External validation of a minimal-resource model to predict reduced estimated glomerular filtration rate in people with type 2 diabetes without diagnosis of chronic kidney disease in Mexico: a comparison between country-level and regional performance

Background

Patients with type 2 diabetes are at an increased risk of chronic kidney disease (CKD) hence it is recommended that they receive annual CKD screening. The huge burden of diabetes in Mexico and limited screening resource mean that CKD screening is underperformed. Consequently, patients often have a late diagnosis of CKD. A regional minimal-resource model to support risk-tailored CKD screening in patients with type 2 diabetes has been developed and globally validated. However, population heath and care services between countries within a region are expected to differ. The aim of this study was to evaluate the performance of the model within Mexico and compare this with the performance demonstrated within the Americas in the global validation.

Methods

We performed a retrospective observational study with data from primary care (Clinic Specialized in Diabetes Management in Mexico City), tertiary care (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán) and the Mexican national survey of health and nutrition (ENSANUT-MC 2016). We applied the minimal-resource model across the datasets and evaluated model performance metrics, with the primary interest in the sensitivity and increase in the positive predictive value (PPV) compared to a screen-everyone approach.

Results

The model was evaluated on 2510 patients from Mexico (primary care: 1358, tertiary care: 735, ENSANUT-MC: 417). Across the Mexico data, the sensitivity was 0.730 (95% CI: 0.689 - 0.779) and the relative increase in PPV was 61.0% (95% CI: 52.1% - 70.8%). These were not statistically different to the regional performance metrics for the Americas (sensitivity: p=0.964; relative improvement: p=0.132), however considerable variability was observed across the data sources.

Conclusion

The minimal-resource model performs consistently in a representative Mexican population sample compared with the Americas regional performance. In primary care settings where screening is underperformed and access to laboratory testing is limited, the model can act as a risk-tailored CKD screening solution, directing screening resources to patients who are at highest risk.

1130. Ensovibep antiviral activity in ambulatory patients with COVID-19 is independent of baseline anti-SARS-CoV-2 antibodies and exhibits minimal selective pressure – Results from the placebo-controlled EMPATHY trial

Background

Ensovibep is a multi-specific DARPin (designed ankyrin repeat protein) antiviral in clinical development for treatment of COVID-19. In the Phase 2 EMPATHY study, ensovibep demonstrated greater viral load decline versus placebo. Here we report (1) the efficacy of ensovibep in patients with and without anti-SARS-CoV-2 antibodies at baseline and (2) SARS-CoV-2 mutation emergence data with treatment.

Methods

Eligible ambulatory patients with ≥2 COVID-19 symptoms (onset within 7 days) and positive SARS-CoV-2 rapid antigen test on day of dosing, were randomized (1:1:1:1) to ensovibep (600, 225 or 75 mg) or placebo as single, IV infusion. Chemiluminescent immunoassays were used for antibody detection (SARS-CoV-2 S1/S2 IgG and SARS-CoV-2 IgM). A pre-specified subgroup analysis was performed based on baseline anti-SARS-CoV-2 antibody status. Analysis of changes in viral genome from baseline to post baseline was performed to evaluate treatment-emergent mutations.

Results

Of the patients analyzed, 48.5% had anti-SARS-CoV-2 antibodies at baseline. Baseline log₁₀ SARS-CoV-2 viral load (mean ±SD) was similar across groups [ensovibep (all doses) 6.5 ±1.5, placebo 6.2 ±1.5]; > 90% were infected with the Delta (B.1.617.2) variant. SARS-CoV-2 viral load reduction up to Day 8 showed similar effects in favor of ensovibep compared with placebo regardless of the presence of anti-SARS-CoV-2 antibodies (Figure 1). Patients in ensovibep 75 mg, 600 mg, and placebo groups had comparable incidences of emergent mutations, with a higher incidence in the 225 mg group. Based on analysis of 70% of the expected viral sequencing data, two mutations in the key binding residues of ensovibep were observed (Y489H and F486L) in a total of three patients treated with ensovibep. These patients either cleared virus by Day 8 or mutations were transient (occurred at a single time point but not later in the course of infection). Figure 1

Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial

BACKGROUND

Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection.

OBJECTIVE

To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone.

DESIGN

Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978).

SETTING

Multinational, multicenter trial.

PARTICIPANTS

Adults hospitalized with COVID-19.

INTERVENTION

Intravenous ensovibep, 600 mg, or placebo.

MEASUREMENTS

Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90.

RESULTS

An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep).

LIMITATION

The trial was prematurely stopped because of futility, limiting power for the primary outcome.

CONCLUSION

Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Transcatheter aortic valve implantation (balloon-expandable versus self-expandable valves) - what echocardiographic parameters should we evaluted?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) is currently the recommended treatment for aortic stenosis (AS) in high or intermediate-risk or inoperable patients. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the two major types of transcatheter heart valves (TTHV). Despite major diferences, both designs are recomended, however, there are only limited data available for the comparison of newer generation BEV and SEV.

Purpose

Compare echocardiographic and clinical parameters, during 1 year of follow-up of a balloon-expandable (BS) versus self-expanding (SE) transcatheter aortic valve implantantation, with emphasis on the composite endpoits proposed by uptade Valve Academic Researc Consortium (VARC-2).

Methods

Retrospective, comparative study in patients with symptomatic severe AS with a high operative risk, who implanted BEV or SEV between January 2016 and December 2019. All patients underwent echocardiographic study before an after the procedure (on the day , 6 months and 1 year of follow up), clinical data were collected. The following ecocardiographic parameters were evaluated: transvalvular and prosthetic aortic gradientes and paravalvular leak (PVL).

