Acute heart failure: does etiology matter?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (pts) with acute heart failure (AHF) are a heterogeneous population. The etiology of the heart disfunction may play a role in prognosis. Risk stratification at admission may help predict in-hospital complications and needs.

Objective

To explore predictors of in-hospital mortality (IHM), post discharge early mortality [1-month mortality (1mM)] and late mortality [1-year mortality (1yM)] and early and late readmission, respectively 1-month readmission (1mRA) and 1-year readmission (1yRA), in our center population, using real-life data.

Methods

Based on a single-center retrospective study, data collected from patients (pts) admitted in the Cardiology department with AHF between 2010 and 2017. Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. The pts were divided in 3 groups: ischemic etiology (IE), valvular etiology (VE) and other etiologies (OE), which included hypertensive and idiopathic cardiomyopathies). Statistical analysis used non-parametric tests and Kaplan-Meyer survival analysis.

Results

We included 300 pts admitted with AHF. Mean age was 67.4 ± 12.6 years old and 72.7% were male. 37.7% had previous history of revascularization procedures, 66.9% had hypertension, 41% were diabetic and 38% had dyslipidaemia. The heart failure was of IE in 45%, VE in 22.7% and of OE in 32.3% of the cases.

There were no significant differences between groups regarding body mass index, Killip-Kimball class, systolic blood pressure at admission, blood tests aspects at admission (namely, creatinine, sodium or urea), inotropes’ usage or need of non-invasive or invasive ventilation. However, IE group had higher percentage of males comparing to VE e OE (83.0% vs 55.9% vs 70.1%, respectively, p < 0.001), higher rates of prior revascularization procedures (68.9%, vs 19.1%, vs 7.2%, p < 0.001) and higher rates of traditional cardiovascular risk factors, namely hypertension (74.1% vs 55.9% vs 57.7%, p = 0.014), diabetes mellitus (48.1% vs 27.9% vs 27.8%, p = 0.002) and dyslipidaemia (48.9% vs 30.9% vs 40.2%, p = 0.022). OE group was younger compared to IE and VE (63.9 ± 13.5 vs 68.9 ± 11.1 vs 69.5 ± 13.0 years old, respectively, p = 0.003). VE group had less left ventricle disfunction comparing to IE and VE groups (left ventricle ejection fraction 40.8 ± 14.1 vs 32.2 ± 9.8 vs 31.6 ± 12.8%, respectively, p < 0.001).

The groups showed no significant differences regarding IHM (IE 5.2% vs VE 8.8% vs OE 2.1%, p = 0.146), 1mRA (IE 8.1&, VE 7.4%, OE 3.1%, p = 0.276) or 1yRA (IE 55.6%, VE 54.4%, OE 47.4%, p = 0.449). However, VE group had higher rates of 1mM (VE 13.2% vs IE 8.9% vs OE 3.1%, p = 0.05) and 1yM compared to IE and OE (33.8% vs 30.4% vs 17.5%, respectively, p = 0.34). These aspects are represented in Kaplan Meier survival curves.

Conclusion

In our population, the etiology of heart failure was predictor of early and late post-discharge mortality but not readmission.

Cardiovascular risk factors as predictors of heart failure during hospitalization for Acute Coronary Syndromes

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

Cardiovascular risk factors (CVRF) are a growing health problem in developed countries. These patients have a higher prevalence of acute coronary syndromes (ACS) and as a consequence ACS complication, like heart failure (HF). HF after an ACS is a common complication and CVFR can influence its manifestation.

Objective

Evaluate the impact of the CVRF in HF during the hospitalization for ACS.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. Patients were divided in two groups: A – without new onset of HF during the hospitalization for ACS and B – with new onset of HF during the hospitalization for ACS. CVFR was defined by body mass index, diabetes, arterial hypertension, smoking, neoplasia, dyslipidemia, coronary artery disease, chronic kidney disease and peripheral arterial disease. Logistic regression was performed to assess predictors of new onset HF in these patients.

