Impact of right and left ventricular dysfunction on long-term outcome of moderate to severe secondary mitral regurgitation patients without surgical/interventional treatment

Background

Secondary mitral regurgitation (SMR) is common in aging population and related with poor outcome. Impact of right ventricular (RV) dysfunction with or without left ventricular (LV) dysfunction in this population remains unclear. The purpose of this study was to investigate the prevalence of isolated RV dysfunction and biventricular dysfunction, and to determine their prognostic implication in moderate to severe SMR without surgical/interventional treatment.

Methods

A total of 1090 consecutive moderate to severe SMR patients without surgical/interventional treatment hospitalized in our hospital center between 2009 and 2018 (aged 75±12 years, 60.4% male) were included. Transthoracic echocardiography was performed at baseline to define the cardiac morphology, function and severity of MR. Clinical and echocardiographic characteristics were analyzed. All patients completed at least 1-year clinical follow-up by reviewing the medical records or telephone interview. The primary endpoint was defined as all-cause death.

Results

A total of 521 patients (47.8%) reached the primary endpoint during the follow-up period [median 23 (8–40) months].

Mean left ventricular ejection fraction (LVEF) was 44.6±16.2%, and percent of patients with LVEF <50% (LV dysfunction) was 59.3%. RV dysfunction was defined as a reduced tricuspid annular plane excursion (TAPSE<17mm) or an increased systolic pulmonary artery disease (sPAP>40mmHg). Patients were divided into 4 subgroups: 1) preserved biventricular function: n=136 (12.5%); 2) isolated LV dysfunction: n=97 (8.9%); 3) isolated RV dysfunction: n=308 (28.3%); 4) biventricular dysfunction: n=549 (50.4%). The mortality in above group was 27.2%, 36.1%, 50.0%*† and 53.7%*†, respectively (*P<0.05 vs preserved biventricular function; †P<0.05 vs. isolated LV dysfunction).

Multivariable survival analysis showed that isolated LV dysfunction (adjusted HR 1.78, P=0.016), isolated RV dysfunction (HR 1.59, P=0.013), or biventricular dysfunction (HR=2.14, P<0.001) were independently associated with increased all-cause mortality, after adjustment for age, sex and other clinical covariates associated with mortality including NYHA class, atrial fibrillation, hypertension, diabetes, hyperuricemia, coronary artery diseases, chronic respiratory diseases, sleep disturbance, and kidney dysfunction.

Conclusions

Right ventricular dysfunction is associated with significantly higher mortality in patients with secondary mitral regurgitation without surgical/interventional treatment as compared to patients with preserved biventricular function and isolated LV dysfunction. Future studies are warranted to observe if operative strategy could significantly improve the outcome in SMR patients complicating with right ventricular dysfunction.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research

Septal mitral annular systolic excursion but not global longitudinal strain predicts outcome in non-ischemic heart failure patients with reduced ejection fraction and mild diastolic dysfunction

Background

Speckle tracking derived global longitudinal strain (GLS) could provide incremental prognostic information over left ventricular ejection fraction (LVEF) in the general population and a variety of cardiovascular diseases. Mitral annular systolic excursion (MAPSE) is a classical echocardiographic index with prognostic implication in patients with various cardiovascular diseases. Present study aimed to test the hypothesis that reduced GLS is superior to MAPSE on predicting all-cause mortality in non-ischemic heart failure patients with reduced ejection fraction.

Methods

A total of 952 patients with non-ischemic heart failure and reduced LVEF, who referred to our department between 2009 and 2017, were included in this study (mean age: 66±15 years, 68.8% male). All patients underwent a routine transthoracic echocardiography examination at baseline visit. Standard echocardiographic measurements were conducted according to recent guidelines. GLS was derived from the segmental averaging (18-segment) of the three apical views. M-mode MAPSE of septal and lateral walls were obtained from standard apical 4-chamber view. All patients completed at least one-year clinical follow-up by telephone interview or clinical visit. The primary endpoint was defined as all-cause mortality or heart transplantation (HTx).

Results

Over a median follow-up period of 27 (14–40) months, 259 (27.2%) patients died and 9 (0.9%) underwent HTx. MAPSE_septal was significantly lower in non-survivors than in survivors (6 (5–8) vs. 7 (5–8) mm, P=0.009), while LVEF (36% vs. 36%, P=0.927) and GLS (−9.6% vs. −9.8%, P=0.473) were similar between non-survivors and survivors. All-cause mortality was significant higher in patients with MAPSE_septal<5mm than those with MAPSE_septal ≥5mm (34.9% vs. 26.7%, P=0.032). All-cause death increased in proportion with increased severity of diastolic dysfunction (DD, 20.4%, 29.6% and 34.0% in patients with mild, moderate and severe DD, P=0.002).

Multivariable Cox regression analysis showed that reduced MAPSE_septal (<5mm, HR=1.451, 95% CI=1.079–1.951, P=0.014) was independently associated with increased all-cause mortality adjusted for clinical confounders including age, sex, NYHA class, atrial fibrillation, diabetes, hyperuricemia, chronic respiratory diseases, sleep disturbance, while MAPSE_lateral, LVEF, and GLS were not outcome determinants in this patient cohort.

