Abnormal immune activation and fibrosis of epicardial adipose tissue in people living with HIV: results from the PIECVIH study

Background

Increased Epicardial Adipose Tissue (EAT) volume has been associated with increased risk of CAD in people living with HIV (PLWH). However, the underlying mechanisms remain unknown.

Purpose

We conducted the PIECVIH study to compare EAT properties in relation with CAD between PLWH and HIV-negative patients, all undergoing coronary artery bypass graft (CABG).

Methods

The PIECVIH study is a cross sectional prospective study performed in a single center enrolling 11 ART-controlled PLWH and 11 matched (age ± 3 years and sex) HIV-negative patients requiring CABG. During surgery, EAT and thoracic subcutaneous fat samples were taken. Gene expression was analyzed in samples with sufficient mRNA quality (7 PLWH and 7 HIV− for subcutaneous fat, 9 PLWH and 8 HIV− samples for EAT). The expression of 30 genes, mainly related to inflammation, immune activation, fibrosis and adipokines, was evaluated and related to the expression of the reference gene 18S.

Results

The mean age of the cohort was 59.8 years (100% male). The cardiovascular risk profile was quite similar between both groups including 66% smokers, 64% hypercholesterolemia, 36% hypertriglyceridemia and 56% hypertension. However, HIV− subjects had a higher prevalence of diabetes (73% vs 18%, p=0.002) and a higher body mass index than HIV− (23,2 vs 27.5 kg/m2, p=0.017). The level of gene expression of all tested genes was not different between PLWH and HIV− subjects in subcutaneous fat. Conversely, in EAT, the relative expression of IL-6 and CCL2 was 3–5-fold higher in samples issued from PLWH than from HIV−: respectively 0.46 vs 0.13 (p=0.03) and 1.13 vs 0.24 (p=0.03). Moreover, only in EAT, and only in PLWH, the expression of the chemokines CCL2 and CCL5 and of the macrophage immune activation markers (CD68, CD163, CD206), was globally related to the expression of genes involved into fibrosis: collagen genes (COL1A1, COL3A1, COL3A1, COL6A2, COL6A3), TGFB, LOX (lysyl-oxidase) and ASAH1 (acid ceraminidase). Only in EAT and only in PLWH, the expression of IGF1 and CES (carboxylesterase 1), two genes associated with increased cardiovascular risk, was related to the expression of genes associated with immune activation, fibrosis and vascularization (VEGFA). Only in PLWH, the Gensini score, evaluating the severity of CAD, was associated with EAT expression of collagen 6 and of the CV risk factors IGF1 and CES.

Conclusion

In very high CV risk subjects undergoing CABG, inflammation/immune activation of EAT was higher in PLWH as compared to controls. In EAT of PLWH, immune activation was strongly associated with fibrosis stressing for a dysfunctional EAT. Moreover, the severity of CAD, as addressed by the Gensini score, was associated with collagen 6 expression, a deleterious collagen in the context of EAT fibrosis. We propose that in PLWH, altered EAT immune profile and fibrosis could be responsible for reported accelerated CAD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French Agency for Research on AIDS and Viral Hepatitis

Coronary artery calcium score in people living with HIV. Results from the French CAC study

Background

People living with HIV (PLWH) have a higher risk of CAD. Whether coronary artery calcification (CAC) score could better stratify the CV risk remains debated in this middle age population.

Purpose

We conducted the French CAC score study to compare the CAC score between PLHIV and HIV− subjects at intermediate risk.

Methods

689 subjects (257 PLHIV and 432 HIV−) were consecutively addressed for CV risk evaluation including CAC score assessment in 2 centers between 2013 and 2019. Subjects were included if they were 18 years'old or older, had no known cardiovascular disease and had a CAC score along with cardiometabolic assessment.

Results

The mean age of the cohort was 59.3 years ± 10.7 and predominantly male (54%). PLHIV were younger (55.8 years ± 9.1 vs 61.3±11.3, p<0.004), with a lower rate of diabetics (18% vs 26%, p=0.009) and lower levels of total cholesterol, LDLc, and HDLc (2.0 mmol/l vs, 2.2 mmol/l; 1.2 mmol/L vs 1.3 mmol/L; and 1.2 mmol/L vs 1.4 mol/L respectively, all p<0.001). The prevalence of hypertension, dyslipidemia and obesity was similar between PLHIV and the HIV− group (40%, 43% and 21%, respectively). No differences were observed in CV therapies prescribed including antihypertensive drugs and statins between PLHIV and the HIV− group (39% vs 37%, p=0.54 and 46% vs 39%, p=0.065). In contrast, PLHIV had higher rate of triglycerides (1.4 mmol/L vs 1.2 mmol/L, p=0.01), higher rate of active smoking (28% vs 14%, p<0.001), CRP level (4.0 mg/L vs 2.9 mg/L, p<0.001) along with higher black ethnicity representation (17% vs 5%;, p<0.001). 96% of PLHIV were under antiretroviral therapy at the time of enrollment with 88% who had been exposed to protease inhibitors. In subjects who had carotid and/or limb ultrasound evaluation (67% and 45% respectively in PLHIV and HIV), no increased rate of arterial stenosis >50% was found (13% vs 8%, p=0.16). Concerning, CV risk estimation using 10-year ASCVD and HEART scores, we observed that the median ASCVD score was similar between PLHIV and HIV− group (10.7% vs 9.8, p=0.15) but that PLHIV had a higher HEART score (3.0% vs 2.0%, p<0.001). The repartition between the ASCVD or HEART scores classes between the 2 groups was similar with 80% of the cohort classified as low or intermediate CV risk with the ASCVD score and 88% at intermediate or borderline CV risk with the HEART score. However, no statistically significant differences was found between the 2 groups regarding the prevalence of CAC = 0 (41% vs 44%, p=0.52) and the median CAC score (7.7 vs 8.2, p=0.81).

