Epicardial fat volume outperforms classic clinical scores for predicting atrial fibrillation relapse after pulmonary vein isolation

Background

Epicardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF), but its relevance to clinical practice remains uncertain. The aim of this study was to compare the performance of the amount of epicardial fat with previously published clinical scores of AF-relapse risk after pulmonary vein isolation (PVI).

Methods

We assessed 575 patients (354 men, age 61±11 years, 449 paroxysmal AF) with symptomatic AF undergoing cardiac CT prior to a PVI procedure. Epicardial fat was quantified on contrast-enhanced images using a new simplified semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence at 12 months. Epicardial fat was compared against the following scores: MB-LATER, APPLE, DR-FLASH, and ATLAS.

Results

Median follow-up was of 22 months (IQR 12–35), 232 patients relapsed, 130 patients (27%) within the first 12 months. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.03, 95% CI: 1.53–2.69, p<0.001), indexed left atrial (LA) volume (HR 1.02 per mL/m2, 95% CI: 1.01–1.02, p<0.001), and indexed pericardial fat volume (HR 1.55 per mL/m2, 95% CI: 1.43–1.67, p<0.001). Based on the ROC curve analysis, the epicardial fat showed greater discriminative power, with a C-statistic of 0.76 (95% CI: 0.71–0.81) against 0.67 (p=0.007 for pairwise comparison of ROC curves), 0.67 (p=0.01), 0.63 (p<0.001) and 0.57 (p<0.001) for the MBLATER, APPLE, DR-FLASH and ATLAS scores, respectively. The C-statistic for indexed LA volume and non-paroxysmal AF AUC were of 0.63 (p<0.001) and 0.61 (p<0.001), respectively.

Conclusion

Pericardial fat volume is a strong independent predictor of AF relapse after PVI, outperforming clinical scores of post-PVI AF. The underlying mechanisms of this association deserve further study.

ROC Curve Analysys

Funding Acknowledgement

Type of funding source: None

Lung water quantification by cardiac magnetic resonance imaging: a novel prognostic tool in hf

Background

Cardiac magnetic resonance (CMR) imaging has recently been proposed to quantify lung water density (LWD, %) non-invasively. Given that pulmonary congestion plays a key role in the pathophysiology of Heart Failure (HF), we designed a study to assess the prognostic significance of a simplified LWD measure in patients with HF and reduced left ventricular ejection fraction (LVEF).

Methods

We conducted a single-center retrospective study of consecutive patients with HF and LVEF <50% who underwent CMR on a 1.5T scanner. Those with severe interstitial lung disease or chronic liver disease were excluded. All measurements were performed in a parasagittal plane at the right midclavicular line on a standard HASTE sequence, which is widely available in all CMR studies. As previously reported, LWD was determined by the lung-to-liver signal ratio multiplied by 0.7. A cohort of 102 healthy controls was used to derive the upper limit of normal (mean ± 2SD) of the LWD (21.2%). The primary endpoint was a composite of all-cause death or HF hospitalization.

Results

A total of 290 HF patients (mean age 64±12 years, 74.8% male, 56.2% of ischemic etiology) with a mean LVEF of 34±10% were included. LWD measurement took on average 35±4 seconds and showed excellent inter-observer agreement (intra-class correlation coefficient >0.90). LWD was increased in 65 (22.4%) patients. Compared to those with normal LWD, the former were more symptomatic (NYHA ≥III: 29.2% vs. 1.8%; p=0.017) and had higher median NT-proBNP [1973 (IQR: 809–3766) vs 802 (IQR: 355–2157pg/mL); p<0.001]. During a median followup of 21 months (IQR: 13–29), 20 (6.9%) patients died and 40 (13.8%) had at least one HF hospitalization. In multivariate analysis, LVEF (HR per 1%: 0.96; CI-95%: 0.93–0.99; p=0.024), creatinine (HR per 1mg/dL: 2.43; CI-95%: 1.25–4.71; p=0.009) and LWD (HR per 1%: 1.06; CI-95%: 1.01–1.12; p=0.013) were independent predictors of the primary endpoint. The findings were mainly driven by an association between LWD and HF hospitalization (HR per 1%: 1.08; CI-95%: 1.03–1.13; p=0.002).

Conclusions

A CMR-derived method for LWD quantification independently predicts an increased risk of death or HF hospitalization in HF patients with LVEF <50%. Our results support LWD measurement as a simple, reproducible and widely available method, further adding to the prognostic role of CMR in this population.

Funding Acknowledgement

Type of funding source: None

A machine-learning algorithm to predict atrial fibrillation recurrence after a pulmonary vein isolation procedure

Background

Contemporary risk models to predict the recurrence of atrial fibrillation (AF) after pulmonary vein isolation have limited predictive ability. Models with high specificity seem particularly suited for the setting of AF ablation, where they could be used as gatekeepers to withhold intervention in patients with low likelihood of success. Machine learning (ML) has the potential to identify complex nonlinear patterns within datasets, improving the predictive power of models. This study sought to determine whether ML can be used to better identify patients who will relapse within one year of an AF ablation procedure.