Results

14717 patients were included, 2287 in group B (15.5%). Both groups were similar regarding body mass index (27.5 ± 4.3 vs 27.2 ± 4.4, p = 0.254). Curiously the group A exhibited higher prevalence of smoking status (29.8 vs 16.6%, p < 0.001). On the other hand, group B presented more females (25.0 vs 35.7%, p < 0.001), arterial hypertension (68.7 vs 78.2%, p < 0.001), diabetes mellitus (28.5 vs 43.1%, p < 0.001), dyslipidemia (62.2 vs 64.3%, p = 0.023), coronary artery disease (19.6 vs 25.6%, p < 0.001), neoplasia (4.4 vs 7.0%, p < 0.001), peripheral arterial disease (5.2 vs 15.8%, p < 0.001) and chronic kidney disease (4.6 vs 10.0%, p < 0.001). Logistic regression revealed that body mass index, diabetes, arterial hypertension, neoplasia and dyslipidemia were not predictors of HF during the hospitalization for ACS. Nevertheless, female gender (odds ratio (OR) 1.37, p < 0.001, confidence interval (CI) 1.22-1.54), chronic kidney disease (OR 1.59, p < 0.001, CI 1.33-1.90) and peripheral arterial disease (OR 1.54, p < 0.001, CI 1.27-1.86) were predictors of new onset of HF during hospitalization for ACS. Curiously, smoking seems to have a protective effect (OR 0.68, p < 0.001, CI 0.59-0.78) in new onset HF in ACS patients.

Conclusions

Chronic kidney disease and peripheral arterial disease were predictors of new onset of HF in during hospitalization for ACS.

Predictors of early and late re-hospitalization and mortality in non-ST elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Introduction

Regarding prognosis, acute coronary syndromes (ACS) are heterogeneous. Non-ST elevation myocardial infarction (NSTEMI) is a subtype of ACS. In-hospital (IH) and post-hospitalization (PH) risk stratification is crucial.

Objective

To identify predictors of IH and PH mortality (early and late), as well as predictors of early and late re-admission (RA) in our center population suffering NSTEMI, using real-life data.

Methods

Based on a single-center retrospective study, data collected from admissions between 1/01/2018 and 11/12/2019. Patients (pts) who survived the ACS and were discharged from the hospital were included. Concerning prognosis, we assessed 1-month M and RA (1mM and 1mRA), 6-month M and RA (6mM and 6mRA), 1-year M and RA (1yM and 1yRA).

Results

268 pts with ACS, 59.7% were males and mean age was 66.4 ± 12.5 years old. NSTEMI was the diagnosis in 66.4% and ST elevation myocardial infarction (STEMI) in 31%. Mean creatinine was 1.2 ± 1ml/min, mean sodium was 138 ± 3mmol/L, mean blood urea nitrogen (BUN) was 21 ± 12mg/dL and mean haemoglobin (Hb) was 13.6 ± 1.9g/dL. 88.2% of the pts presented in Killip-Kimball class (KKC) 1, 5.7% in KKC 2, 5.7% in KKC 3 and 0.4% in KKC IV; furthermore, 4.1% of the pts presented de novo AF. Concerning coronary artery disease, 250 were submitted to coronary angiography – 18.8% had no lesions or non-significant lesions (stenosis <50%), 34.8% had one significant lesion, 23.2% had 2 significant lesions and 23.2% had 3 or more. Regarding left ventricle (LV) function, 70.5% of the pts had no LV dysfunction, 15.7% had mild LV impairment (LVI), 9.3% moderate LVI and 4.5% had severe LVI. 8.4% of the patients experienced IH complications, such as auriculoventricular block, heart failure, ventricular tachycardia, stroke, cardiorespiratory arrest and major haemorrhage, during hospitalization. 1mM rate was 1.9% and 1yM rate was 7.8%.

KKC (p = 0.001), BUN (p = 0.007), LV function (p= 0.001) and de novo AF (p = 0.46) were predictors of 1mM. Age (p = 0.004), KKC (p = 0.031), BUN (p = 0.002), sodium (p = 0.037), creatinine (p = 0.001), Hb (p = 0.003), LV function (p < 0.001), de novo AF (p < 0.001) and occurrence of IH complications (p < 0.001) were predictors of 1yM. Age (p = 0.010), male gender (p = 0.19), Hb (p = 0.031), de novo AF (p < 0.001) and occurrence of IH complications (p = 0.001) were predictors of 1mRA. Age (p = 0.004), smoking (p = 0.040), hypertension (p = 0.040), glycemia at admission (p = 0.031), Hb (p = 0.004), LV function (p = 0.019), de novo AF (p < 0.001) and occurrence of IH complications (p < 0.001) were predictors of 1yRA.

Conclusion

This study suggests that de novo AF and occurrence of IH complications are very important prognosis factors regarding early and late mortality and readmission rates.

Acute Coronary Syndrome - reinfarction predictors and outcomes

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Reinfarction (RI) is a potential complication of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of RI in the setting of ACS.

Objective

To evaluate predictors and prognosis of RI in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) without data on previous cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without RI; GB - pts with RI during hospitalization. Logistic regression and survival analysis were performed.

