Cardiovascular disease in low- and middle-income countries associated with environmental factors

There is a growing recognition that the profound environmental changes that have occurred over the past century pose threats to human health. Many of these environmental factors, including air pollution, noise pollution, as well as exposure to metals such as arsenic, cadmium, lead, and other metals, are particularly detrimental to the cardiovascular health of people living in low-to-middle income countries (LMICs). Low-to-middle income countries are likely to be disproportionally burdened by cardiovascular diseases provoked by environmental factors. Moreover, they have the least capacity to address the core drivers and consequences of this phenomenon. This review summarizes the impact of environmental factors such as climate change, air pollution, and metal exposure on the cardiovascular system, and how these specifically affect people living in LMICs. It also outlines how behaviour changes and interventions that reduce environmental pollution would have significant effects on the cardiovascular health of those from LMICs, and globally.

2023 World Heart Federation guidelines for the echocardiographic diagnosis of rheumatic heart disease

Rheumatic heart disease (RHD) is an important and preventable cause of morbidity and mortality among children and young adults in low-income and middle-income countries, as well as among certain at-risk populations living in high-income countries. The 2012 World Heart Federation echocardiographic criteria provided a standardized approach for the identification of RHD and facilitated an improvement in early case detection. The 2012 criteria were used to define disease burden in numerous epidemiological studies, but researchers and clinicians have since highlighted limitations that have prompted a revision. In this updated version of the guidelines, we incorporate evidence from a scoping review, an expert panel and end-user feedback and present an approach for active case finding for RHD, including the use of screening and confirmatory criteria. These guidelines also introduce a new stage-based classification for RHD to identify the risk of disease progression. They describe the latest evidence and recommendations on population-based echocardiographic active case finding and risk stratification. Secondary antibiotic prophylaxis, echocardiography equipment and task sharing for RHD active case finding are also discussed. These World Heart Federation 2023 guidelines provide a concise and updated resource for clinical and research applications in RHD-endemic regions.

Toward a Universal Definition of Etiologies in Heart Failure: Categorizing Causes and Advancing Registry Science

Heart failure (HF) is a well-described final common pathway for a broad range of diseases however substantial confusion exists regarding how to describe, study, and track these underlying etiologic conditions. We describe (1) the overlap in HF etiologies, comorbidities, and case definitions as currently used in HF registries led or managed by members of the global HF roundtable; (2) strategies to improve the quality of evidence on etiologies and modifiable risk factors of HF in registries; and (3) opportunities to use clinical HF registries as a platform for public health surveillance, implementation research, and randomized registry trials to reduce the global burden of noncommunicable diseases. Investment and collaboration among countries to improve the quality of evidence in global HF registries could contribute to achieving global health targets to reduce noncommunicable diseases and overall improvements in population health.

Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

Epidemiology and risk factors for hyperkalaemia in heart failure

Patients with heart failure (HF), particularly those with impaired renal function receiving renin-angiotensin-aldosterone system inhibitors (RAASis), are at risk of hyperkalaemia; when hyperkalaemia is severe, this can have serious clinical consequences. The incidence, prevalence, and risk factors for hyperkalaemia reported in randomized trials of RAASis may not reflect clinical practice due to exclusion of patients with elevated serum potassium (sK+ ) or severe renal impairment: information on patients managed in routine clinical care is important to understanding the actual burden of hyperkalaemia. This paper reviews the available clinical epidemiology data on hyperkalaemia in HF and considers areas requiring further research. Observational studies published since 2017 that focused on hyperkalaemia, included patients with HF, and had ≥1000 participants were considered. Hyperkalaemia occurrence in HF varied widely from 7% to 39% depending on the setting, HF severity, follow-up length, and concomitant medications. Rates were lowest in patients with newly diagnosed HF and highest in patients with greater disease severity; comorbidities, such as chronic kidney disease and diabetes, and RAASi use, reflected commonly identified risk factors for hyperkalaemia in patients with HF. Hyperkalaemia was most often mild; however, from the limited data available, persistence of mild hyperkalaemia was associated with an increased risk of mortality and major adverse cardiovascular events. There were also limited data available on the progression of hyperkalaemia. Recurrence was common, occurring in one-quarter to two-fifths of hyperkalaemia cases. Despite HF guidelines recommending close monitoring of sK+ , 55-93% of patients did not receive appropriate testing before or after initiation of RAASi or in follow-up to moderate/severe hyperkalaemia detection. Many of the observational studies were retrospective and from a single country. There is a need for international, prospective, longitudinal, observational studies, such as the CARE-HK in HF study (NCT04864795), to understand hyperkalaemia's prevalence, incidence, and severity; to identify and characterize cases that persist, progress, and recur; to highlight the importance of sK+ monitoring when using RAASi; and to assess the impact of newer HF therapies and potassium binders in clinical practice. Data from both clinical trials and observational studies with adjustments for confounding variables will be needed to assess the contribution of hyperkalaemia to clinical outcomes.

Toward a Better Understanding of Cardiovascular Risk in the Transgender and Gender-Diverse Community: A Global Call to Action

On World Heart Day 2022, the Mexican Society of Cardiology, the Inter-American Society of Cardiology, and the World Heart Federation collaborated on a public call to action regarding the increased risk of adverse cardiovascular health outcomes in transgender and gender diverse (TGD) individuals. The aim of this article is to unpack the numerous factors that contribute to this, such as the social stigma faced by members of the TGD community, their reduced access to clinical care, and the scarcity of research regarding the unique needs of their community, which makes it difficult for clinicians to provide individualized medical care. Decreasing the incidence of adverse cardiovascular events among TGD individuals requires interventions such as educational reform in the medical community, an increase in inclusive research studies, and broader social initiatives intended to reduce the stigma faced by TGD individuals.

Repurposing the β3-Adrenergic Receptor Agonist Mirabegron in Patients With Structural Cardiac Disease: The Beta3-LVH Phase 2b Randomized Clinical Trial

Importance

Left ventricular (LV) hypertrophy contributes to the onset and progression of heart failure (HF), particularly for patients with pre-HF (stage B) for whom no treatment has yet proven effective to prevent transition to overt HF (stage C). The β3-adrenergic receptors (β3ARs) may represent a new target, as their activation attenuates LV remodeling.

Objective

To determine whether activation of β3ARs by repurposing a β3AR agonist, mirabegron, is safe and effective in preventing progression of LV hypertrophy and diastolic dysfunction among patients with pre- or mild HF.

Design, Setting, and Participants

The Beta3-LVH prospective, triple-blind, placebo-controlled phase 2b randomized clinical trial enrolled patients between September 12, 2016, and February 26, 2021, with a follow-up of 12 months. The trial was conducted at 10 academic hospitals in 8 countries across Europe (Germany, Poland, France, Belgium, Italy, Portugal, Greece, and the UK). Patients aged 18 years or older with or without HF symptoms (maximum New York Heart Association class II) were screened for the presence of LV hypertrophy (increased LV mass index [LVMI] of ≥95 g/m2 for women or ≥115 g/m2 for men) or maximum wall thickness of 13 mm or greater using echocardiography. Data analysis was performed in August 2022.

Intervention

Participants were randomly assigned (1:1) to mirabegron (50 mg/d) or placebo, stratified by the presence of atrial fibrillation and/or type 2 diabetes, for 12 months.

Main Outcomes and Measures

The primary end points were LVMI determined using cardiac magnetic resonance imaging and LV diastolic function (early diastolic tissue Doppler velocity [E/e'] ratio assessed using Doppler echocardiography) at 12 months. Patients with at least 1 valid measurement of either primary end point were included in the primary analysis. Safety was assessed for all patients who received at least 1 dose of study medication.

Results

Of the 380 patients screened, 296 were enrolled in the trial. There were 147 patients randomized to mirabegron (116 men [79%]; mean [SD] age, 64.0 [10.2] years) and 149 to placebo (112 men [75%]; mean [SD] age, 62.2 [10.9] years). All patients were included in the primary intention-to-treat analysis. At 12 months, the baseline and covariate-adjusted differences between groups included a 1.3-g/m2 increase in LVMI (95% CI, -0.15 to 2.74; P = .08) and a -0.15 decrease in E/e' (95% CI, -0.69 to 0.4; P = .60). A total of 213 adverse events (AEs) occurred in 82 mirabegron-treated patients (including 31 serious AEs in 19 patients) and 215 AEs occurred in 88 placebo-treated patients (including 30 serious AEs in 22 patients). No deaths occurred during the trial.

