Advances in the Construction and Application of Thyroid Organoids

Organoids are complex multicellular structures that stem cells self-organize in three-dimensional (3D) cultures into anatomical structures and functional units similar to those seen in the organs from which they originate. This review describes the construction of thyroid organoids and the research progress that has occurred in models of thyroid-related disease. As a novel tool for modeling in a 3D multicellular environment, organoids help provide some useful references for the study of the pathogenesis of thyroid disease.

[Clinicopathological and molecular diagnostic features of early-onset gastric cancer: a study based on data from a single-center dedicated gastric cancer database]

Objective: To clarify the clinicopathological, especially molecular, features of early-onset gastric cancer with the aim of informing analysis of treatment strategies. Methods: In this retrospective case-control study, we examined data from a dedicated gastric cancer database in Zhongshan Hospital affiliated to Fudan University. The original cohort comprised 2506 patients with gastric cancer who had undergone gastrectomy in Zhongshan Hospital Fudan University from July 2020 to October 2021, including 198 with early-onset gastric cancer (aged ≤45 years) and 2,308 with non-early gastric cancer. We used a simple random sampling method to select 396 of the 2,308 patients aged >45 years (ratio of 1:2) as the control group and then compared molecular diagnostic data and clinicopathological features of the two groups. Results: The median age was 39 years in the early-onset gastric cancer group, while 66 years in the control group. The clinicopathological features of early-onset gastric cancer included female predominance (59.1% [117/198] vs. 27.8% [110/396], χ2=54.816, P<0.001), less comorbidity (32.3% [64/198] vs. 57.1% [226/396], χ2=32.355, P<0.001), poorer differentiation (93.9% [186/198] vs. 74.5% [295/396], χ2=30.777, P<0.001) and higher proportion of diffuse type (40.4% [80/198] vs. 15.9% [63/396], χ2=69.639, P<0.001), distant metastasis (7.1% [14/198] vs. 2.8% [11/396], χ2=6.034, P=0.014). Regarding treatment, distal gastrectomy was more commonly performed than proximal gastrectomy (55.1% [109/198] vs. 47.0% [186/396], 1.5% [3/198] vs. 8.3% [33/396], χ2=11.644, P=0.003). Family history of gastric cancer, TNM stage, tumor size, lymph node dissection, nerve invasion, nodes harboring metastases, range of lymph node dissection, digestive tract reconstruction procedure, implementation of laparoscopic surgery, combined resection, and preoperative treatment did not differ significantly between the two groups (all P>0.05). Molecular diagnosis showed there was a smaller percentage of mismatch repair deficiency in the early-onset gastric cancer than in the control group (1.0% [2/198] vs. 10.1% [40/396], χ2=16.301, P<0.001), and a higher rate of positivity for Claudin 18.2 (77.8% [154/198] vs. 53.0% [210/396], χ2=5.442,P<0.001). HER-2 and Epstein-Barr virus positivity rates did not differ significantly between the two groups. Conclusion: Early-onset gastric cancer is a distinct type of gastric cancer with a high degree of malignancy, and treatment targeting Claudin 18.2 may be effective.

[Short-term outcome of patients after transcatheter aortic valve replacement receiving different anticoagulants]

Objective: To compare the safety and efficacy of different anticoagulants in patients with indications for anticoagulation after transcatheter aortic valve replacement (TAVR). Methods: This is a retrospective study. Patients who underwent TAVR from April 2016 to February 2022 in Guangdong Provincial People's Hospital and had indications for anticoagulation were included and divided into two groups according to the type of anticoagulants, i.e. non-vitamin K antagonist oral anticoagulant (NOAC) and warfarin, and patients were followed up for 30 days. The primary endpoint was the combination of death, stroke, myocardial infarction, valve thrombosis, intracardiac thrombosis and major bleeding. The incidence of endpoints was compared between two groups, and multivariate logistic regression analysis was applied to adjust the bias of potential confounders. Results: A total of 80 patients were included. Mean age was (74.4±7.1) years, 43 (53.8%) were male. Forty-nine (61.3%) patients used NOAC, 31 used warfarin, and major indication for anticoagulants was atrial fibrillation (76/80, 95.0%). The adjusted risks of the primary endpoint (OR=0.23, 95%CI 0.06-0.94, P=0.040) of NOAC were lower than that of warfarin, mainly driven by a lower risk of major bleeding (OR=0.19, 95%CI 0.04-0.92, P=0.039). Conclusions: The short-term outcome of NOAC is better than that of warfarin in patients with indications for anticoagulation after TAVR. Randomized controlled trials of large sample size with long-term follow-up are needed to further testify this finding.

[Expression changes of NaV channel subunits correlate with developmental maturation of electrophysiological characteristics of rat cerebellar Purkinje neurons]

OBJECTIVE

To investigate the variations in the expression of voltage-gated sodium (Na_v) channel subunits during development of rat cerebellar Purkinje neurons and their correlation with maturation of electrophysiological characteristics of the neurons.

METHODS

We observed the changes in the expression levels of Na_V1.1, 1.2, 1.3 and 1.6 during the development of Purkinje neurons using immunohistochemistry in neonatal (5-7 days after birth), juvenile (12-14 days), adolescent (21-24 days), and adult (42-60 days) SD rats. Using whole-cell patch-clamp technique, we recorded the spontaneous electrical activity of the neurons in ex vivo brain slices of rats of different ages to analyze the changes of electrophysiological characteristics of these neurons during development.

