Cardiac magnetic resonance characterization and prediction of left ventricular thrombus after ST-segment elevation myocardial infarction

Background

Left ventricular thrombus (LVTh) is an uncommon yet serious complication after ST-segment elevation myocardial infarction (STEMI). Late gadolinium enhancement (LGE) sequences in cardiac magnetic resonance (CMR) imaging allows for accurate detection of LVTh. However, the implications of CMR to predict and characterize LVTh occurrence is this population is unclear.

Purpose

We aim to characterize the incidence, outcomes, and predictors of LVTh after STEMI by CMR imaging.

Methods

Our registry comprised 455 patients admitted for a first reperfused STEMI in our university hospital. Baseline characteristics were recorded. All patients underwent early (1-week) and late (6-month) CMR. Left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were measured. LGE sequences were used to analyze the presence of LVTh. Patients with LVTh at 6-month CMR underwent an additional CMR 1 year after admission. Univariate and multivariate comparisons were performed to study the ocurrence of LVTh in the first 6 months after STEMI.

Results

Mean age was 58.24±11.69 years, most patients were male (82.6%) and anterior infarction occurred in more than half of the cohort (52.7%). LVTh was detected in 36 (7.9%) patients in the first 6 months after STEMI. Anticoagulation was initiated in all cases. Of these, 27 patients had LVTh at early (1-week) CMR, but 9 had LVTh at late (6-month) CMR with no prior evidence of LVTh at early CMR. A total of 6 patients had persisting LVTh at 1-year CMR (37.5% of patients with 6-month LVTh). In multivariable analysis, anterior infarction (HR 6.6 [1.91–22.83], p<0.001) and 1-week CMR-LVEF (HR 0.97 [0.93–0.99], p=0.04) and MVO (HR 1.19 [1.02–1.39], p=0.03) independently predicted the occurrence of LVTh in the first 6 months after STEMI. We computed a risk score of LVTh assigning 1 point to each of these variables (anterior infarction, CMR-LVEF <50% and MVO >3.5 segments), which allowed us to stratify the risk of LVTh in the first 6 months after STEMI (0.6% if 0 points, 3.8% if 1 point, 14.4% if 2 points, and 31.2% if 3 points).

Conclusions

CMR imaging soon after STEMI can contribute relevant prognostic value regarding LVTh occurrence after the acute event. Patients with anterior infarction, LVEF <50% and MVO in >3.5 segments at early (1-week) CMR have the highest risk of LVTh in the first 6 months after STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Clinical benefit of direct oral anticoagulants vs. vitamin-K antagonist in octogenarians with atrial fibrillation

Background

Direct oral anticoagulants (DOACs) have demonstrated to the be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with atrial fibrillation (AF). AF prevalence increases exponentially with age but octogenarians were underrepresented in clinical trials.

Methods

We performed a metanalysis with currently available studies that assessed the effect of DOACS vs. VKA in patients with age ≥80 and AF after performing a systematic search. The primary endpoints analyzed were stroke and all-cause death. Secondary endpoints were major bleeding, according to each study definitions, intracranial bleeding and gastrointestinal (GI) bleeding. The raw numbers of incident end-points reported in each study were used. A random effects model was selected because significant heterogeneity was observed; sensitivity analyses tested potential sources of heterogeneity, publication bias and the small-study effect.

Results

A total of 147,067 patients from 16 studies were included, 71,913 treated with DOACs and 75,154 with VKA. Inclusion criteria for the study was age ≥80 in 13 studies, ≥85 in two and ≥90 in one. Mean age of patients included all the studies was 86.2 (2.6) years. According to the study drug, 34,448 received rivaroxaban; 20,295 apixaban; 14,641 dabigatran, 492 edoxaban and; 2,037 any DOAC. No difference in mean age was observed according to the study drug.

Stroke incidence was available in the 16 studies. DOACs treatment was associated to 28% reduction of stroke (RR: 0.72 95% CI 0.63–0.82; p<0.001) (figure). All-cause mortality could be assessed in 12 studies and DOACs treatment was associated to 18% in mortality (RR: 0.82, 95% CI 0.70–0.96; p=0.012) (figure). DOACs treatment was not associated to reductions in major bleeding (RR: 0.85, 95% CI 0.69–1.04; p=0.108); in contrast, the highest effect of DOACs treatment was a 43% reduction of intracranial bleeding (RR: 0.47, 95% CI 0.36–0.60; p<0.001) (Figure 4). Finally, DOACs treatment was not associated higher of GI bleeding risk (RR: 1.08, 95% CI 0.76–1.53; p=0.678). Metaregression identified inclusion site in North-America (p<0.001), the ELDERCARE-AF results (p=0.023), control arm different than VKA (p=0.006) and the prevalence of hypertension (p=0.042) were outlined as main sources of heterogeneicity for stroke risk reduction. The type of DOAC was the main source of source of heterogeneicity for all-cause mortality (p<0.001) and major bleeding (p=0.03) risk reduction. No small-study effect was found for any endpoint except for intracranial bleeding (Harbor test p=0.029).

Conclusions

Treatment with DOACs in octogenarians reduces the incidence of stroke, all-cause mortality and intracranial bleeding as compared to VKA.

Funding Acknowledgement

Type of funding sources: None.

Downstream testing after exercise ECG stress test – can we predict ischemia on subsequent vasodilator stress cardiac magnetic resonance?