Methods

We assessed 484 patients (294 men, mean age 61±12 years, 76% with paroxysmal AF) who underwent radiofrequency pulmonary vein isolation (PVI) for symptomatic drug-refractory AF. Using this dataset, a machine-learning model based on Support Vector Machines (SVM) was developed to predict AF recurrence within one year of the procedure. The following variables were used to feed the model: type of AF (paroxysmal vs. non-paroxysmal), previous ablation procedure, left atrium (LA) volume, and epicardial fat volume (both derived from pre-ablation cardiac CT). The algorithm was trained in a random sample of 70% of the study population (n=339) and tested in the remainder 30% (n=145).

Results

A total of 130 patients (27%) suffered AF recurrence within one year of the procedure. The ML model predicted AF recurrence with 75% accuracy (95% CI 67–82%), yielding a sensitivity and specificity of 25% (95% CI 13–41%) and 94% (95% CI 88–98%), respectively. The corresponding positive and negative predictive values were 62% (95% CI 39–81%) and 77% (95% CI 67–82%), respectively. The relative weight of the variables in the ML model was: epicardial fat 56%, type of AF 23%, previous ablation 14%, and LA volume 7%. A high-risk subgroup representing 10.8% of patients was identified with the ML algorithm. In this subgroup, one-year recurrence was 62%, representing 24% of the total number of recurrences.

Conclusion

A machine-learning model showed high specificity in the identification of patients who relapse during the first year after AF ablation. In the future, these tools may be useful to improve patient selection.

Funding Acknowledgement

Type of funding source: None

Relationship between epicardial fat and left atrium fibrosis in patients with atrial fibrillation

Background

Epicardial adipose tissue (EAT) has recently been shown to be associated with the presence, severity, and recurrence of atrial fibrillation (AF). Although the pathophysiological mechanisms underlying this association remain to be established, several hypotheses have been put forward, including direct adipocyte infiltration, oxidative stress, and the secretion of adipokines causing inflammation and fibrosis of atrial tissue. We hypothesized that the volume of EAT and the amount of left atrium (LA) fibrosis assessed by non-invasive imaging would be significantly correlated in patients with AF, and that both would predict time to relapse after pulmonary vein isolation (PVI).

Methods

Sixty-eight patients with AF being studied for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) within less than 48h. EAT was quantified on contrast-enhanced CT images. LA fibrosis was quantified on isotropic 1.5mm 3D delayed enhancement CMR for image intensity ratio values >1.20. Radiofrequency PVI was performed using an irrigated contact force-sensing ablation catheter, guided by electroanatomical mapping. After PVI, patients were followed for AF recurrence, defined as symptomatic or documented AF after a 3-month blanking period. Pearson's correlation coefficient was used for gauging the correlation between EATLM volume and LA fibrosis. The relationship between these two variables and time to AF recurrence was assessed by Cox regression.

Results

Most of the 68 patients (46 men, mean age 61±12 years) had paroxysmal AF (71%, n=48). The mean body mass index (BMI) was 28.0±4.0 kg/m2. Patients had a median EATLM volume of 2.4 cm3/m2 [interquartile range (IQR) 1.6–3.2 cm3/m2], and a median estimated amount of LA fibrosis of 8.9 g (IQR 5–15 g), corresponding to 8% (IQR 5–11%) of the total LA wall mass. The correlation between EATLM and LA fibrosis was statistically significant but weak (Pearson's R = 0.38, P=0.001) – Figure 1. During a median follow-up of 22 months (IQR 12–31), 31 patients (46%) suffered AF recurrence. Four predictors of relapse were identified in univariate Cox regression: EATLM (HR 2.19, 95% CI 1.65–2.91, P<0.001), LA fibrosis (HR 1.05, 95% CI 1.01–1.09, P=0.033), non-paroxysmal AF (HR 3.36, 95% CI 1.64–6.87, P=0.001), and LA volume (HR 1.03, 95% CI 1.01–1.06, P=0.006). Multivariate analysis yielded two independent predictors of time to AF relapse: EATLM (HR 2.05, 95% CI 1.51–2.79, P<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08–5.16, P=0.031).

Conclusion

The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism by which EAT and AF are linked. EAT was more strongly associated with AF recurrence than LA fibrosis, which supports the existence of other, more important mediators between EAT and this arrhythmia.

Correlation between EAT and LA

Funding Acknowledgement

Type of funding source: None

Downstream testing after an halted coronary CT angiography due to high coronary artery calcium score

Background and aim

In many centers, coronary artery calcium score (CACS) is performed immediately before coronary CT angiography (CCTA) in order to exclude heavy calcification that could hamper test performance. When high CACS values are found, CCTA is usually aborted and other tests suggested. However, there are no recommendations on which test to pursue, and little data on their diagnostic yield in this setting. The aim of this study was to assess the type and results of downstream testing among patients whose CCTA study was halted due to high CACS.

Methods

Single-centre retrospective study of consecutive patients undergoing CCTA for suspected obstructive coronary artery disease (CAD). A CACS threshold of >400 was generally used to cancel CCTA. Downstream testing and its results were assessed using electronic medical records. A group of consecutive patients with CACS <400 who underwent CCTA was used for comparison.

Results

Of the 795 patients who performed CCTA for suspected CAD, 86 (10.8%), had their test halted due to high CACS (57 men, mean age 71±11 years). In this subgroup, the median pre-test probability for CAD was 27% (interquartile range 25) and the median CACS was 983 (interquartile range 930). Compared to patients who underwent CCTA, those who saw their tests cancelled were older, more frequently male, and had higher prevalence of cardiovascular risk factors and higher pre-test probability for CAD.

