Prognostic role of diagnostic criteria of acute myocardial infarction

Background

The term acute myocardial infarction (AMI) reflects cell death of cardiac myocytes caused by ischaemia. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined AMI by a typical rise and fall in the level of biochemical markers of myocardial necrosis together with criteria of myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI.

Methods

We enrolled all consecutive patients with AMI admitted from 2016 to 2019. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new LBBB); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, in our study evaluated by transthoracic echocardiogram. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and its association were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events.

Results

2386 patients were evaluated. The median follow-up time was 23.3±14.5 months. The total number of events was 703 (29.3%). Kaplan-Meier curves showed that major adverse cardiac events (MACE) were statistically different depending on the diagnostic criteria of AMI at admission. Particularly, clinical criteria alone showed a better predictive value (p<0.001) than other diagnostic AMI criteria. Multivariable Cox-regression model demonstrated that clinical criteria was the independent predictor of good prognosis in patients with AMI (HR=0.43; CI 95% 0.28–0.67; p<0.001). Conversely, the others diagnostic criteria (electrocardiographic and echocardiographic) and the combination of all diagnostic criteria were not independent prognostic factors of MACE (HR=1.1 CI 95% 0.6–2.4, p=0.6; HR=1.1 CI 95% 0.7–1.2, p=0.6; HR=0.9 CI 95% 0.7–1.0, p=0.8 respectively).

Conclusions

Our data suggest that the prognosis is considerably better among patients with a diagnosis of AMI if clinical criteria alone are present at admission. We also demonstrated that clinical criteria are a strong prognostic predictor of good outcomes in patients with AMI. We hypothesize that the absence of electrocardiographic and echocardiographic alterations could indirectly indicate a smaller infarct sizes that contribute to patients' outcome.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): None

Worsening renal function as an outcome predictor in patients with new onset atrial fibrillation on direct oral anticoagulant

Background

In patients with atrial fibrillation (AF), baseline kidney function is used to guide oral anticoagulant (OA) selection and dosing, and chronic kidney disease (CKD) is a significant outcome predictor. However, the incidence of worsening renal function (WRF) and its prognostic role during treatment with direct oral anticoagulants (DOACS) has been poorly explored.

Purpose

To assess the prognostic role of WRF in terms of bleedings and major adverse cardiovascular events (MACEs) in a cohort of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs.

Methods

Between January 2017 and March 2019, we enrolled all the patients with newly diagnosed NVAF and OA indication, treated with DOACs. Renal function was assessed using the mean value of the estimated glomerular filtration rates (eGFR) calculated using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. CHA2DS2-VASc and HAS-BLED scores were used at baseline to estimate the ischemic and hemorrhagic risk, respectively. At follow-up, WRF was identified as a decrease in eGFR of at least 20% while bleedings were classified according to the international society of thrombosis and hemostasis (ISTH) criteria. Finally, we defined AF progression as the transition from paroxysmal to persistent or permanent AF or from persistent to permanent AF.

Results

1009 patients with newly diagnosed NVAF started on DOAC were enrolled. They were followed-up for 21.6±9.5 months. Overall, WRF was observed in 181 cases (18%). Patients with WRF had higher rates of progression of atrial fibrillation (18.5% vs 11.8%, p=0.02), MACEs (20.4% vs 12.9%, p=0.09) and major bleedings (MB) (9,4% vs 4,7%, p=0.013). WRF did not correlate with all bleedings, stroke, or acute coronary syndrome (ACS). However, those who presented WRF using CKD-EPI formula had higher ACS incidence (6.1% vs 2.5%, p=0.015), and generally better-predicted MACEs. At multivariate analysis adjusted for age, hypertension, baseline HAS-BLED score and WRF, the latter emerged as an independent predictor of MB (OR 1.9 95% C.I, 1,059–3,51).

Conclusion

In patients with newly diagnosed NVAF treated with DOACs, WRF is associated with atrial fibrillation progression and MACEs, and emerged as an independent predictor of major bleedings. WRF evaluated with CKD-EPI formula better predicted MACEs.

Funding Acknowledgement

Type of funding sources: None.

Commercial Mannoproteins Improve the Mouthfeel and Colour of Wines Obtained by Excessive Tannin Extraction

In the production of red wines, the pressing of marcs and extended maceration techniques can increase the extraction of phenolic compounds, often imparting high bitterness and astringency to finished wines. Among various oenological products, mannoproteins have been shown to improve the mouthfeel of red wines. In this work, extended maceration (E), marc-pressed (P), and free-run (F) Sangiovese wines were aged for six months in contact with three different commercial mannoprotein-rich yeast extracts (MP, MS, and MF) at a concentration of 20 g/hL. Phenolic compounds were measured in treated and control wines, and sensory characteristics related to the astringency, aroma, and colour of the wines were studied. A multivariate analysis revealed that mannoproteins had a different effect depending on the anthocyanin/tannin (A/T) ratio of the wine. When tannins are strongly present (extended maceration wines with A/T = 0.2), the MP conferred mouthcoating and soft and velvety sensations, as well as colour stability to the wine. At A/T = 0.3, as in marc-pressed wines, both MF and MP improved the mouthfeel and colour of Sangiovese. However, in free-run wine, where the A/T ratio is 0.5, the formation of polymeric pigments was allowed by all treatments and correlated with silk, velvet, and mouthcoat subqualities. A decrease in bitterness was also obtained. Commercial mannoproteins may represent a way to improve the mouthfeel and colour of very tannic wines.