Background

Exercise ECG stress test (ExECG) is useful in the diagnostic work-up of patients with chest pain and known or suspected stable ischemic heart disease (SIHD). However, current guidelines recommend a stress imaging, ischemia-detecting technique such as vasodilator stress cardiac magnetic resonance (vs-CMR) if available. Whether clinical and ExECG variables can predict ischemia on subsequent vs-CMR testing is unknown.

Material and methods

We retrospectively included 289 patients who underwent an ExECG and a subsequent vs-CMR in the year after this test and who didn't undergo a revascularization procedure in this time frame. Clinical, ExECG and vs-CMR variables were included in the registry. vs-CMR was considered positive if ischemia was evident in at least one myocardial segment on stress first-pass perfusion without concomitant necrosis on late gadolinium enhancement imaging. We performed univariate and multivariate analysis to check for the association of variables with the risk of ischemia on vs-CMR.

Results

Mean time from ExECG to vs-CMR was 97,27±88,31 days and 91 vs-CMR were positive for ischemia. Age, male sex, diabetes mellitus, hypertension, dyslipidaemia and personal history of ischemic heart disease, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were predictors of ischemia on vs-CMR in the univariate analysis. On ExECG, time of exercise, exercise capacity, chest pain during ExECG, maximum heart rate (HR) and systolic blood pressure (SBP), % of predicted HR, chronotropic reserve index, maximum and reserve of double product and Duke Treadmill Score were also associated with ischemia on vs-CMR. However, the only independent predictors on multivariate binary logistic regression stepwise analysis were history of PCI (HR 3.79 [2.03–7.09], p<0.001) or CABG (HR 5.57 [1.80–17.26], p=0.003), maximum double product (HR 0.94 [0.90–0.99] per 1000 increase, p=0.02) and Duke Treadmill Score (HR 0.95 [0.91–0.99], p=0.019). Subgroup analysis showed that male sex (HR 1.95 [1.16–3.28], p=0.012), history of ischemic heart disease (HR 4.73 [2.88–7.76], p<0.001) and maximum double product (HR 0.94 [0.90–0.98] per 1000 increase, p=0.006) were predictors of ischemia on vs-CMR in non-revascularized patients (n=212). In revascularized patients (n=77) the only independent predictor was the Duke Treadmill Score on ExECG (HR 0.93 [0.86–0.99], p=0.048).

Conclusions

Several ExECG variables, namely Duke Treadmill Score and parameters of myocardial oxygen consumption such as maximum doble product, can predict the risk of ischemia on subsequent vs-CMR in revascularized and non-revascularized patients with chest pain. This can help select patients who should undergo vs-CMR afeter ExECG for ischemia detection.

Funding Acknowledgement

Type of funding sources: None.

Exercise ECG testing in patients without known ischemic heart disease: predictors of ischemia of downstream vasodilator stress cardiac magnetic resonance

Background

In routine clinical practice, patients with chest pain and suspected stable ischemic heart disease (SIHD) usually undergo an exercise ECG stress test (ExECG) for ischemia detection. However, since the sensitivity of this technique is relatively low, concerns exist that many patients could remain underdiagnosed. We intend to assess the clinical and ExECG predictors of ischemia on subsequent vasodilator stress cardiac magnetic resonance (vs-CMR) to help select which patients should undergo downstream testing after an initial ExECG.

Material and methods

We retrospectively included 197 patients without previous history of ischemic heart disease who underwent an ExECG and a subsequent vs-CMR in the year after this test and who didn't undergo a revascularization procedure in this time frame. Clinical, ExECG and vs-CMR variables were included in the registry. vs-CMR was considered positive if ischemia was evident in at least one myocardial segment on stress first-pass perfusion without concomitant necrosis on late gadolinium enhancement imaging. We performed univariate and multivariate analysis to check for the association of variables with the risk of ischemia on vs-CMR.

Results

Mean time from ExECG to vs-CMR was 88.69±84.32 days and 37 vs-CMR were positive for ischemia. Male sex, less exercise time, less % of maximum predicted exercise capacity, less maximum double product (heart rate x systolic blood pressure) and less double product reserve (DPR = maximum double product - basal double product) were associated with ischemia on vs-CMR on univariate analyses. However, the only independent predictors of ischemia on vs-CMR on multivariate binary logistic regression were male sex (HR 2.62 [CI 95%: 1.13–5.76], p=0.016) and less DPR (HR 0.90 [CI 95%: 0.84–0.97] per 1000 increase, p=0.006). The risk score derived from these two variables had a moderate predictive power (ROC curves, AUC 0.657, p=0.003). The best cut-off point for the DPR was 12400, as derived from the Youden index. It allowed stratification of the risk of ischemia on vs-CMR, which ranged from 9% in women with >12400 DPR, 18.8% in men with >12400 DPR, 24.1% in women with ≤12400 DPR to 42.9% in men with ≤12400 DPR (p=0.005, Figure 1).

Conclusions

Male sex and less double product reserve on ExECG can moderately predict the risk of ischemia on subsequent vs-CMR in patients presenting with chest pain and without previous SIHD. This can help select patients who benefit most from vs-CMR for diagnostic purposes.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Clinical applicability of echocardiographic strict negative criteria for suspected infective endocarditis

Introduction

Infective endocarditis (IE) is an uncommon but potentially lethal disease that requires a timely diagnosis. Echocardiography has a pivotal role in EI diagnosis, but this may lead to an overuse of this technology in clinical daily practice, and it is unclear which patients can benefit from a follow-up study if the initial transthoracic echocardiogram (TTE) shows no signs of IE. The strict negative criteria (good ultrasound quality and no high-risk features such as significant valvular regurgitations or stenosis, pericardial effusion or intracardiac devices) have been recently proposed to avoid unnecessary follow-up echocardiograms.

