P1147Complications in young ICD patients - a retrospective analysis

Introduction

In specific situations implantable cardioverter defibrillator (ICD) therapy is recommended for patients under the age of 40 years. Due to the active lifestyle of this patient population, complication rates in devices with conventional transvenous electrodes may be higher than for the remaining population.

Methods

The ICD-YOUNG study is a retrospective analysis of consecutive patients ≤ 40 years undergoing transvenous or subcutaneous ICD (s-ICD) implantation, device change or lead revision at our centre between July 2006 and December 2017. Rehospitalization for lead failure or device battery depletion was documented.

Results

Out of 586 patients undergoing ICD implantation, 35 patients (6.0%) were ≤ 40 years. Mean age was 30.0 ± 7.2 years, 48.6% were female, 37.1% received ICD therapy for primary prevention and 11.4% primarily received s-ICD. Median follow up was 7.3 (interquartile range, 1.8-12.0) years, with a lower follow up duration in s-ICD patients than conventional ICD patients (median, 2.9 vs. 9.0 years). Over the course of follow-up, 37.1% received successful anti-tachycardia therapy. 19.4% of patients in the conventional ICD group had right ventricular lead problems requiring intervention, while none of the s-ICD patients had to be revised. Time to first device change due to battery depletion and/or device upgrade was similar in young and remaining patients (median 5.4 vs 6.0 years, p = 0.23).

Discussion

Young patients requiring ICD have a high rate of lead problems. In most young patients, s-ICD therapy is an encouraging alternative to conventional ICD therapy with a lower lead failure rate.

3293Atherothrombotic risk and outcomes following guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome:a post-hoc analysis of the TROPICAL-ACS trial

Background

A de-escalation of P2Y12-inhibitor treatment guided by platelet function testing (PFT) has been identified as a safe and alternative treatment strategy in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). However, no specific data are available on the efficacy of such strategy in patients with high atherothrombotic risk (ATR).

Purpose

To investigate the safety and efficacy of guided de-escalation of P2Y12-inhibitor treatment in patients with low- vs. high-ATR.

Methods

The TROPICAL-ACS trial randomized 2,610 biomarker-positive ACS patients 1:1 to either conventional treatment with prasugrel for 12 months (control group) or to a PFT guided de-escalation treatment strategy (guided de-escalation group). The primary endpoint was defined as the composite of cardiovascular mortality (CVM), myocardial infarction (MI), stroke, and clinically overt bleeding (bleeding ≥ grade 2 according to the BARC criteria). The ischemic endpoint was defined as the composite of CVM, MI or stroke. We used semi-parametric Cox regression analysis and interaction testing to assess the effect of low- vs. high-ATR on the primary and ischemic endpoints. High-ATR was defined as one of the following: (i) age ≥65 years or (ii) age <65 and either history of peripheral artery disease or at least two of the following risk-factors: diabetes mellitus, current smoking or renal dysfunction.

Results

Patients with high- (n=990) versus low-ATR (n=1,620) exhibited a higher risk for the primary endpoint (11.0% vs. 6.7%; HR 1.67; 95% CI 1.28–2.18; p<0.001). Guided de-escalation was non-inferior to conventional treatment for the primary endpoint in both patients with high- (10.5% vs. 11.5%; pnon-inferiority = 0.029; Figure 1A) and low-ATR (5.6% vs. 7.7%; pnon-inferiority=0.001; Figure 1B). Moreover, there was no significant interaction in the prognostic value of guided de-escalation between high- and low-ATR groups for both the primary (HR 0.90 [0.61–1.32]; p=0.586 in patients with high-ART vs. 0.71 [0.48–1.04; p=0.082 in patients with low-ATR; pinteraction= 0.394) and combined ischemic endpoints (HR 0.83 [0.44–1.56]; p=0.567 in patients with high-ATR vs. 0.68 [0.35–1.34]; p=0.262 in patients with low-ATR; pinteraction =0.666).

Kaplan-Meier curves

Conclusion

A guided DAPT de-escalation strategy appears to be safe and effective in ACS patients regardless of the atherothrombotic risk. Further studies are needed for refining antiplatelet treatment strategies in ACS patients with varying levels of atherothrombotic risk.

Acknowledgement/Funding

Klinikum der Universität München, Roche Diagnostics, Eli Lilly, and Daiichi Sankyo.

