bluuebunny/crossref_metadata_2025_split huggingface dataset:
P5017Factors associated with a negative D-dimer test in patients diagnosed with acute symptomatic pulmonary embolism
Authors: Barco S , Russo M , Klok F A , Konstantinides S V 
Published: October 2019

Abstract

Background
The recommended diagnostic strategy for suspected acute pulmonary embolism (PE) combines the assessment of pre-test probability, D-dimer level, and -if indicated- computed tomography pulmonary angiography.

Purpose
To evaluate the frequency and potential explanations for negative D-dimer tests in patients diagnosed with acute PE.

Methods
The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. The items of the Simplified revised Geneva Score and the D-dimer levels at diagnosis have been prospectively collected, but they did not necessarily guide management decisions. Quantitative D-dimer was measured on admission either by quantitative latex-based assays or enzyme-linked immunosorbent assays. A negative D-dimer was defined by fixed (0.50 μg/mL) or age-adjusted (age*0.01 μg/mL if age>50) cut-off.

Results
Using the fixed cut-off, a negative D-Dimer was detected in 17 of 773 patients with ultimately diagnosed PE (miss rate 2.2% [95% CI 1.4–3.5]); using the age-adjusted cut-off, the test was discordant with the PE diagnosis in 24 patients (3.1% [2.1–4.6]). In Figure 1, red dots indicate negative D-dimer test by fixed cut-off and blue dots indicate additional negative D-dimer tests by age-adjusted cut-off.
In 448 (59%) patients post-hoc classified as PE-unlikely, 11 (2.5% [1.4–4.3]) and 14 (3.1% [1.9–5.2]) patients had a negative D-dimer using the two different cut-offs, respectively. Haemoptysis on admission, V/Q scan-based diagnosis, and chronic lung disease were associated with a discordant D-dimer, while an inverse association existed for concomitant DVT. In 7 (29%) PE cases with normal D-dimer, PE was verified to be subsegmental also in a post-hoc evaluation. Another seven (29%) patients were receiving anticoagulation at the time of D-dimer assessment.
Figure 1

Conclusions
Our results show that the frequency of discordance between a normal D-dimer test and the diagnosis of acute PE is low, but not negligible. One third of discordant findings were related to subsegmental PE. Physicians should be aware that the risk of obtaining a false-negative D-dimer might be higher in specific subgroups of patients.

Acknowledgement/Funding
The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG
P5020Modified CT-based Bova score may improve the classification of patients with acute pulmonary embolism at risk of adverse events
Authors: Skowronska M Z , Karolak B , Ciurzynski M , Machowski M , Paczynska M , Pacho S , Wyzgal-Chojecka A , Roik M , Kostrubiec M , Kurnicka K , Wisniewska M , Pruszczyk P 
Published: October 2019

Abstract

Background
Whether the Bova score with right ventricle dysfunction (RVD) assessed is computed tomography (CT) may be used for prognosticating adverse events (AE) in normotensive patients with acute pulmonary embolism (PE) is not fully determined.

Aim
To determine: (1)the optimal cut-off for RVD in CT for AE;(2)whether CT-assessed RVD may accurately substitute TTE-assessed RVD and improve the Bova score for risk assessment in PE.

Methods
Post-hoc analysis of a prospective study of 171 consecutive normotensive pts (93F, mean age 64.7 y.o. ±19) with at least segmental APE confirmed in CT. BP, HR, hsTnT and TTE for RVD were assessed within the first 24-hours from admission. CT-RVD was measured from a diagnostic angio-CT using the RV/LV transverse-axis diameter ratio. The Bova score was calculated from patient records. The combined endpoint (PCE) included PE-related death and/or hemodynamic deterioration requiring catecholamines i.v., rescue thrombolysis, cardio-pulmonary resuscitation; the secondary combined endpoint (SCE) included PE and non-PE events as above and hemorrhagic events. Proposed CT-RVD cut-offs and subsequent CT-based Bova vs TTE-based scores were compared using AUROCs and net reclassification improvements (NRI).

