Accounting for the increasing benefits from scarce ecosystems

As people get richer, and ecosystem services scarcer, policy-relevant estimates of ecosystem value must rise.

Observations and properties of the first laboratory fusion experiment to exceed a target gain of unity

An indirect-drive inertial fusion experiment on the National Ignition Facility was driven using 2.05 MJ of laser light at a wavelength of 351 nm and produced 3.1±0.16 MJ of total fusion yield, producing a target gain G=1.5±0.1 exceeding unity for the first time in a laboratory experiment [Phys. Rev. E 109, 025204 (2024)10.1103/PhysRevE.109.025204]. Herein we describe the experimental evidence for the increased drive on the capsule using additional laser energy and control over known degradation mechanisms, which are critical to achieving high performance. Improved fuel compression relative to previous megajoule-yield experiments is observed. Novel signatures of the ignition and burn propagation to high yield can now be studied in the laboratory for the first time.

Haptic sensation-based scanning probe microscopy: Exploring perceived forces for optimal intuition-driven control

We demonstrate a cryogenic scanning probe microscope (SPM) that has been modified to be controlled with a haptic device, such that the operator can 'feel' the surface of a sample under investigation. This system allows for direct tactile sensation of the atoms in and on top of a crystal, and allows the operator to perceive, by using different SPM modalities, sensations that are representative of the relevant atomic forces and tunneling processes controlling the SPM. In particular, we operate the microscope in modes of (1) conventional STM feedback, (2) energy-dependent electron density imaging, (3) q-plus AFM frequency shift based force sensing, and (4) atomic manipulation/sliding. We also use software to modify the haptic feedback sensation to mimic different interatomic forces, including covalent bonding, Coulomb repulsion, Van der Waals repulsion and a full Lennard-Jones potential. This manner of SPM control creates new opportunities for human-based intuition scanning, and also acts as a novel educational tool to aid in understanding materials at an atomic level.

Enhancing the Focus: How Does Parental Incarceration Fit into the Overall Picture of Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs)?

Despite the five million children in the U.S. with an incarcerated parent, there is limited research on risk and protective factors for this population. We analyzed data from the National Survey for Children's Health (2018) to: (1) examine associations among parental incarceration and other adverse childhood experiences (ACEs), (2) characterize the association between parental incarceration and youth mental health outcomes, (3) examine differences in positive childhood experiences (PCEs; collective socialization, community engagement, neighborhood amenities, and family problem solving) by parental incarceration status, (4) examine whether PCEs were protective against mental health problems and if there was an interaction with parental incarceration status, and (5) examine the interaction between PCEs, parental incarceration, and ACEs on mental health problems. Results revealed that children with incarcerated parents had higher odds of experiencing other ACEs, higher odds of having mental health problems, and experienced fewer PCEs compared to children without incarcerated parents. Further, although PCEs were associated with a lower odds of mental health problems for both children with and without incarcerated parents, they did not mitigate the negative impact of parental incarceration on mental health outcomes. While PCEs attenuated the association between ACEs and mental health, parental incarceration status did not significantly moderate the interaction. These results highlight vulnerabilities and potential protective factors for children with incarcerated parents and have important implications for the development of multilevel intervention strategies that seek to promote resilience and reduce risk for this population.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Types and correlates of school absenteeism among students with intellectual disability

BACKGROUND

It appears that students with intellectual disability (ID) are more frequently absent from school compared with students without ID. The objective of the current study was to estimate the frequency of absence among students with ID and the reasons for absence. Potential reasons included the attendance problems referred to as school refusal, where absence is related to emotional distress; truancy, where absence is concealed from parents; school exclusion, where absence is instigated by the school; and school withdrawal, where absence is initiated by parents.

METHODS

Study participants were 629 parents (84.6% mothers) of Australian school students (M_age  = 11.18 years; 1.8% Aboriginal and/or Torres Strait Islander) with an ID. Participants completed a questionnaire battery that included the School Non-Attendance ChecKlist via which parents indicated the reason their child was absent for each day or half-day absence their child had over the past 20 school days. The absence data presented to parents had been retrieved from school records.

