PARADISE-MI – event rates and treatment effect of sacubitril/valsartan v ramipril by the presence or absence of transient pulmonary congestion and/or LVEF less or greater than 40

Background/Introduction

Sacubitril/valsartan was compared to ramipril in patients with acute myocardial infarction in the PARADISE-MI trial. In the whole trial population sacubitril/valsartan did not reduce the composite primary outcome of CV death or incident heart failure compared to ramipril. Whether or not event rates and/or treatment effects vary in patients with different baseline characteristics is unknown.

Purpose

To investigate a) event rates b) the treatment effect of sacubitril/valsartan compared to ramipril and c) safety by the presence or absence of transient pulmonary congestion and/or left ventricular ejection fraction (LVEF) ≤40%.

Methods

PARADISE-MI was a double-blind, randomised clinical trial that compared sacubitril/valsartan to ramipril in 5661 patients with an acute myocardial infarction with either LVEF ≤40% and/or transient pulmonary congestion. 3 groups were investigated: 1) LVEF ≤40% with pulmonary congestion (n=2012) and 2) LVEF ≤40% without pulmonary congestion (n=2596) and 3) LVEF not ≤40% with pulmonary congestion (n=1044).

Results

Patients with pulmonary congestion (with and without LVEF ≤40%) were more likely to have had a prior MI, prior CABG or PCI, had more atrial fibrillation and were more often treated with mineralocorticoid receptor antagonists and diuretics than patients with no pulmonary congestion and LVEF ≤40%. Patients with LVEF ≤40% and pulmonary congestion had more than twice the rate of the primary composite outcome compared to those with LVEF ≤40% without pulmonary congestion: 10.2 (95% CI 9.2–11.3) vs. 4.8 (4.3–5.5) events per 100 patient-years, respectively). Patients with pulmonary congestion and LVEF not ≤40% had an intermediate event rate (6.6, 5.5–7.9, events per 100 patient-years). A similar pattern of event rates was seen for the components of the primary outcome and for all secondary outcomes whether Clinical Events Committee or investigator-reported events were analysed. The treatment effect of sacubitril/ valsartan versus ramipril did not vary between the 3 congestion/ LVEF subgroups. The safety of sacubitril/valsartan compared to ramipril did not vary between congestion/LVEF subgroups.

Conclusion

Patients with pulmonary congestion with or without LVEF ≤40% had higher rates of primary and all secondary outcomes than those without pulmonary congestion and LVEF ≤40%. The treatment effect, and safety, of sacubitril/valsartan compared to ramipril was consistent in patients with or without pulmonary congestion and with or without LVEF ≤40%.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis

Sacubitril/valsartan compared to ramipril in high risk post myocardial infarction patients stratified according use of mineralocorticoid receptor antagonists: insight from PARADISE MI trial

Background

Mineralocorticoid receptor antagonists (MRAs) reduce the risk of cardiovascular death or heart failure admission in patients with myocardial infarction (MI) and left ventricular systolic dysfunction (LVSD) combined with either heart failure (HF) or diabetes. Whether use of MRA and initiation of sacubitril/valsartan are safe and whether MRAs modify the effect of sacubitril/valsartan initiation in high-risk MI patients is unknown.

Purpose

This analysis examined whether background treatment with a MRA modifies the treatment effect and safety of sacubitril/valsartan in patients with a MI and LVSD and/or pulmonary congestion.

Methods

In the PARADISE MI Trial (Prospective ARNI vs. ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction) N=5661 patients were randomized to either sacubitril/valsartan (97/103 mg twice daily) or ramipril (5 mg twice daily) within 7 days of their MI. The primary outcome in this analysis was the composite of worsening HF (HF hospitalization or outpatient worsening) or cardiovascular death evaluated by the clinical endpoint committee (CEC-adjudicated) or the investigators. Safety was defined as symptomatic hypotension, hyperkalemia >5.5 mmol/L or permanent drug discontinuation.

Results

A total of 2338 patients (41%) were treated with an MRA and they were more often Caucasian (79% vs. 73%), had worse left ventricular ejection fraction (34±8 vs. 38±10%), a higher KILLIP Class (63% vs. 55% in class II or more) and a lower estimated Glomerular filtration rate (71 vs. 73 ml/min/1.73 m2), than patients not taking an MRA. Age (63 years), sex (24% females), and frequency of diabetes (42%) did not differ. The treatment effect of sacubitril/valsartan compared with ramipril was similar in patients taking or not taking an MRA: hazard ratio (MRA): (95% confidence interval [CI]): 0.96 (0.77, 1.19) versus (95% CI: 0.87 (0.71, 1.05), respectively, for the primary endpoint (p value for interaction = 0.51) (CEC adjudicated) (Figure 1); similar findings were observed if investigator reported endpoints were evaluated (P=0.61 for interaction). Safety of sacubitril/valsartan compared to ramipril initiation was not changed by +/−MRA use, but an increase in symptomatic hypotension was observed (HR(MRA): 1.37 and HR: 1.39, P<0.001) in both groups (P=0.968 for interaction), whereas an increased risk of hyperkalemia or permanent drug discontinuation was not observed in the sacubitril/valsartan group (P>0.05 for all comparisons).

