Do not underestimate the blood urea nitrogen-to-creatinine ratio in heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The blood urea nitrogen-to-creatinine ratio (BUN/SCr) has been proposed as a prognostic marker in heart failure (HF). We aimed to evaluate whether BUN/SCr predicts mortality outcomes in a real-world Southern European population with decompensated chronic HF.

Methods

We retrospectively studied 1057 patients with chronic HF admitted to our emergency department between November 2016 and December 2017 with acute decompensation. We excluded patients with a GFR <15mL/min/m2 or on dialysis. The incidence of cardiovascular (CV) and all-cause death was evaluated through multivariable logistic regression models and by Kaplan-Meyer survival curves.

Results

1025 patients were included, median age 80 years (IQR 73-85), 52.4% male, mean LVEF 42.8 ± 12.7%, and mean GFR 57.2 ± 23.9 mL/min/m2. Mean BUN/SCr was 24.9 ± 8.2 and mean SBP was 139 ± 29mmHg (r=-0.17, p < 0.001). After a median follow-up of 5 months (IQR 3-11 months), CV and all-cause death occurred in 8.0% and 21.6%, respectively. Mean BUN/SCr was higher in patients with fatal outcomes both for CV (31.3 vs. 24.3, p < 0.001) and all-cause death (28.6 vs. 23.8, p < 0.001). BUN/Scr was grouped by terciles: T1 (<20.78), T2 (20.78-27.15), T3 (>27.15). In the T3 group, the multivariable-adjusted  OR for CV and all-cause death was 5.43 (95% CI 2.20-13.37) and 2.72 (95% CI 1.66-4.46), respectively, compared to the T1 group. No significant differences between T1 and T2 groups.

Conclusions

BUN/SCr at admission predicts CV and all-cause death in patients with chronic HF after an episode of decompensation. BUN/SCr, as an easy-to-use tool, helps to identify those patients who benefit from tight monitoring both during hospitalization and after discharge.

Abstract Figure_1

Does lipoprotein(a) predict cardiovascular events in a long-term follow-up?

Funding Acknowledgements

Type of funding sources: None.

Background

Elevated plasma lipoprotein(a) [Lp(a)] concentrations are associated with an increased risk of atherosclerotic cardiovascular disease and its role in risk categorizing was recognized in the new ESC guidelines for the management of dyslipidaemias. We investigated 1) the association between baseline Lp(a) levels and incident long-term cardiovascular (CV) events and 2) its relationship with type 2 diabetes mellitus (T2DM) in a Southern European population.

Methods

We retrospectively assessed baseline Lp(a) concentrations in a total of 499 patients of a primary prevention cohort followed at the Lipidology Clinic of our hospital, with a median follow-up time of 15 (IQR 12-17) years. Lp(a) was analysed as a continuous variable, as a categorical variable with a 180mg/dL cut-off and by quartiles. We collected data on major CV events (CV death, myocardial infarction, stroke) as a composite outcome. Cox proportional hazard regression analyses were used to estimate hazard ratios (HR) and 95% confidence interval (CI).

Results

Mean age was 48.30 ± 14.41 years and 61.70% were male (n = 499). Median Lp(a) was 36.60 (IQR 0-396) mg/dL and 12.4% of patients had very high Lp(a) (≥180mg/dL); T2DM prevalence was 13.60%. The composite outcome incidence was 10%. At the baseline, individuals with T2DM had lower Lp(a) levels (11.85 IQR 3-330 mg/dL vs. 46.40 IQR 0-396, p < 0.01 mg/dL). There was a moderate inverse correlation between Lp(a) and HbA1c (r = -0.67, p < 0.01) but no significant correlations with lipid profile (total, LDL or HDL), risk scores (SCORE or the ACC pooled cohort equation), age nor gender. We found no relationship between baseline Lp(a) quartiles and composite outcome’s incidence (age-, sex-, and diabetes-adjusted HR: 1.15, 95%CI: 0.71-1.87, p = 0.57) (Figure 1), neither with the individual CV endpoints. Exploratory analysis showed that patients on aspirin had lower Lp(a) levels (29.55 IQR 0-264 mg/dL vs. 63.60 IQR 1-396 mg/dL, p < 0.01).

Conclusion

In a single centre cohort of a primary prevention southern European population, we did not find an association between Lp(a) levels and incident CV events in a 15-year median follow-up time.

