Underlying causes of under-utilization of cardiac resynchronization therapy in real-world heart failure settings

Background

Despite well-established effectiveness of cardiac resynchronization therapy (CRT) in patients with heart failure (HF), it remained significantly under-utilized. The underlying causes are still not well described.

Aim

To investigate how many patients with HF were eligible for CRT and determine underlying causes why CRT was abstained for these patients in real life settings.

Methods

Retrospective review of medical data was carried out in all patients hospitalized for newly diagnosed HF from January 1, 2016 to December 31, 2019. Patients were identified from the local university hospital register with three afiliations by use of international classification of disease (ICD)-10 codes I50.0-I50.9. Medical journals, including electrocardiograms and echocardiograms, were reviewed. The indication for CRT was evaluated three months after mineralocorticoid receptor antagonists (MRA) were initiated as addition to angiotensin converting enzyme inhibitor /angiotensin-receptor blockers and beta-blocker treatment according to European guidelines for heart failure from 2016. Follow-up was minimum one year and up to two years after HF diagnosis.

Results

In 3456 patients with HF, 642 (18.6%) were patients hospitalized for new onset of HF with ejection fraction (EF) <40%. Out of those, 104 (16.2%) patients were excluded because of incomplete medical record as a result of referral to primary care. Finally, 538 were included in this study. Overall, 163 patients (30.3%) met CRT criteria with 22.5%, 2.6%, 1.9% complying with recommendation IA, IIA, IIB respectively, and 3.9% had more than 50% right ventricular pacing. Only 52 (9.7%) of patients received CRT with mean age 69.3±11.5 years, and 69.2% men and EF 31.9% ± 7.6. In all these patients with HF eligible for CRT, no difference was found in baseline data including hypertension, ischemic heart disease, atrial fibrillation, valvular heart disease, diabetes mellitus, stroke, cancer and renal failure nor medical treatment between those received CRT and those without CRT. Among underlying causes of under-utilization of CRT, 24.3% were due to multiple concomitant comorbidities, 4.5% due to patient's own wish, 12.5% due to other reasons such as socioeconomic problems and 58.6% with unknown reasons. Mortality rates were 20.7% in patients without treatment with CRT compared with 7.7% in those who received CRT (p=0.037).

Conclusion

In this real world HF cohort, 1/3 patients were eligible for CRT treatment. However only 1/3 received CRT and 58.6% had no contraindication but did not receive CRT, which emphasize urgent need for structured implementation methods for device treatment in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Heart failure in low risk patients with atrial fibrillation, nationwide registry case-control study based on 227811 patients

Background

Heart failure (HF) is common in patients with atrial fibrillation (AF), and also associated with worse outcome. Consequently, it is commonly included in risk prediction models for AF, used in daily clinical praxis. However, knowledge about the association between solely AF and incidental HF is limited.

Aim

This study aims to evaluate the short and long-term risks for onset of HF in patients with AF and low cardiovascular risk profile.

Methods

All patients with first recorded hospitalization for AF in the Swedish National Patient Register, were included from the 1St January 1987 to 31st December 2018. Each patient with AF was matched by age, sex and county with two controls from the Swedish Total Population Register. Patients <18 years, or with concomitant hypertension, diabetes mellitus, coronary and periphery artery disease, previous stroke or transitory ischemic attack, cardiomyopathy, pulmonary arterial hypertension, congenital heart disease, valvular heart disease and renal failure prior or at baseline were excluded.

Results

In total 227 811 patients and 452 712 controls met the inclusion and exclusion criteria and were included in the study. The incidence rate for incidental HF per 1000 person-year within one year after AF diagnosis was 6.2 (95% CI: 4.5–8.6) among patient 18–34, increased with increasing age and was 142.8 (95% CI: 139.4–146.3) among those >80 years. Within five years the incidence rate decreased in all age categories and was 2.4 (95% CI: 1.8–3.0) among the youngest and 94.0 (95% CI: 92.4–95.6) in the oldest age group. When compared to matched controls from the general population patients with AF had a hazard ratio (HR) and CI 95% to develop HF within one year at 103.9 (46.3–233.1), 34.9 (26.5–45.9), 17.5 (15.5–19.8), 10.3 (9.6–11.1) and 6.1 (5.8–6.4) among patients aged 18–34, 35–49, 50–59, 60–69, 70–79 and >80 years, respectively.

Conclusion

Despite low cardiovascular risk profile AF still carries high risk for developing incidental HF in particular during the first observation year with increasing tendency along with increasing age. Younger patients with AF and without other cardiovascular comorbidities had more than 100 times higher relative risk to develop HF within one year when compared to matched controls.

Funding Acknowledgement

Type of funding sources: None.

Hyperkalemia as a cause of undertreatment with mineralcorticoid receptor antagonists for patients with newly onset of heart failure with reduced ejection fraction

Background

Despite beneficial effects on mortality and morbidity the use of mineralocorticoid receptor antagonists (MRA) in patients with reduced ejection fraction (<40%) (HFrEF) remains poor. Hyperkalemia is assumed as an important cause, but the reported incidence is low and varies hugely. Thus, available data of magnitude of hyperkalemia in real life settings are insufficient to explain why under-utilization of MRA occurred.