Conclusions

As expected, patients taking MRAs had a higher risk. Use of a MRA did not modify the treatment effect and safety of initiation of sacubitril/valsartan compared to ramipril in the post MI setting in patients with LVSD and/or congestion. Our analyses support that sacubitril/valsartan and MRAs can be used simultaneously.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis sponsored Randomized clinical trial

Long-term safety and efficacy of anacetrapib in patients with atherosclerotic vascular disease

AIMS

REVEAL was the first randomized controlled trial to demonstrate that adding cholesteryl ester transfer protein inhibitor therapy to intensive statin therapy reduced the risk of major coronary events. We now report results from extended follow-up beyond the scheduled study treatment period.

METHODS AND RESULTS

A total of 30 449 adults with prior atherosclerotic vascular disease were randomly allocated to anacetrapib 100 mg daily or matching placebo, in addition to open-label atorvastatin therapy. After stopping the randomly allocated treatment, 26 129 survivors entered a post-trial follow-up period, blind to their original treatment allocation. The primary outcome was first post-randomization major coronary event (i.e. coronary death, myocardial infarction, or coronary revascularization) during the in-trial and post-trial treatment periods, with analysis by intention-to-treat. Allocation to anacetrapib conferred a 9% [95% confidence interval (CI) 3-15%; P = 0.004] proportional reduction in the incidence of major coronary events during the study treatment period (median 4.1 years). During extended follow-up (median 2.2 years), there was a further 20% (95% CI 10-29%; P < 0.001) reduction. Overall, there was a 12% (95% CI 7-17%, P < 0.001) proportional reduction in major coronary events during the overall follow-up period (median 6.3 years), corresponding to a 1.8% (95% CI 1.0-2.6%) absolute reduction. There were no significant effects on non-vascular mortality, site-specific cancer, or other serious adverse events. Morbidity follow-up was obtained for 25 784 (99%) participants.

CONCLUSION

The beneficial effects of anacetrapib on major coronary events increased with longer follow-up, and no adverse effects emerged on non-vascular mortality or morbidity. These findings illustrate the importance of sufficiently long treatment and follow-up duration in randomized trials of lipid-modifying agents to assess their full benefits and potential harms.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 48678192; ClinicalTrials.gov No. NCT01252953; EudraCT No. 2010-023467-18.

Underuse of reperfusiontherapy in STEMI with cardiogenic shock. Results of the EORP ACVC EAPCI STEMI registry of the ESC

Aims

To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in ESC member and affiliated countries for patients with ST segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).

Methods and results

ESC EORP prospective international cohort study of admissions with STEMI within 24 hours of symptom onset (196 centers; 26 ESC member and 3 affiliated countries). Of 11462 patients enrolled, 448 (3.9%) had CS. Patients without compared to patients with CS, more frequently received primary PCI (72.5% versus 65.2%) and fibrinolysis (19.0 versus 15.9%) and less frequently had no reperfusion therapy (8.5% versus 19.0%). Mechanical support devices (IABP 11.2%, ECMO 0.7%, other 1.1%) were used infrequently in CS. BARC 2–5 bleeding complications (10.1% versus 3.0%, p&lt;0.01) and stroke (4.2% versus 0.9%, p&lt;0.01) occurred more frequently in patients with CS. In-hospital mortality was ten-fold higher (35.5% versus 3.1%) in patients with CS. Mortality in patients with CS in the groups with PCI, fibrinolysis and no reperfusion therapy were 27.4%, 36.6% and 62.4%, respectively.

Conclusions

In this multi-national registry patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore strategies to improve clinical outcome in STEMI with CS are needed.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC EORP

Cervical re-injection of indocyanine green to improve sentinel lymph node detection in endometrial cancer

OBJECTIVES

To evaluate the role of cervical re-injection of indocyanine green (ICG) to increase the detection rate of sentinel lymph node (SLN) in patients with endometrial cancer (EC) who underwent robotic-assisted surgical staging.

METHODS

We retrospectively identified consecutive EC patients undergoing robotic-assisted staging with SLN biopsy at our Institution between June 2016 and April 2020. Patients were excluded if they had open abdominal surgical approach, neoadjuvant chemotherapy, and advanced stage [International Federation of Gynecology and Obstetrics (FIGO) stage III-IV] at diagnosis. According to our SLN protocol, in case of either unilateral or no SLN detection, we performed an ipsilateral or bilateral cervical re-injection of ICG.

RESULTS

In total, 251 patients meeting inclusion criteria were included in the analysis. At first injection, bilateral detection was achieved in 184 (73.3%), unilateral detection in 57 (22.7%), and no detection in 10 (4.0%) patients. Cervical re-injection was performed in 51 of 67 patients with failed bilateral mapping. After cervical re-injection, bilateral detection rate increased to 94.5% (222/235), while unilateral and no detection were 5.1% (12/235) and 0.4% (1/235), respectively.

CONCLUSIONS

Our results suggest that cervical re-injection of ICG, in case of failed bilateral mapping of SLN, brings about a significant improvement in SLN detection rates, therefore reducing the number of side-specific required lymphadenectomies.

Genetic counselling and testing of adult patients with cardiomyopathies: insight from the EORP cardiomyopathy and myocarditis registry of the European Society of Cardiology

Introduction

Cardiomyopathies comprise a heterogeneous group of diseases, often of genetic origin.

