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

Anti-arrhythmic drugs confer increased risks of bradyarrhythmia in patients undergoing direct current cardioversion for atrial fibrillation

Background

Bradyarrhythmia is a known complication to direct current cardioversion (DC-cardioversion) in patients with atrial fibrillation (AF). However, whether concomitant treatment with anti-arrhythmic drugs (AADs) is associated with an increased risk of bradyarrhythmia in relation to the procedure is unknown.

Purpose

To investigate the short-term risk of bradyarrhythmia associated with AAD treatment in AF patients undergoing DC-cardioversion.

Methods

Using Danish nationwide registers, all AF patients treated with either an AAD (amiodarone, sotalol, dronedarone, flecainide, or propafenone) or rate-lowering drugs (beta-blocker, non- dihydropyridine calcium-antagonist, or digoxin) were identified at their first DC-cardioversion between 2001 and 2016. Patients were excluded if they were under 18 or above 100 years of age or had a pacemaker or implantable cardioverter defibrillator. The event of interest was a composite outcome of either a diagnosis of bradyarrhythmia (sinoatrial arrest, atrioventricular block, or unspecified bradycardia) or a procedure of pacemaker implantation. Patients were followed from the date of DC-cardioversion until event of interest, 90 days after the procedure, or at study end. Absolute risks of bradyarrhythmic events were estimated using the Aalen-Johansen estimator taking the competing risk of death into account. Hazard ratios (HR) with 95% confidence intervals (95% CI) of bradyarrhythmic events were computed using multivariable Cox models adjusted for age, sex, calendar year, as well as relevant comorbidity and concomitant medication.

Results

A total of 22,344 patients were included in the study with 3,224 (14%) individuals treated with an AAD. The median age was 67 years (interquartile range [IQR] 59–73) and most were males (69%). Patients treated with AADs were younger and had more ischemic heart disease, heart failure, and valvular disease. During follow-up we identified 601 cases of bradyarrhythmia. We found an absolute risk of bradyarrhythmic events at 90 days after cardioversion of 3.7% (95% CI 3.1–4.4) for patients treated with an AAD and 2.5% (95% CI 2.3–2.7) for patients treated with rate-lowering drugs (P<0.001) (Figure 1). AAD treatment conferred increased rates of bradyarrhythmia with a multivariable adjusted HR of 1.35 (95% CI: 1.10–1.65) compared to patients treated with rate-lowering drugs.

Conclusion

Using a large nationwide study population of patients with AF undergoing DC-cardioversion, concomitant treatment with AADs was associated with an increased risk of bradyarrhythmic events. Moreover, the absolute risks of bradyarrhythmic events after DC-cardioversion were higher than what has previously been reported. These data provide valuable insights aiding physicians in clinical decision making as well as informing patients prior to the procedure.

Figure 1. Absolute risk and adjusted hazard ratio (HR) of bradyarrythmia. AAD: Anti-arrhythmic drugs. CI: Confidence Interval.

Funding Acknowledgement

Type of funding source: None

Time trends in use of cardioprotective medication in patients with peripheral artery disease between 1997 and 2016: a nationwide study

Background

Peripheral artery disease (PAD) is associated with increased cardiovascular (CV) morbidity and mortality. Aggressive management of risk factors and lifestyle modification may improve outcomes for patients with PAD. The present study aims to investigate changes in use of cardioprotective medication after the incident diagnosis of PAD between 1997 and 2016.

Methods

By using Danish national healthcare registries, we identified all patients with first-time diagnosis of PAD between 1997 and 2016. These patients were classified into 2 main groups: PAD-all (n=167,762) that includes all PAD patients with or without a history of CVD, including myocardial infarction (MI), atrial fibrillation (AF), and stroke (n=167,761) and PAD-only (n=87,935) that comprise patients with PAD without a history of AF, MI, and stroke. We calculated temporal trends and assessed comparative use of cardioprotective medication in the first 12 months after the incident diagnosis of PAD.

Results

Our results showed an improved use of cardioprotective medication temporally in both groups. However, PAD-all were marginally better treated (Aspirin, 3.5% - 48.4%; Clopidogrel, 0% - 17.6%; VKA 0.9% - 7.8%; NOACs 0.0% - 10.1%; Statins, 1.9%- 58.1%; ACE-inhibitors, 1.2% - 20.6%), compared to PAD-only (Aspirin, 2.9% - 54.4%; Clopidogrel, 0% - 11.9%; VKA 0.9% - 2.4%; NOACs 0.0% - 3.4%; Statins, 1.5%- 56.9%; ACE-inhibitors, 0.9% - 17.2%), respectively. Proportion of PAD patients treated with any cardioprotective medication was greater among those with a history of MI or stroke. Whereas, PAD patients with a history of AF were substantially better treated with VKA and NOACs.