Purpose

The objective of this study is to review the contemporary, real-world use of echocardiography in patients with suspected IE and analyze the potential applicability of the strict negative criteria.

Methods

We retrieved all the echocardiograms that were performed in our center for suspected or confirmed IE between January 2014 and December 2018. We defined different groups according to the strict negative criteria and reviewed the electronic clinical history to check if a definitive diagnosis of IE was established or not.

Results

We included a total of 905 TTEs. 451 (49.8%) of them fulfilled the strict negativity criteria (Group 1). In this group, IE was seldom diagnosed (n=4, 0.9%). In 338 (37.4%) patients no signs of IE were evident but they didn't fulfill the strict negative criteria (Group 2). A follow-up echocardiogram and definitive diagnosis of IE were more frequent (n=48, 14.2% and n=20, 5.9%). Finally, in 116 (12.8%) patients the initial TEE showed typical or suggestive signs of IE, in whom the diagnosis was confirmed in 48 (41.4%). The independent predictors of follow-up echocardiography were the previous history of valvular heart disease (HR 2.38 [1.39–3.89], p=0.001) or cancer (HR 0.47 [0.27–0.84], p=0.01), positive blood cultures for Enterococcus (HR 5.01 [2.34–10.73], p<0.001), methicillin-sensitive Staphylococcus aureus (HR 2.8 [1.27–6.17], p=0.011) or Streptococcus (HR 2.36 [1.12–5], p=0.024), and the presence of typical or suggestive signs of infective endocarditis on initial TTE (HR 13.77 [8.6–22.05], p<0.001). A definitive diagnosis of IE was confirmed in a minority of the study population (n=72, 8%). Only one readmission for underdiagnosis of IE during index hospitalization was noted on Group 2.

Conclusions

In a real-life, observational setting only a minority of patients in whom IE was suspected had a definite diagnosis. An initial TTE for suspected IE fulfilling the strict negative criteria predicts both a low probability of requesting a follow-up study and of a definitive diagnosis of IE. Further research should be performed to rationalize echocardiogram requests for suspected IE.

Funding Acknowledgement

Type of funding sources: None.

Residual ST-segment elevation at pre-discharge ECG after STEMI: association with long-term prognosis and structural consequences at 6-month CMR

Introduction

Residual ST-segment elevation after ST-segment elevation myocardial infarction (STEMI) has been traditionally interpreted as a predictor of left ventricular dysfunction and ventricular aneurism. More recently, it has also been associated with more severe structural consequences in cardiac magnetic resonance (CMR) performed soon after STEMI. However, the implications in terms of long-term prognosis of patients and structural consequences in CMR performed late after STEMI are unclear.

Methods

Data was obtained from a prospective registry of reperfused STEMI patients. At pre-discharge ECG, sum and maximum ST-segment elevation (mm), ST-segment resolution (%) and the number of Q-leads with residual ST-segment elevation >1 mm (Q-STE) were assessed. 6-month CMR parameters were quantified: left ventricular ejection fraction (LVEF, %), left ventricular end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI, mL/m2), infarct size (IS, % left ventricular mass) and microvascular obstruction (MVO, % left ventricular mass). The primary end-point was major adverse cardiac events (MACE), defined as all-cause death and/or re-admission for acute heart failure, whichever occurred first.

Results

488 patients were included. Mean age was 58±12 years, 80.3% were males and smoking was the most prevalent cardiovascular risk factor. During a 7-year mean and median follow-up, 92 MACE were registered (19%), 39 all-cause deaths and 53 re-admission for acute heart failure. Q-STE >1 lead was detected in 172 patients (35%) and it was the most potent ECG predictor of MACE (26% vs 15%, p=0.002). Q-STE was also associated with structural changes at 6-month CMR: larger LVEDVI (87,39±27,47 mL/m2 vs 74,31±24,13 mL/m2) and LVESVI (45,45±25,24 mL/m2 vs 32,53±20,85 mL/m2), less LVEF (50,48±13,95% vs 58,75±12,3%) and larger infarct size (24,91±11,6% vs 14,38±11,41%) (p<0.001 for all comparisons, Figure 1). After adjustment for baseline and ECG characteristics, Q-STE (per lead with >1 mm) was independently associated with a higher risk of long-term MACE (HR 1.24 [CI 95%: 1.09–1.40], p=0.001), depressed (<40%) LVEF (HR 1.26 [CI 95%: 1.02–1.56], p=0.03) and large (>30% left ventricular mass) infarct size (HR 1.34 [CI 95%: 1.08–1.67], p=0.008) at 6-month CMR. Survival free from MACE was lower in patients with >1 lead Q-STE (log-rank=9.07, p=0.003) (Figure 2).

Conclusions

Residual ST-segment elevation after STEMI represents a widely available predictor of adverse long-term prognosis and late CMR-derived left ventricular remodelling. It could contribute to select patients who would benefit of close monitoring.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Fondos Europeos de Desarrollo Regional FEDERInstituto de Salud Carlos III Figure 1. Structural changes at 6-month CMRFigure 2. Survival free from MACE

Stress cardiovascular magnetic resonance and mortality in a registry of 2496 elderly patients with chronic coronary syndrome. Prognosis and decision-making

Funding Acknowledgements

Type of funding sources: None.

