P2756Risk of stroke subsequent to infective endocarditis: a nationwide study

Background

Patients with infective endocarditis (IE) are at high risk of cerebral embolization, however little is known about the risk of stroke subsequent to IE in patients with stroke during IE admission.

Purpose

To investigate the risk of stroke after discharge of IE in patients with stroke during IE admission compared with patients without stroke during IE admission.

Methods

Using Danish nationwide registries we identified non-surgically treated patients with IE discharged alive, in the period 1996–2016. The study population was grouped in 1) patients with stroke during IE admission and 2) patients without stroke during IE admission. Crude cumulative risk of stoke were calculated using the Aalen-Johansen estimator accounting for death as a competing risk. Multivariable adjusted Cox proportional hazard analysis was used to compare the associated risk of stroke between groups. We identified differentials in the associated risk of stroke during follow-up between groups (p=0.006 for interaction with time), and follow-up was split into 0–1 year and 1–5 years time periods.

Results

We identified 4,284 patients with IE, 239 patients (5.6%) with stroke during IE admission (median age: 71.9 years, 58.2% males), and 4,045 patients (94.4%) without stroke during IE admission (median age 69.7 years, 64.8% males). The crude cumulative risk of stroke within 1 year of follow-up is shown in Figure Panel A, and with 1 to 5 years of follow-up in Figure Panel B. In multivariable adjusted analyses, the associated risk of stroke was higher in patients with stroke during IE admission within a follow-up period of 1 year, HR 3.21 (95% CI: 1.66–6.20) compared with patients without stroke during IE admission. From 1 to 5 years of follow-up, we identified no difference in the associated risk of stroke between groups, HR 0.91 (95% CI: 0.33–2.50).

Cumulative incidence of stroke

Conclusion

Non-surgically treated patients with IE who had a stroke during IE admission were at significantly higher associated risk of subsequent stroke – although not significant beyond 1 year after discharge from IE. These findings underline the need for identification of causes and mechanisms of recurrent strokes after IE to develop preventive means.

3153Rate versus rhythm control and mortality in atrial fibrillation patients: a Danish nationwide cohort study

Background

Treatment of AF patients with rate or rhythm drug therapy have shown no difference in mortality in clinical trials. However, the generalizability of these trials to real-world populations can be questioned.

Purpose

We aimed to investigate the all-cause and cardiovascular (CV) mortality risk in a nationwide AF cohort by treatment strategy (rate vs. rhythm) and by individual drug classes.

Methods

We queried the Danish nationwide registries from 2000 to 2015 to identify patients with AF. A rate control strategy included the use of one or more of the following medications: beta-blocker, digoxin, and a class-4 calcium channel blocker (CCB). A rhythm control strategy included the use of an anti-arrhythmic drug (amiodarone and class-1C). Primary outcome was all-cause mortality. Secondary outcome was CV mortality. Adjusted incidence rate ratios (IRR) were computed using Poisson regression with time-dependent covariates allowing patients to switch treatment during follow-up.

Results

Of 140,697 AF patients, 131,793 were on rate control therapy and n=8,904 were on rhythm control therapy. At baseline, patients on rhythm control therapy were younger (71 yrs [IQR: 62–78] vs 74 [65–82], p<0.001) more likely male (63.5% vs 51.7% p<0.001), had more prevalent heart failure (31.1% vs 19.4%, p<0.001) and ischemic heart disease (40.1% vs. 23.3%, p<0.001), and had more prior CV-related procedures; PCI (7.4% vs. 4.0% p<0.001) and CABG (15.0% vs. 2.3%, p<0.001).

During a median follow up of 4.0 (IQR: 1.7–7.3) years, there were 64,653 (46.0%) deaths from any-cause, of which 27,025 (19.2%) were CVD deaths. After appropriate adjustments and compared to rate control therapy, we found a lower IRR of mortality and CV mortality in those treated with rhythm control therapy (IRR: 0.93 [95% CI: 0.90–0.97] and IRR 0.84 [95% CI: 0.79–0.90]). Compared with beta-blockers, digoxin was associated with increased risk of all-cause and CV mortality (IRR: 1.26 [95% CI: 1.24–1.29] and IRR: 1.32 [95% CI: 1.28–1.36]), so was amiodarone: IRR for all-cause mortality: 1.16 [95% CI: 1.11–1.21] and IRR for CV mortality: 1.12 [95% CI: 1.05–1.19]. Class-1C was associated with lower all-cause (0.43 [95% CI: 0.37–0.49]) and CV mortality (0.35 [95% CI: 0.28–0.44]).

Figure 1. Models were adjusted for age, sex, ischemic heart disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, valvular atrial fibrillation, bleeding, diabetes, ablation, pacemaker, implantable cardioverter defibrillator, hypertension, heart failure, use of loop diuretics, calendar year, and time on treatment. Abbreviations; CCB; calcium channel blocker, PY; person years.

Conclusions

In a real-world AF cohort, we found that compared with rate control therapy, rhythm control therapy was associated with a lower risk of all-cause and CV mortality. The reduced mortality risk with rhythm therapy could reflect an appropriate patient selection.

Acknowledgement/Funding

The Danish Heart Foundation

P4439Increased risk of out-of-hospital cardiac arrest in patients with psoriasis - a nationwide case-control study

Background

Chronic inflammatory disorders such as psoriasis have been associated with cardiovascular diseases and linked to proarrhythmogenic electrocardiographic changes, including QT-prolongation. However, evidence regarding the risk of out-of-hospital cardiac arrest with a history of psoriasis is lacking.

Purpose

To investigate the association between psoriasis and out-of-hospital cardiac arrest.

Methods

Through the nationwide Danish Cardiac Arrest Registry, we identified adult out-of-hospital cardiac arrest patients of presumed cardiac cause with and without psoriasis between June 2001 and December 2014. The odds of cardiac arrest were estimated using conditional logistic regression in a case-control design where we matched up to nine controls per case on age, sex and ischemic heart disease. The models were adjusted for comorbidities, concomitant pharmacotherapy and socioeconomic position.

Results

A total of 32,447 out-of-hospital cardiac arrest cases were included and matched with 291,999 controls from the general population. The median age was 72 years, 67% were male and 29% had ischemic heart disease. A total of 607 (1.9%) cases and 4662 (1.6%) controls had psoriasis. Compared with cardiac arrest cases without psoriasis, cases with psoriasis had same age (p=0.718) and gender distribution (p=0.794), higher prevalence of comorbidities such as congestive heart failure (25.7% vs 20.2%, p=0.001), chronic kidney disease (8.9% vs 6.2%, p=0.008) and chronic obstructive pulmonary disease (19.0% vs 14.7%, p=0.005) but had same prevalence of cerebral vascular disease (15.8% vs 14.5%, p=0.351) and peripheral vascular disease (13.3% vs 11.1%, p=0.078). In unadjusted and adjusted analyses, psoriasis was significantly associated with increased odds of cardiac arrest (odds ratio (OR) 1.18 [95% confidence interval (CI) 1.08–1.28] and OR 1.13 [95% CI 1.04–1.23], respectively) (Figure 1).

Conclusion

In this nationwide case-control study, psoriasis was significantly associated with increased odds of out-of-hospital cardiac arrest. Focus on risk factors and prevention of cardiovascular disease in patients with psoriasis is warranted.

Acknowledgement/Funding

None

P934Temporal trends in risk of atrial fibrillation and stroke in patients with peripheral artery disease between 1997 to 2015

Objectives

The risk of atrial fibrillation (AF) and stroke in patients with peripheral artery disease (PAD) is an important and inadequately addressed issue. Our aim was to examine temporal trends in the incidence of AF and stroke in patients with PAD.

Methods

Danish nationwide registers were used to identify all patients aged ≥18 years, with first-time diagnosis of PAD between 1997 and 2015. Age-standardized incidence rates per 1.000 person-years were calculated to estimate trends of AF and stroke. Risk of AF and stroke was furthermore estimated by 1-year cumulative-incidence divided into four year-groups.