Conclusion

In this cohort of subjects at intermediate CV risk according to CV risk scores estimation (ASCVD or HEART scores), PLHIV had a similar prevalence of CAC = 0 and median CAC scores as compared to HIV− subjects despite a younger age (6 years). Longitudinal follow up will explore whether this similar CAC score evaluation will be translated into higher CV events.

Funding Acknowledgement

Type of funding sources: None.

Comparison of HIV-Infected and Noninfected Patients Undergoing Bariatric Surgery: The ObeVIH Study

OBJECTIVE

The aim of this study was to compare clinical characteristics and adipose/liver tissue histology analysis in HIV-infected and HIV-uninfected subjects undergoing bariatric surgery.

DESIGN

This was a cross-sectional study of HIV-infected subjects undergoing single-port sleeve gastrectomy with prospective enrolment and frequency age (±5 years), sex, and body mass index (BMI, ± 5 kg/m2) matched on HIV-uninfected subjects.

METHODS

This study was conducted at a single clinical site at Pitié-Salpêtrière hospital-Paris-France comprising 19 HIV-uninfected and 21 HIV-infected subjects with plasma VL < 20 copies/mL, all with a BMI > 40 kg/m2 or >35 kg/m2 with comorbidities. Histology of subcutaneous and visceral abdominal adipose tissue (SCAT/VAT) and liver biopsies was collected during single-port sleeve gastrectomy. Outcomes included anthropometric characteristics, comorbidities, cardiovascular parameters, adipose tissue, and liver histology.

RESULTS

The age of HIV-infected participants was (median, interquartile range IQR) 48 y (42-51), with 76.2% females, a BMI of 41.4 kg/m2 (37.3-44.4), an antiretroviral duration of 16 y (8-21), current integrase strand transfer inhibitor (INSTI)-based regimen in 15 participants and non-INSTI regimen in 6 participants, and a CD4 count of 864/mm3 (560-1066). The age of controls was 43 y (37-51), with 78.9% females and a BMI of 39.2 kg/m2 (36.3-42.6). Anthropometric characteristics, comorbidities, and cardiovascular parameters did not differ according to HIV status and INSTI treatment. The number of macrophage crown-like structures in SCAT was lower in INSTI-treated participants than in HIV-uninfected participants (P = 0.02) and non-INSTI-treated HIV-infected subjects (P = 0.07). Hepatic steatosis and liver disease severity global score were lower in INSTI-treated participants than in non-INSTI-treated HIV-infected participants (P = 0.05 and P = 0.04, respectively).

CONCLUSIONS

HIV-infected and HIV-uninfected subjects undergoing bariatric surgery presented a similar profile regarding anthropometric measures, cardiovascular parameters, and comorbidities. However, INSTI-treated participants presented milder SCAT and liver alterations than non-INSTI-treated participants.

Dunnigan lipodystrophy syndrome: French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins)

Dunnigan syndrome, or Familial Partial Lipodystrophy type 2 (FPLD2; ORPHA 2348), is a rare autosomal dominant disorder due to pathogenic variants of the LMNA gene. The objective of the French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins), is to provide health professionals with a guide to optimal management and care of patients with FPLD2, based on a critical literature review and multidisciplinary expert consensus. The PNDS, written by members of the French National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity (PRISIS), is available on the French Health Authority website (in French). Dunnigan syndrome is characterized by a partial atrophy of the subcutaneous adipose tissue and by an insulin resistance syndrome, associated with a risk of metabolic, cardiovascular and muscular complications. Its prevalence, assessed at 1/100.000 in Europe, is probably considerably underestimated. Thorough clinical examination is key to diagnosis. Biochemical testing frequently shows hyperinsulinemia, abnormal glucose tolerance and hypertriglyceridemia. Elevated hepatic transaminases (hepatic steatosis) and creatine phosphokinase, and hyperandrogenism in women, are common. Molecular analysis of the LMNA gene confirms diagnosis and allows for family investigations. Regular screening and multidisciplinary monitoring of the associated complications are necessary. Diabetes frequently develops from puberty onwards. Hypertriglyceridemia may lead to acute pancreatitis. Early atherosclerosis and cardiomyopathy should be monitored. In women, polycystic ovary syndrome is common. Overall, the management of patients with Dunnigan syndrome requires the collaboration of several health care providers. The attending physician, in conjunction with the national care network, will ensure that the patient receives optimal care through regular follow-up and screening. The various elements of this PNDS are described to provide such a support.

Restoration of normal sinus rhythm in atrial fibrillation: impact of reverse remodelling of right chambers on tricuspid regurgitation severity

Background

The severity of tricuspid regurgitation (TR) in patients with restored normal sinus rhythm (SR) after atrial fibrillation (AF) has been poorly assessed.

Purpose

Our study aimed to assess (1) right chamber remodelling and (2) TR severity in patients with AF who have had their rhythms restored to normal sinus.

Methods

We prospectively evaluated 94 consecutive patients hospitalized for AF who received either ablation, direct current cardioversion, or pharmacological therapy. Patients were divided into two groups according to their cardiac rhythm at 6 months follow up (6M): restoration to SR (SR group, n=54), persistence of AF (AF group, n=40). TR vena contracta (VC), TR grade severity was divided into 4 grades using an integrated approach (0: none or trace; 1: mild; 2: moderate; 3: severe TR). Two dimensional (2D) end diastolic (ED) tricuspid annulus (TA) diameter in the apical 4 chambers view, three-dimensional (3D) indexed volumes (3D Vi) of the right atrium (RA) and right ventricle (RV) in end systole (ES) and ED were acquired using transthoracic echocardiography at admission and at 6M.

