Digital health and cardiovascular healthcare professionals in Portugal: Current status, expectations and barriers to implementation

INTRODUCTION AND OBJECTIVES

Digital health (DH) is a broad concept, bringing together technology and healthcare, that is playing an increasingly important role in the daily routine of healthcare professionals (HCPs) and promises to contribute to the prevention and treatment of cardiovascular disease. There are no solid data on the position of Portuguese HCPs toward the implementation of DH in cardiovascular medicine. This national cross-sectional study aims to provide a snapshot of DH implementation in Portuguese cardiovascular HCP routines and to identify both expectations and barriers to its adoption.

METHODS

An 18-question survey was created specifically for this study and distributed to 1174 individuals on the Portuguese Society of Cardiology mailing list.

RESULTS

We collected 117 valid responses (response rate 10%). Almost all participants had smartphones and laptops, and two-thirds had tablets. Electronic medical information systems were the most used DH tool (84% of respondents) and were considered the most important for improving cardiovascular care. Implantable technologies (sensors and devices), telemedicine and social media were used by more than two out of three respondents and considered «very important» or «extremely important» by most of them. Most participants showed positive expectations regarding the impact of DH in cardiovascular medicine: 78% agreed that DH could improve health outcomes, 64% that it promotes health literacy and 63% that it could decrease healthcare costs. The top-rated barriers were patients' inability to use smartphones, limited access to electronic devices, and lack of legal regulation of DH.

CONCLUSION

Most Portuguese cardiovascular HCPs had at least three electronic devices (mainly smartphones, laptops and tablets) and showed positive expectations regarding DH's current and future impact on cardiovascular medicine. Patient DH literacy, technology adoption, and DH regulation were identified as the most important barriers to increasing the adoption of DH tools in cardiovascular medicine.

Digital flashcards and medical physiology performance: a dose-dependent effect

Use of digital flashcards promotes active recall, spaced repetition, and self-assessment academic principles. This work explores the association and dose-dependent effect of this study method and locomotor (LP) and cardiovascular physiology (CP) grades. A single-faculty cohort study of medical LP and CP students was conducted, and 155 and 676 flashcards, respectively, were created through Moodle. An exploratory analysis examined three exam results (2019), and a confirmatory study used a fourth exam (2021) in another CP cohort. Of 685 students enrolled, 558 participated in the exploratory analysis: 319 (69%) for LP and 311 (84%) for CP, of which 203 LP and 267 CP students were flashcard users. Median grades were higher among flashcard users, and the number of cards reviewed was positively correlated with grades (r = 0.275 to 0.388 for LP and r = 0.239 to 0.432 for CP, P < 0.001). Multiple linear regression models confirmed a positive dose-dependent association between results and the number of flashcards studied: for every 100 LP cards reviewed, exam grades increased 0.44-0.75 on a 0-20 scale range (P < 0.001), and for every 1,000 CP flashcards, results raised 0.81-1.08 values (P < 0.05). These findings were confirmed in the 2021 CP cohort of 269 participants, of whom 67% were flashcard users. Digital flashcard revision has a consistent positive dose-dependent association on LP and CP grades.NEW & NOTEWORTHY Implementing flashcard-based strategies is a feasible way to promote active recall, spaced repetition, and self-assessment, and students are highly adherent to these initiatives. There is a positive dose-dependent association between the number of flashcards reviewed and physiology grades. These results are consistent across different physiology subjects, under different cohorts, over short and medium terms.

Reference Values for Inward Displacement in the Normal Left Ventricle: A Novel Method of Regional Left Ventricular Function Assessment

BACKGROUND

Regional functional left ventricular (LV) assessment using current imaging techniques remains limited. Inward displacement (InD) has been developed as a novel technique to assess regional LV function via measurement of the regional displacement of the LV endocardial border across each of the 17 LV segments. Currently, normal ranges for InD are not available for clinical use. The aim of this study was to validate the normal reference limits of InD in healthy adults across all LV segments.

METHODS

InD was analyzed in 120 healthy subjects with a normal LV ejection fraction, using the three standard long-axis views obtained during cardiac MRI that quantified the degree of inward endocardial wall motion towards the true LV center of contraction. For all LV segments, InD was measured in mm and expressed as a percentage of the theoretical degree of maximal segment contraction towards the true LV centerline. The arithmetic average InD was obtained for each of the 17 segments. The LV was divided into three regions, obtaining average InD at the LV base (segments 1-6), mid-cavity (segments 7-12) and apex (segments 13-17).

RESULTS

Average InD was 33.4 ± 4.3%. InD was higher in basal and mid-cavity LV segments (32.8 ± 4.1% and 38.1 ± 5.8%) compared to apical LV segments (28.6 ± 7.7%). Interobserver variability correlations for InD were strong (R = 0.80, p < 0.0001).

CONCLUSIONS

We provide clinically meaningful reference ranges for InD in subjects with normal LV function, which will emerge as an important screening and assessment imaging tool for a range of HFrEF therapies.

Myocardial stretch-induced compliance is abrogated under ischemic conditions and restored by cGMP/PKG-related pathways

Introduction: Management of acute myocardial infarction (MI) mandates careful optimization of volemia, which can be challenging due to the inherent risk of congestion. Increased myocardial compliance in response to stretching, known as stretch-induced compliance (SIC), has been recently characterized and partly ascribed to cGMP/cGMP-dependent protein kinase (PKG)-related pathways. We hypothesized that SIC would be impaired in MI but restored by activation of PKG, thereby enabling a better response to volume loading in MI. Methods: We conducted experiments in ex vivo rabbit right ventricular papillary muscles under ischemic and non-ischemic conditions as well as pressure-volume hemodynamic evaluations in experimental in vivo MI induced by left anterior descending artery ligation in rats. Results: Acutely stretching muscles ex vivo yielded increased compliance over the next 15 min, but not under ischemic conditions. PKG agonists, but not PKC agonists, were able to partially restore SIC in ischemic muscles. A similar effect was observed with phosphodiesterase-5 inhibitor (PDE5i) sildenafil, which was amplified by joint B-type natriuretic peptide or nitric oxide donor administration. In vivo translation revealed that volume loading after MI only increased cardiac output in rats infused with PDE5i. Contrarily to vehicle, sildenafil-treated rats showed a clear increase in myocardial compliance upon volume loading. Discussion: Our results suggest that ischemia impairs the adaptive myocardial response to acute stretching and that this may be partly prevented by pharmacological manipulation of the cGMP/PKG pathway, namely, with PDE5i. Further studies are warranted to further elucidate the potential of this intervention in the clinical setting of acute myocardial ischemia.

Impact of Coronary Artery Calcium Score Screening on Cardiovascular Risk Stratification of Patients with Atrial Fibrillation Undergoing Ablation

INTRODUCTION

There is a well-established association between atrial fibrillation (AF) and coronary artery disease. Coronary artery calcium score (CACS) is a helpful tool to refine cardiovascular (CV) risk stratification and inform on the best strategies for primary CV prevention. This study aims to evaluate the impact of opportunistic screening with CACS on risk stratification and decision of preventive therapies, in patients with AF.