Results

A total of 121.211 patients with first-time diagnosis of PAD were included. The 1-year cumulative-incidence of AF in patients with PAD were 1.97% for year 1997–2000, 2.63% for year 2001–2005, 2.66% for year 2006–2010, and 2.78% for year 2011–2015, respectively. The 1-year cumulative-incidence of stroke in patients with PAD were 2.71%, 2.71%, 1.95%, and 1.81%, for the 1997–2000, 2001–2005, 2006–2010, and 2011–2015 year-groups respectively. Likewise, the age-standardized incidence rates showed increasing trends of AF during the study period whereas trends of stroke demonstrated a decline (Figure 1). All age-standardized trends were statistically significant (p<0.05).

During the course of study i.e., between 1997 and 2015, the initiation of cholesterol-lowering agents, clopidogrel, and oral anticoagulants increased markedly from 7.0% to 51.3%, 0.1% to 5.9%, and 0.0% to 0.7%, respectively.

Figure 1

Conclusion

The incidence of AF in patients with PAD has significantly increased over time whereas a marked decline has occurred in the incidence of stroke. This suggests that the secondary prevention strategies aimed at reducing risk of stroke are broadly effective. Moreover, due to global aging, earlier and more frequent diagnosis, and improved treatment of cardiovascular risk factors may explain the increasing incidence of AF.

5968Adherence to driving restrictions among patients with an implantable cardioverter defibrillator: insights from a nationwide register-linked survey study

Background

Patients with an implantable cardioverter defibrillator (ICD) are restricted from driving following initial implantation or ICD shock. It is unclear how many patients are aware of, and adhere to, these restrictions.

Purpose

To investigate knowledge of, and adherence to, private and professional driving restrictions in a nationwide cohort of ICD patients.

Methods

A questionnaire was distributed to all living Danish residents ≥18 years who received a first-time ICD between 2013 and 2016 (n=3,913). During this period, Danish guidelines recommended 1 week driving restriction following ICD implantation for primary prevention, and 3 months following either ICD implantation for secondary prevention or appropriate ICD shock, and permanent restriction of professional driving and driving of large vehicles (>3.5 metric tons). Questionnaires were linked with relevant nationwide registries. Logistic regression was applied to identify factors associated with non-adherence.

Results

Of 2,741 questionnaire respondents, 92% (n=2,513) held a valid private driver's license at time of ICD implantation (85% male; 46% primary prevention indication; median age: 67 years (IQR: 59–73)). Of these, 7% (n=175) were actively using a professional driver's license for truck driving (n=73), bus driving (n=45), taxi driving (n=22), large vehicle driving for private use (n=54), or other purposes (n=32) (multiple purposes allowed).

Only 42% of primary prevention patients, 63% of secondary prevention patients, and 72% of patients who experienced an appropriate ICD shock, recalled being informed of any driving restrictions. Only 45% of professional drivers recalled being informed about specific professional driving restrictions (Figure). Most patients (93%, n=2,344) resumed private driving after ICD implantation, more than 30% during the driving restriction period: 34% of primary prevention patients resumed driving within 1 week, 43% of secondary prevention patients resumed driving within 3 months, and 30% of patients who experienced an appropriate ICD shock resumed driving within 3 months. Professional driving was resumed by 35%. Patients who resumed driving within the restricted periods were less likely to report having received information about driving restrictions (all p<0.001) (Figure).

In a multiple logistic regression model, non-adherence was predicted by reporting non-receipt of information about driving restrictions (OR: 3.34, CI: 2.27–4.03), as well as male sex (OR: 1.53, CI: 1.17–2.01), age ≥60 years (OR: 1.20, CI: 1.02–1.64), receipt of a secondary prevention ICD (OR: 2.2, CI: 1.80–2.62), and being the only driver in the household (OR: 1.29, CI: 1.05–1.57).

Conclusion

In this nationwide survey study, many ICD patients were unaware of the driving restrictions, and many ICD patients, including professional drivers, resumed driving within the restricted periods. More focus on communicating driving restrictions might improve adherence.

Acknowledgement/Funding

Danish Heart Foundation, Arvid Nilsson Foundation, Fraenkels Mindefond

86Coronary CT angiography as the first-line diagnostic strategy in patients with non-ST-segment Elevation Acute Coronary Syndrome - The VERDICT trial

Background

In patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) coronary pathology may range from structurally normal vessels to severe coronary artery disease. Current guidelines recommend early invasive coronary angiography (ICA) to guide management strategy.

Purpose

We tested the hypothesis that a strategy of first-line coronary computed tomography angiography (CCTA) may be used to differentiate between significant and nonsignificant coronary artery stenosis in patients with NSTE-ACS.

Methods

We included patients with NSTE-ACS confirmed by ischaemic ECG changes and/or elevated biomarkers of myocardial ischaemia, in whom ICA was feasible within 12 hours. Patients were randomised 1:1 to ICA within 12 hours (Very Early) or 48–72 hours (Standard) and CCTA was conducted prior to ICA. The primary endpoint was the ability of CCTA to rule out significant coronary artery stenosis (≥50% stenosis) expressed as the negative predictive value (NPV) using ICA as the reference standard. The VERDICT trial is registered with ClinicalTrials.gov number NCT02061891.

Results

CCTA was conducted in 1023 patients – Very Early, 2.5 (IQR 1.8, 4.2) hours, N=583 and Standard, 59.9 (IQR 38.9, 86.7) hours, N=440 after establishment of the diagnosis. Significant coronary stenosis was found by ICA in 67.4% of the patients. NPV of CCTA (95% CI) was 90.9% (86.8%-94.1%) and the positive predictive value, sensitivity and specificity were 87.9% (85.3–90.1%), 96.5 (94.9–97.8%) and 72.4 (67.2–77.1%), respectively. False negative patients (24/1023, 2.3%) mostly had lesions in coronary segments with a luminal diameter ≤2.5 mm. NPV was not influenced by patient characteristics or clinical risk profile, including abnormal cardiac troponin, ischaemic ECG changes, or a GRACE risk score>140. CCTA accuracy parameters were similar in Very Early and the Standard strategy group.

Conclusions

First-line CCTA may be used to rule out clinically significant coronary artery disease in patients with NSTE-ACS and thus potentially guide patient management.

Acknowledgement/Funding

This study was funded by the Danish Agency for Science, Technology, and Innovation and the Danish Council for Strategic Research (grant no. 09–066994)

3052Non-vitamin K antagonist oral anticoagulants are safe and effective alternatives to warfarin across subgroups by renal function: results from Danish registries

Background

All non-vitamin K antagonist oral anticoagulants (NOACs) have some degree of renal excretion, and patients with severely reduced renal function have been excluded from randomized controlled clinical trials of stroke prevention in atrial fibrillation (AF). Influence of renal function on outcomes has not been assessed in previous real-world studies of NOACs in AF.

Purpose

To assess influence of renal function on efficacy and safety of dabigatran, rivaroxaban or apixaban vs. warfarin.

Methods

Using nationwide registries, we identified all Danish AF patients who initiated warfarin, dabigatran, rivaroxaban or apixaban between 2012 and 2016. We included patients with a plasma creatinine measurement within 14 days from drug initiation and calculated estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Hazard ratio (HR) of stroke/thromboembolism (TE) or major bleeding according to oral anticoagulation was calculated using multivariable-adjusted Cox regression analyses with warfarin as reference.

