Candidacy and long-term outcomes of subcutaneous implantable cardioverter-defibrillators in current practice in patients with hypertrophic cardiomyopathy

BACKGROUND

In patients with Hypertrophic Cardiomyopathy (HCM) S-ICD is usually the preferred option as pacing is generally not indicated. However, limited data are available on its current practice adoption and long-term follow-up.

METHODS

Consecutive HCM patients with S-ICD implanted between 2013 and 2021 in 3 international centers were enrolled in this observational study. Baseline, procedural and follow-up data were regularly collected. Efficacy and safety were compared with a cohort of HCM patients implanted with a tv-ICD.

RESULTS

Seventy patients (64% males) were implanted with S-ICD at 41 ± 15 years, whereas 168 patients with tv-ICD at 49 ± 16 years. For S-ICD patients, mean ESC SCD risk score was 4,5 ± 1.9%: 25 (40%) at low-risk, 17 (27%) at intermediate and 20 (33%) at high-risk. Patients were followed-up for 5.1 ± 2.3 years. Two patients (0.6 per 100-person-years, vs 0.4 per 100 person-years with tv-ICD, p = 0.45) received an appropriate shock on VF, 17 (24%) were diagnosed with de-novo AF. Inappropriate shocks occurred in 4 patients (1.2 per 100-person-years, vs 0.9 per 100 person-years with tv-ICD, p = 0.74), all before Smart-Pass algorithm implementation. Four patients experienced device-related adverse events (1.2 per 100-person-years, vs 1 per 100 person-years with tv-ICD, p = 0.35%).

CONCLUSIONS

S-ICDs were often implanted in patients with an overall low-intermediate ESC SCD risk, reflecting both the inclusion of additional risk markers and a lower decision threshold. S-ICDs in HCM patients followed for over 5 years showed to be effective in conversion of VF and safe. Greater scrutiny may be required to avoid overtreatment in patients with milder risk profiles.

Fine particulate matter and sleep-disordered breathing severity in a large Italian cohort

BACKGROUND

Air pollution and obstructive sleep apnea (OSA) are both linked with cardiovascular co-morbidities and share similar pathophysiological mechanisms. A causal association between the two has been postulated. However, the results of the studies on this topic are conflicting mainly because of the lack of adjustment for important confounders such as seasonality and temperature. We aimed to evaluate if such an association exists in a highly polluted area like Lombardy region (Italy) when accounting for all confounders.

METHODS

Data of adult patients seen at the Sleep Disorder Centre in Milan from 2010 to 2020 were analysed and the main polygraphic data were retrieved. Air pollutant concentrations of the following pollutants NO2, O3, PM2.5, and PM10 were collected through monitoring stations.

RESULTS

A total of 3493 patients were included: males (2358, 67.5%) mean age 60.1 (SD = 14.3) years, BMI 29.2 (6.2) kg/m2, mean AHI 16.5 (18.1) events/h. After adjusting for all confounders, in the multivariable analysis, the only associations that remained significant were long-term exposure to O3 with indexes of OSA severity (AHI and ODI) but only in spring. Furthermore, a positive association was seen between long-term exposure to PM10 and ODI but in springtime only.

CONCLUSION

The findings of the current study does not support an association between fine particulate matter and OSA severity.

Comparison of office, home and ambulatory blood pressure measurements in hypertensive and suspected hypertensive SWICOS participants

PURPOSE

Hypertension should be confirmed with the use of home BP measurement (HBPM) or 24h ambulatory BP measurement (ABPM). The aim of our study was to compare measurements obtained by OBPM, HBPM and ABPM in individuals with elevated OBPM participating in the population-based Swiss Longitudinal Cohort Study (SWICOS).

MATERIAL AND METHODS

Participants with OBPM ≥140/90 mmHg assessed their BP using HBPM and ABPM. The cut-off for hypertension was ≥135/85 mmHg for HBPM, ≥130/80 mmHg for ABPM. White-coat hypertension (WCH) was defined as normal HPBM and ABPM in participants not taking antihypertensive drugs. Uncontrolled hypertension was defined as hypertension in HBPM or ABPM despite antihypertensive treatment.

RESULTS

Of 72 hypertensive subjects with office BP ≥140/90 mmHg and valid measurements of HBPM and ABPM, 39 were males (aged 62.8 ± 11.8y), 33 were females (aged 57.4 ± 14.2y). Hypertension was confirmed with HBPM and ABPM in 17 participants (24%), with ABPM only in 24 further participants (33%), and with HBPM only in 2 further participants (3%). Participants who had hypertension according to ABPM but not HBPM were younger (59 ± 11 y versus 67 ± 16 y; p < 0.001) and more frequently still working (83% versus 23%; p < 0.001). The prevalence of WCH was 28%. Among the 32 subjects taking antihypertensive drugs, uncontrolled hypertension was found in 49%.

CONCLUSION

This population-based study found a high prevalence of WCH and potential uncontrolled hypertension among individuals with elevated OBPM. This study, therefore, supports the ESH recommendations of complementing OBPM by ABPM or HBPM. The use of HBPM instead of ABPM for the confirmation of hypertension in individuals with elevated OBPM might lead to underdiagnosis and uncontrolled hypertension, in particular in the younger working population. In these individuals, this study suggests using ABPM instead of HBPM.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19

Objective

Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings.

Methods

113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease.

Results

7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O226.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar–arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease.

Conclusions

In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Is pulmonary artery wedge pressure a reliable surrogate of left ventricular end-diastolic pressure during exercise for diagnosing HFpEF in patients with unexplained dyspnea?

Background

Left ventricular end-diastolic pressure (LVEDP) is the gold-standard for the assessment of LV filling pressure. For practical reasons, pulmonary artery wedge pressure (PAWP) is used as a surrogate for LVEDP. However, the interposition of the left atrium (LA) may account discrepancies between LVEDP and PAWP. The imprecision of both end-diastolic (or mid-A) and mean PAWP estimates for LVEDP has been widely described for cardiac catheterization at rest. PAWP measurement during exercise has been advocated to discriminate heart failure with preserved ejection fraction (HFpEF) from non-cardiac dyspnea, with an end-expiratory pathologic threshold ≥25 mmHg. However, a formal comparison of PAWP (either mid-A or mean PAWP) vs LVEDP during exercise has never been performed.

Aim

To compare LVEDP and PAWP during exercise.

Methods

We retrospectively analyzed consecutive patients with unexplained dyspnea and a normal LV ejection fraction, who had a clinical indication of right and left heart catheterization at rest and during exercise to assess unexplained dyspnea. Patients with mitral regurgitation ≥ moderate were excluded. Hemodynamic measurements were always taken at end-expiration.

Results

Forty-six consecutive patients were included in the analysis (80% with a peak mean PAWP ≥25 mmHg). We found a good correlation between both mid-A and mean PAWP on one side, and LVEDP on the other side (R2&gt;0.55). At peak exercise, mid-A PAWP had no bias as compared with LVEDP, while mean PAWP slightly overestimated LVEDP by 1–2 mmHg. However, confidence intervals were quite large (Figure 1), suggesting imprecision of PAWP estimates for LVEDP in the individual patient. A disagreement between mean PAWP and LVEDP, using a threshold of ≥25 mmHg for both variables at peak exercise, was found in 11% of patients. In 4% of them, mean PAWP was ≥25 but LVEDP &lt;25 mmHg, due to the appearance of tall V waves in the PAWP position (LA stiffness), increasing PAWP above LVEDP. In the remaining 7%, LVEDP was ≥25 but PAWP &lt;25 mmHg. The latter patients, in whom HFpEF would have not been diagnosed based on peak PAWP alone, showed a PAWP increase during exercise relative to cardiac output changes (PAWP/CO slope) &gt;2 mmHg/L/min, as an alternative parameter suggesting HFpEF.

Conclusions

In patients with unexplained exertional breathlessness, both mid-A and mean PAWP showed good correlation with LVEDP during exercise with minimal average bias, but their ability to estimate LVEDP was burdened by a relevant imprecision. Therefore, when in these patients peak PAWP is &lt;25 mmHg, its assessment might need to be complemented by additional measurements (including LVEDP or PAWP/CO slope) to maximize the diagnostic power of exercise cardiac catheterization in identifying HFpEF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

Effect of CPAP therapy on blood pressure in patients with OSA: a worldwide individual patient data meta-analysis

Background

Obstructive sleep apnoea (OSA) is a well-known cardiovascular risk factor and is frequently associated with hypertension. The treatment of OSA with continuous positive airway pressure (CPAP) can resolve apnoeas, hypoxia, and sympathetic hyperactivation. Meta-analyses of randomised controlled trials (RCTs) show that CPAP treatment modestly reduces blood pressure (BP) with a pronounced heterogeneity among different OSA patient subgroups.

Purpose

To study the effects of CPAP treatment on BP changes, and to identify predictors of BP response to CPAP through analysis of individual patient data from published RCTs.

