Global prevalence of mortality and LV recovery in women with PPCM – a systematic review and meta-analysis

Introduction

Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications mainly occurring early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death.

Purpose

We aimed to systematically summarize the outcomes of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes.

Methods

For this systematic review and meta-analysis, we performed a comprehensive search of all articles published between January 2000 and June 2021 on PubMed/MEDLINE, Web of Science, Scopus and EBSCO Host, including Academic Search Premier, Africa-Wide Information, CINAHL. All cohort, case-control and cross-sectional studies, as well as control arms of randomized controlled trials (RCTs) reporting on the in-hospital complications and 6- and/or 12-month outcomes of PPCM were considered eligible.

Results

Forty-seven studies (4875 participants across 60 countries) met the eligibility criteria. Hemodynamic and echocardiographic parameters were similar across all continents. In-hospital mortality was reported as 1.9% [95% CI 0.5–4.0] across all regions. About 10% of patients received invasive ventilation, 21.5% inotropic and 3.1% received mechanical support, respectively. Left ventricular (LV) thrombus complicated 9.0% [95% CI 6.5–11.9] of patients and all-cause embolic events (i.e., stroke, arterial embolism, deep vein thrombosis, pulmonary embolus) occurred in 6.1% [95% CI 3.8–8.9]. Arrhythmias were seldomly reported. All-cause mortality was 8.0% [95% CI 5.5–10.8, I2=79,1%) at 6 months and 9.8% [95% CI 6.2–14.0], I2=80.48%) at 12 months respectively. Overall, 44.4% ([95% CI 36.2–52.8], I2=91.7%) of patients recovered their LV function within 6 months and 58.7% ([95% CI 48.1–68.9], I2=75.8%) within 12 months, respectively. The lowest rate of LV recovery was reported by studies conducted in the Middle East (13.6% [95% CI 9.5–18.1], 3 studies), whereas the highest rate of LV recovery was reported for patients from Europe (56.8% [95% CI 38.1–74.7], 6 studies, I2=93.3%). All-cause mortality was highest in Africa and Asia/Pacific. Europe and North America reported the highest prevalence of LV recovery. (Figure 1) Frequent prescription of beta-blockers, ACE-I/ARB and bromocriptine/cabergoline treatment was associated with significantly lower all-cause mortality and better LV recovery (Figure 2).

Conclusion

We identified significant global differences in prescribed treatment, prevalence of in-hospital complications and six- and 12-month outcomes. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in women with PPCM.

Funding Acknowledgement

Type of funding sources: None.

Single pill treatment in daily practice is associated with improved clinical outcomes and all-cause mortality in cardiovascular diseases: results from the START project

Objective

Current guidelines for the management of arterial hypertension, dyslipidemia, or secondary cardiovascular (CV) prevention recommend combination drug treatments with single pill combinations (SPC). This concept is expected to improve adherence to treatment and, as a consequence, to reduce the risk of adverse CV outcomes associated with these clinical conditions. Aim of our study was to assess whether SPC are clinically superior to multi pill combination (MPC) with identical drugs in reducing CV events and al-cause mortality in a huge population under real world conditions in daily practice.

Methods

We analyzed an anonymized claims dataset (AOK PLUS, a statutory German sickness fund) including patients with hypertension and other CV diseases in the years 2012–2017; minimum follow-up was 1 year or until date of death, After 1:1-Propensity Score Matching (PSM), selected CV outcomes (myocardial infarction, stroke, transitory ischemic attack, coronary artery disease, heart failure, acute renal failure, cardiovascular hospitalization, all cause hospitalization) as well as all-cause mortality were compared using Incidence Rate Ratios (IRRs) and non-parametric tests.

Results

50,622 patients (25,311 patients in SPC versus MPC group) aged ≥18 years treated with SPC or identical MPC were followed up for at least 1 year or until death. No significant differences in baseline characteristics were observed after PSM. Nine different clinical outcomes were compared for each group. In all comparisons, significantly lower incidence rate ratios (IRR) were identified for SPC, confirmed by comparison of Kaplan-Meier estimates: stroke (IRR=0.77; 95% CI 0.67–0.88; p<0.001), transitory ischemic attack (IRR=0.61; 95% CI 0.48–0.78; p<0.001), myocardial infarction (IRR=0.76; 95% CI 0.63–0.90; p=0.0016), coronary artery disease (IRR=0.66; 95% CI 0.57–0.77; p<0.001), heart failure (IRR=0.59; 95% CI 0.54–0.64; p<0.001), acute renal failure (IRR=0.54; 95% CI 0.56–0.64; p<0.001) all cause hospitalization (IRR=0.72; 95% CI 0.71–0.74; p<0.001), cardiovascular hospitalization (IRR=0.63; 95% CI 0.57–0.69; p<0.001), and all-cause mortality (IRR=0.62; 95% CI 0.57–0.68; p<0.001). The mean time to first events and time to death were also in favor to SPC (any event: SPC 966.052 days/median 873; MPC 846.936 days/median 647; death: SPC 1,719.424 days; MPC 1,657.248 days; log rank for both comparisons: p<0.001).

Conclusion

In clinical practice, the SPC regimen is associated with a lower incidence of CV events and lower all-cause mortality. Time to the event is also significantly longer in the SPC group compared to MPC. These results strongly support the concept of SPC and the implementation into daily practice to improve patient's prognosis.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): APONTIS PHARMA GmbH & Co. KG

Hydrochlorothiazide does not lead to phototoxic reactions and DNA damage in healthy volunteers the HCTox study

Purpose

Hypertension represents the most common cardiovascular risk factor for premature death worldwide. Hydrochlorothiazide (HCTZ) is one of the most commonly used antihypertensive and diuretic drug worldwide. Recently, pharmacoepidemiologic studies associated the use of HCTZ with increased risk of skin cancer. As a result, prescriptions of HCTZ decreased, leading to worsening of blood pressure therapy in a significant proportion of patients. However, whether HCTZ causes skin cancer remains elusive. We aimed to examine the photosensitive potential of HCTZ in vivo. To further enlighten the pathophysiologic mechanisms of carcinogenesis and phototoxicity caused by HCTZ in vitro, we conducted a series of laboratory experiments.

Methods

This randomized, double-blinded, placebo-controlled clinical trial assessed the phototoxic properties of HCTZ. We randomly assigned 30 healthy adult volunteers in a 2:1 ratio to either HCTZ 25 mg daily or placebo once daily for 15 days. Skin photosensitivity by phototesting for UV-A and UV-B radiation, office blood pressure, serum-vitamin-D status and urinary excretion of thymidine-dimers were measured. To further assess the pathophysiologic mechanisms of possibly HCTZ induced photosensitivity, human keratinocytes (HaCaT) were incubated with HCTZ and then irradiated with UV-B radiation (311 nm one burst of 100 J/cm2). rt-PCR-testing and western blots were performed to analyze reactive oxygen species, inflammation and carcinogenesis.

Results

All 30 participants were adherent to the protocol, as confirmed by toxicological analysis of serum and urine. Skin photosensitivity to exposure of UV-A and UV-B radiation remained unchanged in both groups (UVB-MED: HCTZ Δ = 0.0 J/cm2 vs. placebo Δ = −0.2 J/cm2; p=0.06). No thymidine-dimers were detected in urine of either group. Systolic blood pressure decreased in both groups but was not different between HCTZ and placebo (HCTZ Δ = −5.2 mmHg vs. placebo Δ = −5.4 mmHg; p=0.94). The same was found for diastolic blood pressure (HCTZ Δ = −1.9 mmHg vs. placebo Δ = −4.3 mmHg; p=0.34). Serum-vitamin-D increased in both groups (HCTZ Δ = +2.7 ng/ml vs. placebo Δ = 0.9 ng/ml; p=0.56). In addition, combination of HCTZ and a high intensity burst of UV-B radiation did not increase expression of inflammatory proteins or increase formation of reactive oxygen species (SOD-1, SOD-2, and catalase).

Conclusions

HCTZ did not significantly increase photosensitivity for UV-A or UV-B radiation in healthy volunteers compared with placebo. Moreover, no relevant DNA-damages were detected in either group. HCTZ alone did not increase inflammation, formation of reactive oxygen species or carcinogenesis in human keratinocytes. Furthermore, the combination of a UV-B burst of 100 J/cm2 and HCTZ was not associated with additive effects on inflammation, reactive oxygen species or carcinogenisis.

HCTZ in a cumulative dose of 375 did not increase photosensitivity or DNA-damages in vivo.