Results

We included 14,673 AF patients who started first-time oral anticoagulation within 14 days from AF diagnosis, and our study population comprised 2482 (16.9%) initiators of dabigatran (median age 72, 44.5% women), 3806 (25.9%) initiators of rivaroxaban (median age 75, 48.0% women), 5067 (34.5%) initiators of apixaban (median age 76, 48.8% women), and 3318 (22.6%) initiators of warfarin (median age 75, 45.4% women). eGFR was >50, 30–50 and 15 to <30 mL/min/1.73m2 in 10,281 (83.1%), 2079 (14.2%) and 404 (2.8%) patients at baseline. After adjustment for age, sex, year of inclusion, income, cohabitation status, eGFR, hemoglobin, medications and comorbidities, the HRs for stroke/TE compared to warfarin were 0.94 (95% confidence interval (CI) 0.74–1.20) for dabigatran, 1.06 (CI 0.84–1.34) for rivaroxaban, and 1.10 (CI 0.88–1.36) for apixaban. There were no significant heterogeneities in HRs of stroke/TE across subgroups by eGFR. Apixaban (HR 0.74, CI 0.62–0.89) was associated with lower risk of major bleeding compared to warfarin, rivaroxaban (HR 1.06, CI 0.88–1.27) with risk of major bleeding comparable to warfarin, and there were no significant heterogeneities in risk of major bleeding with rivaroxaban or apixaban across subgroups by eGFR. Dabigatran was associated with lower risk of bleeding among patients with eGFR >50 mL/min/1.73m2, but not among patients with eGFR 30–50 mL/min/1.73m2 (interaction P=0.03).

Conclusions

In a large real-world cohort, renal function had no significant influence on efficacy or safety of apixaban or rivaroxaban when compared with warfarin. Dabigatran was associated with lower risk of bleeding among patients with normal or mildly decreased renal function, but not among patients with moderately decreased renal function.

Acknowledgement/Funding

This study was funded by an unrestricted grant from the Capital Region of Denmark, Foundation for Health Research.

P3470Comparative effectiveness and safety of non-vitamin K oral anticoagulants and warfarin in non-valvular atrial fibrillation - a cohort study in 3 Nordic countries

Background

Non-vitamin K oral anticoagulants (NOACs) are an alternative to warfarin in the prevention of stroke in non-valvular atrial fibrillation (NVAF). Nordic countries have high quality of warfarin treatment, making them an especially suitable setting for assessing effectiveness and safety of NOACs against warfarin.

Purpose

The BEYOND Pooled (BEnefit of NOACs studY of nOn-valvular AF patieNts in NorDic countries) study compared risks of ischaemic or haemorrhagic stroke/systemic embolism (S/SE), and risk of bleeding with acute hospitalisation with an overnight stay (bleeding) in NVAF patients treated with apixaban, dabigatran or rivaroxaban, each compared with warfarin treatment.

Methods

A cohort study of treatment-naïve adult NVAF patients dispensed apixaban, dabigatran, rivaroxaban or warfarin was identified from 01 Jan 2013 to 31 Dec 2016. The population and study variables were identified from national registries in Denmark, Norway and Sweden. After 1:1 propensity score (PS) matching for each NOAC-warfarin comparison, individual-level data were pooled across the countries. Cox proportional-hazards regression was used to estimate adjusted hazard ratios (aHRs) of the endpoints.

Results

PS matched NOAC cohort sizes were: apixaban (55,696) dabigatran (28,526) and rivaroxaban (30,701), and the total follow-up in the PS-matched population was 291,171 years (mean 1.3 years). During the follow-up, 35,450 oral anticoagulation (OAC) patients had a S/SE and 38,620 OAC patients had bleeding. Adjusted HRs for the two endpoints are presented in the table. PH assumption has not been formally tested but cum incidence curves did not indicate substantial differences in the effects over time.

Table 1. Adjusted hazard ratios (aHR) of stroke/systemic embolism and bleeding for non-vitamin K oral anticoagulants versus warfarin Endpoint Apixaban vs Warfarin: aHR (95% CI) Dabigatran vs Warfarin: aHR (95% CI) Rivaroxaban vs Warfarin: aHR (95% CI) Stroke/SE 0.93 (0.85–1.03) 0.89 (0.80–1.00) 0.97 (0.88–1.08) Bleeding 0.72 (0.67–0.77) 0.87 (0.80–0.95) 1.12 (1.04–1.20)

Conclusions

Relative to warfarin, apixaban and dabigatran were associated with lower rates of bleeding whereas rivaroxaban was associated with a higher rate. The three NOACs had comparable rates of stroke and systemic embolism relative to warfarin.

Acknowledgement/Funding

This study was funded by the Pfizer/Bristol-Myers Squibb Alliance.

1096Diastolic myocardial dysfunction by tissue doppler imaging predicts outcome following isolated coronary artery bypass grafting

Background

Myocardial tissue velocities by tissue Doppler imaging (TDI) have proven superior predictors of outcome to left ventricular ejection fraction (LVEF) in ischemic heart disease, with early diastolic myocardial relaxation velocity (e') being an early sign of LV dysfunction in the ischemic cascade.

Purpose

We hypothesized that e' predicts outcome after coronary artery bypass grafting (CABG).

Methods

We included patients treated with isolated CABG (n=679). Before surgery, all patients had an echocardiogram performed with TDI to measure tissue velocities: systolic (s'), e' and late diastolic (a'). Endpoint was all-cause mortality retrieved from national registries. We performed Cox regressions and C-statistics. Net reclassification index was used to test improvement of EuroSCOREII.

Results

Of 679 patients, 79 (n=12%) died during follow-up (median: 3.8 years (IQR: 2.8; 5.0y). Follow-up was 100%. Mean age was 68 years, LVEF 50%, and 86% were male. All tissue velocities were univariable predictors of outcome (s': HR=1.46 [1.21; 1.78], p<0.001; e': HR=1.55 [1.33; 1.81], p<0.001; a': HR=1.19 [1.06; 1.33], p=0.004, per 1cm/s decrease for all). Overall, e' provided the highest C-statistics of all the tissue velocities (c-stat=0.69). In multivariable adjustments, e' remained an independent predictor after adjusting for clinical, biochemical and echocardiographic confounders (HR=1.24 [1.03; 1.49], p=0.022, per 1cm/s decrease). LVEF <40% modified the relationship between e' and outcome, so e' did not predict outcome in these patients (p for interaction = 0.013). However, e' was an independent predictor after multivariable adjustments in patients with LVEF >40% (HR=1.39 [1.11; 1.74], p=0.005, per 1cm/s decrease). When split by the median (−4.95cm/s), patients in the lowest group had a 3-fold increased risk of death (HR=3.31 [1.98; 5.56], p<0.001) compared to patients in the highest group (figure).

The e' improved the net reclassification improvement index when added to EuroSCOREII, with a net reclassification of 39%.

Conclusion

After CABG, e' is a strong predictor of all-cause mortality and improves the predictive value of the established prediction model, the EuroSCOREII. We identified a possible effect modifier in LVEF, such that e' was a strong predictor in patients with LVEF >40% and not when LVEF is below 40%.

3149Regional strain patterns according to hypertension and left ventricular hypertrophy in the general population

Background

A pattern of reduced basal longitudinal strain (BLS) is often observed in hypertension (HT) and with altered left ventricular (LV) geometry. Whether this pattern is associated with poor outcome is unclear. We hypothesized that BLS becomes incrementally more impaired in the transition from HT to LV hypertrophy (LVH) and is a predictor of outcome.

Methods

We investigated 1,096 participants from a community-based cohort study who had an echocardiogram with speckle tracking performed. Regional strain was calculated as: BLS, midventricular and apical strain. The participants were stratified by LV geometry: LVH vs. non-LVH (LVH defined as left ventricular mass index >116 g/m2 for men and >96g/m2 for women). Outcome was major adverse cardiovascular events (MACE) defined as incident myocardial infarction, heart failure, and cardiovascular death.

