Prognostic impact of adding Coronary Calcium Score to European SCORE2 in an asymptomatic Portuguese population

Introduction

The new European SCORE2 estimates the combined risk of fatal and non-fatal cardiovascular (CV) events, in contrast with SCORE's use for CV mortality only. Although controversial, several studies point out that Coronary Artery Calcification (CAC) scoring could improve CV risk stratification in primary prevention.

Purpose

Assess the impact of including CAC score to the new SCORE2 in MACE prediction and CV risk stratification in an asymptomatic Portuguese population.

Methods

The new SCORE2 was calculated in a population-based cohort of 1,014 individuals (mean age 58.6±8.5 years) without known CV disease and diabetes. Population was stratified into three SCORE2 risk categories (low-, moderate- and high-risk). According to the Hoff's nomogram, CAC score was categorized into: low CAC (0≤CAC<100 or P<50); moderate CAC (100≤CAC<400 or P50–75) and high or severe CAC (CAC≥400 or P>75). Kaplan-Meier survival curves were estimated and a multivariate regression analysis predicted the MACE risk for both scores. C-statistic methodology evaluated the ability of CAC when added to the SCORE2 model in MACE prediction.

Results

Kaplan-Meier curves showed that the highest categories of both scores presented a worst survival. Cox regression analysis showed that the highest categories of both CAC and SCORE2 remained in the equation with an increased MACE risk (HR) of 3.69 (p=0.008) and 9.87 (p=0.005), respectively, when compared with the lowest categories. C-statistic demonstrated that the predictive value for MACE increased from 0.668 (SCORE2 model) to 0.787 when CAC was included (p=0.012), showing a better predictive and discriminative capacity for MACE.

Conclusions

Our results highlight the importance of adding CAC score to SCORE2 in primary prevention to improve cardiovascular risk stratification and MACE risk prediction. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Lipoprotein(a) and cardiovascular outcomes in patients with coronary artery disease and impaired glucose metabolism

Introduction

Lipoprotein(a) [Lp(a)] is an LDL-like molecule composed of a part of apolipoprotein(a) bounding covalently to apolipoprotein B-100. High plasma Lp(a) levels were associated with MACE in stable CAD patients. Recent research shows contradictory results in stable CAD patients with high Lp(a) plasmatic levels and impaired glucose metabolism in MACE occurrence.

Purpose

Investigate whether high Lp(a) levels were associated with MACE in CAD patients with impaired glucose metabolism, at an extended follow-up.

Methods

A prospective cohort of 1,127 CAD patients with impaired glucose metabolism (pre-diabetes and diabetes) was observed during 4.9±3.4 years. Pre-diabetes was considered when fasting plasma glucose ranged from 5.6 to 6.9 mmol/L, or hemoglobin A1c levels ranging from 5.7 to 6.4%. Lp(a) levels ≥30 mg/dL were considered high. Bivariate and multivariate Cox regression analysis evaluated the risk of Lp(a) ≥30 mg/dL for MACE occurrence. Kaplan-Meier curves estimated the survival probability for high and low Lp(a) levels.

Results

Of the patients with Lp(a) levels ≥30, 44.4% presented MACE and 32.0% had no MACE (p<0.0001). Cox regression analysis with smoking, hypertension, dyslipidemia, physical inactivity and kidney failure (creatinine clearance <60 mL/min) showed that high Lp(a) remained in the equation as an independent risk factor for MACE (HR=1.24; p=0.031). The Kaplan-Meier showed, at 10-year' follow-up, a better survival in the group with lower Lp(a) levels (p=0.023).

Conclusion

Our study demonstrated that high Lp(a) levels were an independent predictor of MACE and cardiovascular mortality in a CAD population with impaired glucose metabolism. Lp(a) measurement may help further risk stratification for diabetes and pre-diabetes patients suffering CAD. With the recent development of drugs that selectively lower Lp(a) levels, this marker can become a clinical target for reducing CVD risk.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Genetic information or coronary artery calcium score? What is more helpful in today's clinical practice?

Introduction

Coronary artery calcium (CAC) score has emerged as the most predictive cardiovascular risk marker in asymptomatic individuals, capable of adding prognostic information beyond the traditional risk factors (TRF). Genetic risk score (GRS) significantly improves cardiovascular genetic risk assessment at the individual level providing a more personalized measure of disease risk.

Purpose

We intend to evaluate which tool, added to TRF, is more valuable in predicting and discriminating cardiovascular events and death (MACE) - GRS or CAC score?

Methods

We performed a prospective study with 1153 participants without CAD history at baseline (74.2% male, age 51.7±8.3 years) during a mean follow-up of 5.4±3.4 years. We selected 14 SNPs previously associated with CAD presenting a risk (HR) for cardiovascular events ≥1. A weighted GRS was calculated, as the sum of these 14 risk alleles weighted by the corresponding effect size in prognostic (HR), and subsequently, subdivided into tertiles. CAC (Agatson) score was calculated in all participants and categorized into: low CAC (0≤CAC<100 or P<50); moderate CAC (100≤CAC<400 or P50–75) and high or severe CAC (CAC≥400 or P>75). Two models were created with TRF baseline (hypertension, smoking, body mass index, dyslipidemia, diabetes, chronic kidney disease, physical inactivity): 1) plus wGRS and 2) plus CAC score categories. Cox Regression Analyses and C-statistic assessed the predictive and discriminative capacity of both models.

Results

For model 1, Cox regression presented an HR of 4.292 for TRF (p=0.007) and 2.713 for 3rd tertile of wGRS (0.036). A modest but statistically significant improvement in MACE discriminative capacity was verified by adding wGRS to TRF, increasing the C-statistic from 0.617 to 0.687 (ΔC=0.070; p=0.013). On the other hand, model 2 better discriminated MACE when the CAC score (C-statistic = 0.765) was added to TRF (ΔC=0.148; p=0.001). Cox regression displayed an HR of 4.42 for TRF (p=0.015) and an HR of 4.55 for high-risk CAC score (p=0.001).

Conclusion

Our results suggest that adding a polygenic risk score to conventional risk factors provides a modest improvement in the discrimination of first-onset MACE. However, the CAC score added to the traditional model allows better discrimination of MACE compared to wGRS. CAC score could be helpful for MACE prediction, at least in individuals belonging to the higher genetic risk group. However, further investigation is required before clinical implementation.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Prognostic role of adding a genetic risk score to the new European SCORE2 in a cardiovascular events prediction, in a moderate-risk region

Introduction

The new SCORE2 provides risk estimates for the combined outcome of fatal and non-fatal cardiovascular disease (CVD) events, in contrast with SCORE's use for CVD mortality only. Genetic predisposition to CVD is not considered in SCORE2 for prevention and treatment.