Results
70 (41%) low-risk patients and 101 (59%) intermediate-risk pts classified according to the ESC algorithm. The PCE occurred in 5 pts, the SCE in 23 pts. TTE-Bova showed AUROC=0.918 (0.806–1.0; p=0.000) for the PCE, and 0.623 (0.545–0.696; p=0.000) for the SCE. The NRIs for the investigated cut-offs for CT-Bova vs TTE-Bova for the PCE are presented in the Table. AUROCs for SCE for CT-Bova vs TTE-Bova are presented in the Figure.
Comparison of CT-Bova and TTE-Bova NRIs for CT-Bova vs TTE-Bova for primary endpoint CT-Bova AUROC (95% CI) RV/LV cut-off No of points NRI (SE) p >0.9 2 0.02 (0.03) 0.58 – >1.0 2 0.17 (0.04) 0.00 0.948 (0.903–0.976)* >1.1 2 0.06 (0.20) 0.75 – when >1.0 and >1.2 1; 2 0.20 (0.04) 0.00 0.927 (0.877–0.961)* AUROC for TTE-Bova 0.918 (0.806–1). AUROC, area under the receiver-operator curve; NRI, net reclassification improvement; SE, standard error. *Denotes no significant differences in AUROCs for CT-based Bova with investigated cut-offs.
AUROC for CT-Bova RV/LV>1.0 and TTE-Bova

Conclusion
CT-based Bova with RV/LV>1.0 for RVD is non-inferior to TTE-based score in the prediction of PE-related in-hospital adverse events in normotensive patients and might improve the stratification of the occurrence of any adverse event. A modified score with a two-step cut-off for RV/LV (1 point for >1.0 and 2 points for >1.2) may more accurately predict PE-related events.
P5237Continued financial benefits of LATIN telemedicine program from avoiding unnecessary transfer of patients
Authors: Mehta S , Botelho R , Niklitschek S , Fernandez F , Cade J , Cavalcanti R , Dusilek C , Estrada A , Lacativa M A , Cardoso R , Frauenfelder A , Matheus C , Vieira D , Torres M A , Vallenilla I 
Published: October 2019

Abstract

Background
Latin America Telemedicine Infarct Network (LATIN) employed telemedicine to construct a population-based AMI program in Brazil, Colombia, Mexico, and Argentina. It increased access, accuracy and guidelines-based care and addressed fiscal issues. Previously, we demonstrated a cost and benefit analysis (CBA) of LATIN based upon avoiding unnecessary transfers and hospitalization. We have performed a scrupulous follow up of this initial observation with a long-term follow up from all expanded LATIN sites.

Purpose
To demonstrate that telemedicine avoids unnecessary transfer of patients.

Methods
784,947 patients at LATIN spokes (small clinics in remote areas) were screened and CBA measured at hubs, spokes and telemedicine centers. Technology, transfer, inpatient, and procedure-related costs were included. A sensitivity analysis was performed for worst and best scenarios of costs, revenues, and savings. A comparison with Avera e-Emergency (Sioux Falls, SD) Telemedicine program, involving 85 rural hospitals in 7 states, is provided (13% transfer avoidance).

Results
Of 784,947 screened patients, 8,448 had STEMI (1.08%); 3,911 (46.3%) were urgently reperfused, 3,049 (78%) with PPCI. Time to Telemedicine Diagnosis was 3 min. With efficient triage, costs for non-AMI patients was controlled. LATIN expenses, including for IT and experts, were $272, and for transfer and indirect care, $1,068. Net savings/patient were $796. Savings, till date, range between $187.4 million and $62.4 million (Best scenario −30% transfer avoidance; Worse scenario −10% transfer avoidance).

Conclusions
Longitudinal analysis firms the trend of enormous cost savings with LATIN. Telemedicine avoids unnecessary transfers and hospitalization and it is a cost-effective strategy for population-based AMI programs.
P5240The cost of pacemaker complications
Authors: Brough C 
Published: October 2019

Abstract

Background
The implantation rate of de novo pacemakers across ESC member countries continues to increase (21,595 per million in 2007 to 28,413 per million in 2016), with an anticipated growth in revision procedures. Revision procedures have a higher rate of complications than de novo implants, all with an associated cost which is infrequently reported in literature.

Purpose
We report the complications/re-operations of standard pacemaker procedures and patient morbidity to 1 year, with all complications micro-costed.

Methods
A retrospective cohort analysis of all pacemaker procedures at a single UK centre was conducted between April 2008–2016. Complications/ re-operations were defined as; 1. Any pneumothorax, 2. Pericardial effusion on transthoracic echocardiogram performed due to clinical concern, 3. Haematoma requiring surgical evacuation, 4. Lead intervention, 5. Device reburial, 6. System explant 7. System re-implant and 8. System upgrade.

