The Measurement of Acculturation in Neuropsychological Evaluations of Hispanic/Latino Individuals across the Lifespan: A Scoping Review of the Literature

OBJECTIVE

Acculturation has been linked to health outcomes in Hispanics/Latinos (H/Ls). However, there is equivocal evidence of a relationship between acculturation and neuropsychological outcomes. Various factors limit the ability to subject the evidence to systematic/meta-analytic review. We sought to examine the current state of the literature in the context of H/Ls and neuropsychology and describe the various limitations of measuring acculturation across the lifespan.

METHOD

Applying a scoping review approach, we identified unique stand-alone (e.g., questionnaires) measures of acculturation. We focused on psychometric (e.g., internal consistency) and other characteristics (e.g., language, structure/format) and description of the validation samples (e.g., cultural background/country of origin).

RESULTS

A total of 40 unique acculturation measures were identified. Measures spanned various domains (e.g., language proficiency, food preference, music choice), and relied heavily on linguistic behavioral characteristics. Internal consistency varied from unacceptable to clinically acceptable ranges. Variable approaches to development and validation were reported. Validation samples varied from 22 to 2,048 respondents (median = 380), most of which represented a general adult population. Only eight measures were validated for use in pediatric populations; none were developed specifically for use with older adults.

CONCLUSIONS

Published measures are outdated, evidence highly variable psychometric and methodological weaknesses, and lack a lifespan perspective. Several themes in the types of items considered elemental to the acculturative process are revealed and findings are summarized via an "ABC" framework, categorizing items as antecedents, behaviors, and consequent acculturative changes, that lends itself to clinical and research settings.

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.

Confidentiality in medical images through a genetic-based steganography algorithm in artificial intelligence

Nowadays, image steganography has an important role in hiding information in advanced applications, such as medical image communication, confidential communication and secret data storing, protection of data alteration, access control system for digital content distribution and media database systems. In these applications, one of the most important aspects is to hide information in a cover image whithout suffering any alteration. Currently, all existing approaches used to hide a secret message in a cover image produce some level of distortion in this image. Although these levels of distortion present acceptable PSNR values, this causes minimal visual degradation that can be detected by steganalysis techniques. In this work, we propose a steganographic method based on a genetic algorithm to improve the PSNR level reduction. To achieve this aim, the proposed algorithm requires a private key composed of two values. The first value serves as a seed to generate the random values required on the genetic algorithm, and the second value represents the sequence of bit locations of the secret medical image within the cover image. At least the seed must be shared by a secure communication channel. The results demonstrate that the proposed method exhibits higher capacity in terms of PNSR level compared with existing works.

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<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<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.

Association of extracellular vesicle inflammatory proteins and mortality

Even before the COVID-19 pandemic declines in life expectancy in the United States were attributed to increased mortality rates in midlife adults across racial and ethnic groups, indicating a need for markers to identify individuals at risk for early mortality. Extracellular vesicles (EVs) are small, lipid-bound vesicles capable of shuttling functional proteins, nucleic acids, and lipids. Given their role as intercellular communicators and potential biomarkers of disease, we explored whether circulating EVs may be markers of mortality in a prospective, racially, and socioeconomically diverse middle-aged cohort. We isolated plasma EVs from 76 individuals (mean age = 59.6 years) who died within a 5 year period and 76 surviving individuals matched by age, race, and poverty status. There were no significant differences in EV concentration, size, or EV-associated mitochondrial DNA levels associated with mortality. We found that several EV-associated inflammatory proteins including CCL23, CSF-1, CXCL9, GDNF, MCP-1, STAMBP, and 4E-BP1 were significantly associated with mortality. IL-10RB and CDCP1 were more likely to be present in plasma EVs from deceased individuals than in their alive counterparts. We also report differences in EV-associated inflammatory proteins with poverty status, race, and sex. Our results suggest that plasma EV-associated inflammatory proteins are promising potential clinical biomarkers of mortality.

Understanding the role of maternal antibodies on protection from enteric pathogens

A major function of the microbiota is to shield the host from infection with pathogens via a process called colonization resistance. High affinity, T cell-dependent antibodies, produced through interaction between CD4 T follicular helper (Tfh) cells and germinal center (GC) B cells, can modulate gut microbiota diversity and function. We discovered that mice lacking maternal antibodies display increased levels of Tfh and GC B cells in gut draining lymphoid tissues such at the mesenteric lymph nodes and Peyer’s patches. This response is seen in the context of colonization by microbes as germ-free mice lacking maternal antibodies do not show increased Tfh and GC B cell responses.

Given the importance of Tfh cells and TD antibody responses in regulating host-microbe interactions, we tested whether the elevation in Tfh and GC B cells seen in maternal antibody deficient pups alter susceptibility to colonization by the pathogen Salmonella typhimurium. We infected maternal antibody sufficient and deficient pups with the model pathogen Salmonella typhimurium via oral gavage. To block the Tfh and GC B cell response, we treated half of the pups from each group with anti-inducible T cell co-stimulator ligand (aICOSL) while the other half received an isotype control antibody. We found no difference in Salmonella typhimurium burden in the spleen, liver or cecum between maternal antibody sufficient or deficient pups treated aICOSL or isotype control antibody. Taken together, our data suggest that maternal antibodies and the subsequent rise in Tfh and GC B cells do not alter susceptibility to Salmonella typhimurium colonization later in life.

Supported by AAI Careers in Immunology Fellowship

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.

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

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

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.

Cognition and the Predictive Utility of Three Risk Scores in an Ethnically Diverse Sample

BACKGROUND

Various factors, such as age, cardiovascular concerns, and lifestyle patterns, are associated with risk for cognitive decline and Alzheimer's disease (AD). Risk scores model predictive risk of developing a disease (e.g., dementia, stroke). Many of these scores have been primarily developed in largely non-Hispanic/Latino (non-H/L) White samples and little is known about their applicability in ethno-racially diverse populations.

OBJECTIVE

The primary aim was to examine the relationship between three established risk scores and cognitive performance. These relationships were compared across ethnic groups.

METHODS

We conducted a cross-sectional study with a multi-ethnic, rural-dwelling group of participants (Mage = 61.6±12.6 years, range: 40-96 years; 373F:168M; 39.7% H/L). The Cardiovascular Risk Factors, Aging and Dementia (CAIDE), Framingham Risk Score (FRS), and Washington Heights-Inwood Columbia Aging Project (WHICAP) score were calculated for each participant.