Purpose

Evaluate the impact of adding a Genetic Risk Score (GRS) to the new European SCORE2 in MACE prediction and estimate the additional value in cardiovascular risk stratification in an asymptomatic Portuguese population.

Methods

A prospective study was performed in a population-based cohort of 1,100 individuals without known CVD and diabetes (mean age 53.3±6.9 years). For all included participants, SCORE2 was calculated and three risk categories were considered: low-, moderate- and high-risk. A 33-SNP GRS was constructed and two groups were analyzed: lower and higher than the GRS median. Kaplan-Meier survival curves were created and a Cox regression model was performed with the two scores to assess MACE risk. C-statistic methodology compared the model between SCORE2 solely and SCORE2 plus GRS.

Results

After Kaplan-Meier analysis for MACE occurrence, the high categories of SCORE 2 and GRS showed worst survival when compared to the lower categories (p<0.0001). Cox regression presented an HR of 8.528 (p=0.001) for high-risk SCORE2 and an HR of 4.520 (p<0.0001) for GRS higher than the median. C-statistic demonstrated that the SCORE2 predictive value was 0.678, increasing to 0.792 when GRS was included (p=0.0005).

Conclusions

In this work, combining SCORE2 with multiple genetic loci gathered into a GRS, improved the identification of patients with the worst prognosis. This new tool may be of great utility in risk stratification in primary prevention. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Transcription factor 21 and prognosis in a coronary population

Introduction

TCF21 is a member of the basic helix-loop-helix (bHLH) transcriptor factor family, being critical for embryogenesis of the heart. It regulates epicardium-derived cells differentiation into smooth muscle (SMC) and fibroblast lineages. The biological roles of TCF21 in epicardial fate determination and the progression of atherosclerosis remains a controversial issue.

Purpose

Investigate the impact of the TCF21 rs12190287 G>C variant on the prognosis of a coronary artery disease (CAD) cohort.

Methods

A prospective study was performed with 1,713 CAD patients (mean age 53.3±7.8; 78.7% male) surveyed in terms of MACE occurrence in an extended follow-up of 5.0±4.3. TCF21 rs12190287 was genotyped and analysed using the dominant model (GC+CC) and, subsequently, compared with the wild-type GG to evaluate the survival probability by Kaplan-Meier. A Cox regression analysis with all the risk factors and genetic models was performed to assess the independent variables associated with the prognosis of CAD patients.

Results

GG wild genotype was present in 9.5% of the population, GC in 43.2% and the risk genotype CC accounted for 47.3% of the CAD patients. The dominant model GC+CC showed a worse survival throughout the follow-up period. After multivariate Cox regression analysis, this model remained in the equation as an independent risk factor for MACE occurrence with an HR of 1.41 (p=0.033) together with multivessel disease, physical inactivity, chronic kidney disease (CKD) and diabetes.

Conclusion

TCF21 rs12190287 is a risk factor for prognosis in our population. The role of this gene may influence fundamental SMC processes in response to vascular stress, accelerating atherosclerosis progression and may represent a target for future therapies.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

ZNF259 rs964184 variant is associated with dyslipidemia and coronary artery disease in the young population

Introduction

Coronary artery disease (CAD) is a dynamic inflammatory disease caused by atherosclerosis. GWAS showed that ZNF259 rs964184 encoding zinc finger protein (ZPR1) was associated with dyslipidemia and CAD. Recent research found that ZPR1 transcription is up-regulated in the brain of mice fed a high-fat diet, influencing the cell cycle, apoptosis, and RNA metabolism in neurons. This process at the heart vessels may increase oxidative stress and CAD.

Purpose

Study the association between the ZNF259 rs964184 C>G polymorphism with dyslipidemia and CAD susceptibility in a Portuguese population.

Methods

A case-control study was performed with 3,160 individuals, namely 1,723 CAD patients (mean age 53.3±7.9; 78.7% male) and 1,437 controls (mean age 52.8±7.8; 76.3% male). Participants were stratified into two age groups (<45 and >55 years). ZNF259 rs964184 C>G was genotyped and analysed using the dominant model (CG+GG vs CC). Multivariate logistic regression was performed in both age groups to investigate whether rs964184 polymorphism was associated with dyslipidemia and CAD susceptibility.

Results

The dominant model of ZNF259 was associated with dyslipidemia (OR=1.85; 95% CI: 1.22–2.79; p=0.003) and CAD (OR=1.46; 95% CI: 1.02–2.09; p=0.036) in the younger population under 45 years. In the >55 years group, this model was associated with dyslipidemia (OR 1.46; 95% CI: 1.06–2.01; p=0.020) but not with CAD. After multivariate logistic regression, the CG+GG remained an independent risk factor for CAD susceptibility only in the population <45 years (OR=1.60; 95% CI: 1.03–2.50; p=0.037).

Conclusion

ZNF259 rs964184 is a risk factor for dyslipidemia in the whole population. Dyslipidemia may up-regulate ZPR1 transcription, enhancing the vulnerability of coronary endothelial cells to both oxidative stress and inflammatory response, increasing CAD susceptibility. This mechanism seems more relevant at the cellular level in young patients representing a possible prophylactic and therapeutic target, especially in this age group.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

A Genetic Risk Score englobing variants associated with coronary artery disease is a good marker for prognosis in an asymptomatic population

 

Genome-wide association studies have identified several loci linked to coronary artery disease, and coronary atherosclerosis progression. However, the impact of the genetic contribution to MACE occurrence in sub-clinical atherosclerosis is unknown.

Purpose

This study intended to assess the relationship between a set of single nucleotide popymorphism (SNP) associated with CAD by GWAS and the MACE occurrence in an asymptomatic population. After that evaluate whether a wGRS englobing these variants is useful to estimate the prognostic.

Methods

Prospective study performed in an asymptomatic cohort from GENEMACOR population-based sample of 1114 subjects aged 51.7±8.3, 74.2 male, without prior coronary artery disease. Coronary Artery Calcium (CAC) score was assessed by coronary computed tomography (Agatston method), and two categories were considered 1–99 and >100. 33 SNP were evaluate to assess the significantly associated with prognostic. A weighted (wGRS) was constructed as the sum of the risk alleles weighted by the corresponding effect size (HR). Cox regression analysis adjusted for the main risk factors, calcium score (CAC) and wGRS to assess the risk of MACE during follow-up. Kaplan Meier assessed the survival.