Background. In recent guidelines, non-invasive imaging techniques play a pivotal role in the management of chronic coronary syndrome (CCS). The elderly represent a large percentage of our routine CCS population and risk stratification in this scenario is challenging. The potential of vasodilator stress cardiovascular magnetic resonance (CMR) for this purpose is unknown.

Purpose. We explore the prognostic value and the usefulness for decision-making of the ischemic burden determined by vasodilator stress CMR imaging in a large cohort of elderly patients with known or suspected CCS.

Methods. The study group was made up of 2496 patients older than 70 years submitted to vasodilator stress CMR for known or suspected CCS in our health department from 2001 to 2016 (mean age 76 ± 4 years, 52% male). Clinical and vasodilator stress CMR characteristics were prospectively recorded. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Its association with all-cause mortality and the effect of vasodilator stress CMR-guided revascularization (within the following 3 months) were analyzed retrospectively.

Results. During a median follow-up of 4.58 years, 430 deaths (17.2%) were recorded. A larger ischemic burden was an independent predictor of mortality: hazard ratio [95% confidence intervals]: 1.04 [1.01-1.07] for each additional ischemic segment, p = 0.006). This association also occurred in patients over 80 years of age and in women (p < 0.001). Compared to non-revascularized patients, revascularization associated with worse outcomes at low ischemic burden and exerted protective prognostic effect in patients with extensive ischemia both in the whole group (p for interaction = 0.003) and in 496 patients matched 1:1 by a propensity score (p = 0.06).

Conclusions. Vasodilator stress CMR represents a valuable tool to stratify risk in elderly patients with known or suspected CCS and might be helpful to guide decision-making in this scenario.

Abstract Figure 1

Prognostic value of vasodilator stress CMR in elderly patients with known or suspected chronic coronary syndrome

Background

In recent guidelines, non-invasive imaging techniques play a pivotal role in the management of chronic coronary syndrome (CCS). The elderly represent a large percentage of our routine CCS population and risk stratification in this scenario is challenging. The potential of vasodilator stress cardiovascular magnetic resonance (vs-CMR) for this purpose is unknown.

Purpose

We explored the prognostic value of the ischemic burden, as derived from vs-CMR, in elderly patients with known or suspected CCS.

Methods

From the general cohort of 6389 patients with known or suspected CCS submitted to undergo vs-CMR in our health department from 2001 to 2016, we performed a subanalysis of the 1225 patients >70 year-old (mean age 77±5 years, 51% male). Clinical and vs-CMR characteristics were prospectively recorded. The ischemic burden (at stress first-pass perfusion imaging) was computed (using the 17-segment model). The occurrence of major adverse cardiac events (MACE) defined as all-cause death and/or non-fatal myocardial infarction (whichever occurred first) was retrospectively revised using the electronic regional health system registry.

Results

During a median follow-up of 2.7 years, 203 MACEs were registered (17%). Age (77±4 vs. 76±5 years) was not significantly different in patients with and without MACE. Larger left ventricular (LV) end-diastolic and end-systolic volume indexes, more depressed LV ejection fraction, more extensive areas with late gadolinium enhancement and ischemic burden were detected in patients with MACE (p<0.001 for all comparisons). In non-revascularized patients (n=1118), the MACE rate ranged from 13% (in patients with 0–1 ischemic segments) to 35% (in those with >8 ischemic segments, p<0.001 for the trend). In the small subset of revascularized patients (n=107), revascularization exerted a non-significant protective effect only in patients with extensive ischemic burden (>5 segments).

Conclusions

Vasodilator stress CMR represents a valuable tool to stratify risk in elderly patients with known or suspected CCS and might be helpful to guide decision-making.

Figure 1

Funding Acknowledgement

Type of funding source: None

A novel clinical and stress cardiac magnetic resonance score to predict long-term all-cause mortality in patients with known or suspected chronic coronary syndrome

Background

Vasodilator stress cardiac magnetic resonance (stressCMR) has shown robust diagnostic and prognostic value in patients with known or suspected chronic coronary syndrome (CCS). However, it is unknown whether integration of several prognostic stressCMR parameters, such as the ischemic burden (number of segments with first-pass stress-induced perfusion defects -PD-) and left ventricular ejection fraction (LVEF), with clinical variables can improve risk prediction in this population.

Purpose

We aim to explore the usefulness of a clinical-stressCMR score to predict the risk of all-cause mortality in patients with known or suspected CCS submitted to undergo a stressCMR.

Methods

We included 6187 patients in a large prospective multicenter registry (mean age 65.18±11.51 years, 37.3% female) which underwent stressCMR for known or suspected CCS. Several clinical and stressCMR variables were collected, such as LVEF, end-diastolic and end-systolic volume indices, ischemic burden and segments with necrosis (with late gadolinium enhancement imaging).

