Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

P77 SIEMENS ARTIS VD11 ANGIOGRAPH‘S POTENTIAL WITH THE CLEARSTENT PROTOCOL IN PERFORMING PERCUTANEOUS CORONARY ANGIOPLASTY: FIRST EXPERIENCES

Objectives

The use of the CLEARstent image functions allows you to highlight fine structures, for example the expansion of a stent. Composite images are created by averaging several frames of a scene and considering the alignment of the markers of a stent. If an ECG signal is available, the cardiac phase is also considered. Using the CLEARstent function allows you to create special reference images from any scene or natively acquired fluoroscopic scene. The goal of CLEARstent images is to optimize the procedural result of mechanical cardiac revascularization and to improve the outcomes of treated patients.

Methods

The use of the Siemens Artis VD11 angiograph requires specific technical and medical knowledge and skills regarding, at least, radiation protection, safety procedures and patient safety. The people who work with the system, who use it and who move it must have acquired this knowledge and skills in their working life The application training was provided to the medical–technical–nursing staff of the Hemodynamics Unit of the “San Luca” PO of Vallo della Lucania “by qualified Siemens personnel. The application training offered by Siemens is binding before any use of the system

Results

701 coronary angiography procedures and 118 urgent revascularizations were performed at our Hemodynamics Unit in the period from 11/27–2020 to 12/21–2021, period of use of the aforementioned angiograph, 701 coronary angiography procedures and 118 revascularizations in an emergency pattern ( STEMI–NSTEMI at high risk). In all mechanical myocardial revascularization procedures, the opening and optimal positioning of the coronary stents were verified with the CLEARstent system. There was no periprocedural complication.

Conclusions

The CLEARstent system allows to highlight fine structures, for example hypo–expanded stents, creating special reference images from any negatively acquired fluoroscopic scene, consequently allowing optimal positioning and opening of a coronary stent. Therefore, it is inserted together with intracoronary imaging techniques (IVUS, OCT) as a further aid to guide percutaneous interventions in order to optimize the acute procedural outcome of PCI and to improve the clinical outcomes of treated patients.

P60 COVID–19 (YEAR 2021) AND ACUTE MYOCARDIAL INFARCTION‘ TIME–DEPENDENT NETWORK: HUB–HEMODYNAMIC UNIT‘S EXPERIENCES

Objectives

The sudden SARS–CoV–2 emergency, has so far led to over 283 million infections and more than 5 million deaths globally, has put a strain on countries around the world. The result was a difficulty in accessing care both on an outpatient basis which resulted, in regione Campania, in a reduction in hospitalizations for ACS in the period Mar–Jun 2020 (1183) compared to the same period in 2019 (1862) (Agenas data ). The trend was inevitably reversed in the year 2021, with the new availability of access to treatment, due to both the reduction of restrictions and the vaccination coverage of the population, with a marked increase in hospitalizations for ACS as well as in the Hospital “ San Luca ”of Vallo della Lucania (Sa).

Methods

Cardiovascular diseases in 2021 are the leading cause of death in the world with 18.5 million lives lost a year and the leading cause also in Italy for both men (31.7%) and women (37.7%) ) with 230 thousand deaths certified by Istat, after 18 months of pandemic denounce a real war bulletin … The provincial cardiology network plays a fundamental role in the timeliness of the transfer to Hub centers such as the PO San Luca in the management of acute coronary syndromes.

Results

704 coronary angiography procedures and 118 emergency revascularizations (STEMI–NSTEMI at high risk Grace risk score> 140). Periprocedural complications were recorded around 0.5% (35) in line with the literature‘s data, all manageable and related to the femoral or radial puncture access.

Conclusions

In the year 2021, due to the reduction of restrictions and the marked increase in vaccination coverage, there was an increase in the number of hospitalizations for ACS and consequently in the mechanical myocardial revascularizations performed in Emergency (Stemi and Nstemi at high risk with Grace Risk Score> 140) probably linked to the lack of clinical–instrumental follow–up on an outpatient basis and day–hospital admissions in the year 2020 due to Covid–19 restrictions. At the Hemodynamics of the “San Luca” hospital (medium–volume center about 700 procedures / year), 118 emergency revascularisations were performed at 30.12.2021, compared to 82 in the same period of the year 2020.