Aim

To determine the incidence and magnitude of documented hyperkalemia and potential risk of hyperkalemia in patients with HFrEF in a real-world HF population.

Methods

Patients aged 18–85 years at the time of the baseline, hospitalized for newly onset of HFrEF between

2016–01–01 and 2019–12–31, were identified retrospectively and consecutively from hospital discharge records, by use of international classification of disease (ICD)-10 codes I50.0-I50.9 as principal diagnosis. Potential higher risk of hyperkalemia was based on an overall assessment of current potassium level, presence of diabetes mellitus and eGFR <30 ml/min at patient level.

Results

In total, 3456 patients with HF were identified, 642 (18.6%) were eligible, hospitalized for newly onset of HFrEF (66.8±12.7 years, 68.4% men and EF 29.4% ±6.8%). After six months 336 (52.3%) did not have MRA of which 279 (83%) never received MRAs and 57 (17%) had MRAs discontinued. Among patients on MRA treatment, 306 (14.4%) needed dose reduction. Occurrence of hypertension, ischemic heart disease, diabetes mellitus and renal dysfunction at baseline did not differ between groups with or without MRA. The incidence and magnitude of documented and potentially higher risk of hyperkalemia were assessed both at baseline and as highest potassium within six months after established diagnosis. Among patients without MRA after six months, at baseline only 3 (0.9%) patients had documented S/P-K ≥6 mmol/L, 7 (2.1%) patients had S/P-K 5.5–5.9 mmol/L and 26 (7.7%) patients had S/P-K 4.8–5.4 mmol/L. Moreover, 12.4% had potentially high risk of hyperkalemia at baseline. During the six-month follow up after initiation of HF therapy, 15 (4.5%) patients had documented hyperkalemia with S/P-K ≥6 mmol/L,

23 (6.8%) patients had S/P-K 5.4–5.9 mmol/L, and 123 (36.6%) patients had S/P-K 4.8–5.4 mmol/L during at least one occasion. Besides, 13.4% had potentially high risk of hyperkalemia. Hyperkalemia occurred frequently

(40.4% vs 36.4%) in patients with discontinuation and dose reduction of MRA. Figure 1 presents the distribution of patients with risk of or documented hyperkalemia in the group without MRA.

Conclusions

Hyperkalemia was the most common cause for both discontinuation and dose reduction of MRA. Hyperkalemia was also increased significantly from baseline and during subsequent up-titration, with 4.6-fold increased risk for borderline hyperkalemia (S/P-K 4.8–5.4). This might explain why physicians refrain from prescribing MRAs to patients with HFrEF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Vifor Pharma

Serotonin and early life stress interact to shape brain architecture and anxious avoidant behavior - a TPH2 imaging genetics approach

BACKGROUND

Early life stress has been associated with emotional dysregulations and altered architecture of limbic-prefrontal brain systems engaged in emotional processing. Serotonin regulates both, developmental and experience-dependent neuroplasticity in these circuits. Central serotonergic biosynthesis rates are regulated by Tryptophan hydroxylase 2 (TPH2) and transgenic animal models suggest that TPH2-gene associated differences in serotonergic signaling mediate the impact of aversive early life experiences on a phenotype characterized by anxious avoidance.

METHODS

The present study employed an imaging genetics approach that capitalized on individual differences in a TPH2 polymorphism (703G/T; rs4570625) to determine whether differences in serotonergic signaling modulate the effects of early life stress on brain structure and function and punishment sensitivity in humans (n = 252).

RESULTS

Higher maltreatment exposure before the age of 16 was associated with increased gray matter volumes in a circuitry spanning thalamic-limbic-prefrontal regions and decreased intrinsic communication in limbic-prefrontal circuits selectively in TT carriers. In an independent replication sample, associations between higher early life stress and increased frontal volumes in TT carriers were confirmed. On the phenotype level, the genotype moderated the association between higher early life stress exposure and higher punishment sensitivity. In TT carriers, the association between higher early life stress exposure and punishment sensitivity was critically mediated by increased thalamic-limbic-prefrontal volumes.

CONCLUSIONS

The present findings suggest that early life stress shapes the neural organization of the limbic-prefrontal circuits in interaction with individual variations in the TPH2 gene to promote a phenotype characterized by facilitated threat avoidance, thus promoting early adaptation to an adverse environment.

Segregating domain-general from emotional context-specific inhibitory control systems - ventral striatum and orbitofrontal cortex serve as emotion-cognition integration hubs

Inhibitory control hierarchically regulates cognitive and emotional systems in the service of adaptive goal-directed behavior across changing task demands and environments. While previous studies convergently determined the contribution of prefrontal-striatal systems to general inhibitory control, findings on the specific circuits that mediate emotional context-specific impact on inhibitory control remained inconclusive. Against this background we combined an evaluated emotional Go/No Go task with fMRI in a large cohort of subjects (N=250) to segregate brain systems and circuits that mediate domain-general from emotion-specific inhibitory control. Particularly during a positive emotional context, behavioral results showed a lower accuracy for No Go trials and a faster response time for Go trials. While the dorsal striatum and lateral frontal regions were involved in inhibitory control irrespective of emotional context, activity in the ventral striatum (VS) and medial orbitofrontal cortex (mOFC) varied as a function of emotional context. On the voxel-wise whole-brain network level, limbic and striatal systems generally exhibited highest changes in global brain connectivity during inhibitory control, while global brain connectivity of the left mOFC was less decreased during emotional contexts. Functional connectivity analyses moreover revealed that negative coupling between the VS with inferior frontal gyrus (IFG)/insula and mOFC varied as a function of emotional context. Together these findings indicate separable domain- general as well as emotional context-specific inhibitory brain systems which specifically encompass the VS and its connections with frontal regions.

