Risk of pericardiac effusion after cardiac implantable electronic device implantation a nationwide study

Funding Acknowledgements

Type of funding sources: None.

Background

Procedural pericardiac effusion (PE) is considered a major complication to implantation of cardiac implantable electronic devices (CIED), including permanent pacemakers (PM), cardiac resynchronization therapy devices with defibrillators (CRT-D) or without (CRT-P), and implantable cardioverter defibrillators (ICD), as it can cause life threatening cardiac tamponade. Very little is known about risk factors for procedural PE.

Aim

To identify the patient- and procedure related risk factors associated with clinically relevant procedural PE.

Methods & Results

This is a nationwide retrospective observational cohort study based on data on 51.599 patients from the Danish Pacemaker Register. Included were all Danish patients who received their first PM, CRT or ICD from 2000 – 2018. Procedural PE was defined related to the invasive procedure if it occurred within 1 months after the invasive procedure and no cancer was diagnosed before the procedure. Pre-specified risk factors, including sex, age, year, implantation center-type and device type were analyzed by multivariable logistic regression models to estimate the association with PE. A total of 78 (0.2%) patients were diagnosed with procedural PE, with a median age of 73 years and 43% were females. In adjusted logistic regression analysis age > 70, heart failure [aOR 1.64 (1.01;2.67)], ischemic heart disease [aOR 1.84 (1.13;2.99)], direct oral anticoagulation [aOR 1.77 (1.13–2.77.)], amiodarone use [aOR 3.03 (1.75–5.22)], beta blocking agent [aOR 2.26 (1.23 –4.14)], university hospitals [aOR 2.59 (1.18 –5.67)] and PM implantation [aOR 3.38 (1.77;6.45)], were associated with PE.

Conclusion

Procedural PE is a rare complication after CIED implantation in Denmark. Importantly most of the risk factors for PE are modifiable. Optimizing the modifiable risk factors may reduce the risk of complication.

Familial clustering of unexplained heart failure - A Danish nationwide cohort study

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This project has received funding from the European Union’s Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381, and the European Union’s COST programme under acronym PARQ, registered under grant agreement No CA19137.

Background

Although family history of heart failure (HF) is associated with increased risk of HF, the extent to which a family history contributes to the risk of HF needs further investigation.

Purpose

To determine whether a family history of unexplained HF in first-degree relatives (children or sibling) increases the rate of unexplained HF.

Methods

Using Danish nationwide registry data (1978-2017), we identified patients (probands) diagnosed with first unexplained HF (HF without any known comorbidities) in Denmark, and their first-degree relatives. All first-degree relatives were followed from the HF date of the proband and until an event of unexplained HF, exclusion diagnosis, death, emigration, or study end, whichever occurred first. Using the general population as a reference, we calculated adjusted standardized incidence ratios (SIR) of unexplained HF in the three groups of relatives using Poisson regression models.

Results

We identified 57,845 first-degree relatives to individuals previously diagnosed with unexplained HF. Having a family history was associated with a significantly increased unexplained HF rate of 2.08 (95% CI 1.82-2.38) (Figure 1). The estimate was higher among siblings (SIR 4.82 [95% CI 3.17-7.32]). Noteworthy, the rate of HF increased for all first-degree relatives when the proband was diagnosed with HF in a young age (≤50 years, SIR of 3.60 [95% CI 2.37-5.47]) and having >1 proband (SIR of 2.73 [95% CI 1.14-6.56]). The highest estimate of HF was observed if the proband was ≤40 years at diagnosis (6.12 [95% CI 3.39-11.05]) (Figure 2).

Conclusion

A family history of unexplained HF was associated with a two-fold increased rate of unexplained HF among first-degree relatives. If the proband age was ≤40 years, the risk was six-folded. These findings suggest that screening families of unexplained HF with onset below 50 years is indicated.

Systolic blood pressure and effects of screening for atrial fibrillation with long-term continuous monitoring

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The LOOP Study was supported by Innovation Fund Denmark [grant number 12-1352259], The Research Foundation for the Capital Region of Denmark, The Danish Heart Foundation [grant number 11-04-R83-A3363-22625], Aalborg University Talent Management Program, Arvid Nilssons Fond, Skibsreder Per Henriksen, R og Hustrus Fond, the European Union’s Horizon 2020 program [grant number 847770 to the AFFECT-EU consortium], Læge Sophus Carl Emil Friis og hustru Olga Doris Friis’ Legat, and an unrestricted grant from Medtronic.

Background

The recently published LOOP Study was a randomized controlled clinical trial to evaluate systematic atrial fibrillation (AF) screening with long-term continuous monitoring in an elderly population at risk and found no significant reduction in stroke. However, the screening effects seemed to differ across levels of systolic blood pressure (SBP). It is well-known that hypertension constitutes a prominent risk factor for clinical AF and stroke alike, but data on the impacts of SBP on subclinical AF and hereby AF screening efficacy are lacking.

Purpose

With this post hoc analysis of the LOOP Study, we aimed to provide insights into the interaction between SBP and benefits of systematic AF screening.

Methods

The LOOP Study randomized individuals aged 70-90 years with ≥1 stroke risk factor (hypertension, diabetes, heart failure, or previous stroke) and without prior AF to either monitoring with implantable loop recorder (ILR) and initiation of oral anticoagulation upon detection of new-onset AF episodes lasting ≥6 minutes, or usual care (control group). In total, 5997 participants with available SBP measurements at enrolment were included in the present analysis. The interaction between SBP and ILR screening efficacy on stroke or systemic arterial embolism (SAE), as indicated by hazard ratio (HR) for ILR versus control, was assessed with polynomial moving-average regression. The lowest SBP threshold with significant screening benefits was further determined and used to examine clinical outcomes and the occurrence of AF with respect to dichotomized SBP. Additionally, penalized spline models were employed to assess AF occurrence by SBP as a continuous variable.

Results

HR of stroke/SAE for ILR versus control decreased with increasing SBP and the lowest threshold for significant screening benefits was at SBP ≥150 mmHg. ILR screening of participants with SBP ≥150 mmHg yielded a 45% risk reduction of stroke/SAE (HR 0.55 [0.37-0.82]). Within the ILR group, SBP ≥150 mmHg was associated with an increased risk of AF episodes ≥24 hours as compared to lower SBP (HR 1.57 [1.01-2.45]), but not with the overall occurrence of AF (HR 1.14 [0.95-1.36]). No significant association between SBP and AF occurrence in the ILR group was reported in penalized spline models either (p-value: 0.73).

Conclusions

The benefits of ILR screening for AF on stroke/SAE increased with increasing blood pressure. SBP ≥150 mmHg was associated with a 1.5-fold increased risk of AF episodes ≥24 hours, along with an almost 50% risk reduction of stroke/SAE by ILR screening.

Socioeconomic position and initiation of SGLT-2 inhibitors or GLP-1 receptor agonists in patients with type 2 diabetes – a Danish nationwide observational study

Background

Between 2015 and 2017, Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucacon-like-peptide-1 receptor agonists (GLP-1 RA) were shown to reduce cardiovascular events in patients with type 2 diabetes and cardiovascular disease. Thus, in 2018, guidelines were updated to favor these drugs in patients with cardiovascular disease and type 2 diabetes. Lower socioeconomic position may adversely affect use of SGLT-2 inhibitors and GLP-1 RA.

Purpose

We aimed to examine socioeconomic differences in initiation of SGLT-2 inhibitors and GLP-1 RA in a contemporary population of patients with type 2 diabetes.

