Hypertrophic cardiomyopathy and atrial fibrillation: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the European Society of Cardiology

Background

Current guidelines for AF management underline a complex approach to detecting and treating atrial fibrillation (AF). Hypertrophic cardiomyopathy (HCM) is commonly associated with AF.

Purpose

To assess the clinical characteristic and prognosis in patients with HCM and AF.

Methods and results

Overall, 1739 adult patients with HCM (711/40.9% female; median age at diagnosis: 55.5 years) were enrolled in the EURObservational Research Programme – Cardiomyopathy/Myocarditis Long-Term Registry. Baseline clinical characteristics and adverse cardiovascular endpoints at 1-year follow-up were analysed.

Results

At baseline, AF was found in 478 (27.5%) subjects (paroxysmal: 54.7%, persistent: 17.6%, permanent: 27.7%). Newly diagnosed AF was identified during 1-year follow-up in 48 (2.8%) subjects with HCM.

The presence of AF was associated with higher age (59.6±13.8 vs 50.8±16.1, p<0.001); BMI (27.7±5.1 vs 26.6±4.6 kg/m2, p<0.001); more advanced NYHA class (NYHA I/II and III/IV: 75.1 and 24.9 vs 86.2 and 13.8%, p<0.001); more frequent history of diabetes (14.6 vs 8.4%, p<0.001); arterial hypertension 43.4 vs 34.6%, p<0.001); renal impairment (15.4 vs 6.35%, p<0.001); and history of sustained VT (10.8 vs 6.35%, p<0.001). AF patients were characterized by lower left ventricular ejection fraction (LV EF) (59±12 vs 63±11%, P<0.001), left atrium (LA) dilatation (48.9±9.1 vs 42.4±7.7%, p<0.001), increased pulmonary artery systolic pressure (37.8±13.7 vs 29.6±12.6 mmHg, p<0.001), distribution of LV hypertrophy (p=0.032) and more advanced LV diastolic dysfunction (p<0.001).

On multivariate logistic regression analysis, independent predictors of AF in the HCM population were: age at enrolment (OR 1.068, P<0.001); LVEF (OR 0.978, p<0.001); and LA diameter (OR 1.094, p<0.001).

Oral anticoagulation (OAC) was administered in 69.5% of patients with AF (vitamin K antagonist: 48.5%; direct OAC: 21%). ICD was implanted in 26.8% in AF and 16.9% in non-AF subjects (p<0.001). PVI was performed in 9.9% of AF patients only.

The annual incidence of stroke/TIA was higher in AF than in the non-AF population (2.64 vs 0.85%, p=0.009). There was a trend towards increased death from any cause in the AF population (3.39 vs 1.74%, p=0.05). There were no differences in SCD-risk score between AF and non-AF subjects.

Conclusion

The study reveals a high prevalence of AF in patients with HCM that corresponds with more advanced symptoms, increased prevalence of comorbidities, structural and functional heart remodelling along with inadequate anticoagulation and a significant increase in the risk of stroke. The clinical characteristics of HCM-AF patients indicate that the ESC recommended complex AF approach “CC To ABC” is appropriate in this population.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Current use of cardiac magnetic resonance in tertiary referral centres for the diagnosis of cardiomyopathy: the ESC EORP Cardiomyopathy/Myocarditis Registry

Aims 

Cardiac magnetic resonance (CMR) is recommended in the diagnosis of cardiomyopathies, but it is time-consuming, expensive, and limited in availability in some European regions. The aim of this study was to determine the use of CMR in cardiomyopathy patients enrolled into the European Society of Cardiology (ESC) cardiomyopathy registry [part of the EURObservational Research Programme (EORP)].

Methods and results 

Three thousand, two hundred, and eight consecutive adult patients (34.6% female; median age: 53.0 ± 15 years) with cardiomyopathy were studied: 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM), and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC). CMR scans were performed at baseline in only 29.4% of patients. CMR utilization was variable according to cardiomyopathy subtypes: from 51.1% in ARVC to 36.4% in RCM, 33.8% in HCM, and 20.6% in DCM (P < 0.001). CMR use in tertiary referral centres located in different European countries varied from 1% to 63.2%. Patients undergoing CMR were younger, less symptomatic, less frequently had implantable cardioverter-defibrillator (ICD)/pacemaker implanted, had fewer cardiovascular risk factors and comorbidities (P < 0.001). In 28.6% of patients, CMR was used along with transthoracic echocardiography (TTE); 67.6% patients underwent TTE alone, and 0.9% only CMR.

Conclusion 

Less than one-third of patients enrolled in the registry underwent CMR and the use varied greatly between cardiomyopathy subtypes, clinical profiles of patients, and European tertiary referral centres. This gap with current guidelines needs to be considered carefully by scientific societies to promote wider availability and use of CMR in patients with cardiomyopathies.

Genetic counselling and testing of adult patients with cardiomyopathies: insight from the EORP cardiomyopathy and myocarditis registry of the European Society of Cardiology

Introduction

Cardiomyopathies comprise a heterogeneous group of diseases, often of genetic origin.

Purpose

We assessed the current practice of genetic counselling and testing of adult cardiomyopathy patients in the prospective ESC EORP cardiomyopathy registry.

Methods

3 208 adult patients from sixty-nine centres in 18 countries were enrolled. Clinical data on genetic counselling and testing and on the presentation of cardiomyopathies were gathered.

Results

Genetic counselling was performed in 60.8% of all patients (75.4% in hypertrophic (HCM), 39.2% in dilated (DCM), 70.8% in arrhythmogenic right ventricular (ARVC) and 49.2% in restrictive cardiomyopathy (RCM), p&lt;0.001). Comparing European geographical areas, genetic counselling was performed from 42.4% to 83.3% (p&lt;0.001). It was provided by a cardiologist (85.3%), geneticist (15.1%), genetic counsellor (11.3%), or a nurse (7.5%), (p&lt;0.001). Genetic testing was performed in 37.3% of all patients (48.8% in HCM, 18.6% in DCM, 55.6% % in ARVC and 43.6% in RCM, p&lt;0.001). Index patients with genetic testing were younger at diagnosis, had more familial disease, family history of sudden cardiac death or implanted cardioverter defibrillators but less comorbidities than those not tested (p&lt;0.001 for each comparison). At least 1 disease causing variant was found in 41.7% of index patients with genetic testing (43.3% in HCM, 33.3% in DCM, 51.4% in ARVC and 42.9% in RCM, p=0.13).

Conclusion

We report on the practice of genetic counselling and testing in cardiomyopathies in Europe. Genetic counselling and testing were performed in a substantial proportion of patients but less often than recommended by European guidelines, and much less in DCM than in HCM and ARVC, despite evidence for genetic background.

Funding Acknowledgement

Type of funding source: None

CCS patients with polyvascular disease are a high risk but heterogenous subset of patients: insights from the CLARIFY registry

Introduction

Polyvascular disease constitutes a powerful predictor of cardiovascular events, is found in 10 to 15% of chronic coronary syndromes (CCS) patient. Smoking and diabetes mellitus are strongly associated with polyvascular disease. Risk stratification is key to select the most appropriate therapeutic strategy for a given patient.

Purpose

We aimed to describe 5-year ischaemic risk of CCS patients according to vascular disease phenotype and diabetic or smoking status.

