Phenotypic Expression and Outcomes in Patients with the p.Arg301Gln GLA Variant in Anderson-Fabry Disease

The p.Arg301Gln variant in the α -galactosidase A gene (GLA) has been poorly described in the literature. The few reports show controversial information, with both classical and nonclassical Anderson-Fabry Disease (AFD) presentation patterns. The aim of this study was to analyze the penetrance, clinical phenotype, and biochemical profile of an international cohort of patients carrying the p.Arg301Gln genetic variant in the GLA gene. This was an observational, international, and retrospective cohort case series study of patients carrying the p.Arg301Gln variant in the GLA gene associated with AFD disease. Forty-nine p.Arg301Gln GLA carriers, 41% male, were analyzed. The penetrance was 63% in the entire cohort and 1.5 times higher in men. The mean age of symptoms onset was 41 years; compared to women, men presented symptoms earlier and with a shorter delay to diagnosis. The typical clinical triad-cornea verticillate, neuropathic pain, and angiokeratomas-affected only 20% of the cohort, with no differences between genders. During follow-up, almost 20% of the patients presented some type of nonfatal cardiovascular and renal event (stroke, need for dialysis, heart failure, and arrhythmias requiring intracardiac devices), predominantly affecting men. Residual levels were the most common finding of α-GAL A enzyme activity, only a few women had a normal level; a small proportion of men had undetectable levels. The incidence of combined outcomes including all causes of death was 33%, and the cumulative incidence of all-cause mortality was 9% at the follow-up. Patients carrying the p.Arg301Gln GLA variant have a high penetrance, with predominantly cardiorenal involvement and clinical onset of the disease in middle age. Only a small proportion showed the classic clinical presentation of AFD. As in other X-linked diseases, males were more affected by severe cardiovascular and renal events. This genotype-phenotype correlation could be useful from a practical clinical point of view and for future decision making.

Exercise-induced left fascicular block: A forgotten sign of coronary disease

A 55-year-old patient presented with stable angina pectoris with normal physical examination on rest electrocardiogram and cardiac echocardiogram. Treadmill test revealed exercise-induced left posterior fascicular block, which is an uncommon and easily unnoticed marker of coronary artery disease. A dobutamine stress echocardiogram was performed, with a clearly positive result. Coronary angiography revealed critical stenosis in the right coronary artery.

Clinical outcomes of patients presenting with spontaneous coronary artery dissection versus takotsubo syndrome: a propensity score analysis

Background:

Spontaneous coronary artery dissection and takotsubo syndrome are non-atherosclerotic causes of acute coronary syndromes. They share clinical features including female predominance and frequent triggers. We compared the outcomes of patients with spontaneous coronary artery dissection and patients with takotsubo syndrome with similar clinical characteristics.

Methods:

Patients with spontaneous coronary artery dissection (n=81) or takotsubo syndrome (n=341) were 1:1 propensity matched according to age, sex, cardiovascular risk factors and clinical presentation. We compared baseline characteristics, effects on left ventricular function, and recurrence of major adverse cardiovascular events; defined as a composite of new hospitalisation for cardiac cause, clinical recurrence (spontaneous coronary artery dissection/takotsubo syndrome), myocardial infarction and death.

Results:

Propensity score yielded 78 pairs: 85% were women, whose average age was 55.3±12.6 years, 28% had two or more cardiovascular risk factors, 37% presented with ST-segment elevation and 5% presented with cardiogenic shock. In the spontaneous coronary artery dissection group, 50% (39/78) of cases involved the left anterior descending artery and 18% (14/78) underwent revascularisation. After a median follow-up of 5 years (interquartile range 2.4–5), major adverse cardiovascular events were significantly higher in the spontaneous coronary artery dissection group (18% (14/78) vs. 8% (6/78); hazard ratio 3.40, 95% confidence interval 1.2–9.4). This was mainly driven by early readmissions for cardiac causes (17% vs. 5%, P=0.007). Spontaneous coronary artery dissection was associated with higher peak values of creatinine kinase during admission (creatinine kinase/upper limit of normality 2.49 vs. 1.21, P<0.001). Binary left ventricular systolic dysfunction was more prevalent in the takotsubo syndrome group (22% vs. 53%, P<0.001), but no significant differences were noted at follow-up (6% vs. 1%, P=0.181).

Conclusions:

In this cohort of middle-aged predominantly female patients presenting with acute coronary syndromes, the diagnosis of spontaneous coronary artery dissection compared to takotsubo syndrome conferred a worse long-term clinical outcome, mainly driven by an increased risk of rehospitalisation for cardiac causes.

P5477Usefulness of hypocalcemia at admission as a prognostic marker in patients with acute coronary syndromes

Background

Few studies have focused on the role of serum calcium levels (SCa) in patients with acute myocardial infarction (AMI).

Purpose

This study aimed to analyze the value of SCa as a prognostic marker in patients with AMI, including both with or without ST elevation.

Methods

From January-2015 to December-2017, all consecutive patients with AMI admitted to a tertiary care hospital were included. For the purpose of this study, total SCa levels were recorded at admission in each patient. Blood samples were obtained at the first medical contact when the patient arrived to the hospital. Patients were classified according to quartiles depending on their SCa at admission: Q1, under 8.3 mg/dl (N=300); Q2, between 8.4–8.7 mg/dl (N=264); Q3, between 8.8–9.1 mg/dl (N=279) and Q4, over 9.1 mg/dl (N=283).