Funding Acknowledgement

Type of funding sources: None.

Association of heart rate with heart failure outcomes and the effects of empagliflozin in patients with preserved ejection fraction – EMPEROR-Preserved trial

Background and objective

High resting heart rate (HR) associates with cardiovascular death (CVD) and heart failure hospitalisation (HFH) in patients with reduced ejection fraction (HFrEF), but data are sparse in patients with preserved (HFpEF) or mildly reduced (HFmrEF) ejection fraction. Empagliflozin reduced the risk of CVD and HFH in HFpEF in the EMPEROR-Preserved trial. This study analyses the influence of HR on outcomes in patients with left ventricular ejection fraction (LVEF) >40% in EMPEROR-Preserved and evaluates the effects of empagliflozin across HR categories.

Methods

Patients (n=5988) with HFpEF (LVEF >40%) were categorised to HR <70 beats per minute (bpm), 70–75 bpm and >75 bpm. The composite of CVD or HFH (primary outcome), first HFH, CVD, recurrent HFH and all-cause mortality were studied in the HR groups and in patients separated by sinus rhythm (SR) or atrial fibrillation (AF) and true HFpEF (EF ≥50%) or HFmrEF (EF 40–49%).

Results

Empagliflozin did not influence HR over time. At HR >75 bpm, the primary outcome (hazard ratio: 1.31, 1.13–1.52, p=0.0003), time to first HFH (hazard ratio: 1.25, 1.04–1.49, p=0.02), recurrent HFH (hazard ratio: 1.29, 1.05–1.60, p=0.02), CVD (hazard ratio: 1.49, 1.21–1.84, p=0.0001) and all-cause mortality (hazard ratio: 1.49, 1.28–1.73, p<0.0001) were increased compared to HR of <70 bpm with HR 70–75 bpm showing intermediate results. The influence of HR on the primary outcome was only observed in SR (p trend=0.005), but not in AF (p trend=0.55). Patients with true HFpEF (≥50%) or HFmrEF (40–49%) showed similar effects. The treatment effects of empagliflozin to reduce the primary outcome, time to first HFH and recurrent HFH were not modified by HR.

Conclusions

HR in SR, but not in AF, predicts heart failure outcomes in HFpEF and HFmrEF, but the effects of empagliflozin were not modified by HR.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance

Blood pressure reduction in higher cardiovascular risk patients in the Global SYMPLICITY Registry

Background/Introduction

The Global SYMPLICITY Registry (GSR) was designed to evaluate the safety and efficacy of renal denervation (RDN) in real-world patients. Inclusion and exclusion criteria are limited to allow assessment of the effects of RDN on patients with a wide range of comorbidities. The current analysis examines blood pressure (BP) reduction after RDN in higher cardiovascular risk patients.

Purpose

To evaluate blood pressure reduction after RDN in higher cardiovascular risk patients in GSR.

Methods

GSR is a prospective all-comers registry to evaluate the safety and efficacy of RDN. Patients are enrolled in GSR and receive radiofrequency RDN using the Symplicity Flex or Symplicity Spyral catheter. Office and ambulatory BP are measured at each follow-up (3, 6, 12, 24, and 36 months). In this post-hoc analysis, changes from baseline in office and 24-hour ambulatory systolic blood pressure were assessed in patients at higher cardiovascular risk. Higher risk was defined using baseline office systolic or diastolic BP as well as additional risk factors (Figure 1).

Results

As of March 2021, there were 2621 patients characterized as higher cardiovascular risk in GSR. Baseline characteristics included mean age 60.7±12.1 years, 57.6% male, 37.9% type 2 diabetes, 35.8% hypocholesterolemia, 19.7% eGFR <60 mL/min/1.73 m2, 16.2% left ventricular hypertrophy, 10.2% previous stroke and 9.3% previous myocardial infarction. Baseline office systolic BP (OSBP) was 168.8±22.7 mmHg and baseline ambulatory systolic BP (ASBP) 155.3±18.6 mmHg. Mean OSBP reductions after RDN in this higher risk population ranged from −13.1 mmHg at 3 months to −17.5 mmHg at 24 months and −18.9 mmHg at 36 months, and mean ASBP reductions ranged from −7.8 mmHg at 3 months to −9.8 mmHg at 24 months and −9.3 mmHg at 36 months (Figure).

Conclusions

Higher risk patients in GSR had sustained office and ambulatory systolic BP reductions out to 3 years after catheter-based radiofrequency RDN.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic

Sex differences in cardiovascular research

Background

Women are underrepresented in cardiovascular publications. We sought to investigate sex-specific differences in cardiovascular research over the last decade.

Methods and results

All 387,463 cardiovascular publications between 2010–2019 were retrieved from Web-of-Science and analyzed regarding the authors' sex, the average impact factor (IF), the number of citations, co-authors per article, and international collaborations. The number of cardiovascular research articles increased between 2010–2019 from 19,960 to 29,604 articles per year. The number of articles written by female first authors increased by 48.3% (6434 articles in 2010 and 11,343 articles in 2019) and by 35.0% for male first authors (13,526 articles in 2010 and 18,261 articles in 2019). The last/senior author was more likely to be female in articles with female first authors compared with male first authors (28.2% vs. 14.1%; odds ratio 2.48, 95% confidence interval 2.43–2.53, p<0.001). The average IF for articles by female first authors was lower compared to male (3.1±3.8 vs. 3.5±4.9, p<0.001). Likewise, the H-Index was lower for female than male first authors (1.07±0.74 vs. 1.25±0.98, p<0.001), as was the number of citations per articles (14.0±31.1 vs. 18.0±68.8 citations, p<0.001). Female first authors had fewer co-authors per article than their male peers (7.4±19.6 vs. 8.2±35.2; p<0.001) and were less represented in articles with >15 co-authors (3,623 articles by female and 8,941 by male first authors; ratio female to male 0.41). Scientific advancement as the ratio between female to male first authorships was highest in publications from Latin America (ratio 0.92) and lowest in Asia (ratio 0.40). Female authorship articles reached the highest IF in North America (average IF 3.7), the lowest Africa (average IF 1.8).

Conclusions

Publications in cardiovascular research have increased over the last decade, particularly by female authors. Female researchers are cited less often compared with their male peers and publish with fewer co-authors. The IF remains lower for articles by female researchers. Efforts to further increase women-led research activities are needed

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Cardiac SocietyGerman Research Foundation (DFG)

Predictors of blood pressure response after renal denervation beyond pretreatment blood pressure

Background

The principle of initial value (Wilder's law of initial value) proposes that the “direction of response of body function to any agent depends to a large degree on the initial value of that function”. Indeed, in several trials on renal denervation (RDN), pre-treatment blood pressure (BP) has been consistently and repeatedly found to predict the decrease in BP after RDN. Efforts to discover further statistically significant and clinically meaningful predictors of BP response to RDN failed.

Objective

By use of a new methodological approach, we aimed to determine predictors of BP response after RDN in patients with resistant hypertension.

Methods

The study population comprised 266 patients with resistant hypertension (mean age 62 years, 34% females, mean BMI 30.5 kg/m2, 27% had coronary heart disease, 42% had diabetes mellitus and 61% had hypercholesterolaemia) who underwent radiofrequency RDN with the Symplicity catheter at the Universities of Homburg and Erlangen. Clinical data including 24h ambulatory BP (ABP) were obtained prior to, and 3, 6 and 12 months after RDN. The primary parameter of response was defined as change in 24-hour systolic ABP after 6 months from pre-treatment values. As expected, change in 24h systolic ABP correlated with pre-treatment 24h systolic ABP (r2 linear = 0.225, p<0.001), with change in 24h systolic ABP = 73.82 + 0.55 x pre-treatment 24h systolic ABP. To overcome the predominant role of the pre-treatment BP that may mask other factors, we calculated for each individual patient the “expected systolic ABP decrease” by applying this regression equation and the “excessive systolic ABP decrease” by subtracting the measured from expected change in 24h systolic ABP. We divided the study population into 2 groups (above [responders] and below [non-responders] of the median change in excessive 24h systolic ABP.