METHODS

Cross-sectional study including patients with AF or atrial flutter undergoing cardiac computed tomography for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. CACS was assessed in patients without coronary artery disease using the Agatston method.

RESULTS

A total of 474 patients were included (93% with AF, mean age of 58 ± 10 years, 62% male). CACS >0 was present in 254 (54%) patients. According to CACS and the Society of Cardiovascular Computed Tomography recommendations, 25% of the patients would be candidates for statin therapy and 17% would be candidates for changes in the current statin intensity; in 11 patients (8%), acetylsalicylic acid would be recommended.

CONCLUSION

In our study, more than half of the patients undergoing cardiac computed tomography before AF catheter ablation had CACS above zero. Our findings suggest that an opportunistic evaluation of CACS at the time of ablation can be an important tool to improve CV risk stratification, with important clinical and therapeutic implications.

Higher coronary artery calcium score is associated with increased risk of atrial fibrillation recurrence after catheter ablation

BACKGROUND

Coronary artery calcium score (CACS) is associated with an increased risk of atrial fibrillation (AF) development, but scarce data are available regarding the impact on AF recurrence. This study aims to assess the impact of CACS on AF recurrence following catheter ablation.

METHODS

Retrospective study of patients with AF undergoing cardiac computed tomography (CCT) before ablation (2017-2019). Patients with coronary artery disease (CAD), significant valvular heart disease and previous catheter ablation were excluded. A cut-off of CACS ≥ 100 was used according to literature.

RESULTS

A total of 311 patients were included (median age 57 [48, 64] years, 65% men and 21% with persistent AF). More than half of the patients had a CACS > 0 (52%) and 18% a CACS ≥ 100. Patients with CACS ≥ 100 were older (64 [59, 69] vs 55 [46, 63] years, p ​< ​0.001), had more frequently hypertension (68% vs 42%, p ​< ​0.001) and diabetes mellitus (21% vs 10%, p ​= ​0.020). During a median follow-up of 34 months (12-57 months), 98 patients (32%) had AF recurrence. CACS ≥ 100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 2.0; 95% confidence interval [CI], 1.3-3.1, p ​= ​0.002). After covariate adjustment, CACS ≥ 100 and persistent AF remained independent predictors of AF recurrence (HR, 1.7; 95% CI, 1.0-2.8, p ​= ​0.039 and HR, 2.0; 95% CI, 1.3-3.2, p ​= ​0.004, respectively).

CONCLUSION

An opportunistic evaluation of CACS could be an important tool to improve clinical care considering that CACS ≥ 100 was independently associated with a 69% increase in the risk of AF recurrence after first catheter ablation.

Epicardial adipose tissue volume is not an independent predictor of atrial fibrillation recurrence after catheter ablation

INTRODUCTION AND OBJECTIVES

Previous studies have suggested that epicardial adipose tissue (EAT) could exert a paracrine effect in the myocardium. However, few studies have assessed its role in the risk of atrial fibrillation (AF) recurrence. This study aimed to evaluate the association between EAT volume, and its attenuation, with the risk of AF recurrence after AF ablation.

METHODS

A total of 350 consecutive patients who underwent AF ablation were included. The median age was 57 [IQR 48-65] years and 21% had persistent AF. Epicardial fat was quantified by multidetector computed tomography using Syngo.via Frontier-Cardiac Risk Assessment software, measuring pericardial fat volume (PATV), EAT volume, and attenuation of EAT posterior to the left atrium. AF recurrence was defined as any documented episode of AF, atrial flutter, or atrial tachycardia more than 3 months after the procedure.

RESULTS

After a median follow-up of 34 [range, 12-57] months, 114 patients (33%) had AF recurrence. Univariable Cox regression showed that patients with an EAT volume ≥ 80mL had an increased risk of AF recurrence (HR, 1.65; 95%CI, 1.14-2.39; P=.007). However, after multivariable adjustment, EAT volume did not remain an independent predictor of AF recurrence (HR, 1.24; 95%CI, 0.83-1.87; P=.3). Similar results were observed with PATV. Patients with lower attenuation of EAT did not have a higher risk of AF recurrence (log-rank test, P=.75).

CONCLUSIONS

EAT parameters including the evaluation of EAT volume, PATV and EAT attenuation were not independent predictors of AF recurrence after catheter ablation.

Oral Presentation No. 75 Impact of thoracic aortic calcification measured by computed tomography in clinical outcomes in patients undergoing cardiac surgery

The presence of thoracic aortic calcification (TAC) has been shown to increase the risk of cardiovascular and cerebrovascular events. Few studies have evaluated the relationship between CT measured by computed tomography (CT) before cardiac surgery and clinical outcomes, and the relationship is still unclear.

This study aimed to analyse the impact on clinical outcomes of the presence of TAC in patients undergoing cardiac surgery. A retrospective unicentre analysis of patients undergoing a noncontrast CT prior to cardiac surgery was performed. TAC was quantified using a volume-rendering method. The percentiles of TAC volume (TACV) were used to determine the relative standing. Demographic data, risk factors and clinical outcomes were comparable between groups. A P-value &lt; 0.05 is statistically significant.

The mean TACV was 2.45 ± 2.79 cm3, and the median and 75th percentiles were 1.45 and 4.06 cm3, respectively. Of the total of 121 patients, 26 (21.5%) had high TACV. Table 1 shows the baseline demographic and risk factors. There was no significant difference in risk factors and personal history between groups except for age (P-value = 0.02), hypertension (P-value = 0.04) and coronary artery disease (P-value &lt; 0.01). Regarding clinical outcomes, there was no significant difference in clinical outcomes except for acute kidney failure (P-value = 0.04), which was not significant in multivariate analysis.

In conclusion, aortic calcification is a recurrent finding, to which there seems to be a contribution from hypertension-related vascular damage, especially in older ones. In patients undergoing cardiac surgery, TACV appears not to be related to clinical outcomes in multivariate analysis. However, large-scale studies are needed to confirm these results.

Role of epicardial adipose tissue volume as predictor of atrial fibrillation recurrence

Funding Acknowledgements

Type of funding sources: None.

Background

Several studies have demonstrated the relation between general obesity and atrial fibrillation (AF). Epicardial adipose tissue (EAT), due to its local paracrine effect and the intimate relation with the atrium, could influence AF recurrence rates, but very few studies have explored this association.

Purpose

In this study we aimed to evaluate if EAT could be a predictor of AF recurrence after an AF ablation procedure.

Methods

We included all consecutive patients submitted to AF ablation (2017-2019) who performed a computed tomography scan prior to the procedure. EAT volume was semi-automatically reconstructed by manually tracing the pericardium. Adipose tissue was defined in the range between -150 and -50 Hounsfield units. Recurrence was defined as any documented (ECG/Holter) episode of AF, atrial flutter or atrial tachycardia after 3 months of the procedure. Logistic regression with a restricted cubic polynomial transformation was used to model the non-linear relationship between recurrence and EAT volumes. Inspection of the partial effect curves suggested that a cutoff for EAT volume ≥80mL could stratify patients at risk of recurrence and a Time-to-event analysis was carried.