Methods

Study groups who had published RCTs on the effect of CPAP therapy on BP in OSA were invited to share the individual patient data (i.e. BP values, history of hypertension and antihypertensive drugs use). The outcomes of interest were the group-difference (BP at follow-up – BP at baseline) in office and out-of-office BP. Data analysis was performed with a one-step approach using a linear regression model, with treatment as covariate, including a random effect. An additional analysis was performed by stratifying patients in three subgroups: normotension, controlled hypertension and uncontrolled hypertension, based on BP at baseline, history of hypertension or treatment with antihypertensive drugs. Lastly, we evaluated the determinants of CPAP associated BP changes.

Results

Individual patient data from 34 parallel-group RCTs (n=7,456, 72% males, body mass index, BMI 31.9±14.8 kg/m2, age 58.6±10.9 years, apnoea-hypopnoea index, AHI 35.5±20.6 /hour) were analysed. The overall CPAP effect was larger for 24-BP compared to office BP measurements (Table 1), the highest reductions being observed for nocturnal BP. The stratified analysis showed a consistent BP lowering effect in the group of patients with uncontrolled hypertension whereas there was no significant BP change in those with controlled hypertension or in normotensives (figure 1). Higher BP levels at baseline and history of hypertension were independent predictors of BP reduction by CPAP for office and 24-BP measurements. Younger age and more severe nocturnal oxygen desaturations predicted a larger treatment effect on office BP only.

Conclusions

BP response to CPAP in OSA patients varies in different patient groups as a function of baseline BP, the greatest reduction being observed in younger patients with uncontrolled BP. Thus, our individual patient data meta-analysis indicates that younger patients with uncontrolled hypertension and more severe nocturnal oxygen desaturations measured by minimum SpO2 are likely to benefit the most from CPAP treatment in terms of BP reduction.

Funding Acknowledgement

Type of funding sources: None.

Right heart adaptation during exercise in pulmonary arterial hypertension and in pulmonary hypertension due to heart failure with preserved ejection fraction

Background

Right heart failure (RHF) represents the final step of distinct diseases, such as pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF). RHF may be defined by the inability of the heart to maintain a normal cardiac output (CO) or to do so at the expense of high right atrial pressure (RAP), at rest or during exercise.

However, exercise hemodynamic features suggestive of RHF, as well as their determinants, have still not been defined.

Aim

We sought to i. define the limits of normal of RAP increase during exercise; ii. describe the behavior of RAP during exercise in PAH and in PH-HFpEF, and its relation to right heart afterload and preload.

Methods

We retrospectively analyzed data from consecutive patients referred for suspicion of PH, who underwent both a resting and exercise right heart catheterization at two centers with identical methodology. We included patients with PH-HFpEF or PAH. Right heart adaptation to exercise was described either using absolute or CO-normalized RAP increase during exercise (RAP/CO slope), this latter representing the inverse of the Frank-Starling reserve. A control cohort of subjects with normal hemodynamics at rest and during exercise served to define abnormal increase in RAP, i.e. values of RAP and RAP/CO slope &gt; mean ± 2 standard deviation of controls.

Estimated stressed blood volume (eSBV), as a measure of effective preload, was computed using a commercially-available software.

Results

80 patients were included in the analysis, of which 29 were PH-HFpEF, 30 PAH and 21 controls.

HFpEF patients were older than PAH patients and with a higher burden of cardiovascular comorbidities (p&lt;0.05). Sex representation, BMI, and NTproBNP values were similar in the two groups.

Mean pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and total vascular resistance (TPR) were higher in PAH than in PH-HFpEF both at rest and during exercise (p&lt;0.01), in spite of similar CO (Table 1). At rest, eSBV did not differ between HFpEF and PAH, but it was higher in HFpEF at peak exercise.

On average, PH-HFpEF had higher resting and peak RAP than PAH, as well as higher RAP/CO slope (Figure 1).

The upper limit of normal of exercise RAP and of RAP/CO slope, as determined in control subject, was 12 mmHg and 1.55 mmHg/L/min. A higher rate of HFpEF patients, compared with PAH, had a RAP/CO slope and a peak RAP above normal limits (78% and 91% of PH-HFpEF vs 47% and 44% of PAH, respectively, p&lt;0.001).

RAP/CO slope in the whole cohort was associated with eSBV but not with right ventricular afterload measures (PAP, TPR, PVR).

Conclusions

PH-HFpEF display more frequently a steeper increase of RAP during exercise than PAH patients in spite of similar CO, suggesting a more exhausted Frank-Starling reserve. The steep RAP increase during exercise seems to reflect a dysfunctional preload rather than an afterload-mismatch.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease

Background

Pulmonary hypertension (PH) is associated with a poor prognosis in patients with left heart disease (LHD). Several hemodynamic variables have been shown to predict outcome, including pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and the diastolic pressure gradient (DPG). We sought to provide an updated analysis on the association of these variables with prognosis in PH-LHD.

Methods

We performed a systematic literature review including studies reporting association measurements between DPG and/or PVR and/or PAC and death in PH-LHD patients. These hemodynamic variables were extracted to estimate the pooled hazard ratio (HR) of adverse outcome for each one, and cumulative meta-analysis was performed to investigate temporal trends in the effects reported in the literature as well as the impact of sample size.

Results

17 articles were identified, including 9716 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, we found that PVR (HR, 1.09; 95% CI: 1.06–1.12), DPG (HR, 1.02; 95% CI: 1.01–1.02) and PAC (HR, 0.73; 95% CI: 0.76–0.81) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG (Figure 1). Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD (either heart failure with preserved or reduced left ventricular ejection fraction, or valvular heart disease). Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018 (Figure 2).

Conclusions

Despite the heterogeneity of PH-LHD group and the intrinsic limitations of each variable, PVR, DPG, and PAC have an established prognostic value in PH-LHD. The strongest correlation with PVR and PAC supports their use in defining disease severity and identifying a subgroup of patients at higher risk of adverse outcome. We believe that these results are consistent through the years and unlikely to change with the addition of further studies.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

Prognostic power of a new index of right ventricle-pulmonary artery coupling based on right ventricular volumes in patients with secondary tricuspid regurgitation

Background

Although echocardiographic surrogates of right ventricular -arterial coupling (RVAC) have been reported to be associated with outcome in patients with moderate or severe secondary tricuspid regurgitation (STR), pulmonary artery systolic pressure (SPAP) is difficult to be estimated using echocardiography in patients with severe STR.

Purpose

Accordingly, we evaluated the predictive power of indexes of RVAC obtained using RV volumes measured using three-dimensional echocardiography (3DE).

Methods

We prospectively enrolled 180 patients with moderate or severe STR and complete two-dimensional, Doppler and 3DE data. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome.

Results

After a median follow up of 24 months (IQR: 2–48), 72 patients (40%) reached the primary endpoint. Most of the echocardiographic parameters of RV function were associated with outcomes. Among the different parameters of RVAC, the receiver operating curve (ROC) analysis selected the ratio between (RV stroke volume [SV]-RegVol)/ RV End-systolic volume (ESV) (i.e. the RV forward SV/ESV) as the best predictor of the combined endpoint (AUC 0.80 [IC 95% 0.73–087]), with a threshold value of 0.49.

Event-free survival of patients with RV forward SV/ESV higher and lower 0.49 has been performed (Figure 1).

Multivariable Cox proportional hazards models were constructed (Figure 2). Adding sequentially the 3D-RVEF, TAPSE/SPAP and the forward RV SV/RV ESV on top of a basal model made of TR severity, New York Heart Association (NYHA) functional class and tricuspid anulus plane systolic excursion (TAPSE), the χ2 of the model increased from 40 to 43 (p=0.13) by adding 3D RVEF, from 43 to 46 (p=0.04) by adding TAPSE/SPAP, and from 46 to 51 (p=0.02) by adding RV forward SV/ESV. Severe TR (HR 3.53 [CI 95%: 1.84–6.78], p&lt;0.001) and RV forward SV/ESV &lt;0.49 (HR 2.45 [CI 95% 1.16–5.18], p=0.02) were the only parameters independently associated with outcome.

Conclusions

The RV forward SV/ESV is an index of RVAC obtained by 3DE which is independent from SPAP and it is strongly associated with the occurrence of death or heart failure hospitalization in patients with STR.

Funding Acknowledgement

Type of funding sources: None.

A meta-analysis of exercise hemodynamics in heart failure with preserved ejection fraction: the relevance of PAWP/CO slope

Background

Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current hemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise hemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects.

Methods

We performed a systematic literature review following the PRISMA statement until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all hemodynamic variables were evaluated, stratified according to body position (supine/upright exercise). The PAWP / cardiac output (CO) slope during exercise was extrapolated.