Inter-subject phase synchronization differentiates neural networks underlying physical pain empathy

Recent approaches for understanding the neural basis of pain empathy emphasize the dynamic construction of networks underlying this multifaceted social cognitive process. Inter-subject phase synchronization (ISPS) is an approach for exploratory analysis of task-fMRI data that reveals brain networks dynamically synchronized to task-features across participants. We applied ISPS to task-fMRI data assessing vicarious pain empathy in healthy participants (n = 238). The task employed physical (limb) and affective (face) painful and corresponding non-painful visual stimuli. ISPS revealed two distinct networks synchronized during physical pain observation, one encompassing anterior insula and midcingulate regions strongly engaged in (vicarious) pain and another encompassing parietal and inferior frontal regions associated with social cognitive processes which may modulate and support the physical pain empathic response. No robust network synchronization was observed for affective pain, possibly reflecting high inter-individual variation in response to socially transmitted pain experiences. ISPS also revealed networks related to task onset or general processing of physical (limb) or affective (face) stimuli which encompassed networks engaged in object manipulation or face processing, respectively. Together, the ISPS approach permits segregation of networks engaged in different psychological processes, providing additional insight into shared neural mechanisms of empathy for physical pain, but not affective pain, across individuals.

Oxytocin facilitates socially directed attention

Socially directed gaze following is an important component of social interaction and communication, allowing us to attend mutually with others to objects or people so that we can share their experience and also learn from them. This type of joint social attention is impaired in disorders such as autism. Previous research has demonstrated that the neuropeptide oxytocin can facilitate attention toward social cues, although to date no study in humans has investigated its influence on socially directed gaze or on associations of the latter with autistic and empathic traits. In a within-subject, randomized, placebo-controlled trial we used eye-tracking to investigate the effects of intranasal oxytocin (24 IU) on socially directed gaze toward one of two objects in 40 adult male subjects. Subjects viewed videos of an actor and actress directing their gaze toward one of two objects by either moving only their eyes, moving both their eyes and head, or moving their eyes and head and pointing with a finger. Results showed that OXT increased the proportion of time subjects viewed the object the actor or actress were looking/pointing at across all three conditions, although unexpectedly we found no associations with trait autism or empathy under either placebo or OXT treatments. These findings demonstrate that OXT can facilitate socially directed gaze following to promote mutual attention toward objects which may be potentially beneficial therapeutically in disorders with impaired social communication and interaction.

The impact of time-updated resting heart rate on cause-specific mortality in a random middle-aged male population: a lifetime follow-up

Background

High resting heart rate (RHR) is associated with increased adverse events. However, the long-term prognostic value in a general population is unclear. We aimed at investigating the impact of RHR, based on baseline as well as time-updated, on mortality in a middle-aged men cohort.

Methods

A random population sample of 852 men, all born in 1913 was followed from age 50 until age 98 with repeated examinations including RHR during 48 years. The impact of baseline and time-updated RHR on cause-specific mortality was assessed using Cox proportional hazards models and cubic spline models.

Results

Baseline RHR ≥90 beats per minute (bpm) was associated with higher all-cause mortality as compared to RHR 60–70 bpm (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.17–2.19, P=0.003), but not with cardiovascular (CV) mortality. A time-updated RHR <60 bpm (HR 1.41, 95% CI 1.07–1.85, P=0.014) and a time-updated RHR of 70–80 bpm (HR 1.34, 95% CI 1.02–1.75, P=0.036) were both associated with higher CV mortality as compared with the RHR of 60–70 bpm after multivariable adjustment. Analyses using cubic spline models confirmed that the association of time-updated RHR with all-cause and CV mortality complied with a U-shaped curve with 60 bpm as a reference.

Conclusions

In this middle-aged men cohort, a time-updated RHR at 60–70 bpm was associated with lowest CV mortality, suggesting that time-updated RHR could be a useful long-term prognostic index in the general population.

RHR and Mortality

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): In recent years, funding has been received from the Swedish state under the agreement between the Swedish government and the county councils relating to the economic support of research and education under the ALF agreement (ALFGBG-721351).

Trends in outcome and patient composition in dilated cardiomyopathy in Sweden over time

Background

We studied prognosis and patient composition over time in dilated cardiomyopathy (DCM): a well-defined category of heart failure (HF), often affecting younger individuals. We expected improved prognosis over time, due to emerging diagnostic and therapeutic options.

