Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Gender Differences in Medical Student Perceptions of a Career in Cardiology

BACKGROUND

Worldwide, the cardiology profession has an under-representation of women. We assessed medical students' perceptions of cardiology as a career choice with the aim of identifying barriers to gender diversity.

METHOD

An anonymous survey was distributed to medical students studying at three Australian medical universities. Questions pertained to demographics, year and stage of medical training, desire to pursue cardiology, and perceived barriers to a cardiology career. Results were analysed according to identified gender and desire to pursue or not pursue a cardiology career. Multivariable logistic regression evaluated for independent associations. The primary outcome were barriers identified to pursuing a career in cardiology.

RESULTS

From 127 medical student respondents (86.6% female, mean age 25.9±4.8 years), 37.0% stated they wanted to pursue a career in cardiology (39.1% of women versus 23.5% of men, p=0.54). The top four perceived barriers to a cardiology career included: poor work-life balance (92/127, 72.4%), physician training process (63/127, 49.6%), on-call requirements (50/127, 39.4%) and lack of flexibility (49/127, 38.6%), with no gender differences. Women were more likely to report gender-related barriers (37.3% versus 5.9%, p=0.01) and less likely to identify procedural aspects as a barrier (5.5% women versus 29.4% men, p=0.001). Students in their pre-clinical years were more likely to want a career in cardiology (odds ratio 3.0, 95% confidence interval 1.2-7.7, p=0.02).

CONCLUSIONS

A high proportion of female and male medical students want to pursue a career in cardiology with both genders identifying major barriers of poor work-life balance, lack of flexibility, on-call requirements and the training process.

Radiation protection for healthcare professionals working in catheterisation laboratories during pregnancy: a statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the ESC Regulatory Affairs Committee and Women as One

The European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the European Society of Cardiology (ESC) Regulatory Affairs Committee and Women as One support continuous review and improvement, not only in the practice of assuring patients a high quality of care but also in providing health professionals with support documents to help them in their career and enhance gender equity. Recent surveys have revealed that radiation exposure is commonly reported as the primary barrier for women pursuing a career in interventional cardiology or cardiac electrophysiology (EP). The fear of foetal exposure to radiation during pregnancy may lead to a prolonged interruption in their career. Accordingly, this joint statement aims to provide a clear statement on radiation risk and the existing data on the experience of radiation-exposed cardiologists who continue to work in catheterisation laboratories (cath labs) throughout their pregnancies. In order to reduce the barrier preventing women from accessing these careers, increased knowledge in the community is warranted. Finally, by going beyond simple observations and review of the literature, our document suggests proposals for improving workplace safety and for encouraging equity.

Sex Differences in Outcome and Prescribing Practice in ST-elevation MI Patients with Multivessel Disease and Incomplete Revascularisation

Objective: To investigate the extent to which multivessel disease, incomplete revascularisation and prescribing differences contribute to sex-based outcome disparities in patients with ST-elevation MI (STEMI) and establish whether differences in cardiac death and MI (CDMI) rates persist at long-term follow-up. Methods and results: This observational study evaluates sex-based outcome differences (median follow-up 3.6 years; IQR [2.4–5.4]) in a consecutive cohort of patients (n=2,083) presenting with STEMI undergoing percutaneous coronary intervention). Of the studied patients 20.3% (423/2,083) were women and 38.3% (810/2,083) had multivessel disease (MVD). Incomplete revascularisation was common. The median residual SYNTAX score (rSS) was 5.0 (IQR [0–9]) in women and 5.0 (IQR [1–11]) in men (p=0.369), and in patients with MVD it was 9 (IQR [6–17]) in women and 10 (IQR [6–15]) in men (p=0.838). The primary endpoint CDMI occurred in 20.3% of women (86/423) and in 13.2% of men (219/1,660) (p=0.028). Differences persisted following multivariable risk adjustment: female sex was independently associated with CDMI (aHR 1.33; IQR [1.02–1.74]). Women with MVD had CDMI more often than all other groups (p<0.001 for all). Significant sex-based prescribing differences were evident: women were less likely to receive guideline-recommended potent P2Y12 inhibitors than men (31% versus 43%; p=0.012), and differences were particularly evident in patients with MVD (25% in women versus 45% in men, p=0.011). Conclusion: Sex-based differences in STEMI patient outcome persist at long-term follow-up. Poor outcomes were disproportionately found in women with MVD and those with rSS>8. Observed differences in P2Y12 prescribing practices may contribute to poor outcomes for women with MVD and incomplete revascularisation.

Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention

AIMS

Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact).

METHODS AND RESULTS

All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4-2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2-0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2-3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7-2.0).

CONCLUSION

Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI.

