Correlates and prognostic impact of acute heart failure at the acute stage of ST-elevation and non-ST-elevation myocardial infarction according to diabetic status: the FAST-MI registries

Background

Diabetes mellitus (DM) predisposes to cardiovascular diseases including acute myocardial infarction (AMI) and acute heart failure (AHF).

Purpose

Analysing the French Registries of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 and 2010, we assessed correlates of AHF occurring at the acute stage of ST-elevation AMI (STEMI) and non-ST-elevation AMI (NSTEMI), as well as the prognostic impact of AHF on 5-year mortality according to diabetic status.

Methods

The FAST-MI 2005 and 2010 registries included 7,839 consecutive patients admitted for AMI (4,250 STEMI and 3,589 NSTEMI). Vital status at 5 years was available in >96% of the patients. Binary logistic regression analysis was used to determine independent correlates of AHF and Cox multivariate analysis was used to determine independent correlates of 5-year mortality. Long-term survival curves were estimated using the Kaplan Meier method and comparisons were made using log-rank tests.

Results

2,151 patients presented with DM (27,4%) and 629 patients (8,0%) were treated by insulin (DMi). DM patients were older (70.0 vs. 64.6 years; p<0.001), with more comorbidities and more severe coronary artery disease. AHF (pulmonary edema or cardiogenic shock) was the most frequent in-hospital complication (12.5%) and was twice as frequent in DM patients (20.2% vs. 9.6%; adjusted OR=1.66; 95% confidence interval: 1.43–1.94; P<0.001). AHF was more frequently observed in DM patients on insulin therapy compared with DM patients not receiving insulin (29.1% vs 16.6%; adjusted OR=1.53; 95% CI: 1.20–1.96; P=0.001). The significant difference in AHF between DM patients and patients without DM was found in both STEMI (18.8% vs 8.0%; P=0.001) and in NSTEMI (21.3% vs 11.9%; P=0.001) patients.

After multivariate analysis on confounders (risk factors, previous medical history, type of AMI, year of survey and medications used before the index AMI), compared with patients without DM nor AHF, those with AHF without DM and those with DM without AHF had a 50% increase in 5-year mortality (adjusted HR=1.50; 95% CI: 1.32–1.69; P<0.001 and adjusted HR=1.46; 95% CI: 1.23–1.74; P<0.001) while the risk of 5-year death was doubled in those with both DM and AHF (adjusted HR=1.97; 95% CI: 1.66–2.34; P<0.0001).

Conclusion

AHF is the most frequent complication of AMI and is twice as common in DM patients. It is associated with reduced 5-year survival in non-diabetic and DM patients, with the worst outcomes in patients with both conditions (AHF and DM). In AMI, new management strategies are needed to prevent AHF and improve survival in DM patients with AHF.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The FAST-MI 2005 and 2010 registries are the propriety of the French Society of Cardiology and were funded by grants from the following companies: Amgen, AstraZeneca, Bayer, BMS, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, Pfizer, Sanofi, and Servier, and by a grant from the French National Health Insurance body (CNAM-TS).

Cardiac troponin I and BNP for predicting zero Agatston score in patients with diabetes mellitus

Background

Coronary artery calcifications (CAC) scoring assessed by the Agatston score has shown an excellent prognostic value in large studies, particularly in diabetic patients, with a very low rate of cardiovascular events in patients with a zero Agatston score. Moreover, recent studies have suggested that high-sensitive cardiac troponin I (hs-cTnI) and brain natriuretic peptide (BNP) may be useful for detecting subclinical atherosclerosis, especially in diabetic patients. However, the link between hs-cTnI/BNP and the Agatston score has not been investigated in this population.

Purpose

The aim of this study was to investigate if hs-cTnI and BNP can bring additional value to predict zero Agatston score in patients with diabetes mellitus in addition to usual risk factors.

Material

Between 2015 and 2019, CAC score was prospectively performed in consecutive patients with diabetes mellitus with high cardiovascular risk. Patients with symptoms or known coronary artery disease were excluded. Within 24h from CT exam, peripheral blood samples were taken to measure hs-cTnI and BNP. The relationship between serum hs-cTnI/BNP concentrations and zero Agatston score was evaluated using univariate and multivariate binomial models. 77 variables have been used to build the model. The implication of hs-cTnI and BNP in this multivariate model was evaluated using nested models associated with Chi-squared test of independence.