Conclusions

In this study, mirabegron therapy had a neutral effect on LV mass or diastolic function over 12 months among patients who had structural heart disease with no or mild HF symptoms.

Trial Registration

ClinicalTrials.gov Identifier: NCT02599480.

Sex-stratified patterns of emergency cardiovascular admissions prior and during the COVID-19 pandemic

The COVID-19 pandemic has had a significant impact on global public health, with long-term consequences that are still largely unknown. This study aimed to assess the data regarding acute cardiovascular hospital admissions in five European centers before and during the pandemic. A multicenter, multinational observational registry was created, comparing admissions to the emergency departments during a 3-months period in 2020 (during the pandemic) with the corresponding period in 2019 (pre-pandemic). Data on patient demographics, COVID-19 test results, primary diagnosis, comorbidities, heart failure profile, medication use, and laboratory results were collected. A total of 8778 patients were included in the analysis, with 4447 patients in 2019 and 4331 patients in 2020. The results showed significant differences in the distribution of cardiovascular diseases between the two years. The frequency of pulmonary embolism (PE) increased in 2020 compared to 2019, while acute heart failure (AHF) and other cardiovascular diseases decreased. The odds of PE incidence among hospitalized patients in 2020 were 1.316-fold greater than in 2019. The incidence of AHF was 50.83% less likely to be observed in 2020, and the odds for other cardiovascular diseases increased by 17.42% between the 2 years. Regarding acute coronary syndrome (ACS), the distribution of its types differed between 2019 and 2020, with an increase in the odds of ST-segment elevation myocardial infarction (STEMI) in 2020. Stratification based on sex revealed further insights. Among men, the incidence of AHF decreased in 2020, while other cardiovascular diseases increased. In women, only the incidence of STEMI showed a significant increase. When analyzing the influence of SARS-CoV-2 infection, COVID-positive patients had a higher incidence of PE compared to COVID-negative patients. COVID-positive patients with ACS also exhibited symptoms of heart failure more frequently than COVID-negative patients. These findings provide valuable information on the impact of the COVID-19 pandemic on acute cardiovascular hospital admissions. The increased incidence of PE and changes in the distribution of other cardiovascular diseases highlight the importance of monitoring and managing cardiovascular health during and post pandemic period. The differences observed between sexes emphasize the need for further research to understand potential sex-specific effects of COVID-19 on cardiovascular outcomes.

The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary center

INTRODUCTION AND OBJECTIVES

Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach.

METHODS

We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections.

RESULTS

A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group.

CONCLUSION

Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.

Conduction Disorders And Their Clinical Impact After Sutureless/Rapid Deployment Aortic Bioprosthesis

INTRODUCTION

Aortic stenosis remains the number one heart valve pathology. The drive to improve the surgical outcomes brought to focus rapid deployment valves (RDV), which reduce aortic cross-clamping and cardio-pulmonary bypass (CPB) times. However, some centers have reported a higher rate of conduction abnormalities and permanent pacemaker (PPM) implantation. The aim of this study was to investigate the incidence of conduction abnormalities after aortic valve replacement with RDV, as well as its impact on immediate postoperative outcomes.

METHODS

Retrospective analysis of associated conductions disorders and PPM implantation rates, as well as post-operative outcomes of all patients undergoing isolated aortic valve replacement between April 2014 and December 2019 with an RDV. Comparative analysis between the group with PPM implantation and the one with no PPM implantation. Patients with previous PPM implantation, reoperations and patients with missing pre or postoperative ECG data were excluded.

RESULTS

We studied 201 patients. The majority of conduction abnormalities were left bundle branch block (54,0%). Twenty-six PPM were implanted (12,6%). Pre-operative characteristic between the groups were similar and little differences were found in regard to most complications. However, the PPM group showed significantly higher rates of stroke (7.7% vs 0.0%, p=0.016) and hemodynamic support for longer than 24 hours (60.0% vs 36.1%, p=0.028). From the multivariable analysis, preoperative right bundle branch block was the only independent risk factor associated with PPM.

CONCLUSIONS

PPM implantation rates with RDV are relatively high and are associated with prolonged hospital and ICU stays, postoperative stroke rates and requirement of aminergic support. Their use should be made on a case-by-case basis taking into consideration the existence of preoperative conduction disorders, especially right bundle branch block.

Toward a better understanding of cardiovascular risk in the transgender and gender-diverse community: a supplement to the Tijuana Declaration

On World Heart Day 2022, the Mexican Society of Cardiology, the Inter-American Society of Cardiology, and the World Heart Federation collaborated on a communication regarding the increased risk of adverse cardiovascular health outcomes in transgender and gender-diverse (TGD) individuals. This document, called the Tijuana Declaration, urged the global cardiovascular community to work toward understanding and mitigating this problem. This article aims to unpack the numerous factors that lead to it. An example is the social stigma faced by members of the TGD community, which leads to increased stress and risk for cardiovascular complications. TGD patients are also more likely to have insufficient access to health care, and those that do receive care are often faced with providers that are not adequately educated about the unique needs of their community. Finally, there is some evidence to suggest that gender-affirming hormone therapies have an impact on cardiovascular health, but studies on this subject often have methodological concerns and contradictory findings. Decreasing the incidence of adverse cardiovascular events in this community requires interventions such as educational reform in the medical community, an increase in research studies on this topic, and broader social initiatives intended to reduce the stigma faced by TGD individuals.

Sutureless bioprosthesis for aortic valve replacement: Surgical and clinical outcomes

BACKGROUND

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The aging population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis has shown promising results, especially in complex procedures and in patients requiring concomitant surgeries.

OBJECTIVES

Assess the clinical and hemodynamic performance, safety, and durability of the Perceval® prosthetic valve.

METHODS

This single-center retrospective longitudinal cohort study collected data from all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20 ± 5.08 years; 45.4% female; mean EuroSCORE II 2.91 ± 2.20%), the majority had aortic stenosis.

RESULTS

Overall mean cross-clamp and cardiopulmonary bypass times were 33.31 ± 14.09 min and 45.55 ± 19.04 min, respectively. Mean intensive care unit and hospital stay were 3.32 ± 3.24 days and 7.70 ± 5.82 days, respectively. Procedural success was 98.99%, as two explants occurred. Four valves were reimplanted due to intraoperative misplacement. Mean transvalvular gradients were 7.82 ± 3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary for 3.1%. Early mortality was 2.0%. We report no structural valve deterioration, strokes, or endocarditis, and one successfully treated valve thrombosis.

CONCLUSIONS

Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to a 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for the treatment of isolated aortic valve disease.

Rapid deployment bioprostesis for aortic valve stenosis: single center short and long-term outcomes

Background

Despite recent advances, surgical aortic valve replacement (SAVR) remains the gold standard for most of the patients with aortic valve stenosis. The ageing population, with increased comorbidities and the rising of minimally invasive techniques, led to the development of new prosthetic devices of easier and faster implantation.

Purpose

This study aimed to analyse short and long-term outcomes of SAVR with rapid-deployment (RD) aortic bioprosthesis for isolated aortic valve stenosis

Method

Singe center, retrospective longitudinal cohort study of patients with isolated aortic valve stenosis who underwent elective aortic valve replacement using RD devices between 2014 and December 2021.

Continuous variables are presented with median (IQR) and were analyzed using Mann-Whitney test. Categorical variables are presented in percentage or frequency and were analyzed using chi-square test. Kaplan-Meyer survival curve was constructed base on collected data from national registry.

Results

A RD device was implanted in 358 patients with a median age of 75,8 years and Euroscore II of 2,3. Median cross clamp and extracorporeal circulation time were 27,4 and 36,7 min, respectively. No significant paravalvular leaks.

Intensive care unit (ICU) length of stay was 3 days with acute renal lesion (any stage-53,2%; Dialysis-2,5%), need for hemodynamic support (63,1%) and new onset atrial fibrillation (33,6%) being the most frequent post-operative complications. Stroke occurred in 0,6% of cases and mortality was 1,1%. Pacemaker implementation rate of 11%.

