1.051–2.152, p=0.025), but not lower fat mass (p=0.34), were associated with elevated risk of primary outcome after multivariate adjustment. Kaplan-Meier curves with p value by Log-rank test were shown in figure. In subgroup analysis, negative impact of lower ASMI was significant regardless of sex and LVEF category, whereas negative impact of low bone mass was significant only in 78 female patients with reduced LVEF.

Figure 1

Conclusions

Indices about muscle and bone mass rather than fat mass had prognostic impact in HF. The impact of each body component may different according to sex and LVEF.
248Real-world Outcome of the ESC 0/1-hour Algorithm when Routinely Applied in Early Presenters
Authors: Twerenbold R , Costabel J P , Campos R , Arbucci R , Nestelberger T , Boeddinghaus J , Rubini M , Wussler D , Lambardi F , Resi S , Trivi M , Mueller C
Published: October 2019

Background

The European Society of Cardiology (ESC) recommends the use of a 0/1h-algorithm for rapid triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn). Concerns were articulated about its efficacy and particularly safety when applied in patients presenting early (≤3 hours) after chest pain onset, as hs-cTn concentrations might still be very low or even undetectable in these high-risk patients.

Purpose

We aimed to assess the real-world effectiveness, efficacy, and ultimately safety of the ESC 0/1h-algorithm when routinely applied in early presenters.

Methods

In a prospective international multicenter study enrolling unselected patients presenting with suspected NSTEMI to the ED, patients were assessed according to the ESC 0/1h-algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care. Patients with ST-segment elevation myocardial infarctions were excluded. Safety was quantified by the 30-day incidence of major adverse cardiac events (MACE, defined as the composite of cardiovascular death and myocardial infarction including the index event) in the rule-out group and in outpatients.

Results

Among 2296 patients, 819 (36%) were early presenters. NSTEMI prevalence in early presenters was 11%. Effectiveness was very high as 97% of patients triaged towards rule-out by the ESC 0/1h-algorithm did not require additional cardiac investigations including hs-cTnT measurements at later time points (e.g. 3–12h) or coronary CT-angiography in the ED. Median time to discharge or transfer from the ED was 150 minutes [q1130, q3215]. Efficacy of the ESC 0/1h-algorithm was very high: 67% of patients were triaged towards rule-out and 14% towards rule-in of NSTEMI. Overall, 75% of early presenters underwent outpatient management. Safety of rule-out and outpatient management were excellent in early presenters with a 30-day MACE incidence of both 0% and comparable with 0.3% and 0.1% in late presenters, respectively (p=ns).

Conclusions

These real-world data document for the first time the excellent effectiveness, efficacy and particularly safety of the ESC 0/1h-algorithm when routinely applied in early presenters. No differences in safety could be observed when compared with late presenters.
260Identification of differential roles of microRNA-33a and -33b during atherosclerosis progression with genetically modified mice
Authors: Horie T , Koyama S , Kimura T , Ono K
Published: October 2019

Background

MicroRNAs (miRs) are small non-protein-coding RNAs that bind to specific mRNAs and inhibit translation or promote mRNA degradation. Recent reports, including ours, indicated that miR-33a located within the intron of sterol regulatory element-binding factor (SREBF) 2 targets cholesterol transporter ATP-binding cassette protein A1 (ABCA1) or other anti-atherogenic targets and contributes to atherogenesis. Its inhibition or deletion is known to result in the amelioration of atherosclerosis. However, mice lack the other member of miR-33 family, miR-33b, which exists in humans. Precise evaluation and comparison of the responsibilities of these two miRs during the progression of atherosclerosis are essential and need to be investigated.

