S-Adenosyl-l-methionine restores brain mitochondrial membrane fluidity and GSH content improving Niemann-Pick type C disease

Niemann-Pick type C (NPC) disease is a lysosomal storage disorder characterized by impaired motor coordination due to neurological defects and cerebellar dysfunction caused by the accumulation of cholesterol in endolysosomes. Besides the increase in lysosomal cholesterol, mitochondria are also enriched in cholesterol, which leads to decreased membrane fluidity, impaired mitochondrial function and loss of GSH, and has been shown to contribute to the progression of NPC disease. S-Adenosyl-l-methionine (SAM) regulates membrane physical properties through the generation of phosphatidylcholine (PC) from phosphatidylethanolamine (PE) methylation and functions as a GSH precursor by providing cysteine in the transsulfuration pathway. However, the role of SAM in NPC disease has not been investigated. Here we report that Npc1-/- mice exhibit decreased brain SAM levels but unchanged S-adenosyl-l-homocysteine content and lower expression of Mat2a. Brain mitochondria from Npc1-/- mice display decreased mitochondrial GSH levels and liquid chromatography-high resolution mass spectrometry analysis reveal a lower PC/PE ratio in mitochondria, contributing to increased mitochondrial membrane order. In vivo treatment of Npc1-/- mice with SAM restores SAM levels in mitochondria, resulting in increased PC/PE ratio, mitochondrial membrane fluidity and subsequent replenishment of mitochondrial GSH levels. In vivo SAM treatment improves the decline of locomotor activity, increases Purkinje cell survival in the cerebellum and extends the average and maximal life spam of Npc1-/- mice. These findings identify SAM as a potential therapeutic approach for the treatment of NPC disease.

Difficulties in emotion regulation and well-being in breast cancer

Objective

Breast cancer is responsible for disruptive changes in women's lives, causing them to experience diverse and intense negative emotions that can affect their perception of well-being. The present study aimed to characterize difficulties in emotion regulation (ER), according to Gratz and Roemer's multidimensional assessment, in women with breast cancer and to relate them with General Well-Being and its different domains: Physical, Social/Familial, Emotional, and Functional.

Method

Ninety-five Portuguese women with breast cancer aged between 32 and 75 years answered a sociodemographic and clinical questionnaire and the Portuguese versions of the Difficulties in Emotion Regulation Scale and the Functional Assessment of Cancer Therapy - General. Data were collected in an oncology public hospital.

Results

In general, difficulties in ER presented negative correlations with General Well-Being and its domains. The multiple regression analysis findings indicated that two specific types of difficulties, Limited Access to ER Strategies and Lack of Emotional Clarity, play a significant role in predicting well-being, especially in the Emotional domain, which was most compromised in these patients.

Conclusions

These difficulties should be approached within psycho-oncological interventions as they are essential contributors to improving emotional and general well-being and fostering psychological adaptation to breast cancer.

Psychometric analysis of the body responsiveness questionnaire in the Portuguese population

Body responsiveness refers to the tendency to be attuned to the body's needs and use interoceptive information to guide behavior. Despite its potential beneficial effect on the development of positive body image, this construct is currently understudied. To boost research in this area, we examined the factor structure, gender invariance, and psychometric properties of a Portuguese translation of the Body Responsiveness Questionnaire (BRQ). A total of 650 men and women (aged 18-80 years) completed the Portuguese BRQ. To assess its convergent validity, participants also completed measures of body appreciation, emotion regulation, depression symptoms, and psychological quality of life. Exploratory factor analysis indicated a two-factor structure of the BRQ, which was upheld using confirmatory factor analysis: "Importance of Interoceptive Awareness" (ω = .85-.87) and "Perceived Connection" between body and mind (ω = .71-.74). BRQ scores had partial scalar invariance across gender, and no significant gender differences. Convergent and known-groups validity was supported. Participants with overweight/obesity (vs. normal weight) and middle-aged adults (vs. young adults) assigned higher importance to body signals to guide behavior. The Portuguese version of the BRQ is a psychometrically sound measure of body responsiveness and it may contribute to a comprehensive assessment of positive body image to guide intervention.

Differences among a Portuguese cohort of BRCA pathogenic/likely pathogenic variants carriers choosing risk-reducing mastectomy or intensive breast surveillance

PURPOSE

Women with BRCA1 and BRCA2 (BRCA1/2) pathogenic/likely pathogenic (P/LP) variants have a higher risk to develop breast and ovarian cancer. In structured high-risk clinics, risk-reducing measures are adopted. This study aimed at characterizing these women and identify factors that may have influenced their choice between risk reduction mastectomy (RRM) and intensive breast surveillance (IBS).

METHODS

This study reviewed retrospectively 187 clinical records of affected and unaffected women with P/LP variants of the BRCA1/2 genes, from 2007 to 2022, of which 50 chose RRM, while 137 chose IBS. The research focused on personal and family history and tumor characteristics and their relation with the preventive option chosen.

RESULTS

Among women with personal history of breast cancer, a higher proportion opted for RRM compared to those asymptomatic (34.2% vs 21.3%, p = 0.049), with younger age determining the option for RRM (38.5 years vs 44.0 years, p < 0.001). Among women with personal history of ovarian cancer, a higher proportion opted for RRM compared to those without that history (62.5% vs 25.1%, p = 0.033), with younger age determining the option for RRM (42.6 years vs 62.7 years, p = 0.009). Women who had bilateral salpingo-oophorectomy were more likely to choose RRM than those who did not (37.3% vs 18.3%, p = 0.003). Family history was not associated with preventive option (33.3% vs 25.3, p = 0.346).

CONCLUSIONS

The decision for the preventive option is multifactorial. In our study, personal history of breast or ovarian cancer, younger age at diagnosis, and previous bilateral salpingo-oophorectomy were associated with the choice of RRM. Family history was not associated with the preventive option.

Zonal expression of StARD1 and oxidative stress in alcoholic-related liver disease

Alcoholic-related liver disease (ALD) is one of the leading causes of chronic liver disease and morbidity. Unfortunately, the pathogenesis of ALD is still incompletely understood. StARD1 has emerged as a key player in other etiologies of chronic liver disease, and alcohol-induced liver injury exhibits zonal distribution. Here, we report that StARD1 is predominantly expressed in perivenous (PV) zone of liver sections from mice-fed chronic and acute-on-chronic ALD models compared to periportal (PP) area and is observed as early as 10 days of alcohol feeding. Ethanol and chemical hypoxia induced the expression of StARD1 in isolated primary mouse hepatocytes. The zonal-dependent expression of StARD1 resulted in the accumulation of cholesterol in mitochondria and increased lipid peroxidation in PV hepatocytes compared to PP hepatocytes, effects that were abrogated in PV hepatocytes upon hepatocyte-specific Stard1 KO mice. Transmission electron microscopy indicated differential glycogen and lipid droplets content between PP and PV areas, and alcohol feeding decreased glycogen content in both areas while increased lipid droplets content preferentially in PV zone. Moreover, transmission electron microscopy revealed that mitochondria from PV zone exhibited reduced length with respect to PP area, and alcohol feeding increased mitochondrial number, particularly, in PV zone. Extracellular flux analysis indicated lower maximal respiration and spared respiratory capacity in control PV hepatocytes that were reversed upon alcohol feeding. These findings reveal a differential morphology and functional activity of mitochondria between PP and PV hepatocytes following alcohol feeding and that StARD1 may play a key role in the zonal-dependent liver injury characteristic of ALD.

Civic engagement among foreign-born and native-born older adults living in Europe: a SHARE-based analysis

Civic engagement is one of the cornerstones of participatory democracy and fundamental to preventing old-age social exclusion. Even though civic engagement late-in-life has received considerable attention, there is a lacuna of research on older migrants' civic engagement. This study aims therefore to examine potential predictors of civic engagement in terms of formal volunteering and participation in political organisations among foreign-born and native-born older adults in Europe. Attention is hereby given to how socio-structural resources and social capital are associated with civic engagement, and whether these associations differ between foreign-born and native-born. Data from wave 7 of the Survey of Health, Ageing and Retirement in Europe [n = 74,150; 5710 of them are foreign-born] were used in multivariable logistic regression analyses. Results show that socio-structural and social capital variables are positively associated with volunteering and participation in political organisations, both in native-born and foreign-born older adults. The study also suggests that place of birth (in Europe vs. outside Europe) and age-upon-migration play a role in predicting civic engagement among foreign-born older adults, and are therefore features worth considering when studying older migrants' civic engagement.

Mitochondrial cholesterol: Metabolism and impact on redox biology and disease

Cholesterol is a crucial component of membrane bilayers by regulating their structural and functional properties. Cholesterol traffics to different cellular compartments including mitochondria, whose cholesterol content is low compared to other cell membranes. Despite the limited availability of cholesterol in the inner mitochondrial membrane (IMM), the metabolism of cholesterol in the IMM plays important physiological roles, acting as the precursor for the synthesis of steroid hormones and neurosteroids in steroidogenic tissues and specific neurons, respectively, or the synthesis of bile acids through an alternative pathway in the liver. Accumulation of cholesterol in mitochondria above physiological levels has a negative impact on mitochondrial function through several mechanisms, including the limitation of crucial antioxidant defenses, such as the glutathione redox cycle, increased generation of reactive oxygen species and consequent oxidative modification of cardiolipin, and defective assembly of respiratory supercomplexes. These adverse consequences of increased mitochondrial cholesterol trafficking trigger the onset of oxidative stress and cell death, and, ultimately, contribute to the development of diverse diseases, including metabolic liver diseases (i.e. fatty liver disease and liver cancer), as well as lysosomal disorders (i.e. Niemann-Pick type C disease) and neurodegenerative diseases (i.e. Alzheimer's disease). In this review, we summarize the metabolism and regulation of mitochondrial cholesterol and its potential impact on liver and neurodegenerative diseases.

Janus kinase 2 inhibition by pacritinib as potential therapeutic target for liver fibrosis

BACKGROUND AND AIMS

Janus kinase 2 (JAK2) signaling is increased in human and experimental liver fibrosis with portal hypertension. JAK2 inhibitors, such as pacritinib, are already in advanced clinical development for other indications and might also be effective in liver fibrosis. Here, we investigated the antifibrotic role of the JAK2 inhibitor pacritinib on activated hepatic stellate cells (HSCs) in vitro and in two animal models of liver fibrosis in vivo .