Results

A total cohort of 1126 patients was included, 679 (60.3%) had STEMI and 447 (39.7%) were NSTEMI patients. Patients in the Q1 had more in-hospital complications, such as heart failure, bleeding events, new onset AMI, atrioventricular block and contrast induced nephropathy. Patients in the Q1 had higher in-hospital and one-year mortality as compared to that of patients in the Q2-Q4. After multivariate adjustment (Table), low SCa (<8.3mg/dl) remained as an independent predictor of in-hospital mortality (OR 2.91, 95% CI (1.15–7.41), p=0.025). These results were consistent in STEMI and NSTEMI patients.

Multivariable analysis Variable OR (95% CI) p GRACE score 1.00 (0.99–1.02) 0.727 CRUSADE score 1.03 (1.01–1.06) 0.011 Age (per year) 1.05 (1.00–1.09) 0.034 STEMI 1.35 (0.41–4.46) 0.617 Diabetes 2.57 (0.97–6.79) 0.056 Low SCa (<8.3) 2.91 (1.15–7.41) 0.025 Killip class at admission   1 Reference   2 4.73 (1.31–17.1) 0.018   3 6.83 (1.70–27.5) 0.007   4 9.83 (1.44–67.1) 0.020 STEMI: ST segment elevation myocardial infarction; SCa: Serum calcium levels; OR: Odds ratio; CI: Confidence interval.

Conclusion

In patients with AMI, low SCa levels at admission (<8.3mg/dl) are independently associated with higher mortality.

Screening of extra-coronary arteriopathy with magnetic resonance angiography in patients with spontaneous coronary artery dissection: a single-centre experience

Background

Current consensus recommends extended vascular investigation in patients with spontaneous coronary artery dissection (SCAD). We here report our experience with the use of magnetic resonance angiography (MRA) for screening extra-coronary arteriopathy in patients presenting with SCAD.

Methods

Patients presenting with SCAD in a Spanish centre underwent prospective contrast-enhanced MRA to assess the cephalic and abdominopelvic arterial territories. Fibromuscular dysplasia (FMD) was diagnosed following European consensus criteria. Other vascular abnormalities were recorded separately. Two vascular radiologists supervised the acquisitions and independently analysed the results for all cases.

Results

Forty patients with SCAD [mean age 50.9±8.6 years, 90% (n=36) women] were included in the study, 12 patients declined to participate and 5 were excluded (metallic implanted devices). All enrolled patients underwent the screening protocol without complications. MRA demonstrated at least one extra-coronary vascular abnormality in 16 patients (40%): 5 (12.5%) were diagnosed with FMD, 6 (15%) showed arterial tortuosity, 3 (7.5%) had non-FMD focal stenoses, and 2 (5%) were found to have small aneurysms at the celiac trunk and splenic artery. No intracranial aneurysms were detected. At a mean follow-up of 4±3 years from the index episode, two cases experienced SCAD recurrences, one in a patient with FMD and the other one in a patient with arterial tortuosity. No deaths or strokes occurred.

Conclusions

Systematic extended vascular study with MRA was feasible and demonstrated associated extra-coronary arteriopathy in a substantial proportion of patients presenting with SCAD; however, none required additional intervention or led to vascular events. MRA, being a radiation-free modality, may be the preferred method for screening extracoronary arteriopathy in SCAD, a condition primarily affecting young and middle-age women sensitive to the risks of radiation.

Sex differences in treatment and prognosis of acute coronary syndrome with interventional management

OBJECTIVE

Female sex has been associated with differences in diagnostic and management of acute coronary syndrome (ACS). Our aim was to analyze sex differences in ACS with interventional management in a tertiary care hospital.

METHODS

Patients with ACS admitted to a Spanish tertiary care referral center were included prospectively and consecutively. All patients included in the study underwent a coronary angiography.

RESULTS

From the total cohort of 1214 patients, 290 (24%) were women. Women were older (71 ± 12.8 vs 64 ± 13.4 years, p < 0.001) and showed lower ischemic risk and higher hemorrhagic risk scores (GRACE 159 ± 45 vs 171 ± 42, p = 0.005; CRUSADE 41 ± 19 vs 28 ± 17, p < 0.001). There were no significant differences in time to coronary angiography and revascularization rates between sex groups. A lower proportion of women received high-potency antiplatelet agents (29% vs 41.3%, p = 0.004). In-hospital evolution and one-year mortality were similar between groups.

CONCLUSIONS

In our population, there were no gender differences in management and prognosis of ACS. Differences in risk profile among groups could have an influence on antiplatelet therapy.

TBC: A simple algorithm to rule out abnormalities in electrocardiograms of patients with pacemakers

BACKGROUND

The aim of the study was to create a straightforward method to rule out abnormalities in electrocardiograms (ECGs) performed in patients with pacemakers.

METHODS

The TBC method screens the ECG for any of the following findings: Tachycardia with pacing spikes, Bradycardia without spikes and Chaos with spikes unrelated to QRS-T complexes. T was considered to advise for patient assessment and B and C to require referral for urgent pacemaker evaluation. The diagnostic accuracy of the algorithm was validated using a cohort of 151 ECGs with normal and dysfunctional pacemakers. The effect of the algorithm was then evaluated for diagnostic skills and management of patients with pacemakers by non-cardiologists, comparing their diagnostic accuracy before and after teaching the algorithm.

RESULTS

The TBC algorithm had a sensitivity of 86% and a specificity of 94% in diagnosing a malfunctioning pacemaker. The diagnostic skills and patient referral were significantly improved (74.8% vs. 89.5%, p < 0.001; and 57.4% vs. 83%, p < 0.001).

CONCLUSIONS

TBC is an easy to remember and apply method to rule out severe abnormalities in ECGs of patients with pacemakers. TBC algorithm has a very good diagnostic capability and is easily applied by non-expert physicians with good results.