Methods

All patients from the Swedish Heart Failure Registry (SwedeHF) fulfilling criteria for DCM (exclusion of ischemic, valvular, or alcoholic etiology and affirmed by clinical judgment in the protocol) (n=3739), were analyzed with respect to three time periods of inclusion in the registry, 2003–2007 (n=814), 2008–2011 (n=1448), 2012–2016 (n=1477), regarding mortality, transplantations, and hospital admissions during one year after inclusion.

Results

Over the three time periods, registered cohorts were older with time (mean 59.3 years/ 60 years/ 61.0 years, p=0.0035), and the proportion of females incresased (24.1% / 27.2% / 30.7%, p=0.0006).

For clinical variables, the distribution of left ventricular ejection fraction (LVEF) with time showed significantly higher LVEF (p=0.0024), and functional classification (NYHA) showed lower class (p=0.0011). Hypertension as a comorbidity (i.e. not judged to be responsible for HF) was more frequently occurring with time: (34.0%/ 40.6%/ 44.1%, p<0.0001). As for HF treatment: use of device increased (p<0.0001 for categorical combinations), mineralocorticoid receptor antagonists (MRA) increased (41.9%/ 37.3%/ 46.7%, p=0.0023), and diuretics dropped (76.1%/ 71.1%/ 67.0%, p≤0.0001) in the different cohorts with time.

Mortality (6.9%, 5.1%, 5.5%), transplantation (0.5%, 0.8%, 0.6%) and hospital admissions for HF (28.4%, 26.3%, 24.6%) were stable over time (ns for all), whereas cardiovascular (CV) (33.8%, 33.8%, 29.7%, p=0.043) and all cause admissions (39.1%, 38.8%, 33.7%, p=0.0099) decreased. After adjustment for age, sex, LVEF, NYHA, hypertension and device treatment only all cause admissions remained significantly decreased.

Conclusion

In this nationwide study between 2003–2016, one-year outcome in DCM in Sweden remained stationary over time, despite advances in HF therapy. During the time period, we observed a continuous change in the clinical profile in the DCM population.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Region Västra Götaland agreement concerning research and education of physicians.

Lifelong cumulative incidence of acquired aortic stenosis and its predictors in a large middle-aged men population followed up to 42 years

Background

Acquired aortic stenosis (AS) is the most common valvular disorder that rises exponentially with age; it has high mortality after symptoms appear. Factors that predict the development of AS are still unknown. Some studies imply that the atherosclerotic factors are involved in the development of AS, but the findings have been heterogeneous.

Purpose

To estimate lifelong cumulative incidence of AS and analyse its predictors.

Methods

We included a random sample of men, born 1915–1925 in Gothenburg, Sweden, and examined them in 1970–1973 (participation rate 75%). They were between 47 and 55 years in the beginning and 57–65 years when the examination-period ended. Out of 7493 men 57 were excluded due to myocardial infarction prior to baseline; 7436 were thus followed from the inclusion date until a discharge diagnosis of AS or death, with a maximum follow up time of 42 years and mean follow-up time 26.8 years. Men with AS were identified from the Swedish National Patient Register and those who died from the Swedish Cause of Death Register. We used machine learning to identify the most important factors that predict AS. For these factors, we then estimated hazard ratios for the risk to acquire AS through Cox proportional hazards model.

Results

The lifelong cumulative incidence to acquire AS was 2.66% (198 out of 7436 individuals). For men with measurements approximately at the quartiles of the pulse pressure distribution, more specifically 44, 52, 62 mm Hg, the estimated cumulative risk were 1.97%, 2.74% and 3.07% respectively. For the body mass index (BMI) we had accordingly for measurements around 23, 25 and 27 kg/m2 estimated cumulative risk 2.52%, 2.80%, 2.79% respectively. For cholesterol values of 5, 6 and 7 mmol/l (approximately at quartile divisions) the estimated cumulative risk was 1.77%, 1.79% and 3.20% respectively. The estimated cumulative risks for the younger, with age around 47 and the older participants, with age around 55 were 1.76% and 2.68 respectively. Men with family history of infarction in a sibling had an estimated cumulative risk at 4.66% level whereas those with not at 2.51%.

The factors that were significantly associated with the development of AS in the Cox proportional model are: cholesterol level (HR=1.24, CI 95% 1.11–1.39, p=0.0001), pulse pressure (HR=1.01, CI 95% 1.01–1.02, p=0.0037), BMI (HR=1.06, CI 95% 1.02–1.11, p=0.0089), age (HR=1.11, CI 95% 1.04–1.19, p=0.0010) and family history of myocardial infarction in a sibling (HR=2.38, CI 95% 1.50–3.79, p=0.0002).

Conclusion

Lifelong cumulative incidence of acquired AS is approximately 2.7%. Multiple factors known also to be associated with arteriosclerosis were identified to increase the life-long risk of developing AS.

Funding Acknowledgement

Type of funding source: None

Trends in cause-specific readmissions in heart failure with preserved versus reduced and mid-range ejection fraction

Background

It remains unclear whether the readmission of heart failure (HF) patients has decreased over time and how it differs among HF with preserved ejection fraction (EF) (HFpEF) versus reduced EF (HFrEF) and mid-range EF (HFmrEF).