RESULTS

The expression of Na_V subunits in rat cerebellar Purkinje neurons showed significant variations during development. Na_V1.1 subunit was highly expressed throughout the developmental stages and increased progressively with age (P < 0.05). Na_V1.2 expression was not detected in the neurons in any of the developmental stages (P > 0.05). The expression level of Na_V1.3 decreased with development and became undetectable after adolescence (P < 0.05). Na_V1.6 expression was not detected during infancy, but increased with further development (P < 0.05). Na_V1.1 and Na_V1.3 were mainly expressed in the early stages of development. With the maturation of the rats, Na_V1.3 expression disappeared and Na_V1.6 expression increased in the neurons. Na_V1.1 and Na_V1.6 were mainly expressed after adolescence. The total Na_V protein level increased gradually with development (P < 0.05) and tended to stabilize after adolescence. The spontaneous frequency and excitability of the Purkinje neurons increased gradually with development and reached the mature levels in adolescence. The developmental expression of Na_V subunits was positively correlated with discharge frequency (r=0.9942, P < 0.05) and negatively correlated with the excitatory threshold of the neurons (r=0.9891, P < 0.05).

CONCLUSION

The changes in the expression levels of Na_V subunits are correlated with the maturation of high frequency electrophysiological properties of the neurons, suggesting thatmature Na_V subunit expressions is the basis of maturation of electrophysiological characteristics of the neurons.

Research progress into adipose tissue macrophages and insulin resistance

In recent years, there has been an increasing incidence of metabolic syndrome, type 2 diabetes, and cardiovascular events related to insulin resistance. As one of the target organs for insulin, adipose tissue is essential for maintaining in vivo immune homeostasis and metabolic regulation. Currently, the specific adipose tissue mechanisms involved in insulin resistance remain incompletely understood. There is increasing evidence that the process of insulin resistance is mostly accompanied by a dramatic increase in the number and phenotypic changes of adipose tissue macrophages (ATMs). In this review, we discuss the origins and functions of ATMs, some regulatory factors of ATM phenotypes, and the mechanisms through which ATMs mediate insulin resistance. We explore how ATM phenotypes contribute to insulin resistance in adipose tissue. We expect that modulation of ATM phenotypes will provide a novel strategy for the treatment of diseases associated with insulin resistance.

[Clinicopathological features and prognostic factors of gastric intermediate-risk gastrointestinal stromal tumor after surgical resection: a retrospective study]

Objective: To investigate the clinicopathological features, treatment and prognosis of gastric intermediate-risk gastrointestinal stromal tumor (GIST), so as to provide a reference for clinical management and further research. Methods: A retrospective observational study of patients with gastric intermediate-risk GIST, who underwent surgical resection between January 1996 and December 2019 at Zhongshan Hospital of Fudan University, was carried out. Results: Totally, 360 patients with a median age of 59 years were included. There were 190 males and 170 females with median tumor diameter of 5.9 cm. Routine genetic testing was performed in 247 cases (68.6%, 247/360), and 198 cases (80.2%) showed KIT mutation, 26 cases (10.5%) showed PDGFRA mutation, and 23 cases were wild-type GIST. According to "Zhongshan Method"(including 12 parameters), there were 121 malignant and 239 non-malignant cases. Complete follow-up data were available in 241 patients; 55 patients (22.8%) received imatinib therapy, 10 patients (4.1%) experienced tumor progression, and one patient (PDGFRA mutation, 0.4%) died. Disease-free survival (DFS) and overall survival rate at 5 years was 96.0% and 99.6%, respectively. Among the intermediate-risk GIST, there was no difference in DFS between the overall population, KIT mutation, PDGFRA mutation, wild-type, non-malignant and malignant subgroups (all P>0.05). However, the non-malignancy/malignancy analysis showed that there were significant differences in DFS among the overall population (P<0.01), imatinib treatment group (P=0.044) and no imatinib treatment group (P<0.01). Adjuvant imatinib resulted in potential survival benefit for KIT mutated malignant and intermediate-risk GIST in DFS (P=0.241). Conclusions: Gastric intermediate-risk GIST shows a heterogeneous biologic behavior spectrum from benign to highly malignant. It can be further classified into benign and malignant, mainly nonmalignant and low-grade malignant. The overall disease progression rate after surgical resection is low, and real-world data show that there is no significant benefit from imatinib treatment after surgery. However, adjuvant imatinib potentially improves DFS of intermediate-risk patients with tumors harboring KIT mutation in the malignant group. Therefore, a comprehensive analysis of gene mutations in benign/malignant GIST will facilitate improvements in therapeutic decision-making.

Fine-Tuning of Entangled Two-Photon Absorption by Controlling the One-Photon Absorption Properties of the Chromophore

The detailed analysis of the sum-over-state formula for the entanglement-induced two-photon absorption (ETPA) transition moment shows that the magnitude of the ETPA cross-section is expected to vary significantly depending on the coherence time T_e and the relative position of just two electronic states. Moreover, the dependency on T_e is periodic. These predictions are confirmed by molecular quantum mechanical calculations for several chromophores.