A multiparametric ICD algorithm for heart failure risk stratification and management: an analysis in clinical practice

Funding Acknowledgements

Type of funding sources: None.

Introduction

The HeartLogic algorithm combines multiple implantable cardioverter defibrillator (ICD) sensors to identify patients at risk of heart failure (HF) events.

Purpose

We sought to evaluate the risk stratification ability of this algorithm in clinical practice. We also analyzed the alert management strategies adopted in the study group and their association with the occurrence of HF events.

Methods

The HeartLogic feature was activated in 366 ICD and cardiac resynchronization therapy ICD patients at 22 centers. The HeartLogic algorithm automatically calculates a daily HF index and identifies periods IN or OUT of an alert state on the basis of a configurable threshold (in this analysis set to 16).

Results

The HeartLogic index crossed the threshold value 273 times (0.76 alerts/patient-year) in 150 patients over a median follow-up of 11 months [25-75 percentile: 6-16]. Overall, the time IN the alert state was 11% of the total observation period. Patients experienced 36 HF hospitalizations and 8 patients died of HF (rate: 0.12 events/patient-year) during the observation period. Thirty-five events were associated with the IN alert state (0.92 events/patient-year versus 0.03 events/patient-year in the OUT of alert state). The hazard ratio in the IN/OUT of alert state comparison was (HR: 24.53, 95% CI: 8.55-70.38, p < 0.001), after adjustment for baseline clinical confounders. Alerts followed by clinical actions were associated with a lower rate of HF events (HR: 0.37, 95% CI: 0.14-0.99, p = 0.047). No differences in event rates were observed between in-office and remote alert management. By contrast, verification of HF symptoms during post-alert examination was associated with a higher risk of HF events (HR: 5.23, 95% CI: 1.98-13.83, p < 0.001).

Conclusions

This multiparametric ICD algorithm identifies patients during periods of significantly increased risk of HF events. The rate of HF events seemed lower when clinical actions were undertaken in response to alerts. Extra in-office visits did not seem to be required in order to effectively manage HeartLogic alerts, while post-alert verification of symptoms seemed useful in order to better stratify patients at risk of HF events.

Clinical profile and in-hospital course of patients with primary and secondary takotsubo syndrome: single center experience

Background

Takotsubo syndrome (TTS) is an acute cardiac disease increasingly recognized in a variety of clinical scenarios. Heart Failure Association of the ESC classified TTS in primary (occurring in the setting of psychological or emotional trigger or without clear identifiable stressors) and secondary (triggered by physical stressors or other critical illnesses). However, the clinical profile and outcome of these different subtypes is still controversial.

Aim of the study

To compare baseline features, clinical presentation and in-hospital outcomes in patients with primary or secondary TTS in a single referral center.

Methods

Overall study population included 210 patients (mean age 66.1±12.2 years, 14 male); 165 and 45 with primary and secondary TTS, respectively; consecutively enrolled from 2012 to 2019 in our center. Clinical, instrumental and laboratory data and in-hospital events were also recorded in both groups.

Results

Compared to patients with primary TTS, patients with secondary form were older (70.6±14.6 vs 64.9±11.2 years; p=0.006) and more frequently man (13.3% vs 4.8%; p=0.043). Several comorbidities such as diabetes (23.8% vs 8.9%; p=0.008); pulmonary (45.2% vs 12.9%; p<0.001); neurologic (23.8% vs 9.7%; p=0.015); nephro-urologic (31% vs 13.5%; p=0.008); psychiatric (42.9% vs 26.5%; p=0.039) and orthopedic (28.6% vs 13.5%; p=0.020) diseases were prevalent in secondary TTS patients. Atypical presentation with higher incidence of dyspnea was significantly prevalent (42.2% vs 19.4%; p=0.002) in secondary group. The number of patients with ST-T elevation on admission was similar (80% vs 77%; p=0.5) in both groups. Prolonged QT interval in a majority of secondary TTS patients (46.3% vs 28.4%; p=0.029) was detected. Peak levels of troponin, creatine-kinase and myoglobin did not differ between the two groups. Echocardiography revealed larger left ventricular end-diastolic and end-systolic volumes (62.7±25.3 vs 50.6±14.3 ml/mq; p=0.024 and 35.1±14.5 vs 28.7±9 ml/mq; p=0.048) at presentation in secondary TTS, however no differences in baseline left ventricular ejection fraction were detected. Furthermore, the prevalence of apical ballooning was similar between the two groups. Of note, secondary TTS patients experienced more frequently acute heart failure (40.5% vs 23.1%; p=0.024), hyperkinetic arrhythmia (9.1% vs 1.9%; p=0.022), cardiogenic shock (15.9% vs 3.2%; p=0.002), and mechanical ventilation use (9.3% vs 1.3%; p=0.006) during the acute phase. In-hospital stay (10.8±6.9 vs 7.4±6.2 days, p=0.004) was longer in this cohort.