RESULTS

All three scores were significantly associated with cognition in both H/L and non-H/L groups. In H/Ls, cognition was predicted by FRS: β= -0.08, p = 0.022; CAIDE: β= -0.08, p < 0.001; and WHICAP: β= -0.04, p < 0.001. In non-H/Ls, cognition was predicted by FRS: β= -0.11, p < 0.001; CAIDE: β= -0.14, p < 0.001; and WHICAP: β= -0.08, p < 0.001. The strength of this relationship differed between groups for FRS [t(246) = -4.61, p < 0.001] and CAIDE [t(420) = -3.20, p = 0.001], but not for WHICAP [t(384) = -1.03, p = 0.30], which already includes ethnicity in its calculation.

CONCLUSION

These findings support the utility of these three risk scores in predicting cognition while underscoring the need to account for ethnicity. Moreover, our results highlight the importance of cardiovascular and other demographic factors in predicting cognitive outcomes.

Violence, Place, and Strengthened Space: A Review of Immigration Stress, Violence Exposure, and Intervention for Immigrant Latinx Youth and Families

Latinx immigrant families are greatly impacted by US policies and practices that limit immigrant families' and children's rights. This article reviews the effects of such policies and the growing literature examining migration experiences. Latinx immigrant youth and parents may encounter multiple stressors across the stages of migration, including physical and structural violence, fear, poverty, and discrimination, which contribute to higher rates of mental health problems in this population. Despite significant trauma exposure, immigrants demonstrate incredible resilience within themselves, their families, and their communities and through movements and policies aimed at protecting their rights. Numerous culturally relevant universal, targeted, and intensive interventions were developed to magnify these protective factors to promote healing, advance immigration reform, and provide trauma-informed training and psychoeducation. Psychologistsplay a crucial role in implementing, evaluating, and advocating for accessible and collaborative approaches to care so that Latinx immigrant families have the resources to combat the harmful sequelae of immigration stress.

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.

Comparison of clinical and echocardiographic scores to predict pre-capillary pulmonary hypertension

Funding Acknowledgements

Type of funding sources: None.

Background

Right heart catheterization (RHC) is the gold-standard method to confirm the diagnosis of Pulmonary Hypertension (PH) and to differentiate between pre- and post-capillary PH. However, RHC is an invasive and sometimes low-available procedure, which cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to predict pre-capillary PH. We aimed to compare the performance of four of these scores in a population with suspected PH.

Methods

We retrospectively included consecutive patients who underwent RHC for suspected PH. If the non-invasive evaluation was clearly suggestive of left heart disease, RHC was dispensed being considered not clinically relevant. We also excluded patients with congenital heart disease. We compared the performance of four scores to predict pre-capillary PH: Score 1 (Opotowsky et al.), score 2 (Richter et al.), score 3 (Berthelot et al.) and score 4 (D’Alto et al..

Results

Of the 142 included patients, 76 patients had pre-capillary PH, 42 had post-capillary PH and 24 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in the majority of our patients (82% for score 1, 100% for score 2, 98% for score 3 and 83% for score 4). The AUC to predict pre-capillary PH using these scores were 0.74 for score 1, 0.77 for score 2, 0.82 for score 3 and 0.70 for score 4 (p = 0.37). Using the best cut-off points for each score, the score 3 correctly classified the highest percentage of patients (75.5%), with a sensitivity of 92% and a specificity of 60% to predict pre-capillary PH.

Conclusion

Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with a fairly good performance. Score 3 (Berthelot et al.) was the score with the highest discrimination power. Validation of these scores in larger cohorts of patients with suspected PH are needed.

Clinical and echocardiographic characteristics Interpretation Opotowsky et al. LA diameter (&lt;32 mm: +1, &gt;24 mm: -1), mid-systolic notch or acceleration time &lt;80 msec (+1), E/e’&gt;10 (-1) Score ≥ 0 has a sens. 100% and a spec. 62% for pre-capillary PH Richter et al. Age &gt; 68 years (+1), BMI &gt; 30 kg/m2 (+1), absence of RV enlargement (+1), LA enlargement (+1) Score &gt;4 predicted post-capillary PH (AUC 0.78) Berthelot et al. Atrial fibrillation (+2), diabetes mellitus (+1), LA enlargement (15 ≤ LAA &lt; 19: +1, 19 ≤ LAA &lt; 24: +2, ≥ 19 cm2: +3), RV end-diastolic area (&lt;27 cm2: +2), LV mass index (46 &lt; LVMI ≤ 62: +1, 62 &lt; LBMI ≤ 81: +2,&lt; 81 cm2: +3) Score &lt;5 ruled out post-capillary PH D’Alto et al E/e" ≤ 10 (+2), dilated non-collapsible IVC (+2), EI ≥ 1.2 (+1), right-to-left heart chamber dimension ratio &gt; 1 (+1), RV forming the heart apex (+1) Score ≥ 2 has a sens. 99% and a spec. 54% for pre-capillary PH (AUC 0.85) Table 1. The clinical and echocardiographic scores evaluated in this study. AUC: area under the curve, EI: eccentricity index, IVC: inferior vena cava, LA: left atrial, LAA: left atrial area, LV: left ventricle, LVMI: left ventricle mass index, PH: pulmonary hypertension, Sens.: sensibility, Spec.: specificity, RV: right ventricle Abstract Figure.

Predictors of survival in patients with precapillary pulmonary hypertension

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although the perceived prognosis of patients with precapillary pulmonary hypertension (PH) is poor, the natural history of this condition is very heterogeneous. In this study we sought to identify predictors of poor outcomes which could help refine prognosis.

Methods

We studied consecutive patients referred to our centre from 12/2016 to 11/2018 with confirmed precapillary PH. A range of clinical, laboratory, echocardiographic and right heart catheterization (RHC) data variables were collected to assess predictors of survival. Outcome was defined as mortality from any cause.

Results

Of the 80 included patients, 51 (64%) were female and mean age was 60.5 ± 16.0 years. The majority of patients (45%) had pulmonary arterial hypertension (group 1) and 41% were chronic thromboembolic pulmonary hypertensive disease patients (group 4). During a median follow-up of 18.7 [IQR 12.3 – 26.7] months, 10 patients (12.5%) died. New York Heart Association (NYHA) functional class (HR 19.4 [95% CI 2.56 - 147.5], p = 0.004) was the strongest predictor of mortality, whereas higher haemoglobin (HR 0.70 [0.49 - 0.99], p= 0.047) and 6-minute walking distance (6MWD) expressed as percentage of predicted (HR 0.96 [0.93 - 0.99], p = 0.004) were associated with better survival overall. Echocardiographic parameters such as eccentricity index (HR 3.35 (95% CI 1.11 - 10.0), p = 0.031), short pulmonary acceleration time (HR 0.98 [95% CI 0.96 - 0.99], p = 0.008), the presence of moderate to severe tricuspid regurgitation (HR 6.46 [95% CI 1.67 - 25.0], p = 0.007) and pericardial effusion (HR 3.86 [95% CI 1.12 - 13.4], p = 0.033) were also associated with death. Traditional right ventricular function parameters such as fractional area change, tricuspid annular plane systolic excursion (TAPSE) and S velocity of the lateral annular tricuspid annulus did not predict mortality in these patients. Invasive pressures and pulmonary vascular resistance measured by RHC were also not associated with mortality. In multivariable analysis, NYHA functional class was the only independent predictor of mortality in patients with precapillary PH (HR 14.5 [95% CI 2.3 - 146.8], p = 0.006).

