Neonatal Birth Weight With Daily Compared With Every-Other-Day Glucose Monitoring in Gestational Diabetes Mellitus: A Randomized Controlled Trial

OBJECTIVE

To assess whether universal use of every-other-day glucose monitoring in patients with gestational diabetes mellitus (GDM) resulted in similar birth weights and medication use and was preferred by the patient compared with traditional daily glucose monitoring.

METHODS

This was a noninferiority randomized controlled trial conducted at a single New York City hospital between April 2021 and May 2022. Patients with singleton pregnancies who were diagnosed with GDM after 20 weeks of gestation and had a minimum of 7 days of previous daily blood glucose testing were randomly assigned to test blood glucose values daily or every other day. The primary outcome was neonatal birth weight. We calculated a total sample size of 196 participants needed for noninferiority to be tested, assuming the mean birth weight in the every-other-day group, compared with the daily group, was no higher than the predefined noninferiority margin of 200 g (80% power and one-sided alpha of 0.05). Postrandomization characteristics, including blood glucose values and medication initiation and timing, were recorded. Satisfaction with treatment group was assessed using the validated Oxford Maternity Diabetes Treatment Satisfaction Questionnaire.

RESULTS

A total of 197 patients were randomized: 98 in the daily group and 99 in the every-other-day group. Baseline characteristics were similar between groups. The mean neonatal birth weight was similar between groups (mean±SD 3,090±418 g among newborns in the daily group compared with 3,181±482 g among newborns in the every-other-day group). For the primary outcome, the every-other-day group was found to be noninferior to the daily group with an upper confidence limit for the mean difference in mean birth weight of 197 g, which was below the noninferiority margin of 200 g (P=.046). Postrandomization, there were no significant differences in the number of patients who required medication, the gestational age at which medication was started, or the type of medication used. Average fasting and postprandial glucose values were similar between groups. There was an increase in adherence to treatment group in those randomized to every-other-day blood sugars, but no difference in patient satisfaction.

CONCLUSION

In patients with GDM, testing blood glucose values every other day was as effective as testing daily, without apparent effects on birth weight, medication initiation, or glucose control. Reduced frequency of blood glucose monitoring might help decrease the emotional, physical, and financial burden experienced by patients with GDM.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04857073.

Upright exercise stress echocardiography may unmask dynamic left ventricular obstruction also beyond hypertrophic cardiomyopathy

Background

Dynamic left ventricular outflow obstruction (LVOTO) during exercise stress echocardiography (ESE) is recommended in hypertrophic cardiomyopathy (HCM) to identify the obstructive phenotype.

Aim

To assess left ventricular outflow gradient (LVOTG) during ESE in different conditions.

Methods

In a single-group, prospective, observational study, we performed peak and/or post-treadmill ESE with systematic assessment of LVOTG in the orthostatic position by continuous-wave Doppler in 1333 subjects (837 males, mean age 38,2±20 ranging from 6 to 87 years) recruited over a period of twenty years, from 2001 to 2021. Peak LVOTG ≥30 mm Hg was considered abnormal for LVOTO during ESE. We enrolled 7 different populations: asymptomatic healthy controls (n=35); HCM (n=81); genotype-positive, phenotype negative asymptomatic HCM (n=6); patients with chest pain symptoms, suspected myocardial ischemia and either normal coronary arteries (INOCA, n=131,or with very low pre-test probability of coronary artery disease (probable INOCA, n=416) and; fatigue and suspected heart failure with preserved ejection fraction (HFpEF, n=206); amateur athletes with ischemia-like ECG changes during exercise-test or symptoms such as near syncope or chest pain or dizziness (n=457); aborted sudden death and with negative screening (n=1).

Results

Technical success rate of LVOTG assessment was 1333/1333 at rest and at peak stress (feasibility 100%). Imaging and analysis time were <1 minute. LVOTG at rest was present in 25 pts (2.8%) of the overall population: 23 HCM, 1 INOCA, and 1 HFpEF. Overall prevalence during ESE was 432/1333 (32%). During ESE, LVOTO (see Figure 1 and 2) was 0% (0/35) in normals, 58% (47/81) in HCM (23 with obstruction at rest), 33% (2/6) in genotype-positive, phenotype negative HCM, 37% (33/131) in INOCA, 40% (135/416) in athletes and 1/1 in the patient with aborted sudden death on strenuous exercise.

Conclusion

LVOTO in orthostatic position is detectable during treadmill ESE in several cardiovascular conditions associated with symptoms such as dyspnea, chest pain or near syncope, and even in asymptomatic patients with genotype-positive, phenotype-negative HCM. The identification of the obstructive phenotype is easy to capture during ESE without any significant additional imaging and analysis burden and can be important also outside HCM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

1037 Differences in reverse remodelling between ischemic and non-ischemic left ventricular segments as assessed by myocardial work after sacubitril-valsartan therapy

Introduction

Myocardial work (MW) is a new transthoracic echocardiographic (TTE) parameter that enhances the information provided through left ventricular (LV) global longitudinal strain (GLS), allowing to investigate LV performance even in cases of changes in afterload.