Results

We studied 106 patients (81 ± 8 years, 60% female) with severe AS (mean gradient of 49 ± 12 mmHg), who were threated with BE or SE transcatheter aortic valve. Comparative analysis between BEV vs SEV, showed: there were no statistically significant in mean transprosthetic gradients (9.5 ± 4.8 vs 10 ±6.2; p = 0.49). There were no statistically significant differences between BE and SE valves in the cumulative incidence of death from any cause (21% vs. 28%; p = 0.49), death from cardiovascular causes (3.3% vs. 0%; p= 0.26), all strokes (1.6% vs. 1.6%; p = 0.85), pacemaker implatation (18% vs. 15% p = 0.79); major bleeding (3.3% vs 6.5%; p = 0.18) and renal injury (1.6% vs. 2.1%: p = 0.67). There were statistically significant differences between BE and SE valves in the cumulative incidence of moderate or severe PVL (5% vs. 23.9%; p = 0.009) and repeat hospitalization (11.6% vs. 28%;p = 0.04). Device sucess was achieved in 97 % for BEV vs 91% for SEV (p = 0,39). The early safety at 30 days was observed in 5% for BVE vs. 4.3% for SVE (p = 0.87). The clinical efficacy after 30 days was achieved in 1,6% for BVE vs. 4.3% for SVE (p = 0.03), with higher incidence of moderate or severe PVL. The composite endpoint valve safety occured in 3,3 % for BVE vs 26% for SVE (p &lt; 0,001), with moderate or severe PVL in 23%.

Conclusion(s): In patients with symptomatic severe aortic stenosis who implanted BEV or SEV transcatheter aortic valve there was a significant improvement in the hemodynamic status. The present study suggests that use of SEV was associated with a higher risk of PVL and repeat hospitalization, with a endpoint clinical efficacy after 30 days (4,3%) and time-related valve safety (26%).

Mitral valve prolapse: impact of mitral valve disjunction in a large single-center

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite being known for more than a century, mitral valve prolapse (MVP) is an

entity not fully understood with controversial data regarding the prognosis.

Aim

To characterize a sample of patients with MVP and to access the frequency of

complications associated with MVP (arrhythmias, hospital admissions and death).

Methods

Single-center retrospective study of consecutive patients with MVP documented in

transthoracic echocardiogram between January 2014 and October 2019. MVP was defined as

systolic displacement of the mitral leaflet into the left atrium≥ 2 mm from the mitral annular

plane. Demographic, clinical, echo, EKG data were collected as well as major adverse events at follow-up. Categorical variables were reported in absolute number and/or % and continuous variables were reported as mean and SD or median and IQR. The results were obtained using Chi-square and ANOVA tests.

Results

247 patients were included (mean age 62.9 ± 18 years, 61% male). The mean

distance of the MVP was 6mm (IQR 5-9). The posterior mitral valve leaflet (PL) was the most

frequently involved (49%), followed by involvement of both leaflets (BL) (27%) and the anterior

leaflet (AL) (25%). Patients with MVP of PL were older compared to patients with BL and AL

involvement (68 ±15 vs 58 ± 17 vs 59 ± 22 years, respectively, p &lt; 0.001) and had longer QT

interval (419 ± 35 vs 403 ± 25 vs 410 ± 34ms, respectively, p = 0.013). 70.4% (174) had

significant MR. Mitral annulus disjunction (MAD) was present in 9.3% (n = 23). The mean LVEF was 63% ± 6.3% and LV mass was 124,7 ± 41g/m2. Most of the patients were in sinus rhythm (SR) (78%). 13.3% had hospital admission for cardiovascular cause and 8.5% (n = 21) died.

During a mean follow-up of 30 ± 19 months, 25.1% of the patients had de novo atrial fibrillation (AF), 8 patients (3%) were submitted to supraventricular dysrhythmia ablation. 16.2% had premature ectopic ventricular complexes, 2.4% non-sustained VT, 0.4% sustained VT, 0.8% needed ICD, 8.5% had a pacemaker. 25% of the patients underwent mitral valve intervention (23.9% to surgical intervention and 3 to percutaneous). 12% of the patients had a hospital admission for CV cause and 8.5% of the patients died.

In multivariate analysis, hospitalization for CV cause (OR 7.27, p = 0.011, CI 95% 1.59- 33.3), higher NYHA class (III-IV) (p = 0.036 OR 5.7 CI95% 1.125-28.84) and the presence of LBBB (p = 0.021 OR = 6.78 CI95% 1.13-28.85) were independent predictors of mortality.

MAD was not associated with the outcomes. SR (OR 0.3, p = 0.014, CI95% 0.119-0.786) and prolapse (OR 0.37, p = 0.035, CI95%0.148-0.935) according to the ESC classification (comparing to flail and billowing) predicted survival.

Conclusion

MVP was traditionally described as a benign entity. However, in our population it was associated with significant mitral regurgitation, some requiring intervention. Besides that, 44% had arrhythmias, with AF occurring in about 25%, hospitalization in 13.3% and cardiovascular death in 8.5%.

Regression of left ventricular mass after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Regression of left ventricular mass (LVM) after transcatheter aortic valve implantation (TAVI) is an important parameter of left ventricular reverse remodeling and is associated with less hospitalizations 1year after TAVI. The association between LVM índex (LVMi) at 6 months and outcome 1 year after TAVI is unclear.