Methods and results

The difference between miR-33a and miR-33b in vitro and in vivo were analyzed from multiple directions using genetically modified miR-33a knock-out (KO) and miR-33b knock-in (KI) humanized mice. At first, we performed transcriptomic analysis of primary cultured hepatocytes transfected with synthetic miR-33a, miR-33b, and a control miR and found similar potential target repression and targeting motif of miR-33a and miR-33b in vitro. However, we noticed distinct expression patterns of miR-33a and miR-33b in several organs. By crossing miR-33a KO and miR-33b KI mice, we established four strains with or without miR-33a and miR-33b. Comparison of these strains showed distinct distribution and regulation of miR-33 family. In particular, comparison between mice with only miR-33a (wild-type mice) and mice with only miR-33b (miR-33a−/− miR-33b+/+) revealed 4-fold predominant expression of miR-33b in the liver. Such differential expression resulted in a reduced expression of target genes such as ABCA1 and worsened serum cholesterol profile in mice with only miR-33b. On the contrary, in macrophages the expression levels of miR-33 family genes were similar and their effects on target genes and cholesterol efflux capacity to ApoA-I or HDL cholesterol (HDL-C) were almost comparable. To evaluate the whole body atherogenic potency, we developed ApoE−/− miR-33a+/+ miR-33b−/− mice and ApoE−/− miR-33a−/− miR-33b+/+ mice. ApoE−/− miR-33a−/− miR-33b+/+ mice developed increased atherosclerotic plaque compared with ApoE−/− miR-33a+/+ miR-33b−/− mice, in line with the predominant expression of miR-33b in the liver and decreased serum HDL-C levels whose lower cholesterol efflux capacity were confirmed in 3H-labeled macrophages. On the contrary, a bone marrow transplantation study showed no significant difference in atherosclerosis and serum cholesterol profile, and this was consistent with the relevant expression levels of miR-33a and miR-33b in bone marrow cells.

Conclusions

miR-33 family exhibited differences in distribution and regulation, and particularly in the progression of atherosclerosis, miR-33b would be more potent than miR-33a.
443Natural history of arterial morbidity in vascular ehlers-danlos syndrome
Authors: Frank M , Adham S , Pitoccho F , Denarie N , Mousseaux E , Jeunemaitre X
Published: October 2019

Background

Vascular Ehlers-Danlos syndrome (vascular EDS) is a rare inherited connective tissue disorder, responsible of exceptional organ fragility. The disease is caused by pathogenic COL3A1 variants with a dominant negative effect, except for variants leading to haploinsufficiency. The course of the disease is characterized by the occurrence of recurrent spontaneous arterial accidents (dissections, aneurysm formation, spontaneous ruptures), typically of medium size arteries.

Purpose

To describe the natural history of arterial accidents in a molecularly characterized population of patients with vascular EDS, that benefited from repeated standardized vascular monitoring in a tertiary referral centre.

Methods

All patients from the French natural reference centre for vascular EDS were included in a retrospective cohort study. Standardized monitoring of arterial beds was performed at molecular diagnosis (baseline) and every 15 months thereafter in clinically silent patients, by CT-angiogram or MRA, and by vascular Doppler Ultrasound. In case of symptomatic arterial accidents, diagnostic imaging was also reviewed for arterial defects. Arterial lesions were sorted by date of diagnosis and staged by anatomical location and by type of defect.

Results

Between January 2000 and March 2017, n=144 patients (n=91 index, Sex Ratio 0.68) were diagnosed with vascular EDS at a mean age of 34.0 [25.0; 41.0] years, and regularly followed-up in our centre for a median 5.80 [3.45; 8.80] years. Types of COLA3A1 variants were glycine substitutions (68%), splice-site (31.8%) and those leading to haplosufficiency (8.3%). During follow-up a median 1.57 [0.9; 3.0] arterial accidents per 5 years occurred and n=17 (11.8%) patients died. At first referral, a majority of patients (68.8%) had already presented a disease-related event, predominantly arterial ones, totalling 232 arterial defects (dissections, 72%; aneurysms, 11.2%; ruptures, 9%; carotid cavernous fistula, 4.3% and arteriovenous fistula, 0.9%). Vascular assessment at baseline identified another 255 arterial defects in the same patients that had not been reported previously. At each further vascular monitoring, one third (36%) of patients presented with new arterial defects, a majority of which (66%) were clinically silent. Moreover, 15% of patients at each vascular assessment had evolved on previously diagnosed arterial lesions (healing or aggravation). Notably, neither symptomatic arterial event nor silent evolutivity occurred in haploinsufficient patients.