Left ventricular ejection fraction as an imaging biomarker to guide cardiac resynchronisation therapy in heart failure patients: a multimodal comparison of 2D and 3D echocardiography and CMR

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The authors acknowledge financial support from the Department of Health through the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust and by the NIHR MedTech Co-operative for Cardiovascular Disease at Guy’s and St Thomas’ NHS Foundation Trust. This work was supported by the Wellcome/EPSRC Centre for Medical Engineering [WT 203148/Z/16/Z]. MSN was funded by a clinical lectureship awarded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the DoH, EPSRC, MRC or the Wellcome Trust.

Introduction – Imaging derived left ventricular ejection fraction (LVEF) has an important role to guide initiation of medical therapy and device insertion in patients with heart failure and reduced ejection fraction (HFrEF). Previous studies have reported the correlation and agreement of LVEF in various patient populations, but sparse evidence exists on patients with heart failure referred for Cardiac Resynchronisation Therapy (CRT) using 2D and 3D echocardiography (2DE & 3DE) and cardiovascular magnetic resonance (CMR).

Objectives – To determine the correlation and agreement of LVEF as determined by 2DE, 3DE and CMR in a cohort of HF patients referred for assessment of CRT.

Methods – Patients with suspected HFrEF referred for assessment for CRT therapy were included in this single centre study. Patients underwent 2DE, 3DE and CMR to derive LVEF, LVESV and LVEDV. Correlation was determined with Pearson’s correlation, agreement with Bland-Altman analysis and Cohen’s kappa analysis for agreement using a dichotomous cut off of LVEF ≤35% as a threshold for CRT insertion (Ponikowski, 2016).

Results - 55 patients (mean age 71 ± 9.2, 76% male) were included. The mean LVEF for 2DE, 3DE, CMR and were 32.4 ± 8.6, 32.1 ± 9.6 and 30.3 ± 9.5 respectively. CMR had a significantly lower LVEF compared to 2DE (p = 0.03).

There was good correlation between 3DE & CMR and 2DE & CMR, and excellent correlation between 3DE and 2DE for LVEF (Table 1). There was for trend for CMR to underestimate LVEF compared to 2DE and 3DE, with small biases although wide limits of agreement (Figure 1). There was excellent correlation of LVEDV and LVESV across all 3 techniques. CMR underestimated volumes compared to 2DE and 3DE with large biases and wide LOA.

The kappa coefficient agreement at threshold level for CRT insertion (LVEF ≤35%) was fair for 3DE and CMR (0.379, p = 0.004) and 2DE and CMR (0.462, p = 0.001), and moderate for 3DE and 2DE (0.575, p ≤ 0.001).

Conclusion – Whilst LVEF is not the only indicator to guide CRT insertion, it remains an important imaging parameter for clinical decision making. We observed large biases in left ventricular volumes between 2D, 3D and CMR. However, whilst the overall bias in LVEF is small, the wide limits of agreement (LOA) observed may represent an area of clinical uncertainty, which may impact on the dichotomous imaging threshold for CRT insertion.

Comparison of indices between modalities LVEF Correlation (r) LVEF Bias & LOA (%±SD) EDV Correlation (r) EDV Bias & LOA (mL ± SD) ESV Correlation (r) ESV Bias & LOA (mL ± SD) 3DE vs CMR 0.676 (p < 0.001) +1.75 ± 15.4 0.896 (p < 0.001) -82.16 ± 42.8 0.937 (p < 0.001) -61.3 ± 34.9 3DE vs 2DE 0.872 (p < 0.001) +0.48 ± 4.5 0.909 (p < 0.001) -10.31 ± 28.3 0.936 (p < 0.001) -8.42 ± 20.5 2DE vs CMR 0.675 (p < 0.001) +2.35 ± 14.6 0.876 (p < 0.001) -67.35 ± 36.3 0.898 (p < 0.001) -51.42 ± 30.1 Abstract Figure. Bland-Altman Plot LVEF by 3DE & CMR

Application of RNA-sequencing to identify biomarkers in broiler chickens prophylactic administered with antimicrobial agents

Antimicrobial (AM) resistance is largely acknowledged as one of the biggest global health and food safety challenges and the overuse of AMs is known to generate resistance in bacteria that may affect both animals and humans. Poultry meat is the second most-produced meat in the European Union and in recent years consumers are becoming more concerned about food safety, traceability, and animal welfare in poultry rearing system, increasingly requiring meats from broilers reared without AMs. In the present study, we performed RNA sequencing to analyze 64 liver and 54 muscle transcriptomic profiles in broilers reared without treatment or treated with different classes of AMs. Moreover, we validated the most differentially expressed genes among the treated groups to detect putative novel biomarkers able to discriminate meats of broilers reared without AMs. The PDK4, IGFBP1, and RHOB genes were identified as putative novel hepatic biomarkers, discriminating broilers treated with AMs compared to broilers reared without treatments. The whole transcriptome changes revealed the liver as a valuable target organ for AM administration screening. In addition, our results suggest a leading effect of the coccidiostat when associated with AMs, influencing several biological processes. Our study showed that RNA sequencing is a powerful and valuable method to detect aberrant regulated genes and to identify biomarker candidates for AM misuse detection in farm animals. Further validation on larger sample size and a wider spectrum of AMs are needed to confirm the viability of the aforementioned biomarkers in poultry population.

Admission blood glucose level as an ischemic stroke risk modifier in patients with new-onset non-valvular atrial fibrillation

Background

Several scores have been proposed to assess the stroke risk in patients with non-valvular atrial fibrillation (NVAF). However, type 2 diabetes mellitus (T2DM) is considered a major stroke risk factor regardless of glycemic control. Whether basal blood glucose level modifies the risk of stroke in NVAF is still unclear.