Results

At 6M, in the SR group a significant improvement in TR VC (Figure A) and TR grade (Figure B) were noted, whereas there was no differences in the AF group (0.41 vs. 0.42cm, p=0.24 for TR VC; 1.70 vs. 1.76, p=0.16 for mean TR grade). In the SR group a significant reduction in 3D ES RV Vi, 2D ED TA diameter, 3D ES and ED Vi of the RA (Table) were observed. Regression of TR VC was correlated with regression of right cavities parameters (ρ=0.47, p&lt;0.001 for 2D ED TA diameter; ρ=0.34, p&lt;0.005 for 3D ES RA Vi; ρ=0.33, p&lt;0.005 for 3D ED RV Vi; ρ=0.29, p&lt;0.005 for 3D ES RV Vi).

Conclusion

Restoration of normal SR in patients with AF results in beneficial remodelling of right cavities at 6M of follow-up which were associated with a significant decrease in TR severity. Strategies for normal SR restoration in patients with AF and TR should be vigorously attempted.

TR Evolution

Funding Acknowledgement

Type of funding source: None

Prognosis of acute kidney injury during acute heart failure: the role of diuretics

Background

Acute kidney injury (AKI) frequently occurs after diuretic treatment initiation during acute heart failure (AHF). Treatment-induced hemoconcentration seems associated with improved prognosis. Transient AKI, with or without hemoconcentration, is of unsettled prognosis.

Purpose

We aimed to determine the independent prognostic values of transient AKI, persistent AKI and hemoconcentration in the context of hospitalized AHF.

Methods

Data were obtained from our institution's Clinical Data Warehouse. Patients that visited our unit at least once were screened. All hospitalizations in our institution were examined (&gt;30 hospitals). Inclusion criteria were: ≥1 hospitalization with ≥1 recorded furosemide administration and ≥1 AHF ICD-10 code. Only the first hospitalization fulfilling these criteria was considered. AKI during 1–13 days following first furosemide administration was defined based on Kidney Disease Improving Global Outcome guidelines. Hemoconcentration was defined as an increase in serum proteins ≥5 g/l during the same period. We performed multivariate logistic regression to determine which characteristics were predictive of AKI. We used Cox regression of 100-days all-cause mortality using several confounders to determine the prognostic values of transient AKI (lasting &lt;14 days), persistent AKI (lasting ≥14 days) and hemoconcentration. To account for immortality bias, AKI and hemoconcentration were treated as time-dependent covariates.

Results

We included 579 patients in the study. Median follow-up was 114 days. AKI following furosemide initiation occurred in 234 patients (40.4%). Patients that experienced AKI more frequently suffered from chronic kidney disease (43.6% vs. 33%, p=0.01) or presented with right ventricular dilatation (12% vs. 6.7%, p=0.04). Independent predictors of AKI were arterial hypertension (adjusted OR: 1.86 [1.08–3.22]), elevated serum creatinine at baseline (adjusted OR: 1.07 [1.01–1.14] per 10 μmol/l increase) and initial intravenous furosemide (adjusted OR: 2.42 [1.39–4.29]). Death during follow-up occurred in 35% of patients in the AKI group compared to 21% in the non-AKI group (p&lt;0.001). In Cox regression, persistent AKI was independently associated with increased mortality in a period of 100 days following furosemide initiation (adjusted HR: 2.31 [1.07–4.99]). Transient AKI was not significantly associated with mortality (adjusted HR: 0.64 [0.34–1.19]). Hemoconcentration was independently associated with decreased mortality (adjusted HR: 0.46 [0.27–0.79]).

Conclusion

In the context of hospitalized AHF, AKI that developed 1–13 days after furosemide initiation and that lasted ≥14 days was independently associated with decreased 100 days survival. Hemoconcentration, using a clinically relevant definition, was independently associated with improved survival. These findings show that serum creatinine and proteins, routinely used and with limited cost, accurately stratify mortality risk during AHF.

Kaplan-Meier curves

Funding Acknowledgement

Type of funding source: None

Impact of rhythm in non-valvular atrial fibrillation on four cardiac chamber deformation imaging

Background

Few studies have assessed the evolution of cardiac chambers deformation imaging in patients with atrial fibrillation (AF) according to cardiac rhythm outcome.

Purpose

To evaluate cardiac chamber deformation imaging in patients admitted for AF and the evolution at 6-month follow-up (M6).

Methods

In forty-one consecutive patients hospitalised for AF two-dimensional transthoracic echocardiography was performed at admission (M0) and after six months (M6) of follow up. In addition to the usual parameters of chamber size and function, chamber deformation imaging was obtained including global left atrium (LA) and right atrium (RA) reservoir strain, global left ventricular (LV) and right ventricular (RV) free wall longitudinal strain. Patients were divided into three groups according to their cardiac rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) (n=23), AF at M0 and AF at M6 (AF-AF) (n=11), SR at M0 (spontaneous conversion before the first echocardiography exam) and SR in M6 (SR-SR) (n=7)

Results

In comparison with SR patients (n=7), at M0, AF patients (n=34)) had lower global LA reservoir strain (+5.2 (+0.4 to 12.8) versus +33.2 (+27.0 to +51.5)%; p&lt;0.001), lower global RA reservoir strain (+8.6 (−5.4 to 11.6) versus +24.3 (+12.3 to +44.9)%; p&lt;0.001), lower global LV longitudinal strain (respectively −12.8 (−15.2 to −10.4) versus −19.1 (−21.8 to −18.3)%; p&lt;0.001) and lower global RV longitudinal strain (respectively −14.2 (−17.3 to −10.7) versus −23.8 (−31.1 to −16.2)%; p=0.001). When compared with the AF-SR group at M0 the AF-AF group had no significant differences with regard to global LA and RA reservoir strain, global LV and RV longitudinal strain (Table). Between M0 and M6 there was a significant improvement in global longitudinal strain of the four chambers in the AF-SR group whereas no improvements were noted in the AF-AF and SR-SR group (Figure).