Results

Between 25718 pts with ACS, RI occurred in 223 (0.87%). Regarding epidemiological factors and past history, GB was older (70 ± 12 vs 67 ± 14, p < 0.001), had higher rates of hypertension (77.4% vs 70.6%, p = 0.028), previous stroke (12.1% vs 7.2%, p = 0.005), peripheric arterial disease (10.0% vs 5.5%, p = 0.004) and chronic obstructive pulmonary disease (8.6% vs 4.4%, p = 0.003). GB had higher rates of non-ST-elevation myocardial infarction (MI) (54.3% vs 45.9%, p = 0.012) and GA had higher rates of ST-elevation MI (42.4% vs 35.9%, p = 0.049). The groups were similar regarding blood pressure (p = 0.285), heart rate (p = 0.796) and Killip-Kimball class at admission, but GB had higher levels of brain natriuretic peptide (392 vs 180, p = 0.005). GB had higher rates of multivessel disease (62.8% vs 51.6%, p = 0.002), left ventricle dysfunction (50.0% vs 39.1%, p = 0.002), higher needs of mechanical ventilation (6.3% and vs 1.9%, p < 0.001) non-invasive ventilation (5.4% vs 1.7%, p < 0.001). Logistic regression confirmed that peripheric arterial disease (p = 0.011, OR 1.93, CI 1.17-3.19), multivessel disease (p = 0.003, OR 1.69, CI 1.20-2.39) and lower left ventricle function (p < 0.001, OR 2.42, CI 1.69-3.47) were predictors of RI in the setting of ACS. Event-free survival was similar between groups (p = 0.399).

Conclusion

RI in the setting of ACS was associated multivessel disease and left ventricle disfunction, however, 1-year prognosis was similar to pts who didn’t suffer RI.

Acute heart failure: is ACTION-ICU useful?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (pts) with acute heart failure (AHF) are a heterogeneous population. Risk stratification at admission may help predict in-hospital complications and needs. ACTION ICU score is validated to estimate the risk of complications requiring ICU care in non-ST elevation acute coronary syndromes.

Objective

To validate ACTION-ICU score in AHF as predictor of in-hospital M (IHM), post discharge early M [1-month mortality (1mM)] and 1-month readmission (1mRA), in our center population, using real-life data.

Methods

Based on a single-center retrospective study, data collected from pts admitted in the Cardiology department with AHF between 2010 and 2017. Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. Statistical analysis used non-parametric tests, logistic regression analysis and ROC curve analysis.

Results

We included 300 pts admitted with AHF. Mean age was 67.4 ± 12.6 years old and 72.7% were male. 37.7% had previous history of revascularization procedures, 66.9% had hypertension, 41% were diabetic and 38% had dyslipidaemia. Mean heart rate was 95.5 ± 27.5bpm, mean systolic blood pressure (SBP) was 131.2 ± 37.0mmHg, mean urea level at admission was 68.8 ± 40.7mg/dL, mean sodium was 137.6 ± 4.7mmol/L, mean glomerular filtration rate (GFR) was 57.1 ± 23.5ml/min. 35.3% were admitted in Killip-Kimball class (KKC) 4. Mean ACTION-ICU score was 10.4 ± 2.3. Inotropes’ usage was necessary in 32.7% of the pts, 11.3% of the pts needed non-invasive ventilation (NIV), 8% needed invasive ventilation (IV). IHM rate was 5% and 1mM was 8%. 6.3% of the pts were readmitted 1 month after discharge.

Older age (p < 0.001), lower SBP (p = 0,035), presenting in KKC 4 (p < 0.001, OR 8.13) and need of inotropes (p < 0.001) were predictors of IHM in our population. Older age (OR 1.06, p = 0.002, CI 1.02-1.10), lower SBP (OR 1.01, p = 0.05, CI 1.00-1.02) and lower left ventricle ejection fraction (LVEF) (OR 1.06, p < 0.001, CI 1.03-1.09) were predictors of need of NIV. None of the studied variables were predictive of need of IV. LVEF (OR 0.924, p < 0.001, CI 0.899-0.949), lower SBP (OR 0.80, p < 0.001, CI 0.971-0.988), higher urea (OR 1.01, p < 0.001, CI 1.005-1.018) and lower sodium (OR 0.92, p = 0.002, CI 0.873-0.971) were predictors inotropes’ usage.

ACTION-ICU was able to predict IHM (OR 1.51, p = 0.02, CI 1.158-1.977), 1mM (OR 1.45, p = 0.002, CI 1.15-1.81) and inotropes’ usage (OR 1.22, p = 0.002, CI 1.08-1.39), but not 1mRA, the need of IV or NIV.

ROC curve analysis revealed ACTION-ICU performs well when predicting IHM (Area under curve (AUC) 0.729, confidence interval (CI) 0.59-0.87), inotropes’ usage (AUC 0.619, CI 0.54-0.70) and 1mM (AUC 0.705, CI 0.58-0.84).

