SGLT2i uptake among heart failure patients with reduced ejection fraction: ongoing prescriber hesitancy and how to address this

Background

The evidence of mortality benefit from sodium-glucose transport protein 2 inhibitors (SGLT2i) in the management of heart failure with reduced ejection fraction (HFrEF) has been observed since 2019. Its first-line use in HFrEF, regardless of diabetes status, has been recommended by The European Society of Cardiology (ESC) since September 2021. Yet prescriber hesitancy surrounding SGLT2i use is still an under investigated issue resulting in centres falling short of gold-standard care. A simple review of pharmacotherapy pattern can alert clinicians to under prescribing of SGLT2i inhibitors and respond by improving adherence to guidelines.

Purpose

To describe the pharmacotherapy pattern of HFrEF patients attending an outpatient (Heart Failure Support Unit) HFSU in Ireland.

Methods

A retrospective analysis was performed in HFrEF patients actively attending the HFSU. Active attendance was considered a single engagement with the service between 1st January 2021 and 31st December 2021, and patients who have not died, been transferred to another service, or loss to follow-up. Information collected from digital records included patient demographic, comorbidities, baseline investigations, and pharmacotherapy pattern. Sensitivity analysis was performed for patients with type 2 diabetes (T2DM).

Results

156 HFrEF patients were actively attending the HFSU. The mean age was 72.1 (±12.5) years and majority were male 114 (73.1%). The following pharmacotherapy pattern was revealed: angiotensin-converting enzyme inhibitors/ angiotensin II receptor blockers (ACEi/ARBs) 80 (51.3%), ARNi 55 (35.3%), β-blockers 142 (91.0%), mineralocorticoid receptor antagonist (MRA) 58 (37.2%), SGLT2i 9 (5.8%) and Ivabradine 9 (5.8%). Sensitivity analysis for T2DM patients (n=45) reveals a pattern of ACEi/ARBs 46.7%, ARNi 37.8%, β-blockers 95.6%, MRA 42.2%, SGLT2i 20.0% and Ivabradine 8.9%. All 9 instances of SGLT2i use were in T2DM patients. Since identification of SGLT2i under-prescribing, an interim review on 28th February 2022 revealed that total SGLT2i prescription had increased by 19 (211.1%), all of which were outside the T2DM population.

Conclusions

SGLT2i is still under prescribed for HFrEF management and prescriptions have the tendency to be restricted to T2DM patients. Identification of pharmacotherapy pattern can alert clinicians to prescriber hesitancy and increase new SGLT2i prescriptions outside the T2DM population.

Funding Acknowledgement

Type of funding sources: None.

The role of contrast-enhanced ultrasound in neurosurgical disease

Contrast-enhanced ultrasound (CEUS) is a relatively new imaging modality in the realm of neurosurgical disease. CEUS permits the examination of blood flow through arteries, veins, and capillaries via intravascular contrast agents and allows vascular architectural mapping with extreme sensitivity and specificity. While it has established utility in other organ systems such as the liver and kidneys, CEUS has not been studied extensively in the brain. This report presents a review of the literature on the neurosurgical applications of CEUS and provides an outline of the imaging modality’s role in the diagnosis, evaluation, and treatment of neurosurgical disease.

P951The factors influencing total ischaemic time in patients presenting with STEMI in an Irish tertiary referral centre

Background

Despite highly functioning primary percutaneous coronary intervention (PPCI) programmes, STEMI is still associated with significant morbidity and mortality. The European Society of Cardiology STEMI guidelines in 2017 introduced a novel metric relating to STEMI patients: “total ischaemic time”. This time-period starts at the onset of chest pain and ends at wire cross, and it is thought to accurately reflect burden of myocardial destruction.

Aims

To assess the total ischaemic time of patients presenting with STEMI in an Irish tertiary referral centre and the factors influencing delays in presentation and treatment.