Results

A total of 354 patients (66% male, median age 57 years [IQR 48–65] and 21% persistent AF) were included. During a median follow-up of 34 months [IQR 24-43], 117 patients (33%) had AF recurrence. These patients had a significantly greater EAT volume (76 mL [IQR 55-111] vs 72 mL [IQR 48-95], p=0.03) when compared to those without recurrence. Also, patients with higher EAT volume (≥ 80mL) had a higher risk of recurrence compared to patients with lower volume (Figure 1, log-rank test p=0.007). After adjusting for clinical risk factors (age, gender, hypertension, diabetes mellitus, obesity, thyroid disease, AF type and left atrial enlargement), higher EAT volume did not remain an independent predictor of AF recurrence (Figure 2, HR 1.25 [95% CI, 0.83-1.86] p=0.3).

Conclusion

In this cohort of patients with AF submitted to catheter ablation, EAT volume ≥80mL was associated with increased risk of AF recurrence. However, it was not an independent predictor of AF recurrence after adjustment to clinical risk factors.

Higher coronary calcium score is associated with increased risk of atrial fibrillation recurrence

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with atrial fibrillation (AF) referred for catheter ablation routinely undergo cardiac computed tomography (CCT) for procedure planning. An opportunistic evaluation of coronary artery calcium score (CACS) can be an important tool to improve clinical care. It is already known that CACS is associated with a high risk of AF development, particularly if values are above 100, but few data are available regarding the impact of CACS in AF recurrence after ablation.

Purpose

To assess the impact of CACS on atrial fibrillation recurrence following catheter ablation.

Methods

Retrospective, single-centre cohort study of consecutive patients with AF undergoing CCT for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. Patients with known history of coronary artery disease (CAD) and moderate to severe valvular heart disease were excluded. CACS was assessed using the Agatston method. Recurrence was defined as any documented episode of AF, atrial flutter or atrial tachycardia after 3 months from procedure. Patients were stratified in CACS&lt;100 and CACS≥100. Explorative analysis incorporated Kaplan-Meier survival curves and Cox regression.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. More than half of the patients had a CACS&gt;0 (n=185, 52%) and 63 patients (18%) had a CACS≥100. Patients with CACS≥100 were older (63 ± 7 vs 54 ± 12 years, p&lt;0.001), had higher prevalence of hypertension (68% vs 43%, p&lt;0.001) and diabetes mellitus (21% vs 10%, p=0.012) and higher left atrial volume (39 ± 9 vs 35 ± 9 ml/m2, p=0.018). After a median observation time of 34 months (IQR 24-43), 117 patients (33%) had AF recurrence.

CACS≥100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 1.85; 95% confidence interval [CI], 1.23-2.79, p=0.003) (Fig. 1). After covariate adjustment (age, gender, hypertension, diabetes mellitus, obesity, thyroid disease, AF type and left atria enlargement) CACS≥100 remained an independent predictor of the risk of AF recurrence (HR, 1.68; 95% CI, 1.05-2.70, p=0.03) as well as persistent AF (HR, 1.91; 95% CI, 1.23-3.00, p=0.004) (Fig. 2).

Conclusion

In patients with AF undergoing catheter ablation, without previous history of CAD, a CACS≥100 was independently associated with a 68% increase in the risk of AF recurrence.

Association of epicardial adipose tissue and coronary artery calcium score in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Both coronary artery calcium (CAC) and epicardial adipose tissue (EAT) had been implicated in coronary artery disease (CAD) and risk of future adverse cardiovascular events. There are scarce data regarding the assessment and association of EAT volume and CAC score (CACS) in atrial fibrillation (AF) patients.

Purpose

To assess the association between EAT volume and the presence and severity of CAC in patients with AF.

Methods

Retrospective and single-centre study including consecutive patients with AF undergoing contrast-enhanced cardiac computed tomography for catheter ablation planning, from 2017 to 2019. Patients with known history of CAD and moderate to severe valvular heart disease were excluded. Baseline clinical and demographical data were collected, as well as their cardiovascular risk, based on the SCORE (Systematic Coronary Risk Evaluation) system and cardiovascular risk categories. We assessed CACS (Agatston method) and EAT volume and analysed their association. EAT was defined as the adipose tissue accumulated between the visceral pericardium and the myocardium and was semi-automatically reconstructed by manually tracing the pericardium. Patients were split into three groups according to CACS: 0, 1-99 and ≥100. A logistic regression (LR) analysis was performed to explore the relationship between EAT volume and the presence of CAC (CACS&gt;0), adjusted for age, gender, obesity, diabetes mellitus and hypertension.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. A CHA2DS2-VASc score ≥2 was present in 130 (37%) patients and most patients had low to moderate cardiovascular risk (n=213, 82%). More than half of the patients had a CACS&gt;0 (n=185, 52%), of which 63 patients (18%) had a CACS≥100. The mean EAT volume was 79 ± 39 ml. There was a significant association between EAT volume and the presence of CAC: CACS=0 69 ± 34 ml vs CACS 1-99 84 ± 38 ml vs CACS ≥100 95 ± 45 ml (p&lt;0.001) (Fig. 1). After covariate adjustment (LR model R2 = 0.373, p &lt;0.0001), the presence of CAC was not associated with EAT volume (OR 1.00, 95%CI 1.00 - 1.01, p=0.2) or obesity, and only with higher age, male gender, hypertension and diabetes mellitus (Fig. 2).

Conclusion

In our cohort of patients with AF undergoing catheter ablation we observed an association between EAT and CACS. Nevertheless, EAT volume was not an independent predictor of CACS and only the classical cardiovascular risk factors remained significant.

Twitter promotion is associated with higher citation rates of cardiovascular articles: the ESC Journals Randomized Study

The association between the dissemination of scientific articles on Twitter and online visibility (as assessed by the Altmetric Score) is still controversial, and the impact on citation rates has never been rigorously addressed for cardiovascular medicine journals using a randomized design. The ESC Journals Study randomized 695 papers published in the ESC Journal Family (March 2018-May 2019) for promotion on Twitter or to a control arm (with no active tweeting from ESC channels) and aimed to assess whether Twitter promotion was associated with an increase in citation rates (primary endpoint) and of the Altmetric Score. This is the final analysis including 694 articles (one paper excluded due to retraction). After a median follow-up of 994 days (interquartile range: 936-1063 days), Twitter promotion of articles was associated with a 1.12 (95% confidence interval: 1.08-1.15) higher rate of citations, and this effect was independent of the type of article. Altmetric Attention Score and number of users tweeting were positive predictors for the number of citations. A social media strategy of Twitter promotion for cardiovascular medicine papers seems to be associated with increased online visibility and higher numbers of citations.