Method

We analyzed data from 32 703 consecutive CCS outpatients (45 countries) enrolled between November 2009 to June 2010 in the prospective observational CLARIFY registry. Three mutually exclusive groups were compared: Coronary artery disease (CAD) alone, CAD with peripheral artery disease (PAD) or cerebrovascular disease (CVD) (CAD+1), CAD with CVD and PAD (CAD+2). Primary outcome was a composite of cardiovascular death, myocardial infarction or stroke, adjusted on age, sex and geographic origin at 5 years.

Results

At baseline, 26440 (80.8%) patients were diagnosed with CAD alone, 4967 (15.2%) had CAD+1, 1296 (4%) had CAD+2. Overall, 9501 (29%) patients were diabetics, 19184 (58.7%) were smokers or ex-smokers and only 9220 (28.2%) were free of these two major cardiovascular risk factors. Primary outcome increasing gradually according to the number of arterial diseases locations from 8.4% (95% CI 8.09–8.73) in patients with CAD alone to 17.4% (95% CI 16.95–17.83) of CAD+2 patients (p&lt;0.001). Subgroup analysis according to diabetes or smoking status further enriched risk stratification from 7% (95% CI 6.48–7.59) in non-diabetic, non-smoking CAD alone patients to 20.3% (95% CI 19.08–21.44) in diabetics and smokers CAD+ 2 patients (Figure 1). Diabetic CAD alone patients had a comparable risk to that of non-diabetic and non-smoking polyvascular patients, 9.8% (95% CI 8.82–10.68) vs 10.3% (95% CI 9.61–10.96), p=0.38. Outcome was similar between polyvascular diabetic patients, regardless of the number of arterial diseases, 15.5% (95% CI 14.31–16.60) for CAD+1 and 15.0 (95% CI 13.88–16.13) for CAD+2, p=0.83. Smoking increased 5-year risk proportionally to the number of symptomatic arterial bed, 8.2% (95% CI 7.72–8.68) vs 11.8% (95% CI 11.18–12.31) vs 17.9% (95% CI 17.18–18.54), respectively for CAD alone, CAD+1 and CAD+2.

Conclusion

CCS patients with polyvascular disease remain at high risk of ischaemic events in the contemporary practice with widespread secondary prevention therapies. Polyvascular is a very heterogenous subset of patients with ischaemic risk varying not only according to the number of vascular bed diseased but also according to smoking and diabetes status, two conditions present in the vast majority of CCS patients. Diabetes confers upfront a maximal increased risk. Identification of higher risk subsets in polyvascular patients can potentially identify those that could derived the greatest benefit from new secondary prevention strategies.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique-Hôpitaux de Paris

High prevalence of familial and genetic disease in children with cardiomyopathies: baseline paediatric data from the ESC EORP Cardiomyopathy and Myocarditis registry

Background

Previous studies on paediatric cardiomyopathies have provided useful information on their epidemiology and clinical presentation but have been limited by a lack of detailed data on genetic testing and aetiology.

Purpose

The purpose of this study was to examine the frequency of familial and genetic disease among children with cardiomyopathy enrolled in the European Society of Cardiology (ESC) Cardiomyopathy and Myocarditis EORP Long-Term Registry (CMY-LT).

Methods

633 individuals aged &lt;18 years with hypertrophic cardiomyopathy [HCM; n=387 (61%)], dilated cardiomyopathy (DCM; n=205 (33%)], restrictive cardiomyopathy [RCM; n=28 (4%)] and arrhythmogenic right ventricular cardiomyopathy [ARVC; n=11 (2%)] were enrolled by 26 centres from 14 countries. Mean age at diagnosis was 5.2 (±5.4) years and there was a male predominance [n=372 (59%)] across all cardiomyopathy subtypes, with the exception of DCM in those diagnosed &lt;10 years of age (p=0.005). 541 (87%) were probands compared to 83 (13%) first-degree relatives.

Results

Overall, 253 patients (47% of those reported) had familial disease; in those diagnosed between 10 and 18 years of age, familial disease was most frequent in HCM and least frequent in DCM [57 (55%) vs 12 (32%); p=0.046]. Genetic testing was performed in 414 (68%) patients. In those diagnosed &lt;10 years, genetic testing was more frequently performed in HCM [128 (67%) vs 33 (37%) in DCM, 10 (56%) in RCM and 1 (50%) in ARVC; p=0.008]; in those aged 10–18, genetic testing was most frequent in ARVC [n=8 (89%)] followed by HCM [n=81 (69%)], RCM [n=1 (50%)] and DCM [n=22 (46%); p=0.007]. A causative mutation was reported in 250 patients (60%), with a higher yield in those aged 10–18 vs &lt;10 years [77 (69%) vs 172 (57%), p=0.032]. In those &lt;10 years, the prevalence of reported causative mutations was highest in HCM [128 (67%) vs 10 (56%) in RCM, 1 (50%) in ARVC and 33 (37%) in DCM; p&lt;0.001]; in those 10–18 years, there was no significant difference in prevalence of reported causative variants between cardiomyopathy subtypes. Rare disease phenocopies were reported in 171 patients (27%): malformation syndromes [n=75 (12%)]; neuromuscular disorders [n=49 (8%)]; inborn errors of metabolism [n=20 (3%)]; mitochondrial [n=18 (3%)]; and chromosomal [n=15 (2%)]. Phenocopies were reported most frequently in patients &lt;10 years [135 (30%) vs 35 (20%) in those aged 10–18 years; p=0.008], particularly in HCM in those &lt;10 years [n=110 (41%); p&lt;0.001 vs other subtypes] and DCM in those aged 10–18 years [n=18 (38%); p=0.03 vs other subtypes].

Conclusion

This study confirms the heterogeneous aetiology of childhood cardiomyopathies and demonstrate a higher prevalence of familial disease than previously reported in paediatric populations. Genetic testing is performed in a high proportion of patients, with a high yield of reported causative variants.

Funding Acknowledgement

Type of funding source: None

Prognosis in patients with prior myocardial infarction and PEGASUS-TIMI 54 criteria in the CLARIFY registry

Background/Introduction

The PEGASUS-TIMI 54 trial showed that prolonged treatment with ticagrelor reduces the cumulative occurrence of ischemic adverse events. CLARIFY is the biggest real life registry on chronic coronary syndrome.

Purpose

- To evaluate the percentage of patients eligible for long-term ticagrelor therapy in the CLARIFY registry.

– To compare the outcome of this subgroup of patients with those with PEGASUS exclusion criteria or without PEGASUS inclusion criteria.

Methods

Within the CLARIFY population, we selected post MI patients and we excluded those with missing info (post MI evaluable population). Then, we divided patients into 3 groups: excluded (meeting PEGASUS exclusion criteria, namely use of P2Y12 receptor antagonists or chronic oral anticoagulant, any stroke, coronary-artery bypass grafting in the past 5 years); eligible (meeting PEGASUS high-risk inclusion criteria, namely age≥65 years; diabetes; multivessel disease; creatinine clearance &lt;60 ml/min) and ineligible (not meeting PEGASUS high-risk inclusion criteria).

We therefore compared the ischemic (CV death, MI and stroke) and bleeding (major bleeding) outcome of the 3 groups adjusting for age, sex, smoking and geographical region.

Results

Among the 11811 post-MI evaluable patients, 4706 (39.8%) were included in the eligible group, 5715 (48.4%) in the excluded group, and 1390 in the ineligible group (11.8%). Both the ischemic and bleeding endpoints were significantly different among the 3 groups with the excluded patients with the worst and ineligible patients with the best outcome (see table). The same trend was shown for CV death, while the occurrence of MI was not significantly different among the 3 groups. In the eligible group, the ratio between ischemic and bleeding events was 6:1, whereas between CV death and major bleeding was 3.5:1.