Results

Neither pre-treatment 24h systolic or diastolic ABP, nor office systolic or diastolic BP differed between the two groups (all p>0.20). Following RDN, 24h systolic ABP decreased in the responders by −23.3±16 vs non-responders +1.4±11 mmHg at 6 month, and 24h systolic ABP values were also significantly lower in responders at 3 and 12 months (all p<0.001), without difference in number of antihypertensive drugs between the groups. Of all clinical variables at baseline, office heart rate (65.6 vs 68.7±12 bpm, p=0.024) and HbA1c (6.07±0.88 vs. 6.37±1.23%, p=0.035) were lower in responders compared with non-responders. Finally, a multiple regression analysis confirmed that pre-treatment 24h systolic ABP (beta +0.565, p<0001), HbA1c (beta −0.167, p=0.004) and office HR (beta +0.106, p=0.057) were independent predictors of decrease in 24h systolic ABP.

Conclusion

In patients with resistant hypertension, lower HbA1c and office HR were identified as predictors of BP response in addition to pre-treatment BP. This finding may help to identify hypertensive patients who benefit most from RDN.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Extramural grant provided vy Medtronic INc

Increased risk of heart failure is associated with chronic habitual hypohydration that elevates serum sodium above 142 mmol/l suggesting lifelong optimal hydration as preventive measure

Background

With increasing prevalence of heart failure (HF) owing to the aging population, identification of preventive measures that delay onset of the disease and their implementation become increasingly important. Recent studies demonstrated that chronic subclinical hypohydration accelerates degenerative changes and increases prevalence of many age-dependent degenerative diseases including heart failure (1). Worldwide surveys find wide differences in habitual water intake between and within countries and substantial prevalence of hypohydration in general population (2). Hypohydration elevates extracellular sodium triggering activation of water conservation mechanisms when serum sodium exceeds a threshold around 142 mmol/l. These adaptive responses include secretion of antidiuretic hormone and activation of the renin angiotensin aldosterone system (3), important contributors to pathogenesis of HF.

Purpose

The purpose of this study was to evaluate whether serum sodium concentration at middle age of 44–66 years as a measure of hydration habits is a significant predictor for left ventricular hypertrophy (LVH) and HF events 25 years later at age of 70–90 years.

Methods

Data from Atherosclerosis Risk in Communities (ARIC) study were obtained from the BioLINCC data repository. In ARIC study, 15,792 44–66 year-old participants were evaluated over 5 visits spanning 25 years (Figure 1A). Two separate logistic regression models were used in the study, where the dependent variable is diagnosis of LVH and HF at visit 5 (age:70–90 years), and the predictors are serum sodium concentration measured at visits 1 and 2 (age: 44–66 years), age, gender, total cholesterol, glucose, eGFR, BMI, smoking and hypertension statuses.

Results

Midlife serum sodium is associated with LVH and HF diagnosis 25 years later at visit 5 both with adjustment for age only (LVH: OR=1.24, 95% CI 1.15–1.34, P<0.001; HF: OR=1.06, 95% CI 1.02–1.10, P=0.006) and in fully adjusted model (LVH: OR=1.20, 95% CI 1.11–1.30, P<0.001; HF: OR=1.11, 95% CI 1.01–1.22, P=0.031) (Figure 1B). Cornell voltage criteria used for LVH diagnosis is elevated in participants with higher serum sodium and demonstrates sharper increase with age indicating accelerated hypertrophic LV remodeling (Figure 1C). These associations are reflected in increased prevalence of HF and LVH in 70–90 year-old participants whose middle age serum sodium exceeded 142 mmol/l (Figure 1D).

Conclusions

Habitual life-long hypohydration increases risk to develop LVH and HF. Keeping serum sodium below 142 mmol/l by drinking appropriate amount of liquids may slow down decline in cardiac function and decrease prevalence of HF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): NHLBI Intramural program

Application of win ratio methodology in the Global SYMPLICITY Registry for patients with atrial fibrillation or obstructive sleep apnea

Background/Introduction

The win ratio is a new methodology which utilizes multiple hierarchical endpoints to evaluate clinical outcomes in trials. The win ratio may have added benefit in device therapy trials like renal denervation (RDN) where anti-hypertensive medication burden can influence blood pressure (BP) changes.

Purpose

In this analysis, we applied the win ratio to patients in the Global SYMPLICITY Registry (GSR) to quantify potential differences in RDN efficacy according to different comorbidities, specifically atrial fibrillation and obstructive sleep apnea.

Methods

All patients in GSR had an RDN procedure with the Symplicity Flex or Symplicity Spyral catheter. For the win ratio analysis, ambulatory systolic BP (ASBP) measurements, office systolic BP (OSBP) measurements and the number of prescribed anti-hypertensive medications at 6 months were included as hierarchical endpoints. Patients were divided into 1 of 2 groups: with or without atrial fibrillation (AF) at baseline. Each patient was compared with every other patient in the opposing group first according to ASBP to determine “win”, “lose” or “tie” with a threshold of 5 mmHg. Then, ties from the ASBP comparison underwent the comparison using OSBP with a threshold of 10 mmHg. Any tie for a pair comparing OSBP resulted in comparison of number of anti-hypertensive medications with a threshold of 1. Comparisons of ASBP and OSBP were adjusted for baseline SBPs by using residuals from a linear regression. The analysis was repeated for patients grouped according to history of obstructive sleep apnea (OSA) at baseline.

Results

In March 2020, 336 patients with AF at baseline and 2,394 patients with no AF were compared in GSR, resulting in 336 x 2394 = 804,384 pairwise comparisons for the win ratio analysis. A total of 285,709 “wins”, indicating greater ASBP reduction, OSBP reduction, and/or fewer number of anti-hypertensive medications occurred in the AF group compared to the no AF group. Conversely, 256,511 “losses”, meaning greater BP reduction and/or number of medications occurred in the no AF group. The win ratio was thus calculated as 1.11 (95% CI: 0.98, 1.28, p=0.081) indicating similar BP reduction and medication burden after RDN in patients with or without AF in GSR (Figure). Using these methods, the win ratio for patients with and without OSA was calculated to be 0.98 (95% CI: 0.85, 1.13, p=0.81), also indicating similar RDN efficacy regardless of presence of OSA at baseline (Figure). Previously published results of the win ratio analysis of RDN and sham control patients in the SPRYAL HTN-ON MED trial reported a win ratio in favor of RDN of 2.78 (95% CI: 1.58, 5.48, p<0.001).

Conclusions

Application of the win ratio methodology to patients in GSR demonstrated similar efficacy of RDN to patients regardless of whether they had comorbidities of atrial fibrillation or obstructive sleep apnea.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic

Outcomes of novel pacing technologies with right ventricular pacing as a primary strategy for patient undergoing transvenous permanent pacing regardless of pacing indication

Background

Right ventricular pacing (RVP) may cause electrical and mechanical desynchrony leading to impaired left ventricular ejection fraction (LVEF). We investigated the outcomes of RVP with His bundle pacing (HBP) and left bundle branch pacing (LBBP) for patients requiring a de novo permeant pacemaker (PPM) irrespective of baseline pacing indication.

Methods and results

Systematic review of randomized clinical trials and observational studies comparing HBP or LBP with RVP for de novo PPM implantation between 01 January 2013 and 17 November 2020 using MEDLINE and Embase. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Random and fixed effects meta-analyses of the effect of pacing technology on study outcomes (all-cause mortality, heart failure hospitalization (HFH), left ventricular ejection fraction, QRS duration, lead revision, atrial fibrillation and procedure and pacing metrics) were performed. Overall, 7 studies were included. HBP compared with RVP was associated with decreased mortality (risk ratio [RR] 0.76, 95% CI 0.59 to 0.98), preservation of LVEF (mean difference [MD] 1.2, 95% CI −1.37 to 3.8 vs. −5.22, 95% CI: −6.94 to −3.51), increased procedure duration (MD 15.17 min, 95% CI: 11.27 to 19.07) and more lead revisions (RR 6.30, 95% CI: 2.31 to 17.19). LBBP compared with RVP was associated with shorter paced QRS durations (MD 5.6 ms, 95% CI −6.4 to 17.6) vs. (51.0 ms, 95% CI 39.2 to 62.9) and increased procedure durations (MD 37.78 min, 95% CI: 20.04 to 55.51).

Conclusion

Of the limited studies published, this meta-analysis found that HBP and LBBP were superior to RVP in maintaining physiological ventricular activation as an initial pacing strategy. Well conducted comparative studies are required to understand the impact of such novel pacing strategies on clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Central hemodynamic effects in patients with chronic coronary syndrome after long-term ivabradine therapy

Objectives

We sought to assess central hemodynamic effects in 23 patients (18 male, 5 female) with a resting heart rate (HR) of ≥70 beats per minute (bpm) and chronic coronary syndrome after long-term ivabradine therapy (6 months) by cardiac magnetic resonance (CMR).