Results

During a mean and median follow-up of 5.85±3.82 years we registered 682 (11%) all-cause deaths. Several clinical and all stressCMR variables were associated with all-cause mortality in univariate analysis. However, the only independent predictors of all-cause mortality in multivariate analysis were age (HR 1.07 [1.06–1.08] per year, p<0.001), male sex (HR 1.36 [1.15–1.61], p<0.001), diabetes mellitus (HR 1.6 [1.37–1.87], p<0.001), LVEF (0.98 [0.97–0.98] per %, p<0.001) and ischemic burden (HR 1.04 [1.02–1.06] per segment with stress-induced PD, p=0.001). By means of the chi-square increase at each step of the stepwise multiparametric Cox regression we created a clinical-stressCMR score that included these variables (age, male sex, diabetes mellitus, LVEF and ischemic burden) kept in their continuous state if possible. This score showed a good performance to predict all-cause mortality (area under the curve = 0.716 [0.697–0.735], p<0.001). Dividing the population into quintiles according to the clinical-stressCMR score allowed for a stratification of the annualized risk of all-cause mortality (0.39%/year, 0.94%/year, 1.62%/year, 2.63%/year and 3.83%/year, respectively; log-rank 420.33 and p<0.001 for Kaplan-meier curves).

Conclusions

A novel clinical-stressCMR, which includes clinical (age, male sex, and diabetes mellitus) and stressCMR (LVEF and ischemic burden) variables, can provide robust prediction and stratification of the risk of all-cause mortality in a population of patients with know or suspected CCS.

Figure 1. Clinical-stress CMR score

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and by Generalitat Valenciana (GV/2018/116).

Echocardiographic strict negative criteria for suspected infective endocarditis. Can we avoid unnecessary echocardiograms?

Background

Infective endocarditis (IE) is an uncommon but potentially lethal disease that require a timely diagnosis. Transthoracic echocardiography (TTE) has a pivotal role in diagnosis and follow-up and should be requested if there is a clinical suspicion of IE. However, it is unclear which patients can benefit from a follow-up echocardiogram if the initial TTE shows no signs of IE. The strict negative criteria (SNC) have been recently proposed to avoid unnecessary follow-up echocardiograms.

Purpose

The objective of this study is to review the contemporary, real-world use of echocardiography in patients with suspected IE and analyze the possible effect that incorporating the SNC would have in our clinical practice.

Methods

We searched the echocardiography database for the words “endoc” and “veget” to find the tests that were performed for suspected or confirmed IE between January 2014 and December 2018. We extracted and manually reviewed all the echocardiographic data and applied the SNC to patients with an initial negative TTE. We reviewed the electronic clinical history to check if a final diagnosis of IE was established or not.

Results

We included a total of 957 echocardiograms in our registry. 493 (51.5%) did not meet the SNC. The main reasons for exclusion were the occurrence of more than mild valvular regurgitation (n=293, 30.6%), the presence of typical or suggestive signs of IE (n=128, 13.3%), the evidence of more than mild valvular stenosis or sclerosis (n=105, 10.9%) and a suboptimal ultrasound quality (n=90, 9.4%). Globally, a follow-up echocardiogram was performed in 143 (14.9%) patients. Only in 25 (5.4%) of patients which fulfilled the SNC a follow-up echocardiogram was requested, compared to 60 (16%) patients which neither fulfilled the SNC nor showed echocardiographic signs of IE and 68 (53.5%) patients in which the SNC weren't met but showed echocardiographic signs of IE (p<0.001). After performing a binary logistic regression model, the only independent predictor of follow-up echocardiography in patients who didn't met the SNC was the presence of typical or suggestive signs of infective endocarditis on initial TTE (HR 2.84 [2.17–3.71], p<0.001).

Conclusions

1. In a real-life, observational setting an initial TTE for suspected IE that fulfilled the defined SNC predicts a low probability of requesting a follow-up echocardiography (5.4%), even though these criteria were neither reported by the echocardiographist nor probably known by the clinician in charge of the patient.

2. The number of echocardiograms avoided by applying these criteria in this context is low.

3. A follow-up echocardiogram was requested more frequently if the SNC weren't met, especially when typical or suggestive signs of IE were described in the initial TTE (53.5% vs 16%). This factor seems to be the only independent echocardiographic variable that predicts the probability of requesting a follow-up echocardiogram in this subgroup of patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Chest pain of unknown coronary origin: can exercise ECG testing contribute to long-term risk prediction on top of vasodilator stress cardiac magnetic resonance?

Background

The prognostic value of both exercise ECG testing (ExECG) and vasodilator stress cardiac magnetic resonance (VS-CMR) is well-known in patients with chest pain of unknown coronary origin. However, it is unknown whether performing both techniques can improve the risk stratification of these patients.

Purpose

We aim to confirm the additive prognostic value of ExECG and VS-CMR in a real-world cohort of patients with chest pain of unknown coronary origin.

Methods

We retrospectively included 288 patients in which ExECG and VS-CMR had been subsequently performed within one year. Clinical, ExECG and VS-CMR variables were registered. We performed univariate and multivariate analysis to check for the association of variables with the risk of MACE, defined as a combined endpoint of acute coronary syndrome (ACS), admission for heart failure (aHF) or all-cause death.

Results

During a mean follow-up of 4.2±2.15 years, we registered 27 MACE (15 ACS, 8 aHF and 8 all-cause deaths). The history of hypertension, previous coronary artery disease and/or coronary artery bypass grafting, lower maximal heart rate during ExECG (maxHR) and more extensive ischemic burden (segments with perfusion defects -PD- on stress first-pass perfusion) and myocardial necrosis (number of segments with necrosis at late gadolinium enhancement imaging) associated with the MACE endpoint. However, the only independent predictors of MACE were maxHR during ExECG (HR 0.98 [0.96–0.99], p=0.01) and more extensive segments with PD in the VS-CMR (HR 1.2 [1.07–1.34], p=0.002). We identified the best cut-off using the Youden index derived from receiver operating characteristics (ROC) analysis to predict MACE - it was ≤130bpm for maxHR during ExECG and ≥2 segments with PD on VS-CMR. These cathegories allowed us to stratify the annualized rate of MACE, which was very low (0.97%/year) in patients with normal maxHR and no PD on VS-CMR, intermediate in patients with only abnormal maxHR (1.98%/year) or PD on VS-CMR (3.24%/year) and high in patients with both abnormal maxHR and segments with PD (6.26%/year). Adding maxHR to the multivariable model including stress-induced PD by VS-CMR significantly improved the predictive power of MACE as derived from the continuous reclassification improvement index (0.47 [0.10–0.81], p<0.05).