Results

BLS and midventricular strain were significantly reduced when comparing normal participants without HT to participants with HT, whereas only BLS was reduced when comparing participants with HT to those with LVH (figure). Overall, patients with LVH showed both reduced BLS and midventricular strain (BLS: −17.5 vs −19.2%, p<0.001; midventricular strain: −19.2 vs. −19.9%, p=0.007 for LVH and non-LVH, respectively) compared to non-LVH, whereas apical strain was similar between groups.

During a median follow-up of 12.9 years (13.5; 14.9 years) there were 139 events. Only BLS was reduced in patients with MACE (BLS: −18.0 vs −19.1%, p=0.002) compared to patients without outcome. Both BLS and midventricular strain were univariable predictors of MACE in patients with LVH (BLS: HR=1.20 [1.04; 1.20], p=0.002; midventricular strain: HR=1.08 [1.00; 1.17], p=0.049) but not in patients without LVH (BLS: HR=1.02 [0.97; 1.08], p=0.46; midventricular strain: HR=1.01 [0.94; 1.07], p=0.88). Both measures were independent predictors after multivariable adjustment for clinical risk factors: age, gender, smoking, hypertension, and cholesterol (BLS: HR=1.08 [1.00; 1.16, p=0.048; midventricular strain: HR=1.10 [1.00; 1.20], p=0.049).

Regional strain by HT and LV geometry

Conclusion

BLS and midventricular strain, but not apical strain, becomes incrementally impaired in the transition from normal to LVH, and is associated with poor outcome. In regional strain analyses, BLS provides the highest predictive value for outcome in patients with LVH.

Acknowledgement/Funding

None

P2442Myocardial performance index predicts mortality in people with obstructive lung function from the general population

Background

Forced expiratory volume in one second (FEV1) is a significant predictor of mortality in patients with obstructive lung function (OL). Whether echocardiography can be used to identify patients at high risk, and whether it provides incremental prognostic information on mortality in patients with OL, remains unknown.

Methods

In a large, low-risk general population study, 1873 participants underwent a health examination with spirometry and echocardiography, including tissue Doppler imaging (TDI). The myocardial performance index (MPI) was calculated as the sum of the isovolumic contraction time (IVCT) and the isovolumic relaxation time (IVRT) divided by the left ventricle ejection time (LVET). Spirometry included measurements of (FEV1) and the forced vital capacity (FVC). OL was defined as FEV1/FVC <0.70. The primary endpoint was all-cause mortality.

Results

The mean age was 59±16 years, 57% were women, 43% had hypertension, 11% had diabetes, and 6% had ischemic heart disease. Of the 1873 included participants, 288 (15%) were classified as having OL at baseline. During follow up (median 13.7 years (IQR 13.2–16.2)), 584 (31%) persons died, hereof 178 (62%) in the subgroup of participants with OL and 406 (26%) in the subgroup of participants with normal lung function.

OL was associated with presence of left ventricular hypertrophy (higher left ventricular mass index), impaired diastolic function (lower E, higher A, lower E/A ratio, longer deceleration time, lower e' and higher E/e'), lower global longitudinal strain, and higher MPI.

In unadjusted analysis, higher MPI was associated with all-cause mortality for participants with OL (HR=1.18 (1.11–1.26), p<0.001, per 0.1 increase) and for participants with normal lung function (HR=1.42 (1.34–1.50), p<0.001, per 0.1 increase). The predictive value of MPI was significantly modified by the presence of obstructive lung function (p<0.001).

After multivariable adjustment for age, sex, FEV1/FVC, heart rate, systolic blood pressure, smoking status, body mass index (BMI), hypertension, diabetes, ischemic heart disease, ischemic stroke and heart failure at baseline, MPI remained an independent predictor of all-cause mortality (HR=1.19 (1.06–1.34), p=0.004, per 0.1 increase) for participants with OL but not for participants with normal lung function (HR=1.02 (0.94–1.11), p=0.598, per 0.1 increase).

When adding the MPI to the updated Age, Dyspnea and Obstruction (ADO) index, MPI provided incremental prognostic information beyond the updated ADO index, as determined from a significant increase in the Harrell's C-statistics (0.785 to 0.792, p=0.003).

Conclusion

Presence of OL is associated with subtle impairment of left ventricular systolic function, impaired left ventricular diastolic function, and higher MPI. MPI is an independent predictor of mortality in people with OL and provides incremental prognostic information regarding all-cause mortality in this population.

Acknowledgement/Funding

Herlev & Gentofte University Hospital PhD fund

P4779High facility preference for rivaroxaban in atrial fibrillation increases risk of major bleeding compared to facility preference for apixaban

Background

No randomized trial has compared efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF). Previous real-world comparisons could be biased by patient characteristics of importance for treatment selection, but instrumental variables could potentially account for measured and unmeasured confounders.

Purpose

To compare efficacy and safety of rivaroxaban and apixaban using facility preference for type of NOAC as instrumental variable.

Methods

AF patients started on apixaban or rivaroxaban were identified using nationwide registries. We categorized patients according to facility preference for type of NOAC, measured as percentage of the prior 20 AF patients started on rivaroxaban in the same facility. Occurrence of stroke/thromboembolism (TE), major bleeding, myocardial infarction and all-cause mortality during two years of follow-up were investigated using adjusted Cox regressions. To further examine general frailty according to facility preferences we also investigated occurrence of cancer, urogenital tract infection, dehydration and fracture.

Results

We analyzed 6264 AF patients initiated on rivaroxaban or apixaban. Compared with patients treated in facilities that used rivaroxaban in 0–20% of cases, the adjusted hazard ratio for bleeding was 1.05 when treated in a facility with 25–40% use; 1.40 with 45–60% use; 1.50 with 65–80% use; and 1.81 for 85–100% use (Ptrend=0.002). Higher facility level use of rivaroxaban was not associated with increased risk of stroke/TE (Ptrend=0.06), myocardial infarction (Ptrend=0.87) or all-cause mortality (Ptrend=0.91), and there was no association between facility preference for rivaroxaban and risk of cancer (Ptrend=0.83), urogenital tract infection (Ptrend=0.49), dehydration (Ptrend=0.91) or fracture (Ptrend=0.47).

Characteristics by facility preference Percent of previous AF patients from facility started on rivaroxaban P for trend 0–20% 25–40% 45–60% 65–80% 85–100% No. of patients 1406 1421 1551 930 956 Received rivaroxaban, (%) 279, (19.8) 499, (35.1) 711, (45.8) 632, (68.0) 774, (81.0) <0.001 Standard dose, (%) 1216, (86.5) 1232, (86.7%) 1366, (88.1%) 793, (85.3%) 824, (86.2%) 0.62 Median age, (interquartile range) 70, (63.3–74) 69, (63–74) 70, (64–74) 70, (64–75) 70, (63–75) 0.11 Below median income, (%) 740, (52.6) 699, (49.2) 764, (49.3) 458, (49.3) 471, (49.3) 0.31 Prior stroke, (%) 99, (7.0) 115, (8.1) 134, (8.6) 69, (7.4) 74, (7.7) 0.56 Prior bleeding, (%) 136, (9.7) 141, (9.9) 163, (10.5) 91, (9.8) 97, (10.1) 0.51 Antiplatelet therapy, (%) 445, (31.7) 465, (32.7) 491, (31.7) 303, (32.6) 317, (33.2) 0.49

Rate of events according to instrument

Conclusion

High facility preference for rivaroxaban increases risk of major bleeding compared to facility preference for apixaban.

Acknowledgement/Funding

This study was funded by an unrestricted grant from the Capital Region of Denmark, Foundation for Health Research.

5878Renal insufficiency is associated with progressive increase in risk of cardiovascular death in patients without preexisting cardiovascular disease

Introduction and aims

Chronic kidney disease has previously been observed to be associated with increased cardiovascular risk. Observations are however predominantly limited to patients with either severe or end-stage renal disease. We investigate the associated risk of diminishing renal function with cardiovascular death across all levels of non-dialysis dependent renal insufficiency.