Different cellular landscape of four types of non-diseased cardiac valves contributes to their differences in susceptibility of pathological remodeling and disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): National Natural Science Foundation of China

Background

Exploring the mechanisms of valvular heart disease (VHD) at the cellular level may be useful to identify new therapeutic targets; however, the comprehensive cellular landscape of non-diseased human cardiac valve leaflets remains unclear.

Methods

The cellular landscapes of non-diseased human cardiac valve leaflets (five aortic valves, five pulmonary valves, five tricuspid valves, and three mitral valves) from end-stage heart failure patients undergoing heart transplantation were explored using single-cell RNA sequencing (scRNA-seq). Bioinformatics was used to identify the cell types, describe the cell functions, and investigate cellular developmental trajectories and interactions. Differences among the four types of cardiac valve at the cellular level were summarized. Pathological staining was performed to validate the key findings of scRNA-seq. An integrative analysis of our single-cell data and published genome-wide association study-based and bulk RNA sequencing-based data provided insights into the cell-specific contributions to calcific aortic valve diseases.

Results

Six cell types were identified among 128,412 cells from non-diseased human cardiac valve leaflets. Valvular interstitial cells were the largest population, followed by myeloid cells, lymphocytes, valvular endothelial cells, mast cells, and myofibroblasts. The four types of cardiac valve had distinct cellular compositions. The intercellular communication analysis revealed that valvular interstitial cells were at the center of the communication network. The integrative analysis of our scRNA-seq data revealed key cellular subpopulations involved in the pathogenesis of calcific aortic valve diseases.

Conclusions

The cellular landscape differed among the four types of non-diseased cardiac valve, which might explain their differences in susceptibility to pathological remodeling and VHD.

Genome-wide identification and expression analysis of NAC family genes in Ginkgo biloba L

NAC (NAM, ATAF, CUC2) transcription factors constitute one of the largest families of plant-specific transcription factors with important roles in plant growth and development and in biotic and abiotic stresses. The physicochemical properties, gene structure, cis-acting elements and expression patterns of NAC transcription factors in Ginkgo biloba were analysed using bioinformatics, and expression of this gene family was analysed via quantitative reverse transcription PCR. The family of G. biloba NAC transcription factors had 50 members, distributed on 12 chromosomes and divided into 11 groups. Members in the same group share a similar gene structure and motif distribution. Transcriptome data analysis of G. biloba showed that 35 genes were expressed in eight tissues. Correlation analysis suggested that GbNAC007 and GNAC008 might be involved in flavonoid biosynthesis. Expression levels of 12 GbNACs under cold, het, and salt stresses were analysed. Results indicate that NAC transcription factors play an important role in response to abiotic stresses. This study provides a reference for the functional analysis of the G. biloba family of NAC transcription factors, as well as a resource for studies on the involvement of this family in responses to abiotic stresses and flavonoid biosynthesis.

Differences in phenotypes, symptoms, and survival in patients with cardiomyopathy-a prospective observational study from the Sahlgrenska CardioMyoPathy Centre

Introduction

Cardiomyopathy is the fourth most common cause of heart failure. The spectrum of cardiomyopathies may be impacted by changes in environmental factors and the prognosis may be influenced by modern treatment. The aim of this study is to create a prospective clinical cohort, the Sahlgrenska CardioMyoPathy Centre (SCMPC) study, and compare patients with cardiomyopathies in terms of phenotype, symptoms, and survival.

Methods

The SCMPC study was founded in 2018 by including patients with all types of suspected cardiomyopathies. This study included data on patient characteristics, background, family history, symptoms, diagnostic examinations, and treatment including heart transplantation and mechanical circulatory support (MCS). Patients were categorized by the type of cardiomyopathy on the basis of the diagnostic criteria laid down by the European Society of Cardiology (ESC) working group on myocardial and pericardial diseases. The primary outcomes were death, heart transplantation, or MCS, analyzed by Kaplan-Meier and Cox proportional regression, adjusted for age, gender, LVEF and QRS width on ECG in milliseconds.

Results

In all, 461 patients and 73.1% men with a mean age of 53.6 ± 16 years were included in the study. The most common diagnosis was dilated cardiomyopathy (DCM), followed by cardiac sarcoidosis and myocarditis. Dyspnea was the most common initial symptom in patients with DCM and amyloidosis, while patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) presented with ventricular arrythmias. Patients with ARVC, left-ventricular non-compaction cardiomyopathy (LVNC), hypertrophic cardiomyopathy (HCM), and DCM had the longest time from the debut of symptoms until inclusion in the study. Overall, 86% of the patients survived without heart transplantation or MCS after 2.5 years. The primary outcome differed among the cardiomyopathies, where the worst prognosis was reported for ARVC, LVNC, and cardiac amyloidosis. In a Cox regression analysis, it was found that ARVC and LVNC were independently associated with an increased risk of death, heart transplantation, or MCS compared with DCM. Further, female gender, a lower LVEF, and a wider QRS width were associated with an increased risk of the primary outcome.