Patient's downstream testing is illustrated in Figure. From the 86 patients enrolled, 12 are currently waiting for downstream tests and were excluded from further analysis. Overall, 35 patients ended up performing invasive coronary angiography (ICA, 47.3%) of whom 19 (54.3%) had significant CAD. Among those who underwent non-invasive testing (N=19, 25.7%), 10 (52.6%) had significant ischemia and 4 (21%) underwent additional testing with ICA. In 24 patients (32.4%), no downstream testing was pursued. Finally, 17 (22.3%) patients underwent coronary revascularization, either percutaneous (N=10, 13.5%) or surgical (N=7, 10.8%).

Conclusion

Invasive coronary angiography is the most frequently used downstream test when CCTA is halted due to high CACS values, and shows significant CAD in roughly half of the cases. Considering the high prevalence of significant CAD, direct referral for ICA (with the possibility of invasive functional testing) seems a reasonable approach.

Funding Acknowledgement

Type of funding source: None

Pre-test probability of obstructive coronary artery disease in the new guidelines: too much, too little or just enough?

Background

Previous 2013 ESC guidelines recommended the use of the Modified Diamond-Forrester method to assess the pre-test probability (PTP) of obstructive coronary artery disease (CAD). The 2019 ESC Chronic Coronary Syndrome guidelines updated this recommendation with a major downgrade in PTP. The aim of this study was to compare the performance of these two methods in patients with stable chest pain undergoing coronary computed tomography angiography (CCTA) for suspected CAD.

Methods

We performed a retrospective analysis on prospectively collected data from a cohort of consecutive patients undergoing CCTA for suspected CAD from October 2016 to 2019. Key exclusion criteria were age <30 years-old, known CAD, suspected acute coronary syndrome or symptoms other than chest pain. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. Whenever invasive coronary angiography (ICA) was subsequently performed, patients were reclassified if luminal stenosis was <50%. The two PTP prediction models were assessed for calibration and discrimination.

Results

A total of 320 patients (median age 63 years [IQR 53–70], 59% women) were included. Chest pain characteristics were: 48% atypical angina, 38% non-anginal chest pain, 14% typical angina. The observed prevalence of obstructive CAD was 16.3% (n=52). Patients with obstructive CAD were more often male, were significantly older and had a higher prevalence of typical angina and cardiovascular risk factors (except for family history of CAD). On average, individual PTP was 22.1% lower in the new guidelines. The 2013 prediction model significantly overestimated the likelihood of obstructive CAD (mean PTP 37.3% vs 16.3%; relative overestimation of 130%, p-value for miscalibration 0.005). The updated 2019 method showed good calibration for predicting the likelihood of obstructive CAD (mean PTP 15.2% vs 16.3%; relative underestimation of 6.5%, p-value for miscalibration 0.712). The two approaches showed similar discriminative power, with a C-statistics of 0.730 and 0.735 for the 2013 and 2019 methods, respectively (p-value for comparison 0.933). Stratification by gender produced similar results.

Conclusions

In patients with stable chest pain undergoing CCTA, the updated 2019 prediction model allows for a more precise estimation of pre-test probabilities of obstructive CAD than the previous model. Adoption of this new score may improve disease prediction and change the downstream diagnostic pathway in a significant proportion of cases.

Graph 1

Funding Acknowledgement

Type of funding source: None

Mechanical Dispersion as a powerful echocardiographic predictor of outcomes after Myocardial Infarction

Introduction

Several studies have addressed the importance of transthoracic echocardiography (TTE) in risk prediction of subsequent adverse events after ST elevation myocardial infarction (STEMI). While several traditional echo parameters have a well-established prognostic value, data derived from 2D-Speckle Tracking Echocardiography (2DSTE) needs further investigation.

Objectives

To determine if 2DSTE parameters provide additional information beyond conventional echocardiography to predict long-term adverse outcomes in patients admitted with STEMI

Methods

Retrospective, single-center study, that included all patients without previous cardiovascular events admitted with STEMI (who underwent primary coronary angioplasty) between 2015 and 2017. Patients with poor acoustic windows, severe valvular disease, irregular heart rhythm, and those who died during hospital stay were excluded. We reviewed all pre-discharge TTE to assess conventional parameters of LV systolic and diastolic function and data obtained by 2DSTE: global longitudinal strain (GLS) and peak strain dispersion (PSD), an index that is the standard deviation from time to peak strain of all segments over the entire cardiac cycle. Demographic and clinical data was obtained through electronic hospital records. Minimum follow-up was 2 years. The primary endpoint was a composite of all-cause mortality and cardiovascular re-admission at follow-up. Survival analysis was used to determine independent predictors of the primary endpoint.

Results

377 patients were included, mean age 62±13 years, 72% male. Mean LVEF was 50±10% with 19% of patients having LVEF <40%. Mean indexed left atrium volume (LAVi) was 33±10 ml/m2, mean GLS was −14±4%, and PSD was 60±22 msec. Average follow-up was 36±11 months, with a combined endpoint of mortality and hospitalization of 27% (n=102)

Univariate analysis of echocardiographic variables revealed an association between heart rate, LVEF, indexed LV end-systolic volume, indexed stroke volume, LAVi, GLS and PSD with the endpoint. However, on multivariate analysis only LAVi [HR 1.030 (95% CI 1.009 - 1.051), p-value = 0.005] and PSD [HR 1.011 (95% CI 1.002 - 1.020), p-value = 0.012] remained independent predictors of the primary endpoint.