Subgroup analysis showed that mild DD (n=269), reduced MAPSE_septal were significantly associated with increased all-cause mortality (adjusted HR=3.734, 95% CI=1.850–7.536, P<0.001), while MAPSE_septal was not a risk factor of all-cause mortality in the subgroup of moderate to severe DD (n=667, HR=1.314, P=0.108).

Conclusions

Septal MAPSE, but not LVEF or GLS, serves as an independent determinant of all-cause mortality in non-ischemic heart failure patients with reduced LVEF and mild diastolic dysfunction.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research

Severe fever with thrombocytopenia syndrome virus: a systematic review and meta-analysis of transmission mode

Severe fever with thrombocytopenia syndrome (SFTS) is a disease with a high case-fatality rate that is caused by infection with the SFTS virus (SFTSV). Five electronic databases were systematically searched to identify relevant articles published from 1 January 2011 to 1 December 2019. The pooled rates with 95% confidence interval (CI) were calculated by a fixed-effect or random-effect model analysis. The results showed that 92 articles were included in this meta-analysis. For the confirmed SFTS cases, the case-fatality rate was 0.15 (95% CI 0.11, 0.18). Two hundred and ninety-six of 1384 SFTS patients indicated that they had been bitten by ticks and the biting rate was 0.21 (95% CI 0.16, 0.26). The overall pooled seroprevalence of SFTSV antibodies among the healthy population was 0.04 (95% CI 0.03, 0.05). For the overall seroprevalence of SFTSV in animals, the seroprevalence of SFTSV was 0.25 (95% CI 0.20, 0.29). The infection rate of SFTSV in ticks was 0.08 (95% CI 0.05, 0.11). In conclusion, ticks can serve as transmitting vectors of SFTSVs and reservoir hosts. Animals can be infected by tick bites, and as a reservoir host, SFTSV circulates continuously between animals and ticks in nature. Humans are infected by tick bites and direct contact with patient secretions.

Comparison of the Total, Diazotrophic and Ammonia-Oxidizing Bacterial Communities Between Under Organic and Conventional Greenhouse Farming

Organic greenhouse farming is an innovative system that may maintain a high yield and healthy agroecosystem. There have been no rigorous studies on the comparison of total and nitrogen-cycling bacterial community in vegetable soils between organic and conventional farming management at large scale. A survey of bacterial community and nitrogen cycles from soils under organic and conventional greenhouse farming was performed at 30 sites, covering seven soil types with 4 to 18 years of organic farming history. Communities of the total, diazotrophs and ammonia-oxidizing bacteria were studied with high-throughput sequencing of the 16S rRNA, nifH and amoA genes, respectively. Organic greenhouse farming did not influence alpha diversities. Beta diversities among the total (26/30) and diazotrophic (17/19) bacteria differed between farming systems, but compositional differences in ammonia-oxidizing bacteria between the two farming systems were only detected at 6 sites. Despite the effects of farming system on most bacterial genera were varied across different sites, organic greenhouse farming persistently selected for a few genera, possibly for the biodegradation of organic carbon with high molecular weight (Hyphomicrobium, Rubinisphaera, Aciditerrimonas, Planifilum, Phaselicystis, and Ohtaekwangia), but against putative ammonia oxidizing (Nitrosospira, Nitrosopumilus) and diazotrophic (Bradyrhizobium) bacterial genera, as determined by 16S rRNA analysis. Diazotrophic bacteria affiliated with nifH cluster 1J were preferentially associated with organic greenhouse farming, in contrast to Paenibacillus borealis. In summary, this study provides insights into the complex effects of organic greenhouse farming on the total, diazotrophic and ammonia oxidizing bacterial communities across different environmental context.

1141 Daytime Napping Trajectory Over Time And Its Association With Cognitive Aging: A 13-year Community-based Longitudinal Study Of Older Adults

Introduction

Daytime napping is common in elderly adults and has been associated with cognitive impairment. Prior studies have assessed napping at one time point, making it difficult to examine the longitudinal progression of napping and its association with cognitive aging. We examined objectively measured daytime napping longitudinally across different stages of Alzheimer’s disease (AD): from no cognitive impairment (NCI), to mild cognitive impairment (MCI), and to Alzheimer’s dementia.

Methods

We studied 1,066 participants (female: 810; age: 81.0±7.3 [SD]) in the Rush Memory and Aging Project who have been followed for up to 13 years. Motor activities of up to 10 days were recorded annually and used to assess napping objectively. We defined daytime napping episodes as segments between 10AM and 7PM with continuous zero-activity for ≥10min but <1h (to avoid off-wrist periods). Segments that were <5min apart were merged. Cognitive and clinical evaluations were administered annually to render a clinical diagnostic classification of NCI, MCI, or Alzheimer’s dementia. To examine how napping duration and frequency change with the progression of AD, we performed linear mixed-effects models with 2 change points anchored at the diagnoses of MCI and AD while adjusted for age, sex, and education.