Methods

Prospective cohort analysis was conducted on all patients presenting with STEMI from October 2017 to January 2019. Patients were included if they had a culprit lesion that was successfully revascularized. All information was recorded at time of presentation. Bayesian statistics were employed to conduct the analysis.

Results

158 patients were recruited. Mean age was 61 (range29–96). Male:female ratio 5:1 in this cohort. Average total ischaemic time was 409.4mins ±501.4. The average time from chest pain to “call for help” (i.e. patient delay) was 208.3mins ±397.8, which represented 50.89% of the total ischaemic time (see Figure 1). The average time from “call for help” to first medical contact (FMC) was 18.4mins ±30.07. Average time from FMC to ECG was 44.9mins ±151.16, and was dependent upon type of FMC (Primary care 127mins vs paramedic 25mins p=0.030932). After FMC, 48.7% of patients had an ECG performed in under 10mins as per guidelines. After ECG was performed, 46.4% of patients had ECG to “wire cross” time under 90mins as per guidelines; 65.8% were within 120 mins and 91.4% were within 180mins. Those presenting to their general practitioner as FMC were significantly less likely to have both an ECG <10mins (NNH 2.84 95% CI 1.79–6.91) and ECG to wire time of <90mins (NNH 6.13 95% CI 2.88–48.70).

As age increased, so too did total ischaemic time (Pearson R=0.164, p=0.043), which was dependent on increasing patient delay with age (Pearson R=0.2181, p=0.0066). Women had a higher total ischaemic time than men (546 vs 382mins p=0.0233). This was determined to be as a result of: a numerically higher patient delay (220 vs 206 mins, p=0.214) and women having a longer time from FMC to ECG (104mins vs 34mins, p=0.0021).

Conclusion

Over 50% of the total ischaemic time was due to patient delay, suggesting a role for cardiovascular awareness programmes. Increasing age was associated with longer patient delay, indicating a need for directed awareness in this demographic. Women had a higher total ischaemic time, and waited a significantly longer time for ECG following FMC; highlighting the need for awareness amongst healthcare professionals of atypical clinical features associated with STEMI in women. Patients who attended their GP waited longer for an ECG and, once performed, were less likely to be revascularised within 90mins.

P2656Real-world Outcomes for STEMI in octogenarians and nonagenarians: A 5-year review from an Irish primary PCI centre

Background

Progress made by modern healthcare has led to improved life expectancy across the globe. This progress, however, also means that individuals are living with more chronic illnesses and co-morbidities than in previous generations. Due to this aging population, we can expect increasing rates of STEMI in octogenarians and nonagenarians in the future. The challenge of older patients with STEMI is that they are particularly high-risk for complications. At present, very little is known about the outcomes of STEMI in the very old population because they were under-represented in previous studies. Many cardiologists around the world have been hesitant in performing primary percutaneous coronary intervention (PPCI) in octogenarians and nonagenarians due to fear of complications and poor outcomes.

Purpose

To review the trend of octogenarians and nonagenarians presenting with STEMI and to assess the 30-day and 1-year mortality rates.

Methods

A single-centre retrospective observational study was conducted. All patients presenting with STEMI between January 2012 and December 2017 were reviewed. Individuals aged 80 years or older were included for the purpose of this analysis. Patient level data was collected by chart review and individuals were identified using the local STEMI database. Standard Bayesian statistics were employed for analysis.

Results

1,268 patients presented with STEMI during this period. 172 (13.6%) were 80 years or older. Of this subgroup, 159/172 (92.4%) were true STEMI (figure 1). 124/159 (77.9%) patients were brought to the catheterization lab and 35/159 (22%) were managed medically on the ward.107/159 (67.29%) were treated with PPCI. Patients in the PPCI group had a 30-day mortality rate of 20.6% while those in the medically managed group had a mortality rate of 37.1%; with a trend towards statistical significance (p=0.07). The one-year mortality rate in patients treated with PPCI was 22.4% which was significantly lower than those who received medical management 48.6% (p=0.005).