Current role and future perspectives of cardiac rehabilitation in coronary heart disease

Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

Coronary calcification by computed tomography in patients with paroxysmal and persistent atrial fibrillation undergoing catheter ablation

Introduction

Cardiac computed tomography (CCT) is routinely performed for pulmonary vein isolation (PVI) planning in patients with paroxysmal or persistent atrial fibrillation (AF). This imaging method can also identify coronary artery calcium (CAC).

Purpose

To evaluate the prevalence of CAC in patients with paroxysmal and persistent AF undergoing catheter ablation.

Methods

Cross-sectional study including patients with AF/atrial flutter (AFL) undergoing CCT for ablation procedure planning from 2017 to 2019. Baseline clinical and demographic data were collected and CAC score was assessed using the Agatston method. Patients with paroxysmal and persistent AF/AFL (defined according to 2020 European Society of Cardiology guidelines for the diagnosis and management of AF) were compared.

Results

A total of 474 patients were included (441 with AF and 33 with AFL), with a mean age of 57±12 years, of which 295 (62%) were males. CHA2DS2-VASc score was ≥1 (male) or ≥2 (female) in 278 (64%) patients and most patients had a low to moderate cardiovascular risk (259, 80%). CAC was identified in 254 (54%) patients. AF/AFL was paroxysmal in 348 (75%) patients and persistent in 116 (25%). Baseline characteristics and cardiovascular risk factors were similar between groups except for diabetes mellitus (33 [10%] vs 22 [20%], p=0.012) and valvular heart disease (13 [4%] vs 18 [16%], p&lt;0.001) that were more prevalent in patients with persistent AF/AFL. Patients with persistent AF/AFL had higher left atrial volume and left ventricle mass (36±8 vs 43±12 ml/m2, p&lt;0.001 and 90±22 vs 96±22 g/m2, p=0.041). CAC was more frequently present in patients with persistent AF/AFL (175 [50%] vs 72 [62%], p=0.028), especially CAC score &gt;100 (58 [17%] vs 35 [30%], p=0.002). After multivariate analysis, CAC score&gt;100 remained an independent predictor of persistent AF/AFL (OR 2.12, 95% CI 1.18–3.82, p=0.013) along with higher left atrial volume (OR 1.06, 95% CI 1.03–1.08, p&lt;0.001).

Conclusion

In this study, coronary artery calcium was present in more than half of AF/FLA patients undergoing catheter ablation. Patients with persistent AF/AFL showed higher calcium scores and this could derive from chronic, more advanced disease. Especially in those patients, opportunistic CV risk screening and CAC-guided clinical management might be clinically useful.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery calcium in patients with atrial fibrillation undergoing catheter ablation – an opportunity to personalize cardiovascular and thromboembolic risk management

Introduction

There is a well-established association between atrial fibrillation (AF) and coronary artery disease (CAD). Coronary artery calcium score (CACS) is a helpful tool to refine cardiovascular risk stratification and guide strategies of cardiovascular (CV) primary prevention.

Purpose

To evaluate the prevalence and clinical implications of CACS in terms of CV and thromboembolic risk stratification and preventive therapies, in patients with AF and atrial flutter (AFL) undergoing catheter ablation.

Methods

Cross-sectional study including patients with AF/AFL undergoing multidetector computed tomography (MDCT) for ablation procedure planning from 2017 to 2019. Baseline clinical and demographical data were collected. CV and thromboembolic risks were evaluated based on the SCORE (Systematic Coronary Risk Evaluation) system and CHA2DS2-VASc score. CACS was assessed in patients without history of coronary artery disease using the Agatston method.

Results

A total of 474 patients were included (441 with AF and 33 with AFL, mean age of 58±10 years, 62% male). Excluding those over 70 years of age (n=50, 11%), most patients had low (n=69, 22%) or moderate (n=188, 60%) CV risk and 277 (64%) patients had a CHA2DS2-VASc score ≥1 (male) or ≥2 (female). Overall, 265 patients (65%) were under chronic anticoagulation and 157 (39%) were under statin therapy. CAC was present in 254 (54%) patients and showed a multivessel distribution in 62% of the cases. The left main stem was affected in 81 (17%) patients and the left anterior descending artery in 211 (45%). Incorporating CACS&gt;100 as a variable in CHA2DS2-VASc score (vascular disease parameter in patients without history of vascular disease) would have resulted in a significant score reclassification (n=87, 20%) and identification of new potential candidates for anticoagulation (n=12, 3%). Additional, anticoagulation would be indicated as a class IA recommendation in more 26 (6%) patients. Twenty three percent of patients with zero calcium were taking statins, and only 7% of patients with a CACS &gt;300 were on high-intensity statin therapy. According to the recommendations and based on their CACS and current therapy, 103 (25%) patients would be candidates for statin therapy and 69 (17%) patients would be candidates for changes in the current statin therapy intensity (Table 1).

Conclusion

In our study, more than half of the patients undergoing MDCT before AF/AFL catheter ablation had coronary calcium above zero. Our findings suggest that an opportunistic evaluation of CACS can be clinically valuable in thromboembolic risk stratification and management of preventive pharmacological strategies such as anticoagulation and statins.

Funding Acknowledgement

Type of funding sources: None.

Metformin improves diastolic dysfunction of non-diabetic patients with metabolic syndrome: the MET-DIME randomized trial

Background

Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors, including abdominal obesity, dyslipidaemia, arterial hypertension and abnormal glucose homeostasis, which occur together more frequently than by chance. Diastolic dysfunction (DD) is one of the most frequent manifestations of subclinical cardiac involvement of MetS, ultimately leading to heart failure with preserved ejection fraction. Metformin's new potential therapeutic actions include prevention of cardiac remodeling and fibrosis.

Purpose

We aimed to evaluate if metformin improves diastolic function (DF) in non-diabetic patients with MetS.

Methods

A prospective, randomized, open-label, blinded-endpoint trial was conducted over 24 months. Fifty-four non-diabetic adults with MetS and DD (defined as mean e'&lt;10.2cm/s or &lt;7.2cm/s for individuals 40–59 and 60–65 years old, respectively) were randomized to lifestyle counseling (control arm) or lifestyle counseling plus metformin (intervention arm) on a target dose of 1000 mg bid (figure 1). The primary endpoint was the change in mean e' velocity, assessed at 6, 12 and 24 months. Secondary endpoints included improvements in insulin resistance (HOMA-IR), functional capacity (peak oxygen uptake – VO2) and QoL (SF-36 score). Linear mixed effects modelling was used for longitudinal data analysis based on modified intention-to-treat (mITT) and per-protocol (PP) approaches.