Results

Of the studied 33 SNPs previously associated with CAD (GWAS), only 4 presented the significant association with MACE occurrence: CDKN2B-AS1 rs4977574, HNF4A rs1884613,

APOE rs7412/rs429358A and GJA4A rs 618675. After Cox regression analysis the wGRS remained in the equation (HR=2.834); p=0.012, together with CAC score (HR 3.35); p=0.012; diabetes (HR=2.398); p=0.032 and age (HR=1.056; p=0.049. WGRS above the median presented a worst survival rate (p=0.006).

Conclusion

The wGRS englobing: CDKN2B-AS1 rs4977574, HNF4A rs1884613, APOE rs7412/rs429358A and GJA4A rs 618675 is independently associated with cardiovascular events in an asymptomatic population. CDKN2B-AS1 rs4977574 gene expression modulates the progression and severity of vascular calcification in vascular smooth muscle cells (VSMCs), HNF1α-AS1 is an important regulatory molecule in cancer biology and cardiovascular disease (its expression may regulate VSMCs, and high expression promotes atheroprotection). More research is crucial for understand prognosis in asymptomatic population.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPE

Clinical determinants and barriers to cardiac rehabilitation enrolment of patients with heart failure with reduced ejection fraction

Introduction

Cardiac rehabilitation (CR) is a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF). Despite the robust evidence supporting its safety and benefits, there is an incomplete understanding of the reasons of the underutilization of CR programs in HFrEF. These reasons are complex and probably encompass healthcare system- and patient-level barriers.

Purpose

To study the clinical determinants and barriers to enrolment in a CR program for HFrEF patients.

Methods

We conducted a study of consecutive heart failure patients followed at a dedicated HFrEF cardiology clinic from January 2019 to April 2021. Patients were divided according to previous enrolment in CR program. Data were collected from electronic health records, and in case of missing data patients were asked by telephone about the reason for not participating in CR using a structured and validated questionnaire for this purpose.

Results

Of 228 patients with HFrEF, 60% had not been enrolled in a CR program; they were older (63 vs 58 years; p<0.01) and more likely to have comorbidities such as hypertension (56% vs 41%; p=0.03) or concomitant chronic obstructive pulmonary disease (20% vs 8%; p=0.01). Conversely, patients enrolled in CR programs were more likely to have a previous history of acute myocardial infarction (34% vs 20%; p=0.02). Regarding heart failure-related clinical features (NYHA functional class, LVEF, ICD/CRT), we did not find any significant differences between groups. The main reasons for not being enrolled in CR programs were: no medical referral (31%), concomitant medical problems (27%) such as musculoskeletal problems, patient refusal (11%) and geographical distance to the hospital (9%).

Conclusion

Despite the high proportion (40%) of HFrEF patients who underwent CR program compared to previous studies, the enrolment to CR can be further improved. The main barriers are related to health professionals (no referral), healthcare system (geographical distance to the hospital) and patients (concomitant noncardiac problems). Innovative strategies should target these factors to increase the delivery of CR program in HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Study protocol: use of a smartphone application to support the implementation of a complex physical activity intervention (+Stay Active) in women with gestational diabetes mellitus-protocol for a non-randomised feasibility study

INTRODUCTION

Physical activity (PA) interventions have a promising role in the management of gestational diabetes mellitus (GDM). Digital technologies can support PA at scale and remotely. The protocol describes a study designed to determine the feasibility and acceptability of a complex intervention; known as +Stay Active. +Stay Active combines motivational interviewing with a bespoke behaviour change informed smartphone application (Stay-Active) to augment PA levels in women with GDM.

METHODS AND ANALYSIS

This is a non-randomised feasibility study using a mixed methods approach. Participants will be recruited from the GDM antenatal clinic at the Women Centre, John Radcliffe Hospital, Oxford. Following baseline assessments (visit 1) including self-reported and device determined PA assessment (wearing a wrist accelerometer), women will be invited to participate in an online motivational interview, then download and use the Stay-Active app (Android or iOS) (visit 2). Women will have access to Stay-Active until 36 weeks gestation, when engagement and PA levels will be reassessed (visit 3). The target sample size is 60 women. Primary outcomes are recruitment and retention rates, compliance and assessment of participant engagement and acceptability with the intervention. Secondary outcomes are assessment of blood glucose control, self-reported and device determined assessment of PA, usage and structured feedback of participant's attitudes to +Stay Active, assessment of health costs and description of maternal and neonatal outcomes. This study will provide key insights into this complex intervention regarding engagement in smartphone technology and the wearing of accelerometers. These data will inform the development of a randomised controlled trial with refinements to intervention implementation.

ETHICS AND DISSEMINATION

The study has received a favourable opinion from South Central-Hampshire B Research Ethics Committee; REC reference: 20/SC/0342. Written informed consent will be obtained from all participants. Findings will be disseminated through peer-reviewed journals, conferences and seminar presentations.

TRIAL REGISTRATION NUMBER

ISRCTN11366562.

Leadership skills training in Psychiatry: A European-based cross-sectional survey

Introduction

Leadership in healthcare organisations is crucial to continually improve and provide high quality compassionate care. Leadership development and training enables the psychiatrists in developing these essential skills. Focusing on how to enhance leadership development through leadership skills training and experiential learning should be a priority. However, little is known about the extent to which this leadership skills training is available across Europe in the early stage of the career of psychiatrists.

Objectives

To investigate the access to leadership development opportunities among European psychiatric trainees and early career psychiatrists (ECPs) and their perceptions related to leadership skills training.

Methods

Cross-sectional study, using an online survey consisting of multiple-choice questions and free text responses.

Results

Participants from 33 European countries took part in this survey, where the majority were female. More than half were general adult psychiatric trainees and more than a quarter ECPs. About half indicated having no access to leadership skills training within their training program, with only about 10% being satisfied with the training received. About half sought additional training outside their program. A vast majority requested training in leadership skills to be included in a psychiatric training program.

Conclusions

Our study provides an overview of important gaps in availability and access to leadership skills training amongst psychiatric trainees and ECPs across Europe. We hope that this study will help inform future actions pertaining to development and improvement of leadership skills training for trainees and ECPs across Europe.

Disclosure

No significant relationships.

Psychiatry training goes virtual: the experience of the first online edition of the EPA Research Summer School

Introduction

The European Psychiatric Association (EPA) Summer School allows psychiatric trainees and early career psychiatrists (ECPs) from all over Europe to meet, network, and learn together. After the 2020 edition being cancelled due to COVID-19, the 10th edition in 2021 focused for the first time on research and was conducted remotely.

Objectives

To provide an overview and feedback about the first Virtual EPA Research Summer School as a new way to encourage international networking during COVID-19.