Methods

We evaluated HF patients index hospitalized from January 2004 to December 2011 in the Swedish Heart Failure Registry with 1-year follow-up. Outcome measures were the first occurring all-cause, cardiovascular (CV) and HF readmissions.

Results

Totally 20,877 HF patients (11,064 HFrEF, 4,215 HFmrEF, 5,562 HFpEF) were included in the study. All-cause readmission was highest in patients with HFpEF, whereas CV and HF readmissions were highest in HFrEF. From 2004 to 2011, HF readmission rates within 6 months (from 22.3% to 17.3%, P=0.003) and 1 year (from 27.7% to 23.4%, P=0.019) in HFpEF declined, and the risk for 1-year HF readmission in HFpEF was reduced by 7% after adjusting for age and sex (P=0.022). Likewise, risk factors for HF readmission in HFpEF changed. However, no significant changes in cause-specific readmissions were observed in HFrEF. Time to the first readmission did not change significantly from 2004 to 2011, regardless of EF subgroup (all P-values>0.05).

Conclusions

Although the burden of all-cause readmission remained highest in HFpEF versus HFrEF and HFmrEF, a declining temporal trend in 6-month and 1-year HF readmission rates was found in patients with HFpEF, suggesting that non-HF-related readmission represents a big challenge for clinical practice.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The SwedeHF was funded by the Swedish National Board of Health and Welfare, the Swedish Association of Local Authorities and Regions.

Temporal trends in cause-specific readmissions and their risk factors in heart failure patients in Sweden

Background

It remains unclear whether readmissions of patients with heart failure (HF) have decreased over time in an era of improved therapy and management of HF. This study aimed to determine the temporal short- and long-term trends of cause-specific rehospitalization and their risk factors in a Swedish context.

Methods

HF patients in the Swedish Heart Failure Registry (SwedeHF) were investigated. Maximum follow-up time was 1 year. Outcomes included the first occurrence of all-cause, cardiovascular (CV) and HF rehospitalizations. Cox proportional hazards models were performed to determine the impact of increasing years on risk for rehospitalization and its known risk factors.

Results

Totally, 25,644 index-hospitalized HF patients SwedeHF from 2004 to 2011 were enrolled in the study. For 8 years, the incidence risk of 1-year all-cause rehospitalization remained unchanged, whereas the incidence risk of CV (P=0.038) or HF (P=0.0038) rehospitalization decreased. After adjustment for age and sex, a 3% decrease per every second year was observed for 1-year CV and HF rehospitalizations (P<0.05). However, time to the first occurring all-cause, CV and HF rehospitalization did not change significantly from 2004–2011 (P-values 0.13–0.87). When two study periods (2004–2005 vs. 2010–2011) were compared, the risk factor profile for rehospitalization was found to change.

Conclusions

Throughout the 8-year study period, CV- and HF-related rehospitalizations decreased, whereas all-cause rehospitalization remained unchanged, indicating a parallel increase in non-CV rehospitalization in the HF patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The SwedeHF was funded by the Swedish Society of Cardiology and the Swedish Heart-Lung Foundation.

Temporal trends in incidence of heart failure in relation to age and gender in western Sweden 2008–2017

Background

During the last decades we have witnessed gradually improved cardiovascular primary and secondary prevention, while life expectancy is increasing, with a growing population of elderly people. Heart failure is a disease of the elderly and end stage of other cardiac diseases. Accordingly, trends in incidence of heart failure are dynamic and may differ by age and gender

Purpose

To investigate overall trends in incidence for HF over the last decades in Western Sweden. Additionally we wanted to study incidence in relation to age and gender.

Method

The VEGA database is an administrative database of all patients managed in hospital care (through direct linkage to the Swedish nationwide patient registry) and/or in primary care facilities (private and public) living in Western Sweden. All patients with a main or contributory diagnosis of HF (I50) >18 years of age between 2008 and 2017 were included in our cohort. HF incidence was calculated based on the entire population of Vastra Gotaland (a region of Western Sweden).

Results

The adult population in Western Sweden increased by 8% from 2008 (n=1,234,609) to 2017 (n=1,338,906), with 69% <60 years of age and 50% female, both constant over time.

In total, 62,229 incident cases of HF were identified during 2008–2017. In 2008 we identified 6464 cases with a mean age of 78.7 (11.5) and 49.8% (n=3222) male patients, while in 2017 5,727 cases were identified with a mean age of 78.3 (11.8) and 52.5% (n=3006) male cases.

The yearly incidence rate of HF remained constant over the 10-year period but with large variations by age and gender. A constantly higher incidence of HF was seen for men compared to women in all age categories. Although overall incidence remained constant in the last decade, we did observe decreasing incidence among those >80 years of age with incidence rates dropping from 4.4% to 3.0% between 2008–2017 (80–90 years) and from 7.8 to 5.5% in the same period (>90 years of age). A similar pattern was seen in both men and women in these age groups with incidence decreasing over the last ten years.

Conclusion

The overall incidence of HF remained unchanged over the last decade. However a declining trend in incidence was observed in the oldest part of the population, who, however, constitutes only approximately 5% of the population. Our findings emphasize the need for implementation of effective preventive strategies for HF.