Methods

Through the Danish nationwide registers, we identified all patients with type 2 diabetes who initiated second-line add-on therapy after metformin monotherapy between December 10, 2012, and December 31, 2018. Patients aged 40–79 years and without a history of end-stage renal disease were included. We measured socioeconomic position according to level of income: Low = 1st quartile; Middle = 2nd and 3rd quartile; High = 4th quartile. Based on multivariable logistic regression models adjusted for age, sex, cohabitation status, duration of type 2 diabetes, comorbidities, and cardiovascular medications, we reported the standardised probabilities of initiating each drug class at time of first intensification according to income group and time period: 2012–2014, 2015–2017, and 2018.

Results

The 33,201 patients had a median age of 63 years (interquartile range 53–69). The probability of initiating a SGLT-2 inhibitor or a GLP-1 RA increased over time in all income-groups. In each time period, the standardised probability of initiating a SGLT-2 inhibitor or a GLP-1 RA at time of first intensification increased with increasing income (Figure): in 2012–2014, from 9.6% (95% confidence interval (CI) 8.4–10.9) in the lowest income group to 14.4% (CI 12.9–15.9) in the highest income group; in 2015–2017, from 19.5% (CI 18.3–20.7) to 24.6% (CI 23.3–25.9); in 2018, from 39.9% (CI 37.5–42.3) to 50.7% (CI 48.2–53.1). The absolute difference between high and low income groups increased over time, reaching 10.8% (CI 7.3–14.3) in 2018. A similar trend was observed in both subgroups of patients with and without established cardiovascular disease (data not shown). Initiation of a dipeptidyl peptidase-4 (DPP-4) inhibitor increased with income in the early time periods, but this trend reversed in 2018 (Figure). Initiation of sulfonylureas (SU) showed a consistent inverse association with income in each time period.

Conclusions

Low socioeconomic position was consistently associated with a lower probability of initiation of a GLP-1 RA or a SLGT-2 inhibitor at time of first intensification of antidiabetic treatment, even after guidelines recommended these drugs to patients with established cardiovascular disease. These disparities may adversely affect cardiovascular outcomes in patients with low socioeconomic position.

Funding Acknowledgement

Type of funding sources: None.

Prodromal symptoms of out-of-hospital cardiac arrest among patients calling emergency and non-emergency medical help services

Background

Early identification of individuals at risk of out-of-hospital cardiac arrest (OHCA) remains difficult. Little is known about symptoms presented when contacting a medical helpline prior to OHCA.

Aim

To examine the registered prodromal symptoms when patients phoned to seek medical help prior to OHCA.

Methods

OHCA patients (≥18 years) were identified from the Danish Cardiac Arrest Registry (2014–2018) and linked with calls to the non-emergency (1813-Medical Helpline) and Emergency Medical Services 1–1-2 (112). We examined (1) symptoms registered within 30 days before OHCA, categorized into eight groups and stratified by time-period and call-type; (2) hospital diagnoses and medical prescriptions according to symptom groups within 180 days before these calls.

Results

Among 974 OHCA patients who called in total within 30 days before OHCA, 816 OHCA patients (males 57%, median age 76 years [Q1-Q3: 65–84]) had a registered symptom and some of them called more than once (1,145 calls by 816 patients). Overall, the most reported group of symptoms was “Other” (29%), containing a diverse group of prodromal symptoms registered by the caregiver that did not fit into the other categories (Figure), followed by breathing problems (15%). When stratified by time-period (Figure) the most common symptom group remained “Other”. This was followed by symptoms related to the Central Nervous System (CNS)/Unconsciousness (17%) for the time-period within 0–7 days before OHCA, and by breathing problems (19%) and trauma/exposure (17%) for the time-period within 8–30 days before OHCA (Figure). When stratified by call-type, most patients (60.8%) called the 1813-Medical Helpline, where “Other” (35%) and abdominal/back/urinary (14%) symptom groups were the most common. While breathing problems (24%) and CNS/Unconsciousness (21%) were highly reported among calls to 112. Within 180-days before contact with the medical helpline, independently of the symptom group presented, respiratory-related hospital diagnoses and antibiotic medications were common.

Conclusions

Patients with OHCA who called emergency and non-emergency medical helpline 30 days before OHCA had diverse prodromal symptoms; the largest category were “Other” symptoms, followed by breathing-related symptoms.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 under the ESCAPE-NET program;Helsefonden Figure 1. Classification of the prodromal symptoms among patients that called for medical assistance. Stratified by the time-period within 0–7 days and 8–30 days before OHCA. The number of calls within 0–7 days before OHCA = 471 (399 patients), and the number of calls within 8–30 days before OHCA = 674 (500 patients).

Effect of empagliflozin in hfref patients treated with angiotensin receptor neprilysin inhibitor an analysis of EMPIRE HF

Introduction

Inhibition of neprilysin/valsartan (ARNi) or sodium glucose cotransporter 2 (SGLT2) in patients with heart failure (HF) and reduced ejection fraction (HFrEF) has been shown to reduce the risk of Cardiovascular death and hospitalization for HF. Recent trails suggested that SGLT2 reduces the risk for cardiovascular death or hospitalization for HF, regardless of underlying ARNi treatment and that the effect may even be greater in those receiving the combination. Whether there exist an interaction between effect of ARNi and SGLT2 on functional endpoints related to mechanism of action is unknown.

Purpose

This post-hoc analysis of the randomized double-blinded Empire HF trial evaluated the influence of ARNi on the effect of the SGLT2 Empagliflozin on N-terminal prohormone B-type natriuretic peptide (NT-proBNP), pulmonary capillary wedge pressure (PCWP), Left ventricular end-systolic and end-diastolic volumes index; (LVESVI) (LVEDVI), left atrial volume index (LAVI), Left ventricular ejection fraction (LVEF), and Kansas City Cardiomyopathy Questionnaire (KCCQ) HFrEF patients.

Methods

Empire HF trial randomized 190 patients with HFrEF (LVEF ≤40%) to placebo or empagliflozin (10 mg/day), on top of recommended treatment for HFrEF, for 12 weeks of treatment. A total of 58 (31%) received ARNi at baseline and no patients initiated ARNi during study period.

Results

Patients on ARNi were well-treated with a similar baseline characteristic as those who were not treated with ARNi (Table 1). Patients with ARNi had a lower systolic blood pressure (P=0.01), with a higher NT-proBNP (P<0.001) when compared with those not receiving ARNi. When compared to placebo, empagliflozin did not reduce the ratio of change of NT-proBNP with or without ARNi (0.94 [95% CI, 0.75 to 1.19] pg/ml; P=0.62) and (1.02 [95% CI, 0.86 to 1.22] pg/ml; P=0.78), respectively, adjusted (age, atrial fibrillation) interaction P=0.57. Empagliflozin reduced PCWP regardless of ARNi treatment (with ARNi; −4.9 [95% CI, −9.1 to −0.6] mmHg; P=0.02) and (without ARNi; −2.1 [95% CI, −3.8 to −0.4] mmHg; P=0.01), adjusted interaction P=0.20. Overall, empagliflozin was associated with a reduction in LVESVI, LVEDVI, and LAVI volumes, but no effect on LVEF. However, Empagliflozin combined with ARNi at baseline, significantly reduced LVEDVI (−11.2 [95% CI, −21.2 to −1.2] ml/m2; P=0.03), but not without ARNI (−2.9 [95% CI, −8.7 to 2.9] ml/m2; P=0.32), adjusted interaction P=0.13. Treatment-by-subgroup interaction P-values for LVESVI, LAVI, and LVEF analysis were >0.05 (Figure 1). KCCQ total symptom score were significantly increased in those not receiving ARNi (5.4 [95% CI, 1.1 to 9.6]; P=0.013), but not with ARNi (−4.0 [95% CI, −10.3 to 2.3]; P=0.22), adjusted P=0.02.