Myocardial infarction in young adults: are the risk profile and mortality outcomes different from older patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The incidence of acute myocardial infarction (AMI) among young patients is increasing. The YOUNG-MI Registry reported that those under 40 years had similar risk profiles and outcomes compared to those aged 41 to 50. We aimed to evaluate cardiovascular risk factors and mortality outcomes in two age cohorts from southern European.

Methods

We retrospectively evaluated 4758 patients admitted to our coronary intensive care unit between 2004 and 2017 with AMI. We only included patients <60 years in two subgroups: cohort A < 50 years and cohort B 50-60 years. 

Results

From the 1233 patients included (mean age 50.5 ± 6.5 years, 82.2% male), 53% had STEMI. Cohort B had higher rates of hypertension (59.8 vs. 42.9%, p < 0.001), diabetes (41.8 vs. 28.9%, p < 0.001), and dyslipidemia (59.4 vs. 46.4%, p < 0.001), while cohort A had higher rates of familial premature coronary artery disease (20.9 vs. 13.2%, p < 0.001) and smoking habits (54.4 vs. 40.0%, p < 0.001). Regarding coronary angiography, cohort B had higher rates of obstructive disease in each epicardial artery, except for left main involvement and non-obstructive disease (Fig. 1). Cohort A had lower all-cause mortality rates at the index hospitalization (1.3 vs. 3.2%, p = 0.045), 6-months (2.9 vs.5.4, p = 0.038), 1-year (3.1 vs. 6.3%, p = 0.014), and 3-years (3.6 vs 8.4, p = 0.001). After multivariable adjustment, we found no relationship between age cohorts and all-cause mortality for any follow-up timing: HR 1.57 (95% CI 0.56-4.37), 1.37 (95% CI 0.50-3.74), and 0.92 (95% CI 0.35-2.39) at 6-months, 1-year, and 3-years, respectively.

Conclusion

Among patients who suffer AMI, those under 50 years old have a different risk profile, compared to the 50-60 years cohort. However, there is no significant difference in all-cause mortality.

Abstract Figure.

RHOBTB2 p.Arg511Trp Mutation in Early Infantile Epileptic Encephalopathy-64: Review and Case Report

Early infantile epileptic encephalopathy-64 (EIEE 64), also called RHOBTB2-related developmental and epileptic encephalopathy (DEE), is caused by heterozygous pathogenic variants (EIEE 64; MIM#618004) in the Rho-related BTB domain-containing protein 2 (RHOBTB2) gene. To date, only 13 cases with RHOBTB2-related DEE have been reported. We add to the literature the 14th case of EIEE 64, identified by whole exome sequencing, caused by a heterozygous pathogenic variant in RHOBTB2 (c.1531C > T), p.Arg511Trp. This additional case supports the main features of RHOBTB2-related DEE: infantile-onset seizures, severe intellectual disability, impaired motor functions, postnatal microcephaly, recurrent status epilepticus, and hemiparesis after seizures.

Postpartum headache after epidural anaesthesia: Who to blame?

INTRODUCTION

Epidural analgesia is considered the preferred analgesic choice during labour. Post dural puncture headache (PDPH) is considered a potential complication of this analgesic technique and is a frequently hypothesis for any headache occurring after delivery. It is essential that anaesthetists and obstetricians are familiar with other possible differential diagnosis for postpartum headache (PPH).

CASE DESCRIPTION

37-year-old female presented after delivery with intense occipital pulsatile headache associated with neck radiation, nausea and vomiting, hemodynamically stable and normal neurologic physical examination. Abnormalities in thyroid hormone levels were found. CT-scan findings suggested pituitary apoplexy.

DISCUSSION

There are many differential diagnoses for PPH and some are rarely considered, such as pituitary apoplexy. It is essential to differentiate signs and symptoms of each diagnosis, since many of them overlap.

CONCLUSION

Not all postpartum headaches are PDPH and the first suspected diagnosis may not always be accurate.

Biliary tract anatomical variance - the value of MRCP

SUMMARY Duplication of the common bile duct (CBD) is a rare congenital anomaly of the bile ducts that should be diagnosed prior to surgery in order to optimise management and prevent complications. We report a case of a patient presenting with choledocholithiasis and type Va duplicated extrahepatic bile duct that was missed on ultrasonography. The atypical course prompted further imaging with magnetic resonance cholangiopancreatography (MRCP), which identified the aberrant bile duct and assisted in safe preoperative and operative management. This case highlights the importance of accurate pre-interventional imaging and agrees with the reclassification of duplications of the CBD. Keywords: bile duct, extrahepatic, anomaly, duplicated, injury

This Place Is Full of It: Towards an Organizational Bullshit Perception Scale

This study evaluated the psychometric properties of the Organizational Bullshit Perception Scale (OBPS) using two samples of employees of organizations in various sectors. The scale is designed to gauge perceptions of the extent of organizational bullshit that exists in a workplace, where bullshit is operationalized as individuals within an organization making statements with no regard for the truth. Analyses revealed three factors of organizational bullshit, termed regard for truth, the boss and bullshit language. The three factors are consistent with existing literature in the field of organizational bullshit and offer further insight into how employees view workplace bullshit. The OBPS constitutes three subscales measuring these factors. Future researchers should seek to validate the OBPS and further develop the identified factors of organizational bullshit.