P3515Gender differences in plasma levels and prognostic value of NT-proBNP in chronic heart failure

Background

Natriuretic peptides are established biomarkers of heart failure (HF). The existence of gender-related differences in circulating levels and prognostic value are still controversial.

Methods

Individual patient data from studies assessing cardiac biomarkers (N-terminal fraction of pro-B-type natriuretic peptide - NT-proBNP - and high-sensitivity troponin T) for risk prediction in stable chronic HF were analysed.

Results

Women (n=1964, 23%) had higher median [interquartile interval] NT-proBNP concentrations than men (1678 [659–4215] vs. 1294 [522–2973] ng/L, p<0.001). Female gender predicted higher NT-proBNP independently from age, body mass index, glomerular filtration rate, left ventricular ejection fraction (LVEF), and atrial fibrillation.

Over a 2.4-year follow-up (1.6–3.2), 2351 patients (27%) died, and cardiovascular death occurred in 1558/8271 (19%). HF hospitalization was recorded in 2088/7944 (26%) over 2.0 years (1.3–2.6). Women and men had similar areas under the curve for the 3 endpoints, with higher cut-offs among women: all-cause death, 2328 ng/L vs. 1319 ng/L; cardiovascular death, 2328 ng/L vs. 1413 ng/L; HF hospitalization, 1265 ng/L vs. 907 ng/L. In the prognostic model above, the risk of the three endpoints increased by 32%, 35%, and 17%, respectively, per doubling of NT-proBNP in women, and by 41%, 45%, and 30% in men.

Conclusions

Women with chronic HF display higher NT-proBNP levels than men in the whole population as well as across many patient subgroups. This difference is not entirely explained by heterogeneity in age, BMI, or renal function. NT-proBNP holds independent prognostic significance in both genders, although alternative prognostic cut-offs might be considered for women.

P4587Impact of diabetes mellitus on myocardial revascularisation method in the light of the 2018 ESC/EACTS guidelines: Results from the PROUST Study

Background/Introduction

Results of currently available randomized trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The 2018 ESC/EACTS guidelines on myocardial revascularization do not recommend PCI in patients with diabetes and SYNTAX score ≥23.

Purpose

We aimed to compare the all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics.

Methods

The study group comprised consecutive diabetics with angiographically proven three-vessel CAD (≥50% diameter stenosis) and/or unprotected left main CAD (≥50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG between 2008 and 2010. All-cause mortality was ascertained by telephone contacts and/or from Mortality Registries.

Results

Using the hospital data system, 5145 patients were screened and 4803 elected not to follow the inclusion criteria. Out of 342 included patients, 177 patients underwent PCI and 165 patients were referred for CABG. Patients with whom CABG was performed were significantly older (64.69±8.8 vs. 62.6±9.4, p=0.03), more often on insulin treatment (91/165=55.2% vs. 26/177=14.7%, p<0.01), had more complex anatomical characteristics i.e. higher SYNTAX scores (32.5 IQR (15) vs. 18.0 IQR (15), p<0.01) and with left main stenosis (70/165=42.4% vs. 7/177=4.0%, p<0.01), compared to patients treated with PCI. The cumulative incidence rates of all-cause death were significantly different between PCI and CABG at 4 years (16/177=9.0% vs. 26/165=15.7%, respectively, log-rank p=0.03). There was a higher incidence of all-cause mortality in PCI patients with intermediate (23–32) and high (≥33) SYNTAX scores compared with those with low (0–22) SYNTAX scores (6/32=18.8% vs. 6/124=4.8%, log-rank p=0.01; 4/21=19.1% vs. 6/124=4.8%, log-rank p=0.02, respectively). On the contrary, patients who underwent CABG displayed similar morality rates irrespective of the SYNTAX scores (SYNTAX 0–22: 5/34=14.7%; SYNTAX 23–32: 9/54=16.7%; SYNTAX ≥33: 12/77=15.6%; log-rank p=0.9). Finally, when compared with CABG, more deaths were observed following PCI with intermediate and high SYNTAX scores (intermediate SYNTAX (23–32) PCI: 6/32=18.8% vs. CABG: 26/165=15.8%, log-rank p=0.94; high SYNTAX (≥33) PCI: 4/21=19.1% vs. CABG 26/165=15.8%, log-rank p=0.87).

