Early systolic lengthening in patients with ST-elevation myocardial infarction: a novel tool for risk stratification

Funding Acknowledgements

Type of funding sources: None.

Background

After an ST-elevation myocardial infarction (STEMI), the risk of subsequent cardiovascular events is high. Risk stratification at index hospitalization remains a core challenge, especially in patients with subtle changes in LV function. Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force and it has been correlated with infarct size and prognosis in STEMI patients with mildly impaired LV function. In this study, we aimed to evaluate the correlation of ESL with common echocardiographic parameters and its prognostic value in STEMI patients with preserved LV function.

Methods

We retrospectively included all the patients admitted to an intensive care unit with STEMI and a left ventricle ejection fraction ≥55% from January to June of 2016. Patients with inadequate image quality for speckle tracking echocardiographic examination were excluded (n = 14). We evaluated the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)], and ESL duration.

Results

A total of 37 patients were included in the study. Mean age was 63 ± 12 years with a male preponderance (81%). All patients were submitted to complete revascularization. Median values of the ESL index and ESL duration were 7% (IQR, 4%–10%) and 37 msec (IQR, 21–55 msec), respectively. No significant differences were found between ESL index and ESL duration groups, except for a higher prevalence of heart failure at hospitalization in both highest groups, and women were more prevalent in the ESL index higher group (Tables 1 and 2). ESL index was correlated with post-systolic index (PSI) (r2 = 0.34, p = 0.04) and showed a weak correlation with E/A ratio (r2=-0.37, p = 0.02). ESL duration was correlated with ESL index (r2 = 0.76, p < 0.001) and PSI (r2 = 0.43, p = 0.008). During a median follow-up of 3.2 years (interquartile range, 2.9–3.4 years), 7 (18.9%) patients experienced major adverse cardiovascular events (MACE), a composite of heart failure admission, myocardial infarction, and all-cause mortality Both ESL index (HR 2.5; 95%CI 1.2–5.3; P = 0.02) and ESL duration (HR 1.7; 95%CI 1.1–2.7; P = 0.02) were independent predictors of MACE. Both associations remained significant after adjusting for clinical confounders.

Conclusions

In our cohort of STEMI patients with preserved LV function, assessment of ESL yielded important and significant prognostic information on MACE. ESL may be a useful tool to enhance routine risk stratification in this population. Abstract TABLE 1  Abstract TABLE 2

Outcomes of radiofrequency catheter ablation for persistent and long-standing persistent atrial fibrillation

Introduction

Catheter ablation has become the first-line treatment for symptomatic patients with atrial fibrillation (AF). Several approaches of substrate ablation have been used for persistent and long-standing persistent AF and the best protocol procedure is yet to be established. The purpose of this study was to evaluate the outcomes of patients submitted to catheter ablation of persistent and long-standing persistent AF adding extra-pulmonary substrate approaches to pulmonary vein isolation.

Methods

We retrospectively studied 67 consecutive patients referred for the first procedure of catheter ablation of persistent or long-standing persistent AF from May 2016 to October 2018. The first 27 patients were subjected to pulmonary vein isolation and complex fractionated atrial electrograms (CFAE) ablation (group 1) and the last 40 patients were subjected to a tailored approach guided by voltage map areas and CFAE (group 2). Patient characteristics, procedure details and follow-up were assessed, and predictors of recurrence were determined.

Results

Mean age was 59±11 years with 58% being male. During a mean follow-up of 16±6 months 27% of the patients showed AF recurrence. There were no differences in baseline characteristics of group 1 and 2. A higher recurrence rate was found in group 1 by comparison with group 2 (40.7% vs 17.5%, Log Rank X2 = 5.076, P=0.024) (Figure 1). Also, recurrence was associated with a longer AF duration, an increased baseline Brain Natriuretic Peptide (BNP), an increased left atrium (LA) volume, the presence of hyperthyroidism, the absence of sinus rhythm after procedure, the inducibility of AF post-ablation and the absence of an antiarrhythmic drug at hospital discharge. After adjustment for other confounders, the patient group (HR 5.16 [1.23–21.71] P=0.025), a long-standing AF (HR 9.09 [1.41–58.82] P=0.020), the BNP value at admission (HR 1.03 [1.01–1.05] P=0.033) and the LA volume index (HR 1.13 [1.02–1.25] P=0.017) were the only independent predictors of recurrence.

Conclusion

Ablation of persistent and long-standing persistent AF is feasible with good results when a substrate approach is added to pulmonary vein isolation. A tailored approach seems to be more efficient, showing best outcomes in mid-term follow-up. A long-standing AF, higher BNP value and the LA enlargement are important predictors of recurrence and should be used to better select patients and to manage follow-up.

Funding Acknowledgement

Type of funding sources: None.

Interventional cardiology in times of COVID-19: impact on a terciary centre

Introduction

Cardiovascular diseases are the leading cause of death worldwide and the pandemic caused by coronavirus disease 2019 (COVID-19) has forced profound changes in the care of patients with cardiac conditions. In Portugal, an increase in mortality beyond that attributed solely to COVID-19 was observed. We aimed to realize how COVID-19 has changed the activity of our Interventional Cardiology Unit.

Methods

We retrospectively assessed all patients submitted to any interventional procedure in 2019 and 2020 in our hospital. A total of 7621 patients and 9163 procedures were evaluated. The mean weekly numbers of coronarography, angioplasty, right heart catheterization and structural heart intervention during 2019 were assessed and were compared with the first COVID-19 wave (comprising March and April 2020) and the second COVID-19 wave (including the time period from October to end of December 2020).