Methods

The School was organized by the EPA Secretary for Education, and 4 Faculty members. It started with a “breaking the ice session” one week before and then a two-days meeting on 23-24 September 2021 using an online video-platform. This was preceded by all the 21 participants (from 18 different countries) recording a short 4-minute video presentation, which was uploaded and shared with other participants and Faculty.

Results

Participants were divided on a voluntary basis into three working groups: 1) “Drug repurposing: overcoming challenges in pharmacoepidemiology” 2) “Psychopathological research in psychiatry”; 3) “How to conduct a cross-sectional survey?”. The Summer School program was composed of plenary sessions with lectures by the Faculty members, discussion sessions, and working groups time. At the end, each group presented a summary of the work done to the rest of the participants.

Conclusions

Although the remote format limits social interactions during the Summer School, overall participants’ high satisfaction and productivity indicate that not only online formats, but also the topic of research might be covered in future editions.

Disclosure

No significant relationships.

Concomitant diagnosis of bipolar disorder and tuberous sclerosis - a case report

Introduction

Tuberous sclerosis is a multisystem genetic disorder. It is associated with significant psychiatric comorbidity mainly autistic disorders, hyperkinetic disorders, depression and anxiety. It is rarely associated with psychosis and bipolar disorder.

Objectives

To describe the case of a 34-year-old male with concomitant diagnosis of bipolar disorder and tuberous sclerosis.

Methods

Case report based on clinical records. Brief literature review using articles searched in the PubMed/MEDLINE database using the terms “tuberous sclerosis”, “bipolar disorder” and “neuropsychiatric”.

Results

The patient presented at our Emergency Department 3 years ago with a mixed episode with psychotic symptoms with 1 month of duration. Prior history of two hypomanic episodes, but no depressive episodes. High baseline functionality. Sporadic use of alcohol and cannabis. No family history of psychiatric or neurological diseases. Diagnostic work-up showed no relevant results, aside from small calcifications in brain CT. He was admitted to our ward and medicated with aripiprazol (titrated up to 30 mg), leading to full remission of the clinical picture. The patient was referred to our outpatient clinic and stayed with medication for 1,5 years. One year after, he presented a sudden episode of mutism and perplexity with quick remission. The EEG wielded no relevant results. New brain CT showed signs of tuberous sclerosis. He was referred to Neurology and subsequent assessments, including brain MRI, led to the fulfilment of clinical criteria for tuberous sclerosis.

Conclusions

This case illustrates the possibility of concomitant diagnosis of bipolar disorder and tuberous sclerosis. The possible association between these disorders is discussed.

Disclosure

No significant relationships.

A cardiac magnetic resonance myocardial strain patterns analysis in left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recently, a classification with four types of septal longitudinal strain patterns was described using a speckle tracking based strain analysis in echocardiography suggesting pathophysiological continuum of LBBB-induced LV remodeling. Little data exist on feature tracking cardiac magnetic resonance (FT-CMR) in LBBB patients, and whether such patterns could be reproduced in CMR is not established yet.

Purpose

In this study, we aimed to: 1) Assess and reproduce the new strain patterns classification by CMR and 2) Evaluate its association with LV remodeling and myocardial scar in a LBBB cohort.

Methods

Single center registry which included LBBB patients with septal flash (SF) referred to CMR to assess the structural cause of LV dysfunction. LBBB was defined according to Strauss criteria as strict LBBB, non-strict LBBB or nonspecific LV conduction delay.

A semi-automated FT-CMR was used to quantify myocardial strain and detect the four septal longitudinal and radial strain patterns, according to the recent classification (LBBB-1 through LBBB-4) – Figure. Extent of SF was visually scored as mild, moderate, or prominent.

Results

A total of 115 patients were included (mean age 66±11 years; 57% men; 38% with ischemic heart disease). Median duration of QRS was 150± 26ms and majority of the patients (n=90, 78%) were classified as strict LBBB.

In longitudinal strain analyses LBBB-1 was observed in 23 (20%), LBBB-2 in 37 (32.1%), LBBB-3 in 25 (21.7%), and LBBB-4 in 30 (26%) patients. Patients at higher LBBB stages (longitudinal or radial pattern) had more prominent septal flash, greater LV volumes, lower LV ejection fraction and lower absolute global longitudinal, circumferential and radial strain values compared with patients in less advanced stages (p < 0.05 for all) - table.

There was no difference between patterns in clinical characteristics, ischemic etiology, QRS duration and time delay between septal and lateral LV wall.

Late gadolinium enhancement (LGE) was found in 63 patients (54.8%), with a septal location in 34 (29.6%) patients, lateral in 4 (3.5%) patients, septal and lateral in 11 (9.6%) patients. Furthermore, no difference was found for LGE presence, distribution or location between the four strain patterns.

Conclusions

Among patients with LBBB, our study found a good association between longitudinal and radial strain patterns with the degree of LV remodeling and LV dysfunction by FT-CMR analysis. Additionally, myocardial fibrosis didn’t seem to interfere with the staged LBBB classification.

Long-term outcomes in patients with potential reversible causes of bradycardia

Funding Acknowledgements

Type of funding sources: None.

Introduction

Hyperkalemia and negative chronotropic drugs are well known causes of reversible bradycardia. Their synergic combination may result in BRASH syndrome (Bradycardia, Renal failure, Atrioventricular blockade, Shock, and Hyperkalemia), a consequence of the vicious cycle between bradycardia, renal failure and worsening hyperkalemia, leading ultimately to multiorgan dysfunction. In potentially reversible bradycardia, drug discontinuation or metabolic correction is recommended before permanent pacemaker (PPM) implantation.

Objectives

To determine the long-term prognosis in patients with potentially reversible symptomatic bradycardia.

Methods

We retrospectively reviewed 176 patients who presented to the emergency department with symptomatic bradycardia, between January 2015 and August 2016. Patients without any reversible cause of bradycardia were excluded. Participants were stratified into three groups according to the reversible causes of bradycardia: patients with hyperkalemia, with or without acute renal injury (ARI) (group 1); patients taking negative chronotropic drugs, with or without ARI (group 2); patients with BRASH syndrome (combination of hyperkalemia and negative chronotropic drugs, with or without ARI) (group 3). The primary endpoint was PPM implantation after discharge. Secondary endpoints included: bradycardia-related rehospitalization, heart failure (HF) hospitalization, all-cause mortality and a composite of all the previous endpoints.