Inequalities after STEMI in National Health Service: is there really a postcode lottery?

Background and purpose

Failure to address the impact of social determinants of health attenuates efficacy of proven prevention recommendations, namely because important considerations related to socioeconomic disadvantage are not captured by existing cardiovascular disease (CDV) risk stratification methods. We aimed to assess how socioeconomic determinants influence recurrent MI and all-cause death after myocardial infarction (MI) in Portugal.

Methods

We conducted a retrospective, observational cohort study, including all patients with a ST-elevation MI (STEMI) admitted to and discharged alive from an intensive cardiac care unit between 2004 and 2017 (n=1809). The median (interquartile range) follow-up was 6 (4–9) years. We used survival models to assess the relationship between their municipal (i) income by purchasing power per capita (PPC), (ii) geographical accessibility to health care, (iii) illiteracy, iv) residential socioeconomic deprivation and recurrent MI and all-cause mortality. To assess residential socioeconomic deprivation, each individual's residential postcode was matched to the recently validated Portuguese version of European Deprivation Index (EDI). The index was categorized into quintiles (Q1-least deprived to Q5-most deprived).

Results

The mean age was 64±14 years; 74% were male. Regarding individual socioeconomic variables, PPC (HR 1.19; 95% CI 0.97–1.47 for Tertile 1 vs Tertile 2; HR 1.28; 95% CI 1.04–1.56 for Tertile 1 vs Tertile 3 and HR 1.07; 95% CI 0.85–1.34 for Tertile 2 vs Tertile 3) and medical appointments in primary health centers per inhabitant (HR 0.90; 95% CI 0.75–1.09 for Tertile 1 vs Tertile 2; HR 1.23; 95% CI 0.95–1.61 for Tertile 1 vs Tertile 3 and HR 1.37; 95% CI 1.06–1.76 for Tertile 2 vs Tertile 3) were predictors of all-cause mortality, but not recurrent MI; however, in multivariate analysis adjusted for sex, age and ejection fraction, this association was no longer significant (HR 1.00; 95% CI 0.99–1.00 and, HR 1.00; 95% CI 0.89–1.17, respectively). Additionally, no evident association between illiteracy and all-cause mortality or MI was present. Concerning EDI, demographic data was similar among the quintiles (Table 1). Although EDI quintiles were not associated with all-cause mortality (HR 1.17; 95% CI 0.82–1.66 for Q5 vs Q1), the EDI was an independent predictor of recurrent MI (Figure 1). On multivariate analysis, adjusted for age, sex, hypertension, diabetes and LDL cholesterol, the HR for the most deprived (Q5) to the least deprived (Q1) quintile was 1.91 (95% CI 1.05–3.49) for MI.

Conclusions

Our study shows clear socioeconomic differentials in cardiovascular outcomes in patients with STEMI which suggests that accounting for socioeconomic deprivation might improve risk prediction and therefore disease prognosis.

Funding Acknowledgement

Type of funding source: None

Strauss formula: a great and easy tool to manage congestion in acute heart failure

Background

Approaching the congestive patient is a complex task that requires the combination of different assessment methods. The Strauss formula uses variations in haemoglobin and haematocrit to estimate plasma volume variations (PVV) and haemoconcentration. However, this formula was only validated in outpatients followed with chronic heart failure. We aimed to assess the applicability of this formula to hospitalized patients for acute heart failure (AHF).

Methods

We conducted a single-centre, retrospective, observational study of 302 patients who were admitted to our hospital for AHF during 2016 and were discharged alive. Baseline clinical, laboratory and demographic characteristics were evaluated at admission and the Strauss formula was applied, as PVV (%) = 100 x [(Hb A / Hb D) x (1 − Hct D) / (1 − Hct A)] − 100), where A = admission and D = discharge. At discharge, we considered that a positive change (≥0%) in PV regarding the admission was linked to an increase in PV (haemodilution); a negative change (<0%) correlated to a decrease in the PV (haemoconcentration). The primary endpoint was a composite of cardiovascular death (CV-death) and HF readmission at 3-months.