Results

At baseline, participants had 1.44±0.04 (mean±standard error) naps with an accumulated duration of 35.0±1.1 min per day. Napping duration increased by 5.2±0.3 min and frequency increased by 0.21±0.01 times every year (both p<0.0001). The rate of increase was more than doubled after MCI diagnosis with an annual increase of 11.4±0.7 min in duration and 0.40±0.02 times in frequency (both p<0.0001); these were doubled further after AD diagnosis with an annual change of 26.3±3.1 min in duration and 0.84±0.08 times in frequency (both p<0.0001).

Conclusion

Daytime napping duration and frequency increase with aging, and the increase was accelerated with AD progression.

Support

This work was supported by NIH grants RF1AG064312, RF1AG059867, R01AG017917, and R01AG56352.

1159 Sleep Traits And Incident Delirium During A Decade Of Follow-up In 173,000 Participants

Introduction

Delirium is an acute decline in attention and cognition that is with associated long-term cognitive dysfunction in elderly patients. Accumulating evidence points to strong associations between sleep health and disorders of the brain. We tested whether baseline sleep duration, chronotype, daytime dozing, insomnia or sleep apnea predict incident delirium during hospitalization.

Methods

We studied participants from the UK Biobank who have been followed for up to 10 years until 2017. We included 173,221 participants (mean age 60±5; range 50-71 at baseline) who had at least one episode of hospitalization/surgery and were free from prior episodes of delirium. Delirium diagnosis, hospitalization and surgical events were derived using ICD-10 coding. Multivariate logistic regression models were performed to examine the associations of self-reported baseline sleep duration (<6hrs/6-9h/>9h), daytime dozing (often/rarely), insomnia (often/rarely) and presence of sleep apnea (ICD-10 and self-report) with incident delirium during follow-up. Models were adjusted for demographics, education, Townsend deprivation index, and major confounders (number of hospitalizations/surgical procedures, BMI, diabetes, major cardiovascular diseases and risk factors, major neurological diseases, major respiratory diseases, cancer, alcohol, depression/anxiety, sedatives/sleep aides, antipsychotics, steroids and opioids).

Results

In total, 1,023 (5.7 per 1,000 subjects) developed delirium. A prior diagnosis of sleep apnea (n=1,294) saw almost a two-fold increased odds (OR 1.96, 95% CI: 1.30-2.30 p=0.001) while those who often had daytime dozing were also at increased risk (OR 1.35, 95% CI: 1.02-1.80, p=0.025). Both these effects were independent of each other. No independent effects on incident delirium were observed from sleep duration, insomnia, or chronotype.

Conclusion

Certain sleep disturbances, in particular sleep apnea and daytime dozing, are independently associated with an increased risk for developing delirium. Further work is warranted to examine underlying mechanisms and to test whether optimizing sleep health can reduce the risk of developing delirium.

Support

This work was supported by NIH grants T32GM007592, RF1AG064312, and RF1AG059867.

0032 Timing of Daily Rhythm of Cardiac Autonomic Control Contributes to Weight Loss Resistance, Independent of Daily Energy Intake and Physical Activity Level

Introduction

Obesity is a major health problem. Many treatments have been designed to help overweight/obese people to lose weight, but their effectiveness is highly variable. The same treatments may work for some persons while others have no responses — weight loss resistance. We tested whether the daily rhythm of cardiac autonomic control contributes to weight loss resistance.

Methods

We studied 39 overweight/obese Caucasian women (BMI>25; age: 21–62 years old) who completed (1) an obesity dietary treatment of up to 30 weeks with weekly assessments of body weight, and (2) ambulatory monitoring of electrocardiogram (ECG) for up to 3.5 days. Heartbeat intervals were derived from ECG. Cardiac autonomic control was assessed in each 1-h bin by examining the temporal correlation in heartbeat fluctuations — a nonlinear measure that quantifies the delicate dynamic interplay between sympathetic and vagal outflows. Daily rhythm was estimated using the cosinor analysis.

Results

Weight loss was highly variable (range: 0.68%-21.78 % of initial body weight). The correlation in heartbeat fluctuations displayed a 24-h rhythm (p<0.0001) with fewer correlations (more random) during the nighttime. The phase (peak timing) of the rhythm was highly variable, i.e., 10AM to 8PM for most participants, and after midnight in four participants. Weight loss evolution depended on the phase (p=0.006) in a nonlinear manner. Specifically, participants with the phase between 2PM-8PM lost weight faster than those with phases before 2PM and those after 8PM. The effect was independent of total energy intake, physical activity level, and sleep/wake schedules.

Conclusion

Cardiac autonomic control in overweight/obese women displayed a daily rhythm. The timing of the rhythm had previously un-identified contributions to weight loss. The inter-individual differences in the timing may reflect different circadian regulation of autonomic function and its interaction with the daily behavioral cycle.

Support

This work was supported by NIH grants R01AG048108, RF1AG059867, RF1AG064312, R01AG017917, and R01NS078009.

