The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.

Endothelial dysfunction due to decreased nitric oxide bioavailability in dysglycaemic subjects and first-degree relatives of type 2 diabetic patients

Background/Introduction

Oxidative stress plays an important role in the pathogenesis of type 2 diabetes mellitus.

Purpose

We aimed to investigate oxidative stress and nitrites/nitrates concentrations at baseline and during postprandial hyperglycaemia in 40 first-degree relatives (FDR) of type 2 diabetic patients with normal oral glucose test (OGTT), 40 subjects with abnormal OGTT (dysglycaemic) and 20 subjects with normal OGTT without parental history of diabetes (normoglycaemic).

Methods

Perfused boundary region (PBR) of the sublingual microvessels with a diameter 5–25μm (Microscan, Glycocheck), a marker of endothelial glycocalyx integrity, coronary flow reserve (CFR) in the distal left anterior descending coronary artery, left ventricular global longitudinal strain (GLS), malondialdehyde (MDA), protein carbonyls (PC) and nitrites/nitrates plasma levels were assessed at 0 and 120 min of a 2-hour OGTT. Insulin sensitivity was evaluated using Matsuda and insulin sensitivity index (ISI).

Results

In all subjects, there were no significant changes in MDA and PC at 120 min after OGTT (p>0.05). Compared with normoglycaemic subjects, in FDR and dysglycaemic subjects, nitrites/nitrates levels were significantly decreased at 120 min (−24% versus −30% versus −3%, respectively) with a parallel increase in PBR (+7% versus +10% versus −3%) and a reduction in CFR (−11% versus −14% versus −6%) and GLS (−4% versus −4% versus +0.1%) (p<0.05 for all comparisons). The percent reduction of nitrites/nitrates levels was associated with abnormal values of Matsuda and ISI, reversely related with the percent increase of PBR (r=−0.60, p=0.001) and positively related with the percent decrease of CFR (r=0.39, p=0.038) and GLS (r=0.48, p=0.008).

Conclusion

Insulin resistance determines acute endothelial responses during OGTT leading to reduced nitric oxide production with resultant coronary and myocardial dysfunction in FDR and dysglycaemic subjects.

Funding Acknowledgement

Type of funding sources: None.

Differences in coronary flow reserve and flow-mediated dilation between plaque psoriasis and psoriatic arthritis

Background/Introduction

Psoriatic disease is associated with increased cardiovascular risk through mechanisms of inflammation and oxidative stress.

Purpose

We aimed to investigate endothelial glycocalyx, coronary microcirculatory function and flow-mediated dilation in patients with plaque psoriasis and psoriatic arthritis.

Methods

In 311 patients (mean age: 52±12 years) with psoriatic disease (185 with plaque psoriasis and 126 with psoriatic arthritis) and 150 controls with similar age, sex and atherosclerotic risk factors, we assessed: (1) Perfused boundary region (PBR) of the sublingual microvessels with a diameter 5–25μm using Sidestream Dark Field camera (Microscan, Glycocheck). Increased PBR indicates impaired glycocalyx integrity. (2) Coronary flow reserve (CFR) in the distal left anterior descending coronary artery, (3) Flow-mediated dilation (FMD) of the brachial artery, and (4) LV global longitudinal strain (GLS) using speckle-tracking echocardiography.

Results

Compared with controls, patients with psoriatic disease had higher PBR (2.14±0.29 versus 1.78±0.25μm, p<0.001) and lower CFR (2.86±0.93 versus 3.39±0.68, p<0.001), FMD (6.97±3.9 versus 9.1±2.1, p<0.001) and GLS (−17.4±3.8 versus −21.9±1.5%, p<0.001). There was not significant difference between the two study groups (plaque psoriasis and psoriatic arthritis) in PBR (2.14±0.28 versus 2.14±0.31μm, p=0.990) and GLS (−17.2±3.9 versus −17.6±3.8%, p=0.297). Patients with psoriatic arthritis had more impaired CFR (2.75±0.85 versus 2.96±0.99, p=0.045) and FMD (5.45±3.2 versus 7.76±4, p=0.003) compared to patients with plaque psoriasis.

Conclusions

Patients with psoriatic disease have impaired endothelial, vascular and myocardial function compared with controls. Coronary microcirculatory function and flow-mediated dilation are more affected in psoriatic arthritis compared with plaque psoriasis.

Funding Acknowledgement

Type of funding sources: None.

The additive predictive value of arterial stiffness for outcome to endothelial glycocalyx and SCORE in middle age individuals: 6 years follow-up

Background/Aim

Arterial stiffness is involved in the clinical course of atherogenesis. We have previously shown that PBR, a marker of glycocalyx integrity is predictor of cardiovascular events in patients without established cardiovascular disease. The purpose of this study was to investigate whether altered arterial properties of the vessels confers predictively and additively to estimation of cardiovascular risk.

Methods

Pulse wave velocity carotid-femoral (PWVc-f), the gold standard method to assess arterial stiffness, was measured non-invasively by Complior device. Increased PWV(c-f), especially above 10 m/s, indicates increased arterial stiffness. We measured baseline PWV(c-f) in 600 apparently healthy subjects (47.61±13.84 years old, 50.1% males), without established cardiovascular disease. We prospectively monitored the occurrence of major cardiovascular events (MACE-death, myocardial infarction, stroke and heart failure hospitalization) during a 6-year follow-up period using electronic records and clinic visits.

Results

Fifty-seven MACEs were documented during follow-up. In univariate analysis, subjects with increased PWV were found to exert greater risk for MACEs (hazard ratio (HR): 1.09, 95% CI: 1.02–1.17, p=0.01). In all subjects, PWV predicted higher risk for MACEs in a model including PBR, sex, age, hyperlipidemia, diabetes, hypertension, current smoking, family history of coronary artery disease and treatment with ACEi/ARBs or lipid lowering agents (HR: 1.12; 95% CI: 1.04–1.17, p=0.029,net reclassification improvement (NRI): 23%; C-statistic: from 0.644 to 0.697). However, only in participants older than 50 years old, PWV was an independent and additive predictor of outcome when added in a model including PBR, SCORE, those risk factors not included in SCORE (diabetes, family history of CAD) and medication (HR: 1.09; 95% CI: 1.02–1.13, NRI: 23.8%, C-statistic increase from 0.703 to 0.762, p<0.01).

Conclusion

Arterial stiffness is an independent and additive predictor to endothelial glycocalyx and SCORE for adverse outcome at 6 years follow-up in individuals over 50 years old.

Funding Acknowledgement

Type of funding sources: None.

Biologics improve endothelial, vascular and left ventricular myocardial function in patients with psoriatic arthritis

Background/Introduction

Psoriatic arthritis is characterized by systemic inflammation leading to an increased risk of cardiovascular diseases.

Purpose

We aimed to investigate the effects of biologics on endothelial glycocalyx, vascular and left ventricular (LV) myocardial function in patients with psoriatic arthritis.