Results

Mean age was 65.2±16.6 years with 72% being male. In the first COVID-19 wave there was a significant reduction in the mean weekly numbers of all procedures, with a 64% decline in coronarographies (30.9±29.3 vs 87.2±12.9, P<0.001), 48% in angiographies (15.7±10.9 vs 30.2±5.7, P=0.004), 51% in right heart catheterizations (5.3±5.9 vs 10.9±4.5, P=0.002) and 57% in structural heart interventions (1.1±1.9 vs 2.6±2, P=0.044). Although there was an evident recovery in activity (figure 1), comparing to 2019, the second wave also showed a significant lower number of procedures, with 24% fewer coronarographies (66.6±20.6 vs 87.2±12.9, P=0.003) and 13% fewer angiographies (26.4±7.6 vs 30.2±5.7, P=0.004). Contrariwise, in the second wave there was no difference in the number of right heart catheterizations (7.3±6.1 vs 10.9±4.5, P=0.055) or structural heart interventions (1.6±1.6 vs 2.6±2, P=0.106).

Conclusions

In our Interventional Cardiology Unit, COVID-19 led to a significant reduction of procedures in the first and second pandemic waves. The effect on the increase in morbidity and mortality has yet to be determined. Health authorities should focus attention in defining measures to amend the consequences of this documented activity reduction.

Funding Acknowledgement

Type of funding sources: None.

Heart failure with reduced ejection fraction: predicting exercise intolerance with echocardiography

Introduction

Cardiopulmonary exercise testing (CPET) is routinely used in the prognostic evaluation of patients with heart failure with reduced ejection fraction (HFrEF). Left ventricular ejection fraction (LVEF) is a strong prognostic marker but have shown a bad correlation with exercise capacity. The aim of this study is to assess the relationship between echocardiographic parameters and exercise capacity in HFrEF patients.

Methods

We retrospectively assessed all patients with HFrEF submitted to CPET and echocardiography between March and September of 2019. 73 patients were eligible for analysis. ANOVA test was used to compare Weber class groups regarding echocardiographic parameters. Multivariate linear regression with a stepwise approach was used to assess independent predictors of peak VO2 uptake. ROC curves were compared to assess the best parameter to discriminate a peak VO2 &lt;10 ml/kg/min (Weber class D).

Results

Mean age was 53.4±11.7 years with 72.6% being male. Mean LVEF was 29.2±7.7% and mean peak VO2 was 13.4±3.8 ml/kg/min. Between the Weber class groups, significant differences were found in left (LV) and right ventricular (RV) longitudinal strain (P&lt;0.001 and P=0.005 respectively), in the left and right atrial reservoir strain (P=0.009 and P&lt;0.001 respectively), in pulmonary velocity acceleration time (P=0.002) and in maximal tricuspid regurgitation velocity (TRmax) (P=0.014). Left ventricular ejection fraction, tricuspid annular plane systolic excursion, and ratio E/e' were not significantly different among exercise capacity groups. Additionally, only RV longitudinal strain (r2=0.225, P=0.008) and TRmax (r2=0.073, P=0.030) were independent predictors of peak VO2. RV longitudinal strain showed the best accuracy in discriminating a Weber class of D (AUC=0.731, 95% CI: 0.613–0.848, P=0.005) with a calculated cut of −8.6% and with a negative predictive value of 95%.

Conclusion

RV longitudinal strain and TRmax seem to be the best echocardiographic predictors of exercise intolerance in patients with HFrEF. Since CPET is not widely available, these echocardiographic parameters can be clinically useful as a surrogate prognostic factor.

Funding Acknowledgement

Type of funding sources: None.

Real-world, very long-term follow up survival of incident patients with pulmonary hypertension

Background

Pulmonary hypertension (PH) is a clinical syndrome characterized by an increase in pulmonary artery pressure. Among the five groups of PH, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) stand out due to their ominous prognosis without specific treatment. However, very long-term outcomes data are scarce.

Purpose

We aimed to assess the very long-term survival of PAH and CTEPH patients followed in a Portuguese PH referral center.

Methods

Between January 2009 and January of 2020, all incident PH cases were consecutively enrolled in a prospective cohort study. A total of 177 patients were followed up for a median of 5.0 [interquartile range 2.3–8.7] years. Kaplan-Meier survival analysis was used to estimate 1-, 5- and 9-year survival and multivariate regression was used to predict independent prognostic factors.

Results

Mean age was 49±20 years with a clear female preponderance (67%). The most common PH subgroups were congenital heart disease (PAH-CHD) (n=62; 35%), followed by CTEPH (n=52; 29,4%), connective tissue disease (PAH-CTD) (n=31; 17.5%), idiopathic/hereditary PAH (I/HPAH (n=22; 12.4%) and portopulmonary hypertension (PoPH) (n=8; 4.5%) (Table 1). PAH-specific drugs were used in 91% of the patients, dual combination therapy in 47.5%, and triple combination in 12.4%. The remaining 9% successfully received non-pharmacological treatment, namely cardiac surgery in PAH-CHD (n=7) and endarterectomy or angioplasty in CTEPH (n=9). Survival rates at 1-, 5- and 9-years were 97%, 80% and 66%, respectively. Age (hazard ratio [HR] 1.02; 95% CI 1.01–1.04; P=0.049), BNP [HR 2.04 (1.16–3.60); P=0.01], admission for decompensation of heart failure (HF) [HR 3.15 (1.71–5.83); P&lt;0.001] and PH type [P=0.01] were predictors of all-cause mortality. PAH-CHD had the better long-term survival (9-year survival of 83%), whereas PAH-CTD and PoPH were associated with a worse prognosis (9-year survival of 24% and 28%, respectively) (Figure 1). Regarding admissions for decompensated right HF, BNP was an independent predictor [HR 3.39 (2.12– 5.43); P&lt;0.001] and no difference was found between PH etiologies.