We determined that a PSD value higher than 52 msec has a sensitivity of 76% and a negative predictive value of 83% for mortality and hospitalization, and that this cut-off point discriminates patients at a higher risk of events in Kaplan-Meier Survival analysis with a Log-Rank p-value=0.001.

Conclusion

PSD derived by longitudinal strain analysis is a promising prognostic predictor after STEMI. PSD outperformed conventional echocardiographic parameters in the risk stratification of STEMI patients at discharge.

Kaplan-Meier Survival Curves

Funding Acknowledgement

Type of funding source: None

Combined endocardial and epicardial ventricular tachycardia ablation for ischemic and nonischemic dilated cardiomyopathy

Background

Patients with ischemic (IHD) and nonischemic (NICM) dilated heart disease and reduced left ventricular ejection fraction are at increased risk of ventricular tachycardias (VTs) or sudden cardiac death. VT catheter ablation is an invasive treatment modality for antiarrhythmic drugs-resistant VT that reduces arrhythmic episodes, improves quality of life and improves survival in patients with electrical storm. Direct comparison of the outcomes from combined and non-combined endoepicardial ablations is limited by patient characteristics, follow-up durations, protocols heterogeneity and scarcity of randomized trials. We aim to investigate the long-term clinical outcomes of these 2 strategies in the IHD and NICM populations.

Methods

Multicentric observational registry including 316 consecutive patients who underwent combined (C-ABL) and non-combined (NC-ABL) endoepicardial ventricular tachycardia (VT) ablation for drug-resistant VT between January 2008 and July 2019. Chagas' disease patients were excluded. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-days mortality and procedure-related complications.

Results

Most of the patients were male (85%), with IHD (67%) and a mean age of 63±13 years. During a mean follow-up of 3±2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified storm (ES) at presentation (HR=2.17; 95% CI 1.44–3.25), IHD (HR=0.53, 95% CI 0.36–0.78), left ventricular ejection fraction (LEVF) (HR=0.97, 95% CI 0.95–0.99), New York Heart Association (NYHA) functional class III or IV (HR=1.79, 95% CI 1.13–2.85) and C-ABL (HR=0.49, 95% CI 0.27–0.92) as independent predictors of VT recurrence. In 135 patients undergoing two or more ablation procedures only C-ABL (HR=0.36, 95% CI 0.17–0.80) and ES at presentation (HR=2.42, 95% CI 1.24–4.70) were independent predictors of arrhythmia recurrence. The independent predictors of all-cause mortality were ES (HR=2.17, 95% CI 1.33–3.54), LVEF (HR=0.95, 95% CI 0.92–0.98), age (HR=1.03, 95% CI 1.01–1.05), NYHA functional class III or IV (HR=2.04, 95% CI 1.12–3.73), and C-ABL (HR=0.22, 95% CI 0.05–0.91). The survival benefit was only seen in patients with a previous ablation (P for interaction=0.04) – Figure 1. Mortality at 30-days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P=0.777), as was the complication rate (10.3% vs. 15.1% respectively, P=0.336).

Conclusion

A combined endo-epicardial approach appears to be associated with greater VT-free survival and overall survival in ischemic and nonischemic patients undergoing repeated VT catheter ablations. Both strategies seem equally safe.

Survival analysis for C-ABL vs NC-ABL

Funding Acknowledgement

Type of funding source: None

Epicardial adipose tissue: the genetics behind an emerging cardiovascular marker

Background

Increasing evidence points epicardial adipose tissue (EAT) as an emerging cardiovascular risk marker. Whether genetic polymorphisms are associated with a higher EAT burden is still unknow. Genetic risk score (GRS) is an emerging method that attempts to establish correlation between single nucleotide polymorphisms (SNPs) and clinical phenotypes.

Aim

Evaluate the role of genetic burden and its association to EAT.

Methods

996 patients (mean age 59±8, 78% male) were prospectively enrolled in a single center. EAT was measured on cardiac CT using a modified simplified method. Patients were divided into 2 groups (above vs. below the median EAT volume).

We studied different polymorphisms across the following gene-regulated pathways: oxidation, renin-angiotensin system, cellular, diabetes/obesity and dyslipidemia pathways. Genotyping was performed by TaqMan allelic discrimination assay. A multiplicative genetic risk score (mGRS) was constructed and represents the genetic burden of the different polymorphisms studied. To evaluate the relation between genetics and EAT volume, we compared both groups by: global mGRS, gene cluster/axis mGRS and individual SNPs.

Results

Patients with above-median EAT volume were older, had higher body mass index (BMI) and higher prevalence of hypertension, diabetes and dyslipidemia (p<0.05). Patients with higher EAT volumes presented a higher global mean GRS (p<0.001), with the latter remaining an independent predictor for higher EAT volumes (OR 1.3, 95% CI 1.2–1.5), alongside age and BMI.

In the analysis by gene clusters, patients with more epicardial fat consistently presented a higher polymorphism burden (translated by a higher mGRS level) across numerous pathways: oxidation, renin-angiotensin system, cellular, diabetes/obesity and dyslipidemia. After adjusting for confounders and other univariate predictors of higher fat volume, the following have emerged as independently related to higher EAT volumes: mGRS comprising the genes of different clusters, age and BMI.