Results

Twenty-seven studies were identified, providing data for 2180 HFpEF patients and 682 controls. At peak exercise, HfpEF cohorts showed a summary estimate of PAWP at peak which was twice as high as compared with control cohorts (30; 95% CI: 29–31 mmHg and 16; 95% CI: 15–17 mmHg, respectively), as well as of delta PAWP (15; 95% CI: 14–16 mmHg and 7; 95% CI: 6–8 mmHg, respectively), and of right atrial pressure (18; 95% CI: 16–19 mmHg and 8; 95% CI: 8–9 mmHg, respectively). These differences persisted after adjustment for age, sex, body mass index, body position. Additionally, summary estimates of PAWP at peak performed during supine exercise was slightly higher than that obtained in upright position only for HFpEF cohorts (supine position: 31; 95% CI: 30–32 mmHg vs upright position; 26; 95% CI: 25–27 mmHg, respectively, p-value&lt;0.01). However, peak PAWP values were highly heterogeneous among the cohorts (I2=93%), with a relative overlap with controls (Figure 1). HFpEF had a significantly larger impairment in the hemodynamic response to exercise, witnessed by a steeper summary PAWP/CO slope than controls (3.75; 95% CI: 3.20–4.28 mmHg/L/min and 0.95; 95% CI: 0.30–1.59 mmHg/L/min, p-value &lt;0.0001), even after adjustment for covariates (p=0.007) (Figure 2). Finally, summary estimates of PAWP/CO slope were higher in HFpEF cohorts performing exercise in the supine position compared with those in upright position (p&lt;0.0001 and p=0.0002 at non-adjusted and adjusted analysis, respectively), but not in control cohorts (p=0.135 and p=0.966 at non-adjusted and adjusted analysis, respectively).

Conclusions

Despite methodological heterogeneity across centers, the hemodynamic profile of HFpEF patients is consistent across studies and characterized by a higher left and right filling pressure at rest compared with controls, enhanced by physical exercise. A PAWP/CO slope cut-off &gt;2 mmHg/L/min seems to retain validity also for studies conducted in the supine position, potentially overcoming the need of different supine and upright PAWP cut-offs.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

New definition of hypotension in patients with reflex syncope using 24-hour ambulatory blood pressure monitoring (SynABPM Study)

Background

Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking.

Purpose

We hypothesized that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM than control subjects and we aimed to define the SBP cut-off values that allow identification of patients with hypotensive susceptibility.

Methods

We compared ABPM data from reflex syncope patients and controls, matched by average 24-hour SBP, age, sex and hypertension. Patients with constitutional hypotension, orthostatic hypotension, predominant cardioinhibition or competing causes of syncope were excluded. Daytime and night-time SBP drops (&lt;110, 100, 90, 80 mmHg) were assessed. Findings were validated in an independent sample.

Results

In the Derivation cohort, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drop &lt;90 mmHg provided the best diagnostic yield (91% specificity, 32% sensitivity, Odds Ratio [OR]=4.6, p=0.001). Two or more-daytime drops &lt;100 mmHg achieved 84% specificity and 40% sensitivity (OR=3.5, p=0.001). Results were confirmed in the Validation cohort: one or more daytime SBP drop &lt;90 mmHg provided 94% specificity and 29% sensitivity (OR=6.2, p&lt;0.001), while two or more daytime SBP drops &lt;100 mmHg achieved 83% specificity and 35% sensitivity (OR=2.6, p&lt;0.001) (Figure 1).

Conclusion

SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope.

Funding Acknowledgement

Type of funding sources: None.

P232 EXERTIONAL BREATHLESSNESS IN HYPERTROPHIC CARDIOMYOPATHY: OBSTRUCTION–INDEPENDENT SYMPTOMS IN A “PARADOXICAL” RESPONSE TO EXERCISE

A 66–y.o. man with hypertrophic cardiomyopathy presented with residual exertional dyspnea NYHA III a few years after surgical myectomy, mitral valve repair and ICD implantation. Echocardiography showed residual mild septal hypertrophy and mitral regurgitation (MR), and a variable obstruction of left ventricular outflow tract (LVOT), witnessed by a pressure gradient ranging from 15 to 50–70 mmHg (Figure 1). Exercise echocardiography did not suggest exercise–induced LVOT obstruction (LVOTO) or functional MR. We thus performed a thorough invasive hemodynamic evaluation at rest and during exercise. LVOTO was present at rest, with a maximum pressure gradient of 90–100 mmHg and typical “spike–and–dome” configuration of the aortic pulse contour (Figure 2), with LV end–diastolic pressure (LVEDP) at the upper limit of normal (15 mmHg) and normal pulmonary hemodynamics. During exercise, we observed a paradoxical reduction of the LVOTO (30–40 mmHg at peak, Figure 2). Pulmonary hypertension developed during exercise, due to LV diastolic dysfunction, witnessed by a marked increase in pulmonary artery wedge pressure and LVEDP (up to 25 mmHg and 30 mmHg at peak, respectively). Cardiac output (CO) reserve was at the lower limits of normal, mainly due to chronotropic incompetence, responsible for a mildly reduced exercise capacity (peak oxygen consumption was 20 mL/Kg/min, 75% of predicted). Thus, cardiac catheterization confirmed the presence of a relevant LVOTO at rest, that was not directly related to exertional symptoms. These latter were mainly attributable to LV diastolic dysfunction and reduced CO reserve. These findings helped us driving treatment decision in a tailored way: beta–blockers were not uptitrated, because of their negative inotropic effect, and high–risk septal reduction therapies were excluded, since exertional symptoms were unrelated to LVOTO. However, an attempt to reduce LVOTO was done by DDD sequential pacing through the ICD. Pacing could induce mechanical dyssynchrony and reduce LVOTO by increasing the end–systolic LVOT diameter. The simultaneous echocardiographic monitoring highlighted an acute reduction of LVOT gradient from 50–70 mmHg to 20–30 mmHg (Figure 3).

This case suggests that, in well–selected cases, patients’ management based on pathophysiological reasoning may help to define the etiopathogenetic mechanism underlying symptoms, and to drive treatment decision in a patient–centered way.

P284 THE RIGHT HEART ADAPTATS TO EXERCISE MORE EFFICIENTLY IN PULMONARY ARTERIAL HYPERTENSION THAN IN PULMONARY HYPERTENSION DUE TO HEART FAILURE WITH PRESERVED EJECTION FRACTION

Background

Right heart failure (RHF) represents the final step of distinct diseases, differently involving the pulmonary circulation, such as pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF). Exercise may unmask right heart maladaptation as a sign of RHF, but cut–offs for right atrial pressure (RAP) rise during exercise remain to be defined. We hypothesized that PH–HFpEF may present with worse right heart adaptation to exercise than PAH due to increased chamber stiffness and dysfunctional preload.

Aim

We sought to describe the behavior of RAP during exercise in PAH and in PH–HFpEF, and the mechanisms underlying right heart maladaptation.

Methods

We performed a retrospective analysis of data (2007–2021) obtained from patients with either PAH or PH–HFpEF who underwent a right heart catheterization at rest and during exercise. Right heart adaptation to exercise was described using either absolute or cardiac output (CO)–normalized RAP increase during exercise (RAP/CO slope). Patients with non–cardiac dyspnea (NCD) served to define RAP limits of normality. Estimated stressed blood volume (eSBV), as a measure of effective preload, was computed based on hemodynamics using a commercially–available software.

Results

Ninety–four patients were included (32 PH–HFpEF, 32 PAH and 30 NCD). The upper limit of normal for absolute peak RAP and RAP/CO slope were 12 mmHg and 1.55 mmHg/L/min. Compared with PH–HFpEF, PAH patients showed higher systolic, diastolic and mean pulmonary artery pressure (PAP) as well as higher indices of right ventricular afterload both at rest and during exercise, but lower filling pressures and similar CO (Figure 1).In particular, PH–HFpEF had higher peak RAP and higher RAP/CO slope than PAH (Figure 1,2). Additionally, 78% and 91% of PH–HFpEF, as compared with 47% and 44% of PAH had a RAP/CO slope and a peak RAP above normal, respectively (p &lt; 0.001). PH–HFpEF presented with higher increase in eSBV, and higher peak eSBV values than PAH (p &lt; 0.05), despite similar resting levels. RAP/eSBV slope was upward shifted (at a given effective preload, RAP was higher) while CO/eSBV slope was flatter (at a given effective preload, CO was lower) in PH–HFpEF as compared with PAH (Figure 3).

Conclusions

PH–HFpEF display worse right heart maladaptation to exercise than PAH, likely due to a combination of increased right heart stiffness and a more exhausted Frank–Starling reserve.