APPROACH AND RESULTS

Transcriptome analyses of JAK2 in human livers and other targets of pacritinib have been shown to correlate with profibrotic factors. Although transcription of JAK2 correlated significantly with type I collagen expression and other profibrotic genes, no correlation was observed for interleukin-1 receptor-associated kinase and colony-stimulating factor 1 receptor. Pacritinib decreased gene expression of fibrosis markers in mouse primary and human-derived HSCs in vitro . Moreover, pacritinib decreased the proliferation, contraction, and migration of HSCs. C 57 BL/6J mice received ethanol in drinking water (16%) or Western diet in combination with carbon tetrachloride intoxication for 7 weeks to induce alcoholic or nonalcoholic fatty liver disease. Pacritinib significantly reduced liver fibrosis assessed by gene expression and Sirius red staining, as well as HSC activation assessed by alpha-smooth muscle actin immunostaining in fibrotic mice. Furthermore, pacritinib decreased the gene expression of hepatic steatosis markers in experimental alcoholic liver disease. Additionally, pacritinib protected against liver injury as assessed by aminotransferase levels.

CONCLUSIONS

This study demonstrates that the JAK2 inhibitor pacritinib may be promising for the treatment of alcoholic and nonalcoholic liver fibrosis and may be therefore relevant for human pathology.

Neprilysin-dependent neuropeptide Y cleavage in the liver promotes fibrosis by blocking NPY-receptor 1

Development of liver fibrosis is paralleled by contraction of hepatic stellate cells (HSCs), the main profibrotic hepatic cells. Yet, little is known about the interplay of neprilysin (NEP) and its substrate neuropeptide Y (NPY), a potent enhancer of contraction, in liver fibrosis. We demonstrate that HSCs are the source of NEP. Importantly, NPY originates majorly from the splanchnic region and is cleaved by NEP in order to terminate contraction. Interestingly, NEP deficiency (Nep-/-) showed less fibrosis but portal hypertension upon liver injury in two different fibrosis models in mice. We demonstrate the incremental benefit of Nep-/- in addition to AT1R blocker (ARB) or ACE inhibitors for fibrosis and portal hypertension. Finally, oral administration of Entresto, a combination of ARB and NEP inhibitor, decreased hepatic fibrosis and portal pressure in mice. These results provide a mechanistic rationale for translation of NEP-AT1R-blockade in human liver fibrosis and portal hypertension.

The non-selective Rho-kinase inhibitors Y-27632 and Y-33075 decrease contraction but increase migration in murine and human hepatic stellate cells

BACKGROUND

The Rho-kinase ROCK II plays a major role in the activation of hepatic stellate cells (HSC), which are the key profibrotic and contractile cells contributing to the development of chronic liver disease. Inhibition of ROCK II ultimately blocks the phosphorylation of the myosin light chain (MLC) and thus inhibits stress fibre assembly and cell contraction. We investigated the effects of the ROCK inhibitors Y-33075 as well as Y-27632 in murine and human hepatic stellate cells.

METHODS

Primary isolated HSC from FVB/NJ mice and the immortalized human HSC line TWNT-4 were culture-activated and incubated with Y-27632 and Y-33075 (10nM to 10μM) for 24h. Protein expression levels were analyzed by Western Blots and transcriptional levels of pro-fibrotic markers and proliferative markers were evaluated using real-time qPCR. Migration was investigated by wound-healing assay. Proliferation was assessed by BrdU assay. Contraction of HSC was measured using 3D collagen matrices after incubation with Y-27632 or Y-33075 in different doses.

RESULTS

Both Rho-kinase inhibitors, Y-27632 and Y-33075, reduced contraction, fibrogenesis and proliferation in activated primary mouse HSC (FVB/NJ) and human HSC line (TWNT-4) significantly. Y-33075 demonstrated a 10-times increased potency compared to Y-27632. Surprisingly, both inhibitors mediated a substantial and unexpected increase in migration of HSC in FVB/NJ.

CONCLUSION

ROCK inhibition by the tested compounds decreased contraction but increased migration. Y-33075 proved more potent than Y27632 in the inhibition of contraction of HSCs and should be further evaluated in chronic liver disease.

Dietary and genetic disruption of hepatic methionine metabolism induce acid sphingomyelinase to promote steatohepatitis

Alcoholic (ASH) and nonalcoholic. (NASH).steatohepatitis are advanced.stages.of.fatty.liver.disease.Methionine adenosyltransferase 1A (MAT1A) plays a key role in hepatic methionine metabolism and germline Mat1a deletion in mice promotes NASH. Acid sphingomyelinase (ASMase) triggers hepatocellular apoptosis and liver fibrosis and has been shown to downregulate MAT1A expression in the context of fulminant liver failure. Given the role of ASMase in steatohepatitis development, we investigated the status of ASMase in Mat1a^-/- mice and the regulation of ASMase by SAM/SAH. Consistent with its role in NASH, Mat1a^-/- mice fed a choline-deficient (CD) diet exhibited macrosteatosis, inflammation, fibrosis and liver injury as well as reduced total and mitochondrial GSH levels. Our data uncovered an increased basal expression and activity of ASMase but not neutral SMase in Mat1a^-/- mice, which further increased upon CD feeding. Interestingly, adenovirus-mediated shRNA expression targeting ASMase reduced ASMase activity and protected Mat1a^-/- mice against CD diet-induced NASH. Similar results were observed in CD fed Mat1a^-/- mice by pharmacological inhibition of ASMase with amitriptyline. Moreover, Mat1a/ASMase double knockout mice were resistant to CD-induced NASH. ASMase knockdown protected wild type mice against NASH induced by feeding a diet deficient in methionine and choline. Furthermore, Mat1a^-/- mice developed acute-on-chronic ASH and this outcome was ameliorated by amitriptyline treatment. In vitro data in primary mouse hepatocytes revealed that decreased SAM/SAH ratio increased ASMase mRNA level and activity. MAT1A and ASMase mRNA levels exhibited an inverse correlation in liver samples from patients with ASH and NASH. Thus, disruption of methionine metabolism sensitizes to steatohepatitis by ASMase activation via decreased SAM/SAH. These findings imply that MAT1A deletion and ASMase activation engage in a self-sustained loop of relevance for steatohepatitis.

Enhanced sweet taste perception in obesity: Joint analysis of gustatory data from multiple studies

Introduction

While sweet taste perception is a potential determinant of feeding behavior in obesity, the supporting evidence is inconsistent and is typically associated with methodological limitations. Notably, possible associations between sweet taste perception and measures of food reward remain undetermined.

Materials and methods

We conducted a cross-sectional analysis comparing 246 individuals with severe obesity and 174 healthy volunteers using a validated method for taste perception assessment. We included gustatory variables, namely intensity and pleasantness ratings of sour, salt, sweet, and bitter tastants, and taste thresholds assessed by electrogustometry. Reward-related feeding behavior, including hedonic hunger, food addiction, feeding behavior traits, and acceptance of foods and alcohol, was evaluated using self-rated scales for comparison with gustatory measures.

Result

In logistic regressions adjusted for age, gender, educational level, and research center, we found that a greater likelihood of belonging to the obesity group was associated with higher sweet intensity ratings (OR = 1.4, P = 0.01), hedonic hunger, food addiction symptoms, restrained and emotional eating (1.7 < OR ≤ 4.6, all P ≤ 0.001), and lower alcohol acceptance (OR = 0.6, P = 0.0002). Using principal component analysis, we found that while hedonic hunger, food addiction, and emotional eating were strongly interrelated, they were not associated with sweet intensity perception that, in turn, had a closer relationship with alcohol acceptance and restrained eating.

Conclusion

We found that individuals with obesity report higher sweet taste intensity ratings than healthy controls. Furthermore, while psychological measures of reward-related feeding behavior assess a common construct, sweet intensity perception may represent a different obesity-related dimension.

PUBLISHING IN INTERNATIONAL JOURNALS AND THE EXPECTATION IT PLACES ON OUR WRITING: TIPS FROM AGEING & SOCIETY

Understanding the differences between academic writing genres is crucial to nailing down the craft that is writing for peer-review journal publication. Based on the experience of Ageing & Society, this presentation will bring attention to the different readers that peer-reviewed journals cater to and how these differences impact how we craft manuscripts about the research we conduct. Using this as a starting point, as well as allusions to how data collected in specific national settings can be reported so that it can be used to contribute to ongoing international debates in social gerontology, this presentation offers the Editor-in-Chief’s top 10 tips for publishing in international peer-reviewed journals. By bringing specific attention to the routines that Ageing & Society utilize, and the expectations that its editors place on the different sections of a manuscript, this presentation aims to give attendees valuable insights into how to write for peer-reviewed outlets.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Pembrolizumab-Induced Sarcoid-Like Reaction of the Breast

Introduction/Objective

Immunotherapy provides an efficacious and durable therapeutic option for patients with advanced-stage neoplastic disease. Related adverse events are several. Sarcoid-like granulomatous reaction is a rare, not severe complication, more frequent in skin, lung and lymph nodes. It should not be misdiagnosed as tumor recurrence or progression.

Methods/Case Report

Case Report.

Results (if a Case Study enter NA)

Female 50 years old. Smoker for 40 years until 2016. Reumathoid arthritis at age 50. Palmo-plantar psoriasiform dermatitis since 2016. Sporadic corticoids use and topic therapy. Lung adenocarcinoma in june 2021, multifocal, acinar-papillary, pT4-pN1- pM1a. TPS PD-L1 70%. In treatment with pembrolizumab since july 2021, without toxicities. In november 2021, after 6 doses, PET/CT shows mild growth of bilateral nodules. Stereotaxic breast biopsy for microcalcifications of recent appereance in january 2022. Pathology report: “Sarcoid-like reaction. Microcalcifications, present in biopsied material, not visualized after cuts of all tissue (mecanically displaced). PAS, Grocott and Ziehl-Neelsen negatives”. Currently, after 16 cycles of pembrolizumab, the patient is in good condition.

Conclusion

Sarcoid-like reaction (epithelioid non necrotizing granulomas), during immunotherapy is rare, can be seen especially in skin, lung, mediastinal lymph nodes. For some authors it would be a marker for therapy response and correlated with improve overall survival. It is very important to differentiate this reaction with progression or recurrence of tumor disease. Our case is the first immunotherapy induced sarcoid-like reaction described in the mammary gland.

Mechanical circulatory support devices in left main occlusion: a multicenter study from 2008 to 2020

Introduction

Evidence of benefit in the use of mechanical circulatory support devices (MCS) in patients with acute myocardial infarction (AMI) is scarce. We aimed to evaluate the clinicalcharacteristics, prognosis and factors associated with the use of MCS in patients with AMI due to left main (LM) occlusion.

Methods

We performed a retrospective multicenter study of 128 consecutive patients with AMI with ≤12h of presentation with LM occlusion submitted to immediate reperfusion between January 1, 2008, until December 31, 2020 in three terciary hospitals of Portugal. Among this cohort, we divided patients into two groups according to the use of MCS devices.