Conclusions

ExECG and VS-CMR can have an additive prognostic value to predict the long-term risk of MACE in patients with chest pain of unknown coronary origin. Patients with maxHR during ExECG ≤130bpm and ≥2 segments with PD on VS-CMR are at the highest risk of MACE.

Figure 1. MACE risk stratification.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and by Generalitat Valenciana (GV/2018/116).

Impact of the dynamics of ejection fraction on risk stratification in a large multicenter registry of STEMI patients using sequential CMR

Background

Left ventricular ejection fraction (LVEF) has traditionally been used as the cornerstone for risk stratification after ST-segment elevation myocardial infarction (STEMI) and it can be accurately quantified by cine cardiovascular magnetic resonance (CMR). In recent years, the additional prognostic value of contrast CMR-derived infarct size (IS) and microvascular obstruction (MVO) has been demonstrated.

Purpose

We explored the impact of sequential assessment of CMR-derived LVEF on dynamic risk stratification after STEMI.

Methods

Data were obtained from three prospective registries of reperfused STEMI patients (n=1036) in whom LVEF, IS and MVO were sequentially quantified by CMR (at least at 1 week and at 6 months). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (HF), whichever occurred first. Late events were regarded as those occurring after the 6-month CMR.

Results

During a mean and median follow-up of 5 years, 105 first MACE (10%, 36 deaths and 69 HF) and 82 late MACE (8%, 35 deaths and 47 HF) were registered. From 1-week to 6-month CMR, LVEF improved (49±12 vs. 53±12%), IS decreased (21±14 vs 17±12% of LV mass) and MVO vanished (1.3±1.9 vs. 0.1±0.7% of LV mass), p<0.001 for all comparisons. At 1-week CMR, 207 patients (20%) displayed reduced LVEF (r-LVEF, <40%), 328 (32%) mid-range LVEF (mr-LVEF, 40–50%) and 501 (48%) preserved LVEF (p-LVEF, >50%). At 6-month CMR, 144 patients (14%) displayed r-LVEF, 247 (24%) mr-LVEF and 645 (62%) p-LVEF. The total MACE rate was higher (p<0.001) only in patients with r-LVEF at 1 week (22%) vs. 7% in those with mr-LVEF and 7% in those with p-LVEF. Similarly, the late MACE rate was higher (p<0.001) only in patients with r-LVEF at 6 months (20%) vs. 7% in those with mr-LVEF and 5% in those with p-LVEF. The late MACE rate was very low in patients with sustained mr- or p-LVEF (41/794, 5%), intermediate in those with improved LVEF from r-LVEF at 1 week to mr- or p-LVEF at 6 months (12/98, 12%) and high in patients with sustained r-LVEF (22/109, 20%) or worsened LVEF from mr- or p-LVEF at 1 week to r-LVEF at 6 months (7/35, 20%), p<0.001 for the trend. Using a Markov approach, only r-LVEF (at any time assessed) significantly related to a higher MACE rate.

Conclusions

Of available CMR parameters, LVEF persists as the pivotal index for simple post-STEMI risk stratification. Mid-range or preserved LVEF in acute phase associates with excellent long-term outcome. Changes in LVEF provide valuable dynamic prognostic information. Maintenance of mid-range or preserved LVEF in chronic phase occurs in the majority of patients and associates with a very low risk of late clinical events. Whereas late improvement reaching at least mid-range LVEF exerts salutary effects, detection of reduced LVEF at this point identifies the small subset of patients at high risk in the long term.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants).

Risk stratification in patients discharged for STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance

Background

CMR permits robust risk stratification of discharged STEMI patients but an indiscriminate use in all cases is unfeasible.

Purpose

We evaluated the usefulness of left ventricular ejection fraction (LVEF) by echocardiography (Echo) as the gatekeeper for identifying those patients discharged for ST-segment elevation myocardial infarction (STEMI) who benefit most from cardiac magnetic resonance (CMR) for prognostic purposes.

Methods

Echo and CMR were performed in 1119 patients discharged for STEMI included in a multicenter registry. The prognostic power of CMR beyond Echo-LVEF was assessed using C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

Results

During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 re-admissions for acute heart failure). Lesser Echo-LVEF and CMR-LVEF associated with the occurrence of MACE but only CMR-LVEF and microvascular obstruction were independent predictors. The MACE rate significantly increased only in patients with CMR-LVEF <40% (≥50%: 7%, 40–49%: 9%, <40%: 27%, p<0.001). The majority of patients (629, 56%) displayed Echo-LVEF ≥50% and most of them (94%) were at the “safe zone” (CMR-LVEF >40%). On the other hand, 490 patients (44%) exhibited Echo-LVEF <50% and 33% of them were incorrectly classified either in the “safe zone” (CMR-LVEF ≥40%) or in the “risk zone” (CMR-LVEF <40%). C-statistic, NRI and IDI demonstrated potent reclassification for MACE prediction by CMR in patients with Echo-LVEF <50% but not in those with Echo-LVEF ≥50%.