Conclusions

Around 40% of CLARIFY post-MI patients could benefit from prolonged ticagrelor therapy. In this group of patients, ischemic risk seems to be higher than the bleeding one.

Ischemic & bleeding risk in the 3 groups

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): CLARIFY registry was funded by Servier

Ascending aorta: descending thoracic aorta ratio as an additional metric to early individually oriented diagnoses of abnormalities. A non-contrast enhanced cardiac CT study

Background

Coronary artery calcium (CAC) detection is the established indication for a non-contrast enhanced cardiac computed tomography (NCE-CCT). Other information, beyond CAC, can be derived from the NCE-CCT. Amongst them, data regarding thoracic aorta and its abnormalities might be of interest.

Aims

We aimed at examination whether mutual proportion of ascending aorta and descending thoracic aorta diameters (AAD:DAD ratio) could be diagnostically relevant.

Methods

This retrospective study included 4372 patients out of 5905 subjects undergoing NC-CCT during the last decade, in whom the thoracic aorta and pulmonary artery trunk were within common limits (AAD≤40mm, DAD&lt;30mm, PAD&lt;30mm). 213 persons without CVD risk factors and CAC=0 were qualified into control group (1), and 4159 patients with CVD risk factor(s) ≥1 into examined group (2) of. The range of AAD/PAD ratio normality was referenced from the group 1. In addition body mass index and CAC score were accounted for.

Results

The AAD/PAD ratio in control group was 1.35±0.22 with the normal range between 1.12 and 1.57. The 90th percentile values for AAD have been established. In patients with CAC=0, amongst those with normal BMI the increased AAD:DAD ratio (&gt;1.57), indicating high AAD, was found in 18 /43 cases with AAD&gt;90 percentile (41.2%) and in 21/498 with normal AAD (4.2%). The respective proportions in overweight patients were 23/86 (26.7%) and 12/694 (1.7%), and in obese patients 13/67 (19.4%) and 5/397 (1.3%). In patients with CAC&gt;0, and normal BMI the increased AAD:DAD ratio was found in 10/38 cases with AAD&gt;90% (26.3%) and in 14/458 with normal ascending aorta size (3.1%). Proportions in overweight patients were 23/92 (25.0%) and 15/859 (1.75%), while in obese patients were 17/107 (15.9%) and 13/579 (2.2%), resp. Normal AAD:PAD ratio in patients with established AAD increase (&gt;90 percentile), irrespective of BMI, might suggest accompanying increase in PAD. Lower AAD:PAD ratio indicated a relative increase of the DAD. Mean values of AAD and DAD in relation to BMI and CAC categories along with their ratio are presented in table 1.

Conclusions

Evaluation of thoracic aorta in NC-CCT enhanced diagnostic scope of NCE-CCT. The AAD/DAD ratio, being independent of age, gender and body constitution, does not require adjustment, should be considered as additional metric for early diagnoses of thoracic aorta abnormalities well before absolute values reach the arbitrary cut-off levels.

Table 1

Funding Acknowledgement

Type of funding source: None

Baseline features and management in adult and pediatric clinically suspected and biopsy-proven myocarditis in the cardiomyopathy and myocarditis long-term EORP registry

Background

The Myocarditis section of the EORP Cardiomyopathy and Myocarditis Long-term Registry is a prospective, observational, multinational registry of adult and pediatric patients enrolled using the ESC 2013 diagnostic criteria of clinically suspected (CS) or biopsy-proven (BP) myocarditis (myoc).

Purpose

i) To obtain a real-world snapshot of features and management of myoc; ii) to assess features at presentation in CS and in BP myoc and by age.

Methods

581 patients (68% male), 493 adults, aged 34.9 (SD 18.5) years, and 88 children, aged 8.1 (SD 5.2) years, were divided into 3 groups (G): G1 (n=234, 40%), CS myoc plus cardiac magnetic resonance (CMR) confirmed; G2 (n=222, 38,2%), BP myoc; G3 (n=125, 21.5%), CS myoc, no or normal or inconclusive CMR. Baseline features, procedures, medications were analysed in the total population, in adults vs children, and among G.

Results

In all patients: pseudo-infarct presentation with normal coronary arteries is common (58%), as is heart failure (HF) with or without chest pain and troponin release (58%), followed by arrhythmia (41.9%). In children new-onset HF is more common than in adults (29/32, 90% vs 90/190, 47%, p=0.001). In both adult and pediatric G2 BP myoc, HF and arrhythmia were more common than in CS myoc. Left and right ventricular (RV) echocardiography and CMR function indexes and troponins were lower, NT-pro BNP was higher in G2 BP myoc vs G1 and G3 CS myoc. On CMR oedema and/or Late Gadolinium Enhancement (LGE) were found in 57.4% of adult and in 31.3% of paediatric G2 BP myoc. Endomyocardial biopsy (EMB) was obtained in a similar proportion in children (31/88, 35.2%) and adults (185/493, 37.5%, p=NS), ventricular assist devices were more commonly implanted in G2 children (8/32, 25%) than in G2 adults (4/190, 2.1%, p=0.001), ICD tended to be less common in G2 children (2/32, 6.3%) than in G2 adults (48/190, 25%, p=0.07). In all patients EMB, mainly RV (75.8%), had a low complication rate (4.7%), similar in adults vs children, with no procedure-related death. Histology findings were: lymphocitic myoc (78.9%), giant cell (10.9%), sarcoid (6.9%), non specific (16%). Viral genome was found in 44% of patients (most common PVB19, 21.7%, HHV6, 9.5%). In all patients HF and antiarrhytmic drugs were more frequently used in G2, antivirals in a patient minority, steroids in 24.7%, immunosuppression (IS) in 22.6%. In children steroids or IS were given regardless of G, in adults mainly to G2 BP myoc patients, in keeping with the ESC 2013 expert reco's.

Conclusions

EMB is safe in children and adults and is still the diagnostic gold standard, since CMR failed to identify myoc in a high proportion of G2 BP patients. Etiology-directed therapy was used in a minority of G2 cases, and/or regardless of etiology, thus there is room for improved management. G2 BP patients were older, sicker, had worse biventricular function, more medications and ICDs; follow-up may show their worse outcome.

Funding Acknowledgement

Type of funding source: None

Availability and applicability of cardiac magnetic resonance imaging in diagnosis in cardiomyopathies: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the ESC

Background

Cardiac magnetic resonance (CMR) constitutes a gold standard in the diagnosis of cardiomyopathies. Regardless of CMR advantages, the method is time-consuming, high-cost, with limited availability in some European regions.

Purpose

To assess the availability and applicability of CMR for establishing the diagnosis in different populations of patients with cardiomyopathies.

Methods

Overall, 3208 adult patients with cardiomyopathy (1119 / 34.9% females; median age at diagnosis: 49.0 years): 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM) and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in EURObservational Research Programme (EORP) – Cardiomyopathy/Myocarditis Long-Term Registry were analysed.

Results

CMR scan was performed as a baseline diagnostic method in 29.4% of patients; CMR was a single diagnostic method in 0.9% of patients and in 28.6% of patients CMR was used along with transthoracic echocardiography (TTE). In 67.6% of patients TTE was at the baseline the single diagnostic imaging method. Prevalence of CMR use in different cardiomyopathies was as follows: 20.6% in DCM, 33.8% in HCM, 36.4% in RCM and 51.1% in ARVC (p&lt;0.001). Range of CMR applicability in different European regions was diverse from 0% up to 63.2%.