Purpose

We assessed the current practice of genetic counselling and testing of adult cardiomyopathy patients in the prospective ESC EORP cardiomyopathy registry.

Methods

3 208 adult patients from sixty-nine centres in 18 countries were enrolled. Clinical data on genetic counselling and testing and on the presentation of cardiomyopathies were gathered.

Results

Genetic counselling was performed in 60.8% of all patients (75.4% in hypertrophic (HCM), 39.2% in dilated (DCM), 70.8% in arrhythmogenic right ventricular (ARVC) and 49.2% in restrictive cardiomyopathy (RCM), p&lt;0.001). Comparing European geographical areas, genetic counselling was performed from 42.4% to 83.3% (p&lt;0.001). It was provided by a cardiologist (85.3%), geneticist (15.1%), genetic counsellor (11.3%), or a nurse (7.5%), (p&lt;0.001). Genetic testing was performed in 37.3% of all patients (48.8% in HCM, 18.6% in DCM, 55.6% % in ARVC and 43.6% in RCM, p&lt;0.001). Index patients with genetic testing were younger at diagnosis, had more familial disease, family history of sudden cardiac death or implanted cardioverter defibrillators but less comorbidities than those not tested (p&lt;0.001 for each comparison). At least 1 disease causing variant was found in 41.7% of index patients with genetic testing (43.3% in HCM, 33.3% in DCM, 51.4% in ARVC and 42.9% in RCM, p=0.13).

Conclusion

We report on the practice of genetic counselling and testing in cardiomyopathies in Europe. Genetic counselling and testing were performed in a substantial proportion of patients but less often than recommended by European guidelines, and much less in DCM than in HCM and ARVC, despite evidence for genetic background.

Funding Acknowledgement

Type of funding source: None

Poor attainment of blood pressure, lipids and diabetes targets in people at high cardiovascular risk in Europe: a report from the ESC-EORP EUROASPIRE V Survey in 16 European countries

Introduction

The EUROASPIRE V survey in primary care was carried out by the European Society of Cardiology, EURObservational Research Programme in 2017–2018 and investigated the risk factor management in patients at high cardiovascular (CVD) risk in16 European countries.

Purpose

To provide an audit the implementation of the 2016 Joint European Societies' guidelines on CVD prevention in people at high risk of developing CVD in primary care and to see whether the practice of preventive cardiology had improved by comparison with the previous EUROASPIRE IV survey in 2014–2015.

Methods

All patients were free of coronary or other atherosclerotic diseasebut considered at high CVD risk since they had been started on blood pressure and/or lipid and/or glucose lowering treatments. They were interviewed and examined by means of standardized methods ≥6 months after the start of therapy.

Results

2,759high CVD risk individuals (58% females), mean age 59 (SD 12) years, were interviewed and examined (participation rate 70%). The risk factor control was very poor, with less than half (47%) of patients on blood pressurelowering medication reaching the target of &lt;140/90 mmHg (&lt;140/85 mmHg in people with self-reported diabetes). Among treated dyslipidaemic patients only 47% attained LDL-cholesterol target of &lt;2.6 mmol/L. Among treated type 2 diabetic patients, 65% achieved the HbA1c target of &lt;7.0mmol/L. However, many patients on no antihypertensive or lipid-lowering medications had elevated blood pressure (43%) and elevated LDL-cholesterol (81%), respectively. The use of blood pressure lowering medication in people with hypertension was: ACE inhibitors/ARBs 79%, beta-blockers 37%, diuretics 36% and calcium channel blockers 32%; with 42% on one, 34% on two, 18% on three and 6% on ≥4 blood pressure lowering drugs. Among people on lipid-lowering medication, statins were prescribed in 97% and fibrates in 3%. Less than two-thirds of patients reported complete adherence with the intake of their blood pressure and lipid-lowering medications. The comparison with EUROASPIRE IV in the same centres that took part in both surveys showed no change in the BP management. There was a slight improvement in the control of LDL-cholesterol and glucose in patients with diabetes.

Conclusions

The results of EUROASPIRE V clearly demonstrate that the control of blood pressure, LDL-cholesterol and diabetes in patients at high CVD risk remains poor with large proportions not achieving the targets defined in the prevention guidelines. There is a considerable potential to raise the standards of preventive cardiology and to improve the management of patients at high CVD risk in Europe.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Society of Cardiology

Death, hospitalization, emergency department visits and out-patient visits in patients with heart failure in contemporary practice: results from the prospective Europeam 9069-patient ARIADNE registry

Background

In Europe, heart failure (HF) is managed in variable settings and frequently in office-based practice. In HF with reduced ejection fraction (HFrEF) there is now extensive evidence based therapy, but implementation is inconsistent, variable and overall inadequate. The Assessment of Real lIfe cAre –Describing EuropeaN hEart failure management (ARIADNE) registry aimed to assess in detail how outpatients with HFrEF are managed in Europe in contemporary practice.

Methods

ARIADNE was a prospective non-interventional registry of patients with HFrEF (NYHA class II-IV) treated by office-based cardiologists or selected primary care physicians (recognized as HF specialists) in a real world setting. Patients were enrolled in 687 centres in 17 European countries, and studied at baseline and after 6 and 12 months. Key pre-specified outcomes were deaths, hospitalizations, emergency department visits, and office visits, and their primary reasons.