Conclusions

This review demonstrates that there is a high mortality rate with STEMI in those aged 80 years or above, however, patients who are treated with PPCI tend to do better and have a significantly lower mortality rate at 1-year. The incidence of STEMI in the very old cohort is likely to continue to rise and this may prove challenging. PPCI remains the most feasible treatment approach towards STEMI and this should not be biased based on age, however, interventionists will need to take into account patient suitability on a case-by case basis. Octogenarians who undergo angiography and PPCI as required have 77.6% survival at 1 year (figure 1) with 92.4% likelihood of going home and don't require long term nursing home care.

Acknowledgement/Funding

University Hospital Limerick

Abstract P2-14-05: Can an internal surgical adhesive facilitate drain-free mastectomy and reduce overall invasiveness?-A prospective, randomized, controlled, multicenter non-inferiority trial

Introduction: Mastectomy closure without drains has many potential advantages. Flap fixation techniques have shown to be an effective alternative to drains. This study tested the non-inferiority of a surgical adhesive in overall invasiveness compared to standard wound closure with drains. Methods: This trial (ClinicalTrials.gov Identifier: NCT02958449) recruited seventy-seven patients undergoing eighty-four mastectomies +/- SLNB (n=84) at eleven international centers. Procedures were prospectively randomized to standard wound closure with drains (SWC; n=41) or wound closure without drains using a high strength lysine-based adhesive named TissuGlu® (TG; n= 43). The primary outcome measured assessed overall invasiveness using the number of post-operative clinical interventions, including drain removals and needle aspirations. Secondary endpoints included total wound drainage, cumulative days of treatment, days to drain removal and wound healing related complications. A patient questionnaire evaluating quality of life measures was also administered. Results: Subjects in the TissuGlu® group required significantly fewer post-operative clinical interventions (1.25 ± 1.39 TG vs. 2.03 ± 1.45 SWC, p = &lt;.0001) compared to the Control group and had fewer cumulative days of treatment (defined as days of drains being in place and / or days on which an aspiration occurred; 2.14 ± 4.15 TG vs. 5.76 ± 4.02 SWC, p = &lt;0.0001). Presence of a drain was associated with significantly higher pain and lower mobility scores. Conclusion: The study demonstrates that flap fixation with this adhesive can permit drain-free mastectomy closure, reducing overall invasiveness and patient morbidity.

Citation Format: Eichler C, Paepke S, Ohlinger R, Mathias W, Scheffen I, Lux M, Hadad S, Kiernan T, Whisker L, Kaushik M, King P. Can an internal surgical adhesive facilitate drain-free mastectomy and reduce overall invasiveness?-A prospective, randomized, controlled, multicenter non-inferiority trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-05.

Abstract P5-15-07: Knowledge of oncotype Dx recurrence score increases confidence and concordance in adjuvant decisions of U.K. oncologists

Introduction

The addition of Oncotype Dx Recurrence Score (RS) to the assessment of patients with ER positive, HER2 negative, node negative breast cancer has led to a reduction in the use of adjuvant chemotherapy. However, crude measurement of this reduction masks a more complex scenario. Prior to the introduction of routine Oncotype DX testing by NHS England, we wished to explore in more detail the potential impact of the knowledge of the RS on the therapeutic discussion. This study analyses the impact of RS on the adjuvant therapy recommendations within a UK Cancer Centre. In particular, it examines how the degree of certainty the oncologist has about the best option changes with knowledge of RS and how this influences concordance of decision making between oncologists.