The mean follow-up time was 6,7 years with 90% 5-years survival rate. Mean gradients of 11,2±4,8 mmHg at 6 months

Conclusion

Surgical treatment of aortic valve stenosis using RD devices is safe, with a low mortality rate. ICU length of stay and hospital length of stay are reduced. Follow-up shows an excellent long-term survival and hemodynamic performance.

Funding Acknowledgement

Type of funding sources: None.

Impact of Left Ventricular Ejection Fraction on Clinical Outcomes in Bicuspid Aortic Valve Disease

BACKGROUND

The prognostic impact of left ventricular ejection fraction (LVEF) in patients with bicuspid aortic valve (BAV) disease has not been previously studied.

OBJECTIVES

The purpose of this study was to determine the prognostic impact of LVEF in BAV patients according to the type of aortic valve dysfunction.

METHODS

We retrospectively analyzed the data collected in 2,672 patients included in an international registry of patients with BAV. Patients were classified according to the type of aortic valve dysfunction: isolated aortic stenosis (AS) (n = 749), isolated aortic regurgitation (AR) (n = 554), mixed aortic valve disease (MAVD) (n = 190), or no significant aortic valve dysfunction (n = 1,179; excluded from this analysis). The study population was divided according to LVEF strata to investigate its impact on clinical outcomes.

RESULTS

The risk of all-cause mortality and the composite endpoint of aortic valve replacement or repair (AVR) and all-cause mortality increased when LVEF was <60% in the whole cohort as well as in the AS and AR groups, and when LVEF was <55% in MAVD group. In multivariable analysis, LVEF strata were significantly associated with increased rate of mortality (LVEF 50%-59%: HR: 1.83 [95% CI: 1.09-3.07]; P = 0.022; LVEF 30%-49%: HR: 1.97 [95% CI: 1.13-3.41]; P = 0.016; LVEF <30%: HR: 4.20 [95% CI: 2.01-8.75]; P < 0.001; vs LVEF 60%-70%, reference group).

CONCLUSIONS

In BAV patients, the risk of adverse clinical outcomes increases significantly when the LVEF is <60%. These findings suggest that LVEF cutoff values proposed in the guidelines to indicate intervention should be raised from 50% to 60% in AS or AR and 55% in MAVD.

074 No valvular heart disease or pulmonary artery hypertension with fenfluramine for up to 3 years

Rationale

Fenfluramine (FFA) has been shown in 2 randomised, placebo-controlled clinical trials to reduce convulsive seizures in children with Dravet Syndrome (DS). We report an update on the cardiovascular safety of DS patients treated with FFA for up to 3 years.

Methods

327 patients who completed one of the three phase 3 trials enrolled in this open-label extension (OLE) study (NCT02823145). All were assessed with transthoracic echocardiography (TTE). They were assessed for Valvular Heart Disease (VHD) and Systolic pulmonary artery pressure.

Results

One patient had a finding of mild MR (considered physiologic) during the study. One patient demonstrated mild (considered pathologic) AR at Month 15. A transoesophageal echocardiogram (TOE) performed at 6 weeks found absent AR with trace MR. No abnormalities of valve morphology were found on TOE or on TTE. No VHD or PAH was observed in any patient during the OLE.

Conclusions

This study demonstrates the absence of clinically significant VHD or PAH supporting a positive benefit-risk profile for FFA in the treatment of patients with DS.

Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial

AIMS

To investigate the impact of patiromer on serum potassium level and its ability to enable specified target doses of renin-angiotensin-aldosterone system inhibitor (RAASi) use in patients with heart failure and reduced ejection fraction (HFrEF).

METHODS AND RESULTS

A total of 1642 patients with HFrEF and current or a history of RAASi-related hyperkalemia were screened and 1195 were enrolled in the run-in phase with patiromer and optimization of RAASi therapy (≥50% recommended dose of angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, and 50 mg of mineralocorticoid receptor antagonist [MRA] spironolactone or eplerenone). Specified target doses of RAASi therapy were achieved in 878 (84.6%) patients; 439 were randomized to patiromer and 439 to placebo. All patients, physicians, and outcome assessors were blinded to treatment assignment. The primary endpoint was between-group difference in adjusted mean change in serum potassium. Five hierarchical secondary endpoints were assessed. At the end of treatment, the median (interquartile range) duration of follow-up was 27 (13, 43) weeks, the adjusted mean change in potassium was +0.03 mmol/L in the patiromer group and +0.13 mmol/L in the placebo group (difference in adjusted mean change between patiromer and placebo: -0.10 [95% confidence interval, CI -0.13, -0.07] mmol/L, P<0.001). Risk of hyperkalemia >5.5 mmol/L (hazard ratio [HR] 0.63; 95% CI 0.45, 0.87; P=0.006), reduction of MRA dose (HR 0.62; 95% CI 0.45, 0.87; P=0.006), and total adjusted hyperkalemia events/100 person-years (77.7 vs. 118.2; HR 0.66; 95% CI 0.53, 0.81; P<0.001) were lower with patiromer. Hyperkalemia-related morbidity-adjusted events (win ratio 1.53, P<0.001) and total RAASi use score (win ratio 1.25, P=0.048) favored the patiromer arm. Adverse events were similar between groups.

CONCLUSION

Concurrent use of patiromer and high-dose MRAs reduces the risk of recurrent hyperkalemia (ClinicalTrials.gov: NCT03888066).

Cardiorespiratory fitness assessment on active patients who kept attending their phase III exercise-based cardiac rehabilitation during the COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorespiratory fitness (CRF) is a powerful predictor of all-cause mortality among individuals with coronary artery disease (CAD). A structured community-based phase III cardiac rehabilitation (CR) is very important in lifelong maintenance of phase II CRF and health gains. During the COVID-19 pandemic, CR programs had to adapt, mainly using new technologies and remote follow-up. The CRF impact in patients (Ps) who kept going their phase III program, during this troubled era is still unknown.

Purpose

Assess the variation in CRF and prognostic parameters in Ps with CAD who maintain high adherence levels in their phase III CR before and during the COVID-19 pandemic.

Methods

A cohort of Ps enrolled in a community-based phase 3 CR program, with active participation at the end of 2019, was included in this retrospective study. The inclusion criteria for this study were high levels of attendance (>80%) to the CR program before and during COVID-19 and high levels of physical activity with more than 150 mins of moderate to vigorous physical activity (MVPA). All Ps were evaluated with transthoracic echocardiography (TTE) and a cardiorespiratory exercise test (CPET) in a cycloergometer in 2019 and between october and november of 2021. All Ps had used accelerometers to measure their physical activity levels and dual-energy absorptiometry (DEXA) scan to evaluate their body composition. Between 2020 and 2021, Ps had online (in lockdown periods) and face to face exercise training sessions, 3xtimes per week, 60 mins each exercise session.

A t-test paired two sample for means was used to compare CPET variables before the beginning of the first COVID lockdown (end of 2019) and after the removal of the majority of restrictions (end of 2021).

Results

A total of 30 Ps with high levels of adherence were included (99.6% male, 65 ± 9 years old). In this cohort, the majority had history of an ACS before the referral to the CR program (73.3%) and 55.6 ± 10.4% of left ventricular ejection fraction.

There was no significant difference in body mass index (27.9 ± 3.2 kg/m2 vs 28.1 ± 3.6 kg/m2, p=0.493 but there was a significant increase in the percentage of body fat mass (30.1 ± 5.7% vs 31.0 ± 6.6%, p= 0.042). There was a maintenance on MVPA levels (352 ± 137 minutes/week vs 313 ± 194 minutes/week, p = 0.106) during this period.

When comparing the 2 CPET results, Ps achieved higher exercise loads in the 2021 test (175 ± 51W vs 185 ± 52W, p=0.005), higher VO2 peak (25.3 ± 6.9 ml/kg/min vs 21.5 ± 6.3 ml/kg/min, p =0.001) and higher percentage of predicted VO2max (78.8 ± 16.8% vs 95.27 ± 20.8%, p = 0.001).

Conclusion

In spite of all the difficulties in maintaining a phase III CR program during the COVID-19 pandemic, we observed that in physically active CAD Ps, with the aid of new technologies and remote follow-up (during the lockdown periods) and face to face exercise sessions, it is still possible to have functional gains and improvements in CRF.