Purpose

Evaluate and compare LVMi, before TAVI and 6 months after, and determine the association between LVMi regression and clinical outcomes at 1-year follow-up.

Methods

Retrospective, comparative study in patients with symptomatic severe aortic stenosis with a high operative risk, after TAVI. All patients underwent echocardiographic study before TAVI and 6 months of follow-up, the LVMi (by the Devereux formula) was evaluated. Associations between LVMi regression (percent change between baseline and 6 months after TAVI), rehospitalization rate and death at 1 year of follow-up were examined.

Results

We studied 50 patients, 82% with moderade or severe LVMi before TAVI. Comparative analysis between ecocardiography study before and 6 months after TAVI, showed there was statistically significant decrease in LVMi (150,7 ± 38 g/m2 vs 132 ± 36 g/m2; p = 0.03). LVMi moderate or severe (between 130 and 154 g/m2) at 6 months was associated with biggest hospitalization rate (p = 0,03).Comparative analysis between regression of LVMi (before and 6 months after TAVI) and death, showed: decrease of 5% and 10% in LVMi was independently associated with death at 1 year (p = 0,77 vs p = 0,4).

Conclusions

Patients with severe symptomatic aortic stenosis treated with TAVI who had a significant decrease of LVMi after 6 months of follow-up had lower hospitalization rates, but decrease of LVMi is independently associated with death at 1 year of follow-up.

Artificial intelligence for early diagnosis of lung cancer through incidental nodule detection in low- and middle-income countries-acceleration during the COVID-19 pandemic but here to stay

Although the coronavirus disease of 2019 (COVID-19) pandemic had profound pernicious effects, it revealed deficiencies in health systems, particularly among low- and middle-income countries (LMICs). With increasing uncertainty in healthcare, existing unmet needs such as poor outcomes of lung cancer (LC) patients in LMICs, mainly due to late stages at diagnosis, have been challenging-necessitating a shift in focus for judicious health resource utilization. Leveraging artificial intelligence (AI) for screening large volumes of pulmonary images performed for noncancerous reasons, such as health checks, immigration, tuberculosis screening, or other lung conditions, including but not limited to COVID-19, can facilitate easy and early identification of incidental pulmonary nodules (IPNs), which otherwise could have been missed. AI can review every chest X-ray or computed tomography scan through a trained pair of eyes, thus strengthening the infrastructure and enhancing capabilities of manpower for interpreting images in LMICs for streamlining accurate and early identification of IPNs. AI can be a catalyst for driving LC screening with enhanced efficiency, particularly in primary care settings, for timely referral and adequate management of coincidental IPN. AI can facilitate shift in the stage of LC diagnosis for improving survival, thus fostering optimal health-resource utilization and sustainable healthcare systems resilient to crisis. This article highlights the challenges for organized LC screening in LMICs and describes unique opportunities for leveraging AI. We present pilot initiatives from Asia, Latin America, and Russia illustrating AI-supported IPN identification from routine imaging to facilitate early diagnosis of LC at a potentially curable stage.

Real-world evaluation of molecular testing and treatment patterns for EGFR mutations in non-small cell lung cancer in Latin America

Lung cancer is a leading cause of cancer-related deaths in Latin America, with non-small cell lung cancer (NSCLC) being the most prevalent. The current study aimed to report real-world data on epidermal growth factor receptor (EGFR) mutational testing and treatment regimens at diagnosis and progression in patients with metastatic NSCLC across four Latin American countries (Argentina, Chile, Colombia and Uruguay). A retrospective, multicenter, observational study was conducted in patients with NSCLC using medical records from participating countries. The study population was categorized into two cohorts: Cohort 1 comprised of newly diagnosed, treatment-naïve patients with stage IV NSCLC; and cohort 2 comprised of stage IV NSCLC EGFR mutation (EGFRm)-positive patients who had progressed after first- or second-generation EGFR-tyrosine kinase inhibitor (TKI) treatment. Measures included demographic variables, health characteristics, treatment regimen, molecular testing rate and turnaround time at diagnosis and at progression for cohorts 1 and 2, respectively. Descriptive statistics were used to summarize all study measures. Of the 462 patients enrolled, 431 were newly diagnosed or treatment naïve with metastatic NSCLC. In cohort 1, the majority of patients with private health insurance (57.31%) underwent molecular diagnosis while only 41.3% of patients within the public sector had access to testing. The average molecular testing rate in cohort 1 varied across countries, with Argentina having the highest testing rate (79%) and Uruguay the lowest (27.63%). EGFRm was observed in 22% of patients. Cohort 2 comprised 31 patients who had progressed after first- or second-generation EGFR-TKI treatment and of these, only 22 (70.97%) underwent testing after progression. Access to molecular testing is still a challenge impacting the choice of first-line treatment in Latin American patients with NSCLC. These findings underline the unmet needs of ensuring early diagnosis, molecular profiling and use of correct treatment to alleviate NSCLC burden in the region.

STEMI with mid-range ejection fraction: a group of intermediate risk not to be forgotten

Background

Reduced left ventricular ejection fraction (LVEF) &lt;40% is an important negative prognostic factor in the setting of ST-elevation acute myocardial infarction (STEMI). On the other hand, data concerning mid-range LVEF (mrEF) post-STEMI are scarce. Consequently, recommendations regarding reassessment of LVEF or administration of neurohormonal medication in this group of patients (pts) are also lacking.

