The safety of sodium glucose transporter 2 inhibitors and trends in clinical and hemodynamic parameters in patients with left ventricular assist devices

BACKGROUND

The safety and impact of sodium glucose transporter 2 inhibitors (SGLT2-I) in patients with left ventricular assist devices (LVAD) are unknown.

METHODS

A retrospective analysis of all consecutive patients who underwent LVAD Heart Mate 3 (HM3) implantation at a single medical center and received SGLT2-I therapy following surgery was conducted. LVAD parameters, medical therapy, laboratory tests, echocardiography, and right heart catheterization (RHC) study results were recorded and compared before and after initiation of SGLT2-I.

RESULTS

SGLT2-I medications were initiated in 29 (21%) of 138 patients following HM3 implantation (23 (79%) received Empagliflozin and 6 (21%) Dapagliflozin). The mean age at the time of LVAD implantation was 62 ± 6.7 years, 25 (86%) were male, and 23 (79%) had diabetes mellitus. The median time from HM3 implantation to SGLT2-I initiation was 108 days, IQR (26-477). Following SGLT2-I therapy, the daily dose of furosemide decreased from 47 to 23.5 mg/day (mean difference = 23.5 mg/d, 95% CI 8.2-38.7, p = 0.004) and significant weight reduction was observed (mean difference 2.5 kg, 95% CI 0.7-4.3, p = 0.008). Moreover, a significant 5.6 mm Hg reduction in systolic pulmonary artery pressure (sPAP) was measured during RHC (95% CI 0.23-11, p = 0.042) in a subgroup of 11 (38%) patients. LVAD parameters were similar before and after SGLT2-I initiation (p > 0.2 for all). No adverse events were recorded during median follow-up of 354 days, IQR (206-786).

CONCLUSION

SGLT2-I treatment is safe in LVAD patients and might contribute to reduction in patients sPAP.

Current treatment and immunomodulation strategies in Acute Myocarditis

Myocarditis is an inflammatory disease of the myocardium characterized by a great heterogeneity of presentation and evolution. Treatment of myocarditis is often supportive and the evidence for immunosuppression is scarce and debated. Conventional treatment is based on clinical presentation, ranging from conservative to advanced mechanical assist devices. In this setting, immunosuppression and immunomodulation therapies are mostly reserved for patients presenting with major clinical syndromes. In this review, we will summarise the current evidence and strategies for conventional and immunosuppressive treatments for patients presenting with acute myocarditis.

Levetiracetam Interaction with Direct Oral Anticoagulants: A Pharmacovigilance Study

BACKGROUND

Levetiracetam is widely used in post-stroke epilepsy. However, it is suspected to possess P-glycoprotein (P-gp) induction properties, and therefore, a potentially significant interaction with direct oral anticoagulants (DOACs). We aimed to search for ischemic stroke signals with levetiracetam and the DOACs.

METHODS

In this retrospective pharmacovigilance study, we used the FAERS database to identify ischemic stroke events associated with DOACs and concomitant use of levetiracetam. We evaluated disproportionate reporting by the adjusted reporting odds ratio (adjROR) and the lower bound of the shrinkage 95% confidence interval. When shrinkage is positive, an increased risk of a specific adverse event occurrence is emphasized over the sum of the individual risks when these same drugs are used separately.

RESULTS

We identified 1841 (1.5%), 3731 (5.3%), 338 (4.9%), and 1723 (1.3%) ischemic stroke reports with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. The adjROR of the interaction effect was 3.57 (95% CI 2.81-4.58) between DOACs and levetiracetam. The shrinkage analysis detected an interaction between each of the DOACs and levetiracetam. The logistic model and shrinkage analysis failed to detect an interaction when queried for hemorrhagic stroke. A significant signal in the classical enzyme inducer, carbamazepine, strengthened our results (adjROR; 8.47, 95% CI 5.37-13.36).

CONCLUSIONS

Our study shows a strong signal for the levetiracetam interaction with the DOACs. Our findings suggest implementation of a drug monitoring strategy.

Atrial fibrillation in young hospitalized patients: Clinical characteristics, predictors of new onset, and outcomes

BACKGROUND

Atrial fibrillation (AF) in young adults is an uncommon and not well studied entity.

METHODS

Consecutive patients aged 18-45 years admitted to internal or cardiology services in a large tertiary medical center (January 1, 2009 through December 31, 2019) were included. Clinical, electrocardiographic, and echocardiographic data were compared between patients with and without AF at baseline. Predictors of new-onset AF in the young were identified using multivariate Cox regression model among patients free of baseline AF.

RESULTS

Final cohort included 16,432 patients with median age of 34 (IQR 26-41) years of whom 8914 (56 %) were men. Patients with AF at baseline (N = 366; 2 %) were older, more likely to be men, and had higher proportion of comorbidities and electrocardiographic conduction disorders. Male sex, increased age, obesity, heart failure, congenital heart disease (CHD) and the presence of left or right bundle branch block were all independently associated with baseline AF in a multivariate model (p < 0.001 for all). Sub-analysis of 10,691 (98 %) patients free of baseline AF identified 85 cases of new-onset AF during a median follow up of 3.5 (IQR 1.5-6.5) years. Multivariate model identified increased age, heart failure, and CHD as independent predictors of new-onset AF. Finally, the CHARGE-AF risk score outperformed the CHA2DS2-VASc score in AF prediction [AUC of ROC 0.75 (0.7-0.8) vs. 0.56 (0.48-0.65)].

CONCLUSIONS

AF among hospitalized young adults is not rare. Screening for new-onset AF in young post hospitalization patients may be guided by specific clinical predictors and the CHARGE-AF risk score.

Serum Magnesium Is Associated with Long-Term Survival of Non-ST-Elevation Myocardial Infarction Patients

BACKGROUND

Low serum magnesium (sMg) is associated with cardiovascular risk factors and atherosclerotic disease.

OBJECTIVE

To evaluate the association between sMg levels on admission and clinical outcomes in hospitalized non-ST-elevation myocardial infarction (NSTEMI) patients.

METHODS

A retrospective analysis of all patients admitted to a single tertiary center with a primary diagnosis of NSTEMI. Patients with advanced chronic kidney disease were excluded. Clinical data were collected and compared between lower sMg quartile patients (Q1; sMg < 1.9 mg/dL) and all other patients (Q2-Q4; sMg ≥ 1.9 mg/dL).

RESULTS

The study cohort included 4552 patients (70% male, median age 69 [IQR 59-79]) who were followed for a median of 4.4 (IQR 2.4-6.6) years. The median sMg level in the low sMg group was 1.7 (1.6-1.8) and 2.0 (2.0-2.2) mg/dL in the normal/high sMg group. The low sMg group was older (mean of 72 vs. 67 years), less likely to be male (64% vs. 72%), and had higher rates of comorbidities, including diabetes, hypertension, and atrial fibrillation (59% vs. 29%, 92% vs. 85%, and 6% vs. 5%; p < 0.05 for all). Kaplan-Meier survival analysis demonstrated significantly higher cumulative death probability at 4 years in the low sMg group (34% vs. 22%; p log rank <0.001). In a multivariable analysis model adjusted for sex, significant comorbidities, coronary interventions during the hospitalization, and renal function, the low sMg group exhibited an independent 24% increased risk of death during follow up (95% CI 1.11-1.39; p < 0.001).

CONCLUSIONS

Low sMg is independently associated with higher risk of long-term mortality among patients recovering from an NSTEMI event.

Ventricular arrhythmias in patients with hypertrophic cardiomyopathy: Prevalence, distribution, predictors, and outcome

BACKGROUND

Hypertrophic cardiomyopathy (HCM) carries an increased risk of sudden cardiac death. Ventricular fibrillation (VF) is thought to be the common culprit arrhythmia.

OBJECTIVE

The purpose of this study was to describe the incidence and predictors of sustained ventricular arrhythmias (VTAs) in HCM patients.

METHODS

We retrospectively analyzed all patients with HCM and an implantable cardioverter-defibrillator (ICD) from a prospectively derived registry in 2 tertiary medical centers. Clinical, electrocardiographic, echocardiographic, ICD interrogation, and genetic data were collected and compared, first between patients with and without VTAs and then between patients with only VF and those with ventricular tachycardia (VT) with or without VF.

RESULTS

Of the 1328 HCM patients, 207 (145 [70%] male; mean age 33 ± 16 years) were implanted with ICDs. Over a mean follow-up of 10 ± 6 years, 37 patients with ICDs (18%) developed sustained VTAs. These were associated with a family history of sudden cardiac death and a personal history of VTAs (P = .036 and P = .001, respectively). Sustained monomorphic VT was the most common arrhythmia (n = 26, 70%) and was linked to decreased left ventricular (LV) ejection fraction and increased LV end-systolic and end-diastolic diameters. Antitachycardia pacing (ATP) successfully terminated 258 (79%) of the 326 VT events. Mortality rates were comparable between patients with and without VTAs (4 [11%] vs 29 [17%]; P = .42) and between those with and without ICDs (24 [16%] vs 85 [20%]; P = .367).

CONCLUSION

VT rather than VF is the most common arrhythmia in patients with HCM; it is amenable to ATP and is associated with lower LV ejection fraction and higher LV diameters. Therefore, ATP-capable devices may be considered in HCM patients with these LV features.

Significance of Anteroseptal Late Gadolinium Enhancement Among Patients With Acute Myocarditis

Anteroseptal location of late gadolinium enhancement (LGE) in patients with acute myocarditis (AM) detected by cardiovascular magnetic resonance may indicate an independent marker of unfavorable outcomes according to recent data. We aimed to evaluate the clinical characteristics, management, and inhospital outcomes in patients with AM with positive LGE based on its presence in the anteroseptal location. We analyzed data from 262 consecutive patients hospitalized with a diagnosis of AM with positive LGE within 5 days of hospitalization (n = 425). Patients were divided into 2 groups: those with anteroseptal LGE (n = 25, 9.5%) and those with non-anteroseptal LGE (n = 237, 90.5%). Except for age that was higher in patients with anteroseptal LGE, the demographic and clinical characteristics did not differ significantly between both groups including past medical history, clinical presentation, electrocardiogram parameters, and lab values. Moreover, patients with anteroseptal LGE were more likely to present with reduced left ventricular ejection fraction and to receive congestive heart failure treatments. Although univariate analysis showed that patients with anteroseptal LGE were more likely to have inhospital major adverse cardiac events (28% vs 9%, p = 0.003), there was no difference inhospital outcomes on multivariable analysis between both groups (hazard ratio, 1.17 [95% confidence interval, 0.32 to 4.22], p = 0.81). A higher left ventricular ejection fraction in either echocardiography or cardiovascular magnetic resonance corresponded to better inhospital outcomes regardless of the presence or absence of anteroseptal LGE. In conclusion, the presence of anteroseptal LGE did not confer additional prognostic value for inhospital outcomes.