Conclusions

Echo-LVEF <50% identifies the subset of discharged STEMI patients who may benefit most from CMR in terms of long-term risk prediction.

Figure 1. LVEF reclassification

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants).

Implication of anti-angiogenic VEGF-A165b in angiogenesis and systolic function after reperfused myocardial infarction

Background

Angiogenesis participates in re-establishing microcirculation after myocardial infarction (MI).

Purpose

In this study, we aim to further understand the role of the anti-angiogenic isoform vascular endothelial growth factor (VEGF)-A165b after MI and explore its potential as a co-adjuvant therapy to coronary reperfusion.

Methods

Two mice MI models were formed: 1) permanent coronary ligation (non-reperfused MI), 2) transient 45-min coronary occlusion followed by reperfusion (reperfused MI); in both models, animals underwent echocardiography before euthanasia at day 21 after MI induction. Serum and myocardial VEGF-A165b levels were determined. In both experimental MI models, functional and structural implication of VEGF-A165b blockade was assessed. In a cohort of 104 ST-segment elevation MI patients, circulating VEGF-A165b levels were correlated with cardiovascular magnetic resonance-derived left ventricular ejection fraction at 6-months and with the occurrence of adverse events (death, heart failure and/or re-infarction).

Results

In both models, circulating and myocardial VEGF-A165b presence was increased 21 days after MI induction. Serum VEGF-A165b levels inversely correlated with systolic function evaluated by echocardiography. VEGF-A165b blockage increased capillary density, reduced infarct size, and enhanced left ventricular function in reperfused, but not in non-reperfused MI experiments. In patients, higher VEGF-A165b levels correlated with depressed ejection fraction and worse outcomes.

Conclusions

In experimental and clinical studies, higher serum VEGF-A165b levels associates with a worse systolic function. Its blockage enhances neoangiogenesis, reduces infarct size, and increases ejection fraction in reperfused, but not in non-reperfused MI experiments. Therefore, VEGF-A165b neutralization represents a potential co-adjuvant therapy to coronary reperfusion.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (Exp. PIE15/00013, PI17/01836, PI18/00209 and CIBERCV16/11/00486).

Impact of Diabetes Mellitus and Frailty on Long-Term Outcomes in Elderly Patients with Acute Coronary Syndromes

OBJECTIVES

Diabetes mellitus (DM) and frailty are common in older patients with acute coronary syndromes (ACS). No data exists about its prognostic impact on long-term outcomes and their possible interaction in this setting.

DESIGN

Observational prospective study.

SETTING

Multicenter registry conducted in 44 hospitals in Spain.

PARTICIPANTS

Consecutive patients with ACS aged 80≥years.

MEASUREMENTS

A comprehensive geriatric evaluation was performed during hospitalization, including frailty assessment by the FRAIL score. The impact of DM and frailty on the incidence of mortality/readmission at 24 months was analysed by a Cox regression model.

RESULTS

A total of 498 patients were included (mean age 84.3 years). Prevalence of previous DM was 199/498 (40.0%). The rate of frail patients was 135/498 (27.1%). The incidence of mortality/readmission was higher frail patients (HR 2.49) (both p<0.001). In contrast, DM was not significantly associated to a higher rate of outcomes (HR 1.23, p=0.060) in the whole cohort. Among non-frail patients, patients with DM had a similar incidence of mortality or readmission (p=0.959). In contrast, among frail patients, DM was significantly associated with a higher incidence of events (HR 1.51, p=0.034).

CONCLUSIONS

Unlike frailty status, DM was not associated to poorer long-term outcome in elderly patients with ACS. Among frail patients the presence of DM seems to provide additional prognostic information.

P1475Risk stratification after STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance

Introduction

Cardiac magnetic resonance (CMR) has emerged as the most potent non-invasive imaging technique for risk stratification after ST-segment elevation myocardial infarction (STEMI) but an indiscriminate use in all patients is unfeasible. Echocardiography (Echo) has been universally used for prognostication in this scenario. We hypothesized that left ventricular ejection fraction (LVEF) by Echo can represent the gatekeeper for selecting those patients who benefit most from CMR for prognostic purposes.

Methods

Data were obtained from a large prospective registry of reperfused STEMI patients (n=516) in whom Echo (2D and Doppler variables) and CMR (cine images, microvascular obstruction and infarct size) were simultaneously recorded at pre-discharge (7±2 days). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (whichever occurred first). Patients were categorized in reduced LVEF (r-LVEF, <40%), mid-range LVEF (mr-LVEF, 40–49%) and preserved LVEF (p-LVEF, ≥50%). Hierarchical multivariate Cox regression analyses including first clinical+Echo variables and then CMR variables where carried out. C-statistics, “net reclassification” (NRI) and “integrated discrimination” (IDI) indexes were obtained.