Results

A total of 105 patients were included (52.4% female; mean age 79.8±8.6 years). Group 1 was comprised by 15 patients (14.3%), group 2 by 69 patients (65.7%) and group 3 by 21 patients (20%, figure 1). The incidence of each event is presented in figure 2. During a mean follow-up of 3.2±2.1 years, PPM was implanted in 60 patients (57.1%) – 51 during hospital stay (85%) and 9 after discharge (15%). Across all groups, approximately 50% of the patients needed PPM implantation at some point, without significant differences between groups (p=0.508). Group 3 had the lowest need of in-hospital PPM (38.1%) but the highest bradycardia-related readmissions (9.5%). Nevertheless, post-discharge PPM implantation was still higher in group 1 (33.3%), followed by group 3 (22.2%). There were no significant differences in the post-discharge PPM implantation rate between groups (p=0.76). In groups 1 and 3 the composite endpoint (73.3% and 76.2%, respectively) was significantly more frequent than in group 2 (44.9%, p=0.046 and p=0.012, respectively).

Conclusions

Nearly half of the patients with an episode of reversible bradycardia needed a PPM at some point. Given the advanced age of most patients with bradycardia secondary to metabolic derangement and/or drug toxicity, it is possible that this unveils underlying conduction system disease, which is likely to recur without PPM implantation.

Supraventricular arrhythmias in MINOCA patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

De novo atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS). However, 5-15% of patients (pts) admitted with suspected acute myocardial infarction have no significant lesions on coronary angiography (>50%) (MINOCA). Contrary to initial beliefs, MINOCA is not a benign disease, given that mortality and incidence of adverse events is similar to ACS.

Objective

To evaluate predictors and prognosis of AF in the setting of MINOCA.

Methods

Based on a multicenter retrospective study, data collected from admissions between 2013 and 2020. Pts without data on cardiovascular history or uncompleted clinical data were excluded. We included 7590 pts with non-ST elevation myocardial infarction (NSTEMI). Between those, 1561 (19.2%) were MINOCA. We divided MINOCA pts in 2 groups (G): GA – MINOCA with de novo AF; GB – MINOCA without de novo AF during in-hospital stay.

Results

MINOCA pts’ mean age was 65±13, 62% were male and 2.1% had de novo AF. GA pts were older (76±10 vs 65±13, p<0.001), had higher rates of Killip-Kimball class (KKC) >I (27.8% vs 9.7%, p=0.027) and kidney function impairment (50% vs 10.2%, p<0.001), lower haemoglobin at admission (13±1.5 vs 13.7±1.8, p=0.038), higher rates of diuretics (56.3% vs 17.6%, p<0.001) and amiodarone usage during hospitalization (31.3% vs 3.6%, p<0.001) and higher rates of left ventricle ejection fraction (LVEF)<50% (47.1% vs 19.1%, p=0.009). The Gs were similar regarding gender, times from symptoms to admission, cardiovascular risk factors and past history of heart failure, stroke or ACS, and heart rate and systolic arterial tension at admission. In the global population, older age (p=0.001, OR 1.87, CI 1.23-2.72), KKC>I (p=0.004, OR 1.76, CI 1.19-2.61) and LVEF<50% (p<0.001, OR 2.25, CI 1.5-3.38) were predictors of AF during hospitalization. In MINOCA pts, only older age (p=0.014, OR 4.2, CI 1.34-13.2) and LVEF<50% (p<0.001, OR 7.44, CI 2.17-25.47) were predictors of de novo AF. Regarding 1 year-prognosis, the occurrence of AF in MINOCA pts was associated with worse outcomes, namely 1year-mortality (log rank=0.002) and 1-year all cause readmission (log rank 0.028)

Conclusion

As expected, AF in the setting of MINOCA is associated with poorer prognosis. Pts with older age and LV dysfunction are at higher risk of de novo AF in this population.

Home-based cardiac rehabilitation can reduce anxiety and depression in heart failure patients

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). CIAFEL, UnIC and UMIB are supported by national funds through Fundação para a Ciência e Tecnologia, I.P. [(UIDB/00617/2020), (UIDB/00051/2020 and UIDP/00051/2020), and (UIDB/00215/2020 and UIDP/00215/2020), respectively]. CS received an individual grant from CAPES [BEX 0554/14-6].

Introduction

The current COVID-19 pandemic has led to significant changes in physical and mental health and has become a major challenge for cardiac rehabilitation (CR) programs. CR is an essential component in the treatment of heart failure (HF), as it improves cardiorespiratory fitness and quality of life, as well as reducing hospitalization rates. COVID-19 pandemic increased social isolation, and the CR centers were closed. Center-based CR requires the patient to travel to the hospital, which increases the risk of SARS-CoV-2 infection in this high-risk population. In this context, home-based CR can be an excellent strategy to reduce the physical and mental consequences of the social isolation imposed by the COVID-19 pandemic.

Objective

To test the effectiveness of a home-based CR program on cardiorespiratory fitness and anxiety and depression levels in individuals with HF during covid-19 pandemic.

Methods

Forty-two individuals with HF (age: 61.3±12.0; LVEF: 37.5±11.2) were included in this study. The exercise training program consisted in 12 weeks of combined exercise training (2x/week; 60min/day, 60-80% VO2peak), with 4 supervised exercise sessions in the hospital context and the remaining at home. Patients were monitored using a heart rate monitor and weekly phone calls. The following parameters were evaluated: cardiorespiratory fitness through the 6-minute walk test (6MWT) and anxiety and depression levels through the Hospital Anxiety and Depression Scale (HADS).

Results

After the home-based CR program, there was a significant increase in the 6MWT of 49 meters (95%IC: 38 to 60; p<0.001) and a significant decrease in anxiety levels of -1.12 points (95%CI: - 2.163 to -0.075 p=0.036). No significant changes were found in depression levels (p=0.954). Furthermore, the improvements in cardiorespiratory fitness were significantly associated with the reduction in the levels of anxiety (r= -0.281; p=0.028) and depression (r=: -0.278; p=0.030).

Conclusions

The home-based CR program was able to improve cardiorespiratory fitness and this improvement was associated with a decrease in anxiety and depression levels in individuals with HF. The results suggest that home-based CR can be an important strategy to minimize the physical and mental impact induced by social isolation imposed by COVID-19 pandemic in HF patients.

Short-term outcomes in patients with non-ST-segment elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Introduction

The proportion of non-ST-segment elevation myocardial infarction (NSTEMI) is increasing among the acute coronary syndromes (ACS). Reinfarction (RI) is a potential complication in high-risk patients with NSTEMI and it will cause an impact on these patients’ prognosis.

Purpose

Identify high-risk patients with RI and their prognosis in the setting of NSTEMI.