Conclusion

This study gives an extensive insight into distribution, nature and timeline of arterial defects in patients with vascular EDS in a large patient cohort. Besides known and expected arterial morbidity and mortality, a consistent proportion of clinically silent patients developed new arterial lesions, suggesting that progression of arterial pathology in vascular EDS is not limited to symptomatic arterial events.
454Potential real-world benefits of low-dose rivaroxaban in Chinese stable cardiovascular patients
Authors: Yan B P Y , Chan C K Y , Lai W H S , To O T L
Published: October 2019

Background

Low dose rivaroxaban-plus-aspirin has been shown to reduce cardiovascular (CV) events in patients with stable atherosclerotic vascular disease compared to aspirin alone in the COMPASS trial.

Purpose

We aimed to estimate the potential benefit of low dose rivaroxaban plus aspirin in reduction of major adverse cardiovascular event (MACE, the composite of cardiovascular death, stroke, or myocardial infraction [MI]) among COMPASS-like patients in a Chinese population.

Methods

We retrospectively analyzed 18,693 patients with stable coronary artery disease (CAD) and/or peripheral artery disease (PAD) from 3 hospitals in Hong Kong between 2013 and 2017 for a median follow-up of 36 (IQR 19–52) months. 4,594 (24.6%) COMPASS-like patients were identified based on COMPASS trial inclusion and exclusion criteria. We estimated the absolute risk reduction (ARR) in MACE and number needed to treat (NNT) in COMPASS-like patients based on results from the COMPASS trial (NCT01776424).

Results

Of 4,594 COMPASS-like patients (58.1% males, mean age 75.0±13.0 years), 92.5% patients were diagnosed with CAD, 5.6% PAD, and 1.9% combined CAD/PAD. Overall, 3-year MACE rate was 7.9%; 7.8% in patients with CAD, 6.6% in PAD and 18.4% in combined CAD/PAD (log-rank p<0.01). 3-year CV mortality rate was 3.7% (3.6%, 3.5%, 11.5% in CAD, PAD and combined CAD/PAD respectively, log-rank p<0.01); 3-year stroke rate was 3.2% (3.0%, 4.6%, 6.9% in CAD, PAD and combined CAD/PAD respectively, log-rank p=0.03); and 3-year MI rate was 2.2% (2.3%, 0%, 6.9% in CAD, PAD and combined CAD/PAD respectively, log-rank p<0.01). Among COMPASS-like patients, estimated ARR in MACE with the use of rivaroxaban-plus-aspirin was 1.9% (NNT=53); 0.8% ARR (NNT=123) for CV death, 1.3% ARR (NNT=74) for stroke and 0.3% ARR (NNT=325) for MI.

Conclusion

Our results demonstrated that a significant proportion of “real world” Chinese patients with stable cardiovascular diseases were COMPASS-like patients. Potential clinical benefit of the addition of low dose rivaroxaban to aspirin therapy may be greater in our population than that observed in the trial, with lower number needed to treat.
463Temporal trends in latecomer ST-segment elevation myocardial infarction patients: Insights from the AMIS Plus Registry 1997–2017
Authors: Roberto M , Radovanovic D , Biasco L , Quagliana A , Erne P , Rickli H , Pedrazzini G , Moccetti M
Published: October 2019

Introduction

A relevant proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) has a late presentation after symptoms onset. Temporal trends deriving from a large real-word scenario for this subgroup of patients are lacking.

Purpose

The aim of the present study was to provide a comprehensive analysis of temporal trends in latecomer STEMI patients, with particular regard to implementation of evidence-based treatments in this population and major in-hospital outcomes.