Results

During a mean and median follow-up of 4 years, 86 first MACE (17%) were registered (39 deaths and 47 re-admissions for acute heart failure). In the whole study group (n=516), the independent predictors of MACE were time to revascularization (min), GRACE score, CMR-LVEF (%) and CMR-microvascular obstruction (% of LV mass); C-statistic 0.82 (p<0.001). The MACE rate in patients with r-LVEF, mr-LVEF and p-LVEF was 47%, 23% and 11% by Echo-LVEF and 45%, 17% and 8% by CMR-LVEF. LVEF was lower by CMR than by Echo (51±13 vs. 54±10, p<0.001) and r-LVEF was more frequently detected by CMR (n=94, 18%) than by Echo (n=48, 9%), p<0.001. CMR significantly improved clinical+Echo stratification in those 112 patients (22%) with mr-Echo-LVEF (C-statistitics 0.74 vs 0.82; NRI and IDI: p<0.05) but it did not in those 355 patients (69%) with p-Echo-LVEF (C-statistitics 0.75 vs 0.76; NRI and IDI: non-significant) and in those 49 patients (9%) with r-Echo-LVEF (C-statistitics 0.77 vs 0.77; NRI and IDI: non-significant).

Figure 1. Risk stratification after STEMI

Conclusions

Applied in an individualized manner, Echo-LVEF appears as a useful gatekeeper for a selective use of CMR soon after STEMI for prognostic purposes. The event rate is high in patients with reduced Echo-LVEF and low in those with preserved Echo-LVEF; CMR does not seem to significantly improve risk stratification in these scenarios. Nevertheless, the occurrence of mid-range Echo-LVEF permits discriminating the specific subset of STEMI patients (less than a quarter) who really benefit from pre-discharge CMR in terms of risk assessment.

Acknowledgement/Funding

Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).

5877Comorbidity assessment for mortality risk stratification in elderly patients with acute coronary syndrome

Background

The Charlson's is the most used comorbidity index. It comprises 19 comorbidities, some of which are infrequent in elderly patients with acute coronary syndrome (ACS), while some others are manifestations of cardiac disease rather than comorbidities.

Purpose

Our goal was to simplify comorbidity assessment in elderly non-ST-segment elevation ACS patients.

Methods

The study group consisted of 1 training (n=920, 76±7 years) and 1 testing (n=532; 84±4 years) cohorts. The end-point was all-cause mortality at 1-year follow-up. Comorbidities were assessed selecting those medical disorders other than cardiac disease that were independently associated with mortality by multivariable analysis.

Results

A total of 130 (14%) patients died in the training cohort. Six comorbidities were predictive: renal failure, anemia, diabetes, peripheral artery disease, cerebrovascular disease and chronic lung disease. The increase in the number of comorbidities yielded a gradient of risk on top of well-known clinical predictors: ≥3 comorbidities (27% mortality, HR=1.90, 95% CI 1.20–3.03, p=0.006); 2 comorbidities (16% mortality, HR=1.29, 95% CI 0.81–2.04, p=0.30); and 0–1 comorbidities (7.6% mortality, reference category). The discrimination accuracy (C-statistic= 0.80) and calibration (Hosmer-Lemeshow test, p=0.20) of the predictive model using the 6 comorbidities was comparable to the predictive model using the Charlson index (C-statistic=0.80; Hosmer-Lemeshow test, p=0.70). Similar results were reproduced in the testing cohort (≥3 comorbidities: 24% mortality, HR=2.37, 95% CI 1.25–4.49, p=0.008; 2 comorbidities: 14% mortality, HR=1.59, 95% CI 0.82–3.07, p=0.20; 0–1 comorbidities: 7.5% reference category).

Kaplan-Meyer curves for mortality

Conclusion

A simplified comorbidity assessment comprising 6 comorbidities provides useful risk stratification in elderly patients with ACS

Acknowledgement/Funding

This work was supported by grants from Spain's Ministry of Economy and Competitiveness through the Carlos III Health Institute

Position statement for the management of comorbidities in psoriasis

BACKGROUND

The association between psoriasis and some diseases has become relevant in recent years. Providing appropriate management of psoriasis from an early stage requires prompt diagnosis and treatment of concomitant diseases and to prevent any potential comorbidity. This approach should consider the adverse events of the drugs used to treat psoriasis potentially related to the onset of comorbidities.

OBJECTIVE

To provide the dermatologist with an accurate and friendly tool for systematizing the diagnosis of psoriasis-associated comorbidities, which generally escapes the scope of the dermatology setting, and to facilitate decision-making about the referral and treatment of patients with comorbidities.

METHODS

These position statement recommendations were developed by a working group composed of ten experts (four dermatologists, one cardiologist, one rheumatologist, one gastroenterologist, one nephrologist, one endocrinologist and one psychiatrist) and two health services researchers. The expert group selected the psoriasis comorbidities considered according to their relevance in the dermatology setting. The recommendations on diagnostic criteria are based on the current clinical practice guidelines for each of the comorbidities. The information regarding the repercussion of psoriasis medical treatments on associated comorbid diseases was obtained from the summary of product characteristics of each drug.

RESULTS

Recommendations were developed to detect and refer the following psoriasis comorbidities: psoriatic arthritis, cardiovascular risk factors (diabetes, dyslipidaemia, obesity, hypertension and metabolic syndrome), non-alcoholic fatty liver disease, inflammatory bowel disease, kidney disease and psychological disorders (anxiety and depression). In addition, alcohol consumption and tobacco consumption were included. The tables and figures are precise, easy-to-use tools to systematize the diagnosis of comorbidities in patients with psoriasis and facilitate the decision-making process regarding referral and treatment of patients with an associated disease.

CONCLUSION

The application of these position statement recommendations will facilitate the dermatologist practice, and benefit psoriasis patients' health and quality of life.