Repeat pulmonary vein isolation and anterior line ablation using a novel point-by-point pulsed-field ablation system

BACKGROUND

Pulsed-field ablation (PFA) is a nonthermal energy source for ablation of cardiac arrhythmias. This study investigated the prospective outcomes of a novel PFA generator in conjunction with a commercially available, contact force-sensing, focal ablation catheter.

OBJECTIVE

The purpose of this study was to assess the feasibility, safety, and lesion characteristics of point-by-point PFA in consecutive patients undergoing repeat ablation of atrial fibrillation (AF).

METHODS

The study involved reisolation of pulmonary veins (PVs) with electrical reconnection and the creation of an anterior line (AL) in patients with anterior substrate or durable pulmonary vein isolation (PVI).

RESULTS

In 24 patients (46% female; mean age 67 ± 10 years; 67% persistent AF), successful reisolation of 27 of 27 reconnected PVs (100%) was performed. In 19 patients, AL ablation was performed, with bidirectional block in 16 (84%), median ablation time 26 [21, 33] minutes, and first-pass bidirectional block in 13 patients (68%). Acute AL reconduction occurred in 8 of 19 patients (42%). Among these 8 patients, a subsequent sustained block of the AL was achieved in 5 (63%). Ultra-high-density electroanatomic mapping revealed homogeneous but relatively large low-voltage areas in the ablated regions. Median procedural, left atrial dwell, and fluoroscopy times were 100 [90, 109] minutes, 83 [75, 98] minutes, and 10 [8, 13] minutes, respectively. No major or minor complications occurred.

CONCLUSION

This study demonstrated feasibility, acute efficacy, and safety of point-by-point PFA for repeat PVI and AL ablation. Further studies are warranted to assess the long-term durability and comparison with established ablation methods.

Correlation of systolic and diastolic blood pressure with echocardiographic phenotypes of cardiac structure and function from three German population-based studies

Arterial hypertension is considered a risk factor for the development of heart failure. Here we investigate cross-sectional associations of systolic and diastolic blood pressure with subtle functional and morphological changes of left ventricular echocardiographic parameters representing early dysfunction in three representative German population-based studies. We assessed 26,719 individuals without symptomatic heart failure from the Hamburg City Health Study (HCHS, n = 7396, derivation cohort), the Gutenberg Health Study (GHS, 14,715, validation cohort) and the Study of Health in Pomerania (SHIP, 4608, validation cohort). Multivariable linear regression analyses with systolic and diastolic blood pressure as continuous exposure variables were adjusted for common cardiovascular risk factors and antihypertensive medication. Both systolic and diastolic blood pressure were consistently associated with measures of left ventricular hypertrophy (β per standard deviation (SD) for LV mass (g) and systolic blood pressure: 5.09 (p < 0.001); diastolic blood pressure: 2.29 (p < 0.001) in HCHS). Systolic blood pressure correlated with declining diastolic function (β per SD for E/e': 0.29, p < 0.001 in HCHS) and diastolic blood pressure with declining systolic function (β per SD for LVEF, in %: - 0.15; p = 0.041 in HCHS) in all cohorts. Pending further validation, our results from three independent German population samples suggest differential effects of systolic versus diastolic blood pressure on left ventricular structure and function.

Coffee consumption and associations with blood pressure, LDL-cholesterol and echocardiographic measures in the general population

Coffee, next to water the most widespread beverage, is attributed both harmful and protective characteristics concerning cardiovascular health. This study aimed to evaluate associations of coffee consumption with cardiac biomarkers, echocardiographic, electrocardiographic parameters and major cardiovascular diseases. We performed a cross-sectional analysis of 9009 participants of the population-based Hamburg City Health Study (HCHS), enrolled between 2016 and 2018 median age 63 [IQR: 55; 69] years. Coffee consumption was classified into three groups: < 3 cups/day (low), 3-4 cups/day (moderate), > 4 cups/day (high). In linear regression analyses adjusted for age, sex, body mass index, diabetes, hypertension, smoking, and additives, high coffee consumption correlated with higher LDL-cholesterol (β = 5.92; 95% CI 2.95, 8.89; p < 0.001). Moderate and high coffee consumption correlated with lower systolic (β = - 1.91; 95% CI - 3.04, - 0.78; p = 0.001; high: β = - 3.06; 95% CI - 4.69, - 1.44; p < 0.001) and diastolic blood pressure (β = - 1.05; 95% CI - 1.67, - 0.43; p = 0.001; high: β = - 1.85; 95% CI - 2.74, - 0.96; p < 0.001). Different levels of coffee consumption did neither correlate with any investigated electrocardiographic or echocardiographic parameter nor with prevalent major cardiovascular diseases, including prior myocardial infarction and heart failure. In this cross-sectional analysis, high coffee consumption correlated with raised LDL-cholesterol levels and lower systolic and diastolic blood pressure. However, major cardiovascular diseases including heart failure and its diagnostic precursors were not associated with coffee consumption, connoting a neutral role of coffee in the context of cardiovascular health.