Methods

One hundred twenty patients (mean age: 51±11 years) with psoriatic arthritis were randomized to receive biologics [n=60; anti-tumor necrosis factor-α (etanercept, adalimumab, infliximab), anti-interleukin (IL)-12/23 (ustekinumab) or anti-IL-17 (secukinumab)] or nonbiologics (n=60; methotrexate or cyclosporine). At baseline and 4 months post-treatment, we measured: (1) Perfused boundary region (PBR) of the sublingual microvessels with a diameter 5–25μm using Sidestream Dark Field camera (Microscan, Glycocheck). Increased PBR indicates impaired glycocalyx integrity. (2) Pulse wave velocity (PWV - Complior; ALAM Medical), (3) Coronary flow reserve (CFR) in the distal left anterior descending coronary artery, (4) Flow-mediated dilation (FMD) of the brachial artery and (5) LV global longitudinal strain (GLS) using speckle-tracking echocardiography.

Results

Compared with baseline, all patients had reduced PWV (11±2.1 versus 10.3±1.5m/s, p=0.001) and increased FMD (5.45±3.2 versus 9.77±4.7, p=0.004) at 4 months. PBR remained unchanged in both study groups (p>0.05). Compared with nonbiologics, biologics resulted in a greater reduction of PWV (−10% versus −4%) and in a greater increase of CFR (+11% versus −1%), FMD (+102% versus +56%) and GLS (+10% versus −2%) (p>0.05 for all comparisons) 4 months post-treatment. In patients treated with biologics, the percent increase of GLS post-treatment was related with the percent reduction of PWV (r=−0.28, p=0.034) and with the percent increase of FMD (r=0.42, p=0.006).

Conclusion

In psoriasis arthritis, biologics confers a greater improvement of endothelial, vascular and LV myocardial function compared with nonbiologics after 4-month treatment.

Funding Acknowledgement

Type of funding sources: None.

First-degree relatives of type-2 diabetic patients and dysglycaemic patients have impaired endothelial function due to decreased bioavailability of nitric oxide

Background/Introduction

Oxidative stress plays an important role in the pathogenesis of type 2 diabetes.

Purpose

We investigated oxidative stress in first-degree relatives of type-2 diabetes patients (FDR) since they are more prone to develop type-2 diabetes, at baseline and during postprandial hyperglycemia in comparison with dysglycaemic or normoglycaemic subjects. We evaluated these results in relation to vascular function.

Methods

We studied 40 FDR with normal oral glucose test (OGTT), 40 subjects with abnormal OGTT (dysglycaemic) and 20 subjects with normal OGTT without parental history of diabetes (normoglycaemic) with similar demographical and clinical characteristics. Glucose and insulin levels, pulse wave velocity (PWV-Complior, ALAM), central systolic blood pressure (cSBP) and augmentation index (AI) were measured at baseline, 30, 60, 90 and 120min during OGTT. Perfused boundary region (PBR-Microscan, Glycocheck) of the sublingual arterial microvessels (high PBR values represent reduced glycocalyx thickness), plasma concentrations of malondialdehyde (MDA) and protein carbonyls (PCs) as markers of lipid peroxidation and protein oxidation, respectively, and nitrite/nitrates levels as markers for NO biosynthesis, were assessed at baseline and at 120min of OGTT. Insulin sensitivity was evaluated using Matsuda and insulin sensitivity index (ISI).

Results

FDR and dysglycaemics patients had higher fasting insulin, reduced ISI, Matsuda index as well as increased PBR (2.5±0.5 vs. 2.5±0.6 vs. 2.4±0.3μm), increased PWV (8.9±1.1 vs. 10.3±2.4 vs. 8.0±1.5m/s), AI, MDA, PCs and nitrite/nitrate than normoglycaemic subjects (p<0.05 for all comparisons). ISI was negatively related with PBR and MDA (r=−0.35 and r=−0.34, p<0.05) at baseline in FDR and dysglycaemics. During OGTT, AI was similarly reduced in both normoglycaemics and FDR whereas AI was significantly increased in dysglycaemics at 120min (p<0.05). PBR was increased by 7.5% and 4% at 120min in dysglycaemics and FDR, respectively, while remained unchanged in normoglycaemics (p<0.05). In dysglycaemics and FDR, nitrite/nitrate levels were significantly decreased at 120min (52.85±8.22 vs. 36.31±4.36 and 48.23±7.20 vs. 34.70±4.71nmol/ml, respectively, p<0.05) while they were remained unchanged in normoglycaemics likely leading to a greater decrease of MDA (−83% vs. −40% vs. −48%) and of PCs (−28% vs. −7% vs. −16%) in normoglycaemics compared with dysglycaemics and FDR (p<0.05).

Conclusions

Insulin resistance determines acute endothelial responses during postprandial hyperglycemia leading to reduced NO production and thus facilitating augmentation of oxidative stress during postprandial hyperglycemia in dysglycaemic patients and FDR of diabetic patients.

Funding Acknowledgement

Type of funding sources: None.

Effects of hormone replacement therapy on endothelial function, arterial stiffness and myocardial deformation in women with Turner syndrome

Background/Introduction

Turner syndrome (TS) is associated with increased cardiovascular risk.

Purpose

We investigated whether hormone replacement therapy (HRT) affects endothelial function, arterial stiffness and myocardial deformation in women with TS.

Methods

Twenty-five women with TS were studied in the estrogen phase of the HRT and two months after discontinuation of HRT. The following measurements were made: flow-mediated dilatation (FMD) of the brachial artery, pulse wave velocity (PWV-Complior) and central systolic blood pressure (cSBP), carotid intima-media thickness (cIMT), aortic (Ao) elastic indexes-namely Ao strain, distensibility, stiffness index and pressure strain modulus (Ep)-and left ventricular (LV) global longitudinal strain (GLS) using speckle tracking echocardiography. Ten healthy female of similar age and BMI served as control group.

Results

Compared to controls, women with TS on HRT had higher PWV (9.1±2.4 vs. 7.5±0.5m/s), cSBP (130±15 vs. 121±6mmHg), cIMT (0.66±0.06 vs. 0.55±0.05mm), aortic stiffness index, Ep and LA strain, and lower FMD (7.2±4 vs. 10.5±2.3%), Ao strain, Ao distensibility and GLS (−18.8±2.7 vs. −21.9±1.5%) (P<0.05 for all comparisons). Two months after discontinuation of HRT, all women increased FMD (11.7±6 vs. 7.2±4%) and reduced PWV (7.8±1.7 vs. 9.1±2.4m/s) and cSBP (123±14 vs. 130±15mmHg). There were no statistically significant changes in BMI, cIMT and GLS (P>0.05 for all comparisons). The percent decrease of cSBP was associated with the percent decrease of PWV (r=0.54) and reversely related with the percent increase of FMD (r=−0.57) (P<0.05 for all comparisons).

Conclusion

HRT in women with TS may deteriorate endothelial function contributing to increased arterial stiffness and central arterial blood pressure.

Funding Acknowledgement

Type of funding sources: None.