Amongst the 33 genes analyzed, only MTHFR677 polymorphisms (a gene with a critical role in regulating plasma homocysteine levels) emerged as significantly related to higher EAT volumes in our population (OR 1.4, 95% CI: 1.100–1.684, p=0.005).

Conclusion

Patients with a higher polymorphism burden in genes involved in the oxidation, renin-angiotensin, cellular, diabetes/obesity and dyslipidemia pathways present higher levels of epicardial fat. This potential association seems to be independent from the expected association between epicardial fat and cardiovascular risk factors. To our knowledge, this is the first time such genetic profiling has been done, casting further insight into this complex matter.

Funding Acknowledgement

Type of funding source: None

Disproportionate functional mitral regurgitation: clinical validation of a new conceptual framework

Background

Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR.

Methods

Patients with at least mild FMR and reduced LVEF (<50%) who underwent transthoracic echocardiography between 2010 and 2014 were retrospectively identified in our laboratory database. Optimal medical therapy (including cardiac resynchronization when indicated) for ≥3 months was a prerequisite for inclusion. Hemodynamically significant FMR was defined as regurgitant fraction >50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the haemodynamic burden of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF <30% and 30–49%).

Results

A total of 289 patients (median age 69 years [IQR 60–77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm2 (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: <10mL: 41%; 10–20mL: 18%; 20–30mL: 15% and >30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p<0.001).

During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF <30% subgroup, age (HR 1.05 per year [1.02–1.08]; p<0.001), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.042) and TAPSE (HR 0.92 per mm [0.86–0.99]; p=0.030) were independent predictors of mortality. In the LVEF 30–49% subgroup, age (HR 1.05 per year [1.02–1.08]; p=0.003), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.020) and disproportionate FMR (HR 1.02 per mL [1.01–1.03]; p=0.01) were independently associated with increased mortality.

Conclusions

Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF<30%, where the degree of biventricular dysfunction seems to outweigh all other echocardiographic parameters, leaving FMR as a bystander.

Figure 1

Funding Acknowledgement

Type of funding source: None

Human identification by the analysis of palatal rugae printed in complete dentures

The study of palatal rugae is shown to be scientifically valid to human identification due to the unique number and style of the palatal ridges. Dentures provide an array of data and specifics that allow for the individualization of their wearers. This article describes the identification of edentulous, skeletonized remains through the analysis of the palatal rugae printed on the complete upper denture and subsequent comparison with the palatal rugae of an old complete denture of an unknown missing person. The analyses focus on the form, classification, location, and size of the palatal rugae which, in conjunction with the information obtained from the anthropological examination, resulted in a positive identification of the cadaver. This method has a significant impact on the identification process, particularly when other identification methodologies and techniques cannot be implemented. This case report highlights the importance of palatal rugae in human identification in cases of edentulous cadavers.

AB0223 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS IS A RELIABLE AND RESPONSIVE TOOL IN CLINICAL practice

Background:

Physician’s global assessment of disease activity (PhGA) is highly influential upon treatment decisions taken by rheumatologists, surpassing the impact of DAS28. [1, 2]. However, data regarding its psychometric properties are scarce.

Objectives:

To evaluate the reliability and responsiveness of PhGA.

Methods:

We included two consecutive visits of RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected including tender (TJ28) and swollen (SJC28) joints in 28 count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-3v-CRP, DAS28-3v-ESR, DAS28-4v-CRP, DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm. Changes (Δ) between the two visits were calculated. Only patients without missing data were included. Correlations between ΔPhGA and change of other variables were assessed using Pearson’s correlations. Reliability was evaluated through Intraclass Correlation Coefficient (ICC) between two consecutive appointments in a subgroup of patients with stable disease activity (Δ DAS28-4vESR [-0.6 to 0.6]. An ICC above 0.8 was considered indicative of excellent reliability. Sensitivity to change was assessed in the subgroup of patients who improved their disease activity at least 0.6 on DAS28-4V-ESR, through Standardized Response Mean (SRM). The respective intervals of confidence were obtained through bootstrapping procedures. SRM above 0.8 were considered large. Independent factors associated with ΔPhGA were identified through multivariate linear regression analysis. p<0.05 was considered statistically significant

Results:

121 RA patients (84.3% female and 64.0±12.6 years) were included. Δ PhGA was weakly correlated with ΔCRP (r=0.23), Δ PGA (r=0.31) and Δ pain (r=0.37). Moderate to strong correlations were observed with Δ DAS28-3V-ESR (r=0.55), Δ SJC28 (r=0.56), Δ DAS28-3V-CRP (r=0.58), Δ DAS28-3V-CRP (r=0.60), Δ TJ28 (r=0.62) and Δ DAS28-4V-CRP (r=0.63). ICC between two consecutive visits was 0.7, [95%CI:0.47-0.83] and SRM was -1.01 [95%CI:-1.26-(-0.73)]. In the multivariate regression analysis, ΔSJC28 (β=4.01; 95% CI:3.07 to 4.96) and Δ Pain (β=0.18; 95%CI: 0.07 to 0.28) remained as independent factors associated with ΔPhGA (R2:0.49, p<0.01)

Conclusion:

In this study, PhGA showed a high reliability and sensitivity to change regarding disease activity, in clinical practice. Changes in SJC had the strongest association with change in PhGA scoring, but Δ Pain was also significantly correlated (graph 1).