1135 Longer And More Frequent Naps Predict Incident Alzheimer’s Dementia In Community-based Older Adults

Introduction

Excessive napping duration has been associated with cognitive decline. The effect of napping frequency is less understood, and little is known about the development of Alzheimer’s dementia associated with napping. We tested whether longer or more frequent naps in the elderly are linked to the development of incident Alzheimer’s dementia.

Methods

We studied 1,180 older adults (age: 81.0±7.3 [SD]) in the Rush Memory and Aging Project who have been followed for up to 14 years. Motor activities of up to 10 days were recorded at baseline to assess napping characteristics objectively. We defined daytime napping episodes as motor activity segments between 10AM and 7PM with continuous zero-activity for ≥10min but <1h (to avoid off-wrist periods). Segments that were <5min apart were merged. Alzheimer’s dementia diagnosis was determined using the criteria of the National Institute of Neurological and Communicative Disorders and Strone and the Alzheimer’s Disease and Related Disorders Association. Cox proportional hazards models were performed to examine the associations of daily napping duration and frequency with incident AD.

Results

Of 1,180 non-demented participants at baseline (including 264 with mild cognitive impairment), 277 developed Alzheimer’s dementia within 5.74±3.36 years. On average, participants napped for 38.3±1.0 (SE) min and1.56±0.04 (SE) times per day at baseline. After adjustment for age, sex, and education, every 30-min increase in daily napping duration was associated with a 20% increase in the risk of incident AD (95% confidence interval [CI]: 9%-31%; p=0.0002). One more nap per day was associated with a 19% increase in the risk of AD (95% CI: 8%-30%; p=0.0003). These associations remained after further adjustment for total sleep time.

Conclusion

Longer and more frequent daytime naps predict a higher risk of incident Alzheimer’s dementia. Future studies are needed to examine specific underlying mechanisms.

Support

This work was supported by NIH grants RF1AG064312, RF1AG059867, R01AG017917, and R01AG56352.

0259 Shiftworkers are at Increased Risk of Developing Chronic Pain and Opioid Use Disorders: A Study of 116,000 UK Biobank Participants Over a Decade

Introduction

In the current epidemic of opioid-related deaths, and widespread use of opioids to treat chronic pain, there is a pressing need to understand the underlying risk factors that contribute to such devastating conditions. Shiftwork has been associated with adverse health outcomes. We tested whether shiftwork during middle age is linked to the development of chronic pain and opioid misuse.

Methods

We studied 116,474 participants in active employment between 2006–2010 (mean age 57±8; range 37–71) from the UK Biobank, who have been followed for up to 10 years until 2017. We included participants who were free from all forms of self-reported pain, and were not taking opioid medications at baseline. Chronic pain and opioid use disorder diagnoses were determined using hospitalization records and diagnostic coding from ICD-10. Multivariate logistic regression models were performed to examine the associations of shiftwork status (yes/no) and nightshift frequency (none/occasional/permanent) and with incident chronic pain and/or opioid use disorder during follow-up. Models were adjusted for demographics, education, Townsend deprivation index, major confounders (BMI, diabetes, bone fractures/injuries, operations, peripheral vascular disease, joint/inflammatory diseases, cancer, standing/manual labor at work) and covariates (smoking, alcohol, high cholesterol, depression/anxiety, and cardiovascular diseases).

Results

In total, 190 (1.6/1,000) developed chronic pain or opioid use disorders. Shiftworkers (n=17,673) saw a 1.5-fold increased risk (OR 1.56, 95% CI: 1.08–2.24, p=0.01) relative to day workers. Within shiftworkers, those who reported occasional nightshift work (n=3,966) were most vulnerable (OR 1.57, 95% CI: 1.06–2.34, p=0.02). Results remained similar after adjusting for baseline sleep duration, chronotype and insomnia.

Conclusion

Shiftwork, and in particular rotating nightshift work is associated with increased risk for developing chronic pain and opioid use disorders. Replication is required to confirm the findings and to examine underlying mechanisms.

Support

This work was supported by NIH grants T32GM007592, RF1AG064312, and RF1AG059867.

Paracetamol for patent ductus arteriosus in preterm infants: a UK national survey

Introduction: Evidence is emerging that paracetamol is a safe and effective alternative therapy for haemodynamically significant patent ductus arteriosus (hsPDA). Although there is no consensus opinion on its routine use for PDA in preterm infants, paracetamol is being used increasingly in many centres to treat hsPDA.Objective: We conducted a national survey to review the current practice in the UK and the prevalence of paracetamol use for hsPDA closure in preterm infants.Method: A web-based and telephone survey on the use of paracetamol for hsPDA closure in preterm infants was conducted. All neonatal intensive care and local neonatal units across the UK were contacted between May and August 2018.Results: 98% (143/146) neonatal units responded. The first-line medication for hsPDA closure was ibuprofen in 92% (131/143) units. 33% (47/143) of units used paracetamol; three units used it as first-line. The dose and duration of paracetamol varied greatly among the units with a dose of 15 mg/kg 6 hourly in 62% (29/47) units and a duration of 3 and 5 days in 33% (14/42) and 31% (13/42) of units, respectively. 44% (19/43) of units did routine blood investigations using paracetamol for monitoring patients on treatment and 21% (9/43) took paracetamol level in addition to other tests.Conclusion: 33% of the neonatal units across the UK offered paracetamol to treat hsPDA in preterm infants. Currently, there is a variation in practice regarding the dose, duration of paracetamol and monitoring of infants during its use for hsPDA closure. One strategy would be to develop national guidance once strong evidence is established to support its routine use for hsPDA in preterm infants.