Results

Over 20 months, we enrolled 9069 patients; median age 69 (19–96) years, 24% women, with 30% older than 75 years, 61% NYHA class II, with a median EF 35% (30–40%).

Over a median follow-up of 353 (1–631) days, 382 patients (4.3%) died, with 171 cardiovascular deaths (1.9%). The rates of total hospitalizations overall, for HF, and for non-HF cardiovascular reasons were 19.3, 8.1, and 4.8 per 100 patient years, respectively; and rates of emergency department visits overall, for HF reasons, and for non-HF CV reason were 7.7, 1.6, and 1.8, respectively. The number of HF office visits were on average 1.0 per patient.

Conclusions

In this large multinational HFrEF registry with detailed data on cause-specific outcomes and health care utilization, incidence of death was low and outpatient HF visits were few, but incidence of HF and CV hospitalization and emergency department visits was high.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis AG, Switzerland

Treatment with sacubitril/valsartan in European outpatients with chronic heart failure in Europe: results from ARIADNE registry

Background

Recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan (S/V) was introduced as a novel therapeutic option into European guidelines for the management of heart failure (HF). The Assessment of Real lIfe cAre –Describing EuropeaN hEart failure management (ARIADNE) registry provides real world information about its use and efficacy in real life in outpatients with heart failure with reduced ejection fraction (HFrEF) in Europe.

Methods

ARIADNE was a prospective registry of patients with HFrEF (NYHA II-IV, reduced EF) treated by office-based cardiologists or selected primary care physicians (recognized as HF specialists) in a real world setting. 9069 HFrEF patients were enrolled from 674 investigators in 17 European countries, and followed over 12 months. Out of 8787 patients fulfilling criteria for analysis, 52.5% of the patients received S/V treatment at baseline, whereas 47.5% continued on their previous individualized heart failure medication. Results of S/V patients are reported here.

Results

The mean age of patients prescribed S/V was 67.3 years, mainly NYHA class II or III (49.7% and 48.2%, respectively), and mean LVEF of 32.7%. Common documented comorbidities were arterial hypertension (63.7%), coronary heart disease (62.4%), dyslipidemia (50.3%), diabetes (32.5%), and chronic kidney disease (24.1%).

Of the 4143 patients in the S/V group, 89.9% received S/V at baseline, 74.8% received S/V in combination with a β-blocker; 47.8% with a β-blocker and MRA.

Within 6 months of the observational period, 693 (17.4%) of the S/V patients were hospitalized, of which 46.8% and 28.7%, had HF related and non-HF cardiovascular (CV) hospitalizations. Emergency room visits without hospitalization were documented for 3.4% of S/V patients in the same time period; stroke and myocardial infarction occurred in 22 (0.5%) and 24 (0.6%) of the S/V patients, respectively. Cardiac catheterization or coronary angiography procedures were applied to 1.7% and 2.8% of the S/V patients. Total mortality was 4.3% (S/V 3.8%; non-S/V 5.0%), cardiovascular mortality 1.9% (S/V 1.8%; non-S/V 2.2%), during the 12 month observational period.

The proportion of S/V patients in NYHA class III or IV decreased in the course of the study from 44.6% to 24.0%. After 12 months of follow up, 46.3% of patients with NYHA class III had a reported improvement to NYHA class II. Consistently, mean LVEF increased to 37.9%. The percentage of S/V patients with LVEF &lt;22.5% decreased from 11.5% to 5.8%. KCCQ overall summary score increased by 1.9 points. An improvement of ≥5 points, denoting a clinically meaningful increase, was reported for 36.2% of S/V patients.

Conclusions

Data from the ARIADNE prospective registry portray a diverse, multinational study cohort receiving sacubitril/valsartan under real-world conditions. Throughout the study, symptoms and quality of life improved with the use of S/V.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis AG, Switzerland

Baseline characteristics and clinical features of patients with heart failure with reduced ejection fraction: a European real-world, non-interventional registry study

Background

Heart failure (HF) is a major medical and economic burden that is often managed in office based practices. Recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan (S/V) was introduced as novel therapeutic option into European guidelines for the management of HF. The ARIADNE registry aims to provide information on how outpatients with HF with reduced ejection fraction (HFrEF) are managed in Europe, in light of this novel treatment option.

Methods

ARIADNE was a prospective registry of patients with HFrEF treated by office-based cardiologists (OBC) or selected primary care physicians (recognized as HF specialists; PCP) in a real world setting. HFrEF patients were included prospectively, independently of whether treatment had been changed recently or not. 9069 patients were recruited from 687 centres in 17 European countries.