Results

Mean age was 76±11 years and 57% were male. At baseline, 92% were on clinical-haemodynamic profile B, with a median NT-proBNP of 2157 (IQR 1161–4242) pg/dL, a mean of glomerular filtration rate (GFR) of 63±57 mL/min/m2, a mean haemoglobin of 12±2 g/dL and a mean haematocrit of 38±6%. At discharge, the median plasma volume variation was −1.1% (IQR – 9.6 to 7.8) and the distribution of PVV values in the histogram reveals that a large proportion of patients (44%) increased or maintained plasma volume (PVV ≥0% – haemodilution). The group of patients who decreased plasma volume at discharge was slightly younger (75 vs 78 years, p=0.044), showing higher numerical decreases in NT-proBNP, gamma-glutamyl transferase (gGT) and bilirubin at discharge. A positive change in PV (PVV >0%) during admission almost doubled the risk for readmission and CV-death at 3-months [OR 1.9 (95% CI: 1.1 to 3.1, p=0.026], after adjusting for age and sex.

Conclusions

In this work, we demonstrate that PVV, as calculated by the Strauss formula, increases or is unchanged in 44% of patients admitted with AHF and is strongly associated with a composite of 3-months CV death and HF readmission. Tools to guide the management of residual congestion are of great importance to assess the optimal discharge timing.

Funding Acknowledgement

Type of funding source: None

Can left atrial mechanics predict anticoagulation in cryptogenic stroke?

Introduction

Ischemic stroke is a leading cause of death and disability in the Western world, frequently due to cardioembolism and atherothromboembolism. Cryptogenic strokes occur without a well-defined aetiology after a standard vascular and cardiac evaluation, and secondary prevention may include antiplatelet therapy while awaiting results of long-term cardiac monitoring. In this study, we aimed to identify echocardiographic predictors of paroxysmal atrial fibrillation (AF) latter identified in follow-up of patients with cryptogenic stroke.

Methods

We retrospectively assessed all patients with cryptogenic stroke admitted in our hospital in the last 2 years. Only patients in normal sinus rhythm with a minimum of 24 hours of cardiac monitoring at admission and 24 hours Holter monitor within 6 months after discharge were included. Echocardiographic measures included left ventricle ejection fraction, left atrium (LA) volume, left and right atrium longitudinal strain, left and right ventricle longitudinal strain, E/A ratio, E/e' ratio, isovolumetric relaxation time (IVRT) and E wave deacceleration time. Echocardiographic data was assessed to determine its accuracy to identify AF.

Results

The study included 32 patients with a mean age of 72±10 years and a male preponderance (87.5%). AF was identified in 12 (37.5%) patients. This group of patients had a larger indexed LA volume (44.3 vs 29.1 mL/m2, p=0.043), a lower IVRT (87 vs 116 ms, p=0.028), and a lower LA longitudinal strain in contractile (6.7 vs 13.6%, p<0.001) and in reservoir phase (17.1 vs 23.6%, p=0.042). All other variables were not significantly different among groups, including LA longitudinal strain in conduit phase. LA longitudinal strain in contractile phase showed the best predictive power with an area under the ROC curve of 0.925 (95% CI 0.82–1 p=0.001). The cut-off value that best predicted AF was 8.17% with a sensitivity of 1 and specificity of 0.9.

Conclusion

LA longitudinal strain in contractile phase is a powerful method to identify AF in cryptogenic stroke. When reduced, anticoagulation may be considered in order to prevent recurrence. Further studies are warranted to reproduce these results in larger cohorts.

Funding Acknowledgement

Type of funding source: None

Hyperbaric oxygen for radiation-induced cystitis: A long-term follow-up

INTRODUCTION AND OBJECTIVES

Bladder complications may be seen in up to 12% of patients treated with pelvic irradiation. Hyperbaric oxygen therapy (HBOT) is an option for the management of radiation-induced hemorrhagic cystitis (RIHC). The aim of this study was to evaluate the efficacy of HBOT in radiation cystitis and to identify the predictive factors for a successful outcome.

MATERIAL AND METHODS

We retrospectively reviewed 105 patients diagnosed with RIHC which were treated with HBOT between 2007 and 2016 in our institution. Patients received 100% oxygen in a multiplace hyperbaric chamber at 2.4atm for 80minutes. All patients fulfilled a questionnaire documenting symptom severity pre-HBOT and at the end of the follow-up period.