Trends in HF incidence 2007-2018

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish agreement between the government and the county councils concerning economic support for providing an infrastructure for research and education of doctors (ALF), and the Regional Development Fund, Västra Götaland County, Sweden (FOU-VGR)

Increasing home-time for patients with heart failure in Sweden 1992–2008

Background

Heart failure (HF) reduces survival and is one of the most common causes of hospitalizations in the elderly, imposing a major economic burden on the health care system, with frequency of rehospitalizations often used in interventional and observational studies in patients with HF. Home-time is a novel end-point measuring time spent alive and out of hospital and is easier for both clinicians and patients to relate to. Given the advances in treatment of HF over the last decades we postulated that an increase in home-time would follow.

Purpose

To investigate whether home-time for patients with HF has changed over the last decades in Sweden and if home-time differs between patients of working age and those retired, or between men and women.

Methods

Patients aged 18–84 years with a first hospitalization for HF in Sweden between 1992 and 2008 were identified using the National Inpatient Register which was linked to the Swedish Cause of Death Register. Information on rehospitalizations and mortality was collected and followed over a time period of 4 years. The patients were divided into two age groups: (i) <65 years and (ii) >65 years. The cut off 65 years was chosen being the official age of retirement over the study period in Sweden.

Results

A total of 324,907 patients were included in this study, mean age 73.5 years (standard deviation 9.3). Only 15.6% were <65 and 45.1% were women. In total, average home-time was 70.1% of the total follow up time, 2.1% of time was spent in hospital while, during a mean of 27.9% of the 4 year-period, patients were no longer alive. A small increase in home-time was observed over the study period. The older age group spent 67.7% at home compared with 83% in the younger group. After taking differences in mortality into account, the difference in home-time was no longer significant, with 92.7 and 95.8% home-time for the older and younger age groups, respectively. Over the entire study period older men had less home-time compared with older women. Since 1998 the reverse was true in younger men and women, where younger men had more home-time than younger women. Home-time increased for all subgroups over the study period with the most pronounced increase for younger men (see figure 1).

Conclusion

Home-time for patients in Sweden increased over the study period and the increase was more marked for younger patients, where men spent more time at home than women.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish state (ALF), The Swedish Heart and Lung Foundation, Västra Götaland Region, The Göteborg Medical Society

[Clinicopathological features and prognosis of 59 patients with platelet-derived growth factor α-mutant gastrointestinal stromal tumor]

Objective: Platelet-derived growth factor α (PDGFRA)-mutant gastrointestinal stromal tumor (GIST) is a relatively rare disease, whose clinicopathological characteristics and prognosis have been poorly studied. In this paper, the clinicopathological features and prognostic factors of PDGFRA-mutant GIST are investigated to provide more data for its understanding and treatment. Methods: A retrospective case-control study was used to collect the medical records of patients with GIST who underwent surgical resection in Zhongshan Hospital of Fudan University from January 2015 to August 2019. Patients with PDGFRA-mutant GIST were enrolled, and those with synonymous PDGFRA mutations, non-tumor-related deaths, and lack of clinicopathological data were excluded. The clinicopathological data were collected and the risk factors associated with prognosis were analyzed. Results: Among the enrolled 59 patients, there were 41 males (69.5%) and 18 females (30.5%) with the median age of 60 (25-79) years. All tumors originated from the stomach. The tumor size was 5 (3-7) cm, and the mitotic count was 2 (1-4)/50 high-power fields (HPF). According to the modified NIH risk stratification, 8 cases were classified as very low risk (13.6%), 25 cases as low risk (42.4%), 14 cases as moderate risk (23.7%), and 12 cases as high risk (20.3%). There were 7 cases of exon 12 mutation and 52 cases of exon 18 mutation (including 36 cases of D842V mutation). A comparison of clinicopathological features between the D842V mutation group and the non-D842V mutation group showed no statistically significant difference (all P>0.05). During a median follow-up of 21 (0-59) months, the 1- and 3-year relapse-free survival (RFS) rates of all the patients were 96.6% and 91.5%, respectively. There were 8 cases of recurrence and 3 cases of death. Six GIST patients with D842V mutation had tumor recurrence after operation, of whom 4 cases achieved varying degrees of tumor remission after being treated with dasatinib or avapritinib. Log-rank analysis showed that the overall survival (OS) of male was better than that of female (100% vs. 83.3%, P=0.046), but there was no significant difference in OS among patients with different risk grades (P=0.057). The RFS and OS of patients with D842V mutation and non-D842V mutation, exon 12 and exon 18 mutation were similar (all P>0.05). Univariate Cox analysis showed that RFS was associated with gender (P=0.010), tumor size (P=0.042), mitotic count (P=0.003), and the modified NIH risk stratification (P=0.042), while multivariate analysis revealed that higher risk grade was an independent risk factor for recurrence of PDGFRA-mutant GIST (HR=12.796, 95%CI: 1.326-123.501, P=0.028). Gender was an independent factor for recurrence, and the risk of recurrence in males was lower than that in females (HR=0.154, 95%CI: 0.028-0.841, P=0.031). Conclusions: Gender and the modified NIH risk stratification are independent risk factors for recurrence of PDGFRA-mutant GIST, while patients with D842V and non-D842V mutation, and exon 12 and exon 18 mutation have a similar risk of recurrence and death.

