435 Left ventricular reverse remodeling and angiotensin ii receptor blocker neprilysin inhibitor - a real-world data

BACKGROUND

Although sacubitril/valsartan (ARNI) improves the NYHA functional class and prognosis in patients with heart failure with reduced ejection fraction (HFrEF), its impact on reverse remodelling is uncertain. We assessed left ventricular reverse remodeling in a cohort of HFrEF patients treated with ARNI.

METHODS

We conducted a single-centre, retrospective, observational study of 200 HFrEF patients started on ARNI during 2018. Of these, we analysed 100 patients treated with the maximum, target dose (97/103 mg bid). Baseline clinical, laboratory and demographic characteristics were evaluated and a clinical and echocardiographic follow-up, including left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (GLS), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV) and mitral valve regurgitation (MR), were conducted from ARNI initiation to a 3-month landmark.

RESULTS

Mean age was 59 ± 13 years and 85% were male. At baseline, 63% were on NYHA II, 34% in NYHA III and 3% in NYHA IV functional class. Mean systolic blood pressure was 125 ± 16 mmHg, median NT-proBNP was 773 pg/dL (IQR 386-1569) and mean LVEF 27 ± 7%. Median time between initiation of the drug and reaching the target dose was 10 weeks. Functional class significantly improved; at baseline, 37% of patients were in NYHA III-IV; 3 months after target dose, only 6% remained in NYHA III-IV (p = 0.005). Half of patients (48.6%) improved LVEF (from 27 ± 7% to 31 ± 10%, mean increase 4.2 ± 8.8%; 95%CI 2.1 to 6.3, p < 0.001) and in one quarter (24.6%) LVEF improved over 35% (p < 0.001). In a echocardiographic subgroup analysis, including a random sample of 35 patients, we found a significant improvement in GLS 1.5 ± 2.9 (95%CI 0.4 to 2.6%, p = 0.009), a significant decrease in LVESV and LVEDV 29 ± 3 mL (95%CI -42.6mL to -15.4mL, p < 0.001) and 31 ± 47ml (95% CI -48 to -15, p < 0.001), respectively, and a significant improvement in MR severity (p = 0.001).

CONCLUSIONS

We observed that in an HFrEF patient population treated with ARNI there was a significant clinical improvement, who may be explained by a robust impact on reverse remodelling, even on a short-time of follow-up. An interesting finding was that 24.6% improved LVEF above the 35% cut-off, and therefore lost an indication for a prophylactic implantable cardioverter defibrillator.

The impact of the economic crisis on the mental health of Portuguese primary-school children

Objective

To measure the impact of the economic crisis on the mental health correlates of Portuguese children attending primary school during 2016.

Methods

Cross-sectional analysis of primary school-aged children and their parents (n = 1157), conducted in public and private schools of three Portuguese districts. Parent reports of children mental health symptoms (Strengths and Difficulties Questionnaire - SDQ) and children self-reports of health-related quality of life (KIDSCREEN-27) and depressive, anxiety and stress symptoms (Depression, Anxiety and Stress Scales, Children version - DASS-C), were compared according to a set of yes/no questions on how the economic crisis changed the normal aspects of routine life (e.g. During the financial crisis did you had to use savings? Started buying cheaper food?). Linear regression models were fitted for the SDQ, the KIDSCREEN-27 and the DASS-C as dependent variables adjusted for children sex, socioeconomic status and district of residence.

Results

Affirmative answers to the crisis impact questions were associated with more frequent psychosocial functioning problems in children, with poorer self-reported health-related quality of life and with more frequent symptoms of depression, anxiety and stress.

Conclusions

Portuguese children mental health correlates show significant worse scores for those whose parents declared having to change daily routine habits as a result of the recent macroeconomic financial crisis, compared to those who did not change habits. Public Health programs should be developed to mitigate the potential negative impact of the financial crisis to the mental health of children.

Key messages

A negative impact on children mental health was observed as a result of the economic crisis. Public health programs designed to mitigate the impact of the economic crisis should include primary-school aged children.

P6404Myocardial infarction with nonobstructive coronary arteries: does aspirin have a place in the treatment of this entity?