Apremilast improves endothelial glycocalyx and microvascular perfusion: a possible protective mechanism against COVID-19

Background/Introduction

The phosphodiesterase 4 inhibitor apremilast is an approved treatment option for psoriasis.

Purpose

We aimed to investigate the effects of apremilast on endothelial glycocalyx, vascular and left ventricular (LV) myocardial function in psoriasis.

Methods

Ninety patients with psoriasis were randomized to receive apremilast (n=30), anti-tumor necrosis factor-a (etanercept, n=30), or cyclosporine treatment (n=30). At baseline and 4 months post-treatment, we measured: (1)Perfused boundary region (PBR) of the sublingual microvessels with a diameter 5–25μm using a dedicated camera (Sidestream Dark Field imaging, Microscan, Glycocheck). Increased PBR indicates reduced glycocalyx thickness. Perfused microvascular density (PMD), an index of microvascular perfusion, was also measured. (2)Pulse wave velocity (PWV - Complior; ALAM Medical) and central systolic blood pressure (cSBP), and (3)LV global longitudinal strain (GLS) and percent difference between peak twisting and untwisting at mitral valve opening (%dpTw-UtwMVO) using speckle-tracking echocardiography.

Results

Compared with baseline, PBR20–25 decreased only after apremilast treatment (−13% at 4 months, P<0.05) whereas no statistically significant changes in PBR20–25 were observed after etanercept or cyclosporine. Compared with etanercept and cyclosporine, apremilast resulted in a greater increase of PMD (+12% versus +3% versus +3%) and in a higher reduction of PWV (−10% versus −3% versus +8%) and cSBP (−8% versus −2% versus +7%) at 4 months. Apremilast showed a greater increase of GLS (+12% versus +5% versus +2%) and %dpTw-UtwMVO (+15% versus +3% versus +3%) than etanercept and cyclosporine (P<0.05 for all comparisons). Changes of PBR and PMD post-apremilast treatment correlated with a concomitant reduction of PWV and cSBP (P<0.05).

Conclusions

In psoriasis, apremilast confers a greater improvement of endothelial glycocalyx, microvascular perfusion and LV myocardial function compared with etanercept or cyclosporine treatment. Apremilast restores glycocalyx integrity and thus reduces vascular permeability to pro-inflammatory molecules. This may explain the beneficial effects of apremilast on COVID-19.

Funding Acknowledgement

Type of funding sources: None.

Endothelial glycocalyx integrity and microvascular perfusion are associated with novel echocardiographic markers and carotid intima-media thickness in patients with psoriasis

Background/Introduction

Psoriasis has been associated with vascular and myocardial dysfunction through mechanisms of inflammation and oxidative stress.

Purpose

We aimed to evaluate sublingual microvascular perfusion and glycocalyx barrier properties in psoriasis patients, as well as their correlation with coronary microcirculatory function and markers of myocardial deformation and atherosclerosis (carotid intima-media thickness, cIMT).

Methods

We examined 297 patients with psoriasis and 150 controls, adjusted for age, sex, and atherosclerotic risk factors. Perfusion boundary region (PBR), a marker of glycocalyx barrier function, was measured non-invasively in sublingual microvessels with a diameter ranging from 5–25μm using a dedicated camera (Sidestream Dark Field imaging, Microscan, GlycoCheck). Increased PBR indicates reduced glycocalyx thickness. Indexes of microvascular perfusion, including red blood cell (RBC) filling percentage and functional microvascular density, were also calculated. We measured coronary flow reserve (CFR), cIMT and markers of myocardial deformation by speckle tracking imaging utilizing echocardiography [peak twisting, the percentage changes between peak twisting, and untwisting at mitral valve opening (%dpTw-UtwMVO), at peak (%dpTw-UtwPEF), and the end of early LV diastolic filling (%dpTw-UtwEDF)].

Results

Psoriasis patients had higher PBR5–25 compared to controls (2.13±0.29 versus 1.78±0.25μm, p<0.05). There was an inverse association of PBR5–25 with perfused microvascular density (r=−0.42, p<0.001) and RBC fraction (r=−0.80, p<0.001). In psoriatic population, PBR5–25 was inversely correlated to CFR (r=−0.30, p=0.045). Increased values of PBR5–9 were associated with reduced untwisting at the end of the mitral inflow E wave (r=−0.24, p=0.006) and reduced %dpTw-UtwMVO (r=−0.35, p<0.001). Furthermore, decreased RBC filling percentage and perfused microvascular density were related to worse LV longitudinal strain and increased cIMT (p<0.05). Finally, a positive correlation between perfused microvascular density and %dpTw-UtwMVO was observed in patients with psoriasis (p<0.05).

Conclusion

Endothelial glycocalyx thickness is reduced in patients with psoriasis and is associated with impaired coronary and myocardial function, and vascular atherosclerosis.

Funding Acknowledgement

Type of funding sources: None.

Association of endothelial glycocalyx integrity and microvascular perfusion with novel echocardiographic markers and carotid intima-media thickness in patients with psoriasis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Psoriasis has been associated with vascular and myocardial dysfunction through mechanisms of inflammation and oxidative stress.

Purpose

We aimed to evaluate sublingual microvascular perfusion and glycocalyx barrier properties in psoriasis patients, as well as their correlation with coronary microcirculatory function, markers of myocardial deformation and atherosclerosis (carotid intima-media thickness, IMT).

Methods

We examined 241 patients with psoriasis and 160 controls, adjusted for age, sex, BMI, smoking, LV mass, heart rate, hyperlipidemia, and office SBP. Perfusion boundary region (PBR), a marker of glycocalyx barrier function, was measured non-invasively in sublingual microvessels with a diameter ranging from 5-25 µm using a dedicated camera (Side field dark imaging,  Micrsoscan, Nedelrands). Increased PBR indicates reduced glycocalyx thickness. Indexes of microvascular perfusion, including red blood cell (RBC) filling percentage and functional microvascular density, were also calculated. We measured coronary flow reserve (CFR), carotid IMT and markers of myocardial deformation by speckle tracking imaging utilizing echocardiography [peak twisting, the percentage changes between peak twisting, and untwisting at mitral valve opening (%dpTw – UtwMVO), at peak (%dpTw – UtwPEF), and the end of early LV diastolic filling (%dpTw – UtwEDF)].

Results

Psoriasis patients had higher PBR (PBR5-25: 2.131 ± 0.296 vs. 1.769 ± 0.306; PBR5-9: 1.183 ± 0.150 vs. 1.051 ± 0.132; PBR10-19: 2.318 ± 0.581 vs. 1.993 ± 0.365; PBR20-25: 2.650 ± 0.461 vs. 2.269 ± 0.492, all p < 0.05) and impaired LV twisting-untwisting markers compared to controls (pTw: 14.8 ± 7.8 vs. 13.9 ± 3.5; UtwMVO: 10.3 ± 7.3 vs. 9 ± 4.3; %dpTw – UtwMVO: 31 ± 4.1 vs. 38 ± 7; pTwVel: 105 ± 83 vs. 89 ± 21; pUtwVel: -100 ± 53 vs. -93 ± 31, all p < 0.05).