Results

Regarding the baseline characteristics no statistically significant differences were found, except for the presence of cerebrovascular disease (2.9% in group with vs 16.9% in group without MCS, p=0.007) and peripheral artery disease (8.8% in group with vs 22% in group without MCS, p=0.037). We observed that the use of MCS devices was statistically different between the three centers (47.8%, 42%, 8.7%, p&lt;0.001). No differences were found at presentation for ST-segment elevation vs non-ST segment elevation AMI (p=NS). The presence of cardiogenic shock (72.4% vs 45.8%, p=0.002), cardiac arrest (27.5% vs 23.7%, p=0.034) and more severe thrombolysis in myocardial infarction (TIMI) flow at presentation (55.1% vs 35.6%, p=0.015) were more frequent in group with MCS. The rate of 1-year cumulative mortality was high in both groups (31/59=52.5% in the group without vs 47/69=68.1%, p=NS). Also, no statistically significant differences were found in terms of survival, but we observed a trend to higher mortality in those who received MCS as Kaplan-Meier survival curves show (log rank=0.062). Finally, in multivariable analysis, older age [odds ratio (OR), 0.935; 95% CI, 0.87–0.99], the presence of diabetes (OR, 0.223; 95% CI, 0.056–0.88), peripheral artery disease (OR, 0.070; 95% CI, 0.009–0.566) and extra-hospitalar cardiac arrest (OR, 0.06; 95% CI, 0.007–0.543) were characteristics associated with lower odds of receiving MCS. Contrarily, male sex (OR, 5; 95% CI, 1–20.4) and the presence of cardiogenic shock (OR, 5.7; 95% CI, 1.42–23) were factors associated with higher use of MCS.

Conclusion

The use of MCS does not seem to modify prognosis in patients admitted withAMI due to left main occlusion. Only cardiogenic shock and male gender were predictors of MCS use.

Funding Acknowledgement

Type of funding sources: None.

Clinical determinants and barriers to cardiac rehabilitation enrolment of patients with heart failure with reduced ejection fraction

Introduction

Cardiac rehabilitation (CR) is a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF). Despite the robust evidence supporting its safety and benefits, there is an incomplete understanding of the reasons of the underutilization of CR programs in HFrEF. These reasons are complex and probably encompass healthcare system- and patient-level barriers.

Purpose

To study the clinical determinants and barriers to enrolment in a CR program for HFrEF patients.

Methods

We conducted a study of consecutive heart failure patients followed at a dedicated HFrEF cardiology clinic from January 2019 to April 2021. Patients were divided according to previous enrolment in CR program. Data were collected from electronic health records, and in case of missing data patients were asked by telephone about the reason for not participating in CR using a structured and validated questionnaire for this purpose.

Results

Of 228 patients with HFrEF, 60% had not been enrolled in a CR program; they were older (63 vs 58 years; p&lt;0.01) and more likely to have comorbidities such as hypertension (56% vs 41%; p=0.03) or concomitant chronic obstructive pulmonary disease (20% vs 8%; p=0.01). Conversely, patients enrolled in CR programs were more likely to have a previous history of acute myocardial infarction (34% vs 20%; p=0.02). Regarding heart failure-related clinical features (NYHA functional class, LVEF, ICD/CRT), we did not find any significant differences between groups. The main reasons for not being enrolled in CR programs were: no medical referral (31%), concomitant medical problems (27%) such as musculoskeletal problems, patient refusal (11%) and geographical distance to the hospital (9%).

Conclusion

Despite the high proportion (40%) of HFrEF patients who underwent CR program compared to previous studies, the enrolment to CR can be further improved. The main barriers are related to health professionals (no referral), healthcare system (geographical distance to the hospital) and patients (concomitant noncardiac problems). Innovative strategies should target these factors to increase the delivery of CR program in HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Does Religiosity/Spirituality Play a Role in Function, Pain-Related Beliefs, and Coping in Patients with Chronic Pain? A Systematic Review

This systematic review examined the extent to which measures of religiosity/spirituality (R/S): (1) are associated with pain, function, pain-related beliefs (beliefs), coping responses, and catastrophizing in people with chronic pain; and (2) moderate the association between beliefs, coping and catastrophizing, and pain and function. Experimental and observational studies examining at least one of these research questions in adults with chronic pain were eligible. Two reviewers independently performed eligibility screening, data extraction, and quality assessment. Twenty studies were included. Most studies focused on the association between R/S and pain or function. When significant associations emerged, those between R/S and psychological function were weak to strong and positive; those between religious/spiritual well-being and pain and physical dysfunction were negative, but weak. Few studies examined the associations between R/S and beliefs/coping/catastrophizing; none examined the moderation role of R/S. The findings suggest that R/S is associated with pain and psychological function in people with chronic pain, and that viewing oneself as being "spiritual," regardless of religion, may contribute to positive psychological adjustment. More research is needed to determine the reliability of this finding. PROSPERO registry CRD42018088803.

Mitochondria and the NLRP3 Inflammasome in Alcoholic and Nonalcoholic Steatohepatitis

Alcoholic (ASH) and nonalcoholic steatohepatitis (NASH) are advanced stages of fatty liver disease and two of the most prevalent forms of chronic liver disease. ASH and NASH are associated with significant risk of further progression to cirrhosis and hepatocellular carcinoma (HCC), the most common type of liver cancer, and a major cause of cancer-related mortality. Despite extensive research and progress in the last decades to elucidate the mechanisms of the development of ASH and NASH, the pathogenesis of both diseases is still poorly understood. Mitochondrial damage and activation of inflammasome complexes have a role in inducing and sustaining liver damage. Mitochondrial dysfunction produces inflammatory factors that activate the inflammasome complexes. NLRP3 inflammasome (nucleotide-binding oligomerization domain-like receptor protein 3) is a multiprotein complex that activates caspase 1 and the release of pro-inflammatory cytokines, including interleukin-1β (IL-1β) and interleukin-18 (IL-18), and contributes to inflammatory pyroptotic cell death. The present review, which is part of the issue "Mitochondria in Liver Pathobiology", provides an overview of the role of mitochondrial dysfunction and NLRP3 activation in ASH and NASH.

Addressing child undernutrition in Tanzania with the ASTUTE program

BACKGROUND

Optimal infant and young child feeding practices (IYCFP) reduce childhood stunting and are associated with additional health benefits. In Tanzania, IYCFP are far from optimal where 32% of children under the age of 5 years are stunted. The purpose of this study was to examine whether behavior change communication focused on reducing child undernutrition was associated with improved IYCFP in Tanzania.

METHODS

A cross-sectional survey was administered to approximately 10,000 households with children under the age of 2 at baseline and endline. Bivariate analyses and logistic regression was used to examine the relationship between exposure to behavior change communication and timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, timely complementary feeding (CF), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD).

RESULTS

Mothers who heard a radio spot about IYCFP were more likely than mothers who had not heard a radio spot about IYCFP to begin complementary foods at six months. Their children were also more likely to achieve MMF, MDD, and MAD with odds ratios of 2.227 (p = 0.0061), 1.222 (p = 0.0454), 1.618 (p =  < .0001), and 1.511 (p = 0.0002), respectively. Mothers who saw a TV spot about IYCFP were more likely to have greater odds of knowing when to begin complementary feeding, feeding their child a minimally diverse diet (4 food groups or more), and serving a minimum acceptable diet with odds ratios of 1.335 (p = 0.0081), 1.360 (p = 0.0003), and 1.268 (p = 0.0156), respectively.

CONCLUSION

Exposure to behavior change communication in Tanzania was generally associated with some increased knowledge of optimal IYCFP as well as practicing IYCF behaviors. Behavior change communication planners and implementers may want to consider conducting similar campaigns as an important component of behavior change to reduce undernutrition and poor health outcomes in developing settings.

Reducing adverse impacts of Amazon hydropower expansion

Proposed hydropower dams at more than 350 sites throughout the Amazon require strategic evaluation of trade-offs between the numerous ecosystem services provided by Earth's largest and most biodiverse river basin. These services are spatially variable, hence collective impacts of newly built dams depend strongly on their configuration. We use multiobjective optimization to identify portfolios of sites that simultaneously minimize impacts on river flow, river connectivity, sediment transport, fish diversity, and greenhouse gas emissions while achieving energy production goals. We find that uncoordinated, dam-by-dam hydropower expansion has resulted in forgone ecosystem service benefits. Minimizing further damage from hydropower development requires considering diverse environmental impacts across the entire basin, as well as cooperation among Amazonian nations. Our findings offer a transferable model for the evaluation of hydropower expansion in transboundary basins.

Breast cancer patients presenting with cardiotoxicity - risk factors and role of cardioprotective drugs

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent advances in cancer treatment have led to improved survival, albeit with cardiovascular adverse effects being some of the most frequent and feared consequences. Patient’s risk stratification, prevention and treatment are still to be fully elucidated. Our aim was to evaluate the risk and therapy of cardiotoxicity (CT) secondary to cancer treatment in a subset of patients with breast cancer (BC).

Methods

We collected a retrospective cohort of female with BC treated with conventional chemotherapy (CHT) and/or anti-HER2-targeted therapies (AHT) referred to Cardio-oncology consultation from January 2017 to March 2020. All patients were evaluated before CHT and at least at 3, 6 and 12-months with echocardiogram and cardiac biomarkers, namely high sensitivity troponin I (hs-cTnI) and brain natriuretic peptide (BNP). CT was defined as left ventricle ejection fraction (LVEF) under 50% or decline of at least 10% in LVEF during follow-up. As cardioprotective drugs (CPD) we considered renin-angiotensin-aldosterone system inhibitors and beta-blockers.

Results

A total of 203 women were enrolled, with mean age 50.9 ± 10.9 year-old. As for the cardiovascular risk factors, 23.5% had hypertension, 32.4% dyslipidaemia, 9.8% diabetes and 33.0% were smokers or previous smokers. The majority of patients had a high or very-high CT risk score (98.5% with score ≥ 5) and 35.5% were already on CPD before CHT. All patients were submitted to CHT: anthracyclines (AC) and AHT were applied to 83.8% and 41.7% of patients, respectively, with 27.9% of patients on both therapies; 81.4% were submitted to radiotherapy (RT). At presentation, all patients had normal cardiac function with mean LVEF of 62.9% and mean global longitudinal strain (GLS) of -19.4; mean hs-cTnI and BNP were 3.3 ng/L and 33.4 pg/mL, respectively. During a median follow-up of 16 months, 8.5% of patients developed CT, leading to initiation or titration of CPD in 76.9% and treatment interruption in 23.5%; most of them recovered (88.2%). During treatment there was a significantly increase of hs-cTnI (mean 19.7 ng/L at 3 months, p &lt; 0.001) and a decrease of GLS and LVEF at 12 months (decrease of 1.1 and 2.2%, respectively, both p &lt; 0.001). Both AHT and AHT plus AC were significantly associated with CT (p = 0.002 and p &lt; 0.001, respectively), with an extremely high prevalence in the latter group (19.6%). Nor CVRF neither RT raised the risk of CT. Although patients on CPD did not had lower prevalence of CT (5.6% vs 10.2%, p = 0.268), its initiation was associated with a higher rate of cardiac function recovery (100.0% vs 66.7%, p = 0.057).