Admission Serum Magnesium Levels Is Associated with Short and Long-Term Clinical Outcomes in COVID-19 Patients

BACKGROUND

In the face of the global pandemic that the coronavirus disease 2019 (COVID-19) has created, readily available prognostic markers may be of great use.

OBJECTIVE

To evaluate the association between serum magnesium (sMg) levels on admission and clinical outcomes in hospitalized COVID-19 patients.

METHODS

We retrospectively analyzed all patients admitted to a single tertiary center with a primary de novo diagnosis of COVID-19. Patients were followed for a mean of 10 ± 7 months. Demographic, clinical and laboratory data were collected and compared between five groups of patients according to sMg quintiles on hospital admission.

RESULTS

The cohort included 1522 patients (58% male, 69 ± 17 years old). A low sMg level (1st quintile) was associated with higher rates of diabetes and steroid use, whereas a high sMg level (5th quintile) was associated with dyslipidemia, renal dysfunction, higher levels of inflammatory markers and stay in the intensive care unit. All-cause in-hospital and long-term mortality was higher in patients with both low and high sMg levels, compared with mid-range sMg levels (2nd, 3rd and 4th quintiles; 19% and 30% vs. 9.5%, 10.7% and 17.8% and 35% and 45.3% vs. 23%, 26.8% and 27.3% respectively; p < 0.001 for all). After adjusting for significant clinical parameters indicating severe disease and renal dysfunction, only low sMg state was independently associated with increased mortality (HR = 1.57, p < 0.001).

CONCLUSIONS

Both low and high sMg levels were associated with increased mortality in a large cohort of hospitalized COVID-19 patients. However, after correction for renal dysfunction and disease severity, only low sMg maintained its prognostic ability.

The burden of heart failure in cardiac intensive care unit: a prospective 7 years analysis

AIMS

The profiles of patients at cardiac intensive care units (CICU) have evolved towards a patient population with an increasing number of co-morbid medical conditions and acute heart failure (HF). The current study was designed to illustrate the burden of HF patients admitted to CICU, and evaluate patient characteristics, in-hospital course and outcomes of CICU patients with HF compared with patients with acute coronary syndrome (ACS).

METHODS AND RESULTS

A prospective study including all consecutive patients admitted to the CICU at a tertiary medical centre between 2014 and 2020. The main outcome was a direct comparison between HF and ACS patients in processes of care, resource use, and outcomes during CICU hospitalization. A secondary analysis compared ischaemic versus non-ischaemic HF aetiology. Adjusted analysis evaluated parameters associated with prolonged hospitalization. The cohort included 7674 patients with a total annual CICU admissions of 1028-1145 patients. HF diagnosis patients represented 13-18% of the annual CICU admissions and were significantly older with higher incidence of multiple co-morbidities compared with patients with ACS. HF patients also required more intensive therapies and demonstrated higher incidence of acute complications as compared with ACS patients. Length of stay at the CICU was significantly longer among HF patients compared with patients with ACS (either STEMI or NSTEMI) (6.2 ± 4.3 vs. 4.1 ± 2.5 vs. 3.5 ± 2.1, respectively, P < 0.001). HF patients represented a disproportionately higher amount of total CICU patient days during the study period, as the total length of hospitalization of HF patients was 44-56% out of the total cumulative days in CICU of patients with ACS every year. In hospital mortality rates were also significantly higher among patients with HF compared with STEMI or NSTEMI (4.2% vs. 3.1% vs. 0.7%, respectively, P < 0.001). Despite several differences in baseline characteristics between patients with ischaemic versus non-ischaemic HF, which can be attributed mainly to disease aetiology, hospitalization length and outcomes were similar among the groups regardless of HF aetiology. In multivariable analysis for the risk of prolonged hospitalization in the CICU adjusted to potential significant co-morbidities associated with poor outcomes, HF was found to be an independent and significant parameter associated with the risk of prolonged hospitalization with an OR of 3.5 (95% CI 2.9-4.1, P < 0.001).

CONCLUSIONS

Patients with HF in CICU have higher severity of illness with a prolonged and complicated hospital course, all of which can substantially increase the burden on clinical resources.

Data processing pipeline for cardiogenic shock prediction using machine learning

Introduction

Recent advances in machine learning provide new possibilities to process and analyse observational patient data to predict patient outcomes. In this paper, we introduce a data processing pipeline for cardiogenic shock (CS) prediction from the MIMIC III database of intensive cardiac care unit patients with acute coronary syndrome. The ability to identify high-risk patients could possibly allow taking pre-emptive measures and thus prevent the development of CS.

Methods

We mainly focus on techniques for the imputation of missing data by generating a pipeline for imputation and comparing the performance of various multivariate imputation algorithms, including k-nearest neighbours, two singular value decomposition (SVD)-based methods, and Multiple Imputation by Chained Equations. After imputation, we select the final subjects and variables from the imputed dataset and showcase the performance of the gradient-boosted framework that uses a tree-based classifier for cardiogenic shock prediction.

Results

We achieved good classification performance thanks to data cleaning and imputation (cross-validated mean area under the curve 0.805) without hyperparameter optimization.

Conclusion

We believe our pre-processing pipeline would prove helpful also for other classification and regression experiments.

High Attendance Rate of Family Members During Physician Rounds Is Predictive of Worse Clinical Outcomes: A Historic Cohort Study

BACKGROUND

The prognosis of long-term clinical outcomes for each patient is of utmost importance.

OBJECTIVES

To evaluate the association between rates of family attendance during rounds and long-term outcomes.

METHODS

We conducted a historic cohort study.

RESULTS

We followed 200 consecutive patients for a median of 19 months. Within the group of patients that had family members present in > 75% of rounds, the 30-day re-hospitalization rate was tenfold higher (P = 0.017). The overall prognosis (including median survival length) of patients who had the highest rates of family attendance (> 75%) was significantly worse compared to patients who had lower rates (P = 0.028). High rates of family attendance were found to correlate with other established risk factors for long-term mortality, including advanced age (r = 0.231, P = 0.001) and in-hospital delirium.

CONCLUSIONS

High family attendance during physician rounds in an internal medicine department is associated with worse patient prognosis.

Large multicenter evaluation of clinical outcomes of transcatheter aortic valve implantation in different age groups: results from the Israeli TAVI registry

Introduction

Transcatheter aortic valve implantation (TAVI) is becoming the preferred treatment for elderly patients with severe aortic stenosis. Clinical outcomes of these patients according to different age groups and especially in the very old population are under reported.

Purpose

To describe clinical characteristics at baseline, according to different age groups, and to compare clinical outcomes in the very old population with other patients undergoing the procedure.

Methods

Data was extracted from the Israeli National TAVI Registry. Clinical outcomes in very old patients (above the age of 90 years) were compared with younger patients. Multivariable analysis for 30-day and 1-year mortality were performed. Procedural complication was defined as one or more of the following: need for permanent pacemaker, major vascular complication, severe acute kidney injury and major stroke.

Results

A total of 5,936 patients who underwent TAVI from 2008 to 2021 were analyzed (age 81.6±7.1 years, 50.6% female). Patients older than 90 years of age had more comorbidities than the younger population (STS score for mortality 6.4%±3.8% vs. 4.1%±4.8%, p&lt;0.001). Independent correlates for 30-day mortality included STS score (OR=1.01, 95% CI [1.03–1.13], p&lt;0.001) and procedural complication (OR=4.29, 95% CI [2.24–8.20], p&lt;0.0001). Independent correlates for 1-year mortality included chronic obstructive pulmonary disease (OR=1.83, 95% CI [1.28–2.60]; p=0.001), atrial fibrillation (OR=1.71, 95% CI [1.31–2.23]; p&lt;0.001 (STS score); OR=1.13 95% CI [1.09–1.18]; p&lt;0.001), and procedural complication) OR=2.58, 95% [1.89–3.50]; p&lt;0.001).

Conclusions

Although older patients undergoing TAVI had a higher risk profile, short- and long-term survival of these patients were associated significantly more with procedural complications than with patient age. It seems that extreme patient age alone should not be viewed as a consideration for not performing valve replacement, as long as the risk for procedural complications does not seem to be severely elevated.

Funding Acknowledgement

Type of funding sources: None.

Serum uric acid levels significantly improve the accuracy of cardiovascular risk score models

Background

This study evaluated the impact of serum uric acid (sUA) on the accuracy of atherosclerotic cardiovascular disease (ASCVD) pooled cohort equations (PCE) model, Systematic Coronary Risk Evaluation score 2 (SCORE2) and SCORE2-Older Persons (OP).

Methods

We evaluated 19,789 asymptomatic self-referred adults aged 40–79 years who were screened annually in a preventive healthcare setting. All subjects were free of cardiovascular disease and diabetes at baseline. sUA levels were expressed as a continuous as well as dichotomous variable (categorized into sex-specific tertiles, with the upper tertiles defined as high sUA). Mortality and cancer data were available for all subjects from nationwide registries. The primary endpoint was the composite of death, acute coronary syndrome and stroke, after excluding subjects diagnosed with lymphatic spread cancer during follow up.