Methods and results

In a cross-over design, all patients were treated with ivabradine (Iva, 7.5 mg bid) and placebo for 6 months each. CMR was performed three times (at baseline, after 6 and 12 months) to determine left ventricular (LV) function parameters, including end-diastolic and end-systolic volumes (EDVi, ESVi), stroke volume (SVi) and ejection fraction (EF) as well as volume-time curve (VTC) parameters, including peak ejection rate (PER), peak ejection time (PET), peak filling rate (PFR), peak filling time from ES (PFT), peak ejection rate normalized to EDV (PER/EDV) and peak filling rate normalized to EDV (PFR/EDV) for global LV function (systolic and diastolic) assessment. Flow measurements of the ascending aorta were performed with phase-contrast velocity imaging.

Treatment with Iva led to a HR reduction of 11.4 bpm (Iva 58.8±8.2 bpm vs placebo 70.2±8.3 bpm, p<0.0001).There was no difference in LVEF (%) (Iva 57.4±11.2 vs placebo 53.0±10.9, p=0.18), EDVi or ESVi. SVi (ml/m2) remained comparatively unchanged after long-term treatment with Iva (Iva 40.6±9.6 vs placebo 35.7±8.8, p=0.08). VTC parameters reflecting systolic LV function (PER, PET) were unaffected by Iva, while both PFR and PFR/EDV were significantly increased (PFR/EDV (s-1) Iva 2.4±0.4 vs placebo 2.1±0.4, p=0.03). There was a trend to longer PFT during treatment with Iva, though not reaching statistical significance. Medium and maximum aortic flow were not affected by treatment with Iva, while mean velocity (cm/s) was significantly reduced (Iva 6.7±2.7 vs placebo 9.0±3.4, p=0.01). Aortic flow parameters were correlated to aortic distensibility (AD), as surrogate parameter for arterial stiffness. AD was significantly correlated to both aortic flow and flow velocity, whereby mean velocity showed the strongest correlation to AD (r=0.74 [0.61 to 0.83], p<0.0001).

Conclusion

Systolic LV function was unaffected by treatment with Iva, while the filling during diastole was significantly improved. While medium and maximum aortic flow were not affected by Iva, mean velocity was significantly reduced. Aortic distensibility as surrogate parameter for arterial stiffness was significantly correlated to aortic mean velocity. This study confirms the underlying physiological principle of the If-current inhibitor Ivabradine.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): This work was supported by the Deutsche Herzstiftung (German Heart Foundation) (F/14/11 to F.C.) and the Deutsche Forschungsgemeinschaft (DFG KFO 196 to U.L., S.H.S and M.B. and SFB TTR 219, S-01 to M.B.). The Saarland University Medical Center has received an unrestricted grant from Servier (France).

First-in-man experience with ultrasound renal denervation for treatment of recurrent ventricular arrhythmias

Background/Introduction

Ventricular arrhythmias (VA) are common in patients with chronic heart failure (CHF) and can be refractory to drugs and catheter ablation. Promising results of sympathomodulatory treatment have been reported in these patients.

Purpose

This first in man study aims at investigating catheter-based renal denervation (RDN) using ultrasound energy for treatment of refractory VA in patients with CHF.

Methods

Four patients (age 65±10 years, all male, left ventricular ejection fraction 36±7%, global longitudinal strain (GLS) −10±3%) with CHF (n=1 ischemic cardiomyopathy, n=3 non-ischemic cardiomyopathy) and refractory VA were treated with RDN using ultrasound energy. All patients had undergone endo- or epicardial catheter ablation for recurrent ventricular tachycardia (VT) or fibrillation (VF) in the past and were on at least 2 antiarrhythmic drugs. Computer tomography angiography was performed at baseline, duplex ultrasound of renal arteries, ambulatory blood pressure monitoring (ABPM) and ICD interrogations were performed before, 1 day and 3 months post RDN.

Results

Bilateral RDN using an ultrasound-based catheter were performed with at least 2 sonications in each main branch of the left and right renal artery. In this analysis, mean follow-up time was 113±12 days. All RDN procedures were performed without any complications. No renal artery stenoses during follow-up. Arrhythmic burden (measured as VT/VF episodes) within 3 months before RDN requiring ICD therapy was reduced from 3 [1.5–54.5] episodes of anti-tachycardia pacing (ATP) and 0.5 [0–1.25] adequate ICD shocks to 1 [0.75–1] episode of ATP. There were no adequate ICD shocks after 3 months. Mean 24-hour ABP before RDN was 94±8/65±9 mmHg with no change in BP following 3 months (SBP 92±1 mmHg, DBP 62±6 mmHg after 3 months). There was no change in left ventricular GLS (−10±3% before, −9±4% after RDN) or ejection fraction (36±7% before and after RDN).

Conclusions

RDN using ultrasound energy in patients with CHF and refractory VA was safely performed with no changes in blood pressure and reduced the arrhythmic burden after 3 months follow-up.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): ReCor Medical Inc.

Markers of cholesterol metabolism and cardiovascular outcomes in patients with chronic kidney disease

Background

In dialysis patients statins are less effective than in other high risk patients due to a shift from cholesterol synthesis towards cholesterol absorption. The CARE FOR HOMe study investigates whether a shift towards cholesterol absorption occurs in non-dialysis chronic kidney disease (CKD), and whether the ratio of campesterol-to-lathosterol predicts cardiovascular outcomes in non-dialysis CKD patients.

Methods

In this analysis 251 participants suffering from CKD (KDIGO 2–4) without lipid-lowering drugs were included and followed for major atherosclerotic events (MACE). Additionally, all-cause death and the composite endpoint MACE and all-cause death were explored. We performed univariate and multivariate Cox regression analysis, adjusting for age, gender, estimated glomerular filtration rate (eGFR), log-transformed albuminuria, prevalent cardiovascular disease, current smoking, diabetes mellitus, systolic blood pressure and body mass index. The primary hypothesis was that patients with a high campesterol-to-lathosterol ratio had a higher event rate.

Results

Neither lathosterol-to-cholesterol (r=0.022; p=0.730), nor campesterol-to-cholesterol (r=0.041; p=0.519) nor campesterol-to-lathosterol (r=−0.103; p=0.105) correlated with eGFR. During follow-up of 5.1±2.1 years, 47 participants suffered from MACE, 46 participants died and 61 reached the composite endpoint of MACE or all-cause death. In univariate Cox regression analysis, campesterol-to-lathosterol did not predict atherosclerotic cardiovascular events (HR 0.740; 0.368–1.487), all-cause death (HR 0.564; 0.277–1.145) or the composite endpoint (HR 0.652; 0.355–1.196). After full adjustment: campesterol-to-lathosterol was not associated with all three endpoints; MACE (HR 1.064; 0.507–2.231), all-cause death (HR 0.818; 0.420–1.594) and MACE and all-cause death (HR 0.956; 0.525–1.744).

Conclusion

Markers of cholesterol metabolism were not associated with eGFR in patients with impaired renal function (KDIGO 2–4). Campesterol-to-lathosterol did not predict future MACE or all-cause death in non-dialysis CKD. These findings do not support the concept that patients with impaired renal function (KDIGO 2–4) benefit in particular from ezetimibe treatment. Further research is required to address this hypothesis in dialysis patients.

Funding Acknowledgement

Type of funding source: None

Left ventricular longitudinal strain in professional athletes, a useful tool to detect an athletes hearts?

Background

Professional cyclists frequently present with physiological adaptations to endurance exercise with an increase in left ventricular wall thickness and mass. Global longitudinal strain (GLS) is an early and sensitive echocardiographic method to detect left ventricular dysfunction. However, it is unclear whether GLS is able to differentiate between athlete's hearts or different pathological conditions of left ventricular hypertrophy.

Methods

A total of 87 professional athletes (37 professional cyclists, 29 professional soccer players, and 21 professional handball players) were compared to 125 patients with different forms of left ventricular hypertrophy (17 hypertrophic obstructive cardiomyopathy (HOCM), 36 hypertensive heart disease (HHD), 35 severe aortic valve stenosis (AVS); 37 untrained individuals served as controls. Examinations were performed between October 2018 to October 2019. All subjects underwent echocardiographic examination, including GLS.