Conclusion

Patients submitted to AHT or AHT plus AC were at higher risk of developing CT. This and the significant LVEF decline during follow-up highlight the importance of long-term-monitoring of these patients. CPD seemed to be associated with cardiac recovery, although this finding needs further validation.

Impact of severe mitral annular calcification on mitral regurgitation after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who are at intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequent in patients with aortic stenosis, and its presence is associated with increased cardiovascular morbidity and mortality. Not infrequently, it is associated with significant morphologic and functional abnormalities of the mitral valve apparatus.

Purpose

 The aim of this work is to evaluate the relationship between severe MAC and the presence and development of significant mitral regurgitation after TAVI.

Methods

 We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019. Clinical, echocardiographic and procedure-related data were collected until a follow-up of 6 months. Statistical analysis was conducted on IBM SPSS® Statistics software. Descriptive statistics were calculated for all variables. Sample T-test, Chi-square and Wilcoxon sign test were used. A p-value &lt; 0.05 was considered significant. The presence and severity of MAC was defined according to echocardiographic data. Severe MAC was defined by the presence of calcification of more than half of the mitral annular circumference.

Results

 A total of 343 patients were enrolled in the study. The mean age of the population was 80 ± 8 years, 45% were male. Mean functional area was 0.75 ± 0.18 cm2, mean transvalvular pressure gradient was 48 ± 15 mmHg and the mean left ventricular ejection fraction (LVEF) was 54 ± 14%.  MAC was detected in 231 (67%) patients. In 44 (19%) of these patients, MAC was graded as severe. Patients with severe MAC tended to have higher prevalence of moderate (27.3 vs 20.4%, p = 0.30) as well as severe (4.5 vs 1.8%, p = 0.24) mitral regurgitation at baseline. After TAVI, the prevalence of moderate mitral regurgitation at 6 months was similar between both groups (22.5 vs 20.4%, p = 0.76). Although not reaching statistical significance, patients with severe MAC had higher prevalence of severe mitral regurgitation at 6 months post-procedure (12.2 VS 5.0%, p = 0.07) as well as higher incidence of worsening of mitral regurgitation (34.2 vs 23.7%, p = 0.16). The proportion of patients that had improvement (13.2 vs 15.0%, p = 0.76) or no change (52.6 vs 61.3%, p = 0.31) in the degree of mitral regurgitation was similar in both groups. 

Conclusion

 The presence of severe MAC at baseline echocardiography in patients undergoing TAVI may be associated with worsening of mitral regurgitation after the procedure. These patients tend to have higher prevalence of severe mitral regurgitation post-TAVI. Further studies are needed in order to further elucidate this association.

Can aortic calcium score predict new conduction disturbances in pos-transcatheter aortic valve implantation?

Funding Acknowledgements

Type of funding sources: None.

Background

Transcatheter aortic valve implantation (TAVI) may be the first line treatment for severe aortic stenosis according to overall patient characteristics. Semi-quantitative Agatston score (AS), which quantifies aortic calcium by cardiac computed tomography (CCT), has knowledgeable practical and clinical implications, and is performed in TAVI diagnostic workup. Since conduction disturbances continue to be the most frequent complication, further refinements are required to predict high-risk patients.

Purpose

To access if aortic AS relates with new conduction disturbances and permanent pacemaker (PPM) implantation in patients undergoing TAVI.

Methods

We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019; patients with previous permanent pacemaker (PPM) or had no aortic AS were excluded. Clinical and electrocardiogram (ECG) data were collected at admission and after the procedure. All categorical variables are reported as numbers and percentages. Continuous variables were analyzed using the two-tailed unpaired Student’s t-test and are reported as mean values and the standard deviation. Statistical analysis was performed using the IBM SPSS.

Results

172 patients with a mean age 79 ± 9.1 years old were included (see table 1 for baseline characteristics). AS was on average 3008 ± 2262 (see table 2 for remaining diagnostic workup and procedure characteristics).

Comparing AS with new conduction disturbances, no statistically significant difference was found for new complete left branch block (LBBB) (no vs new LBBB, AS: 3179 ± 2555 vs 2637 ± 1388, p= 0,15) and with new complete atrioventricular block (AVB) (no vs new AVB, AS: 2834 ± 1520 vs 4485 ± 5285, p = 0.2). Considering PPM implantation after TAVI, there was a tendency for higher AS and PPM implantation (no vs PPM implantation, AS: 2756 ± 1451 vs 4242 ± 4310, p = 0.07).

In patients who had pre-ballooning, there was no difference relating to AS; however, in patients who had no pre-ballooning there was a trend to higher AS and PPM implantation (no vs PPM implantation, AS: 2417 ± 1301 vs 4616 ± 4969, p = 0.06). No statistically significant difference was found when comparing earlier (Portico, CoreValve Evolut R) vs newer valves (CoreValve Evolut Pro; Edward Sapiens 3; Accurate Neo).

Conclusion

Aortic calcium measured by Agatston score did not show a correlation with new LBBB or new AVB after TAVI. Nevertheless, it seems to be a trend for higher AS and PPM implantation; this was more noticeable when pre-ballooning was not performed. Further studies are needed in order to further elucidate this association. Abstract Figure. Patients baseline characteristics  Abstract Figure. TAVI diagnostic workup and procedure

Ethnicity and race in access and usage of health and social care: results from a scoping review

Scholarship on ethnicity and old age is at a crossroad now that increased diversity is a given in older populations. The same holds true for the study of the role that ethnicity and race play in access and usage of health and social care in old age. This presentation relies on a scoping review of scholarship published between 1998 and 2020 that brings attention to the ways in which ethnicity & race – as grounds for stratification and disadvantage - are made sense of in this scholarship. The presentation will describe the topics that the review divulged, whether racism has been acknowledged in this scholarship so far, and how this has been the case. In doing so, this presentation will argue that if we are to address the inequalities that older ethnic minorities face we need not only a diversity-astute research agenda but also an injustice-aware one.

Quality of life in patients with inflammatory bowel disease: the role of positive psychological factors

Objective

To identify differences in quality of life (QoL) of patients with inflammatory bowel disease (IBD) between diagnosis (Crohn’s Disease and Ulcerative Colitis), gender (male and female), treatment condition (with and without surgery), and attachment styles (secure, preoccupied, and disconnected); to examine associations between QoL, sociodemographic, clinical, and positive psychological variables; to determine whether sociodemographic, clinical, and positive psychological variables predict QoL.

Method

The sample included 70 participants diagnosed with IBD (Mage = 43.37 years, SD = 12.81), of whom 71.4% were females and 67.1% had Crohn’s Disease. Positive psychological variables (meaning in life, positive body image, and attachment styles), sociodemographic (age, education, gender) and clinical variables (diagnosis, disease duration, surgery) were assessed as independent variables. QoL was the dependent variable, analyzed through four domains (physical, psychological, social, environment).

Results

Participants with a secure attachment style reported higher QoL (physical, psychological, and social) than participants with a preoccupied attachment style. Strong positive correlations were found between positive psychological variables and QoL. Body appreciation was a significant predictor of three QoL domains (physical, psychological, and environment). Meaning in life made a unique contribution to the social QoL regression model, and it was also a significant predictor of psychological QoL. Body acceptance by others was a significant predictor of physical QoL, whereas disease duration and education predicted environment QoL. Attachment styles did not predict any QoL domain.

Conclusion

The most significant predictors of QoL in patients with IBD were body appreciation and meaning in life. Body acceptance by others and body appreciation were the main predictors of physical QoL. Psychological interventions for patients who suffer from IBD should address body appreciation and meaning in life.

Bone scintigraphy in the diagnosis of transthyretin amyloidosis: a different performance in Portuguese hereditary variant?

Introduction

Bone scintigraphy using radioactive technetium-99m and 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) has been increasingly used to diagnose myocardial involvement of mutated or wild-type transthyretin amyloidosis (ATTR).

However, most studies that proved a high sensitivity and specificity of the technique were not in patients with the “Portuguese variant” (Val30Met) mutation in transthyretin (TTR). Other authors had already suggested that in these patients the DPD scan could be less accurate.

Methods

Observational study of patients referred to Cardiology clinic with suspicion of ATTR cardiomyopathy. We only included patients with data from echocardiogram and DPD scan.

For statistical analyses, SPSS was used, p&lt;0.05 for statistical significance. Logistic regressions were used to test an association between DPD result and different covariates.

Results

Of 273 patients referred with suspicion of cardiac ATTR, we studied 97 patients that did an echocardiogram and a DPD scan.

Among the 75 cases with mutated TTR (Val30Met), median age was 36 (IQR 34) and 60% were males. 60 had increased ventricular wall thickness (IVWT) &gt;12 mm, but only 24 had a positive DPD (defined as a visual score &gt;2). Even though a higher wall thickness was associated with a positive DPD (p=0.004), 18 patients with a negative scan had IVWT &gt;14 mm. The DPD results was significantly associated with prior liver transplantation (LT) – p&lt;0.001; 95% CI (7.1; 503.6) – and age at first symptoms – p&lt;0.001; 95% CI (1.036; 1.113); 66.7±10.5 versus 34.8±10.2 years-old for those with and without a positive scan, respectively. Interestingly, fewer patients with a positive scan had neurologic symptoms (74% versus 96%, p=0.009), ophthalmologic, urologic or renal involvement, even though creatinine clearance was on average lower (p=0.01). We did not find a significant association between DPD result and sex, conduction disorders, NT-proBNP, troponin T or treatment with tafamidis. Patients on tafamidis had on average lower IVWT, independent of age (median of 13 versus 14 mm; p=0.020). 4 patients with negative DPD did an endomyocardial biopsy, that was positive for amyloid in 3 cases.

In comparison, in the 22 cases with wild-type TTR, there were significantly more males (86%) and patients were older (median age was 81 (IQR 9)). All patients had IVWT (that was significantly higher than in mutated ATTR) and DPD scan was negative in only 2 patients (that had a visual score of 1). Systolic dysfunction was significantly more frequent (59% versus 8%). The occurrence of death or hospitalization for heart failure was significantly higher.

Conclusions

DPD-scintigraphy seems more sensitive in patients with late onset mutated ATTR or with wild-type ATTR. It is less accurate in early onset patients with Val30Met mutation and particularly if they underwent LT. In those patients, further investigation is needed before excluding myocardial involvement.

Funding Acknowledgement

Type of funding sources: None.