Results

Mean age of study population was 50±8 years and 69% were men. During median follow up of 6 years [2.0–13.1], 1,658 (8%) subjects reached the study endpoint. ASCVD, SCORE2 risk and high sUA were all independently associated with the study endpoint in the multivariable Cox regression model (p&lt;0.001 for all). Continuous net reclassification improvement analysis showed an improvement of 13% in the accuracy of classification when high sUA was added to the PCE and SCORE2 models (p&lt;0.001 for both). sUA remained independently associated with the study endpoint among normal-weight subjects in the SCORE 2 model (HR 1.3, 95% CI 1.1–1.6) but not among overweight individuals (p for interaction = 0.01). Addition of sUA to the models in normal-weight subgroup (N=6,624) resulted in a significant 20% improvement in the model performance for both SCORE2 and ASCVD when sUA was incorporated as dichotomous variable (p&lt;0.001 for ASCVD and p=0.026 for SCORE2 model).

Conclusions

sUA significantly improves classification accuracy of PCE and SCORE 2 models. This effect is especially pronounced among normal weight subjects.

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of mean transmitral pressure gradient in degenerative non-rheumatic mitral valve: insights from a vast echocardiographic database

Background

The incidence and prevalence of senile, non-rheumatic mitral valve disease are increasing and there is a renewed interest in new transcatheter structural cardiac interventions intended to treat that valvular disorder. While the severity of rheumatic mitral valve disease can be accurately assessed by echocardiography using various parameters, including mean transmitral pressure gradient, these methods have been questioned for quantifying senile mitral valve disorder and their prognostic significance is still unknown.

Aims

The current study aims to document the natural history of patients with elevated senile mean transmitral pressure gradient (MG) and assess its prognostic significance.

Methods

A vast institutional echocardiography database was retrospectively analyzed from 2009 to 2020 for all patients aged over 60 years with a detailed echocardiography report with valid measurement of transmitral gradients. Patients with rheumatic valvular disease or who underwent surgical or transcatheter valvular replacement/repair were excluded. All-cause mortality was set to be the primary outcome, and survival models utilizing univariable and adjusted multivariable analysis for various clinical and echocardiographic variables were applied.

Results

A total of 5524 patients consisted of the final cohort. They were stratified by the MG into three groups: MG &lt;3 (2914 patients, 53%), 3≤MG&lt;6 (2079 patients, 37.6%) and MG ≥6 mmHg (531 patients,9.6%). The mean age of the total cohort was 77.2±7.9 years; 60.5% were female, 33.3% with diabetes mellitus, 15.1% with chronic kidney disease, and 14.1% with ischemic heart disease. An Adjusted Cox proportional hazard regression model demonstrated that MG is independently associated with all-cause mortality (adjusted HR 1.04 per 1 mmHg increase, 95% CI 1.02–1.05, p&lt;0.001). Moreover, an elevated MG was associated with a rise in all-cause mortality (HR of 1.15 and 1.4 for patients with 3≤MG&lt;6 and MG ≥6 mmHg, respectively (Fig. 1).

Conclusion

The elevated mean transmitral gradient in senile non-rheumatic valves is an independent predictor for all-cause mortality. Interventions and prospective trials intended to mitigate that risk should be needed.

Funding Acknowledgement

Type of funding sources: None.

Admission serum magnesium levels associated with short- and long-term clinical outcomes in COVID-19 patients

Introduction

In the face of the global pandemic coronavirus disease 2019 (COVID-19) has created, readily available prognostic markers may be of great use.

Purpose

To evaluate the association between serum magnesium levels (sMg) on admission and clinical outcomes in hospitalized COVID-19 patients.

Methods

We retrospectively analyzed all consecutive patients admitted to our medical center with a primary de novo diagnosis of COVID-19.Demographic, clinical and laboratory data were extracted from the electronic medical record. Clinical outcomes were compared between five groups of patients according to the quintiles of sMg on hospital admission.

Results

From 2,433 consecutive COVID-19 patients during the years 2020–2021, we included 1,522 patients with sMg on admission (1–3 day of hospitalization) (58% male, 69±17 years old). Patients were followed for a mean of 10±7 months. A low sMg level (1st quintile) was associated with higher rates of diabetes and steroid use, whereas a high sMg level (5th quintile) was associated with dyslipidemia, chronic kidney disease, andhigher levels of inflammatory markers (Table 1). Both low and high sMg levels were associated with lower oxygen saturation during hospitalization. All-cause in-hospital and long-term mortality was higher in patients with both low and high sMg levels, compared with mid-range sMg levels (2nd, 3rd and 4thquintiles; 19% and 30% vs. 9.5%, 10.7% and 17.8% and 35% and 45.3% vs. 23%, 26.8% and 27.3% respectively; p<0.001 for all) (Figure 1).

Conclusions

Both low and high sMg levels were associated with worse short- and long-term clinical outcomes and all-cause mortality in a large cohort of hospitalized COVID-19 patients. Thus, admission sMg levels may play a prognostic role in risk stratificationof COVID-19 patients.

Funding Acknowledgement

Type of funding sources: None.

Effect of levosimendan infusion prior to left ventricular assist device implantation on right ventricular failure

Objective

Investigate the safety and efficacy of preoperative levosimendan in patients undergoing left ventricular assist device (LVAD) implantation.

Methods

Consecutive patients who received LVADs (HeartMate-2, 3, HVAD) in a single tertiary medical center (2012–2018). INTERMACS profile 1 patients were excluded. The primary outcome was post-LVAD right ventricular failure (RVF) and inhospital mortality rates. The secondary outcomes included other clinical, echocardiographic and hemodynamic parameters at follow-up.

Results

Final cohort consisted of 62 patients (40[65%] in the levosimendan group and 22[35%] in the no-levosimendan group). Post-operative RVF rate and inotrope or ventilation support time were similar in the levosimendan and no-levosimendan groups (7.5% vs. 13.6%; P = 0.43, median of 51 vs. 72 h; P = 0.41 and 24 vs. 27 h; P = 0.19, respectively). Length of hospitalization, both total and in the intensive care unit, was not statistically significant (median days of 13 vs. 16; P = 0.34, and 3 vs. 4; P = 0.44, respectively). Post-operative laboratory and echocardiographic parameters and in-hospital complication rate did not differ between the groups, despite worse baseline clinical parameters in the Levosimendan group. There was no significant difference in the in-hospital and long term mortality rate (2.5% vs. 4.5%; P > 0.999 and 10% vs. 27.3% respectively; P = 0.64).

Conclusions

Levosimendan infusion prior to LVAD implantation was safe and associated with comparable results without significant improved post-operative outcomes, including RVF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01915-6.

Ethnic inequalities in treatment with clozapine

Introduction

Ethnic disparities in treatment with clozapine, the antipsychotic recommended for treatment-resistant schizophrenia (TRS), have been reported. However, these investigations frequently suffer from potential residual confounding. For example, few studies have restricted the analyses to TRS samples and none has controlled for benign ethnic neutropenia.

Objectives

This study investigated if service-users’ ethnicity influenced clozapine prescription in a cohort of people with TRS.

Methods

Information from the clinical records of South London and Maudsley NHS Trust was used to identify a cohort of service-users with TRS between 2007 and 2017. In this cohort, we used logistic regression to investigate any association between ethnicity and clozapine prescription while adjusting for potential confounding variables, including sociodemographic factors, psychiatric multimorbidity, substance use, benign ethnic neutropenia, and inpatient and outpatient care received.

Results

We identified 2239 cases that met the criteria for TRS. Results show that after adjusting for confounding variables, people with Black African ethnicity had half the odds of being treated with clozapine and people with Black Caribbean or Other Black background had about two-thirds the odds of being treated with clozapine compared White British service-users. No disparities were observed regarding other ethnic groups, namely Other White background, South Asian, Other Asian, or any other ethnicity.

Conclusions

There was evidence of inequities in care among Black ethnic groups with TRS. Interventions targeting barriers in access to healthcare are recommended.

Disclosure

During the conduction of the study, DFdF, GKS, and RH received funds from the NIHR Maudsley Biomedical Research Centre. For other activities outside the submitted work, DFdF received research funding from the UK Department of Health and Social Care, Janss

Correlates of late-onset antipsychotic treatment resistance

Introduction

There is emerging evidence of heterogeneity within treatment-resistance schizophrenia (TRS), with some people not responding to antipsychotic treatment from illness onset and a smaller group becoming treatment-resistant after an initial response period. It has been suggested that these groups have different aetiologies. Few studies have investigated socio-demographic and clinical differences between early and late onset of TRS.

Objectives

This study aims to investigate socio-demographic and clinical correlates of late-onset of TRS.

Methods

Using data from the electronic health records of the South London and Maudsley, we identified a cohort of people with TRS. Regression analyses were conducted to identify correlates of the length of treatment to TRS. Analysed predictors include gender, age, ethnicity, positive symptoms severity, problems with activities of daily living, psychiatric comorbidities, involuntary hospitalisation and treatment with long-acting injectable antipsychotics.

Results

We observed a continuum of the length of treatment until TRS presentation. Having severe hallucinations and delusions at treatment start was associated shorter duration of treatment until the presentation of TRS.

Conclusions

Our findings do not support a clear cut categorisation between early and late TRS, based on length of treatment until treatment resistance onset. More severe positive symptoms predict earlier onset of treatment resistance.

Disclosure

DFdF, GKS, EF and IR have received research funding from Janssen and H. Lundbeck A/S. RDH and HS have received research funding from Roche, Pfizer, Janssen and Lundbeck. SES is employed on a grant held by Cardiff University from Takeda Pharmaceutical Comp

Failed shocks in hypertrophic cardiomyopathy patients: prevalence, predictors and outcome

Funding Acknowledgements

Type of funding sources: None.

Introduction

An implantable cardioverter-defibrillator (ICD) is used in selected high-risk hypertrophic cardiomyopathy (HCM) patients in order to prevent sudden arrhythmic death. The unique features of this population raise concerns regarding the reliability of successful defibrillation.

Purpose

To describe the rate and discover potential predictors of failed shocks in HCM patients.

Methods

We retrospectively evaluated all HCM patients with an ICD from a single tertiary medical center. Clinical, electrocardiographic and echocardiographic data were collected and compared among patients with and without failed shocks.