In psoriatic population, levels of PBR5-25 and PBR10-19 were inversely correlated to CFR (r=-0.15 and r=-0.17). The first one was also reversely related to peak LV untwisting at aortic valve closure (r=-0.14). Increased levels of PBR5-9 were associated with reduced untwisting at end of the mitral inflow E wave (UtwEDF, r=-0.13) and reduced percentage difference between peak twisting and untwisting at MVO (%dpTw-UntwMVO) (r=-0.15). Furthermore, decreased RBC filling percentage and perfused microvascular density were related to worse LV longitudinal strain (4-chamber) (r=-0.15), and increased IMT (r=-0.14). Finally, a positive correlation between perfused microvascular density and %dpTw-UntwMVO was observed in patients with psoriasis (r = 0.14). All correlations were statistically significant (p < 0.05).

Conclusion

Endothelial glycocalyx thickness is reduced in patients with psoriasis and is associated with impaired coronary and myocardial function, and vascular atherosclerosis.

Effects of heat-not-burn compared to combustible cigarettes on coronary flow, myocardial work index and vascular function

Funding Acknowledgements

Type of funding sources: None.

Aim/Introduction:

Heat-not-burn cigarette (HNBC) constitutes a non-combustible smoke product.

Purpose

We compare the effects of heat-not-burn and conventional cigarettes on coronary flow, myocardial and vascular function, platelet activation and oxidative stress.

Methods

We compared the effects of HNBC to those of tobacco cigarette (TCig), on arterial stiffness, oxidative stress, and platelet activation, acutely and after 1 month of switching to HNBC, as well as on endothelial, myocardial, and coronary function after 1 month of switching to HNBC. In the acute study, 50 smokers were randomized into smoking a single Tcig or an HNBC and after 60 minutes were crossed over to the alternate smoking (HNBC or Tcig). For the chronic phase, 75 smokers were examined. Of those, 50 were switched to HNBC and 25 continued Tcig for 1 month. Pulse wave velocity (PWV) and biomarkers [malondialdehyde (MDA), protein carbonyls (PC), and thromboxane B2 (TXB2)] were assessed in the acute and chronic study. Myocardial deformation [global longitundinal strain (GLS), myocardial work index (GWI) and wasted myocardial work (GWW)], coronary flow reserve (CFR) by Doppler echocardiography, total arterial compliance (TAC), and flow-mediated dilation (FMD) were additionally assessed in the chronic study.

Results

Compared to baseline, TCig smoking acutely increased exhaled CO, PWV, MDA, and TxB2 (p < 0.05), while no changes were observed after HNBC. Compared to resuming Tcig smoking, switching to HNBC for 1 month improved CO (mean change: -55% vs -2.4%), FMD ( +55% vs +15%), CFR (+46% vs +4%), TAC (+9% vs -0.5%), GLS (+6% vs +1%), GWW (-19% vs +0.5%), MDA (-19% vs 1 %), and TxB2 (-12% vs 4%) (p < 0.05 for all comparisons).

Conclusions

HNBCs exert a less detrimental effect on vascular, cardiac and platelet function than combustible tobacco.

Effects of glucagon like peptide-1 receptor agonists and their combination with sodium-glucose cotransporter-2 inhibitors on myocardial deformation and work index in type 2 diabetes: 1 year follow up

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction:

Type-2 diabetes mellitus (T2DM) exacerbates mechanisms of atherosclerosis and heart failure.

Purpose

We investigated the effect of novel antidiabetic drugs, glucagon like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on myocardial function.

Methods

A hundred-sixty T2DM patients (age: 58 ± 10years) were randomized to insulin (n = 40), liraglutide (n = 40), empagliflozin (n = 40) or their combination (GLP-1RA + SGLT-2i) (n = 40) as add-on to metformin. We measured at baseline and 1 year post-treatment: a) global LV longitudinal strain (GLS), systolic (GLSR) and diastolic (GLSR E) strain rate, global circumferential (GCS) and radial (GRS) strain, peak twisting (pTw), peak twisting velocity (pTwVel) and peak untwisting velocity (pUtwVel), b) global myocardial work index (GWI), global constructive (GCW) and global wasted work (GWW) derived by pressure-myocardial strain loops using speckle tracking imaging.

Results

After 1 year of treatment, all patients improved GLS, GCS, GRS and pUtwVel (p < 0.05). GLP-1RA or GLP-1RA + SGLT-2i provided a greater increase of GLS (11.5% and 13% vs. 6.8% and 2.3%), GWI (12.7% and 17.4% vs. 3.1% and 2%), GCW (12.3% and 15% vs. 2.2% and 7.8%) and a greater reduction of GWW (38.7% and 41.6% vs. 13.5% and 4.9%) compared with insulin or SGLT-2i, despite a similar HbA1c reduction (p < 0.05 for all comparisons) (Table). Patients under combined treatment with GLP-1RA + SGLT-2i achieved a 2-fold reduction of pTw and a 2-fold increase of pUtwVel than those under each one regimen or insulin (p < 0.05). The dual therapy showed the greatest effect on measured myocardial markers in LVEF < 55% (p < 0.05).

Conclusions

One year treatment with GLP-1RA or combination of GLP-1RA and SGLT-2i resulted in a greater improvement of myocardial deformation and effective cardiac work than insulin or SGLT-2i treatment, independently of glycemic control in T2DM.

All patients (n = 160) Insulin (n = 40) GLP-1RA (n = 40) SGLT-2i (n = 40) GLP-1RA + SGLT-2i (n = 40) p-value GLS, % Baseline -16.4 ± 3.7 -16.4 ± 3.5 -16.2 ± 3.5 -17 ± 4 -16 ± 4 0.139 1 year -17.9 ± 3.9 -17.6 ± 4.2 -18.3 ± 3.5 -17.4 ± 3.4 -18.4 ± 4.7 0.003 GWI, mmHg% Baseline 1538 ± 430 1644 ± 416 1510 ± 403 1536 ± 535 1463 ± 362 0.116 1 year 1692 ± 412 1696 ± 377 1730 ± 318 1568 ± 456 1772 ± 499 0.006 pTw, deg Baseline 15.7 ± 6 16 ± 5.1 15.6 ± 5 15.2 ± 6 16.1 ± 8 0.910 1 year 14.6 ± 5.1 15.4 ± 5.4 14.4 ± 5.4 14.7 ± 4.6 14 ± 5 0.034 pUtwVel, deg/s Baseline -104 ± 42 -100 ± 44 -107 ± 41 -101 ± 28 -111 ± 54 0.550 1 year -116 ± 49 -107 ± 55 -114 ± 45 -108 ± 38 -134 ± 61 0.017 Table

Arterial wall stiffness in patients with abdominal aortic aneurysms and concomitant coronary artery disease

Introduction

Pulse wave velocity (PWV) is a valid, clinically feasible marker of arterial stiffening, and a strong predictor of outcomes. In patients with abdominal aortic aneurysms (AAA) alterations in arterial wall composition and inflammation were proposed as possible contributors to increased arterial stiffness.