Conclusion

In our population, ACTION-ICU score was able to predict IHM, 1mM and inotropes’s usage.

Acute heart failure: predicting early in-hospital outcomes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (P) with acute heart failure (AHF) are a heterogeneous population. Risk stratification at admission may help predict in-hospital complications and needs. The Get With The Guidelines Heart Failure score (GWTG-HF) predicts in-hospital mortality (M) of P admitted with AHF. ACTION ICU score is validated to estimate the risk of complications requiring ICU care in non-ST elevation acute coronary syndromes.

Objective

To validate ACTION-ICU score in AHF and to compare ACTION-ICU to GWTG-HF as predictors of in-hospital M (IHM), early M [1-month mortality (1mM)] and 1-month readmission (1mRA), using real-life data.

Methods

Based on a single-center retrospective study, data collected from P admitted in the Cardiology department with AHF between 2010 and 2017. P without data on previous cardiovascular history or uncompleted clinical data were excluded. Statistical analysis used chi-square, non-parametric tests, logistic regression analysis and ROC curve analysis.

Results

Among the 300 P admitted with AHF included, mean age was 67.4 ± 12.6 years old and 72.7% were male. Systolic blood pressure (SBP) was 131.2 ± 37.0mmHg, glomerular filtration rate (GFR) was 57.1 ± 23.5ml/min. 35.3% were admitted in Killip-Kimball class (KKC) 4. ACTION-ICU score was 10.4 ± 2.3 and GWTG-HF was 41.7 ± 9.6. Inotropes’ usage was necessary in 32.7% of the P, 11.3% of the P needed non-invasive ventilation (NIV), 8% needed invasive ventilation (IV). IHM rate was 5% and 1mM was 8%. 6.3% of the P were readmitted 1 month after discharge.

Older age (p < 0.001), lower SBP (p = 0,035) and need of inotropes (p < 0.001) were predictors of IHM in our population. As expected, patients presenting in KKC 4 had higher IHM (OR 8.13, p < 0.001). Older age (OR 1.06, p = 0.002, CI 1.02-1.10), lower SBP (OR 1.01, p = 0.05, CI 1.00-1.02) and lower left ventricle ejection fraction (LVEF) (OR 1.06, p < 0.001, CI 1.03-1.09) were predictors of need of NIV. None of the variables were predictive of IV. LVEF (OR 0.924, p < 0.001, CI 0.899-0.949), lower SBP (OR 0.80, p < 0.001, CI 0.971-0.988), higher urea (OR 1.01, p < 0.001, CI 1.005-1.018) and lower sodium (OR 0.92, p = 0.002, CI 0.873-0.971) were predictors of inotropes’ usage.

Logistic regression showed that GWTG-HF predicted IHM (OR 1.12, p < 0.001, CI 1.05-1.19), 1mM (OR 1.10, p = 1.10, CI 1.04-1.16) and inotropes’s usage (OR 1.06, p < 0.001, CI 1.03-1.10), however it was not predictive of 1mRA, need of IV or NIV. Similarly, ACTION-ICU predicted IHM (OR 1.51, p = 0.02, CI 1.158-1.977), 1mM (OR 1.45, p = 0.002, CI 1.15-1.81) and inotropes’ usage (OR 1.22, p = 0.002, CI 1.08-1.39), but not 1mRA, the need of IV or NIV. ROC curve analysis revealed that GWTG-HF score performed better than ACTION-ICU regarding IHM (AUC 0.774, CI 0.46-0-90 vs AUC 0.731, CI 0.59-0.88) and 1mM (AUC 0.727, CI 0.60-0.85 vs AUC 0.707, CI 0.58-0.84).

Conclusion

In our population, both scores were able to predict IHM, 1mM and inotropes’s usage.

Acute Coronary Syndrome follow up: Portuguese experience

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

Acute coronary syndrome is a major health problem, with several acute and chronic complications. So, it is imperative identifying factors that can be associated with better and worse prognosis during the follow up these patients.

Objective

Evaluate predictors of mortality, cardiovascular readmission and all causes of readmission at 1 year follow up in ACS patients.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. Logistic regression was performed to assess predictors of mortality, cardiovascular readmission and all causes of readmission at 1 year follow up in ACS patients.