Results

Forty-nine patients (mean age=51.8±6.4; 55% males) were included in the mITT analysis. Metformin use, on top of lifestyle counseling, led to an increase in mean e' velocity during follow-up (figure 2), with results at 24 months of +0.67±1.90cm/s (vs. −0.33±1.50cm/s in the control group, p=0.056), which reached statistical significance in PP analysis (+0.80±1.99cm/s vs. −0.37±1.52cm/s, p=0.039). In a random intercept linear mixed model adjusting for age, gender, treatment with drugs targeting the renin-angiotensin-aldosterone axis, presence of heart failure and baseline degree of DD, both mITT and PP analysis showed a statistically significant improvement of DF with metformin over time (β-coefficient=0.28, standard error (SE)=0.13, p=0.034, and β-coefficient=0.35, SE=0.14, p=0.011, respectively). This effect was independent of the observed reduction in insulin resistance. There were no differences regarding peak VO2 nor SF-36 score.

Conclusions

Treatment with metformin of non-diabetic MetS patients with DD, on top of lifestyle counseling, was associated with improved diastolic function.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Merck Study algorithmPrimary endpoint results

Cardiac rehabilitation in elderly myocardial infarction survivors: focus on circulatory power

Exercise-based cardiac rehabilitation (EBCR) is paramount after an acute myocardial infarction (AMI). Older individuals have been reported as having a worse prognosis after an AMI, and some series have reported differences in the functional response to EBCR. The peak circulatory power (CP), a non-invasive parameter, has been described as a surrogate for the cardiac power, showing promising results as a comprehensive measure of the cardiovascular response. Whilst this, data concerning the impact of EBCR on CP, particularly among elderly individuals, remains elusive. To address this issue, an observational, retrospective study including all patients admitted due to an AMI who completed a phase II EBCR programme between 11/2012 and 4/2017, was conducted, with CP being analysed by a symptom-limited cardiopulmonary exercise test. A total of 379 patients, 30% aged ≥65 years-old, were included. CP significantly improved after the EBCR programme (in all patients, as well as in both subgroups). Older patients presented lower CP than their younger counterparts at the beginning and the end of the programme, while presenting smaller improvements (122 ± 540 vs 293 ± 638 mmHg mL/kg/min, p = 0.013). This was maintained after adjusting for several potential confounding factors. A contemporary ECBR programme was associated with significant improvements in CP among AMI patients. Though those aged ≥65 years-old presented smaller improvements in CP than younger individuals, these still presented significant increases in this parameter. These results highlight the importance of EBCR in this challenging higher risk group of patients.

Prevalence, multimodality imaging characterization, and mid-term prognosis of quadricuspid aortic valves: an analysis of eight cases, based on 160 004 exams performed during 12 years in a tertiary care hospital

AIMS

Quadricuspid aortic valve (QAV) is a rare abnormality, which may cause aortic regurgitation (AR) requiring surgical intervention in some patients. The characteristics associated with aortic valve functional degeneration in patients with QAV are still unknown. The aim of this study is to describe QAV prevalence, characterize the disease by multimodality imaging, evaluate predictors of severe AR, and assess mid-term prognosis.

METHODS AND RESULTS

Retrospective search in imaging exams database of one tertiary centre, for patients diagnosed with QAV between January 2007 and September 2019. QAV was characterized by cardiac computed tomography, transthoracic/transoesophageal echocardiography, and cardiac magnetic resonance. A total of 160 004 exams were reviewed and eight patients with QAV were identified (50% men, mean age 53.5 ± 10.7 years). The prevalence of QAV was 0.005%. During a median follow-up of 52 months (interquartile range 16-88), there were no deaths. Seven patients (88%) had pure AR (three severe, one moderate, and three mild) and one patient (12%) had moderate AR and moderate aortic stenosis. Three patients (38%) with severe AR underwent valve surgery (two replacements and one repair). Analysis of predictors of severe AR was not statistically significant.

CONCLUSION

QAV is a rare congenital cardiac defect, with a prevalence of 0.005% in our study. Its predominant functional abnormality was regurgitation and about one-third of the patients required aortic valve surgery. Multimodality imaging may play a pivotal role in assessing patients with QAV with significant valve dysfunction or associated congenital heart disease and improve their treatment strategy.

Metformin in non-diabetic patients with metabolic syndrome and diastolic dysfunction: the MET-DIME randomized trial

PURPOSE

Metabolic syndrome (MetS) affects one out of 3 adults in the western world and is associated with preclinical diastolic dysfunction that impairs functional capacity and quality of life (QoL). This randomized trial was designed to evaluate if the addition of metformin to the standard treatment of non-diabetic patients with MetS improves diastolic dysfunction.

METHODS

Prospective, randomized, open-label, blinded-endpoint trial. Fifty-four non-diabetic adults with MetS and diastolic dysfunction were randomized to lifestyle counseling or lifestyle counseling plus metformin (target dose 1000 mg bid). The primary endpoint was the change in mean e' velocity (assessed at baseline, 6, 12 and 24 months). Secondary endpoints were improvements in insulin resistance, functional capacity and QoL. Linear mixed effects modeling was used for longitudinal data analysis using modified intention-to-treat (mITT) and per-protocol (PP) approaches.

RESULTS

Forty-nine patients were included in the mITT analysis (mean age = 51.8 ± 6.4; 55% males). Metformin treatment was associated with a significant decrease in HOMA-IR. There was a significantly different mean change in e' velocity during the study period between trial arms, both in the mITT (at 24 months, change of +0.67 ± 1.90 cm/s in metformin arm vs. -0.33 ± 1.50 cm/s in control arm) and PP populations (+0.80 ± 1.99 cm/s in metformin arm vs. -0.37 ± 1.52 cm/s in control arm), using a random intercept linear mixed model. There were no significant differences in peak oxygen uptake and SF-36 scores between trial arms.

CONCLUSIONS

Treatment with metformin of non-diabetic MetS patients with diastolic dysfunction, on top of lifestyle counseling, is associated with improved diastolic function.

Peguero-Lo Presti criteria for diagnosis of left ventricular hypertrophy: a cardiac magnetic resonance validation study

AIMS

The diagnostic performance of the new Peguero-Lo Presti ECG criteria for left ventricular hypertrophy (LVH) has not been validated by cardiac magnetic resonance (CMR). The aim of this study was to evaluate and compare the diagnostic performance of Peguero-Lo Presti, Cornell and Sokolow--Lyon voltage criteria for LVH as defined by CMR in an all-comers European population.

METHODS

A total of 240 consecutive patients referred for CMR who had a concomitant electrocardiogram for review were evaluated. LVH group patients were defined according to the reference values for sex and age of left ventricular mass index (LVMi). A control group, adjusted by sex, was randomly selected from a population without LVH. We applied the ECG voltage criteria to both groups and evaluated their diagnostic accuracy. Diagnostic sensitivity and specificity were compared.

RESULTS

Two hundred and forty patients (mean age 63 years; 65% men) were divided into two groups (LVH n = 149; control n = 91). The main causes of LVH were hypertension (24.8%) and hypertrophic cardiomyopathy (21.5%). The remaining patients of this group had a diagnosis of dilated cardiomyopathy (14.8%), valvular heart disease (7.4%) and infiltrative cardiomyopathy (2.0%). Overall, the sensitivity for LVH diagnosis of the Peguero-Lo Presti criteria outperformed both the Cornell (47 vs. 29%, P < 0.001) and Sokolow--Lyon voltage criteria (vs. 25%, P < 0.001). The specificities of all the criteria were above 94%, without significant differences between them.