Figure 1.

Graph 1 – Explicative model to variations on PhGA

References:

[1]Choy T et al. Rheum (Oxford, England). 2014;53(3):482-90.

[2]Rohekar G et al. Jour Rheum. 2009;36(10):2178.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

THU0111 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: WHAT DO WE REALLY MEAN?

Background:

Physician’s global assessment of disease activity (PhGA) is included in some scores of disease activity and, demonstrably, plays a major role upon treatment decisions in rheumatoid arthritis (RA) [1, 2, 3]. Therefore, understanding the reasons underlying the physician´s assessment is crucial.

Objectives:

To understand the reasons underlying the physician´s assessment.

Methods:

Cross-sectional study, including consecutive RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected through a standardized protocol, including 28 tender (TJ28) and swollen (SJC28) joints count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-4v-CRP and DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm, Health Assessment Questionnaire (HAQ), European Quality of Life-5 Dimensions (EQ-5D) and Hospital Anxiety and Depression Scale (HADS). Correlation between PhGA and other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.05 in univariate analysis were included in multivariable linear regression (stepwise model).

Results:

392 RA patients (80.6% female, 65.3±12.6 years) were included. PhGA was weakly correlated with CRP (r=0.23), TJC28 (r=0.35), PGA (r=0.26), HAQ (r=0.31) and EQ5D (r=-0.21). Moderate correlations were observed with SJC28 (r=0.45) and DAS-4V-CRP (r=0.48). In multivariable analysis, SJC28 (β=4.14, 95%CI:3.16-5.12), CRP (β=0.22; 95%CI: 0.02-0.03), HAQ (β=4.46, 95%CI:1.50-7.42) and PGA (β=0.08; 95%CI:0.00-0.16) remained as independent correlates of PhGA (R2=0.27, p<0,05).

Conclusion:

In this study, PhGA was associated with SJC28, CRP, HAQ and PGA, suggesting that physicians adopt a comprehensive reading of the disease into account. However, a large proportion of the variance of PhGA remains unexplained. Given its driving role in treatment decisions, the need to standardize and better understand PhGA seems to deserve a closer attention.

References:

[1]Ward MM, et al. Art Car Res. 2017;69(8):1260-5.

[2]Desthieux C, et al. Art Car Res (Hoboken). 2016;68(12):1767-73.

[3]Kaneko Y, et al. Mod Rheumatol. 2018;28(6):960-7.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

459Direct oral anticoagulants are an effective therapy for left ventricular thrombus formation

Background and aim

Left ventricular thrombus is a frequent complication of myocardial infarction (MI) and heart failure with severely depressed ejection fraction. Once diagnosed, anticoagulation for up to 6-months is recommended, but clinical experience with direct oral anticoagulation (DOAC) is limited to a few case reports. Our aim is to test DOAC LV thrombus resolution efficacy against warfarin.

Methods

Single-centre retrospective cohort study of consecutive patients with recently diagnosed LV thrombus, either after acute myocardial infarction or heart failure with reduced ejection fraction, from January 2009 till December 2018. Thrombus diagnosis and subsequent assessments were performed with echocardiography and complemented with cardiac magnetic resonance, when appropriate. Decisions regarding the type, dose and duration of anticoagulation and any concomitant antiplatelet therapy were left to physician's judgement.

Results

In a population of 66 patients (51 male, mean age 69±12 years), 13 received DOAC therapy, with the remainder receiving vit. K antagonists. One from each group was lost to follow up. The DOAC subgroup had higher prevalence of atrial fibrillation, higher left ventricular end-diastolic volumes and worse wall motion severity score index (WMSI). The duration of anticoagulant therapy, concomitant single or dual antiplatelet therapy and overall follow up were similar between strategies. Thrombus remission was observed in 91.7% (n=11) and 59.6% (n=31) patients within DOAC and warfarin group, respectively. Risk of unsuccessful resolution was reduced by 35% relative to the warfarin group (RR 0.65; 95% CI [0.491–0.862]; p-value 0.035) (figure).

figure

Conclusion

DOAC seems to be an effective alternative to vitamin-K antagonists in patients with LV thrombus.

P5699Endocardial vs. epicardial ventricular tachycardia ablation: a propensity score matched analysis

Introduction

Direct comparisons of long-term clinical outcomes of endocardial vs. epicardial catheter ablation techniques for drug-resistant ventricular tachycardia (VT) have been scarcely reported.

We aim to compare the long-term efficacy and safety of endocardial vs. epicardial catheter ablation (END-ABL and EPI-ABL, respectively) in a propensity score (PS) matched population.

Methods

Single-center observational registry including 215 consecutive patients who underwent END-ABL (181) or EPI-ABL (n=34) for drug-resistant VT between January 2007 and June 2018. Efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. A propensity score was used to match patients in a 1:1 fashion according to the following variables: VT storm at presentation, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class III/IV at presentation, ischemic ethology, presence of implantable cardioverter-defibrillator (ICD), and previous endocardial catheter ablation. Independent predictors of VT recurrence were assessed by Cox regression.

