Medium term survival in patients over ninety years-old undergoing pacemaker implantation

Background

According to the Italian National Statistical Institute, the 12-month probability of survival in the general population between 90 and 94 years-old is 26%. Pacemaker (PM) implantation is often an urgent and necessary intervention, but in these patients the benefit in terms of quality and duration of life is unclear.

Purpose

To analyze characteristics, outcome and factors associated with survival in patients who had turned 90 at the time of PM implant.

Methods

All the PM implants performed in patients ≥90 from 1/1/2019 to 12/31/2020 were analyzed. Clinical parameters, device characteristics and follow-up data were extrapolated from the SuitEstensa Ebit reporting system; the exitus was verified by analyzing data from the Regional Health System.

Results

During the study interval, among the 554 patients undergoing PM implantation in our Center, 69 (12%) were ≥90 years-old (mean age 92±2 years, 46% male; complete/advanced AV block in 76%). Twenty-six (38%) patients had history of atrial fibrillation and 19 (28%) ischemic heart disease. A cardiological co-morbidity (excluding AF) was present in 23 patients (33%). Oncological, pneumological and neurological comorbidities were present in 12 (18%), 19 (28%) and 32 (46%) respectively. Renal impairment was present in 25 patients (36%). In 47 patients (68%) there were at least 2 co-morbidities. After implantation (single-chamber in 36, dual-chamber in 25 and VDD single-lead dual-chamber in 8 patients) complications occurred in 3 patients (2 pneumothorax and 1 lead dislodgment). Remote monitoring was activated in 57 patients (83%).

Within August 31st 2021 (mean follow-up 288±193 days) 24 patients died (35%, 219±241 days after implant). Five patients (19% of patients implanted in 2019) died within 12 months. No patients died for device malfunction. Three patients died because of COVID-19 pneumonia.

Renal dysfunction (Hazard Ratio-HR 8.05, p=0.002) and the presence of 2 or more co-morbidities (HR 6.03; p=0.015) were associated with a higher risk of death at univariate analysis; other significant variables were diabetes (HR 2.34; p=0.038), left ventricular ejection fraction (LVEF) (HR 0.70 for 5% variation; p=0.005), walking impairment (HR 2.99, p=0.006), the presence of oncological (HR 2.21; p=0.003), pneumological (HR 2.55; p=0.024) and neurological (HR 1.90, p=0.007) comorbidities. At multivariable analysis the only significant parameter associated with survival was LVEF (0.76 for 5% difference; p=0.043)

Conclusions

At our Center, patients ≥90 years-old undergo PM implantation mainly for advanced AVB. The good survival in the medium term, even better than expected in the general population, does not justify a too conservative attitude especially, but exclusively, in patients with less comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of myocardial inflammation in patients with undefined left ventricular arrhythmogenic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

Etiology identification and risk stratification represent major issues for patients presenting with undefined left ventricular arrhythmogenic cardiomyopathy (ULVACM).

Purpose

To investigate the role of genetics and histology for ULVACM classification, management, and risk assessment.

Methods

We retrospectively analyzed a multicenter cohort of patients (screened n=1037) with ULVACM defined by ventricular arrhythmia (VA) onset, nonischemic late gadolinium enhancement (LGE) limited to the LV, and no severe dilated cardiomyopathy (LVEF≥40%). We selected patients undergoing both next generation sequencing (NGS) screening and endomyocardial biopsy (EMB) for etiology definition. When feasible, immunosuppressive therapy (IST) was used to target active myocardial inflammation (AMI). The study endpoint was a composite of cardiac death, heart transplantation and malignant VAs (VT, VF, appropriate ICD treatment).

Results

The study cohort is composed by 135 ULVACM patients (age 43±14 years, 63% males, LVEF 55±7 %). NGS identified pathogenic or likely-pathogenic variants (PVs/LPVs) consistent with ACM in 21 cases (16%), whereas EMB showed AMI in 78 patients (58%), including 13/21 PVs/LPVs+ (62%). After reclassification of 86 patients (64%), only 49 (36%) remained ULVACM. IST was started in 41/78 AMI patients (53%), including 9/13 PVs/LPVs+ (69%). Twenty patients (15%) met the study endpoint by 12 months, and 36 (27%) by the end of the study (60±27 months). Beyond malignant VT onset, AMI was the only predictor of events by 12 months (HR 5.0, 95%CI 1.4-18.1, p=0.007). No prognostic role was found for PVs/LPVs, except for the subgroup (n=77) with nonsustained VT onset. Among AMI patients, those treated by IST had a significantly lower occurrence of events, both by 12-months (1/41 vs. 16/37, p<0.001) and later (HR 0.05, 95%CI 0.01-0.21, p<0.001). Results were independently confirmed in PVs/LPVs+ and PVs/LPVs- cases. Excluding the IST population, the association of multiple factors among VT onset, PVs/LPVs, and AMI, resulted in an improved discrimination of arrhythmic risk profiles.

Conclusion

The combined genetic and histological workup allowed reclassification of up to 64% ULVACM patients, and substantially contributed into prognostic assessment. Furthermore, EMB identified suitable candidates for IST, who showed better outcomes irrespectively of their genotype.

