Early and short-term intensive management after discharge for patients hospitalized with acute heart failure: a randomized study (ECAD-HF)

AIMS

Hospitalization for acute heart failure (HF) is followed by a vulnerable time with increased risk of readmission or death, thus requiring particular attention after discharge. In this study, we examined the impact of intensive, early follow-up among patients at high readmission risk at discharge after treatment for acute HF.

METHODS AND RESULTS

Hospitalized acute HF patients were included with at least one of the following: previous acute HF < 6 months, systolic blood pressure ≤ 110 mmHg, creatininaemia ≥ 180 µmol/L, or B-type natriuretic peptide ≥ 350 pg/mL or N-terminal pro B-type natriuretic peptide ≥ 2200 pg/mL. Patients were randomized to either optimized care and education with serial consultations with HF specialist and dietician during the first 2-3 weeks, or to standard post-discharge care according to guidelines. The primary endpoint was all-cause death or first unplanned hospitalization during 6-month follow-up. Among 482 randomized patients (median age 77 and median left ventricular ejection fraction 35%), 224 were hospitalized or died. In the intensive group, loop diuretics (46%), beta-blockers (49%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (39%) and mineralocorticoid receptor antagonists (47%) were titrated. No difference was observed between groups for the primary endpoint (hazard ratio 0.97; 95% confidence interval 0.74-1.26), nor for mortality at 6 or 12 months or unplanned HF rehospitalization. Additionally, no difference between groups according to age, previous HF and left ventricular ejection fraction was found.

CONCLUSIONS

In high-risk HF, intensive follow-up early post-discharge did not improve outcomes. This vulnerable post-discharge time requires further studies to clarify useful transitional care services.

Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

Diagnostic score of cardiac involvement in AL amyloidosis

AIMS

Early diagnosis of cardiac involvement is a key issue in the management of AL amyloidosis. Our objective was to establish a diagnostic score of cardiac involvement in AL amyloidosis and to compare it with the current consensus criteria [i.e. left ventricular hypertrophy >12 mm and N-terminal pro b-type natriuretic peptide (NT-proBNP) >332 ng/L].

METHODS AND RESULTS

We carried out a prospective and multicenter study on AL amyloidosis patients who underwent cardiac evaluation including clinical examination, electrocardiography (ECG), cardiac biomarkers, transthoracic echocardiography (TTE), and cardiac magnetic resonance imaging (CMR). Cardiac involvement was based on CMR and/or endomyocardial biopsy. In a derivation cohort of 114 patients (82 with cardiac involvement), the highest diagnostic accuracy was observed with NT-proBNP and troponin blood levels, TTE-derived global longitudinal strain (LS), and apical to basal LS gradient. By using multivariate analysis, we established a diagnostic score including global LS ≥-17% (1 point), apical/(basal + median) LS ≥0.90 (1 point), and troponin T >35 ng/L (1 point). A score >1 was associated with sensitivity of 94% and specificity of 97%, an area under the curve of 0.98 [95% confidence interval (CI) 0.93-0.99] as well as a net reclassification index of 0.39 (95% CI 0.28-0.46) when compared with consensus criteria. In a validation cohort of 73 AL amyloidosis patients, the area under the receiver operating characteristic curve of the diagnostic score was 0.97 (95% CI 0.90-0.99).

CONCLUSION

Combining T troponin blood levels and two echo-derived strain parameters leads to very high accuracy for diagnosing cardiac involvement in AL amyloid patients.

Vericiguat for the treatment of heart failure: mechanism of action and pharmacological properties compared with other emerging therapeutic options

INTRODUCTION

The significant morbidity and mortality in patients with heart failure (HF), notably in the most advanced forms of the disease, justify the need for novel therapeutic options. In the last year, the soluble guanylate cyclase (sGC) stimulator, vericiguat, has drawn the attention of the medical community following the report of reduced clinical outcomes in patients with worsening chronic HF (WCHF).

AREAS COVERED

The authors review the available data on the mechanism of action of vericiguat (cyclic guanosine monophosphate (cGMP) pathway), its clinical development program, its role in HF management, and its future positioning in the therapeutic recommendations.

EXPERT OPINION

cGMP deficiency has deleterious effects on the heart and contributes to the progression of HF. Different molecules, including nitric oxide (NO) donors, phosphodiesterase inhibitors, and natriuretic peptides analogues, target the NO-sCG-cGMP pathway but have yielded conflicting results in HF patients. Vericiguat acts as a sGC stimulator thus targeting the NO-sGC-cGMP pathway by a different mechanism that complements the current pharmacotherapy for HF. Vericiguat has shown an additional statistical add-on therapy efficacy by reducing morbi-mortality in patients with WCHF. A better evaluation of HF severity might be an important determinant to guide the use of vericiguat among the available therapies.