Results

In all 212 participants/patients included a preserved ejection fraction >50% (mean 61±7%) was detected. Left ventricular mass index (LVMI) in professional cyclists (165.5±37.1 g/m2) was increased when compared to professional soccer players (97.3±12.4 g/m2, p<0.001), professional handball players (92.2±15.8 g/m2, p<0.001) and healthy controls (94.3±20.7 g/m2, p<0.001), as well as to patients with HHD (129.2±30.0 g/m2, p<0.001), or AVS (140.1±35.4 g/m2, p=0.064), but not to patients with HOCM (159.7±39.4 g/m2, p=0.64). Professional cyclists (−21.0±3.5%) achieved higher average GLS values than professional soccer (−18.4 ± %, p=0.004) or handball players (−18.4 ± %, p=0.021), healthy controls (−19.0±3.0%, p=0.008), HOCM (−15.0±6.5%, p<0.001), HHD (−13.8±5.9%, p<0.001), and AVS (−16.0±7.0%, p<0.001) (Figure 1).

Conclusion

In professional cyclists, higher LVMI and average GLS values were detected compared to professional soccer and handball players with lower excessive endurance exercise, as well as untrained healthy controls. Average GLS can help to differentiate between athletes' hearts in professional cyclists compared to pathologic patterns in different diseases characterized by left ventricular hypertrophy with elevated LVMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Persistence and cardiovascular outcomes with ramipril, atorvastatin, ASA as a single pill compared to the multi pill combination. A subanalysis of the START study, a claims data analysis

Background/Introduction

Large randomized clinical trials have shown the efficacy of aspirin (ASA), angiotensin converting enzyme inhibitors (ACEI) and statins (S) in secondary prevention. However, adherence to medication is low in patients suffering from a cardiovascular event and decreases with each additional tablet. Therefore, a single pill (SP) approach is considered to increase drug persistence and decrease cardiovascular events in this patient population.

Purpose

Data that show an advantage for a SP regimen containing ASA, ACEI, and S compared to the identical loose combination (LC) regarding persistence, and clinical outcomes under conditions of daily practise in one study are missing. We conducted the START study to answer these questions. A subset, in which we anlysed data from patients in secondary prevention is presented here.

Methods

The START study was a retrospective, non-interventional analysis of an anonymised claims dataset covering patients suffering from cardiovascular diseases insured by the German AOK PLUS public health insurance in the years 2012–2017. Patients at age ≥18 years with an indication for the use of a combination treatment in cardiovascular disorders – including the use of ASA, ramipril, and atorvastatin - in a SP or identical LC were followed up to 1 year. After 1:1-Propensity Score Matching (PSM) persistence (defined as redemption of prescription with a lack >60 days) and clinical outcomes were compared using non-parametric tests.

Results

Before PSM, 564,941 patients had a cardiovascular event in the medical history, 427,046 suffered from coronary artery disease. 275 received the three substances described above as SP, 6,662 as LC. After PSM, data from 211 patients were suitable for further analysis in each group. Baseline characteristics were comparable between SP and LC groups. Persistence to treatment was significant lower in the LC group (Hazard Ratio, HR, 0.25 [95% CI 0.19–0.34], p<0.001). 8 clinical outcomes were analysed. Lower Incidence Rate Ratio (IRR) was found in the SP group for myocardial infarction (IRR 0.46; 95% CI 0.07–2.36), stroke (IRR 0.51; 95% CI 0.04–4.46), transitory ischemic attac (IRR 0.77; 95% CI 0.01–60.12), coronary artery disease (IRR 0.60; 95% CI 0.25–1.43), and all cause mortality (IRR 0.38; 95% CI 0.06–1.79). All cause hospitalisation was significant lower in the SP group (IRR 0.58; 95% CI 0.47–0.72; p<0.001).

Conclusion

The number of patients receiving a SP regimen in secondary prevention was relatively low. However, persistence to medication was significantly higher in the SP group. In addition, a tendency for a lower IRR was also observed for cardiovascular events and all cause mortality in the SP group. The results of our analysis support the use of a SP regimen in secondary prevention of cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Single pill regimen improves persistence and leads lo better clinical outcome compared to identical multi pill combination. Results of START, a German claims data analysis

Background/Introduction

The current ESC/ESH-Guidelines for the treatment of arterial hypertension (AH) recommend initiation and escalation of medical treatment using renin–angiotensin–aldosterone system (RAAS) blocker, diuretics (D) and/or calcium channel blockers (CCB). They also recommend a single pill (SP) regimen to improve persistence, to increase blood pressure control and to reduce cardiovascular events.

Purpose

Data showing an advantage for a SP regimen compared to the identical loose combination (LC) regarding all these parameters in a single study are missing. We report now the results comparing SP with identical LC regarding persistence and cardiovascular outcomes in daily practice.

Methods

This was a retrospective, non-interventional analysis of an anonymized claims dataset covering patients suffering from cardiovascular diseases insured by the German AOK PLUS public health insurance in the years 2012–2017. Patients at age ≥18 years with an indication for the use of a combination of RAAS-blockers, D and/or CCB as SP or identical LC were followed up for 1 year. After 1:1-Propensity Score Matching (PSM) persistence (defined as redemption of prescription with a lack >60 days) and clinical outcomes were compared using non-parametric tests.

Results

After PSM, baseline characteristics were comparable between SP and LC groups. Each group included 10,801 patients with valsartan/amlodipine, 1,026 with candesartan/amlodipine, 1,823 with amlodipine/valsartan/hydrochlorothiazide (HCT), and 15,349 with ramipril/amlodipine as SP or identical LC. 8 clinical outcomes were compared for each combination. Persistence to treatment was significant higher in the SP group. In 27 of 32 comparisons a significantly lower Incidence Rate Ratio (IRR) was identified for SP. This was confirmed by time-to-event-analysis. The largest patient group (ramipril/amlodipine) showed a significant lower risk for SP observed for stroke (IRR=0.746; 95% CI 0.627–0.886; p<0.001), transitory ischemic attack (IRR=0.693; 95% CI 0.496–0.963; p=0.023), myocardial infarction (IRR=0.623; 95% CI 0.493–0.784; p<0.001), coronary artery disease (IRR=0.579; 95% CI 0.462–0.723; p<0.001), heart failure (IRR=0.468; 95% CI 0.409–0.534; p<0.001), all cause hospitalization (IRR=0.670; 95% CI 0.652–0.687; p<0.001), cardiovascular hospitalization (IRR=0.596; 95% CI 0.519–0.685; p<0.001), and all cause mortality (IRR=0.526; 95% CI 0.463–0.596; p<0.001) compared to LC.

Conclusion

A SP regimen improves persistence to medication, reduces cardiovascular events and total mortality compared to identical LC. The results of the START study strongly support the use of a SP concept in the AH medication treatment as recommended by the current ESH/ESC-Guidelines for the treatment of AH.

Funding Acknowledgement

Type of funding source: None

Fibrotic remodeling of left ventricle in the murine remnant kidney model of chronic kidney disease is independent of arterial hypertension

Background

Cardiac fibrosis and arterial hypertension are common in patients with chronic kidney disease (CKD). We studied the mechanisms of cardiac fibrogenesis and the role of blood pressure in mice with CKD.

Methods and results

10-week-old male C57/BL6N (BL6) and SV129 wildtype (WT) mice were underwent 5/6 nephrectomy (remnant kidney model, RKM) or sham operation for 10 weeks. RKM significantly elevated plasma creatinine and urea. RKM elicited both interstitial and replacement renal and left ventricular (LV) (BL6: SHAM 5.6±0.4%, RKM 7.3±0.7%, p=0.04; SV129: SHAM 6.0±0.5%, RKM 14±2%, p=0.001) fibrosis as assessed by picrosirius red staining. In parallel, the number of cardiac fibroblasts per mm2 (BL6: SHAM 36±4, RKM 85±13, p=0.001; SV129: SHAM 82±11, RKM 200±34, p=0.006) was increased in RKM mice. With regard to possible mechanisms, cardiac oxidative stress as shown by co-immunostaining for intracellular fibronectin and 8-hydroxyguanosine (BL6: SHAM 44±14%, RKM 60±24%, p=0.03; SV129: SHAM 51±6%, RKM 70±7%, p=0.04) and the percentage of CXCR4+ fibroblasts in the myocardium (BL6: SHAM 47±5%, RKM 62±4%, p=0.04; SV129: SHAM 63±5%, RKM 81±3%, p=0.005) were increased. Furthermore, the number of circulating CD45+ / collagen I+ fibrocytes (FACS) in the peripheral blood was increased by RKM in BL6 (SHAM 100±23%, RKM 443±252%, p=0.04) and diminished in SV129 (SHAM 100±19%, RKM 43±11%, p=0.01), while an opposite regulation was seen in the bone marrow. To further confirm the role of bone-marrow derived fibroblasts in renal and cardiac remodeling 10-week-old WT BL6 mice were subjected to transplantation of bone marrow from 10-week-old WT BL6 mice expressing green fluorescent protein (GFP)+ ubiquitously. 28 days later, RKM or SHAM-operation was performed. RKM significantly increased the number of GFP+ fibroblasts in kidney and LV-myocardium. CKD significantly decreased myocardial capillarization assessed by immunostaining for podocalyxin in both mouse lines. In parallel, myocardial protein expression of fibrosis regulators fibronectin, collagen I, CTGF and Hif1a were up-regulated and expression of the active form of eNOS (phospho-S1177) was reduced.