Results

The mean age of all patients was 68.1 years (S/V: 67.3 years, Non-S/V: 68.9 years). The majority of patients were in NYHA class II (61.3%), or NYHA class III (37.1%) overall, while more patients in the S/V group showed NYHA class III (S/V: 42.8%, Non-S/V: 30.9%). Mean LVEF was slightly lower in the S/V group than in the Non-S/V group (S/V: 32.7%, Non-S/V: 35.4%, overall 34.0%). The most frequently observed signs of HF were dyspnoea upon effort, followed by fatigue, palpitations on exertion at baseline. More patients tend to have more severe symptoms in the S/V groups (e.g. for dyspnoea on effort, Non-S/V: moderate 40.8%, severe 8.6%; S/V: moderate 46.4%, severe 14.1%). 44.0% of patients from the S/V group and 39.3% of non-S/V patients reported at least one hospitalization within 12 months prior to baseline, of which 73.3% in S/V and 69.9% in non-S/V patients were due to HF., At baseline, 44.7% of the patients used a CV device, of which most were implantable cardioverter defibrillator (ICD: Non-S/V 54.2%, S/V: 52.8%), implantable cardioverter defibrillator (CRT-ICD:Non-S/V 21.9%, S/V: 27.0%), and pacemaker (Non-S/V: 13.4%, S/V: 10.5%). The mean KCCQ overall summary score was 62.6 in the S/V group and 69.5 in the Non-S/V group at baseline.

83.9% of patients were treated with ARB or ACEi in Non-S/V group, (ACEi 57.3%, ARB 26.9%). The most frequently taken drug combinations in either group were ACEi/ ARB or S/V with β -blockers (Non-S/V 69.3%, S/V 67.3%). 40.2% in the Non-S/V group and 42.9% in S/V groups used a combination of ACEi/ARB or S/V, β-blocker and MRA.

Conclusions

The ARIADNE prospective registry provides insights and reflects variations in HF treatment practices in outpatients in Europe and the way S/V was introduced by OBCs and specialized PCPs in a real-world setting. In the observed population, S/V is more often prescribed to slightly younger patients with slightly lower LVEF, there was a greater observed percentage of S/V patients NYHA class III, with lower quality of life measurements and with more severe symptoms and recent hospitalizations for heart failure.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis Pharma AG

Comparison between laparoscopy and laparotomy in the surgical re-staging of granulosa cell tumors of the ovary

OBJECTIVE

To evaluate the role of laparoscopic (LPS) and laparotomic (LPT) re-staging in patients with incompletely surgically staged ovarian granulosa cell tumors (OGCT).

METHODS

We conducted a medical chart retrospective analysis of all patients with sex cord stromal tumors (SCSTs) who were managed in our division between March 1994 and March 2017. After a complete review of surgical and pathological notes, patients with incomplete staging were restaged according to the FIGO guidelines. Statistical analysis was conducted using Statistical Package version 20.0 for Windows (SPSS, Inc., Chicago, Illinois).

RESULTS

Out of a total of 170 patients SCSTs, 84 patients (49,5%) received primary surgery that included a hysterectomy; 86 patients (50,5%) underwent fertility-sparing surgery. Eighty-one patients (48%) with diagnosis of OGCT were incompletely surgically staged at another institution. We evaluated our results in terms of laparoscopic approach (56 patients) and open treatment (25 patients). Among the IA patient's group, 1 was upstaged to IIB stage and 2 to IIIB; among patients with IC stage, 1 was upstaged to IIA, 2 to IIB and 1 to IIIB stage. Adjuvant chemotherapy was given to the upstaged patients with final stage IIB-IIIC. No statistically significant difference between laparoscopy and open-surgery was detected in terms of upstaged patients after second surgery (p = 0,36).

CONCLUSION

According to our series, laparoscopic restaging compared to the open approach seems to be a feasible and efficient technique to complete surgical staging in patients with GCTs incorrectly staged. Surgical restaging seems to upstage a considerable number of OGCT, mainly in the initial stage IC group of patients. However, the impact of restaging on final outcome and survival remains to be demonstrated.

4329Mega-studies in heart failure, effect dilution in examination of new therapies

Aims

All phase 3 studies in patients with acute heart failure (AHF) and HF with preserved ejection fraction (HFpEF) have failed in the last decades. We explore the likelihood that the negative results are due to chance and/or to study size and dilution of statistical power.

Methods and results

First, using simulations, we examined the probability that a positive finding in phase 2 would result in studying truly effective drugs in phase 3. We simulated phase 2 studies under six scenarios where the range of true relative risk (RR) for an outcome of interest varied from 0.5 (major benefit) to 1.15 (some harm). The proportion of simulated studies where the RR <0.8 (we assumed that a 20% or greater risk reduction reflects an effective drug) ranged from 6% to 42% across the six scenarios studied. To further simulate “real life” clinical research, we simulated a continuous surrogate outcome that was linearly related to the true RR in each simulation of each scenario. Regardless of criteria considered for a positive phase 2 trial, results suggest that even in our worst-case scenario, where overall only 6% of drugs taken into phase 2 are effective, roughly 20% of phase 3 studies, if appropriately powered, should have yielded positive results. Given this, we then explored study size in AHF research, as a potential explanation for the high failure rate in these studies. Comparison of published phase 2 and 3 clinical trials with registries in AHF suggest that populations in both large and small trials differ from “real life”. Meta-regression models suggest that both control event rates, and in the serelaxin program as an example, treatment effects, decline with increasing study size greatly reducing power (figure). This effect dilution might be explained by an increasing proportion of patients enrolled in studies who cannot benefit from the study drug.