Impact of cardiac rehabilitation on inflammation in patients with ischaemic cardiomyopathy

Introduction

The benefits of cardiac rehabilitation (CR) in patients with ischaemic cardiomyopathy are well-known. However, inflammatory states have been associated to an increased risk of cardiovascular events.

Purpose

Evaluate the impact of CR in the serum levels of inflammatory biomarkers and identify potential predictors of that effect.

Methods

We retrospectively studied consecutive patients with ischaemic cardiomyopathy who completed a CR programme between 2011 and 2017. Patients underwent a supervised exercise training protocol, twice a week during a period of 8 to 12 weeks. Functional capacity was evaluated by metabolic equivalents assessed prior the beginning and 3 months after the programme with a symptom limited exercise treadmill test. Patients without levels of serum C-reactive protein at beginning and at the end of CR programme were excluded. Median variation of serum C-reactive protein was assessed and two groups were defined: one with levels above that and one with levels below.

Results

Of 250 patients (60.3±11.1 years, 84% male), 67% were admitted after an acute myocardial infarction. Left ventricular ejection fraction ≤40% before CR was present in 32% of individuals. Median levels of serum C-reactive protein before CR were 8.8 (3.1–21.7) mg/L and median variation after CRP was a decrease of 5.1 (0.9–17.7) mg/L (p&lt;0.001). Before CR, higher levels of serum C-reactive protein were seen in obese (15.7 [8–52.7] versus 8.8 [3.2–27.8], p=0.04) and those with higher NT-proBNP (p&lt;0.001). Patients with decrease of &gt;5.1mg/L of serum C-reactive protein had lower prevalence of hypertension (18% versus 30%, p=0.02), higher prevalence of obesity (16% versus 7%, p=0.03), lower levels of HDL cholesterol (38.3 [11.1] versus 43.2 [12.6], p&lt;0.001) and higher levels of NT-proBNP (1079 [610.3–1988] versus 488 [215–777], p&lt;0.001) at baseline. An increase of at least of 10% of functional capacity after CR was reached in 65% of patients, similar between groups. Patients with decrease of serum C-reactive protein &gt;5.1mg/L had also higher reduction of NT-proBNP after CR comparing to baseline (491.1 [142.7–948.5] versus 162.0 [30.9–295.2], p&lt;0.001).

Conclusions

Serum levels of inflammatory biomarkers decreased after CR in patients with ischaemic cardiomyopathy. Normotension, obesity, lower HDL and higher levels of natriuretic peptides are associated to a better response.

Funding Acknowledgement

Type of funding sources: None.

Orthostatic hypotension in hereditary ATTR Val30Met amyloidosis: predictors and associated clinical features

Introduction

The prevalence of orthostatic hypotension (OH) in patients with mutated transthyretin (TTR) amyloidosis (mATTR) is 40–60%. According to previous studies, OH is frequent and an early feature in patients with Val30Met mutation (the most prevalent form of mATTR).

Aim

To characterize TTR Val30Met patients with OH and to identify clinical characteristics associated with OH development.

Methods

Retrospective study of consecutive Val30Met TTR patients with suspected cardiac involvement observed at our cardiology clinic during 2019. Two groups were defined: group 1: patients without OH; group 2: patients with OH. Data was obtained by chart review. Statistically significant predictors of OH were found using logistic regression.

Results

We included a total of 248 patients (group 1 – 173; group 2 – 75). Group 1 patients were 52% male, median age 45 [interquartile range (IQR) 39–55] and median age at onset 34 (IQR 29,75–46,25) years. Left ventricle hypertrophy [LVH, defined as maximal LV wall thickness (LVT) ≥12 mm] occurred in 26,5%, with median maximal LVT 10 mm (IQR 9–12); 49,7% had conduction disturbances, 30,6% gastrointestinal (GI), 17,3% genitourinary (GU) manifestations and 5% were in Coutinho staging ≥2/3. Group 2 had 56% male, median age of 49 years at evaluation (IQR 42–65) and 35 years at onset (IQR 30–59). LVH was present in 42,9%, with median maximal LVT 11 mm (IQR 10–14); 74,7% had conduction disturbances, 56% GI and 42,7% GU manifestations and 21% were in Coutinho staging ≥2/3.

In univariate analysis, higher age (p=0,005), presence of LVH (p=0,009), conduction disturbances (p&lt;0,001), GU manifestations (p&lt;0,001) and higher Coutinho staging (p&lt;0,001) were all associated with the presence of OH, while age at onset was not (p=0,648). In multivariate analysis, only Coutinho staging [odds ratio (OR) 2.609; 95% confidence interval (95% CI) 1.344–5.065] and GU manifestations (OR 3,151; 95% CI 1,595–6,225) were found to be significant predictors of OH.

Conclusion

Our study suggests that OH is more associated with GU manifestations and Neurologic staging, than with amyloid cardiomyopathy or age, suggesting a predominant neurogenic component. The prevalence of OH in our sample of Val30Met patients was lower than previously described.

Funding Acknowledgement

Type of funding sources: None.

The world upside down – after 20 years follow-up of dextro-transposition of the great arteries

Introduction

Congenital Heart Disease (CHD) affects under 1% of newborns and thanks to its prognosis improvement, most patients survive until adulthood. Dextro-transposition of the great arteries (dTGA) is a CHD classically palliated with atrial switch (ATS) procedure and nowadays corrected with an arterial switch (ARS), with better clinical outcomes. Nevertheless, several post-ATS patients remain alive and questions persist regarding their long-term prognosis.

Purpose

To observe a group of dTGA patients followed in an Adult CHD outpatients clinic, access their comorbidities, surgical interventions, complications and clinical outcomes.

Methods

We retrospectively analyzed a group of dTGA patients born between 1974 and 2001. Clinical features were collected and time-to-event statistics were analyzed. Adverse event was defined as at least one of the follows: death, stroke, myocardial infarction or coronary revascularization, arrhythmia and ventricular, valvular or conduct dysfunction.

Results

A total of 80 patients were enrolled with a mean follow-up of 26 years after surgery: 46% were female, median age 27 (19–57) year-old. Concerning other concomitant defects, 25% had ventricular septal defect, 12% pulmonary stenosis, 3% aortic coarctation and 1% single coronary ostium. ATS palliation was performed in 54% of patients (Senning procedure in 95%) and ARS (Jatene procedure) in 45% of patients; median age at procedure was 13 months and 10 days, respectively. During follow-up, almost all patients submitted to ARS remained in sinus rhythm (97%) versus 64% of ATS patients (p=0.037). The latter group had higher incidence of arrythmias (40% vs 3%, p=0.013), mostly atrial flutter or fibrillation (present in 28%), followed by bradyarrhythmia (10%); median time from surgery to first arrhythmic event in these patients was 23 years. Also, systemic ventricle systolic dysfunction (SVSD) and chronotropic incompetence were significantly higher in ATS (41% vs 3%, p&lt;0.001 and 46% vs 9%, p=0.005, respectively); mean time to SVSD was 29 years. In respect to long-term outcomes in ARS, the most frequent complications were moderate to severe aortic regurgitation, pulmonary stenosis and regurgitation, occurring in 21%, 7% and 3%, respectively. Concerning both groups, mean time to first adverse-event was 21 years. Regarding gender and demographic features, there were no differences in time-to-adverse-event, comparing patients living in urban versus rural neighbourhoods and female versus male (Log Rank, p=0.368 and p=0.693). Only one patient died, submitted to ATS, at 46 years-old, from chronic heart failure.

Conclusion

After a long-term free of events, ATS patients experienced more arrhythmic complications and SVSD. ARS complications were anastomosis related. This report highlights the efforts that should be made to identify late complication is this particular population. Of note, no demographic or gender differences were observed.

Funding Acknowledgement

Type of funding sources: None. Gender analysis

Sex disparities in lipid-lowering therapy and dyslipidemia control in a coronary rehabilitation program

Introduction

Lipid control is one of the most important secondary cardiovascular prevention targets. Although cardiovascular disease is the most common cause of death for both genders, several studies have consistently shown that women are less likely to receive guideline-recommended secondary prevention medications after an acute coronary syndrome (ACS).

Purpose

To compare sex disparities in dyslipidemia control in a secondary prevention population with ACS in light of the ESC Dyslipidemia Guidelines.

Methods

We retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an ACS from January 2011 to October 2019. Clinical data was collected at presentation and during 12 months follow-up. Doses of atorvastatin ≥40 mg, rosuvastatin ≥20 mg or a combination of a statin and ezetimibe were considered high-intensity LDL-lowering therapy (HIT).

Results

Of a total of 881 patients enrolled, mean age 55.0±10.0 year-old, 16.1% were female. At baseline there were no differences respecting clinical features between genders. At admission, 51.4% of patients had ST-elevation myocardial infarction and, concerning to cardiovascular risk factors, 63% patients had dyslipidemia, 46% had hypertension, 19% were diabetic, 76% were smokers or previous smokers, 27% had family history of coronary disease and 12% had previous coronary disease (ACS or &gt;50% coronary artery stenosis). At hospital admission, females and males had similar mean LDL-levels [120.7 vs 118.1 mg/dL, t(708)=0.691, p=0.496]. The vast majority of patients from both genders were prescribed with statins on hospital discharge (99.5%) and maintain it during follow-up (99.3%). Female patients received more HIT during follow-up (67.8% vs 53.9% at baseline, p=0.015; 75.6% vs 59.0% after CRP, p=0.003; and 79.8% vs 65.1% at 1-year-follow-up, p=0.007). During follow-up, at the end of the CRP (about 3 months after event), male patients exhibit a better control of LDL [82.0 vs 75.6 mg/dL, t(597)=2.4, p=0.016)] with 12.8% vs 16.4% below 55 mg/dL and 29.8% vs 44.5% below 70 mg/dL (p=0.008). At 1-year follow-up, both genders exhibited similar LDL-control due to a worsening control of the male population (81.9 vs 80.6 mg/dL, t(540)=0.52, p=0.605). Only 13.3% of females had LDL below 55 mg/dL (vs 12.9%, p=0.921) and 32.5% below 70 mg/dL (vs 37.0%, p=0.432).

Conclusion

This real-life study showed that guideline recommended LDL target is not achieved in the majority of patients, even under a structured CRP. Unlike other reports, there were more women receiving potent anti-dyslipidemic therapy. Nevertheless, women showed a poor control of LDL-concentration after three months of ACS and a similar control after 1-year; this highlights the uncertainties concerning the efficacy of lipid-lowering therapy in women, an underrepresented population in clinical trials.

Funding Acknowledgement

Type of funding sources: None.

HER2 positive breast cancer: is there a preventive role of cardioprotective drugs?