Results

A total of 99 patients (77% male, 45±17 years old) were analyzed. Over a median follow up of 6.3 years (IQR 2.6-10.7), 20 patients developed sustained ventricular arrhythmia (VTA). Of those, 18 patients received appropriate shocks from their ICD. VTA was associated with younger age at diagnosis, history of syncope and thicker maximal LV width. Six patients experienced at least one failed shock. The likelihood of failed shocks was similar when single or dual coil electrodes were used (dual coils in 67% of patients with failed shocks and 50% in those without), and the only predictor was increased wall thickness [OR 1.2 (1.07-1.38) per 1 mm]. All-cause mortality was low and similar in patients with an without failed shocks (0% vs 8%, P=0.5)

Conclusions

Failed shocks are a rare entity in HCM patients. Increased maximal LV width was the only predictor of those events. Our findings support avoiding defibrillation threshold testing routinely, but may indicate its need in patients with extreme LV wall thickening (≥23 mm).

Characterization of heart failure patients with reverse left ventricular remodelling post-angiotensin receptor blockers/neprilysin inhibitors therapy

Aims

To assess the effect of angiotensin receptor blockers/neprilysin inhibitors (ARNI) on left ventricular (LV) ejection fraction (LVEF) and LV dimensions in a real‐life cohort of heart failure and reduced ejection fraction (HFrEF) patients, while analysing patient characteristics that may predict reverse LV remodelling.

Methods and results

The ARNI‐treated HFrEF patients followed at a single tertiary medical centre HF‐outpatient clinic were included in the study. Clinical and echocardiographic parameters were evaluated prior to ARNI initiation, and while on ARNI therapy, assessing patient characteristics associated with reverse LV remodelling. The cohort included 91 patients (mean age 60.5 years, 90% male) and 47 (52%) patients exhibited ARNI responsiveness, defined as an increase in LVEF during therapy. Overall, LVEF increased by 19% post‐ARNI (23.8 to 28.4%, P < 0.001). Subgroup analysis revealed several parameters associated with significant LVEF improvement, including baseline LVEF <30%, non‐ischaemic HF aetiology, lack of cardiac resynchronization therapy (CRT), better initial functional class and ARNI initiation within 3 years from HF diagnosis (P ≤ 0.001 for all). Significant reduction in LV dimensions was noted in patients with lower initial LVEF, non‐ischaemic HF and no CRT. Further combined subgrouping of the study population demonstrated that patients with both LVEF <30% and a non‐ischaemic HF gained most benefit from ARNI with an average of 51% improvement in LVEF (19.9 to 30%, P < 0.001).

Conclusions

The ARNI treatment response is not uniform among HFrEF patient subgroups. More pronounce reverse LV remodelling is associated with early ARNI treatment initiation in the course of HFrEF, and in those with LVEF <30%, non‐ischaemic HF and no CRT.

Low ALT values amongst hospitalized patients are associated with increased risk of hypoglycemia and overall mortality: a retrospective, big-data analysis of 51 831 patients

BACKGROUND

Sarcopenia and frailty influence clinical patients' outcomes. Low alanine aminotransferase (ALT) serum activity is a surrogate marker for sarcopenia and frailty. In-hospital hypoglycemia is associated, also with worse clinical outcomes.

AIM

We evaluated the association between low ALT, risk of in-hospital hypoglycemia and subsequent mortality.

DESIGN

This was a retrospective cohort analysis.

METHODS

We included patients hospitalized in a tertiary hospital between 2007 and 2019. Patients' data were retrieved from their electronic medical records.

RESULTS

The cohort included 51 831 patients (average age 70.88). The rate of hypoglycemia was 10.8% (amongst diabetics 19.4% whereas in non-diabetics 8.3%). The rate of hypoglycemia was higher amongst patients with ALT < 10 IU/l in the whole cohort (14.3% vs. 10.4%, P < 0.001) as well as amongst diabetics (24.6% vs. 18.8%, P < 0.001). Both the overall and in-hospital mortality were higher in the low ALT group (57.7% vs. 39.1% P < 0.001 and 4.3% vs. 3.2%, P < 0.001). A propensity score matching, after which a regression model was performed, showed that patients with ALT levels < 10 IU/l had higher risk of overall mortality (HR = 1.21, CI 1.13-1.29, P < 0.001).

CONCLUSIONS

Low ALT values amongst hospitalized patients are associated with increased risk of in-hospital hypoglycemia and overall mortality.

Low ALT levels are associated with poor outcomes in acute coronary syndrome patients in the intensive cardiac care unit

BACKGROUND

Frailty is an underrecognized and important entity that bears worse prognosis. Although low serum alanine aminotransferase (ALT) can serve as a novel marker of frailty, its use was never assessed in acute coronary syndrome (ACS) patients.

METHODS

A retrospective analysis of hospitalized ACS patients in the intensive cardiac care unit (ICCU)between 1/5/2011 and 1/12/2020 at a single tertiary medical center.

RESULTS

The study included 3956 patients after excluding patients with ALT >40 IU/L, cirrhosis, and missing data, followed for a medianduration of 47 months (IQR 20-77).Patients were stratified into two groups based on their first ALT measurement within the index hospitalization: low-normal ALT group (ALT ≤10 IU/L) vs. high-normal ALT group (ALT >10 IU/L). Patients with ALT≤10 IU/L were older (mean age 71 years vs. 65 years, p<0.001), presented more frequently with non-ST elevation myocardial infarction (66.4% vs. 53.2%, p< 0.001), had higher rates of comorbiditiesat baseline, and had a lower Norton score upon admission. Hospitalization length was longer in the low-normal ALT group (p< 0.001). Although the in-hospital mortality rate was similar between the groups (0.9% vs. 0.7%, p = 0.99), long-termmortality was significantly higher in the low-normal ALT group (22.7% vs. 7.9%, p< 0.001). In a multivariate regression model ALT ≤10 IU/l was associated with increased mortality (HR 2.1, 95% CI 1.46-3).

CONCLUSIONS

Lower serum ALT is associated with worse outcomes in ACS patients admitted to the ICCU.

Permanent pacemaker implantation post transcatheter aortic valve replacement- the role of pacing burden

Introduction

Previous studies have provided inconsistent results regarding the clinical impact of new permanent pacemaker (PPM) post TAVR. Our aim is to evaluate whether new PPM post TAVR is associated with higher 1-year mortality and/or heart failure hospitalizations and whether pacing burden is related to adverse outcomes.

Results

Overall, 1245 patients underwent TAVR between the years 2008–2019 and were included in our analysis with a median follow up of 2.3 years (IQR 1–4). 191 (15%) had a new PPM implantation during index admission. Compared to patients without PPM those implanted had significantly higher 1-year mortality rate (18% vs 11%, p-0.007) as well has higher combined outcome of mortality and HF hospitalizations. There was no difference in pacing burden between survivors and non survivors in all models examined: first and last clinic visit, maximal pacing during the first-year post implantation and the difference in pacing trend between visits. Older age, peripheral artery disease (PAD) and previous myocardial infarction (MI) were independently associated with mortality or combined outcome of mortality and HF hospitalizations.

Conclusion

New pacemaker implantation post TAVR is associated with higher 1-year mortality and HF hospitalization, however pacing burden isn't associated with adverse clinical course.

Funding Acknowledgement

Type of funding sources: None.

The effect of early invasive strategy on mortality outcome in patients with chronic kidney disease presenting with non-ST segment elevation myocardial infarction

Background

Current guidelines recommend an early invasive strategy for patients with non-ST segment elevation myocardial infarction (NSTEMI).

Purpose

To evaluate whether early invasive strategy is associated with better outcome among patients with chronic kidney disease (CKD).

Methods

Retrospective cohort analysis of consecutive patients with NSTEMI between 2008 and 2021. Glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation. Invasively treated patients were dichotomized into early (&lt;24 hours) and non-early groups. Mortality data was available for all patients from a national registry. Multivariate Cox regression models with interaction analysis were applied.

Results

Final study population comprised 7,107 NSTEMI patients, of whom 3,172 (45%) had eGFR &lt;60 ml/min/1.73m2. 1,988 (28%) and 973 (14%) patients had eGFR under 45 and 30 ml/min/1.73m2, respectively. 3,529 (50%) patients were treated invasively, among them 1837 (52%) underwent early invasive strategy. Patients in the early invasive group were younger (64 vs. 68 years, p&lt;0.001) and were less likely to have comorbidities including kidney disease. During a median follow-up of 3 years (IQR 1.2–5.2), 2,552 (36%) patients died. Kaplan Meier survival analysis demonstrated that the cumulative probability of death was 50%, 15%, and 6% among patients in the conservative, non-early, and early invasive groups respectively (p Log-rank &lt;0.001). Subgroup analysis of invasively managed patients showed that early invasive strategy was associated with a significant 32% reduced risk of death in a multivariate model (95% CI 0.56–0.82, p&lt;0.001), but this associated benefit was modified by eGFR (p for interaction 0.045). The modification effect of CKD on the association of early invasive strategy with outcome was most pronounced among invasively treated patients with eGFR &lt;45 ml/min/1.73m2, with no survival benefit for early invasive approach in these patients (HR 0.8, 95% CI 0.57–1.14, p=0.221 vs. HR 0.6 95% CI 0.45–0.72, p&lt;0.001; p for interaction=0.046).

Conclusion

Among invasively treated NSTEMI patients, the benefit of early invasive strategy is modified by CKD, and limited to those with eGFR ≥45 ml/min/1.73m2.

Funding Acknowledgement

Type of funding sources: None.

Incident cardiovascular events among middle-age men are associated with increased risk of subsequent prostate cancer diagnosis

Introduction

Prostate cancer is the second most common malignancy in men worldwide, but incidence is highly dependent on screening.

Purpose

We aimed to examine whether incident cardiovascular disease (CVD) events are associated with increased risk of future prostate cancer in middle-aged men.

Methods

We evaluated asymptomatic self-referred men who participated in a screening program. All subjects were free of CVD and cancer at baseline. CVD was defined as the composite of acute coronary syndrome, percutaneous coronary intervention, or stroke. Study endpoint was the development of cancer during follow up. Cancer and mortality data were available for all subjects from national registries. Cox regression models were applied with CVD as a time-dependent covariate and death as a competing risk event.