Conclusions

In this cohort of incident PH patients, the overall 9-year survival rate was 66%. PAH-CHD patients had better overall prognosis, while patients with PAH-CTD and PoPH had the worst prognosis. Additionally, older age, higher BNP and admission for HF were associated with higher mortality.

Funding Acknowledgement

Type of funding sources: None.

Cardiopulmonary exercise testing; do circulatory and ventilatory power predict cardiovascular outcomes in patients with heart failure

Background

Cardiopulmonary exercise testing (CPET) has an important role in mortality prediction in heart failure (HF) and patient selection for heart transplant. New indices as circulatory power (CP) and ventilatory power (VP) have been proposed as predictors of cardiac events. In addition, VP predicts mean pulmonary artery pressure (mPAP) in patients with pulmonary arterial hypertension.

Purpose

We aimed to analyse the prognostic value of classic and new CPET variables in patients with HF.

Methods

We retrospectively assessed consecutive patients with HF who underwent CPET in a single-centre between 2013 and 2017. New CPET variables were collected: CP was defined as the product of peak O2 uptake and peak systolic blood pressure (SBP), while VP was defined as peak SBP divided by the minute ventilation–CO2 production (VE/VCO2) slope. The primary endpoint was a composite of all-cause mortality, heart transplant, or HF hospitalization. Survival analysis was performed using Kaplan-Meier curves and multivariable Cox regression.

Results

Overall, 216 patients (mean age 55.4±10.9, 77.3% male) were included, 38.4% with ischemic HF, and mean left ventricle ejection fraction (LVEF) 30±14%. Most patients were evaluated through the modified Naughton (76.3%), the original Naughton (19.0%), and Bruce protocols (4.7%). Regarding classic CPET variables: mean pVO2 16.8±6.0 mL O2 kg–1 min–1, mean percent-predicted pVO2 62.6±23.9%, median VE/VCO2 slope 37.3 [32.6–44.5], exercise oscillatory ventilation (EOV) present in 13.9%, resting partial pressure of end-tidal carbon dioxide (PETCO2) ≥33 mmHg with an increase of 3–8 mmhg during exercise in 17.1%, and mean peak SBP 128.8±27.2 mmHg. Median circulatory power was 1927 [1404–2694] mmHg·min/mL/kg and mean ventilatory power 3.47±1.32 mmHg. After a median follow-up of 5 [4–6] years, the primary endpoint occurred in 66.2% of patients (rehospitalization, heart transplant, and all-cause death occurred in 57.0%, 25.9%, and 32.4%, respectively). In Cox regression multivariate analysis, the primary endpoint was predicted by pVO2 (HR 0.90, 95% CI: 0.87–0.93), percent-predicted pVO2 (HR 0.97, 95% CI: 0.96–0.98), VE/VCO2 slope (HR 1.04, 95% CI: 1.03–1.06), VP (HR 0.62, 95% CI: 0.52–0.73) but not CP (HR 0.99, 95% CI: 0.98–1.01). Kaplan-Meier curves according to the LVEF are depicted in Fig. 1A. ROC analysis (Fig. 1B) revealed that VP (AUC 0.768) has higher discriminative power for the primary endpoint, compared to pVO2 (AUC 0.741). One hundred and twenty-seven patients also underwent right heart catheterization: mean mPAP was 30.6±12.9 and it was not correlated with VP (r=−0.06, p=0.47).

Conclusion

CPET variables are good predictors of all-cause mortality, heart transplant, or HF hospitalization. Ventilatory power (but not circulatory power) is an additional useful variable in event prediction. On the other hand, VP is not correlated with mPAP in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Do not underestimate the blood urea nitrogen-to-creatinine ratio in heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The blood urea nitrogen-to-creatinine ratio (BUN/SCr) has been proposed as a prognostic marker in heart failure (HF). We aimed to evaluate whether BUN/SCr predicts mortality outcomes in a real-world Southern European population with decompensated chronic HF.

Methods

We retrospectively studied 1057 patients with chronic HF admitted to our emergency department between November 2016 and December 2017 with acute decompensation. We excluded patients with a GFR &lt;15mL/min/m2 or on dialysis. The incidence of cardiovascular (CV) and all-cause death was evaluated through multivariable logistic regression models and by Kaplan-Meyer survival curves.

Results

1025 patients were included, median age 80 years (IQR 73-85), 52.4% male, mean LVEF 42.8 ± 12.7%, and mean GFR 57.2 ± 23.9 mL/min/m2. Mean BUN/SCr was 24.9 ± 8.2 and mean SBP was 139 ± 29mmHg (r=-0.17, p &lt; 0.001). After a median follow-up of 5 months (IQR 3-11 months), CV and all-cause death occurred in 8.0% and 21.6%, respectively. Mean BUN/SCr was higher in patients with fatal outcomes both for CV (31.3 vs. 24.3, p &lt; 0.001) and all-cause death (28.6 vs. 23.8, p &lt; 0.001). BUN/Scr was grouped by terciles: T1 (&lt;20.78), T2 (20.78-27.15), T3 (&gt;27.15). In the T3 group, the multivariable-adjusted  OR for CV and all-cause death was 5.43 (95% CI 2.20-13.37) and 2.72 (95% CI 1.66-4.46), respectively, compared to the T1 group. No significant differences between T1 and T2 groups.