RESULTS

Across all students, absence occurred on 7.9% of the past 20 school days. In terms of school attendance problems as defined in existing literature, school withdrawal accounted for 11.1% of absences and school refusal for 5.3% of absences. Students were also absent for other reasons, most commonly illness (32.0%) and appointments (24.2%). Of students with more than one absence (n = 217; 34.5%), about half were absent for more than one reason. Students attending mainstream schools had lower attendance than those attending special schools.

CONCLUSIONS

Students with ID were absent for a range of reasons and often for multiple reasons. There were elevated rates of school withdrawal and school refusal. Understanding the reasons for absenteeism can inform targeted prevention and intervention supports.

Measurement of Dark Ice-Ablator Mix in Inertial Confinement Fusion

We present measurements of ice-ablator mix at stagnation of inertially confined, cryogenically layered capsule implosions. An ice layer thickness scan with layers significantly thinner than used in ignition experiments enables us to investigate mix near the inner ablator interface. Our experiments reveal for the first time that the majority of atomically mixed ablator material is "dark" mix. It is seeded by the ice-ablator interface instability and located in the relatively cooler, denser region of the fuel assembly surrounding the fusion hot spot. The amount of dark mix is an important quantity as it is thought to affect both fusion fuel compression and burn propagation when it turns into hot mix as the burn wave propagates through the initially colder fuel region surrounding an igniting hot spot. We demonstrate a significant reduction in ice-ablator mix in the hot-spot boundary region when we increase the initial ice layer thickness.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Associations between DAPT score and long-term mortality post PCI

Introduction

The dual antiplatelet therapy (DAPT) score was developed to identify patients more likely to derive benefit (score ≥2) or harm (score &lt;2) from DAPT beyond 1-year post PCI. There is no study which looked at the DAPT score and long term outcomes post PCI in Australia.

Purpose

We sought to examine long-term mortality after PCI by the DAPT score in patients treated with DAPT per local guidelines.

Methods

We examined data from the MIG PCI database from 2005 to 2018 in whom the DAPT score could be derived and grouped them as score ≥2 or &lt;2. Long-term mortality was assessed from National Death Index linkage. The primary endpoint was long-term mortality examined using survival analysis. Secondary endpoints included 30-day ischaemic outcomes and in-hospital major bleeding.

Results

Out of 27,740 patients in the study, 9,401 (33.9%) had DAPT score ≥2. They were younger and included more females and higher prevalence of renal impairment. DAPT score ≥2 patients had higher in-hospital major bleeding, 30-day mortality, MI and target vessel revascularisation. DAPT score ≥2 patients had lower long-term survival to 12 years (p&lt;0.001 for all).

Conclusion

A third of all-comer PCI patients had DAPT score ≥2 with greater short-term risk of ischaemic and bleeding outcomes, as well as long-term mortality. Theoretically, those with DAPT score ≥2 would benefit from longer duration of DAPT as ischaemic risk outweighs bleeding risk. However, given our finding of increased short-term bleeding risk and long-term mortality, dynamic bleeding risk assessment should be undertaken to guide pharmacotherapy strategies.

Funding Acknowledgement

Type of funding sources: None.

Results from a phase 1 multiple ascending dose study demonstrating safety and selectivity of aldosterone synthase inhibitor CIN-107

Background

CIN-107 is a highly potent, selective, and competitive small molecule inhibitor of aldosterone synthase that is a potential treatment for disorders associated with elevated aldosterone levels, including hypertension and primary aldosteronism. This randomized, double-blind, placebo-controlled phase 1 study evaluated the safety, pharmacokinetics, and pharmacodynamics of multiple ascending doses of CIN-107 in healthy volunteers.