Transcatheter aortic valve implantation (balloon-expandable versus self-expandable valves) - what echocardiographic parameters should we evaluted?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) is currently the recommended treatment for aortic stenosis (AS) in high or intermediate-risk or inoperable patients. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the two major types of transcatheter heart valves (TTHV). Despite major diferences, both designs are recomended, however, there are only limited data available for the comparison of newer generation BEV and SEV.

Purpose

Compare echocardiographic and clinical parameters, during 1 year of follow-up of a balloon-expandable (BS) versus self-expanding (SE) transcatheter aortic valve implantantation, with emphasis on the composite endpoits proposed by uptade Valve Academic Researc Consortium (VARC-2).

Methods

Retrospective, comparative study in patients with symptomatic severe AS with a high operative risk, who implanted BEV or SEV between January 2016 and December 2019. All patients underwent echocardiographic study before an after the procedure (on the day , 6 months and 1 year of follow up), clinical data were collected. The following ecocardiographic parameters were evaluated: transvalvular and prosthetic aortic gradientes and paravalvular leak (PVL).

Results

We studied 106 patients (81 ± 8 years, 60% female) with severe AS (mean gradient of 49 ± 12 mmHg), who were threated with BE or SE transcatheter aortic valve. Comparative analysis between BEV vs SEV, showed: there were no statistically significant in mean transprosthetic gradients (9.5 ± 4.8 vs 10 ±6.2; p = 0.49). There were no statistically significant differences between BE and SE valves in the cumulative incidence of death from any cause (21% vs. 28%; p = 0.49), death from cardiovascular causes (3.3% vs. 0%; p= 0.26), all strokes (1.6% vs. 1.6%; p = 0.85), pacemaker implatation (18% vs. 15% p = 0.79); major bleeding (3.3% vs 6.5%; p = 0.18) and renal injury (1.6% vs. 2.1%: p = 0.67). There were statistically significant differences between BE and SE valves in the cumulative incidence of moderate or severe PVL (5% vs. 23.9%; p = 0.009) and repeat hospitalization (11.6% vs. 28%;p = 0.04). Device sucess was achieved in 97 % for BEV vs 91% for SEV (p = 0,39). The early safety at 30 days was observed in 5% for BVE vs. 4.3% for SVE (p = 0.87). The clinical efficacy after 30 days was achieved in 1,6% for BVE vs. 4.3% for SVE (p = 0.03), with higher incidence of moderate or severe PVL. The composite endpoint valve safety occured in 3,3 % for BVE vs 26% for SVE (p &lt; 0,001), with moderate or severe PVL in 23%.

Conclusion(s): In patients with symptomatic severe aortic stenosis who implanted BEV or SEV transcatheter aortic valve there was a significant improvement in the hemodynamic status. The present study suggests that use of SEV was associated with a higher risk of PVL and repeat hospitalization, with a endpoint clinical efficacy after 30 days (4,3%) and time-related valve safety (26%).

Regression of left ventricular mass after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Regression of left ventricular mass (LVM) after transcatheter aortic valve implantation (TAVI) is an important parameter of left ventricular reverse remodeling and is associated with less hospitalizations 1year after TAVI. The association between LVM índex (LVMi) at 6 months and outcome 1 year after TAVI is unclear.

Purpose

Evaluate and compare LVMi, before TAVI and 6 months after, and determine the association between LVMi regression and clinical outcomes at 1-year follow-up.

Methods

Retrospective, comparative study in patients with symptomatic severe aortic stenosis with a high operative risk, after TAVI. All patients underwent echocardiographic study before TAVI and 6 months of follow-up, the LVMi (by the Devereux formula) was evaluated. Associations between LVMi regression (percent change between baseline and 6 months after TAVI), rehospitalization rate and death at 1 year of follow-up were examined.

Results

We studied 50 patients, 82% with moderade or severe LVMi before TAVI. Comparative analysis between ecocardiography study before and 6 months after TAVI, showed there was statistically significant decrease in LVMi (150,7 ± 38 g/m2 vs 132 ± 36 g/m2; p = 0.03). LVMi moderate or severe (between 130 and 154 g/m2) at 6 months was associated with biggest hospitalization rate (p = 0,03).Comparative analysis between regression of LVMi (before and 6 months after TAVI) and death, showed: decrease of 5% and 10% in LVMi was independently associated with death at 1 year (p = 0,77 vs p = 0,4).

Conclusions

Patients with severe symptomatic aortic stenosis treated with TAVI who had a significant decrease of LVMi after 6 months of follow-up had lower hospitalization rates, but decrease of LVMi is independently associated with death at 1 year of follow-up.

Cardiovascular Risk Factors and Clinical Outcomes among Patients Hospitalized with COVID-19: Findings from the World Heart Federation COVID-19 Study

BACKGROUND AND AIMS

Limited data exist on the cardiovascular manifestations and risk factors in people hospitalized with COVID-19 from low- and middle-income countries. This study aims to describe cardiovascular risk factors, clinical manifestations, and outcomes among patients hospitalized with COVID-19 in low, lower-middle, upper-middle- and high-income countries (LIC, LMIC, UMIC, HIC).

METHODS

Through a prospective cohort study, data on demographics and pre-existing conditions at hospital admission, clinical outcomes at hospital discharge (death, major adverse cardiovascular events (MACE), renal failure, neurological events, and pulmonary outcomes), 30-day vital status, and re-hospitalization were collected. Descriptive analyses and multivariable log-binomial regression models, adjusted for age, sex, ethnicity/income groups, and clinical characteristics, were performed.

RESULTS

Forty hospitals from 23 countries recruited 5,313 patients with COVID-19 (LIC = 7.1%, LMIC = 47.5%, UMIC = 19.6%, HIC = 25.7%). Mean age was 57.0 (±16.1) years, male 59.4%, pre-existing conditions included: hypertension 47.3%, diabetes 32.0%, coronary heart disease 10.9%, and heart failure 5.5%. The most frequently reported cardiovascular discharge diagnoses were cardiac arrest (5.5%), acute heart failure (3.8%), and myocardial infarction (1.6%). The rate of in-hospital deaths was 12.9% (N = 683), and post-discharge 30 days deaths was 2.6% (N = 118) (overall death rate 15.1%). The most common causes of death were respiratory failure (39.3%) and sudden cardiac death (20.0%). The predictors of overall mortality included older age (≥60 years), male sex, pre-existing coronary heart disease, renal disease, diabetes, ICU admission, oxygen therapy, and higher respiratory rates (p < 0.001 for each). Compared to Caucasians, Asians, Blacks, and Hispanics had almost 2-4 times higher risk of death. Further, patients from LIC, LMIC, UMIC versus. HIC had 2-3 times increased risk of death.

CONCLUSIONS

The LIC, LMIC, and UMIC's have sparse data on COVID-19. We provide robust evidence on COVID-19 outcomes in these countries. This study can help guide future health care planning for the pandemic globally.

Left ventricular remodelling in bicuspid aortic valve disease

AIMS

Characterization of left ventricular (LV) geometric pattern and LV mass could provide an important insight into the pathophysiological adaptations of the LV to pressure and/or volume overload in patients with bicuspid aortic valve (BAV) and significant (≥moderate) aortic valve (AV) disease. This study aimed to characterize LV remodelling and its prognostic impact in patients with BAV according to the predominant type of valvular dysfunction.