Purpose

To assess the current treatment and prognosis of STEMI with mrEF.

Methods

Retrospective study including all consecutive pts hospitalized for STEMI and submitted to primary percutaneous coronary intervention in a Cardiology centre in 2018. Pts were divided into 3 groups according to LVEF assessed before hospital discharge: preserved EF (pEF: LVEF ≥50%), mid-range EF (mrEF: LVEF 40–49%) and reduced EF (rEF: LVEF &lt;40%). We analysed clinical characteristics, treatment, evolution of LVEF post-STEMI and clinical outcomes - death, myocardial infarction (MI) and hospitalization for heart failure (HF) – of the mrEF group and compared it with pEF.

Results

188 pts with a mean age of 61 years were admitted for STEMI in 2018. The majority (58%, n=109) had pEF; 29% (n=55) had mrEF and 13% (n=24) were in the rEF group. Pts in the mrEF group had similar baseline characteristics to the others. However, compared with pEF, culprit-lesion was more often located in left main or left anterior descending arteries (80% vs 35%, p&lt;0.001) and NT-proBNP levels were higher in mrEF pts (2270 vs 881 pg/mL, p&lt;0.001).

At discharge, all mrEF patients were medicated with a renin-angiotensin-aldosterone blocker and 91% with a beta-blocker.

After a median of 8 months, LVEF improved a mean of 4% (± 9%) in the mrEF group. However, in 12.5% LVEF worsened to &lt;40% (vs 0 in the pEF group, p=0.006).

At a median follow-up of 2.6 years, there was an increase in mortality according to the EF group (pEF 4% vs mrEF 13% vs rEF 48%, log-rank: p&lt;0.001 – fig. 1) with a hazard ratio (adjusted for age) of 3.75 (95% CI 1.1–12.8, p=0.035) for mrEF vs pEF. There was also a non-significant tendency to higher rates of the composite endpoint of MI and hospitalization for HF in the mrEF group vs pEF (8.2% vs 2.9%, p=0.213).

Conclusions

This study confirms previous reports of the worse prognosis of STEMI with mrEF and suggests the existence of a continuum of risk of adverse clinical outcomes according to LVEF. Therefore, this group of intermediate risk might also benefit from neurohormonal medication, which is only specifically recommended for rEF in current STEMI guidelines. It also highlights the importance of a closer follow-up (with reassessment of LVEF) of mrEF pts since a non negligeable proportion ultimately progress to rEF and may require additional medical treatment or even an implantable cardioverter defibrillator. Further research with larger samples is required to identify predictors of worsening LVEF and assess the impact of neurohormonal modulation in this population.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier Survival Analysis

Diagnostic and prognostic contribution of 99mTc-DPD scintigraphy in transthyretin V30M cardiac amyloidosis

Background

Early diagnosis and prognostic stratification of hereditary transthyretin amyloidosis (ATTR) are crucial. Previous findings suggested that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy presents suboptimal accuracy to detect ATTR cardiomyopathy caused by V30M mutation, particularly in patients with onset of symptoms under 50 years of age. Furthermore, its prognostic value has never been evaluated in ATTR caused by this mutation.

Purpose

To assess the diagnostic value of DPD scintigraphy to detect cardiomyopathy in a large cohort of patients with ATTR-V30M mutation and to explore its prognostic value regarding mortality.

Methods

Of the 305 ATTR-V30M mutation carriers followed prospectively and who underwent DPD scintigraphy, 288 individuals [median age 46 (39–56); 49% male] without myocardial thickening attributable to other causes were enrolled in the study. Amyloid cardiomyopathy was defined by septal thickness ≥13mm not attributable to other causes plus at least one of the following criteria: (1) late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) ratio &lt;1.60; (2) electrical heart disease (arrhythmia or cardiac conduction defect); or (3) amyloid infiltration documented in biopsy.

Results

Amyloid cardiomyopathy was identified in 41 (14.2%) patients and 44 (15.3%) individuals presented abnormal cardiac DPD uptake. Individuals with cardiac DPD retention had 27-fold higher likelihood of having amyloid cardiomyopathy (OR: 27.4; 95% CI 11.6–65.0; P&lt;0.001). However, DPD scintigraphy presented suboptimal accuracy to detect ATTR cardiomyopathy (89.9%) with limitations in sensitivity (56.1%), specificity (95.6%), positive predictive value (67.7%) and negative predictive value (92.9%).

During a mean follow-up 33.6±1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with amyloid cardiomyopathy (HR: 14.1; 95% CI 4.9–40.7; P&lt;0.001), 13 times higher in those with abnormal cardiac DPD uptake (HR: 12.59; 95% CI % 4.56–34.72; P&lt;0.001) and 10 times higher in those with H/M MIBG ratio &lt;1.60 (HR: 10.40; 95% CI 2.95–36.69; P&lt;0.001). The prognostic value of ventricular thickness and cardiac DPD uptake was additive: patients without septal thickening and no cardiac DPD retention had excellent prognosis (5-year mortality of 0.75%), while those with septal thickening and/or abnormal DPD retention presented 5-year mortality rates ranging from 39.9 to 53.3%.

Conclusions

DPD scintigraphy is valuable in the evaluation of ATTR-V30M mutation carriers, particularly for prognostic stratification purposes, identifying patients at higher risk of death.

Funding Acknowledgement

Type of funding sources: None.