Methods

Based on a multicenter retrospective study, data collected from admissions between January 2013 and January 2020. Patients without data on previous cardiovascular history or uncompleted clinical data were excluded. Patients were divided in 2 groups (G): G1 – patients without RI; G2 - patients with RI during hospitalization. Logistic regression and survival analysis were performed.

Results

7180 patients were admitted with NSTEMI, RI occurred in 71 pts (0.99%). Regarding epidemiological and past history G2 was older (71±12 vs 66±12, p=0.001), had higher rates of previous stroke (15.9% vs 7.0%, p 0.003) and peripheric arterial disease (6.3% vs 6.1%, p=0.004). The groups were similar regarding arterial hypertension (p=0.74), diabetes type 2 (p=0.11) and dyslipidaemia (p=0.48).

G2 had higher levels of brain natriuretic peptide (45.5% vs 24.5%, p&lt;0.001) and lower levels of haemoglobin (20.3% vs 7.9%, p&lt;0.001). Patients taking prasugrel (2% vs 0.3%, p=0.002) or ticagrelor (6.1% vs 2.2%, p&lt;0.001) previously to the admission were more susceptible to have RI. Patients with severe left ventricular systolic dysfunction (3.4% vs 2.6%, p&lt;0.001), need of invasive (2.8% vs 0.8%, p&lt;0.001) or non-invasive (4.2% vs 1.3%, p&lt;0.001) ventilation and percutaneous coronary intervention (PCI) (80.3% vs 64.7%, p0.006) had higher rates of RI.

Logist regression confirmed that PCI (p=0.03, OR 2.22, CI 1.08-4.53), previous stroke (p=0.02, OR 0.58, CI 0.37-0.92) and pts previously taking prasugrel (p=0.02, OR 1.85, CI 1.11-3.10) were predictors of RI in the setting of NSTEMI.

Conclusion

RI in the setting of NSTEMI was associated with PCI, previous stroke and pts previously taking prasugrel. One year prognosis was poorer for patients who suffered RI.

Can we prevent the occurrence of stroke in patients admitted with non-ST-segment elevation myocardial infarction?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardio-cerebral vascular diseases are a leading cause of deaths worldwide.

Stroke is a potential complication in high-risk patients who had non-ST-segment elevation myocardial infarction (NSTEMI).

Purpose

Identify high-risk patients with stroke and their prognosis in the setting of NSTEMI.

Methods

Based on a multicenter retrospective study, data collected from admissions between January 2013 and January 2020. Patients without data on previous cardiovascular history or uncompleted clinical data were excluded. Patients were divided in 2 groups (G): G1 – patients who suffered stroke; G2 - patients without stroke. Logistic regression and survival analysis were performed.

Results

7180 patients were admitted with NSTEMI, stroke occurred in 35 patients (0.49%). Regarding epidemiological and past history G1 was older (72±9 vs 66±12, p= 0.004), had more females (54.3% vs 45.75, p&lt;0.001), had higher rates of type 2 diabetes mellitus (51.3% vs 35.2%, p=0.05), previous strokes / transient ischemic attack (24.2% vs 7.0%, p=0.007) and dementia (3.3% vs 0.8%, p&lt;0.001). Arterial hypertension (77.1 vs 72.8%, p=0.56), dyslipidaemia (61.8% vs 63.0%, p=0.88) and smoking (17.6% vs 26.0%, p=0.27) were similar between groups. Patients who presented with chest pain (72.7% vs 92.0%, p&lt;0.001) and patients who were not revascularized were more likely to suffer a stroke (43.3% vs 17.5%, p&lt;0.001).

Logist regression only confirmed that females were more likely to have a stroke (p&lt;0.001, OR 4.13, CI 1.87-9.15) and patients who presented with chest pain (p=0.001, OR 0.23, CI 0.10-0.54). One year event-free survival was higher in patients who did not have stroke (95.3% vs 80.0%, p=0.005, OR 4.50, CI 1.43-14.15)

Conclusion

Since sex gender and form of presentation of NSTEMI are not modifiable factors we cannot prevent strokes from happening in the context of NSTEMI.

Impact of a home-based cardiac rehabilitation program in heart failure during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). CIAFEL, UnIC and UMIB are supported by national funds through Fundação para a Ciência e Tecnologia, I.P. [(UIDB/00617/2020), (UIDB/00051/2020 and UIDP/00051/2020), and (UIDB/00215/2020 and UIDP/00215/2020), respectively]. CS received an individual grant from CAPES [BEX 0554/14-6].

Introduction

Cardiac rehabilitation (CR) is an evidence-based recommended treatment of heart failure (HF) patients. During the COVID-19 pandemic, the shutdown of CR centers was necessary to limit the infection risk among high-risk patients. The integration of a home-based CR (HBCR) program in CR units can help to improve the delivery of care and improve cardiovascular outcomes of HF patients.

Purpose

To assess the effectiveness of an HBCR program in HF patients.

Methods

This is a sub­study of the EXercise InTervention in Heart Failure trial (EXIT-HF), which include forty-nine HF patients (preserved and reduced ejection fraction). The HBCR program consisted in 12-week combined exercise program (60%-80% of peak oxygen consumption (VO2 peak)), 2 training sessions per week, for a total of 24 sessions. Patients performed 4 supervised training sessions and the remaining sessions at home. All patients performed a cardiopulmonary exercise test (VO2 peak), the 6-minute-walking test (6MWT), collected blood analysis (plasma NT-proBNP), and answered the Minnesota Living with Heart Failure Questionnaire.

Results

Forty-two patients (86%) complete at least 80% of prescribed training sessions (age: 61.1±12; FEVE: 37.1±10.8). The HBCR program improve VO2 peak from 18.3 to 20.1ml/kg/min (+1.8 ml/kg/min; 95%IC:1.4 to 2.4; p<0.001) and the walked distance at the 6MWT from 462 to 512 meters (+49 meters; 95%IC: 38 to 60; p<0.001). In addition, overall quality of life was improved (-13 points; 95%IC:-7.8 to -18.5; p<0.001), as well physical (-6.3 points; 95%IC:-3.5 to -9; p<0.001) and emotional dimension of quality of life (-2.8points ; 95%IC: -0.9 to -4.7; p=0.06). No significant change was found in NT-proBNP levels (820±1220 vs 674±903; p=0.285).

Conclusions

Our results showed that HBCR is feasible and can improve functional capacity and quality of life in HF patients.