Conclusion

In this post hoc analysis the effects on empagliflozin to reduce PCWP and LV volumes were not diminished in patients receiving ARNi, however KCCQ change were diminished in patients receiving ARNi.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was supported by the Danish Heart Foundation [grant numbers 17-R116-A7714-22076, 18-R124-A8573-22107]; Steno Diabetes Center Odense, Denmark [grant number 3363] and A.P. Møller Foundation for the Advancement of Medical Science [grant number 17-L-0339]. Table 1. Baseline characteristicsFigure 1. Change in echo variables +/− ARNi

Elevated markers of liver function are associated with poorer outcomes in HFREF: an analysis of DAPA-HF

Background

Abnormalities of liver tests in patients with heart failure with reduced ejection fraction (HFrEF) is a well-recognised phenomenon. We examined the prognostic value of measures of liver function in a large contemporary cohort of patients with HFrEF enrolled in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial

Methods

In this post-hoc analysis of the DAPA-HF trial we studied 4625 patients with liver function tests available at baseline. Cox proportional hazards models were used to assess the association between liver tests (total bilirubin, alkaline phosphatase [ALP], alanine transaminase [ALT], aspartate transaminase [AST]) and the Model for End-stage Liver Disease excluding INR (MELD-XI) score (calculated as 5.11 Ln [total bilirubin as mg/dL] + 11.76 Ln [creatinine as mg/dL] + 9.44), and the risk of the primary composite endpoint (hospitalisation or urgent visit for heart failure or cardiovascular death). Models were adjusted for age, sex, race, region, systolic blood pressure, heart rate, LVEF, eGFR, log-transformed NT-proBNP, NYHA class, history of hypertension, stroke, myocardial infarction, atrial fibrillation, heart failure aetiology and randomized treatment to dapagliflozin and stratified by diabetic status at baseline. An interaction term between each measure and the effect of treatment on the primary composite outcome was tested as a fractional polynomial.

Results

Total bilirubin, ALP, and MELD-XI score were associated with a higher risk of all the primary outcome (Figure 1) but not ALT or AST. These relationships persisted after adjustment: total bilirubin per log unit increase (HR=1.46; 95% CI 1.28 – 1.67, p<0.001), ALP per log unit increase (HR=1.39; 95% CI 1.15 – 1.66, p<0.001), MELD-XI per 1 SD increase (HR 1.27; 95% CI 1.13 – 1.42, p<0.001). The effect of dapagliflozin on the primary outcome was not modified by the baseline levels of either total bilirubin, ALP or MELD-XI score (Figure 2)

Conclusions

Higher total bilirubin, ALP and MELD-XI score were independently associated with a higher risk of cardiovascular death or worsening HF and may be useful routinely available biomarkers to assess prognosis. The efficacy of dapagliflozin was the not modified by baseline levels of any of these markers.

Funding Acknowledgement

Type of funding sources: None. Figure 2

Age- and Sex-Specific Rates of Heart Failure and other Adverse Cardiovascular Outcomes in Systemic Sclerosis

Background

Age at disease onset and sex appear to modify the disease course in patients with systemic sclerosis (SSc). Although patients with SSc have a higher risk of adverse cardiovascular outcomes than people without SSc, there are few data on age- and sex-specific risks of heart failure (HF) and other adverse cardiovascular outcomes in patients with SSc.

Objectives

To investigate the long-term rates of HF and other adverse cardiovascular outcomes (including arrhythmias, myocardial infarction, ischemic stroke, venous thromboembolism, and pulmonary hypertension) in a nationwide cohort of patients with SSc compared with the background population according to age and sex, separately.

Methods

Using Danish nationwide registries, all patients >18 years with newly diagnosed SSc (1996–2018) were identified. SSc patients were matched at a 1:4 ratio by age, sex, and comorbidities with controls from the background population without SSc. Rates of outcomes according to age (above/below median age) and sex were compared between cases and controls using Cox regression.

Results

Of the 2,019 patients diagnosed with SSc, 1,569 patients were matched with 6,276 controls from the background population (median age 55 years, 80.4% women). SSc was associated with a higher rate of HF in both women (HR 2.99 [95% CI, 2.18–4.09]) and men (HR 3.01 [1.83–4.95]) (Pfor interaction=0.88), with similar findings for other cardiovascular outcomes.For age interaction, SSc was associated with an increased rate of HF in patients <55 years (HR 4.14 [2.54–6.74]) and ≥55 years (HR 2.74 [1.98–3.78]), with similar effect of younger and older groups on HF (P for interaction=0.21), and other cardiovascular outcomes.

Conclusions

SSc was associated with an increased long-term rate of cardiovascular outcomes compared with a matched background population, with similar extent in different gender and age groups.

Funding Acknowledgement

Type of funding sources: None. Adjusted hazard ratios according to sexAdjusted hazard ratios according to age

Increased prevalence of premature coronary atherosclerosis after preeclampsia

Background

Women with preeclampsia have increased risk of manifest coronary artery disease later in life. However, it remains unknown if and when premature coronary atherosclerotic stages can be identified. This knowledge could enable early intervention in women considered at high risk for future manifest coronary artery disease.

Purpose

Using cardiac computed tomography, we aimed to investigate the prevalence of premature coronary atherosclerosis in women with previous preeclampsia in comparison with women from the general population.

Methods

Women, aged 40–55 years, with previous preeclampsia were recruited in the CPH-PRECIOUS study and compared 1:1 with age- and parity-matched women from the CGPS. Both groups underwent a cardiac computed tomography, including a contrast-enhanced coronary computed tomography angiography and a non-contrast coronary artery calcium scoring, as well as an overall assessment of cardiovascular risk factors imbedded in an extensive questionnaire. Cardiac computed tomography examinations were analysed blindly. The main outcome of the study was the prevalence of any coronary atherosclerosis defined as any plaque at coronary computed tomography angiography or a calcium score >0 in case of a non-diagnostic coronary computed tomography angiography.

Results

A total of 1,424 women were included (715 women with previous preeclampsia and 709 controls from the general population). Women with previous preeclampsia were more likely to have cardiovascular risk factors (hypertension, dyslipidaemia, diabetes mellitus). The prevalence of any coronary atherosclerosis was significantly higher in the preeclampsia group (27.4% vs. 20.0%) (P=0.001). A calcium score >0 was also more prevalent in the preeclampsia group (16.6% vs. 11.8%) (P=0.009). Preeclampsia remained an independent risk factor for the presence of any coronary atherosclerosis after adjusting for cardiovascular risk factors (age, hypertension, dyslipidaemia, diabetes, smoking, body mass index, parity) (OR=1.37, 95% CI (1.05–1.79), P=0.021).

Conclusion

Women with previous preeclampsia are more likely show premature signs of coronary atherosclerosis compared with an age- and parity matched control group from the general population. Preeclampsia is an independent risk factor for premature coronary atherosclerosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationSkibsreder Per Henriksen, R og Hustrus FondKong Christian den Tiendes FondBrødrene Hartmanns FondHans og Nora Buchards FondArvid Nilssons FondAnita og Tage Therkelsens FondLægefondenAase og Ejnar Danielsens FondHjertecentrets Forskningsudvalg (Rigshospitalet)Direktør Kurt Bønnelycke og Hustru Fru Grethe Bønnelyckes FondLægeforeningens ForskningsfondTorben & Alice Frimodt FondHenry og Astrid Møllers Fond

Left atrial remodeling and cerebrovascular disease assessed by magnetic resonance imaging in patients undergoing continuous heart rhythm monitoring

Background

Atrial remodeling and atrial fibrillation (AF) have both been associated with cerebrovascular lesions. We wished to investigate the possible direct association between atrial remodeling and cerebrovascular disease including white matter lesions and lacunar infarcts in patients with and without atrial fibrillation (AF) as documented by implantable loop recorder (ILR).