3 Tesla magnetic resonance imaging in patients with cardiac implantable electronic devices: a single centre experience

AIMS

Three Tesla (T) magnetic resonance imaging (MRI) provides critical imaging information for many conditions. Owing to potential interactions of the magnetic field, it is largely withheld from patients with cardiac implantable electronic devices (CIEDs). Therefore, we assessed the safety of 3T MRI in patients with '3T MRI-conditional' and 'non-3T MRI-conditional' CIEDs.

METHODS AND RESULTS

We performed a retrospective single-centre analysis of clinically indicated 3T MRI examinations in patients with conventional pacemakers, cardiac resynchronization devices, and implanted defibrillators from April 2020 to May 2022. All CIEDs were interrogated and programmed before and after scanning. Adverse events included all-cause death, arrhythmias, loss of capture, inappropriate anti-tachycardia therapies, electrical reset, and lead or generator failure during or shortly after MRI. Changes in signal amplitude and lead impedance were systematically assessed. Statistics included median and interquartile range. A total of 132 MRI examinations were performed on a 3T scanner in 97 patients. Thirty-five examinations were performed in patients with 'non-3T MRI-conditional' CIEDs. Twenty-six scans were performed in pacemaker-dependent patients. No adverse events occurred during or shortly after MRI. P-wave or R-wave reductions ≥ 50 and ≥ 25%, respectively, were noted after three (2.3%) scans, all in patients with '3T MRI-conditional' CIEDs. Pacing and shock impedance changed by ± 30% in one case (0.7%). Battery voltage and stimulation thresholds did not relevantly change after MRI.

CONCLUSION

Pending verification in independent series, our data suggest that clinically indicated MRI scans at 3T field strength should not be withheld from patients with cardiac pacemakers or defibrillators.

3 Tesla magnetic resonance imaging in patients with cardiac electronic implantable devices: a single center experience

Background

Cardiac magnetic resonance imaging (MRI), a key method guiding medical diagnosis and therapy, is increasingly performed at 3 Tesla (T) field strength. Growing evidence suggests a relatively safe conductance of 1.5 T MRI in patients with cardiac implantable electronic devices (CIEDs), leading to conditional certification of some CIEDs for MRI. However, data on the safety of MRI imaging at 3 T in patients with CIEDs are scarce.

Purpose

We analysed the safety of clinically indicated 3 T MRI in patients with “3T MRI-conditional” and “3 T MRI-non-conditional” CIEDs.

Methods

We performed a retrospective single-center analysis of consecutive patients with CIEDs labelled by the manufacturer as “MRI non-conditional”, “1.5 T MRI-conditional” and “3 T MRI-conditional”. Patients underwent clinically indicated 3 T MRI of different thoracic and non-thoracic body regions from April 2020 to February 2022. Devices were interrogated and programmed appropriately before and after scanning. Statistics included median and interquartile range. Measurements of device and lead function and integrity before and after scanning were assessed. Adverse events included all-cause death, arrhythmias, loss of capture, inappropriate anti-tachycardia therapies, electrical reset and lead or generator failure during or shortly after MRI scan.

Results

One hundred twenty-eight 3 T MRI scans were performed in 94 patients (mean age 72±16 years, 36.2% female). 3T MRI scans were performed in patients with “non-MRI-conditional” devices (n=9), “1.5 T MRI-conditional” devices (n=22), and “3 T MRI-conditional” devices (n=97). Patients were pacemaker-dependent in 24 MRI scans. After MRI, lead impedance had changed by 100 Ohms or more in seven cases (4 atrial and 3 right ventricular leads). P-wave (−25%) reduction was noted in one, R-wave (−50%) reduction in two cases. Right atrial and ventricular threshold exceeded the limit of 0,5V in one case each only in “3 T MRI-conditional” devices. No clinically relevant adverse events occurred.

Conclusion

3 T MRI was safely conducted in patients with “3 T MRI-conditional” and “non-MRI conditional” CIEDs in our single-center study. Pending verification in independent series, our data suggest that clinically indicated 3T MRI scans should not be withheld from patients with cardiac pacemakers or defibrillators.

Funding Acknowledgement

Type of funding sources: None.

Coffee consumption and cardiovascular health in the general population

Background

Coffee, next to water the most widespread beverage, is attributed both harmful and protective characteristics concerning cardiovascular health. This study aimed to evaluate associations of coffee consumption with cardiac biomarkers, echocardiographic, and electrocardiographic parameters as well as major cardiovascular diseases.