Results

The PS yielded two groups of 31 patients each well matched for baseline characteristics (Table 1). Over a median follow-up of 2 years (IQR 1–3), 58% (n=18) ENDO-ABL patients had VT recurrence vs. 26% (n=8) in the EPI-ABL group (P=0.020). The yearly rates of VT recurrence were 28%/year for END-ABL vs. 11%/year for EPI-ABL (P=0.021). Multivariate survival analysis identified previous endocardial ablation (HR= 3.52; 95% CI 1.17–10.54, p=0.026) and VT storm at presentation (HR=3.57; 95% CI 1.50–8.50, p=0.004) as independent predictors of VT recurrence. EPI-ABL was independently associated with fewer VT recurrences (HR=0.28; 95 CI 0.12–0.69, p=0.005), but only in patients with a previous endocardial ablation (p for interaction = 0.004) – Figure A.

No patients died at 30-days post-procedure. Hospital length of stay was similar between END-ABL and EPI-ABL (5 vs. 4 days respectively, p=0.139), as was the complication rate (6.5% vs. 12.9% respectively, p=0.390), although driven by different causes (Table 1).

Conclusion

VT storm at presentation and previous catheter ablation were independent predictors of VT recurrence. In patients with a previous failed endocardial catheter ablation, epicardial ablation seems to provide greater VT-free survival than repeat endocardial ablation. Both strategies seem equally safe.

1204Pericardial fat volume outperforms classic risk markers in the prediction of relapse after pulmonary vein isolation

Introduction

Pericardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF), but its relevance to clinical practice remains uncertain. The aim of this study was to assess the relative importance of pericardial fat as predictor of recurrence after pulmonary vein isolation (PVI).

Methods

We assessed 453 patients (278 men, age 61±13 years, 348 paroxysmal AF) with symptomatic AF undergoing cardiac CT prior to a PVI procedure. Pericardial fat was quantified on contrast-enhanced images using a new simplified semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence.

Results

Over a median follow-up of 14 months (IQR 7–23), 170 patients (38%) relapsed. Survival analysis showed significant differences in AF-free survival across tertiles of pericardial fat (Figure). Pericardial fat volume was weakly correlated to body mass index [(BMI), Pearson's R=0.34]. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.08, 95% CI: 1.51–2.87, p<0.001), indexed left atrial (LA) volume (HR 1.02 per mL/m2, 95% CI: 1.01–1.02, p<0.001), and indexed pericardial fat volume (HR 1.50 per mL/m2, 95% CI: 1.37–1.64, p<0.001). Based on the Wald test, indexed pericardial fat volume was the strongest of these predictors of relapse (X2 values of 20, 13, and 77, respectively). The population attributable risk (PAF) was higher for pericardial fat (PAF=37% for 1st vs 4th quartile) vs LA volume (PAF=11% for 1st quartile vs 4th quartile) and non-paroxysmal AF (PAF=23%). Pericardial fat volume also showed greater discriminate power than indexed LA volume, with a C-statistic of 0.80 (95% CI 0.76–0.85) vs. 0.61 (95% CI 0.55–0.66), p for difference <0.001. The method for quantifying pericardial fat showed high inter-observer reproducibility (Pearson's R=0.90) and was quick to perform (38±3 seconds).

Conclusion

Pericardial fat volume is a strong independent predictor of AF relapse after PVI, outperforming classic risk markers such as LA volume and type of AF. The underlying mechanisms of this association deserve further study. Meanwhile, this simple parameter may help select patients who are more likely to derive sustained benefit from AF ablation.

P5018Prognosis of pulmonary embolism 30-day mortality risk based on five admission parameters: the PoPE score

Background

Pulmonary embolism (PE) is a serious and potentially fatal form of venous thromboembolism. The Pulmonary Embolism Severity Index (PESI), and its simplified version (sPESI), are widely used for risk stratification and mortality prediction, however, the elevated number of parameters make them difficult to use an apply in everyday practice.

Purpose

To provide a simple and easy-to-perform sensible score based on five clinical and metabolic parameters obtained in arterial blood gas (ABG) at admission: Altered Mental State (AMS), Shock Index (SI), Partial Pressure of Oxygen/Fraction of Inspired Oxygen ratio (PaO2/FiO2), blood pH and arterial lactate concentration (Lac), and to compare its performance to predict 30-day (early) mortality.

Material and methods

In retrospective multicentric observational case-control study, 1037 patients with confirmed PE were admitted in a 24-month period. We evaluated medical charts in order to calculate PESI and sPESI risk scores. Multivariate analysis was performed to identify clinical and ABG independent predictors of all-cause mortality. Discriminative power was accessed by Receiver Operating Characteristic (ROC) curve.