Methods

Cardiac and cerebral MRI scans were acquired in a cross-sectional study including participants ≥70 years of age with stroke risk factors (history of hypertension, diabetes mellitus, congestive heart failure and/or previous stroke) but without known AF. Cerebrovascular disease was visually rated using the Fazekas scale and number of lacunar strokes. Left atrial (LA) (see figure) and ventricular volumes and function were analyzed, and associations between atrial remodeling and cerebrovascular disease were assessed with logistic regression models. Multivariable models were adjusted for sex, age, diabetes, hypertension, heart failure and history of stroke/transient ischemic attack. The analyses were stratified according to sinus rhythm or any AF during three months of continuous ILR monitoring to account for subclinical AF.

Results

Of 200 participants investigated, 87% had a Fazekas score≥1 and 45% had ≥1 lacunar infarct. Within three months of ILR implantation, AF was detected in 28 (14%) participants, while 172 (86%) had sinus rhythm only. Results are summarized in table. For participants with sinus rhythm, lower LA passive emptying fraction was associated with Fazekas score after multivariable adjustment, while LA total emptying fraction was borderline significant, and increased LA maximum and minimum volumes were associated with lacunar infarcts. There were no significant associations in patients with AF.

Sensitivity analyses showed similar results with longer screening periods for AF.

Conclusions

In patients free from AF as documented by ILR monitoring, we found an independent association between LA passive emptying and Fazekas score, and between atrial volumes and lacunar infarcts. This supports that atrial remodeling alone without AF is associated with an increased risk of cerebrovascular lesions.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Innovation Fund, DenmarkThe Research Foundation for the Capital Region of Denmark

Infarct size following loading with ticagrelor/prasugrel versus clopidogrel in ST-segment elevation myocardial infarction

Background

Treatment with newer direct-acting anti-platelet drugs (Ticagrelor and Prasugrel) prior to primary percutaneous coronary intervention (PCI) is associated with improved clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI) when compared with Clopidogrel.

Purpose

We retrospectively compared infarct size following non-randomized treatment with

Ticagrelor/Prasugrel versus Clopidogrel in a population of STEMI patients treated with primary PCI.

Methods

Patients were loaded with Clopidogrel, Ticagrelor or Prasugrel in the ambulance before primary PCI. Infarct size and myocardial salvage index were calculated using cardiac magnetic resonance (CMR) during index admission and at three-month follow-up.

Results

693 patients were included in this analysis. Clopidogrel was given to 351 patients and Ticagrelor/Prasugrel to 342 patients. The groups were generally comparable in terms of baseline and procedural characteristics. Median infarct size at three-month follow-up was 12.9% vs 10.0%, in patients treated with Clopidogrel and Ticagrelor/ Prasugrel respectively (p<0.001), and myocardial salvage index was 66% vs 71% (p<0.001). Results remained significant in a multiple regression model (p<0.001).

Conclusion

Pre-hospital loading with Ticagrelor or Prasugrel compared to Clopidogrel, was associated with smaller infarct size and larger myocardial salvage index at three-month follow-up in patients with STEMI treated with primary PCI.

Infarct size at three month follow-up

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Novo Nordisk Foundation. The Alfred Benzon Foundatioun.

Efficacy and safety of clopidogrel, ticagrelor, and prasugrel in an all-comers population of patients with ST-segment elevation myocardial infarction

Background

Until 2009, aspirin and clopidogrel were recommended for most patients with acute coronary syndrome (ACS). After 2009, this recommendation was changed to aspirin combined with prasugrel or ticagrelor since randomised trials had demonstrated reduced cardiovascular mortality and ischemic events, however with a slight increase in bleeding risk. Randomised clinical trials often include selected patients and the results may not be generalisable to an all-comers population of high-risk ACS patients.

Purpose

To compare efficacy and safety of clopidogrel, ticagrelor, and prasugrel in all-comers patients with ST-segment elevation myocardial infarction (STEMI).

Methods

The Eastern Danish Heart Registry was utilised to identify all consecutive STEMI patients admitted to the capital region from 2009–2016. By individual linkage to Danish nationwide registries, claimed drug prescriptions and end points were obtained. Patients alive a week after discharge were included and stratified according to clopidogrel, ticagrelor, or prasugrel treatment, and followed for 18 months. The risk of the primary efficacy end point (a composite of all-cause mortality, recurrent myocardial infarction, and ischemic stroke) and the safety end point (bleeding events leading to hospital admission) were assessed by multivariate Cox proportional-hazard models.

Results

In total, 4841 STEMI patients were included (clopidogrel [n=1222], ticagrelor [n=1820], prasugrel [n=1799]). The median age was 66 (IQR 57–76) for clopidogrel, 64 (IQR 54–73) for ticagrelor, and 59 (IQR 51–67) for prasugrel, and only 19% were women of the prasugrel treated patients (29% for clopidogrel, 25% for ticagrelor). Treatment with anticoagulant therapy was 21% for clopidogrel treated patients (4% for ticagrelor, 5% for prasugrel). Number of events and incidence rates/100 years (IR) for the primary efficacy end point were 165 (IR 9.7) for clopidogrel, 134 (IR 5.1) for ticagrelor, and 107 (IR 4.1) for prasugrel, and for bleeding events 57 (IR 3.3) for clopidogrel, 60 (IR 2.3) for ticagrelor, and 55 (IR 2.1) for prasugrel treatment. Compared with clopidogrel, a reduction in the primary efficacy end point was found in patients treated with both ticagrelor (HR 0.47, 95% CI 0.36–0.63, p<0.001) and prasugrel (HR 0.49, 95% CI 0.36–0.67, p<0.001) with no difference in bleeding events (HR 0.71, 95% CI 0.45–1.13, p=0.15 and HR 0.72, 95% CI 0.44–1.17, p=0.18, respectively). No differences were found between prasugrel and ticagrelor treated patients for the primary efficacy end point (HR 0.83, 95% CI 0.60–1.16, p=0.28) or safety end point (HR 0.97, 95% CI 0.61–1.54, p=0.90).

Conclusion

Ticagrelor and prasugrel treatment in all-comers STEMI patients were associated with reduced rates of all-cause mortality and ischemic events without an increase in bleeding events when compared with clopidogrel treatment. No differences in efficacy or safety were found between prasugrel and ticagrelor treated patients.

Efficacy+safety end points at 18 months

Funding Acknowledgement

Type of funding source: None

Surgical treatment for infective endocarditis over three decades: a nationwide study

Background

An increasing number of patients with infective endocarditis (IE) are treated surgically over time. It is important to know how this affects patient outcome. Current studies are mainly from tertiary centres which may bias estimations of outcomes. We have therefore conducted a nationwide study of surgical outcomes during admission for IE over three decades.

Purpose

We set out to examine temporal trends in use of valve surgery for IE and these patients' characteristics and related outcomes in Denmark in the period 1998–2017.