Purpose

To evaluate the risk of ischemic stroke according to the presence of T2DM and admission blood glucose (ABG) level in patients with new-onset NVAF starting direct oral anticoagulants (DOACs).

Methods

We analyzed all consecutive patients with NVAF at our outpatient clinic from January to December 2018. The study population was constituted by 1014 patients with new-onset NVAF starting DOACs. Baseline characteristics were evaluated in the overall cohort whereas outcomes were assessed for 915 patients. The median follow-up time was 19.6±12.9 months.

Results

Overall, 50.3% were male with a mean age of 73.9±12.5 years. Diabetic NVAF patients were more frequently male (p=0.04) with higher prevalence of dyslipidemia (p<0.001), hypertension (p<0.001), severe renal impairment (p=0.02), peripheral vasculopathy (p=0.007) and history of myocardial infarction (p<0.001) compared to non-diabetic NVAF. Conversely, no differences were observed between subgroups in terms of age (p=0.8). Baseline blood glucose level was significantly higher in the diabetic NVAF population (160±67 mg/dL vs 119±39 mg/dL; p<0.001). As expected, the mean CHA2DS2-VASc score was significantly higher in diabetic NVAF compared to non-diabetic group (4.7±1.4 vs 3.2±1.5; p<0.001).

During a 2 year-follow up period, we collected 27 (3.0%) ischemic stroke. As expected, the rates of stroke were significantly higher in diabetic NVAF (7.6% vs 2.3%, p<0.001). Also, the ABG was significantly greater in NVAF who had an ischemic stroke compared to others (160±68 mg/dL vs 119±39 mg/dL, p=0.005). The incidence of stroke was almost five-time greater in NVAF with ABG level major than 150 mg/dl (9.8% vs 1.9%, p<0.001).

At multivariate Cox-regression model adjusted for age, sex and presence of T2DM, blood glucose level at admission was the only independent predictor of ischemic stroke at follow up (HR 1.01, 95% CI 1.001–1.02; p=0.03). Finally, another multivariate Cox-regression model, adjusted for the mean CHA2DS2-VASc score, showed that the ABG level still remained a strong independent predictor of ischemic stroke at follow up (HR 1.012, 95% CI 1.003–1.02; p=0.01).

Conclusions

Diabetic NVAF had a worse baseline profile and higher stroke risk compared to non-diabetic NVAF. Baseline blood glucose level was an independent predictor of stroke regardless of the presence of T2DM or stroke risk profile. These findings underline the role of basal blood glucose level as a potential stroke risk modifier and therefore emphasize the importance of its routine determination to better stratify the stroke risk in NVAF starting DOACs.

Funding Acknowledgement

Type of funding source: None

Diagnostic accuracy of cardiac computed tomography and 18F-fluorodeoxyglucose with positron emission tomography/computed tomography in cardiac masses

Background

Understanding the nature of cardiac masses represents a challenge for clinicians in order to select the appropriate therapeutic strategies. The diagnostic accuracy of cardiac computed tomography (CT) and 18F-fluorodeoxyglucose (18F-FDG) with positron emission tomography/CT (PET/CT) in identifying the nature of cardiac masses has not been evaluated before in a large population.

Purpose

To assess the diagnostic value of CT and 18F-FDG PET/CT in defining the nature of cardiac masses, integrating morphologic features and metabolic activity.

Methods

Out of 223 we selected a final cohort 60 patients which underwent cardiac CT scan and 18F-FDG PET/CT. All masses had histological certain, apart from thrombi, in which was defined radiologic resolution after adequate anticoagulant treatment. For each mass, eight morphologic CT signs and standardized uptake value (SUVmax, SUVmean), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) in 18F-FDG PET, were evaluated.

Results

Twenty patients had benign cardiac masses and 40 patients malignant cardiac masses. Irregular tumour margins, pericardial effusion, invasions, solid nature of the mass, mass diameter, TC contrast up-take and pre-contrast characteristics were strongly associated with the malignant nature of cardiac masses (p<0.001). Additionally, the presence of at least four CT signs was able to discriminate malignancies, withsensitivity of 95% and specificity of 95% (AUC=0.988, 95% CI 0.969–1). The mean value of SUVmax, SUVmean, MTV and TLG was significantly higher in malignant cardiac masses than in benign lesions (p<0.001). ROC curve for diagnostic accuracy of 18F-FDG PET/CT parameters in detecting malignant lesions showed an excellent performance of SUV (AUC=0.948, 95% CI 0.891–1), MTV (AUC=0.928, 95% CI 0.841–1) and TLG (AUC=0.961, 95% CI 0.902–1).

Conclusions

In patients with cardiac masses, cardiac computed tomography and 18F-FDG PET/CT findings provide independent and incremental prognostic information regarding their nature. A systematic use of CT and 18F-FDG PET/CT is therefore useful for diagnostic and therapeutic purposes.

PET-CT evaluation of cardiac masses

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): S. Orsola Malpighi Hospital, University of Bologna

Coronary blood flow in myocardial infarction with nonobstructive coronary arteries

Background

Myocardial infarction (MI) is mainly caused by atherosclerotic plaque thrombosis but several registries show that in 1–13% of cases MI occurs in the absence of obstructive coronary artery disease (MINOCA) utilizing the conventional cut-off of <50% stenosis. MINOCA is generally related to coronary arteries abnormalities (epicardial or microvascular dysfunction – MINOCA-co). However, non-coronary conditions may underlie MINOCA as a consequence of supply-demand mismatch (MINOCA-nco). The TIMI flow gradient (TFG) and the corrected TIMI frame count (CTFC) are established methods able to respectively provide a qualitative and semiquantitative estimation of epicardial blood flow at rest. No studies have yet evaluated these indices in patients with MINOCA.