Methods

All STEMI patients included in the AMIS Plus Registry from January 1997 to December 2017 were included and patient-related delay was assessed: 27 231 patients were available for the final analysis. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or >12 hours, respectively).

Results

22 928 patients were earlycomers (84%) and 4303 patients were classified as latecomers (16%). Across the study period we observed a significant decrease in prevalence of late presentation from 22% to 12.3% (p<0.001, Figure 1). In latecomer STEMI patients there was a gradual uptake of evidence-based pharmacological treatments with an increase in discharge prescription of P2Y12 inhibitors from 6% to 90.7% (p<0.001). Similarly, a marked increase in percutaneous coronary intervention (PCI) rate was observed (12.1–86.6%; p<0.001). Across this 20-year period, in-hospital mortality was reduced to a third (to an absolute rate of 4.5%, p<0.001) and a significant reduction in prevalence of both cardiogenic shock (14.6–4.3%) and re-infarction (5.4–0.2%) during the index hospitalisation was observed (p<0.001 for both variables). Length of hospitalisation in acute care facilities significantly decreased from 10 (6,14) days to 4 (1,7) days (p<0.001). At multivariate analysis, PCI had a strong independent protective effect toward in-hospital mortality (odds ratio 0.3, 95% confidence interval 0.187 to 0.480).

Figure 1

Conclusion

The present study provides a comprehensive picture of temporal trends in late presentation in STEMI over the last 20 years in Switzerland. During the study period in latecomer STEMI population there was a gradual uptake of evidence-based pharmacological treatments and a marked increase in PCI rate. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%) and this reduction seems to be mainly associated with the increasing implementation of PCI.
479Preoperative global longitudinal strain is the best predictor of mortality following transcatheter aortic valve replacement
Authors: Povlsen J A , Rasmussen V G , Vase H , Jensen K T , Terkelsen C J , Christiansen E H , Mathiassen O N , Poulsen S H
Published: October 2019

Background

Prognosis after transcatheter aortic valve replacement (TAVR) is variable. This might depend on preoperative evaluation of myocardial performance by other measurements than ejection fraction (EF).

Purpose

The aim of this study was to investigate the predictive value of preoperative global longitudinal strain (GLS) and the guidelines specified subtypes of aortic stenosis (AS) on mortality following TAVR.

Methods

We included 511 patients with severe AS who underwent TAVR in the period July 2012–June 2017.

Patients were divided into guidelines-specified subgroups based on EF (EF: ≥50 (NEF) or <50% (LEF)), peak gradient (PG: ≥4 (HG) or <4 m/s (LG)) and flow status (stroke volume index (SVI): ≥35 (NF) or <35 ml/min/kg (LF)): (1) HG-NEF (n=228), (2) HG-LEF (n=91), (3) LG-LF-NEF (n=71) and (4) LG-LF-LEF (n=121). We also investigated the effect of replacing EF by GLS in the guideline specified subgroups (GLS ≤−14 (HGLS) and GLS >−14% (LGLS)).

Results

Mean follow up time was 1033 days. Mean age was 80.2±7.1 years. Median overall survival was 5.3±0.3 years. Comorbidity burden was higher in patients with LF – and LEF status in terms of a higher median plasma creatinine (103 [85; 135], p<0.001) and EurologII score (6.1 [3.4; 9.6], p<0.001).

LG-LF-LEF AS was associated with a significantly worse outcome compared with all other groups (p<0.005, Fig. 1A). High gradient status, irrespective of EF (p=0.88), was associated with the best prognosis with a median survival of 5.0±0.5 and 5.5±0.1 years for NEF and LEF, respectively.

Overall and in patients with HG-NEF, impaired GLS (>−14%) was associated with poor outcome (Fig. 1B–D). There was a trend towards a poorer prognosis with GLS >−14% in LG-LF-NEF AS (p=0.10).

In an univariate analysis impaired GLS >−14% (HR 2.04, p<0.005), LG-LF-LEF status (HR 1.82, p=0.001), PG <4m/s (HR 1.74, p=0.001) and tricuspid regurgitation gradient >30 mmHg (HR 1.63, p<0.001) were significant predictors of mortality in contrast to EF, SVI, age, gender and plasma creatinine.