Cardiac troponin I and BNP for predicting zero Agatston score in patients with diabetes mellitus

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Coronary artery calcifications (CAC) scoring assessed by the Agatston score has shown an excellent prognostic value in large studies, particularly in diabetic patients, with a very low rate of cardiovascular events in patients with a zero Agatston score. Moreover, recent studies have suggested that high-sensitive cardiac troponin I (hs-cTnI) and brain natriuretic peptide (BNP) may be useful for detecting subclinical atherosclerosis, especially in diabetic patients. However, the link between hs-cTnI/BNP and the Agatston score has not been investigated in this population.

PURPOSE

The aim of this study was to investigate if hs-cTnI and BNP can bring additional value to predict zero Agatston score in patients with diabetes mellitus in addition to usual risk factors.

METHODS

Between 2015 and 2019, CAC score was prospectively performed in consecutive patients with diabetes mellitus with high cardiovascular risk. Patients with symptoms or known coronary artery disease were excluded. Within 24h from CT exam, peripheral blood samples were taken to measure hs-cTnI and BNP. The relationship between serum hs-cTnI/BNP concentrations and zero Agatston score was evaluated using univariate and multivariate binomial models. 77 variables have been used to build the model. The implication of hs-cTnI and BNP in this multivariate model was evaluated using nested models associated with Chi-squared test of independence.

RESULTS

A total of 844 patients with diabetes were enrolled (61 ± 7 years, 57% men, mean diabetes duration 18 years). In this population, 294 (35%) had a zero Agatston score, 253 (30%) an Agatston score from 1 to 100, 161 (19%) from 101 to 400, and 136 (16%) higher than 400. In univariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.63 [95% CI, 1.51-5.01]; p &lt; 0.001 and OR, 1.09 [95% CI, 1.01-1.22]; p = 0.03). In multivariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.38 [95% CI, 1.51-4.76]; p = 0.009 and OR, 1.18 [95% CI, 1.07-1.32]; p = 0.001). Among the 77 variables, the multivariate model including age, gender, smoking, dyslipidaemia, duration of the diabetes, arterial hypertension, presence of diabetic neuropathy, hs-cTnI and BNP concentrations, significantly discriminated the zero Agatston score (AUC = 0.81; p &lt; 0.001). The most discriminant threshold was ≤ 3ng/l for hs-cTnI and &lt;17ng/l for BNP. In nested models, both hs-cTnI and BNP brought information to this multivariate model to predict a zero Agatston score (respectively p = 0.003 and p &lt; 0.001 to the Chi-squared test). Moreover, removing hs-cTnI and BNP from the model results in a significant reduction in model performance (AUC = 0.79; p = 0.004).

CONCLUSIONS

Cardiac biomarkers hs-cTnI and BNP are associated with a zero Agatston score, which is correlated with a very low risk of cardiovascular events in asymptomatic patients with diabetes mellitus.

Abstract Figure. ROC curve to predict zero Agatston score

Characterization of non-response to cardiac resynchronization therapy by post-procedural computed tomography

INTRODUCTION

Causes of non-response to cardiac resynchronization therapy (CRT) include mechanical dyssynchrony, myocardial scar, and suboptimal left ventricular (LV) lead location. We aimed to assess the utility of Late Iodine Enhancement Computed Tomography (LIE-CT) with image subtraction in characterizing CRT non-response.

METHODS

CRT response was defined as a decrease in LV end-systolic volume > 15% at 6 months. LIE-CT was performed after 6 months, and analyzed global and segmental dyssynchrony, myocardial scar, coronary venous anatomy, and position of LV lead relative to scar and segment of latest mechanical contraction.

RESULTS

We evaluated 29 patients (age 71 ± 12 years; 72% men) including 18 (62%) responders. All metrics evaluating residual dyssynchrony such as wall motion index and wall thickness index were worse in non-responders. There was no difference in presence and extent of scar between responders and non-responders. However, in non-responders, the LV lead was more often over an akinetic/dyskinetic area (72% vs. 22%, p = .007), a fibrotic area (64% vs. 8%, p = .0007), an area with myocardial thickness < 6 mm (82% vs. 22%, p = .002), and less often concordant with the region of maximal wall thickness (9% vs. 72%, p = .001). Among the 11 non-responders, eight had at least another coronary venous branch visualized by CT, including three (27%) coursing over a potentially interesting myocardial area (free of scar, with normal wall motion, and with a myocardial thickness ≥6 mm).