Purpose

To evaluate the clinical characteristics of patients with MINOCA and the angiographic indices in MINOCA-co versus MINOCA-nco.

Methods

Among all consecutive patients undergoing coronary angiogram at our Centre for MI based on the 4th Definition of Myocardial Infarction, the ones showing <50% coronary artery stenosis were retrospectively analyzed; patients with previous coronary stenting were excluded from the study. According to the presence or absence of pre-specified criteria of supply-demand mismatch (SAP >180 mmHg, DAP >110 mmHg, HR >110 bpm, Hb <6 gr/dl, SatO2 <91% or P/F ratio <300), the study cohort was divided into MINOCA-nco and MINOCA-co, respectively. We defined as slow flow phenomenon a TFG < = 2 and/or a CTFC >40 for the left anterior descending artery, >27 for the right coronary artery and >24 for the left circumflex.

Results

453 patients were retrospectively evaluated and 112 (24.7%) met the inclusion criteria. Mean age was 68±13.2 years and 41 (36.6%) were males. MINOCA-co was the more prevalent entity accounting for 73 (65.2%) patients while 39 (34.8%) were MINOCA-nco. The two subgroups presented similar baseline characteristics with regards to gender and classic cardiovascular risk factors including hypertension, hypercholesterolemia, diabetes and smoking habit. Peripheral vasculopathy was more prevalent in MINOCA-nco patients (MINOCA-nco=15.4% vs. MINOCAco= 4.2%; p=0.04). Regarding the angiographic indices, there was no statistically significant difference in TFG between subgroups; conversely, the number of patients with a slow flow phenomenon as defined by CTFC was significantly higher in the MINOCA-nco group (MINOCAnco= 25.7% vs. MINOCA-co=9.8%; p=0.039).

Conclusions

Our data suggest that among patients with MINOCA clinical characteristics were not useful in differentiating between the two disease entities (MINOCA-nco vs. MINOCA-co). However, MINOCA-nco patients had higher coronary flow impairment as evaluated by CTFC. The pathophysiological reason is still not clear; we hypothesized that, in this clinical setting, an increased heart rate, systemic arterial pressure or low oxygen supply might worsen unbalanced coronary perfusion.

Funding Acknowledgement

Type of funding source: None

Myocardial infarction with non-obstructive coronary artery disease: the prognostic role of infarct size predictors

Background

In patients with Acute Myocardial Infarction (AMI) the levels of cardiac troponin T and absolute neutrophil count have been shown to correlate with infarct scar size and left ventricular ejection fraction (LVEF) as well as conferring a risk for major cardiovascular adverse events (MACE). In the context of myocardial infarction with non-obstructive coronary arteries (MINOCA) the prognostic role of such indicators has never been explored.

Purpose

To evaluate the prognostic role of known myocardial infarct size indicators in a MINOCA population compared to patients with obstructive AMI (Ob – AMI).

Methods

Among 1990 patients admitted to our coronary care unit from 2016 to 2019 with AMI, we enrolled 186 consecutive MINOCA patients according to the current ESC diagnostic criteria. We compared troponin peak levels, absolute neutrophil count at the time of hospital admission and LVEF in MINOCA patients versus Ob–AMI. Furthermore we assessed the prognostic value of these indicators. All-cause mortality and a composite end - point of all-cause mortality and myocardial re-infarction were evaluated. The median follow-up time was 19.6±12.9 months.

Results

MINOCA patients were more frequently females (64,9% vs 35,1%; p<0.001), non-smokers (42,3% vs 61,8%; p<0.001) with a lower prevalence of diabetes (9.9% vs 23.7%; p<0.001) compared to the Ob-AMI population. Conversely, no differences were found in hypertension and dyslipidemia. As far as infarct size predictors are concerned, MINOCA patients showed lower levels of troponin value and absolute neutrophil count measured at the time of hospital admission (1838.27±601.0 ng/L vs 13543±3350.6 ng/L; p<0.001, 6.7±1.36x109/L vs 7.1±1.29x109/L; p=0.001, respectively). Moreover, these patients exhibited a higher LVEF (56.1±10% vs 49.3±11%; p<0.001) as compared to Ob-AMI.

Among our MINOCA patients, 13 (10.6%) all-cause deaths and 3 (4.3%) myocardial re-infarction were observed during follow-up. Multivariable Cox-regression model demonstrated that mean troponin level, absolute neutrophil count and LVEF were not independent predictors of MACE (HR = 1.0, 95% CI: 0.9–1.1, p=0.6; HR = 0.96, 95% CI: 0.9–1.1, p=0.187; HR = 0.9, 95% CI: 0.79–1.02, p=0. 12 respectively).

Conclusion

MINOCA patients show a similar prognosis compared to the worldwide AMI population.

However, in this study the outcome in the MINOCA population was not influenced by commonly used infarct size predictors, in contrast to what is observed in Ob-AMI patients. These results once again emphasize both the complexity of MINOCA patients and the importance of a better understanding of the different underlying pathophysiological mechanisms.