Results

Final study population included 18,282 subjects. Median age was 47 years (Interquartile range [IQR] 41–54). During median follow up time of 12 years (IQR 4–17) 2,047 (11%) subjects developed CVD, 406 (2.2%) developed prostate cancer and 694 (4%) died. Compared with patients who were free of CVD or prostate cancer during follow up, risk of death was 4, 6 and 15 times higher for patients who developed CVD event, prostate cancer, or both during follow up, respectively (p &lt;.001 for all). Time dependent survival analysis showed that subjects who developed CVD during follow up were 60% more likely to develop prostate cancer (95% Confidence Interval [CI] 1.2–2.1, p=.001). However, after multivariable adjustment, this association was no longer significant. Interaction analysis demonstrated that the association of incident CVD with the risk of future cancer diagnosis was age dependent such that in middle-aged men (age≤55 years; N=14,473) incident CVD was associated with a significant 70% increased risk of subsequent cancer diagnosis in multivariable model (95% CI 1.13–2.6, p=.011, p for interaction=.002). Exploratory analysis of men younger than 55 showed that independent association of incident CVD with subsequent cancer diagnosis was different among subjects with normal body mass index (BMI) (≤25 kg/m2) compared with those with increased BMI (HR 0.55; 95% CI [0.22–1.42]; p value=0.23 vs. 1.6; 95% CI [1.007–2.54]; p value=.047; p for interaction=.058, respectively).

Conclusion

Incident CVD is independently associated with increased risk of subsequent prostate cancer diagnosis among men ≤55 years. Routine prostate cancer surveillance should be considered after CVD event in this population.

Funding Acknowledgement

Type of funding sources: None.

Predictors of deterioration in cardiorespiratory fitness among healthy adults: the importance of sex and obesity

Introduction

Cardiorespiratory fitness (CRF) is associated with cardiovascular co-morbidities and is a strong predictor of adverse cardiovascular outcomes. However, data on the natural history of cardiorespiratory fitness among healthy subjects is limited.

Purpose

This study investigated what are the predictors of deterioration in CRF over time.

Methods

We investigated 36,239 men and women who were annually screened in a tertiary medical center and completed an exercise stress test in all visits, with a total of 175,596 annual visits. Subjects who failed to complete maximal exercise stress test according to the Bruce protocol at their first baseline visit were excluded. In addition, subjects with less than five visits to the center or those who developed ischemic heart disease during follow-up were excluded. Fitness was categorized into age- and sex-specific quintiles (Q) according to Bruce protocol treadmill time. Change in CRF between the first baseline visit and the fifth visit was used to calculate fitness deterioration. The primary study endpoint was defined as the lower sex-specific quintile of change in metabolic equivalents (METS) between visits 1 and 5. Logistic regression models were applied.

Results

Final study population included 10,841 subjects. The mean age of the study population was 49±10 years, the mean BMI was 26±4, and 8107 (75%) were men. Median METS at baseline were 10.8 (IQR 9–12.6) and 11.1 (IQR 9.4–13) at the first and fifth visit, respectively (p&lt;0.001 for METS between visits). Overall, 2189 (20%) subjects met the study endpoint. CFR deterioration was higher among women as compared to men (p=0.023). Out of obesity, hypertension, fasting blood glucose, LDL, and HDL cholesterol, after adjustments for age, sex, and baseline CFR, only obesity was independently associated with fitness deterioration in the multivariate model (OR=1.4 95% CI 1.2–1.5, p&lt;0.001). The association of obesity with fitness deterioration was modified by sex such that the risk of CRF deterioration was more pronounced in women (OR=1.6 95% CI 1.3–2, p&lt;0.001) than in men (OR=1.3 95% CI 1.1–1.4, p&lt;0.001).

Conclusion

Obesity is an independent predictor of future CRF deterioration. The effect of obesity on future CRF deterioration is more pronounced among women as compared to men.

Funding Acknowledgement

Type of funding sources: None.

Invasive management in elderly patients with non-ST elevation myocardial infarction is beneficial regardless of frailty status

Introduction

Elderly patients are underrepresented in clinical trials evaluating the management of non-ST elevation myocardial infarction (NSTEMI) patients. Moreover, frailty status is often not reported in these trials.

Purpose

To evaluate the association of invasive management with outcome among elderly (≥80) patients presenting with NSTEMI by frailty status.

Methods

Retrospective cohort of consecutive elderly patients who were hospitalized with NSTEMI as a primary clinical diagnosis between 2008 to 2019. Primary outcome was all-cause mortality. Frailty status was estimated as a continuous variable as well as categorized to low, medium, and high. Cox regression models were applied with stratification by frailty status. Additional sensitivity analyses were conducted including propensity score matching (PSM) and inverse probability treatment weighting (IPTW) models.

Results

Study population included 2,317 patients with median age of 86 years (IQR 83–90) of whom 1,243 (54%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs. 44%, p&lt;.001). During the follow up (median of 19 months, [IQR 4–41]), 1,599 (69%) patients died. Kaplan Meier survival curves (Figure 1) show that the cumulative probability of death at 19 months was 50% among patients who were managed conservatively compared with 21% among invasively managed patients (p Log rank &lt;.001). In the multivariable Cox model, invasive approach was associated with a significant 39% decrease in the risk of death (95% CI 0.53–0.71). The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 [0.58–0.93], 0.65 [0.50–0.85] and 0.52 [0.34–0.78], respectively; p for interaction NS). Results were consistent with PSM and IPTW analyses (HR of 0.6 [0.50–0.71] and 0.67 [0.55–0.82], respectively). Additional sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results.

Conclusions

Invasive approach is associated with improved survival among elderly patients with NSTEMI irrespective of frailty status. Our results support and extend recent ESC recommendations for the management of elderly patients with NSTEMI

Funding Acknowledgement

Type of funding sources: None. Figure 1

Increased rate of new-onset left bundle branch block in patients with bicuspid aortic stenosis undergoing TAVR; data from a national registry

Background

There is a growing interest in transcutaneous aortic valve replacement (TAVR) therapy among patients with bicuspid severe aortic stenosis (BAV). Conduction disturbances remain a frequent complication of TAVR, and new-onset permanent LBBB (NOP-LBBB) post-TAVR may be a marker of worse outcomes.

Purpose

To evaluate primarily the rate of NOP-LBBB following TAVR among patients with BAV as compared to tricuspid severe aortic stenosis (TAV).

Methods

Patients enrolled in the multicenter (5 centers) Bicuspid AS TAVR Registry were reviewed and compared with patients with TAV. Patients with prior aortic valve replacement, other valve morphologies and those with preprocedural LBBB or pacemaker were excluded. NOP-LBBB was defined as LBBB first detected and persisting 30-days following TAVR.

Results

A total of 387 patients (66 with BAV, 321 with TAV), age 80.3±7.3, 47% females were analyzed. The device success rates were 95% in both groups without any conversions to surgery. The rate of NOP-LBBB was significantly higher among patients with BAV vs. TAV (29.2% vs. 16.9%, p=0.02). However, the rate of post procedural pacemaker implantation was similar (14.8% vs. 12.5%; respectively, p=0.62). In BAV and TAV groups, 1-year mortality (6.1% vs. 7.2%; respectively, p=0.75) and stroke rates (6.1% vs. 3.5%; respectively, p=0.3) were not significantly different. Multivariate analysis identified BAV as an independent predictor of NOP-LBBB (OR=2.7, 95% CI 1.3–5.4). Furthermore, BAV subtypes with raphe (type 1) were identified as independent predictors of NOP-LBBB (OR=3.2, 95% CI: 1.5–6.7).

Conclusions

Patients with BAV undergoing TAVR have greater risk for developing NOP-LBBB compared with patients with TAV and the presence of raphe was associated with increased risk of NOP-LBBB. The prognostic significance for this finding warrants further evaluation in future studies.

Funding Acknowledgement

Type of funding sources: None.

Incident cardiovascular events among healthy subjects are associated with increased risk of subsequent cancer diagnosis

Introduction

While Cardiovascular disease (CVD) and cancer share common risk factors, data on the temporal association between the occurrence of CVD and cancer is limited.

Purpose

This study investigated the association between incident CVD events future cancer among apparently healthy subjects.

Methods

We evaluated asymptomatic self-referred adults who participated in a screening program. All subjects were free of CVD and cancer at baseline. CVD was defined as the composite of acute coronary syndrome, percutaneous coronary intervention, or stroke. Study endpoint was the development of cancer during follow up. Cancer and mortality data were available for all subjects from national registries. Cox regression models were applied with CVD as a time-dependent covariate and death as a competing risk event.

Results

Final study population included 26,574 subjects. Median age was 46 years (Interquartile range [IQR] 40–53) and 69% were men. During median follow up time of 10 years (IQR 3–16) 2,463 (9%) subjects developed CVD, 2,040 (8%) developed cancer and 869 (3%) died. Most common cancer types were prostate among men (N=406, 2.2%) and breast among women (N=283, 3.4%). Compared with patients who were free of CVD and cancer during follow up, risk of death was 5, 34 and 54 times higher for patients who developed CVD event, cancer, or both during follow up, respectively (p &lt;.001 for all). Time dependent survival analysis showed that subjects who developed CVD during follow up were 50% more likely to develop cancer in a univariate model (95% Confidence Interval [CI] 1.3–1.7, p&lt;.001). Interaction analysis demonstrated that the association of incident CVD with the risk of future cancer diagnosis was age dependent such that in younger subjects (≤52 years; N=19,052) incident CVD was associated with a significant 30% increased risk of subsequent cancer diagnosis (95% CI 1.03–1.67, p=.027) while in older subjects incident CVD was not associated with increased risk of cancer in the multivariable model (p for interaction =.018).

Conclusion

Incident CVD is independently associated with increased risk of subsequent cancer diagnosis among young adults. Active cancer surveillance should be considered among young patients recovering from a CVD event.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary hypertension is associated with systemic arterial hypertension among patients with normal diastolic function

Introduction

The association of pulmonary and systemic arterial hypertension is believed to be mediated through hypertensive left heart disease. The purpose of the current study was to investigate whether pulmonary arterial hypertension (PAH) is associated with systemic arterial hypertension among patients with apparently normal left heart diastolic function.