Results

1492 patients were included, 141 die during the first year. Age > 75 years old (odds ratio (OR) 2.557, p < 0.001, confidence interval (CI) 1.727-3.785), heart rate < 60 (OR 2.686, p = 0.008, CI 1.296-5.569), cardiogenic shock (OR 6.726, p = 0.012, CI 1.512-29.915), creatinine >2mg/dL (OR 1.956, p = 0.023, CI 1.099-3.480), left ventricular ejection fraction <50% (OR 1.911, p = 0.001, CI 1.284-2.844), nitrate (OR 1.589, p = 0.020, CI 1.074-2.351), ivabradine (OR 1.831, p = 0.011, CI 1.146-2.924), aldosterone antagonists (OR 1.632, p = 0.020, CI 1.079-2.468), diuretic (OR 1.625, p = 0.023, CI 1.069-2.472) and mechanical complication d (OR 55.518, p < 0.001, CI 11.516-267.655) were predictors of mortality of 1 year of follow up. Regarding cardiovascular readmission was registered in 291 patients, of a total 1412. Were predictors of cardiovascular readmission previous history of heart failure (OR 1.467, p = 0.003, CI 1.135-1.895), cardiogenic shock (OR 3.447, p = 0.039, CI 1.068-11.128), acetylsalicylic acid previous to ACS (OR 1.751, p = 0.008, CI 1.285-2.385), multivessel disease (OR 1.667, p = 0.002, CI 1.206-2.306), left ventricular ejection fraction <50% (OR 1.489, p = 0.003, CI 1.145-1.938), nitrate (OR 1.812, p < 0.001, CI 1.403-2.341), aldosterone antagonists (OR 1.572, p = 0.004, CI 1.155-2.140) and sustained ventricular tachycardia (OR 55.518, p < 0.001, CI 11.516-267.655). On the other hand 411 patients was readmitted (all causes), in 1455 patients with follow up. Were predictors of all causes of readmission previous history of heart failure (OR 1.347, p = 0.025, CI 1.039-1.747), previous chronic obstructive pulmonary disease (OR 1.456, p = 0.041, CI 1.016-2.087), atrial fibrillation (OR 1.439, p = 0.027, CI 1.041-1.988), acetylsalicylic acid previous to ACS (OR 1.473, p = 0.001, CI 1.161-1.869), left ventricular ejection fraction <50% (OR 1.456, p = 0.001, CI 1.166-1.819), nitrate (OR 1.478, p < 0.001, CI 1.192-1.831), aldosterone antagonists (OR 1.493, p = 0.003, CI 1.148-1.943) and sustained ventricular tachycardia (OR 3.792, p = 0.004, CI 1.540-9.337). Conclusions: Left ventricular ejection fraction <50%, nitrate as discharge therapeutic and aldosterone antagonists as discharge therapeutic were predictors of mortality, cardiovascular readmission and readmission for all causes at 1 year follow up.

Stroke in acute coronary syndrome: predictors and prognosis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Stroke is a potential complication of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of stroke in the setting of ACS.

Objective

To evaluate predictors and prognosis of stroke in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) without data on previous cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without stroke; GB - pts with stroke during hospitalization. Logistic regression was performed to assess predictors of stroke in ACS. Survival analysis was evaluated through Kaplan Meier curve.

Results

Population – 25711 pts with ACS, CA occurred in 154 (0.6%). Regarding epidemiological factors and past history, GB was older (72 ± 12 vs 67 ± 14, p < 0.001), had higher rates of females (53.2% vs 27.5%, p < 0.001), diabetes (43.9% vs 31.5%, p < 0.001), previous stroke (13.3% vs 7.2%, p = 0.004), peripheric arterial disease (9.2% vs 5.5%, p = 0.044) and dementia (6.8% vs 1.7%, p < 0.001), and had lower rates of smoking (16.6% vs 26.7%, p = 0.005), dyslipidaemia (53.5% vs 61.6%, p = 0.047) and previous ACS (12.7% vs 20.6%, p = 0.017. GB had longer times from first symptoms to admission (340min vs 240min, p = 0.011). The groups were similar regarding diagnosis, namely non-ST-elevation myocardial infarction (MI) (p = 0.345) and ST-elevation MI (p = 0.541). GB had higher heart rate (HR) (84 ± 24 vs 77 ± 19, p = 0.001), presented more frequently in Killip-Kimball class (KKC) ≥2 (28.0% vs 15.1%, p < 0.001), in atrial fibrillation (AF) (16.4% vs 7.1%, p < 0.001) and with higher brain-natriuretic peptide levels (545 vs 180, p < 0.001). The groups were similar regarding culprit lesion and number of lesions. GB had more left ventricle (<50%) dysfunction (51.4% vs 39.1%, p < 0.001) and needed more frequently mechanical ventilation (10.4% vs 1.9%, p < 0.001) and provisory pacemaker (8.4% vs 1.5%, p < 0.001).