Conclusion

Initial atrial and ventricular deformations were not associated with rhythm outcome at six-month follow up in AF. The improvement in strain in all four chambers strain suggests global reverse remodelling all cardiac cavities with the restoration of sinus rhythm.

Evolution of strain between M0 and M6

Funding Acknowledgement

Type of funding source: None

P350 Right atrial remodelling in atrial fibrillation using three dimensional transthoracic echocardiography and strain imaging

Background

Evaluation of right atrial cavities and right atrial (RA) remodelling in atrial fibrillation (AF) has been poorly studied.

Purpose

The aim of this study was to evaluate in AF, the role of three-dimensional (3D) transthoracic echocardiography (TTE) and strain to refine the evaluation of the RA according to evolution of cardiac rhythm ad mid-term follow-up.

Methods

A complete 2D and 3D TTE was performed in patient hospitalized for AF. In addition to the usual parameters, RA parameters were specifically assessed: 3D RA end-systolic (ES) and end-diastolic (ED) volume, RA ejection fraction (EF) and the global longitudinal strain (GLS) of the RA. A complete clinical evaluation and electrocardiogram were performed at admission (M0) and 6 months after inclusion (M6) to determine the cardiac rhythm at follow-up.

Results

34 consecutive patients hospitalized for AF were analysed. At M0, there was no significant difference between 2D RA ES volume and the 3D RA ES volume. Three groups of patients were individualized according to cardiac rhythm at M0 and M6: AF at M0 and AF at M6 (AF-AF), AF at M0 and sinus rhythm (SR) at M6 (AF-SR), SR at M0 (spontaneous reduction before the admission ECG) and SR at M6 (SR-SR). At M0 echocardiography, in the AF-AF group and AF-SR in comparison with SR-SR group were as follow: the 3D RA ED volume was significantly higher (respectively 21.6 (18.2-26.6) and 26.9 (19.4-36.8) versus 11.3 (6.9-16.6) mL/m2 ; p = 0.0025), the 3D RAEF was significantly lower (42.2 (35.1-44.7) and 34.5 (24.1-38.6) versus 57.6 (53.4-62.2)%; p = 0.0105) and the RA GLS was also significantly lower (7.6 (6.5-10.5) and 9.1 (5.8-11.2) versus 26.6 (22.0-35.0)%; p = 0.0001) (Figure 1).

Conclusion

3D ultrasound and strain could be useful tools for evaluating the anatomical and functional RA remodelling in AF, to be further validated in a larger ongoing study.

Abstract P350 Figure 1

P5338Atherosclerotic cardiovascular events in people living with Human Immunodeficiency Virus

Background

People living with Human Immunodeficiency Virus (PLWHIV) under antiretrovirals have an increased risk of atherosclerotic cardiovascular disease (ASCVD) events. The risk factors associated with ASCVD events in this high risk population are various including traditional vascular risk factors and specific HIV-related factors. However their respective influence is questionable.

Purpose

Our aim was to determine the incidence of ASCVD events in a large cohort of PLWHIV and to identify the risk factors associated.

Methods

We conducted a longitudinal observational cohort study of asymptomatic PLWHIV at high risk of ASCVD addressed to our preventive cardiovascular unit for non-invasive cardiovascular evaluation. The first ASCVD event was censored and included CV death, acute coronary syndromes, coronary and peripheral revascularizations (PCI or CABG or endarterectomy or limb procedures) and ischemic strokes.

Results

From January 2003 to December 2014, 763 consecutive asymptomatic PLWHIV were enrolled (mean age of 51.3±8.3 years, 87% men, 90% were free of known coronary artery disease, mean Left ventricular ejection fraction 60%). At baseline, traditional CV risk factors were as follow: 54% had dyslipidemia, 43% hypertension, 35% were active smokers, 22% had family history of CAD and 11% were diabetics. Statins were prescribed in 38% of the cohort, aspirin in 14%, clopidogrel in 14% betablockers in 14%, RAS blockers in 32%, Calcium channel blockers in 8%. At baseline, median duration of HIV seropositivity was 19.8 years (14.0–23.6), 94% were under ARV predominantly protease inhibitors (68%). Median CD4 cell count was 545/mm3 (404–745) and 92% had undetectable HIV viral load. During a median follow up of 5.8 years (3.7–8.7), 58 (7.3%) subjects had a first ASCVD event (incidence of 12.70 [9.78–16.51] per 1000 persons-years) including 5 cardiovascular deaths, 14 ACS, 20 coronary revascularizations, 13 peripheral vascular procedures and 6 strokes) with a median time of occurrence of 3.1 years (1.5–5.1). CV death (first and second ASCVD events) occurred in 8 patients (22%) after CV death related to malignancies (33%) but before deaths related to unexplained causes (21%), infectious disease (13%), liver disease (8%) and suicides (3%). Coronary events including coronary death, MI, and coronary revascularization occurred in 39 patients (5.2%); Incidence of 8.28 [6.00–11.43] per 1000 persons-years. Conventional multivariate Cox model shows that age and tobacco were the independent risk factors associated with ACSVD events [Hazard ratio (HR) 1.04, 95% CI 0.99–1.09, p=0.05 and HR 2.17, 95% CI 1.07–4.38, p=0.03].