P356 PREVALENCE AND PROGNOSTIC IMPACT OF LIPID GOAL ATTAINMENT AND PATIENT ADHERENCE TO LOWERING LIPID TREATMENT: DATA FROM COMMUNITY ITALIAN SETTING

Aims

The aim of the study was to provide real–world data on low–density lipoprotein cholesterol (LDL–C) goal achievement at the time of current 2019 ESC/EAS Guidelines, treatment patterns and patient adherence to lowering lipid treatment (LLT).

Methods and Results

This community–based study identified patients with at least one LDL–C measurement and cardiological evaluation from 01–Jan–2016 to 31–Dec–2018. Patients risk stratification and LDL–C target achievement were assessed according to 2019 EAS/ESC guidelines. To identify the proportion of patients at LDL–C target, only patients with an available LDL–C evaluation after 1 year from baseline were considered (7317 patients, 51% of initial cohort 14317 pts). Of those, 492 pts (7%) presented LDL–C at target. Among them, 187 were at very high risk (4% of very high risk subgroup) and 47 at high risk (3% of high risk subgroup). Statin intolerance was reported in 7,5% of patients (1073 out of 14317). The adherence evaluation was performed in patients having 1–year of follow–up and at least one statin purchase. It was estimated through the Proportion of Days Covered (PDC), defining as adherent patients with a PDC value ≥ 75%. 8332 (58% of initial cohort 14317 pts) met the selection criteria for PDC calculation. Of those, 3346 (40%) patients resulted as adherent (46% and 22% in very high e high CV risk categories). In a multivariable Cox regression model, adjusted for age, sex, risk factors and comorbidities, patients adherence emerged as a protective factor (HR 0.62; 95% CI 0.43–0.89; p = 0,010).

Conclusion

In a real–world setting, the achievement of LDL–C target and patient adherence was suboptimal across different CV risk categories. In a full adjusted survival model, patient adherence was independently associated with a prognosis improvement.

C67 CARDIOVASCULAR RISK CLASSIFICATION AND LIPID LOWERING TREATMENT PRESCRIPTIONS IN A REAL–WORLD: INSIGHT FROM ITALIAN COMMUNITY COHORT

Background

Lipid lowering treatment (LLT) and LDL–C target across CV risk categories might prompt consideration on further lower LDL–C levels advocated by last EAS/ESC guidelines.

Aim

The aim of the study was to provide current prevalence, clinical characteristics, LLT across different CV risk classes at the time of publication of current ESC/EAS Guidelines. Short–term prognosis was also addressed.

Methods and Results

This community–based study enrolled 6851 patients (mean age 71 years) with an LDL–C measurement and cardiological evaluation from 01–Jan–2018 until 31–Dec–2018. Of those, 4578 (67%) patients were at very high risk, 1494 (22%) at high risk, 420 (6%) at moderate risk, and 359 (5%) at low risk according to EAS/ESC 2019 guidelines. Dyslipidemia was present in three quarter of patients, and 3888 (57%) received LLT. High Efficacy (potency to reduce LDL–C ≥ 50%) LLT was prescribed in 21% of patients (23% and 10% in very high and high risk categories). There was a statistically significant difference between CV categories with respect to demographic, CV risk factors, and comorbidities. Patients at very high risk were more frequently elderly with a high proportion of patients affected by atherosclerotic CVD (ASCVD) and non–cardiac comorbidities. 394 (9%) patients at very high risk and 102 (7%) patients at high risk presented LDL–C at target. Among very high risk patients, 439 (10%) were treated with ezetimibe. At 24 months of follow–up, death occurred in 676 (8%) patients. In survival curves, adjusted for age and comorbidities, an increased risk of death and CV hospitalization was confirmed in the high risk and very high risk categories. Similar trend was confirmed considering composite endpoint of myocardial infarction and stroke.

Conclusion

In a contemporary population the strategy to achieve the ambitious LDL–C target of current Guidelines continue to be largely suboptimal and LLT is widely underused. This underlines the huge unmet need when assessed more aggressive LDL–C target advocated in current EAS/ESC guidelines.

COVID-19 and renin-angiotensin system inhibition: role of angiotensin converting enzyme 2 (ACE2) - Is there any scientific evidence for controversy?

Renin-angiotensin system (RAS) blockers are extensively used worldwide to treat many cardiovascular disorders, where they are effective in reducing both mortality and morbidity. These drugs are known to induce an increased expression of angiotensin-converting enzyme 2 (ACE2). ACE2 acts as receptor for the novel SARS coronavirus-2 (SARS-CoV-2) which raising the important issue of possible detrimental effects that RAS blockers could exert on the natural history and pathogenesis of the coronavirus disease-19 (COVID-19) and associated excessive inflammation, myocarditis and cardiac arrhythmias. We review the current knowledge on the interaction between SARS-CoV-2 infection and RAS blockers and suggest a scientific rationale for continuing RAS blockers therapy in patients with COVID-19 infection.