Methods

Based on cross-referencing of data from numerous nationwide health care registers, patients with a recorded plasma creatinine measurement were identified in Denmark between 1997 and 2017. Patients with preceding cardiovascular disease, end-stage renal disease, age <18 years, and patients with events within a 30 days quarantine period after their first-time plasma creatinine measurement were excluded. Estimated glomerular filtration rates (eGFRs) were calculated from the first recorded plasma creatinine. Hazard ratios for two-year risk of cardiovascular death were computed for strata of renal function in a multiple Cox regression model with adjustment for age and gender, and cumulative incidences were estimated using the Aalen-Johansen estimator.

Results

In total 2,000,626 patients were identified. Median follow-up was 3.6 years (IQR 1.7–9.0 years). A total of 22,657 (0.01%) cardiovascular deaths were recorded. Patients were predominantly female (54%), median age was 40 years (IQR 29–63 years), and median eGFR was 98 ml/min/1.73m2 (IQR 83–117 ml/min/1.73m2). Hazard ratios with confidence intervals of cardiovascular death were 0.85 [0.82–0.89], 1.24 [1.18–1.31], 2.02 [1.89–2.15], and 3.19 [2.91–3.49] for the eGFR strata 90–60 ml/min/1.73m2, 59–45 ml/min/1.73m2, 44–30 ml/min/1.73m2, <30 ml/min/1.73m2, respectively (eGFR >90 ml/min/1.73m2 as reference).

Cumulative incidence

Conclusion

In a nationwide cohort of non-dialysis treated patients without pre-existing cardiovascular disease, renal dysfunction was associated with progressive increase in risk of cardiovascular death in patients with eGFR <60 ml/min/1.73m2.

P4774Older patients with atrial fibrillation and comorbidities are less likely to be treated with oral anticoagulation: insights from a nationwide study

Background

Older patients with atrial fibrillation (AF) often have multiple chronic conditions adding complexity to treatment decisions. However, regarding older AF patients, the association between multimorbidity and quality of care has not been explored previously in a non-selected nationwide cohort.

Purpose

To investigate the association between morbidity burden and the treatment with oral anticoagulation therapy (OAC) and rhythm-control strategies in patients >65 years of age with incident AF in Denmark.

Methods

Using Danish nationwide registers, we identified all Danish AF patients >65 years of age hospitalized for incident AF between 2010 and 2016. Using logistic regression models, we estimated the association between morbidity burden (<2, 2–3, 4–5, and >5 comorbidities) and the likelihood of receiving AF specific treatments. Estimates were reported as odds ratios with 95% confidence intervals (OR, 95% CI) with <2 comorbidities as reference. The primary outcome of interest was OAC therapy initiation. Secondary outcomes were initiation of anti-arrhythmic drugs (Class IC and Class III) and AF related procedures (electrical cardioversion and radiofrequency ablation). All models were adjusted for age, sex and calendar year.

Results

A total of 49,802 AF patients were eligible for inclusion, with a median age of 77.5 years (Interquartile range [IQR] 71.8–83.8) and 24,983 (50.2%) were male. A total of 25,181 (50.6%) patients had <2 comorbidities, 18,714 (37.6%) had 2–3 comorbidities, 4,891 (9.8%) had 4–5 comorbidities, and 1,016 (2.0%) patients had >5 comorbidities. The median CHA2DS2-VASc score ranged from 3 (IQR 2–3) to 5 (IQR 4–5) in patients with <2 comorbidities and >5 comorbidities, respectively.

Increasing morbidity burden was associated with decreasing odds of being treated with OAC therapy with the lowest odds in patients with >5 comorbidities (OR 0.39, 95% CI 0.34–0.45) compared with AF patients with <2 comorbidities. (Figure 1) Using morbidity burden as a continuous variable, an increment of one comorbidity was associated with decreasing odds of initiating OAC therapy (OR 0.85, 95% CI 0.84–0.86).

Morbidity burden was associated with increased odds of being prescribed anti-arrhythmic medication with the highest odds in patients with >5 comorbidities (OR 2.50 95% CI 2.08–2.99). In contrast, having >5 comorbidities was associated with decreased odds of AF related procedures (OR 0.32, 95% CI 0.23–0.43) compared to patients with <2 comorbidities.

Forest plot of OAC initiation factors

Conclusion

Morbidity burden is strongly associated with OAC initiation and rhythm-control strategies in older patients with incident AF. Older AF patients with multimorbidity are less likely to be treated with OAC although these are the patients who benefit most from treatment. Therefore, initiatives and quality improvement programs should be done to close this important gap between clinical trials and clinical practice.

4178Insulin treatment is associated with increased risk of device-treated ventricular tachyarrhythmia in patients with diabetes and heart failure

Background

It is debated whether insulin use is associated with a pro-arrhythmic effect. There is paucity of studies investigating this aspect in patients with heart failure (HF), where use of insulin is associated with an increased mortality risk.

Purpose

We aimed to investigate whether patients receiving insulin had higher risk of device-treated ventricular tachyarrhythmia (VTA) in a population of HF patients with medically treated diabetes and primary prevention implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy with defibrillator (CRT-D).

Methods

Information on ICD/CRT-D implantation and therapy, comorbidities, diabetes, diabetes-related complications and medication were obtained through Danish nationwide registers. From 2007 through 2016 we identified all primary prevention ICD/CRT-D implantations in HF patients with diabetes, defined as treatment with antidiabetic medication within one year prior to implantation. Patients were divided into two groups; Insulin treated vs. non-insulin treated patients. Endpoints of interest were VTA, defined as appropriate ICD therapy, and all-cause mortality. Cumulative incidence curves and adjusted Cox proportional Hazards regression analyses were used to assess risk of outcomes. Adjustment variables included age, gender, ischemic heart disease (IHD), left ventricular ejection fraction (LVEF), ICD vs. CRT-D, diuretic use (as a proxy for severity of HF), prior VTA and diabetes-related complications, identified from diagnosis codes for diabetic nephro-, retino-, and neuropathy, multiple diabetic complications and unspecified diabetic complications.

Results

We identified 1240 patients with HF and diabetes with a primary prevention ICD/CRT-D. The majority of patients had type 2 diabetes (94%). Of these 479 patients (39%) were treated with insulin and 761 (61%) were not. Patients were primarily male (85%) with mean age of 66.9±8.3 years, mean LVEF of 25.6±7.5%, 42% had CRT-D and 58% ICD, without differences between the groups. The insulin-treated group had a higher occurrence of diabetes-related complications (81% vs. 42%, p<0.01) and IHD (95% vs. 90%, p<0.01).

During a mean follow-up of 3.1±2.1 years, 74 insulin treated patients (16%) and 86 non-insulin treated patients (11%) experienced VTA (p=0.034), with higher 5-year cumulative incidence of VTA in the insulin group.

Insulin treatment was associated with significantly increased risk of VTA (HR = 1.45; 95% CI [1.04–2.03], p=0.031) and all-cause mortality (HR=1.27; 95% CI [1.03–1.58], p=0.027), as compared with non-insulin treated patients.

Figure 1

Conclusion

In HF patients with diabetes implanted with a primary prevention ICD/CRT-D, treatment with insulin was associated with a significant 45% increased risk of device-treated ventricular tachyarrhythmias and 27% increased risk of all-cause mortality. These findings support further clinical trials to evaluate the safety of insulin in patients with HF and type 2 diabetes.

P4628A multiple biomarker approach for risk assessment after ST-segment elevation myocardial infarction

Background

Several biomarkers independently predict outcome following ST-segment elevation myocardial infarction (STEMI). We hypothesized that combining information from multiple circulating biomarkers with numerous pathophysiological pathways may improve biomarker risk stratification following a STEMI.