METHODS AND RESULTS

In this international, multicentre BAV registry, 1345 patients [51.0 (37.0-63.0) years, 71% male] with significant AV disease were identified. Patients were classified as having isolated aortic stenosis (AS) (n = 669), isolated aortic regurgitation (AR) (n = 499) or mixed aortic valve disease (MAVD) (n = 177). LV hypertrophy was defined as a LV mass index >115 g/m2 in males and >95 g/m2 in females. LV geometric pattern was classified as (i) normal geometry: no LV hypertrophy, relative wall thickness (RWT) ≤0.42, (ii) concentric remodelling: no LV hypertrophy, RWT >0.42, (iii) concentric hypertrophy: LV hypertrophy, RWT >0.42, and (iv) eccentric hypertrophy: LV hypertrophy, RWT ≤0.42. Patients were followed-up for the endpoints of event-free survival (defined as a composite of AV repair/replacement and all-cause mortality) and all-cause mortality. Type of AV dysfunction was related to significant variations in LV remodelling. Higher LV mass index, i.e. LV hypertrophy, was independently associated with the composite endpoint for patients with isolated AS [hazard ratio (HR) 1.08 per 25 g/m2, 95% confidence interval (CI) 1.00-1.17, P = 0.046] and AR (HR 1.19 per 25 g/m2, 95% CI 1.11-1.29, P < 0.001), but not for those with MAVD. The presence of concentric remodelling, concentric hypertrophy and eccentric hypertrophy were independently related to the composite endpoint in patients with isolated AS (HR 1.54, 95% CI 1.06-2.23, P = 0.024; HR 1.68, 95% CI 1.17-2.42, P = 0.005; HR 1.59, 95% CI 1.03-2.45, P = 0.038, respectively), while concentric hypertrophy and eccentric hypertrophy were independently associated with the combined endpoint for those with isolated AR (HR 2.49, 95% CI 1.35-4.60, P = 0.004 and HR 3.05, 95% CI 1.71-5.45, P < 0.001, respectively). There was no independent association observed between LV remodelling and the combined endpoint for patients with MAVD.

CONCLUSIONS

LV hypertrophy or remodelling were independently associated with the composite endpoint of AV repair/replacement and all-cause mortality for patients with isolated AS and isolated AR, although not for patients with MAVD.

Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study

BACKGROUND

Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality.

METHODS

This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm² and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality.

RESULTS

Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm² and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm² at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm² at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality.

CONCLUSIONS

Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.

Trends in mortality of adult congenital heart disease patients in the last 4 decades

Introduction

Medical, surgical, and technological advances over the past decades increased the life expectancy of congenital heart disease (CHD) patients (pts), with &gt;90% reaching adulthood. Nonetheless, mortality for adults with CHD (ACHD) is still higher than for the general population.

Purpose

To analyse trends in mortality and causes of death of ACHD.

Methods

Retrospective analysis of pts followed in an ACHD outpatient clinic, in one tertiary center, who died between 1980 and December 2020. Data relating to the cardiac diagnosis, symptoms, interventions, comorbidities, and causes of death were analysed.

Results

During a median follow-up of 8.9 years (IQR 2.2–17), 251 pts of 3725 (6.7%) died during the study period: 127 males (51%), mean age at death 44.9±18.1 years, 54% with severe CHD. The majority of these death was CHD-related (171 pts – 68.1%) with no statistically significant differences over the years vs non-cardiovascular death (Table 1). However, a paradigm shift was noticed: in the first years the main cardiac cause was sudden-death that was replaced by heart failure in the last decade. Also, the mean age at death increased over the years (33±14.9 years until 2000 vs 52.3±17 years after the year 2010, p&lt;0.001) as the number of implantable devices (4 vs 20, p=0.05).

Conclusion

Causes of death of ACHD patients are in the majority still CHD-related. However, in the last decade, according to the increase in life expectancy, heart failure became the leading cause of death.

Funding Acknowledgement

Type of funding sources: None.

Fetal and maternal outcomes in patients with tetralogy of Fallot

Introduction

Women with tetralogy of Fallot (TOF) have an increased risk of adverse cardiac and neonatal events during pregnancy. The aim was to assess fetal and maternal outcomes in patients (pts) with uncorrected and corrected TOF.

Methods

Retrospective analysis of cardiological and obstetric data in women with TOF followed at our institution. Pregnancy and neonatal outcomes were compared in patients (pts) submitted to corrective surgery vs pts with no previous intervention and in pts with or without cyanosis.

Results

51 women (median age 27 years; median number of previous interventions of 2), 22% with cyanosis, who experienced 126 pregnancies resulting in 73 live births A previous corrective surgery was found in 78% (40 pts), while 4% (2 pts) had previous palliative surgery and 18% (9 pts) no previous procedure. We found that women that were not submitted to previous intervention had a significant higher incidence of preterm birth (56% vs 17.5%, p=0.029), spontaneous abortion (56% vs 10%, p=0.006) and stillbirth (22% vs 0%). No difference was found for obstetric complications between groups. Cyanotic pts also demonstrated higher incidence of low birth weight (LBW) (36% vs 7.5%, p=0.031), preterm birth (54% vs 17.5%, p=0.021), spontaneous abortion (55% vs 10%, p=0.004) and stillbirth (18% vs 0%). There were no cardiac complications during pregnancy nor evident deterioration on cardiac status. Congenital heart disease was reported in 2 infants (3% of live births).

Conclusions

Pregnancy is well tolerated in pts with TOF. In our population, even in uncorrected TOF and in pts with cyanosis, there were no cardiac complications during pregnancy, although those pts had worse fetal outcomes. An explanation for the low incidence of cardiac events may be less severe forms of the disease, allowing survival into adulthood without intervention.

Funding Acknowledgement

Type of funding sources: None.

Diagnostic and prognostic contribution of 99mTc-DPD scintigraphy in transthyretin V30M cardiac amyloidosis

Background

Early diagnosis and prognostic stratification of hereditary transthyretin amyloidosis (ATTR) are crucial. Previous findings suggested that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy presents suboptimal accuracy to detect ATTR cardiomyopathy caused by V30M mutation, particularly in patients with onset of symptoms under 50 years of age. Furthermore, its prognostic value has never been evaluated in ATTR caused by this mutation.

Purpose

To assess the diagnostic value of DPD scintigraphy to detect cardiomyopathy in a large cohort of patients with ATTR-V30M mutation and to explore its prognostic value regarding mortality.

Methods

Of the 305 ATTR-V30M mutation carriers followed prospectively and who underwent DPD scintigraphy, 288 individuals [median age 46 (39–56); 49% male] without myocardial thickening attributable to other causes were enrolled in the study. Amyloid cardiomyopathy was defined by septal thickness ≥13mm not attributable to other causes plus at least one of the following criteria: (1) late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) ratio &lt;1.60; (2) electrical heart disease (arrhythmia or cardiac conduction defect); or (3) amyloid infiltration documented in biopsy.

Results

Amyloid cardiomyopathy was identified in 41 (14.2%) patients and 44 (15.3%) individuals presented abnormal cardiac DPD uptake. Individuals with cardiac DPD retention had 27-fold higher likelihood of having amyloid cardiomyopathy (OR: 27.4; 95% CI 11.6–65.0; P&lt;0.001). However, DPD scintigraphy presented suboptimal accuracy to detect ATTR cardiomyopathy (89.9%) with limitations in sensitivity (56.1%), specificity (95.6%), positive predictive value (67.7%) and negative predictive value (92.9%).

During a mean follow-up 33.6±1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with amyloid cardiomyopathy (HR: 14.1; 95% CI 4.9–40.7; P&lt;0.001), 13 times higher in those with abnormal cardiac DPD uptake (HR: 12.59; 95% CI % 4.56–34.72; P&lt;0.001) and 10 times higher in those with H/M MIBG ratio &lt;1.60 (HR: 10.40; 95% CI 2.95–36.69; P&lt;0.001). The prognostic value of ventricular thickness and cardiac DPD uptake was additive: patients without septal thickening and no cardiac DPD retention had excellent prognosis (5-year mortality of 0.75%), while those with septal thickening and/or abnormal DPD retention presented 5-year mortality rates ranging from 39.9 to 53.3%.

Conclusions

DPD scintigraphy is valuable in the evaluation of ATTR-V30M mutation carriers, particularly for prognostic stratification purposes, identifying patients at higher risk of death.

Funding Acknowledgement

Type of funding sources: None.

Pregnancy outcomes in women with severe congenital heart disease – a specialized centre experience

Introduction

Progress in pediatric cardiology and cardiac surgery has dramatically raised the number of women with severe complex congenital heart disease (SC-CHD) that reach reproductive age. Pregnancy (P) in this group of women has an increased risk of adverse cardiac and neonatal events and its predictive factors are not fully defined. Our purpose was to assess the experience of our center regarding P and neonatal outcomes in women with SC-CHD.

Methods

Retrospective analysis of obstetric data in women with CHD followed at our institution. P and neonatal outcomes were evaluated regarding patients presenting SC-CHD and mild and moderate complexity CHD (MMC-CHD), according to ESC guidelines CHD complexity classification.