The population with CMR use was younger, less symptomatic, with decreased prevalence of other cardiovascular risk factors and of associated cardiovascular diseases as compared to the population diagnosed without CMR scanning (p&lt;0.001).

Abnormal CMR results were present in 93.4% of patients with the highest percentage in RCM (95.8%) and HCM (94.9%) followed by DCM (91.5%) and the lowest abnormal CMR scan ratio in ARVC (87.7%) (p=0.030). The majority of CMR examinations comprised the assessment of late gadolinium enhancement (LGE, 93.3% at baseline). Presence of CMR LGE was observed in 69.3% of all patients: 59.1% in DCM, 73.8% in HCM, in 63.9% in ARVC and with the highest prevalence in RCM (83.3%) (p&lt;0.001).

Conclusion

The study reveals real-life data on the low availability and applicability of CMR in adult patients with cardiomyopathies. The analysis shows the advantages of CMR imaging but also identifies the gaps between recommendations and clinical practice. Improvement regarding access, training and reimbursement is necessary to offer CMR to cardiomyopathy patients in accordance with the ESC guidelines.

Funding Acknowledgement

Type of funding source: None

Atrial fibrillation, anticoagulation management and risk of stroke in the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the European Society of Cardiology

Aims

Cardiomyopathies are a heterogeneous group of disorders that increase the risk for atrial fibrillation (AF). The aim of the study is to assess the prevalence of AF, anticoagulation management, and risk of stroke/transient ischaemic attack (TIA) in patients with cardiomyopathy.

Methods and results

Three thousand two hundred eight consecutive adult patients with cardiomyopathy (34.9% female; median age: 55.0 years) were prospectively enrolled as part of the EURObservational Research Programme Cardiomyopathy/Myocarditis Registry. At baseline, 903 (28.2%) patients had AF (29.4% dilated, 27.5% hypertrophic, 51.5% restrictive, and 14.7% arrhythmogenic right ventricular cardiomyopathy, P < 0.001). AF was associated with more advanced New York Heart Association class (P < 0.001), increased prevalence of cardiovascular risk factors and co‐morbidities, and a history of stroke/TIA (P < 0.001). Oral anticoagulation was administered in 71.7% of patients with AF (vitamin K antagonist: 51.6%; direct oral anticoagulant: 20.1%). At 1 year follow‐up, the incidence of cardiovascular endpoints was as follows: stroke/TIA 1.85% (AF vs. non‐AF: 3.17% vs. 1.19%, P < 0.001), death from any cause 3.43% (AF vs. non‐AF: 5.39% vs. 2.50%, P < 0.001), and death from heart failure 1.67% (AF vs. non‐AF: 2.44% vs. 1.31%, P = 0.033). The independent predictors for stroke/TIA were as follows: AF [odds ratio (OR) 2.812, P = 0.005], history of stroke (OR 7.311, P = 0.010), and anaemia (OR 3.119, P = 0.006).

Conclusions

The study reveals a high prevalence and diverse distribution of AF in patients with cardiomyopathies, inadequate anticoagulation regimen, and high risk of stroke/TIA in this population.

P961 Diagnostic use of proportion between ascending aorta and left atrium in patients referred for coronary artery calcium scoring

Background

Non-contrast-enhanced cardiac computed tomography (NCE-CCT) is currently used for coronary artery calcium (CAC) scoring. Meanwhile, other cardiac, vascular and extra-cardiac structures can be evaluated. Data about ascending aorta (AA) and left atrium (LA) has been quantified separately in a few studies. Their mutual proportion has not been examined, as yet.

Aim. We hypothesize that mutual proportion between AA and LA size might help for diagnosing their enlargement before absolute cut-off values are reached.

Method

Among 7950 patients who had NCE-CCT with a 64 raw scanner (Aquillion, Toshiba) within the last decade in our center, in 797 persons the AA diameter (at the level of pulmonary artery bifurcation) and LA diameter and area (highest value) were measured. Raw AAD values were qualified as abnormal if exceeded upper normal limit UNL) for age and height. Weight, BMI and BSA has not been used in order to avoid falsified results in obese patients. The ratio AAD:LAD was quantified as low (&lt;0.8), normal (0.8-1.2) and high (&gt;1.2).

Results

There were 45 patients (5.6%) who had AAD higher than age-height predicted UNL, including 24 patients with a raw AAD &gt;43mm (3.0%). The other 752 has their AAD within limits. The means of AAD were 42.9 ± 3.2mm and 33.6 ± 3.6mm (p &lt; 0.001). LA size differed significantly, both in diameters 38.5 ± 7.4 vs 34.2 ± 5.6mm (p &lt; 0.001) and areas 2138 ± 593 vs 1837 ± 481 mm2 (p &lt; 0.001). Data regarding mutual relationship are shown in the fig.1. It is seen that normal mutual proportion (AOLARel =1) in patients with high AAD means that LAD was also increased (left graph, red open square). In 603 patients with normal AAD corresponded with normal LAD. The AAD:LAD &gt;1.2 in 845 subjects might suggest increased AAD in spite to normal raw diameter. Similar rules were found in respect to the LA area.

Conclusions

Ascending aorta and left atrium enlargement are infrequently recognized in patients referred to CAC scoring. Mutual proportion between AA and LA size might complement diagnostic approach of their abnormalities.

P334Prospective FU in various subtypes of cardiomyopathies: insights from the EORP Cardiomyopathy Registry of the ESC

Background

The EORP Cardiomyopathy Registry is a prospective, observational, multinational registry of consecutive patients with cardiomyopathies. The objective of this report is to describe the outcomes at one year of follow-up of adult patients (>18 years old) enrolled in the registry.

Methods

A total of 3,208 patients (median age: 55.0 (43.0; 64.0) years, males: 65.1%) were recruited at baseline. Follow-up data at 1 year were obtained in 2,713 patients (84.6%), including 1,420 with hypertrophic (HCM), 1,105 dilated (DCM), 128 arrhythmogenic right ventricular (ARVC) and 60 restrictive cardiomyopathy (RCM).

Results

Improvement of symptoms (NYHA, chest pain, syncope) was globally observed over time (p<0.001 for each). Additional invasive therapeutics were performed during follow-up: implantation of ICD (primary prevention) (N=109 patients, 5.2%), pacemaker (N=28, 1.2%), heart transplant (N=30, 1,1%), ablation for atrial or ventricular arrhythmia (0.5% & 0.1%). The proportion of patients with history of AF increased from baseline to FU in 3.6% (from 28.2% to 31.8%). ICD therapy at 1 year was delivered more frequently in ARVC then in DCM, HCM and RCM (11.4%, 9.0%; 8.1%, 0% respectively for primary prevention). Major cardiovascular events (MACE) occurred in 29.3% of RCM, 10.5% of DCM, 7.9% of ARVC and 5.3% of HCM. MACE were globally higher in index patients compared to relatives (10.8% vs 4.4%, p<0.001).

When considering geographical areas, MACE were higher in East Europe (13.1%) and lower in South Europe (5.3%) (univariate); heart transplant was higher in West Europe (2.40%) and lower in South Europe (0.25%) (univariate).