Results
6,408 pacemaker procedures were performed; 1,261 single chamber (66.5% primary implant, 27.8% generator replacement, 2.0% lead revision, 1.7% generator and lead, 1.9% reburial); 3,465 dual chamber (61.8% primary implant, 29.7% generator replacement, 3.0% lead revision, 3.3% generator and lead, 0.5% upgrade, 1.7% reburial) and 1,682 CRTP (66.7% primary implant, 8.1% generator replacement, 5.2% lead revision, 1.2% generator and lead, 17.1% upgrade, 1.7% reburial). Table 1 demonstrates the rate of complications according to index procedure and 12 month morbidity.
The total cost of rectifying complications was €1,280,285; primary implants €454,860, generator replacements €298,394, system reburials €217,785, lead revisions €61,818, upgrades €99,140 and generator and lead procedures €148,288.
Table 1. Complication and Re-Operation Rates According to Index Procedure and 12 Month Morbidity Index Procedure 12 Month Morbidity Complication/ Re-operation rate (%) (%) Single chamber Dual chamber CRTP Single chamber Dual chamber CRTP Primary 1.8 3.9 4.8 2.5 5.0 5.1 Generator replacement 2.8 3.2 5.9 3.1 3.9 5.9 Generator and lead 18.2 13.0 14.3 22.7 13.9 14.3 Upgrade – 11.1 7.6 – 11.1 8.0 Lead only 4.0 11.7 9.2 4.0 14.6 9.2 Reburial 16.7 16.9 32.1 16.7 18.6 32.1

Conclusion
Complication and re-operation rates are dependent upon the procedure performed and the complexity of device. Expenditure on rectifying complications is significant (€2,560,570 over 8 years).
P5252Can functional MR imaging supersede angiography? An audit of stress cardiac MRI outcomes compared those seen in the CE-MARC trials
Authors: Brown A , Thomas H , Matthews I , Runnett C , Lee A , Ripley D 
Published: October 2019

Abstract

Background
Recent studies have compared the performance of cardiac MRI (CMR) with coronary angiography. The CE-MARC trial established CMR's high diagnostic accuracy for coronary artery disease (CAD). Following these results, and those of CE-MARC 2, which showed reduced unnecessary angiography rates with CMR-guided care, we increased our adoption of CMR as an investigation of choice for CAD at our centre.

Purpose
In patients who have a CMR for stable angina, what is the outcome after detection of CAD, how do findings compare with angiography, and do those without CAD identified go on to have a major adverse cardiovascular event (MACE)?

Method
We performed a retrospective audit of all stress CMR performed from August 2016 to March 2017 at our hospital in North England. All patients were followed up for a minimum of 12 months.
NICE guideline care was used during the study period. The CE-MARC trial was used for quality standards and to compare results.

Results
91 stress CMRs were performed. 13 were excluded as they were performed on out-of-area patients. Median follow up was 14.5 months.
Of the remaining 78 patients, 34 (43%) had a positive CMR. 20/34 (59%) proceeded to angiogram. In 16/20 of patients, CMR findings correlated with angiogram findings. A PPV of 80%. The PPV in CE-MARC was 77.2% (72.1–81.6).
Of those who did not proceed to angiography, 8/14 had non-viable myocardium, 3 continued with medical management, in two it was unclear. 3/34 (8.8%) with positive CMR had a MACE.
44 patients had a negative CMR. Three had an angiogram during follow up. All were negative. There was a MACE in 1/44 (2.3%).

Conclusion
The audit population has a similar PPV to that of CE-MARC.
MACE rates at 12 months were similar to CE-MARC which suggests that the trial results are reproducible in our setting. The wider use of CMR can therefore improve investigation and management for patients with stable angina.
The audit is limited by the small number of patients proceeding to angiogram and the ability to confirm negative CMR results.
P5255Culprit vessel related myocardial mechanics and prognostic implications following acute myocardial infarction
Authors: Backhaus S J , Kowallick J T , Stiermaier T , Lange T , Koschalka A , Navarra J L , Lotz J , Kutty S , Bigalke B , Gutberlet M , Feistritzer H J , Hasenfuss G , Thiele H , Eitel I , Schuster A 
Published: October 2019

Abstract

Background
Prognosis in acute myocardial infarction (AMI) depends on the amount of infarct related artery (IRA) subtended myocardium and associated damage but has not been described in great detail. Consequently, we sought to describe IRA associated pathophysiological consequences using cardiac magnetic resonance (CMR).

Methods
1235 AMI patients (n=795 ST-elevation (STEMI) and 440 non-STEMI) underwent CMR following percutaneous coronary intervention. Blinded core-laboratory data were compared according to left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA) regarding major adverse clinical events (MACE) within 12 months. Left ventricular (LV) global longitudinal/circumferential/radial (GLS/GCS/GRS) as well as left atrial (LA) total (εs), passive (εe) and active (εa) strains were determined using CMR-feature tracking. Tissue characterisation included infarct size (IS) and microvascular obstruction.