Results

A total of 1037 patients were included in the final analysis. Mean age was 69.5 +16.6 years, 39.5% (n=410) were males. Median length of stay was 11.0 [IQR 7.0–18.0] days. Early mortality was 12.6% (n=131). SI and Lac were significantly higher in patients with early mortality (0.81 [IQR 0.66–1.01] vs 0.68 [IQR 0.57–0.82], and 2.63 [IQR 1.60–4.64] mmol/L vs 1.32 [IQR 1.00–1.90] mmol/L, respectively, p<0.0001 for both). PaO2/FiO2and pH were significantly lower in patients with early mortality (231 +120 vs 303 +103, and 7.39 +0.14 vs 7.43 +0.07, respectively, p<0.0001 for both). There was a significantly higher proportion of patients with altered mental status (Glasgow Coma Scale <15) in patients with early mortality (55.0% vs 18.5%, c2(1)=85.3, p<0.0001). Multivariate analysis is summarized in Table 1. Stratified analysis was based on the approximate cut-off value for the last quartile of SI (0.85) and Lac (2.50 mmol/L) and for the first quartile of PaO2/FiO2 (250) and pH (7.35). Based on the similar beta coefficient values for each variable, we attributed 1 point in the presence of each following conditions: GCS <15, SI >0.85, PaO2/FiO2<250, pH <7.35 and Lac >2.50 mmol/L with a total PoPE scorerange 0–5. The PoPE score yielded a good prognostic performance in predicting in-hospital death using ROC analysis (AUC 0.806, 95% CI 0.767–0.845, p<0.0001). The PoPE score performance was superior when compared with PESI (AUC 0.806 vs 0.695, AUC difference 0.111, p<0.0001) and sPESI (AUC 0.806 vs 0.622, p<0.0001) – Figure 1. A PoPEscore of 1 has a sensitivity of 93% and a specificity of 48% in predicting early all-cause mortality.

Conclusions

The PoPE scoreproves an easy and simple tool with good performance which can predict early eraly 30-day mortality in patients admitted for PE.

P6326Which results of the cardiopulmonary exercise test deserve greatest attention to establish the prognosis in heart failure?

Background and aim

Limitation of exercise tolerance is one of the cardinal manifestations of heart failure (HF). Cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise integrative physiology involving the pulmonary, muscular, and oxidative cellular systems. We aimed to identify which data collected during a CPET shows the best prognostic performance with respect to predicting mortality or the need for heart transplantation (HT).

Methods

Single-centre retrospective cohort study of consecutive HF patients performing a CPET for functional and prognostic HF evaluation from October 1996 till May 2018. Left ventricular ejection fraction was not an exclusion criterion. A Cox model was fit with time to death or heart transplantation (whichever recorded first within 5 years) as the dependent variable and CPET parameters as the independent variables. Both unadjusted and adjusted covariate Cox regressions were performed. ROC curve analysis was used to determine whether the significant variables, as a model, could reliably predict the study endpoint.

Results

The study population consisted of 513 patients, median age 58 (IQ 16) years, and 74.9% male. The majority had reduced ejection fraction (75.4%), and the most common HF aetiology was ischemic heart disease (55.8%). During the 5-years follow up, 126 patients died and 60 underwent heart transplantation. In unadjusted Cox regression, nearly all CPET variables were significantly associated with the study endpoint. After covariate adjustment, with prior exclusion of redundant variables, three measures remained associated with the study endpoint: peak VO2 consumption (hazard ratio [HR] 0.85; 95% confidence interval [CI], 0.81–0.90); VE/VCO2 slope (HR 1.02; 95% CI, 1.00–1.02); presence of oscillatory ventilatory pattern (HR 3.73; 95% CI, 2.43–5.72). As a model, these 3 variables showed a strong discriminatory ability (c-statistic 0.87; 95% CI, 0.83–0.90) (see figure) for the study endpoint.

Figure 1

Conclusion

When using the CPET for prognostic stratification of HF patients, the presence of an oscillatory ventilatory pattern, the peak VO2 and the VE/VCO2 slope are the most important tools on which clinicians should focus.

P5423Exercise oscillatory ventilation improves the performance of prognosis scores currently used for heart failure

Background and aim

Several prognostic risk scores are available for heart failure with reduced ejection fraction (HFrEF), and are used, together with other criteria, to help decide the ideal timing for listing candidates for a heart transplant. The detection of an oscillatory ventilatory pattern (OVP) during cardiopulmonary exercise testing (CPET) has been associated with more advanced HF and a worse prognosis, but was not considered in the development of all the current risk scores. We evaluated whether OVP adds significant prognostic information to four contemporary HF scores.

Methods

Single-centre retrospective cohort study of consecutive HFrEF patients undergoing CPET for functional and prognostic assessment from October 1996 till May 2018. The Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) and Metabolic Exercise Cardiac Kidney Index (MECKI) were obtained in each patient. Cox model was fit with time to death or urgent transplant (whichever came first within 2 years) as the dependent variable and OVP and respective HF score as the independent variables. We further assessed the added discriminative power by performing ROC curve comparisons.

Results

We studied 387 patients, median age 58 (IQR 49; 65) years, and 77% were male. The most common HFrEF aetiology was ischemic heart disease (54%). Median peak oxygen consumption was 15,7 mL/kg/min (IQR 12,8; 20,0). OVP was present in 150 (39%) patients. Over the 2-year follow-up period, 48 patients died, and 52 underwent heart transplantation (of which 25 were urgent). HFSS showed the weakest (c-statistic 0,625; 95% [CI] 0,54–0,71) and MECKI score the strongest (c-statistic 0,819; 95% [CI] 0,76–0,88) discriminatory ability. Contrasting with NTproBNP value, the presence of OVP predicted the study endpoint independently of the HF prognosis score used (see table). Adding the occurrence of OVP to the HFSS and the MAGGIC scores significantly improved their prognostic performance (see Table).

Conclusion

An OVP is a common finding in HFrEF patients undergoing CPET, and adds prognostic information to contemporary HF prognosis scores. Systematic evaluation of this easily available criterion may assist the decision on the appropriate timing for heart transplantation listing.