Conclusions

Despite symptomatic improvement in most cases, there is still a significant burden of arrhythmic and heart failure events in patients with cardiomyopathies. Outcomes were different not only according to cardiomyopathy subtypes but also in relatives versus index patients.

Acknowledgement/Funding

None

P5010Use of risk score to identify lower and higher risk subsets among COMPASS-Eligible patients with stable CAD. Insights from the CLARIFY Registry

Background

The COMPASS trial showed that a combination of rivaroxaban and aspirin improved cardiovascular (CV) outcomes in patients with stable coronary artery disease (CAD) compared with aspirin alone, at the expense of increased bleeding. An important issue is to identify in this broad population, patients who are likely to derive the greatest benefit without too great a bleeding risk.

Purpose

To evaluate the performance of the CHA2DS2VaSc (range from 0 to 9), the REACH Recurrent Ischemic Score (RIS) (range from 0 to ≥29) and the REACH Bleeding Risk Score (BRS) (range from 0 to 22) to identify patients with the most favourable trade-off between ischemic and bleeding events, among CAD patients eligible to COMPASS

Methods

We used the CLARIFY Registry, an international registry of >30.000 patients with stable CAD. COMPASS inclusion and exclusion criteria were applied to the CLARIFY population with complete data (n=15.185) to define the “COMPASS eligible population”. Patients at high bleeding risk (REACH BRS >10), were excluded in accordance to COMPASS exclusion criteria. Patients were categorized as low-intermediate (0–1) or high (≥2) CHA2DS2VaSc; low (0–12) or intermediate (13–19) REACH RIS, and low (0–6) or intermediate (7–10) REACH BRS. The ischemic outcome was a composite of CV death, MI or stroke, and the bleeding outcome was a composite of bleeding leading to either admission or transfusion, or haemorrhagic stroke.

Results

The COMPASS-eligible population comprised 5.142 patients (33.9%). Ischemic and bleeding outcome for this group were 2.3 [2.1–2.5] and 0.5 [0.4–0.6] events/100 patient-years, respectively. Patients with high CHA2DS2VaSc score, intermediate REACH BRS and RIS represented 95.5% (n=4.913), 83.8% (n=4.309) and 37.6% (n=1.934) of the population. Regarding ischemic risk, patients with intermediate REACH RIS had the higher ischemic risk (3.0 [2.6–3.4] vs 1.9 [1.7–2.1] for patients with low REACH RIS, p<0.001), followed by intermediate REACH BRS (2.5 [2.2–2.7] vs 1.5 [1.2–2.0] for patients with low REACH BRS, p=0.0003) and high CHA2DS2VaSc score (2.4 [2.2–2.6]), compared to the overall population. Patients with low CHA2DS2VaSc had the lowest ischemic risk (0.6 [0.3–1.3]) compared to the overall population. Regarding bleeding risk, there were no differences between patients categorized according to CHA2DS2VaSc (0.5 [0.2–1.15] vs 0.5 [0.4–0.6], p=0.95) REACH BRS (0.4 [0.3–0.7] vs 0.5 [0.4–0.6], p=0.80) or REACH RIS (0.4 [0.3–0.5] vs 0.5 [0.4–0.7], p=0.26).

Ischemic (blue) and bleeding (red) event

Conclusions

Among a broad population of CAD patients eligible to COMPASS, low CHA2DS2VaSc score identify a small subset of patients with very low ischemic risk which is unlikely to benefit from the adjunction of low dose rivaroxaban to standard therapy. Patients with intermediate REACH Recurrent Ischemic Score had higher ischemic risk, without increased bleeding risk and may be optimal candidates from adjunction of low dose rivaroxaban.

Acknowledgement/Funding

None

2211Prevalence, incidence and prognostic implications of left bundle branch block in patients with stable coronary artery disease. an analysis from the CLARIFY registry

Background

The prevalence, and prognostic implication of left bundle branch block (LBBB) in general population and patients admitted for acute myocardial infarction (MI) as been extensively studied. However, data are scarce about patients with stable coronary artery disease (CAD) and it remains unclear whether LBBB is only a marker of a severe cardiomyopathy or an independent predictor of events in these patients.

Purpose

We aimed to describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. Additionally, we aimed to describe the incidence of newly diagnosed LBBB that occurred without recent myocardial infarction.

Methods

CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was collected at baseline and at each follow-up visit, and patients were considered to have LBBB if the length of the QRS complex was of more than 120 milliseconds. Patients with previous pacemaker implantation of internal cardiac defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation.

Results

From the 23.457 patients with available data regarding LBBB status, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) had at least one LBBB assessed during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2±10.1 versus 63.6±10.4 years, p<0.0001), history of coronary artery bypass grafting (29.2% vs 23.7%, p<0.0001), diabetes (35.1% vs 28.4%, p<0.0001), and HF (25.2% vs 16.8%, p<0.0001) (Table). In unadjusted analysis, patients with LBBB had a higher risk of primary outcome (13.4% vs 8.7%, p<0.0001) and each secondary outcome. In multivariate analysis taking into account several possible confounders, there was no difference in the rate of CV death, MI or stroke between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). However, patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, p<0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, p<0.0001) (Figure).

Outcomes according to LBBB status

Conclusion

The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The overwhelming majority of newly diagnosed LBBB were not contemporary of documented myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, including all cause mortality but with a higher risk of pacemaker implantation and hospitalization for heart failure. To our knowledge this is the first study reporting such results in a broad population of stable CAD patients.

Acknowledgement/Funding

None

Management strategies and 5-year outcomes in Polish patients with stable coronary artery disease versus other European countries: data from the CLARIFY registry

INTRODUCTION An international registry of ambulatory patients with stable coronary artery disease (CLARIFY) allows a comparison of management and outcomes in real‑life setting. OBJECTIVES We aimed to compare the management strategies and 5‑year outcomes in patients from Poland and from other European countries. PATIENTS AND METHODS Stable coronary artery disease was defined as previous myocardial infarction (MI) or revascularization, coronary stenosis greater than 50%, or documented symptomatic myocardial ischemia. Patients were followed on an annual basis for 5 years. RESULTS Among the total of 32 703 patients, 1000 were enrolled in Poland, and 17 326 in other European countries. Polish patients were younger, with a higher proportion of women, smokers, and patients with previous MI, dyslipidemia, and hypertension. Patients in both cohorts received adequate medical treatment, with more Polish patients receiving β‑blockers. Blood pressure and lipid control to target was similar and remained low in both cohorts. Diabetes control and successful smoking cessation rates were lower in Poland than in other European countries. Polish patients more often underwent percutaneous coronary intervention. All‑cause (8.5% vs 7.9%; P = 0.81) and cardiovascular death rates (5.3% vs 4.9%; P = 0.82) did not differ between the groups, but fatal or nonfatal MI occurred more often in the Polish cohort (5% vs 3.1%; P = 0.006). Angina control was better in Poland than in other European countries (Canadian Cardiovascular Society class II-IV, 11.5% vs 15.8% of patients; P <0.001). CONCLUSIONS Risk factor control was insufficient both in patients from Poland and in those from other European countries. The more frequent use of revascularization in Polish patients was not linked to improved outcomes, but, together with more extensive prescription of β‑blockers, might have contributed to better angina control.

Transcatheter paravalvular leak closure and hemolysis - a prospective registry

INTRODUCTION

Paravalvular leak (PVL) related to a surgical prosthetic valve may be associated with clinically significant hemolysis. The influence of transcatheter PVL closure (TPVLC) on hemolysis remains uncertain.