Conclusion

In this nationwide study, use of cardioprotective medication increased considerably with time, but there remains an underuse of guideline-recommended therapy in patients with PAD.

Funding Acknowledgement

Type of funding source: None

Unsupervised machine learning generated clusters of left ventricular strain curves identifies patients in risk of heart failure and cardiovascular death following acute myocardial infarction

Background

Today myocardial deformation, also known as strain, is assessed by the global longitudinal strain (GLS) which only provides information about the maximal deformation during systole. Hence, a lot of information obtained from different patterns of deformation curves might be undiscovered. Unsupervised Machine leaning (uML) is capable of identifying similar patterns of deformation curves. Identifying different phenotypical patterns from myocardial deformation curves might provide insights into the pathophysiological development of cardiac disease and entail useful prognostic information.

Purpose

To investigate whether uML can group specific patterns of myocardial deformation curves which provide prognostic information on heart failure and/or cardiovascular death (HF/CVD) following ST-segment elevation myocardial infarction (STEMI).

Methods

A total of 319 STEMI patients had an echocardiogram performed at median 2 days after primary percutaneous coronary intervention (pPCI). Speckle tracking echocardiography analysis divided the left ventricle into 18 segments. Standardisation of the cardiac cycle was done using linear interpolation and complete strain data (mean of all segments) as function of time throughout the cardiac cycle was used as input for the uML algorithm. Clusters were identified using a K-means cluster analysis algorithm. Primary endpoint was the composite of heart failure (HF) and/or cardiovascular death (CVD). Median follow-up time was 1423 days (IQR: 91; 1660).

Results

Mean age was 62 years, 75% were male and 130 (41%) suffered incident HF/CVD during follow-up. The uML algorithm grouped patients into three clusters containing 97, 104, and 118 patients respectively. GLS curves of the three clusters are illustrated in the Figure 1. Incidence of HF/CVD increased significantly from cluster 1 through 3 (24% vs. 39% vs. 60%, P<0.001). In multivariable Cox regressions adjusting for the variables in the score risk chart model all three clusters were significantly associated with future HF/CVD (Figure 1). Cluster models provided significant incremental prognostic information when comparing C-statistics (0.64 vs. 0.62, p=0.029)

Conclusion

Unsupervised Machine Learning clusters of left ventricular deformation curves identifies patients in risk of HF/CVD following STEMI treated with pPCI, and provides incremental prognostic information to the score risk chart model.

Figure 1. GLS curves of the three clusters

Funding Acknowledgement

Type of funding source: None

Decreasing mortality in patients with simple congenital heart disease: a Danish nationwide study

Background

The long-term mortality in patients with simple congenital heart disease (SCHD) compared with the general population is not well-described.

Purpose

To investigate the 10-year mortality in individuals with and without SCHD and whether it has changed since 1977 using contemporary data.

Method

By linking Danish nationwide registries, we identified all individuals with and without a SCHD diagnosis who were alive at age 40 between 1977–2006. Excluded were individuals with moderate or severe congenital heart disease. SCHD was defined as isolated ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA) or pulmonary stenosis (PS). The population was followed from age 40 until death or emigration, whichever came first. We predicted 10-year all-cause mortality according to each year of inclusion. Reported was 10-year all-cause mortality and mortality ratios (SCHD vs non-SCHD) with 95% confidence intervals (CI) by calendar year groups (1977–1986, 1987–1996, 1997–2006).

Results

We identified 2,040 individuals with SCHD (VSD: 27.5%, ASD: 62.2%, PDA 6.8%, PS: 3.5%), of which 1,121 (55.0%) were female, and 2,083,277 individuals without SCHD, of which 1,028,769 (49.4%) were female. In individuals with SCHD the 10-year all-cause mortality decreased over time in both men (1977–1986: 12.3% [11.8–12.9%], 1987–1996: 9.0% [7.4–10.5%], 1997–2006: 5.0% [4.3–5.7%]) and women (1977–1986: 7.7% [7.5–7.9%], 1987–1996: 4.9% [3.9–6.0%], 1997–2006: 1.2% [0.7–1.7%]), whereas the 10-year risks were somewhat stable in individuals without SCHD for both men (1977–1986: 3.2% [3.2–3.2%], 1987–1996: 3.3% [3.2–3.3%], 1997–2006: 2.9% [2.7–3.0%]) and women (1977–1986: 2.4% [2.3–2.4%], 1987–1996: 2.1% [2.1– 2.2%], 1997–2006: 1.7% [1.6–1.8%]) (Figure 1, panel A). The mortality ratio decreased over time in both men (1977–1986: 3.9 [3.7–4.1], 1987–1996: 2.7 [2.3–3.2], 1997–2006: 1.7 [1.5–1.9]) and women (1977–1986: 3.3 [3.2–3.3], 1987–1996: 2.3 [1.8– 2.7], 1997–2006: 0.7 [0.4–1.0]) (Figure 1, panel B) remaining significantly higher for men, but not women, in 1997–2006.