P245 A RARE CAUSE OF OVERESTIMATION OF PULMONARY PRESSURE BY ECHOCARDIOGRAPHY: WHEN HEMODYNAMICS RELIEVES ECHOCARDIOGRAPHY AND ECHOCARDIOGRAPHY EXPLAINS HEMODYNAMICS

Echocardiography is the gatekeeper of the diagnostic workflow of pulmonary hypertension (PH). However, it lacks precision, and right heart catheterization (RHC) may be needed in selected cases. A morbidly obese 47–year–old woman (BMI= 58 Kg/m2) with dyspnea NYHA II was referred to our Center after a high probability of PH was found at echocardiography, this latter performed as a routine assessment before bariatric surgery. Despite a suboptimal acoustic window, the tricuspid regurgitant jet profile was well–defined, with an estimated systolic pulmonary artery pressure (PAP) of 100 mmHg. There were no overt echocardiographic signs of left heart disease. During RHC, mean PAP was just above normal values, with filling pressures at the upper limit of normal (Figure 1), high cardiac index (3.6 L/min/m2) and normal pulmonary vascular resistance (1.4 WU). The echocardiographic estimate of high systolic PAP was explained by an intraventricular RV pressure gradient of about 100 mmHg (Figure 2). Oximetry ruled out a significant intracardiac shunt. Since resting hemodynamics did not explain the patient’s symptoms, the patient pre–test probability of having heart failure with preserved ejection fraction (HFpEF) was intermediate–high, and PAWP was in a grey–zone. Accordingly, we performed an exercise RHC. The test eventually unmasked HFpEF, as witnessed by an abnormal increase of PAWP and LV end–diastolic pressure (Figure 1 panel C and D). Exercise capacity was mildly reduced (71% of predicted) due to peripheral limitation with normal cardiac and respiratory reserves. Transesophageal echocardiography was then performed. It showed a muscular obstruction below the infundibulum dividing the RV into a high–pressure apical portion and a low–pressure infundibulum (Figure 3). This rare congenital anomaly was also associated with a restrictive perimembranous ventricular septal defect. Double–chambered RV has been reported to present rarely in adults, but it might be a cause of false Doppler echocardiographic estimate of PAP. Based on a meticulous invasive hemodynamic characterization at rest and during exercise, integrated with cardiovascular imaging, we could perform such a diagnosis. This congenital anomaly did not fully explain the patient’s symptoms, which may better be attributed to cardiovascular complication of obesity (HFpEF). Accordingly, we referred the patient for bariatric surgery first, postponing the indication to cardiac surgery during the follow–up.

P283 PROGRESSION OF PULMONARY ARTERIAL HYPERTENSION OR LEFT HEART DISEASE? DO EXERCISE!

An 80–year–old man, diagnosed with idiopathic pulmonary arterial hypertension (PAH) in 2012 and treated with sildenafil, experienced his first hospitalization for heart failure in June 2019. He had several cardiovascular risk factors (overweight, hypertension, diabetes) and comorbidities (ischemic heart disease, and mild chronic obstructive pulmonary disease), whose progression was excluded. Since this event, he complained a progressive deterioration of the exertional dyspnea (NYHA III), with overt signs of fluid overload, right chambers dilation and high NTproBNP (1366 ng/L). However, the center taking care of this patient neither decided to fully re–evaluate him nor to escalate PAH–treatment due to his clinical profile (high suspicion of left heart disease, LHD). He then came to our pulmonary hypertension (PH) center where we decided to perform a cardiac catheterization, which showed the persistence of precapillary PH with high pulmonary vascular resistance, PVR (7.6 WU), low cardiac output, CO (2.2 L/min/m2), high right atrial pressure, RAP (12 mmHg). Pulmonary artery wedge pressure (PAWP) and left ventricular end–diastolic pressure (LVEDP) were at the upper limits of normal (13 mmHg and 16 mmHg, respectively) (Figure 1). Based on these “borderline” PAWP values, with an intermediate–high pre–test probability of left heart disease, we performed an exercise test with concomitant gas–exchange analysis on a cycle ergometer in the cath lab (Figure 2). Exercise induced a steep increase in pulmonary pressure (TPR 9 WU), unrelated to an exaggerate increase in PAWP or LVEDP (whose peak values reached 20 mmHg, with a PAWP/CO slope &lt;2 mmHg/L/min), but entirely dependent on the precapillary component. Transpulmonary gradient (TPG)/CO slope was high, leading to an absent reduction in PVR (6.4 WU at peak), associated to severe increase in RAP (27 mmHg at peak, RAP/PAWP 1.4) (Figure 3). CO reserve was reduced (at peak 3.4 L/min/m2), due to both reduced increase in stroke volume and chronotropic incompetence. Accordingly, functional capacity was moderately–severely reduced (peak oxygen consumption was 8 ml/kg/min, 39% of predicted), with exercise hyperventilation. Once excluded LHD as the responsible of clinical worsening, and in consideration of the high–intermediate risk profile of this patient, we upgraded the PAH–specific therapy by adding macitentan, obtaining a subjective clinical improvement and a 3–years period of clinical stability.

C64 UNMASKING THE PREVALENCE OF AMYLOID CARDIOMYOPATHY IN THE REAL WORLD: RESULTS FROM PHASE 2 OF AC–TIVE STUDY, AN ITALIAN NATIONWIDE SURVEY

Background

Clinicians need to identify patients with amyloid cardiomyopathy (AC) at an early stage, due to the availability of disease–modifying therapies. Some echocardiographic findings may rise the suspicion of AC, also in patients with mild or no symptoms, addressing second level diagnostic tests.

Aim

To investigate the prevalence of AC in consecutive patients ≥55 years undergoing clinically indicated, routine transthoracic echocardiogram in Italy and presenting echocardiographic signs suggestive of AC.

Methods

This is a prospective multicentric study conducted in Italy. It comprises two phases: 1) a recording phase consisting in a national survey on prevalence of possible echocardiographic red flags of AC in consecutive unselected patients ≥55 years undergoing routine echocardiogram (previously published) and 2) an AC diagnostic phase involving a diagnostic work–up for AC to investigate AC prevalence among patients with at least one echocardiographic red flag (herein presented). Patients that in Phase 1 presented an “AC suggestive” echocardiogram (i.e., at least one red flag of AC in hypertrophic, non–dilated left ventricles with preserved ejection fraction) underwent clinical evaluation, blood and urine tests and scintigraphy with bone tracer. Diagnosis of transthyretin related–AC (ATTR–AC) was made in presence of grade 2–3 Perugini uptake at scintigraphy and absence of monoclonal protein. The study was registered at ClinicalTrials.gov (#NCT04738266).

Results

Of the 5315 screened echocardiograms, 381 exams (7.2%) were classified as “AC suggestive” and proceeded to Phase 2. 217 patients completed Phase 2 investigations. Main reasons for the 164 non–entering patients into Phase 2 were death (n = 49) and refusal to participate (n = 66). A final diagnosis of AC was made in 62 patients with an estimated prevalence of 28,6% (95% CI: 22,5%–34,7%). ATTR–AC was diagnosed in 51 and AL–AC in 11 patients, ascertaining a prevalence of 23,5% (95% CI: 17,8%–29,2%) and 5,1% (95% CI: 2,2%–8,0%), respectively.

Conclusion

Among a cohort of consecutive unselected patients ≥55 years with echocardiographic findings suggestive of AC, the prevalence of AC ranged from 23% up to 35%. Although ATTR–AC was predominant, AL–AC was diagnosed in a significant number of cases. Echocardiography has a fundamental role in screening patients, raising the suspicion of disease and orienting diagnostic work–up for AC.

P296 HIDDEN PERICARDIAL CONSTRICTION IN A PATIENT WITH CHRONIC PERICARDIAL EFFUSION AND “UNEXPLAINED” DYSPNEA

Constrictive physiology leads to exertional symptoms related to restrained diastolic filling and intracardiac/intrathoracic dissociation. However, these hemodynamic abnormalities might not be evident in some patients. A 55–year–old woman was referred to our center to perform a right and left cardiac catheterization because of “unexplained” dyspnea. Three years before she was found to have a large idiopathic pericardial effusion. Anti–inflammatory therapy did not result in any improvement. Since then, the patient complained dyspnea NYHA II–III, in the absence of any clinical and imaging sign of tamponade/pericardial constriction. At rest, there was no sign of constriction, but a relative hypovolemic status characterized by low pulmonary and filling pressures and cardiac output (CO) at the lower limits of normal. After a 500 mL saline load and passive legs raising, Kussmaul’s and “M” signs appeared on the right atrial pressure curve (Figure 1), the pulmonary artery wedge pressure (PAWP) – left ventricular end–diastolic pressure (LVEDP) gradient difference between expiration and inspiration was &gt;5 mmHg (Figure 2), and ventricular systolic pressures went out of phase by 180°. Both right and left filling pressures as well as pulmonary pressures steeply increased in a concordant manner by about 10 mmHg after fluid load, in absence of a relevant increase in CO (Figure 3). Physical exercise performed thereafter showed an additional mild increase with a plateau pattern of all pressures, suggesting an upward–shift of the pressure/flow relationship (Figure 3). All these signs suggested a latent constrictive physiology. Despite this, the patient showed an optimal CO reserve coupled with a normal exercise capacity (peak oxygen consumption, VO2, 127% of predicted) that would have argued against our hypothesis. We then performed a diagnostic and evacuative pericardiocentesis. After the drainage of 130 ml of pericardial fluid, LV transmural pressure increased and CO at rest was fully normalized. Moreover, no hemodynamic sign of constriction could be observed even after a 1000 ml saline load. The patient reported disappearance of exertional breathlessness, objectivated by an increase in peakVO2 by 20% as compared with the previous test. Thus, our case underscores how subtle the hemodynamic impact of pericardial effusion can be, with the need of well–tailored diagnostic exams to explain otherwise “unexplained” patients’ symptoms, with potential therapeutic implications.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Funding Acknowledgements

Type of funding sources: None.