Method

This was a prospective study of 735 patients with STEMI treated with primary percutaneous coronary intervention. Seventeen biomarkers were drawn before revascularization, including adrenalin, noradrenalin, C-reactive protein (CRP), neutrophil gelatinase-associated lipocalin (NGAL), pro-atrial natriuretic peptide (pro-ANP), alfa-defensin, adiponectin, troponin I, hemoglobin, thrombocyte, and total leukocyte count. The primary outcome was a composite of cardiovascular death or heart failure (CVD/HF) identified by national registries. In the effort to identify the best model, the population was randomly split into two equally sized groups, a derivation cohort and a validation cohort. We used classification and regression tree (CART) analysis to develop a risk model. The identified risk model was hereafter applied to the whole cohort.

Results

Mean age was 63 years, 74% were male and 33% had hypertension. During a median follow-up time of 5.0 years (3.2; 5.0), we observed 185 primary events. After including all biomarkers in the initial model, the CART analysis created a risk model including pro-ANP, NGAL, and CRP (Figure 1a). The risk of CVD/HF increased incrementally with increasing risk group (Figure 1b). The risk remained significantly higher in groups 3 and 4 after multivariable adjustments (hazard ratio (HR)=3.38 [95% confidence interval (CI): 1.60; 7.16] p=0.001 and HR=6.55 [95% CI: 2.73; 15.76] p<0.001, respectively) when compared with group 1.

Figure 1

Conclusion

We developed a risk model based on multiple biomarkers (NGAL, CRP, and pro-ANP) determined from a CART analysis which may ease risk stratification after STEMI.

Acknowledgement/Funding

Sif Rasmussen received a scholarship grant from Herlev & Gentofte Hospital and the P. Carl Petersens Fond during preparation of this manuscript.

5226The majority of 30-day survivors of in-hospital cardiac arrest are alive one-year post-arrest without anoxic brain damage, admission to nursing home or need of in-home care

Background

Survivors of in-hospital cardiac arrest are at risk of anoxic brain damage that can lead to admission to nursing home or need of in-home care. However, studies on long-term outcomes after in-hospital cardiac arrest are scarce with previous research focusing on short term measures such as survival-to-discharge.

Purpose

This study aimed to investigate the composite endpoint of nursing home admission or anoxic brain damage among 30-day survivors of in-hospital cardiac arrest within the first-year post-arrest. As a sub analysis, we also investigated the additional need of in-home care.

Methods

All in-hospital cardiac arrests in 13 Danish hospitals during 2013–2015 were identified from the DANARREST register. Inclusion criteria were indication for a resuscitation attempt and survival to day 30. Patients who, prior to arrest, already lived in a nursing home, and/or had anoxic brain damage were excluded. In the sub analysis patients who received in-home care prior to arrest were also excluded. The DANARREST data was linked to nationwide registries including the National Patient Register and administrative nursing home and home care registries using the Danish Civil Registration Number, a unique personal identification number that is given to every citizen in Denmark.

Results

The primary study population comprised of 454 (26.3%) 30 day-survivors out of 1723 eligible patients. Median age was 67 (Q1-Q3 57–75); 301 (66.9%) were men. In this group, the 1-year risk of anoxic brain damage or nursing home admission was 4.6% (95% CI 2.7%- 6.6%) with a competing risk of death of 15.6% (95% CI 12.3%-19.0%), leaving 79.8% alive without anoxic brain damage or nursing home admission at one-year follow-up (see Figure 1A).

The sub study population comprised of 343 30-day survivors with a 1-year risk of anoxic brain damage, nursing home admission or need of in-home care of 23.6% (95% CI 19.1%-28.1%). The competing risk of death was 7.6% (95% CI 4.8%-10.4%), leaving 68.8% alive without anoxic brain damage, nursing home admission or need of in-home care at one-year follow-up (see Figure 1B).

Figure 1

Conclusion

The majority of 30-day survivors of in-hospital cardiac arrest were alive at one-year follow-up without being diagnosed with anoxic brain damage, admitted to nursing home or without need of in-home care.

P2441The prognostic value of left atrial dyssynchrony in the general population

Introduction

Parameters derived from left atrial (LA) speckle tracking such as LA peak reservoir strain and LA dyssynchrony are potent predictors of cardiovascular morbidity and mortality in various patient populations. However, whether LA dyssynchrony as evaluated by speckle tracking is associated with long-term outcome in the general population is currently unknown.

Methods

In a cohort study with participants from the general population 385 participants without atrial fibrillation (AF), ischemic heart disease (IHD), heart failure (HF) or previous ischemic stroke (IS) had a health examination and an echocardiogram, including LA speckle tracking, performed. LA dyssynchrony was defined as the standard deviation of the time to peak regional atrial reservoir strain values. The endpoints were all-cause mortality, a combined endpoint of AF and IS, and a combined endpoint of major adverse cardiovascular events (MACE) comprised of acute myocardial infarction (AMI), HF or cardiovascular death (CVD).

Results

Median LA dyssynchrony was 42 ms (IQR: 22–58 ms), 60% percent of included participants were women, mean age was 55 years (SD 16 years), 34% had hypertension and 7% had diabetes mellitus. During a median follow up of 16.1 years (IQR 15.0–16.3 years), 83 (22%) participants died, 60 (15%) reached the composite endpoint of AF and IS, and 38 (10%) reached the composite MACE endpoint.

Increasing LA dyssynchrony was associated with increasing age, lower estimated glomerular filtration rate, lower E/A ratio, lower e' and higher E/e'. In a univariable Cox regression, LA dyssynchrony was a significant predictor of all-cause mortality (HR 1.07, 95% CI 1.02–1.11, p=0.001, per 10 ms increase) but was not significantly associated with the combined endpoint of AF and IS (HR 1.05, 95% CI 1.00–1.10, p=0.064, per 10 ms increase) nor MACE (HR 1.04, 95% CI 0.98–1.12, p=0.22, per 10 ms increase). However, when adjusted for age, LA dyssynchrony did not predict all-cause mortality (HR 1.03, p=0.28), the combined endpoint of AF and IS (HR 1.01, p=0.83), or MACE (HR 0.99, p=0.88,). Similarly, after further adjustment for age, sex, smoking status, systolic blood pressure and cholesterol, LA dyssynchrony did not predict any of the study outcomes (All-cause mortality: HR 1.01, p=0.72) (AF and IS: HR 0.98, p=0.88) (MACE: HR 1.00, p=0.93).

Conclusion

In this general population study, LA dyssynchrony was not an independent predictor of all-cause mortality and did not predict MACE nor a composite outcome consisting of AF and IS.

P4757Vitamin k antagonists are associated with higher risk of osteoporotic fractures compared to non-vitamin k antagonist oral anticoagulants among atrial fibrillation patients: a nationwide cohort study

Background/Introduction

Osteoporotic fractures are associated with high mortality and reduced life quality in an elderly population. Several studies report an increased risk of fractures among patients treated with oral anticoagulants (OAC), however, only sparse research has been made to clarify the difference between treatment with vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOACs) regarding the risk of osteoporotic fractures.

Purpose

The purpose of this study was to evaluate the risk of osteoporotic fractures among patients with atrial fibrillation (AF) in long-term VKA or NOAC treatment.

Methods

Patients with AF were identified using Danish national registries and were included when they had undergone 180 days OAC treatment, and only if they had no prior use of osteoporosis medication. The study period was from 1 January 2013 until 30 June 2017, and patients were followed for 2 years, or until death, outcome or emigration. Outcomes were hip fracture, major osteoporotic fracture, any fracture, initiation of osteoporosis medication, and a combined endpoint. G-formula was used to determine standardized absolute risk, and multiple covariate adjusted Cox regressions were used to calculate hazard ratios (HR).

Results

Overall, 37,350 patients with AF were included; 32.6% received VKA treatment (median age 72 years, 61.8% men) and 67.4% received NOAC treatment (median age 73 years, 55.9% men). The standardized absolute 2-year risk of any fracture was low among NOAC treated patients (3.1%; 95% CI: 2.9% to 3.3%), and among VKA treated patients (3.8%; 95% CI: 3.4% to 4.2%).