[Effectiveness evaluation of health belief model-based health education intervention for patients with hypertension in community settings]

Objective: To evaluate the effectiveness of health belief model-based health education intervention in improving blood pressure control of patients with hypertension in community settings. Methods: From September 2016 to September 2017, 400 newly diagnosed patients with hypertension were recruited from 6 community healthcare centers with comparable population size and health services in the Shunyi District of Beijing. All community healthcare centers were randomly assigned to the intervention group (206 patients) and the control group (194 patients). Patients in the intervention group received 3 lectures (20-30 min for each) of health belief model-based health education. Patients in the control group received usual care. The basic characteristics, health beliefs, and health literacy were collected, and blood pressure was measured before and after the intervention, respectively. The difference-in-difference model was used to analyze the change of blood pressure and the influencing factors between two groups before and after the intervention. Results: A total of 134 patients in the intervention group and 129 patients in the control group completed the study. After adjusting for the age, gender, family income, medical insurance, chronic diseases and family history, the score of perceived barriers was increased by 1.65 (P=0.016), and perceived seriousness was decreased by 0.73 (P=0.018). The systolic blood pressure of patients was decreased by 7.37 mmHg (1 mmHg=0.133 kPa, P=0.001) and diastolic blood pressure was decreased by 4.07 mmHg (P=0.014), respectively. The β (95%CI) values were -7.37 (-11.88,-2.86) and -4.07 (-7.30, -0.84). The perceived susceptibility and self-efficacy had a significant influence on the blood pressure of patients (P<0.05). Conclusion: Health belief model-based health education intervention could significantly improve the blood pressure control of patients with hypertension in the community settings.

161 Impact of right ventricular dysfunction on outcome in heart failure patients with mid-range ejection fraction with and without chronic respiratory diseases

Background

The impact of right ventricular (RV) dysfunction on outcome of heart failure patients with mid-range left ventricular ejection fraction (HFmrEF, 40-49%) is not well characterized yet. In this study, we observed the association between echocardiography defined RV dysfunction with outcomes and if the outcome was jointly affected by co-existed chronic respiratory diseases (CRD: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome) in HFmrEF patients

Methods

1090 HFmrEF patients referred to our department between 2009 and 2017 were included in this study. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (15-38) months. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed with the use of multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

Mean age was 69 ± 13 years and 73.4% were male. The proportion of NYHA functional class III or IV was 24.8%. CRD was identified in 209 (19.2%) patients. 280 patients (25.7%, without CRD: 204, with CRD: 76) died and 2 patients (without CRD) underwent HTx. All-cause mortality/HTx was significantly higher in HFmrEF patients with CRD than without CRD (36.4% vs. 23.4%, P &lt; 0.001).

Besides CRD, Cox regression analysis showed that age, body mass index, and cardiac risk factors and comorbidities including diabetes, atrial fibrillation, dyslipidemia, coronary artery disease, kidney dysfunction (eGFR &lt;60ml/min/1.73qm), anemia were associated with increased all-cause mortality/HTx (all P &lt; 0.05). Multivariable Cox regression models showed that sPAP (HR 1.015, P = 0.002) and TAPSE (HR 0.962, P = 0.004) were independent determinants of all-cause mortality/HTx in patients without CRD, while sPAP served as independent determinant of all-cause mortality/HTx In patients with CRD (HR 1.018, P = 0.026) after adjusted for above mentioned confounders.

Patients without CRDs were further grouped into those with normal (sPAP ≤ 40mmHg and TAPSE≥14mm, n = 513); mild to moderate (sPAP &gt; 40mmHg or TAPSE &lt; 14mm, n = 387) and severe RV dysfunction (sPAP &gt; 40mmHg and TAPSE &lt; 14mm, n = 88). Severe RV dysfunction was independently associated with a 2-fold increased all-cause mortality/HTx as compared to normal RV function (HR 2.209, 95% CI 1.455-3.355, P &lt; 0.001).

Conclusions

Increased sPAP and reduced TAPSE are independent determinants of all-cause mortality in HFmrEF patients without CRD, and sPAP is an independent determinant of all-cause mortality in HFmrEF patients with CRD. Moreover, HFmrEF patients with severe RV dysfunction face a 2-fold increased all-cause mortality, as compared to patients with normal RV function and no CRD.

P904 Impact of significant functional mitral regurgitation and aortic stenosis on outcome of HFrEF patients

Background

Concomitant aortic stenosis (AS) and functional mitral regurgitation (FMR) are common in patients with left ventricular dysfunction. We evaluated the impact of significant valve diseases on outcome of patients with reduced left ventricular ejection fraction (HFrEF, LVEF &lt; 40%).