Background

Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, assessment of TR severity is pivotal. Calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are still the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations.

Purpose: The aims of our study were

(1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC.

Methods

Forty-one patients with functional TR (73.5 ± 11.8 years,51% men,36% sinus rhythm,17% severe), underwent 2D  and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RVSV) – left ventricular forward SV (LVSV), where RVSV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI)  (Fig. 1). TR RVol by PISA was calculated as EROA x VTITR. Uncorrected EROA was calculated using the formula: 6.28 r2 xVa/ PeakVTR (r - PISA radius, Va, aliasing velocity, PeakVTR – TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 x Va (α/180)/ PeakV TR (PISAac), where α was measured using a protractor generated by dedicated software.

Results

Application of AC to PISA method resulted in larger EROA and RVol (0.34± 0.38 cm2 vs 0.24± 0.24cm2 and, 25.2± 19.3 mL vs 18.6 ± 13.1mL, respectively). The percentage change in EROAac was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias -3.95mL, LOA ± 6.41 mL,  r= .987; p&lt; .001) than the conventional PISA without AC (bias -10.5 mL, LOA ± 15 mL, r= .975). Angle correction resulted in a change of TR severity in 32% of cases (Fig. 2) and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs 52%, 22/41 without AC).

Conclusions

Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to 1/3 of patients with functional TR. Abstract Figure. Representation of study method  Abstract Figure. Reclassification of TR severity

Automated left atrial volume measurement by two-dimensional speckle-tracking echocardiography: feasibility, accuracy and reproducibility

Funding Acknowledgements

Type of funding sources: None.

Introduction - A by-product of left atrial (LA) strain analysis is the automated measurement of LA maximal volume (LAVmax), which may decrease the time of echocardiography reporting, and increase the reproducibility of the LAVmax measurement. However, the automated measurement of LAVmax by two-dimensional speckle-tracking analysis (2DSTE) has never been validated.

Purpose – Accordingly, we sought to: i. assess the feasibility of automated LAVmax measurement by 2DSTE; ii.  compare the automated LAVmax by 2DSTE with conventional two-dimensional (2DE) biplane and three-dimensional echocardiography (3DE) measurements; and iii. evaluate the accuracy and reproducibility of the three echocardiography techniques.

Methods – LAVmax (34­-197 mL) were prospectively obtained from 198/210 (feasibility 94%) consecutive patients with various cardiac diseases (median age 67 years, 126 men) by 2DSTE, 2DE and 3DE.

Results – 2DE and 2DSTE measurements resulted in similar LAVmax values (bias = 1.5 mL, limits of agreement, LOA ± 7.5 mL), and slightly underestimated 3DE LAVmax (biases=-5 mL, LOA ± 17 mL, and -6 mL, LOA ± 16 mL, respectively). LAVmax by 2DSTE and 2DE were strongly correlated to those obtained by cardiac magnetic resonance (CMR) (r=.946, and r=.935, respectively; p&lt;.001). However, LAVmax obtained by 2DSTE (bias=-9.5 mL, LOA ± 16 mL), and 2DE (bias=-8 mL, LOA ± 17 mL) were significantly smaller than those measured by CMR. Conversely, 3DE LAVmax were similar to CMR (bias=-2 ml, LOA ± 10 mL). Excellent intra- and inter-observer intraclass correlation coefficients were found for 3DE (0.995 and 0.995), 2DE (0.990 and 0.988), and 2DSTE (0.990 and 0.989).

Conclusion – Automated LAVmax measurement by 2DSTE is highly feasible, highly reproducible, and provided similar values to conventional 2DE calculations in consecutive patients with a wide range of LAVmax. Abstract Figure. Echocardiography and CMR correlations  Abstract Figure. Echocardiography techniques correlations

Prognostic value of different echocardiographic indices reflecting right ventriculo-arterial coupling in a large cohort of patients with various cardiac diseases

Funding Acknowledgements

Type of funding sources: None.

Introduction – Non-invasive parameters used to assess right ventricular (RV) function, i.e. tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (RVEF), and RV free-wall longitudinal strain (RVFWLS) have shown their prognostic implications. However, since they are extremely load dependent, they do not provide an accurate representation of the RV intrinsic performance. On the other end, invasive indices of RV-arterial coupling (RVAC) derived from pressure-volume loops are not routinely performed, rising the urgency for more feasible, and reliable non-invasive estimates of RVAC.

Purpose – To: i. evaluate the prognostic value of echocardiography-derived RVAC surrogates: RVEF/systolic pulmonary artery pressure (sPAP), RVFWLS/sPAP, TAPSE/sPAP, FAC/sPAP, and RV stroke volume/end-systolic volume (SV/ESV), ii. identify the cut-off values associated to all-cause mortality; and iii. compare their prognostic value with that of classical parameters of RV function.

Methods – We prospectively enrolled 366 patients with various cardiac diseases, undergoing clinically-indicated comprehensive two- and three-dimensional echocardiography.

Results – During a mean follow-up of 7.6 ± 1 years, 80 (21.9%) patients died. At univariable Cox regression, most of the echocardiographic parameters were related to all-cause mortality. The echocardiographic parameters with significance at univariable analysis (p &lt; 0.01) were included in a multivariable regression model. Left ventricular ejection fraction (LVEF), RVEF, TAPSE, RVEF/sPAP and RVFWLS/sPAP remained independently associated to all-cause mortality (p &lt; 0.05 for all). Subsequently, they were tested in receiving operator characteristics (ROC) curves. At ROC analysis, RVEF/sPAP (area under the curve, AUC = 0.807, p &lt; 0.001) and RVFWLS/sPAP (AUC = 0.743, p &lt; 0.001) showed the greatest predictive value (p &lt; 0.001 between them). However, all RV parameters significantly improved their prognostic values after indexing for sPAP (p &lt; 0.01 for all). The best cut-offs to predict the outcome were 1.5 for RVEF/sPAP (specificity 71%, sensitivity 83%) and 0.67 for RVFWLS/sPAP (specificity 72%, sensitivity 68%). At Kaplan-Meier analysis, patients with reduced RVAC (less than the predefined cut-offs) had significantly lower probability of survival (p &lt; 0.001 for all).

Conclusion – RVAC surrogates provide incremental prognostic value compared to standard RV functional measurements. RVEF/sPAP, with a cut-off value of 1.5, was the best parameter for risk stratification, and was independently related to all-cause mortality. Abstract Figure. Prognostic value of RVAC surrogates  Abstract Figure. Kaplan-Meier curves survival probability

Right heart chambers geometry and function in patients with the atrial and the ventricular phenotypes of functional tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

Introduction — Atrial functional tricuspid regurgitation (A-FTR) is a recently defined phenotype of FTR associated with persistent/permanent atrial fibrillation. Differently from the classical ventricular form of FTR (V-FTR), patients with A-FTR might present with severely dilated right atrium (RA) and tricuspid annulus (TA), and with preserved right ventricular (RV) size and systolic function. However, the geometry and function of the RV, RA and TA in patients with A-FTR and V-FTR remain to be systematically evaluated.

Purpose — Accordingly, we sought to: i. study the geometry and function of the RV, RA and TA in A-FTR by two- and three-dimensional transthoracic echocardiography; and ii. compare them with those found in V-FTR.

Methods — We prospectively analysed 113 (44 men, age 68 ± 18 years) FTR patients (A-FTR = 55 and V-FTR = 58) that were compared to two groups of age- and sex-matched controls to develop the respective Z-scores.

Results — The severity of FTR, and the degree of TA dilation were similar in A-FTR and V-FTR patients. The Z-scores of RV size were significantly larger, and those of RV function were significantly lower in V-FTR than in A-FTR (p &lt; 0.001 for all). The RA was significantly enlarged in both A-FTR and V-FTR compared to controls (p &lt; 0.001, Z-scores &gt; 2), with similar RA maximal volumes (RAVmax) between A-FTR and V-FTR (p = 0.2). Whereas, the RA minimal volumes (RAVmin) were significantly larger in A-FTR than in V-FTR (p = 0.001).