Methods

Consecutive patients who had echocardiographic evaluation between 2007 and 2019. Patients with disease states that are known to be associated with PAH including diastolic dysfunction were excluded from the analysis. Estimated right ventricular systolic pressure (RVSP) was extracted for all patients from the echocardiographic reports. PAH was defined as estimated RVSP &gt;40 mmHg. Multivariate logistic regression models were applied.

Results

Final study population included 25,916 patients with a median age of 59 (IQR 44–69), of whom 12,501 (48%) were male and 13,265 (51%) had systemic arterial hypertension. Compared with normotensive patients, hypertensive patients were 3.2 times more likely to have PAH (95% CI; 2.91–3.53, p&lt;0.001). A multivariate model adjusted for clinical and echocardiographic parameters that are known to be associated with PAH demonstrated that hypertensive patients are almost 3 times more likely to have PAH (95% CI 2.45–3.15, p&lt;0.001). The association was significant in multiple subgroups but was more significant among women compared with men (OR 3.1 vs. 2.4, p for interaction &lt;0.001).

Conclusions

PAH is associated with systemic arterial hypertension irrespective of left heart disease. The association is more pronounced among women.

Funding Acknowledgement

Type of funding sources: None. Estimated RVSP &gt;40 by Systolic BP

Low ALT levels are associated with poor outcomes in acute coronary syndrome patients admitted to the intensive cardiac care unit

Background

Frailty is an under recognized and important entity that bears worse prognosis.

Purpose

Although low serum alanine aminotransferase (ALT) can serve as a novel marker of frailty, its use was never assessed in acute coronary syndrome (ACS) patients.

Methods

A retrospective analysis of hospitalized ACS patients in the intensive cardiac care unit (ICCU) between 1/5/2011 and 1/12/2020 at a single tertiary medical center.

Results

The study included 3956 patients after excluding patients with ALT &gt;40 IU/L, cirrhosis and missing data, followed for a median duration of 47 months (IQR 20–77). Patients were stratified into two groups based on their first ALT measurement within the index hospitalization: low-normal ALT group (ALT ≤10 IU/L) vs. high-normal ALT group (ALT &gt;10 IU/L). Patients with ALT≤10 IU/L were older (mean age 71 vs. 65, P&lt;0.001), presented more frequently with non-ST elevation myocardial infarction (66.4% vs. 53.2%, P&lt;0.001), had higher rates of comorbidities at baseline, and had a lower Norton score upon admission. Hospitalization length was longer in the low-normal ALT group (P&lt;0.001). Although the in-hospital mortality rate was similar between the groups (0.9% vs. 0.7%, P=0.99), long-term mortality was significantly higher in the low-normal ALT group (22.7% vs. 7.9%, P&lt;0.001). In a multivariate regression model ALT ≤10 IU/l was associated with increased mortality (HR 2.1, 95% CI 1.46–3).

Conclusion

Lower serum ALT is associated with worse outcomes in ACS patients admitted to the ICCU.

Funding Acknowledgement

Type of funding sources: None. 5-year survival according to baseline ALForest plot of variables associated with

Clinical and echocardiographic parameters associated with left ventricular recovery after TAVI

Introduction

The relationship between severe Aortic Stenosis (AS) and Left Ventricular (LV) dysfunction is well established. However, there is a paucity of data regarding LV functional recovery after TAVI.

Purpose

To study the clinical and echocardiographic parameters associated with LV functional recovery after TAVI.

Methods

We evaluated all patients who underwent TAVI between 2009–2020 in a tertiary medical center. We included patients with pre-procedural LV Ejection Fraction (LVEF) of 40% and below. All patients had baseline and in-hospital post-procedural echo, and their clinical characteristics were recorded in a designated TAVI registry. LV functional recovery was defined as an absolute increase in at least 10% in LVEF post-procedurally. No LV recovery was defined as an absolute change of up to ±10% in post-procedure LVEF, and LVEF deterioration was defined as an absolute decrease of more than 10% in post-procedural LVEF compared to baseline. Univariate analysis consisting clinical and echocardiographic factors for LV functional recovery was performed, followed by logistic regression adjusting for confounders.

Results

Out of 1,349 consecutive TAVI patients, 100 (7.4%) had LVEF of 40% or less. There were 69 (69%) men with a mean age of 82±8 years, and average BMI of 27±4 kg/m2. Prior coronary artery disease and hypertension were present in 34 (34%) and 21 (21%) of patients, respectively. Out of these 100 patients, 32 (32%) had achieved LV functional recovery and no patient had experienced LVEF deterioration (FIGURE). Mean Left Ventricular End Systolic Diameter (LVESD) was 3.79 and 4.43 in the LV functional recovery and no LV recovery groups, respectively. Mean aortic pressure gradient was higher among patients who had LV functional recovery compared to no LV recovery (45.9 vs. 31.5 mmHg, respectively). Multivariable analysis revealed parameters that were independently associated with LV functional recovery: Coronary artery disease – OR 5.29 (95% CI 1.59–20.44), LVESD – OR 0.87 (95% CI 0.8–0.95) for each 1 mm increment and mean aortic pressure gradient – OR 1.91 (95% CI 1.21–3.28) per each 10 mmHg increment.

Conclusion

In patients with severe AS and LV dysfunction undergoing TAVI, the presence of coronary artery disease, increased aortic pressure gradient and reduced LVESD were associated with early LV functional recovery.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The association of tissue doppler E/e' ratio with poor survival is modified by gender and is attenuated with advanced age

Introduction

Contemporary guidelines recommend a universal cutoff of 14 for the ratio between early mitral flow wave and early diastolic mitral annulus velocity measured by tissue doppler (E/e' ratio). While age-dependent normal E/e' values have been suggested, outcome data is lacking.

Purpose

We sought to evaluate the modification effect of age and gender on the prognostic value of the E/e' ratio.

Methods

Consecutive patients who underwent echocardiographic evaluation between 2009 and 2021 (N=104,315) in a single tertiary cardiovascular center. Patients with left or right ventricular dysfunction, any significant valvular disease, structural heart disease or evidence of pulmonary hypertension were excluded. Cancer and mortality data were available for all subjects from national registries. Patients with a metastatic malignancy at baseline or during follow up were excluded. Cox regression models were applied.

Results

Overall, 44,541 patients were included in the final analysis. Mean age was 55±17, 59% were male and 63% of the exams were performed in an outpatient setting. An elevated E/e' ratio above 14 was documented in 2,598 (7%) patients. During a median follow-up of 5.7 (IQR 2.8–9.1) years, 5,015 (11.3%) patients died. Kaplan Meier survival analysis demonstrated that the cumulative probability of death at 6 years was 23.4% (21.6–25.3) among patients with elevated E/e' ratio compared with 9.7% (9.3–10.0) among patients with E/e'&lt;14 (p Log rank &lt;0.001). This difference was less significant as age progressed (figure 1). Multivariate cox-regression model yielded consistent results such that an elevated E/e' ratio was associated with 2.66-fold increased risk of death during follow up (95% CI 2.44–2.89, p&lt;0.001), and there was a decline in the increased risk and significant as age advanced in both genders (figure 2). Interaction analysis was significant for both gender and age such the association of elevated E/e' ratio with poor survival was more significant among men compared with women and among young vs. older subjects. Among women, elevated E/e' was associated with 2.4-fold increased risk of death versus 2.7-fold increased risk among men. Similarly, the hazard ratio for death associated with elevated E/e' was 2.29 (95% CI 1.74–3.02), 1.8 (95% CI 1.5–2.1), 1.13 (95% CI 0.97–1.31) and 1.07 (95% CI 0.92–1.25) for the age groups of &lt;60, 60–70, 70–80 and &gt;80, respectively. In a sensitivity analysis, similar findings were seen in when excluding patients with mild hypertrophy (maximal wall thickness &gt;12mm) and without any mitral annulus calcification.

Conclusion

In apparently normal hearts, an elevated E/e' ratio is independently associated with increased mortality. This association is more pronounced among men and is attenuated with increased age. This study supports the need for gender-specific and age-specified outcome data with respect to measures of diastolic dysfunction.

Funding Acknowledgement

Type of funding sources: None. Survival by age and gender groupsE/e' &gt;14 and mortality by age and gender

Characteristics of aortic root and vascular anatomy in bicuspid versus tricuspid aortic valve anatomy

Background

Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).

Purpose

This study sought to compare aortic root, aorta and iliofemoral artery anatomy in patients with bicuspid versus tricuspid AS.

Methods

172 patients with bicuspid AS and 331 patients with tricuspid AS underwent pre-procedural computed tomography (CT) evaluation before TAVR. Dimensions, calcification, and tortuosity of the iliofemoral arteries were evaluated and the dimensions of aortic root, aorta, and left subclavian arteries were determined.

Results

Dimensions of aortic root, aorta, left subclavian, and iliofemoral arteries were consistently and significantly larger in bicuspid than in tricuspid AS (P&lt;0.001). Patients with bicuspid AS had significantly lower subclavian, aorta, and iliofemoral arteries calcification, lower tortuosity index and lower maximal tortuosity angle compared to patients with tricuspid AS (P&lt;0.001 for all) even after adjustment for baseline characteristics (Figure). Compared to tricuspid AS the prevalence of porcelain aorta and aneurysm in the descending aorta and iliofemoral arteries were significantly less common in bicuspid valve anatomy. After adjustment for baseline characteristics Bicuspid valve anatomy was associated with lower odds of vascular calcification (odds ratio (OR) 0.82: 95% CI 0.52–0.93; P=0.001).

Conclusions

Bicuspid AS was associated with larger dimensions of aortic root, aorta, subclavian, and iliofemoral arteries compared with tricuspid AS. Low vascular calcification and decreased tortuosity index of iliofemoral arteries characterized bicuspid anatomy. Further studies are needed to evaluate the impact of bicuspid vascular anatomy on vascular complications after TAVR.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation in the young: clinical characteristics, predictors of new onset and outcomes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) onset in the young (≤45 years) is uncommon and not well studied.

Purpose

Identifying the determinants of AF in this population in order to help direct timely diagnosis, appropriate follow up and management.