Conclusions

During a 4-year follow-up, CABG in comparison with PCI was associated with a higher rate of all-cause death, which can be accounted for by older age and comorbidities. In diabetics, our analysis is suggestive that PCI probably should be avoided in patients with SYNTAX ≥23, which is in concordance with the most recent guidelines. Individualized risk assessment as well as quantification of CAD by SYNTAX score remains essential in choosing appropriate revascularization method in patients with diabetes and complex CAD.

Acknowledgement/Funding

None

P1725Current spectrum and 1-year mortality of cardiogenic shock in Europe. Results of the CULPRIT-SHOCK randomized clinical trial and registry

Background

An early invasive strategy with coronary revascularization has been shown to improve prognosis in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Little is known about the current spectrum, treatment and 1-year mortality in patients with CS undergoing early angiography in Europe.

Methods

We evaluated baseline characteristics, treatments and 1-year outcome in a large number of patients with CS included into the prospective CULPRIT-SHOCK randomized trial and the accompanying registry. Between April 2013 and April 2017, a total of 1075 patients with cardiogenic shock were screened at 83 European centers, of whom 706 (65.6%) were included in the randomized trial RCTand 369 into the registry.

Results

The median age was 67 years and 25% were female. In total, 55% of patients had pre-hospital resuscitation, 6% underwent fibrinolysis before angiography, 65% presented with ST-elevation myocardial infarction, 15% with left bundle branch block, and 20% with non-ST-elevation myocardial infarction. The majority of patients (80%) needed mechanical ventilation. Catecholamines were used in 90% and mechanical support in 29.5% of the patients (IABP 38.5%, ECMO 22%, Impella 33%, other 7%). Total 30-day and 1-year mortality was 46% and 52%, respectively. Mechanical complications were observed in 2.1% of patients, the latter had a 30-day and 1-year mortality of 62% and 67%, respectively. The mortality related to the extent of coronary artery disease is shown in the table.

1-vessel (14%) 2-vessel (31%) 3-vessel (55%) Left main (15%) 30-day mortality 36% 44% 51% 53% 1-year mortality 39% 50% 57% 64%

Conclusions

This first report including data of the prospective CULPRIT-SHOCK randomized trial as well as the accompanying registry demonstrates the high-risk clinical characteristics of patients with AMI complicated by CS undergoing contemporary treatment. Despite an early invasive strategy mortality in patients with AMI complicated by CS in Europe is still high and is related to the extent of coronary artery disease.

P2580Changes in extracellular vesicles during and after STEMI and potential influences of remote ischemic conditioning

Background

Due to their role in transportation of different molecules, such as microRNAs and mRNAs, extracellular vesicles (EVs) enable inter-cellular communication. Therefore, they are potential biomarkers in several kinds of disease. Information on their kinetics during acute and subacute ST-elevation myocardial infraction (STEMI) is limited and potential influence of remote ischemic conditioning (RIC) has not been investigated in humans so far.

Methods

We conducted a randomized, controlled trial in patients with first-ever STEMI; all patients received primary percutaneous coronary intervention (PCI). Additionally, the interventional group received a protocol of RIC (5 min inflation of a blood pressure cuff on the left upper arm to 200mmHg, 5 min deflation, 4 repetitions in total), whereas controls received sham-intervention (cuff placement). Citrate-plasma for EV analysis was taken prior to (baseline) and immediately after PCI, as well as after 24 hours, 4 days and 1 months. EVs were characterized by a high-sensitive flow cytometer using fluorescence-triggering. EVs were defined as being positive for the intra-vesicular marker CalceinAM or superficial expression of phosphatidylserine (PS; target of Lactadherin) in addition to another superficial epitope. Mixed-models were used to investigate changes over time; time and RIC were treated as fixed effects, patients were treated as random effects to account for the multiple testing design.