MATERIAL AND METHODS

The prospective registry included patients undergoing TPVLC due to PVL-related heart failure and/or hemolysis. Procedural data, laboratory markers of hemolysis and heart failure status were recorded at baseline, discharge and at 1- and 6-month follow-up.

RESULTS

Of 116 patients from all those qualified for TPVLC, 79 fulfilled the inclusion/exclusion criteria. Hemolysis was significantly more frequent in patients with mitral location of PVL and with calcifications in its channel. After TPVLC prompt reduction of lactate dehydrogenase activity (617.0 (342.0-899.0) vs. 397 (310.0-480.5) IU/l, p < 0.05) and gradual resolution of anemia (hemoglobin (HGB) 11.7 (10.4-13.8) vs. 13.4 (12.9-13.8) g%, p < 0.05) over 6 months were noted. Effective closure of PVL (> 90% reduction of PVL cross-sectional area) resulted in a more prominent increase of red blood cell count and HGB than in patients with residual regurgitation. The TPVLC-related exacerbation of hemolysis was recorded in 14 patients. Its risk was aggravated by presence of significant hemolysis at baseline or residual flow either by a partially uncovered channel or across the occluder. Reduction of hemolysis after successful TPVLC was sustained in 6-month follow-up.

CONCLUSIONS

Risk factors for PVL-related hemolysis were the presence of calcifications in the defect and mitral location of PVL. The TPVLC effectively reduced hemolysis if at least 90% reduction of PVL cross sectional area was achieved. The effect was sustained in 6-month follow-up. Incomplete closure of PVL may increase the magnitude of hemolysis after TPVLC, but it occurred rarely.

Association between socioeconomic status and cardiovascular risk

BACKGROUND

Cardiovascular disease (CVD) is one of the major health problems of the modern societies. Socioeconomic status (SES) is an important predictor of CVD and its risk factors.

AIM

To examine whether SES is related to an increased cardiovascular (CV) risk in the population of southwestern Poland.

METHODS

The study population comprised 2027 subjects, including 929 (45.8%) men and 1098 (54.2%) women participating in the WOBASZ study. From this population, we selected a subgroup of 1821 subjects free from CVD, including 816 men and 1005 women, all with defined SES. Their CV risk was estimated using the SCORE risk algorithm and an analysis of the relationship between SES indicators and the SCORE risk was performed.

RESULTS

We found a negative correlation between the SCORE risk and SES (p = 0.0005). In the overall study group and among participating women, the SCORE risk was significantly lower among subjects with high SES (SES score > 12). This relation was also noted in men and women aged 30–39 years (p = 0.02), women aged 30–39 years (p = 0.0001) and 40–49 years (p = 0.04), and in men aged 70–74 years (p = 0.046). With an increase in SES, the proportion of high CVD risk subjects decreased significantly in the overall study population and in those aged 30–39 years (p = 0.01). Similar relations were observed in women in the entire age range and those aged 30–39 years (p = 0.01). We found that SES had a significant effect on the rate of high CVD risk in all study subgroups aged 30–39 years (odds ratio 0.57, 95% CI 0.39–0.85, p = 0.005 in men and women overall; odds ratio: 0.6, 95% CI 0.37–0.99, p = 0.045 in men; and odds ratio: 0.4, 95% CI 0.16–0.99, p = 0.01 in women).

CONCLUSIONS

Socioeconomic status was found to be a predictor of high CVD mortality risk in men and women aged 30–39 years.

Effects of Transendocardial Delivery of Bone Marrow-Derived CD133+ Cells on Left Ventricle Perfusion and Function in Patients With Refractory Angina: Final Results of Randomized, Double-Blinded, Placebo-Controlled REGENT-VSEL Trial

RATIONALE

New therapies for refractory angina are needed.

OBJECTIVE

Assessment of transendocardial delivery of bone marrow CD133⁺ cells in patients with refractory angina.

METHODS AND RESULTS

Randomized, double-blinded, placebo-controlled trial enrolled 31 patients with recurrent Canadian Cardiovascular Society II-IV angina, despite optimal medical therapy, ≥1 myocardial segment with inducible ischemia in Tc-99m SPECT who underwent bone marrow biopsy and were allocated to cells (n=16) or placebo (n=15). Primary end point was absolute change in myocardial ischemia by SPECT. Secondary end points were left ventricular function and volumes by magnetic resonance imaging and angina severity. After 4 months, there were no significant differences in extent of inducible ischemia between groups (summed difference score mean [±SD]: 2.60 [2.6] versus 3.63 [3.6], P=0.52; total perfusion deficit: 3.60 [3.6] versus 5.01 [4.3], P=0.32; absolute changes of summed difference score: -1.38 [5.2] versus -0.73 [1.9], P=0.65; and total perfusion deficit: -1.33 [3.3] versus -2.19 [6.6], P=0.65). There was a significant reduction of left ventricular volumes (end-systolic volume: -4.3 [11.3] versus 7.4 [11.8], P=0.02; end-diastolic volume: -9.1 [14.9] versus 7.4 [15.8], P=0.02) and no significant change of left ventricular ejection fraction in the cell group. There was no difference in number of patients showing improvement of ≥1 Canadian Cardiovascular Society class after 1 (41.7% versus 58.3%; P=0.68), 4 (50% versus 33.3%; P=0.63), 6 (70% versus 50.0%; P=0.42), and 12 months (55.6% versus 81.8%; P=0.33) and use of nitrates after 12 months.

CONCLUSION

Transendocardial CD133⁺ cell therapy was safe. Study was underpowered to conclusively validate the efficacy, but it did not show a significant reduction of myocardial ischemia and angina versus placebo.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01660581.

Causes of hospitalization and prognosis in patients with cardiovascular diseases. Secular trends in the years 2006-2014 according to the SILesian CARDiovascular (SILCARD) database

INTRODUCTION Despite the progress in cardiology in recent years, cardiovascular (CV) diseases remain the main cause of death in European countries. The knowledge concerning the structure of hospital admissions for CV diseases and clinical outcomes is fragmentary. OBJECTIVES The aim of the study was to analyze the characteristics and outcome of patients with CV disease, hospitalized between 2006 and 2014 and included in the Silesian Cardiovascular Database (SILCARD) covering a population of 4.6 million patients. PATIENTS AND METHODS SILCARD is based on the data from the Regional Department of the National Health Fund in Poland. The enrollment criteria were any hospitalization at a department of cardiology, cardiac surgery, diabetology or vascular surgery and hospitalization with a cardiovascular diagnosis at a department of internal medicine or intensive care. The data come from 310 hospital departments and 1863 outpatient clinics, and contain information on 487 518 patients and 956 634 hospitalizations. RESULTS Heart failure (20%) and stable coronary artery disease (18.5%) were the most frequent primary causes of hospitalization. The number of hospitalizations due to heart failure, aortic stenosis, and pulmonary embolism significantly increased. The highest 12‑month mortality was reported in patients with heart failure and pulmonary embolism (>30%). A decrease in 12‑month mortality in patients with heart failure, stable coronary artery disease, myocardial infarction, and atrial fibrillation was noted, although for some disease entities, it remained relatively high. CONCLUSIONS Between the years 2006 and 2014, in‑hospital and 12‑month mortality showed a trend for decline in many disease entities, with considerable space for prognostic improvement.