1177 The additive prognostic value of end-systolic pressure-volume relation by CMR in patients with with known or suspected coronary artery disease

Background

The variation between rest and peak stress end-systolic pressure-volume relation is an afterload-independent index of left ventricular contractility. This index is easily obtained during routine stress echocardiography but can be derived also during a stress cardiovascular magnetic resonance (CMR) exam, that is the gold standard for the quantification of biventricular volumes.

Purpose

The aim of this study was to assess for the first time the prognostic value ofdelta rest-stress ESPVR (DESPVR) by dipyridamole stress-CMR in patients with known or suspected coronary artery disease (CAD).

Methods

One hundred and sixty-six consecutive patients (37 females, main age 61.96 ± 10.05 years) who underwent dipyridamole stress-CMR in a high volume CMR Laboratory were considered. Abnormal wall motion and perfusion at rest and after dipyridamole were analysed. Macroscopic myocardial fibrosis was detected by the late gadolinium enhancement (LGE) technique. The ESPVR was evaluated at rest and peak stress from raw measurement of systolic arterial pressure by cuff sphygmomanometer and end-systolic volume by biplane Simpson method.

Results

An abnormal stress CMR was found in 39 (23.5%) patients; 24 patients had a reversible stress perfusion defect in at least one myocardial segment and 15 a reversible stress perfusion defect plus worsening of stress wall motion in comparison with rest. Myocardial fibrosis was detected in 69 patients (41.6%). A DESPVR < 0.009 was detected in 74 patients (44.6%).

During a median follow up of 55.51 months (IQ range 33.20 months), 54 patients (32.5%) experienced major cardiac events: 5 deaths, 2 ventricular arrhythmias, 18 coronary syndromes, and 29 heart failure hospitalization.Reversible perfusion deficit, DESPVR < 0.009, diabetes and family history were significant univariate prognosticators. In the multivariate analysisthe independent predictive factors were reversible perfusion deficit (hazard ratio-HR = 2.17, P = 0.010), DESPVR < 0.009 (HR = 1.92, P = 0.028) and diabetes (HR = 2.42, P = 0.004). The Kaplan–Meier curve for DESPVR is shown in Figure 1. The log-rank test revealed a significant difference (P = 0.003).

Conclusions

DESPRV assessed by CMR provides a prognostic stratification in patients with known or suspected coronary artery disease, in addition to that supplied by reversible perfusion deficit and diabetes.

Abstract 1177 Figure 1

P5285Pressure-volume relationship by cardiovascular magnetic resonance: feasibility and clinical implications

Background

The variation between rest and peak stress end-systolic pressure-volume relation (ESPVR; the Suga index) is easily obtained during routine stress echocardiography and has been established as a reasonably load-independent index of myocardial contractile performance that provides prognostic information above and beyond regional wall motion.

Purpose

This is the first study assessing the delta rest-stress ESPVR (DESPVR) by stress Cardiovascular Magnetic Resonance (CMR).

Methods

Eighty-five consecutive patients (19 females, main age 62.99±9.26 years) who underwent dipyridamole stress-CMR in a high volume CMR Laboratory were considered. The ESPVR was evaluated at rest and peak stress from raw measurement of systolic arterial pressure by cuff sphygmomanometer and end-systolic volume by biplane Simpson method.

Results

Mean ESPVR index at rest and peak stress was, respectively, 4.52±2.26 mmHg/mL/m2 and 4.62±2.32 mmHg/mL/m2 and mean DESPVR was 0.11±1.19 mmHg/mL/m2.

DESPVR was not associated to age or sex.

An inverse relationship between rest left ventricular end-diastolic volume index (LVEDVI) and both rest and peak ESPVR was present (R=-0.805 P<0.0001 and R=-0.795 P<0.0001, respectively), but it was absent when the DESPVR was considered (R=0.170 P=0.121).

An abnormal stress CMR was found in 22 patients and the DESPVR was comparable between patients with normal and abnormal stress exam.

During a median follow-up of 60.62 months (IQ range 36.78 months), 27 cardiovascular events occurred: 3 deaths, 1 ventricular arrhythmias, 9 coronary syndromes, 14 heart failure hospitalization. At receiver-operating characteristic (ROC) curve analysis, a DESPVR<0.009 predicted the presence of future cardiac events with a sensitivity of 0.70 and a specificity of 0.64 (P=0.049).

Conclusions

We showed for the first time that dipyridamole stress CMR can be used for the assessment of DESPVR. DESPVR was shown to be independent from chamber size and, as a consequence, can be used for a comparative assessment of patients with different diseases. DESPVR by CMR can provide a prognostic stratification and the optimal cutoff for relevant events was 0.009.

Radon survey in schools in north-east Italy

During the year 2000 the Regional Agency for Environmental Protection (ARPA) of Friuli Venezia Giulia together with the Pordenone Province carried out a survey to determine the radon concentration in the schools. About 900 measurements have been carried out in 300 schools located both in the mountainous and in the flat territory. Moreover, geological information was gathered. both on a regional scale and, where possible, on a small detailed scale. The purpose of this study is to consider the possibility of using all the data collected to discover some radon prone areas. The first results of this study seem to locate some radon prone areas where the cover consists of very permeable gravelly deposits.