Conclusion

Eccentricity index, short pulmonary acceleration time, moderate to severe tricuspid regurgitation and pericardial effusion were associated with poor survival. Functional class was the strongest independent predictor of mortality in precapillary PH patients. These parameters may help stratify the risk of death in this heterogenous population.

Diabetes and pre-infarct angina. Time to rethink comorbidities in the reperfusion-injury phenomenon?

Background

Pre-infarct angina (PIA) has been shown to reduce reperfusion injury and infarct size in patients with ST-elevation myocardial infarction (STEMI) and currently represents the most efficient form of myocardial conditioning yet discovered. The role of diabetes on ischemic preconditioning remains controversial – while some pre-clinical studies suggest that diabetes blunts ischemic conditioning, clinical studies are lacking.

Methods

We retrospectively evaluated consecutive patients with STEMI admitted in our hospital from January 2008 to August 2018 who underwent primary angioplasty (PCI). PIA was defined as chest, arm or jaw pain during the preceding 48h before STEMI diagnosis. Peak creatine kinase and peak Troponin T levels were used as a surrogate of infarct size. Ischemic time (IT) was defined as the time between the onset of symptoms to the restoration of flow after either guidewire passage, thrombus aspiration or first balloon inflation.

Results

Of the 1143 included patients, 74% (n=845) were male and mean age was 62.6±13.1 years. A quarter of STEMI-patients had diabetes (25%, n=285). Almost a third of the patients (32%, n=359) had a history of angina in the preceding 48h before STEMI (PIA). The proportion of PIA was similar between diabetic and non-diabetic patients. In patients with diabetes, PIA was associated with lower creatine kinase (CK) (1144 [500–2212] vs 1715 [908–3309] U/L, p=0.0029) and Troponin T (TnT 3.30 [1.90–6.58] vs 4.88 [2.50–9.58] ng/mL, p=0.0022) despite similar IT as compared to those without PIA (328 [200–554] vs. 258 [180–530] minutes, p=0.1365). In non-diabetic patients, PIA was not significantly associated with infarct size (TnT 3.74 [2.23–7.11] vs 4.56 [2.44–7.77] ng/mL, p=0.1945; CK 1549 [910 - 2909] vs 1793 [996 - 3078] U/L, p=0.0653) even after adjustment for the increased ischemic time (240 [150–550] vs. 210 [140–405] minutes, p=0.0128) (β=−0.12, p=0.085 for CK and β=−0.11, p=0.183 for TnT). A significant interaction was observed between the existence of PIA and diabetes on peak TnT (p=0.026 for interaction) and CK (p=0.047 for interaction), which was independent of the culprit vessel and IT. During a median follow-up period of 18.0 [12.1–25.5] months, 268 (24.0%) MACE events have occurred (165 deaths, 27 strokes, 46 myocardial infarctions and 26 target vessel revascularization). PIA was associated with a significant reduction in the incidence of MACE (HR 0.66 (95% CI: 0.48–0.89)) driven by a reduction on mortality (HR 0.44 (95% CI: 0.28–0.70)). Diabetes was associated with an increased incidence of MACE (HR 1.42 (95% CI: 1.07–1.89)). No interaction was found between diabetes and PIA on their effect on MACCE events.

Conclusion

PIA is a strong predictor of favourable outcomes in the setting of STEMI. The effect of PIA on myocardial protection in patients with STEMI undergoing primary PCI seems to be modulated by the presence of diabetes.

Distribution of Peak CK and Peak TnT

Funding Acknowledgement

Type of funding source: None

Iatrogenic transthyretin cardiac amyloidosis after sequential liver transplantation

Introduction

Sequential liver transplantation (SLT) uses livers excised from patients with hereditary transthyretin-related amyloidosis during liver transplantation as grafts to other patients with severe hepatic pathologies and a reserved prognosis. We intended to investigate the development of cardiac manifestations consistent with iatrogenic transthyretin amyloidosis (iATTR).

Methods

We retrospectively analyzed the medical records of 72 consecutive patients submitted to SLT between 2007 and 2010, who received livers with V30M mutation.

Results

Our sample had 79% male patients and a mean age at transplantation of 55±6 years. Median follow-up time was 80 months, were 44% of the patients died. One-year mortality rate after SLT was 7%. Clinical manifestations of iATTR occurred in 29% of individuals, on average 6 years after SLT, and amyloid was seen in 76% of those who underwent a biopsy. Left ventricular hypertrophy (LVH) was identified in 42 (58%) patients at baseline. Considering 39 patients that had an echocardiography at baseline and during follow-up, 22 (61%) presented de novo LVH or basal LVH worsening during follow-up, with a significant increase of wall thickness (11±1 to 13±3 mm; p&lt;0.001). They had similar age at presentation (55±5 vs 58±5, p=0.249) and incidence of hypertension (52% vs 64%, p=0.365) but higher incidence of chronic kidney disease (CKD; 68% vs 29%, p=0.023). Mortality during follow-up was higher in patients with de novo LVH or worsening LVH but not significantly, probably due to the sample size (23% vs 7%, p=0.221, log rank test p=0.262). Considering the global sample, significant conduction changes were rarely seen (1 patient); however, there was a trend towards an increase in PR interval and atrial fibrillation was reported in 8% of cases.

Conclusions

In our sample, probable iATTR was often seen within a decade after SLT. Further investigation of LVH needs to be made in these patients, as it can represent amyloid cardiomyopathy, but other contributing factors such as hypertension, CKD and age need to be taken into consideration. In our sample, development of a possible infiltrative pattern was relatively more common and conduction disorders were rarer than one would extrapolate from hereditary early onset ATTR V30M patients. Further studies may help us clarify if indeed these patients behave like late onset ATTR V30M. Our data suggests that these patients should probably undergo periodic cardiac imaging during follow-up.