Results

The study enrolled 680 women with CHD (median age, 27.2 years) who experienced 1262 pregnancies, resulting in 998 live births. A previous corrective procedure was found in 334 women (49.1%). CHD complexity was considered mild, moderate and severe in 263 (38.7%), 359 (52.8%) and 58 (8.5%), respectively. SC-CHD included 38 women with cyanotic CHD and 18 with pulmonary vascular disease. The most common heart defect in SC-CHD pts was cyanotic tetralogy of Fallot (19.0%), followed by dextro-transposition of the great arteries with atrial switch /palliative procedure (13.8%) – Figure 1.

Pts with SC-CHD had successful deliveries in 56.1% comparing with 82.1% in MMC-CHD. Women with SC-CHD had significantly higher incidence of preterm birth (24.6% vs 7.4%, p&lt;0.001), spontaneous abortion (26.3% vs 12.3%, p=0.004) and neonatal mortality (10.3% vs 2.3%) comparing with MMC-CHD. Low birth weight was also extremely more frequent in the SC-CHD group (44.7% vs 8.5%, p&lt;0.001). No difference was found relating to the presence of CHD in infants from SC-CHD mothers compared to off-spring from MMC-CHD (8.4 vs 5.3%, p=0.407). Cesarian deliveries had similar rates independently of increased CHD complexity (34.2% vs 32.1%). Overall, pregnancy was quite well tolerated, although cardiac complications were more common in SC-CHD P (0.4% vs 4.3%, p 0.013). Only one maternal death was registered, during 1st trimester, in a woman with a large unrepaired ventricular septal defect and cyanosis.

Conclusion

Severe complex CHD remains a challenging condition for pregnancy with increased maternal and neonatal morbimortality. This emphasizes the importance of extensive prepregnancy counselling and centralization of care to address specific risks and requirements of the condition.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Severe CHD

Palliative Care in Heart Failure: Challenging Prognostication

Heart failure (HF) is a chronic progressive disease with high morbimortality and poor quality of life (QoL). Palliative care significantly improves clinical outcomes but few patients receive it, in part due to challenging decisions about prognosis. This retrospective study, included all patients consecutively discharged from an Acute Heart Failure Unit over a period of one year, aiming to assess the accuracy of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in predicting mortality. Additionally, predictors of death at one and three years were explored using a multivariate regression model. The MAGGIC score was useful in predicting mortality, without significant difference between mortality observed at three-years follow-up compared with a mortality given by the score (p=0.115). Selected variables were statistically compared showing that poor functional status, high New York Heart Association (NYHA) at discharge, psychopharmacs use, and high creatininemia were associated with higher mortality (p<0.05). The multivariate regression model identified three predictors of one-year mortality: psychopharmacs baseline use (OR=4.110; p=0.014), angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) medication at discharge (OR=0.297; p=0.033), and higher admission's creatinine (OR=2.473; p=0.028). For three-year mortality outcome, two variables were strong independent predictors: psychopharmacs (OR=3.330; p=0.022) and medication with ACEI/ARB at discharge (OR=0.285; p=0.018). Models' adjustment was assessed through the receiver operating characteristic (ROC) curve. The best model was the one-year mortality (area under the curve, AUC 81%), corresponding to a good discrimination power. Despite prognostication, when setting goals of care an individualised patient-centred approach is imperative, based on the patient's objectives and needs. Risk factors related to poorer outcomes should be considered, in particular, higher NYHA at discharge which also represents symptom burden. Hospitalisation is an opportunity to optimize global care for heart failure patients including palliative care.

Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity

INTRODUCTION

Cancer chemotherapy increases the risk of heart failure. This cost-effectiveness study analyzes cardio-oncology imaging assessment of left ventricular ejection fraction (LVEF) using a Portuguese healthcare payer perspective and a five-year time horizon.

METHODS

Two cardioprotective strategies were assessed: universal cardioprotection (UCP) for all patients and cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX). A Markov model, informed by the retrospective clinical course of breast cancer patients followed in a Portuguese public hospital, was developed to assess the cost-effectiveness of LVEF cardio-oncology imaging assessment. Data on transition probabilities, costs and utilities were retrieved from both the retrospective data and published literature to assess the cost-effectiveness of LVEF echocardiographic assessment. Costs and utilities of the cardioprotective strategies were assessed over a five-year range, using probabilistic sensitivity analyses.

RESULTS

In the reference case of a 63-year-old breast cancer patient treated with cardioprotection initiated on diagnosis of EF-CTX, the five-year time horizon (4.22 QALYs and €2594 cost over five years) dominated UCP (3.42 QALYS and €3758 cost over five years). Under a time horizon of five years at a willingness-to-pay threshold of €22 986, over 65.7% of simulations provided additional QALYs. Monte Carlo simulation of the Markov model had no effect on the model's conclusions.

CONCLUSION

In the Portuguese public healthcare system and under specific hypotheses, from a healthcare payer perspective, EF-CTX-guided cardioprotection for patients at risk of chemotherapy-related cardiotoxicity provides more QALYs at lower cost than UCP.

Patient profiling in heart failure for tailoring medical therapy. A consensus document of the Heart Failure Association of the European Society of Cardiology

Despite guideline recommendations and available evidence, implementation of treatment in heart failure (HF) is poor. The majority of patients are not prescribed drugs at target doses that have been proven to positively impact morbidity and mortality. Among others, tolerability issues related to low blood pressure, heart rate, impaired renal function or hyperkalaemia are responsible. Chronic kidney disease plays an important role as it affects up to 50% of patients with HF. Also, dynamic changes in estimated glomerular filtration rate may occur during the course of HF, resulting in inappropriate dose reduction or even discontinuation of decongestive or neurohormonal modulating therapy in clinical practice. As patients with HF are rarely naïve to pharmacologic therapies, the challenge is to adequately prioritize or select the most appropriate up-titration schedule according to patient profile. In this consensus document, we identified nine patient profiles that may be relevant for treatment implementation in HF patients with a reduced ejection fraction. These profiles take into account heart rate (<60 bpm or >70 bpm), the presence of atrial fibrillation, symptomatic low blood pressure, estimated glomerular filtration rate (<30 or >30 mL/min/1.73 m² ) or hyperkalaemia. The pre-discharge patient, frequently still congestive, is also addressed. A personalized approach, adjusting guideline-directed medical therapy to patient profile, may allow to achieve a better and more comprehensive therapy for each individual patient than the more traditional, forced titration of each drug class before initiating treatment with the next.

The impact of COVID-19 outbreak on urolithiasis emergency department admissions, hospitalizations and clinical management in central Italy: a multicentric analysis

Introducción y objetivos

Nuestro objetivo fue evaluar el impacto de la enfermedad del coronavirus de 2019 (COVID-19) en los ingresos en los servicios de urgencias (SU), las hospitalizaciones y el manejo clínico de los pacientes con urolitiasis.

Pacientes y métodos

Realizamos un análisis retrospectivo multicéntrico de las admisiones en los servicios de urgencias de tres departamentos de urología de gran volumen (uno directamente implicado en el tratamiento de los pacientes de COVID-19 y dos no implicados) en Roma (Italia) entre marzo y abril de 2020 y en el mismo período de 2019. Se realizó un análisis estadístico del número de admisiones por urolitiasis, la tasa de complicaciones, hospitalización y el tipo de tratamiento recibido.

Resultados

Fueron incluidos 304 pacientes en el análisis. Se observó una reducción significativa en el número global de pacientes ingresados en urgencias por urolitiasis entre 2019 y 2020 (48,8%). Además, con respecto a la elección del tratamiento de los pacientes hospitalizados, se informó un aumento estadísticamente significativo de los procedimientos de extracción de cálculos en comparación con el drenaje urinario en 2020 (p = 0,015).

Conclusiones

Durante la pandemia de la COVID-19 en Roma ha habido una reducción significativa de los ingresos en urgencias por urolitiasis. Los pacientes ingresados en el SU tuvieron más complicaciones, necesitaron hospitalización con más frecuencia y en cuanto al manejo clínico, se prefirió la extracción temprana de los cálculos, en vez del drenaje urinario. Todos los urólogos deben ser conscientes de que en los próximos meses podrían enfrentar un mayor número de admisiones por urolitiasis y un manejo de casos más complicados.