Purpose

The present study aimed to compare aortic elastic properties in patients with abdominal aortic aneurysms (AAA), with or without coronary artery disease (CAD), as well as healthy individuals.

Methods

A total of 130 patients with AAA, eligible for interventional repair, and 30 healthy individuals, comprising the control group (HC), were evaluated. Study groups did not differ in anthropometrical characteristics and CV risk factors. Presence of CAD was identified by coronary angiography. Aortic PWV (aPWV) was measured using the Arteriograph method.

Results

aPWV was found considerably higher in AAA patients compared to HC group (11.5±2.9 vs. 7.3±1.6 m/s, p<0.001), after adjustment for age, sex and mean arterial pressure (MAP). Interestingly, among patients with AAA, those with concomitant CAD (n=41) had higher aPWV than those without CAD (12.5±2.9 vs. 11.0±3.0 m/s, p=0.03), after adjustment for age, sex and MAP. In receiver-operator-curve (ROC) analysis, the area under the curve (AUC) of aPWV for the prediction of CAD presence in the AAA study group was 0.72 [95% confidence interval (CI): 0.55–0.84, p=0.03]. According to this, the best cut-off was a value of aPWV above 12.8 m/s (78% sensitivity and 73% specificity). This cut-off was identified as a significant predictor of CAD presence in the AAA study population according to univariate logistic regression analysis (OR=2.51, 95% CI: 1.79–5.19, p=0.02). After adjustment for age, sex, dyslipidemia, smoking and MAP in multivariate logistic regression analysis, the cut-off aPWV level remained independently associated with the presence of CAD (OR=1.64, 95% CI: 1.19–4.08, p=0.03).

Conclusion

The co-existence of CAD and AAA is characterized by a greater arterial stiffness. This finding supports a role of measuring arterial stiffness markers when evaluating AAA patients' cardiovascular risk and selecting endovascular stents with more favorable elastic properties. Further studies are needed to explore whether aPWV values could be used to as a screening tool to detect CAD or to guide treatment in AAA patients.

Funding Acknowledgement

Type of funding source: None

Differential effects of heat-not-burn and conventional cigarettes on coronary flow, myocardial and vascular function, platelet activation and oxidative stress

 

Heat-not-burn cigarette (HNBC) constitutes a non-combustible smoke product.

Methods

We compared the effects of HNBC to those of tobacco cigarette (TCig), on arterial stiffness, oxidative stress, and platelet activation, acutely and after 1 month of switching to HNBC, as well as on endothelial, myocardial, and coronary function after 1 month of switching to HNBC. In the acute study, 50 smokers were randomised into smoking a single Tcig or an HNBC and after 60 minutes were crossed over to the alternate smoking (HNBC or Tcig). For the chronic phase, 75 smokers were examined. Of those, 50 were switched to HNBC and 25 continued Tcig for 1 month. Pulse wave velocity (PWV) and biomarkers [malondialdehyde (MDA), protein carbonyls (PC), and thromboxane B2 (TXB2)] were assessed in the acute and chronic study. Myocardial deformation [global longitundinal strain (GLS), myocardial work index (GWI) and wasted myocardial work (GWW)], coronary flow reserve (CFR) by echocardiography, total arterial compliance (TAC), and flow-mediated dilation (FMD) were additionally assessed in the chronic study.

Results

Compared to baseline, TCig smoking acutely increased exhaled CO, PWV, MDA, and TxB2 (p<0.05), while no changes were observed after HNBC. Compared to resuming Tcig smoking, switching to HNBC for 1 month improved CO (mean change: −55% vs −2.4%), FMD (+55% vs +15%), CFR (+46% vs +4%), TAC (+9% vs −0.5%), GLS (+6% vs +1%), GWW (−19% vs +0.5%), MDA (−19% vs 1%), and TxB2 (−12% vs 4%) (p<0.05 for all comparisons).

Conclusions

HNBCs exert a less detrimental effect on vascular, cardiac and platelet function than tobacco

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Hellenic Association of Lipidiology, Atherosclerosis and Vascular disease

Effects of glucagon like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors and their combination on vascular function and myocardial work index in patient with type-2 diabetes

Background/Introduction

Type-2 diabetes mellitus (T2DM) is associated with endothelial and myocardial dysfunction.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on vascular and cardiac function of T2DM patients.

Methods

A hundred-sixty T2DM patients were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) perfused boundary region (PBR) of the sublingual arterial microvessels (marker of glycocalyx thickness), b) pulse wave velocity (PWV), central systolic blood pressure (cSBP), c) global LV longitudinal (GLS), circumferential (GCS) and radial (GRS) strain, d) the ratio PWV/GLS, as an index of ventricular-arterial interaction, e) myocardial work index (GWI) using speckle tracking imaging.

Results

Twelve months post-treatment, all patients improved PBR, PWV, GLS, GCS and GRS (p<0.05). GLP-1RA, SGLT-2i and their combination showed a greater reduction of PBR, PWV and cSBP than insulin, despite a similar HbA1c reduction (p<0.05). GLP-1RA or GLP-1RA+SGLT-2i provided a greater decrease of PWV/GLS (28.1% and 31% vs. 11.1% and 14.5%) and a greater increase of GWI (12.7% and 17.4% vs. 3.1% and 2%) compared with insulin or SGLT-2i. SGLT-2i or GLP-1RA+SGLT-2i showed a greater decrease of PWV (10.1% and 13%), cSBP than insulin or GLP-1RA (PWV: 3.6% and 8.6%) (p<0.05 for all comparisons) (Table 1). The dual therapy showed the greatest effect on measured markers in patients with LVEF <55% (p<0.05).

Conclusions

Twelve-month treatment with GLP-1RA, SGLT-2i and their combination showed a greater improvement of vascular markers and effective cardiac work than insulin in T2DM. The combined therapy was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None

In-hospital prognosis of patients with primary and secondary acute heart failure diagnosis

Introduction

Secondary acute heart failure (AHF) during hospitalization for another primary diagnosis is a frequent in-hospital complication.

Purpose

This analysis aims to describe differences in prognosis of these patients in comparison with patients admitted for AHF (primary AHF diagnosis) and also identify factors associated with in-hospital mortality.

Methods

This is a sub-analysis of the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF), which enrolled 4953 patients from 9 countries. All parameters univariately associated with in-hospital mortality in the primary and secondary AHF groups were included in the multivariate logistic regression model.

Results

Secondary AHF diagnosis was observed in 24.1% (N=1196) of the total study cohort. These patients demonstrated almost double all-cause in-hospital mortality rates compared to patients with primary AHF (16.9% versus 8.9%, p<0.001).