The 7+ Habits of Highly Effective Medical Directors

Medical Directors in the pharmaceutical industry are responsible for fulfilling multiple roles, including scientific expert, conscience keeper and people leader, as well as being the external face of the organisation. The capabilities described in the book The 7 Habits of Highly Effective People® are not just the integral qualities of a successful leader, they are important capabilities that are critical to becoming an impactful medical leader too. As scientific, functional and enterprise leaders, country and cluster Medical Directors must possess these seven qualities. Each of the seven habits can be adapted and utilised to shape the specific areas that Medical Directors are responsible for: intuitive creativity, patient centricity, prioritisation, enterprise leadership, communication and behavioural change, building a team, partnering and scientific and technological leadership. To excel in their function, current and future Medical Directors need to sharpen their existing skills and build specific capabilities. Energy management in physical, mental, emotional and spiritual domains is the way forward.

Acute coronary syndrome in COVID-19 times: could it be business as usual?

Funding Acknowledgements

Type of funding sources: None.

Background

In an attempt to cope with the COVID-19 pandemic, several measures of social distancing and reorganization of health care systems have been adopted. In Portugal, these included suspending elective clinical activity and a temporary national lockdown. Data from multiple centres, including central hospitals in Portugal, has shown a reduction in hospital admissions for acute coronary syndrome (ACS) during the COVID-19 outbreak. Fear of going to the hospital and physical inactivity have been pointed as possible explanations.

Purpose

to assess the impact of this pandemic and the measures taken against it on the pattern of admissions and treatment of patients with ACS in a district hospital. 

Methods

A single-centre retrospective study was conducted in the Cardiology Department of a Portuguese district hospital, capable of performing 24h percutaneous coronary intervention. We analyzed the admissions for ACS during the peak of the first COVID-19 outbreak in Portugal (16th of March to 3rd of May 2020, coinciding with the suspension of elective activity) and compared it with two control periods: one immediately preceding the study period (27th of January to 15th of March - 2020 control) and one exactly one year before (16th of March to 3rd of May 2019 - 2019 control).

Results

During the 7 weeks of the first COVID-19 outbreak, 46 patients were hospitalized for ACS in our department, while 54 had been admitted during the 2020 control period and 40 in the 2019 control period, with a mean of 7 admissions/week (vs 8 and 6, respectively; p > 0.05). There were no significant differences between the study group and both controls regarding basal characteristics. Their presentation did not differ: the majority of patients (57%) was admitted for ST-elevation myocardial infarction and median time from symptom onset to admission to the emergency room was 3 hours, with 4% of patients presenting in Killip class ≥III (p > 0.05 for all). We also found no significant differences in the treatment administered nor in the outcomes (96% submitted to coronary angiography, median length of hospitalization of 4 days and in-hospital mortality rate of 2%, p > 0.05 for all). 

Conclusions

Our study suggests that the reduction in admissions for ACS during the COVID-19 outbreak is not universal. Additionally, severity at presentation, treatment administered and outcomes did not seem to differ. The relatively low prevalence of COVID-19 in our hospital"s region might be the cause, since people might fear and refrain less from going to the hospital. Larger studies with other centres in low-prevalence regions are needed to confirm this hypothesis.

FLABRA, frontline approach for BRCA testing in an ovarian cancer population: a Latin America epidemiologic study

Aim: FLABRA evaluated the prevalence of BRCA mutations, genetic counseling and management approaches in patients with ovarian cancer in Latin America. Patients & methods: Patients with ovarian cancer from six Latin-American countries were enrolled. Tumor samples were tested for BRCA mutations (BRCA^mut). In cases with BRCA^mut, blood samples were analyzed to determine germline versus somatic mutations. Medical records were reviewed for counseling approach and treatment plan. Results: From 472 patients enrolled, 406 samples yielded conclusive results: 282 were BRCA wild-type (BRCA^wt), 115 were BRCA^mut and nine were variants of uncertain significance. In total, 110/115 were tested for germline mutations (77 germline and 33 somatic). Conclusion: Tumor testing to identify mutations in BRCA1/2 in ovarian cancer can help optimize treatment choices, meaning fewer patients require germline testing and genetic counseling, a scant resource in Latin America. Clinical trial registration: NCT02984423 (ClinicalTrials.gov).

Left atrial mechanics improvement after initiation of sacubitril-valsartan

Introduction

Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality. Recently, in the PARADIGM-HF, sacubitrilvalsartan was superior to enalapril in reducing death and hospitalization for heart failure, and there is a growing interest in determining the structural changes besides reverse left ventricular remodelling.

Purpose

To determine if, in patients treated with sacubitril-valsartan, there was a change in left atrial (LA) mechanics quantified by two-dimensional strain echocardiography (2D-STE).

Methods

A total of 38 consecutive patients with HFrEF, followed in an outpatient heart failure clinic, were recruited. Population characteristics are summarized in Table 1. 2D-STE was used to measure left atrial strain in the reservoir phase (LASr) (Figure 1) and strain rate (LA-SR) before and 3 months after initiation of sacubitril-valsartan.

Results

There was a significant improvement in LASr (11.3±6.5% vs 14.2±7.4%, p=0.006) and LA-SR (0.55±0.25 s-1 vs 0.69±0.31 s-1, p=0.008) after initiation of sacubitril-valsartan. There was also a significant reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (1443.5 pg/ml (Interquartile range [IQR], 772–2912) vs 1112.0 pg/ml (IQR, 510–1455), p=0.016) and a tendency towards reduction in left atrial volume index (LAVI) (54.6±17.0 ml/m2 vs 51.4±18.8 ml/m2, p=0.053). The change in LASr and LA-SR was not related with the dose of sacubitril-valsartan (p=0.089).