Optical Coherence Tomography of De Novo Lesions and In-Stent Restenosis in Coronary Saphenous Vein Grafts (OCTOPUS Study)

BACKGROUND

The OCTOPUS registry prospectively evaluates the procedural and long-term outcomes of saphenous vein graft (SVG) PCI. The current study assessed the morphology of de novo lesions and in-stent restenosis (ISR) in patients undergoing PCI of SVG.

METHODS AND RESULTS

Optical coherence tomography (OCT) of SVG lesions in consecutive patients presenting with stable CAD and ACS was carried out. Thirty-nine patients (32 de novo and 10 ISR lesions) were included in the registry. ISR occurred in 5 BMS and 5 DES. There were no differences in the presence of plaque rupture and thrombus between de novo lesions and ISR. Lipid-rich tissue was identified in both de novo lesions and in ISR (75% vs. 50%, P=0.071) with a higher prevalence in BMS than in DES (23% vs. 7.5%; P=0.048). Calcific de novo lesions were detected in older grafts as compared with non-calcific atheromas (159±57 vs. 90±62 months after CABG, P=0.001). Heterogeneous neointima was found only in ISR (70% vs. 0, P<0.001) and was observed with similar frequency in both BMS and DES (24% vs. 30%, P=0.657). ISR was detected earlier in DES than BMS (median, 50 months; IQR, 18-96 months vs. 27 months; IQR, 13-29 months, P<0.001).

CONCLUSIONS

OCT-based characteristics of de novo and ISR lesions in SVG were similar except for heterogeneous tissue, which was observed only in ISR. (Circ J 2016; 80: 1804-1811).

Long-term follow-up of renal arteries after radio-frequency catheter-based denervation using optical coherence tomography and angiography

Optical coherence tomography (OCT) imaging at the time of renal denervation (RDN) showed that procedure might cause spasm, intimal injury or thrombus formation. In the present study, we assessed the healing of renal arteries after RDN using OCT and renal angiography in long-term follow-up. OCT and renal angiography were performed in 12 patients (22 arteries) 18.41 ± 5.83 months after RNS. There were no adverse events or complications during the long-term follow-up. In ten patients (83 %), significant reductions of blood pressure was achieved without a change of the antihypertensive medications. We demonstrated the presence of 26 areas of focal intimal thickening identified by OCT in 10 (83 %) patients and in 14 (63 %) arteries. The mean area of focal intimal thickening was 0.054 ± 0.033 mm(2). No vessel dissection, thrombus, intimal tear or acute vasospasm were observed during the OCT analysis. Also, the quantitative angiography analysis revealed a significant reduction of the minimal and proximal lumen diameters at follow-up as compared to measurements obtained before RDN. Renal arteries have a favorable "long-term" vessel healing response after RDN. Focal intimal thickening and a modest reduction of the minimal lumen diameter may be observed after RF denervation. Further studies are needed to determine whether intravascular imaging may be helpful in evaluating the vessel healing of RF RDN.

A single-centre, randomised study on platelet reactivity after abrupt or gradual discontinuation of long-term clopidogrel therapy in patients after percutaneous coronary intervention

BACKGROUND

Clinical studies have suggested increased risk of thrombotic events after planned cessation of clopidogrel therapy, due to increased platelet reactivity (platelet rebound); however, in many studies platelet function was not assessed before introducing clopidogrel. Patients who are scheduled to stop clopidogrel therapy, do it abruptly, so a gradual drug cessation might provide a beneficial treatment strategy.

AIM

To determine whether a clopidogrel discontinuation results in platelet rebound hyperaggregability with increased activity compared to pre-treatment values and to assess whether abrupt or tapering clopidogrel cessation may affect platelet reactivity.

METHODS

Patients with stable coronary artery disease (n = 49), on chronic acetylsalicylic acid treatment, who underwent coronary angiography, and were scheduled for elective percutaneous coronary intervention with stent implantation were en-rolled. Patients were randomised to either a tapering clopidogrel discontinuation during a two-week period (tapering group, n = 25) or abrupt drug cessation (abrupt group, n = 24). After 12 months of dual antiplatelet therapy with clopidogrel and acetylsalicylic acid, we performed three follow-up visits with blood sampling. Platelet aggregation was assessed using a mul-tiple electrode aggregometer at inclusion, at cessation day, and seven and 14 days after complete clopidogrel discontinuation. The primary endpoint was the level of adenosine-diphosphate (ADP)-induced platelet aggregation. We also analysed platelet function in the ASPI test and platelet count as secondary endpoints.

RESULTS

In 36 patients included in the main analysis, we found significant differences between the two study groups in the levels of ADP-induced platelet aggregation at days seven and 14 after cessation of clopidogrel (p = 0.004 and p = 0.04, respectively). In the abrupt group, platelet aggregation returned to the values similar to baseline at day seven. There were no significant differences between baseline, seven, and 14 days after drug cessation (p = 0.92 and p = 0.37, respectively). However, in the tapering group, ADP values at seven and 14 days after drug cessation were significantly decreased, comparing to baseline (p < 0.0001 and p = 0.009, respectively). For the ASPI test and platelet count we did not find significant differ-ences between the groups. All values returned to levels similar to the baseline. During the follow-up there were no serious cardiovascular events or bleedings.

CONCLUSIONS

Tapering vs. abrupt discontinuation of clopidogrel treatment results in significantly lower platelet aggregation values after 14 days from complete drug cessation. We found no evidence of a platelet rebound effect.

Impact of anaemia on long-term outcomes in patients treated with first- and second-generation drug-eluting stents; Katowice-Zabrze Registry

BACKGROUND

Coexisting anaemia is associated with an increased risk of major adverse cardiac and cerebrovascular events (MACCE) and bleeding complications after percutaneous coronary intervention (PCI), especially in patients with acute coronary syndrome.

AIM

To assess the impact of anaemia in patients with coronary artery disease (CAD) treated with first- and second-generation drug-eluting stents (DES) on one-year MACCE.

METHODS AND RESULTS

The registry included 1916 consecutive patients (UA: n = 1502, 78.3%; NSTEMI: n = 283, 14.7%; STEMI/LBBB: n = 131, 6.8%) treated either with first- (34%) or second-generation (66%) DES. The study population was divided into two groups: patients presenting with anaemia 217 (11%) and without anaemia 1699 (89%) prior to PCI. Anaemia was defined according to World Heart Organisation (haemoglobin [Hb] level < 13 g/dL for men and < 12 g/dL for women). Patients with anaemia were older (69, IQR: 61-75 vs. 62, IQR: 56-70, p < 0.001), had higher prevalence of co-morbidities: diabetes (44.7% vs. 36.4%, p = 0.020), chronic kidney disease (31.3% vs. 19.4%; p < 0.001), peripheral artery disease (10.1% vs. 5.4%, p = 0.005), and lower left ventricular ejection fraction values (50, IQR: 40-57% vs. 55, IQR: 45-60%; p < 0.001). No difference between gender in frequency of anaemia was found. Patients with anaemia more often had prior myocardial infarction (MI) (57.6% vs. 46.4%; p = 0.002) and coronary artery bypass grafting (31.3% vs. 19.4%; p < 0.001) in comparison to patients without anaemia. They also more often had multivessel disease in angiography (36.4% vs. 26.1%; p = 0.001) and more complexity CAD as measured by SYNTAX score (21, IQR: 12-27 points vs. 14, IQR: 8-22 points; p = 0.001). In-hospital risk of acute heart failure (2.7% vs. 0.7%; p = 0.006) and bleeding requiring transfusion (3.2% vs. 0.5%; p < 0.001) was significantly higher in patients with anaemia. One-year follow-up showed that there was higher rate of death in patients with anaemia. However, there were no differences in MI, stroke, target vessel revascularisation (TVR) and MACCE in comparison to patients with normal Hb. There were no differences according to type of DES (first vs. second generation) in the population of patients with anaemia.