Funding Acknowledgement

Type of funding source: None

The predictor role of worsening renal function in patients with new onset atrial fibrillation on direct oral anticoagulant

Background

Chronic kidney disease (CKD) is an important outcome predictor in patients with atrial fibrillation (AF). Moreover, renal function at baseline is used to guide oral anticoagulant (OA) selection and dosing at initial treatment. The prognostic role of worsening renal function (WRF) during treatment with direct oral anticoagulants (DOACS) has been poorly explored.

Purpose

To estimate the prognostic role of WRF in terms of major adverse cardiovascular events (MACEs) in a series of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs.

Methods

Among all patients with newly diagnosed NVAF and indication for OA between January 2017 and December 2018, we enrolled those treated with DOACs. Renal function at baseline and during follow-up was assessed with estimated glomerular filtration rates (eGFR). eGFR was calculated as a mean value of Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. The hemorrhagic risk at baseline was estimated with the main available scores (HAS-BLED, ATRIA and ORBIT). WRF was defined as a decrease in eGFR of at least 20%. MACEs were evaluated according to the type of DOAC and the WRF. Major bleedings (MB) were defined according to the ISTH definition.

Results

The study population was constituted by 249 patients with newly diagnosed NVAF started on DOAC and followed for a median time of 14.1±8.6 months. Overall, WRF was observed in 58 cases (23.3%). Patients with WRF had significative higher rates of death (10.3% versus 3.1%, p=0.025) and MB (13.8% versus 4.7%, p=0.016). The incidence of bleeding events, acute coronary syndromes and stroke was not affected by WRF. Interestingly, CG formula better predicted the incidence of MB as compared to the other formulas (p=0.006). The type of DOAC did not significantly impact the observed renal impairment and had no effect on the occurrence of MACEs in patients showing WRF. The predictors of WRF were found to be age, female sex, low hemoglobin level and left ventricle end telediastolic volume. At multivariate analysis, WRF was identified as an independent predictor of MB (OR 3.1, 95% C.I, 1.12–8.58), regardless of the baseline bleeding risk.

Conclusion

This is the first prospective study to evaluate the impact of worsening renal function on cardiovascular events in patients with atrial fibrillation treated with DOACs. A significant WRF emerged as an independent predictor of death and MB. The specific DOAC did not affect either the entity of worsening renal function or the incidence of cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Impact of type 2 diabetes mellitus and blood glucose admission levels in patients with myocardial infarction with non obstructive coronary artery disease (MINOCA)

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinically entity and represents 5% to 10% of all patients with myocardial infarction (MI). Besides type 2 diabetes mellitus (DM), which is a common comorbidity in patients hospitalized for an acute coronary syndrome, high glucose levels (HGL) at admission are frequently observed in this context. The risk of major adverse cardiovascular events following acute coronary syndrome is increased in people with DM and HGL. However, evidence regarding diabetes and high glucose level among MINOCA patients is lacking.

Purpose

To examine the incidence of major adverse cardiovascular events (MACEs) in diabetic and non-diabetic MINOCA patients as well as according to HGL at presentation.

Methods

Among 1995 patients with acute MI admitted to our coronary care unit from 2016 to 2018, we enrolled 186 consecutive MINOCA patients according to the current ESC diagnostic criteria. HGL at admission was defined as serum glucose level above 180 mg/dl. All-cause mortality and a composite end-point of all-cause mortality and myocardial re-infarction were compared. The median follow-up time was 19.6±12.9 months.

Results

Diabetic MINOCA patients were older (mean age 75.5±9.6 vs 66.5±14.7; p=0.002) and with higher prevalence of hypertension (p=0.016). Conversely, there were no significant differences in gender, BMI, dyslipidemia and atrial fibrillation. Similarly, no significant differences were observed regarding clinical and ECG presentation, echocardiographic features and laboratory tests. The rates of death (30.8% vs 8.3%; p=0.013) and MACEs (22.2% vs 6.8%; p=0.025) were significantly higher in MINOCA-DM patients; conversely, no significant differences were observed for re-MI (p=0.58). At multivariate regression model adjusted for age and sex, type 2 DM was not an independent predictor of all cause deaths (p=0.36) and MACE (p=0.24).

Patients with admission HGL had similar baseline characteristics, cardiovascular risk factors, clinical presentations, echocardiographic features and troponin values as compared to patients with no-HGL. HGL at admission was associated with higher incidence of all-cause-death (p<0.001) and MACE (p=0.003) during follow-up compared to patients with no HGL; conversely, no significant differences were observed in the incidence of re-MI (p=0.7). Multivariate analysis adjusted for age and sex demonstrated that HGL was an independent predictor of death (HR 6.25; CI 1.64–23.85; p=0.007) and MACEs (HR 6.17; CI 1.79–21.23, p=0.004).

Conclusion

In MINOCA patients, HGL was an independent risk factor for both MACEs and death while type 2 DM was not correlated with these hard endpoints. As a consequence, HGL could have a still unexplored pathophysiological role in MINOCA. Properly powered randomized trials are warranted.

Funding Acknowledgement

Type of funding source: None

Outcomes in patients with cardiac masses: the underestimated burden of pseudotumours

Background

Cardiac masses (CMs) include benign and malignant formations. So far, clinical presentation and prognosis have been reported only in small series without discriminating between subtypes. We investigated the clinical presentation and long-term prognosis of patients with cardiac masses stratifying our results according to the lesions' nature.

Methods

We enrolled all consecutive patients admitted to our Institution between 1999 and 2018 with imaging evidence of CMs. Definitive diagnosis was achieved by histologic examination or by radiological evidence of thrombotic resolution after anticoagulant treatment. The study population was classified as benign or malignant and subsequently into 4 subtypes: pseudo-tumours, primary benign tumours, primary malignant tumours and secondary tumours. Cardiovascular and non-cardiovascular mortality was described.