In patients with primary AHF, negative prognostic factors included older age (>75 years) (OR 2.01, 95% CI 1.24–3.26, p=0.004), acute coronary syndromes (ACS) (OR 2.71, 95% CI 1.57–4.69, p<0.001), chronic renal disease (OR 2.02, 95% CI 1.13–3.61, p=0.017), presence of cold extremities (OR 2.04, 95% CI 1.23–3.40, p=0.006), in-hospital treatment with CPAP (OR 2.55, 95% CI 1.20–5.41, p=0.014), dobutamine (OR 2.55, 95% CI 1.52–4.28, p<0.001), dopamine (OR 3.03, 95% CI 1.74–5.27, p<0.001) and noradrenaline (OR 4.76, 95% CI 2.32–9.76, p<0.001). Favorable predictors were systolic blood pressure ≥100 mmHg on admission (OR 0.54, 95% CI 0.31–0.94, p=0.031), in-hospital treatment with ACEIs (OR 0.07, 95% CI 0.03–0.16, p<0.001), ARBs (OR 0.30, 95% CI 0.13–0.70, p=0.005) and vitamin-K antagonists (OR 0.06, 95% CI 0.007–0.44, p=0.006).

In secondary AHF, independent predictors of in-hospital mortality included left ventricular ejection fraction (LVEF) <40% (OR 2.36, 95% CI 1.17–4.75, p=0.016), age >75 years (OR 2.23, 95% CI 1.09–4.54, p=0.026), ACS (OR 3.55, 95% CI 1.50–8.39, p=0.004), diabetes (OR 2.26, 95% CI 1.23–4.16, p=0.008), pre-admission treatment with digoxin (OR 7.27, 95% CI 1.83–28.87, p=0.005), in-hospital medication with dobutamine (OR 2.43, 95% CI 1.28–4.61, p=0.006), dopamine (OR 2.29, 95% CI 1.12–4.67, p=0.022) and noradrenaline (OR 4.14, 95% CI 1.76–9.76, p=0.001). Covariates independently associated with survival benefit in secondary AHF were pre-admission treatment with diuretics (OR 0.29, 95% CI 0.09–0.88, p=0.030) and in-hospital treatment with ACEIs (OR 0.17, 95% CI 0.07–0.39, p<0.001) and aspirin (OR 0.27, 95% CI 0.11–0.69, p=0.006).

Conclusion

Patients with secondary AHF experienced a more complicated in-hospital course with worse prognosis, compared to primary AHF. LVEF <40%, age >75 years, ACS, diabetes, pre-admission treatment with digitalis, in-hospital medication with dobutamine, dopamine and noradrenaline were identified as independent negative prognostic factors of in-hospital mortality in secondary AHF patients.

Funding Acknowledgement

Type of funding source: None

18F-FDG PET/CT brain glucose metabolism as a marker of different types of depression comorbidity in chronic systolic heart failure patients

Background/Introduction

Depression comorbidity is an important issue in heart failure (HF) disease. Results from the recent prospective randomized trial MOOD-HF did not provide a rationale for the indiscriminate use of antidepressants in depressed HF patients.

Purpose

The study investigated whole-brain and regional-brain glucose metabolism in HF patients with 18F-FDG PET/CT and its association with depression comorbidity.

Methods

Twenty-nine hospitalized patients with symptomatic systolic HF disease (LVEF<40%), NYHA class II-IV and mean age of 55.5±12.0 years participated in the study. All patients had echocardiography, blood sampling, HF-adapted and psychometric questionnaires before discharge and a brain 18F-FDG PET/CT scan after discharge. Semi-automated PET/CT image analysis was performed on all patients and 30 matched controls. The metabolic index SUVmean was calculated for the whole-brain and three brain regions (prefrontal cortex, amygdala and hippocampus), implicated in depression pathogenesis. A standardized SUVmean was also estimated by dividing depression-related regional-brain SUVmean with the whole-brain SUVmean.

Results

HF patients had lower average whole-brain SUVmean (3.90±1.49 vs 5.10±1.35, p=0.001), average regional-brain SUVmean (4.57±2.31 vs 9.96±3.58, p<0.001) and average standardized SUVmean (1.28±0.60 vs 2.07±1.32, p<0.001) compared to controls.

Whole-brain SUVmean had a statistically significant correlation to patient age (r=−0.39, p=0.031), NYHA class (p=0.027), LVEF in the major group of 21 NYHA III-IV patients (p=0.018), diabetes comorbidity (p=0.001), creatinine levels (r=−0.49, p=0.005) and depression (r=−0.36, p=0.049). Regional-brain SUVmean was correlated to whole-brain SUVmean (r=0.53, p=0.002) and depression (r=0.46, p=0.011). The standardized SUVmean, in particular, was found to be a robust index that could differentiate HF patients with “epiphenomenal” (>0.93) or “real” (≤0.93) depression.

Conclusion

HF patients with more severe disease showed whole-brain and regional-brain hypometabolism in 18F-FDG PET/CT scan, which is consistent with impaired cerebral perfusion.

Depressed HF patients (Beck Depression Inventory score >13) exhibited different metabolic patterns that could be used to differentiate between “epiphenomenal” and “real” depression. Namely, presence of whole-brain hypometabolism suggested “epiphenomenal” depression. Absence of whole-brain hypometabolism suggested “real” depression. When the pattern of whole-brain hypometabolism included significant relative, depression-related regional hypometabolism (standardized SUVmean ≤0.93), “real” depression was the most likely diagnosis. The distinction is important, as different types of comorbid depression suggest different treatment approach.

Summarizing figure

Funding Acknowledgement

Type of funding source: None

Glucagon like peptide-1 receptor agonists and their combination with sodium-glucose cotransporter-2 inhibitors improve myocardial deformation and work index in type-2 diabetes after 12-month treatment

Background/Introduction

Type-2 diabetes mellitus (T2DM) exacerbates mechanisms of atherosclerosis and heart failure.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on LV myocardial function of T2DM patients.

Methods

A hundred-sixty T2DM patients (age: 58±10 years) were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) global LV longitudinal strain (GLS), systolic (LongSr) and diastolic (LongSrE) strain rate, global circumferential (GCS) and radial (GRS) strain, peak twisting (pTw), peak twisting velocity (pTwVel) and peak untwisting velocity (pUtwVel), b) global myocardial global work index (GWI), global constructive (GCW) and global wasted myocardial work (GWW) derived by pressure-myocardial strain loops using speckle tracking imaging.

Results

At 4 and 12 months post-treatment, all patients improved GLS, GCS, GRS and pUtwVel (p<0.05). At 12 months, GLP-1RA or GLP-1RA+SGLT-2i provided a greater increase of GLS (11.5% and 13% vs. 6.8% and 2.3%), GCS (11.9% and 14.6% vs. 7.3% and 3.4%), GRS (3.8% and 4.3% vs. 2.2% and 1.6%), GWI (12.7% and 17.4% vs. 3.1% and 2%), GCW (12.3% and 15% vs. 2.2% and 7.8%) and a greater reduction of GWW (38.7% and 41.6% vs. 13.5% and 4.9%) compared with insulin or SGLT-2i, despite a similar HbA1c reduction (p<0.05 for all comparisons) (Table). Patients under combined treatment with GLP-1RA+SGLT-2i achieved a 2-fold reduction of pTw and a 2-fold increase of pUtwVel than those under each one regimen or insulin (p<0.05). The dual therapy showed the greatest effect on measured myocardial markers in patients with LVEF <55% (p<0.05).