Methods

A total of 1264 consecutive HFrEF patients referred to our department between 2009 and 2017 were screened. Transthoracic echocardiography was performed at baseline visit in all patients. Patients with primary MR or received mitral valve operation before or after baseline visit (n = 64) as well as patients underwent aortic valve replacement (AVR) before baseline visit (n = 66) were excluded. Finally, 1134 HFrEF patients were included for final analysis, and all completed a median clinical follow-up of 26 (12-40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx).

Results

Moderate or severe FMR or AS was detected in 902 (79.5%) and in 119 (10.5%) patients by echocardiography, respectively. Of patients with significant AS, 47 patients underwent AVR shortly after baseline visit. In total, 353 (31.2%, including HTx n = 11) HFrEF patients died or underwent HTx during follow-up.

Age, body mass index, diabetes, atrial fibrillation, coronary artery disease, chronic respiratory diseases, and renal dysfunction (all P &lt; 0.05) were defined as clinical covariates associated with all-cause mortality/HTx and served as potential confounders in the multivariable Cox regression models. All-cause mortality/HTx was significantly higher in HFrEF patients with significant FMR than patients without significant FMR (33.8% vs. 20.7%, P &lt; 0.001).

Multivariable Cox regression analysis showed significant FMR remained as an independent determinant of all-cause mortality/HTx in patients with HFrEF after adjusted for above mentioned confounders (HR 1.39, 95% CI 1.02-1.90, P = 0.035).

Patients with significant AS without AVR faced increased risk of all-cause mortality/HTx as compared to patients without significant AS (HR 2.34, P &lt; 0.001), while risk of all-cause mortality/HTx was significantly lower in patients with significant AS and underwent AVR as compared to patients without significant AS after adjustment for confounders (HR 0.36, P = 0.008).

In the subgroup of HFrEF patients with significant FMR, significant AS without AVR was independently associated with increased all-cause mortality/HTx as compared to patients without significant AS (HR 2.30, P &lt; 0.001), while outcome is better in AS and FMR patients underwent AVR as compared to patients with significant FMR and without significant AS (survival: 85.4% vs. 67.5%, P &lt; 0.001; HR 0.34, P = 0.010) after adjustment for potential confounding factors.

Conclusion

Moderate to severe FMR and/or AS is incrementally related to higher all-cause mortality/HTx in HFrEF patients. AVR could significantly improve the survival of HFrEF patients with concomitant significant AS and FMR.

P1751 Right ventricular dysfunction in heart failure patients with reduced ejection fraction with and without chronic respiratory diseases: A treacherous combination for the ominous outcome?

Background

Right ventricular (RV) dysfunction is common in heart failure patients. In the present study, we determined the impact of echocardiography defined RV dysfunction on outcomes in heart failure patients with reduced ejection fraction (&lt;40%, HFrEF) with and without chronic respiratory diseases (CRDs: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome).

Methods

A total of 1264 HFrEF patients (Mean age: 68 ± 13 years; male: 76.3%) referred to our department between 2009 and 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (12-40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed by multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

The proportion of NYHA functional class III-IV was 42.2%. Mean LVEF was 29.4 ± 7.0%. CRDs was identified in 276 (21.8%) patients, 399 (30.5%, without CRDs n = 290, with CRDs n = 109) patients died (n = 386) or underwent HTx (n = 13). All-cause mortality/HTx was significantly higher in HFrEF patients with CRDs than without CRDs (39.5% vs. 29.4%, P = 0.001).

Cox regression analysis showed that age, BMI, and other cardiac risk factors and comorbidities including diabetes, atrial fibrillation, coronary artery disease, kidney dysfunction, and anemia were associated with all-cause mortality/HTx (all P &lt; 0.05) besides CRDs. Multivariable Cox regression models showed that sPAP (HR 1.016, P &lt; 0.001), TAPSE (HR 0.964, P = 0.003), RAA (HR 1.030, P &lt; 0.001), and RVD (HR 1.029, P &lt; 0.001) were independent determinants of all-cause mortality/HTx in HFrEF patients without CRDs, but not in HFrEF patients with CRDs after adjusted for above mentioned confounders.

With the cut-off values (sPAP &gt; 40mmHg, TAPSE &lt; 12mm, RAA &gt; 25cm², and RVD &gt; 36mm) derived from the 3rd quartiles, patients without CRDs were further grouped as normal RV function (all 4 parameters normal, n = 427); mild to moderate RV dysfunction (1 or 2 parameters abnormal, n = 467) and severe RV dysfunction (≥3 parameters abnormal, n = 94). Risk of all-cause mortality/HTx was significantly higher in HFrEF patients with severe (51.1%) and mild to moderate RV dysfunction (34.7%) as compared to patients with normal RV function (18.7%, severe vs. normal: HR 1.616 , 95% CI 1.232-2.119, P = 0.001; mild to moderate vs. normal HR: 2.657, 95% CI 1.845-3.824, P &lt; 0.001).

Conclusions

RV dysfunction is significantly associated with increased all-cause mortality in HFrEF patients without CRDs. Increased sPAP, RAA, RVD and decreased TAPSE are independent determinants of worse outcomes in HFrEF patients without CRDs, but not in HFrEF patients with CRDs.