Conclusions

The SCMPC database offers a unique opportunity to explore the spectrum of cardiomyopathies over time. There is a large difference in characteristics and symptoms at debut and a remarkable difference in outcome, where the worst prognosis was reported for ARVC, LVNC, and cardiac amyloidosis.

[A deep-learning model for the assessment of coronary heart disease and related risk factors via the evaluation of retinal fundus photographs]

Objective: To develop and validate a deep learning model based on fundus photos for the identification of coronary heart disease (CHD) and associated risk factors. Methods: Subjects aged>18 years with complete clinical examination data from 149 hospitals and medical examination centers in China were included in this retrospective study. Two radiologists, who were not aware of the study design, independently evaluated the coronary angiography images of each subject to make CHD diagnosis. A deep learning model using convolutional neural networks (CNN) was used to label the fundus images according to the presence or absence of CHD, and the model was proportionally divided into training and test sets for model training. The prediction performance of the model was evaluated in the test set using monocular and binocular fundus images respectively. Prediction efficacy of the algorithm for cardiovascular risk factors (e.g., age, systolic blood pressure, gender) and coronary events were evaluated by regression analysis using the area under the receiver operating characteristic curve (AUC) and R² correlation coefficient. Results: The study retrospectively collected 51 765 fundus images from 25 222 subjects, including 10 255 patients with CHD, and there were 14 419 male subjects in this cohort. Of these, 46 603 fundus images from 22 701 subjects were included in the training set and 5 162 fundus images from 2 521 subjects were included in the test set. In the test set, the deep learning model could accurately predict patients' age with an R² value of 0.931 (95%CI 0.929-0.933) for monocular photos and 0.938 (95%CI 0.936-0.940) for binocular photos. The AUC values for sex identification from single eye and binocular retinal fundus images were 0.983 (95%CI 0.982-0.984) and 0.988 (95%CI 0.987-0.989), respectively. The AUC value of the model was 0.876 (95%CI 0.874-0.877) with either monocular fundus photographs and AUC value was 0.885 (95%CI 0.884-0.888) with binocular fundus photographs to predict CHD, the sensitivity of the model was 0.894 and specificity was 0.755 with accuracy of 0.714 using binocular fundus photographs for the prediction of CHD. Conclusion: The deep learning model based on fundus photographs performs well in identifying coronary heart disease and assessing related risk factors such as age and sex.

Sex-related differences in long-term outcome of heart failure in low-risk patients with atrial fibrillation. A Swedish registry case-control study

Background

Knowledge about sex-related differences regarding long-term risk of heart failure (HF) among patients with atrial fibrillation (AF) is limited.

Aim

To evaluate the impact of sex on risks for new onset HF in patients with AF.

Methods

All patients from the Swedish National Patient Register, with a first-time diagnosis of AF between 1987 and 2018 were identified and compared with two matched controls without AF from the Total Population Register. Patients &lt;18 years, or any previous cardiovascular disease, diabetes mellitus and renal failure at the baseline were excluded.

Results

In total 227,811 patients and 452,712 controls were included; 44.5% were women. The mean age (SD) for men was 65.5 (15) vs. 72.7 (13) in women (p&lt;0.0001). The incidence rate for HF onset per 1000 person-years within one and five years after AF diagnosis was 77.3 (75.5–79.1) and 45.0 (44.3–45.7) in women vs. 66.5 (65.0–68.0) and 35.3 (34.8–35.9) in men, respectively. The incidence rate for HF onset increased with age in both patients with AF and controls, but was generally more pronounced in women. Women had 26% and 34% higher risk for HF onset, within five and thirty years, respectively. The highest risk for HF onset was found in women 18–34 years and 35–49 years of age, HR 24.64 (95%, confidence interval (CI) 7.59–80.0) and 8.09 (95%, CI 6.34–10.33) vs. 9.86 (95%, CI 6.81–14.27) and 6.52 (95%, CI 5.87–7.25) in equally old men. The mortality rate after HF was 42.3% and 33.1% in women and men with AF (p&lt;0.0001).

Conclusion

In this nationwide, register-based cohort study, when compared to matched controls we found that the risk for HF onset was higher in women with AF, particularly in reproductive age, highlighting great importance of further research for prevention of HF in young women with AF but without any other cardiovascular risk factors.

Funding Acknowledgement

Type of funding sources: None.

[The relationship between peripheral blood mitochondrial DNA copy number and incident risk of liver cancer: a case-cohort study]