Conclusion

In individuals with simple congenital heart disease aged 40 years, the 10-year mortality decreased dramatically over time for both men and women. Despite decreasing mortality, men with SCHD, but not women, remained at a higher 10-year mortality compared to individuals without SCHD.

Figure 1. Temporal trends in 10-year mortality

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Danish Heart Foundation

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

The Copenhagen chronic kidney disease echo study (COInCYDE)

Background

The cardiovascular mortality of patients with chronic kidney disease (CKD) is 2–10 times higher than in the average population.

Purpose

To estimate the prevalence of abnormal cardiac function or structure across the stages CKD 1 to 5nonD.

Method

Prospective cohort study. Patients with CKD stage 1 to 5 not on dialysis, aged 30 to 75 (n=875) and age-/sex-matched controls (n=173) were enrolled consecutively. All participants underwent a health questionnaire, ECG, morphometric and blood pressure measurements. Blood and urine were analyzed. Echocardiography was performed. Left ventricle (LV) hypertrophy, dilatation, diastolic and systolic dysfunction were defined according to current ESC guidelines.

Results

63% of participants were men. Mean age was 58 years (SD 12.6 years). Mean eGFR was 46.7 mL/min/1,73 m (SD 25.8) for patients and 82.3 mL/min/1,73 m (SD 13.4) for controls. The prevalence of elevated blood pressure at physical exam was 89% in patients vs. 53% in controls. Patients were more often smokers and obese.

Left ventricular mass index (LVMI) was slightly, albeit insignificantly elevated at CKD stages 1 & 2 vs. in kontrols: 3.1 g/m2, CI: −0.4 to 6.75, p-value 0.08. There was no significant difference in LV-dilatation between patients and controls.

Decreasing diastolic and systolic function was observed at CKD stage 3a and later: LVEF decreased 0.95% (CI: −1.5 to −0.2), GLS increased 0.5 (CI: 0.3 to 0.8), and OR for diastolic dysfunction increased 3.2 (CI 1.4 to 7.3) pr. increment CKD stage group.

Conclusion

In accordance to previous studies, we observe in the CPHCKD cohort study signs of early increase of LVMI in patients with CKD stage 1 & 2. Significant decline in systolic and diastolic cardiac function is apparent already at stage 3 CKD.

Figure 1. Estimated GFR vs. GLS & histogram of GLS

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): The Capital Region of Denmark

Diabetes mellitus is associated with higher risk of third degree atrioventricular block – a Danish nationwide registry study

Background

Diabetes mellitus (DM) is a risk factor for cardiovascular disease and sudden cardiac death. Increasing evidence shows that DM may be associated with electric disturbances including arrhythmias and atrioventricular block (AVB). However, the association of DM and AVB has never been confirmed in large studies.

Purpose

The present study aims to determine the association of DM and third-degree AVB.

Method

A nationwide nested case-control study of patients >40 years with third-degree AVB between 1995 and end of 2017, matched 1:2 on age and gender with controls from the Danish background population. DM was defined if patients were prescribed oral antidiabetics or insulin, or if they were diagnosed with an ICD10 code of DM type I or II. Data on medication, comorbidity, and outcomes were collected from Danish nationwide registries. Conditional logistic regression was used to estimate hazard ratio (HR) and 95% confidence intervals (95% CI) of third degree AVB.

Results

Out of a total population of 8,964,086, we located a total of 32,722 cases with third degree AVB, that were matched 1:2 with 65,422 controls, with a mean age of 75.3 years and 59.1% males. The case group had more DM 18,5% vs 13,3%, acute myocardial infarction 27,0% vs 16.0%, stroke 18.5% vs 16.2%, heart failure 20.0% vs 8.5% and chronic kidney disease 4.7% vs 2.5% compared to the control group. In multivariable analysis adjusted for comorbidities DM remained significantly associated with third degree AVB [HR 1.30 (95% CI: 1.25–1.35)] (Figure)

Conclusion

In this nationwide population study, DM was associated with a higher risk of third degree AVB compared to matched controls without DM. This suggests a low threshold for use of ECG evaluation in case of dizziness or syncope in DM patients, and further, that ECG should be a part of routine controls of DM patients.

Risk of third degree AV block

Funding Acknowledgement

Type of funding source: None

Rapid recognition of out-of-hospital cardiac arrest by emergency medical dispatchers is associated with improved survival

Background

Emergency medical dispatchers' (EMD) recognition of out-of-hospital cardiac arrest (OHCA) is an essential part of the first link in the Chain of Survival. However, it is unknown whether the time-to-recognition of OHCA by EMD during an emergency call is associated with survival.