NOAC was associated with a significantly lower relative risk of any fracture (HR: 0.85; 95% CI: 0.74 to 0.97), of major osteoporotic fractures (HR: 0.85; 95% CI: 0.72 to 0.99), and of initiating osteoporotic medication (HR: 0.82; 95% CI: 0.71 to 0.95). A combined endpoint showed that patients treated with NOAC had a significantly lower risk of suffering from any fracture or initiating osteoporosis medication (HR: 0.84; 95% CI: 0.76 to 0.93).

Adjusted relative two-year risks

Conclusion

In a nationwide population, the absolute risk of osteoporotic fractures was low among AF patients on OAC, but NOAC was associated with a significantly lower risk of osteoporotic fractures compared to VKA.

Acknowledgement/Funding

Scholarship from The Copenhagen University Hospital Herlev and Gentofte

2138Usefulness of left atrial strain for predicting incident atrial fibrillation and ischemic stroke in the general population

Background

Left atrial (LA) enlargement is an established independent predictor of incident atrial fibrillation (AF). However, the prognostic value of left atrial peak reservoir strain (LA RS) in predicting incident AF in participants from the general population is currently unknown. It is our hypothesis that decreased LA RS can reveal early atrial dysfunction.

Purpose

The aim of this study was to investigate if LA RS can be used to predict AF and ischemic stroke in the general population.

Methods

A total of 405 participants (mean age 56±16 years, 41% male) from the general population underwent a health examination including two-dimensional speckle tracking echocardiography of the LA. LA RS was calculated as the average from the three apical views. The primary endpoint was incident AF at follow-up. All participants with known AF and prior stroke at baseline were excluded (n=54). The secondary endpoint consisted of the composite of AF and ischemic stroke.

Results

During a median follow-up of 16 years (interquartile range, 13.6–16.2 years), 36 participants (9%) were diagnosed with incident AF and 30 (7%) experienced an ischemic stroke, resulting in 66 (16%) experiencing the composite outcome. The risk of AF increased incrementally with decreasing tertile of LA RS, being approximately 10-fold higher in the 1st tertile as compared to the 3rd tertile (HR 9.82; 95% CI (2.95–32.63), p<0.001; figure).

LA RS was a univariable predictor of AF with 41% increased risk per 5% decrease in LA RS (per 5% decrease: HR 1.41; 95% CI (1.18–1.67), p<0.001). However, the prognostic value of LA RS was modified by age (p=0.002 for interaction). After adjusting for clinical and echocardiographic parameters the LA RS predicted AF in participants aged <65 years (per 5% decrease: HR 1.86; 95% CI (1.20–2.90), p=0.006). In contrast, LA RS did not predict AF in participants aged >65 years (per 5% decrease: HR 0.95; 95% CI (0.73–1.23), p=0.69).

LA RS was also a univariable predictor of the composite outcome of AF and ischemic stroke (per 5% decrease: HR 1.29; 95% CI (1.14–1.46), p<0.001). After multivariable adjustment the LA RS predicted AF and ischemic stroke in participants aged <65 years (per 5% decrease: HR 1.33; 95% CI (1.03–1.72), p=0.030).

Furthermore, LA RS provided incremental prognostic information over the left atrial volume index (LAVI) with regard to predicting AF (Harrell's C-statistics 0.69 vs. 0.75, p=0.044) and the composite of AF and ischemic stroke (Harrell's C-statistics 0.59 vs. 0.66, p=0.027) in participants from the general population.

Conclusion

In a low risk general population, the LA RS provides novel prognostic information on the long-term risk of AF and ischemic stroke, especially in participants aged <65 years. In addition, LA RS provides incremental prognostic information over the LAVI in predicting AF and ischemic stroke in the general population.

P3427Prognostic performance of echocardiography, electrocardiogram, albuminuria, plasma proBNP and hs-TnI in patients with type 2 diabetes

Background

A range of diagnostic tests including echocardiography, albuminuria, electrocardiogram (ECG), plasma measurement of high sensitivity troponin T (hs-TnI) and pro-brain natriuretic peptide (proBNP) have been suggested as cardiovascular (CV) risk predictors in patients with type 2 diabetes. In this study we examined prognostic yield from these risk markers.

Methods

A total of 1,030 out-patients followed at a large secondary care diabetes clinic were recruited. Echocardiography was considered feasible in patients in sinus rhythm with adequate image quality (n=886). Abnormal echocardiography was defined as a left ventricular ejection fraction (LVEF) <50%; a ratio of early diastolic mitral inflow velocity to early diastolic septal annular velocity (E/e'septal) ≥15; increased left ventricular mass index (>95 g/m2 for women and >115 g/m2 for men) or left atrial volume index >34 ml/m2. ECG was performed in 983 patients and was considered abnormal in the presence of abnormal Q-waves; ST-T segment deviation or bundle branch block. We measured urine albumin (n=1,009) and proBNP/hs-TnI (n=933). The end-point of CV event was a composite of CV death and hospitalization with myocardial infarction/revascularization, stroke, peripheral artery disease or heart failure.

Results

The median follow-up was 4.7 years (interquartile range: 4.0 to 5.3) and 174 patients suffered an CVD event. All markers except hs-TnI were significantly (p<0.001) associated with the composite outcome: Abnormal echocardiogram: Hazard ratio (95% confidence interval): 2.39 (1.69–3.37); albuminuria 2.01 (1.47–2.76); abnormal ECG 2.35 (1.72–3.21); log2(proBNP) 1.60 (1.47–1.75) and hs-TnI 1.05 (0.92–1.19). The findings persisted after adjusting for clinical variables, but after adjusting for the other markers, only log2(proBNP) remained associated with the composite outcome (1.50 (0.20–1.73), p<0.001), figure. Measured by C-index model performance was highest with proBNP (0.70 (0.65–0.75)) and similar to clinical variables (0.71 (0.67–0.76)). Combining risk markers only resulted in very limited increase in C-index (echocardiogram, albuminuria, ECG and proBNP: 0.71 (0.66–0.76)).

Uni- and multivariables

Conclusions

This study identifies proBNP measurement in plasma over echocardiography, ECG and albuminuria for risk prediction in patients with type 2 diabetes. The diagnostic yield in considering more than one risk marker was limited in this population.

P3783A higher habitual flavonoid intake is associated with a lower risk of atrial fibrillation

Background

Our understanding of how diet affects future risk of atrial fibrillation (AF) is limited. Evidence suggests that higher habitual intakes of flavonoids, bio-active compounds found in plant-based foods and beverages, lower cardiovascular disease risk, attenuate inflammation, and may have anti-arrhythmic properties.

Purpose

To investigate the association between flavonoid intake and clinically apparent AF in a large cohort of Danish men and women.

Methods

Baseline data from 55 634 participants without AF of the Danish Diet, Cancer and Health Study, recruited from 1993 to 1997, were cross-linked with Danish nationwide registries. Flavonoid intake was calculated from validated food frequency questionnaires using the Phenol-Explorer database. Associations between flavonoid intake and AF hospitalisation were examined using restricted cubic splines based on Cox proportional hazards models with adjustments for age, sex, BMI, smoking status, physical activity, alcohol intake, income, and hyperthyroidism.