Shock Wave Intravascular Lithotripsy: Shock the Rock

Complex coronary artery disease with severe coronary calcification can be challenging to treat, with a higher risk of procedural complications and major adverse cardiac events. Intravascular lithotripsy (IVL) is a pioneering technology for the treatment of critically calcified coronaries. IVL utilizing localized pulsatile sonic pressure waves at low pressure provides a novel approach for lesion preparation of severely calcified plaques. The deliverability and ease of use are also likely to increase access and use of IVL, and combination therapy with other devices shows promise.

Under-representation of Women as Proceduralists and Patients in TAVR and TMVr Procedures: Data, Implications and Proposed Solutions

Women are under-represented among transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr) operators. This review assesses the representation of women as patients and as proceduralists and trial authors in major structural interventions. Women are under-represented as proceduralists in structural interventions: only 2% of TAVR operators and 1% of TMVr operators are women. Only 1.5% of authors in landmark clinical TAVR and TMVr trials are interventional cardiologists who are women (4/260). Significant under-representation and under-enrolment of women in landmark TAVR trials is evident: the calculated participation-to-prevalence ratio (PPR) is 0.73, and in TMVr trials, the PPR is 0.69. Under-representation of women is also evident in registry data (PPR = 0.84 for TAVR registries and for TMVr registries). In structural interventional cardiology, women are under-represented as proceduralists, trial participants and patients. This under-representation has the potential to affect the recruitment of women to randomised trials, subsequent guideline recommendations, selection for treatment, patient outcomes and sex-specific data analysis.

International consensus statement on challenges for women in cardiovascular practice and research in the COVID-19 era

The challenges to academic and professional development and career advancement of women in cardiology (WIC), imposed by the pandemic, not only impinge the female cardiologists' "leaky pipeline" but also make the "leakiness" more obvious. This consensus document aims to highlight the pandemic challenges WIC face, raise awareness of the gender equity gap, and propose mitigating actionable solutions derived from the data and experiences of an international group of female cardiovascular clinicians and researchers. This changing landscape has led to the need for highly specialized cardiologists who may have additional training in critical care, imaging, advanced heart failure, or interventional cardiology. Although women account for most medical school graduates, the number of WIC, particularly in mentioned sub-specialties, remains low. Moreover, women have been more affected by systemic issues within these challenging work environments, limiting their professional progression, career advancement, and economic potential. Therefore, it is imperative that tangible action points be noted and undertaken to ensure the representation of women in leadership, advocacy, and decision-making, and increase diversity in academia. Strategies to mitigate the negative impacts of the pandemic need to be taken during this COVID-19 pandemic to ensure WIC have a place in the field of Cardiology.

Milk intake and incident stroke and CHD in populations of European descent: a Mendelian randomisation study

Higher milk intake has been associated with a lower stroke risk, but not with risk of CHD. Residual confounding or reverse causation cannot be excluded. Therefore, we estimated the causal association of milk consumption with stroke and CHD risk through instrumental variable (IV) and gene-outcome analyses. IV analysis included 29 328 participants (4611 stroke; 9828 CHD) of the European Prospective Investigation into Cancer and Nutrition (EPIC)-CVD (eight European countries) and European Prospective Investigation into Cancer and Nutrition-Netherlands (EPIC-NL) case-cohort studies. rs4988235, a lactase persistence (LP) SNP which enables digestion of lactose in adulthood was used as genetic instrument. Intake of milk was first regressed on rs4988235 in a linear regression model. Next, associations of genetically predicted milk consumption with stroke and CHD were estimated using Prentice-weighted Cox regression. Gene-outcome analysis included 777 024 participants (50 804 cases) from MEGASTROKE (including EPIC-CVD), UK Biobank and EPIC-NL for stroke, and 483 966 participants (61 612 cases) from CARDIoGRAM, UK Biobank, EPIC-CVD and EPIC-NL for CHD. In IV analyses, each additional LP allele was associated with a higher intake of milk in EPIC-CVD (β = 13·7 g/d; 95 % CI 8·4, 19·1) and EPIC-NL (36·8 g/d; 95 % CI 20·0, 53·5). Genetically predicted milk intake was not associated with stroke (HR per 25 g/d 1·05; 95 % CI 0·94, 1·16) or CHD (1·02; 95 % CI 0·96, 1·08). In gene-outcome analyses, there was no association of rs4988235 with risk of stroke (OR 1·02; 95 % CI 0·99, 1·05) or CHD (OR 0·99; 95 % CI 0·95, 1·03). Current Mendelian randomisation analysis does not provide evidence for a causal inverse relationship between milk consumption and stroke or CHD risk.

Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs)

Introduction

There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.

Purpose

We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.

Methods

All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.

Results

Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.

Conclusion

Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.

Funding Acknowledgement

Type of funding sources: None.