MicroRNA-411 plays a protective role in diabetic retinopathy through targeted regulating Robo4

OBJECTIVE

The aim of this study was to explore the role of microRNA-411 in diabetic retinopathy (DR) and to further understand its mechanism of action.

MATERIALS AND METHODS

A rat model of diabetes (20 in the DM group) and a normal control group (20 in the control group) was established. The changes in blood glucose and body weight were compared between the two groups. At the same time, the expression changes in microRNA-411 and Roundabout 4 (ROBO4) in the two groups of rats were detected. The biological prediction of the potential binding sites of ROBO4 and microRNA-411 was verified by the Dual-Luciferase reporter gene assay, and the regulatory relationship of microRNA-411 to ROBO4 was verified in human retinal pigment epithelial cells (ARPE-19). Meanwhile, we investigated the effects of high glucose and hypoxia on the viability of ARPE-19 cells and explored whether microRNA-411 has a regulatory role in the effects. Finally, a cell reverse experiment was designed to verify whether microRNA-411 functions through ROBO4.

RESULTS

Compared with the NC group, the blood glucose of the DM group was significantly increased while the body weight was reduced. In addition, the expression level of microRNA-411 was markedly decreased in diabetic rats, and the mRNA and protein levels of ROBO4 were notably increased, which were all dependent on time. Biological prediction revealed that ROBO4 might be a potential target gene of microRNA-411, and the results of the Dual-Luciferase reporter gene assay confirmed that there is a binding relationship between them; meanwhile, microRNA-411 was proved to be able to inhibit the expression level of ROBO4 in vivo and in vitro. Both high glucose and hypoxia could inhibit the proliferation of ARPE-19 cells and increase the monolayer permeability. Additionally, up-regulation of microRNA-411 or down-regulation of ROBO4 could partially reverse this phenomenon. Cell reverse experiment showed that overexpression of ROBO4 partially reversed the protective effect of microRNA-411 on DR.

CONCLUSIONS

MicroRNA-411 was down-regulated in the rat model of diabetic retinopathy and played a protective role in this disease, which might be achieved by negatively regulating the expression level of ROBO4.

P3551Right ventricular dysfunction in heart failure patients with reduced ejection fraction with and without chronic respiratory diseases: A treacherous combination for the ominous outcome?

Background

Right ventricular (RV) dysfunction is common in heart failure patients. In the present study, we determined the impact of echocardiography defined RV dysfunction on outcomes in heart failure patients with reduced ejection fraction (<40%, HFrEF) with and without chronic respiratory diseases (CRDs: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome).

Methods

A total of 1264 HFrEF patients (Mean age: 68±13 years; male: 76.3%) referred to our department between 2009 and 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (12–40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed by multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

The proportion of NYHA functional class III-IV was 42.2%. Mean LVEF was 29.4±7.0%. CRDs was identified in 276 (21.8%) patients, 399 (30.5%, without CRDs n=290, with CRDs n=109) patients died (n=386) or underwent HTx (n=13). All-cause mortality/HTx was significantly higher in HFrEF patients with CRDs than without CRDs (39.5% vs. 29.4%, P=0.001).

Cox regression analysis showed that age, BMI, and other cardiac risk factors and comorbidities including diabetes, atrial fibrillation, coronary artery disease, kidney dysfunction, and anemia were associated with all-cause mortality/HTx (all P<0.05) besides CRDs. Multivariable Cox regression models showed that sPAP (HR 1.016, P<0.001), TAPSE (HR 0.964, P=0.003), RAA (HR 1.030, P<0.001), and RVD (HR 1.029, P<0.001) were independent determinants of all-cause mortality/HTx in HFrEF patients without CRDs, but not in HFrEF patients with CRDs after adjusted for above mentioned confounders.

With the cut-off values (sPAP>40mmHg, TAPSE<12mm, RAA>25cm2, and RVD>36mm) derived from the 3rd quartiles, patients without CRDs were further grouped as normal RV function (all 4 parameters normal, n=427); mild to moderate RV dysfunction (1 or 2 parameters abnormal, n=467) and severe RV dysfunction (≥3 parameters abnormal, n=94). Risk of all-cause mortality/HTx was significantly higher in HFrEF patients with severe (51.1%) and mild to moderate RV dysfunction (34.7%) as compared to patients with normal RV function (18.7%, severe vs. normal: HR 1.616, 95% CI 1.232–2.119, P=0.001; mild to moderate vs. normal HR: 2.657, 95% CI 1.845–3.824, P<0.001).

Conclusions

RV dysfunction is significantly associated with increased all-cause mortality in HFrEF patients without CRDs. Increased sPAP, RAA, RVD and decreased TAPSE are independent determinants of worse outcomes in HFrEF patients without CRDs, but not in HFrEF patients with CRDs.