CONCLUSION

LIE-CT with image subtraction allows a comprehensive characterization of patients after CRT and may provide clues for management of non-responders.

High-sensitivity cardiac troponin T and NT-proBNP for ruling-in and ruling-out of cardiac amyloidosis

Background

Cardiac amyloidosis (CA) is caused by the extracellular deposition of misfolded proteins into insoluble amyloid fibrils, the 2 most common forms being transthyretin (ATTR) and immunoglobulin light chain (AL) amyloidosis. Chronic elevation of cardiac troponins and natriuretic peptides is common in CA and predicts worse outcome. The diagnostic yield of biomarkers of cardiac damage for CA has been less investigated.

Purpose

We aimed to evaluate the ruling-in/out values for the diagnosis of CA of high-sensitivity cardiac troponin T (hs-cTnT) and of N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP).

Methods

We studied 275 consecutive patients referred to two tertiary Centers in Italy (n=184) and France (n=91) with the clinical suspicion of CA due to the presence of a plasma cell dyscrasia or an unexplained left ventricular (pseudo)hypertrophy. CA was confirmed by the combination of suggestive features on imaging techniques (echocardiography, cardiac magnetic resonance, diphosphonate scintigraphy) and biopsy examination. All patients underwent a full baseline characterization including hs-cTnT and NT-proBNP. Biomarkers values corresponding to a negative likelihood ratio &lt;0.1 or a positive likelihood ratio &gt;10 were respectively chosen as rule-out and rule-in cut-offs for CA.

Results

CA was confirmed in 161 (59%) patients, who had either AL amyloidosis (n=96, 60%) or ATTR amyloidosis (n=65, 40%). At time of evaluation, 97 (35%) patients (34 CA vs. 63 controls, p=0.112) were hospitalized for decompensated heart failure. Patients with CA showed higher hs-cTnT (65 ng/L [44–122] vs. 31 [18–42], p&lt;0.001) and NT-proBNP (4260 ng/L [2006–8911] vs. 1199 [468–3357], p&lt;0.001) than those without CA. The area under the curve (AUC) values for hs-cTnT and NT-proBNP were 0.832 and 0.744 respectively (p=0.002 for the difference). The combination of the two biomarkers (AUC=0.836) improved discrimination over NT-proBNP (p=0.004), but not over hs-cTnT (p=0.423). A hs-cTnT value &lt;15 ng/L (sensitivity=100%, negative predictive value=100%, true negatives=13, false negatives=0) and a NT-proBNP &lt;550 ng/L (sensitivity=98%, negative predictive value=89%, true negatives=33, false negatives=4) were selected as rule-out cut-offs. A hs-cTnT level ≥80 ng/L (specificity=96%, positive predictive value=93%, true positives=71, false positives=5) was optimal for ruling in amyloidosis, while no rule-in cut-off could be selected for NT-proBNP. hs-cTnT values of either ≥80 or &lt;15 ng/dL could effectively rule-in/out 89 (32%) patients.

Conclusions

Plasma hs-cTnT and NT-proBNP have diagnostic value in patients with suspected CA. Stand-alone hs-cTnT levels &lt;15 or ≥80 ng/L may help to exclude or confirm the diagnosis of CA in up to one third of patients undergoing a diagnostic screening for the disease.

Figure 1

Funding Acknowledgement

Type of funding source: None

Cardiac troponin I and BNP for predicting zero Agatston score in patients with diabetes mellitus

Background

Coronary artery calcifications (CAC) scoring assessed by the Agatston score has shown an excellent prognostic value in large studies, particularly in diabetic patients, with a very low rate of cardiovascular events in patients with a zero Agatston score. Moreover, recent studies have suggested that high-sensitive cardiac troponin I (hs-cTnI) and brain natriuretic peptide (BNP) may be useful for detecting subclinical atherosclerosis, especially in diabetic patients. However, the link between hs-cTnI/BNP and the Agatston score has not been investigated in this population.

Purpose

The aim of this study was to investigate if hs-cTnI and BNP can bring additional value to predict zero Agatston score in patients with diabetes mellitus in addition to usual risk factors.