Methods

Using Danish nationwide registries, we included patients with first-time IE (1998–2017). The study population was categorized into four groups of five-year intervals (1998–2002, 2003–2007, 2008–2012, 2012–2017). Annual number of patients with IE and the proportion who underwent valve surgery during admission were reported. Kaplan-Meier estimates and multivariable logistic regression analyses were used to compare the associated 30-day mortality risk between calendar periods. Kaplan-Meier estimates and multivariable adjusted Cox proportional hazard analyses were used compare the associated 1-year mortality risk between calendar periods.

Results

A total of 8,455 patients with first-time IE were identified in the period of 1998–2017 of which 1,906 (22.5%) underwent valve surgery (1998–2002; N=320, 2003–2007; N=468, 2008–2012; N=528, 2013–2017; N=595). The proportion of patients who underwent surgery was 21.5% in 1998 and 19.4% in 2017 (P=0.02 for trend). See figure.

For patients undergoing surgery, the median age and proportion of males increased from 58.3 years (P25-P75: 48.2–67.4) and 69.1% to 66.7 years (P25-P75: 55.2–73.0) and 73.1% in 1998–2002 and 2013–2017, respectively. Patients had an increasing burden of comorbidities including diabetes (10.3% to 14.3%), hypertension (16.9% to 37.5%) and renal disease (9.1% to 9.6%) across calendar periods. The 30-day mortality risk for patients with IE who underwent valve surgery was 10.0% (1998–2002), 10.8% (2003–2007), 6.4% (2008–2012) and 8.5% (2013–2017), respectively (P=0.09). One-year mortality risk for patients with IE who underwent valve surgery was 16.7% (1998–2002), 21.2% (2003–2007), 15.2% (2008–2012) and 16.6% (2013–2017), respectively (P=0.08). The declining 30-day and 1-year mortality was statistically significant over time when adjusting for patient characteristics (P=0.01 and P≤0.0001, respectively).

Conclusion

From a nationwide, unselected cohort of patients with first-time IE, around 1/5 undergo surgery during admission. Surgical IE-cases are older and sicker now compared to 10–20 years ago. In spite of this, there was a trend towards a decreased associated 30-day and 1-year mortality over time. Our data show a lower rate of surgery in IE than in most prior studies and we believe that this is due to the nationwide, unselected nature of our study.

Infective endocarditis and surgery

Funding Acknowledgement

Type of funding source: None

Severity of congenital Long QT Syndrome disease onset and risk of depression, anxiety, and mortality: a nationwide study

Introduction

The congenital Long QT Syndrome (cLQTS) is associated with an increased risk of sudden cardiac death (SCD). Thus, cLQTS patients are susceptible to develop depression or anxiety, both of which have been associated with poor outcomes including risk of mortality.

Aim

We examined if a cLQTS diagnosis and the severity of cLQTS disease onset was associated with an increased risk of depression, anxiety, and all-cause mortality compared with a matched control population.

Methods

Using Danish nationwide registries and inherited cardiac disease clinics, we identified all patients with known cLQTS (1994–2016) who were ≥18 years at the time of diagnosis. The disease onset for cLQTS was identified as asymptomatic, ventricular tachycardia [VT]/ syncope, aborted SCD [aSCD], or unknown (i.e. no available information). After cLQTS diagnosis, we determined the risk of depression (i.e. depression diagnosis or prescription of antidepressants), anxiety (i.e. anxiety diagnosis or prescription of anxiolytics), and mortality using multivariable Cox proportional hazards regression. Patients were followed for three years. An age and gender matched control population was identified (matching 1:4). Competing risk analysis with death as competing risk was used to generate cumulative incidence plots.

Results

Overall, 428 cLQTS patients were identified of which 107/428 (25%) developed depression or anxiety after being diagnosed with cLQTS compared with 285/1712 (16.6%) from the control population (p<0.001). The severity of disease onset was identified for 229/428 (55%) cLQTS patients; 104 (24%) were asymptomatic, 89 (21%) had VT/ syncope, and 36 (8.4%) had aSCD. A graded relationship between the severity of cLQTS disease onset and risk of depression or anxiety was identified (Figure 1). In multivariable models, patients with aSCD as disease onset had a higher risk of developing depression or anxiety compared with asymptomatic cLQTS patients (HR=2.34, CI: 1.03–5.32). Furthermore, previous depression (HR=6.38, CI: 4.80–8.48) and anxiety (HR=4.20, CI: 3.15–5.59) was found as associated risk factors. However, no risk was associated with concurrent treatment with beta-blockers (HR=1.23, CI: 0.90–1.69). During follow-up, 8 cLQTS patients died of which 4 had developed depression or anxiety (50%). No significant association between all-cause mortality and depression or anxiety was found, although numbers were low (P=0.22).

Conclusion

The prevalence of depression and anxiety was high among cLQTS patients after diagnosis. Moreover, a graded relationship between severity of disease onset and risk of depression or anxiety was identified. These findings highlight a need for increased awareness following a cLQTS diagnosis in order to reduce the risk of adverse outcomes.

Cumulative incidence curve

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Fund of Rigshospitalet

Risk of heart failure associated with thiazide diuretics compared with calcium channel blockers in patients with type 2 diabetes: a nationwide nested case-control study

Background

Thiazide diuretics and calcium channel blockers (CCB's) are two important and widely used antihypertensive drugs classes among patients with type 2 diabetes (T2D). The risk of developing heart failure (HF) is increased in patients with T2D but whether use of these two drugs are associated with changes in HF risk is unknown.

Purpose

To examine and compare the association of two different classes of antihypertensive drugs, thiazide diuretics and CCB's, with the development of new onset HF in patients with T2D.

Methods

The study cohort comprised T2D patients >40 years on metformin and renin-angiotensin system inhibitor (RAS-i) without a history of HF or use of loop diuretics identified in Danish health care registers (period 1995 to 2015). A nested case-control study was conducted by matching all HF cases on sex, age and duration of T2D with 10 controls from the T2D population. Exposure was defined as three redeemed prescriptions of either a thiazide diuretic or a CCB up to 365 days before index, which corresponds to one year of antihypertensive therapy. Conditional logistic regression adjusted for comorbidities (atrial fibrillation, chronic obstructive pulmonary disease and anemia) was used to estimate and compare the treatment effect of thiazide diuretics and CCB's, with patients receiving neither of the two drugs as reference.

Results

The study population consisted of 170,514 T2D patients using metformin and RAS-i, comprising 13,814 HF cases each matched on sex, age and duration of T2D with 10 controls. The median age was 62 years and 55% were men. T2D patients, who had received antihypertensive treatment with only thiazide diuretics one year prior to index had a significantly lower risk of HF compared to the reference group who did not receive treatment with neither thiazide diuretics or CCB's: Hazard ratio (HR) 0.79 [95% confidence interval (CI) 0.74–0.85]. Patients who had received treatment with only CCB's had a comparable risk of HF: HR 0.98 [95% CI 0.94–1.02]. Patients who had received treatment with both thiazide diuretics and CCB's were not associated with a lower risk of HF: HR 1.01 [95% CI 0.96–1.08].

Conclusion

Patients with T2D who received antihypertensive therapy with thiazide diuretics for at least one year had a significantly lower risk of HF compared to those who were not treated with either thiazide diuretics or CCB's. No association between use of CCB's and HF was observed. Use of thiazide diuretics may prevent development of HF in T2D and a randomized clinical trial evaluating diuretics is patients with T2D is warranted.

Risk of new onset heart failure

Funding Acknowledgement

Type of funding source: None

Temporal trends in utilization of transcatheter aortic valve implantation and patient characteristics – a nationwide cohort study

Introduction

In recent years, there has been a surge in the utilization of transcatheter aortic valve implantation (TAVI) for the treatment of severe symptomatic aortic stenosis. Randomized controlled trials have compared TAVI to surgical aortic valve replacement (SAVR) in patients at high-, intermediate-, and low perioperative risk. As TAVI continues to be utilized in patients with lower risk profiles, it is important to investigate the temporal trends in “real-world” patients undergoing TAVI.