Impact of reproductive factors on major cardiovascular disease risk in women: a Mendelian randomization study

Background

Cardiovascular disease is a major cause of morbidity and mortality in women. Multiple observational studies have explored the role of female reproductive history on the risk of cardiovascular disease and suggested that factors such as high parity and early menarche are associated with higher rates of cardiovascular disease later in life. However, effect estimates derived from observational studies are liable to influence by residual confounding and bias in study design. We utilise Mendelian randomisation to explore causal pathways underlying this association by leveraging genetic variability in reproductive factors using instrumental variable analysis.

Methods

Uncorrelated single nucleotide polymorphisms (r2&lt;0.001) were extracted from summary statistics of published sex-specific genome wide association studies (GWAS) for the exposures of age at first birth (n=131,987, unit = years), number of live births (n=193,953, coded into three categories of &lt;2, 2 or &gt;2 live births), age at menarche (n=329,345, unit = years) and age at menopause (n=106,048, unit = years). Genetic association estimates for the outcomes of coronary artery disease, ischaemic stroke, stroke of any type, heart failure and atrial fibrillation were extracted from GWAS analyses on respectively 122,733 cases, 34,217 cases, 40,585 cases, 47,309 cases and 60,620 cases. All GWAS studies were on populations of predominantly European ancestry. Inverse-variance weighted MR was utilised for primary analyses; sensitivity analyses using MR-Egger and weighted median MR were carried out.

Results

Earlier age at first birth was associated with increased risk of coronary artery disease (OR per 1-year lower age = 1.49, 95% CI 1.28–1.74, p&lt;0.001). Lower age at menarche was also associated with increased risk of coronary artery disease (OR per 1-year lower age = 1.10, 95% CI 1.06–1.14, p&lt;0.001) and increased risk of heart failure (OR 1.12, 95% CI 1.07–1.17, p&lt;0.001). Finally, higher number of live births was associated with increased risk of atrial fibrillation (OR per increase in category of &lt;2, 2 or &gt;2 live births = 2.91, 95% CI 1.16–7.29, p=0.023), increased risk of heart failure (OR 1.90, 95% CI 1.28–2.82, p=0.001), increased risk of ischaemic stroke (OR 2.07, 95% CI 1.22–3.52, p=0.007) and of stroke of any type (OR 1.86, 95% CI 1.03–3.37, p=0.039).

Conclusion

The results of this study support the emerging evidence of female-specific risk factors for cardiovascular disease, by demonstrating that that earlier age at first birth, higher number of live births, and earlier menarche are all associated with increased cardiovascular morbidity in women. The results notably highlight parity as a major sex-specific risk factor of likely causal relevance. These findings support the inclusion of reproductive history in the routine evaluation of cardiovascular risk in females and identify key markers of risk that may be used to target primary prevention measures.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Research Council GEPSI 946647 for EAWSBritish Heart Foundation RG/16/3/32175 for FSN

Selenium concentration and cardiovascular disease risk: Mendelian randomization study

Background/Introduction

Selenium has been associated with cardiovascular disease (CVD) risk in observational studies; however, the causality of the association remains unestablished.

Purpose

To examine the associations of selenium concentrations with 15 CVDs using Mendelian randomization analysis.

Methods

Genetic variants significantly associated with concentrations of toenail and blood (TAB) and blood selenium in mild linkage disequilibrium (r2 &lt;0.3) were used as instrumental variables. Summary-level data for 15 CVDs were obtained from the UK Biobank study (n=367,561), FinnGen study (n=218,792), and six international consortia. The inverse variance weighted method accounting for linkage disequilibrium was used to estimate the associations. Results for one outcome from different sources were combined using the fixed effect meta-analysis method. Bonferroni correction was used to account for multiple testing, and associations with P value ≤0.003 (0.05 / 15 outcomes) were described as significant. Associations with P value between ≤0.05 and &gt;0.003 were regarded as suggestive associations.

Results

Genetically predicted concentrations of TAB selenium were not significantly associated with the risk of the 15 CVDs. However, there were suggestive associations of genetically predicted higher concentrations of TAB selenium with increased risk of atrial fibrillation and peripheral artery disease. The odds ratio per one-unit increase in log-transformed concentrations of TAB selenium was 1.07 (95% confidence interval, 1.01–1.12; P=0.019) for atrial fibrillation and 1.20 (95% confidence interval, 1.05–1.38; P=0.008) for peripheral artery disease. We observed no associations between genetically predicted blood selenium concentrations and risk of the 15 CVDs.

Conclusions

Genetically predicted higher concentrations of TAB or blood selenium were not associated with a lower risk of CVD, which suggests that high selenium status may not prevent CVD development. The suggestive positive associations of TAB selenium with atrial fibrillation and peripheral artery disease warrants verification.