Material

Between 2015 and 2019, CAC score was prospectively performed in consecutive patients with diabetes mellitus with high cardiovascular risk. Patients with symptoms or known coronary artery disease were excluded. Within 24h from CT exam, peripheral blood samples were taken to measure hs-cTnI and BNP. The relationship between serum hs-cTnI/BNP concentrations and zero Agatston score was evaluated using univariate and multivariate binomial models. 77 variables have been used to build the model. The implication of hs-cTnI and BNP in this multivariate model was evaluated using nested models associated with Chi-squared test of independence.

Results

A total of 844 patients with diabetes were enrolled (61±7 years, 57% men, mean diabetes duration 18 years). In this population, 294 (35%) had a zero Agatston score, 253 (30%) an Agatston score from 1 to 100, 161 (19%) from 101 to 400, and 136 (16%) higher than 400. In univariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.63 [95% CI, 1.51–5.01]; p&lt;0.001 and OR, 1.09 [95% CI, 1.01–1.22]; p=0.03). In multivariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.38 [95% CI, 1.51–4.76]; p=0.009 and OR, 1.18 [95% CI, 1.07–1.32]; p=0.001). Among the 77 variables, the multivariate model including age, gender, smoking, dyslipidaemia, duration of the diabetes, arterial hypertension, presence of diabetic neuropathy, hs-cTnI and BNP concentrations, significantly discriminated the zero Agatston score (AUC = 0.81; p&lt;0.001). The most discriminant threshold was ≤3ng/l for hs-cTnI and &lt;17ng/l for BNP. In nested models, both hs-cTnI and BNP brought information to this multivariate model to predict a zero Agatston score (respectively p=0.003 and p&lt;0.001 to the Chi-squared test). Moreover, removing hs-cTnI and BNP from the model results in a significant reduction in model performance (AUC = 0.79; p=0.004).

Conclusions

Cardiac biomarkers hs-cTnI and BNP are associated with a zero Agatston score, which is correlated with a very low risk of cardiovascular events in asymptomatic patients with diabetes mellitus.

ROC curve to predict zero Agatston score

Funding Acknowledgement

Type of funding source: None

Delayed acute myocarditis and COVID-19-related multisystem inflammatory syndrome

Precise descriptions of coronavirus disease 2019 (COVID‐19)‐related cardiac damage as well as underlying mechanisms are scarce. We describe clinical presentation and diagnostic workup of acute myocarditis in a patient who had developed COVID‐19 syndrome 1 month earlier. A healthy 40‐year‐old man suffered from typical COVID‐19 symptoms. Four weeks later, he was admitted because of fever and tonsillitis. Blood tests showed major inflammation. Thoracic computed tomography was normal, and RT–PCR for SARS‐CoV‐2 on nasopharyngeal swab was negative. Because of haemodynamic worsening with both an increase in cardiac troponin and B‐type natriuretic peptide levels and normal electrocardiogram, acute myocarditis was suspected. Cardiac echographic examination showed left ventricular ejection fraction at 45%. Exhaustive diagnostic workup included RT–PCR and serologies for infectious agents and autoimmune blood tests as well as cardiac magnetic resonance imaging and endomyocardial biopsies. Cardiac magnetic resonance with T2 mapping sequences showed evidence of myocardial inflammation and focal lateral subepicardial late gadolinium enhancement. Pathological analysis exhibited interstitial oedema, small foci of necrosis, and infiltrates composed of plasmocytes, T‐lymphocytes, and mainly CD163⁺ macrophages. These findings led to the diagnosis of acute lympho‐plasmo‐histiocytic myocarditis. There was no evidence of viral RNA within myocardium. The only positive viral serology was for SARS‐CoV‐2. The patient and his cardiac function recovered in the next few days without use of anti‐inflammatory or antiviral drugs. This case highlights that systemic inflammation associated with acute myocarditis can be delayed up to 1 month after initial SARS‐CoV‐2 infection and can be resolved spontaneously.

Prognostic value of cardiopulmonary exercise testing in cardiac amyloidosis

AIMS

In amyloid patients, cardiac involvement dramatically worsens functional capacity and prognosis. We sought to study how the cardiopulmonary exercise test (CPET) could help in functional assessment and risk stratification of patients with cardiac amyloidosis (CA).