CONCLUSION

In an all-comers European population with LVH defined by CMR, the criteria of Peguero-Lo Presti showed increased sensitivity for this diagnosis, when compared with the Sokolow--Lyon and Cornell voltage criteria. As such, they could become the preferred ECG diagnostic tool when evaluating patients at risk for LVH.

Metformin in non-diabetic patients with metabolic syndrome and diastolic dysfunction: the MET-DIME randomized trial

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Merck

Background

Metabolic syndrome (MetS) affects one out of 3 adults in the western world and is associated with preclinical diastolic dysfunction that impairs functional capacity and quality of life (QoL).

Purpose

This randomized trial was designed to evaluate if the addition of metformin to the standard treatment of non-diabetic patients with MetS improves diastolic dysfunction.

Methods

Prospective, randomized, open-label, blinded-endpoint trial. Fifty-four non-diabetic adults with MetS and diastolic dysfunction were randomized to lifestyle counseling or lifestyle counseling plus metformin (target dose 1000 mg bid). The primary endpoint was the change in mean e’ velocity (assessed at baseline, 6, 12 and 24 months). Secondary endpoints were improvements in insulin resistance, functional capacity and QoL. Linear mixed effects modelling was used for longitudinal data analysis using modified intention-to-treat (mITT) and per-protocol (PP) approaches.

Results

Forty-nine patients were included in the mITT analysis (mean age = 51.8 ± 6.4; 55% males). Metformin treatment was associated with a significant decrease in HOMA-IR. There was a significantly different mean change in e’ velocity during the study period between trial arms, both in the mITT (at 24 months, change of +0.67 ± 1.90cm/s in metformin arm vs. -0.33 ± 1.50cm/s in control arm) and PP populations (+0.80 ± 1.99cm/s in metformin arm vs. -0.37 ± 1.52cm/s in control arm), using a random intercept linear mixed model. There were no significant differences in peak oxygen uptake and SF-36 scores between trial arms.

Conclusion

Treatment with metformin of non-diabetic MetS patients with diastolic dysfunction, on top of lifestyle counseling, is associated with improved diastolic function.

Abstract Figure.

Social media in cardiovascular medicine: a contemporary review

Social media increasingly impact both the private and professional lives of the majority of the population, including individuals engaged in cardiovascular healthcare and research. Healthcare providers across the world use social media platforms such as Twitter or Facebook to find medical and scientific information, to follow scientific meetings, to discuss individual clinical cases with colleagues, and to engage with patients. While social media provide a means for fast, interactive and accessible communication without geographic boundaries, their use to obtain and disseminate information has limitations and the potential threats are not always clearly understood. Governance concerns include a lack of rigorous quality control, bias due to the pre-selection of presented content by filter algorithms, and the risk of inadvertent breach of patient confidentiality. This article provides information and guidance regarding the role and use of social media platforms in cardiovascular medicine, with an emphasis on the new opportunities for the dissemination of scientific information and continuing education that arise from their responsible use.

The impact of digital flashcards on cardiovascular physiology academic performance in a medical course – a dose-dependent effect between the amount of training and academic success

Background

Digital flashcards are used to review factual knowledge through active-recall and spaced-repetition, while allowing subsequent self-assessment.

Purpose

To assess if using digital flashcards is associated with cardiovascular physiology academic success and better knowledge retention in short- and medium-terms, through a dose-dependent effect.

Methods

We conducted a single-faculty cohort study of 2nd-year medical students enrolling in cardiovascular physiology course, using a platform comprising 676 original flashcards. The grades from 0–20 scale of three exams were analyzed, being the latest optional and performed 1 month after the end of the course. One-sample t-test was used to compare the grades between flashcard users versus non-users, and the amount of training was correlated with the exams results using Pearson's correlation. Also, multiple linear regression models were created, using the respective grades as the dependent variable. A p value of &lt;0.05 was considered statistically significant.

Results

From 312 students enrolled, 279 agreed to participate in this study, and 87% used the platform. Flashcard-users exhibited higher grades versus non-users (11.83±3.57 vs. 9.50±3.55, p&lt;0.001; 12.47±3.03 vs. 11.45±3.24, p=0.225; 10.24±4.66 vs. 7.51±4.46, p=0.041; 1st, 2nd and 3rd exams, respectively). Among flashcard-users, the amount of training was positively correlated with the academic success (r=0.366, r=0.350, r=0.286; 1st, 2nd and 3rd exams, respectively, p≤0.001 for all). Multiple linear regression models showed a statistically significant association between the theoretical exam results and the number of flashcards studied – for every 1000, there was an increase in 0.98 (p=0.001), 1.22 (p=0.017) and 1.00 (p=0.022) in the grades of the 1st, 2nd and 3rd exams, respectively.

Conclusion

Studying cardiovascular physiology through digital flashcards has a moderate correlation with the exams results, exhibiting a positive and consistent dose-dependent effect, both in short- and medium-terms. Therefore, this strategy seems to improve academic success by increasing knowledge retention.

Study algorithm

Funding Acknowledgement

Type of funding source: None

Is coronary computed tomography angiography a good choice for elders and high probability cases?

Introduction

Coronary computed tomography angiography (cCTA) is widely considered the optimal non-invasive test to rule out coronary artery disease (CAD) and the gatekeeper for invasive coronary angiography (ICA). However, its diagnostic utility in elderly patients (pts) and in cases of high pre-test probability (PTP) is still questioned.

Aim

To determine whether older age and high PTP are correlated with non-diagnostic cCTA scans in pts with suspected chronic coronary syndrome (CCS).

Methods

Single-centre retrospective study of 302 pts with suspected CAD assigned to two groups: (A) 207 pts aged ≥70 years (y); (B) 95 aged &lt;70y. Younger pts were randomly selected from our database. We excluded pts with known history of CAD and suspected acute coronary syndrome. A 192x2 dual-source CT equipment was used. Baseline demographic and clinical characteristics were collected as well as scan features and findings. We defined high PTP according to clinical Morise score. Our endpoint was the obtention of diagnostic scan (all segments evaluable). Multivariate analysis was performed to assess the determinants of non-diagnostic scans. We used SPSS Statistics 22 for statistical analysis.