Methods

A panel of five breast oncologists reviewed 50 consecutive cases, collected from November 2012 until November 2014, across two hospitals. Oncologists allocated each case to one of four treatment categories: chemotherapy recommended (CRec), chemotherapy discussed with a bias towards recommended (CDis), chemotherapy discussed with a bias toward endocrine therapy alone (EDis) or endocrine therapy only advised (ERec). The cases were analysed blindly and in random order without and with RS . The degree to which knowledge of RS altered treatment recommendation was analyzed. Other outcomes included the proportion of patients who were scored ERec compared with any other outcome, the trend towards definitive recommendations, the impact of RS on concordant decision making and the degree to which outcome was stratified by RS result. Chi squared and Spearman's coefficient statistical tests were used in analysis.

Results

Knowledge of the RS altered the recommended treatment category in 66.7% of cases (p&lt;0.001).

Alterations in treatment recommendations in response to Oncotype Recurrence Score in addition to pathological parameters CRec (n)CDis (n)EDis (n)ERec (n)Without RS2% (1)40% (20)52% (26)6% (3)With RS12% (6)16% (8)26% (13)46% (23)

Overall, RS correlated significantly with treatment recommendation. Oncologists were confident to recommend endocrine therapy alone in 46% of patients when RS was known compared with only 6% of patients without RS. Complete concordance between oncologists increased with the knowledge of RS from 14% to 64%.

Conclusion

Discussion of adjuvant chemotherapy with patients who have ER positive, HER2 negative, node negative breast cancer can be complex and, at times, confusing for the patient, leading to increased distress. This study shows that, in addition to the previously recognised reduction in overall use of chemotherapy, the knowledge of the RS increased the proportion of patients for whom the oncologist felt confident in making a firm treatment recommendation. An added benefit was to increase concordance between different oncologists compared to that achieved when relying on standard pathological features.

Citation Format: Kiernan T, Olsson-Brown AC, Innes H, Holcombe C, Thorp N, O'Hagan J, Wong H, Palmieri C, O'Reilly S. Knowledge of oncotype Dx recurrence score increases confidence and concordance in adjuvant decisions of U.K. oncologists. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-15-07.

VA Cooperative Study on Alcoholic Hepatitis. IV. The significance of clinically mild alcoholic hepatitis--describing the population with minimal hyperbilirubinemia

As part of a large multicenter Veterans Administration Cooperative Study of Alcoholic Hepatitis, 89 patients with clinically mild biopsy-proven disease were followed for at least 30 months. Although clinical and laboratory abnormalities were minimal, cirrhosis was present in 38%, and mortality was 22% at 30 months. Clinical features suggesting more advanced disease (i.e., ascites and encephalopathy) and laboratory parameters for the diagnosis of alcoholic hepatitis and/or cirrhosis were imprecise and frequently misleading. The histologic diagnosis of cirrhosis correlated best with changes in immunoglobulin A, prothrombin time, and SGOT/SGPT. However, by using logistic discriminant analysis on 26 commonly available laboratory tests to diagnose cirrhosis, only a 72% sensitivity and 88% specificity could be obtained. Mortality in the patients with cirrhosis (10/34) was significantly higher at 1 and 2 yr compared with patients without cirrhosis (10/55, p less than 0.01). The high mortality in noncirrhotics may have resulted from progression to cirrhosis subsequent to the initial evaluation. Thus, liver biopsy in this population with minimal disease seems necessary to establish both an accurate diagnosis and the reversibility of the disease.