Results
LAD and LCx were associated with higher mortality compared to RCA lesions (4.6% and 4.4% vs 1.6%). LAD lesions showed largest IS (16.8%), largest ventricular (LV ejection fraction (EF) 47.4%, GLS −13.2%, GCS −20.8%) and atrial (εs 20.2%) impairment. There was less impairment in LCx (IS 11.8%, LVEF 50.8%, GLS −17.4%, GCS −25.0%, εs 20.7%) followed by RCA lesions (IS 11.3%, LVEF 50.8%, GLS −19.1%, GCS −26.6%, εs 21.7%). In AUC analyses εs (LAD, RCA) and GLS (LCx) best predicted MACE (AUC>0.69). Multivariate analyses identified εs (p=0.017) in LAD and GLS (p=0.034) in LCx infarcts as independent predictors of MACE.

Conclusions
CMR allows IRA specific phenotyping and characterisation of morphologic and functional changes. These alterations carry infarct specific prognostic implications and may represent novel diagnostic and therapeutic targets following AMI.

Acknowledgement/Funding
DZHK - German Centre for Cardiovascular Research
P5257Prediction of 12-month cardiovascular event-free survival with regadenoson perfusion cardiovascular magnetic resonance
Authors: Weiss H , Behm P , Gastl M , Kelm M , Boenner F 
Published: October 2019

Abstract

Background
To identify and stratify coronary artery disease (CAD) non-invasively, cardiovascular magnetic resonance (CMR) derived perfusion imaging holds a class Ia recommendation.
As Gold standard, hyperemia is induced by an intravenous application of adenosine in a body weight adapted dosage over a constant time. However, adenosin has two disadvantages: 1.) efficacy of adenosine to induce maximal hyperemia via peripheral line is imperfect and 2.) additional adenosine specific effects exclude patients having comorbidities (e.g. AV-blocks and obstructive lung disease). Fortunately, regadenoson as aselective A2A-receptor agonist has the main advantages of being easier to handle (bolus application) and to be not restricted to patients without specific comorbidities. However, there is a lack of comprehensive data on the prognostic value of regadenoson perfusion CMR to predict clinical endpoints. To assess the predictive value of regadenoson perfusion CMR, our hypothesis was, that a “negative” ischemia test result by regadenoson-CMR predicted freedom from MACE at 12 month.

Methods
676 patients, with known or suspected CAD with intermediate risk were retrospectively analyzed from May 2015 till December 2016. Cardiovascular risk factors (CVRF) like age, sex, arterial hypertension, dis-/hyperlipidemia, cigarette smoking status and diabetes were documented. All included patients received perfusion CMR (Philips 1.5 Tesla) with regadenoson (0.4 mg) and a positive ischemia test was defined as perfusion defects in ≥1,5 cardiac segments (using the 17-segment model). Major cardiovascular events (MACE) were defined as cardiovascular death, rehospitalisation due to myocardial infarction and rehospitalisation due to revascularization. The follow-up time was 12 month.

Results
80,3% (n=543) of all analyzed patients showed negative ischemia testing in CMR and were thus followed up for 12 month. From these patients, 284 (52,3%) had a pre-existing coronary artery disease. The mean age regarding only the patients with negative ischemia was 66 years (65% male and 35% female) with 1,35±1,03 CVRF. The primary endpoint (MACE) occurred in 6 patients (1,1%): 3 (0,6%) died due to cardiovascular events, 1 (0,2%) suffered from a myocardial infarction and 2 (0,4%) received coronary revascularization. Consequently, an event-free survival was correctly predicted in 98,9% of all patients. No undesirable adverse reactions have appeared.

Conclusion
Regadenoson-CMR predicts a very low MACE-rate and an event-free survival in 98,9% in over 500 patients. In our study, Regadenoson was well tolerated and no side effects were reported.
P5270Impaired myocardial deformation assessed by cardiac magnetic resonance is associated with increased arrhythmic risk in hypertrophic cardiomyopathy
Authors: Barbosa A R , O'neill C M , Ruivo C , Cruz I , Sousa O , Dias Ferreira N , Braga P , Rocha Lopes L 
Published: October 2019

Abstract

Background
Strain techniques, such as feature tracking cardiac magnetic resonance (FT-CMR), have emerged as a promise for more accurate evaluation of cardiac function compared to ejection fraction. In hypertrophic cardiomyopathy (HCM) patients, impaired myocardial deformation measured by FT-CMR has been associated with severity of hypertrophy and presence of late gadolinium enhancement (LGE) but associations with clinical severity and prognosis are scarce.