Purpose

To investigate temporal trends in the utilization of TAVI and examine changes in patient characteristics of patients undergoing first-time TAVI.

Methods

Using complete Danish nationwide registries, we included all patients undergoing first-time TAVI between 2008 and 2017. To compare patient characteristics, the study population was stratified according to calendar year in the following groups: 2008–2009, 2010–2011, 2012–2013, 2014–2015, and 2016–2017.

Results

We identified 3,534 patients undergoing first-time TAVI. In 2008–2009, 180 patients underwent first-time TAVI compared with 1,417 patients in 2016–2017, resulting in a 687% increase in TAVI procedures performed. During the study period, the median age remained stable (2008–2009: Median age 82 year [25th–75th percentile: 78–85] vs. 2016–2017: Median age 81 years [25th–75th percentile: 76–85]; P-value: 0.06). The proportion of men undergoing first-time TAVI increased over the years (2008–2009: 49.4% vs 2016–2017: 54.9%; P-value for trend: <0.05), also the proportion with diabetes increased (2008–2009: 12.2% vs. 2016–2017: 19.3%; P-value for trend: <0.05). The proportion of patients with a history of stroke decreased over the years (2008–2009: 13.9% vs. 2016–2017: 12.1%; P-value for trend: <0.05). The same trend was seen in patients with a history of myocardial infarction (2008–2009: 24.4% vs. 2016–2017: 11.9%; P-value for trend: <0.05), ischaemic heart disease (2008–2009: 71.7% vs. 2016–2017: 29.4%; P-value for trend: <0.05), and heart failure (2008–2009: 45.6% vs. 2016–2017: 29.4%; P-value for trend: <0.05).

Conclusions

In this nationwide study, there was a marked increase in the utilization of TAVI in the years 2008–2017. Patients undergoing first-time TAVI had a decreasing comorbidity burden, while the age of the patients at first-time TAVI remained stable.

Funding Acknowledgement

Type of funding source: None

Increasing time to thrombolysis is associated with worse long-term outcomes in patients with ischaemic stroke: a nationwide study

Background

It is well-established that the short-term benefits of intravenous thrombolytic therapy are reduced with increasing treatment delay in patients with acute ischaemic stroke. However, there is a paucity of contemporary data on the association between time from symptom onset to initiation of thrombolysis and long-term outcomes. With improving post-stroke survival in the Western world, data on time to thrombolysis and subsequent long-term outcomes are warranted in order to provide further insight into the importance of time to treatment.

Purpose

To examine the long-term risk of adverse outcomes according to time from symptom onset to intravenous thrombolytic therapy in patients with acute ischaemic stroke.

Methods

In this observational cohort study, we identified all patients with first-time ischaemic stroke treated with intravenous thrombolysis between 2011–2015 and alive at discharge through the Danish National Stroke Registry. Patients who received thrombolysis after >270 min were excluded. Using multivariable Cox regression, we examined associations between time from symptom onset to thrombolysis and risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as each of these components separately. Patients were followed until the outcome of interest, emigration, or December 31, 2017.

Results

Of the 4,313 patients with first-time ischaemic stroke treated with intravenous thrombolysis, 4,119 were alive at discharge (median age 69 years [25th-75th percentile 59–78 years], 60% males). The median follow-up was 3.3 years (25th-75th percentile 2.3–4.7 years). The median time from symptom onset to initiation of thrombolytic therapy was 140 min (25th-75th percentile 106–187 min), and the median National Institutes of Health Stroke Scale score at presentation was 5 (25th-75th percentile 3–10). The unadjusted absolute 3-year risks of the composite outcome, death, recurrent ischaemic stroke, and dementia according to time to thrombolysis are displayed in the figure. Compared with thrombolysis within 90 min, time to thrombolysis >90 min was associated with a higher relative risk of the composite outcome (91–180 min: adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI], 1.13–1.68]; 181–270 min: adjusted HR 1.42 [95% CI 1.15–1.76]). The risks of each component of the composite outcome according to time to thrombolysis were similar to results for the composite endpoint, as illustrated in the figure.

Conclusions

In this nationwide cohort of patients with acute ischaemic stroke treated with thrombolysis, increasing time from symptom onset to initiation of intravenous thrombolytic therapy was associated with higher long-term risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as all three outcomes separately. These data indicate that long-term outcomes of patients with ischaemic stroke treated with intravenous thrombolysis can be greatly improved by reducing treatment delay.

Time to thrombolysis and outcomes

Funding Acknowledgement

Type of funding source: None

Long-term mortality in patients with infective endocarditis who undergo aortic root replacement versus isolated aortic valve replacement

Background

Infective endocarditis (IE) with involvement of the aortic root (root abscess or aortic prosthetic valve endocarditis (PVE)) is associated with high mortality and morbidity, and it often requires root replacement. IE-guidelines recommend surgery in patients with aortic root involvement (class B recommendation), but the surgical technique is challenging, and the perioperative risk is high. Long-term data are sparse for these high-risk patients and may help better select appropriate patients for surgery.

Purpose

We set out to investigate the short- and long-term mortality for patients with destructive aortic valve endocarditis who underwent aortic root replacement. For comparison, we included those who underwent isolated aortic valve replacement for IE (isolated AVR).

Methods

We included patients with first-time IE from 2000 to 2016 who underwent aortic valve surgery identified from The Eastern Danish Thoracic surgery database. Patient characteristics were identified by cross-linking Danish nationwide databases. Patients who underwent aortic root replacement were compared with those who underwent isolated AVR. Kaplan-Meier plots and multivariable Cox regression analyses were used to estimate and compare the associated 30-days and 10-year mortality risks between groups.

Results

We included 368 patients with aortic valve IE who underwent AVR surgery; 126 patients underwent aortic root replacement and 242 underwent isolated AVR. Median age for root replacement patients was 65.4 years (interquartile range [IQR] 56.2–73.0) compared with 62.1 years (IQR 52.3–71.6) for isolated AVR patients. In the root replacement group, 40.5% had prosthetic valve endocarditis (PVE), whereas 6.6% had PVE in the isolated AVR group. 30-day mortality was 12.7% (CI95: 7.6%-19.2%) in the root replacement group and 7.0% (CI95: 4.3%-10.7%) in the isolated AVR group (P=0.06). Estimated 10-year mortality was 54.4% (CI95: 40.3%-67.6%) in the root replacement group and 45.3% (CI95: 35.7%-54.5%) (P=0.07) after isolated AVR (figure 1). At up to 10 years follow-up, there was no significant difference in adjusted mortality between the groups, adjusted HR=1.34 (CI 95: 0.90–2.00).

Conclusion

Patients with IE who underwent aortic root replacement surgery more often had a prosthetic heart valve, were older, and were more often male. There was no significant difference in long-term mortality between the groups. Nonetheless, long-term mortality was high – 50% of patients died by 10 years, and our results underline the need for stringent patient selection.

Figure 1

Funding Acknowledgement

Type of funding source: None

Heart failure in survivors of out-of-hospital cardiac arrest – factors associated with reduced systolic ventricular function at follow-up

Background

Survival after out-of-hospital cardiac arrest (OHCA) has increased in recent years but is still only 10%. Little is known about the association between post-resuscitation comorbidity and heart failure after discharge from the initial OHCA-admission.