Objective: To investigate the association between peripheral blood mitochondrial DNA copy number (mtDNAcn) and incident risk of liver cancer. Methods: At the baseline of Dongfeng-Tongji (DFTJ) cohort, 27 009 retirees were recruited from Dongfeng Motor Corporation in 2008. After excluding people without baseline DNA, with current malignant tumor and loss of follow-up, 1 173 participants were randomly selected into a sub-cohort by age-and gender-stratified sampling method at a proportion of 5% among all retirees. A total of 154 incident liver cancer cases identified from the cohort before December 31, 2018 (4 cases had been selected into the sub-cohort) were selected to form the case cohort of liver cancer. For the above 1 323 participants, their baseline levels of mtDNAcn in peripheral blood cells were measured by using quantitative real-time PCR method. The restricted cubic spline analysis was used to fit the shape of the association between baseline mtDNAcn and incident risk of liver cancer. The weighted Cox proportional hazards model was used to estimate the hazard ratio (HR) and 95%CI. Results: In this case-cohort study, the median follow-up time was 10.3 years. The restricted cubic spline analysis indicated that the relationship between peripheral blood mtDNAcn and incident risk of liver cancer followed a U-shaped pattern (P_non-linear<0.05). All case-cohort population were divided into four subgroups by sex-specific quartiles of mtDNAcn levels among sub-cohort participants, when compared to participants in the Q₂ subgroup of mtDNAcn, those in the Q₁ subgroup (HR=2.00,95%CI:1.08-3.70) and Q₄ subgroup (HR=4.11,95%CI:2.32-7.26) both had a significantly elevated risk of liver cancer, while those in the Q₃ subgroup (HR=1.05,95%CI:0.54-2.05) had not. There were no significant multiply interaction effects of aging, gender, tobacco smoking, alcohol drinking and history of chronic hepatitis on the above association (P_interaction>0.05). Conclusion: Both extremely low and high baseline level of mtDNAcn in peripheral blood cells are associated with an increased risk of incident liver cancer, but the underlying mechanisms need to be further clarified.

Sex-related differences among young adults with heart failure in Sweden

BACKGROUND

Differences between the sexes among the non-elderly with heart failure (HF) have been insufficiently evaluated. This study aims to investigate sex-related differences in early-onset HF.

METHODS

Patients aged 18 to 54 years who were registered from 2003 to 2014 in the Swedish Heart Failure Register were included. Each patient was matched with two controls from the Swedish Total Population Register. Data on comorbidities and outcomes were obtained through the National Patient Register and Cause of Death Register.

RESULTS

We identified 3752 patients and 7425 controls. Of the patients, 971 (25.9%) were women and 2781 (74.1%) were men with a mean (standard deviation) age of 44.9 (8.4) and 46.4 (7.3) years, respectively. Men had more hypertension and ischemic heart disease, whereas women had more congenital heart disease and obesity. During the median follow-up of 4.87 years, 26.5 and 24.7 per 1000 person-years male and female patients died, compared with 3.61 and 2.01 per 1000 person-years male and female controls, respectively. The adjusted hazard ratios for all-cause mortality, compared with controls, were 4.77 (3.78-6.01) in men and 7.84 (4.85-12.7) in women (p for sex difference = 0.11). When HF was diagnosed at 30, 35, 40, and 45 years, women and men lost up to 24.6 and 24.2, 24.4 and 20.9, 20.5 and 18.3, and 20.7 and 16.5 years of life, respectively.

CONCLUSION

Long-term mortality was similar between the sexes. Women lost more years of life than men.

Aetiology of tinea capitis in China: A multicentre prospective study

BACKGROUND

Tinea capitis is still common in developing countries, such as China. Its pathogen spectrum varies across regions and changes over time.

OBJECTIVES

This study aimed to clarify the current epidemiological characteristics and pathogen spectrum of tinea capitis in China.

METHODS

A multicentre, prospective descriptive study involving 29 tertiary hospitals in China was conducted. From August 2019 to July 2020, 611 patients with tinea capitis were enrolled. Data concerning demography, risk factors and fungal tests were collected. The pathogens were further identified by morphology or molecular sequencing when necessary in the central laboratory.

RESULTS

Among all enrolled patients, 74.1% of the cases were 2- to 8-year-olds. The children with tinea capitis were mainly boys (56.2%) and more likely to have an animal contact history (57.4% vs. 35.3%, P = 0.012) and zoophilic dermatophyte infection (73.5%). The adults were mainly females (83.3%) and more likely to have anthropophilic agent infection (53.5%). The most common pathogen was zoophilic Microsporum canis (354, 65.2%), followed by anthropophilic Trichophyton violaceum (74, 13.6%). In contrast to the eastern, western and northeastern regions where zoophilic M. canis predominated, anthropophilic T. violaceum predominated in central China (69.2%, P < 0.0001), where the patients had the most tinea at other sites (20.3%) and dermatophytosis contact (25.9%) with the least animal contact (38.8%). Microsporum ferrugineum was the most common anthropophilic agent in the western area, especially in Xinjiang Province.

CONCLUSIONS

Boys aged approximately 5 years were mainly affected. Dermatologists are advised to pay more attention to the different transmission routes and pathogen spectra in different age groups from different regions.

Underlying causes of under-utilization of cardiac resynchronization therapy in real-world heart failure settings

Background

Despite well-established effectiveness of cardiac resynchronization therapy (CRT) in patients with heart failure (HF), it remained significantly under-utilized. The underlying causes are still not well described.

Aim

To investigate how many patients with HF were eligible for CRT and determine underlying causes why CRT was abstained for these patients in real life settings.

Methods

Retrospective review of medical data was carried out in all patients hospitalized for newly diagnosed HF from January 1, 2016 to December 31, 2019. Patients were identified from the local university hospital register with three afiliations by use of international classification of disease (ICD)-10 codes I50.0-I50.9. Medical journals, including electrocardiograms and echocardiograms, were reviewed. The indication for CRT was evaluated three months after mineralocorticoid receptor antagonists (MRA) were initiated as addition to angiotensin converting enzyme inhibitor /angiotensin-receptor blockers and beta-blocker treatment according to European guidelines for heart failure from 2016. Follow-up was minimum one year and up to two years after HF diagnosis.