Conclusions

Twelve-month treatment with GLP-1RA or combination of GLP-1RA and SGLT-2i showed a greater improvement of myocardial deformation and effective cardiac work than insulin or SGLT-2i treatment in T2DM. The combined therapy as second line was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None

Sodium-glucose cotransporter-2 inhibitors and their combination with glucagon like peptide-1 receptor agonists improve endothelial glycocalyx and arterial stiffness in type-2 diabetes

Background/Introduction

Type-2 diabetes mellitus (T2DM) is associated with endothelial and arterial dysfunction.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i)and their combination on endothelial and arterial function of T2DM patients.

Methods

A hundred-sixty T2DM patients (age: 58±10 years) were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40)as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) perfused boundary region (PBR) of the sublingual arterial microvessels (ranged from 5 to 25μm) using Sideview Darkfield imaging. Increased PBR indicates reduced glucocalyx thickness, b) pulse wave velocity (PWV-Complior), central systolic blood pressure (cSBP) and augmentation index (AI) of the aortic pulse wave.

Results

Twelve months post-treatment, all patients improved PBR, PWV and AI (p<0.05). GLP-1RA, SGLT-2i and their combination showed a greater reduction of PBR, PWV and cSBP than insulin, despite a similar HbA1c reduction (p<0.05). SGLT-2i or combined therapy with GLP-1RA and SGLT-2i showed a greater decrease of PWV (−10.1% and −13% vs. −3.6% and −8.6%) and cSBP (−3% and −5.5% vs. −0.8% and −1.5%)than insulin or GLP-1RA (p<0.05 for all comparisons). GLP-1RA or GLP-1RA+SGLT-2i provided a greater decrease of AI (−42.7% and −48.6% vs. +6.2% vs. −3.8%) compared with insulin or SGLT-2i (Table). The dual therapy showed the greatest effect on measured markers in patients with LVEF <55% (p<0.05).

Conclusions

Twelve-month treatment with SGLT-2i and its combination with GLP-1RA, showed a greater improvement on arterial elastic properties than GLP1RA or insulin treatment in T2DM. The combined therapy as second line was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None

414 Ventricular-arterial interaction predicts response to cardiac resynchronization therapy: a link with improvement of endothelial function and arterial elastic properties

Background

Endothelial dysfunction (ED) is a hall mark of chronic heart failure and has been linked to disease progression, hospitalizations and mortality.

Purpose

to evaluate the impact of cardiac resynchronization therapy (CRT) in ED and to determine predictors of response to CRT

Methods

CRT recipients from 19/07/2016 until 19/10/2018 were studied at baseline and 3 months after. In each visit we evaluated a 12 lead ECG, carotid to femoral pulse wave velocity (cfPWV), flow-mediated dilatation of the brachial artery (FMD), left ventricle ejection fraction (LVEF) and left ventricle (LV) global longitudinal strain (GLS). We evaluated arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography and the ratio of cfPWV to GLS, as valid markers of ventricular-arterial interaction. We also assessed the layer of endothelial glycocalyx by measurement of Perfused Boundary Region (PBR) of the sublingual microvessel range:5-25 microns.

Results

32 patients with a mean age 65.5 (±10.9) years and severe LV systolic dysfunction were enrolled. During follow-up, LVEF, GLS, LVESV and all ED markers exhibited significant improvement (table 1). 23 patients were responders. Among the baseline vascular function markers, only the ratio cfPWV/GLS predicted response to CRT (OR: 0.245, 95%CI: 0.042-0.759, p = 0.044).Threshold analysis showed that the best threshold of cfPWV/GLS for response to CRT was 2.75 (specificity: 0.67%, sensitivity: 0.94%).

Conclusions

After 3 months of CRT, endothelial function, arterial elasticity and ventricular arterial interaction are improved. The baseline ratio cfPWV/GLS, a novel marker of ventricular arterial interaction, can be applied to predict response to CRT.

table 1 Baseline Follow-up Change Measurement mean (sd) mean (sd) mean (sd) p-value SBP (mmHg) 126 (19) 128 (16) 2.18 (11.98) 0,465 DBP (mmHg) 79 (9) 80 (9) 1.06 (8.58) 0,618 LVEF (%) 27 (7) 35 (9) 7.50 (4.77) <0.001 LVESV (mL) 151 (42) 120 (46) -26.91 (17.20) <0.001 GLS (%) 6.47 (2.89) 9.33 (4.18) 2.85 (2.28) <0.001 FMD (%) 5.88 (2.79) 10.25 (3.67) 4.37 (3.34) <0.001 Ea/Ees 2.81 (1.10) 2.04 (0.99) -0.77 (0.47) <0.001 cfPWV 11.11 (2.61) 10.01 (2.45) -1.10 (1.56) 0,003 PBR 5-25(microns) 2.26 (0.20) 2.14 (0.24) -0.13 (0.25) 0,028 cfPWV/GLS 2.18 (1.46) 1.45 (1.11) -0.73 (0.55) <0.001 Measurements at baseline, follow-up and their change during study

Abstract 414 Figure. picture 1

P301Preserved global longitudinal strain predicts left ventricular reverse remodeling one year after edge-to-edge mitral valve repair in functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has emerged as an effective treatment modality for high surgical risk patients with severe functional mitral regurgitation (FMR). Novel echocardiographic parameters, such as deformation imaging and their predictive significance have not been analyzed in this group of patients.

Purpose

The purpose of this study is to identify echocardiographic predictors of response in patients with FMR undergoing PMVR.

Methods

We retrospectively analyzed 44 consecutive patients with ischemic or dilated cardiomyopathy, reduced ejection fraction and severe functional MR (FMR), aged 71±9 years, 71% males, LVEF 30.9±8.7%, mitral valve effective regurgitant orifice area (EROA)>20mm2, regurgitant volume (RV) >30ml and logistic EuroSCORE 22±14.7%. At baseline and 1-year after PMVR we assessed echocardiographic parameters such as LV longitudinal strain (LVGLS) and peak left atrial longitudinal strain (PALS) using speckle tracking echocardiography, LV end-systolic and end-diastolic volumes (LVESV, LVEDV), LA volume, MR severity by Doppler echocardiography along with BNP levels, NYHA class and 6 minute walking distance.

Results

One year after edge-to-edge repair there was a significant reduction of MR (74.2% had mild to moderate MR, 22.6% moderate-to-severe MR and 3.2% severe MR) and BNP levels (933±943pg/ml to 669±824pg/ml), improvement of NYHA class (3.11±0.55 to 2.0±0.6, P<0.05) and increase of the 6 minute walking distance (251±141 to 296±148m, P<0.05). LA volume was reduced (132.5±62.1ml to 115.2±57.7ml) and PALS was improved (6.89±3.47 to 7.94±5.27) (P<0.05 for all comparisons). Baseline LVGLS did not change significantly post intervention (−8.8±4.1 vs. −8.8±3.9, P=0.7) but the baseline value predicted the percentage difference in LVEDV (r=−0.61, P<0.01), LVESV (r=−0.47, P=0.03), BNP (r=0.45, P=0.04) and NYHA class (r=0.63, P<0.01). The best reverse LV remodeling was found in patients with GLS better than −10% and the trend was that the better the GLS the greater the LVEDV and LVESV reduction post-intervention. Additionally, patients with GLS between −10% and −5% had the largest improvement in BNP (P<0.05) and NYHA class (P=0.005).