Funding Acknowledgement

Type of funding source: None

Supraventricular ectopic activity as a predictor of atrial fibrillation – what we didn't see 10 years ago

Background

Cardioembolism induced by atrial fibrillation (AF) is responsible for up to 33% of all ischemic strokes. 24-hour Holter monitoring in stroke and transient ischemic attack (TIA) patients is used as a routine investigation to search for occult paroxysmal atrial fibrillation (PAF), which may have crucial prognostic impact. Excessive supraventricular ectopic activity (ESVEA) is also a stroke risk factor, probably related to the risk of developing AF.

Purpose

To observe the incidence of AF at a long-term follow-up and to evaluate the clinical, electrocardiographic and echocardiographic predictors of new onset AF in stroke patients.

Methods

Patients in sinus rhythm who performed Holter between October 2009 and October 2011 in the setting of post stroke or TIA were included; patients with previous AF were excluded. These patients were followed for 8 to 10 years. Clinical, electrocardiographic and echocardiographic data were collected. ESVEA was defined by ≥500 premature atrial contractions per 24 hours or any sustained supraventricular tachycardia episode.

Results

104 patients were included, 54% were male, with a mean age of 63.8±14.7 years at the time of the event. In relation to cardiovascular risk factors, 59% had hypertension, 47% dyslipidemia, 14% diabetes, 44% were smokers or previous smokers; 67% of patients were high consumers of alcohol. 79.8% had a stroke and 21.2% a TIA. 24-hour Holter monitoring revealed ESVEA in 13.5% of patients and PAF in 1.9%. All patients with PAF had a previous stroke and were older than 55.

At a follow-up of 8–10 years, new onset AF was detected in 11.5%; these patients had similar mortality comparing to those in sustained sinus rhythm (21.2% vs 16.7%, p=0.724). Alcohol intake, an established risk factor for development of AF, was associated with a non-significant increase of AF (17.3% vs 11.5%) while the presence of cardiovascular risk factors was not associated with AF development. We found a statistically significant difference between patients with and without ESVEA concerning to new onset of AF (35.7% vs 8.0%, p=0.010). ESVEA seems to be related with a higher mortality at a long follow-up, although this difference wasn't statistically significant (35.7% vs 18.2%, p=0.132). Concerning to echocardiographic parameters, patients whit left atrium enlargement showed a higher incidence of AF at follow-up (14.7% vs 7.9%), and the presence of mitral regurgitation were not related with new onset of AF. Patients' age was also not related with new onset of AF during follow-up.

Conclusion

Atrial fibrillation is considered the main cause of stroke. Our study showed that ESVEA is a strong predictor of new onset AF and highlights that Holter monitoring could be an important tool not only to diagnose AF but also to identify patients in risk of develop AF. Diagnostic of new AF during long-term follow up didn't correlate with higher mortality.

Funding Acknowledgement

Type of funding source: None

Hereditary transthyretin amyloidosis: predictors of conduction disease

Introduction

Pacemakers are frequently needed due to a high prevalence of conduction disease in mutated ATTR amyloidosis (mATTR). We aimed to identify the variables associated with the need of pacemaker implantation in this population.

Methods

We retrospectively studied 255 patients with suspicion of heart involvement of mATTR observed at our cardiology clinic during the last year. Clinical and outcome data were retrieved by chart review. We have defined the need for pacemaker implantation as: 1) the formal guidelines indications or 2) Ventricular pacing &gt;10% in patients who had prophylactic pacemaker implantation prior to liver transplantation (LT). This way, we have defined 3 different groups: group 1: patients with no evidence of conduction disease; group 2: patients with conduction disease, but no formal indication for pacemaker implantation; and group 3: patients with formal indication for pacemaker implantation or ventricular pacing &gt;10% in patients who had prophylactic pacemaker implantation prior to hepatic transplantation.

Results

We included 255 patients (50±14 years, 53% male, 52.5% treated with tafamidis and 27% had prior LT, and 10% with atrial fibrillation), 43.3% with no evidence of conduction disease, 32.3% with conduction disease, but no formal indication for pacemaker implantation and 24.4% with formal indication for pacemaker implantation. Patients with formal indication for pacemaker implantation were older, with longer duration of neurologic manifestations, with higher concentration of both Troponin T and NT-proBNP and with higher number of organs affected. In multivariate analysis, longer duration of neurologic manifestations (OR 1.090 – 95% IC: 1.036–1.145, p-value 0.001), Left ventricular (LV) maximal wall thickness (OR 1.230 – 95% CI: 1.070–1.414, p-value 0.004), neurologic staging (OR 3.420 – 95% CI: 1.443–8.104, p-value 0.005) and higher number of organs affected (OR 1.719 – 95% CI: 1.218–2.424, p-value 0.002) all showed to be independent predictors of the need for pacemaker implantation, in contrast to LV ejection fraction and serum concentration of Troponin T and NT-proBNP. We've also found a statistical significant association between conduction disease and ophthalmic manifestations.

Conclusions

Our findings suggest that the need for pacemaker implantation in patients with mATTR is closer linked to the duration, severity and affected number of organs than to cardiac biomarkers or echocardiographic findings.

Funding Acknowledgement

Type of funding source: None

Methods for quantification of cannabinoids: a narrative review

BACKGROUND

Around 144 cannabinoids have been identified in cannabis plant, among them tetrahydrocannabinol (THC) and cannabidiol (CBD) are the most prominent ones. Because of the legal restrictions on cannabis in many countries, it is difficult to obtain standards to use in research; nonetheless, it is important to develop a cannabinoid quantification technique with pharmaceutical applications for quality control of future therapeutic cannabinoids.

METHOD

To find relevant articles for this narrative review paper, a combination of keywords such as medicinal cannabis, analytical, quantification and cannabinoids were searched for in PubMed, EMBASE, MEDLINE, Google Scholar and Cochrane Library (Wiley) databases.

RESULTS

The most common cannabinoid quantification techniques include gas chromatography (GC) and high-performance liquid chromatography (HPLC). GC is often used in conjunction with mass spectrometry (MS) or flame ionization detection (FID). The major advantage of GC is terpenes quantification however, for evaluating acidic cannabinoids it needs to be derivatised. The main advantage of HPLC is the ability to quantify both acidic and neutral forms of cannabinoids without derivatisation which is often with MS or ultraviolet (UV) detectors.

CONCLUSION

Based on the information presented in this review, the ideal cannabinoid quantification method is HPLC- MS/MS for the cannabinoids.

Using technology to access health information: greater WASH knowledge/behaviors in Indonesian mothers

Background

Despite attention, childhood stunting in Indonesia persists. Proper WASH (Water, Sanitation, and Hygiene) practices help lower childhood stunting. As internet access in Indonesia grows, seeking health information online is increasing. However, research on using technology to increase WASH knowledge and behaviors in Indonesia is limited. The purpose of this study is to assess whether Indonesian women using technology to access health information have higher WASH knowledge and behaviors.