GLS >−14% emerged as the only significant outcome predictor in a multivariate analysis (HR 1.93, p<0.05).

Figure 1

Conclusion

Impaired global longitudinal strain >−14% was the best individual echocardiographic predictor of overall survival in symptomatic severe AS and could identify a subgroup of patients with HG-NEF AS with a worse prognosis.
P303Prognostic value of diastolic wall strain in patients with asymptomatic severe aortic stenosis
Authors: Suwa Y , Miyasaka Y , Taniguchi N , Harada S , Shiojima I
Published: October 2019

Background

Diastolic wall strain (DWS) has been reported to be associated with left ventricular (LV) stiffness and worse clinical outcomes. We sought to assess the utility of this new index for prediction of prognosis in asymptomatic patients with severe aortic stenosis (AS).

Methods

Asymptomatic severe AS patients [peak flow velocity (PFV) ≥4.0m/s, mean pressure gradient (mPG) ≥40mmHg, aortic valve area (AVA) ≤1.0cm2, or indexed AVA ≤0.6cm2/m2)] diagnosed between July 2007 and April 2016 were included in this study. Patients with significant mitral valve disease, posterior wall motion abnormality, prior cardiac surgery, hypertrophic cardiomyopathy, and LV ejection fraction <50% were excluded. DWS was calculated with a validated formula [DWS = (posterior wall thickness at end-systole − posterior wall thickness at end-diastole)/posterior wall thickness at end-systole]. All study patients were prospectively followed up to last visit or death until November 2017, and predictive value of all-cause death was assessed using Cox-proportional hazards modeling. Patients who underwent aortic valve replacement (AVR) during the study period were censored on the date of surgery.

Results

A total of 184 asymptomatic severe AS, 138 (age 76±9year-old, men 41%, PFV 3.9±1.0m/s, mPG 38±19mmHg, AVA 0.83±0.18cm2, indexed AVA 0.56±0.13cm2/m2) met all study criteria. Of whom, 43 (31%) underwent AVR and 28 (20%) died during a mean follow-up of 25±28months. In a multivariable model after adjusting for clinical and echocardiographic variables, advancing age (per10yrs; HR=2.19, 95% CI=1.19–4.03, P<0.05), history of hemodialysis (HR=4.31, 95% CI=1.30–14.35, P<0.05), and low-DWS (DWS <0.30) (HR=2.83, 95% CI=1.25–6.40, P<0.05) were independent predictors of all-cause death. In the Kaplan-Meier estimates of cumulative survival stratified by DWS status were shown (Figure).

The Kaplan-Meier estimates of survival

Conclusion

Low-DWS provides prognostic information in patients with asymptomatic severe AS.
P309R' wave in precordial leads V1-V2 in patients from the young SCD-SOS cohort
Authors: Carrington M , Creta A , Santos R , Teixeira R , Goncalves L , Providencia R
Published: October 2019

Introduction

Sudden Cardiac Death – Screening Of risk factorS (SCD-SOS) survey aimed to screen for warning signs of potential channelopathies and cardiomyopathies that may course with sudden cardiac death in the young (≤40 years old) and consisted in an ECG and a digital-based previously validated questionnaire.

Purpose

We aimed to study clinical and electrocardiographic characteristics of young patients from the SCD-SOS cohort who presented with an r'-wave in precordial leads V1 and V2.

Methods

All the ECG were screened for the detection of an r'-wave in precordial leads V1 and V2. The ECGs selected were reviewed by a second investigator (agreed in 97.7% of the cases). We performed classical descriptive statistics and multivariate logistic regression to compare patients with and without r'-wave in these leads.