Conclusions

BUN/SCr at admission predicts CV and all-cause death in patients with chronic HF after an episode of decompensation. BUN/SCr, as an easy-to-use tool, helps to identify those patients who benefit from tight monitoring both during hospitalization and after discharge.

Abstract Figure_1

Does lipoprotein(a) predict cardiovascular events in a long-term follow-up?

Funding Acknowledgements

Type of funding sources: None.

Background

Elevated plasma lipoprotein(a) [Lp(a)] concentrations are associated with an increased risk of atherosclerotic cardiovascular disease and its role in risk categorizing was recognized in the new ESC guidelines for the management of dyslipidaemias. We investigated 1) the association between baseline Lp(a) levels and incident long-term cardiovascular (CV) events and 2) its relationship with type 2 diabetes mellitus (T2DM) in a Southern European population.

Methods

We retrospectively assessed baseline Lp(a) concentrations in a total of 499 patients of a primary prevention cohort followed at the Lipidology Clinic of our hospital, with a median follow-up time of 15 (IQR 12-17) years. Lp(a) was analysed as a continuous variable, as a categorical variable with a 180mg/dL cut-off and by quartiles. We collected data on major CV events (CV death, myocardial infarction, stroke) as a composite outcome. Cox proportional hazard regression analyses were used to estimate hazard ratios (HR) and 95% confidence interval (CI).

Results

Mean age was 48.30 ± 14.41 years and 61.70% were male (n = 499). Median Lp(a) was 36.60 (IQR 0-396) mg/dL and 12.4% of patients had very high Lp(a) (≥180mg/dL); T2DM prevalence was 13.60%. The composite outcome incidence was 10%. At the baseline, individuals with T2DM had lower Lp(a) levels (11.85 IQR 3-330 mg/dL vs. 46.40 IQR 0-396, p &lt; 0.01 mg/dL). There was a moderate inverse correlation between Lp(a) and HbA1c (r = -0.67, p &lt; 0.01) but no significant correlations with lipid profile (total, LDL or HDL), risk scores (SCORE or the ACC pooled cohort equation), age nor gender. We found no relationship between baseline Lp(a) quartiles and composite outcome’s incidence (age-, sex-, and diabetes-adjusted HR: 1.15, 95%CI: 0.71-1.87, p = 0.57) (Figure 1), neither with the individual CV endpoints. Exploratory analysis showed that patients on aspirin had lower Lp(a) levels (29.55 IQR 0-264 mg/dL vs. 63.60 IQR 1-396 mg/dL, p &lt; 0.01).

Conclusion

In a single centre cohort of a primary prevention southern European population, we did not find an association between Lp(a) levels and incident CV events in a 15-year median follow-up time.

Myocardial infarction in young adults: are the risk profile and mortality outcomes different from older patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The incidence of acute myocardial infarction (AMI) among young patients is increasing. The YOUNG-MI Registry reported that those under 40 years had similar risk profiles and outcomes compared to those aged 41 to 50. We aimed to evaluate cardiovascular risk factors and mortality outcomes in two age cohorts from southern European.

Methods

We retrospectively evaluated 4758 patients admitted to our coronary intensive care unit between 2004 and 2017 with AMI. We only included patients &lt;60 years in two subgroups: cohort A &lt; 50 years and cohort B 50-60 years. 

Results

From the 1233 patients included (mean age 50.5 ± 6.5 years, 82.2% male), 53% had STEMI. Cohort B had higher rates of hypertension (59.8 vs. 42.9%, p &lt; 0.001), diabetes (41.8 vs. 28.9%, p &lt; 0.001), and dyslipidemia (59.4 vs. 46.4%, p &lt; 0.001), while cohort A had higher rates of familial premature coronary artery disease (20.9 vs. 13.2%, p &lt; 0.001) and smoking habits (54.4 vs. 40.0%, p &lt; 0.001). Regarding coronary angiography, cohort B had higher rates of obstructive disease in each epicardial artery, except for left main involvement and non-obstructive disease (Fig. 1). Cohort A had lower all-cause mortality rates at the index hospitalization (1.3 vs. 3.2%, p = 0.045), 6-months (2.9 vs.5.4, p = 0.038), 1-year (3.1 vs. 6.3%, p = 0.014), and 3-years (3.6 vs 8.4, p = 0.001). After multivariable adjustment, we found no relationship between age cohorts and all-cause mortality for any follow-up timing: HR 1.57 (95% CI 0.56-4.37), 1.37 (95% CI 0.50-3.74), and 0.92 (95% CI 0.35-2.39) at 6-months, 1-year, and 3-years, respectively.

Conclusion

Among patients who suffer AMI, those under 50 years old have a different risk profile, compared to the 50-60 years cohort. However, there is no significant difference in all-cause mortality.

Abstract Figure.

Left atrial functional assessment and mortality in patients with severe aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe. Both symptoms and systolic dysfunction can appear late in the course of the disease, being often synonym of irreversible damage to the myocardium when found. Thus, there is a necessity to find other sensitive markers present at an earlier stage of the disease. 

Purpose

Our primary aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.

Methods

We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated all 3 left atrial (LA) functional phases (reservoir, conduit and pump) by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and own patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.