Purpose

To investigate the effect of time-to-recognition on 30-day survival among patients with recognised OHCA.

Methods

We linked data on OHCAs occurring in the Capital Region of Denmark from 2016 through 2017 to records of corresponding emergency calls. We defined recognition as dispatching an ambulance with an appropriate priority level and subsequently defined time-to-recognition as the time from start of the call to the time of dispatching the ambulance. Among patients with recognised OHCA, we performed uni- and multivariate logistic regression to investigate the association of time-to-recognition and 30-day survival and reported odds ratios (OR) with 95% confidence intervals (CI).

Results

Among 2,382 patients with OHCA, 94.2% were recognised, in which median age was 73.6 years, 61.6% were males and median time-to-recognition was 0.8 minutes (interquartile range 0.7 minutes). Patients for whom time-to-recognition was up to (but not including) one minute had more than three-fold higher probability of surviving 30 days (15.5%) compared to patients for whom time-to-recognition was three or more minutes (4.5%) (Figure 1). Time-to-recognition was significantly associated with 30-day survival: OR 0.75 per minute (95% CI 0.62–0.91, P<0.005), and results were similar in the adjusted analysis: OR 0.72 per minute (95% CI 0.58–0.90, P<0.005).

Conclusion

Rapid recognition of OHCA by EMD resulted in improved survival rate of patients. This was particularly evident when time-to-recognition was three or more minutes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Hjerteforeningen

Importance of familial predisposition to heart failure to the risk of anthracycline related cardiotoxicity: a nationwide study

Background/Introduction

Anthracycline-based chemotherapy has improved the prognosis in cancer and hematological malignancies but is associated with the development of heart failure (HF). Besides well-known cardiac risk factors and cumulative dose of anthracycline, recent research has suggested that genetic variations associated with cardiomyopathies may increase the risk of HF associated with anthracycline. However, the importance of familial predisposition for the risk of developing anthracycline associated cardiotoxicity is unknown.

Purpose

To evaluate the risk of anthracycline related HF in patients with vs. without a first-degree relative with HF.

Methods

In the nationwide Danish registries, patients treated with anthracycline from 2004–2016 were identified. Primary outcome was a subsequent diagnosis of HF. Follow-up was 10 years or December 31, 2017. Familial relations were identified in the Danish Family Registry, which hold all persons born since 1942. Exposure was a first-degree biological relative (parent or sibling) with a diagnosis of HF. Risk of HF was evaluated in a cumulative incidence function with death as competing event and in a Fine and Grey model adjusted for age, sex, prevalent ischemic heart disease, atrial fibrillation, hypertension and chronic obstructive pulmonary disease.

Results

A total of 11.651 patients (mean age 48.0 (SD±8.6), 12.2% male gender) were evaluated after exclusion of 46 with pre-anthracycline HF. Mean follow-up was 4.4 years (SD±2.9). In the group with a first-degree relative with HF (n=1.608) 35 patients (2.2%) was diagnosed with HF vs. 133 (1.3%) in the group without a first-degree relative with HF (n=10.043) corresponding to incidence rates per 1000 patient years of 5.2 (95% CI: 3.8–7.3) vs. 3.0 (95% CI: 2.5–3.5). The cumulative incidence of HF was higher in the first-degree relative HF group (Figure 1a), yielding an adjusted hazard ratio of 1.53 (95% CI: 1.05–2.24, p=0.03) for HF associated with anthracycline. All-cause mortality showed a trend towards higher risk in the later 5 years of follow-up in the first-degree relative HF group with a 10-year risk of 32.4% (95% CI: 28.4–36.5) vs. 26.1% (95% CI: 24.9–27.4) but no significant difference in the Kaplan-Meier estimate (p=0.08) (Figure 1b).

Conclusion

In this nationwide register-based study having a first-degree relative with HF was associated with a small but increased risk of anthracycline related HF, yielding attention towards the family predisposition, when estimating the risk of cancer therapy related cardiotoxicity.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Odense University Hospital

Prognostic value of global longitudinal layer specific strain for patients with heart failure with reduced ejection fraction

Background

Novel echocardiographic software allows for layer-specific evaluation of myocardial deformation by 2-dimensional speckle tracking echocardiography. Endocardial, epicardial- and whole wall global longitudinal strain (GLS) may be superior to conventional echocardiographic parameters in predicting all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF).

Purpose

The purpose of this study was to investigate the prognostic value of endocardial-, epicardial- and whole wall GLS in patients with HFrEF in relation to all-cause mortality.

Methods

We included and analyzed transthoracic echocardiographic examinations from 1,015 patients with HFrEF. The echocardiographic images were analyzed, and conventional and novel echocardiographic parameters were obtained. A p value in a 2-sided test <0.05 was considered statistically significant. Cox proportional hazards regression models were constructed, and both univariable and multivariable hazard ratios (HRs) were calculated.