Conclusion

In this population of HFrEF patients LA mechanics, as determined by 2D-STE, as well as NT-proBNP levels, significantly improved after treatment with sacubitril-valsartan.

Figure 1. Left atrial strain

Funding Acknowledgement

Type of funding source: None

Predictors of relapse after improved ejection fraction in patients with heart failure

Background

Patients with systolic dysfunction with improvement in left ventricular ejection fraction (LVEF) present a more favorable clinical profile when compared to those that maintain dysfunction. However, little is known about the characteristics of patients who “relapse” after LVEF improvement.

Purpose

Evaluate prevalence, clinical characteristics and outcomes of patients in whom ejection fraction declined after previous improvement.

Methods

We retrospectively studied patients followed at a heart failure (HF) clinic with LVEF improvement after an initial diagnosis of HF with reduced ejection fraction (EF), which was defined as having an LVEF &gt;40% on follow-up. We then evaluated the presence of LVEF “relapse” in these patients – a decline in LVEF to &lt;50% or &lt;40%, in cases where it recovered to preserved EF or to mid-range EF, respectively. We analysed patient demographics, clinical parameters and outcomes and used logistic regression to assess the predictors of LVEF “relapse”.

Results

98 patients were studied, 70 (71%) male, median age 69 (58–76) years.

Fifty-four (55%) patients had recovered EF (&gt;50%) and in 44 (45%) it had improved to mid-range values. In 36 (37%) occurred LVEF “relapse”: in 10 (10%) patients to an EF 40–50% and in 88 (90%) to an EF&lt;40%.

Ischemic cardiomyopathy and non-ischemic dilated cardiomyopathy were the main HF aetiologies (38% and 35%, respectively).

During a median follow-up of 7 years, 39 (40%) patients had at least one HF hospitalization. Global mortality was 30%, with no significant statistical difference between the two groups.

In univariate analysis, HF duration, type 2 diabetes mellitus (T2DM), left main or left anterior descending coronary (LAD) disease, valvular heart disease (VHD) and chronic kidney disease (CKD) predicted LVEF “relapse”.

In multivariate analysis, T2DM, left main or LAD disease and VHD were the only predictors of LVEF “relapse” (Table).

Conclusion

In this group of patients, LVEF “relapse” after it had initially improved was frequent and was predicted by the presence of T2DM, left main or LAD disease and VHD. Despite improved systolic function, these patients remain at high risk, thus the need to maintain treatment.

Funding Acknowledgement

Type of funding source: None

P578Multipoint pacing in cardiac resynchronization therapy - how to improve remodeling criteria and its impact in quality of life

Background

Despite the reduction in mortality and hospitalization rates, resynchronization therapy still has 30-40% of non-responders. Several studies are ongoing to evaluate if novel programming techniques such as multipoint pacing (MPP) increase the conversion rate of non-responder to responder to CRT. However, there is still lack of information about conversion to super-responders and the impact in quality of life of MPP.

Purpose

To evaluate the impact of MPP in conversion to super-responders and its impact in the quality of life of patients.

Methods

Randomized clinical trial of non-AF patients with indication for CRT and who implanted the Quartet™ quadripolar left ventricle (LV) lead. After implant, CRTs were programmed on biventricular pacing according to the latest activated area for 6 months. After a 6-month follow-up, patients were randomized in a 1:1 fashion to MPP ON or MPP OFF. MPP was programmed with the two widest spaced LV electrodes and with a LV1-LV2 to LV2-RV delay of 5ms. Patients were followed-up for 12 months with a 6-month evaluation of NTproBNP, echocardiographic remodeling criteria (LV end systolic volume (ESV) and LV ejection fraction), and quality of life (QoL) evaluated by EQ-5D, Minnesota Living with Heart Failure (MLWHF) questionnaire and 6-minute walk test (6MWT).

Results

 76 patients were included in this trial, 62 with a completed 12-month follow-up (average age 67.2 ± 10.2 years old, 32.3% female gender, dilated cardiomyopathy in 77.4%). Among these patients, 24 were randomized to MPP ON, 28 to MPP OFF. Six patients died and 4 were lost to follow-up. Baseline clinical and echocardiographic characteristics were similar between groups (p = NS).

At 6 months, the overall response rate (reduction in ESV≥15%) was 75%. At twelve months, patients randomized to MPP ON had a super-response rate (reduction in ESV≥30%) higher than patients with MPP OFF (75% vs 39.3%, p = 0.01).

Between 6-12 months, patients assigned to MPP ON had a higher reduction in ESV (93.4 ± 52.3mL to 82.1 ± 40.5mL, p = 0.04) and an improvement in LVEF (38.3 ± 9.8% to 45.1 ± 11.1%, p &lt; 0.01) compared to patients with MPP OFF (92.2 ± 47.3mL to 95.4 ± 47.5mL, p = NS; 37.1 ± 12.0% to 40.2 ± 9.2%, p = NS). Additionally, QoL of patients with MPP ON improved during follow up (EQ-5D 78.3% to 86.3%, p &lt; 0.01; MLWHF 12.1 to 6.6, p = 0.03, 6MWT 316m to 239m, p = NS; NTproBNP 1608 ± 2450pg/mL to 775 ± 914pg/mL, p = NS) and was unchanged in MPP OFF patients (76.6% to 74.2%; MLWHF 12.7 to 12.7; 6MWT 338m to 299m, NTproBNP 1112 ± 1442pg/mL to 1383 ± 2118pg/mL, for all p = NS).