RESULTS

After a median of 40 HBOT sessions, there was success rate of 92,4% in the control of hematuria. During our follow-up period (median of 63 months) 24,7% patients presented with recurrence of hematuria. The mean score of the questionnaire-assessed variables: dysuria, urinary frequency and hematuria, was significantly lower after the follow-up period (P<.05). Our data shows that the sooner HBOT is delivered after the first episode of hematuria, better response rates are achieved and lower recurrences concerning hematuria were registered (P<.05). No serious complications were observed.

CONCLUSIONS

Our results support the safety and long-term benefits of HBOT on RIHC and other distressful bladder symptoms, which represents an expected improvement of quality of life in our patients.

Correlates of children's physical activity during the COVID-19 confinement in Portugal

OBJECTIVES

The aim of the study was to understand the role of household variables on the percentage of physical activity (%PA) during the coronavirus disease 2019 (COVID-19) confinement in Portugal.

STUDY DESIGN

A cross-sectional study design using an anonymous online survey was launched to assess how Portuguese families with children aged younger than 13 years adjusted their daily routines to the confinement.

METHODS

Separate analyses of variance were performed to investigate how factors such as the number of children, age, sex, the housing characteristics, and the adults' job situation can affect the percentage of time for PA (%PA).

RESULTS

Findings, based on data from 2159 children, indicate that (1) boys and girls did not differ in the %PA on any of the age-groups; (2) children with an outdoor space and who had other children in the household were significantly more active (P < .001); (3) children from families with all adults working from home showed lower levels of %PA; and (4) being younger, having a big outdoor space, having other children in the household, and having at least one adult free from working from home were significant positive predictors of children's %PA, explaining 21% of the overall variance.

CONCLUSION

Time allocated for PA during this period is reduced compared with what is usually reported on normal days. It is necessary to find strategies to increase children's PA, especially in families in which both parents are working and have no outdoor space.

Evaluation of MMP-10 and TIMP-1 levels associated with Resveratrol supplementation

Introduction Resveratrol (RSV) is a natural phytoalexin present in abundance in grapes, berries, peanuts and red wine. The main benefits of resveratrol ingestion are due to its anti-inflammatory and antioxidant properties. This compound also induces therapeutic benefits in the remodelling of extracellular matrix (ECM), which plays an important role in the regulation of the activity of matrix metalloproteinases (MMPs) and its tissue inhibitors of metalloproteinases (TIMPs). The MMPs are a family of zinc dependent endopeptidases, with an important role in the physiological and pathological remodelling of ECM, once the activity of MMPs can be regulated by TIMPs. This regulation is essential, since if there is an imbalance between the MMPs and TIMPs there’s destruction of the ECM, leading to the development of several pathologies.

Objectives Evaluate RSV potential by determining serum and salivary levels of MMP-10 and TIMP-1.

Methodology The study population included 27 undergraduates between the ages of 18 and 30, divided into a control group (placebo) and an intervention group, supplemented with 100 mg RSV/day, during 30 days. MMP-10 and TIMP-1 levels were determined by slot blot. The results were analysed using a GraphPad Prism version 5 software for Windows (GraphPad Software, San Diego, California, USA).

Results It was verified the existence of a linear correlation between the serum and salivary levels of TIMP-1, as well as a tendency of increase of this biomarker after RSV supplementation. In all indicators studied, supplementation with this compound wasn’t harmful.

Conclusion The rising trend verified at TIMP-1 in both fluids may reflect benefits in the individuals under study, demonstrating that saliva has potential as a study biofluid for this type of biochemical markers. It was also verified that supplementation with this compound did not damage the evaluated parameters and, therefore, the RSV potential shouldn’t be rejected.

RETIRADO: El impacto de la pandemia de COVID-19 en la utilización de los servicios urológicos de urgencias

Este artículo ha sido retirado a petición del autor del artículo. La editorial lamenta los inconvenientes ocasionados.

Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal

Psychiatric symptoms in Huntington's disease the importance of reliable information – A case report

Introduction

Huntington's Disease is an autosomal dominant neurodegenerative disease characterized by motor, psychiatric and cognitive symptoms. Irritability, affective disorders, apathy and psychosis are among the most frequent psychiatric symptoms and can predate the pre-clinical period.

Objective

The authors’ goal is to understand the complexity of Huntington's disease clinical presentation. Additionally, we present an illustrative clinical case.

Aims

To convey the importance of collecting reliable information in order to make a proper diagnosis.