Funding Acknowledgement

Type of funding sources: None.

Alcohol consumption and telomere length: Mendelian randomization clarifies alcohol's effects

Alcohol's impact on telomere length, a proposed marker of biological aging, is unclear. We performed the largest observational study to date (in n = 245,354 UK Biobank participants) and compared findings with Mendelian randomization (MR) estimates. Two-sample MR used data from 472,174 participants in a recent genome-wide association study (GWAS) of telomere length. Genetic variants were selected on the basis of associations with alcohol consumption (n = 941,280) and alcohol use disorder (AUD) (n = 57,564 cases). Non-linear MR employed UK Biobank individual data. MR analyses suggested a causal relationship between alcohol traits, more strongly for AUD, and telomere length. Higher genetically-predicted AUD (inverse variance-weighted (IVW) β = -0.06, 95% confidence interval (CI): -0.10 to -0.02, p = 0.001) was associated with shorter telomere length. There was a weaker association with genetically-predicted alcoholic drinks weekly (IVW β = -0.07, CI: -0.14 to -0.01, p = 0.03). Results were consistent across methods and independent from smoking. Non-linear analyses indicated a potential threshold relationship between alcohol and telomere length. Our findings indicate that alcohol consumption may shorten telomere length. There are implications for age-related diseases.

COVID-19 Pandemic Impact on Percutaneous Coronary Intervention for Acute Coronary Syndromes: An Australian Tertiary Centre Experience

Background

Countries who suffered large COVID-19 outbreaks reported a decrease in acute coronary syndrome (ACS) presentations and percutaneous coronary intervention (PCI). The impact of the pandemic in countries like Australia, with relatively small outbreaks yet significant social restrictions, is relatively unknown. There is also limited and conflicting data regarding the impact on clinical outcomes, symptom-to-door time (STDT) and door-to-balloon time (DTBT).

Methods

Consecutive ACS patients treated with PCI were prospectively recruited from a tertiary hospital network in Melbourne, Australia. The pre-pandemic period (11 March 2019–10 March 2020) was compared to the pandemic period (11 March 2020–10 May 2020) using an interrupted time series analysis with a primary endpoint of number PCI-treated ACS per day. Secondary endpoints included STDT, DTBT, total mortality and major adverse cardiac events (MACE).

Results

A total 984 ACS patients (14.8% during the pandemic period) received PCI. Mean number of PCI-treated ACS per day did not differ between the two periods (2.3 vs 2.4, p=0.61) with no difference in STDT [+51.3 mins, 95% confidence interval (CI) -52.4 to 154.9, p=0.33], 30-day mortality (5% vs 5.3%, p=0.86) or MACE (5.2% vs 6.1%, p=0.68). DTBT was significantly longer during the pandemic versus the pre-pandemic period (+18.1 mins, 95% CI 1.6–34.5, p=0.03) and improved with time (slope estimate: -0.76, 95% CI -1.62 to 0.10).

Conclusions

Despite significant social restrictions imposed in Melbourne, numbers of ACS treated with PCI and 30-day outcomes were similar to pre-pandemic times. DTBT was significantly longer during the COVID-19 pandemic period, likely reflecting infection control measures, which reassuringly improved with time.

Work-life balance: a comparison of women in cardiology and other specialties

OBJECTIVE

Significant gender disparities exist in some medical specialties, particularly cardiology. We assessed work, personal life and work-life balance in women in cardiology in Australia and New Zealand (NZ), compared with other specialties, to determine factors that may contribute to the lack of women in the specialty.

METHODS

This study is a prospective survey-based cohort study comparing cardiology and non-cardiology specialties. An online survey was completed by female doctors in Australia and NZ, recruited via email lists and relevant social media groups. The survey included demographics, specialty, stage of training, work hours/setting, children and relationships, career satisfaction, income and perceptions of specialty.

RESULTS

452 participants completed the survey (median age 36 years), of which 57 (13%) worked in cardiology. Of all respondents, 84% were partnered and 75% had children, with no difference between cardiology and non-cardiology specialties. Compared with non-cardiology specialties, women in cardiology worked more hours per week (median 50 hours vs 40 hours, p<0.001), were more likely to be on call more than once per week (33% vs 12%, p<0.001) and were more likely to earn an annual income >$3 00 000 (35% vs 10%, p<0.001). Women in cardiology were less likely to agree that they led a balanced life (33% vs 51%, p=0.03) or that their specialty was female friendly (19% vs 75%, p<0.001) or family friendly (20% vs 63%, p<0.001).

CONCLUSIONS

Compared with other specialties, women in cardiology reported poorer work-life balance, greater hours worked and on-call commitments and were less likely to perceive their specialty as female friendly or family friendly. Addressing work-life balance may attract and retain more women in cardiology.