As a possible confounder, tail-cuff blood pressure was moderately enhanced (Ø 30mmHg) 9 weeks after nephrectomy. In a control experiment using the vasodilator hydralazine (250 mg/L/day), peripheral blood pressure was equalized in all 4 experimental groups, but the extent of LV fibrosis and expression of the above-mentioned fibrosis markers remained unchanged.

Conclusions

Chronic kidney disease in the RKM model elicits left ventricle fibrosis by increasing myocardial protein expression of fibrosis regulators, reduction of myocardial capillarization and mobilization / recruitment of circulating fibroblasts, independently of blood pressure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft

Multiple Magnetic Bilayers and Unconventional Criticality without Frustration in BaCuSi_{2}O_{6}

The dimerized quantum magnet BaCuSi_{2}O_{6} was proposed as an example of "dimensional reduction" arising near the magnetic-field-induced quantum critical point (QCP) due to perfect geometrical frustration of its interbilayer interactions. We demonstrate by high-resolution neutron spectroscopy experiments that the effective intrabilayer interactions are ferromagnetic, thereby excluding frustration. We explain the apparent dimensional reduction by establishing the presence of three magnetically inequivalent bilayers, with ratios 3∶2∶1, whose differing interaction parameters create an extra field-temperature scaling regime near the QCP with a nontrivial but nonuniversal exponent. We demonstrate by detailed quantum Monte Carlo simulations that the magnetic interaction parameters we deduce can account for all the measured properties of BaCuSi_{2}O_{6}, opening the way to a quantitative understanding of nonuniversal scaling in any modulated layered system.

HtrA-dependent adherence and invasion of Campylobacter jejuni in human vs avian cells

The aim of this study was to investigate whether HtrA is responsible for differences in adherence and invasion of Campylobacter jejuni towards human and chicken cell lines. Gentamicin protection assays were performed with either human Caco-2 or chicken 2G4 cells using C. jejuni strain NCTC11168 to compare the adhesion and invasion rates towards these two cell types. The results revealed significant differences in the adhesion and invasion rates between the human and avian cells. Deletion of the Campylobacter htrA gene, coding for the dual function of serine protease and chaperonin with a role in pathogenesis, led to a reduction of the rates in both cell lines. Using a single-amino acid substitution mutant (ΔhtrA/htrA^S197A ) that lacked protease activity, but retained chaperonin activity, we show that the first is involved in the invasion of human Caco-2 and chicken 2G4 cells, whereas the latter mutant invaded at lower levels. Adherence towards the chicken cells is higher than towards Caco-2 cells and this is also dependent on HtrA. Together, these data suggest that the proteolytic activity of HtrA is involved in the difference in host response of C. jejuni towards human and chicken-derived cells. SIGNIFICANCE AND IMPACT OF THE STUDY: Campylobacter jejuni is the main cause for bacterial foodborne enterocolitis worldwide. While colonization of the human intestine can lead to severe problems, avian hosts - as the major source of infection - remain unaffected by the bacteria. We showed that the bacterial serine protease and chaperonin HtrA are involved in adhesion and invasion in both species and not responsible for the discrepancy of virulence between the different hosts. In future, HtrA might act as a target for inhibitors to avoid or eradicate colonization in chickens as a less problematic alternative to antibiotics in commercial livestock breeding.

P2561Withdrawal of simulated obstructive sleep apnea partially reverses atrial arrhythmogenic substrate in rats

Background

Obstructive sleep apnea (OSA) is associated with structural alterations of the left atria (LA) and increased occurrence of atrial fibrillation (AF). Obstructive respiratory events lead to intermittent hypoxia (IH) and ineffective inspiration against the occluded upper airways, which result in intrathoracic and cardiac transmural pressure changes. Data on reversibility of LA-structural remodeling processes after withdrawal of OSA are still missing.

Objectives

Aim of the study was to develop a novel AF animal model mimicking intrathoracic pressure changes in addition to IH and to analyze the effect of OSA-withdrawal on atrial remodeling reversibility.

Method

In sedated rats (2% isoflurane), IH (n=9) was applied by intermittent increase in the respiratory dead volume. Standardized obstructive respiratory events were induced by defined intermittent negative upper airway pressure (INAP = inverse CPAP) applied via a customized mask connected to a negative pressure device (n=9). One minute of IH or INAP was followed by a rest period of nine minutes for four hours every second day. Rats with comparable anesthesia were used as controls (CTR). After three weeks, the animals were sacrificed. To analyze atrial structural remodeling reversibility, additional INAP-rats (n=5) were sacrificed after INAP-withdrawal of three weeks and compared to respective CTR (n=7).

Result

Blood pressure was not affected by IH or INAP. Intermittent desaturation and post-apneic hyperventilation were comparable in INAP- and IH-rats, but INAP-rats showed significantly higher breathing efforts during apneas compared to IH-rats. LA connexin43 (Cx43) protein expression assessed by quantitative immunofluorescence was reduced in both groups compared to CTR (0.77±0.07% in CTR vs. 0.45±0.06% in IH, p=0.02; CTR vs. 0.39±0.06% in INAP, p=0.005). However, LA interstitial fibrosis content (7.03±0.58% vs. CTR, p=0.01) and LA myocyte diameters (13.23±0.34μm vs. CTR, p=0.03) were increased in INAP-rats, but not in IH-rats. This was associated with longer inducible AF-durations in INAP-rats (11.65±4.43s vs. 0.72±0.33s in CTR, p=0.03) but not in IH-rats (1.28±0.33s vs. CTR, p=0.31). Three weeks of INAP-withdrawal (INAP-W) normalized interstitial fibrosis content (INAP-W vs. CTR, p=0.50) and LA-myocyte diameter (INAP-W vs. CTR, p=0.31). However, LA Cx43 protein expression remained low after three weeks of INAP withdrawal and inducible AF-episodes were still prolonged compared to respective CTR.

Conclusion

Application of INAP in rats mimics important components of OSA beyond IH and allows the study of an arrhythmogenic substrate in the atrium independent of the development of risk factors. In our model, withdrawal of INAP resulted in partial reversibility of structural LA remodeling but was not sufficient to abolish inducible AF-episodes completely. Future clinical studies are warranted to determine the anti-arrhythmic effect of isolated sleep apnea treatment in AF-patients.

Acknowledgement/Funding

Else Kröner-Fresenius-Stiftung, SFB-TRR219-M02/S-02

P748Afterload-induced TRIF-dependent signaling promotes fibrosis but not cardiomyocyte hypertrophy

Background

Pressure overload dependent cardiac remodeling is characterized by a continuous functional loss of cardiomyocytes, cardiomyocyte hypertrophy, cell death and fibrosis. The relevance of the MyD88- and NFκB-independent inflammatory TRIF (TIR-domain-containing adapter protein inducing IFN-β) signaling pathway in myocardial hypertrophy is incompletely understood.

Methods and results

The murine model of afterload induced myocardial hypertrophy (trans-aortic constriction, TAC) was used to investigate the time dependent chemokine expression in C57Bl/6J Wild type (WT) mice after intervention. Myd88- as well as TRIF-dependent chemokines reached their expression maximum at d7 post intervention. This time point was determined for further investigations on TRIF knockout-mice (TRIF−/−) compared to WT mice. While left ventricular (LV) mRNA-expression of TNFalpha and IL6 was upregulated in TRIF−/− mice, CXCL10, CXCL11, RANTES and pathway molecule IRF3 remained unchanged. In the stage of established hypertrophy (35 days after TAC) cytokine levels returned to baseline in WT as well as in TRIF−/− mice.