Methods and results

We performed a cross-sectional analysis of 9,009 participants a large German population-based cohort study, enrolled between 2016 and 2018 median age 63 [IQR: 55; 69] years. Coffee consumption was classified into three groups: &lt;3 cups/day (low), 3–4 cups/day (moderate), &gt;4 cups/day (high). In linear regression analyses adjusted for age, sex, body mass index, diabetes, hypertension, and smoking, moderate and high coffee consumption were associated with LDL-cholesterol (β=2.08; 95% CI: 0.14, 4.03, p=0.036; β=5.69; 95% CI: 2.91, 8.47; p&lt;0.001). Moderate and high coffee consumption were negatively associated with systolic (β=−1.6; 95% CI: −2.66, −0.54; p=0.003; β=−2.63; 95% CI: −4.15, −1.12; p=0.001) and diastolic blood pressure (β=−0.8; 95% CI: −1.38, −0.22; p=0.007; β=1.28; 95% CI: −2.11, −0.45; p=0.002). Different levels of coffee consumption did neither correlate with any investigated electrocardiographic or echocardiographic parameter nor with prevalent major cardiovascular diseases, including prior myocardial infarction and heart failure.

Conclusions

In this cross-sectional analysis, moderate and high coffee consumption was positively associated with LDL-cholesterol and negatively associated with systolic and diastolic blood pressure. However, major cardiovascular diseases including heart failure and its diagnostic precursors were not associated with coffee consumption, connoting a neutral role of coffee in the context of cardiovascular health.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft [Grant Number TH1106/5-1; AA93/2-1]The Foundation Leducq [Grant Number 16 CVD 03]

Association between periodontitis and heart failure in the general population

AIMS

Data on the association between periodontitis and preclinical cardiac alterations remain scarce. The aim of the current study is to determine if periodontitis is associated with morphological and functional cardiac changes measured by transthoracic echocardiography as well as different heart failure (HF) phenotypes.

METHODS

Participants from the population-based Hamburg City Health Study [ClinicalTrial.gov (NCT03934957)], who underwent transthoracic echocardiography and periodontal screening were included. Periodontitis was classified according to Eke and Page (none/mild, moderate, severe). The 2021 ESC HF guidelines were applied and HF was classified into HF with preserved ejection fraction (HFpEF, ejection fraction ≥50%), HF with mid-range and reduced ejection fraction [HF(m)rEF, ejection fraction <50%], and HF in general [HFpEF and HF(m)rEF]. Due to limited size, all subjects with LVEF <50% and symptoms or signs of HF were classified as HF with reduced and mildly reduced ejection fraction [HF(m)rEF].

RESULTS

Within 6209 participants with full periodontal examination, we identified an overlap of n = 167 participants with periodontitis and HF. Participants with severe periodontitis showed a higher burden of cardiovascular risk factors (men at advanced age, diabetes mellitus, hypertension) when compared with participants with none/mild periodontitis. After adjustment for age, sex, body mass index, smoking, diabetes, hypertension, atrial fibrillation, and coronary artery disease, severe periodontitis was significantly associated with HF(m)rEF (odds ratio: 3.16; 95% CI: 1.21, 8.22; P = 0.019), although no association was found for HFpEF and HF in general.

CONCLUSIONS

The current study demonstrated that severe periodontitis was significantly associated with HF(m)rEF, although no relevant associations were found with HFpEF and HF in general as well as echocardiographic variables. The results implicate a potential target group, who need special attention from cooperating physicians and dentists. Future studies are warranted to verify whether systemic inflammation could be the link between the two diseases.

Comparison of cine cardiac magnetic resonance and echocardiography derived diameters of the aortic root in a large population-based cohort

Transthoracic echocardiography (TTE) and cine cardiac magnetic resonance imaging (CMR) are established imaging methods of the aortic root. We aimed to evaluate the comparability of measurements in TTE and standard cine CMR sequences of the aortic root. Our study included 741 subjects (mean age 63.5 ± 8 years, 43.7% female) from the Hamburg City Health Study (HCHS). Subjects underwent CMR and TTE. Aortic root measurements were performed at the level of the aortic annulus (AoAn), sinus of Valsalva (SoV), and sinotubular junction (STJ) by standard cine CMR in left ventricular long axis and left ventricular outflow tract view. Measurements were performed applying the leading-edge to leading-edge (LL) convention and inner-edge to inner-edge (II) convention in TTE and the II convention in CMR. Inter correlation coefficients (ICCs) demonstrated high inter- and intraobserver reproducibility for CMR and TTE measurements of SoV and STJ (ICCs 0.9–0.98) and moderate reproducibility for AoAn (ICCs 0.68–0.91). CMR measurements of SoV and STJ showed strong agreement with TTE: while correlations were comparable (r = 0.75–0.85) bias was lower with TTE II (bias − 0.1 to − 0.74) versus TTE LL measurements (mean bias − 1.49 to − 2.58 mm). The agreement for AoAn was fair (r = 0.51–0.57) with variable bias (mean bias 0.39–3.9). Standard cine CMR and TTE derived aortic root measurements are reproducible and comparable with higher agreement for TTE II instead of LL measurements. These results support an interchangeable application of TTE and standard CMR for screening of aortic root diseases thereby possibly reducing redundant multimodality imaging.

Safety of pulsed-field ablation in patients with cardiac implantable electronic devices. A single-center pilot study

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulsed-field ablation (PFA) is a novel energy source to perform pulmonary vein isolation (PVI) in patients with atrial fibrillation or cavo-tricuspid isthmus ablation (CTI) in patients with atrial flutter. Whether strong electrical fields generated by PFA could change the function and integrity of cardiac implantable electronic devices (CIED) is not known.