Introduction

In patients with breast cancer, anti-HER2-targeted therapies (AHT) are highly associated with cardiotoxicity (CT), being the main reason for treatment interruption in patients receiving adjuvant trastuzumab. Guidelines recommend regular left ventricular ejection fraction (LVEF) assessments and CT's management with cardioprotective drugs (CPD). However, while secondary prevention has already entered clinical practice, primary prevention is still in the research domain. Our aim was to evaluate risk of CT and the role of CPD in a subset of breast cancer patients treated with AHT.

Methods

We retrospectively analyzed a population of breast cancer female patients treated with AHT referred to Cardio-oncology consultation at a tertiary center from January 2017 to March 2020. All patients were evaluated with echocardiogram before treatment initiation and at least at 3, 6, 9 and 12-months. CT was defined as LVEF under 50% or decline of at least 10% in LVEF during follow-up. As CPD we considered renin-angiotensin-aldosterone system inhibitors and beta-blockers.

Results

A total of 85 patients were included with mean age of 52.4±10.2 year-old. Concerning cardiovascular risk factors 11.8% had diabetes, 32.9% dyslipidaemia, 29.4% hypertension and 22.4% were smokers or previous smokers; most patients had a high or very-high CT risk score (98.8% with score ≥5). Besides AHT, 68.2% and 80% were also on anthracyclines and radiotherapy, respectively. Patients were followed for a median follow-up of 16 months. At baseline, mean high sensitivity troponin I was 3.9 ng/L, mean LVEF was 63.1% and mean global longitudinal strain was −19.7, with all patients having normal cardiac function. During follow-up, 15.7% developed CT with a higher prevalence in patients concomitantly on anthracyclines (19.6% vs 7.4%, p=0.151). CPD was initiated or titrated in 84.6% of patients and 30.8% needed to suspend AHT; overall 92.3% of CT patients recovered. Unlike AHT suspension, CPD initiation after CT was associated with a higher rate of cardiac function recovery (100.0% vs 50.0%, p=0.020). When comparing patients already medicated with CPD before cancer treatment (41.7%) to those naïve of CPD, the first group presented a significative lower incidence of CT [2.9% vs 25.0%, p=0.006, OR=0.09 (95% CI 0.01 – 0.72)]. When analysed all sample (with or without CT), patients already on CPD also presented a higher LVEF at 6 months follow-up (62.5% vs 59.2%, t(69)=−2.4, p=0.017 at 6 months), despite a non-significative lower LVEF at baseline (62.3% vs 63.6%, p=0.139). Medication with statins before chemotherapy didn't reduce the risk of CT.

Conclusion

Pre-treatment with CPD was significantly associated with a lower prevalence of CT and a higher LVEF at 6-months follow-up. CPD initiation after CT was associated with cardiac function recovery. These results highlights the importance of cardiac evaluation in HER2+ patients and strengthen the primary prevention field in these patients.

Funding Acknowledgement

Type of funding sources: None.

Emergent coronary angiography in a 90-plus population – outcomes at 5-years follow-up

Introduction

Elderly people represents a vulnerable and increasing population presenting with acute coronary syndrome (ACS). Several data suggest the benefit of an early revascularization in ST-elevation (STE)-ACS or non-STE-ACS with positive troponin. However questions persist considering the unavoidable adverse prognosis, patient's functional and cognitive status, comorbidities and preferences.

Purpose

To evaluate a group of very old patients who underwent emergent coronary angiography (CA).

Methods

We retrospectively analyzed a group of very old patients (≥90 year-old) who underwent emergent CA from January 2008 to September 2020. Clinical features were collected; survival and MACE were compared with an aged-matched control population with ACS not submitted to emergent CA. MACE was defined as a composite of all-cause death, ischemic stroke, ACS or hospitalization for acute heart failure.

Results

A total of 34 patients were enrolled: 56% female, with mean age 92±2 year-old. As for the cardiovascular risk factors, 88% had hypertension, 49% dyslipidaemia, 12% diabetes and 15% were previous smokers. Concerning other comorbidities, 27% had atrial fibrillation, 21% chronic kidney disease, 12% had cerebrovascular disease and median modified Rankin scale for neurologic disability was 2. Almost all patients had STE-ACS, 68% anterior and 29% inferior, inferolateral or inferoposterior infarction; 3% had infarction of indeterminate location. In CA, 65% had multivessel disease, 14% of them involving left main coronary artery; coronary intervention was performed in 71% of patients (mostly stent implantation), the remaining 29% had no invasive treatment. Concerning to clinical status, median troponin was 131 517 ng/L and median BNP 496 pg/mL; 36% of patients evolved in Killip class III or IV and only 32% of patients had normal left ventricular systolic function. Regarding mortality, 38% of patients died in the index-event versus 25% in the aged-matched control group (p=0.319). During five years of follow-up, there was no significant difference in mortality between the two groups (Log Rank, p=0.403) and more than 50% of patients died in two years. Comparing MACE occurrence, both groups were similar (Log Rank, p=0,662), with more than 80% having at least one event in five years.

Conclusion

Very old patients submitted to emergent CA had a high percentage of multivessel disease, left ventricular dysfunction and mortality during hospitalization. Compared to an aged-matched control group, they showed no survival or MACE benefit of emergent CA strategy during a five-years follow-up. Although this is a small study, these findings highlight the efforts that should be made to optimize care in this vulnerable population, under-represented in the clinical trials. Special caution should be given to avoid possible unnecessary discomfort in this setting.

Funding Acknowledgement

Type of funding sources: None. MACE analysis

Sphingomyelin synthase 1 mediates hepatocyte pyroptosis to trigger non-alcoholic steatohepatitis

OBJECTIVE

Lipotoxic hepatocyte injury is a primary event in non-alcoholic steatohepatitis (NASH), but the mechanisms of lipotoxicity are not fully defined. Sphingolipids and free cholesterol (FC) mediate hepatocyte injury, but their link in NASH has not been explored. We examined the role of free cholesterol and sphingomyelin synthases (SMSs) that generate sphingomyelin (SM) and diacylglycerol (DAG) in hepatocyte pyroptosis, a specific form of programmed cell death associated with inflammasome activation, and NASH.

DESIGN

Wild-type C57BL/6J mice were fed a high fat and high cholesterol diet (HFHCD) to induce NASH. Hepatic SMS1 and SMS2 expressions were examined in various mouse models including HFHCD-fed mice and patients with NASH. Pyroptosis was estimated by the generation of the gasdermin-D N-terminal fragment. NASH susceptibility and pyroptosis were examined following knockdown of SMS1, protein kinase Cδ (PKCδ), or the NLR family CARD domain-containing protein 4 (NLRC4).

RESULTS

HFHCD increased the hepatic levels of SM and DAG while decreasing the level of phosphatidylcholine. Hepatic expression of Sms1 but not Sms2 was higher in mouse models and patients with NASH. FC in hepatocytes induced Sms1 expression, and Sms1 knockdown prevented HFHCD-induced NASH. DAG produced by SMS1 activated PKCδ and NLRC4 inflammasome to induce hepatocyte pyroptosis. Depletion of Nlrc4 prevented hepatocyte pyroptosis and the development of NASH. Conditioned media from pyroptotic hepatocytes activated the NOD-like receptor family pyrin domain containing 3 inflammasome (NLRP3) in Kupffer cells, but Nlrp3 knockout mice were not protected against HFHCD-induced hepatocyte pyroptosis.

CONCLUSION

SMS1 mediates hepatocyte pyroptosis through a novel DAG-PKCδ-NLRC4 axis and holds promise as a therapeutic target for NASH.

The Specific NLRP3 Antagonist IFM-514 Decreases Fibrosis and Inflammation in Experimental Murine Non-Alcoholic Steatohepatitis

Background and Aims: Activation of the inflammasome NLRP3 (NOD-, LRR- and pyrin domain containing 3) contributes to the development of non-alcoholic fatty liver disease (NAFLD) and progression to non-alcoholic steatohepatitis (NASH). Therefore, this study explored the therapeutic effects of a novel and selective NLRP3 antagonist in a murine dietary model of NASH.

Methods: Groups of 12-week-old ApoE^-/- mice were fed ad lib for 7 weeks with a methionine/choline deficient (MCD) and western diet (WD). After 3 weeks of diet-induced injury, mice were injected i. p. with the NLRP3 antagonist IFM-514 (100 mg/kg body weight) or vehicle (0.5% carmellose) every day, 5 days/week for a further 4 weeks. Several markers of inflammation, fibrosis and steatosis were evaluated. Whole transcriptome sequencing and panel RNA expression analysis (NanoString) were performed.

Results: IFM-514 inhibited IL-1β production in mice challenged with 20 mg/kg lipopolysaccharide, and in mouse and human inflammatory cells in vitro. IFM-514 inhibited hepatic inflammation in the in vivo non-alcoholic steatohepatitis model assessed by H&E staining and in the hepatic gene expression of inflammasome-related proinflammatory cytokines. This effect was associated with significant reduction in caspase-1 activation. Similarly, IFM-514 was efficacious in vivo in MDC-fed ApoE^-/- mice, markedly reducing portal pressure, Sirius red staining and 4-hydroxyproline content compared to vehicle-treated mice. Moreover, IFM-514 significantly reduced hepatic steatosis in MCD-fed ApoE^-/- mice, as evidenced by NAFLD scores, oil red O staining, hepatic triglycerides and gene expression. In WD treated animals, similar trends in inflammation and fibrosis were observed, although not sufficient IFM-514 levels were reached.

Conclusion: Overall, IFM-514 reduced liver inflammation and fibrosis, with mild effects on liver steatosis in experimental murine NASH. Blocking of NLRP3 may be an attractive therapeutic approach for NASH patients.

Emotional processing in recovered anorexia nervosa patients: A 15 year longitudinal study

OBJECTIVE

This 15 years longitudinal study aimed to examine whether difficulties in cognitive processing of emotions persisted after long-term recovery from anorexia nervosa (AN), and its link to anxiety and depression.

METHOD

Twenty-four females, who were tested longitudinally during their acute and recovered AN phases, and 24 healthy control (HC) women, were screened for anxiety, depression, alexithymia, emotion regulation difficulties (ER; only assessed in recovery phase), and completed an experimental task to analyse emotional experience.

RESULTS

In spite of significant improvement in alexithymia, anxiety, and depression with AN recovery, some emotion functioning difficulties did not normalize. The occurrence of comorbid anxiety and depression explained the reduced ability to identify, understand, and accept emotions in long-term recovery (relative to controls), but not the increased global difficulty in using ER strategies, which revealed a more stable nature of deficit. With recovery, negative emotions linked to situations addressing food and body weight are felt more intensely.

CONCLUSIONS

Managing emotions, especially the negative ones, remains a challenge for individuals recovered from AN. Under this circumstance, maladaptive eating behaviour can serve as an affect regulatory function, increasing the risk of relapse. Emotional education is an important avenue in protecting long-term AN relapse.