P3545Association between diastolic dysfunction and two-year survival in heart failure patients with mid-range or reduced left ventricular ejection fraction

Background

Extensive studies have demonstrated prognostic impact of echocardiographic defined diastolic dysfunction (DD) in patients with preserved as well as reduced left ventricular ejection fraction (LVEF). Nevertheless, it remains controversial whether evaluation of DD could provide additional prognostic information in heart failure (HF) patients with impaired systolic function. The purpose of present study, therefore, is to investigate the prognostic impact of echocardiography-defined DD on survival in HF patients hospitalized in our centre from 2009 to 2017 with mid-range LVEF (HFmrEF, LVEF 41–49%) and reduced LVEF (HFrEF, LVEF<40%).

Methods

A total of 2018 patients with echocardiography-evidenced LVEF<50% and hospitalized in our centre between July 2009 to December 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 24 (IQR 13–36) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Patients were divided into mild, moderate and severe DD according to recent guidelines.

Results

The mean age was 69±13 years in the HFmrEF group and 68±13 years in the HFrEF group. All-cause mortality/HTx rate was significantly higher in the HFrEF (all-cause death n=318 and HTx n=11, 30.9%) group than in patients with HFmrEF (all-cause death n=235 and HTx n=2, 24.9%, P=0.003). All-cause mortality/HTx rate increased in proportion to DD severity in HFmrEF patients: 17.1% (54/315) in the mild DD group, 25.4% (115/452) in the moderate DD group, and 37.0% (68/184) in the severe DD group (P<0.001) and in HFrEF patients: 18.9% (43/228) in the mild DD group, 30.3% (146/482) in the moderate DD group, and 39.2% (140/357) in the severe DD group (P<0.001). Multivariable Cox regression analysis showed that Doppler parameter early-diastolic mitral inflow velocity to septal mitral annular velocity ratio (E/E') >14 (HR 1.41, 95% CI 1.06–1.89, P=0.020) and peak tricuspid regurgitation velocity (TRVmax) >2.8m/s (HR 1.75, 95% CI 1.33–2.29, P<0.001) were independent determinants of all-cause mortality/HTx in patients with HFmrEF; while E/E'>14 (HR 1.48, 95% CI 1.08–2.04, P=0.015) remained as an independent determinant of all-cause mortality/HTx in patients with HFrEF after adjustment for clinical and other echocardiographic confounders. Besides DD-related parameters, after adjustment with age and sex, lower tricuspid and mitral annular plane systolic excursions (TAPSE and MAPSE) were also closely related to higher mortality/HTx rate in both HFmrEF and HFrEF patients.

Figure 1. Kaplan-Meier curves

Conclusion

Our results indicate that all-cause mortality/HTx rate increases in proportion to DD severity in both HFmrEF and HFrEF patients.

P4513Impact of right ventricular dysfunction on outcome in heart failure patients with mid-range ejection fraction with and without chronic respiratory diseases

Background

The impact of right ventricular (RV) dysfunction on outcome of heart failure patients with mid-range left ventricular ejection fraction (HFmrEF, 40–49%) is not well characterized yet. In this study, we observed the association between echocardiography defined RV dysfunction with outcomes and if the outcome was jointly affected by co-existed chronic respiratory diseases (CRD: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome) in HFmrEF patients

Methods

1090 HFmrEF patients referred to our department between 2009 and 2017 were included in this study. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (15–38) months. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed with the use of multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

Mean age was 69±13 years and 73.4% were male. The proportion of NYHA functional class III or IV was 24.8%. CRD was identified in 209 (19.2%) patients. 280 patients (25.7%, without CRD: 204, with CRD: 76) died and 2 patients (without CRD) underwent HTx. All-cause mortality/HTx was significantly higher in HFmrEF patients with CRD than without CRD (36.4% vs. 23.4%, P<0.001).

Besides CRD, Cox regression analysis showed that age, body mass index, and cardiac risk factors and comorbidities including diabetes, atrial fibrillation, dyslipidemia, coronary artery disease, kidney dysfunction (eGFR <60ml/min/1.73qm), anemia were associated with increased all-cause mortality/HTx (all P<0.05). Multivariable Cox regression models showed that sPAP (HR 1.015, P=0.002) and TAPSE (HR 0.962, P=0.004) were independent determinants of all-cause mortality/HTx in patients without CRD, while sPAP served as independent determinant of all-cause mortality/HTx In patients with CRD (HR 1.018, P=0.026) after adjusted for above mentioned confounders.

Patients without CRDs were further grouped into those with normal (sPAP≤40mmHg and TAPSE≥14mm, n=513); mild to moderate (sPAP>40mmHg or TAPSE<14mm, n=387) and severe RV dysfunction (sPAP>40mmHg and TAPSE<14mm, n=88). Severe RV dysfunction was independently associated with a 2-fold increased all-cause mortality/HTx as compared to normal RV function (HR 2.209, 95% CI 1.455–3.355, P<0.001).

Conclusions

Increased sPAP and reduced TAPSE are independent determinants of all-cause mortality in HFmrEF patients without CRD, and sPAP is an independent determinant of all-cause mortality in HFmrEF patients with CRD. Moreover, HFmrEF patients with severe RV dysfunction face a 2-fold increased all-cause mortality, as compared to patients with normal RV function and no CRD.