Methods

We retrospectively evaluated all patients aged ≤45, admitted to the internal and cardiology wards between January 2009 and December 2019 at a large tertiary center. Clinical, electrocardiographic and echocardiographic data were collected and compared among patients with and without AF at baseline. A subgroup of patients with no AF at baseline and a subsequent hospital visit were followed for development of new onset AF (NOAF).

Results

A total of 16,432 patients (55.5% male, 33 ±8.3 years old) were analyzed. At baseline, patients with AF (n = 366) tended to be older, more often male, and had a higher proportion of comorbidities and ECG conduction disorders, compared with the patients without AF (n = 16,066). Male sex, increased age, obesity, heart failure (HF) and the presence of left or right bundle branch block (LBBB and RBBB, respectively) were all strongly and independently associated with young-onset AF. A total of 10,691 patients were followed for a median of 41.5 (16.6-78.6) months, during which 85 patients developed NOAF (equivalent to 0.5%/year). Increased age, hypertension, HF, RBBB and LBBB were independent predictors of NOAF. CHARGE-AF score outperformed CHA2DS2-VASc score in NOAF prediction [AUC of ROC 0.75 (0.7-0.8) vs. 0.56 (0.48-0.65)].

Conclusions

The annual risk of NOAF among young adults admitted to the hospital is noteworthy. NOAF may be predicted by clinical risk factors and the CHARGE-AF score. Characteristic No AF (N = 16066) AF (N = 366) Total (N = 16432) P value Age- yr. 33.06 ± 8.3 36.8 ± 7.3 33.1 ±8.3 &lt;0.0001 Male gender 8914 (55.5) 240 (65.6) 9154 (55.7) &lt;0.0001 BMI- kg/m2 25.5 ± 5.75 27.48 ± 6.36 25.2 ± 5.8 &lt;0.0001 HTN 2679 (16.7) 73 (19.9) 2752 (16.7) 0.098 CHF 124 (0.8) 13 (3.6) 137 (0.8) &lt;0.0001 PR interval &gt; 200ms 117 (1.3) 15 (9.1) 132 (1.5) &lt;0.0001 QRS interval &gt; 120ms 220 (2.4) 25 (8.4) 245 (2.6) &lt;0.001 LBBB 29 (0.2) 6 (1.6) 35 (0.2) &lt;0.0001 LVEF &lt; 40 323 (10.1) 35 (16.9) 358 (10.5) 0.002 CHA2DS2-VASc 0.75 ±0.75 0.73 ±0.84 0.74 ±0.76 0.647 CHARGE AF 6.3 ±1.1 6.8 ±0.9 6.32 ±1.06 &lt;0.001

Reducing drug prescription errors and adverse drug events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient setting

BACKGROUND

Drug prescription errors are made, worldwide, on a daily basis, resulting in a high burden of morbidity and mortality. Existing rule-based systems for prevention of such errors are unsuccessful and associated with substantial burden of false alerts.

OBJECTIVE

In this prospective study, we evaluated the accuracy, validity, and clinical usefulness of medication error alerts generated by a novel system using outlier detection screening algorithms, used on top of a legacy standard system, in a real-life inpatient setting.

MATERIALS AND METHODS

We integrated a novel outlier system into an existing electronic medical record system, in a single medical ward in a tertiary medical center. The system monitored all drug prescriptions written during 16 months. The department's staff assessed all alerts for accuracy, clinical validity, and usefulness. We recorded all physician's real-time responses to alerts generated.

RESULTS

The alert burden generated by the system was low, with alerts generated for 0.4% of all medication orders. Sixty percent of the alerts were flagged after the medication was already dispensed following changes in patients' status which necessitated medication changes (eg, changes in vital signs). Eighty-five percent of the alerts were confirmed clinically valid, and 80% were considered clinically useful. Forty-three percent of the alerts caused changes in subsequent medical orders.

CONCLUSION

A clinical decision support system that used a probabilistic, machine-learning approach based on statistically derived outliers to detect medication errors generated clinically useful alerts. The system had high accuracy, low alert burden and low false-positive rate, and led to changes in subsequent orders.

The usefulness of coronary artery calcium score to rule out obstructive coronary artery disease before transcatheter aortic valve replacement

Introduction

Coronary clearance in patients undergoing TAVR is performed by invasive coronary angiography (ICA) or computed tomography angiography (CTA). We aimed to investigate whether CTA-derived low coronary calcium (CAC) score may rule out obstructive coronary artery disease (CAD) in these patients.

Methods

We included 232 consecutive patients with severe aortic stenosis (mean age 80±8; 50% female) who underwent both pre-TAVR CTA and ICA between 2012–2019. Obstructive CAD was defined as a &gt;50% in left main or &gt;70% in the 3 main epicardial vessels. Patients with prior coronary stents or bypass grafts were excluded. CAC score was calculated by Agatston method. Receiver operating characteristic (ROC) was applied to establish the CAC threshold for obstructive CAD, and adjustment for age, gender, diabetes and renal failure was applied.

Results

CAC scores range was 3.5–5200 (median = 1028). Eighty-eight patients (38%) had obstructive CAD. ROC curves showed high negative predictive value (NPV) for LAD - CAC score 280, NPV 95%; LCX - CAC score 320, NPV 93%; and RCA - CAC score 347, NPV 90% (figure). Binary logistic regression confirmed CAC score cutoffs per vessel as an independent predictor of obstructive CAD [LAD (OR 3.9, CI 1.1–14, p-0.033); CX (OR 5.7, CI 2.4–12, p&lt;0.001); RCA (OR-5.6, CI 2.5–12, p&lt;0.001)].

Conclusion

CAC score per-vessel can be useful to rule out obstructive CAD in patients with severe aortic stenosis undergoing TAVR. Using specific CAC cut offs can identify patients who may omit ICA

CAC per vessel

Funding Acknowledgement

Type of funding source: None

Right ventricular function and systolic pressure effect on survival of patients with tricuspid regurgitation

 

Severe tricuspid regurgitation (TR) is associated with poor outcome. The current analysis investigated the long term outcome of TR patients.

Methods

Historical retrospective cohort of all cardiovascular patients evaluated at a tertiary heart center between 2007 and 2019. The current analysis included all patients who underwent echocardiographic evaluation. TR severity was extracted for all patients from the echocardiographic reports. Primary outcome was all cause mortality and was available for all patients from the national population register.

Results

Final cohort included 97,561 subjects, of whom 42,187 (43%) were outpatients. Mean age was 66±17 and 55,976 (57%) were men. Mild, moderate and severe TR was documented in 27,389 (28%), 2,871 (3%) and 1,812 (2%) patients, respectively. During a median follow up of 50 months [IQR 22–83] 18,476 (19%) patients died. Kaplan-Meier survival analysis demonstrated increased risk of death with increasing degree of TR (FIGURE; p Log rank &lt;0.001). Multivariate cox regression with adjustment to age, gender, BMI and echocardiographic predictors of adverse outcome showed that compared with no or mild TR, patients with moderate or severe TR were 10% and 45% more likely to die (95% CI: 1.02–1.18, p=0.009 and 1.34–1.57 p&lt;0.001 respectively). Interaction analysis with adjustment to known predictors of poor survival demonstrated that the association of severe TR with survival was dependent on right ventricle (RV) dysfunction and estimated RV systolic pressure (RVSP) with a more pronounced effect on patients with severe RV dysfunction (HR of 1.38 [1.07–1.80] vs. 1.09 [1.00–1.19], p for interaction = 0.01) and a more pronounced effect on patients with estimated RVSP &lt;40 mmHg (HR of 1.60 [1.21–2.11] vs. 1.14 [1.03–1.25], p for interaction &lt;0.001). Finally, a propensity score matching of patients with severe TR (N=1,154) and matched controls with no or mild TR successfully demonstrated that patients with severe TR were 27% more likely to die during follow up (95% CI: 1.14–1.42, p&lt;0.001).

Conclusions

Severe TR is independently associated with poor survival. The association is modified by RV dysfunction and estimated RVSP. This report supports the need for studies to evaluate TR interventions on patients' clinical outcomes.

Kaplan Meier Survival Curves

Funding Acknowledgement

Type of funding source: None

Invasive- versus computed tomography-angiography for the evaluation of coronary artery disease among elderly patients undergoing transcatheter aortic valve implantation

Background

Coronary artery disease (CAD) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend that percutaneous coronary intervention (PCI) of &gt;70% proximal coronary lesions prior to TAVI. The aim of the current study was to evaluate two approaches to CAD diagnosis pre-TAVI.

Methods

We investigated 2,027 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural CAD assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results (N=831) or mandatory invasive angiography (IA) (N=1,196). Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

Results

Mean age of the study population was 86±4, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (32% vs. 17%, p&lt;0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were significantly lower among the IA group (0.1% vs. 1.5%, p=0.001). However, multivariate binary logistic regression analysis adjusted for age, gender and cardiovascular risk factors failed to show association between centers strategy and peri-procedural MI. Periprocedural bleeding rates were similar between the groups (3.5% vs. 2.9%, p=0.477). Thirty day, and 1-year mortality crude rates were similar between the groups (2.5% vs. 3.4%, p=0.25, and 10.2% vs. 12.0%, p=0.19). Multivariate cox regression adjusted for age, gender and cardiovascular risk factors did not find association between CAD clearance strategy and outcome.

Conclusions

In elderly patients, CTA driven approach for CAD evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.

Funding Acknowledgement

Type of funding source: None

Right atrium to pulmonary capillary wedge pressure ratio is associated with right ventricular failure and mortality after left ventricular assist device surgery

Introduction

Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. We investigated the role of right atrium to pulmonary capillary wedge pressure (RA/PCWP) ratio as a preoperative predictor of postoperative RVF after LVAD surgery.

Methods

A retrospective analysis of all consecutive patients who received continuous-flow LVADs (HeartMate 2, 3, and HVAD) between August 2012 and May 2018 in a single tertiary center. INTERMACS profile 1 patients were excluded. RA/PCWP ratio was calculated for the entire cohort and divided into quartiles (Q). Patients were stratified into high (Q4) vs. low (Q1–3) RA/PCWP ratio. The primary end point was the composite of in hospital mortality and RVF (defined as the need for a right ventricular assist device or inotrope dependence for &gt;7 days). The secondary endpoint was readmission within 14 days after discharge.