Conclusion

Traditional vascular risk factors (age and active smoking) are associated with the occurrence of ASCVD events predominantly coronary artery disease in our observational cohort of asymptomatic PLWIHV at high risk for ASCVD. Cardiovascular prevention including tobacco cease action is mandatory in the aging HIV population.

P5341Predictive factors of atherosclerotic cardiovascular diseases events in HIV-HVC co-infected patients: results from hepavih ANRS co13 cohort

Introduction

Several studies highlighted an increased risk of cardiovascular disease (CVD) in HIV-HCV co-infected patients without clearly identifying specific virologic factors associated with atherosclerotic CVD (ASCVD) events.

Purpose

Hence, we analyzed data collection from the French nationwide ANRS CO13 HEPAVIH cohort to determine the incidence of ASCVD events in HIV-HCV co-infected patients and the predictive factors associated with its occurrence.

Methods

The French multicenter nationwide ANRS CO13 HEPAVIH clinic-based cohort collected prospective clinical and biological data from HIV-HCV co-infected patients followed-up in 28 different university hospitals between December 2005 to November 2016. Participants with at least one year of follow-up were included. Primary outcome was the occurrence of major ASCVD events (cardiovascular death, acute coronary syndrome, coronary revascularization and stroke). Secondary outcomes were total ASCVD events including major ASCVD events and minor ASCVD events (peripheral arterial disease [PAD]). Incidence rates were estimated using Aalen-Johansen method and factors associated with ASCVD identified with Cox proportional hazards models.

Results

A total of 1213 patients were included: median age 45.4 years [42.1–49.0], 70.3% men, current smoking 70.2%, overweight 19.5%, liver cirrhosis 18.9%, chronic alcohol consumption 7.8%, diabetes mellitus (5.9%), personal history of CVD 2.7%, and statins use 4.1%. After a median follow-up of 5.1 years [3.9–7.0], 44 participants experienced at least one ASCVD event (26 major ASCVD event, and 20 a minor event). Incidences for total, major and minor ASCVD events were of 6.98 [5.19; 9.38], 4.01 [2.78; 6.00], and 3.17 [2.05; 4.92] per 1000 person-years, respectively. Personal history of CVD (Hazard Ratio (HR)=13.94 [4.25–45.66]), high total cholesterol (HR=1.63 [1.24–2.15]), low HDL cholesterol (HR=0.08 [0.02–0.34]) and undetectable HIV viral load (HR=0.41 [0.18–0.96]) were identified as independent factors associated with major ASCVD events while cirrhosis status, liver fibrosis and HCV sustained viral response were not.

Cumulative incidence of CV events

Conclusion

HIV-HCV co-infected patients experience a high incidence of ASCVD events both coronary and peripheral artery diseases. Traditional CV risk factors are the main determinants of ASCVD whereas undetectable HIV viral load seems to be protective. Management of cholesterol abnormalities and controlling viral load are essential to modify this high cardiovascular risk.

Acknowledgement/Funding

Agence Natoinale de Recherche sur le SIDA et les Hépatites virales

How to improve the quality of a disease management program for HIV-infected patients using a computerized data system. The Saint-Antoine Orchestra program

OBJECTIVES

The emergence of non-AIDS-related events in the HIV-infected population experiencing a longer life expectancy implies the implementation of a comprehensive approach of HIV clinical management through better access to care, prevention, and early diagnosis of co-morbidities.

METHODS

The Orchestra program is a computer-assisted HIV care and support tool implemented since December 2004 in the outpatient clinic of a University Hospital set in Paris, France. The intervention aims at improving access to HIV information care and support specifically targeted five areas of actions: cardiovascular risk factors; gynecological follow-up; anti-hepatitis B virus (HBV) vaccine coverage; sexuality and prevention of sexually transmitted infections; and compliance to antiretrovirals. The impact of this program was examined prospectively on a "before-after" basis after a two-year implementation.

RESULTS

In the two-year period, 1717 patients were regularly followed. The level of the database information significantly increased in time (low density lipoprotein (LDL) cholesterol and glycemia were informed in 74% of patients at inclusion versus 95% at two years, and 83% versus 97%, p < 0.001, respectively). The number of targeted interventions was also higher. For eligible women, papanicolaou smears and mammography were prescribed in 52% of cases after intervention, versus 44% at inclusion, p0.04 and 83% versus 50%, p < 0.001, respectively. Indicators of care eventually improved significantly. Initially 72% non-adherent patients declared to be adherent after the intervention ( p < 0.001) and 67% of patients with initial LDL-hypercholesterolemia normalized their LDL level within two years ( p < 0.001).

CONCLUSION

The Orchestra program has provided a unique opportunity to assess and improve prevention and management of co-morbidities in HIV patients.