Results

During a median follow-up time of 40 months, 171 patients (16.8%) died. A lower endocardial (HR 1.17; 95% CI (1.11–1.23), per 1% decrease, p<0.001), epicardial (HR 1.20; 95% CI (1.13–1.27), per 1% decrease, p<0.001), and whole wall (HR 1.20; 95% CI (1.14–1.27), per 1% decrease, p<0.001) GLS were all associated with higher risk of death (Figure 1). Both endocardial (HR 1.12; 95% CI (1.01–1.23), p=0.027), epicardial (HR 1.13; 95% CI (1.01–1.26), p=0.040) and whole wall (HR 1.13; 95% CI (1.01–1.27), p=0.030) GLS remained independent predictors of mortality in the multivariable models after adjusting for significant clinical parameters (age, sex, total cholesterol, mean arterial pressure, heart rate, ischemic cardiomyopathy, percutaneous transluminal coronary angioplasty and diabetes) and conventional echocardiographic parameters (left ventricular (LV) ejection fraction, LV mass index, left atrial volume index, deceleration time, E/e', E-velocity, E/A ratio and tricuspid annular plane systolic excursion). No other echocardiographic parameters remained an independent predictors after adjusting. Furthermore, endocardial, epicardial and whole wall GLS had the highest C-statistics of all the echocardiographic parameters.

Conclusion

Endocardial, epicardial and whole wall GLS are independent predictors of all-cause mortality in patients with HFrEF. Furthermore, endocardial, epicardial and whole wall GLS were superior prognosticators of all-cause mortality compared with all other echocardiographic parameters.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev and Gentofte Hospital

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

Relationship between cardiac structure and function and atrial fibrillation related hospitalizations following catheter ablation

Background

Even though catheter ablation (CA) is an effective treatment for atrial fibrillation (AF), AF-related hospitalizations and cardioversions are common following this procedure.

Purpose

To investigate whether echocardiographic measures of left atrial (LA) function could predict AF-related hospitalizations and cardioversions.

Methods

This was a substudy of a trial that randomized patients to amiodarone vs place to reduce AF recurrence following CA. Transthoracic echocardiography was performed prior to CA and included assessment of: end-systolic and end-diastolic LA volumes, emptying fraction (LAEF), atrial strain, and global longitudinal strain (GLS). Poisson regression was used to assess predictive value for AF-related hospitalizations and cardioversions. Multivariable adjustments were made for: age, gender, ejection fraction, AF burden, AF subtype, dyspnea, and class 1c antiarrhythmics.

Results

Of the 212 patients, 80 were hospitalized for AF (206 times), and 77 were cardioverted (192 times) within the 6 months follow-up period. Mean age was 60 years, 83% were men, and mean LVEF was 50%. In univariable analyses, LA volumes, LAEF and GLS were predictors of the outcomes but did not remain significant predictors after multivariable adjustments. During echocardiography 162 patients were in sinus rhythm and 50 had AF rhythm. Rhythm during the echocardiogram modified the association between GLS and outcomes (p for interaction <0.05 for both endpoints), such that GLS predicted both AF-related hospitalizations and cardioversions in patients with sinus rhythm but not AF during the echocardiogram (figure).

Conclusion

Global longitudinal strain predicts AF-related hospitalizations and cardioversions after CA, but only in patients presenting in sinus rhythm during the echocardiogram. Patients presenting with impaired global longitudinal strain should be considered high-risk patients following CA who may benefit from close follow-up.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Danish Heart Foundation

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

Contacts to the healthcare system prior to out-of-hospital cardiac arrests

Background

Patients who suffer a sudden out-of-hospital cardiac arrest (OHCA) may be preceded by warning symptoms and healthcare system contact. Though, is currently difficult early identification of sudden cardiac arrest patients.

Purpose

We aimed to examine contacts with the healthcare system up to two weeks and one year before OHCA.

Methods

OHCA patients were identified from the Danish Cardiac Arrest Registry (2001–2014). The pattern of healthcare contacts (with either general practitioner (GP) or hospital) within the year prior to OHCA of OHCA patients was compared with that of 9 sex- and age-matched controls from the background general population. Additionally, we evaluated characteristics of OHCA patients according to the type of healthcare contact (GP/hospital/both/no-contact) and the including characteristics of contacts, within two weeks prior their OHCA event.