Results

In 3456 patients with HF, 642 (18.6%) were patients hospitalized for new onset of HF with ejection fraction (EF) &lt;40%. Out of those, 104 (16.2%) patients were excluded because of incomplete medical record as a result of referral to primary care. Finally, 538 were included in this study. Overall, 163 patients (30.3%) met CRT criteria with 22.5%, 2.6%, 1.9% complying with recommendation IA, IIA, IIB respectively, and 3.9% had more than 50% right ventricular pacing. Only 52 (9.7%) of patients received CRT with mean age 69.3±11.5 years, and 69.2% men and EF 31.9% ± 7.6. In all these patients with HF eligible for CRT, no difference was found in baseline data including hypertension, ischemic heart disease, atrial fibrillation, valvular heart disease, diabetes mellitus, stroke, cancer and renal failure nor medical treatment between those received CRT and those without CRT. Among underlying causes of under-utilization of CRT, 24.3% were due to multiple concomitant comorbidities, 4.5% due to patient's own wish, 12.5% due to other reasons such as socioeconomic problems and 58.6% with unknown reasons. Mortality rates were 20.7% in patients without treatment with CRT compared with 7.7% in those who received CRT (p=0.037).

Conclusion

In this real world HF cohort, 1/3 patients were eligible for CRT treatment. However only 1/3 received CRT and 58.6% had no contraindication but did not receive CRT, which emphasize urgent need for structured implementation methods for device treatment in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Heart failure in low risk patients with atrial fibrillation, nationwide registry case-control study based on 227811 patients

Background

Heart failure (HF) is common in patients with atrial fibrillation (AF), and also associated with worse outcome. Consequently, it is commonly included in risk prediction models for AF, used in daily clinical praxis. However, knowledge about the association between solely AF and incidental HF is limited.

Aim

This study aims to evaluate the short and long-term risks for onset of HF in patients with AF and low cardiovascular risk profile.

Methods

All patients with first recorded hospitalization for AF in the Swedish National Patient Register, were included from the 1St January 1987 to 31st December 2018. Each patient with AF was matched by age, sex and county with two controls from the Swedish Total Population Register. Patients &lt;18 years, or with concomitant hypertension, diabetes mellitus, coronary and periphery artery disease, previous stroke or transitory ischemic attack, cardiomyopathy, pulmonary arterial hypertension, congenital heart disease, valvular heart disease and renal failure prior or at baseline were excluded.

Results

In total 227 811 patients and 452 712 controls met the inclusion and exclusion criteria and were included in the study. The incidence rate for incidental HF per 1000 person-year within one year after AF diagnosis was 6.2 (95% CI: 4.5–8.6) among patient 18–34, increased with increasing age and was 142.8 (95% CI: 139.4–146.3) among those &gt;80 years. Within five years the incidence rate decreased in all age categories and was 2.4 (95% CI: 1.8–3.0) among the youngest and 94.0 (95% CI: 92.4–95.6) in the oldest age group. When compared to matched controls from the general population patients with AF had a hazard ratio (HR) and CI 95% to develop HF within one year at 103.9 (46.3–233.1), 34.9 (26.5–45.9), 17.5 (15.5–19.8), 10.3 (9.6–11.1) and 6.1 (5.8–6.4) among patients aged 18–34, 35–49, 50–59, 60–69, 70–79 and &gt;80 years, respectively.

Conclusion

Despite low cardiovascular risk profile AF still carries high risk for developing incidental HF in particular during the first observation year with increasing tendency along with increasing age. Younger patients with AF and without other cardiovascular comorbidities had more than 100 times higher relative risk to develop HF within one year when compared to matched controls.

Funding Acknowledgement

Type of funding sources: None.

Hyperkalemia as a cause of undertreatment with mineralcorticoid receptor antagonists for patients with newly onset of heart failure with reduced ejection fraction

Background

Despite beneficial effects on mortality and morbidity the use of mineralocorticoid receptor antagonists (MRA) in patients with reduced ejection fraction (&lt;40%) (HFrEF) remains poor. Hyperkalemia is assumed as an important cause, but the reported incidence is low and varies hugely. Thus, available data of magnitude of hyperkalemia in real life settings are insufficient to explain why under-utilization of MRA occurred.

Aim

To determine the incidence and magnitude of documented hyperkalemia and potential risk of hyperkalemia in patients with HFrEF in a real-world HF population.

Methods

Patients aged 18–85 years at the time of the baseline, hospitalized for newly onset of HFrEF between

2016–01–01 and 2019–12–31, were identified retrospectively and consecutively from hospital discharge records, by use of international classification of disease (ICD)-10 codes I50.0-I50.9 as principal diagnosis. Potential higher risk of hyperkalemia was based on an overall assessment of current potassium level, presence of diabetes mellitus and eGFR &lt;30 ml/min at patient level.