Purpose

In OHCA-survivors we aimed to describe predictors of left ventricular (LV) dysfunction, defined as LV ejection fraction (LVEF) <40%, at follow-up.

Methods

A consecutive cohort of OHCA-patients with cardiac cause from 2007 to 2011 without a pre-OHCA congestive heart failure diagnosis (according to the Danish National Patient Registry, which holds data on all Danish citizens) were retrospectively examined. Logistic regression analyses were used to assess factors associated with LV dysfunction (LVEF <40%) at follow-up after a median of 6 months. Follow-up was not performed systematically in the OHCA-survivors and data from follow-up was assessed by reading of patient charts.

Results

A total of 365 OHCA-survivors with a mean age of 61 years were discharged alive from hospital. LVEF <40% at hospital discharge was seen in 54% (n=184, 7% missing), and at follow-up after a median of 6 months 19% (n=69) of the total OHCA-cohort of survivors still had LV dysfunction. Factors associated with LV dysfunction at follow-up were chronic ischemic heart disease (IHD) prior to OHCA (odds ratio (OR) = 2.9 (95% CI: 1.2 – 7.1)) and ST-elevation myocardial infarction (STEMI) as cause of OHCA (OR = 2.9 (1.4–6.0)), whereas age, gender, high comorbidity burden prior to OHCA or pre-hospital circumstances (including shockable cardiac arrest rhythm) were not.

Conclusion

More than half of OHCA-survivors with LVEF <40% at hospital discharge improved LV function and LV dysfunction at follow-up after a median of 6 months after discharge was present in 1 in 5 (19%) of the cohort. Chronic IHD and STEMI were the only factors significantly associated with LV dysfunction at follow-up. A systematic follow-up including echocardiography in the outpatient clinic for OHCA-survivors is recommended especially in patients with reduced LV function at discharge and in STEMI-patients in order to assess the appropriateness of heart failure medication and an implantable cardiac defibrillator.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Danish Foundation Trygfonden

Declining incidence and mortality of ischaemic stroke between 1996–2016: a nationwide study

Background

The incidence and mortality of ischaemic heart disease have been declining over many years. The development with ischaemic stroke is less well studied, and with an increasing elderly population, there is a need for large-scale studies. Recent changes in stroke prevention and treatments may have affected the incidence and mortality of ischaemic stroke.

Purpose

To examine time trends and sex and age differences in the incidence and mortality of first-time ischaemic stroke in Denmark between 1996–2016.

Methods

In this observational cohort study, we used Danish nationwide registries to identify all individuals >18 years of age admitted with a first-time diagnosis of ischaemic stroke between 1996–2016. We calculated age- and sex-stratified annual incidence rates and absolute 30-day and 1-year mortality risks. Further, we calculated annual incidence rate ratios using multivariable Poisson regression, odds ratios for 30-day mortality using multivariable logistic regression, and hazard ratios for 1-year mortality using multivariable Cox regression.

Results

The study population consisted of 224,617 individuals >18 years of age with first-time ischaemic stroke between 1996–2016. The figure displays the unadjusted incidence rates and 1-year mortality risks of ischaemic stroke by calendar year. The overall unadjusted incidence rates of ischaemic stroke per 1,000 person-years increased from 1996 (2.43 [95% confidence interval [CI], 2.38–2.47]) to 2002 (2.91 [95% CI, 2.86–2.96]) and then gradually decreased to below the initial level until 2016 (1.99 [95% CI, 1.95–2.03]). Men had higher incidence rates than women in all age groups except in patients between 18–30 years and >85 years. The absolute mortality risk decreased between 1996–2016 (30-day mortality from 17.1% to 7.6% and 1-year mortality from 30.9% to 17.3%). Women had higher mortality than men in the age groups 55–64 years and >85 years. Similar trends were observed for all analyses after multivariable adjustment.

Conclusions

The overall incidence of first-time hospitalization for ischaemic stroke increased from 1996–2002 and then gradually decreased to below the initial level until 2016. The absolute 30-day and 1-year mortality risk decreased between 1996–2016. These findings correspond to the increased awareness of stroke prevention and introduction of new treatment options during the study period.

Trends in stroke incidence and mortality

Funding Acknowledgement

Type of funding source: None

Risk of infective endocarditis among patients with tetralogy of fallot

Introduction

Patients with tetralogy of Fallot (ToF) are considered at high risk of infective endocarditis (IE) as a result of altered hemodynamics and multiple surgical and interventional procedures including pulmonary valve replacement (PVR). The overall survival of patients with ToF has increased in recent years. However, data on the risk of adverse outcomes including IE are sparse.

Purpose

To investigate the risk of IE in patients with ToF compared with controls from the background population.

Methods

In this nationwide observational cohort study, all patients with ToF born in 1977–2017 were identified using Danish nationwide registries and followed from date of birth until occurrence of an outcome of interest (i.e. first-time IE), death, or end of study (July 31, 2017). The comparative risk of IE among ToF patients versus age- and sex-matched controls from the background population was assessed.

Results

A total of 1,156 patients with ToF were identified and matched with 4,624 controls from the background population. Among patients with ToF, 266 (23.0%) underwent PVR during follow-up. During a median follow-up time of 20.4 years, 38 (3.3%) patients and 1 (0.03%) control were admitted with IE. The median time from date of birth to IE was 10.8 years (25th-75th percentile 2.8–20.9 years). The incidence rates of IE per 1,000 person-years were 2.2 (95% confidence interval (CI) 1.6–3.0) and 0.01 (95% CI 0.0001–0.1) among patients and controls, respectively. In multivariable Cox regression models, in which age, sex, pulmonary valve replacement, and relevant comorbidities (i.e. chronic renal failure, diabetes mellitus, presence of cardiac implantable electronic devices, other valve surgeries), were included as time-varying coefficients, the risk of IE was significantly higher among patients compared with controls (HR 171.5, 95% CI 23.2–1266.7). Moreover, PVR was associated with an increased risk of IE (HR 3.4, 95% CI 1.4–8.2).

Conclusions

Patients with ToF have a substantial risk of IE and the risk is significantly higher compared with the background population. In particular, PVR was associated with an increased risk of IE. With an increasing life-expectancy of these patients, intensified awareness, preventive measures, and surveillance of this patient group are advisable.

Figure 1. Cumulative incidence of IE

Funding Acknowledgement

Type of funding source: None

Hemoglobin level at stabilization is associated with long-term all-cause mortality in patients with left-sided endocarditis, a POET substudy

Background

Left-sided infectious endocarditis (IE) has a high 1-year mortality. Anemia is a common finding in patients with IE, yet little is known about frequency, severity, and associated outcomes in this setting.

Purpose

To examine the relationship between Hemoglobin (Hgb) level measured at IE stabilization (time of randomization) in the Partial Oral versus intravenous Antibiotic Treatment of Endocarditis (POET) trial - and long-term all-cause mortality.

Methods

In the POET trial, 400 patients with left-sided IE were randomized, after medical and/or surgical stabilization, to conventional antibiotic treatment or partial oral treatment. Only non-surgically treated patients were considered in this study. Patients were divided by quartiles into four groups based on Hgb level at randomization.

Results

We examined 248 patients with non-surgically treated IE. Median time from diagnosis of IE to randomization was 14 days (IQ 12–19). At long-term follow-up (median 3.2 years, IQ 2.18–4.60), 71 patients had died (28.6%). Patients in the lowest quantile (Hgb ≤6.0 mmol) had a HR of 4.17 (95% CI 1.81–9.61, p<0.001) for death compared to patients in the highest quantile (Hgb >7.5 mmol/L). This association remained significant after multivariable adjustment for age, sex, renal disease, C-Reactive Protein, and Prosthetic heart valve (HR 2.69, 95% CI 1.11–6.50); p=0.028).