Methods

1,740 mothers with children under the age of two were randomly selected with three-stage cluster sampling. They were surveyed and interviewed about handwashing and sanitary defecation benefits, steps, and practices. Adjusted and unadjusted logistic and linear regression models were used to compare WASH outcomes between those who used technology to access health information and the control group. The models controlled for mother's age, mother's education, and total household income.

Results

Participants who used technology to access health information were more likely to know the benefits (OR = 2.603; CI = 1.666-4.067) and five critical times (OR = 1.217; CI=.969-1.528) of proper handwashing. Mothers were more likely to know the risks of open defecation (OR = 1.627; CI = 1.170-2.264) and understand disease transmission from stool (OR = 1.894; CI = 1.438-2.495). Those using technology to access health information were more likely to report using a gooseneck, squat toilet, septic tank, or closed ground to discard feces than the control group (OR = 3.858; CI = 2.628-5.665).

Conclusions

Using technology to access health information was associated with increased handwashing and defecation knowledge and safe elimination of feces. It was not associated with an increase in handwashing with soap. Technology can be used to increase WASH knowledge and behavior, but further research is needed to effectively use technology to increase optimal handwashing behaviors.

Key messages

Increasing technology access may encourage good water, sanitation and hygiene behavior change. Using technology to access health information yielded safer defecation practices but not better handwashing practices. Further research is needed.

Exposure to a National Communication Campaign to Prevent Stunting in Indonesia

Background

Reducing childhood stunting continues to be a priority in Indonesia. In 2015, the National Nutrition Communication Campaign (NNCC) implemented mass media and interpersonal communication (IPC) interventions to disseminate stunting-related information. The purpose of this study was to understand the factors associated with exposure to the media and IPC components of NNCC. The mass-media component was designed to influence attitudes, norms, and behaviors, while the IPC component was designed to develop skills to lead to behavior change.

Methods

The media campaign targeted a national audience and the IPC component of the campaign operated at a district level. IMA World Health collected data in three rural districts targeted with both media and IPC intervention components. Using simple random sampling, a sample of 1,734 caregivers was collected. Responses relating to demographic and socioeconomic factors, use of social media and WhatsApp, and electronic device ownership were analyzed using multiple linear regression analyses.

Results

Participants averaged 28.9 years old and most completed primary school. Exposure to the media component was higher than exposure to IPC. Ownership of an internet-accessible device (IAD) and social media use was negatively associated with exposure to IPC. Mothers who used a device to access health information were more likely to have been exposed to the media component. Exposure to the media campaign was positively associated with owning an IAD with WhatsApp.

Conclusions

Access to internet-accessible devices was predictive of positive exposure to mass-media and negative exposure to IPC. This latter finding was unexpected and may suggest people with IADs consume health online and feel less inclined to participate in IPC activities. Caregivers with technology and internet access may benefit from media-based interventions, whereas those with limited access may benefit from traditional interpersonal mediums.

Key messages

Future community health efforts in similar rural regions, should consider the use of both mass media and interpersonal communication interventions to influence health behaviors. Use of internet-accessible technology was positively related to exposure to the mass media campaign while negatively related to IPC exposure.

P1718 Multi-modal imaging characterization of contained aortic subannular rupture after transcatheter aortic valve implantation

INTRODUCTION

Aortic annular rupture is a potentially catastrophic complication after transcatheter aortic valve implantation (TAVI), with an estimated incidence of 1%. Rupture occurs in the anatomical device landing zone, that extends from the aortic root to the distal left ventricular outflow tract (LVOT). It usually occurs in the context of highly calcified aortic valve and LVOT, implantation of balloon-expandable valves, valve oversizing and overdilation to treat paravalvular leakage.

CASE REPORT

An 80-year old woman with no past relevant medical history was admitted to our Cardiology Department with decompensated heart failure because of symptomatic severe aortic stenosis, moderate aortic regurgitation and mild left ventricular (LV) dysfunction. She was already in waiting list for TAVI procedure, after being refused for conventional aortic valve replacement due to a "porcelain" aorta. Her pre-operative angiography showed no significant coronary heart disease, and the cardiac computed tomography (cardiac-CT) revealed a severely calcified aortic valve (Agatston score = 4940). An Acurate neo L (27mm) valve was implanted after clinical stabilization with no immediate complications. Because of paravalvular regurgitation, sequential post-dilation was performed with 25mm and 26mm balloons. Post-procedural angiography showed no contrast extravasation (Panel A). In the first hours after the procedure, she was hypotensive with non-specific mild chest discomfort. The EKG showed sinus rhythm with left anterior fascicular block. A transthoracic echocardiogram revealed a moderate pericardial effusion, with no signs of tamponade, and a moderate "paravalvular leak "at the level of the non-coronary cusp to a pulsatile cavity, between the aortic root and the left atrium (Panel B and C). The patient evolved with haemodynamic and electrical stability with no recurrence of chest discomfort. A retrospective cardiac-CT was performed that confirmed the presence of a multilobular cavity below the left coronary artery in continuous with the LVOT, compatible with a contained subannular aortic rupture (Panel E and F), at the level of previous gross calcification in the pre-operative cardiac-CT (Panel D). The case was discussed in Heart Team and a conservative strategy was adopted due to clinical stability and inoperable condition. The patient was discharged at day 28, after CT reavaluation,, that demonstrate similar findings.

CONCLUSION

We report a rare and potentially fatal complication of TAVI with a self-expandable valve. This clinical case illustrates how balloon post-dilation to treat moderate post-procedural paravalvular regurgitation lead to tearing of a highly calcified aortic annulus. A multi-modality imaging approach, with echocardiography and computer tomography, was essential for full anatomical definition of the subannular rupture, clinical decision-making and for follow-up surveillance.

Abstract P1718 Figure. Panel A,B,C,D,E,F.

P1310 Prosthetic valve endocarditis or thrombus?