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is still a clinical enigma that is being increasingly recognised, as the number of coronary angiographies we perform in our centres also increase. However, the treatment for this entity is still a matter of important debate, not only due to the different causative mechanisms of this disease but also because there are no major trials regarding MINOCA treatment.

Purpose

To determine the association between acetylsalicylic acid (ASA) use after discharge and mortality after discharge in MINOCA patients admitted to a coronary care unit (CCU).

Methods

We analyzed data from 370 (11.7% of the global sample) patients admitted with MINOCA in our CCU. Patients with other final diagnoses, missing mortality data, previous acute myocardial infarction, contra-indications to aspirin and known heart failure before admission were excluded. All patients underwent transthoracic echocardiography and coronary angiography at any point during hospitalisation. After adjusting data for relevant comorbidities we then compared mortality after hospital discharge between the ASA group and the no-ASA group.

Results

Of all MINOCA patients admitted in our CCU, 84 (22.7%) were diagnosed with ST-elevation myocardial infarction (STEMI) and 286 (77.3%) with non-ST elevation myocardial infarction (NSTEMI). 296 (80%) patients received ASA after discharge. Both groups were homogeneous as we did not find any significant differences between groups regarding age (p=0.106), left ventricle ejection fraction (p=0.100), GRACE score at hospitalisation (p=0.150), Killip-Kimball class at hospitalisation (p=0.604), incidence of acute kidney injury (p=0.450), maximum c-reactive protein during stay (p=0.804) and low-density lipoprotein levels at hospitalization (p=0.055). There was also no difference in the incidence of diabetes (p=0.350), exposure to daily stress (p=0.767), active smoking (p=0.569), dyslipidemia (p=0.229), hypertension (p=0.057) and type of myocardial infarction (STEMI vs NSTEMI – p=0.215). In this MINOCA cohort (5 years follow-up) a total of 47 patients died (12.7%). ASA vs. no-ASA 1-month (3.1% vs. 0.0%, p=0.214), 6-month (4.5% vs. 1.4%, p=0.317), 1-year (5.9% vs 5.6%, p=0.900), 3-year (10.5% vs. 8.3%, p=0.668) and 5-year (13.3% vs. 12.5%, p=0.860) all-cause mortality was not significantly different. The same non-significant trend towards higher mortality with ASA was obtained when survival curves were taken into account.

Conclusions

MINOCA remains a challenging entity. In our study, the systematic use of ASA in all patients following MINOCA was not associated with better survival after long-term follow-up.

P4751Underdosing fragile patients - Are we helping or harming?

Background

An individualized approach should be taken regarding the utilization of direct oral anticoagulants (DOAC) in frail and elderly populations with atrial fibrillation (AF). We hypothesized that among an elderly and frail population, where the risk of bleeding, both real and perceived, is very high, the proportion of patients with a dose regimen different from the formal indication would be particularly high due to potential underdosing.

Methods

We conducted a retrospective, observational study enrolling 327 patients with AF admitted to an Internal Medicine ward during a 1-year period and discharged with a DOAC prescription. We divided the population in 2 groups: patients prescribed a reduced dose without formal dose reduction criteria (underdosed, n=170) and the rest of the population (n=157), which included adequately dosed patients, both with normal dose (n=99) and correctly reduced dose (n=43) and overdosed patients (n=15). A 1-year follow-up was completed for all patients, assessing the following outcomes: all-cause mortality, stroke, systemic embolism and major bleeding.

Results

Patients were elderly (81.9±7.68) and frail (Katz index 3.35±2.36). Apixaban was the most commonly prescribed NOAC (38.8%), followed by rivaroxaban (36.4%) and dabigatran (24.8%). Among underdosed patients, apixaban was prescribed in 45.3% of patients, dabigatran in 29.4% and rivaroxaban 25.3%. Although only 18.3% of patients had clinical criteria for dose reduction, 65.4% were discharged with reduced dose and thus 52% were underdosed.

Regarding 1-year outcomes, mortality (40.8% vs 25.5%, RR=1.6, p=0.003) and the combined stroke, systemic embolism and major bleeding event rate (10.1% vs 3.2%, RR=3.16, p=0.015) were higher for underdosed patients.