Figure 1. Power at two-sided 0.05 significance level to detect an effect size of hazard ratio of 0.65 (left) or 0.8 (right) with a placebo event rate of 10% (top) and 20% (bottom) at N=100 at various treatment effect dilutions with increasing sample size.

Conclusion

These data suggest that it is unlikely that the very high rate of negative AHF phase III trials can be explained by chance alone. Potentially, our tendency to increase sample size does not necessarily increase statistical power, due to more heterogenous populations leading to reduced event rates and treatment effects.

P3424Gender differences in the implementation of CVD prevention In patients with coronary disease: Results from the EUROASPIRE V Survey

Introduction

EUROASPIRE V was a cross-sectional survey carried out by the European Society of Cardiology, EURObservational Research Programme in 2016–2017 in 27 European countries

Purpose

To describe gender differences in lifestyle and risk factor management, and the use of cardioprotective drug therapies in patients with coronary heart disease in Europe.

Methods

Patients <80 years with coronary disease (CABG, PCI or an acute coronary syndrome) were identified from the hospital medical records and interviewed and examined by trained staff ≥6 months and ≤2 years later using standardized methods including central laboratory measurements.

Results

A total of 8,261 (25.8% females), mean age 63.6 (SD 9.6) were interviewed, with a median time between the index event and interview 1.12 years (IR 0.82–1.56). Women were older (mean age 65.4 years [SD 9.2] vs 63.0 [9.7] and had a lower level of education than men.Comparing women with men, the prevalence of the risk factors were as follows: current smoking 12.8% vs 20.7%,obesity (BMI ≥30 kg/m2) 45.7% vs 34.9%, central obesity (waist circumference ≥102 cm in men or ≥88 cm in women) 78.0% vs 51.8%, raised blood pressure (BP ≥140/90 mmHg, ≥140/80 mmHg in patients with diabetes) 47.1% vs 46.0%, elevated LDL-cholesterol (≥1.8 mmol/l) 77.9% vs 68.5% and self reported diabetes 33.1% vs 28.0%. Reported use of prophylactic drug therapies for the same comparison was: antiplatelets 91.8% vs. 92.8%; beta-blockers 81.8% vs. 80.8%; ACE inhibitors/ARBs 75.0% vs. 75.3%; and statins 76.8% vs. 82.2%. The therapeutic control of blood pressure, LDL-cholesterol and diabetes (HbA1c <7 mmol/L) was: 48.2% vs 49.9%; 25.7% vs 34.1% and 48.5% vs 56.7%, respectively.

Conclusions

The results show that women with coronary disease have higher prevalence of obesity, central obesity, elevated LDL-cholesterol and self-reported diabetes than men. There were no differences in terms of blood pressure management. All coronary patients require professional support to make lifestyle changes and manage risk factors more effectivelyin order to reduce their risk of recurrent cardiovascular events.

Acknowledgement/Funding

ESC-EORP supported by Amgen, Eli Lilly, Pfizer, Sanofi, Ferrer and Novo Nordisk

P3784Impact of progressively impaired renal function on major adverse outcomes in European patients with atrial fibrillation: a report from the ESC EORP-AF long-term general registry

Background

Renal function is an important predictor of major adverse outcomes in the general population. In the setting of atrial fibrillation (AF), renal dysfunction may act both as a risk factor and a proxy of vascular risk factors and comorbidities.

Methods

We analyzed the association of renal function, as estimated glomerular filtration rate (eGFR) using the CKD-EPI formula, with 1-year outcomes in a “real-world” cohort of European AF patients from the EORP-AF Long-Term General Registry.

Results

7725 were available for this analysis. Of these, 1294 (16.7%) had normal renal function (≥90 mL/min/1.73 m2), 3848 (49.8%) mildly reduced renal function (60–89 mL/min/1.73 m2), 2311 (29.9%) moderately reduced renal function (30–59 mL/min/1.73 m2) and 272 (3.5%) severely reduced renal function (<30 mL/min/1.73 m2). CHA2DS2-VASc and HAS-BLED scores values increased across eGFR strata (p<0.0001). Among patients qualifying for oral anticoagulant (OAC) therapy, those with severely impaired renal function were less often prescribed with any OAC (79.8%, p<0.0001), more likely with vitamin K antagonist (62.9%) than non-vitamin K antagonist oral anticoagulants (16.9%) (p<0.0001). At 1-year follow-up the rates of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death progressively increased with worsening renal function, up to 20.7% in patients with severe dysfunction (p<0.0001). Rates of CV death and all-cause death were higher in severe renal dysfunction (16.9% and 21.3%; p<0.0001). Cox regression analysis (adjusted for known predictors) showed that eGFR <30 mL/min/1.73 m2, compared to normal renal function was associated with an increased risk of all the adverse outcomes (Table). eGFR decrease by 10 mL/min/1.73 m2 was associated with increased risks (Table).

Any TE/ACS/CV Death CV Death All-Cause Death mL/min/1.73 m2 HR (95% CI) HR (95% CI) HR (95% CI) eGFR ≥90 (ref.) – – – eGFR 60–89 0.99 (0.67–1.46) 0.81 (0.44–1.51) 0.74 (0.47–1.19) eGFR 30–50 1.12 (0.74–1.69) 1.00 (0.53–1.89) 0.95 (0.59–1.54) eGFR <30 2.47 (1.52–3.99) 2.73 (1.36–5.49) 2.16 (1.25–3.72) eGFR (by 10 mL/min/1.73 m2 decrease) 1.11 (1.05–1.17) 1.18 (1.10–1.27) 1.11 (1.03–1.18) ACS = Acute coronary syndrome; CI = Confidence interval; CV = Cardiovascular; eGFR = estimated Glomerular Filtration Rate; HR = Hazard ratio; TE = Thromboembolic event.