Conclusion — Despite similar degrees of FTR, RAVmax and TA size, A-FTR patients show larger RAVmin than V-FTR patients. Conversely, V-FTR patients show dilated, more elliptic and dysfunctional RV than A-FTR patients. Abstract Figure. A-FTR versus V-FTR  Abstract Figure. Remodelling patterns in A-FTR and V-FTR

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

The influence of drug therapy for obstructive sleep apnoea on couple life. Qualitative study grounded theory

Background

Obstructive sleep apnoea (OSA) is characterised by the collapse of the upper airway during sleep, which determine intermittent hypoxia and sleep fragmentation leading to snoring, impaired cognitive function, excessive daytime sleepiness, and cardiovascular impairments. These disorders have a significant impact on the quality of life and health of both patient and partner, determining stress and frustration also to the couple relationship, and to the workplace. Although the gold standard of treatment for OSA is the use of continuous positive airway pressure (CPAP), many patients find it uncomfortable both for them and for their partners (difficulty in partner intimacy, fear of disturbing their partner's sleep) with consequent low adherence to treatment in about 50% of OSA patients.

For these reasons, efforts to develop drug therapies for the treatment of OSA have been ongoing for at least 20 years. Recently, we conducted a randomized controlled trial (RCT) in Italy to test the combination of reboxetine (a noradrenergic agent) and oxybutynin (an antimuscarinic) for OSA treatment with promising results. The aim of this study is to understand how OSA drug therapy has influenced couples' life.

Methods

The study was conducted from February to March 2020 by the research nurse who participated during the trial. We interviewed 11 patients participating in the pharmacological RCT and 7 partners. The data analysis was conducted in order to collect the subjects' answers in categories, and to identify a core category as the central element for the explanation of the process.

Results

Interviews permitted to extrapolate 6 main categories and the relative subcategories for patients: 1) OSA: unconscious danger; 2) OSA and couple life (subcategories: sleepiness and nervousness, lack of sleep); 3) transitory situations; 4) drug therapy and couple (subcategories:change in intimacy and sleep quality); 5) motivation to help others (subcategories: therapy recommended for everyone; intention to continue); 6) partner awareness helps in adherence to therapy (subcategories: partner as caregiver, presence and proximity, partner support). While for partners, 7 main categories and the relative subcategories emerged: 1) apprehension and concern for the partner; 2) repercussions on daily life (subcategorie: discomfort); 3) OSA and the couple's lives; 4) drug therapy and couple; 5) support during therapy (subcategorie: before therapy, during therapy); 6) changes during drug therapy; 7) recommended therapy (subcategories: helping others, partner support). “The OSA is our problem” was the core category of the study that linked the categories together.

Conclusions

Drug therapy is well embraced by both patients and partners as it allows the couple to recover intimacy during sleep and in daily life. The results of this study provide useful information on the need to involve the partner in order to promote adherence to therapy.

Funding Acknowledgement

Type of funding sources: None.

Cardiovascular death risk in mid-range ejection fraction heart failure: insights from cardiopulmonary exercise test

Background

The pivotal role of cardiopulmonary exercise testing (CPET) in the assessment of functional capacity and prognosis of patients with heart failure with reduced ejection fraction (HFrEF), either as a single CPET parameter (i.e. peak oxygen uptake, peak VO2), as a combination of CPET parameters (i.e. oxygen uptake at the anaerobic threshold (AT) and ventilatory efficiency (VE/VCO2 slope), or as a part of more comprehensive scores (i.e. Metabolic Exercise combined with Cardiac and Kidney Indexes, MECKI) is well established. Just few studies are available with respect a possible role of CPET in risk stratification of patients in HF with midrange EF (HFmrEF) subset, namely HF patients with LVEF between 40% and 49%.

Purpose

The aim of the present large Italian multicenter study was to characterize and to compare stable HFmrEF and HFrEF patients in terms of exercise capacity as well as of instrumental and laboratory variables. We analyzed a possible independent and incremental prognostic value of CPET parameters in identifying those HFmrEF patients at high cardiovascular death risk.

Methods

We retrospectively analyzed clinical and CPET data of stable HF patients with HFrEF and HFmrEF from the MECKI Score database. Five-thousand-seven-hundred-eleven patients, 4,535 with HFrEF and 1,176 with HFmrEF, were considered for the study. The end-point was cardiovascular death at 5 years. The median follow-up was 1343 days (25th–75th range, 627–2403 days).

Results

Cardiovascular death occurred in 552 HFrEF (12.2% event rate) and 61 HFmrEF (5.2% event rate) patients. At multivariate analysis, an independent role of variables included in the MECKI score (age, atrial fibrillation, LVEF, haemoglobin, sodium, MDRD, AT identification, VO2 at AT, peak VO2 also expressed as percentage of the maximum predicted, VE/VCO2 slope) was confirmed in HFrEF group (C-index=0.744) whereas, in the HFmrEF group, only age and peak VO2 remained outcome predictors (C-index=0.745).

We identified a peak VO2 &lt;55% of predicted and a VE/VCO2 slope &gt;31 as the most accurate cut-off values able to identify a HFmrEF subgroup with a cardiovascular mortality rate significantly higher than the overall HFmrEF (5.2% vs 8.5%) (Figure 1). By using both cut-off values contextually, we recognized a relatively small HFmrEF population with a cardiovascular risk quite similar to the HFrEF sample (11.4% vs 12.2%) (Figure 1).

Conclusions

Present data support the CPET as a useful tool in the HFmrEF management. Besides the peak VO2, which resulted as a strong independent outcome predictor, also a number of other CPET variables were associated to the cardiovascular death risk. Particularly, a peak VO2 ≤55% of the maximum and a VE/VCO2 slope ≥31 identified a HFmrEF subgroup of patients with a high cardiovascular death risk, similar to the one observed in the HFrEF group.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Cardiopulmonary exercise testing in COVID-19 patients at 3 months follow-up

Background

Long-term effects of Coronavirus Disease of 2019 (COVID-19) and their sustainability are of the utmost relevance. For the chronic phase, the main concerns are the development of pulmonary interstitial disease and/or lingering cardiovascular involvement. How to intercept, assess, and treat these patients with long-term consequences of COVID-19 remains uncertain.

Purpose

We aimed to determine: 1) functional capacity of COVID-19 survivors by cardiopulmonary exercise testing (CPET); 2) those characteristics associated with CPET performance; 3) safety and tolerability of CPET.

Methods

We prospectively enrolled consecutive patients with laboratory-confirmed COVID-19 discharged alive at a single hospital in northern Italy. At 3-month from hospital discharge, complete clinical evaluation, trans-thoracic echocardiography, cardiopulmonary exercise testing (CPET), pulmonary function test (PFT), and dominant leg extension (DLE) maximal strength evaluation were performed.

Results

From 225 patients discharged from March to November 2020 we excluded 12 incomplete/missing cases, and 13 unable to perform CPET leading to a final population of 200 patients. At PFT all median parameters were within normality range.

Median percent-predicted peak oxygen uptake (%pVO2) was 88% (78.3–103.1). Ninety-nine (49.5%) patients had %pVO2 below, whereas 101 (50.5%) above the 85% predicted value (indicating normality).

Sixteen (16.2%) patients had respiratory, 28 (28.9%) cardiac, 21 (21.2%) mixed-cardiopulmonary, and 34 (34.3%) non-cardiopulmonary limitation of exercise. One-hundred sixty (80.0%) patients complain at least one symptom, without relationship with peakVO2.

Multivariate linear regression analysis showed percent-predicted forced expiratory volume in one-second (β=5.29, p=0.023), percent-predicted diffusing capacity of lungs for carbon monoxide (β=6.31, p=0.001), and DLE maximal strength (β=14.09, p=0.008) independently associated with peakVO2.

At sensitivity analysis, the results of previous multivariate linear regression analysis were also similar among sub-groups of patients with no previous significant disease in anamnesis (cardiovascular disease except for arterial hypertension, respiratory disease, kidney disease, or cancer) and of those with a length of hospital stay ≤7 days.

None major event was reported during/after CPET, whereas only two cases (1.0%) had a mild symptomatic hypotension post exercise. None of the involved health professionals developed COVID-19.

Conclusions

CPET after COVID-19 is safe and about 1/3rd of COVID-19 survivors show functional capacity limitation mainly explained by muscular impairment, calling for future research to identify patients at higher risk of long-term effects that may benefit from careful surveillance and targeted rehabilitation.

Funding Acknowledgement

Type of funding sources: None.

Dark blood ischemic LGE segmentation using a deep learning approach

Funding Acknowledgements

Type of funding sources: None.