Combining mutation and horizontal gene transfer in a within-host model of antibiotic resistance

Antibiotics are used extensively to control infections in humans and animals, usually by injection or a course of oral tablets. There are several methods by which bacteria can develop antimicrobial resistance (AMR), including mutation during DNA replication and plasmid mediated horizontal gene transfer (HGT). We present a model for the development of AMR within a single host animal. We derive criteria for a resistant mutant strain to replace the existing wild-type bacteria, and for co-existence of the wild-type and mutant. Where resistance develops through HGT via conjugation we derive criteria for the resistant strain to be excluded or co-exist with the wild-type. Our results are presented as bifurcation diagrams with thresholds determined by the relative fitness of the bacteria strains, expressed in terms of reproduction numbers. The results show that it is possible that applying and then relaxing antibiotic control may lead to the bacterial load returning to pre-control levels, but with an altered structure with regard to the variants that comprise the population. Removing antimicrobial selection pressure will not necessarily reduce AMR and, at a population level, other approaches to infection prevention and control are required, particularly when AMR is driven by both mutation and mobile genetic elements.

POS0295 NO CAUSAL EFFECTS OF GENETICALLY DETERMINED SERUM URATE LEVELS ON THE RISK OF ALL-CAUSE AND SITE-SPECIFIC CANCER: A MENDELIAN RANDOMIZATION STUDY

Background:

Positive associations between urate levels and gout and the risk of some cancer types (urogenital, prostate, gastrointestinal and lung) have been reported in a number of observational studies; however, whether the relationship is causal remains uncertain.

Objectives:

The study aim was to evaluate a causal effect of genetically determined serum urate (SU) concentrations on cancer risks (overall and major cancer types) in individuals with European ancestry using Mendelian randomization (MR) analyses design.

Methods:

We used the individual-level data from two population-based Swedish cohorts including middle-aged subjects (mean follow-up = 21.2 years), Malmö Diet Cancer and Malmö Preventive Project (MDC/MPP), for one-sample MR setting. Data from a total of 17,597 individuals (n = 17,597 for SU at baseline, diagnoses during follow-up: 5659 for all-cause, 516 for bladder, 545 for lung, 791 for bowel, 1521 for prostate and 729 for breast cancer) was included. For two-sample MR, summary-statistic data for SU was obtained from Global Urate Genetic Consortium (GUGC: n = 110,347), while UK-Biobank data was employed for several major cancer outcomes (n = 36,815 for all-cause, 2,245 for bladder, 2,590 for lung, 4,488 for bowel, 6,474 for prostate and 10,274 for breast cancer). The definitions for cancer endpoints were matched for ICD9 and 10 codes between MDC/MPP and UK-Biobank cohorts. For both MR settings, a set of 26 urate-associated single nucleotide variants was selected to build-up the SU instrument (SU-instr) to test for a causal effect of SU on cancer outcomes. Statistical analysis, adjusted for age and sex, was done using multiple conventional MR methodologies and MR package in R (v4.0.2). A p < 0.05 was designated as statistically significant.

Results:

We found no causal effect of our SU-instr on neither all-cause nor site-specific cancer across all MR analyses (all p > 0.05). In MDC/MPP, SU-instr did not show a causal effect on the risk of all-cause [OR = 1.06, p = 0.32], bladder [OR = 0.96, p = 0.84], lung [OR = 1.26, p = 0.17], bowel [OR = 0.96, p = 0.81], prostate [OR = 1.05, p = 0.62], and breast [OR = 0.99, p = 0.98] cancer. Similar findings were made in the two-sample settings. Detailed results are provided in Table 1.

Conclusion:

Our MR study, using a series of causal inference approaches, does not support a causal effect of genetically determined SU for major cancer outcomes. There is no evidence to support changing SU levels by lifestyle or pharmacological intervention to attenuate the risk of major cancer types.

Table 1.

Results from a range of MR analyses for causal effect of SU on cancer risk in MDC/MPP (one-sample MR) and GUGC and UK-Biobank (two-sample MR) cohorts