Results

We identified 172 patients with CMs, 125 benign and 47 malignant. Benign lesions were often incidentally diagnosed in the left heart chambers whereas malignancies were usually detected in the pericardium and right sections, resulting in more advanced symptoms. Over time – median follow-up of 48 months - survival of patients with benign formations was three-fold greater than patients with malignancies (p<0.001) with no differences in cardiovascular mortality. Patients with pseudo-tumours showed a significantly lower survival than primary benign tumours (p=0.018) while no difference was found within the malignant stratum between primary and secondary neoplasms.

Conclusions

CMs are a heterogeneous entity where advanced symptoms and a pericardial involvement suggest malignant forms, which exhibit a poor outcome. Among patients with benign lesions, pseudo-tumours were associated with reduced survival, supposedly as a consequence of the different underlying conditions.

Funding Acknowledgement

Type of funding source: None

Effect of Different Enological Tannins on Oxygen Consumption, Phenolic Compounds, Color and Astringency Evolution of Aglianico Wine

Background: In the wine industry, in addition to condensed tannins of grape origin, other commercial tannins are commonly used. However, the influence of oxygen uptake related to different tannin additions during the post fermentative phase in wine has not been completely investigated. In this study, we evaluated the influence of four different commercial tannins (namely, condensed tannins, gallotannins, ellagitannins and tea tannins) during four saturation cycles. Method: Wine samples were added with four different tannin classes (30 g/hL) as to have 5 different experimental samples: control, gallotannins (GT), condensed tannins (CT), ellagitannins (ET), and tea tannins (TT). The chemical composition of the four commercially available tannin mixtures was defined by means of NMR and high-resolution mass spectrometry. After the addition of tannins, each wine sample was oxidized by air over four cycles of saturation. During the experiment oxygen consumption rate (OCR), sulfur dioxide consumption, acetaldehyde production, phenolic compounds, chromatic characteristics, astringency measured by the reactivity towards saliva proteins and astringency subqualities were evaluated. Results: The experiment lasted 52 days. The addition of tannins influenced the oxygen consumption on the 1st day of the saturation cycles and, in the case of TT, a higher total consumption of oxygen was also detected. Acetaldehyde increased during the experiment while the native anthocyanins decreased throughout the oxidation process. Conclusion: Wines added with tannins featured improved color intensities with respect to the control; the addition of TT, GT and ET slightly promoted the formation of short polymeric pigments; the astringency, determined before and at the end of the experiment, decreased in all the samples, including the control wine, and mostly in the ET and GT samples.

Listeria monocytogenes clones in Italian food products: virulence and environmental adaptation

Background

Food is the main source of Listeria monocytogenes (Lm) infection. Lm is a highly heterogeneous species composed of hypervirulent and hypovirulent clones. Understanding the distribution of Lm clonal complexes (CCs) in different food categories has strong implications for risk assessment. The aim of this work was to analyse collection of Lm strains of National Reference Laboratory (NRL Lm) in order to assess link between genetic profile and matrices and the level of pathogenicity of circulating strains based on CCs.

Methods

NRL Lm database actually consists of 906 sequenced strains isolated in 10 years from 5 food compartments (meat, fish, dairy, vegetables and composite dishes). Epidata were analysed to remove redundant strains based on the same epidemiological description. After that, WGS data from 465 Lm strains were investigated. In silico MLST was defined and Roary 3.12.0 was used to obtain a pan-genome profile. Genes were later uploaded to Pasteur Institute platform for characterization.

Results

In silico MLST identified 36 CCs and 6 singleton. CC9 (23.0%), CC8 (15.3%) and CC121 (13.3%) were the prevalent CCs. In particular, CC9 was present in 35.2% of meat samples and CC8 in 25.8% of fish samples. Pan genome profile revealed high prevalence (>98%) of genes related to biofilm formation and resistance to environmental stress in CC9 strains and genes involved in tolerance to quaternary ammonium compounds in CC121 strains.

Conclusions

Results, in particular for meat products, confirmed in Italy, the prevalence of hypovirulent Lm strains previously observed at European Union level. The high presence of stress resistance and disinfectant tolerance genes in these strains could make them able to persist in food-production environment and should be taken into account evaluating the health hazards. In fish product is also relevant the prevalence of CC8 strains which are potentially highly pathogenic and have been responsible of recent European multi country outbreak.

Key messages

Pangenome of Listeria monocytogenes isolated from Italian food revealed high presence of disinfectant tolerance and stress resistance genes in meat products and virulence genes in fish products. Listeria monocytogenes CC9 and CC121 prevalence in Italian meat product confirms occurrence of hypovirulent strains detected at European Union level.

Analysis of power from palm oil solid waste for biomass power plants: A case study in Aceh Province

Nowadays, the solid waste produced from palm oil has become one of the essential oils in the world in general and especially in Indonesia. Biomass waste is processed through substantial quantities of palm oil extraction. With the reduction in fossil fuels in recent years, it has had an impact on the deterioration of electricity supply at the National and International levels. Biomass is a renewable energy that can replace conventional energy. Besides, power generation from biomass is environmentally friendly and sustainable. This simulation was conducted to analyze the maximum power from the burning of oil palm biomass for the electricity generation. The novelty of the article is the performance and behavior of palm oil biomass-based co-fuel in the power generation process. The biomass wastes used in this simulation include OPF, EFB, PKS, and OPM. The results of this simulation indicate that the maximum power produced with OPF can produce 49.54 MW with variations in the flow rate of biomass at 8 kg/s. While at the time of recycling up to 100% OPM biomass produces 61.05 MW higher than OPF, EFB and PKS. Meanwhile, the OPF-PKS mixed biomass can produce 106.15 MW of power plants when the airflow rate reaches 171 kg/s. The overall results of the simulation for the analysis of the maximum power that can be used as a power station show suitability and can apply in rural/remote areas. Besides, the availability of oil palm biomass in Aceh Province is also sufficient to overcome electricity shortages and reduce dependence on conventional energy.