None is known about the effects of Sacubitril-Valsartan (LCZ696) therapy in MW parameters.

Purpose

Compare the changes in MW parameters between ischemic and non-ischemic segments after LCZ696 therapy.

Methods

The study was a prospective evaluation of chronic Heart Failure (HF) patients with optimized standard of care therapy and LV ejection fraction ≤40%, in which LCZ696 therapy was started and no other HF treatment was expected to change.

A TTE study was performed before and 6 months after LCZ696 therapy, using the GE Vivid E95 ultrasound system. A semiautomated analysis of GLS was performed after two-dimensional images were acquired in the standard apical 4-, 3- and 2 chamber views. MW and related indices were estimated using custom software.

Two groups were created according to the 17 segment model TTE study before LCZ696 therapy:

G1 (ischemic group): dyskinesia/akinesia/hypokinesia segments in patients with ischemic HF etiology;

G2 (non-ischemic group): normokinesia segments in patients with ischemic and all segments in patients with non-ischemic HF etiology;

Results

Of the 42 patients, 35 (83.3%) completed the six-months follow-up with LCZ696, since 2 patients (4.8%) died and 5 patients (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years, with ischemic etiology in 15 (42.9%), resulting in a total of 26.5% segments for G1.

Baseline global MW index (GWI) had no statistical difference between G1 and G2 (566.1 VS 584.8mmHg%, p = 0.257), but baseline MW efficiency (GWE) were significantly lower in G1 (71.9 VS 78.8%, p < 0.001).

The table represents the mean values for MW parameters in G1 and G2 before and 6 months after LCZ696 therapy, with a significantly increase in GWI and GWE values in both groups. Despite no difference in the increase in GWE (p = 0.872), the increase in GWI were higher in G2 than G1 (p < 0.001).

Conclusion

MW seems to be a new tool providing signs of reverse remodelling and better cardiac performance in ischemic and non-ischemic segments after LCZ696 therapy.

Table 1 Time 0 6 months p GWI in ischemic segments (mmHg%) 566.1 ± 364.0 696.5 ± 445.2 <0.001 GWE in ischemic segments (%) 71.9 ± 25.0 78.9 ± 19.1 0.009 GWI in non-ischemic segments (mmHg%) 584.8 ± 434.3 812.3 ± 442.0 <0.001 GWE in non-ischemic segments (%) 78.8 ± 21.2 85.7 ± 15.8 0.004 MW data before and after six months of LCZ696 therapy

P1429 B-Type natriuretic peptide prediction of right catheterization parameters in the first year after heart transplant

Introduction

Despite being the gold-standard for hemodynamic assessment, right heart catheterization (RHC) was overcome by plasma B-Type Natriuretic Peptide (BNP) levels in daily clinical routine. However, in the first year after heart transplantation (HT), the relationship between BNP and adverse hemodynamics have yielded conflicting results.

Purpose

The aim of this study was to evaluate whether BNP values can be used to estimate adverse hemodynamics in the first year after HT.

Methods

Prospective study of consecutive RHC performed in the first year after HT (according to the endomyocardial biopsies program). Plasma BNP levels were measured at the same day.

The area under the curve (AUC) was analysed to find the BNP values with higher sensitivity and specificity to detect adverse hemodynamics.

Results

From 2017 to 2018, 50 RHC were performed. Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

Prediction of adverse hemodynamics by AUC results are represented in the table. BNP values were significantly increased in patients with pulmonary capillary wedge pressure (PCWP) >12mmHg (p < 0.001), cardiac index <2.5L/min/m2 (p = 0.001), mean pulmonary artery pressure (mPAP) ≥25mmHg (p < 0.001), pulmonary vascular resistance > 1,5WU (p = 0.044) and right atrial pressure >5mmHg (p = 0.003).

BNP >500pg/ml had a sensitivity of 78.3% and 87.5% and a specificity of 76.0% and 67.7% to detect PCWP >12mmHg and mPAP ≥25mmHg, respectively.

Conclusion Significant associations were found between BNP values and adverse hemodynamics in RHC, supporting the clinical utility of BNP in the first year after HT.