Purpose
To analyse the association between left ventricular strain measured by FT-CMR, morphologic features and prognostic markers in patients with HCM.

Methods
Retrospective analysis of clinical, echocardiography, Holter and CMR data of HCM patients aged ≥16 years followed at two referral centres. Ventricular arrhythmias (VA) were defined as non-sustained or sustained ventricular tachycardia or sudden cardiac arrest. Sudden cardiac death (SCD) risk was evaluated using the score proposed by the European Society of Cardiology. LGE extension was evaluated using the American Heart Association 17-segment model. FT-CMR was used to evaluate global peak systolic longitudinal (GLS), radial (GRS) and circumferential (GCS) strains - GLS was averaged from three standard longitudinal views while GRS and GCS were averaged from the basal, mid and apical LV short-axis planes.

Results
A total of 109 HCM patients (59.2±16.2 years old; 60.6% males) were included; mean follow-up was 39±25 months. Mean LV mass was 170.6±70.3g, LVEF was 63.7±10.0% and the number of segments with LGE was 3.14±3.32. Mean GLS, GRS and GCS were −14.8±4.0%, 34.4±13.3% and −17.5±4.8%, respectively. Impaired strain was associated with higher LV mass (GLS: r=0.46, GRS: r=−0.46, GCS: r=0.47, p<0.001 for all), reduced LVEF (GLS: r=−0,33, GRS: r=0,44, GCS: r=−0.41, p<0.003 for all) and LGE extension (GLS: r=0.26, GRS: r=−0.38, GCS: r=0.38, p<0.01 for all).
SCD risk score was 3.12%±2.98 (8 patients scored as high risk) and VA were documented in 26 patients (26%). Patients with VA had worse strain values than those without (GLS −13.2±4.12 vs −15.5±3.71, p=0.011; GCS −15,8±5.22 vs −18.3±4.24, p=0.017). Patients with high estimated risk of SCD also had worse strain values than those at low/intermediate risk (GLS −12.2±3.57 vs −15.1±3.83, p=0.048; GCS −14.5±4.26 vs −17.9±4.54, p=0.047). A correlation between SCD risk and GLS and GCS was observed (r=0.32, p=0.004; r=0.23, p=0.03, respectively).

Conclusions
In our population, worse strain measurements were associated with a more severe HCM phenotype, presence of VA and a higher estimated risk of SCD. Strain assessed by FT-CMR may improve risk stratification in HCM patients.
P5277Head to head comparison of MOLLI sequences against hs-troponin in patients with biopsy proven myocarditis
Authors: Vasquez M , Zainal H , Zhou H , Arcari L , Sokalskis V , Vasa-Nicotera M , Zeiher A , Nagel E , Puntmann V 
Published: October 2019

Abstract

Introduction
Increase in native T1 mapping values provides insight into presence of disease and its evolution. Despite the surge of evidence, the immediate clinical application of these techniques is complicated by several variants of T1 mapping sequences, whose diagnostic bioequivalence is not known.

Methods
We undertook an intra-individual comparison of two native T1 measurements based on modified Look-Locker (MOLLI) schemes, MOLLI 3(2)3(2)5 (flip angle, FA 50°, T1-FFM) and MOLLI 5(3)3 (FA 35°, T1 Long) in 30 patients with myocarditis proven by left ventricular endomyocardial biopsy. We examined their agreement with high-sensitive troponin T (hs-TnT) levels, as the reference standard for myocyte injury. All patients underwent a routine cardiovascular magnetic resonance (CMR) scan using a 3-Tesla clinical scanner. Native T1 values were estimated using a septal region of interest (ROI) in a single mid ventricular short axis (SAX) slice. Areas of late gadolinium enhancement (LGE) were excluded from ROIs. Venous blood was sampled at the time of the CMR study and hs-TnT analyzed using standardized commercially available test kits. A p value <0.05 was considered statistically significant.

Results
Native T1 by T1-FFM was moderately associated with MOLLI 5(3)3 (FA 35°) (Pearsons r=0.877, p<0.0001), however the Bland Altman analysis showed a poor agreement with a fixed bias of 46ms (p 0.001) and evidence of proportional bias (p 0.008). There was a significant correlation between native T1-FFM and hs-TnT (rho=0,500, p 0.018), whereas T1 Long showed no association (rho=0,374, p 0,086).

Conclusions
Although native T1 by T1 Long showed a moderate correlation with the native T1 FFM in patients with biopsy proven myocarditis, only T1 FFM had a significant correlation with hsTnT suggesting a greater sensitivity for myocardial injury.