Results

After a median [IQR] follow-up of 21 [18–22] years, 6 301 participants were hospitalised with AF. Non-linear associations were observed for total flavonoid intake and for all flavonoid sub-classes. For total flavonoid intake, after adjusting for potential lifestyle confounders and compared to participants in quintile 1 (median intake: 173 mg/day), those in quintile 3 (median intake: 320 mg/day) and quintile 4 (median intake: 494 mg/day) had a significantly lower risk of AF, with hazard ratios (95% CI) of 0.93 (0.87, 0.99) and 0.92 (0.86, 0.98), respectively. Compared to median intake in the lowest quintile, a total flavonoid intake of 1000 mg/day was associated with a lower risk of AF in smokers [0.86 (0.77, 0.96)] but not in non-smokers [0.96 (0.88, 1.05)], a lower risk of AF in high alcohol consumers [>20 g/d: 0.84 (0.75, 0.94)] but not in low-to-moderate alcohol consumers [<20 g/d: 0.97 (0.89, 1.06], a trending lower risk of AF in diabetics [0.76 (0.51, 1.14)] but not in non-diabetics [0.95 (0.89, 1.02)], and a trending lower risk of AF in those with ischaemic heart disease [0.84 (0.65, 1.09)] but not in those without [0.96 (0.89, 1.03), Figure 1].

Figure 1

Conclusion

We observed an inverse association between total flavonoid intake and AF, most notably in sub-populations with known lifestyle and disease risk factors for AF. This finding warrants investigation in randomised controlled trials. If confirmed, ensuring the adequate consumption of flavonoid-rich foods, particularly in individuals “at risk”, may be an important strategy to mitigate AF risk.

Acknowledgement/Funding

The Danish Diet, Cancer, and Health Study was funded by the Danish Cancer Society.

P4765Men who live alone have poor anticoagulation control: results from Danish registries

Background

Efficacy and safety of vitamin K antagonists (VKAs) depend on quality of anticoagulation control, usually measured as time in therapeutic range (TTR). Factors that predict low TTR on VKAs could be used to identify patients who might benefit from interventions, or who would be better treated with a non-VKA oral anticoagulant (NOAC). Patients living alone may have difficulties in taking their medications, managing their diets, or coming to clinic for monitoring.

Purpose

To assess influence of cohabitation status on TTR with VKA among men and women.

Methods

We identified all Danish patients with atrial fibrillation (AF) who initiated VKA between 1997 and 2012, and studied patients who had 6 months of continuous VKA use and international normalized ratio (INR) monitoring. Patients were divided according to sex and whether they lived alone or with others. We calculated TTR using the Rosendaal method, and INR variability using Fihns method. We used a linear regression model to test for associations between TTR and covariates, and adjusted for age, income, medications and comorbidities.

Results

We identified 4,772 AF patients with 6 months of continuous VKA use and INR monitoring. 713 (15%) were men living alone, 1,073 (23%) were women living alone, 2,164 (45%) were men not living alone and 822 (17%) were women not living alone. INR was measured a median of 11 (interquartile range 8–15) times during the 180 days of VKA use, but men who lived alone had 0.6 (95% confidence interval (CI): 0.2 to 1.2) fewer INR measurements during the period. Median TTR was lowest among men living alone (57.2%), followed by women living alone (58.8%), women not living alone (61.0%) and men not living alone (62.5%). After multivariable adjustment, men who lived alone had a 3.6% (CI −5.6 to −1.6) lower TTR compared with men not living alone, but women who lived alone did not have significantly lower TTR (P=0.80) compared with women not living alone. Living alone had significantly greater effect on TTR among men than among women (interaction P=0.02). Men living alone also had higher adjusted INR variability (0.2, CI 0.0 to 0.4) compared with men not living alone.

Conclusion

Living alone was significantly related to low quality of anticoagulation control among men, but not among women.

Acknowledgement/Funding

this study was funded by an unrestricted grant from the Capital Region of Denmark, Foundation for Health Research

3154The incidence of atrial fibrillation continues to increase across all socioeconomic subgroups: 30-year time trends from a Nationwide cohort

Introduction

The incidence rate of atrial fibrillation (AF) has increased substantially throughout the last decades. Socioeconomic factors such as income and education are well known to be associated with the development of cardiovascular disease, however, the impact on long-term trends of AF incidence rates is yet to be described.

Purpose

This nationwide cohort study examined the temporal trends of AF incidence rates over a span of 30 years (from 1987 to 2016) in Denmark. Furthermore, the impact of income and education was outlined.

Method

Patients were identified through linkage across Danish national registries from 1987 to 2016. We extracted data on the total number of inhabitants in Denmark aged ≥18 years, and used their age, sex, civil status, income and educational level for each calendar year. Data on socio economics were available from 1994. Income was defined by the average income over the prior 5 years and grouped into low (&lt;q1),&gt;Q3). Educational level was divided into primary school, high school, bachelor's degree, or master's degree. We defined incident AF as all first-time in- and outpatient diagnoses of AF. The incidence rates of AF were age-standardized per 1000 person-years for each calendar year and calculated for men and women separately.

Results

A total of 6,968,997 Danish inhabitants aged ≥18 years contributed to the study population from 1987 to 2016, and 393,183 (6%) developed AF over the study period. The age-standardized incidence rates of AF per 1000 person-years increased from 1.23 (CI 1.15:1.30) to 4.05 (CI 3.93:4.17) for men and from 1.13 (CI 1.06:1.30) to 3.56 (CI 3.44:3.68) for women from 1987 to 2016. Income status and educational level influenced the age-standardized incidence rates more significantly in women than men. The incidence rate from 1994 to 2016 for women with low income increased by a factor of 2.1 from 2.0 (CI 1.89:2.21) to 4.36 (CI 4.03:4.73). However, the high income group increased by a factor of 1.6 (from 1.74 (CI 1.10:3.32) to 2.83 (CI 2.29:3.55) per 1000 person-years). Moreover, the incidence rate for women with low educational level increased from 1.60 (CI 0.95:5.97) to 4.01 (CI 3.80:4.23) per 1000 person-years. The high educational group increased only by 1.2 (from 2.55 (CI 0.77:10.38) to 3.1 (CI 3.32:4.11) per 1000 person-years).

Conclusion

In a nationwide population, the incidence rate of AF continued to increase during a 30-year period. All socioeconomic subgroups experienced an increase in AF incidence, but the impact of low socioeconomic status was more significant among women than among men. The progressive growth in AF incidence has significant public health implications.

Acknowledgement/Funding

Danish Heart Foundation

P623Regional Longitudinal Strain for Prediction of Left Ventricular Thrombus Formation following Acute Myocardial Infarction

Background

Left ventricular thrombus (LVT) formation is a dangerous complication to acute myocardial infarction (MI).

Purpose

We hypothesized that regional strain impairment was predictive of LVT formation.

Methods

We included 373 prospectively enrolled patients with ST-segment elevation MI treated with primary percutaneous intervention. All patients had an echocardiogram performed a median of 2 days post-MI. Using logistic regression, we investigated the predictive value of left ventricular (LV) speckle tracking, conventional echocardiographic measures and well-known echocardiographic features of LVT formation including LV smoke, aneurysm and valvular regurgitations.

Results

Overall, the mean age was 62 years, 75% were male, 5% had prior MI, and 48% had anterior infarcts. Mean LVEF was 46% and absolute global longitudinal strain (GLS) was 12%.

Of 373 patients, 31 (8%) developed LVT in follow-up echocardiograms. Patients with LVT more frequently had anterior infarcts, prior MI, lower LVEF, lower e', lower GLS and regional strain, and these were all univariable predictors of LVT formation.

In multivariable analysis (including anterior infarcts, prior MI, LVEF, e'), GLS and regional strain remained independent predictors of LVT formation (GLS: OR: 1.17 [1.00; 1.36], midventricular strain: OR: 1.19 [1.03; 1.38], apical strain: 1.12 [1.00; 1.25], p<0.05 for all) (figure)

In a combined diagnostic model, including anterior infarct, impaired LVEF (<42%) and apical strain (<8%), the sensitivity and negative predictive value was 100%, with a specificity and positive predictive value of 38 and 13%, respectively.

Regional strain and risk of LVT

Conclusion

In MI patients, anterior infarct, LVEF and apical strain were strong predictors of LVT formation. Reduced apical strain indicates a markedly increased LVT risk.