One-sample MRCancer typeIVW2SLSGRSOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder0.96(0.68; 1.36)0.840.550.99(0.70; 1.42)0.990.94(0.67; 1.34)0.76Lung1.26(0.90; 1.77)0.170.891.29(0.91; 1.82)0.141.26(0.90; 1.77)0.17Bowel0.96(0.72; 1.28)0.810.440.95(0.72; 1.27)0.770.97(0.73; 1.28)0.83Prostate1.05(0.84; 1.31)0.620.841.04(0.83; 1.30)0.721.04(0.83; 1.30)0.69Breast0.99(0.74; 1.33)0.980.110.98(0.73; 1.32)0.920.98(0.73; 1.32)0.94All-cause1.06(0.93; 1.21)0.320.61.07(0.94; 1.21)0.281.07(0.94; 1.21)0.29Two-sample MRCancer typeIVWWeighted medianMR-EggerOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder1.02(0.88; 2.16)0.770.361.03(0.86; 2.10)0.71.03(0.83; 2.13)0.75Lung0.86(0.73; 1.08)0.070.040.86(0.73; 1.09)0.090.84(0.66; 1.16)0.15Bowel0.82(0.69; 1.02)0.03< 0.00010.89(0.78; 1.06)0.060.92(0.72;1.67)0.52Prostate1.00(0.91; 2.64)0.970.720.98(0.88; 2.17)0.770.94(0.83; 1.45)0.37Breast0.97(0.88; 1.95)0.670.00021.00(0.91; 2.70)0.990.95(0.81; 1.59)0.46All-cause0.96(0.90; 1.20)0.18< 0.00010.97(0.92; 1.23)0.210.93(0.86; 1.12)0.11

OR; odds ratio, 95% CI; 95% confidence interval, IVW; Inverse variance weighted method, 2SLS; two-stage least square, GRS; genetic risk score, p-Het; p-value for heterogeneity.

Disclosure of Interests:

None declared

Gender equity within medical specialties of Australia and New Zealand: cardiology's outlier status

BACKGROUND

Gender disparity remains a prominent medical workforce issue, extending beyond surgical specialties with low proportions of female doctors.

AIMS

To examine female representation within Australia and New Zealand (NZ) among physician specialties and certain comparator surgical specialties with a focus on cardiology as an outlier of workforce gender equality.

METHODS

Data of practising medical specialists, new consultants and trainees were sought from the Australian Health Practitioner Regulation Agency, the Medical Council of NZ and the Royal Australasian College of Surgeons (2015-2017). The stratified data pertaining to interventional cardiologists were obtained through direct contact with individual hospitals (from 2017 to 2018) and derived from state-based cardiac registries.

RESULTS

In Australia and NZ, there were fewer female practising adult medicine physician consultants (n = 8956, 32%, P < 0.001), with gender disparities seen across most physician specialties. Cardiology (15%) was the only physician specialty with <20% representation; gastroenterology (23%), neurology (27%) and respiratory medicine (29%) had <30% female representation at the consultant level. The rates of cardiology (15%) and interventional cardiology (5%) were similar to general surgery (15%) and orthopaedics (4%). Although more than half of physician trainees are female, and most physician specialties are approaching or have equal gender ratios at the trainee level, cardiology (23%) and interventional cardiology (9%) remain significantly underrepresented.

CONCLUSIONS

Cardiology is the only physician specialty with <20% female consultants, and this disparity is reflected throughout every stage of the cardiology training programme. Increased awareness and proactive strategies are needed to improve gender disparity within this underrepresented medical specialty.

Cardiovascular risk factors and lifestyle behaviours in relation to longevity: a Mendelian randomization study

BACKGROUND

The American Heart Association introduced the Life's Simple 7 initiative to improve cardiovascular health by modifying cardiovascular risk factors and lifestyle behaviours. It is unclear whether these risk factors are causally associated with longevity.

OBJECTIVES

This study aimed to investigate causal associations of Life's Simple 7 modifiable risk factors, as well as sleep and education, with longevity using the two-sample Mendelian randomization design.

METHODS

Instrumental variables for the modifiable risk factors were obtained from large-scale genome-wide association studies. Data on longevity beyond the 90^th survival percentile were extracted from a genome-wide association meta-analysis with 11,262 cases and 25,483 controls whose age at death or last contact was ≤ the 60^th survival percentile.

RESULTS

Risk factors associated with a lower odds of longevity included the following: genetic liability to type 2 diabetes (OR 0.88; 95% CI: 0.84;0.92), genetically predicted systolic and diastolic blood pressure (per 1-mmHg increase: 0.96; 0.94;0.97 and 0.95; 0.93;0.97), body mass index (per 1-SD increase: 0.80; 0.74;0.86), low-density lipoprotein cholesterol (per 1-SD increase: 0.75; 0.65;0.86) and smoking initiation (0.75; 0.66;0.85). Genetically increased high-density lipoprotein cholesterol (per 1-SD increase: 1.23; 1.08;1.41) and educational level (per 1-SD increase: 1.64; 1.45;1.86) were associated with a higher odds of longevity. Fasting glucose and other lifestyle factors were not significantly associated with longevity.

CONCLUSION

Most of the Life's Simple 7 modifiable risk factors are causally related to longevity. Prevention strategies should focus on modifying these risk factors and reducing education inequalities to improve cardiovascular health and longevity.