Conclusion

In our population, patients with CRT programmed with MPP ON, when compared to MPP OFF, had an improvement in the super-response rate and in quality of life. These results may be consequence from a more favorable reverse remodeling due to MPP, with a higher reduction in the LV end systolic volume.

Abstract Figure.

P1246 The Eustachian valve: a structure not so innocent

Background

The eustachian valve is an embryological remnant of the inferior vena cava (IVC) valve. It is usually absent or inconspicuous and has no known function in the normal adult. However, there are reports suggesting that the EV is not as innocent as we thought. The EV can be a site of infective vegetations or be mistaken for a thrombus or tumor. The EV can also make interventional procedures (closure of ASD (atrial septal defect) or ablation for atrial flutter) more laborious.

Clinical Case

A 80 year-old female patient was referred to the emergency department after an episode of acute palpitations, right chest pain, followed by syncope. She had a previous medical history of type 2 diabetes and epilepsy. On admission she was normotensive (104/67mmHg). The ECG showed atrial fibrillation with heart rate of 180 beats per minute. The echocardiogram show slight dilation of the right ventricle and bilateral atrial dilatation. The blood tests documented an elevated D-dimers 2,73 μg/mL, troponin (hs-TNT 27ng/L) and NT-proBNP 4339pg/ml, with a normal renal function.

Computed tomographic (CT) pulmonary angiography revealed filling defects on the segmentar and subsegmentar inferior lobes, compatible with the diagnosis of pulmonary embolism and also revealed a dilatation of the main pulmonary trunk (35mm).

Based on this result the patient start anticoagulation with low molecular weight heparin and heart rate control with bisoprolol. However besides of this strategy the patient remain in atrial fibrillation without a controlled hear rate and an transesophageal echocardiography (TOE) was performed.

The TOE shown a small freely mobile mass – thombi - at the inferior vena cava-right atrium (IVC-RA) junction tethered at the eustachian valve; a small atrial septal defect (4mm) – ostium secundum type – with a left to right shunt; and a preserved biventricular function (figure 1).

Based on this exams we optimize the therapy with digoxin and amiodarone with a good control of the heart rate and patient was discharge on warfarine, bisoprolol and digoxin asymptomatic and to be reevaluated on cardiology clinic.

Discussion/Conclusion: The eustachian valve in adult is an embryological remainder of the fetal venous sinus valve. This structure is located in the right atrium and is a common, not pathological, echocardiographic finding. It is known that a small percentage of the pulmonary embolisms, thrombi are discovered in the right side of the heart; however, their presence on the Eustachian valve is very unusual. Besides this in our particular case in the present we will have also to ensure that the anticoagulation is effective to avoid that the trombi migrates into the systemic circulation by the atrial septal defect.

Abstract P1246 Figure.

P3808iBox-CRT: Better response, less complicated, equally fast

Introduction

The optimization of the left ventricle (LV) pacing site guided by the electrical delay increases CRT response rate (RR), however it's necessary to develop technology that allows its universal use.

Purpose

The aim is automatically, and operator-independent, access the conduction delay between the right ventricular (RV) stimulus and the LV available veins in order to select the LV pacing site. It is further intended to compare the total procedure and radiation times in relation to an historical control group.

Methods

Prospective, single-center study that included patients undergoing CRT implant according to the current ESC Guidelines. All patients were submitted to a clinical, electrocardiographic and echocardiographic basal evaluation prior to CRT implantation and at 6 months of follow-up.

To evaluate conduction delays between the RV lead and the LV available veins (RV-LV delay), an external interface - intelligent Box for CRT (iBox-CRT) was used. Four measurements in at least two different tributary veins were made. The implant of all the LV leads was guided by the longest measured delay.

A positive response to CRT was defined as an improvement of >10% in left ventricle ejection fraction (LVEF) or a reduction of end-systolic volume (ESV)>15%. The results were compared to a control group (CG) of pts submitted to CRT implantation in the conventional way.

Results

60 patients were included (68.3% males, 38% ischemic, mean age 67.4±10.2 years) and submitted to CRT implant (37 CRT-P; 23 CRT-D). At basal evaluation, LVEF was 28±7%, end-diastolic volume (EDV) was 200±73ml and ESV 145±64ml. CG (n=51) had similar characteristics.

The RR was 85.7%, significantly higher compared to the CG (55.9%, p=0.003). The ESV reduced 38.2±3% in responders vs 5.7±2% in non-responders (NR) (p=0,005), EDV reduced 33.3±16% in responders vs 13.6±10% in NR (p=0.002), the mean LVEF improved 11% in responders vs −1% in NR (p=0.02).

At follow-up, the mean ESV in the study group (SG) was 89±44 ml vs 132±75ml in the CG (p=0.002) and the EDV 136±51 vs 190±78 (p=0.007).

In addition to a much better response rate, the responders in the study group had significantly higher mean LVEF at follow-up (39±11% vs 37±7%, p=0.032).

The mean intra-procedure RV-LV delay was 187±34mseg. In the responder group the baseline delay was usually higher (190±35 msec) vs NR group RV-LV delay (165±23 msec; p=NS).

Compared with CG, the automatic assessment of RV-LV delay with iBox-CRT did not increase fluoroscopy time (15±16min vs 18±16; p=NS) and shortened procedure time (65±34 vs 108±83min, p<0.005).