Effect of Self-monitoring of Blood Pressure on Blood Pressure Control in Pregnant Individuals With Chronic or Gestational Hypertension: The BUMP 2 Randomized Clinical Trial

Importance

Inadequate management of elevated blood pressure is a significant contributing factor to maternal deaths. The role of blood pressure self-monitoring in pregnancy in improving clinical outcomes for the pregnant individual and infant is unclear.

Objective

To evaluate the effect of blood pressure self-monitoring, compared with usual care alone, on blood pressure control and other related maternal and infant outcomes, in individuals with pregnancy hypertension.

Design, Setting, and Participants

Unblinded, randomized clinical trial that recruited between November 2018 and September 2019 in 15 hospital maternity units in England. Individuals with chronic hypertension (enrolled up to 37 weeks' gestation) or with gestational hypertension (enrolled between 20 and 37 weeks' gestation). Final follow-up was in May 2020.

Interventions

Participants were randomized to either blood pressure self-monitoring using a validated monitor and a secure telemonitoring system in addition to usual care (n = 430) or to usual care alone (n = 420). Usual care comprised blood pressure measured by health care professionals at regular antenatal clinics.

Main Outcomes and Measures

The primary maternal outcome was the difference in mean systolic blood pressure recorded by health care professionals between randomization and birth.

Results

Among 454 participants with chronic hypertension (mean age, 36 years; mean gestation at entry, 20 weeks) and 396 with gestational hypertension (mean age, 34 years; mean gestation at entry, 33 weeks) who were randomized, primary outcome data were available from 444 (97.8%) and 377 (95.2%), respectively. In the chronic hypertension cohort, there was no statistically significant difference in mean systolic blood pressure for the self-monitoring groups vs the usual care group (133.8 mm Hg vs 133.6 mm Hg, respectively; adjusted mean difference, 0.03 mm Hg [95% CI, -1.73 to 1.79]). In the gestational hypertension cohort, there was also no significant difference in mean systolic blood pressure (137.6 mm Hg compared with 137.2 mm Hg; adjusted mean difference, -0.03 mm Hg [95% CI, -2.29 to 2.24]). There were 8 serious adverse events in the self-monitoring group (4 in each cohort) and 3 in the usual care group (2 in the chronic hypertension cohort and 1 in the gestational hypertension cohort).

Conclusions and Relevance

Among pregnant individuals with chronic or gestational hypertension, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly improved clinic-based blood pressure control.

Trial Registration

ClinicalTrials.gov Identifier: NCT03334149.

Effect of Self-monitoring of Blood Pressure on Diagnosis of Hypertension During Higher-Risk Pregnancy: The BUMP 1 Randomized Clinical Trial

Importance

Inadequate management of elevated blood pressure (BP) is a significant contributing factor to maternal deaths. Self-monitoring of BP in the general population has been shown to improve the diagnosis and management of hypertension; however, little is known about its use in pregnancy.

Objective

To determine whether self-monitoring of BP in higher-risk pregnancies leads to earlier detection of pregnancy hypertension.

Design, Setting, and Participants

Unblinded, randomized clinical trial that included 2441 pregnant individuals at higher risk of preeclampsia and recruited at a mean of 20 weeks' gestation from 15 hospital maternity units in England between November 2018 and October 2019. Final follow-up was completed in April 2020.

Interventions

Participating individuals were randomized to either BP self-monitoring with telemonitoring (n = 1223) plus usual care or usual antenatal care alone (n = 1218) without access to telemonitored BP.

Main Outcomes and Measures

The primary outcome was time to first recorded hypertension measured by a health care professional.

Results

Among 2441 participants who were randomized (mean [SD] age, 33 [5.6] years; mean gestation, 20 [1.6] weeks), 2346 (96%) completed the trial. The time from randomization to clinic recording of hypertension was not significantly different between individuals in the self-monitoring group (mean [SD], 104.3 [32.6] days) vs in the usual care group (mean [SD], 106.2 [32.0] days) (mean difference, -1.6 days [95% CI, -8.1 to 4.9]; P = .64). Eighteen serious adverse events were reported during the trial with none judged as related to the intervention (12 [1%] in the self-monitoring group vs 6 [0.5%] in the usual care group).

Conclusions and Relevance

Among pregnant individuals at higher risk of preeclampsia, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly earlier clinic-based detection of hypertension.

Trial Registration

ClinicalTrials.gov Identifier: NCT03334149.

Applying the behaviour change wheel to develop a smartphone application 'stay-active' to increase physical activity in women with gestational diabetes

BACKGROUND

Physical activity (PA) interventions are an important but underutilised component in the management of gestational diabetes mellitus (GDM). The challenge remains how to deliver cost effective PA interventions that have impact on individual behaviour. Digital technologies can support and promote PA remotely at scale. We describe the development of a behaviourally informed smartphone application (Stay-Active) for women attending an NHS GDM clinic. Stay-Active will support an existing motivational interviewing intervention to increase and maintain PA in this population.

METHODS

The behaviour change wheel (BCW) eight step theoretical approach was used to design the application. It provided a systematic approach to understanding the target behaviour, identifying relevant intervention functions, and specifying intervention content. The target behaviour was to increase and maintain PA. To obtain a behavioural diagnosis, qualitative evidence was combined with focus groups on the barriers and facilitators to PA in women with GDM. The findings were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework to identify what needs to change for the target behaviour and linked to appropriate intervention functions. Finally, behaviour changes techniques (BCT) and modes of delivery that are most likely to serve the intervention functions were selected. Current evidence, patient focus groups and input from key stakeholders informed Stay-Active's development.

RESULTS

We found that psychological capability, reflective and automatic motivation, social and physical opportunity needed to change to increase PA in women with GDM. The four key intervention functions identified were Enablement, Education, Persuasion and Training. Stay-Active incorporates these four intervention functions delivering ten BCTs including: goal setting, credible source, self-monitoring, action planning, prompts and cues. The final design of Stay-Active delivers these BCTs via an educational resource centre, with goal setting and action planning features, personalised performance feedback and individualised promotional messages.

CONCLUSION

The BCW has enabled the systematic and comprehensive development of Stay-Active to promote PA in women with GDM within an NHS Maternity service. The next phase is to conduct a trial to assess the feasibility and acceptability of a multi-component intervention that combines Stay-Active with PA Motivational Interviewing.

Postpartum blood pressure self-management following hypertensive pregnancy: protocol of the Physician Optimised Post-partum Hypertension Treatment (POP-HT) trial

INTRODUCTION

New-onset hypertension affects approximately 10% of pregnancies and is associated with a significant increase in risk of cardiovascular disease in later life, with blood pressure measured 6 weeks postpartum predictive of blood pressure 5-10 years later. A pilot trial has demonstrated that improved blood pressure control, achevied via self-management during the puerperium, was associated with lower blood pressure 3-4 years postpartum. Physician Optimised Post-partum Hypertension Treatment (POP-HT) will formally evaluate whether improved blood pressure control in the puerperium results in lower blood pressure at 6 months post partum, and improvements in cardiovascular and cerebrovascular phenotypes.