Significance of megamitochondria in alcoholic liver disease

The significance of megamitochondria in the alcoholic liver injury of humans was investigated as part of a large Veterans Administration cooperative study of the natural history of alcoholic hepatitis. Two hundred twenty patients were clinically stratified into the following three groups according to disease severity using serum bilirubin and prothrombin time as indicators: Group 1 (mild disease), serum bilirubin levels less than 5 mg/dl and prothrombin time prolonged for less than 4 s; group 2 (moderate disease), serum bilirubin levels greater than 5 mg/dl but prothrombin time prolonged for less than 4 s; and group 3 (severe disease), serum bilirubin levels greater than 5 mg/dl and prothrombin time prolonged for greater than 4 s. Megamitochondria were observed in 20% of the patients (45 of 220). Of these, 43 patients were in groups 1 and 2 of severity and only 1 patient belonged in group 3. The association of megamitochondria with cirrhosis was infrequent (33%, 15 of 45 patients). The differences in severity correlated with the differences in mortality: in patients with megamitochondria, only 1 had died at 6 mo compared with 40 deaths in patients without megamitochondria. By 12 mo, there were two deaths in patients with megamitochondria versus 51 deaths in those patients without. No complications were present in 72% of patients with megamitochondria versus 39% for those without. Infection, gastrointestinal bleeding, pancreatitis, hyperglycemia, azotemia, delirium tremens, seizures, and hepatic encephalopathy were all more common in patients without megamitochondria. The patients with megamitochondria appear to represent a subcategory of alcoholic hepatitis with a milder degree of clinical severity, lower incidence of cirrhosis, fewer complications, and good long-term survival.

VA cooperative study on alcoholic hepatitis. II: Prognostic significance of protein-calorie malnutrition

Three hundred and fifty-two patients with alcoholic hepatitis were evaluated for protein-calorie malnutrition (PCM). In order to facilitate data analysis of nutritional status, a PCM score was calculated for each patient using eight nutritional parameters. The PCM score correlated significantly with mortality, clinical severity of the liver disease, and biochemical liver dysfunction. When 30 day changes in the PCM scores were compared with 30 day caloric intake (expressed as percent basal energy expenditure (BEE], a marginally significant correlation was observed (p = 0.05). However, those patients who showed improvement in their PCM score over 30 days of hospitalization also improved their 6-mo and 1-yr survival. These data indicate that nutrition, as determined by the PCM score, has prognostic significance. Additional studies are needed to establish the beneficial role for vigorous protein-calorie nutritional therapy in the management of alcoholic hepatitis.

Disease-specific amino acid infusion (F080) in hepatic encephalopathy: a prospective, randomized, double-blind, controlled trial

Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.

Short-term and long-term survival in patients with alcoholic hepatitis treated with oxandrolone and prednisolone

A cooperative study was conducted to determine the efficacy of 30 days of treatment with either a glucocorticosteroid (prednisolone) or an anabolic steroid (oxandrolone) in moderate or severe alcoholic hepatitis. One hundred thirty-two patients with moderate disease and 131 with severe disease were randomly assigned to one of three treatments: prednisolone, oxandrolone, or placebo. During the 30 days, mortality in the groups receiving steroid therapy was not significantly different from mortality in the placebo group. Thirteen per cent of the moderately ill patients and 29 per cent of the severely ill patients died. Although neither steroid improved short-term survival, oxandrolone therapy was associated with a beneficial effect on long-term survival. This was especially true in patients with moderate disease: among those who survived for one or two months after the start of treatment the conditional six-month death rate was 3.5 per cent after oxandrolone and 19 to 20 per cent after placebo (P = 0.02). No consistent long-term effect was associated with prednisolone therapy.

Ethanol and cell replication in the digestive tract

Ethanol-induced injury of the intestines, liver and pancreas evokes a regenerative response which is characterized by a series of morphological and biochemical adaptive responses in subcellular organelles, and an increase in chromosomal protein and DNA replication. Patterns of cell replication vary with the system involved, the amount of injury and the presence of essential precursors or catalysts needed for cell replication. Maintenance of normal cell replacement patterns in the digestive tract of the alcoholic requires correction of deficits and interruption of alcohol intake. An inadequate or excessive regenerative response is of key importance in perpetuating tissue injury in the alcoholic. Regenerative capacity has been evaluated in man by measurement of circulating levels of CEA and alpha-fetoprotein; unfortunately, there is often no correlation between cell replication and these parameters in the malnourished alcoholic. Studies of mitoses or organelle changes in biopsies of intestines and liver are valuable; however, accurate monitoring of regeneration is possible only by kinetic studies utilizing incorporation of tritiated thymidine into DNA.