Conclusions

The iBox-CRT use enabled an automatic and operator independent RV-LV delays measurement, in order to implant the LV lead at the most delayed site. This technique translated into a major increase in CTR response rate, not compromising the procedure duration nor increasing the radiation exposure.

BRCA1 and BRCA2 mutations and clinical interpretation in 398 ovarian cancer patients: comparison with breast cancer variants in a similar population

Background

Ovarian cancer is the leading cause of death worldwide among gynecologic malignancies. The recent approval of inhibitors of poly (ADP-ribose) polymerase (iPARP) in the treatment of ovarian cancer in the presence of a BRCA1/2 mutation has sparked the analysis of women with such diagnosis, which can further benefit from the detection of carriers in the family. Germline sequence and large rearrangements for BRCA1/2 were tested in 398 consecutive epithelial ovarian cancer (EOC) patients.

The aim of this study was to identify the frequency and spectrum of germline BRCA1/2 pathogenic alterations in a cohort of patients with ovarian serous carcinoma, with a view to adequately selecting patients for prevention through family counseling and correlating this frequency with platinum sensitivity as a guidance to identify patients eligible for iPARP in our population.

Results

A total of 96 patients carried a pathogenic germline mutation, accounting for an overall 24.1% mutation incidence. Among mutation carriers, BRCA1 showed 62.5% incidence, BRCA2 rendered 36.5%, and one patient exhibited a mutation in both genes. Three pathogenic mutations were recurrent mutations detected five, three, and four times and represented 12.5% of the mutated samples. Worth highlighting, a 50% mutation incidence was detected when breast and ovarian cancer coexisted in the same patient. Novel mutations amounted to 9.4% of the total mutations, as compared to 4.7% in breast cancer. Forty out of 60 BRCA1 mutations were beyond the ovarian cancer cluster region (OCCR), in stark contrast with 22 out of 36 BRCA2 mutations being inside the OCCR. Taken together, germline BRCA1/2 mutations in EOC patients showed a distinct mutational spectrum compared to our previously published data on breast cancer patients.

Conclusions

In sum, our study provides novel data on ovarian BRCA1/2 mutation prevalence worldwide, enhances adequate patient selection for family counseling and prevention, and sheds light on the benefits of iPARP treatment.

Electronic supplementary material

The online version of this article (10.1186/s40246-018-0171-5) contains supplementary material, which is available to authorized users.

Social Media Monitoring and Adverse Drug Reaction Reporting in Pharmacovigilance: An Overview of the Regulatory Landscape

In the context of the European Union's Innovative Medicines Initiative (IMI) project titled Web-Recognizing Adverse Drug Reactions (WEB-RADR; http://web-radr.eu ), which focuses on the assessment of new data sources and the optimization of the collection of information on suspected adverse reactions in pharmacovigilance, a survey was performed in 182 countries/jurisdictions in 2014 to 2015. The goal was to gather information on existing practices, guidance, and legal requirements on social media monitoring to identify potential safety issues related to medicines. The survey response rate was 100%. The results revealed that 80% of the surveyed countries do not have such necessities despite the fact that 63% of these countries have an established national pharmacovigilance system. Among the countries having an established pharmacovigilance system, only 29% have specific requirements, most countries do have similar provisions as set out in the EU guidelines on Good Pharmacovigilance Practices (GVP). A small subset of countries within the European Economic Area (EEA) have requirements that exceed those stated in GVP, namely, Italy, France, Sweden, and the UK. Outside the EEA, Turkey and the United States have also developed further guidance. The outcome of the survey will inform the development of a future policy framework on the further use of social media as new pharmacovigilance data source in the EEA. In addition, this paper elaborates on some current practical case management issues encountered by companies based on the existing regulatory guidance.

Integration of all information sources in a clinical environment

If evidence-based medicine (EBM) is to become fully integrated with patient care then we believe it essential that reference sources must be readily available at the point of healthcare delivery and be seamlessly integrated with access to the medical record. We have employed a user-centred design approach to develop a prototype ward-based clinical workstation, which uses Web technology to provide consistency of both user and data interfaces. Two sources of information are required for our work: the first is an Electronic Patient Record (EPR); the second is the reference material. As a first stage towards a clinical workstation to support EBM, the most commonly required sources of reference material were identified using semi-structured interviews. A first prototype system to evaluate the potential for a workstation to support EBM was constructed by developing a Web-based interface to the hospital’s laboratory Results Reporting System (RRS). Links between this and the most commonly used reference sources identified in the semi-structured interviews were established. An evaluation of this prototype suggested a high acceptability of both the user interface and of the concept of a clinical workstation which allows access to both patient specific and reference data.

Structural and enzymatic characterization of HP0496, a YbgC thioesterase from Helicobacter pylori

YbgC proteins are bacterial acyl-CoA thioesterases associated with the Tol-Pal system. This system is important for cell envelope integrity and is part of the cell division machinery. In E. coli, YbgC associates with the cell membrane and is part of a protein network involved in lipid biogenesis. In the human pathogen Helicobacter pylori, a putative homologue of YbgC, named HP0496, was found to interact with the cytotoxin CagA by two different studies. We have determined its crystal structure and characterized its enzymatic activity. The structure of HP0496 shows that it is a member of the hot-dog family of proteins, with a epsilongamma tetrameric arrangement. Finally, enzymatic assays performed with the purified protein showed that HP0496 is an acyl-CoA thioesterase that favors long-chain substrates.