Results

From a total of 14669 patients who had an ECG performed as part of the SCD-SOS survey, 17% displayed an r'-wave in precordial leads V1 and V2 and 0.4% had complete right bundle branch block (RBBB). Patients with rSr' pattern had a mean age of 20±5 years old, 54% of them were male, they had a mean body mass index (BMI) of 22±3kg/m2, and 54% practiced sports regularly, with a mean of 5±4 hours of physical activity per week. Regarding previous symptoms reported by these individuals, 24% (n=487) reported a transient loss of consciousness, 15% (n=310) a reflex syncope, 3% (n=58) had unexplained syncope and 21% (n=425) palpitations. Sudden death in relatives before 50 years-old was present in 11% (n=172) of the patients with an r'-wave in V1-V2. After adjusting for heart rate and physical activity, PQ interval (OR 1.007 - CI95% 1.004–1.010, p<0.001), QTc interval (OR 1.009 - CI95% 1.005–1.012, p<0.001), male gender (OR 2.438 - CI95% 2.144–2.772, p<0.001) and BMI (OR 0.881 - CI95% 0.864–0.900, p<0.001) were independently associated with the presence of r'wave in precordial leads V1-V2. Unexplained syncope, palpitations and family history of sudden death were not associated with r'-wave in the young SCD-SOS population.

Conclusions

We conclude that r'-wave in V1-V2 is a frequent finding in the young population and that it is associated with higher PQ and QTc intervals. The prognostic implications of this pattern are unknown, but thorough differential diagnosis is warranted since this pattern may correspond to incomplete RBBB/athlete's ECG, and may also be suggestive of other potentially serious conditions such as Type 2 Brugada pattern and multiple causes of right ventricular enlargement. Finally, this pattern is also associated with male gender and lower BMI, suggesting a dependence on anatomical factors.
P324Impact of impaired right ventricular strain on the prognosis of HFpEF
Authors: Lejeune S , Roy C , Slimani A , Amzulescu M , Pasquet A , Vancraeynest D , Beauloye C , Vanoverschelde J L , Gerber B , Pouleur A C
Published: October 2019

Background

Right ventricle (RV) strain has emerged as an accurate and sensitive tool for RV function assessment and is a powerful predictor of survival in heart failure with reduced ejection fraction. The impact of impaired RV strain on prognosis of HFpEF patients however, remains unclear.

Purpose

We sought to analyze RV global longitudinal strain (RV-GLS) by 2D speckle tracking echocardiography (STE) in controls and HFpEF patients and determine its prognostic value.

Methods

Between January 2015 and June 2017, we prospectively enrolled 163 consecutive patients with HFpEF (78±9 years, 62% women) and 27 age and sex matched controls (76±5 years, 67% women). All patients underwent complete 2D echography. Myocardial deformation was assessed on a dedicated four chambers view, with a speckle tracking software. Due to poor tracking quality, RV-GLS could not be analyzed in 14 patients (7.4%). Impaired RV-GLS was defined as a GLS above −17.5% corresponding to the mean + 2 SD of age and sex matched controls. HFpEF patients were followed up for a combined outcome of all-cause mortality and first HF hospitalization.

Results

Mean RV-GLS was significantly altered in HFpEF patients compared to controls (−21.7±4.9% vs −25.9±4.2%; p<0.001). 28 HFpEF patients (19%) had an impaired RV-GLS.

During a mean follow-up of 19±9months, 73 HFpEF patients (49%) reached the combined outcome (15 all cause deaths and 58 first HF hospitalization). In univariate Cox regression analysis, loop diuretic medication (HR 1.92 [1.10–3.32], p=0.021), low hemoglobin (HR 0.85 [0.75–0.97], p=0.013), low eGFR (HR 0.97 [0.96–0.99], p<0.001), E wave velocity (HR 1.01 [1.00–1.02], p<0.001), septal E/e' (HR 1.03 [1.00–1.05], p=0.011) and impaired RV-GLS (HR 2.01 [1.19–3.40], p=0.009) were significantly associated with worse prognosis.