Results

In total, 3456 patients with HF were identified, 642 (18.6%) were eligible, hospitalized for newly onset of HFrEF (66.8±12.7 years, 68.4% men and EF 29.4% ±6.8%). After six months 336 (52.3%) did not have MRA of which 279 (83%) never received MRAs and 57 (17%) had MRAs discontinued. Among patients on MRA treatment, 306 (14.4%) needed dose reduction. Occurrence of hypertension, ischemic heart disease, diabetes mellitus and renal dysfunction at baseline did not differ between groups with or without MRA. The incidence and magnitude of documented and potentially higher risk of hyperkalemia were assessed both at baseline and as highest potassium within six months after established diagnosis. Among patients without MRA after six months, at baseline only 3 (0.9%) patients had documented S/P-K ≥6 mmol/L, 7 (2.1%) patients had S/P-K 5.5–5.9 mmol/L and 26 (7.7%) patients had S/P-K 4.8–5.4 mmol/L. Moreover, 12.4% had potentially high risk of hyperkalemia at baseline. During the six-month follow up after initiation of HF therapy, 15 (4.5%) patients had documented hyperkalemia with S/P-K ≥6 mmol/L,

23 (6.8%) patients had S/P-K 5.4–5.9 mmol/L, and 123 (36.6%) patients had S/P-K 4.8–5.4 mmol/L during at least one occasion. Besides, 13.4% had potentially high risk of hyperkalemia. Hyperkalemia occurred frequently

(40.4% vs 36.4%) in patients with discontinuation and dose reduction of MRA. Figure 1 presents the distribution of patients with risk of or documented hyperkalemia in the group without MRA.

Conclusions

Hyperkalemia was the most common cause for both discontinuation and dose reduction of MRA. Hyperkalemia was also increased significantly from baseline and during subsequent up-titration, with 4.6-fold increased risk for borderline hyperkalemia (S/P-K 4.8–5.4). This might explain why physicians refrain from prescribing MRAs to patients with HFrEF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Vifor Pharma

The impact of time-updated resting heart rate on cause-specific mortality in a random middle-aged male population: a lifetime follow-up

Background

High resting heart rate (RHR) is associated with increased adverse events. However, the long-term prognostic value in a general population is unclear. We aimed at investigating the impact of RHR, based on baseline as well as time-updated, on mortality in a middle-aged men cohort.

Methods

A random population sample of 852 men, all born in 1913 was followed from age 50 until age 98 with repeated examinations including RHR during 48 years. The impact of baseline and time-updated RHR on cause-specific mortality was assessed using Cox proportional hazards models and cubic spline models.

Results

Baseline RHR ≥90 beats per minute (bpm) was associated with higher all-cause mortality as compared to RHR 60–70 bpm (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.17–2.19, P=0.003), but not with cardiovascular (CV) mortality. A time-updated RHR &lt;60 bpm (HR 1.41, 95% CI 1.07–1.85, P=0.014) and a time-updated RHR of 70–80 bpm (HR 1.34, 95% CI 1.02–1.75, P=0.036) were both associated with higher CV mortality as compared with the RHR of 60–70 bpm after multivariable adjustment. Analyses using cubic spline models confirmed that the association of time-updated RHR with all-cause and CV mortality complied with a U-shaped curve with 60 bpm as a reference.

Conclusions

In this middle-aged men cohort, a time-updated RHR at 60–70 bpm was associated with lowest CV mortality, suggesting that time-updated RHR could be a useful long-term prognostic index in the general population.

RHR and Mortality

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): In recent years, funding has been received from the Swedish state under the agreement between the Swedish government and the county councils relating to the economic support of research and education under the ALF agreement (ALFGBG-721351).

Trends in outcome and patient composition in dilated cardiomyopathy in Sweden over time

Background

We studied prognosis and patient composition over time in dilated cardiomyopathy (DCM): a well-defined category of heart failure (HF), often affecting younger individuals. We expected improved prognosis over time, due to emerging diagnostic and therapeutic options.

Methods

All patients from the Swedish Heart Failure Registry (SwedeHF) fulfilling criteria for DCM (exclusion of ischemic, valvular, or alcoholic etiology and affirmed by clinical judgment in the protocol) (n=3739), were analyzed with respect to three time periods of inclusion in the registry, 2003–2007 (n=814), 2008–2011 (n=1448), 2012–2016 (n=1477), regarding mortality, transplantations, and hospital admissions during one year after inclusion.

Results

Over the three time periods, registered cohorts were older with time (mean 59.3 years/ 60 years/ 61.0 years, p=0.0035), and the proportion of females incresased (24.1% / 27.2% / 30.7%, p=0.0006).

For clinical variables, the distribution of left ventricular ejection fraction (LVEF) with time showed significantly higher LVEF (p=0.0024), and functional classification (NYHA) showed lower class (p=0.0011). Hypertension as a comorbidity (i.e. not judged to be responsible for HF) was more frequently occurring with time: (34.0%/ 40.6%/ 44.1%, p&lt;0.0001). As for HF treatment: use of device increased (p&lt;0.0001 for categorical combinations), mineralocorticoid receptor antagonists (MRA) increased (41.9%/ 37.3%/ 46.7%, p=0.0023), and diuretics dropped (76.1%/ 71.1%/ 67.0%, p≤0.0001) in the different cohorts with time.