Results

Overall, mean age was 68±9y and 53% were male. Elderly pts presented more co-morbidities (hypertension: 78.3 vs 54.7%, p&lt;0.01; hyperlipidaemia: 69.1 vs 52.6%, p&lt;0.01; pulmonary disease: 13.0 vs 4.2%, p=0.02) and high PTP more frequently (16.9 vs 6.3%, p&lt;0.01). Total coronary calcium score (CaS) was higher in elderly pts (382.7±658.7 vs 243.5±490.8, p=0.04); per-vessel, both left anterior descending (156.7±254.2 vs 92.2±187.8, p=0.01) and left circumflex (LCX) arteries (65.5±131.3 vs 26.8±67.6, p&lt;0.01) showed higher CaS in the elderly. Multiple calcified plaques (≥5) were also more common in this group (60.4 vs 45.3%, p=0.01). However, the proportion of pts with CaS considered prohibitive for angiography (13.5 vs 7.4%; p=0.12) and calcium blooming artefacts impairing interpretation (14.5 vs 12.5%; p=0.65) did not differ. A diagnostic study was more frequently obtained in younger pts but without reaching statistical significance (69.1 vs 76.8%; p=0.17). Obstructive CAD was equally identified (30.3 vs 30.4%; p=0.92) with a respective per-patient accuracy of 68.4% (13/19) and 57.1% (8/14) comparing with ICA when performed. Multivariate analysis showed that LCX CaS ≥75th percentile and multiple calcified plaques (≥5) were associated with non-diagnostic cCTA scan (Figure 1). High PTP (p=0.83) and age ≥70y (p=0.61) were not associated with the endpoint.

Conclusion

In this comparison study of elderly and young pts undergoing cCTA for suspected CCS, age ≥70y and high PTP were not associated with non-diagnostic tests while multiple calcified lesions and severe LCX calcification predicted inconclusive studies. Our results cast hope on the applicability of cCTA to elderly pts and cases with high PTP, although larger studies are required.

Funding Acknowledgement

Type of funding source: None

Differential impact of a cardiac rehabilitation program in functional parameters according to patient gender

INTRODUCTION

Exercise-based cardiac rehabilitation (EBCR) programs are of paramount importance in the management of acute myocardial infarction (AMI) survivors. Albeit this, female patients tend to be less referred for these programs, while also having a poorer prognosis. We aimed at assessing the impact of a contemporary EBCR program on functional parameters after an AMI, and specifically the impact of gender on its potential benefits.

METHODS

Observational, retrospective cohort study including all patients admitted to a tertiary center due to an AMI who completed a phase II EBCR program after discharge, between November 2012 and April 2017. Functional parameters were assessed by a symptom-limited cardiopulmonary exercise test (CPET). Patients were dichotomized according to gender.

RESULTS

A total of 379 patients were included, 19% of whom were women. After the program, peak oxygen uptake (pVO2) and exercise duration increased significantly (P<0.001). Though female patients presented a lower pVO2 and completed a shorter CPET at both the beginning and end of the study, there were no differences in the magnitude of improvement in these parameters between both groups [pVO2 delta 1.37 ± 3.08 vs 1.31 ± 2.62 mL/kg/min, P=0.876; CPET duration delta 120 (60-167) vs 85 (60-146), P=0.176].

CONCLUSIONS

A contemporary EBCR program was associated with significant improvements in functional parameters, as assessed by CPET. Though female patients had lower levels of pVO2, the benefits of this program were similar among groups. These results highlight the importance of EBCR among this higher risk subset of patients.

Twitter promotion predicts citation rates of cardiovascular articles: a preliminary analysis from the ESC Journals Randomized Study

AIMS

The association between the dissemination of scientific articles on Twitter and online visibility (including Altmetric score) is still controversial and the impact on citation rates has never been addressed for cardiovascular medicine journals.

METHODS AND RESULTS

The ESC Journals Study randomized 696 papers published in the ESC Journals family (March 2018-May 2019) for promotion on Twitter or to a control arm (with no active tweeting from ESC channels) and aimed to assess if Twitter promotion was associated with an increase in citation rate (primary endpoint) and Altmetric score. This is a preliminary analysis of 536 articles (77% of total) published until December 2018 (therefore, papers published at least 6 months before collecting citation and Altmetrics data). In the analysis of the primary endpoint, Twitter promotion of articles was associated with a 1.43 (95% confidence interval 1.29-1.58) higher rate of citations, and this effect was independent of the type of article. Both Altmetric score and number of users tweeting were positively associated with the number of citations in both arms, with evidence of a stronger association (interaction) in the Twitter arm.

CONCLUSION

Therefore, a social media strategy of Twitter promotion for cardiovascular medicine papers seems to be associated with increased online visibility and higher number of citations. The final analysis will include 696 papers and 2-year scientific citation rate and is estimated to be concluded in March 2021.

Early Repolarization Pattern and Left Ventricular Mass in Hypertrophic Cardiomyopathy

BACKGROUND

J-point elevation in the inferior and/or lateral leads is associated with an increased incidence of sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM), although the exact underlying mechanism is not known. As severe left ventricular hypertrophy and late gadolinium enhancement (LGE) are important risk factors for SCD in this population, we aimed to assess whether there was an association between an early repolarization pattern (ERP) and greater left ventricular mass (LVM) and LGE extent among patients with HCM.

METHODS

This was a retrospective cohort study of 85 consecutive patients with HCM who underwent cardiac magnetic resonance (CMR) and had an electrocardiogram without confounders (intraventricular conduction delay, complete left or right bundle branch block, or ventricular paced rhythm). Baseline characteristics and MRI-derived LVM and LGE extent were compared between patients with and without ERP.

RESULTS

ERP was present in 9 out of 85 patients (10.6%). Patients with ERP had greater indexed LVM compared to those without (112.5 ± 26.3 vs. 87.8 ± 24.6 g/m2, p = 0.006). Logistic regression analysis revealed a 4.2-fold increase in the odds of prevalent ERP per standard deviation increase in body surface area-indexed LVM (odds ratio 4.2; 95% CI 1.54-11.4, p = 0.005). There were no statistically significant differences regarding LGE extent between groups.

CONCLUSION

ERP is associated with greater CMR-derived LVM among patients with HCM. This finding could partially explain the association between J waves and a higher risk of SCD in this population. There were no differences in LGE extent. Further studies are needed to confirm this association and evaluate the importance of ERP as a marker of increased risk of SCD in HCM.

Accuracy of three-dimensional echocardiography in candidates for transcatheter aortic valve replacement

The correct determination of aortic annulus dimensions is a crucial step to avoid complications in Transcatheter Aortic Valve Replacement (TAVR). Currently, the gold standard method for the evaluation of the aortic annulus is Multidetector Computed Tomography (MDCT), which is limited by the risk of contrast-induced nephropathy. Three-dimensional transesophageal echocardiography automated software (3DTEEa) have been used as an alternative in patients with contra-indications to MDCT. We aimed to evaluate the accuracy of 3DTEEa-derived aortic annulus dimensions; to assess the influence of calcification in the agreement between 3DTEEa and MDCT; and to determine reclassification in prosthesis size choice if 3DTEEa was the only imaging method. One hundred and seven consecutive patients referred for TAVR were studied. Aortic annulus dimensions were determined using MDCT and 3DTEE manual (3DTEEm) and automated measurements. Valve calcification was assessed with MDCT. Limits of agreement (LOA) were narrower for 3DTEEa (minimum diameter: mean bias 0.60; LOA - 2.94 to 4.14; maximum diameter: mean bias 0.20; LOA - 3.82 to 4.22) as compared to 3DTEEm (minimum diameter: mean bias 0.22; LOA - 3.84 to 4.28; maximum diameter: mean bias - 1.25; LOA - 6.37; 3.86). Compared to MDCT, 3DTEEa overestimated while 3DTEEm underestimated most parameters. No differences were found in average bias between methods according to quartiles of valve calcification. Most patients would have received the same size valve (63.9%) if 3DTEEa was the only available method. Measurement of aortic annulus dimensions using a 3DTEE automatic software is feasible and not influenced by valve calcification. It may be an alternative for patients who cannot undergo MDCT.