Methods

Subjects were randomized into 5 cohorts to receive CIN-107 or placebo once daily for 10 days. Cohorts 1 and 2 were placed on a low salt diet to stimulate aldosterone production and were administered 2.5 or 5.0 mg oral CIN-107, respectively. Cohorts 1 and 2 also underwent an adrenocorticotropic hormone (ACTH) challenge to increase aldosterone and cortisol levels to evaluate the specificity of CIN-107 for targeting aldosterone synthase. Cohorts 3, 4, and 5 were placed on a normal salt diet and were administered 1.5, 2.5, or 0.5 mg oral CIN-107, respectively. Blood samples were collected prior to and after dosing on days 1 and 10 for measurement of plasma CIN-107 concentrations to characterize single-dose and steady-state pharmacokinetics. Pharmacodynamic measurements included plasma aldosterone, cortisol, and electrolytes. Safety assessments included physical examination, electrocardiograms, orthostatic vital signs, and clinical laboratory evaluations.

Results

54 subjects completed the study. There were no deaths, serious adverse events, or discontinuations due to treatment-emergent adverse events (TEAEs). All TEAEs in subjects receiving CIN-107 were mild in severity (Table 1). Plasma concentrations of CIN-107 increased proportionally with ascending doses. CIN-107 was rapidly absorbed, with peak concentrations observed within 4 hours after dosing. The concentration of plasma CIN-107 declined in an apparent biphasic manner with a half-life of 26 to 31 hours. A dose-dependent reduction of plasma aldosterone was observed with CIN-107 doses ≥1.5 mg, regardless of normal or low salt diet. Decreases in plasma aldosterone were observed starting on Day 1 and were sustained, with levels reduced by approximately 51–73% on Day 10 (Figure 1). The inhibition of aldosterone synthase by CIN-107 had no impact on plasma cortisol. CIN-107 resulted in mild dose-dependent decreases in plasma sodium levels and increases in potassium levels, as would be expected from the observed reduction in aldosterone.

Conclusions

Oral administration of CIN-107 was safe and well tolerated in all subjects and resulted in dose-dependent increases in plasma CIN-107 with a half-life that supports once-daily dosing. The dose-dependent decrease in plasma aldosterone and lack of effect on cortisol demonstrate the selective blockade of aldosterone synthase and support continued study in ongoing phase 2 clinical trials evaluating the efficacy and safety of CIN-107 for treatment-resistant or uncontrolled hypertension and primary aldosteronism.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): CinCor Pharma Inc

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Responses to infectious disease outbreaks in supported living environments for individuals with neurodevelopmental disorders: a scoping review

Background: Individuals with neurodevelopmental disorders (NDD) are facing unprecedented challenges due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Congregate living, and conditions associated with NDD place increased challenges during infectious disease outbreaks and there is a need to understand evidence-based response procedures. The aim was to (1) map and synthesize literature regarding emergency response protocol in supported living environments for individuals with NDD and (2) identify gaps in the literature of response protocols in supported living environments for individuals with NDD. Methods: A scoping review was conducted to understand the published literature on emergency response across supported living environments for individuals with NDD during emergency situations and infectious disease outbreaks. Results: The ten studies included in the review detailed protocols including treatment, testing, isolation, surveillance, improved cleaning, use of protective equipment, and contact with public health professionals. The environment of supported living settings, and symptoms associated with NDD impacted the spread and severity of disease. Conclusion: The research findings highlight the susceptibility, severity and impact of infectious disease outbreaks for individuals with NDD in supported living environments. This research will promote the establishment and development of appropriate care and response during emergency situations in supported living environments.

Outcomes after percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (cabg)

Background

In patients with prior CABG requiring subsequent PCI there is uncertainty whether bypass grafts or native coronary arteries should be targeted.

Methods

We analysed data from 2,764 patients with prior CABG in the Melbourne Interventional Group registry (2005–2018), divided into two groups: those undergoing PCI to a native vessel (n=1,928) and those with PCI to a graft vessel (n=836).

Results

Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (prior MI, heart failure, ejection fraction &lt;50%, renal impairment, peripheral and cerebrovascular disease), and high-risk procedural features (ACC/AHA types B2/C lesions). However, patients in the native vessel group were more likely to have PCI to a chronic total occlusion. The majority of graft PCI were to saphenous vein grafts (84%), with 10% to radial and 6% to LIMA/RIMA grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3% vs. 1.5%; p&lt;0.001), coronary perforation (p=0.016) and inpatient stent thrombosis (p=0.028). However, 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCE) were similar. Unadjusted long-term mortality (median follow up 4.8 years) was higher in patients who had undergone a graft PCI (44% vs. 32%, p&lt;0.001), but following Cox proportional hazards modelling, PCI vessel type was not a predictor of long-term mortality (HR 1.13; 95% CI 0.96–1.33, p=0.14).