CONCLUSIONS

In patients with anaemia there is a significantly higher risk of death in 12-month follow-up, but anaemia has no impact on the incidence of MI, repeat revascularisation, stroke and MACCE. There is no advantage of II-DES over I-DES generation in terms of MACCE and TVR in patients with anaemia.

Exercise-induced mobilisation of endothelial progenitor cells in patients with premature coronary heart disease

BACKGROUND

Endothelial progenitor cells (EPC) derive from bone marrow and participate in both endothelial regeneration and development of new blood vessels. EPC also play a role in the atherosclerotic process, and their number correlates negatively with the presence of classical risk factors.

AIM

To evaluate circulating EPC count and their exercise-induced mobilisation in patients with premature coronary artery disease (CAD).

METHODS

The study group included 60 patients with stable CAD diagnosed before 45 years of age. The control group consisted of 33 healthy age- and gender-matched volunteers. Venous blood was sampled 3 times in order to assess circulating EPC count immediately before an exercise test (EPC 0) and at 15 min (EPC 15) and 60 min (EPC 60) after the exercise test.

RESULTS

Circulating EPC count in the study group at rest and at 15 min after exercise was comparable (2.1 vs. 2.1 cell/μL, p = 0.35) and increased significantly at 60 min after exercise in comparison to resting values (2.1 vs. 3.2 cell/μL, p < 0.00001). In the control group, circulating EPC count increased significantly at 15 min after exercise (2.0 vs. 3.5 cell/μL, p < 0.0001) but later decreased at 60 min after exercise, although it remained greater than at rest (2.7 vs. 2.0 cell/μL, p < 0.0002). Circulating EPC count at rest and at 60 min after exercise was comparable in the two groups (2.1 vs. 2.0 cell/μL, p = 0.96; and 3.2 vs. 2.7 cell/μL, p = 0.13, respectively) but it was significantly lower in the study group compared to the control group at 15 min after exercise (2.1 vs. 3.5 cell/μL, p < 0.00001). Circulating EPC count at rest and at 15 min after exercise did not correlate with the number of stenosed coronary arteries but at 60 min after exercise it was greater in patients with one-vessel disease compared to those with two- or three-vessel disease (4.2 vs. 3.4 cell/μL, p = 0.01; and 4.2 vs. 2.3 cell/μL, p = 0.00003). However, no difference in circulating EPC count was seen at 60 min after exercise between patients with two- or three-vessel disease (3.4 vs. 2.3 cell/μL, p = 0.3).

CONCLUSIONS

1. Circulating EPC count at rest is comparable between subjects with premature atherosclerosis and healthy volunteers. 2. A single bout of physical exercise causes a significant increase in circulating EPC count in both groups, but the dynamics of exercise-induced EPC mobilisation is different, with delayed exercise-induced EPC mobilisation in subjects with premature CAD. 3. The extent of atherosclerotic coronary lesions does not influence circulating EPC count at rest.

Circulating microRNAs (miR-423-5p, miR-208a and miR-1) in acute myocardial infarction and stable coronary heart disease

AIM

The microRNAs (miRs) are small non-coding RNAs which regulate expression of multiple genes involved in atherogenesis. MicroRNA are also present in circulation. The aims of this study were: 1) assessment of expression level of miR-1, miR-208a and miR-423-5p in plasma in patients with STEMI, stable CAD and healthy individuals; 2) evaluation of correlation between plasma miRs and left ventricle ejection fraction, end- systolic and end-diastolic diameters and troponin release in patients with STEMI.

METHODS

Study group consisted of 26 patients: 1) acute MI group (N.=17); 2) stable CAD group (N.=4); and 3) subjects with no history of CAD (control group, N.=5). Expression of miR-423-5p, miR-208 and miR-1 was measured in plasma before PCI, 6, 12 and 24 hours later. Expression level ofmiRs was measured using TaqMan® MicroRNA Assays. Expression was assessed by Pfaffl method, and miR-39 was used for normalization of the results.

RESULTS

In stable CAD in comparison to control group the expression level of miR-1, miR-208a and miR-423-5p did not show significant differences. Also there was no significant increase of number of miR copies at 6, 12 and 24 hours after PCI. There was a significantly higher number of miR-423-5p copies in patients with acute MI before the pPCI. After 6, 12 and 24 hours post-procedure the expression level was similar to the control group and significantly lower than the baseline level. Conversely, the expression level of miR-1 and miR-208a were not significantly different than in the control group. In patients with acute MI there were no significant correlations between the expression level of miRs and any of the echocardiographic parameters of LV as well as level of troponin I at any time-point of the follow-up.

CONCLUSION

Early in acute myocardial infarction the expression of miR-423-5p in plasma is significantly increased with subsequent normalization within 6 hours. Potentially it is an early marker of myocardial necrosis.

Traditional, forgotten and new left ventricular systolic function parameters on a 64-row multidetector cardiac computed tomography: a reproducibility study

BACKGROUND

Multidetector computed tomography angiography (MDCT) can provide data regarding cardiac function if a retrospective scanning is applied. We aimed at examination of the reproducibility of traditional and more sensitive parameters of the left ventricular (LV) contractility by means of a 64-row CT in order to establish errors of measurement and to determine limits that allow for a reliable detection of their changes.

METHODS AND RESULTS

A random sample of 25 individuals, including 15 females (aged 64 ± 13 years) and 10 males (54 ± 13 years), who had MDCT examination were retrospectively included in this study. Data reconstructions were performed on a dedicated workstation. In each case, axial image series were created with a 10% step from 0% to 90% of the RR interval using a 2 mm slice thickness. LV volume was determined in each phase. Detailed LV volume changes within phases were analyzed to determine the largest difference between the neighbor phases (peak ejection volume, PEV, mL) during systole and to calculate the peak ejection rate (PER i.e. PEV/phase duration [1/10th of RR interval], mL/s). The derived parameters were calculated as the PER normalized for LVEDV (PER-V, 1/s), the PER normalized for LVM (PER-M, mL/g × s) and the PER normalized for LVEDV times the PER normalized for LVM product (PER-VM, ml/g × s2). Considering the errors percentages, the respective values for intra- and inter-observer errors were around 5% and 8% for standard LV systolic measures. The percentage intra-observer errors' ranged between -7.8% and -10.8%, and the inter-observer errors' ranged between -11.8% and -15.7% for both PEV and PER. For the same reader, the percentage errors ranged between -8.7% and +11.9% for PER-V, -10% and +12.7% for PER-M and -18.2% and +24% for PER-VM. For the independent reader the corresponding values were -15.2% and +15.5%, -12.3% and +16.3%, and -26.6% and +30.9%. The intra- -class coeffi cients for repeated measurements for both the same reader (intra-observer) or independent reader (inter-observer) did reach values above 0.9 and around 0.8, respectively.

CONCLUSIONS

We concluded that traditional LV systolic parameters, as well as more sensitive measures of cardiac contractility could be determined reliably by means of a 64-row MDCT. The errors for global LV systolic function measures amount to about 5%, for PEV and PER about 15% and for the PER-derived parameters about 25%. The measurement errors established might help to assess the signifi cance of changes in repeated MDCT examinations.