Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Impact of COVID-19 pandemic on admissions and management of acute coronary syndrome: a single tertiary cardiac centre experience in the United Kingdom

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Global reports are suggestive of decline in number of patients attending hospital with acute coronary syndromes (ACS) and a reduction in the number of cardiac procedures since the onset of COVID-19 pandemic.

Purpose

The aim of the study was to compare the trend of presentations and management among ACS patients in a single tertiary cardiac centre in the West midlands of United Kingdom (UK) during the early lock down period of COVID-19 pandemic (Group 2020) in comparison to the same period of 2019 (Group 2019).

Methods

In this descriptive study patients’ records were extracted retrospectively from the electronic database who presented with ST segment elevation myocardial infarction (STEMI), non- ST segment elevation myocardial infarction (NSTEMI) and Unstable angina (UA), during the 30 day period from mid-March to mid-April of 2020 (Group 2020), and the same period of 2019 (Group 2019).

Results

In comparison to group 2019, total number of ACS (153 vs 91) including STEMI (70 vs 59), NSTEMI (76 vs 31) and UA (7 vs 1) were lower in group 2020 (Fig 1A). Inter-hospital transfer (IHT) dropped from 2019 to 2020 (55 vs 17). In group 2020, percutaneous coronary angioplasty (PCI) for STEMI was similar to group 2019 (83.05% vs 88.57%) but PCI for NSTEMI were higher (80.65% vs 48.68%). No coronary artery bypass graft (CABG) services were available during the studied period (Fig 1B).  In terms of troponin I (Trop I) levels at the time of admission, 47.25% of all ACS presentations were over 1000ng/L in group 2020 compared to 28.76% in group 2019 (Fig 1C). On assessment of left ventricular ejection fraction (LVEF) at the time of admission, 24% of all ACS were severely impaired (LVEF < 40%) compared to 13.79% in 2019 (Fig 1D). 37 (31 IHT) patients in group 2019 and 16 (11 IHT) patients in group 2020 had no transthoracic echocardiogram data. There was an overall reduction in number of days spent in hospital per ACS patient from 4.78 days in 2019 to 3.70 days in 2020 and a further reduction for STEMI patients from 5.16 days in 2019 to 3.83 days in 2020. 5 ACS patients died in 2020 in comparison to 6 patients in 2019.

Conclusion

The reduced number of admissions is likely to be a result of nation-wide lock-down and public fear. Proportion of ACS patients with high level of troponin I values and severely impaired LVEF may be explained due to late presentation. It remains necessary to address public fear and to ensure that ACS patients are managed in accordance with ACS management guidelines even in the times of COVID-19 pandemic.

Immunophenotypic characterization of human monocyte subsets: possible implications for cardiovascular disease pathophysiology

OBJECTIVES

Monocytes include several subsets with different and sometimes divergent roles in immunity, atherogenesis and reparative processes.

OBJECTIVES

We aimed to perform detailed immunophenotypic and functional characterization of human monocyte subsets.

PATIENTS/METHODS

Analysis of surface markers of blood and bone marrow monocyte subsets and functional characterization of blood monocyte subsets in healthy volunteers was performed using flow cytometry.

RESULTS

In the present study, we show the presence of three subsets which could be unequivocally distinguished by surface expression of CD14, CD16 and CCR2 as CD14(+)CD16(-)CCR2(+) (Mon1), CD14(+)CD16(+)CCR2(+) (Mon2) and CD14(low)CD16(+)CCR2(-) (Mon3) subsets. In comparison with the classic Mon1, the Mon2 subset had the highest expression of Tie2, CXCR4, CD163, CD115, receptors to inter-cellular adhesion molecule-1 (ICAM-1), vascular endothelial growth factor (VEGF), and the highest surface levels of apolipoprotein B and ferritin. In contrast, Mon3 had maximal expression of VCAM-1 receptors and CD204. The Mon2 and Mon3 subsets had significantly lower activity of the NFκB pathway than Mon1. Mon1 and Mon2 had similar phagocytic activity, which was significantly higher compared with Mon3. All three subsets were present in bone marrow, although the relative proportion of Mon2 in bone marrow was about 2.5-fold higher compared with that seen in blood. Significant differences in cytokine production in response to endotoxin stimulation were observed between the three monocyte subsets.

CONCLUSION

Given their immunophenotypic similarity, the newly characterized Mon2 population may represent the previously reported pluripotent progenitor/pro-angiogenic monocytes.