Mortality (6.9%, 5.1%, 5.5%), transplantation (0.5%, 0.8%, 0.6%) and hospital admissions for HF (28.4%, 26.3%, 24.6%) were stable over time (ns for all), whereas cardiovascular (CV) (33.8%, 33.8%, 29.7%, p=0.043) and all cause admissions (39.1%, 38.8%, 33.7%, p=0.0099) decreased. After adjustment for age, sex, LVEF, NYHA, hypertension and device treatment only all cause admissions remained significantly decreased.

Conclusion

In this nationwide study between 2003–2016, one-year outcome in DCM in Sweden remained stationary over time, despite advances in HF therapy. During the time period, we observed a continuous change in the clinical profile in the DCM population.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Region Västra Götaland agreement concerning research and education of physicians.

Lifelong cumulative incidence of acquired aortic stenosis and its predictors in a large middle-aged men population followed up to 42 years

Background

Acquired aortic stenosis (AS) is the most common valvular disorder that rises exponentially with age; it has high mortality after symptoms appear. Factors that predict the development of AS are still unknown. Some studies imply that the atherosclerotic factors are involved in the development of AS, but the findings have been heterogeneous.

Purpose

To estimate lifelong cumulative incidence of AS and analyse its predictors.

Methods

We included a random sample of men, born 1915–1925 in Gothenburg, Sweden, and examined them in 1970–1973 (participation rate 75%). They were between 47 and 55 years in the beginning and 57–65 years when the examination-period ended. Out of 7493 men 57 were excluded due to myocardial infarction prior to baseline; 7436 were thus followed from the inclusion date until a discharge diagnosis of AS or death, with a maximum follow up time of 42 years and mean follow-up time 26.8 years. Men with AS were identified from the Swedish National Patient Register and those who died from the Swedish Cause of Death Register. We used machine learning to identify the most important factors that predict AS. For these factors, we then estimated hazard ratios for the risk to acquire AS through Cox proportional hazards model.

Results

The lifelong cumulative incidence to acquire AS was 2.66% (198 out of 7436 individuals). For men with measurements approximately at the quartiles of the pulse pressure distribution, more specifically 44, 52, 62 mm Hg, the estimated cumulative risk were 1.97%, 2.74% and 3.07% respectively. For the body mass index (BMI) we had accordingly for measurements around 23, 25 and 27 kg/m2 estimated cumulative risk 2.52%, 2.80%, 2.79% respectively. For cholesterol values of 5, 6 and 7 mmol/l (approximately at quartile divisions) the estimated cumulative risk was 1.77%, 1.79% and 3.20% respectively. The estimated cumulative risks for the younger, with age around 47 and the older participants, with age around 55 were 1.76% and 2.68 respectively. Men with family history of infarction in a sibling had an estimated cumulative risk at 4.66% level whereas those with not at 2.51%.

The factors that were significantly associated with the development of AS in the Cox proportional model are: cholesterol level (HR=1.24, CI 95% 1.11–1.39, p=0.0001), pulse pressure (HR=1.01, CI 95% 1.01–1.02, p=0.0037), BMI (HR=1.06, CI 95% 1.02–1.11, p=0.0089), age (HR=1.11, CI 95% 1.04–1.19, p=0.0010) and family history of myocardial infarction in a sibling (HR=2.38, CI 95% 1.50–3.79, p=0.0002).

Conclusion

Lifelong cumulative incidence of acquired AS is approximately 2.7%. Multiple factors known also to be associated with arteriosclerosis were identified to increase the life-long risk of developing AS.

Funding Acknowledgement

Type of funding source: None

Trends in cause-specific readmissions in heart failure with preserved versus reduced and mid-range ejection fraction

Background

It remains unclear whether the readmission of heart failure (HF) patients has decreased over time and how it differs among HF with preserved ejection fraction (EF) (HFpEF) versus reduced EF (HFrEF) and mid-range EF (HFmrEF).

Methods

We evaluated HF patients index hospitalized from January 2004 to December 2011 in the Swedish Heart Failure Registry with 1-year follow-up. Outcome measures were the first occurring all-cause, cardiovascular (CV) and HF readmissions.

Results

Totally 20,877 HF patients (11,064 HFrEF, 4,215 HFmrEF, 5,562 HFpEF) were included in the study. All-cause readmission was highest in patients with HFpEF, whereas CV and HF readmissions were highest in HFrEF. From 2004 to 2011, HF readmission rates within 6 months (from 22.3% to 17.3%, P=0.003) and 1 year (from 27.7% to 23.4%, P=0.019) in HFpEF declined, and the risk for 1-year HF readmission in HFpEF was reduced by 7% after adjusting for age and sex (P=0.022). Likewise, risk factors for HF readmission in HFpEF changed. However, no significant changes in cause-specific readmissions were observed in HFrEF. Time to the first readmission did not change significantly from 2004 to 2011, regardless of EF subgroup (all P-values&gt;0.05).

Conclusions

Although the burden of all-cause readmission remained highest in HFpEF versus HFrEF and HFmrEF, a declining temporal trend in 6-month and 1-year HF readmission rates was found in patients with HFpEF, suggesting that non-HF-related readmission represents a big challenge for clinical practice.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The SwedeHF was funded by the Swedish National Board of Health and Welfare, the Swedish Association of Local Authorities and Regions.