In multivariate Cox analysis, hemoglobin levels (HR 0.83 [0.72–0.96], p=0.01), eGFR (HR 0.98 [0.97–0.99]; p=0.009) and impaired RV-GLS (HR 2.48 [1.38–4.44], p=0.002), were independent predictors of the combined outcome. Kaplan-Meier event free survival curves show that HFpEF patients with RV-GLS above −17.5% had worse prognosis than those with better myocardial deformation (p=0.009, Figure).

Conclusions

RV-GLS is significantly different between controls and HFpEF patients. In HFpEF, impaired RV-GLS is associated with worse prognosis.
P334Prospective FU in various subtypes of cardiomyopathies: insights from the EORP Cardiomyopathy Registry of the ESC
Authors: Gimeno Blanes J R , Elliott P M , Tavazzi L , Tendera M , Kaski J P , Laroche C , Maggioni A , Caforio A , Charron P H
Published: October 2019

Background

The EORP Cardiomyopathy Registry is a prospective, observational, multinational registry of consecutive patients with cardiomyopathies. The objective of this report is to describe the outcomes at one year of follow-up of adult patients (>18 years old) enrolled in the registry.

Methods

A total of 3,208 patients (median age: 55.0 (43.0; 64.0) years, males: 65.1%) were recruited at baseline. Follow-up data at 1 year were obtained in 2,713 patients (84.6%), including 1,420 with hypertrophic (HCM), 1,105 dilated (DCM), 128 arrhythmogenic right ventricular (ARVC) and 60 restrictive cardiomyopathy (RCM).

Results

Improvement of symptoms (NYHA, chest pain, syncope) was globally observed over time (p<0.001 for each). Additional invasive therapeutics were performed during follow-up: implantation of ICD (primary prevention) (N=109 patients, 5.2%), pacemaker (N=28, 1.2%), heart transplant (N=30, 1,1%), ablation for atrial or ventricular arrhythmia (0.5% & 0.1%). The proportion of patients with history of AF increased from baseline to FU in 3.6% (from 28.2% to 31.8%). ICD therapy at 1 year was delivered more frequently in ARVC then in DCM, HCM and RCM (11.4%, 9.0%; 8.1%, 0% respectively for primary prevention). Major cardiovascular events (MACE) occurred in 29.3% of RCM, 10.5% of DCM, 7.9% of ARVC and 5.3% of HCM. MACE were globally higher in index patients compared to relatives (10.8% vs 4.4%, p<0.001).

When considering geographical areas, MACE were higher in East Europe (13.1%) and lower in South Europe (5.3%) (univariate); heart transplant was higher in West Europe (2.40%) and lower in South Europe (0.25%) (univariate).

Conclusions

Despite symptomatic improvement in most cases, there is still a significant burden of arrhythmic and heart failure events in patients with cardiomyopathies. Outcomes were different not only according to cardiomyopathy subtypes but also in relatives versus index patients.

Acknowledgement/Funding

None
P576The first handheld device for autonomic self-detection of symptomatic acute coronary artery occlusion: feasibility, performance and implications for time-efficient self-triage of outpatients with CAD
Authors: Van Heuverswyn F , De Buyzere M , Coeman M , De Pooter J , Drieghe B , Duytschaever M , Gevaert S , Kayaert P , Vandekerckhove Y , Voet J , El Haddad M , Gheeraert P
Published: October 2019

Background

Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion (ACAO). Response time might be reduced by reliable self-detection of ACAO. Currently no self-applicable device can accurately detect ACAO. We have recently shown that an automatic algorithm based upon a three lead system (RELF method) accurately detects ACAO.

Purpose

In this multicenter observational study we tested the operational feasibility, sensitivity and specificity of our RELF method, built into a mobile handheld device, for detection of ACAO.

Methods

Patients with planned elective percutaneous coronary intervention (PCI), who were able to use a smartphone, were asked to perform random ambulatory self-recordings for at least one week. A similar self-recording was made before angioplasty and at 60 s of balloon occlusion.