New onset atrial fibrillation after percutaneous Patent Foramen Ovale closure: how serious is this problem?

Background

Percutaneous Patent Foramen Ovale (pPFO) closure benefits for secondary prevention after cardio-embolic stroke have recently been proved. With the increasing number of cases and procedures, a concern with new onset atrial fibrillation (NOAF) has been raised.

Purpose

To evaluate long-term outcome regarding NOAF rate and to identify its predictors and clinical impact, in a real population submitted to pPFO closure.

Methods

From 2000 to 2017, consecutive patients (P) submitted to pPFO closure in a tertiary centre were prospectively enrolled. The primary endpoint was NOAF rate and secondary endpoints were all-cause, neurologic and cardiac mortality rates and recurrent ischemic events. Previous and follow-up electrocardiographic, echocardiographic and 24-hour heart rhythm monitoring data were analysed. Follow-up was performed through medical visits, medical charts consultation and a phone call based system, in order to assess clinical status, on-going treatment and events.

Results

496 patients were submitted to pPFO. Immediate success was achieved in 98.8% and 9.1% presented a residual shunt on the 1st year TEE. Mean age was 45.0±11.2 years-old with 50.2% of males. The prevalence of hypertension, hypercholesterolemia and atrial septum aneurysm (ASA) was 25.7%, 45.0% and 46.3%, respectively. Pre-procedural mean left atrial (LA) diameter was 36.0±5.3 mm. FU data was available for 490 (98.6%), for a mean FU time of 7.41±3.51 years. 34 P (6.9%) presented ischemic events recurrence (26 strokes and 8 TIA). The primary endpoint was observed in 21 P (4.3%) during the FU period.

Median time to 1st AF episode since PFO closure was 5.90±5.53 years. 11 P (52.3%) initiated oral anticoagulation. In univariate analysis, age (44.6±11.3 vs 51.8±6.0 years, p=0.005) and hypertension (24.7% vs 47.6%, p=0.019) were predictors of NOAF in this population. In multivariated analysis, only age remained a predictor of NOAF (OR 1.05 (1.007–1.101), p=0.025). LA pre pPFO closure dimensions, ASA, device type or size and the presence of residual shunt in TEE were not determinants of AF occurrence. The incidence of NOAF was associated with the need for hospitalization due to cardiac causes (19% vs 3.2%, p=0.001) and a trend towards higher rate of recurrent stroke (4.9% vs 14.3%, p=0.06).

Conclusion

Despite being a highly successful and safe procedure in most patients, pPFO closure was associated with a non-negligenciable rate of NOAF during long-term follow-up. NOAF predictors were related with classical cardiovascular risk factors, such as age and hypertension. None of the procedure or device features were associated with NOAF. Yet, a clinical impact was attributed to NOAF, with more hospitalizations and a trend towards ischemic events recurrence.

As young patients submitted to pPFO closure grow older, prevention strategies to diagnose and treat NOAF should be endeavoured.

Funding Acknowledgement

Type of funding source: None

Anti-anginal drugs-beliefs and evidence: systematic review covering 50 years of medical treatment

Chronic stable angina is the most prevalent symptom of ischaemic heart disease and its management is a priority. Current guidelines recommend pharmacological therapy with drugs classified as being first line (beta blockers, calcium channel blockers, short acting nitrates) or second line (long-acting nitrates, ivabradine, nicorandil, ranolazine, and trimetazidine). Second line drugs are indicated for patients who have contraindications to first line agents, do not tolerate them or remain symptomatic. Evidence that one drug is superior to another has been questioned. Between January and March 2018, we performed a systematic review of articles written in English over the past 50 years English-written articles in Medline and Embase following preferred reporting items and the Cochrane collaboration approach. We included double blind randomized studies comparing parallel groups on treatment of angina in patients with stable coronary artery disease, with a sample size of, at least, 100 patients (50 patients per group), with a minimum follow-up of 1 week and an outcome measured on exercise testing, duration of exercise being the preferred outcome. Thirteen studies fulfilled our criteria. Nine studies involved between 100 and 300 patients, (2818 in total) and a further four enrolled greater than 300 patients. Evidence of equivalence was demonstrated for the use of beta-blockers (atenolol), calcium antagonists (amlodipine, nifedipine), and channel inhibitor (ivabradine) in three of these studies. Taken all together, in none of the studies was there evidence that one drug was superior to another in the treatment of angina or to prolong total exercise duration. There is a paucity of data comparing the efficacy of anti-anginal agents. The little available evidence shows that no anti-anginal drug is superior to another and equivalence has been shown only for three classes of drugs. Guidelines draw conclusions not from evidence but from clinical beliefs.

P542Cardiac autonomic dysfunction and inflammatory response in heart failure - markers for cardiac resynchronization therapy response?

Funding Acknowledgements

FCP

Introduction

Cardiac sympathetic activation and inflammatory response are involved in chronic heart failure (HF) pathophysiology. The severity of autonomic dysfunction and inflammation might be responsible for different responses to HF treatment.

Aim

To evaluate the impact of cardiac autonomic dysfunction, and it´s association with systemic inflammation, on cardiac resynchronization therapy (CRT) response in severe HF patients.

Methods

Single centre, prospective, longitudinal study, including consecutive patients, referred to CRT. Demographic data, HF aetiology and NYHA class were evaluated. Left ventricular (LV) function data (LV ejection fraction - LVEF) by echocardiography, heart to mediastinum early ratio (HMRe) by 123I-MIBG cardiac scintigraphy, and plasmatic TNF-α levels (pg/mL) were determined, at baseline and 4 months after CRT implantation. CRT response was defined by an absolute increase of at least 5% in LVEF at 4 months evaluation after CRT. Patients were divided in 4 groups according to HMRe and TNF-α cut-points: Group I (TNF-α &gt; 2.0 pg/ml + HMRe ≥ 1.6), Group II (TNF-α &gt; 2.0 pg/ml + HMRe &lt; 1.6), Group III (TNF-α ≤ 2.0 pg/ml + HMRe ≥ 1.6) and Group IV (TNF-α ≤ 2.0 pg/ml + HMRe &lt; 1.6). Data was analyzed using descriptive statistics and groups were compared by Fisher"s exact test.

Results

A total of 95 patients were included (age 68.6 ± 10.2 years), 67.4% male and 32.6% female, 40% with diabetes mellitus, 30.5% with ischemic cardiomyopathy, 23.2% in NYHA III/IV, baseline LVEF - 26 ± 7%. At 4 months, LVEF was 40 ± 11%. In total, 73.7% were responders and 26.3% were non-responders to CRT. There were 28 patients (29.5%) with HMRe ≥ 1.6, with 25 responders (89.3%) and 48 patients (50.5%) with TNF-α ≤ 2.0 pg/ml, with 38 responders (79.2%). Group I had 16 patients (16.8%), with 81.2% responders; Group II had 31 patients (32.7%), with 61.3% responders; Group III had 12 patients (12.6%), with 100% responders, and Group IV had 36 patients (37.9%), with 72.2% responders. Conclusion: In patients with severe HF submitted to CRT, combining cardiac autonomic dysfunction and inflammation, associated to high rate of CRT non response. Contrarily, those with preserved cardiac autonomic function and no increased levels of inflammation identified most significantly CRT responders.

CRT response according to HMRe and TNFα HMRe ≥ 1.6 (n = 28) HMRe &lt; 1.6 (n = 67) Responders NO Respondersn (%) Responders NO Respondersn (%) TNF α &gt; 2 pg/mL (n = 47) G I: 13 (81.2%) 3 (18.8%) GII: 19 (61.3%) 12 (38.7%) * TNF α ≤ 2 pg/mL (n = 48) G III: 12 (100%) 0 (0%)* G IV: 26 (72.2%) 10 (27.8%)

P1402Isolation of pulmonary veins with duty-cycled circular multi-polar catheter: randomized controlled clinical trial

Introduction

Pulmonary vein isolation (PVI) is the central element in the ablation of atrial fibrillation (AF), and can be obtained with different ablation modalities. The duty-cycled circular multi-pole catheter PVAC® (Medtronic) allows linear application of radiofrequency energy, with the production of circumferential lesions. Conceptually, it can make ablation simpler and faster in patients with favorable anatomy.