Conclusion

Low Hemoglobin level at stabilization in patients with IE was associated with an increased risk of long-term mortality. Whether intensified treatment of anemia in patients with IE could improve long-term outcome requires investigation.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Danish Heart Foundation, The Capital Regions Research Council

1347The flu vaccine and mortality in hypertension. A Danish nationwide cohort study

Background

Influenza infection is associated with an increased risk of acute myocardial infarction (AMI) and stroke. It is currently unknown whether influenza vaccination may reduce mortality in patients with hypertension.

Purpose

To determine whether influenza vaccination is associated with lower risks of death in hypertensive patients without significant cardiovascular or other chronic disease.

Methods

Using nationwide registers, we identified all patients with hypertension in Denmark during 9 consecutive influenza seasons in the period 2007–2016 who were treated with at least 2 different classes of antihypertensive medication (beta-blockers, diuretics, calcium antagonists or renin-angiotensin system inhibitors). Patients who were not 18–100 years old or had ischemic heart disease, heart failure, chronic obstructive lung disease, cancer or cerebrovascular disease were excluded. Prior to each influenza season we assessed the exposure to influenza vaccination. End-points were death from all causes, from AMI or stroke, or cardiovascular death. For each season, patients were followed from December 1 until April 1 the next year, spanning the period of high influenza activity in Denmark.

Results

A total of 608,452 Patients were followed for a median of 5 seasons (interquartile-range: 2–8 seasons), with total follow-up time of 975,902 person-years. The vaccine coverage during study seasons ranged from 26% to 36%. During follow-up, 21,571 patients died of all-causes (3.5%), 12,270 patients died of cardiovascular causes (2.0%) and 3,846 patients died of AMI/stroke (0.6%). Vaccination was associated with older age, Diabetes Mellitus, atrial fibrillation, lower educational level, lower income and higher medication use. In unadjusted analysis considering all seasons, vaccination was significantly associated with increased risk of all-cause death, cardiovascular death and death from AMI/stroke. However, following adjustment for season, age, sex, comorbidities, medications, income, education, and more, vaccination was significantly associated with reduced risks of all-cause death, cardiovascular death and death from AMI/stroke (Figure).

PY, person-years.

Conclusion

In a nationwide study spanning 9 consecutive influenza seasons including more than 600,000 hypertensive patients without significant cardiovascular disease identified through medication use, influenza vaccination was significantly associated with a reduced risk of death from all-causes, cardiovascular causes and AMI/stroke. Influenza vaccination may improve patient outcome in hypertension.

Acknowledgement/Funding

Daniel Modin was supported by the Herlev & Gentofte University Hospital Internal Research Fund and by the Novo Nordisk Foundation.

P3661Two-fold increase in incidence of infective endocarditis in the period 1997–2016: a Danish nationwide study

Background

Infective Endocarditis (IE) is a disease with high mortality. Previous studies have shown considerable differences and contradicting trends in overall incidence and mortality why data from an unselected nationwide cohort is needed.

Purpose

We investigated temporal trends in the incidence rate and in-hospital mortality of IE in Denmark in the period of 1997–2016.

Methods

We included cases of first-time IE (1997–2016) using Danish nationwide registries. Crude incidence rates were given for each calendar year. Further, incidence rates were reported for subgroups of age and sex. For the analysis of patient characteristics and in-hospital mortality, the study cohort was grouped into four 5-year intervals (1997–2001, 2002–2006, 2007–2011, 2012–2016). Multivariable adjusted Cox proportional hazard model was used to compare in-hospital mortality between groups.

Results

A total of 8,147 patients with IE were identified in the period of 1997–2016. The median age and proportion of males increased from 64.3 years (P25-P75: 48–75.5) and 59.1% to 71.8 years (P25-P75: 62.1–79.9) and 67.1% in 1997–2001 and 2012–2016, respectively. The overall incidence rate (Figure 1) increased from 4.68/100.000-person-years (PY) (CI95: 4.17–5.26) to 8.23/100.000 PY (CI95: 7.53–8.99) in 1997 and 2016, respectively. Male incidence increased from 5.35/100.000 PY (CI95: 4.59–6.23) to 11.03/100.000 PY (CI95: 9.9–12.29) and female incidence increased from 4.03/100.000 PY (CI95: 3.38–4.8) to 5.44/100.000 PY (CI95: 4.67–6.35) in 1997 and 2016 respectively. Incidence rates increased more than seven-fold for the oldest age group (≥80 years) from 1997 to 2016 (6.95/100.000 PY [CI95: 5.32–9.08] to 51.19/100.000 PY [CI95: 43.41–60.38], respectively). In-hospital mortality was significantly lower for patients with IE in the period of 2011–2016 compared with 1997–2001 HR: 0.8 (CI95: 0.69–0.92).

Figure 1

Conclusion

Infective endocarditis incidences are increasing mostly among men and elderly patients. In order to prevent this disease as best as possible, we need more knowledge on causes for this increasing incidence.

P765One-year mortality risk after intensification of outpatient diuretics

Background

Mortality is increased following a hospitalization for heart failure (HF). It is not clear whether outpatient intensification of diuretic confers the same increased risk in the general population with heart failure

Purpose

This study sought to assess 1-year mortality risk after worsening HF, defined either as hospitalization due to HF or as intensified diuretic therapy in an outpatient setting, in a complete nationwide cohort of patients with HF on angiotensin converting enzyme inhibitors/ angiotensin receptor blocker and beta blockers.

Methods

From nationwide administrative registers, we identified all patients in Denmark diagnosed with HF in 2001–2016 and prescribed angiotensin converting enzyme inhibitor/ angiotensin receptor blocker and beta blocker within 120 days. During follow-up we defined worsening HF by the following events: Inpatient worsening (HF readmission) and outpatient worsening (intensified diuretic therapy, defined as the first event of new addition or doubled dosage of loop diuretic therapy or new onset addition of thiazide to loop diuretic therapy). Patients with a worsening event were risk set matched to two HF controls each at time of the event – based on age, sex and calendar year. One-year mortality risk was estimated with Kaplan-Meier and multivariable Cox regression models.

Results

We included 74,990 patients, median age 71 years (interquartile range: 62–79), 36% women. During five years of follow up, 8,727 patients had an inpatient worsening event, and 12,290 had an outpatient worsening event as first event. Absolute risk of 1-year mortality was 22.6% (95%-confidence interval (95%-CI): 21.7%-23.5%) after inpatient worsening, 18.0% (95%-CI: 17.3%-18.7%) after outpatient worsening compared to 9.8% (95%-CI: 9.5%-10.1%) for the matched controls. In a multivariable Cox model adjusted ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease and diabetes, the hazard ratio for mortality among patients experiencing inpatient worsening was 2.46 (95%-CI: 2.33–2.60) and for outpatient worsening was 1.87 (95%-CI: 1.77–1.97), compared with the matched HF controls as reference (figure 1). Among patients who had an outpatient worsening as first event, 1,245 (10.1%) had a subsequent HF readmission within one year.

Conclusion

In a nationwide cohort of patients with HF, outpatient worsening defined by a diuretic intensification was associated with almost 2-fold risk of mortality during the next year. Although HF hospitalization is associated with a higher risk, the need to intensify diuretics in the outpatient setting is a signal to review and intensify efforts to improve HF outcomes.

Acknowledgement/Funding

The Danish Heart Foundation, (grant number 17-R116-A7610-22048)