Conclusions

Early clinical outcomes and risk-adjusted long-term mortality are similar for patients with prior CABG undergoing PCI to a native vessel or a bypass graft.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Alfred Hospital

Trends in intra-aortic balloon pump use in cardiogenic shock in the post-SHOCK II trial era

Background

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit.

Purpose

This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use.

Methods

Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression.

Results

Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction (&lt;35%; 18% vs. 11%), and pre-procedural inotrope use (81% vs. 73%), all p&lt;0.05. IABP use was associated with higher inpatient bleeding (18% vs. 13%) and 30-day MACCE (58% vs. 51%), both p&lt;0.05. The rate of MI-CS increased over time, but after 2012 there was a decline in IABP use (Figure 1). IABP use was a predictor of 30-day MACCE (OR 1.6, 95% CI 1.18–2.29, p=0.003). However, IABP was not associated with in-hospital, 30-day or long-term mortality (45% vs. 47%, p=0.44; 46% vs. 50%, p=0.25; 60% vs. 62%, p=0.39).

Conclusions

Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group

Contemplating the Five Domains model of animal welfare assessment: UK horse owner perceptions of equine well-being

Traditionally, assessment of animal welfare generally focused on physiological signs of health with less consideration of psychological well-being. More recently, the Five Domains model highlighted the concept of all aspects of an animal's life influencing their affective state. In equestrianism, however, there is a lack of awareness of the Five Domains model and, specifically, how different factors may affect the mental well-being of horses (Equus caballus). This divide between scientific research and lay horse owners could compromise equine welfare by failing to recognise horses as sentient beings with species-specific needs. The present study therefore aimed to explore how evidence-based information can be effectively communicated to equestrians (n = 259) through an online survey and whether increased knowledge of equine welfare needs has any impact on horse caregivers' assessment of their own horses' quality of life. Results showed that a simple educational infographic based on the Five Domains model had a significant impact on equestrians' assessment of equine welfare, although longitudinal, empirical studies are needed. Scores on a Likert scale for health, behaviour/human interactions and overall welfare were significantly lower following the intervention but scores for emotional well-being were significantly higher. This may suggest that, whilst the infographic increased participant awareness of the importance of emotional state and the factors affecting welfare, there were difficulties or inconsistencies in objectively assessing these emotions. This highlights the need for equine welfare science to be communicated more proactively to horse owners in an accessible, engaging format.

Plasma desmosine, a biomarker of elastin degradation, predicts outcomes in coronary artery disease

Background

Recent evidence from animal studies suggests that elastin degradation accelerates atherosclerosis and increases risk of plaque rupture and subsequent myocardial infarction and stroke. Desmosine is an elastin-specific degradation product. We analysed the prognostic value of plasma desmosine (pDES) in a cohort of patients with coronary artery disease (CAD).

Methods

Patients with CAD (n=400) undergoing elective coronary angiography were prospectively recruited over 3 years and had bloods drawn for analysis of pDES using a validated stable isotope dilution liquid chromatography-tandem mass spectrometry method. Patients were followed up for 12 months for major adverse cardiovascular events (MACE: composite of death, myocardial infarction, target vessel repeat revascularisation, target lesion revascularisation, and heart failure hospital admission). The upper limit of normal for pDES is 0.35 ng/mL. The predictive value of pDES for MACE was analysed with Cox-proportional hazards ratio (HR) model and Kaplan-Meier survival analysis.