Results

We included 32 patients (16 RIC, 16 control). There was a significant impact of RIC on the changes in platelet (CD41) EVs from baseline (P=0.03, Figure). Furthermore, pro-coagulatory platelet EV (PS+/CD41+) were influenced by time after STEMI (after PCI P=0.017; 24h P=0.005) with significant interaction with RIC immediately and 24h after PCI (P for interaction of time with RIC; after PCI P=0.024, after 24h P=0.008). Likewise, monocyte (CD14) EVs increased significantly with time (4 days P=0.005, 1 Month P<0.001) with significant reduced levels of monocyte EVs by RIC at these time points (P for interaction at 4 days = 0.0493; and 1 month <0.001). There was also a significant change from baseline without any effect of RIC observed in inflammatory/leucocyte EVs (CD66b+; P for change from baseline for all time points <0.001). Pro-coagulatory and inflammatory (PS+/CD15+) EVs were significantly reduced over time (at 24h P=0.007; at 4 days P=0.049, at 1 month P=0.002). Finally, endothelial (CD31+/CD41-) EVs were significantly increased at 1 month after STEMI (P=0.032).

Conclusion

Several circulating EV sub-population are influenced by the acute phase of STEMI. RIC significantly impacts on the changes in platelet EVs during the initial phase after STEMI. Future studies are needed to clarify the functional importance of theses changes and whether this influence is part of a cardioprotective effect of RIC.

Acknowledgement/Funding

LBC for Cardiovascular Research Vienna; ATVB Vienna, a grant of the “Medical Scientific Fund of the Mayor of the City of Vienna”

P4542Revisiting the obesity paradox in heart failure: percent body fat as predictor of biomarkers and outcome

Background

Obesity defined by body mass index (BMI) is characterized by better prognosis and lower plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF). We assessed whether another anthropometric measure, percent body fat (PBF), reveals different associations with outcome and HF biomarkers (NT-proBNP, high-sensitivity troponin T [hs-TnT], soluble suppression of tumorigenesis-2 [sST2]).

Methods

In an individual patient dataset, BMI was calculated as weight (kg)/height (m)2, and PBF through the Jackson-Pollock and Gallagher equations.

Results

Out of 6468 patients (median 68 years, 78% men, 76% ischaemic HF, 90% reduced EF), 24% died over 2.2 years (1.5–2.9), 17% from cardiovascular death. Median PBF was 26.9% (22.4–33.0%) with the Jackson-Pollock equation, and 28.0% (23.8–33.5%) with the Gallagher equation, with an extremely strong correlation (r=0.996, p<0.001). Patients in the first PBF tertile had the worst prognosis, while patients in the second and third tertile had similar survival. The risks of all-cause and cardiovascular death decreased by up to 36% and 27%, respectively, per each doubling of PBF. Furthermore, prognosis was better in the second or third PBF tertiles than in the first tertile regardless of model variables. Both BMI and PBF were inverse predictors of NT-proBNP, but not hs-TnT. In obese patients (BMI ≥30 kg/m2, third PBF tertile), hs-TnT and sST2, but not NT-proBNP, independently predicted outcome.

Conclusion

Patient prognosis improves with either BMI or PBF. Obesity, assessed with BMI or PBF, is associated with lower NT-proBNP but not hs-TnT or sST2. hs-TnT or sST2 are stronger prognostic predictors than NT-proBNP among obese patients.

P789TLR-4 expression predicts mortality in patients with acute heart failure

Background

Inflammation is regarded as an important trigger for disease progression in heart failure (HF) and activation of the inflammatory system was implicated in the pathophysiology of acute heart failure (AHF).

Toll-like receptors (TLRs) play an important role in acute inflammatory processes in critically ill patients by binding to pathogen associated molecular patterns (PAMP) and danger associated molecular patterns (DAMP). However, it is not known whether the expression patterns of TLRs on neutrophils and monocytes are associated with outcome in patients with severe AHF requiring intensive care unit (ICU) admission.

The aim of this prospective, observational study was to analyze whether TLR-expression on monocytes or neutrophils is associated with 30-day survival in patients with severe AHF.

Methods

We included 84 patients with severe AHF admitted to a cardiac ICU. Blood was taken at admission and mean fluorescence activity (MFI) of TLR-2, TLR-4 and TLR-9 on monocytes and neutrophils was analyzed by flow cytometry.

Results

Median age was 64 (IQR 48–74) years and 76.2% of patients were male. Median NT-proBNP was 4941 (IQR 1298–12273) pg/mL and 30-day mortality was 33.3%. TLR-4 expression on monocytes in survivors (740 IQR 694–854) was significantly lower than in non-survivors (871 IQR 723–979; p<0.05). TLR-2 and TLR-9 expression on monocytes and TLR expression on neutrophils was not associated with survival. TLR-4 expression on monocytes was significantly associated with survival independent of age, sex, creatinine and NT-proBNP levels.