Logistic regression confirmed that older age (p = 0.018, OR 1.69, CI 1.10-2.60), female gender (p < 0.001, OR 2.09, CI 1.38-3.15), diabetes (p = 0.002, OR 1.91, CI 1.27-2.86), dementia (p = 0.047, OR 2.13, CI 1.01-4.50), AF (p = 0.024, OR 1.87, CI 1.09-3.21) and lower left ventricle function (p = 0.002, OR 2.01, CI 1.29-3.15) were predictors of stroke in the setting of ACS. Event-free survival was higher in GA than GB (79.9% vs 70.5%, OR 1.58, p < 0.001, CI 1.36-1.83).

Conclusion

As expected, stroke in the setting of ACS is associated with poorer prognosis. Several characteristics of the pts may help to predict the occurrence of stroke during hospitalizations, therefore allowing an earlier identification and prompt treatment.

Cardiovascular risk factors as predictors of completed atrioventricular block during hospitalization for Acute Coronary Syndromes

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

The presence of cardiovascular risk factors (CVRF) are directly related to acute coronary syndrome (ACS) occurrence. ACS is a major health problem with multiple complications. Completed atrioventricular block (CAVB) in context of ACS can impact the patient’s prognosis, and is not clarified if its presence can be predicted only by CVFR.

Objective

Evaluate the impact of the CVRF in CAVB during the hospitalization for ACS.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. Patients were divided in two groups: A – without CAVB during the hospitalization for ACS and B – with CAVB during the hospitalization for ACS. CVFR was defined by body mass index, diabetes, arterial hypertension, smoking, coronary artery disease, neoplasia, dyslipidemia, chronic kidney disease and peripheral arterial disease. Logistic regression was performed to assess predictors of CAVB in these patients.

Results

14031 patients were included, 401 in group B (2.9%). Both groups were similar regarding smoking status (p = 0.920), arterial hypertension (p = 0.928), diabetes mellitus (p = 0.249), peripheral arterial disease (p = 0.352) and chronic kidney disease (p = 0.783). Interestingly the group A exhibited higher body mass index (27.4 ± 4.3 vs 26.9 ± 4.5, p < 0.001), dyslipidemia (62.8 vs 53.6%, p < 0.001) and coronary artery disease (20.7 vs 15.0%, p = 0.001). On the other hand, group B presented more females (26.7 vs 31.5%, p = 0.012), mean age (66 ± 13 vs 71 ± 13, p < 0.001) and neoplasia (4.8 vs 7.1%, p = 0.012). Logistic regression revealed that any of the CVRF were a predictor of CAVB during the hospitalization for ACS. Just, age (odds ratio 1.48, p < 0.001, confidence interval 1.16-1.88) has been a predictor of CAVB during hospitalization for ACS.

Conclusions

Any CVFR was a predictor of CAVB in context of ACS. Age was a predictor of CAVB during hospitalization for ACS.

Heart failure in Acute Coronary Syndrome: predictors and prognosis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Heart failure (HF) is a frequent complication of acute coronary syndromes (ACS). Therefore, it is important to access its impact on prognosis and identify patients (pts) with higher risk of HF.

Objective

To evaluate predictors and prognosis of HF in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Pts without data on cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without HF; GB - pts with HF during hospitalization.