Conclusion

Our results demonstrate that to classify TTS patients in primary or secondary form is clinically relevant. Secondary form generally is associated to higher rate of comorbidities and to atypical presentation. Owing to the worse in-hospital outcome of the secondary TTS patients a tailored and more intensive treatment should be adopted in this cohort.

Funding Acknowledgement

Type of funding source: None

P322 Dynamic changes of left ventricular cardiac mechanics in takotsubo syndrome: a preliminary study

Background

Takotsubo syndrome (TTS) is a transient left ventricular (LV) heart failure due to a reversible systolic dysfunction, usually recovering within days or weeks.

Purpose

To assess the dynamic changes of LV cardiac mechanics in a small cohort of TTS patients through the estimation of myocardial work, a newly developed non-invasive approach which allows correction of global longitudinal strain (GLS) for systolic blood pressure.

Methods

Twenty-four patients (mean age, 63.8 ± 8.4 yy; all female) with TTS diagnosis were retrospectively enrolled. Data from transthoracic two-dimensional and speckle-tracking echocardiography on admission and at 3 months follow-up were collected. Global myocardial work index (GWI, mmHg%) was calculated as the area of the LV pressure (LVP)-strain loop, where LVP was estimated noninvasively using a standard waveform fitted to valvular events and scaled to systolic blood pressure. From GWI we also assessed: global constructive work (GCW, mmHg%: work performed during shortening in systole + negative work during lenghtening in isovolumetric relaxation, IVR), global wasted work (GWW, mmHg%: negative workperformed by a segment during lengthening in systole + work performed during shortening in IVR) and global work efficiency (GWE, %: constructive work divided by the sum of constructive and wasted work). Baseline demographic and clinical features, including in-hospital adverse events as acute heart failure, cardiogenic shock and cardiac death, were also assessed.

Results

On overall population, a reduced ejection fraction (EF) and GLS were detected at hospital admission, with a substantial improvement at discharge and at follow-up (from 41.7 ± 8.3% to 54.5 ± 6.5% to 60.2 ± 4.6% for EF and from -11.7 ± 4.5% to -16.2 ± 4.2 to -21.3 ± 2.8% for GLS, respectively). Similarly, global MWI and MWE both showed a positive trend during the hospital course and at follow-up: MWI increased from 1048.8 ± 580.5 to 1522.4 ± 695.4 to 2021.1 ± 388.6 mmHg% and MWE from 78.7 ± 10.2 to 91.1 ± 4.6 to 94.5 ± 3.8 %. Increasing in MWE has been obtained through an improvement of GCW (from 1195.9 ± 537.2 to 1651.3 ± 700.3 to 2316.8 ± 490.6 mmHg%) and a contemporary decreasing in GWW (from 237.9 ± 137.2 to 106 ± 37.2 to 131.8 ± 150.8 mmHg%).

In-hospital adverse events occurred in 8 (50%) patients. Of note, despite EF and GLS at admission showed no significant differences, patients experiencing in-hospital adverse events showed lower value of acute MWI (725.6 ± 289.6 vs 1371.9 ± 632.1 mmHg%; p= 0.02) and MWE (73.6 ± 3.4 vs 83.8 ± 12.4%; p= 0.04) compared to patients without in-hospital complications.

Conclusion

Non-invasive assessment of myocardial work through echocardiographic strain-based technique could be useful to demonstrate the peculiar dynamic changes of cardiac mechanics and for a better risk stratification in TTS patients.