Results

The operational feasibility of ambulatory self-recordings in enrolled patients with CAD was 59/64 (92.1%, 95% CI: 83.0–96.6). Of all self-recordings 91.1% (n=4567) were automatically classified as successful within one minute. The mean false positive rate during daily life conditions was 4.19% (95% CI: 3.29–5.10). Amongst 65 balloon occlusions, 63 index-tests at 60 s of occlusion were available. The sensitivity for the target conditions “ACAO”, “ACAO with ECG changes” and “ACAO with ECG changes and ST segment elevation myocardial infarction (STEMI) criteria” was respectively 55/63 (0.87; 95% CI: 0.77–0.93), 54/57 (0.95; 95% CI: 0.86–0.98) and 35/35 (1.00). The figure depicts all (n=3936) ST difference vector (STDVn) measurements obtained during ambulatory postural changes, exercise and coronary artery occlusion with and without ECG changes and/or STEMI criteria. Receiver Operator Curve (ROC) for ACAO at different cut-off values of the magnitude of STDVn was 0.973 (95% CI: 0.956–0.990).

Boxplots of all STDVn test recordings

Conclusions

Self-recording with our RELF device is feasible for the majority of patients with CAD. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase survival without overloading emergency services. This is the first clinical study that confirms the proof-of-concept of self-detection of acute coronary artery occlusion in outpatients with CAD.

Acknowledgement/Funding

Ghent University, Industrial Research Fund (IOF reference: F2015/IOF-advanced/084).
P580Performance evaluation of dual vs. single lead automatic, real-world arrhythmic ECG recordings
Authors: Olsson A , Samuelsson M
Published: October 2019

Background

Detection of treatment-demanding paroxysmal arrhythmias can be difficult. Use of single lead ECG recordings for detection of Atrial Fibrillation (AF) has shown to lead to high false positive discovery rates, and requirements of additional manual clinical interpretation or 12-lead ECG to reach satisfactory diagnostic precision. Use of sequential, dual-lead ECG recordings for detection of AF has indicated significant clinical improvement in detection yield of AF and reduction of false positive discovery rates as compared to single lead-ECG.

Methods

The Coala Heart Monitor (Coala Life AB, Stockholm Sweden) system was evaluated by manual interpretation of 1,000 consecutive anonymous printouts of chest- and thumb-ECG waveforms, without any exclusion. The anonymized printouts contained three 10 s. strips of ECG at 25 mm/s, including mean heart rate, RR median and any user-provided annotation but with personal identification and algorithm analysis results blinded. The recordings were derived from actual Coala users with no training, control or influence, under a defined time period. The prevalence of cardiac conditions in the user population was unknown.

The blinded recordings were manually interpreted by a trained cardiologist. The interpretation was compared with the automatic analysis performed by an enhanced algorithm in the Coala Cloud to evaluate ECG signal performance and to calculate performance metrics of a combination of sequential dual chest- and thumb-ECG measurements as compared to the clinical performance metrics of singe lead ECG measurements only.

Results Metric Result using dual chest- and thumb-ECG and P-wave detection algorithm Result based on single lead thumb-ECG only Prevalence of AF in the recordings 14.4% (143 of 990 recordings) 14.4% (143 of 990 recordings) Percentage of recordings with ECG quality good enough to permit manual interpretation. 99,2% (8 of 998 non-readable) 98,7% (13 of 998 non-readable) Negative predictive value (NPV) for detecting AF 0.992 0.995 Positive predictive value (PPV) for detecting AF 0.872 0.647 False positive discovery rate 12.8% 35,3% Sensitivity for detecting AF 0.951 0.972 Specificity for detecting AF 0.976 0.909 Accuracy 0.973 0.919

Conclusion

Based on 1,000 real-world recordings the combination of dual chest- and thumb-ECG with P-wave detection yielded significantly higher Positive Predictive Values as compared to single lead ECG measurements. Dual chest- and thumb-ECG reduced false positive AF indications from 35,3% for single lead-ECG to 12,8% using combined chest- and thumb-ECG with P-wave detection.