New insights into the formation of precipitates of quercetin in Sangiovese wines

Wines produced from Sangiovese (sg) grapes, the most cultivated red grape variety in Italy and widely grown across the world, is often subjected to loss of clarity due to the formation of a deposit constituted by fine needle-shaped crystals. In this work, a qualitative study by ¹H-NMR and ¹³C-NMR analysis of the deposit obtained by filtering cloudy sg wines showed that it was constituted by crystals of quercetin (Q). The analysis of hydro-alcoholic solutions (12% ethanol and pH 3.2.) and red wines added with increasing amounts of Q showed that, above 3 mgL^-1 of Q, a deposit can be detected and, the time necessary for its formation depends on the medium. The comparison among sg and other 11 monovarietal wines showed that sg was the richest in Q and quercetin glycosides (GQ). Both Q and GQ decreased in the analyzed solutions over time and the decrease was faster for Q than for GQ. The controlled exposure to oxygen determined a decrease of Q higher than the 50% of the initial values. Data obtained in this study suggested that practices as micro-oxygenation and wood aging could help to decrease the amount of Q in sg wines.

863Leadless endocardial pacing improves symptoms in patients with failed conventional CRT implant in long term follow up

Funding Acknowledgements

EBR Systems, Inc

OnBehalf

WiSE-CRT and LV-SELECT study and POST-M REGISTRY

Background

The WiSE-CRT (Wireless stimulation endocardial) system has advantages over conventional epicardial CRT. Whenever conventional CRT failed to implant or failed to echocardiographic response, the WiSE-CRT was implanted as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) over the last 8 years. All these studies have reported high rates of clinical and echocardiographic response compared to conventional CRT.

Objectives

The purpose of this analysis was to determine the safety and clinical response in the largest available number of implanted patients (pts) with long term follow up of 2 years and the first, second and third generation of WiSE-CRT devices.

Method

All pts undergoing a WiSE-CRT implantation as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) were analysed (N = 165). Pts were followed-up for 24 months and considered CRT responders if an improvement in NYHA ≥ 1 class from baseline (pre-implant) was achieved.

Results

In total, 165 pts were implanted, demographics include: 68.2 ± 9.6 year’s old, 81.8% male, 49.7% with history of AFib and 54.5% non-ischaemic aetiology. The mean intrinsic QRS duration was 165.0 ± 32.3 msec (28 pts pace-maker dependent). 161 pts had the system successfully implanted with no major complications, 3 (1.8%) pts developed a pericardial effusion and 1 (0.6%) electrode was lost during implantation and recovered surgically. During the 24-month follow-up period, 20 (12.1%) pts died from any cause, 4 (2.4%) pts developed TIA or Stroke and 15 (9.1%) pts had pocket or transmitter infection. There was a significant improvement in NYHA functional class in 63.6% pts and an average improvement of -26.1 (-45.1, -7.1) msec in QRS duration.

Conclusion

Despite a history of failed conventional CRT implantation, pts undergoing CRT upgrades with a WiSE-CRT have a high success rate and a complication rate similar to previously described. In addition endocardial LV pacing led to symptomatic improvements in 64% of patients reaching the 24 month of follow up.

Abstract Figure 1: Forest Plot NYHA Responder Rat

Social inequalities in the metropolitan area of Rome. A multidisciplinary analysis of the urban segregation of the "formerly-Bastogi" compound

BACKGROUND

This study tries to evaluate, through a multidisciplinary approach, the relationship between urban structure, isolation and distribution of social determinants of health, in the so-called "formerly-Bastogi, a compound, with more than 1,500 inhabitants, located in north-western Rome, Italy.

METHODS

The architectural-urban analysis, conducted through site visits and evaluations of urban situation, showed how strongly the compound is isolated from the neighbourhoods, and structurally degraded. The socio-demographic analysis, based on the National Census data, showed significant differences in the distribution of the social determinants of health between "formerly-Bastogi" and the surrounding areas.

RESULTS

The area under study appears to be isolated from the surrounding urban space, both because of social and architectural factors. This situation could have some association with inhabitants' health.

CONCLUSIONS

If our preliminary investigation was useful for a diagnosis of the situation, a more complete - qualitative and quantitative - investigation of the context will be needed to plan appropriate multidisciplinary health-promoting interventions.