Conclusions

In AF patients, impaired renal function at baseline is associated with a progressive increase in the risk of major adverse outcomes during follow up. Severe renal dysfunction is an independent predictor of all the adverse outcomes.

P334Prospective FU in various subtypes of cardiomyopathies: insights from the EORP Cardiomyopathy Registry of the ESC

Background

The EORP Cardiomyopathy Registry is a prospective, observational, multinational registry of consecutive patients with cardiomyopathies. The objective of this report is to describe the outcomes at one year of follow-up of adult patients (>18 years old) enrolled in the registry.

Methods

A total of 3,208 patients (median age: 55.0 (43.0; 64.0) years, males: 65.1%) were recruited at baseline. Follow-up data at 1 year were obtained in 2,713 patients (84.6%), including 1,420 with hypertrophic (HCM), 1,105 dilated (DCM), 128 arrhythmogenic right ventricular (ARVC) and 60 restrictive cardiomyopathy (RCM).

Results

Improvement of symptoms (NYHA, chest pain, syncope) was globally observed over time (p<0.001 for each). Additional invasive therapeutics were performed during follow-up: implantation of ICD (primary prevention) (N=109 patients, 5.2%), pacemaker (N=28, 1.2%), heart transplant (N=30, 1,1%), ablation for atrial or ventricular arrhythmia (0.5% & 0.1%). The proportion of patients with history of AF increased from baseline to FU in 3.6% (from 28.2% to 31.8%). ICD therapy at 1 year was delivered more frequently in ARVC then in DCM, HCM and RCM (11.4%, 9.0%; 8.1%, 0% respectively for primary prevention). Major cardiovascular events (MACE) occurred in 29.3% of RCM, 10.5% of DCM, 7.9% of ARVC and 5.3% of HCM. MACE were globally higher in index patients compared to relatives (10.8% vs 4.4%, p<0.001).

When considering geographical areas, MACE were higher in East Europe (13.1%) and lower in South Europe (5.3%) (univariate); heart transplant was higher in West Europe (2.40%) and lower in South Europe (0.25%) (univariate).

Conclusions

Despite symptomatic improvement in most cases, there is still a significant burden of arrhythmic and heart failure events in patients with cardiomyopathies. Outcomes were different not only according to cardiomyopathy subtypes but also in relatives versus index patients.

Acknowledgement/Funding

None

Recommendations for a standardised educational program in robot assisted gynaecological surgery: Consensus from the Society of European Robotic Gynaecological Surgery (SERGS)

BACKGROUND

The Society of European Robotic Gynaecological Surgery (SERGS) aims at developing a European consensus on core components of a curriculum for training and assessment in robot assisted gynaecological surgery.

METHODS

A Delphi process was initiated among a panel of 12 experts in robot assisted surgery invited through the SERGS. An online questionnaire survey was based on a literature search for standards in education in gynaecological robot assisted surgery. The survey was performed in three consecutive rounds to reach optimal consensus. The results of this survey were discussed by the panel and led to consensus recommendations on 39 issues, adhering to general principles of medical education.

RESULTS

On review there appeared to be no accredited training programs in Europe, and few in the USA. Recommendations for requirements of training centres, educational tools and assessment of proficiency varied widely. Stepwise and structured training together with validated assessment based on competencies rather than on volume emerged as prerequisites for adequate and safe learning. An appropriate educational environment and tools for training were defined. Although certification should be competence based, the panel recommended additional volume based criteria for both accreditation of training centres and certification of individual surgeons.

CONCLUSIONS

Consensus was reached on minimum criteria for training in robot assisted gynaecological surgery. To transfer results into clinical practice, experts recommended a curriculum and guidelines that have now been endorsed by SERGS to be used to establish training programmes for robot assisted surgery.

Detection of Sentinel Nodes by Lymphoscintigraphy and Gamma Probe Guided Surgery in Vulvar Neoplasia

Background

Pathologic lymph node status is the most important prognostic factor in vulvar cancer; however, complete inguinofemoral node dissection is associated with significant morbidity. Intraoperative lymphoscintigraphy associated with gamma detecting probe-guided surgery has proved to be reliable in the detection of sentinel node (SN) involvement in melanoma and breast cancer patients. The present study evaluates the feasibility of the surgical identification of inguinal sentinel nodes using lymphoscintigraphy and a gamma detecting probe in patients with early vulvar cancer.

Methods

Technetium-99-labeled colloid human albumin was administered perilesionally in 44 patients. Twenty patients had T1 and 23 had T2 invasive epidermoid vulvar cancer; one patient had a lower-third vaginal cancer. An intraoperative gamma detecting probe was used to identify SNs during surgery. Complete inguinofemoral node dissection was subsequently performed. SNs underwent separate pathologic evaluation.