METHODS AND RESULTS

We carried out a multicentre study including patients with light chain (AL) or transthyretin (TTR) CA. All patients underwent exhaustive examination including CPET and follow-up. The primary prognostic endpoint was the occurrence of death or heart failure hospitalization. Overall, 150 patients were included (91 AL and 59 TTR CA). Median age, systolic blood pressure, N-terminal pro B-type natriuretic peptide (NT-proBNP) and cardiac troponin T were 70 (64-78) years, 121 [interquartile range (IQR) 109-139] mmHg, 2806 (IQR 1218-4638) ng/L and 64 (IQR 33-120) ng/L, respectively. New York Heart Association classes were I-II in 64%. Median peak oxygen consumption (VO₂ ) and circulatory power were low at 13.0 (10.0-16.9) mL/kg/min and 1730 (1318-2614) mmHg/mL/min, respectively. The minute ventilation/carbon dioxide production slope was increased to 37 (IQR 33-45). A total of 77 patients (51%) had chronotropic insufficiency. After a median follow-up of 20 months, there were 37 deaths and 44 heart failure hospitalizations. At multivariate Cox analysis, peak VO₂  ≤13 mL/kg/min [hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.6-4.8], circulatory power ≤1730 mmHg/mL/min (HR 2.4, 95% CI 1.2-4.6) and NT-proBNP ≥1800 ng/L (HR 2.2, 95% CI 1.1-4.3) were found to be associated with the primary outcome. No events occurred in patients with both peak VO₂  >13 mL/kg/min and NT-proBNP <1800 ng/L, while the association of VO₂  ≤13 mL/kg/min with NT-proBNP ≥1800 ng/L identified a very high-risk subgroup.

CONCLUSION

In CA, CPET is helpful in assessing functional capacity, circulatory and chronotropic responses as well as the prognosis of patients along with cardiac biomarkers.

Hospitalization for acute heart failure: the in-hospital care pathway predicts one-year readmission

In patients with heart failure, some organizational and modifiable factors could be prognostic factors. We aimed to assess the association between the in-hospital care pathways during hospitalization for acute heart failure and the risk of readmission. This retrospective study included all elderly patients who were hospitalized for acute heart failure at the Universitary Hospital Lariboisière (Paris) during 2013. We collected the wards attended, length of stay, admission and discharge types, diagnostic procedures, and heart failure discharge treatment. The clinical factors were the specific medical conditions, left ventricular ejection fraction, type of heart failure syndrome, sex, smoking status, and age. Consistent groups of in-hospital care pathways were built using an ascending hierarchical clustering method based on a primary components analysis. The association between the groups and the risk of readmission at 1 month and 1 year (for heart failure or for any cause) were measured via a count data model that was adjusted for clinical factors. This study included 223 patients. Associations between the in-hospital care pathway and the 1 year-readmission status were studied in 207 patients. Five consistent groups were defined: 3 described expected in-hospital care pathways in intensive care units, cardiology and gerontology wards, 1 described deceased patients, and 1 described chaotic pathways. The chaotic pathway strongly increased the risk (p = 0.0054) of 1 year readmission for acute heart failure. The chaotic in-hospital care pathway, occurring in specialized wards, was associated with the risk of readmission. This could promote specific quality improvement actions in these wards. Follow-up research projects should aim to describe the processes causing the generation of chaotic pathways and their consequences.

P2489What are the main determinants of an increase in bnp level in asymptomatic diabetic patients without known cardiac disease?

Background

Diabetes mellitus is associated with a high risk of heart failure. The predictors of futures heart failure events in diabetic patients are not clearly understood. BNP measurement can be used as a surrogate endpoint for the diagnosis of heart failure. We investigated the determinants of an increase in BNP level in a large cohort of asymptomatic diabetic patients without known cardiac disease

Methods

This prospective study included consecutive stable diabetic (type 1 or 2) patients coming for yearly check-up between March 2015 and July 2018 in the university center for the study of diabetes and its complications. Patients with an history of cardiac disease (coronary artery disease, atrial fibrillation, cardiomyopathy, previous heart failure ...) were excluded. All patients had a complete clinical exam, blood pressure measurement (3 consecutive times – mean of 2 lasts measurements), ECG, and blood sample including HbA1C, risk factors assessment, renal function (CKD-EPI) and BNP measurement. Data are presented as mean±SD or median - Spearman's rank and multivariate regression were used for analysis.