Among underdosed patients, comparing with the rest of the population, the increased ischemic events rate (ischemic stroke and systemic embolism) did not reached statistical significance (3.7% vs. 1.9%, p=0.5), but it did for hemorrhagic events (major bleeding and hemorrhagic stroke) (6.1% vs 0.6%, p=0.01)

On multivariate analysis, even after considering adjustment for age, Katz and CHAD2VAS2C scores, renal function and DOAC prescribed, DOAC underdosing was associated with a higher risk of both ischemic and hemorrhagic events (HR = 3.51, 95% CI 1.08–11.38). However, it lost its independent negative effect regarding mortality (HR 1.32, 95% CI 0.87–1.99).

Survival and event rate in underdosed

Conclusions

There is a significant proportion of frail and elderly patients with AF that are underdosed. This subset has a significant survival disadvantage, eventually reflecting prescription bias. However, underdosed patients have also a higher event rate of both ischemic and hemorrhagic events, suggesting that underdosing fragile patients is not an effective strategy and that instead it may be hazardous.

P2655ST-elevation myocardial infarction in women: a more satisfactory outcome?

Background

Despite all the advances registered in the last decade regarding acute myocardial infarction with ST-segment elevation (STEMI) treatment, this entity remains prevalent and highly lethal. Women constitute a lower proportion of STEMI patients, however, they show important differences when compared to men. Thanks to the lower representation of women in STEMI trials, less is know about this patient subpopulation.

Purpose

To determine and understand gender differences in patients admitted with STEMI in a coronary care unit (CCU).

Methods

Observational retrospective study of patients admitted with STEMI in a CCU, between 2006 and 2017. Patients were split between groups according to gender and were assessed in terms of risk factors, diagnosis, treatment, complications and mortality.

Results

A total of 2516 patients were included in the study. 1833 were men (72.9%) and 682 were women (27.1%). Mean age was superior in women (73.3±13.2 vs. 64.1±12.8 years, p<0.001), and displayed a greater cardiovascular comorbidity burden such as hypertension (79.6% vs. 66.2%, p<0.001) and diabetes (55.8% vs. 45.3%, p<0.001). At admission time women registered a higher mean TIMI (2.79 vs. 2.62, p=0.009) and GRACE score (166.3 vs. 146.3, p<0.001) which did not reflect in a higher hospital stay (mean 4.75 vs. 5.29 days, p=0.043). Before admission women were less treated with aspirin (26.4% vs. 33.2%, p=0.014) and statins (36.8% vs. 46.5%, p=0.001). There were no differences regarding access to revascularization (98% vs. 96.5%, p=0.105) but women presented more normal coronary angiographies (10.2% vs. 3.6%, p<0.001). During hospital stay, women evolved more to Killip-Kimball (KK) class III (4.5% vs. 1.9%, p<0.001) and KK class IV (15.9% vs. 11.2%, p<0.001). Intra-hospital (13.9% vs. 8.2%, p<0.001), 1-month (18.4% vs. 13.2%, p<0.001), 6-month (22.2% vs. 16.1%, p<0.001) and 1-year mortality (25.7% vs. 17.8%, p<0.01) was superior in women. After multivariate analysis heart failure on admission (OR 9.2, CI 95% 6.7–12.8), intravenous amiodarone use (OR 3.5, CI 95% 2.5–4.8), diabetes (OR 2.3, CI 95% 1.8–2.8), female gender (OR 1.6, CI 95% 1.3–2.0) and peak serum creatinine during hospital stay (OR 1.7, CI 95% 1.6–1.9) were independent predictors of 1-year mortality. After adjustment for age, diabetes, hypertension, previous acute myocardial infarction and initial KK, female gender maintained its potency as a significant 1-year mortality predictor.

Conclusions

Women presenting with STEMI register poorer outcomes compared to men. In our study, female gender was considered a good independent predictor of short-term and long-term mortality.