[Low molecular weight heparin and non valvular atrial fibrillation]

Low molecular weight heparin (LMWH) are obtained through chemical or enzyme depolymerisation of unfractioned heparins (UFH). LMWHs present several advantages over UFH: they exhibit a smaller interindividual variability of the anticoagulant effect, they have a greater bioavailability, a longer plasma half-life and do not require monitoring of the anticoagulant effect. LMWH have restrictive indications in AF patients, cardioversion (II level C and TEE for ACC/AHA/ESC and 2C for ACCP guidelines) or use as a bridge therapy (IIB, level C for ACC/AHA/ESC). The ACE study (Anticoagulation for cardioversion using enoxaparin), showed a reduction, though not statistically significant, of 42% of the composite end point (embolic event, major bleeding and death) 2.8% under enoxaparin vs. 4.8 % under conventional treatment, relative risk 0.58, CI 95% 0.23-1.46). Other studies, using dalteparin, confirmed that an anticoagulant treatment using LMWH followed by warfarin was at least as good as conventional management. ACUTE II (Assessment of cardioversion using transesophageal echochardiography), a randomized multicenter trial, compared the efficacy and tolerance of enoxaparin (1 mg/kg every 12 hours) and UFH in 155 patients eligible for a TEE-guided cardioversion. These patients were administered LMWH or UFH for 24 hours before TEE or cardioversion. There were no significative differences regarding the incidence of the study end points, in particular stroke and bleeding, and no death occurred. HAEST (Heparin in acute embolic stroke trial), a randomized, placebo-controlled, double blind trial failed to show the LMWH superiority over aspirin in patients with acute ischemic stroke and atrial fibrillation. Finally, LMWH have been proposed as a bridge therapy in patients under chronic VKA prior to surgery or invasive procedures. This strategy resulted in a low rate of thromboembolic events and major bleedings.

Clinical characteristics and mid-term prognosis of acute coronary syndrome in HIV-infected patients on antiretroviral therapy

OBJECTIVES

Acute coronary syndromes (ACSs) and coronary artery disease are emerging complications in HIV-infected patients on highly active antiretroviral treatment. The aim of this study was to determine the mid-term prognosis of ACS in HIV-infected patients.

METHODS

We evaluated the clinical characteristics and follow-up profile [38+/-15 months; mean+/-standard deviation (SD)] of ACS in 20 HIV-infected patients (mean +/-SD: age 44+/-8 years; range 35-65 years). All had coronary angiograms performed mean time 3+/-48 h after the onset of symptoms.

RESULTS

Eighteen patients were on antiretroviral therapy, of whom 13 patients were on regimens including protease inhibitors (mean duration+/-SD: 19+/-13 months). Fifteen patients had a first episode of ST segment elevation ACS and five had non-ST segment elevation ACS. Tobacco consumption (80%) and hypercholesterolaemia (50%) were the most frequent cardiovascular risk factors. During initial hospitalization, four patients were treated with thrombolysis, two had primary coronary angioplasty and seven had secondary coronary angioplasty. At follow up, 10 patients (50%) had had 18 cardiovascular events: one cardiovascular death, seven episodes of recurrent myocardial ischaemia in four patients, three pulmonary oedemas in two patients, and seven revascularization procedures in five patients.

CONCLUSIONS

This preliminary report highlights the risk of ACS and related complications in HIV-infected patients and raises questions regarding the implications of antiretroviral treatment.

Role of drug eluting stents in diabetic patients

There is a clear need for a large multicentre trial comparing the efficacy of the two available drug eluting stents, sirolimus and paclitaxel, in diabetic patients with multivessel disease.

Œdème pulmonaire aigu lors d’une menace d’accouchement prématuré : rôle de la tocolyse par la nicardipine

Beta adrenergic agonists are still used as first line treatment for preterm labor in many institutions, but their side effects lead to use alternative tocolytic drugs such as calcium channel blockers. We report three cases of pulmonary edema during preterm labor associated with the use of calcium channel blocker, intravenous nicardipine, widely used for tocolysis in France. In this article, potential mechanisms of this severe complication are briefly discussed: pregnancy-induced overload, deleterious hemodynamic effects of calcium channel blockers, concomitant administration of calcium channel blockers and/or beta-agonists and finally concomitant administration of physiological saline and/or glucocorticoids. Based on our experience, we recommend avoiding the association of calcium channel blockers and beta-agonists for preterm labor. Nicardipine, if used, should be administered at an adjusted dose with electric syringe to reduce volume infusion.

[Preventing cerebrovascular accidents during atrial fibrillation]

Atrial fibrillation, the most commonly encountered arrhythmia in clinical practice, is associated with substantial morbidity and mortality. Its incidence and prevalence are increasing, and it represents a growing clinical and economic burden. Recent research has highlighted new approaches to both pharmacological and non-pharmacological management. Pooled data from trials comparing antithrombotic treatment with placebo show that warfarin reduces the risk of stroke by 62% and that aspirin alone reduces the risk by 22%. Overall, in high-risk patients, warfarin was better than aspirin in preventing strokes, with a relative risk reduction of 36%, but the risk of major hemorrhage with warfarin was twice that with aspirin. Anticoagulation treatment needs to be tailored individually for patients on the basis of age, comorbidities, and contraindications. However, warfarin remains under-prescribed in clinical practice, for reasons related to patients (comorbidities) and physicians. The limitations of warfarin treatment have prompted the development of new anticoagulants with predictable pharmacokinetics that do not require as frequent monitoring. Ximelagatran, an oral direct thrombin inhibitor, was compared with warfarin in the SPORTIF program, which found both agents to be broadly effective in the prevention of embolic events, but observed abnormal liver function tests in 6% of patients on ximelagatran. Liver function monitoring during treatment is thus needed. Idraparinux, a factor Xa inhibitor administered by once weekly subcutaneous injections, is being evaluated in patients with atrial fibrillation. The ACTIVE trial is currently assessing the role of aspirin plus clopidogrel, compared with adjusted dose warfarin, in the prevention of vascular events in high-risk patients with atrial fibrillation. Angiotensin-converting enzyme inhibitors and angiotensin II receptor-blocking drugs interfere with atrial remodeling and show promise in atrial fibrillation, as suggested in the LIFE trial. Preliminary studies suggest that statins may reduce the risk of recurrence after electrical cardioversion. Finally, percutaneous methods for occlusion of the left atrial appendage are currently under investigation in patients at high risk of thromboembolism but with contraindications for chronic warfarin.