Aim

To assess the function and integrity of implanted devices before and after pulsed-field ablation.

Methods

This study included consecutive patients with CIED undergoing PFA at a large single center. Real-time CIED electrograms were recorded during PFA applications. CIED were interrogated before and after PFA assessing function (threshold, sensing), integrity (impedance), and arrhythmia episodes.

Results

We performed PFA in six patients (age 69±12 years, 1/6 female, left atrial diameter was 44±3 mm, left-ventricular ejection fraction 40±14%) for PVI in five patients with atrial fibrillation and CTI ablation in one patient with atrial flutter. All patients had CIEDs (one cardiac resynchronization device, two implantable cardioverter-defibrillators, three two-chamber pacemakers). Each patient undergoing PVI received 32 PFA applications of 2.5 s. (4x basket configuration and 4x flower configuration at each pulmonary vein), amounting to a total ablation time of 80 s and resulting in complete PVI in all five patients. For CTI ablation we applied 8 PFA applications of 2.5 s (20 s total ablation time) resulting in CTI blockade. Real-time intracardiac electrograms (iEGM) during PFA applications revealed sensing of single PFA application impulses in three patients and blanking of the iEGM in three patients. Postinterventional device testing revealed no changes in impedance, stimulation threshold or sensing. No leads were dislocated or damaged. No other device malfunctions occurred during the procedure, as well as no other major periprocedural complications occurred.

Conclusion

The function and integrity of pacemakers and defibrillators is not affected by PFA in our patient sample. Larger series are needed to confirm the apparent safety of PFA in patients with CIED.

Heart failure in the general population and impact of the 2021 European Society of Cardiology Heart Failure Guidelines

AIM

The diagnosis of heart failure (HF) has been refined in several steps in recent years, reflecting evolving diagnostic and therapeutic approaches. The European Society of Cardiology (ESC) recently published a modified definition of HF in the 2021 heart failure (HF) guidelines. The impact of this new diagnostic algorithm on the prevalence of HF is not known. The aim of this study was to describe the contemporary prevalence of HF in a representative, completely phenotyped sample from the general population.

METHODS AND RESULTS

This analysis was conducted among 7074 participants (aged 45-78 years, 51.5% women) from the population-based Hamburg City Health Study. Compared with the 2016 version, HF prevalence increased with the 2021 HF guidelines from 4.31% to 4.83% (12% increase). This increase was driven by a higher number of subjects with HF with reduced/mildly-reduced ejection fraction (0.47% to 0.52%; 1.37% to 2.12%), while the number of subjects with HF with preserved ejection fraction decreased from 2.46% to 2.19%. Importantly, this did not impact the known risk factor profiles of the phenotypes. Although four drugs are recommended for all subjects with HFrEF in the new guidelines, several adjunctive therapies are recommended for dedicated cases/scenarios (e.g. <1% eligibility for ivabradine/vericiguat/devices).

CONCLUSION

Heart failure remains common in a contemporary general population sample. The number of patients with HF will increase when the current diagnostic criteria are applied. This offers opportunities to initiate preventive therapies, especially in patients with HFmrEF and HFrEF.

Diastolic dysfunction in individuals with and without heart failure with preserved ejection fraction

AIM

Left ventricular diastolic dysfunction (DD), a common finding in the general population, is considered to be associated with heart failure with preserved ejection faction (HFpEF). Here we evaluate the prevalence and correlates of DD in subjects with and without HFpEF in a middle-aged sample of the general population.

METHODS AND RESULTS

From the first 10,000 participants of the population-based Hamburg City Health Study (HCHS), 5913 subjects (mean age 64.4 ± 8.3 years, 51.3% females), qualified for the current analysis. Diastolic dysfunction (DD) was identified in 753 (12.7%) participants. Of those, 11.2% showed DD without HFpEF (ALVDD) while 1.3% suffered from DD with HFpEF (DDwHFpEF). In multivariable regression analysis adjusted for major cardiovascular risk factors, ALVDD was associated with arterial hypertension (OR 2.0, p < 0.001) and HbA1c (OR 1.2, p = 0.007). Associations of both ALVDD and DDwHFpEF were: age (OR 1.7, p < 0.001; OR 2.7, p < 0.001), BMI (OR 1.2, p < 0.001; OR 1.6, p = 0.001), and left ventricular mass index (LVMI). In contrast, female sex (OR 2.5, p = 0.006), atrial fibrillation (OR 2.6, p = 0.024), CAD (OR 7.2, p < 0.001) COPD (OR 3.9, p < 0.001), and QRS duration (OR 1.4, p = 0.005) were strongly associated with DDwHFpEF but not with ALVDD.

CONCLUSION

The prevalence of DD in a sample from the first 10,000 participants of the population-based HCHS was 12.7% of whom 1.3% suffered from HFpEF. DD with and without HFpEF showed significant associations with different major cardiovascular risk factors and comorbidities warranting further research for their possible role in the formation of both ALVDD and DDwHFpEF.