Impact of stereoacuity on simulated cataract surgery ability

BACKGROUND AND OBJECTIVES

There exists a long-standing perception that diminished stereoacuity has a detrimental effect on microsurgical ability and skills acquisition. This has potential implications on the enrolment of surgical trainees into ophthalmology and other microsurgery specialities. However, strong evidence in this area is lacking. This case-control study aims to establish the exact level of stereopsis impairment at which a statistical drop in surgical performance occurs.

METHODS

Fifty participants were enrolled from the University of Dundee Medical School and the NHS Tayside Foundation Doctor programme. Participants were assessed for their stereopsis level before completing an orientation module on an ophthalmic surgical simulator. They were then required to repeat a task four times. Automated and objective performance levels were recorded and analysed.

RESULTS

Nineteen (38%) had stereopsis lower than the defined normal of 60 seconds of arc (arcsec). Statistical analysis found no correlation between visual acuity and surgical performance. No statistical difference was found between performance scores and stereoacuities of 30, 60 and 120 arcsec. A statistically significant difference was discovered in the surgical performance of participants with a stereoacuity worse than 120 arcsec (total score = -69.85) as compared to the ones with a stereoacuity of 120 arcsec or better (total score = -42.23) with p = 0.010.

CONCLUSIONS

This study provides evidence of a specific level of stereopsis where statistical degradation of surgical performance occurs. The findings of this work may help formulate policy on stereoacuity standards required to commence microsurgical training.

P187 Late outcomes of all patients at a single center with diabetes mellitus undergoing SYNTAX scoring after angiographic screening for the FREEDOM trial

Background

The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-Vessel Disease (FREEDOM) trial randomized only a minority of screened patients with diabetes mellitus (DM) and 2-3 vessel disease (MVD), representing an high risk diabetic MVD cohort.

Methods

Consecutive patients with DM underwent angiographic screening from June 2006  to March 2010 at Liverpool Hospital, Sydney, Australia, for the FREEDOM trial; SYNTAX Scores (SS) were subsequently performed. Patients had late follow-up to determine late rates of death, non-fatal MI and stroke.

Results

Among 1263 patients with DM 833 (66%) had 0-1 vessel disease and 430 (34%) had MVD of whom 139 had prior coronary artery bypass grafting (CABG), and SS were 0 in 272, 1-9 in 336, 10-22 in 264, 23-32 in 109, and 271 patients had SS ≥33. Revascularisation was performed by coronary artery bypass grafting (CABG) in 139 (11%), 486 (38%) underwent PCI, and 638 (51%) did not undergo a revascularization procedure; respective mean ages were 63.5, 64.2 and 64.7 years; p = 0.39, and presentation rates with an ACS were 52%, 57% and 37%; p &lt; 0.05. Amongst patients with MVD, those undergoing CABG had lower rates of MACE than either PCI or medical therapy (22%, 40%, and 51% respectively; p &lt; 0.001). Kaplan-Meier curves (Figure) with respect to SS and late events are shown for: A) Death; B) Non-fatal MI; C) Death/MI/Stroke; D) Late Revascularization. Multi-variable analyses found independent predictors of late mortality were age &gt;75 (HR 6.2), prior MI (HR 1.1), prior CABG (HR 1.6); and LVEF &lt;40% (all p &lt; 0.05). Predictors of late MI were older age, ACS presentation at screening, LVEF &lt; 40% and insulin use.

Conclusions

Among diabetic patients who screened for the FREEDOM Trial, among 34% with MVD CABG was associated with lower rates of non-fatal MI and MACE compared to PCI and medical therapy. The poorest outcomes were observed in DM patients with MVD managed with medical therapy alone.

Abstract P187 Figure. SYNTAX scores &late events in diabetics

P333Late mortality after pharmaco-invasive PCI for STEMI

Background

Worldwide, and in Australia, a large proportion of patients with ST-segment elevation myocardial infarction (STEMI) are unable to undergo timely primary percutaneous coronary intervention (PCI), and so are transferred for PCI after receiving fibrinolytic therapy (so-called pharmaco-invasive PCI).

Methods

Our Hospital, the primary PCI centre for Southwest Sydney, Australia receives patients for both primary PCI and transferred post- fibrinolytic therapy for rescue or prognostic PCI. Associations were determined between late outcomes (bleeding according to Bleeding Academic Research Consortium (BARC) criteria and mortality) and reperfusion strategy, either primary PCI, or pharmaco-invasive PCI, in patients undergoing PCI for STEMI during hospitalization.