Abstract P322 Figure.

Abstract P3-13-08: Preclinical validation of a new tumor imaging agent targeting αvβ3 to detect breast tumor using NIR-light imaging

Surgery is still a essential step for breast cancer treatment. Complete tumor removal during surgery rely on surgeon's ability to differentiate tumor from normal tissue. To date, no intra operative method is available and reliable enough to help the surgeon delineate precisely tumor extension in the adjacent normal tissue. Thus, surgeons rely solely on pre operative imaging techniques to delineate tumor margins. Recent advances made in the field of non-invasive imaging and vectorized nano-size particles have revealed a remarkable potential for improved tumor-margin detection. AngiostampTM is a new fluorescent agent for intra operative imaging. This system provides strong binding on αvβ3 integrin-rich tumor neoangiogenesis. Our general hypothesis is that targeting αvβ3 integrin-rich breast carcinoma neoangiogenesis should provide improved delivery of diagnostic compounds and assist surgeons intra operatively using near-infrared imaging techniques.

We conducted preclinical studies to evaluate the distribution of angiostampTM in vivo in murine breast tumor model and to determine the expression of αvβ3 integrin on human breast specimens.

The capacity of AngiostampTM to target αvβ3 integrin was assessed in 4T1 breast tumor model. After tumor implantation, mices were injected with AngiostampTM or a saline solution. Detection of the tumors was performed at different timepoints (early, progressive and established tumors, N= 24 mices/timepoint) using near infrared (NIR) imaging system (FluobeamTM) to detect fluorescence in tumor tissue.

In parallel, the expression of αvβ3 integrins in normal breast tissue, benign lesions (N=20) and various tumors subtypes (N=120) was assessed by immunohistochemistry.

In mice injected with AngiostampTM, fluorescence was observed only within the tumors with low background. AngiostampTM labeled tumors at all timepoint. No false negative fluorescence was found as confirmed by histopathological analyses.

In humans, the αvβ3 integrin are expressed in normal breast epithelial cells and benign metaplastic or proliferative epithelial lesions. However, due to the density of carcinomatous cells, the level of expression was much higher in breast cancer: 94% of invasive ductal carcinomas and 100% of invasive lobular carcinomas had a membranous staining (moderate to high intensity). Expression in breast cancer was not restricted to tumor subtypes neither hormone receptor expression nor SBR grade.

Based on this preclinical demonstration, AngiostampTM could allow a better intra-operative detection of tumor bed in breast cancer, increasing the efficiency of surgical procedure especially for infraclinic disease and decreasing the rate of second surgery. Preclinical development is ongoing and the first clinical trial is expected in 2017.

Citation Format: Beurrier F, Dutour A, Chen Y, Froc E, Gayet P, Guillermet S, Rizo P, Chopin N, Faure C, Dammaco MA, Klinger S, Ferraioli D, Garin G, Treilleux I. Preclinical validation of a new tumor imaging agent targeting αvβ3 to detect breast tumor using NIR-light imaging [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-08.

[Axillary lymph node dissection after breast reconstruction by pedicled Latissimus dorsi: Operative steps and outcomes]

OBJECTIVES

We retrospectively reviewed all the cases of axillary lymph node dissection (ALND) performed within a year after an immediate breast reconstruction procedure by a pedicled Latissimus dorsi, which is transferred to the anterior thoracic wall through an axillary funnel. Operative technical steps are described taking account of the new anatomical relationship of the axilla.

METHODS

We assessed postoperative immediate complications and late sequelaes.

RESULTS

From 1999 to 2013, 21 ALND were performed. Immediate postoperative period was free of complication in 85% of cases when following the operative steps described in this work. Partial or total necrosis of the reconstructed breast did not occur. With a median follow-up of 64 months, 6 patients (28% of the whole population) presented at least one sequelae like a feeling of heavy arm (n=2, 9%) or a lymphedema (n=3, 14%), a chronic neuropathic pain (n=4, 19%) or a limitation in the arm range of motion (n=2, 9%).

CONCLUSION

ALND after immediate breast reconstruction by a pedicled Latissimus dorsi is feasible and safe, without any additional postoperative complication in comparison with a classic ALND.