[Midterm outcome comparison between patients with bicuspid or tricuspid aortic stenosis undergoing transcatheter aortic valve replacement]

Objective: To compare the prognosis of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) stenosis. Methods: This was a retrospective study. Patients with symptomatic severe aortic stenosis, who underwent TAVR with follow-up time more than one year in Guangdong Provincial People's Hospital from April 2016 to August 2018, were included. According to aortic CT angiography, the patients were divided into BAV group and TAV group. The primary endpoint was the composite event of all-cause death and stroke, and the secondary endpoints were TAVR-related complications. Incidence of clinical endpoints and parameters derived from echocardiography were compared between the groups, and Kaplan-Meier survival analysis was used to compare the composite event between the two groups. Results: A total of 49 patients were included. The age was (73.6±6.3) years, and 25(51.0%) were male. There were 32 patients in BAV group and 17 in TAV group, the follow-up time was 466 (390, 664) days. The incidence of composite endpoint of death and stroke at one year were comparable in BAV and TAV groups (6.3% (2/32) vs. 5.9% (1/17), P=1.00). Kaplan-Meier curves also showed a similar risk of the composite endpoint(HR=1.03，95%CI 0.09-11.24，Log-rank P=0.98) between two groups. The incidence of all-cause death, stroke, myocardial infarction, severe bleeding, major vascular complications, new-onset atrial fibrillation or atrial flutter, and permanent pacemaker implantation were all similar between the two groups(all P>0.05), and there was no acute kidney injury (stage 2 or 3) in both groups. Echocardiographic parameters at one year were similar between the two groups (all P>0.05). Conclusions: The midterm prognosis of TAVR in patients with BAV and TAV stenosis is similar. Clinical trials of large sample size with long-term follow-up are warranted to verify our findings.

Empathic pain evoked by sensory and emotional-communicative cues share common and process-specific neural representations

Pain empathy can be evoked by multiple cues, particularly observation of acute pain inflictions or facial expressions of pain. Previous studies suggest that these cues commonly activate the insula and anterior cingulate, yet vicarious pain encompasses pain-specific responses as well as unspecific processes (e.g. arousal) and overlapping activations are not sufficient to determine process-specific shared neural representations. We employed multivariate pattern analyses to fMRI data acquired during observation of noxious stimulation of body limbs (NS) and painful facial expressions (FE) and found spatially and functionally similar cross-modality (NS versus FE) whole-brain vicarious pain-predictive patterns. Further analyses consistently identified shared neural representations in the bilateral mid-insula. The vicarious pain patterns were not sensitive to respond to non-painful high-arousal negative stimuli but predicted self-experienced thermal pain. Finally, a domain-general vicarious pain pattern predictive of self-experienced pain but not arousal was developed. Our findings demonstrate shared pain-associated neural representations of vicarious pain.

Long-term application potential of urban air mobility complementing public transport: an upper Bavaria example

In this paper, the required models and methods to analyze and quantify the potential demand for urban air mobility (UAM) complementing public transport and possible impacts were defined and applied to the Munich Metropolitan region. An existing agent-based transport model of the study area were used and extended to cover socio-demographic changes up to the year 2030 and intermodal UAM services. An incremental logit model for UAM was derived to simulate demand for this new mode. An airport access model was developed as well. Three different UAM networks with different numbers of vertiports were defined. Sensitivity studies of ticket fare and structure, flying vehicle cruise speed, passenger process times at vertiports and different Urban Air Mobility networks sizes were performed. For the reference case, UAM accounts for a modal share of 0.5%. The absolute UAM demand is concentrated on very short routes; hence, UAM vehicle flight speed variation shows low UAM demand impacts. Kilometer-based fare, number of UAM vehicles per vertiport and passenger process times at vertiports show a significant impact on UAM demand.

Oxytocin Facilitation of Emotional Empathy Is Associated With Increased Eye Gaze Toward the Faces of Individuals in Emotional Contexts

One of the most robust effects of intranasal oxytocin treatment is its enhancement of emotional empathy responses across cultures to individuals displaying emotions in realistic contexts in the Multifaceted Empathy Task (MET). However, it is not established if this effect of oxytocin on emotional empathy is due to altered visual attention toward different components of the stimulus pictures or an enhanced empathic response. In the current randomized placebo-controlled within-subject experiment on 40 healthy male individuals, we both attempted a further replication of emotional empathy enhancement by intranasal oxytocin (24 IU) and used eye-tracking measures to determine if this was associated by altered visual attention toward different components of the picture stimuli (background context, human face, and body posture). Results replicated previous findings of enhanced emotional empathy in response to both negative and positive stimuli and that this was associated with an increased proportion of time viewing the faces of humans in the pictures and a corresponding decrease in that toward the rest of the body and/or background context. Overall, our findings suggest that enhanced emotional empathy following oxytocin administration is due to increased attention to the faces of others displaying emotions and away from other contextual and social cues.