Results

A total of 77 groins were dissected in 44 patients. SNs were identified in all the studied groins. Thirteen cases had positive nodes: the SN was positive in all of them; in 10 cases the SN was the only positive node. Thirty-one patients showed negative SNs: all of them were negative for lymph node metastasis.

Conclusions

Lymphoscintigraphy and SN biopsy under gamma detecting probe guidance proved to be an easy and reliable method for detection of SNs in early vulvar cancer. If these preliminary data will be confirmed, the technique would represent a real progress towards less aggressive treatment in patients with vulvar cancer.

Cost of poor adherence to anti-hypertensive therapy in five European countries

The financial burden for EU health systems associated with cardiovascular disease (CV) has been estimated to be nearly €110 billion in 2006, corresponding to 10% of total healthcare expenditure across EU or a mean €223 annual cost per capita. The main purpose of this study is to estimate the costs related to hypertension and the economic impact of increasing adherence to anti-hypertensive therapy in five European countries (Italy, Germany, France, Spain and England). A probabilistic prevalence-based decision tree model was developed to estimate the direct costs of CV related to hypertension (CV defined as: stroke, heart attack, heart failure) in five European countries. Our model considered adherence to hypertension treatment as a main driver of blood pressure (BP) control (BP < 140/90 mmHg). Relative risk of CV, based on controlled or uncontrolled BP group, was estimated from the Framingham Heart Study and national review data. Prevalence and cost data were estimated from national literature reviews. A national payer (NP) perspective for 10 years was considered. Probabilistic sensitivity analysis was performed in order to evaluate uncertainty around the results (given as 95% confidence intervals). The model estimated a total of 8.6 million (1.4 in Italy, 3.3 in Germany, 1.2 in Spain, 1.8 in France and 0.9 in England) CV events related to hypertension over the 10-year time horizon. Increasing the adherence rate to anti-hypertensive therapy to 70% (baseline value is different for each country) would lead to 82,235 fewer CV events (24,058 in Italy, 7,870 in Germany, 18,870 in Spain, 24,855 in France and 6,553 in England). From the NP perspective, the direct cost associated with hypertension was estimated to be <euro>51.3 billion (8.1 in Italy, 17.1 in Germany, 12.2 in Spain, 8.8 in France and 5.0 in England). Increasing adherence to anti-hypertensive therapy to 70% would save a total of <euro>332 million (CI 95%: €319-346 million) from the NPs perspective. This study is the first attempt to estimate the economic impact of non-adherence amongst patients with diagnosed hypertension in Europe, using data from five European countries (Italy, France, Germany, Spain and England).

Management of recurrent cervical cancer: a review of the literature

OBJECTIVE

The aim of this narrative review is to update the current knowledge on the treatment of recurrent cervical cancer based on a literature review.

MATERIAL AND METHODS

A web based search in Medline and CancerLit databases has been carried out on recurrent cervical cancer management and treatment. All relevant information has been collected and analyzed, prioritizing randomized clinical trials.

RESULTS

Cervical cancer still represents a significant problem for public health with an annual incidence of about half a million new cases worldwide. Percentages of pelvic recurrences fluctuate from 10% to 74% depending on different risk factors. Accordingly to the literature, it is suggested that chemoradiation treatment (containing cisplatin and/or taxanes) could represent the treatment of choice for locoregional recurrences of cervical cancer after radical surgery. Pelvic exenteration is usually indicated for selected cases of central recurrence of cervical cancer after primary or adjuvant radiation and chemotherapy with bladder and/or rectum infiltration neither extended to the pelvic side walls nor showing any signs of extrapelvic spread of disease. Laterally extended endopelvic resection (LEER) for the treatment of those patients with a locally advanced disease or with a recurrence affecting the pelvic wall has been described.

CONCLUSIONS

The treatment of recurrences of cervical carcinoma consists of surgery, and of radiation and chemotherapy, or the combination of different modalities taking into consideration the type of primary therapy, the site of recurrence, the disease-free interval, the patient symptoms, performance status, and the degree to which any given treatment might be beneficial.

[Multiple non-responding ESWL lithiasis in ectopic pelvic kidney: laparotomic surgical management]

A 34 year-old male with multiple lithiasis of ectopic pelvic left kidney, which for 5 years had been causing pain in the left iliac region irradiating to ipsilateral inguinal region and testis. 4 ESWL treatments were unsuccessful. The diagnostic imaging (Angio-CT + Uro-CT) showed ectopic pelvic left kidney with abnormal vascularisation, characterised by multiple lithiasis extending in total area of 4x2 cm with shorter ureter. Right kidney was in normal position. A left pyelocalicolithotomy after DJ stent positioning was performed.

Multiple Non-Responding ESWL Lithiasis in Ectopic Pelvic Kidney: Laparotomic Surgical Management

A 34 year-old male with multiple lithiasis of ectopic pelvic left kidney, which for 5 years had been causing pain in the left iliac region irradiating to ipsilateral inguinal region and testis. 4 ESWL treatments were unsuccessful. The diagnostic imaging (Angio-CT + Uro-CT) showed ectopic pelvic left kidney with abnormal vascularisation, characterised by multiple lithiasis extending in total area of 4×2 cm with shorter ureter. Right kidney was in normal position. A left pyelocalicolithotomy after DJ stent positioning was performed.