BNP prediction AUC values SR HEMODYNAMIC PARAMETERS AUC p 95% CI Best BNP value Sensitivity Specificity Pulmonary capillary wedge pressure (PCWP) > 12mmHg 0.798 <0.001 0.671-0.925 > 500pg/ml 78.3% 76.0% Mean pulmonary artery pressure (mPAP) ≥ 25mmHg 0.830 <0.001 0.714-0.946 > 500pg/ml 87.5% 67.7% Cardiac output < 4L/min 0.833 0.002 0.667-1.000 > 1500pg/ml 77.8% 87.5% Cardiac index (CI) < 2.5L/min/m2 0.810 0.001 0.663-0.957 > 1150pg/ml 76.9% 86.1% Pulmonary vascular resistance (PVR) > 1,5WU 0.678 0.044 0.509-0.848 > 200pg/ml 83.3% 47.1% Right atrial pressure (RAP) > 5mmHg 0.744 0.003 0.607-0.880 > 500pg/ml 70.8% 65.4% BNP prediction

P354 Right heart catheterization parameters, echocardiography parameters and B-Type natriuretic peptide prediction of acute cellular rejection in the first year after heart transplant

Introduction

Since the mid-1970s, the diagnosis of acute cellular rejection (ACR) has been made by endomyocardial biopsy (EMB). Whether B-Type Natriuretic Peptide (BNP), transthoracic echocardiography (TTE) parameters and right heart catheterization (RHC) parameters can detect rejection in heart transplant (HT) patients have yielded conflicting results and did not overcome the use of EMB in the first year after HT.

Purpose

The aim of this study was to evaluate whether BNP, TTE and RHC parameters can be used to detect ACR in the first year after HT.

Methods

Prospective study of consecutive EMB performed in the first year after HT. Plasma BNP levels, TTE and RHC were performed at the same day.

Clinical significant ACR was defined as ≥ 2R, according to the ISHLT 2004 grading. The area under the curve (AUC) was analysed for statistically significant associations to detect ACR.

Results

From 2017 to 2018, 50 EMB were performed with the following results: 2R - 5 (10.0%); 1R- 29 (58.0%); 0 – 16 (32%). Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

AUC results of BNP and several TTE and RHC parameters for the prediction of ACR are represented in the table. Right atrial pressure (RAP) value (p = 0.027) was the only significantly predictor of ACR, while isovolumic relaxation time measured by TTE revealed a borderline significant trend (p = 0.076).

RAP > 10mmHg had a sensitivity of 60.0% and a specificity of 84.4% for detecting ACR.

Conclusion

Detecting ACR without EMB remains a clinical challenge, but RAP measured by RHC was a significant predictor of ACR in the first year after HT, while BNP values did not correlate with ACR.

AUC values PARAMETERS AUC p 95% CI BNP 0.658 0.251 0.405-0.911 Troponin I 0.591 0.507 0.260-0.923 Left ventricular ejection fraction 0.416 0.541 0.218-0.614 E/A 0.480 0.895 0.282-0.678 Deceleration time 0.463 0.463 0.161-0.765 Isovolumic relaxion time 0.745 0.076 0.427-1.000 Cardiac index 0.595 0.488 0.346-0.845 Pulmonary capillary wedge pressure 0.628 0.401 0.329-0.926 Mean pulmonary artery pressure 0.684 0.181 0.511-0.857 Right atrial pressure 0.804 0.027 0.631-0.978 AUC values

4940Early reverse remodelling assessed by myocardial work after sacubitril-valsartan therapy

Introduction

Sacubitril/Valsartan (LCZ696) had prognosis benefit demonstrated in PARADIGM-HF trial, however less is known about his effects in cardiac dimensions and function.

Myocardial work (MW) is a new transthoracic echocardiographic (TTE) parameter. None is known about the effects of LCZ696 therapy in MW parameters.

Purpose

The aim of this study was to prospectively compare several TTE parameters, including MW, before and after LCZ696 therapy.

Methods

Prospective evaluation of chronic HF patients with optimized standard of care therapy and LVEF≤40%, in which LCZ696 therapy was started.

TTE study was performed before and 6 months after LCZ696 therapy. A semiautomated analysis of GLS was performed and MW were estimated using custom software of GE Vivid E95 ultrasound system.

Results

Of the 42 patients, 35 (83.3%) completed the 6 months follow-up, since 2 patients (4.8%) died and 5 patients (11.9%) discontinued treatment for adverse events. Mean age was 58.6±11.1 years with 82.9% of male patients.

LV dimensions and atrial volumes were significantly lower at 6 months of treatment. LVEF had a mean absolute raise of 8.9% and GLS a relative decrease of 27.8%. MW had a significant increase in constructive work (720.2mmHg VS 900.6mmHg, p=0.016) and work efficiency (78.6% VS 86.6%, p=0.027), with a non-significant decrease in the wasted work (150.2mmHg VS 136.8mmHg, p=0.441).