Results

Out of 28,955 OHCA patients (median age of 72 (62–81) years and with 67% male) of presumed cardiac cause, 16,735 (57.8%) contacted the healthcare system (GP and hospital) within two weeks prior to OHCA. From one year before OHCA, the weekly percentages of contacts to GP were relatively constant (26%) until within 2 weeks prior to OHCA where they markedly increased (54%). In comparison, 14% of the general population contacted the GP during the same period (Figure). The weekly percentages of contacts with hospitals gradually increased in OHCA patients from 3.5% to 6.5% within 6 months, peaking at the second week (6.8%), prior to OHCA. In comparison, only 2% of the general population had a hospital contact in that period (Figure). Within 2 weeks of OHCA, patients contacted GP mainly by telephone (71.6%). Hospital diagnoses were heterogenous, where ischemic heart disease (8%) and heart failure (4.5%) were the most frequent.

Conclusions

There is an increase in healthcare contacts prior to “sudden” OHCA and overall, 54% of OHCA-patients had contacted GP within 2 weeks before the event. This could have implications for developing future strategies for early identification of patients prior to their cardiac arrest.

Figure 1. The weekly percentages of contacts to GP (red) and hospital (blue) within one year before OHCA comparing the OHCA cases to the age- and sex-matched control population (N cases = 28,955; N controls = 260,595).

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020

The ESC algorithm for serial high-sensitivity troponin T changes and long-term outcomes in patients with suspected acute coronary syndrome

Background

The fourth universal definition of myocardial infarction (MI) consensus paper suggests that patients with changing troponins not reaching concentrations greater than the 99th percentile may be at high risk and deserve close scrutiny.

Purpose

To determine long-term prognostic implications of high-sensitivity troponin T (hs-TnT) levels and their relative change (Δ) from baseline in subjects with suspected acute coronary syndrome (ACS).

Methods

We conducted a retrospective cohort study through individual participant-level linkage between Danish national registries, including subjects with a final discharge diagnosis of acute MI, unstable angina, suspected MI, or chest pain from March 2013 through December 2016 who had a record of at least two serial hs-TnT measurements during hospitalization. Individuals were followed for 12 months, until the occurrence of an event, or censoring due to emigration. Kaplan-Meier analysis and Cox regression, incorporating the competing risk of death, were used to examine the prognostic implications of serial hs-TnT. Subjects were categorized according to whether their first and second hs-TnT were normal/elevated as well as Δhs-TnT and its direction, the latter employing a modified version of the 0/3-hour diagnostic algorithm proposed by ESC, i.e., using cut-offs for Δhs-TnT of 20% and 50%. The primary outcome was a composite of presumed death from cardiovascular causes, recurrent MI, or repeat revascularization (i.e., not including the index event unless the patient died) within 12 months.

Results

A total of 13,494 individuals (mean age 63.4 years, 39.5% women) were included. Of these, 6129 (45.4%) had a final diagnosis of MI, 941 (7.0%) of unstable angina, and 6414 (47.5%) of either suspected MI or chest pain. Median baseline hs-TnT was 20 ng/l (72.1% elevated), second hs-TnT 27 ng/l (74.6% elevated), Δhs-TnT 4.8%, and time between samples 5.4 hours. At 12 months, 1055 (7.8%) had experienced a primary event. Baseline hs-TnT and Δhs-TnT both displayed a significant association with the primary outcome (P<0.001 for both overall trends and for non-linearity vs. linearity). The Figure shows the prognostic implications of serial hs-TnT. Overall, subjects with two consecutively elevated hs-TnT had the highest 12-month event risk (10.0%), followed by those who went from an elevated to a normal hs-TnT (8.6%), those who went from a normal to an elevated hs-TnT (6.3%), and those with two normal hs-TnT levels (1.6%). The majority either had non-significant Δhs-TnT (−20% to 20%: 56.8%) or a large positive Δhs-TnT (>50%: 30.6%). Individuals with a positive Δhs-TnT (>20%) had a worse prognosis than those without.

Conclusions

An elevated hs-TnT at any time and Δhs-TnT were both determinants of poorer prognosis in subjects with suspected ACS. Individuals with two normal hs-TnT had a good prognosis, irrespective of their Δhs-TnT.

Figure 1

Funding Acknowledgement

Type of funding source: None

Long-term outcomes after in-hospital cardiac arrest: 30-day survival and 1-year follow-up of mortality, anoxic brain damage, nursing home admission and in-home care

AIMS

Long-term functional outcomes after in-hospital cardiac arrest (IHCA) are scarcely studied. However, survivors are at risk of neurological impairment from anoxic brain damage which could affect quality of life and lead to need of care at home or in a nursing home.

METHODS

We linked data on ICHAs in Denmark with nationwide registries to report 30-day survival as well as factors associated with survival. Furthermore, among 30-day survivors we reported the one-year cumulative risk of anoxic brain damage or nursing home admission with mortality as the competing risk.