Results

3743 patients (mean age 57±14 y.o. – 57% male – 78% / 18% / 4% of type 2, type 1 or other type of diabetes respectively – Mean duration of diabetes 17 [1–63] y. – 44% treated with insulin) were studied. Mean±SD / median [min-max] BNP level was 25±39 / 12 [4–737] ng/L. BNP was <20 / 21–35 / 36–50 / 51–100 / 101–400 / >400 ng/L in 69 / 15 / 6 / 7 / 3 / 0.1% of the population respectively. The parameters most correlated with BNP level in type 1 and type 2 diabetes were age, duration of diabetes, renal function, HbA1C, and pulsed pressure. For multivariate analysis, renal function was removed of the model as it was highly correlated with age (r=−0.68). Multivariate analysis demonstrated that in type 1 diabetes, high BNP level was linked to age (p<0.001), pulsed pressure (p<0.001), duration of diabetes (p=0.003) and HbA1C (p=0.02). In type 2 diabetes, high BNP level was linked to age (p<0.0001), pulsed pressure (p<0.0001), duration of diabetes (p=0.005) but not HbA1C (p=0.09). Interestingly the type of treatment (mainly insulin treatment) was not independently related to an increase in BNP level.

Conclusion

Age, pulsed pressure and duration of diabetes are the main determinants of an increased level of BNP in asymptomatic diabetic patients without any history of cardiac disease. This result could help to select a population who could benefit to a more extensive follow up concerning heart failure.

P1658Pharmacological treatment of patients with HFrEF: is it really optimized in case of CRT and/or ICD implantation?

Background

Cardiac resynchronization (CRT) as well as implantable cardiac defibrillator (ICD) in primary prevention should be considered in patients with heart failure and reduced ejection fraction (HFrEF) only when pharmacological treatment has been optimized.

Purpose

we sought to analyze pharmacological treatments according to the presence or not of CRT-P, CRT-D or ICD in real life HFrEF patients by using a multicenter survey.

Methods

the survey (NCT01956539) was carried out between 2015 and 2018 in 32 hospitals and included 2735 patients with HF who gave their consent during consultation or hospitalization. In this study, we analyzed only outpatients with chronic HFrEF treated for more than 6 months.

Results

among 1061 patients studied, 138 had CRT-P or CRT-D and 215 had ICD for primary prevention. The main clinical characteristics were: age 65±13 years, ischemic heart disease in, NYHA classes 1, 2, 3 and 4 in 15%, 52%, 23% and 10% cases respectively, systolic blood pressure 115mmHg [IQR 104–129], heart rate 70bpm [IQR 60–80], eGFR 64ml/min/1.73m2 [IQR 46–83]and LVEF was 30% [IQR 24–34]. The table shows the rate of use of evidence-based drugs and the dose for ACEi/ARB and betablockers, according to the presence of ICD or CRT.

HFrEF CRT-P or D ICD (primary prevention) n=1061 n=138 n=215 Loop diuretics 78.2% 79.7% 74.9% ACEi or ARB 65.2% 75.4% 67.3% Sacubitril/valsartan 5.9% 8.5% 9.5% Betablockers 72.3% 83.9% 76.8% Mineralocorticoid antagonists 45.7% 63.6% 60.2% ACEi/ARB mean % maxi dose 77 81 83 Beta-blockers mean % maxi dose 74 63 79

Conclusion

these results suggest that pharmacological treatment remains poorly optimized in a number of patients with HFrEF who received ICD or CRT

P2733Prognostic value of cardiac dysautonomia in AL amyloidosis

Introduction

Cardiac involvement is the major prognostic factor in patients with light chain amyloidosis (AL). Cardiac dysautonomia can occur early in amyloidosis and can be assess by Iodine-123-metaiodobenzylguanidine (123I-MIBG) scintigraphy. Its prognostic value has been shown in TTR amyloidosis but is unknown in AL amyloidosis. We aimed to evaluate the prognosis impact of cardiac dysautonomia in patients with AL amyloidosis.

Methods

We carried out a prospective study in consecutive patients with biopsy-proven AL amyloidosis. All patients underwent clinical examination, EKG, echocardiography, cardiac MRI and biological tests. The 2012 Mayo clinic prognostic classification was calculated by using blood levels of NT-proBNP, cardiac T troponin and the differential of free light chains as recommended. The sympathetic cardiac innervation was assessed by using 123I-MIBGscintigraphy and measurement of the heart-to-mediastinum uptake ratio (late H/M) in the anterior view of the chest. A cardiac denervation was defined by late H/M <1.8 4h after injection of 3 MBq/kg of 123I-MIBG. The primary end-point was all-cause mortality during follow-up.