Aortic root dimensions as a correlate for aortic regurgitation's severity

To evaluate the prevalence of aortic regurgitation (AR) and associations between the individual aortic root components and AR severity in the general population. The study included the first 10,000 participants of the population-based Hamburg City Health Study (HCHS) of whom 8259 subjects, aged 62.23 ± 8.46 years (51.3% females), enrolled 2016-2018, provided echocardiographic data. 69 subjects with bicuspid valves and 23 subjects with moderate/severe aortic stenosis were excluded. Aortic root dimensions were measured using state-of-the-art cardiac ultrasound, including the aortic annulus, sinus of Valsalva, sinotubular junction (STJ), and ascending aorta, in diastole and systole. The distribution of AR was: 932 (11.4%) mild, 208 (2.5%) moderate, and 20 (0.24%) severe. Patients with moderate or severe AR were predominantly male at advanced age who had hypertension, coronary artery disease, atrial fibrillation, and renal dysfunction. Increasing AR severity correlated with higher absolute and indexed aortic root diameters (e.g., end-diastolic sinus of Valsalva for no-mild-moderate-severe AR in mm ± standard deviation: 34.06 ± 3.81; 35.65 ± 4.13; 36.13 ± 4.74; 39.67 ± 4.61; p < 0.001). In binary logistic regression analysis, all aortic root components showed significant associations with moderate/severe AR. Mid-systolic STJ showed the strongest association with moderate/severe AR (OR 1.33, 95% confidence interval 1.25-1.43, p < 0.001). AR was prevalent in 14.2%, of whom 2.8% showed moderate/severe AR. All assessed aortic root diameters correlated with the prevalence and severity of AR. STJ diameter had the strongest association with moderate/severe AR possibly reflecting the pathophysiological impact of an increasingly dilated STJ in the context of an ageing aorta.

Transthoracic echocardiographic reference values of the aortic root: results from the Hamburg City Health Study

Here we generate up-to-date reference values of transthoracic echocardiographic aortic root dimensions matched by sex, age, and body surface area (BSA) derived from the population-based Hamburg City Health Study (HCHS) cohort. In 1687 healthy subjects (mean age 57.1 ± 7.7, 681 male and 1006 female), derived from the first prospectively-recruited 10,000 HCHS participants, dimensions of the aortic root were measured in systole and diastole using state-of-the-art 2-dimensional transthoracic echocardiography. Diameters were assessed at four levels: aortic annulus, Sinus of Valsalva, sinotubular junction, and ascending aorta. Female sex was associated with significantly smaller absolute aortic root dimensions, while indexing for BSA resulted in a reverse effect at all levels. There was a strong age dependency of all aortic root diameters as well as aortic annulus/sinotubular junction ratio for both sexes. Multivariate analysis revealed age, sex, weight, height, and BSA to be significant determinants of aortic root size. Finally, formulas were generated for the calculation of individual aortic root reference values considering age, sex, weight, and height. We provide population-based reference values of aortic root diameters based on a standardized transthoracic echocardiographic protocol of the population-based HCHS which may support the diagnosis, monitoring, and treatment of aortic root disease.

Applying the ESC 2016, the H2FPEF, and the HFA-PEFF diagnostic algorithms for heart failure with preserved ejection fraction to the general population – a comparative approach

Background

Heart failure with preserved ejection fraction (HFpEF) is common in patients presenting with dyspnoea. Nevertheless, diagnosing HFpEF remains challenging. Recently, different algorithms were developed to predict the likelihood of HFpEF.

Purpose

Our objective was to provide an in-depth comparison of the ESC 2016 algorithm, the H2FPEF- and the HFA-PEFF algorithm for diagnosing and characterising HFpEF in the general population.

Methods

The study included 5,613 participants of the population-based H. City Health Study (HCHS), aged 62±8.7 years (51.1% women), that were enrolled between 2016 and 2019. Exclusion criteria were other common causes of dyspnea. We calculated the prevalence and compared characteristics of HFpEF according to the different diagnostic algorithms applying the ESC 2016 heart failure guidelines and the cut-off values suggested by the authors of the HFA-PEFF and H2FPEF score for defining HFpEF.

Results

Unexplained dyspnea was present in 407 (7.3%) subjects. In those, the estimated prevalence of HFpEF was 20.4% (ESC 2016), 12.3% (H2FPEF), and 7.6% (HFA-PEFF). The majority of subjects was classified as HFpEF not excludable according to the HFA-PEFF (57.7%) and the H2FPEF (59.2%) score. For all algorithms, subjects diagnosed with HFpEF showed elevated age and body mass index as well as a higher prevalence of atrial fibrillation, diabetes, and arterial hypertension compared to those without HFpEF or HFpEF not excludable. The distribution of those comorbidities and risk factors varied between the differently diagnosed HFpEF groups with the highest burden in the HFpEF group defined by the H2FPEF score. The overlap of subjects diagnosed with HFpEF according to the different algorithms was very limited.