Acid ceramidase improves mitochondrial function and oxidative stress in Niemann-Pick type C disease by repressing STARD1 expression and mitochondrial cholesterol accumulation

Niemann-Pick type C (NPC) disease, a lysosomal storage disorder caused by defective NPC1/NPC2 function, results in the accumulation of cholesterol and glycosphingolipids in lysosomes of affected organs, such as liver and brain. Moreover, increase of mitochondrial cholesterol (mchol) content and impaired mitochondrial function and GSH depletion contribute to NPC disease. However, the underlying mechanism of mchol accumulation in NPC disease remains unknown. As STARD1 is crucial in intramitochondrial cholesterol trafficking and acid ceramidase (ACDase) has been shown to regulate STARD1, we explored the functional relationship between ACDase and STARD1 in NPC disease. Liver and brain of Npc1-/- mice presented a significant increase in mchol levels and STARD1 expression. U18666A, an amphiphilic sterol that inhibits lysosomal cholesterol efflux, increased mchol levels in hepatocytes from Stard1f/f mice but not Stard1ΔHep mice. We dissociate the induction of STARD1 expression from endoplasmic reticulum stress, and establish an inverse relationship between ACDase and STARD1 expression and LRH-1 levels. Hepatocytes from Npc1+/+ mice treated with U18666A exhibited increased mchol accumulation, STARD1 upregulation and decreased ACDase expression, effects that were reversed by cholesterol extraction with 2-hydroxypropyl-β-cyclodextrin. Moreover, transfection of fibroblasts from NPC patients with ACDase, decreased STARD1 expression and mchol accumulation, resulting in increased mitochondrial GSH levels, improved mitochondrial functional performance, decreased oxidative stress and protected NPC fibroblasts against oxidative stress-mediated cell death. Our results demonstrate a cholesterol-dependent inverse relationship between ACDase and STARD1 and provide a novel approach to target the accumulation of cholesterol in mitochondria in NPC disease.

Predictors and moderators of outcome of psychotherapeutic interventions for mental disorders in adolescents and young adults: protocol for systematic reviews

BACKGROUND

Adolescence and young adulthood is a risk period for the emergence of mental disorders. There is strong evidence that psychotherapeutic interventions are effective for most mental disorders. However, very little is known about which of the different psychotherapeutic treatment modalities are effective for whom. This large systematic review aims to address this critical gap within the literature on non-specific predictors and moderators of the outcomes of psychotherapeutic interventions among adolescents and young adults with mental disorders.

METHODS

The protocol is being reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement. PubMed and PsycINFO databases will be searched for randomized controlled and quasi-experimental/naturalistic clinical trials. Risk of bias of all included studies will be assessed by the Mixed Methods Appraisal Tool. The quality of predictor and moderator variables will be also assessed. A narrative synthesis will be conducted for all included studies.

DISCUSSION

This systematic review will strengthen the evidence base on effective mental health interventions for young people, being the first to explore predictors and moderators of outcome of psychotherapeutic interventions for a wide range of mental disorders in young people.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020166756 .

Psychedelics: A new era of treatment?

Introduction

Psychedelics - including LSD (lysergic acid diethylamide), psilocybin, DMT (N, N-dimethyltryptamine), ayahuasca and mescaline - have an ancient history across various civilizations. In 1950, after LSD’s discovery by Hofmann, psychedelics enjoyed a short-lived relationship with psychiatry, before prohibitive legislature emerging in response to the recreational use in the mid-1960s. However, the last decade has witnessed a renewed scientific interest in psychedelics - a phenomenon referred to as the ‘Psychedelic Renaissance’.

Objectives

Review the pharmacology of psychedelic drugs and the latest evidence of its therapeutic potentials in anxiety, mood and addictive disorders.

Methods

Literature review performed on PubMed and Google Scholar databases, using the keywords “psychedelics”, “hallucinogens”, “d-lysergic acid diethylamide (LSD)”, “psilocybin”, “ayahuasca”, “mescaline”, “DMT (N,N-dimethyltryptamine)”.

Results

The psychedelics or “classic hallucinogens” can be subdivided into three sub-classes: the plant-derived tryptamines (psilocybin and ibogaine) and phenethylamines (mescaline), and the semisynthetic ergolines (LSD). The therapeutic potentials are mediated by an agonist action on 5-HT2A receptors expressed in frontal and paralimbic structures involved in mood and emotion regulation, introspection, interoception and self-consciousness. Stimulation of 5-HT2ARincreases the glutamatergic tone and neuroplasticity and is accompanied by reduced amygdala activity, reducing anxiety. Experimental, open-label, and RCTs showed anxiolytic, antidepressive, and antiaddictive effects with psychedelics. As examples, psilocybin and LSD reduced anxiety and depression in cancer patients and symptoms of alcohol and tobacco dependence, and ayahuasca reduced depression in treatment-resistant depression.

Conclusions

Despite the promising effects of psychedelics on anxiety, depression and addiction, the evidence is still preliminary, waiting for long-term studies with bigger samples.

Conflict of interest

No significant relationships.

Myocardial infarction in the absence of obstructive coronary artery disease - can the underlying causes be identified by cardiac magnetic resonance?

Funding Acknowledgements

Type of funding sources: None.

Background

 Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA) is a clinical entity that occurs in up to 15% of all acute coronary syndromes (ACS). It is a "working diagnosis", as it is constituted by several etiologies.

Purpose

To identify the utility of CMR in determining the etiological diagnosis of MINOCA events, with potential impact in the therapeutic management of these patients.

Methods

 Patients with MINOCA who were admitted to the Cardiology department at a tertiary center, between 2015 and 2020, were included. MINOCA was defined as an ACS with non-obstructive (&lt;50%) coronary artery disease and no other clinically specific cause, in accordance with definition adopted in the 2020 ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. Patients who did not had a coronary exam (either CT or invasive angiogram) or a CMR were excluded.  All CMR exams were performed in a 3 Tesla equipment using a comprehensive protocol (cine, T2-weighted, and late gadolinium sequences). Clinical, electrocardiographic, echocardiographic and CMR data were collected.

Results

In a population of 29 patients, the mean age was 55 ± 17 years-old at the time of the cardiac event, 51.7% were male. Concerning to cardiovascular risk factors, 58.6% of patients had dyslipidaemia, 51.7% had hypertension, 13.7% were diabetic, 41.4% were smokers or previous smokers and 31.0% had obesity. Atrial fibrillation was present in 3.4% of patients. As for the EKG patterns, 41.4% of the patients had ventricular repolarization changes, 13.8% had a transitory ST elevation pattern, 6.9% had a complete left bundle branch block and 37.9% had a normal EKG; most of the ischemic EKG alterations were on the anterior wall (66.7%). The median high sensitivity I troponin levels were 1877.5 (IQR 225.3 – 5985.8) ng/L. The majority of patients (58.6%) had echocardiographic wall motion abnormalities; of those, the most common (41.1%) were on the left anterior descendent artery territory. CMR (performed at a median of 5 days from presentation) was able to identify the cause for the troponin rise in 58.6% of the cases; late gadolinium enhancement and oedema were present in 41.4% and 62.1% of patients, respectively. The mean left ventricle ejection fraction (EF) was 57.7 ± 8.5% and the mean right ventricle EF was 61.5 ± 6.1%. An ischemic pattern was present in 29.4% of the total population. In 17.6% of the patients findings were consistent with Takotsubo syndrome and in 29.4% with myocarditis.

Conclusion

 CMR established the etiological cause in 58.6% of the cases, with potential implications in medical therapy. These findings highlight the importance of CMR in MINOCA diagnosis and the potential improvement in patient care with multi-modality imaging.

Conduction disturbances after TAVR - a 1-year follow-up

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve replacement (TAVR) is an established procedure to treat patients (pts) with symptomatic severe aortic stenosis. Although conduction disturbances remain the most frequent complication, there is a lack of consensus on their management, which leads to significant differences in permanent pacemaker (PPM) implantation rates between centers.

Purpose

To evaluate new conduction disturbances and PPM implantation in pts undergoing TAVR, peri-procedure and up to 1 year.

Methods

We retrospectively analyzed all pts who underwent TAVR at a tertiary center from October 2014 to November 2019; pts with a previous PPM were excluded (n = 30). Clinical and ECG data were collected at presentation and up to 1 year after implantation, including systematic interrogation of implanted PPM.

Results

340 pts underwent TAVR (57% female, mean age 80 ± 8years). CoreValve Evolut R was the most used valve (41% of pts), followed by CoreValve Evolut Pro (21%) and Acurate Neo (13%). Of the 77% pts who were in sinus rhythm pre-TAVR, 79% had normal atrioventricular (AV) conduction and 20% 1st degree AV block (AVB); 60% had no intraventricular (IV) conduction disturbance, 9% left bundle branch block (LBBB), 7% right bundle branch block (RBBB) and 7% RBBB plus fascicular block.

After TAVR, 50.9% of pts exhibited new conduction disturbances. Regarding AV conduction, 12.4% of pts developed advanced AVB and 20% of pts without previous disturbances developed 1st degree AVB. Concerning IV conduction, the most frequent disturbance was de novo LBBB (n = 109, 32,2%) which resolved in 56% of cases after 6 months. Among pts with previous RBBB, 42% developed advanced AVB; the presence of previous RBBB was the major risk factor for advanced AVB [OR = 8.5 (95% CI 4.1-17.5; p &lt; 0.001)] and PPM implantation [OR = 5.2 (95% CI 2.7-10.0; p &lt; 0.001)], followed by previous 1st degree AVB [OR = 2.3 (95% CI 1.2-4.4; p = 0.016) for PPM implantation]; previous FA or LBBB were not associated with advanced AVB or PPM implantation.

Overall, 19% of pts implanted a PPM post-TAVR (n = 63). The main reason was advanced AVB (60%), followed by LBBB plus 1st degree AVB (22%), isolated LBBB (5%) and alternating bundle branch block (ABBB) (5%). At first PPM evaluation, pts with advanced AVB had a median percentage of ventricular pacing (VP) of 80% (52% had VP &gt;90% and 14% &lt;1%) and one year after-TAVR the median percentage of VP was 83%. Concerning pts with LBBB plus 1st degree AVB, median VP at first assessment was 4% (38% had &lt; 1% of VP). In pts with isolated LBBB or ABBB, median VP at first evaluation was 13% and 11%, respectively.

Conclusion

LBBB was the most frequent de novo conduction disturbance after TAVR, with more than half of the cases resolving in the first 6 months. RBBB, on the other hand, was the major risk factor for advanced AVB and PPM implantation. Advanced AVB was associated with a high percentage of VP at 1-year follow-up, unlike pts with milder degrees of conduction delay.

Long term prognosis of out-of-hospital cardiac arrest due to idiopathic ventricular fibrillation - a tertiary center experience

Funding Acknowledgements

Type of funding sources: None.