Results

Fifty consecutive patients with AL amyloidosis were included. The median age was 68 years old [58–73]. By using both echocardiography and MRI, cardiac involvement was diagnosed in 33 patients (66%) and thirteen of these patients were NYHA class III or IV. By using Mayo clinic classification, patients were I, II, III and IV classes in 9 (18%), 14 (28%), 16 (32%) and 11 (22%) cases respectively. According to echocardiographic data, the median wall thickness of left ventricle was 13 mm [12–15]. The late H/M was 1.51 [1.33–1.67]. Cardiac denervation was found in 44 patients (88%). The 6 patients (12%) with a normal late H/M had no cardiac amyloidosis involvement.

During a median follow-up of 24 months, 9 patients (18%) died. The area under the ROC curve of late H/M for predicting death was 0.74 (CI 95% 0.58–0.86). According to this curve, the best threshold was 1.44 and 7 of the 9 patients who died had late H/M ≤1.44. The figure shows the 2 year-survival according to late H/M. Late H/M ≤1.44 predicted all-cause death irrespective of the Mayo clinic classification: HR 8.0 (CI 95% 2.1–63) after adjustment on the Mayo clinic score (p=0.005). In addition, unplanned hospitalization for heart failure occurred in 8 patients with late H/M ≤1.44 versus 3 patients with late H/M >1.44 (p=0.03).

Survival according to late H/M

Conclusion

Late H/M ≤1.44 is predictive of adverse outcomes in patients with AL amyloidosis, independently of the Mayo Clinic prognostic classification.

P5444Plasma Indoleamine 2,3-dioxygenase is highly predictive of cardiac remodeling after myocardial infarction

Background

Acute myocardial infarction (MI) is associated with a strong inflammatory response resulting from the cardiac insult. On the other hand, such an inflammation may lead and/or worsen adverse left ventricular (LV) remodeling after MI. Among the markers of inflammation is Indoleamine 2,3-dioxygenase (IDO), which production is induced upon inflammation. IDO catalyzes the transformation of tryptophane into kynurenine.

Purpose

We tested plasma IDO activity as a predictor of LV remodeling post-MI.

Methods

The PREGICA cohort recruited prospectively patients who were admitted because of first acute myocardial infarction. Blood samples were collected on admission, at day 4 and at day 6. Echocardiography and cardiac MRI were obtained at day 4 and at 6 months. To be included, the number of akinetic LV wall segments had to be ≥3 on 17 at day 4. IDO activity was the ratio between kynurenine and tryptophane measured by high pressure liquid chromatography coupled with fluorimetric detection. Remodelers were identified as patients with a variation of end-diastolic left ventricular volume (EDLVV) between day 4 and 6 months post-MI >20%.

Results

Among the 292 patients studied (mean age 57y, mean necrosis size 26% on MRI), the median increase in EDLVV was 16.7% and 137 (47%) were classified as remodelers. On admission as well as at day 4, IDO activity was significantly higher in remodelers (8.2±4.2% vs 5.3±2.5% and 8.7±5.7% vs 5.6±4.4%, p<0.001) and remained higher at 6 months post-MI. IDO activity at day 4 was highly predictive of LV remodeling (Figure): AUC = 87% [95% CI 83–91%]; IDO threshold of 5.8% resulted in specificity = 81%, sensitivity = 89%, negative predictive value = 89%, positive predictive value = 80%. In contrast, blood levels of NTproBNP, ST2, Galectin 3 or CRP at day 4 were poorly predictive. In multivariate analysis including other predictive variables at day4 (primary angioplasty, EDLVV, LVEF, necrosis size), increase in IDO activity was significantly associated with LV remodeling (OR 1.21 [95% CI 1.11–1.33].

Conclusions

IDO activity appears as a promising biomarker for the prediction of LV remodeling after MI. Its specific role in postMI remodeling pathways requires further investigation.

Acknowledgement/Funding

PHRC national

101Characterization of the calcium component of vulnerable coronary plaque in patients with NSTEMI: prospective comparison between coronary CT and optical coherence tomography

Background

Acute Coronary Syndrome (ACS) remains a leading cause of mortality worldwide with a high risk of recurrence. Apart culprit plaques, the presence of vulnerable plaques could be associated with the occurrence of future cardiac events and need to adapt treatments. Several studies have demonstrated a role for Coronary Computed Tomographic Angiography (CCTA) to predict the vulnerability of the plaque but with limited analysis of its calcium component. Recent works suggest a role for calcification in this vulnerability.