Conclusion

Unexplained dyspnoea is common in the middle-aged general population. The ESC 2016 algorithm, the H2FPEF-, and the HFA-PEFF score detect different, discordant sub-populations of probands with breathlessness. Further classification of the HFpEF syndrome is desirable.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Innovative medicine initiative Figure 1. Prevalence and concordance of the three HFpEF algorithms in subjects with unexplained dyspnea. Of the 407 subjects with unexplained dyspnea, the prevalence ranged from 20.4% (n=83, ESC 2016 guideline) to 12.3% (n=50, H2FPEF score) and 7.6% (n=31, HFA-PEFF score). The concordance was highest between the ESC 2016 guidelines and the HFA-PEFF score reflected by a kappa coefficient of 0.38 and a reclassification rate of 16%. RecR = reclassification rate.

Applying the ESC 2016, H2 FPEF, and HFA-PEFF diagnostic algorithms for heart failure with preserved ejection fraction to the general population

AIMS

Heart failure with preserved ejection fraction (HFpEF) is common in patients presenting with dyspnoea. Recently, clinical tools were developed to facilitate the diagnosis of HFpEF. Here, we apply the European Society of Cardiology (ESC) 2016 heart failure guidelines and the H2 FPEF and HFA-PEFF scores to a middle-aged sample of the general population and compared the different groups with each other.

METHODS AND RESULTS

This study included the first 10 000 participants of the population-based Hamburg City Health Study. A total of 5613 subjects, aged 62 ± 8.7 years (51.1% women), qualified for the analysis. Unexplained dyspnoea was present in 407 (7.3%) subjects. In those, the estimated prevalence of HFpEF was 20.4% (ESC 2016), 12.3% (H2 FPEF), and 7.6% (HFA-PEFF). The majority of subjects was classified as HFpEF not excludable according to the HFA-PEFF (57.7%) and H2 FPEF (59.2%) scores. For all algorithms, subjects diagnosed with HFpEF showed elevated age and body mass index as well as a higher prevalence of atrial fibrillation, diabetes, and arterial hypertension compared with those without HFpEF or HFpEF not excludable. The distribution of those co-morbidities and risk factors varied between the differently diagnosed HFpEF groups with the highest burden in the HFpEF group defined by the H2 FPEF score. The overlap of subjects diagnosed with HFpEF according to the different algorithms was very limited.

CONCLUSIONS

Unexplained dyspnoea is common in the middle-aged general population. The ESC 2016 algorithm and the H2 FPEF and HFA-PEFF scores detect different, discordant subpopulations of probands with breathlessness. Further classification of the HFpEF syndrome is desirable.

Prevention of coronary obstruction in patients at risk undergoing transcatheter aortic valve implantation: the Hamburg BASILICA experience

OBJECTIVES

This study aimed to assess the clinical outcome of the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary obstruction (BASILICA) technique in a single-center patient cohort considered at high or prohibitive risk of transcatheter aortic valve implantation (TAVI)-induced coronary obstruction.

METHODS

Between October 2019 and January 2021, a total of 15 consecutive patients (age 81.0 [78.1, 84.4] years; 53.3% female; EuroSCORE II 10.6 [6.3, 14.8] %) underwent BASILICA procedure prior to TAVI at our institution. Indications for TAVI were degeneration of stented (n = 12, 80.0%) or stentless (n = 1, 6.7%) bioprosthetic aortic valves, or calcific stenosis of native aortic valves (n = 2, 13.3%), respectively. Individual risk of TAVI-induced coronary obstruction was assessed by pre-procedural computed tomography analysis. Procedural and 30-day outcomes were documented in accordance with Valve Academic Research Consortium (VARC)-2 criteria.

RESULTS

BASILICA was attempted for single left coronary cusp in 12 patients (80.0%), for single right coronary cusp in 2 patients (13.3%), and for both cusps in 1 patient (6.7%), respectively. The procedure was feasible in 13 patients (86.7%) resulting in effective prevention of coronary obstruction, whilst TAVI was performed without prior successful bioprosthetic leaflet laceration in two patients (13.3%). In one of these patients (6.7%), additional chimney stenting immediately after TAVI was performed. No all-cause deaths or strokes were documented after 30 days.

CONCLUSION

The BASILICA technique appears to be a feasible, safe and effective concept to avoid iatrogenic coronary artery obstruction during TAVI in both native and bioprosthetic valves of patients at high or prohibitive risk. ClinicalTrials.gov Identifier: NCT04227002 (Hamburg AoRtic Valve cOhoRt).

Head-to-head comparison of the incremental value of the three established risk markers hs-troponin I, hs-C-reactive protein and NT-proBNP in secondary prevention of coronary artery disease

Background

Risk stratification among patients with coronary artery disease (CAD) and acute coronary syndrome (ACS) is of considerable interest due to the potential to guide secondary preventive therapies. Cardiac troponins as well as the inflammatory biomarker C-reactive protein (CRP) and natriuretic peptides have now emerged as useful blood-based biomarkers for risk stratification concerning incident cardiac events. Nevertheless, it has not been tested, whether one of these biomarkers yields predictive value beyond the others. Thus, we evaluated the head-to-head potential of high-sensitivity troponin I (hsTnI), high-sensitivity (hs) CRP and NT-proBNP as prognostic biomarkers for adverse outcome in patients with manifest CAD.