Clinical Trial Registration:www.ClinicalTrials.gov Oxytocin Modulates Eye Gaze Behavior During Social Processing; registration ID: NCT03293511; URL: https://clinicaltrials.gov/ct2/show/NCT03293511.

The application value of PAX1 and ZNF582 gene methylation in high grade intraepithelial lesion and cervical cancer

PURPOSE

To investigate the possibility of using the methylation level of PAX1/ZNF582 gene as molecular marker to differentiate the progression of cervical cancer.

METHODS

From January 2016 to March 2018, 150 patients, who were admitted to Cervical Disease Diagnosis and Treatment Center of Xuzhu Maternity and Child Care Hospital, were enrolled in this study. Patients were classified into chronic cervicitis (for 19 cases), low-grade squamous intraepithelial lesion (LSIL) (18 cases), high-grade squamous intraepithelial lesion (HSIL) (37 cases) and squamous cell carcinoma (SCC) (31 cases). All patients underwent several tests including Thin-prep cytology test (TCT), HPV DNA detection and detection of methylation level of PAX1/ZNF582 genes.

RESULTS

For diagnosis of HSIL, the area under curve (AUC) was 0.878 (95% CI 0.806 ~ 0.950); the threshold for PAX1 was 12.285, the sensitivity and specificity were 91.9% and 72.8%, respectively. The AUC of ZNF582 gene detection was 0.900 (95% CI 0.842 ~ 0.959), the threshold was 11.56, while the sensitivity and specificity were 97.3% and 76.7%, respectively. Among various tests we conducted, PAX gene detection methods showed the highest specificity (97.30%). PAX1/ZNF582 gene detection method demonstrated the highest accuracy.

CONCLUSIONS

For patients with high-grade cervical lesion and cervical cancer, the methylation level of PAX1/ZNF582 gene could be applied as a noteworthy biomarker for diagnosis and for cervical cancer classification.

Clinical outcomes of different therapeutic modalities for rectal gastrointestinal stromal tumor: Summary of 14-year clinical experience in a single center

OBJECTIVE

The optimal treatment for gastrointestinal stromal tumor (GIST) of the rectum is controversial due to the extremely low incidence of the disease. The aim of the present study was to compare the clinical outcomes of different treatment modalities for rectal GIST by reviewing the 14-year experience in our center.

METHOD

Medical records of rectal GIST patients who received surgical treatment in our center between January 2004 to December 2017 were reviewed retrospectively. Overall survival (OS) and recurrence-free survival (RFS) were used as the observation endpoints.

RESULTS

Included in this study were 71 GIST patients, including 42 patients who underwent local excision (LE) and 29 patients who underwent segmental resection (SR). There were differences in tumor size (P = 0.001) and malignant risk grade (P = 0.007). The LE approach achieved a lower rate of R0 resection than SR (29/42 vs.27/29, P = 0.015) and shorter hospital stay (P = 0.004). Preoperative imatinib mesylate (IM) therapy improved the rate of sphincter-sparing surgery for patients with tumors in the very low segment of the rectum (P = 0.012) and offered better R0 resection margins (P = 0.027). Multivariate analysis showed that the resection margin status (P = 0.014), risk stratification (P = 0.001) and IM therapy (P = 0.042) were independent factors affecting RFS of rectal GIST patients but not the surgical modalities (LE vs. SR, P = 0.802). Multivariate analysis showed no significant impact of these variables on OS.

CONCLUSION

Selection of surgical modalities has no significant impact on the prognosis. Local excision is the preferred surgical modality for resectable rectal GIST by virtue of less injury and shorter hospital stay. IM therapy has proved to be associated with improved RFS for rectal GIST patients.

Impaired cognitive performance under psychosocial stress in cannabis-dependent men is associated with attenuated precuneus activity

BACKGROUND

Deficient regulation of stress plays an important role in the escalation of substance use, addiction and relapse. Accumulating evidence suggests dysregulations in cognitive and reward-related processes and the underlying neural circuitry in cannabis dependence. However, despite the important regulatory role of the endocannabinoid system in the stress response, associations between chronic cannabis use and altered stress processing at the neural level have not been systematically examined.

METHODS

Against this background, the present functional MRI study examined psychosocial stress processing in cannabis-dependent men (n = 28) and matched controls (n = 23) using an established stress-induction paradigm (Montreal Imaging Stress Task) that combines computerized (adaptive) mental arithmetic challenges with social evaluative threat.

RESULTS

During psychosocial stress exposure, but not the no-stress condition, cannabis users demonstrated impaired performance relative to controls. In contrast, levels of experienced stress and cardiovascular stress responsivity did not differ from controls. Functional MRI data revealed that stress-induced performance deteriorations in cannabis users was accompanied by decreased precuneus activity and increased connectivity of this region with the superior frontal gyrus.

LIMITATIONS

Only male cannabis-dependent users were examined; the generalizability in female users remains to be determined.

CONCLUSION

Together, the present findings provide first evidence for exaggerated stress-induced cognitive performance deteriorations in cannabis users. The neural data suggest that deficient stress-related recruitment of the precuneus may be associated with the deterioration of performance at the behavioural level.