Cellular hypertrophy (increase in cardiomyocyte size) as well as echocardiographic determined increase of LV mass was similar in TRIF−/− and WT mice at d7 as well as at d35 after TAC. Additionally at d7 and d35 the fractional shortening function didn't show any differences between the groups after TAC.

On the other hand LV interstitial fibrosis (determined by collagen content) was significantly less distinct in TRIF−/− mice (1.4±0.2%) than in WT mice (2.3±0.3%, (p<0.01 TRIF−/− vs. WT) at d7 following TAC. According to that TGFbeta protein expression was more pronounced in WT (318±85% of sham-operated controls) than in TRIF−/− mice (111±15% of sham-operated controls; p<0.05 TRIF−/− vs. WT). These differences in fibrosis and TGFbeta remained at d35. Even the hydroxyproline concentration was higher in LV tissue of the WT mice than in the TRIF−/− mice d35 after TAC (WT: 93.4±7.7μM, TRIF−/− 54.8±9.0μM, p<0.5 TRIF−/− vs. WT). The expression of TGFbeta signaling pathway associated SMAD proteins (SMAD 3, pSMAD3, SMAD4) was up to two fold higher in WT mice than in TRIF−/− mice. Additionally expression of antifibrotic miR29b was more pronounced in TRIF−/− mice (2.34±0.71) than in WT mice (0.98±0.08) after TAC d7.

Conclusion

In afterload induced hypertrophy TRIF-dependent signaling doesn't influence cardiomyocyte hypertrophy. But TRIF plays an important role in the regulation of fibrosis in pressure overload dependent remodeling. Through the modulation of the TGF-beta signaling pathway and antifibrotic microRNAs TRIF signaling is involved in the development of interstitial fibrosis. Especially in the early stage of the cardiac remodeling.

Acknowledgement/Funding

KFO196

P5266Renal denervation improves diastolic dysfunction in patients with HFpEF - initial results of a multicenter CMR study

Introduction

Renal denervation (RDN) significantly reduces blood pressure (BP) and improves myocardial function in patients with resistant hypertension.

Purpose

This multicenter study aimed to investigate the intermediate term effect of RDN on left ventricular global longitudinal strain (GLS), a surrogate for diastolic myocardial function in RDN patients with proven heart failure with preserved ejection fraction (HFpEF), assessed by cardiac magnetic resonance imaging (CMR).

Methods

We analyzed data from 22 patients with resistant hypertension (mean age 68±6 years). 16 patients underwent renal denervation (RDN) and 6 matched control patients received optimal medical therapy (OMT). Both groups had diastolic dysfunction defined by preserved ejection fraction (EF ≥50%) and pathologically elevated GLS at baseline (GLS >−18%) quantified by cardiac magnetic resonance (CMR). A standardized CMR protocol was performed at baseline (BL) and 6 months follow-up (FU). Left ventricular mass index (LVMI) was quantified in end-diastolic and end-systolic endo- and epicardial contouring in short axis cine-MRI images. GLS was measured by end-diastolic and end-systolic endocardial contouring in 2-, 3- and 4-chamber view cine-MRI images. MRI-Images have been analyzed with Medis, Netherlands.

Results

GLS following RDN patients significantly improved after 6 months by 21% (−14.21% ±3.19 vs. −17.17%± 3.1; p=0.007). In control patients with OMT, no significant change in GLS was detected (−14.77% ±3.05 vs. −17.39% ± 4.49; p=0.327). LVMI was numerically reduced in the RDN group at follow-up but did not reach statistical significance (58.55 g/m2±11.37 vs. 55.46 g/m2±12.76; p=0.085). There was no such effect in control patients with OMT (49.25 g/m2±8.2 vs. 50.18 g/m2±7.27; p=0.665). (See also: Figure A and B).

Conclusions

We found significantly improved diastolic function (GLS) in patients with HFpEF and resistant hypertension undergoing RDN. Future studies are needed to determine whether RDN represents a treatment option in patients with HFpEF.

1420Peripheral edema and headache associated with amlodipine treatment: a meta-analysis of randomized, placebo-controlled trials

Background

Use of amlodipine for treatment of arterial hypertension (AH) and stabile angina pectoris (SAP) is sometimes limited by occurrence of peripheral edema and headache.

Purpose

As these side effects (SE) occur also on placebo in clinical trials, we aimed to explore the true magnitude of this phenomenon by determining the rate and placebo-adjusted rate of these SE.

Methods

We performed a meta-analysis by including all randomized, placebo-controlled trials reporting edema and headache with amlodipine in patients with AH and SAP. Placebo-adjusted rate (%) was determined as follows: (SE amlodipine % − SE placebo %)/SE amlodipine %. Electronic databases PubMed, Web of Science, and Cochrane library were systematically searched for eligible trials published until July 2018. Diseases such as heart failure, severe renal or hepatic disease were not considered. Furthermore, in most of the trials, a wash-out period took place before the study medication was given.

Results

Data from 7,226 patients of 22 trials were analyzed. In most of the analyzed trials, duration of follow up was comparable, and lasted about 8 weeks. All studies were graded as high quality according to Jadad score. Rate of edema was higher on amlodipine compared with placebo (16.6 vs 6.2%, RR: 2.9, 95% CI: 2.5–3.36, p<0.0001). The placebo-adjusted rate was 63%, indicating that 37% of edema cases were unrelated to amlodipine. Treatment with low/medium doses (2.5–5 mg) resulted in lower rates of edema (RR: 2.01, 95% CI: 1.41–2.88, p=0.0001) compared with high dose (10 mg) (RR: 3.08, 95% CI 2.62–3.6, p<0.0001, p for interaction=0.03). For each 5-mmHg reduction in BP one could expect lower rates of edema using a low/medium compared with high dose of amlodipine (3.2 vs. 12.2%). Headache was reduced using amlodipine compared with placebo (7.9 vs 10.9%, RR: 0.77, 95% CI: 0.65–0.90, p=0.002) and was driven by use of low/medium doses (RR: 0.52, 95% CI: 0.40–0.69, p<0.ehz748.00661 versus RR: 0.92, 95%-CI: 0.74–1.15, p=0.45, for high doses, p for interaction =0.002). According to a data from six studies administration of renin-angiotensin-inhibitors as add-on therapy to low/medium dose of amlodipine, resulted in higher BP reduction with equivalent rates of edema in comparison with amlodipine monotherapy (p for interaction = 0.23), which may be advantageous in obtaining guideline-recommended target BP values.

Conclusion

Patients on amlodipine exhibit a dose-dependent 3-fold increased risk of peripheral edema compared with placebo. Of note, up to one third of edema cases on amlodipine might not be induced by amlodipine. Headache is reduced on amlodipine treatment, mainly driven by use of this drug at low/medium doses potentially related to better blood pressure control. Amlodipine used at appropriate doses express the best risk-benefit ratio concerning edema and prevention of headache, thus maintaining treatment adherence, alone or in combination with other drugs.

Acknowledgement/Funding

None

P4997Raf kinase inhibitor protein of the bone marrow contributes to cardiac fibrogenesis in pressure-overloaded myocardium

Background

Raf Kinase Inhibitor Protein (RKIP) regulates myocardial remodeling under conditions of enhanced myocardial oxidative stress in pressure-overloaded left ventricle (LV) modulating myocardial production of reactive oxygen species (ROS). A second mode of action may be the mobilization of circulating fibroblasts (fibrocytes) from the bone-marrow (BM). However the underlying mechanisms are incompletely understood.