Conclusions

Edge-to-edge repair is effective in reducing MR in patients with severe functional MR and has a positive impact in patients' clinical status at one year follow up. A preserved LVGLS seems to be a good predictor of reverse modeling and clinical improvement post intervention.

P709Improvement in endothelial function and arterial elastic properties facilitates response to cardiac resynchronization therapy

Background

Cardiac resynchronization therapy (CRT) is a well-established therapy in heart failure (HF) patients with prolonged QRS. In HF patients, reduced nitric oxide availability and increased oxidative stress promote endothelial dysfunction (ED) and arterial stiffness.

Purpose

To investigate the pathophysiologic changes in endothelium and arterial elastic properties in CRT patients and their correlation to therapy.

Methods

We studied 32 HF patients before and 3 months after CRT implantation. In each visit we performed a 12-lead ECG and assessed markers of endothelial function. Specifically, we examined flow-mediated dilatation of the brachial artery (FMD), carotid to femoral pulse wave velocity (cfPWV), as well as the layer of endothelial glycocalyx using the Perfused Boundary Region (PBR) of the sublingual microvessel range: 5–25 microns. We also evaluated left ventricle ejection fraction (LVEF), left ventricle (LV) global longitudinal strain (GLS) and arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography.

Results

32 HF CRT patients, at age 65.5 (±10.9) years, with reduced LVEF (baseline LVEF: 27±7%, LVESV: 151±42 ml, GLS: 6.47±2.89%) were followed-up for a median of 115 days (IQR: 36). During follow up, all markers of ED demonstrated significant change: FMD was increased by 4.37±3.34% (p<0.001), cfPWV and PBR 5–25 were reduced by 1.10±1.56 (p=0.003) and 0.13±0.25 microns (p=0.028) respectively. LVEF was significantly increased (mean change: 7.50±4.77%) and LVESV was significantly reduced (mean change: −26.91±17.20 ml). 16 of 32 patients were responders (LVESV change ≥15% compared to baseline). Among the changes of the examined markers during follow-up, response to CRT correlated with the change of FMD (OR: 3.10, 95% CI: 1.47–15.51, p=0.039) and change of Ea/Ees (OR: 0.000, 95% CI: 0.000–0.061, p=0,0239).

Effect of change in measurements during follow-up on response to CRT Measurement OR (95% CI) Main effect p-value FMD change 3.100 (1.470–15.513) 0.0397 cfPWV change 0.669 (0.295–1.354) 0.0622 PBR 5–25 change 1.773 (0.008–455.458) 0.828 Ea/Ees change 0.000 (0.000–0.061) 0.0239

Conclusion

Improvement in endothelial function and arterial elastic properties evaluated by FMD and Ea/Ees respectively are related with effective CRT.

Levosimendan in Acute and Advanced Heart Failure: an Expert Perspective on Posology and Therapeutic Application

Levosimendan, a calcium sensitizer and potassium channel-opener, is widely appreciated by many specialist heart failure practitioners for its effects on systemic and pulmonary hemodynamics and for the relief of symptoms of acute heart failure. The drug’s impact on mortality in large randomized controlled trials has been inconsistent or inconclusive but, in contrast to conventional inotropes, there have been no indications of worsened survival and some signals of improved heart failure-related quality of life. For this reason, levosimendan has been proposed as a safer inodilator option than traditional agents in settings, such as advanced heart failure. Positive effects of levosimendan on renal function have also been described. At the HEART FAILURE 2018 congress of the Heart Failure Association of the European Society of Cardiology, safe and effective use levosimendan in acute and advanced heart failure was examined in a series of expert tutorials. The proceedings of those tutorials are summarized in this review, with special reference to advanced heart failure and heart failure with concomitant renal dysfunction. Meta-analysis of clinical trials data is supportive of a renal-protective effect of levosimendan, while physiological observations suggest that this effect is exerted at least in part via organ-specific effects that may include selective vasodilation of glomerular afferent arterioles and increased renal blood flow, with no compromise of renal oxygenation. These lines of evidence require further investigation and their clinical significance needs to be evaluated in specifically designed prospective trials.

Left ventricular ejection fraction as therapeutic target: is it the ideal marker?

Heart failure (HF) consists the fastest growing clinical cardiac disease. HF patients are categorized on the basis of underlying left ventricular ejection fraction (LVEF) into HF with preserved EF (HFpEF), reduced LVEF (HFrEF), and mid-range LVEF (HFmrEF). While LVEF is the most commonly used surrogate marker of left ventricular (LV) systolic function, the implementation of two-dimensional echocardiography in estimating this parameter imposes certain caveats on current HF classification. Most importantly, LVEF could fluctuate in repeated measurements or even recover after treatment, thus blunting the borders between proposed categories of HF and enabling upward classification of patients. Under this prism, we sought to summarize possible procedures to improve systolic function in patients with HFrEF either naturally or by the means of pharmacologic and non-pharmacologic treatment and devices. Therefore, we reviewed established pharmacotherapy, including beta-blockers, inhibitors of renin-angiotensin-aldosterone axis, statins, and digoxin as well as novel treatments like sacubitril-valsartan, ranolazine, and ivabradine. In addition, we assessed evidence in favor of cardiac resynchronization therapy and exercise training programs. Finally, innovative therapeutic strategies, including stem cells, xanthine oxidase inhibitors, antibiotic regimens, and omega-3 polyunsaturated fatty acids, were also taken into consideration. We concluded that LVEF is subject to changes in HF after intervention and besides the aforementioned HFrEF, HFpEF, and HFmrEF categories, a new entity of HF patients with recovered LVEF should be acknowledged. An improved global and refined LV function assessment by sophisticated imaging modalities and circulating biomarkers is expected to render HF classification more accurate and indicate patients with viable-yet dysfunctional-myocardium and favorable characteristics as the ideal candidates for LVEF recovery by individualized HF therapy.

A primary cardiac leiomyosarcoma with mutation at H-ras codon 12

The presence of activating ras mutations in a cardiac leiomyosarcoma which occurred in the right atrium of the heart of a female patient was examined. The tumor had the appearance of leiomyosarcoma in rutine histopathological examination and the definite diagnosis was confirmed by a positive immunohistochemical reaction to smooth muscle actin. Molecular analysis by polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP) technique showed a point mutation of H-ras gene at codon 12. To the best of our knowledge, this is the first report describing ras gene mutation in a cardiac leiomyosarcoma implying a role for the ras oncogenes in the development of this tumor.