One cause of constitutional syndrome in patients previously submitted to valve replacement surgery is a prosthetic endocarditis; this occurs in 1-6% of valve surgeries and has an adverse prognosis. Although this is a likely etiology, it is important to keep other possibilities in mind. This clinical case is about a 61 years old male, with known history of smoking, atrial fibrillation anticoagulated with warfarin (with low TTR), and rheumatic fever in childhood, with severe aortic stenosis/regurgitation and moderate mitral regurgitation. In August 2018 he was admitted in our hospital with mitral valve endocarditis cause by Streptococcus agalactiae. He was submitted to an aortic and mitral valve replacement surgery with 2 bioprothesis. Three months later he was admitted again with weight loss, fatigue, dyspnea for small efforts and worsening anemia. The first diagnosis hypothesis was prosthetic endocarditis. The echocardiogram showed normo-functioning aortic bioprothesis; obstructive mitral bioprothesis with an image suggestive of a vegetation; and a de novo mass in the left auricle, compatible with a thrombus. This clinical case was discussed in Heart Team: as the patient was clinically stable, it was opted for an initial conservative approach; although there was a strong clinical suspicion that all the clinical case was due to thrombotic manifestations (assuming that the vegetations had a non-infectious origin), he was nonetheless medicated with vancomycin, gentamicin and rifampicin, as the diagnosis of early culture negative prosthetic endocarditis could not be discarded. He was anticoagulated with enoxaparin. In the reevaluation echocardiogram there was a significative reduction of the left atrial thrombus and disappearance of the mitral valve vegetation image, with improvement of the mitral valve prosthetic gradients. The case was discussed again in Heart Team: due to the clinical evolution, the hypothesis that this was all caused by a thrombotic manifestation grew stronger; it was opted not to submit the patient to a new surgery and the antibiotic therapy was suspended. To study the pro-thrombotic state and the constitutional syndrome, a full body CT was requested: "hilar-mediastinal and bilateral hilar adenopathy; right supraclavicular adenopathy; splenomegaly with infarcted area." The right hilar adenopathy was biopsied; the pathologic exam revealed non-small cells lung carcinoma. The patient was discharged, medicated with warfarin and oriented to outpatient Oncology consult. Any cancer can be associated with thrombotic manifestations. In this case, considering the heavy smoking burden, lung cancer is one of the first etiologies to consider. The thrombotic manifestations of the non-small cells lung carcinoma are due to a paraneoplastic mechanism and might precede the cancer diagnosis. This clinical case highlights the importance of thinking of different etiologies in the differential diagnosis of a constitutional syndrome.

Abstract P1310 Figure. Left auricle mass

P704 Mechanical complications of acute myocardial infarction in the era of early reperfusion therapy: a case report

Introduction

Left ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction, and its incidence has decreased with the widespread use of reperfusion therapies. Pseudoaneurysm is the result of a free wall rupture contained by pericardial adherences and mural thrombi, which contain the bleeding and prevent cardiac tamponade.

Clinical Presentation

A 68-year-old woman who had hypertension, diabetes mellitus and chronic kidney disease (caused by diabetic nephropathy) was first admitted with acute myocardial infarction of the inferior wall. Emergent coronary angiography revealed proximal occlusion of the right coronary artery. Primary angioplasty was performed with three stents implantation. However due to transitory no reflow, verapamil, nitrate and intracoronary abciximab were administered with recovery of coronary flow. Patient remained stable, without recurrence of symptoms. Echocardiography, at discharge, showed normal biventricular function and no mechanical complications.

Two months later, the patient was readmitted in the emergency room with constant chest pain, fatigue, prostration and loss of appetite beginning ten days earlier and an episode of syncope. Physical examination revealed fever, cardiac auscultation was rhythmic and without murmurs or pericardial friction rub, and pulmonary auscultation revealed crackles in inferior hemithorax. 12-lead electrocardiogram showed sinus rhythm, Q waves and negative T waves in inferior leads. Blood tests revealed leucocytosis, high sensibility troponin I was 28,8 ng/L and brain natriuretic peptide was 264,9 pg/mL. Chest-X-ray demonstrated enlargement of the cardiac silhouette and echocardiography showed moderate to large pericardial effusion with large amounts of fibrin close to right cardiac chambers and a basal inferior pseudoaneurysm with 23 mm x 24 mm; intracavitary contrast was administered without opacification of pericardial space; biventricular function remained normal.

Patient was promptly admitted on Cardiac Intensive Care Unit with diagnosis of pseudoaneurysm due to myocardial infarction. Therapeutic with ticagrelor was suspended and surgical correction was proposed, after discussion in Heart Team. False aneurysm correction was performed with a bovine pericardial patch without complications, and the patient was discharged asymptomatic eight days later.

Conclusion

Even with lower incidence, pseudoaneurysms remains as a potential life-threatening due to its high risk of rupture. Prompt diagnosis, usually with echocardiography and surgical referral are crucial.

Abstract P704 Figure. Inferior Pseudoaneurysm

P863 Large pericardial effusion two months after transcatheter aortic valve implantation: case report of a post-cardiac injury syndrome

We present a case of a 87-year-old female with a symptomatic severe aortic stenosis (aortic valve area 0.9 cm2, mean transvalvular pressure gradient 44 mmHg). She was refused to surgical aortic valve replacement due to marked aortic root calcification. A transcatheter aortic valve (ACCURATE neo™ 27) was electively implanted. In immediate post-procedure, the patient presented an episode of hypotension, rapidly reverted with supportive treatment. A transthoracic echocardiogram (TTE) showed a circumferential mild pericardial effusion (PE) without prosthetic valve disfunction and with preserved biventricular systolic function. Due to paroxysmal episodes of atrial fibrillation, it was decided to withdraw anti-aggregation and to start anticoagulation. Four days after transcatheter aortic valve implantation (TAVI) the patient presented newer intraventricular and atrioventricular conduction disturbance (left bundle branch block and type-I second-degree atrioventricular block). A definitive pacemaker was implanted without complications. PE maintained stable and seven days after TAVI the patient was discharged from hospital.

Two months after TAVI, the patient was admitted to Intensive care unit (ICU) with increasing asthenia, dyspnea and pleuritic thoracic pain over the preceding two weeks. Laboratory workup exhibited elevation of inflammatory markers (leukocytosis and C-reactive protein). A TTE was performed and showed a large circumferential PE (29 mm) with signs of hemodynamic impact (swinging heart, inferior vena cava dilation with &lt;50% inspiratory collapse, right atrial collapse &gt;1/3 of cardiac cycle, proto-diastolic right ventricular collapse and mitral respiratory flow variation &gt;25%). The patient started treatment with anti-inflammatory drugs (aspirin 1000mg every 8h plus colchicine 0.5mg twice daily) and pericardiocentesis was initially postponed. In spite of clinical and echocardiographic improvement, she maintained elevated inflammatory markers and a moderate PE. Prednisolone 30mg daily was added to initial therapy and serial evaluations showed a pronounced reduction of PE as well as of inflammatory markers. Two weeks after admission to ICU the patient was discharged with a residual PE measuring less than 5mm. The previous recent cardiac intervention and the effective response to anti-inflammatory treatment suggest a post-cardiac injury syndrome.