P1772Diagnostic accuracy of a novel electrocardiographic criterion for the diagnosis of left ventricular hypertrophy in hypertrophic cardiomyopathy

Introduction

The 12-lead electrocardiogram (ECG) is a fundamental initial diagnostic modality for the early evaluation of a patient suspected of having hypertrophic cardiomyopathy (HCM). ECG criteria for the diagnosis of left ventricular hypertrophy (LVH) typically have low sensitivity and high specificity. Recently, a novel ECG criterion (Peguero-Lo Presti, PLP) with higher sensitivity (62%) and similar specificity (90%) was developed in a cohort of hypertensive patients, but its accuracy in patients with HCM has not been tested. We hypothesized that Peguero-Lo Presti criterion would improve upon the sensitivity of other criteria, while maintaining high specificity, for the diagnosis of LVH in patients for with HCM.

Methods

We retrospectively analyzed 215 consecutive patients who underwent cardiac magnetic resonance (CMR) between 2010 and 2018 for suspected HCM. All patients aged 18 years or older, who had CMR-confirmed HCM and an ECG without confounders (complete left or right bundle brunch block or paced ventricular rhythm) were included for analysis (n=88). Left ventricular mass (LVM) index and maximum wall thickness were derived from CMR analysis. The PLP criteria was defined as the sum of the deepest S wave (SD) in any lead and the S wave amplitude of lead V4 (SV4). Cornell voltage (CL) and Sokolow-Lyon (SL) were used for comparison. We randomly selected 88 gender-matched patients who performed an ECG and CMR for other clinical reasons and who had no structural heart disease or LVH for use as controls. The DeLong and McNemar's test were used to compare ROC area under the curve (AUC) and sensitivity and specificity, respectively, between the three criteria.

Results

88 patients with HCM (63% male, mean age 56.7±15 years) were analyzed. The mean maximum wall thickness was 19.9±4.4mm and mean indexed LVM was 89.7±27g/m2. 34 patients (38.6%) had increased indexed LVM and 77 (87.5%) had at least one segment with late gadolinium enhancement (LGE). Discrimination by AUC was highest for PLP (0.85 [95% CI 0.8–0.9]), compared to CL (0.79, p=0.03) and SL (0.73, p=0.02). Using literature cut-offs, the sensitivity of PLP (60% [95% CI 50–70%]) was significantly higher compared to CL (40% [95% CI 30–50%, p<0,001) and SL (41%, [95% CI 31–51%], p=0.01), whilst maintaining high specificity (PLP 96%; CL 98%; SL 94%). After adjusting for LVM, the amount of LGE had a positive correlation with PLP amplitude (Spearman's rho=0.6, coef=2.4, p=0.01), but not Cornell or Sokolow. The sensitivity of PLP was significantly higher than CL and Sokolow in patients with LGE (61% vs 44% vs 43%, p<0.05).

Conclusion

The Peguero-Lo Presti criteria demonstrated higher sensitivity and similar specificity when compared to the Cornell and Sokolow-Lyon criteria for the diagnosis of LVH in a cohort of patients with hypertrophic cardiomyopathy. Therefore, they could become the standard ECG diagnostic criteria in patients suspected of having LVH and HCM.

Stretch-induced compliance: a novel adaptive biological mechanism following acute cardiac load

Aims

The heart is constantly challenged with acute bouts of stretching or overload. Systolic adaptations to these challenges are known but adaptations in diastolic stiffness remain unknown. We evaluated adaptations in myocardial stiffness due to acute stretching and characterized the underlying mechanisms.

Methods and results

Left ventricles (LVs) of intact rat hearts, rabbit papillary muscles and myocardial strips from cardiac surgery patients were stretched. After stretching, there was a sustained >40% decrease in end-diastolic pressure (EDP) or passive tension (PT) for 15 min in all species and experimental preparations. Stretching by volume loading in volunteers and cardiac surgery patients resulted in E/E' and EDP decreases, respectively, after sustained stretching. Stretched samples had increased myocardial cGMP levels, increased phosphorylated vasodilator-stimulated phosphoprotein phosphorylation, as well as, increased titin phosphorylation, which was reduced by prior protein kinase G (PKG) inhibition (PKGi). Skinned cardiomyocytes from stretched and non-stretched myocardia were studied. Skinned cardiomyocytes from stretched hearts showed decreased PT, which was abrogated by protein phosphatase incubation; whereas those from non-stretched hearts decreased PT after PKG incubation. Pharmacological studies assessed the role of nitric oxide (NO) and natriuretic peptides (NPs). PT decay after stretching was significantly reduced by combined NP antagonism, NO synthase inhibition and NO scavenging, or by PKGi. Response to stretching was remarkably reduced in a rat model of LV hypertrophy, which also failed to increase titin phosphorylation.

Conclusions

We describe and translate to human physiology a novel adaptive mechanism, partly mediated by titin phosphorylation through cGMP-PKG signalling, whereby myocardial compliance increases in response to acute stretching. This mechanism may not function in the hypertrophic heart.

Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives

BACKGROUND

Pericardial effusion (PE) can develop in several pathological scenarios, and is often initially evaluated by means of echocardiography. Computed tomography (CT) has been used as an aid in the management of patients presenting with PE, in selected cases. The role of CT-guided pericardiocentesis in contemporary practice, however, remains not fully ascertained. We aimed at presenting a systematic review concerning the state-of-the-art of this technique.

METHODS

A systematic review of published data on the use of CT for guiding pericardiocentesis was carried out (search performed on PubMed, ISI Web of Knowledge and Scopus databases).

RESULTS

From title and abstract analysis, 14 articles were included that met the prespecified criteria. After full-text analysis, six articles were excluded. The eight articles under analysis included a total of 635 procedures performed in 571 patients. CT guidance was mostly used in a postoperative setting (364 procedures). Most procedures were done mainly for therapeutic purposes (528 procedures). Success rates ranged from 94% to 100%. Complications ranged from 0% to 7.8%.

CONCLUSION

CT-guided pericardiocentesis is a useful technique in the approach to PE, in several clinical scenarios. Its use can be especially relevant in the postoperative period, as well as in individuals with suboptimal image quality (as assessed by echocardiography, for the moment the first choice in the approach to most cases of PE).