Conclusion

Monocyte TLR-4 expression predicts mortality in patients admitted to a cardiac ICU for severe acute heart failure. This suggests that activation of the innate immune system by TLR-binding of DAMPS may play a significant role in critically ill acute heart failure patients.

P1724Prognostic impact of atrial fibrillation in acute myocardial infarction and cardiogenic shock: results from the CULPRIT-SHOCK trial

Background

It is unclear whether atrial fibrillation (AF) influences prognosis in patients with cardiogenic shock (CS) and multivessel disease.

Purpose

To investigate the prognostic impact of AF in patients with CS complicating acute myocardial infarction (AMI).

Methods

In a subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial, patients were grouped according to the presence of AF during index hospital stay. The primary endpoint was all-cause death at 30 days and the key secondary endpoint was all-cause death at 1 year.

Results

AF was documented in 142 (21%) of 686 patients. AF was not a significant predictor of 30-day (adjusted OR 1.01, 95% CI 0.66–1.56, p=0.95) and 1-year (adjusted OR 0.89, 95% CI 0.58–1.37, p=0.59) all-cause mortality. Patients with AF already on admission showed higher all-cause mortality at 30 days (52 of 90, 58% vs. 19 of 52, 37%; p=0.02) and 1 year (57 of 90, 63% vs. 20 of 52, 39%; p=0.004) compared to patients with newly detected AF during hospital stay. AF was significantly associated with the need for renal replacement therapy (adjusted OR 1.76, 95% CI 1.05–2.94, p=0.03) and longer time to hemodynamic stabilization (4, IQR 1–8 days vs. 3, IQR 1–6 days; p=0.04) at 30 days.

Conclusions

In CS complicating AMI all-cause mortality is similar in patients with and without AF. Adverse outcome was detected in the subgroup of patients showing AF already on hospital admission.

Insulin signaling and insulin response in subcutaneous and retroperitoneal adipose tissue in Holstein cows during the periparturient period

Adipose tissue response to endocrine stimuli, such as insulin, is crucial for metabolic adaptation at the onset of lactation in dairy cows. However, the exact molecular mechanisms behind this response are not well understood. Thus, the aim of this study was to determine the dynamics in protein expression and phosphorylation of key components in insulin signaling in subcutaneous (SCAT) and retroperitoneal (RPAT) adipose tissues of Holstein dairy cows. Furthermore, by ex vivo examinations, response to insulin was assessed in SCAT and RPAT at different time points during the periparturient period. Biopsy samples were taken 42 d prepartum, and 1, 21, and 100 d postpartum. Insulin and glucose concentrations were measured in blood serum in consecutive serum samples from d -42 until d +100. After parturition, the majority of the key components were downregulated in both adipose tissues but recovered by d +100. The extent of hormone-sensitive lipase phosphorylation increased postpartum and remained high throughout the experimental period. Strong differences in molecular response were observed between the 2 depots. The RPAT expressed a remarkably greater extent of AMP-activated kinase phosphorylation compared with SCAT, indicating that AMP-activated kinase as an energy sensor is highly active particularly in RPAT in times of energy scarcity. Consequently, this depot expressed a greater extent of hormone-sensitive lipase phosphorylation over the whole experimental period. Insulin response after parturition appeared to be greater in RPAT too, due to the significantly greater expression of the insulin receptor at d +21 and +100. Although insulin concentrations in plasma were low postpartum, the depot-specific changes in molecular modulation of insulin signaling and insulin response suggested that both adipose tissue depots studied were contributing to the periparturient homeorhetic adaptation, although most likely to a different extent.

Urokinase Antigen in Plasma of Patients with Liver Cirrhosis and Hepatoma

Plasma urokinase antigen levels were studied in 78 patients suffering from liver diseases. Blood was drawn before any specific medication was initiated. Impairment of liver function was comparable in all patients. In both groups of cirrhotic liver disease (alcoholic and non-alcoholic), normal levels of plasma urokinase antigen were found as compared to age-matched control groups. In both groups of patients with hepatomas (with or without a history of liver cirrhosis), however, significantly increased plasma urokinase antigen levels could be determined. These data indicate that an increase in plasma urokinase antigen might rather relate to malignant growth in liver disease than to impaired liver function.