Methods

Plasma levels of hsTnI, hsCRP and NT-proBNP were measured in a cohort of 2,193 patients with documented CAD –including 837 patients with ACS and 1,356 patients with stable angina pectoris (SAP). Cardiovascular death and/or non-fatal acute myocardial infarction (MI) were defined as the main outcome measures. The association of circulating biomarker levels, used after log-transformation, with cardiovascular mortality and non-fatal MI during follow-up was assessed by Cox proportional hazards analyses adjusted according to three different models including cardiovascular risk factors and either the biomarkers hsCRP, NT-proBNP or hsTnI. Additionally, the net reclassification index (NRI) was calculated using the category five-year event probabilities for two models.

Results

During a median follow-up of 3.8 years, a total of 231 events were registered (10.5%). All three biomarkers reliably predicted cardiovascular death and/or MI, as evidenced by survival curves stratified for tertiles of circulating levels.

In Cox regression analyses with adjustments for sex, age, and conventional cardiovascular risk factors, the hazard ratio (HR) per standard deviation (SD) for the prediction of cardiovascular (CV) death and/or non-fatal MI during follow-up was 1.39 [95% CI: 1.24–1.57, p&lt;0.001] for hsTnI, 1.41 [95% CI: 1.24–1.60, p&lt;0.001] for hsCRP, and 1.64 [95% CI: 1.39–1.92, p&lt;0.001] for NT-proBNP. Nevertheless, upon further adjustment for the other two biomarkers, the significance of the association for hsTnI got lost, association for hsCRP attenuated, and only NT-proBNP kept its predictive value and was still strongly associated with the combined endpoint (1.47 [95% CI: 1.19–1.82, p&lt;0.001]), but also with CV death alone (2.42 [95% CI: 1.86–3.15, p&lt;0.001]). Moreover, only NT-proBNP significantly improved C-statistics and net reclassification index (NRI) for the prediction of cardiovascular death.

Conclusions

NT-proBNP reliably predicted cardiovascular death and myocardial infarction in patients with manifest CAD and provides incremental value beyond hsCRP and hsTnI.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): “Stiftung Rheinland-Pfalz für Innovation”, Ministry for Science and Education

Cardio-Renal Biomarker Soluble Urokinase-Type Plasminogen Activator Receptor Is Associated With Cardiovascular Death and Myocardial Infarction in Patients With Coronary Artery Disease Independent of Troponin, C-Reactive Protein, and Renal Function

Background Risk stratification among patients with coronary artery disease (CAD) is of considerable interest due to the potential to guide secondary preventive therapies. Thus, we evaluated the predictive value of soluble urokinase-type plasminogen activator receptor (suPAR) levels for cardiovascular mortality and nonfatal myocardial infarction in patients with CAD. Methods and Results Plasma levels of suPAR were measured in a cohort of 1703 patients with documented CAD as evidenced by coronary angiography-including 626 patients with acute coronary syndrome and 1077 patients with stable angina pectoris. Cardiovascular death and/or nonfatal myocardial infarction were defined as main outcome measures. During a median follow-up of 3.5 years, suPAR levels reliably predicted cardiovascular death or myocardial infarction in CAD, evidenced by survival curves stratified for tertiles of suPAR levels. In Cox regression analyses, the hazard ratio for the prediction of cardiovascular death and/or myocardial infarction was 2.19 (P<0.001) in the overall cohort and 2.56 in the acute coronary syndrome cohort (P<0.001). Even after adjustment for common cardiovascular risk factors, renal function and the biomarkers C-reactive protein, N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin I suPAR still enabled a reliable prediction of cardiovascular death or myocardial infarction with a hazard ratio of 1.61 (P=0.022) in the overall cohort and 2.22 (P=0.005) in the acute coronary syndrome cohort. Conclusions SuPAR has a strong and independent prognostic value in secondary prevention settings, and thereby might represent a valuable biomarker for risk estimation in CAD.

P3642Predictive value of soluble urokinase-type plasminogen activator receptor for cardiovascular death and non-fatal myocardial infarction in patients with coronary artery disease

Introduction

Stratification for subsequent coronary events among patients with coronary artery disease (CAD) is of considerable interest due to the potential to guide secondary preventive therapies. Soluble urokinase-type plasminogen activator receptor (suPAR) is expressed on various cells involved in atherogenesis and plaque instability, and has been associated with poor clinical outcomes in patients with various conditions.

Purpose

In this study we investigated the potential role of suPAR as a prognostic biomarker for adverse outcome in patients with CAD, and acute coronary syndrome (ACS) in particular.