Results

Among 2083 consecutive patients (80% male) with STEMI who underwent PCI (1076 [52%] primary PCI and 1007 [48%] pharmaco-invasive PCI), mortality at 3 years was 8.7%,11.1% after primary PCI and 6.2% after pharmaco-invasive PCI (9.4% after rescue PCI and 4.6% after prognostic PCI); p<0.001 (Figure). Rates of type 2–5 BARC bleeding post-PCI were 35% after primary PCI and 24% after pharmaco-invasive PCI (42% after rescue PCI and 15% after prognostic PCI); p<0.001. while the rate of major bleeding type 3b-5 were 5% after primary PCI and 3% after pharmaco-invasive PCI (8% after rescue PCI and 1% after prognostic PCI); p=0.112.The independent predictors of 3 year mortality were, pre-PCI cardiogenic shock HR=0.25 [95% CI: 0.16–0.39], p<0.001), age (HR=1.05 [95% CI: 1.03–1.06], p<0.001), TIMI 3 flow post-PCI (HR=5.25 [95% CI: 2.51–11.00], p≤0.001), eGFR<60mL/min/1.73m2 (HR=2.90 [95% CI: 1.93–4.34], p≤0.001), post PCI bleeding (HR=2.17 [95% CI: 1.53–3.08], p≤0.001), anterior infarction (HR=1.76 [95% CI: 1.23–2.51], p=0.002), and female gender (HR=1.56 [95% CI: 1.07–2.27], p=0.022); and primary PCI (HR=1.6 [95% CI: 1.18–2.19; p=0.003]. On multi-variable analysis, age, cardiogenic shock presentation, rescue PCI, intra-aortic balloon pump, Pre-procedural anaemia, (all p<0.001) and eGFR<60mL/min/1.73m2 (p=0.006) were associated with bleeding.

Figure 1. Late survival after primary & PI PCI

Conclusion

Among patients with STEMI who underwent pharmaco-invasive PCI had lower mortality rates than to those who had primary PCI, though procedural selection criteria may have been different; bleeding rates were similar. Among suitable patients pharmaco-invasive PCI should be evaluated in large clinical trials.

P6443Late outcomes in patients undergoing PCI for ST elevation myocardial infarction with respect to diabetic status and completeness of revascularisation

Objectives

This paper examines the degree to which the poor prognosis of ST elevation myocardial infarction (STEMI) patients with diabetes mellitus (DM) can be attributed to incomplete revascularization (ICR).

Background

Cardiovascular disease is the most common cause of death for patients with DM; patients with DM often have complex coronary disease and ICR. In STEMI the relative impact of DM and ICR is uncertain as these two factors frequently co-exist, the potential for confounding is high.

Methods and results

Of 589 consecutive STEMI patients, 22% had DM, who compared to patients without DM were of similar age (59 years), were more often female, had more hypertension and dyslipidaemia, but less often were smokers. A residual SYNTAX Score (rSS) >8, which defined ICR, occurred in 33%. Late cardiac death [median 3.5 years] was 4% among those without DM and 12% in those with DM (p=0.002) (p<0.001), and was 3% among 396 with rSS≤8 and 12% in 193 patients with rSS>8 (p<0.001). Patients with both ICR and DM accounted for only 8% of the STEMI population but 30% of all cardiac deaths. At final follow up (3.5 years) cardiac death rates (see Figure) were 22% in patients with both DM and ICR; these were significantly higher than rates in patients with ICR but no-DM (9%, p=0.034), and those with DM and rSS≤8 (6%, p<0.019). Multivariable analysis for cardiac death found a HR for ICR of 2.89 (95% CI 1.31–6.37; p=0.009) and a HR for DM of 5.18 (95% CI 2.45–10.97, p<0.001).

Diabetes, cardiac death & rSS

Conclusions

While ICR in DM patients with STEMI predicts a significantly poorer outcome, the poor prognosis seen in patients with DM is not explained by the degree of ICR alone. Both ICR and DM contribute independently to the risk of cardiac death in STEMI patients.

Multiple resistance to macrocyclic lactones in the sheep scab mite Psoroptes ovis

The astigmatid mite Psoroptes ovis (Acari: Proroptidae) causes the highly contagious and debilitating ovine disease, sheep scab. This ectoparasitic infection has a high economic and animal welfare impact on British sheep farming. Following recent work demonstrating resistance of Psoroptes mites to moxidectin, a widely used macrocyclic lactone (ML) treatment for scab, the current study compared the toxicity of three of the commonly administered macrocylic lactone therapeutic treatments (moxidectin, ivermectin and doramectin) to P. ovis from outbreak populations that had appeared unresponsive to treatment. These outbreak populations were from Wales and south west England. The data presented demonstrate that there is resistance to all three available ML compounds in populations of Psoroptes mites. However, considerable variation in response suggested that resistance alone was not responsible for the reported lack of efficacy in all of the submitted cases; lack of response in others may be associated with inappropriate treatment application or management. These data highlight the importance of the appropriate use of these compounds to manage national scab incidence at levels that are consistent with acceptable animal welfare standards, while attempting to reduce the development and spread of resistance.