Results

After exclusion criteria, a total of 451 patients were included in the analysis (aged 74 ±11years, 54% male) and were followed during a median period of 73 months (interquartile range 44.5). A total of 55.8% of patients underwent AVR and 45,5% of patients registered the primary outcome. Left atrial emptying fraction (LAEF) was the best LA functional parameter in discriminating primary outcome (AUC 0.840, p &lt; 0.001), even when compared to left ventricular ejection fraction, aortic valve area, aortic mean pressure gradient and aortic Vmax. Patients in the lower tercile of LAEF were older, had greater comorbidities, had greater AS severity, with greater degree of diastolic disfunction. After adjustment for clinical and demographic variables, cumulative survival of patients with LAEF &lt;37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (adjusted HR 19.04, 95% CI 8.30-43.67, P &lt; 0.001 and adjusted HR 4.09, 95% CI 1.85-9.06, P = 0.001). Survival was also higher in patients with LAEF 37 to 53% when compared to patients with LAEF &lt;37% (adjusted HR 0.22, 95% CI 0.13-0.37, P &lt; 0.001). All associations remained true after adjustment for AVR (LAEF &lt;37% versus LAEF 37 to 53% and LAEF ≥54%, respectively, adjusted HR 3.97, 95% CI 1.80-8.78, P = 0.001 and adjusted HR 13.95, 95% CI 5.98-32.54, P &lt; 0.001, respectively)

Conclusion(s) In patients with a first diagnosis of severe AS in hospital setting, LA function assessed by volumetric parameters is an independent predictor of all-cause mortality. Compared to classical severity parameters, different LA functional parameters were found to be more potent predictors of death. These data can be useful in clinical practice for risk stratification and therefore for decision of timing for AVR.

Abstract Figure. Survival of patients stratified by group

Epicardial fat tissue: a new tool for identification of coronary artery disease patients?

Introduction

Epicardial fat (EF), the true visceral fat depot of the heart, has been strongly correlated with both coronary artery disease (CAD) incidence and severity. However, the methods for its measurement were not always affordable. Its measurement by echocardiography is fast, accessible and easily reproducible, turning it into a promising clinical tool for assessing cardiovascular risk to predict the incidence of CAD.

Purpose

To determine the correlation between EF tissue dimensions measured by transthoracic echocardiography and the presence of CAD.

Methods

We prospectively analysed data from 196 consecutive patients admitted for acute coronary syndrome in our coronary care unit. All patients underwent diagnostic coronary angiography and echocardiogram during stay. EF dimensions were obtained with transthoracic echocardiography by measuring maximum EF diameter (mm) at the basal right ventricular free wall (PLAXB) level and mid-right ventricular free wall (PLAXM) level [in paraesternal long-axis view (PLAX)] and maximum right-ventricle free wall EF diameter at basal (PSAXB) level and papillary-muscle (PSAXM) level [in paraesternal short-axis view (PSAX)]. All measures were taken at end-systole. Patients were divided in 2 groups according to the presence of significant CAD (sCAD) or not (nCAD), defined as having at least 1 diseased epicardial vessel with a stenosis &gt;50%.

Results

One-hundred and sixty-three (83.2%) had significant CAD. 22 patients (11.2%) were admitted for unstable angina, 60 patients (30.6%) for non-ST elevation myocardial infarction and 93 patients (47,4%) for ST-elevation myocardial infarction. Mean EF diameters were as follows: PLAXB (19,3±5.1 mm), PLAXM (11.3±2.6), PSAXB (10,6±2.8), PSAXM (10.5±2.8). We found a direct correlation between number of diseased epicardial coronary vessels and epicardial fat thickness in PLAXB (r=0.506, p&lt;0.001), PLAXM (r=0.372, p&lt;0.001), PSAXB (r=0.445, p&lt;0.001) and PSAXM (r=0.372, p&lt;0.001). EF was significantly different between groups: PLAXB (20,6±4.4 vs. 13.8±3,8, p&lt;0.001), PLAXM (11.8±2.5 vs. 9.0±1.9, p&lt;0.001), PSAXB (11.1±2.7 vs. 8.3±2.3, p&lt;0.001) and PSAXM (11.0±2.6 vs. 8.2±4, p&lt;0.001). Receiver operating characteristic curve analysis showed that the predictive value of mean right ventricular EF [(PLAXB+PSAXB)/2] for significant CAD was 0.895 (AUC=0.895, CI 95% 0.818–0,972, p&lt;0.001). For a [(PLAXB+PLAXM)/2] value of 12.57 mm, sensitivity was 86.3% and specificity was 79.3%.

Conclusions

In a population of high suspicion of acute coronary syndromes, echocardiographic EF is a sensitive and specific marker of the presence of significant coronary disease and could become an important tool for coronary risk prediction.

Figure 1

Funding Acknowledgement

Type of funding source: None

Inequalities after STEMI in National Health Service: is there really a postcode lottery?

Background and purpose

Failure to address the impact of social determinants of health attenuates efficacy of proven prevention recommendations, namely because important considerations related to socioeconomic disadvantage are not captured by existing cardiovascular disease (CDV) risk stratification methods. We aimed to assess how socioeconomic determinants influence recurrent MI and all-cause death after myocardial infarction (MI) in Portugal.

Methods

We conducted a retrospective, observational cohort study, including all patients with a ST-elevation MI (STEMI) admitted to and discharged alive from an intensive cardiac care unit between 2004 and 2017 (n=1809). The median (interquartile range) follow-up was 6 (4–9) years. We used survival models to assess the relationship between their municipal (i) income by purchasing power per capita (PPC), (ii) geographical accessibility to health care, (iii) illiteracy, iv) residential socioeconomic deprivation and recurrent MI and all-cause mortality. To assess residential socioeconomic deprivation, each individual's residential postcode was matched to the recently validated Portuguese version of European Deprivation Index (EDI). The index was categorized into quintiles (Q1-least deprived to Q5-most deprived).