This case report wants to show that post-cardiac injury syndrome is a diagnosis that should be keep in mind after TAVI.

Abstract P863 Figure. TTE showing large pericardial effusion

555 Right ventricular longitudinal strain of patients with pulmonary hypertension

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Recently, speckle-tracking echocardiography has emerged as a new tool in the RV assessment. In this study, we aimed to study the value of global longitudinal strain in the RV evaluation of these patients.

Methods

We collected clinical, laboratory, echocardiographic and right heart catheterization (RHC) data from consecutive patients referred to an expert tertiary care referral centre from 12/2016 to 11/2018. Global RV systolic peak longitudinal strain (RVS) and RV free wall peak longitudinal strain (RVFWS) (mean of the basal, mid- and apical-segments) were measured by speckle-tracking technique with Echo-Pac software from GE Healthcare®.

Results

Of the 97 included patients, 76% were female. The mean age was 65 ± 15 years. Most patients were in NYHA class II. Median time between TTE and RHC was 70 days [IQR 34 - 184]. Group 2 PH was the most frequent aetiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

Both strain parameters significantly correlated with other echocardiographic parameters such as TAPSE, FAC, Tricuspid S wave, RV diastolic diameter, eccentricity index (EI), systolic pulmonary artery pressure (SPAP), pulmonary acceleration time and presence of RV outflow tract notching. Strain parameters were also associated with pulmonary artery pressures and pulmonary vascular resistance (PVR) measured by RHC. Strain parameters did not correlate with PECP (p &gt; 0.05).

In multivariate analysis, RV global longitudinal strain predicted invasive mean pulmonary artery pressure and PVR independently of TAPSE and FAC (β=1.38, p &lt; 0.001). RV global strain &gt; -17.1 predicted PVR &gt; 3 wood (OR 3.46, CI 1.50 - 8.02, AUC 0.72) and PMAP &gt; 20 mmHg (OR 4.92, CI 1.67 - 14.51, AUC 0.78). TAPSE &lt; 18 mm predicted PVR &gt; 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

RV global and free wall longitudinal strain significantly correlate with other echocardiographic parameters of RV structure and function and with invasive pulmonary artery pressures and PVR.

Abstract 555 Figure.

P1289 Echocardiograhic prediction of pulmonary arterial capacitance in patients with heart failure with preserved ejection fraction

Background

Pulmonary arterial capacitance (PAC) has emerged as one of the strongest hemodynamic predictors of adverse outcomes in a wide spectrum of cardiovascular diseases, including pulmonary hypertension in heart failure with preserved ejection fraction (HFpEF-PH). We aimed to study non-invasive surrogates for PAC using transthoracic echocardiography in this population.

Methods

We retrospectively evaluated consecutive patients referred to an expert tertiary care referral centre from December 2016 to November 2018. Transthoracic echocardiography (TTE) was performed within 1 year of right heart catheterization (RHC). Echo-Pac software from GE Healthcare® was used to perform echocardiographic analysis. PAC was calculated dividing right ventricular stroke volume by pulmonary arterial pulse (systolic – diastolic) pressure, measured by RHC.

Results

Of the 105 enrolled patients, 43 were had HFpEF-PH. Among these, 72% were female and mean age was 68.9 ± 11.2 years. Median time between TTE and RHC was 68 (IQR 34 – 191) days. Most patients were in NYHA class II (60.5%) and class III (34.9%). Fifty eight percent of the patients had history of paroxysmal or permanent atrial fibrillation. This population presented borderline parameters of right ventricle (RV) systolic dysfunction: fractional area change (FAC) 35.3 ± 9.2%, tricuspid annular plane systolic excursion (TAPSE) 18.3 ± 5.1 mm, tricuspid S’ wave 10.4 ± 2.9 and RV global longitudinal strain -15.5 ± 4.0. Regarding invasive assessment, this population presented mean pulmonary artery pressures of 38.8 ± 13.9 mmHg, pulmonary artery wedge pressure of 21.6 ± 6.4 mmHg, pulmonary vascular resistance of 3.9 ± 2.7 Wood and median PAC of 0.13 (IQR 0.09 – 0.19) ml/mmHg. The TAPSE / Pulmonary arterial systolic pressure (PASP) ratio and the Right ventricular outflow track velocity time integral (RVOT VTI) / PASP ratio were the parameters that best correlated with PAC (r = 0.69, p = 0.002 for both parameters) (table 1). These parameters were obtainable in the majority of patients (31/43). Blant-Altman analysis revealed good agreement between these measures and PAC with a mean difference of - 0.17 (CI -0.21 - -0.13) for RVOT VTI / PASP ratio and -0.23 (CI -0.28 - -0.18) for TAPSE /PASP ratio.

Conclusion

In a HFpEF – PH population, TAPSE / PASP and RVOT VTI / PASP are easily obtainable in most patients and significantly correlate with PAC.

Abstract P1289 Figure.

P1505 Echocardiographic assessment of different pulmonary hypertension groups

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Different etiology groups might have different echocardiographic phenotypes. In this study, we aimed to study echocardiographic characterization of the different PH groups and its ability to predict pulmonary vascular disease severity.

Methods

We collected echocardiographic and right heart catheterization (RHC) data from 97 (75% female, age 65 ± 15 years) consecutive patients referred to an expert tertiary care referral PH centre from 12/2016 to 11/2018. Echocardiographic analysis was performed using Echo-Pac software from GE Healthcare®. Group 3 and 5 were not included in the group comparison analysis due to few patients included.

Results

Group 2 PH was the most frequent etiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population as a whole showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

PH group 1 had a significantly lower FAC (26 ± 4%, p = 0.0025), higher eccentricity index (IE) (1.5 ± 0.1, p = 0.01), and more frequently RV outflow tract (RVOT) notching than other groups (62%, p = 0.012). Group 4 presented an intermedium echocardiographic phenotype between group 1 and 2, and showed more abnormal strain values than the other groups. Group 2 had fewer patients in sinus rhythm (atrial fibrillation in 34% of patients, p = 0.02), presented a thicker interventricular septum (11.3 ± 1.8, p = 0.014), a higher FAC (35 ± 3%, p = 0.0025), higher E mitral wave velocity (72 ± 6 cm/s, p &lt; 0.001) and E/E’ ratio (12.7 ± 10.2, p = 0.006), and larger left (45 ± 3 cm3/m3, p &lt; 0.01) and right atria (25 ± 2 cm2, p = 0.03).