Where do we aspire to publish? A position paper on scientific communication in biochemistry and molecular biology

The scientific publication landscape is changing quickly, with an enormous increase in options and models. Articles can be published in a complex variety of journals that differ in their presentation format (online-only or in-print), editorial organizations that maintain them (commercial and/or society-based), editorial handling (academic or professional editors), editorial board composition (academic or professional), payment options to cover editorial costs (open access or pay-to-read), indexation, visibility, branding, and other aspects. Additionally, online submissions of non-revised versions of manuscripts prior to seeking publication in a peer-reviewed journal (a practice known as pre-printing) are a growing trend in biological sciences. In this changing landscape, researchers in biochemistry and molecular biology must re-think their priorities in terms of scientific output dissemination. The evaluation processes and institutional funding for scientific publications should also be revised accordingly. This article presents the results of discussions within the Department of Biochemistry, University of São Paulo, on this subject.

Pretransplant Biopsy of Marginal Kidneys: Is It Necessary?

INTRODUCTION

Pretransplant kidney biopsy from marginal donors is used to guide the decision of whether to accept or discard organs for transplantation; however, there is controversy about this procedure, and the need for a pretransplant biopsy is still a debate. We sought to determine if histologic evaluation before implantation of marginal kidneys would influence the outcome.

METHODS

A retrospective observational cohort study of marginal donor transplants at Centro Hospitalar e Universitário de Coimbra was done. From 2009 to 2016, 650 marginal kidney transplants were analyzed. We evaluated long-term graft survival in a cohort of patients who received marginal kidneys. The recipients were divided into 2 groups based on whether a pretransplant donor biopsy was performed. Continuous variables were summarized by mean and standard deviation or median and range, as applicable. Categorical variables were summarized by relative and absolute frequencies. The survival analysis was obtained and plotted using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

The median age of recipients and donors were statistically different between both groups (P < .001), with the donors and the recipients being younger in the group without a pretransplant biopsy. The median cold ischemia time was higher in the biopsy group (P = .01). The survival analysis showed that graft survival didn't differ between the groups (P = .2).

CONCLUSIONS

Selection of kidneys based on histological findings may not influence the graft survival and implies a higher cold ischemia time. More data are necessary to provide insight into which clinical, histologic, and biochemical parameters are necessary for decision making on kidney acceptance.

Chemical and ecotoxicological effects of the use of drinking-water treatment residuals for the remediation of soils degraded by mining activities

The aim of this study was to evaluate the use of drinking-water treatment residuals (DWTR) in the amendment of a soil affected by mining activities (Aljustrel mine, Portuguese sector of the Iberian Pyrite Belt), considering the effects on its chemical, biochemical and ecotoxicological characteristics. The DWTR had neutral characteristics (pH 6.7) and an organic matter (OM) content of 575 g kg^-1 dry matter (DM), which makes them a potential amendment for the remediation of mine degraded soils, as they may correct soil acidity and reduce the extractable metal fraction. An incubation assay, with soil and DWTR, with or without lime, was carried out to test the doses to be used in the assisted-phytostabilization experiment. Based on the results obtained, the doses of DWTR used were the equivalent to 48, 96, and 144 t DM ha^-1, with and without lime application (CaCO₃ 11 t DM ha^-1). Agrostis tenuis Sibth was used as the test plant. Some amendments doses were able to improve soil characteristics (pH and OM content), to decrease metal extractability by 0.01 M CaCl₂ (especially for Cu and Zn), and to allow plant growth, that did not occur in the non-amended soil. Copper, Pb and Zn concentrations in the plant material were lower than the maximum tolerable level for cattle feed, used as an indicator of risk of entry of those metals into the human food chain. The simultaneous application of DWTR (96 and 144 t ha^-1), with lime, allowed a reduction in the mine soil ecotoxicity, as evaluated by some lethal and sub-lethal bioassays, including luminescence inhibition of Vibrio fischeri, Daphnia magna acute immobilization test, mortality of Thamnocephalus platyurus, and 72-h growth inhibition of the green microalgae Pseudokirchneriella subcapitata. However, DWTR were unable to increase soil microbial activity, evaluated by dehydrogenase activity, an important soil-health indicator. Also, OM content and N_Kjeldahl, concentrations increased slightly but remained low or very low (P and K extractable concentrations were not affected). In general, the bioassays highlighted a decrease in soil ecotoxicity with the presence of lime and DWTR (144 t DM ha^-1). In conclusion, DWTR are recommended to amend acidic soils, with high concentrations of trace elements, but an additional application of organic or mineral fertilizers should be considered.