Methods

Plasma levels of suPAR were measured in a cohort of 1,703 patients (AtheroGene Study) with documented coronary artery disease –including 626 patients with ACS and 1077 patients with stable angina pectoris (SAP). The main outcome measures were defined as cardiovascular death and non-fatal myocardial infarction (MI). Survival curves for the endpoints considered were computed according to thirds of the suPAR distribution. The equality of survival curves was tested using the log-rank test. Multivariable models adjusted for common cardiovascular risk factors and the biomarkers CRP, NT-proBNP and high-sensitivity troponin I (hs-TnI) in particular were also computed.

Results

The prognostic utility of suPAR was evidenced by survival curves stratified for tertiles of circulating suPAR levels –both, in the overall cohort (p=0.00062), and in the ACS cohort (p=0.00099) with a median follow-up of 3,5 years. In multivariable-adjusted Cox regression analyses the hazard ratio (HR) for the prediction of cardiovascular death was 3.60 for log-transformed suPAR levels (p<0.001) in the overall CAD cohort, whereas it was 3.34 (p=0.003) in the ACS cohort. The HR regarding prediction of the combined outcome cardiovascular death and/or non-fatal MI during follow-up was 2.19 (p<0.001) in the overall cohort, and 2.56 (p<0.001) in the ACS cohort. After multivariate adjustment, including conventional cardiovascular risk factors and hs-TnI, suPAR, after log transformation, still enabled a reliable and strong prediction of future cardiovascular death with a HR of 3.17 (p<0.001) in the overall CAD cohort, and a HR of 2.85 (p=0.014) in the ACS cohort.

Conclusions

Our study demonstrates that suPAR has a strong prognostic value independent of hs-TnI in secondary prevention settings, and thereby might represent a valuable biomarker for risk estimation in CAD.

Acknowledgement/Funding

Stiftung Rheinland-Pfalz für Innovation, European Union 7th Framework Programme, DZHK e.V., ERA-Net, Abbott Diagnostics

Predictive value of soluble urokinase-type plasminogen activator receptor for mortality in patients with suspected myocardial infarction

BACKGROUND

Early risk stratification of patients with suspected acute myocardial infarction (AMI) constitutes an unmet need in current daily clinical practice. We aimed to evaluate the predictive value of soluble urokinase-type plasminogen activator receptor (suPAR) levels for 1-year mortality in patients with suspected AMI.

METHODS AND RESULTS

suPAR levels were determined in 1314 patients presenting to the emergency department with suspected AMI. Patients were followed up for 12 months to assess all-cause mortality. Of 1314 patients included, 308 were diagnosed with AMI. Median suPAR levels did not differ between subjects with AMI compared to non-AMI (3.5 ng/ml vs. 3.2 ng/ml, p = 0.066). suPAR levels reliably predicted all-cause mortality after 1 year. Hazard ratio for 1-year mortality was 12.6 (p < 0.001) in the quartile with the highest suPAR levels compared to the first quartile. The prognostic value for 6-month mortality was comparable to an established risk prediction model, the Global Registry of Acute Coronary Events (GRACE) score, with an AUC of 0.79 (95% CI 0.72-0.86) for the GRACE score and 0.77 (95% CI 0.69-0.84) for suPAR. Addition of suPAR improved the GRACE score, as shown by integrated discrimination improvement statistics of 0.036 (p = 0.03) suggesting a further discrimination of events from non-events by the addition of suPAR.

CONCLUSIONS

suPAR levels reliably predicted mortality in patients with suspected AMI.

STUDY REGISTRATION

http://www.clinicaltrials.gov (NCT02355457).

Inflammation-induced NFATc1-STAT3 transcription complex promotes pancreatic cancer initiation by KrasG12D

Cancer-associated inflammation is a molecular key feature in pancreatic ductal adenocarcinoma. Oncogenic KRAS in conjunction with persistent inflammation is known to accelerate carcinogenesis, although the underlying mechanisms remain poorly understood. Here, we outline a novel pathway whereby the transcription factors NFATc1 and STAT3 cooperate in pancreatic epithelial cells to promote Kras(G12D)-driven carcinogenesis. NFATc1 activation is induced by inflammation and itself accelerates inflammation-induced carcinogenesis in Kras(G12D) mice, whereas genetic or pharmacologic ablation of NFATc1 attenuates this effect. Mechanistically, NFATc1 complexes with STAT3 for enhancer-promoter communications at jointly regulated genes involved in oncogenesis, for example, Cyclin, EGFR and WNT family members. The NFATc1-STAT3 cooperativity is operative in pancreatitis-mediated carcinogenesis as well as in established human pancreatic cancer. Together, these studies unravel new mechanisms of inflammatory-driven pancreatic carcinogenesis and suggest beneficial effects of chemopreventive strategies using drugs that are currently available for targeting these factors in clinical trials.

SIGNIFICANCE

Our study points to the existence of an oncogenic NFATc1-STAT3 cooperativity that mechanistically links inflammation with pancreatic cancer initiation and progression. Because NFATc1-STAT3 nucleoprotein complexes control the expression of gene networks at the intersection of inflammation and cancer, our study has significant relevance for potentially managing pancreatic cancer and other inflammatory-driven malignancies.