Introduction

The extent of ischemic scar detected by Cardiac Magnetic Resonance (CMR) with late gadolinium enhancement (LGE) is linked with long-term prognosis, but scar quantification is time-consuming. Deep Learning (DL) approaches appear promising in CMR segmentation.  Purpose: To train and apply a deep learning approach to dark blood (DB) CMR-LGE for ischemic scar segmentation, comparing results to 4-Standard Deviation (4-SD) semi-automated method. Methods: We trained and validated a dual neural network infrastructure on a dataset of DB-LGE short-axis stacks, acquired at 1.5T from 33 patients with ischemic scar. The DL architectures were an evolution of the U-Net Convolutional Neural Network (CNN), using data augmentation to increase generalization. The CNNs worked together to identify and segment 1) the myocardium and 2) areas of LGE. The first CNN simultaneously cropped the region of interest (RoI) according to the bounding box of the heart and calculated the area of myocardium. The cropped RoI was then processed by the second CNN, which identified the overall LGE area. The extent of scar was calculated as the ratio of the two areas. For comparison, endo- and epi-cardial borders were manually contoured and scars segmented by a 4-SD technique with a validated software. Results: The two U-Net networks were implemented with two free and open-source software library for machine learning. We performed 5-fold cross-validation over a dataset of 108 and 385 labelled CMR images of the myocardium and scar, respectively. We obtained high performance (&gt; ∼0.85) as measured by the Intersection over Union metric (IoU) on the training sets, in the case of scar segmentation. With regards to heart recognition, the performance was lower (&gt; ∼0.7), although improved (∼ 0.75) by detecting the cardiac area instead of heart boundaries. On the validation set, performances oscillated between 0.8 and 0.85 for scar tissue recognition, and dropped to ∼0.7 for myocardium segmentation. We believe that underrepresented samples and noise might be affecting the overall performances, so that additional data might be beneficial. Figure1: examples of heart segmentation (upper left panel: training; upper right panel: validation) and of scar segmentation (lower left panel: training; lower right panel: validation). Conclusion: Our CNNs show promising results in automatically segmenting LV and quantify ischemic scars on DB-LGE-CMR images. The performances of our method can further improve by expanding the data set used for the training. If implemented in a clinical routine, this process can speed up the CMR analysis process and aid in the clinical decision-making. Abstract Figure.

Home blood pressure during COVID-19 related lockdown in patients with hypertension

Funding Acknowledgements

Type of funding sources: None.

Abstract

COVID-19 pandemic has induced governments to promote strict containment measures which inevitably altered patients’ lifestyle with potential effects on blood pressure (BP) control. We aimed to evaluate the changes in home BP (HBP) during the COVID-19 related lockdown in a cohort of hypertensive patients.

Consecutive adult patients with arterial hypertension and stable medical treatment were recruited. HBP values were recorded before and after lockdown in March 2020. An additional set of HBP measurements, recorded one year before the pre-lockdown period, were also considered as reference because of similar environmental temperature.

A total of 126 patients were included: 47% males, mean age 66 [58-72], reference HBP 124.78 (9.90)/76.19 (8.10) mmHg. In the whole group, patients during lockdown exhibited lower systolic and diastolic HBP values compared to the pre-lockdown period [123.23 vs 125.05 mmHg, p = 0.008 and 74.45 vs 75.28 mmHg, p = 0.023, respectively]. Patients with uncontrolled HBP showed the most consistent drop of systolic HBP [136.06 (8.36) and 138.0 (2.08) vs 130 (9.35) p = 0.001 and p < 0.001] and diastolic [81.30 (6.75) and 84.9 (1.85) vs 78.78 (9.25), p = 0.018 and p = 0.002] from pre-lockdown to lockdown and when considering reference values taken one year before, respectively. (Figure 1: Mean values at baseline, pre-lockdown and during lockdown in the 3 groups for systolic (A) and diastolic (B) blood pressure (dotted line = uncontrolled BP group, solid line = unstable BP control, dashed line = controlled BP group). *p<.001 (one year before lockdown vs lockdown SBP), #p = 0.001 (pre-lockdown vs lockdown SBP), $p = 0.002 (one year before lockdown vs lockdown DBP), §p = 0.018 (pre-lockdown vs lockdown DBP). Grey box refers to the lockdown period. SBP = systolic blood pressure, DBP = diastolic blood pressure.) 

In conclusion, this study reports for the first time the occurrence of no changes or even a reduction in home BP of treated hypertensive patients during lockdown due to COVID-19. These results may have implications for the management of patients with high blood pressure not only during the current pandemic but also in case of future lockdown conditions.

Pulsatile and resistive systolic loads as determinants of left ventricular remodelling after physical training

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Barts Cardiovascular Biomedical Research Centre

onbehalf

The Marathon Study Consortium

Introduction

Cardiovascular function depends on the inter-relation between heart and vasculature.  The contribution of aorta and peripheral vessels to the total systolic load of the left ventricle (LV) can be represented respectively by a "pulsatile" and a "resistive" component. We sought to understand their interrelation by exploring how LV remodelling occurred with altered load associated with an external stimulus (training). Methods: 237 untrained healthy male and female subjects volunteering for their first-time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided into 4 groups according to the variation (positive versus null or negative) in Total Arterial Compliance Index (TACi), representing the pulsatile component of the LV load, and in Systemic Vascular Resistance Index (SVRI), representing the resistive component of the LV load. Results: 138runners (age 21-69 years; F: 51%) completed the race. Data are reported for each variable as Δ mean [95% Confidence Interval]. In the whole cohort, training was associated with a small increase in LV mass index (+3g/m2, [0, 6 g/m2]), indexed LV end-diastolic volume (EDVi) (+3ml/m2, [-2, 5 3ml/m2]), in LV mass/LVEDV ratio (+0.02g/ml, [0.00, 0.04 g/ml]) and in TACi (+0.02ml/m2, [0.02, 0.38 ml/m2]). SVRi mildly fell (-43dyn·s/cm2[-103, 17dyn·s/cm2]). TACi increase was associated with LVEDVi increase and no change in LV mass/EDV (eccentric remodelling). On the other hand, both TACi reduction and SVRi increase were associated with increase in LV mass/EDV and no significant change in LVEDVi (concentric remodelling). A similar increase in LV mass was observed in all groups. See Table. Conclusion: Cardiac remodelling observed after mild, medium term, unsupervised training seems to be related to the modifications of aorta and peripheral vessels. In particular, a reduction in pulsatile load seems associated with eccentric LV remodelling, while an increase in both pulsatile and resistive with concentric LV remodelling. Further research is needed to understand the interaction between TACi and SVRi.

Table 1 LV EDVi (ml/m2) LV mass index (g/m2) LV mass/EDV TACi increase (n = 75) +4 [0, 9] +3 [0, 7] 0 [-0.03, 0.03] TACi decrease (n = 62) -1 [-6, 4] +3 [0, 8] 0.04 [0.01, 0.07] SVRi increase (n = 63) 0 [-4,4] +3 [0, 7] +0.03 [0, 0.06] SVRi decrease (n = 73) +3 [-3, 7] +3 [-1, 6] +0.01 [-0.02, 0.04]

Superior hypertension control with betablockade in the European Sleep Apnea Database

Background

Arterial hypertension is highly prevalent and frequently difficult to control in patients with obstructive sleep apnea (OSA). High sympathetic activity is a hallmark physiological phenomenon in OSA. We hypothesized that antihypertensive drugs with sympathetic inhibitory properties, in particular beta blockers (BB), may be particularly efficacious in OSA patients.

Methods

Hypertensive OSA patients receiving blood pressure lowing treatment in the European Sleep Apnea Database (ESADA) were analyzed (n=5818, 69% men, age 58±11 years, body mass index 33±7 kg/m2, apnea hypopnea index 34±26 events/h). Antihypertensive medications (BB, diuretic, renin-angiotensin blocker [RAB], calcium channel blocker [CCB], and centrally acting antihypertensive [CAH]) were classified according to ATC code. Office blood pressure was compared in patients with mono- or combination therapy controlling for confounders.

Results

Poorly controlled systolic blood pressure according to the ESC/ESH guidelines was found in 66% of patients. Patients receiving monotherapy with RAB, CCB or CAH had 2.2 [95% CI, 1.4–3.0], 3.0 [1.9–4.1] and 3.0 [1.7–4.7] mmHg higher systolic blood pressure compared with those on BB (adjusted model, p=0.007, 0.008 and 0.017, respectively). In those with a combination of two antihypertensive drugs, systolic blood pressure was 3.3 [2.4–4.3], 2.2 [1.3–4.3] and 2.3 [1.4–3.3] mmHg higher in those on CCB/RAB, diuretic/RAB or BB/RAB compared with those on BB/diuretic (adjusted model, p&lt;0.001, 0.019 and 0.001, respectively).

Conclusions

Uncontrolled blood pressure was common in OSA patients with antihypertensive medication. Patients treated with BB alone or in combination with diuretic was associated with a lower systolic pressure in this large clinical cohort.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Respiratory Society funded Clinical Research Collaboration (2015-2020)

Sex, body size and right atrial volume are the main determinants of tricuspid annulus geometry in healthy volunteers. A 3D echo study using a novel, commercially-available dedicated software package

 

Tricuspid annulus (TA) sizing is essential for percutaneous and surgical procedures. Guidelines recommend to assess TA size by 2D echo (2DE) linear dimension; but TA is a complex 3D structure.