RESULTS

In total, 517 patients (27.3%) survived to day 30 out of 1892 eligible patients; 338 (65.9%) were men and median age was 68 (interquartile range 58-76). Lower age, witnessed arrest by health care personnel, monitored arrest and presumed cardiac cause of arrest were associated with 30-day survival. Among 454 30-day survivors without prior anoxic brain damage or nursing home admission, the risk of anoxic brain damage or nursing home admission within the first-year post-arrest was 4.6% (n = 21; 95% CI 2.7-6.6%) with a competing risk of death of 15.6% (n = 71; 95% CI 12.3-19.0%), leaving 79.7% (n = 362) alive without anoxic brain damage or nursing home admission. When adding the risk of need of in-home care among 343 30-day survivors without prior home care needs, 68.8% (n = 236) were alive without any of the composite events one-year post-arrest.

CONCLUSION

The majority of 30-day survivors of IHCA are alive at one-year follow-up without anoxic brain damage, nursing home admission or need of in-home care.

Incidence of acute myocardial infarction-related cardiogenic shock during corona virus disease 19 (COVID-19) pandemic

Aims

The hospitalization of patients with MI has decreased during global lockdown due to the COVID-19 pandemic. Whether this decrease is associated with more severe MI, e.g. MI-CS, is unknown. We aimed to examine the association of Corona virus disease (COVID-19) pandemic and incidence of acute myocardial infarction with cardiogenic shock (MI-CS).

Methods

On March 11, 2020, the Danish government announced national lock-down. Using Danish nationwide registries, we identified patients hospitalized with MI-CS. Incidence rates (IR) and incidence rate ratios (IRR) were used to compare MI-CS before and after March 11 in 2015–2019 and in 2020.

Results

We identified 11,769 patients with MI of whom 696 (5.9%) had cardiogenic shock in 2015–2019. In 2020, 2132 MI patients were identified of whom 119 had cardiogenic shock (5.6%). The IR per 100,000 person years before March 11 in 2015–2019 was 9.2 (95% CI: 8.3–10.2) and after 8.9 (95% CI: 8.0–9.9). In 2020, the IR was 7.5 (95% CI: 5.8–9.7) before March 11 and 7.7 (95% CI: 6.0–9.9) after. The IRRs comparing the 2020-period with the 2015–2019 period before and after March 11 (lockdown) were 0.81 (95% CI: 0.59–1.12) and 0.87 (95% CI: 0.57–1.32), respectively. The IRR comparing the 2020-period during and before lockdown was 1.02 (95% CI: 0.74–1.41). No difference in 7-day mortality or in-hospital management was observed between study periods.

Conclusion

We could not identify a significant association of the national lockdown on the incidence of MI-CS, along with similar in-hospital management and mortality in patients with MI-CS.

1234 The cardiac isovolumetric contraction time is an independent predictor of cardiovascular morbidity in the general population

Background

Color Tissue Doppler imaging (TDI) M-mode through the mitral leaflet is an easy and precise method to obtain the cardiac time intervals including the isovolumic contraction time (IVCT), the isovolumic relaxation time (IVRT) and the left ventricular ejection time (ET). The myocardial performance index (MPI) is defined as [(IVCT + IVRT)/ET]). It is our hypothesis that the duration of the cardiac time intervals can reveal early cardiac dysfunction.

Purpose

Our aim was to investigate if the cardiac time intervals can be used to predict cardiovascular morbidity in the general population.

Methods

A total of 1,915 participants from the general population (mean age 58 ± 16 years, 42% male) underwent a general health examination including TDI echocardiography. The IVCT, IVRT and ET were measured. The primary endpoint was the composite of ischemic heart disease (IHD), heart failure (HF) and atrial fibrillation (AF). Participants with previous IHD, prevalent HF and AF were excluded (n = 336).

Results

During a median follow-up time of 11 years, 277 (17.5%) participants reached the composite endpoint. Assessing the association between IVCT and the composite outcome, the risk of IHD, HF and AF increased with 20% per 10ms increase in IVCT (per 10 ms increase: HR 1.20; 95% CI (1.11-1.30), p < 0.001; figure). The association remained significant even after multivariable adjustment for clinical and echocardiographic parameters (per 10ms increase: HR 1.11; 95% CI (1.01-1.22), p = 0.037).

IVRT, LVET and MPI were significant predictors of the composite outcome in unadjusted analysis (p < 0.001 for all). However, none remained significant after multivariable adjustment.

Additionally, the IVCT provided incremental prognostic information, as assessed by a significant increase in the net reclassification improvement (NRI) index, beyond the SCORE risk chart (continuous NRI, 0.266; 95% CI, 0.093-0.386) and the ACC/AHA Pooled Cohort Equation (continuous NRI, 0.252; 95% CI, 0.078-0.371).

Conclusion

In a low risk general population, the IVCT provides novel and independent prognostic information on the long-term risk of cardiovascular morbidity.