Results

HF occurred in 4003 (15.6%) out of 25718 pts with ACS. GB was older (74 ± 12 vs 65 ± 13, p < 0.001), had more females (36.3% vs 26.2%, p < 0.001), had higher rates of arterial hypertension (78.4% vs 69.3%, p < 0.001), dyslipidaemia (64.4% vs 61.1%. p < 0.001), previous ACS (25.6% vs 19.7%, p < 0.001,), previous HF (16.4% vs 4.1%, p < 0.001), previous stroke (11.9% vs 6.4%, p < 0.001), chronic kidney disease (CKD) (17.1% vs 5.5%, p < 0.001), chronic obstructive pulmonary disease (COPD) (7.8% vs 3.8%, p < 0.001) and longer times from first symptoms to admission (268min vs 238min, p < 0.001). GA had higher rate of smokers (28.4% vs 16.2%, p < 0.001) and higher rate of non-ST-elevation myocardial infarction (MI) (46.5% vs 43.0%, p < 0.001). GB had higher rates of ST-elevation MI (STEMI) (49.2% vs 41.1%, p < 0.001), namely anterior STEMI (58.1% vs 44.9%, p < 0.001). GB had lower blood pressure (130 ± 32 vs 140 ± 28, p < 0.001), higher heart rate (86 ± 23 vs 76 ± 18, p < 0.001), Killip-Kimball class (KKC) ≥2 (63.2% vs 6.7%, p < 0.001), atrial fibrillation (AF) (15.4% vs 5.7%, p < 0.001), left bundle branch block (7.5% vs 3.1%, p < 0.001) and were previously treated with diuretics (39.1% vs 22.1%, p < 0.001), amiodarone (2.2% vs 1.4%, p < 0.001) and digoxin (2.8% vs 0.7%, p < 0.001). GB had higher rates of multivessel disease (66.0% vs 49.5%, p < 0.001) and planned coronary artery bypass grafting (7.3% vs 6.0%, p < 0.001), reduced left ventricle function (72.3% vs 33.4%, p < 0.001) and needed more frequently mechanical ventilation (8.2% vs 0.9%, p < 0.001), non-invasive ventilation (8.7% vs 0.5%, p < 0.001) and provisory pacemaker (4.5% vs 1.0%, p < 0.001). Logistic regression confirmed females (p < 0.001, OR 1.42, CI 1.29-1.58), diabetes (p < 0.001, OR 1.43, CI 1.30-1.58), previous ACS (p < 0.001, OR 1.27, CI 1.10-1.47), previous stroke (p < 0.001, OR 1.35, CI 1.16-1.57), CKD (p < 0.001, OR 1.76, CI 1.50-2.05), COPD (p < 0.001, OR 2.15, CI 1.82-2.54), previous usage of amiodarone (p = 0.041, OR 1.35, CI 1.01-1.81) and digoxin (p < 0.001, OR 2.30, CI 1.70-3.16), and multivessel disease (p < 0.001, OR 1.64, CI 1.67-2.32) were predictors of HF in the setting of ACS. Event-free survival was higher in GA than GB (79.5% vs 58.1%, OR 2.3, p < 0.001, CI 2.09-2.56).

Conclusion

As expected, HF in the setting of ACS is associated with poorer prognosis. Several features may help predict the HF occurrence during hospitalizations, allowing an earlier treatment.

Norwich COVID-19 testing initiative pilot: evaluating the feasibility of asymptomatic testing on a university campus

Background

There is a high prevalence of COVID-19 in university-age students, who are returning to campuses. There is little evidence regarding the feasibility of universal, asymptomatic testing to help control outbreaks in this population. This study aimed to pilot mass COVID-19 testing on a university research park, to assess the feasibility and acceptability of scaling up testing to all staff and students.

Methods

This was a cross-sectional feasibility study on a university research park in the East of England. All staff and students (5625) were eligible to participate. All participants were offered four PCR swabs, which they self-administered over two weeks. Outcome measures included uptake, drop-out rate, positivity rates, participant acceptability measures, laboratory processing measures, data collection and management measures.

Results

798 (76%) of 1053 who registered provided at least one swab; 687 (86%) provided all four; 792 (99%) of 798 who submitted at least one swab had all negative results and 6 participants had one inconclusive result. There were no positive results. 458 (57%) of 798 participants responded to a post-testing survey, demonstrating a mean acceptability score of 4.51/5, with five being the most positive.

Conclusions

Repeated self-testing for COVID-19 using PCR is feasible and acceptable to a university population.

Complex surgery and perioperative systemic therapy for genitourinary cancer of the retroperitoneum

Objective

The purpose of the present guideline is to recommend surgical or systemic treatment for metastatic testicular cancer; T3b or T4, or node-positive, and metastatic renal cell cancer (rcc); and T3, T4, or node-positive upper tract urothelial (utuc) cancer.

Methods

Draft recommendations were formulated based on evidence obtained through a systematic review of randomized controlled trials, comparative retrospective studies, and guideline endorsement. The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners.

Results

The primary literature search yielded eight guidelines, five systematic reviews, and twenty-seven primary studies that met the eligibility criteria.

Conclusions

Cytoreductive nephrectomy should no longer be considered the standard of care in patients with T3b or T4, or node-positive, and metastatic rcc. Eligible patients should be treated with systemic therapy and have their primary tumour removed only after review at a multidisciplinary case conference (mcc). Adjuvant sunitinib after surgery is not recommended. Patients with venous tumour thrombus should be considered for surgical intervention. Patients with T3, T4, or node-positive utuc should have their tumour removed without delay. Decisions concerning lymph node dissection should be done at a mcc and be based on stage, expertise, and imaging. Adjuvant systemic treatment is recommended for resected high-risk utuc. Patients with metastasis-positive testicular cancer with residual tumour after systemic treatment should be treated at specialized centres. For all complex retroperitoneal surgeries, the evidence shows that higher-volume centres are associated with lower rates of procedure-related mortality, and patients should be referred to higher-volume centres for surgical resection.