Objectives

To evaluate the safety and efficacy of ablation with a PVAC® catheter and to compare it with the conventional technique point-by-point (PbP) with irrigated catheter.

Methods

Clinical trial with single-blinded patients with AF refractory to antiarrhythmic therapy, randomized (1: 1) for ablation with PVAC® or PbP. The ablation strategy consisted of PVI, complemented with ablation of the cavo-tricuspid isthmus in patients with history of concomitant flutter. Monitoring was performed with a 7-day event loop recorder at 3, 6 and 12 months and annually from the 2nd year. Success was defined by AF-free survival or any maintained supraventricular tachycardia (duration &gt; 30seconds).

Results

354 patients (67.5% males, 58 ± 12 years, PbP: 175, PVAC: 179) were included, of which 59.1% had paroxysmal, 26.2% short-standing persistent and 14.7% had long-standing persistent AF. Baseline characteristics were similar between groups. Among patients treated with PVAC, 93.1% of the pulmonary veins were isolated (620/666), similar to the 98.3% immediate success of the PbP group (697/709). Although the complication rate was similar in both groups (PVAC: 4.9% vs. PbP: 7.8%; P = NS), the risk of hemopericardium was lower with PVAC (0% vs. 4.6%; P = 0.013). Two patients treated with PVAC developed stroke (1.13% vs. 0%; P = NS). The duration of the procedure was lower among the patients treated with PVAC [136 (100-180) vs. 230 (188-270) min; P &lt;0.001], with no difference in fluoroscopy time [24.4 (14.5-36.8) vs. 27.1 (17.0-45.0) min]. The success rate after 1st ablation at 36 months was 68%, with no differences between groups. The success rate after multiple ablations increased to 85.8%, with no differences between groups.

Conclusion

The multipolar PVAC catheter can represent an added value in AF ablation, making the procedure simpler and faster, ensuring similar efficacy to the conventional technique and with a lower risk of cardiac tamponade. The present trial suggests the need for clinically manifested stroke risk surveillance, which may be increased with this technique.

Abstract Figure.

World Heart Federation Briefing on Prevention: Coronavirus Disease 2019 (COVID-19) in Low-Income Countries

In December 2019, the novel coronavirus Coronavirus Disease 2019 (COVID-19) outbreak started in Wuhan, the capital of Hubei province in China. Since then it has spread to many other regions, including low-income countries.

Impact of public health initiatives on acute coronary syndrome fatality rates in Portugal

INTRODUCTION AND OBJECTIVE

Every year cardiovascular disease (CVD) causes 3.9 million deaths in Europe. Portugal has implemented a set of public health policies to tackle CVD mortality: a smoking ban in 2008, a salt reduction regulation in 2010 and the coronary fast-track system (FTS) for acute coronary syndrome (ACS) in 2007. Our goal in this study was to analyze the impact of these three public health policies in reducing case-fatality rates from ACS between 2000 and 2016.

METHODS

The impact of these policies on monthly ACS case-fatalities was assessed by creating individual models for each of the initiatives and implementing multiple linear regression analysis, using standard methods for interrupted time series. We also implemented segmented regression analysis to test which year showed a significant difference in the case-fatality slopes.

RESULTS

Separate modeling showed that the smoking ban (beta=-0.861, p=0.050) and the FTS (beta=-1.27, p=0.003) had an immediate impact after implementation, but did not have a significant impact on ACS trends. The salt reduction regulation did not have a significant impact. For the segmented model, we found significant differences between case-fatality trends before and after 2009, with rates before 2009 showing a steeper decrease.

CONCLUSIONS

The smoking ban and the FTS led to an immediate decrease in case-fatality rates; however, after 2009 no major decrease in case-fatality trends was found. Coronary heart disease constitutes an immense public health problem and it remains essential for decision-makers, public health authorities and the cardiology community to keep working to reduce ACS mortality rates.

Echocardiographic Assessment of Cardiac Anatomy and Function in Adult Rats

The use of experimental animal models has become crucial in cardiovascular science. Most studies using rodent models are focused on two-dimensional imaging to study the cardiac anatomy of the left ventricle and M-mode echo to assess its dimensions. However, this could limit a comprehensive study. Herein, we describe a protocol that allows an assessment of the heart chamber size, left ventricular function (systolic and diastolic) and valvular function. A conventional medical ultrasound machine was used in this protocol and different echo views were obtained through left parasternal, apical and suprasternal windows. In the left parasternal window, the long and short axis were acquired to analyze left chamber dimensions, right ventricle and pulmonary artery dimensions, and mitral, pulmonary and aortic valve function. The apical window allows the measurement of heart chamber dimensions and evaluation of systolic and diastolic parameters. It also allows Doppler assessment with detection and quantification of heart valve disturbances (regurgitation or stenosis). Different segments and walls of the left ventricle are visualized throughout all views. Finally, the ascending aorta, aortic arch, and descending aorta can be imaged through the suprasternal window. A combination of ultrasound imaging, Doppler flow and tissue Doppler assessment have been obtained to study cardiac morphology and function. This represents an important contribution to improve the assessment of cardiac function in adult rats with impact for research using these animal models.

Prognostic implications of left ventricular global longitudinal strain in patients with bicuspid aortic valve disease and preserved left ventricular ejection fraction

Aims

In patients with bicuspid aortic valve (BAV) and preserved left ventricular (LV) ejection fraction (EF), the frequency of impaired LV global longitudinal strain (GLS) and its prognostic implications are unknown. The present study evaluated the proportion and prognostic value of impaired LV GLS in patients with BAV and preserved LVEF.

Methods and results

Five hundred and thirteen patients (68% men; mean age 44 ± 18 years) with BAV and preserved LVEF (&gt;50%) were divided into five groups according to the type of BAV dysfunction: (i) normal function BAV, (ii) mild aortic stenosis (AS) or aortic regurgitation (AR), (iii) ≥moderate isolated AS, (iv) ≥moderate isolated AR, and (v) ≥moderate mixed AS and AR. LV systolic dysfunction based on 2D speckle-tracking echocardiography was defined as a cut-off value of LVGLS (−13.6%). The primary outcome was aortic valve intervention or all-cause mortality. The proportion of patients with LVGLS ≤−13.6% was the highest in the normal BAV group (97%) and the lowest in the group with moderate and severe mixed AS and AR (79%). During a median follow-up of 10 years, 210 (41%) patients underwent aortic valve replacement and 17 (3%) died. Patients with preserved LV systolic function (LVGLS ≤ −13.6%) had significantly better event-free survival compared to those with impaired LV systolic function (LVGLS &gt; −13.6%). LVGLS was independently associated with increased risk of events (mainly aortic valve replacement): hazard ratio 1.09; P &lt; 0.001.

Conclusion

Impaired LVGLS in BAV with preserved LVEF is not infrequent and was independently associated with increased risk of events (mainly aortic valve replacement events).

Trimetazidine in cardiovascular medicine

Abnormalities of myocardial energy metabolism appear as a common background of the two major cardiac disorders: ischemic heart disease (IHD) and heart failure (HF). Myocardial ischemia has been recently conceived as a multifaceted syndrome that can be precipitated by a number of mechanisms including metabolic abnormalities. HF is a progressive disorder characterised by a complex interaction of haemodynamic, neurohormonal and metabolic disturbances. HF may further promote metabolic changes, generating a vicious cycle. Thus, targeting cardiac metabolism in IHD patients may prevent the deterioration of left ventricular function, stopping the progression to HF. For these reasons, several studies have explored the potential benefits of trimetazidine (TMZ), an inhibitor of free fatty acids oxidation that shifts cardiac and muscle metabolism to glucose utilization. Because of its mechanism of action, TMZ has been found to provide a cardioprotective effect in patients with angina, diabetes mellitus, and left ventricular (LV) dysfunction, and those undergoing revascularization procedures, without relevant side effects. In addition, the lack of interference with heart rate, arterial pressure, and most of frequent comorbidities, makes TMZ an attractive option for patients and clinicians as well. The impact of TMZ on long term mortality and morbidity in ischemic syndromes and in heart failure need to be conclusively confirmed in properly designed RCT.