Results

The mean age was 64±14 years; 74% were male. Regarding individual socioeconomic variables, PPC (HR 1.19; 95% CI 0.97–1.47 for Tertile 1 vs Tertile 2; HR 1.28; 95% CI 1.04–1.56 for Tertile 1 vs Tertile 3 and HR 1.07; 95% CI 0.85–1.34 for Tertile 2 vs Tertile 3) and medical appointments in primary health centers per inhabitant (HR 0.90; 95% CI 0.75–1.09 for Tertile 1 vs Tertile 2; HR 1.23; 95% CI 0.95–1.61 for Tertile 1 vs Tertile 3 and HR 1.37; 95% CI 1.06–1.76 for Tertile 2 vs Tertile 3) were predictors of all-cause mortality, but not recurrent MI; however, in multivariate analysis adjusted for sex, age and ejection fraction, this association was no longer significant (HR 1.00; 95% CI 0.99–1.00 and, HR 1.00; 95% CI 0.89–1.17, respectively). Additionally, no evident association between illiteracy and all-cause mortality or MI was present. Concerning EDI, demographic data was similar among the quintiles (Table 1). Although EDI quintiles were not associated with all-cause mortality (HR 1.17; 95% CI 0.82–1.66 for Q5 vs Q1), the EDI was an independent predictor of recurrent MI (Figure 1). On multivariate analysis, adjusted for age, sex, hypertension, diabetes and LDL cholesterol, the HR for the most deprived (Q5) to the least deprived (Q1) quintile was 1.91 (95% CI 1.05–3.49) for MI.

Conclusions

Our study shows clear socioeconomic differentials in cardiovascular outcomes in patients with STEMI which suggests that accounting for socioeconomic deprivation might improve risk prediction and therefore disease prognosis.

Funding Acknowledgement

Type of funding source: None

Left atrial emptying fraction: a powerful predictor of events in severe aortic stenosis

Background

Increasing evidence suggests that left atrial (LA) structural and functional changes have an important role in risk stratification and prediction of clinical outcomes. We know from multiple data that left atrial maximum volume (LAVI), measured at end-systole, is a powerful prognostic marker in multiple patient groups. However, recent studies have suggested that this marker may not be the best representative of diastolic function as it does not image the full spectrum of atrial mechanics. Another measure of LA function is the left atrial emptying fraction (LAEF), which has proved to be a significant prognostic marker in many patient groups. Less known is its role in event prediction in severe aortic stenosis patients, a disease with a very important burden in modern societies.

Purpose

The authors hypothesised that LAEF is a powerful predictor of clinical outcomes at 1 year in patients with severe aortic stenosis.

Methods

We retrospectively evaluated 151 patients referred to our echocardiography laboratory with the diagnosis of severe aortic stenosis. All patients underwent transthoracic echocardiography. LA maximum volume was indexed to body surface area. LAEF was calculated as LAVI-LA minimum volume divided by LAVI. Patients were followed for 1 year regarding clinical outcomes. Clinical outcome was defined as a composite of hospital admission for a cardiovascular (CV) cause, emergency department recurrence for a CV cause or CV death. Logistic binary regression was used to evaluate associations of LAEF with the outcome.

Results

A total of 51.7% of patients (n=78) were males. Mean patient age was 76.6±8.0 years. A total of 38.4% of patients were diabetics (n=56), 96% had dyslipidaemia (n=145) and 25% (n=37) had atrial fibrillation. Mean left ventricular ejection fraction (LVEF) was 60.6±7.3, and mean LAVI was 41.4±12.1. In a multivariable regression model including clinical and echocardiographic markers, higher LAVI and pulmonary artery systolic pressure (PASP) were associated with lower LAEF. Receiver operating characteristic curve analysis showed that the predictive value of LAEF for outcomes at 1 year was 0.693 (AUC=0.693, CI 95% 0.578–0.809, p=0.002), performing better than other echocardiographic markers such as LAVI (AUC=0.567, CI 95% 0.440–0.694, p=0.286), PASP (AUC=0.582, CI 95% 0.451–0.714, p=0.191) and LVEF (AUC=0.590, CI 95% 0.464–0.716, p=0.153). After adjustment of baseline characteristics, a LAEF less than 41.3% remained a good predictor of clinical outcomes at 1 year (OR 2.615, CI 95% 1.085–6.305, p=0.32).

Conclusions

In this cohort of severe aortic stenosis patients, a reduced LAEF was associated with greater incidence of cardiovascular events, being a stronger predictor than LAVI, PASP or LVEF. This study suggests that LA dysfunction over LA volumes correlates better with clinical outcomes.

Funding Acknowledgement

Type of funding source: None

Can left atrial mechanics predict anticoagulation in cryptogenic stroke?

Introduction

Ischemic stroke is a leading cause of death and disability in the Western world, frequently due to cardioembolism and atherothromboembolism. Cryptogenic strokes occur without a well-defined aetiology after a standard vascular and cardiac evaluation, and secondary prevention may include antiplatelet therapy while awaiting results of long-term cardiac monitoring. In this study, we aimed to identify echocardiographic predictors of paroxysmal atrial fibrillation (AF) latter identified in follow-up of patients with cryptogenic stroke.

Methods

We retrospectively assessed all patients with cryptogenic stroke admitted in our hospital in the last 2 years. Only patients in normal sinus rhythm with a minimum of 24 hours of cardiac monitoring at admission and 24 hours Holter monitor within 6 months after discharge were included. Echocardiographic measures included left ventricle ejection fraction, left atrium (LA) volume, left and right atrium longitudinal strain, left and right ventricle longitudinal strain, E/A ratio, E/e' ratio, isovolumetric relaxation time (IVRT) and E wave deacceleration time. Echocardiographic data was assessed to determine its accuracy to identify AF.