Results

The study cohort consisted of 59 patients (15 patients in the high RA/PCWP group and 44 patients in the low RA/PCWP group) with a median follow-up of 21 months (Interquartile range 14–31). The mean age was 56±11 years and the majority of patients were male (88%). Patients were classified as INTERMACS profile 2 (34%), 3 (19%) or 4 (47%).

Preoperative clinical, laboratory, and echocardiographic parameters were similar in both groups except for a larger proportion of patients with a dilated right ventricle and above moderate tricuspid regurgitation in the high compared to the low RA/PCWP group (73% vs. 29%; P=0.006 and 40% vs. 2%; P=0.001, respectively). Overall, 7 patients (12%) developed the primary end-point and 9 patients (15%) developed the secondary end-point.

Univariate analysis demonstrated that high RA/PCWP is associated with both primary and secondary end-points (odds ratio [OR], 7.6; 95% confidence interval [CI] 1.2–47.2, P=0.029 and OR, 6.25; 95% CI 1.3–28.5, P=0.018, respectively). On multivariable analysis, the association remained significant after adjustment for INTERMACS score (OR, 10.6; 95% CI 1.4–80.9, P=0.022 and OR, 7.9; 95% CI 1.5–42.2, P=0.015, respectively).

Using receiver operating characteristic curve (ROC) derived cut-points, RA/PCWP &gt;0.57 provided 67% sensitivity and 79% specificity (C-statistic = 0.73) for the prediction of in hospital mortality and RVF and 56% sensitivity and 84% specificity (C-statistic = 0.69) for the prediction of readmissions within 14 days after discharge. In comparison, in our cohort using ROC-derived cut points, pulmonary artery pulsatility index, an established RVF predictor, of less than 1.84 provided 40% sensitivity and 20% specificity (C-statistic = 0.3) for the prediction of inhospital death and RVF.

Conclusion

RA/PCWP ratio may help to identify patients at high risk of developing adverse clinical outcomes, including RVF and mortality, after LVAD surgery.

Funding Acknowledgement

Type of funding source: None

Procedural and remote outcome among patients undergoing urgent trans-catheter aortic valve implantation

Background

Severe aortic stenosis patients suffer frequent heart failure decompensations events often requiring hospitalization. In extreme situations patients can be found with pulmonary edema and cardiogenic shock, unresponsive to medical treatment. Urgent trans-catheter aortic valve implantation (TAVI) has emerged as a treatment option for these high-risk patients.

Methods

We investigated 3,599 patients undergoing TAVI. Subjects were divided into two groups based on procedure urgency: patients who were electively hospitalized for the procedure (N=3,448) and those who had an urgent TAVI (N=151). Peri-procedural complications were documented according to the VARC-2 criteria. In hospital and 1-year mortality rates were prospectively documented.

Results

Mean age of the study population was 82±7, of whom 52% were female. Peri-procedural complication rates was significantly higher among patients with an urgent indication for TAVI compared to those having an elective procedure: valve malposition 3.6% vs. 0.6% (p-value=0.023), valve migration 3.2% vs. 0.9% (p-value=0.016), post procedure myocardial infarction 3.7% vs. 0.3% (p-value=0.004), and stage 3 acute kidney injury 2.6% vs. 0.5%, (p-value=0.02). Univariate analysis found that patients with urgent indication for TAVI had significantly higher in hospital mortality (5.8% vs. 1.4%, p-value&lt;0.001). similarly, multivariate analysis adjusted for age, gender and cardio-vascular risk factors found that patients with urgent indication had more than 5-folds increased risk of in-hospital mortality (OR 5.94, 95% CI 2.28–15.43, p-value&lt;0.001). Kaplan-Meier's survival analysis showed that patients undergoing urgent TAVI had higher 1-year mortality rates compared to patients undergoing an elective TAVI procedure (p-value log-rank&lt;0.001, Figure). Multivariate analysis found they had more than 2-folds increased risk of mortality at 1-year (HR 2.27, 95% CI 1.53–3.38, p&lt;0.001 compared to those having an elective procedure.

Conclusions

Patients with urgent indication for TAVI have higher in-hospital mortality and higher peri-procedural complication rates. However, if these patients survive the index hospitalization, they enjoy good prognosis.

Kaplan-Meier's survival analysis

Funding Acknowledgement

Type of funding source: None

Survival of patients with moderate aortic stenosis: propensity score matching analysis

Introduction and purpose

Data on the survival of patients with moderate aortic stenosis (AS) is conflicting. The purpose of the current analysis was to assess survival of moderate AS patients.

Methods

SHARE is an historical retrospective cohort of all cardiovascular patients evaluated in an Israeli tertiary hospital between 2007 and 2019. The current analysis included all patients who underwent echocardiographic evaluation. Aortic stenosis severity was extracted for all patients from the echocardiographic reports. All-cause mortality and was available for all patients. Subjects with severe AS or aortic valve replacement were excluded from the analysis.

Results

Cohort included 97,561 subjects of whom 42,187 (43.2%) were outpatients. Final cohort included 93,889 patients with a mean age of 66±17 (58% men). There were 2,949 (3%) with moderate AS. During a median follow up of 52 [IQR 22–89] months 17,173 (18%) patients died. Kaplan-Meier survival analysis demonstrated worse cumulative probability of death of 51%±2% vs. 20%±0% at 5 years for patients with moderate AS vs. mild or no AS, respectively (p Log rank &lt;0.001). Sub-analysis of 32,745 patients for whom clinical laboratory and medication data was available yielded consistent results in a comprehensive multivariate model such that patients with moderate AS (N=1,381) were 26% more likely to die (95% CI: 1.17–1.37, p&lt;0.0001). Finally, a propensity score matching of patients with moderate AS and controls with no or mild AS (N=1,381) successfully demonstrated that patients with moderate AS were 40% more likely to die during follow up (95% CI 1.25–1.57, p&lt;0.001; FIGURE). Four-years mortality rates were 2 fold higher for patients with moderate AS compared with controls (OR = 1.96, 95% CI 1.6–2.4, p&lt;0.001). Interaction analysis demonstrated that the association of moderate AS with survival was not dependent on left ventricular ejection fraction.

Conclusion

Moderate AS is associated with worse survival. Our findings underscore the importance of careful clinical observation as well as the need for further studies.

Figure 1

Funding Acknowledgement

Type of funding source: None

Low ALT Levels Associated with Poor Outcomes in 8700 Hospitalized Heart Failure Patients

Sarcopenia and frailty are causes for morbidity and mortality amongst heart failure (HF) patients. Low alanine transaminase (ALT) is a marker for these syndromes and, therefore, could serve as a biomarker for the prognostication of HF patients. We performed a retrospective analysis of all consecutive hospitalized HF patients in our institute in order to find out whether low ALT values would be a biomarker for poor outcomes. Our cohort included 11,102 patients, 35.6% categorized as heart failure with reduced ejection fraction. We excluded patients with ALT > 40 IU/L and cirrhosis. 8700 patients were followed for a median duration of 22 months and included in a univariate analysis. Patients with ALT < 10 IU/L were older (mean age 78.6 vs. 81.8, p < 0.001), had past stroke (24.6% vs. 19.6%, p < 0.001), dementia (7.7% vs. 4.6%, p < 0.001), and malignancy (13.4% vs. 10.2%, p = 0.003). Hospitalization length was longer in the low-ALT group (4 vs. 3 days, p < 0.001), and the rate of acute kidney injury during hospitalization was higher (19.1% vs. 15.6%; p = 0.006). The in-hospital mortality rate was higher in the low-ALT group (6.5% vs. 3.9%; p < 0.001). Long-term mortality was also higher (73.3% vs. 61.5%; p < 0.001). In a multivariate regression analysis, ALT < 10 IU/L had a 1.22 hazard ratio for mortality throughout the follow-up period (CI = 1.09-1.36; p < 0.001). Low ALT plasma level, a biomarker for sarcopenia and frailty, can assist clinicians in prognostic stratification of heart failure patients.

Beneficial effect of awake prone position in hypoxaemic patients with COVID-19: case reports and literature review

We hereby present two case reports of moderate coronavirus disease patients, suffering from profound hypoxaemia, further deteriorating later on. A schedule pre-planned awake prone position manoeuvres were executed during their hospital stay. Following this, the patients' saturation improved, later to be weaned from oxygen support. Paucity of evidence and data regarding this topic led us to review the concept of awake prone position.

Clinical Characterization of 162 COVID-19 patients in Israel: Preliminary Report from a Large Tertiary Center

BACKGROUND

In February 2020, the World Health Organisation designated the name COVID-19 for a clinical condition caused by a virus identified as a cause for a cluster of pneumonia cases in Wuhan, China. The virus subsequently spread worldwide, causing havoc to medical systems and paralyzing global economies. The first COVID-19 patient in Israel was diagnosed on 27 February 2020.

OBJECTIVES

To present our findings and experiences as the first and largest center for COVID-19 patients in Israel.

METHODS

The current analysis included all COVID-19 patients treated in Sheba Medical Center from February 2020 to April 2020. Clinical, laboratory, and epidemiological data gathered during their hospitalization are presented.

RESULTS

Our 162 patient cohort included mostly adult (mean age of 52 ± 20 years) males (65%). Patients classified as severe COVID-19 were significantly older and had higher prevalence of arterial hypertension and diabetes. They also had significantly higher white blood cell counts, absolute neutrophil counts, and lactate dehydrogenase. Low folic acid blood levels were more common amongst severe patients (18.2 vs. 12.9 vs. 9.8, P = 0.014). The rate of immune compromised patients (12%) in our cohort was also higher than in the general population. The rate of deterioration from moderate to severe disease was high: 9% necessitated non-invasive oxygenation and 15% were intubated and mechanically ventilated. The mortality rate was 3.1.

CONCLUSIONS

COVID-19 patients present a challenge for healthcare professionals and the whole medical system. We hope our findings will assist other providers and institutions in their care for these patients.