Background

 Sudden cardiac death (SCD) is an uncommon event in the absence of structural heart disease. However, ventricular fibrillation (VF) may occur in patients with unknown cardiac disease and a comprehensive work-up is needed to further improve diagnostic. Still, a significant and heterogenous group of patients remains labelled of Idiopathic VF and limited data is available regarding their natural history.

Purpose

The aim of this study was to evaluate the clinical outcomes of survivors of an aborted sudden cardiac death due to idiopathic VF or pulseless ventricular tachycardia (VT) and to assess possible predictors of recurrence.

Methods

 Patients who survived an idiopathic VF or pulseless VT between 2005 and 2019 referred to a cardiac defibrillator (ICD) implantation were included. Patients were followed for 1 to 15 years (median follow-up of 7 years). Clinical and device data were collected.

Results

A population of 29 patients, 59% male, with a median age of 50 years (age ranging from 18 to 76) at the time of the aborted SCD was studied. All patients implanted an ICD (69% single chamber, 24% dual chamber and 3% subcutaneous) at the index hospitalization. The initial rhythm was VF in 76% and pulseless VT in 24%. In relation to the context of the arrhythmic event, 48.3% occurred during daily life activities, 13.8% after an emotional stress, 6.9% during efforts and a similar percentage occurred either in rest or asleep. Of note, 12.5% of patients had previous history of syncope. Normal ECG was present in 83% of patients. Family history of SCD was present in 12% of the cases. As for the cardiovascular risk factors, 61.5% had hypertension, 19% dyslipidemia, 17% diabetes, 31% were smokers or previous smokers. Paroxysmal atrial fibrillation was present in 15% of patients. To exclude possible causes of VF, all patients were submitted to coronary angiogram and echocardiogram, 64% to genetic testing, 68% to cardiac magnetic resonance, 20% to electrophysiologic study, 12% to pharmacological provocative test and 4% were submitted to endomyocardial biopsy. At follow-up, an etiological diagnosis was established in 31% of patients: 3 events were attributed to coronary vasospasm, 3 to short coupled polymorphic VT, 1 patient had long QT syndrome, 1 had Brugada syndrome and in 1 patient an ANK2 mutation was identified. As for the clinical outcomes, 8% patients died (from non-arrhythmic causes), 31% patients received appropriate therapies and 19% had unappropriated shocks (of those 60% for sinus tachycardia and 40% for supraventricular tachycardia).

Conclusion

Etiologic diagnosis and prediction of recurrence of arrhythmic events in patients with idiopathic VF is challenging, even with a long-term follow-up and more sophisticated diagnostic evaluation.  Idiopathic VF is a rare but serious condition with recurrence in about one third of patients. Although not free of complications, ICD remains the gold standard of treatment.

Secondary prevention after acute coronary syndrome - can we achieve dyslipidemia guideline targets?

Funding Acknowledgements

Type of funding sources: None.

Lipid control is one of the most important secondary cardiovascular prevention targets. The 4S trialin 1994 was the first study to demonstrate the benefit of statin therapy in coronary artery disease patients. More recently, the FOURIER trial (2017) and the ODYSSEY Outcomes (2018) demonstrated the cardiovascular benefit of adding a PCSK9 inhibitor to optimized antidyslipidemic therapy.

Owing to the growing number of evidence showing the importance of aggressive lipid control, the European Society of Cardiology (ESC) 2019 Dyslipidemia Guidelines changed the recommendation of LDL targets from below 70 mg/dL to below 55 mg/dL in very high risk patients.

In the light of this new recommendation, we retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an Acute Coronary Syndrome at a tertiary center from May 2008 to June 2019. The CRP consisted in a multi-disciplinary approach to these patients, including 8 to 12 weekly sessions of phase II rehabilitation, exercise prescription, nutrition counselling and life-style intervention, with Cardiology follow-up at the end of the CRP (3 months), 6 months and 12 months after the event. Lipid profile was requested at baseline, 3 months and 12 months after the event. Dyslipidemia was defined using the ESC Guidelines definition.

In total, 989 patients were enrolled: the mean age was 54 ± 10 years and 15% were female. Concerning to cardiovascular risk factors, 56.7% of patients had dyslipidaemia, 41.5% had hypertension, 18.1% were diabetic, 73.1% were smokers or previous smokers, 26.0% had family history of coronary disease and 14.0% had previous coronary disease.

At hospital admission, mean LDL concentration was 121,7 ± 38,8 mg/dL with 2,9% of the patients with values below 55 mg/dL and 7,6% below 70 mg/dL. The vast majority of patients were medicated with statin at hospital discharge and maintained the prescription during the follow-up (97.5% and 97.1%, respectively).

At the end of the CRP, there was a significant decrease of LDL values (p &lt; 0.001) with 18.7% patients with LDL below 55 mg/dL and 46.3% below 70 mg/dL (mean LDL 76.6 ±23.6 mg/dL). At 1-year follow-up, the lipid control was better than at admission, but inferior than at the end of the rehabilitation program, both findings statistically significant (11.0% patients were below 55 mg/dL and 33.1% were below 70 mg/dL, with a mean LDL of 82.7 ± 28.3 mg/dL; p &lt; 0.001).

In conclusion, our real-life observational cohort showed that guideline recommended LDL target is not achieved in most of very high-risk patients even in a structured coronary rehabilitation program. Of note, the number of patients at LDL-target decreased from 3 months to 1-year follow-up. This state the importance of a sustained healthy lifestyle and therapy adherence, with aggressive pharmacologic therapy.

An insight on psychiatric insight

Introduction

Insight is a complex and multidimensional phenomenon. Metacognition, awareness of illness or anosognosia are some of the terms used to designate this feature of the mental state exam.

Objectives

To attempt to explore the evolution of the concept of insight as a psychiatric symptom over the years and to bring up some up-to-date features on this theme.

Methods

Literature review, using the most relevant papers, with the keywords “psychiatric insight”, “awareness of illness”, “metacognition” and “phenomenology”.

Results

The term ‘insight’ has been described since 1896 when Kraepelin had noticed that patients with dementia praecox were unaware of their condition. Nowadays, it is recognized in several psychiatric disorders, with different meanings in each one. Overall, insight in psychiatry involves an attempt to see one’s thinking and behaviour ‘objectively’ and comparing it to some representation of mental health. Impaired insight has been linked to poor treatment compliance and outcomes, overall symptom severity, higher relapse, lower self-esteem, and impaired psychosocial functioning. White matter and connectivity problems may be related to poorer insight, as well as impaired frontal lobe functioning. In psychotic disorders, lack of insight is a primary symptom with poorer outcomes. Regarding affective disorders, the lower the mood the better the insight. Neuroimaging has been correlating insight with the inferior frontal gyrus, anterior insula, inferior parietal lobule, and ventromedial prefrontal cortex. In everyday practice, there are scales used to assess insight.

Conclusions

Inferences about patients’ insight are important to evaluate severity of illness, suicidal risk, compliance, and response to treatment.

The universe of brief psychosis

Introduction

Nowadays, ‘Acute and transient psychotic disorders’ in ICD-10 and ‘Brief psychotic disorders’ in DSM-5 are both classifications of the same clinical entity. Over the years, several concepts have been formulated to define the same syndrome.

Objectives

To explore the historical evolution of brief psychotic disorders and relate them to current nosologies.

Methods

Literature review, using the most relevant papers, with the keywords “brief psychosis”, “bouffée délirante”, “cycloid psychosis”, “psychogenic psychosis”, “atypical psychosis” and “holodysphrenia”.

Results

Initially, in 1896, Kahlbaum coined the term ‘dysphrenia’, a group of severe form of psychosis that remitted without showing the typical sequence of disease states and without leaving a lasting alteration. Later, Kraepelin included this kind of disorder in manic depressive illness, which he first named as ‘periodic delirium’ and then as ‘delirious mania’. Magnan, in the pre-Kraepelinian era, created the term ‘bouffée délirante’, a sudden onset of delusional ideas with rapid evolution and intense symptomatology with complete remission usually followed after a short time. Later on, Henry Ey grabbed this entity and renewed it, contrasting it to the defined concept of schizophrenia. Other psychiatric schools have proposed numerous designations: ‘cycloid psychosis’ by Kleist from the German school, ‘psychogenic psychosis’ by Wimmer of the Scandinavian school and ‘holodysphrenias’ by Barahona-Fernandes from the Portuguese school. Cultural variants are also observed, as ‘amok’ seen in Malaysia or ‘shinbyung’ in Korea.

Conclusions

The intensity and polymorphism of brief psychosis present a clinical challenge. The historical evolution may be helpful on recognizing this entity in current clinical practice.

Rational suicide: The paradigm of survival

Introduction

Suicide is an intriguing act of the human being. The reasons behind the violation of an instinct for survival is far from being understood. Besides, the emergence of assisted dying is raising even more questions about the concept of rational suicide, defined as a well-thought-out decision to die by whom is mentally competent.

Objectives

Understand the concept of rational suicide, in parallel with suicide, by exploring the views on this debate over the years and elucidating the relationship with mental disorders, mental capacity and patient’s rights.

Methods

Literature review performed on PubMed and Google Scholar databases, using the keywords “rational suicide”, “assisted death”, “suicide”, “phenomenology”, “mental capacity” and “responsibility for life”.

Results

The theological condemnations of suicide – as sin or crime – were put aside with psychiatric development in the last century. Durkheim was the first important precursor of the contemporary view - suicide is a form of mental illness (psychosis or depression) not compatible with rational deliberation. With the increasingly open debate on assisted dying, this vision is being tested by cases of terminally ill patients subjected to experiences that many wouldn’t choose to tolerate. Moral right to self-determination and needless suffering are examples of arguments in favor of rational suicide.

Conclusions

The need for an open discussion about rational suicide is raising, specifically in relation to psychiatric disorders, mainly to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients.

Disclosure

No significant relationships.

Couplehood as a compass: Spousal perspectives on the diminished everyday competence of partners

Research on spousal relations and caregiving, when one of the persons in the dyad has a dementia diagnosis, has recognized that the degree of diminished everyday competence (DEC) the person with dementia is experiencing has implications for these relations and for how spousal caregiving is ultimately experienced. The present exploratory study uses an inductive approach to analyze data from 22 qualitative interviews with and observation notes on couples living with dementia to shed light on the ways in which the person without dementia views the DEC his/her partner is experiencing. The findings show that spouses can choose to disregard their partners' DEC or to acknowledge it in either an egocentric or a couple-centered way; they also show that spouses' choice of approach does not seem to be dictated by how cognitively impaired their partners have become. This suggests that spouses' approach to partners' DEC deserves more of our attention as it could have implications not only for transitions into spousal caregiving but also for caregiving experiences as such.