Results

The study included 32 patients with a mean age of 72±10 years and a male preponderance (87.5%). AF was identified in 12 (37.5%) patients. This group of patients had a larger indexed LA volume (44.3 vs 29.1 mL/m2, p=0.043), a lower IVRT (87 vs 116 ms, p=0.028), and a lower LA longitudinal strain in contractile (6.7 vs 13.6%, p&lt;0.001) and in reservoir phase (17.1 vs 23.6%, p=0.042). All other variables were not significantly different among groups, including LA longitudinal strain in conduit phase. LA longitudinal strain in contractile phase showed the best predictive power with an area under the ROC curve of 0.925 (95% CI 0.82–1 p=0.001). The cut-off value that best predicted AF was 8.17% with a sensitivity of 1 and specificity of 0.9.

Conclusion

LA longitudinal strain in contractile phase is a powerful method to identify AF in cryptogenic stroke. When reduced, anticoagulation may be considered in order to prevent recurrence. Further studies are warranted to reproduce these results in larger cohorts.

Funding Acknowledgement

Type of funding source: None

P1249 Straight from the heart

Introduction

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge and is still associated with high mortality. Systemic complications are frequently present, and an adequate assessment and management are needed.

Purpose

Our aim is to show the importance of an early recognition of IE complications.

Clinical case

We present a case of 54 years old women with a past medical history unremarkable. The patient presented to the hospital with high fever and was admitted with a diagnosis of a psoas abscess and staphilococus aureus bacteremia. After one week of antibiotic treatment the patient was transferred to an intensive care unit due to septic shock and respiratory failure. The patient needed to be intubated and ventilated and was on treatment with vancomycin and meropenem. During admission, several infectious loci were identified, including cerebral and pulmonar involvement. An echocardiography identified mild mitral regurgitation, moderate tricuspid regurgitation and confirmed the presence of two vegetations, one in tricuspid valve with 30mm and one in mitral valve with 5mm. Nevertheless, the patient improved clinically. After 15 days of treatment, the patient was extubated and was transferred to the cardiology ward for follow-up. Although clinically stable and without any complain, repeated echocardiographic evaluation identified left ventricular apical aneurysm and partial resolution of vegetations. A coronariography was performed and did not identified any coronary lesion. A magnetic resonance confirmed the ischemic aetiology of the lesions and a diagnosis of embolic myocardial infarction was made. Considering a good resolution of infection, and being the patient stable and asymptomatic, she was discharged after 6 weeks of antibiotic therapy for follow up in cardiology and neurosurgery consultations.

Discussion and conclusion

Despite appropriate antimicrobial treatment, embolic complications are common and usually develop during initial stage of IE. This case shows several embolic complications of IE, including embolic myocardial infarction and cerebral embolism. Although aggressive antibiotic administration was successful in this particular case and cardiac surgery was avoided, the identification of complications allowed a more strict follow up and was determinant for a good clinical result.

Abstract P1249 Figure.

P6404Myocardial infarction with nonobstructive coronary arteries: does aspirin have a place in the treatment of this entity?

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is still a clinical enigma that is being increasingly recognised, as the number of coronary angiographies we perform in our centres also increase. However, the treatment for this entity is still a matter of important debate, not only due to the different causative mechanisms of this disease but also because there are no major trials regarding MINOCA treatment.

Purpose

To determine the association between acetylsalicylic acid (ASA) use after discharge and mortality after discharge in MINOCA patients admitted to a coronary care unit (CCU).

Methods

We analyzed data from 370 (11.7% of the global sample) patients admitted with MINOCA in our CCU. Patients with other final diagnoses, missing mortality data, previous acute myocardial infarction, contra-indications to aspirin and known heart failure before admission were excluded. All patients underwent transthoracic echocardiography and coronary angiography at any point during hospitalisation. After adjusting data for relevant comorbidities we then compared mortality after hospital discharge between the ASA group and the no-ASA group.

Results

Of all MINOCA patients admitted in our CCU, 84 (22.7%) were diagnosed with ST-elevation myocardial infarction (STEMI) and 286 (77.3%) with non-ST elevation myocardial infarction (NSTEMI). 296 (80%) patients received ASA after discharge. Both groups were homogeneous as we did not find any significant differences between groups regarding age (p=0.106), left ventricle ejection fraction (p=0.100), GRACE score at hospitalisation (p=0.150), Killip-Kimball class at hospitalisation (p=0.604), incidence of acute kidney injury (p=0.450), maximum c-reactive protein during stay (p=0.804) and low-density lipoprotein levels at hospitalization (p=0.055). There was also no difference in the incidence of diabetes (p=0.350), exposure to daily stress (p=0.767), active smoking (p=0.569), dyslipidemia (p=0.229), hypertension (p=0.057) and type of myocardial infarction (STEMI vs NSTEMI – p=0.215). In this MINOCA cohort (5 years follow-up) a total of 47 patients died (12.7%). ASA vs. no-ASA 1-month (3.1% vs. 0.0%, p=0.214), 6-month (4.5% vs. 1.4%, p=0.317), 1-year (5.9% vs 5.6%, p=0.900), 3-year (10.5% vs. 8.3%, p=0.668) and 5-year (13.3% vs. 12.5%, p=0.860) all-cause mortality was not significantly different. The same non-significant trend towards higher mortality with ASA was obtained when survival curves were taken into account.