TTE data before and after 6 months of LCZ696 treatment Time 0 6 months p LV end-diastolic diameter (mm) 71.3±8.4 66.9±7.6 0.001 LV end-systolic diameter (mm) 57.8±9.4 53.1±9.3 0.002 Interventricular septum (mm) 9.6±1.7 9.9±1.9 0.280 LVEF (%) 29.3±6.4 38.2±8.9 <0.001 GLS (%) −7.0±2.9 −8.9±2.8 0.001 MW – Constructive (mmHg) 720.2±230.5 900.6±343.2 0.016 MW – Wasted (mmHg) 150.2±83.3 136.8±54.2 0.441 MW – Efficiency (%) 78.6±10.8 86.6±12.0 0.027 E/e' 13.7±4.5 12.8±4.9 0.449 Pulmonary artery systolic pressure (mmHg) 38.3±12.2 30.9±10.6 <0.001 Left atrium volume (ml/m2) 51.5±22.6 43.7±15.8 0.004 Right atrium volume (ml/m2) 33.1±4.4 28.5±13.5 0.036 TAPSE (mm) 19.2±4.4 20.0±4.9 0.404

Conclusion

LCZ696 therapy is associated with signs of reverse remodelling in TTE, including an increase in constructive work and work efficiency.

P697Regional analysis of 3D-derived speckle tracking for the assessment of myocardial deformation in breast cancer patients submitted to anthracycline chemotherapy

Introduction

Serial echocardiographic assessment of left ventricular ejection fraction (LVEF) and 2D left ventricular global longitudinal strain (GLS) is the gold standard in screening for cancer therapeutics-related cardiac dysfunction (CTRCD). Myocardial deformation assessed with 3D speckle tracking is not currently used in this setting, because of the lack of standardization and cut-off values, in spite of a potential for a greater reliability.

Methods

Prospective study of female breast cancer patients submitted to anthracycline chemotherapy with or without adjuvant immunotherapy and/or radiotherapy who underwent serial monitoring by 2D and 3D transthoracic echocardiography (ETT). Standard ETT measures and 3D-derived volumetric measures were assessed. Speckle tracking was used to estimate 2D-derived GLS – average and 18 segments – and 3D-derived GLS, global circumferential strain (GCS), global area strain (GAS) and global radial strain (GRS) – average and 17 segments. CTRCD was defined as an absolute decrease in 2D or 3D LVEF >10% to a value <54% or a relative decrease in 2D GLS >15%. Variables were compared using the t-student paired test and the Wilcoxon sign-rank test, when appropriate.

Results

106 patients (mean age 54.6±12.9 years, 33.0% immunotherapy, 16.5% radiotherapy, baseline LVEF 64.5% ± 8.5%, baseline 2D GLS −21.0±2.8) were included. During a mean follow-up of 16.5±9.6 months, an average of 3.9 echocardiographic examinations were performed per patient and 28 patients (26.4%) developed CTRCD. Overall, 3D regional longitudinal strain was determined in 88.9% of the segments analyzed, with lower success rates in the inferobasal (75.0%), the posterobasal (77.7%) and the laterobasal (82.4%) walls. When comparing variables before and during treatment, there was a significant difference in 2D-derived LVEF (64.5 vs. 57.6 p<0.001), 3D-derived LVEF (60.1 vs. 55.7 p 0.002), 2D-derived GLS (−20.6 vs. −18.2 p<0.001), 3D-derived GLS (−13.8 vs. −12.9 p 0.035), 3D-derived GRS (31.9 vs. 33.4 p 0.024), but not in GCS (−14.5 vs. −13.2 p 0.656) and GAS (−21.5 vs. −22.1 p 0.640). Figure 1 shows the segmental analysis of 2D and 3D strain parameters. In 2D GLS, 11 out of 18 segments showed decreased contractility during follow-up (mainly anterior septum and anterior, lateral and inferior walls). In 3D-derived strain parameters, only 3 out 17 for GLS, 2 out of 17 for GCS, 1 out 17 for GRS and none for GAS showed decreased contractility during follow-up.

Segmental analysis of 2D and 3D strain

Conclusion

In this population, there was worsening of 3D GLS and GRS, besides conventional values, such as LVEF and 2D GLS, during anthracycline-based cancer treatment. 3D-derived myocardial deformation parameters show promise in the setting of CTRCD, since 2D and 3D regional strain parameters might shed a light onto the mechanisms of CTRCD, such that subendocardial myocardial fibers seem to be more affected than medial and subepicardial fibers.

Medial frontal cortex lesions: deficits and treatment with nimodipine

Rats with bilateral lesions of the medial frontal cortex were tested in a T-maze for the ability to learn a position habit and to make four reversals of it. Rats with medial frontal cortical lesions showed deficits in reversal learning. In addition, they were found to be hyperactive in an open field. Treatment with the dihydropyridine calcium channel antagonist, nimodipine, did not reduce these behavioral deficits.