Interplay of diabetes and coronary heart disease on cardiovascular mortality

Patients with both diabetes mellitus and prior myocardial infarction are at particularly high risk for cardiovascular mortality.

[Symptomatic left ventricular dysfunction and Behçet disease. Report of 2 cases]

Behçet's disease is associated with cardiac complications which may affect all three cardiac layers in 1 to 6% of cases. Although pericardial and coronary disease are the most common, the myocardium may also be affected. The clinical presentation may be left ventricular dysfunction with signs of dilated cardiomyopathy. The cause of the left ventricular dysfunction is usually coronary artery disease but it can also be inflammatory, resulting in a myocarditis with normal coronary arteries. The authors report two cases of Behçet's disease with symptomatic left ventricular dysfunction presenting as dilated cardiomyopathy with normal coronary arteries in one of the cases. Recent echocardiographic studies suggest that the incidence of myocardial disease is underestimated in this pathology: 20 to 35% of patients with Behçet's disease but no cardiac symptoms had left ventricular diastolic dysfunction. A more attentive investigation of left ventricular diastolic function in these patients should enable earlier diagnosis of this complication.

[A new cause of increased troponin levels: junctional tachycardia]

The authors report 4 cases of acute coronary syndromes with increased troponine levels during junctional tachycardia in patients with angiographically normal coronary arteries. ST segment changes during junctional tachycardia have no predictive value for the detection of coronary artery disease. Increased troponine, a marker of myocardial cellular necrosis, is not a sign of coronary lesions. A disequilibrium between the increased metabolic and energetic requirements of the myocardium and decreased perfusion due to the tachycardia could explain this observation. The recommended management of these patients is not to perform coronary angiography initially in the absence of cerebrovascular risk factors, but rather to document myocardial ischaemia by a non-invasive method such as echocardiography or scintigraphy.

[Does Doppler analysis of hepatic venous flow predict increased right atrial pressure and right ventricular dysfunction?]

The aim of this study was to test the hypothesis that Doppler study of hepatic venous flow, reflecting right atrial pressures and right ventricular dysfunction, allows prediction of increased right atrial pressure and right ventricular dysfunction in patients with right ventricular infarction. The authors studied 30 patients (27 men, mean age 54 +/- 12 years) in sinus rhythm with acute inferior myocardial infarction who underwent right heart catheterisation and Doppler echocardiography including recording of regurgitant and hepatic vein flow within 48 hours of hospital admission. Hepatic venous flow was used to measure peak velocity and velocity time integrals (VTI) of the systolic (S), diastolic (D) and atrial (a) contraction waves. The fraction of systolic filling was calculated: VTI S/VTI S + VTI D. The pressure half-time of pulmonary regurgitant flow (PHT IP) was also measured. Using haemodynamic criteria (non-compliant right atrial pressure wave form or right ventricular end diastolic pressure/pulmonary capillary pressure > or = 0.8), patients were divided into two groups: Group 1: right ventricular infarction (VD+, N = 22). Group 2: no right ventricular infarction (VD-, N = 8). No correlation was observed between Doppler parameters of hepatic venous flow and haemodynamic data, in particular right atrial pressure and pressure wave form. Moreover, no statistically significant difference was observed between the two groups with respect to the Doppler parameters derived from hepatic venous flow. On the other hand, the results confirmed good diagnostic performance of Doppler analysis of pulmonary regurgitant flow: sensitivity 80%, specificity 83%, positive predictive value 94%, negative predictive value 55%. The authors conclude that, in patients with acute inferior wall infarction, Doppler analysis of hepatic venous flow does not allow assessment of right atrial pressure or of ischaemic right ventricular dysfunction.

Acute myopericarditis after diphtheria, tetanus, and polio vaccination

We report the first case of myopericarditis after triple vaccination against diphtheria, tetanus, and poliovirus in a young adult. He presented with fever, acute chest pain, and diffuse ST-segment elevation 2 days after vaccination. Two-dimensional echocardiography findings were normal. Endomyocardial biopsy showed interstitial edema with diapedesis of erythrocytes. Laboratory findings showed inflammatory syndrome and elevated circulating immune complexes. He recovered within a few days with high-dose aspirin treatment and was without complications at 3-month follow-up. We discuss the different hypotheses for infective or hypersensitivity myocarditis.

Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms

OBJECTIVES

The aim of this study was to assess the diagnosis of myocarditis in patients presenting with acute myocardial infarction (MI) and normal coronary angiograms.

BACKGROUND

Most often in these patients, the etiologic diagnosis remains unclear once they are found to have normal coronary arteries. The diagnosis of myocarditis mimicking MI is clinically relevant, because numerous arguments suggest a relation between myocarditis and dilated cardiomyopathy. Myocardial indium-111 (111In)-antimyosin antibody (AMA)/rest thallium-201 (201Tl) imaging allows noninvasive detection of myocarditis.

METHODS

Forty-five patients admitted to three intensive care units for suspicion of acute MI, with normal coronary angiograms, were investigated. Indium-111-AMA planar images and then a dual-isotope rest AMA/201Tl tomographic study were performed. Six-month echocardiographic follow-up was obtained in 80% of the patients with initial left ventricular (LV) wall motion abnormalities.

RESULTS

In eight patients, AMA and 201Tl scintigraphy were negative. In two patients, a matched 201Tl defect and focal AMA uptake suggested acute MI (due to prolonged vasospasm or spontaneously reperfused coronary occlusion). In 17 patients, diffuse AMA uptake over the whole LV suggested diffuse myocarditis. In 18 patients, focal AMA uptake with a normal 201Tl scan suggested diffuse but heterogeneous, or focal myocarditis. Complete functional recovery was observed in 81% of the patients with a pattern of myocarditis.