Conclusions

MINOCA remains a challenging entity. In our study, the systematic use of ASA in all patients following MINOCA was not associated with better survival after long-term follow-up.

P4751Underdosing fragile patients - Are we helping or harming?

Background

An individualized approach should be taken regarding the utilization of direct oral anticoagulants (DOAC) in frail and elderly populations with atrial fibrillation (AF). We hypothesized that among an elderly and frail population, where the risk of bleeding, both real and perceived, is very high, the proportion of patients with a dose regimen different from the formal indication would be particularly high due to potential underdosing.

Methods

We conducted a retrospective, observational study enrolling 327 patients with AF admitted to an Internal Medicine ward during a 1-year period and discharged with a DOAC prescription. We divided the population in 2 groups: patients prescribed a reduced dose without formal dose reduction criteria (underdosed, n=170) and the rest of the population (n=157), which included adequately dosed patients, both with normal dose (n=99) and correctly reduced dose (n=43) and overdosed patients (n=15). A 1-year follow-up was completed for all patients, assessing the following outcomes: all-cause mortality, stroke, systemic embolism and major bleeding.

Results

Patients were elderly (81.9±7.68) and frail (Katz index 3.35±2.36). Apixaban was the most commonly prescribed NOAC (38.8%), followed by rivaroxaban (36.4%) and dabigatran (24.8%). Among underdosed patients, apixaban was prescribed in 45.3% of patients, dabigatran in 29.4% and rivaroxaban 25.3%. Although only 18.3% of patients had clinical criteria for dose reduction, 65.4% were discharged with reduced dose and thus 52% were underdosed.

Regarding 1-year outcomes, mortality (40.8% vs 25.5%, RR=1.6, p=0.003) and the combined stroke, systemic embolism and major bleeding event rate (10.1% vs 3.2%, RR=3.16, p=0.015) were higher for underdosed patients.

Among underdosed patients, comparing with the rest of the population, the increased ischemic events rate (ischemic stroke and systemic embolism) did not reached statistical significance (3.7% vs. 1.9%, p=0.5), but it did for hemorrhagic events (major bleeding and hemorrhagic stroke) (6.1% vs 0.6%, p=0.01)

On multivariate analysis, even after considering adjustment for age, Katz and CHAD2VAS2C scores, renal function and DOAC prescribed, DOAC underdosing was associated with a higher risk of both ischemic and hemorrhagic events (HR = 3.51, 95% CI 1.08–11.38). However, it lost its independent negative effect regarding mortality (HR 1.32, 95% CI 0.87–1.99).

Survival and event rate in underdosed

Conclusions

There is a significant proportion of frail and elderly patients with AF that are underdosed. This subset has a significant survival disadvantage, eventually reflecting prescription bias. However, underdosed patients have also a higher event rate of both ischemic and hemorrhagic events, suggesting that underdosing fragile patients is not an effective strategy and that instead it may be hazardous.

The RHSET service as a regional resource: what price support?

The Rural Health Support, Education and Training (RHSET) advisory service has been a valuable tool for rural and remote organisations wishing to submit applications for health and human service grants. It has enhanced the concept of access and equity for groups in rural and remote areas. Support and networking have been strong factors in the service, which has overcome the limitations of inadequate travel and time resources for part-time project officers providing assistance to organisations seeking grants. Intending grant applicants need to be motivated and enthused to keep working on applications, particularly as there is no guarantee of an affirmative outcome. It needs to be recognised that the positive results likely to arise from a full-time regional service should not be thwarted by the lack of a small Commonwealth funding investment. There is considerable potential for the development of support services in terms of the breadth and depth of services offered to rural and remote health workers.

Role of the posterior capsule in the prevention of postoperative bacterial endophthalmitis: experimental primate studies and clinical implications

The posterior capsule has an important effect on the risk of postoperative bacterial endophthalmitis. In order to investigate whether the posterior capsule inhibited the spread of infection into the vitreous we performed extracapsular cataract extraction in both eyes of 10 primates. In one eye of each primate the posterior capsule was left intact and in the other eye a large posterior capsulectomy was performed. When the anterior chambers were challenged with equivalent inocula of Staphylococcus aureus, one of 10 eyes with an intact posterior capsule developed culture-positive vitreous infection. In contrast, nine of 10 eyes with a large posterior capsulectomy developed culture-positive vitreous infection. In a second experiment we investigated the effect of an intraocular lens on the barrier effect. Ten primates received extracapsular cataract extraction in both eyes and pseudophakic implantation. In one eye of each primate the posterior capsule was left intact and a J-loop monoplanar lens was implanted in the ciliary sulcus. In the other eye of each primate a large posterior capsulectomy was followed by implantation of a monoplanar, non-vaulted pseudophakos into the anterior chamber. None of the 10 eyes with a posterior capsule intact and a posterior chamber lens in place developed positive vitreous cultures or histopathological evidence of vitreous infection. Thus the presence of a posterior chamber lens did not appreciably compromise the barrier effect of the intact posterior capsule. 40% of the eyes with a large posterior capsulectomy and a non-vaulted pseudophakos in the anterior chamber developed culture-positive vitreous infection, and 60% of the eyes showed histopathological evidence of vitreous infection.

Open angle glaucoma in melanosis oculi: response to laser trabeculoplasty

The case for an association between secondary open angle glaucoma and melanosis oculi is strengthened by our recent observation of a teenaged male with advanced glaucomatous damage in the eye with melanosis oculi. This report summarizes his clinical findings, his response to medical therapy and laser trabeculoplasty, and suggests the possibility that melanosis oculi causes secondary open angle glaucoma in patients who are predisposed to primary open angle glaucoma.