METHODS AND ANALYSIS

POP-HT is an open-label, parallel arm, randomised controlled trial involving 200 women aged 18 years or over, with a diagnosis of pre-eclampsia or gestational hypertension, and requiring antihypertensive medication at discharge. Women are recruited by open recruitment and direct invitation around time of delivery and randomised 1:1 to, either an intervention comprising physician-optimised self-management of postpartum blood pressure or, usual care. Women in the intervention group upload blood pressure readings to a 'smartphone' app that provides algorithm-driven individualised medication-titration. Medication changes are approved by physicians, who review blood pressure readings remotely. Women in the control arm follow assessment and medication adjustment by their usual healthcare team. The primary outcome is 24-hour average ambulatory diastolic blood pressure at 6-9 months post partum. Secondary outcomes include: additional blood pressure parameters at baseline, week 1 and week 6; multimodal cardiovascular assessments (CMR and echocardiography); parameters derived from multiorgan MRI including brain and kidneys; peripheral macrovascular and microvascular measures; angiogenic profile measures taken from blood samples and levels of endothelial circulating and cellular biomarkers; and objective physical activity monitoring and exercise assessment. An additional 20 women will be recruited after a normotensive pregnancy as a comparator group for endothelial cellular biomarkers.

ETHICS AND DISSEMINATION

IRAS PROJECT ID 273353. This trial has received a favourable opinion from the London-Surrey Research Ethics Committee and HRA (REC Reference 19/LO/1901). The investigator will ensure that this trial is conducted in accordance with the principles of the Declaration of Helsinki and follow good clinical practice guidelines. The investigators will be involved in reviewing drafts of the manuscripts, abstracts, press releases and any other publications arising from the study. Authors will acknowledge that the study was funded by the British Heart Foundation Clinical Research Training Fellowship (BHF Grant number FS/19/7/34148). Authorship will be determined in accordance with the ICMJE guidelines and other contributors will be acknowledged.

TRIAL REGISTRATION NUMBER

NCT04273854.

The Use of Wearable Pulse Oximeters in the Prompt Detection of Hypoxemia and During Movement: Diagnostic Accuracy Study

Background

Commercially available wearable (ambulatory) pulse oximeters have been recommended as a method for managing patients at risk of physiological deterioration, such as active patients with COVID-19 disease receiving care in hospital isolation rooms; however, their reliability in usual hospital settings is not known.

Objective

We report the performance of wearable pulse oximeters in a simulated clinical setting when challenged by motion and low levels of arterial blood oxygen saturation (SaO₂).

Methods

The performance of 1 wrist-worn (Wavelet) and 3 finger-worn (CheckMe O2+, AP-20, and WristOx2 3150) wearable, wireless transmission–mode pulse oximeters was evaluated. For this, 7 motion tasks were performed: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia exposure followed, in which inspired gases were adjusted to achieve decreasing SaO₂ levels at 100%, 95%, 90%, 87%, 85%, 83%, and 80%. Peripheral oxygen saturation (SpO₂) estimates were compared with simultaneous SaO₂ samples to calculate the root-mean-square error (RMSE). The area under the receiver operating characteristic curve was used to analyze the detection of hypoxemia (ie, SaO₂<90%).

Results

SpO₂ estimates matching 215 SaO₂ samples in both study phases, from 33 participants, were analyzed. Tapping, rubbing, turning pages, and using a tablet degraded SpO₂ estimation (RMSE>4% for at least 1 device). All finger-worn pulse oximeters detected hypoxemia, with an overall sensitivity of ≥0.87 and specificity of ≥0.80, comparable to that of the Philips MX450 pulse oximeter.

Conclusions

The SpO₂ accuracy of wearable finger-worn pulse oximeters was within that required by the International Organization for Standardization guidelines. Performance was degraded by motion, but all pulse oximeters could detect hypoxemia. Our findings support the use of wearable, wireless transmission–mode pulse oximeters to detect the onset of clinical deterioration in hospital settings.

Trial Registration

ISRCTN Registry 61535692; http://www.isrctn.com/ISRCTN61535692

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2019-034404

Normal flow, low gradient aortic stenosis - is LVOT the determinant?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (&gt;40mmHg) and an aortic valve area (AVA ≤1cm2). These patients present with a lower mean gradient (&lt;40mmHg) and area (AVA ≤1cm2). However, the treatment strategies focus on the population with a reduced indexed stroke volume (≤35mL/m2). There is less clarity concerning those with a normal stroke volume. An important determinant of the area and stroke volume is the LVOT diameter, which may have a significant impact in the classification of the severity. There is some literature supporting an expected diameter according to the body surface area.

Purpose

This paper aims to analyse the population with normal flow, low gradient aortic stenosis, as well as compare the impact of the expected LVOT diameter in the classification of patients.

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed as well as echocardiographic variables to properly characterize aortic stenosis.

Results

A total of 79 patients met the criteria for normal flow, low gradient aortic stenosis with a valvular area ≤1cm2.  Mean age was 79.5 ± 8.6 years-old and 38% was male. The mean LVOT diameter was 2.11 ± 0.18 cm which correlated to a mean AVA of 0.88 ± 0.10 cm2. Should the LVOT diameter align with the expected diameter according to the formula [(5,7× BSA +12,1)/10], the mean LVOT diameter would be 2.18 ± 0.11 cm, which correlated to a mean AVA of 0.96 ± 0.22cm2. This represents a statistically significant difference in the value, with the expected diameter being 0.075cm higher than the measured (p = 0.002), which translates in a statistically significant higher AVA (+0.085, p &lt; 0,001). With the above data, 31 (38.8%) patients would have been reclassified as moderate aortic stenosis, according to the recalculated AVA alone. Taking into account the indexed AVA, only 22 (27.8%) patients would be reclassified. 8 other patients (10.1%) would have been reclassified as low flow, low gradient aortic stenosis as the recalculated stroke volume would be lower than 35mL/m2.

Conclusion

This paper reminded us of the importance of an appropriately measured LVOT diameter, and the potential impact in reclassification of valvular heart disease. This is more important when the classification may alter our conduct. Other imaging techniques, such as transoesophageal echocardiogram or CT scan, may obviate the squared error of the LVOT measurement as well as account for the geometry of the LVOT, especially in dubious cases. Abstract Figure.