Successful use of intra-aortic counter pulsation therapy for intractable ventricular arrhythmia in patient with severe left ventricular dysfunction and normal coronary arteries

Intra-aortic balloon pumps (IABP) are commonly used in the setting of an acute myocardial infarction that is complicated by cardiogenic shock or mechanical complications such as a ventricular septal defect or papillary muscle rupture. IABP has also been shown to be useful in patients with refractory and hemodynamically unstable ventricular arrhythmias and refractory post-myocardial infarction angina. We report a case in which IABP was used in a patient with dilated cardiomyopathy and normal coronary arteries, who presented with persistent, recurrent and refractory ventricular tachycardia. His ventricular tachycardia settled immediately with the use of IABP therapy. He subsequently had an implantable defibrillator. The use of IABP is associated with favorable changes in the left ventricular wall tension and reduction in afterload, which could reduce the excitability of the myocardium, thus making it less prone to arrhythmias. The use of IABP is relatively safe and should be considered in patients with refractory ventricular arrhythmias, even if it is not associated with ischemia.

The inferior hypogastric plexus: A different view

The morphology of the inferior hypogastric plexus has been demonstrated in a series of dissections of nulliparous cadavers. Each cadaver was embalmed in a solution containing a significant proportion of methanol which preserved the pliability of the tissues enabling the nerve plexi to be clearly demonstrated. These structures are not normally encountered during general gynaecological surgery and clinicians are often unaware of the possible consequences of injury during vaginal delivery or sustained constipation. Denervation of pelvic organs, with subsequent reinnervation over the medium term, may account for a variety of obstetric and gynaecological syndromes.

Re-examination of the medullary rootlets of the accessory and vagus nerves

The vagus (X) and cranial root of the accessory nerve (crXI) are traditionally described as arising from a series of rootlets from the medulla oblongata. Descriptions of the number of rootlets vary, and the existence of the crXI is contested. Here we report the results of dissections in six embalmed adult human specimens (11 sides). The rootlets forming the vagus were counted at three positions. At emergence from the brainstem there were between 12 and 21 rootlets, at the jugular foramen the range was 12-17, and midway between these two points it was 6-12. In addition, the origin of the most caudal X rootlet (cX) and the most rostral XI rootlet (rXI) was recorded in relation to the spino-medullary junction, defined as the caudal border of the olivary eminence. The position of the cX varied between -1 and +8 mm (median = +2 mm on left, +3.75 mm on right). The rXI varied between -5 and +7 mm (median = -0.5 mm on left, +1.75 mm on right). In five sides, rXI was above the caudal border of the olivary eminence and as such can be defined as being of cranial origin. These observations show the arrangement of rootlets contributing to the vagus to be more complex than what was described previously and provide evidence for the variable existence of a cranial root of the accessory nerve.

Therapeutic implications of hypertension-induced glomerular injury. Comparison of enalapril and a combination of hydralazine, reserpine, and hydrochlorothiazide in an experimental model

Systemic hypertension does not always reflect concomitant glomerular hypertension. At similar levels of systemic hypertension, glomerular injury occurs only in kidneys that lack protective preglomerular vasoconstriction, which results in glomerular hypertension. indeed, glomerular hypertension and glomerular injury do not develop in rats with spontaneous hypertension that have effective preglomerular vasoconstriction. In the experiments reported herein, the normal adaptive response (afferent arteriolar dilation) to a reduction of one and five-sixths of the renal mass in rats with spontaneous hypertension was examined to ascertain whether that response would expose the remaining nephrons to the injurious effects of high perfusion pressure. In addition, the efficacies of two different antihypertensive regimens were compared. Rats with spontaneous hypertension received either no therapy, or a combination of hydralazine, reserpine, and hydrochlorothiazide, or the angiotensin converting enzyme inhibitor enalapril. Three weeks after ablation of one and five-sixths of the renal mass, blood pressure, glomerular filtration rate, urinary protein excretion, and histologic injury scores for mesangial expansion and glomerulosclerosis were determined. Untreated rats with hypertension had severe glomerulosclerosis and mesangial expansion. Both antihypertensive regimens normalized systemic blood pressure and reduced glomerulosclerosis. However, enalapril was more effective than the combination of hydralazine, reserpine, and hydrochlorothiazide in reducing the exaggerated glomerular filtration rate (0.52 +/- 0.40 versus 0.82 +/- 0.10 ml per minute; p less than 0.05), the injury score for mesangial expansion (79 versus 103; p less than 0.05), and the degree of proteinuria (32 +/- 4 versus 42 +/- 3 mg per 24 hours; p less than 0.05). Persistence of hyperfiltration accompanied by increased mesangial expansion, may lead to progression of glomerular damage despite "adequate" control of systemic hypertension, as observed in rats treated with a combination of hydralazine, reserpine, and hydrochlorothiazide.