Methods

A PubMed database review was performed using “Psychiatry”, “Psychiatric”, “Symptoms” and “Huntington's Disease” as keywords; retrieved papers were selected according to their relevance. The patient clinical record was reviewed.

Results

The authors report a case of a 39-year-old woman, who was referred in 2014, to a psychiatrist because of depressive mood and suicidal ideation with two suicidal attempts in the past 5 years. However, she did not disclose her family history of Huntington's disease neither to her GP nor her psychiatrist. She never complied with the treatment plan and was admitted, in November, into a psychiatric unit because of subtle motor changes and apathy, which had resulted in personal neglect. The diagnosis could only be made after a family interview was held and the family medical history was revealed.

Conclusions

Corroborative history from caregivers is of extreme importance in psychiatry. Early detection of symptoms can help mitigate the disease social impact. In our patient's case, by the time of proper diagnosis, she was estranged from her family and had endured distressing psychiatric symptoms without adequate treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

162 Right ventricular function: is longitudinal strain by speckle-tracking an option?

Introduction

Estimation of right ventricular (RV) performance by echocardiography is challenging due to its anatomical and functional distinctiveness. RV longitudinal strain (RVLS) by speckle-tracking (STE) is an innovative tool and recent studies show that it can be used with prognostic significance, although it isn’t yet standardized.

Purpose

In this study, we aimed to evaluate global (G) and free wall (FW) RVLS-STE and its correlation with common RV evaluation methods.

Methods

We conducted a prospective observational study including 65 patients and 20 healthy controls. G and FW RVLS-STE were correlated to tricuspid annular plane systolic excursion (TAPSE), Doppler tissue tricuspid lateral annular systolic velocity (S`) and left ventricle ejection fraction (LVEF). Following current guidelines, a TAPSE higher than 17mm, a peak S` wave velocity higher than 9.5cm/s and a RVLS-STE inferior to -20% was considered normal.

Results

Mean age was 66.34 ± 15.45 years with 61.5% males in the patient group and 31.1 ± 7 years with 50% males in the control group. Echocardiographic findings in patient group included 44.6% with reduced LVEF (EF &lt; 50%), 26.2% with moderate to severe valvular disease, 23% with an elevated systolic pulmonary pressure (&gt; 35mmHg) and 36.9% without significant structural disease. The control group had no pathological signs on echocardiography. Peak S` wave and TAPSE showed a better correlation with FW RVLS-STE (r²=0.41, p &lt; 0.001 and r²=0.46, p &lt; 0.001) than G RVLS-STE (r²=0.27, p &lt; 0.001 and r²=0.30, p &lt; 0.001). A high absolute FW RVLS-STE (&lt; -20%) was a good marker of a normal TAPSE and a normal peak S` wave velocity, with a negative predictive value of 87% and 98% respectively. Comparing to control group, patients with reduced LVEF showed a reduction in TAPSE (27.6 mm vs 18.53 mm, p &lt; 0.001), S` (14.8 cm/s vs 10.84 cm/s, p &lt; 0.001) and FW RVLS-STE (-28.7% vs -15.34%, p &lt; 0.001). Patients with moderate to severe valvular disease also showed a reduction in TAPSE (27.6 mm vs 18.4 mm, p &lt; 0.001), S` (14.8 cm/s vs 10.3 cm/s, p &lt; 0.001) and FW RVLS-STE (-28.7% vs -16.04%, p &lt; 0.001). And finally, patients with elevated systolic pulmonary pressure also showed a reduction in TAPSE (27.6 mm vs 17.94 mm, p &lt; 0.001), S` (14.8 cm/s vs 10.47 cm/s, p &lt; 0.001) and FW RVLS-STE (-28.7% vs -16.7%, p &lt; 0.001).

Conclusion

FW RVLS-STE is better than G RVLS-STE as a RV evaluation method. RVLS-STE is correlated with TAPSE and peak S` wave velocity. It was the only parameter that showed reduction to abnormal values (&gt; -20%) in pathological groups and seems to be an accurate marker of RV function particularly detecting early dysfunction

P320 Left atrial mechanics in moderate mitral valve disease: earlier markers of damage

BACKGROUND

Left atrial (LA) mechanics is impaired in mitral valve disease, but it is not clear whether reservoir, conduit or contractile functions are differentially impaired in stenosis (MS) or regurgitation (MR). We aimed to study LA mechanics in patients with moderate MR or moderate MS and identify discriminators of disease.