Methods and results

To further characterize the role of RKIP in BM cells for myocardial remodeling 10-week-old wild-type (WT) C57BL/6N mice were subjected to transplantation of bone marrow (BMT) from 10-week-old C57BL/6-RKIP-deficient (RKIP−/−) N or WT C57BL/6N mice expressing green fluorescent protein (GFP)+ ubiquitously. 28 days later, transverse aortic constriction (TAC, 360 μm) or SHAM-operation was performed. 5 weeks post TAC, LV systolic pressure (LVSP) and heart weight to tibia length ratio were significantly increased in both types of BMT, compared with corresponding SHAM. Increased afterload elicited myocardial fibrosis as assessed by picrosirius red staining (WT/WT SHAM 15±2.5%, WT/WT TAC 21.3±1.4%, p<0.05; RKIP−/−/WT SHAM 17±2%, RKIP−/−/WT TAC 18±3%, p=ns) and significantly increased the number of LV fibroblasts per mm2 estimated by immunostaining for intracellular fibronectin, which were further reduced by transplantation of RKIP−/−N BM (WT/WT SHAM 5499±313, WT/WT TAC 7493±741 per mm2, p<0.05; RKIP−/−/WT SHAM 5737±259, RKIP−/−/WT TAC 5282±551, per mm2, p=ns). Moreover, transplantation of RKIP−/−N BM significantly diminished the number of circulating BM-derived GFP+ fibroblasts in the peripheral blood and LV myocardium during pressure overload (WT/WT SHAM 961±129, WT/WT TAC 2326±273 per mm2, p<0.05; RKIP−/−/WT SHAM 1041±209, RKIP−/−/WT TAC 1518±107, per mm2, p=ns). The myocardial redox status was assessed by the co-immunostaining for ROS production marker 8-hydroxyguanosin (8-dOHG), cardiomyocyte marker α-sarcomeric actin and fibroblast marker intracellular fibronectin. Pressure overload during 5 weeks significantly increased the percentages of 8-dOHG+cardiomyocytes (WT/WT SHAM 34±9%, WT/WT TAC 63±6%, p<0.05; RKIP−/−/WT SHAM 29±6%, RKIP−/−/WT TAC 31±8%, p=ns) and 8-dOHG+fibroblasts (WT/WT SHAM 57±6%, WT/WT TAC 73±4%, p<0.05; RKIP−/−/WT SHAM 58±2%, RKIP−/−/WT TAC 58±7%, p=ns) in mice transplanted with WT BM but not with RKIP−/−N BM.

Conclusions

In pressure-overload induced enhanced myocardial ROS production, deficiency of RKIP-expression in the bone marrow abrogates left ventricular fibrosis by reduction of myocardial ROS production and mobilization of BM-derived fibroblasts. These findings suggest that the function of RKIP in the bone marrow may be important for maladaptive myocardial remodelling.

Acknowledgement/Funding

Deutsche Forschungsgemeinschaft: KA4024/3-1, SFB TRR219; Saarland University HOMFOR, Dr. Marija Orlovich foundation, Corona foundation s199/10060/2014

P5442The non-steroidal mineralocorticoid receptor antagonist finerenone prevents structural cardiac remodeling

Background

Mineralocorticoid receptor (MR) signaling mediates cardiac fibrosis. We studied the ability of the non-steroidal MR antagonist finerenone to prevent fibrotic remodeling.

Methods and results

In neonatal rat cardiac fibroblasts, finerenone prevented aldosterone-induced nuclear MR translocation. Treatment with finerenone decreased the expression of connective tissue growth factor (CTGF) (74±15% of control, p=0.005) and prevented aldosterone-induced upregulation of CTGF and lysyl oxidase (LOX) completely. Transforming growth factor β (TGF-β) upregulation induced through the Rac1 GTPase activator L-buthionine sulfoximine was attenuated by finerenone.

Transgenic mice with cardiac-specific overexpression of Rac1 (RacET) showed increased left ventricular (LV) end-diastolic (63.7±8.0 vs. 93.8±25.6μl, p=0.027) and end-systolic (28.0±4.0 vs. 49.5±16.7μl, p=0.014) volumes compared to wild-type FVBN control mice. Treatment of RacET mice with 100ppm finerenone over 5 months prevented LV dilatation. Systolic and diastolic LV function was similarly preserved in the three groups. RacET mice exhibited overactivation of MR and 11β hydroxysteroid dehydrogenase type 2. Both effects were reduced by finerenone (reduction about 36%, p=0.030, and 40%, p=0.032, respectively). RacET mice demonstrated overexpression of TGF-β, CTGF, LOX as well as collagen and myocardial fibrosis in the left ventricle. In contrast, expression of these parameters did not differ between finerenone-treated RacET and control mice. Finerenone prevented left atrial dilatation (6.4±1.5 vs. 4.7±1.4mg, p=0.004) and left atrial fibrosis (17.8±3.1 vs. 12.8±3.1%, p=0.046) compared to vehicle-treated RacET mice. The prevalence of atrial arrhythmias at 5 months did not differ between finerenone- and vehicle-treated RacET mice.

Conclusion

Finerenone prevented from MR-mediated structural remodeling in cardiac fibroblasts and in RacET mice. These data demonstrate anti-fibrotic myocardial properties of finerenone.

Anomalous water dynamics in brain: a combined diffusion magnetic resonance imaging and neutron scattering investigation

Water diffusion is an optimal tool for investigating the architecture of brain tissue on which modern medical diagnostic imaging techniques rely. However, intrinsic tissue heterogeneity causes systematic deviations from pure free-water diffusion behaviour. To date, numerous theoretical and empirical approaches have been proposed to explain the non-Gaussian profile of this process. The aim of this work is to shed light on the physics piloting water diffusion in brain tissue at the micrometre-to-atomic scale. Combined diffusion magnetic resonance imaging and first pioneering neutron scattering experiments on bovine brain tissue have been performed in order to probe diffusion distances up to macromolecular separation. The coexistence of free-like and confined water populations in brain tissue extracted from a bovine right hemisphere has been revealed at the micrometre and atomic scale. The results are relevant for improving the modelling of the physics driving intra- and extracellular water diffusion in brain, with evident benefit for the diffusion magnetic resonance imaging technique, nowadays widely used to diagnose, at the micrometre scale, brain diseases such as ischemia and tumours.

Coexistence of Ferromagnetic and Stripe-Type Antiferromagnetic Spin Fluctuations in YFe_{2}Ge_{2}

We report neutron scattering measurements of single-crystalline YFe_{2}Ge_{2} in the normal state, which has the same crystal structure as the 122 family of iron pnictide superconductors. YFe_{2}Ge_{2} does not exhibit long-range magnetic order but exhibits strong spin fluctuations. Like the iron pnictides, YFe_{2}Ge_{2} displays anisotropic stripe-type antiferromagnetic spin fluctuations at (π, 0, π). More interesting, however, is the observation of strong spin fluctuations at the in-plane ferromagnetic wave vector (0, 0, π). These ferromagnetic spin fluctuations are isotropic in the (H, K) plane, whose intensity exceeds that of stripe spin fluctuations. Both the ferromagnetic and stripe spin fluctuations remain gapless down to the lowest measured energies. Our results naturally explain the absence of magnetic order in YFe_{2}Ge_{2} and also imply that the ferromagnetic correlations may be a key ingredient for iron-based materials.

Fractionalized excitations in the partially magnetized spin liquid candidate YbMgGaO4

Quantum spin liquids (QSLs) are exotic states of matter characterized by emergent gauge structures and fractionalized elementary excitations. The recently discovered triangular lattice antiferromagnet YbMgGaO₄ is a promising QSL candidate, and the nature of its ground state is still under debate. Here we use neutron scattering to study the spin excitations in YbMgGaO₄ under various magnetic fields. Our data reveal a dispersive spin excitation continuum with clear upper and lower excitation edges under a weak magnetic field (H = 2.5 T). Moreover, a spectral crossing emerges at the Γ point at the Zeeman-split energy. The corresponding redistribution of the spectral weight and its field-dependent evolution are consistent with the theoretical prediction based on the inter-band and intra-band spinon particle-hole excitations associated with the Zeeman-split spinon bands, implying the presence of fractionalized excitations and spinon Fermi surfaces in the partially magnetized QSL state in YbMgGaO₄.

Recent experiments have indicated that YbMgGaO₄ may be a quantum spin liquid with spinon Fermi surfaces but additional evidence is needed to support this interpretation. Shen et al. show weak magnetic fields cause changes in the excitation continuum that are consistent with spin liquid predictions.

Distinct Nature of Static and Dynamic Magnetic Stripes in Cuprate Superconductors

We present detailed neutron scattering studies of the static and dynamic stripes in an optimally doped high-temperature superconductor, La_{2}CuO_{4+y}. We observe that the dynamic stripes do not disperse towards the static stripes in the limit of vanishing energy transfer. Therefore, the dynamic stripes observed in neutron scattering experiments are not the Goldstone modes associated with the broken symmetry of the simultaneously observed static stripes, and the signals originate from different domains in the sample. These observations support real-space electronic phase separation in the crystal, where the static stripes in one phase are pinned versions of the dynamic stripes in the other, having slightly different periods. Our results explain earlier observations of unusual dispersions in underdoped La_{2-x}Sr_{x}CuO_{4} (x=0.07) and La_{2-x}Ba_{x}CuO_{4} (x=0.095).