P1725 An easily dismissed suspect

Funding Acknowledgements

None

Introduction

Constrictive pericarditis (CP) is a rare etiology of heart failure. Is a chronic inflammatory process, characterized by scarring, fibrosis and pericardial calcification. Several etiologies can be associated with CP, namely infectious, idiopathy and post-surgical. In some cases, CP can extend to the myocardium and/or lead to cardiac dysfunction.

Case Report

58 years old woman, active smoking, referred to the emergency room for tachycardia on a routine electrocardiogram. History of 5 months of fatigue and dyspnea to ordinary activities, with progressive aggravation in the last month, associated with weight loss and episodic palpitations. Upon the physical examination presented jugular vein engorgement and peripheral edema. Admission electrocardiogram with atrial flutter at 150 of ventricular frequencies, without other findings. Thoracic radiography without variation (tenues pericardium enhancement), abdominal echography with moderate ascites. Blood work showed elevated liver enzymes, BNP of 230pg/ml, exclusion of infectious tuberculosis and autoimmune panel with isolated positive rheumatoid factor. Transthoracic echocardiography (TTE) at the emergency room show a non-dilated and global left ventricle hypokinesia, with reduced left ventricular ejection fraction (LVEF) and dilatation of the mitral valve ring in the genesis of moderate mitral regurgitation. Anticongestive and antiarrhythmic therapy started with rhythm conversion and clinical improve. Thoracic computed tomography scan reveals an extensive pericardial calcification. 2 months later TTE reveal a preserved LVEF, pericardial calcification, moderate mitral regurgitation, grade III diastolic dysfunction, respiration-related ventricular septal shift, increased of the mitral E-wave velocity with an E/A of 2.76, the peak mitral E-wave decreases 36% with the inspiration, dilated inferior vena cava without respiratory variation. Cardiac magnetic resonance imaging exposes a septal bounce and pericardial calcification, suggestive signs of constrictive pericarditis. The patient waits for cardiac catheterization for confirmation, being with anticoagulation, ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonist medication, remaining in NYHA class I.

Discussion

Clinical suspicion of CP is key for its identification, since there is not a specific clinical manifestation and generally patients presented heart failure symptoms. Echocardiography is best tool for a clinical physician evaluate heart failure etiologies, and can be used with higher sensitivity and specificity associated to the correct criteria to the diagnosis of CP. Pericardiectomy is the standard treatment, however the moment of its performance is not well established, since patients can remain in NYHA class I several years and the surgical procedure have higher mortality rates.

P631 A misleading EKG and the saviour echo

Introduction

Floating right heart thrombi (in transit from the legs to the pulmonary arteries) are a severe form of venous thromboembolism, with a high early mortality rate without treatment. Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism.

Case Report

Woman, 76 years old. Previous medical history of hypertension, dyslipidaemia, mitral valve repair and hypothyroidism. Recent admission in our cardiology department with de diagnosis of NSTEMI. She performed an echocardiogram that revealed only an enlarged left atrium, with no other changes. EKG only revealed inversion of T waves in V2-V4 with posterior normalization during hospital stay. She underwent to coronary angiography and right dominance without any coronary lesions was showed. The presence of a fistula, with a badly defined route, was also pointed in the coronary angio.

One month after this episode she was admitted again in our emergency department due to onset of dyspnoea and productive cough. The physical examination showed SatO2: 90%; BP: 95/53 mmHg; HR: 100 bpm; Respiratory rate: 27 cpm; Apyretic (36,9ºC). Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination. EKG revealed a sinus tachycardia, HR 122 bpm, with ST elevation in aVR and ST depression in DI, DII, aVL and V2-V6. Presence of S wave in DI and Q wave in DIII. While the EKG was being performed the patient presented a sudden cardiovascular deterioration (with blood pressure (BP: 67/35mmHg) drop and appearance of chest pain). We performed an arterial-blood gas test that revealed: pH7,16; pCO2 26,5; pO78,7; Potassium 4; Sodium 138; lactates 8,8. With these findings we decided to perform an echocardiogram to identify a possible cause for the shock. The echo showed right dilated chambers (with D-shape in parasternal short axis) with dilated IVC. We also point out the presence of a mobile intra-cardiac mass at the level of right atrium, suggestive of thrombus.

We assumed the presence of obstructive shock in the context of pulmonary embolism. Thrombolysis was performed with clinical improvement of the patient. Medical therapy was optimized and heparin was initiated after the patient finished alteplase perfusion.

During hospital stay the patients didn’t have any other cardiovascular complication and went home after 7 days in hospital. A venous doppler was performed before hospital discharge and it revealed the presence of a deep venous thrombosis at the level of right femoral vein.

Conclusion

The authors presented a didactic clinical case where the EKG mislead us to a possible Acute Coronary Syndrome involving the left main artery. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.