METHODS

We conducted a prospective, observational study of 100 patients with isolated moderate MR and 100 patients with moderate MS. LA mechanics with speckle tracking echocardiography (STE) assessed LA reservoir (LA ɛsys and SRs), conduit(LAɛe, SRe), and contractile (LAɛa, SRa) functions. Left ventricle (LV) functional parameters were assessed as well, including LV ejection fraction (LVEF), LV end-diastolic diameter (LVDD) and LV global longitudinal strain (LV-GLS).

RESULTS

The mean age was 67 ± 14 years and 75% were female. Mean left ventricular ejection fraction (LVEF), LV end-diastolic diameter (LVDD), LV global longitudinal strain (LV-GLS) and systolic pulmonary artery pressure (sPAP) did not differ between MR and MS (table 1).LA indexed volume (LAVi) and LA strain did not vary between MR and MS, but strain rate did. SRs and SRe had better values in MR, whereas SRa had worse values in MR (table 1). SRe (&lt;-0.7%) had the superior discriminative power for MR, with an area under the curve of 0.85, sensitivity of 76% and specificity of 85%.

CONCLUSIONS

LA strain rate phases were the only parameters that varied between MR and MS. Contractile phase strain rate was more impaired in MR and conduit phase strain rate in MS. This highly specific data reflect the earlier hemodynamic changes occurring in LA in the setting of mitral valve disease.

mMR mMS P value LVEF (±SD,%) 57.4 ± 6.4 59.6 ± 4.6 0.145 LV-GLS (±SD, %) -17.7 ± 4.5 -17.1 ± 3.5 0.587 sPAP (±SD, mmHg) 30.3 ± 10.5 32.4 ± 8.3 0.387 LAVi (± SD, ml/m2) 46.3 ± 6.4 48.2 ± 7.4 0.281 LAɛs (± SD, %) 15.8 ± 7.3 13.3 ± 9 0.062 LAɛe (± SD, %) 8.4 ± 4.7 7.1 ± 5.4 0.074 LAɛa (± SD, %) 6.3 ± 4.8 7.4 ± 4.5 0.081 LA SRs (± SD, %) 0.8 ± 0.4 0.6 ± 0.3 0.004 LA SRe (± SD, %) -0.9 ± 0.5 -0.5 ± 0.3 &lt;0.001 LA SRa (± SD, %) -0.5 ± 0.4 -0.8 ± 0.5 0.007

P1249 Straight from the heart

Introduction

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge and is still associated with high mortality. Systemic complications are frequently present, and an adequate assessment and management are needed.

Purpose

Our aim is to show the importance of an early recognition of IE complications.

Clinical case

We present a case of 54 years old women with a past medical history unremarkable. The patient presented to the hospital with high fever and was admitted with a diagnosis of a psoas abscess and staphilococus aureus bacteremia. After one week of antibiotic treatment the patient was transferred to an intensive care unit due to septic shock and respiratory failure. The patient needed to be intubated and ventilated and was on treatment with vancomycin and meropenem. During admission, several infectious loci were identified, including cerebral and pulmonar involvement. An echocardiography identified mild mitral regurgitation, moderate tricuspid regurgitation and confirmed the presence of two vegetations, one in tricuspid valve with 30mm and one in mitral valve with 5mm. Nevertheless, the patient improved clinically. After 15 days of treatment, the patient was extubated and was transferred to the cardiology ward for follow-up. Although clinically stable and without any complain, repeated echocardiographic evaluation identified left ventricular apical aneurysm and partial resolution of vegetations. A coronariography was performed and did not identified any coronary lesion. A magnetic resonance confirmed the ischemic aetiology of the lesions and a diagnosis of embolic myocardial infarction was made. Considering a good resolution of infection, and being the patient stable and asymptomatic, she was discharged after 6 weeks of antibiotic therapy for follow up in cardiology and neurosurgery consultations.

Discussion and conclusion

Despite appropriate antimicrobial treatment, embolic complications are common and usually develop during initial stage of IE. This case shows several embolic complications of IE, including embolic myocardial infarction and cerebral embolism. Although aggressive antibiotic administration was successful in this particular case and cardiac surgery was avoided, the identification of complications allowed a more strict follow up and was determinant for a good clinical result.

Abstract P1249 Figure.

P184 Broken heart complications

Introduction

Patients with persistent chest discomfort or other symptoms suggestive of ischaemia and ST segment elevation in two contiguous leads on electrocardiography should be prompt managed to revascularization and emergent angiography for percutaneous intervention in two hours is the preferred reperfusion strategy.