Metagenomic and volatile profiles of ripened cheese obtained from dairy ewes fed a dietary hemp seed supplementation

Chemical and organoleptic properties of dairy products largely depend on the action of microorganisms that tend to be selected in cheese during ripening in response to the availability of specific substrates. The aim of this work was to evaluate the effects of a diet enriched with hemp seeds on the microbiota composition of fresh and ripened cheese produced from milk of lactating ewes. Thirty-two half-bred ewes were involved in the study, in which half (control group) received a standard diet, and the other half (experimental group) took a diet enriched with 5% hemp seeds (on a DM basis) for 35 d. The dietary supplementation significantly increased the lactose in milk, but no variations in total fat, proteins, caseins, and urea were observed. Likewise, no changes in total fat, proteins, or ash were detected in the derived cheeses. The metagenomic approach was used to characterize the microbiota of raw milk and cheese. The phyla Proteobacteria and Firmicutes were in equally high abundance in both control and experimental raw milk samples, whereas Bacteroidetes was less abundant. The scenario changed when considering the dairy products. In all cheese samples, Firmicutes was clearly predominant, with Streptococcaceae being the most abundant family in the experimental group. The reduction of taxa observed during ripening was in accordance with the increment (relative abundance) of the starter culture Lactococcus lactis and Streptococcus thermophilus, which together dominate the microbial community. The analysis of the volatile profile in ripened cheeses led to the identification of 3 major classes of compounds: free fatty acids, ketones, and aldehydes, which indicate a prevalence of lipolysis compared with the other biochemical mechanisms that characterize the cheese ripening.

Psychiatric comorbidity in patients affected by fibromyalgia and/or autoimmune rheumatic diseases: Preliminary results of an observational study

Introduction

Fibromyalgia is characterized by skeletal muscle pain and axial stiffness, with elective multiple points of tenderness (tender points). According to scientific literature, the prevalence of depression, anxiety and a worse quality of life is higher in patients with fibromyalgia. Trauma (sexual abuse and physical aggression) has a key role in the pain perception.

Objectives

To describe the clinical characteristics of patients with fibromyalgia and/or autoimmune rheumatic diseases admitted to O.O.R.R. Foggia (Department of Rheumatology), to detect correlation between fibromyalgia and psychiatric disorders.

Aims

To underline psychiatric comorbidity in patients affected by fibromyalgia and/or autoimmune rheumatic diseases.

Methods

Diagnostic tests at Baseline (T0): Mini International Neuropsychiatric Interview and Structured Clinical Interview for DSM Disorder 2 to assess psychopathology, 12-Item Short Form survey for the quality of life, Diagnostic Criteria for Psychosomatic Research for disorders of somatic symptoms, Insight Scale for the awareness of the disease, Davidson Trauma scales to assess the presence of a post-traumatic stress disorder, Pittsburgh Sleep Quality Index about the quality of sleep. After 3 months (T1): further psychodiagnostic assessment for patients with positive mental status exam in drug treatment.

Results

Affectivity disorders, feelings of anger, irritability, hostility, impaired stress response, increased vulnerability to traumatic events are very frequent in patients affected by fibromyalgia.

Conclusions

The preliminary results of this study show that patients with fibromyalgia have diagnoses of major depression, anxiety disorders, post-traumatic stress disorder and personality disorders (cluster B). Multidisciplinary interventions are needed integrating the rheumatologic therapy with the psychiatric one, based on the detected diagnosis.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

P1248 What are the suspicious echocardiographic features of a malignant cardiac mass?

BACKGROUND

Cardiac Masses (CM) represent a rare and heterogeneous group with a prevalence of 0.3% at autopsy, divided in benign masses - primary tumors and pseudotumors - and malignant ones - primitive tumors and metastasis, either directly invading the heart and pericardium or as a consequence of hematologic spread. 2-D Echocardiography is nowadays the first line approach to define nature and management of CM, but is it enough to guide a therapeutic strategy?

PURPOSE

To evaluate echocardiographic CM malignancy features in patients admitted to our Centre between 1997 and 2017.

MATERIALS AND METHODS

We retrospectively evaluated a population of 180 consecutive patients (45% males; mean age 60 ± 16 years; BMI 25 ± 5 Kg/m2), referred to our echocardiographic lab with suspicion CM. All patients were examined in both left lateral and supine position, and heart was visualized from all available echocardiographic windows. Definite diagnosis was obtained by histologic examination of biopsy, surgical samples or, in cases of cardiac thrombi, by radiological evidence of thrombus resolution after adequate anticoagulant treatment. We excluded normal anatomical variants in the group of pseudotumors due to the impossibility of obtaining histological examination. Comparisons between categorical variables were performed by Chi-square or Fisher exact test. P values ≤ 0.05 were considered significant. Variables with statistical signification lower than p ≤ 0.05 in univariable analysis were included in logistic regression analysis to determinate independent predictors of malignant masses.

RESULTS

We detected 129 benign CM (76% primitive tumors and 24% pseudotumors) and 51 malignant cardiac tumors (45% primitive tumors and 55% metastasis). In 7 cases a poor acoustic window did not allow an optimal examination; in remaining 173 patients, the classical 2-D echocardiogram identified 157 masses with a diagnostic accuracy of 91%. Benign tumors and pseudotumours were localized predominantly in left heart chambers, while malignant primitive tumors and metastasis were mainly detected in right heart, in pericardium or in pulmonary artery branches (p < 0.001). The largest ecocardiographic diameter appeared greater for the malignant masses (mean of 49 ± 26 mm) than benign ones (30 ± 16 mm, p = 0.003). The occurrance of any pericardial effusion (p < 0.001), extension to pericardium (p = 0.01) or to main vessels (p = 0.006) were also associated with malignant masses. Finally, multivariate analysis showed only largest diameter (p = 0.001) and pericardial effusion (p < 0.001) were independent predictors of malignancy.

CONCLUSION

2D Echocardiography is an excellent, non invasive technique for first line evaluation of patients with suspicion CM. It is safe, accurate and have high diagnostic accuracy in identifying CM and their benign or malignant nature. In particular, a large mass associated with any pericardial effusion must pose suspect of malignancy.