PH groups 1 and 4 had higher Pulmonary Vascular Resistance (PVR) and Pulmonary Mean Arterial Pressure (PMAP) values than group 2, which significantly correlated with echocardiographic RV function parameters as TAPSE, FAC, RV global strain and IE. In PH group 2, eccentricity index was the only predictor of PVR (β=4.1, p = 0.018). In this population, a left atria volume &lt; 32.7 cm3/m2 (OR 4.25, CI 1.71 - 10.55) and a E/e’ ratio &lt; 12 (OR 4.72, CI 2.05 - 10.87) predicted PECP &lt; 15 mmHg. RV global strain &gt; -17.1 predicted PVR &gt; 3 wood (OR 3.46, CI 1.50 - 8.02) and PMAP &gt; 20 mmHg (OR 4.92, CI 1.67 - 14.51). TAPSE &lt; 18 mm predicted PVR &gt; 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

Different PH groups present mild echocardiographic differences between them. PH group 1 presented with more echocardiographic signs of RV disfunction, and PH group 2 had higher FAC, E/E’ and larger right and left atria. RV function parameters predicted PVR in PH groups 1 and 4, and EI was the only predictor of PVR in PH group 2.

Abstract P1505 Figure.

1115 Ultra-slow low-dose thrombolytic therapy as an option of treatment in intracardiac thrombus: a case report

We present a case of a 57-year-old male with previously known primary severe mitral regurgitation, who was admitted to the ICU due to massive venous thromboembolism with associated right ventricle dysfunction and with two large mobile right atrial thrombi (2.4 x 1.5 cm and 3.6 x 3.7 cm). Despite of five days with a therapeutic aPTT achieved with unfractionated heparin (UFH), a TTE showed deterioration of the right ventricle systolic function, persistence of the right atrial masses with similar dimensions together with new mobile thrombi on the coronary sinus and on the right pulmonary artery. Due to deterioration of his clinical condition and given the refractoriness to the classical treatment with UFH, it was decided to administer an ultra-slow low-dose thrombolysis protocol, which consisted in a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without bolus. The treatment was continued by 48 consecutive hours, with clinical improvement and important reduction of the right atrial masses with resolution of the coronary sinus and right pulmonary artery thrombi. The patient started hypocoagulation with warfarin bridging with low molecular weight heparin (LMWH). Seven days after alteplase discontinuation there was complete resolution of the intracardiac thrombi. One month after ICU admission a successful mitral valve replacement surgery was conducted. Three months after discharge, the patient is in functional New York Heart Association (NYHA) class I with no cardiovascular events or hospitalizations. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to anticoagulation.

Abstract 1115 Figure. TTE showing right atrial masses

Patient-reported outcomes in multiple sclerosis: Validation of the Quality of Life in Neurological Disorders (Neuro-QoL™) short forms

Background

Patient-reported outcome (PRO) measures have been shown to be effective for tracking treatment outcomes in multiple sclerosis (MS). However, collecting PROs as part of the clinical standard of care can be time-consuming and examination of their validity for use in an MS sample has been limited.

Objective

To determine the discriminant validity of the Quality of Life in Neurological Disorders (Neuro-QoL™) short forms in a real-world MS clinic population.

Design/Methods

Neuro-QoL is a series of questionnaires for tracking physical function, emotional/cognitive health, and social abilities in clinical populations. Neuro-QoL data from 902 MS patients were analyzed for psychometric properties and factor structure.

Results

Neuro-QoL demonstrated acceptable reliability in the moderate-to-good ranges. Moderate support for convergent validity was observed with other measures of MS quality of life, disease severity, and symptoms. However, results from a confirmatory factor analysis suggested poor model fit for most of the 12 domains tested.

Conclusions

These findings support the utility of some of the Neuro-QoL questionnaires in evaluating MS-related PROs. However, additional research may help abridge and strengthen these measures for use in this population.

Rappaport-Vassiliadis Medium for Recovery of Salmonellaspp. from Low Microbial Load Foods: Collaborative Study

Twenty-three laboratories participated in a collaborative study to compare the relative effectiveness of Rappaport-Vassiliadis (RV) medium incubated at 42°C, selenite cystine (SC) broth (35°C), and tetrathionate (TT) broth (35 and 43°C) for recovery of Salmonella from the following foods with a low microbial load: dried egg yolk, dry active yeast, ground black pepper, guar gum, and instant nonfat dry milk. For dry active yeast, lauryl tryptose (LT) broth, incubated at 35°C, was used instead of SC broth. All of the foods were artificially inoculated with single Salmonella serovars, that had been lyophilized before inoculation, at high and low target levels of 0.4 and 0.04 colony forming units/g food, respectively. For analysis of 870 test portions, representing all of the foods except yeast, 249 Salmonella-positive test portions were detected by RV medium, 265 by TT broth (43°C), 268 by TT broth (35°C), and 269 by SC broth (35°C). For analysis of 225 test portions of yeast, 79 Salmonella-positive test portions were detected by RV medium, 79 by TT broth (43°C), 84 by TT broth (35°C), and 68 by LT broth (35°C). RV medium was comparable to, or even more effective than, the other selective enrichments for recovery of Salmonella from all of the foods except guar gum. It is recommended that RV (42°C) and TT (35°C) be used with foods that have a low microbial load, except for guar gum for which SC (35°C) and TT (35°C) are recommended.

Cost-utility analysis of 21-gene assay for node-positive early breast cancer

Background

For women with lymph node (ln)-positive, estrogen receptor-positive, and her2 (human epidermal growth factor receptor 2)-negative breast cancer (bca), current guidelines recommend treatment with both hormonal therapy and chemotherapy. The 21-gene Recurrence Score (rs) assay might be helpful in selecting patients with bca who can be spared chemotherapy when they have 1-3 positive lns and a lower risk of recurrence. In the present study, we performed a cost-utility analysis comparing use of the 21-gene rs assay with current practice from the perspective of a Canadian health care payer.

Methods

A Markov model was developed to determine costs and quality-adjusted life-years (qalys) over a patient's lifetime. Patient outcomes in both study groups were examined based on published clinical trials. Costs were derived primarily from published Canadian sources. Costs and outcomes were discounted at 1.5% annually, and costs are reported in 2016 Canadian dollars. A probabilistic analysis was used, and the model parameters were varied in a sensitivity analysis.

Results

The results indicate that use of the 21-gene rs assay was less costly ($432 less) and more effective (0.22 qalys) than current practice. The probabilistic analysis revealed that 70% of the 10,000 simulated incremental cost-effectiveness ratios were in the southeast quadrant. The results were sensitive to the probability of a low rs and to the probability of receiving chemotherapy in the low-risk rs category and in current practice.

Conclusions

Use of the 21-gene rs assay could be a cost-effective strategy for Ontario patients with estrogen receptor-positive, her2-negative early bca and 1-3 positive lns.