Purpose

Our aim is to show the importance of differential diagnosis in a patient with an initial diagnosis of ST segment elevation myocardial infarction (STEMI).

Clinical case

We present a case of 67 years old women with a past medical history of dyslipidemia and polymyalgia rheumatica, treated with rosuvastatin 10mg id and prednisolone 5 mg id. The patient was admitted to emergency department complaining of chest pain with 3 hours of evolution that started after a period of nausea and vomiting. Physical examination showed slight tachypnea with 22 breath per minute, blood pressure 93/40 mmHg, heart rate 110 beats per minute, oxygen saturation in room air 90%, heart sounds with a systolic murmur II/VI and lung crackles in inferior lobes, with no peripheral oedema. Electrocardiography showed sinus rhythm and ST segment elevation in DI, DII and V2-6. Patient was treated with aspirin 300mg, ticagrelor 180mg, furosemide 40mg, oxygen therapy and was scheduled for emergent coronariography. This procedure revealed no significant coronary lesions and ventriculography identified apical ballooning, diagnosing takotsubo myocardiopathy. Clinical condition starts to deteriorate, and an echocardiography identified akinetic apical and midventricular segments and hyperkinetic basal segments with systolic anterior motion of mitral valve, significant mitral regurgitation and left ventricular outflow tract obstruction (LVOTO) with an intraventricular gradient superior to 60 mmHg. Adequate hemodynamic monitoring and heart rate control allowed a substantial clinical improvement. Two days later a cardiac magnetic ressonance was done, confirmed the diagnosis and identified an apical thrombus. The patient was later discharged stable with oral hypocoagulation with anti-vitamin K antagonist.

Discussion and Conclusion

Takotsubo cardiomyopathy is a unique cardiac syndrome characterized by transient systolic dysfunction witch often mimics acute coronary syndromes (ACS). After exclusion of an ACS, echocardiography is of primordial importance in the assessment of these patients. Left heart failure with pulmonar oedema, mitral regurgitation, LVOTO and thrombus formation were all complications that were present in this clinical case and established the indication to proper therapeutic attitudes.

Abstract P184 Figure.

P780 Left ventricular torsion in severe valvular disease

Introduction

Left Ventricular (LV) torsion is an important component of LV performance. With the development of speckle tracking echocardiography, it became possible and feasible to measure rotation and twisting with a high degree of accuracy. No standard normal values are defined for peak torsion, although mean values around 10° are found in normal subjects with a slight increase with age.

Purpose

In this study we aimed to evaluate torsion in the different types of severe valvular disease.

Methods

We conducted a retrospective, observational study including patients with severe valvular disease with suitable images for torsion analysis. We included 61 patients (21 with severe aortic stenosis (AS), 20 with severe aortic regurgitation (AR) and 20 with severe mitral regurgitation (MR). Circumferential basal and apical strain was performed, and peak torsion was calculated. Results were compared between groups and were related with echocardiographic parameters, including left ventricle ejection fraction (LVEF).

Results

Mean age was 70.3 ± 13.6 years with a male preponderance (66%). Mean LVEF was within normal range in the aortic valve disease group; no significant difference was found in LVEF between AS and AR patients (57 ± 7.7% vs 55 ± 9.7%, p = 0.57). In comparison with the aortic disease group, MR patients had a reduced LVEF (48 ± 17.3% vs 56 ± 8.7%, p = 0.05). Mean peak torsion was 8.9 ± 5.1° in AS, 12.6 ± 4.9° in AR and 7.9 ± 3.2° in MR (p = 0.004). Comparing with aortic valve disease patients, MR patients had a reduced mean peak torsion (7.9 ± 3.2° vs 10.7 ± 5.3°, p = 0.03). In relation with patients with AS, those with AR had a higher peak torsion (12.6 ± 4.9° vs 8.9 ± 5.1°, p = 0.024) and a higher left ventricle end-diastolic volume (87.3 ± 29.1 mL.m-² vs 64.5 ± 24.9 mL.m-², p = 0.011). Circumferential apical strain showed a negative correlation with peak torsion (r²=0.203, p = 0.006) and with LVEF (r²=0.290, p &lt; 0.001). Peak torsion did not demonstrate any significant correlation neither LVEF nor circumferential basal strain.

Conclusion

LV function and peak torsion are more associated with apical than basal circumferential movement. Aortic valve disease is responsible for LV torsion variations in patients with normal ejection fraction, showing an increase in AR and a reduction in AS. In MR patients a reduced LVEF could entails a decrease in peak torsion.