Aim

To identify physiological determinants of TA geometry parameters and their reference values using 3D echo (3DE) and a novel, commercially-available software in healthy volunteers.

Methods

254 healthy volunteers (113 men, mean age 47±11 years) were evaluated by 2D and 3DE. 3DE TA analysis was made in 228 of them (feasibility=90%). TA 3DE area, perimeter, diameters, sphericity index and coaptation (Figure) were assessed at mid-systole using a dedicated software package (4D AutoTVQ, GE Healthcare, Horton, N). 3D right atrial (RA) and ventricular (RV) volumes were measured.

Results

Normal values of 3D TA geometry parameters, RV and RA volumes are presented in table. 3D TA area, perimeter and diameters correlated with BSA (r=0.33 to 0.5, p&lt;0.001) and were larger in men, independently of BSA (p&lt;0.0001). There were no age-related changes in TA parameters (r&lt;0.25, p=0.0001). 2D TA diameters measured in apical 4ch and RV focused views were significantly smaller than 3DE 4ch diameter (16±2 and 16±3 vs 17±3, p&lt;0.0001). RA maximal volumes had the strongest correlation with 3D TA area (r=0.65), compared with RV end-diastolic (r=0.55) and end-systolic (r=0.51) volumes (p&lt;0.0001). By multivariable linear regression, RA maximal volume, sex and BSA, but not RV volumes, were independent predictors of 3D TA area (R2=0.46, p&lt;0.0001).

Conclusions

Reference values for TA metrics should be sex-specific and indexed to BSA. 2DE underestimates TA dimensions. Even if both RA and RV volumes correlate significantly with TA area, only RA maximum volume was an independent predictor of its size at mid-systole.

3D tricuspid annulus parameters

Funding Acknowledgement

Type of funding source: None

Self-monitoring of Blood Pressure in Patients With Hypertension-Related Multi-morbidity: Systematic Review and Individual Patient Data Meta-analysis

BACKGROUND

Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity.

METHODS

A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis.

RESULTS

A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease.

CONCLUSIONS

Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.

Hyperuricemia and Risk of Cardiovascular Outcomes: The Experience of the URRAH (Uric Acid Right for Heart Health) Project

The latest European Guidelines of Arterial Hypertension have officially introduced uric acid evaluation among the cardiovascular risk factors that should be evaluated in order to stratify patient's risk. In fact, it has been extensively evaluated and demonstrated to be an independent predictor not only of all-cause and cardiovascular mortality, but also of myocardial infraction, stroke and heart failure. Despite the large number of studies on this topic, an important open question that still need to be answered is the identification of a cardiovascular uric acid cut-off value. The actual hyperuricemia cut-off (> 6 mg/dL in women and 7 mg/dL in men) is principally based on the saturation point of uric acid but previous evidence suggests that the negative impact of cardiovascular system could occur also at lower levels. In this context, the Working Group on uric acid and CV risk of the Italian Society of Hypertension has designed the Uric acid Right for heArt Health project. The primary objective of this project is to define the level of uricemia above which the independent risk of CV disease may increase in a significantly manner. In this review we will summarize the first results obtained and describe the further planned analysis.

P4685Validation of noninvasive pulmonary artery pressure/flow relationship: echocardiography vs right heart catheterization

Background

Invasive pressure-flow (P/Q) relationship of the pulmonary circulation can detect the presence of pulmonary hypertension (PH) during exercise and provide information on patients' symptoms and assess disease severity. Doppler-echocardiography was reported to provide accurate but imprecise noninvasive estimates of both resting and exercise pulmonary haemodynamics. However, data on the direct comparison of invasive vs noninvasive approaches to build pressure-flow relationship are scarce.

Purpose

To compare echocardiographic estimates with invasive measurements of P/Q relationship of the pulmonary circulation during exercise.

Methods

Patients undergoing a clinically indicated right heart catheterization and echocardiography were studied at rest and during exercise. The ratio between mean pulmonary artery pressure and cardiac output at peak exercise (TPR), as well as P/Q slope throughout exercise were calculated. Both TPR and P/Q slope are abnormal when ≥3 mmHg/L/min. Echocardiographic estimates were compared with invasive measurements.

Results

Sixty patients were included (mean age 65±14 years, 73% female). PH was present at rest in 38 cases (63%), of precapillary origin in 23 (61%). Heart failure with preserved ejection fraction was diagnosed in 23 patients, of which 17 had no PH at rest. TPR at peak exercise and P/Q slope were abnormal (≥3 mmHg/L/min) in the majority of patients (56 and 45 subjects, respectively).

Echocardiographic estimates of P/Q slope and TPR correlated significantly although weakly with invasive measurements (R2=0.38 and 0.56, respectively, p<0.001). Bias of echocardiography for P/Q slope and TPR was 1.1±4.2 and 0.4±2.9 mmHg/L/min, respectively (figure). Sensitivity of echocardiography to detect an abnormal TPR or P/Q slope (i.e. ≥3 mmHg/L/min) was 100 and 98%, respectively, faced by low specificity (0 and 33%, respectively).

Figure 1

Conclusions

Doppler-echocardiography can provide rather accurate and sensitive but imprecise estimates of pressure-flow relationships of the pulmonary circulation during exercise. This intrinsic imprecision may limit its use in clinical practice.

Obstructive sleep apnea syndrome and autonomic dysfunction

Autonomic nervous system (ANS) has been extensively explored in obstructive sleep apnea (OSA). Autonomic alterations in these patients have been described by means of several methods, evaluating ANS function both directly with microneurography and indirectly through baroreflex sensitivity (BRS, by the sequence method or the cross-spectral approach), heart rate variability analysis (HRV, both in the time and frequency domain) during sleep and wake, or conventional laboratory tests, including cold pressor test, hand grip test or measurement of urinary cathecolamine excretion. Several studies in OSA patients have shown ANS alterations, in particular sympathetic overactivity, both acutely during apnea events and chronically during the daytime, being both also involved in cardiovascular consequences of sleep disordered breathing. The association between OSA and sympathetic dysregulation suggests a dose response relationship between OSA severity and the degree of sympathetic overactivity and this association seems to be reversible as the treatment of OSA is implemented. Additionally ANS is involved in regulating visceral and humoral functions to maintain the body homeostasis and in reaction and adaptation to external and internal stressor stimuli. However, the vast majority of studies have focussed on cardiovascular alterations, which are easier to measure, somewhat neglecting the other functions regulated by ANS. More evidence is therefore needed to better characterize the impact that sleep disorder breathing may have on ANS both in the short and long term.

Automated office blood pressure measurements in primary care are misleading in more than one third of treated hypertensives: The VALENTINE-Greece Home Blood Pressure Monitoring study

BACKGROUND

This study assessed the diagnostic reliability of automated office blood pressure (OBP) measurements in treated hypertensive patients in primary care by evaluating the prevalence of white coat hypertension (WCH) and masked uncontrolled hypertension (MUCH) phenomena.

METHODS

Primary care physicians, nationwide in Greece, assessed consecutive hypertensive patients on stable treatment using OBP (1 visit, triplicate measurements) and home blood pressure (HBP) measurements (7 days, duplicate morning and evening measurements). All measurements were performed using validated automated devices with bluetooth capacity (Omron M7 Intelli-IT). Uncontrolled OBP was defined as ≥140/90 mmHg, and uncontrolled HBP was defined as ≥135/85 mmHg.

RESULTS

A total of 790 patients recruited by 135 doctors were analyzed (age: 64.5 ± 14.4 years, diabetics: 21.4%, smokers: 20.6%, and average number of antihypertensive drugs: 1.6 ± 0.8). OBP (137.5 ± 9.4/84.3 ± 7.7 mmHg, systolic/diastolic) was higher than HBP (130.6 ± 11.2/79.9 ± 8 mmHg; difference 6.9 ± 11.6/4.4 ± 7.6 mmHg, p < 0.001). WCH phenomenon (high OBP with low HBP) was observed in 22.7% of the patients, MUCH (low OBP with high HBP) in 15.8%, uncontrolled hypertension (high OBP with high HBP) in 29.9%, and controlled hypertension (low OBP with low HBP) in 31.6%. In multivariate logistic regression analysis, WCH was determined by stage-1 systolic hypertension (odds ratio [OR] 8.6, 95% confidence intervals [CI] 5.7, 13.1) and female gender (OR 1.6, 95% CI 1.1, 2.4), whereas MUCH was determined by high-normal systolic OBP (OR 6.2, 95% CI 3.8, 10.1) and male gender (OR 2.0, 95% CI 1.2, 3.1).

CONCLUSIONS

In primary care, automated OBP measurements are misleading in approximately 40% of treated hypertensive patients. HBP monitoring is mandatory to avoid overtreatment of subjects with WCH phenomenon and prevent undertreatment and subsequent excess cardiovascular disease in MUCH.