Results

During follow-up, there were 36 MACE events. Median pDES level across the entire cohort was 0.3 ng/mL (IQR 0.23–0.41 ng/mL). Patients with a pDES level &gt;0.35 ng/mL were more likely to be male and older with a mean age of 69.7±10.3 years, have a history of prior stroke or transient ischaemic attack (TIA) and COPD. In univariable analysis, a pDES level of &gt;0.35 ng/mL was associated with an increased risk of MACE (HR 4.76, 95% CI: 2.34–9.68, p&lt;0.001). In multivariable analysis, pDES &gt;0.35 ng/mL was associated with risk of MACE after adjustment for age, sex, COPD status and previous stroke and TIA (HR 3.97; 95% CI: 1.82–8.67, p=0.001) (Figure).

Conclusion

Increased elastin degradation as measured by elevated pDES levels, predicts outcomes in patients with CAD independent of traditional cardiovascular risk factors and may play a role as a future biomarker in these patients.

Kaplan-Meier survival analysis

Funding Acknowledgement

Type of funding source: None

Long-term outcomes following percutaneous coronary intervention for patients with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Despite this, data regarding long-term outcomes following percutaneous coronary intervention (PCI) are limited.

Methods

We identified 756 patients with RA from the Melbourne Interventional Group PCI registry (2005–2018) and compared outcomes to the remaining cohort (N=38,579). Cox regression analysis was performed to assess risk of adverse cardiac events including long-term mortality (derived from linkage with the National Death Index [NDI]).

Results

Patients with RA were older (68.9±10.0 vs. 64.6±12.0 years) and more often female (40% vs. 23%), with higher rates of hypertension (70% vs 67%), previous stroke (9% vs 6%), peripheral vascular disease (9% vs 6%), obstructive sleep apnoea (10% vs 5%), chronic lung disease (22% vs 12%), prior myocardial infarction (32% vs 27%), and impaired renal function (eGFR&lt;60 ml/min/1.73m2 in 31% vs 24%), while rates of current smoking were lower (20% vs. 25%), all p&lt;0.05. Lesions were more frequently complex (ACC/AHA type B2/C in 61% vs 57%), required longer stents (&gt;20mm in 39% vs 35%), and rates of no reflow were higher (5% vs 3%), all p&lt;0.05. 30-day mortality was higher (4.4% vs. 3.3%, p=0.04) mainly owing to higher non-cardiac mortality (1.6% vs. 0.8%, p=0.01). National Death Index-linked long-term mortality was 28% vs. 19% (p&lt;0.01) with mean follow-up 4.6 vs. 5.4 years. Risk of 30-day and long-term mortality (including by indication subgroup) are presented in the Table.

Conclusions

Patients with RA undergoing PCI have more comorbidities and longer, more complex coronary lesions. After adjustment, risk of short-term adverse outcomes are similar, while risk of long-term mortality is higher, particularly among patients with acute coronary syndromes.

Funding Acknowledgement

Type of funding source: None

Sex differences in pharmacotherapy and long-term outcomes in patients with ischaemic heart disease and left ventricular dysfunction

Background

Left ventricular dysfunction and ischaemic heart disease are common amongst women, however, women tend to present later and are less likely to receive guideline-directed medical therapy compared to their male counterparts.

Purpose

To investigate if a sex discrepancy exists for optimal medical therapy (OMT) and long-term mortality in a cohort of patients with known ischaemic heart disease (IHD) and left ventricular dysfunction.

Methods

We analysed prospectively collected data from a multicentre registry database collected between 2005–2018 on pharmacotherapy 30-days post percutaneous coronary intervention (PCI) in 13,015 patients with left ventricular ejection fraction (LVEF) &lt;50%. OMT at 30-days was defined as beta-blocker (BB), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) ± mineralocorticoid receptor antagonist (MRA). Long-term mortality was determined by linkage with the National Death Index, with median follow up of 4.7 (IQR 2.0–8.6) years.