Abstract 1234 Figure.

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.

P5012Ten-year trends and outcomes in cardiogenic shock related to first-time acute myocardial infarction: a nationwide population-based cohort study

Introduction

Despite declining incidence and mortality for acute myocardial infarction, cardiogenic shock remains a severe complication with poor in-hospital prognosis. Little is known about the temporal trends in hospitalization with acute myocardial infarction-related cardiogenic shock (AMI-CS) and the long-term prognosis.

Purpose

We aimed to investigate the hospitalization with first-time AMI-CS and subsequent 1-year mortality.

Methods

In this nationwide Danish cohort study we identified from 2005 through 2015 patients with first-time acute myocardial infarction and compared those with and without cardiogenic shock (defined by either an ICD-10 diagnosis code with cardiogenic shock and/or procedure code with inotropes or vasopressors). Patient characteristics and 1-year mortality were compared between groups using Kaplan-Meier plots and multivariable Cox regression analysis.

Results

We included 96,030 patients with acute myocardial infarction of whom 5.4% had cardiogenic shock. Median age was 69.7 years (IQR 59.0–80.1) and 37.5% were female among those without cardiogenic shock and 70.2 years (IQR 61.4–78.1) and 33.0% were female in those with cardiogenic shock. We observed no change in hospitalization with cardiogenic shock during the study period (5.45% in 2006 vs 5.54% for 2016, P for difference 0.6). One-year mortality was higher among those with cardiogenic shock relative those without (See Figure). Crude 1-year mortality risk associated with AMI decreased over time from 23.4% in 2006 vs 11.5% in 2016 (p for difference <0.0001) and this was consistent for AMI patients without CS (21.4% in 2006 vs 9.4% in 2016, p<0.0001) and patients with AMI-CS (58.1% in 2006 vs 46.2% in 2016, p<0.0001). When comparing patients with AMI-CS to those without in multivariable analysis, AMI-CS was associated with a 1-year mortality hazard ratio of 5.38 (95% CI 5.17–6.61)).

Cumulative 1-year mortality among patien

Conclusion

In a large population-based setting, this study suggests that the hospitalization for first-time AMI-CS was stable from 2005 through 2015, while mortality improved with time. However, the grave outcome related to AMI-CS remains with a 5-times higher mortality compared to AMI patients without CS.

Acknowledgement/Funding

Rigshospitalets Research Fund

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)

P1241Five-year risk of death and readmission for heart failure after implantation of de novo and upgrade cardiac resynchronization therapy devices

Background

De novo implantation of cardiac resynchronization therapy devices with and without an implantable cardiac defibrillator (CRT-D and CRT-P, respectively) is associated with a reduced risk of death and re-admission for heart failure (HF). Whether upgrade to CRT-P/D from a brady pacemaker or an implantable cardiac defibrillator is associated with a similar long-term clinical benefit as de novo implantations is unknown.

Purpose

To compare risk of death and HF readmission in patients receiving a de novo versus upgraded CRT-P/D device.

Methods

From the Danish nationwide administrative registers, we identified all patients who had a CRT-D or CRT-P implanted from 2006 through 2016. Patients were excluded if they had endocarditis within 12 months before implantation. The patients were divided into groups based on whether implantation was an upgrade of a previous device or a de novo implantation. The primary endpoint was the composite of all-cause mortality and HF readmission. Risk of the primary endpoint was assessed with Kaplan Meier estimator and multivariable Cox regression models adjusted for age, sex, ischemic heart disease, diabetes and chronic obstructive pulmonary disease.

Results

The study population comprised 6,324 patients, median age 70 years [25th-75th percentile: 63–77], 22% women. In total, 3,635 patients had a CRT-D, of whom 749 (20.6%) were upgraded from an implantable cardioverter defibrillator device and 2,689 patients had a CRT-P, of whom 496 (18.4%) were upgraded from brady-pacemakers. For patients with CRT-D, five-year event-free survival probability was 35.3% for de novo and 20.4% for upgrades (log-rank p-value<0.001). For patients with CRT-P, five-year event-free survival probability was 38.4% for de novo and 33.7% for upgrades (log-rank p-value=0.29) (Figure 1). In the CRT-D group, upgrade was associated with an increased risk of the primary endpoint, hazard ratio (HR): 1.49 (95%-confidence interval (CI): 1.34–1.65, p<0.001). In the CRT-P group, no significant difference between upgrade and de novo was observed, HR: 1.02 (95%-CI: 0.89–1.18, p=0.72).

Figure 1

Conclusions

Upgrade to a CRT-P was associated with a similar long-term clinical outcome as de novo device implantation. This was in contrast to upgrade CRT-D, which was associated with a worse outcome than de novo implantation. To understand the factors underlying this increased risk, more studies are warranted.