Glucose movement into rat interine fluid

The uterine horns of anaesthetized rats were cannulated and 2.5 ml 0.9% NaCl at 37 degrees C were recirculated for up to 90 min. Glucose appeared in the medium, reaching a concentration of approximately 1 mM. Various aspects of the transport process were examined, and it is suggested that the glucose is mainly derived from the plasma, and probably enters the uterine lumen by a process involving facilitated diffusion.

Type B hepatitis after needle-stick exposure: prevention with hepatitis B immune globulin. Final report of the Veterans Administration Cooperative Study

Hepatitis B immune globulin (HBIG) and immune serum globulin (ISG) were examined in a randomized, double-blind trial to assess their relative efficacies in preventing type B hepatitis after needle-stick exposure to hepatitis B surface antigen (HBsAG)-positive donors. Clinical hepatitis developed in 1.4% of HBIG and in 5.9% of ISG recipients (P = 0.016), and seroconversion (anti-HBs) occurred in 5.6% and 20.7% of them respectively (P less than 0.001). Mild and transient side-effects were noted in 3.0% of ISG and in 3.2% of HBIG recipients. Available donor sera were examined for DNA polymerase (DNAP) and e antigen and antibody (HBeAg; anti-HBE). Both DNAP and HBeAg showed a highly statistically significant correlation with the infectivity of HBsAg-positive donors. Hepatitis B immune globulin remained significantly superior to ISG in preventing type B hepatitis even when the analysis was confined to these two high-risk subgroups. The efficacy of ISG in preventing type B hepatitis cannot be ascertained because a true placebo group was not included.

Efficacy of hepatitis B immune serum globulin after accidental exposure. Preliminary report of the Veterans Administration Cooperative Study

A randomised, double-blind, controlled trial has been undertaken to compare the efficacy of hepatitis B immune globulin (H.B.I.G.) with that of immune serum globulin (I.S.G.) for the prophylaxis of viral hepatitis. Participants in the trial were individuals exposed accidentally to material infectious for hepatitis (primarily viral B hepatitis). Preliminary evaluation of the first 302 of the 561 individuals entered into the study indicates that H.B.I.G. significantly reduced the frequencies of both clinical and subclinical hepatitis during the first 3--4 months after the injection. Less than 10% of H.B.I.G. recipients had detectable anti-HBs at the sixth month after the injection, suggesting that H.B.I.G. might need to be given every 3--4 months to continually exposed individuals. Further long-term evaluation is required in order to define more clearly those most likely to benefit from H.B.I.G.

Hepatic disease in asymptomatic parenteral narcotic drug abusers: a Veterans Administration collaborative study

The Veterans Administration is currently conducting a collaborative study in three hospital-based drug treatment clinics to evaluate asymptomatic parenteral drug addicts for evidence of hepatic disease. Preliminary data are presented on 347 patients who have completed at least three months of follow-up evaluation. On admission, abnormal serum transaminase values were demonstrated in one half, HBs Ag in 7 per cent, and anti-HBs in 59 per cent. The frequency of these findings increased during the follow-up evaluation, only 19 (5.5 per cent) remaining entirely free of one or more of these abnormalities. Definable hepatologic disease (acute or chronic hepatitis, alcoholic hepatitis) developed in 46 per cent of the patients. However, among 60 of them subjected to liver biopsy, a poor correlation was noted between the clinical and histologic diagnoses. In particular, routine liver function and immunologic tests did not discriminate between histologically detected chronic active and chronic persistent hepatitis. However, HBs Ag was present significantly more frequently in those with chronic active hepatitis. Wide variability of histologic diagnoses was seen among patients subjected to more than one biopsy, apparent progression and regression of the lesion being noted. This demonstrates the hazard of attempting to assign a prognosis to the disease on the basis of a single liver biopsy specimen, and suggests that repeated biopsies should be mandatory for the evaluation of chronic liver disease in drug addicts.