Results

Mean age was 65±12 years; women represented 20.2% (2,634) of the cohort. Women were on average 5 years older, had higher average BMI, higher rates of hypertension, diabetes, renal dysfunction, prior stroke and rheumatoid arthritis. Men were more likely to have sleep apnoea, be current/ex-smokers and to have had prior myocardial infarction, PCI and bypass surgery. Overall, 72.3% (9,411) of patients were on OMT, which was similar between sexes (72.7% in women vs. 72.2% in men, p=0.58). Rates of BB therapy were similar between sexes (85.2% vs. 84.5%, p=0.38), while women were less likely to be on an ACEi/ARB (80.4% vs. 82.4%, p=0.02) and more likely to be on a MRA (12.1% vs. 10.0%, p=0.003). Amongst those with LVEF ≤35% (n=1,652), BB (88.7% vs. 87.3%, p=0.46), ACEi/ARB (83.3% vs. 82.1%, p=0.59) and MRA use (32.5% vs. 33.3%, p=0.78) was comparable. Aspirin use was similar between sexes (95.3% vs. 95.9%, p=0.12), while women were less likely to be on statin therapy (93.5% vs. 95.3%, p&lt;0.001) and a second antiplatelet agent (94.4% vs. 95.6%, p=0.007). On unadjusted analysis women had significantly higher long-term mortality of 25.4% compared to 19.0% for men (p&lt;0.001). Kaplan-Meier analysis out to 14 years demonstrated that men on OMT have the best long-term survival overall and women on sub-OMT have significantly poorer outcomes compared to men on sub-OMT. However, after adjusting for OMT and other comorbidities there was no difference in long-term mortality between sexes (HR 0.99, 95% CI 0.87–1.14, p=0.94).

Conclusion

From this large multicentre registry, we found similar rates of guideline-directed pharmacotherapy for left ventricular dysfunction between sexes, however women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality amongst women is likely due to differing baseline risk, given that adjusted mortality was similar between sexes.

Kaplan-Meier Survival Analysis

Funding Acknowledgement

Type of funding source: None

P5290Impact of extreme obesity on long-term outcomes following percutaneous coronary intervention

Background

Obesity is a growing health concern worldwide, particularly in developed countries where there has been an unprecedented rise in the proportion of overweight and obese individuals in the population. Previous studies have reported a protective effect of obesity compared to normal BMI in patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether this effect extends to the extremely obese over long-term follow-up.

Objective

To determine whether an obesity paradox persists in contemporary PCI practice over long-term follow-up, and in particular to further evaluate the association between extreme obesity and long-term clinical outcomes after PCI.

Method

We prospectively collected data on 25,645 patients undergoing PCI between 1 January 2005 and 30 June 2017 who were enrolled in the statewide multi-centre Melbourne Interventional Group Registry. This registry collects data on all patients undergoing PCI at 6 academic tertiary hospitals. Patients were stratified by World Health Organization-defined BMI categories. Long-term mortality data was obtained by linkage to the National Death Index (NDI), a database that contains records of all deaths occurring in Australia. The primary endpoint was NDI-linked mortality. Median length of follow-up was 4.4 years (IQR 2.0–7.6 years).

Results

Of the study cohort, 24.6% had normal BMI (18.5–24.9 kg/m2), 0.9% were underweight (BMI <18.5 kg/m2) and 3.3% were extremely obese (BMI ≥40 kg/m2). As BMI increased, mean age decreased while the prevalence of diabetes increased (p<0.001). The proportion of females at both extremes of BMI. Procedural characteristics were similar across the groups although there was more radial access and less femoral access used with increasing BMI (p<0.001). In terms of secondary prevention therapy, underweight patients were significantly less likely to receive a beta blocker, ACE inhibitor and statins, compared to the other BMI groups. In-hospital, 30-day and long-term mortality were all highest for underweight patients (37.7%) and lowest for the moderately obese patients (BMI 35–40 kg/m2) (12.2%). After adjustment for age, comorbidities and presentation with cardiogenic shock, a U-shaped association between the different BMI categories and adjusted hazard ratio for long-term mortality was observed (Figure 1).

Figure 1

Conclusion

An obesity paradox is still apparent in contemporary practice with elevated BMI up to 35 kg/m2 associated with reduced long-term mortality after PCI. However, this protective effect appears not to extend to patients with extreme obesity. Factors behind this phenomenon are likely multifactorial and require further mechanistic and epidemiological studies.