To our knowledge, no studies have been performed to assess if the study of the calcium component of plaques with CCTA can help to predict vulnerability in non-ST elevation myocardial infarction (NSTEMI).

Purpose

To assess if the CCTA study of the calcium component of plaques can help to predict plaque vulnerability defined by intracoronary OCT analysis in patients with non-ST elevation myocardial infarction (NSTEMI).

Methods

Monocentric prospective study of consecutive patients referred for NSTEMI with elevated high-sensitivity cardiac troponin I level (hs-TnI>50 ng/ml) from January to October 2018. CCTA was systematically performed before coronary angiography to assess the presence of CAD. When CCTA demonstrated significant lesions, coronary angiography was performed within 24 hours associated with systematic OCT study of three coronary arteries. Apart culprit plaques, vulnerable plaques were defined in OCT by a fibrous screed thickness <65 microns. Calcified plaques were analysed with CT and then classified into 3 groups: vulnerable culprit plaque (VCP), vulnerable non-culprit plaque (VNCP) and stable plaque (SP).

Results

Of 1478 patients with chest pain, 257 (17%) had NSTEMI with high level of hs-TnI. From this 257 NSTEMI patients, 44 (17%) were without known CAD and among these, 33 (75%) had received coronary angiography with 29 (66% - mean age 59±13 years, 73% men) having coronary anatomy compatible with OCT assessment. A total of 123 calcified plaques were identified. Among them, OCT allowed to identify 77 (63%) SP and 47 calcified vulnerable plaques; 28 (23%) VNCP and 19 (15%) VCP. After CCTA analysis of the calcium component, predictive factors of plaque vulnerability were identified: longer calcification length (p<0.001), larger calcification volume (p<0.001), lower calcium mass (p=0.003), higher single plaque Agatston score (p<0.001), lower sphericity index (p=0.001), more spotty calcifications (p=0.001), as well as more intimal position in the wall (p<0.001). No significant differences were observed comparing VNCP and VCP (Figure).

OCT and “Virtual Histology” CT

Conclusion

CCTA study of the calcium component of plaque allows to identify predictors of plaque vulnerability defined by OCT in patients with NSTEMI.

132Imaging criteria for the diagnosis of heart failure with midrange and preserved LVEF in the real life

Background

According to last ESC guidelines, the diagnosis of heart failure with midrange and preserved left ventricular ejection fraction (HFmrEF-HF and HFpEF) requires at least one of the following imaging criteria: LV hypertrophy with LVMI >115g/m2 in men and 95g/m2 in women, left atria dilation with LAVI >34ml/m2, TDI e' wave average <9cm/s and E/e' average ≥13.

Purpose

We analyzed the prevalence of these imaging criteria in real life patients who are labeled HFmrEF or HFpEF by using a multicenter survey on HF.

Methods

Our survey (NCT01956539) was carried out in 32 hospitals between 2015 and 2018 and included 2735 HF patients who gave their consent during consultation or hospitalization. The diagnosis of HF was left to the discretion of investigators. Besides clinical and biological data, echocardiographic data (<1 month before or <3 months after inclusion) was collected in an electronic database. No echographic variable except the LVEF was mandatory to be included.

Results

Among the 523 and 765 HF patients who were labeled respectively as HFmrEF-HF and HFpEF, the 4 echographic variables required for the diagnosis of HFmrEF or HFpEF were obtained in 512 patients. The median age was 74y [IQR 62–82], HF was de novo in 28%, AF in 34%, median NTproBNP was 1563 pg/mL [IQR 500–4372]. At least one of the 4 diagnostic criteria was present in all patients but 2, and patients had 2, 3 or 4 criteria in 43%, 37% and 1% of cases. The table shows only little differences between HFmrEF and HFpEF or de novo HF regarding the rate of each diagnostic criteria. There was no difference regarding the date of inclusion, i.e. before or after the last ESC guidelines.

Table 1 All HF patients De novo HF HFpEF HFmrEF mrEF or pEF (n=143) (n=293) (n=219) LVMI >115g/m2 (men) or 95g/m2 (women) 69.6% 64.3% 68.6% 70.2% LAVI >34ml/m2 74.2% 73.3% 80.4% 68.9% e' average <9cm/s 64.1% 55.3% 55.9% 76.1% E/e' average ≥13 35.4% 38.6% 37.3% 32.8%

Conclusion

The diagnosis of HFpEF or mrEF may be difficult and requires comprehensive echocardiography including all diagnostic variables because each single diagnostic criteria are present in only 33 to 80% cases.