CONCLUSIONS

Among 45 patients presenting with acute MI and normal coronary angiograms, 38% had diffuse myocarditis and 40% had a scintigraphic pattern of heterogeneous or focal myocarditis. Short-term follow-up showed complete LV functional recovery in 81% of these patients.

[Comparative incidence of protrusive atheromatous plaques of the thoracic artery in patients with atrial fluter and atrial fibrillation]

Although it has been demonstrated recently that in patients with atrial fibrillation, protrusive atheromatous plaques of the thoracic aorta (thickness 4 mm) and left atrial abnormalities such as thrombosis, spontaneous contrast and low atrial blood flow velocities carry an additional embolic risk, this has not yet been studied in atrial flutter. Out of 2493 patients undergoing transoesophageal echocardiography between September 1993 and December 1997, 271 consecutive patients in atrial flutter (N = 41) or fibrillation (N = 230) for over 48 hours, underwent transoesophageal echocardiography before cardioversion. Patients with atrial flutter were compared with those with atrial fibrillation. Their characteristics were comparable with respect to age (68 +/- 13 and 67 +/- 12 years respectively, p = 0.628), sex ratio (men 66 and 54% respectively, p = 0.212), previous thromboembolic disease (5 and 15% respectively, p = 0.126). The incidence of protrusive aortic atheroma (12 and 11% respectively, p = 0.919), of spontaneous contrast in the thoracic aorta (15 and 14% respectively, p = 0.847) were identical in both groups. The left atrium was significantly smaller (3.1 +/- 0.7 and 6 +/- 3 cm2 respectively, p = 0.001), spontaneous atrial contrast less frequent (17 and 37% respectively, p = 0.024) and the velocities of atrial emptying higher (47 +/- 10 and 30 +/- 10 cm/s respectively, p = 0.030) in patients with flutter compared with atrial fibrillation. There was no difference in left ventricular fractional shortening (30 +/- 10 and 33 +/- 13% respectively, p = 0.630), the presence of rheumatic valvular disease (5 and 12%, p = 0.301), left atrial diameter (43 +/- 7 and 45 +/- 8, p = 0.134), right atrial surface area (16 +/- 4 and 17 +/- 6 cm2, p = 0.384) or in intraatrial thrombosis (2 and 3%, p = 0.888) respectively. These results show a high prevalence of protrusive atheroma of the thoracic aorta both in atrial flutter and in atrial fibrillation, and fewer left atrial abnormalities in patients with flutter.

Comparison of echocardiographic markers of embolism in atrial flutter and fibrillation: frequency of protruding atherosclerotic plaques in the thoracic aorta

The potential additional embolic risk of protruding aortic plaques > or = 4 mm and left atrial abnormalities such as thrombus, spontaneous echocardiographic contrast (SEC), low left atrial appendage velocity, recently has been shown in patients with atrial fibrillation (AF). However, the presence and potential role of transesophageal echocardiographic (TEE)-detected protruding aortic plaques > or = 4 mm have not been systematically evaluated in patients with atrial flutter. Among 2493 patients evaluated by TEE, 271 consecutive patients with atrial flutter (n = 41) and AF (n = 230) > or = 2 days duration were included in the study. Clinical and echocardiographic characteristics in consecutive patients with atrial flutter were compared to those in patients with AF, especially atrial morphology and function and atherosclerotic disease of the thoracic aorta. Clinical characteristics of patients with atrial flutter and AF were similar with regard to age (68 +/- 13 and 67 +/- 12, P = 0.628), sex ratio (men, 66% and 54%, P = 0.212), and previous embolic events (5% and 15%, P = 0.126), respectively. The frequency of protruding atherosclerotic plaques > or = 4 mm (12% and 11%, P = 0.919) and SEC (15% and 14%, P = 0.847) in the thoracic aorta was similar in patients with atrial flutter and AF. Left atrial appendage area was smaller (3.1 +/- 0.7 and 6.0 +/- 3.0 cm(2), P = 0.001), left atrial appendage SEC was less frequent (17% and 37%, P = 0.024), and left atrial appendage emptying velocity was higher (47 +/- 10 and 30 +/- 10 cm/s, P = 0.030) in patients with atrial flutter as compared to those with AF. There was no difference between the two groups regarding left ventricular fractional shortening (30 +/- 10% and 33 +/- 13%, P = 0.630), rheumatic valvular disease (5% and 12%, P = 0. 301), left atrial diameter (43 +/- 7 and 45 +/- 8 mm, P = 0.134), right atrial area (16 +/- 4 and 17 +/- 6 cm(2), P = 0.384), left atrial SEC (39% and 53%, P = 0.124), or atrial thrombus ( 2% and 3%, P = 0.888) respectively. Our results point to the high prevalence of protruding atherosclerotic plaques in the thoracic aorta in patients with atrial flutter.

[Diagnostic strategy in acute myocarditis]

Myocarditis is a focalised or diffuse disease of the myocardium. The principal causal agents are viruses in Europe and North America and a parasite in South America (Chagas' disease). The prevalence of acute myocarditis is variable, related to the periodic cycle of viral epidemics. The diagnosis is difficult to establish because the clinical presentation is variable, ranging from asymptomatic forms to rapidly fatal acute congestive heart failure. The diagnostic tools suffer from lack of sensitivity or specificity. Endomyocardial biopsy, despite its low sensitivity, remains the reference investigation as it provides histological proof of the myocarditis. Myocardial scintigraphy with antimyosin antibodies has the advantage of very good sensitivity but with less specificity. The authors discuss the critical indications and limitations of each investigation.