Results

A total of 844 patients with diabetes were enrolled (61±7 years, 57% men, mean diabetes duration 18 years). In this population, 294 (35%) had a zero Agatston score, 253 (30%) an Agatston score from 1 to 100, 161 (19%) from 101 to 400, and 136 (16%) higher than 400. In univariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.63 [95% CI, 1.51–5.01]; p<0.001 and OR, 1.09 [95% CI, 1.01–1.22]; p=0.03). In multivariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.38 [95% CI, 1.51–4.76]; p=0.009 and OR, 1.18 [95% CI, 1.07–1.32]; p=0.001). Among the 77 variables, the multivariate model including age, gender, smoking, dyslipidaemia, duration of the diabetes, arterial hypertension, presence of diabetic neuropathy, hs-cTnI and BNP concentrations, significantly discriminated the zero Agatston score (AUC = 0.81; p<0.001). The most discriminant threshold was ≤3ng/l for hs-cTnI and <17ng/l for BNP. In nested models, both hs-cTnI and BNP brought information to this multivariate model to predict a zero Agatston score (respectively p=0.003 and p<0.001 to the Chi-squared test). Moreover, removing hs-cTnI and BNP from the model results in a significant reduction in model performance (AUC = 0.79; p=0.004).

Conclusions

Cardiac biomarkers hs-cTnI and BNP are associated with a zero Agatston score, which is correlated with a very low risk of cardiovascular events in asymptomatic patients with diabetes mellitus.

ROC curve to predict zero Agatston score

Funding Acknowledgement

Type of funding source: None

Delayed acute myocarditis and COVID-19-related multisystem inflammatory syndrome

Precise descriptions of coronavirus disease 2019 (COVID‐19)‐related cardiac damage as well as underlying mechanisms are scarce. We describe clinical presentation and diagnostic workup of acute myocarditis in a patient who had developed COVID‐19 syndrome 1 month earlier. A healthy 40‐year‐old man suffered from typical COVID‐19 symptoms. Four weeks later, he was admitted because of fever and tonsillitis. Blood tests showed major inflammation. Thoracic computed tomography was normal, and RT–PCR for SARS‐CoV‐2 on nasopharyngeal swab was negative. Because of haemodynamic worsening with both an increase in cardiac troponin and B‐type natriuretic peptide levels and normal electrocardiogram, acute myocarditis was suspected. Cardiac echographic examination showed left ventricular ejection fraction at 45%. Exhaustive diagnostic workup included RT–PCR and serologies for infectious agents and autoimmune blood tests as well as cardiac magnetic resonance imaging and endomyocardial biopsies. Cardiac magnetic resonance with T2 mapping sequences showed evidence of myocardial inflammation and focal lateral subepicardial late gadolinium enhancement. Pathological analysis exhibited interstitial oedema, small foci of necrosis, and infiltrates composed of plasmocytes, T‐lymphocytes, and mainly CD163⁺ macrophages. These findings led to the diagnosis of acute lympho‐plasmo‐histiocytic myocarditis. There was no evidence of viral RNA within myocardium. The only positive viral serology was for SARS‐CoV‐2. The patient and his cardiac function recovered in the next few days without use of anti‐inflammatory or antiviral drugs. This case highlights that systemic inflammation associated with acute myocarditis can be delayed up to 1 month after initial SARS‐CoV‐2 infection and can be resolved spontaneously.

Adherence Tracking With Smart Watches for Shoulder Physiotherapy in Rotator Cuff Pathology: Protocol for a Longitudinal Cohort Study

Background

Physiotherapy is essential for the successful rehabilitation of common shoulder injuries and following shoulder surgery. Patients may receive some training and supervision for shoulder physiotherapy through private pay or private insurance, but they are typically responsible for performing most of their physiotherapy independently at home. It is unknown how often patients perform their home exercises and if these exercises are performed correctly without supervision. There are no established tools for measuring this. It is, therefore, unclear if the full benefit of shoulder physiotherapy treatments is being realized.

Objective

The proposed research will (1) validate a smartwatch and machine learning (ML) approach for evaluating adherence to shoulder exercise participation and technique in a clinical patient population with rotator cuff pathology; (2) quantify the rate of home physiotherapy adherence, determine the effects of adherence on recovery, and identify barriers to successful adherence; and (3) develop and pilot test an ethically conscious adherence-driven rehabilitation program that individualizes patient care based on their capacity to effectively participate in their home physiotherapy.

Methods

This research will be conducted in 2 phases. The first phase is a prospective longitudinal cohort study, involving 120 patients undergoing physiotherapy for rotator cuff pathology. Patients will be issued a smartwatch that will record 9-axis inertial sensor data while they perform physiotherapy exercises both in the clinic and in the home setting. The data collected in the clinic under supervision will be used to train and validate our ML algorithms that classify shoulder physiotherapy exercise. The validated algorithms will then be used to assess home physiotherapy adherence from the inertial data collected at home. Validated outcome measures, including the Disabilities of the Arm, Shoulder, and Hand questionnaire; Numeric Pain Rating Scale; range of motion; shoulder strength; and work status, will be collected pretreatment, monthly through treatment, and at a final follow-up of 12 months. We will then relate improvement in patient outcomes to measured physiotherapy adherence and patient baseline variables in univariate and multivariate analyses. The second phase of this research will involve the evaluation of a novel rehabilitation program in a cohort of 20 patients. The program will promote patient physiotherapy engagement via the developed technology and support adherence-driven care decisions.

Results

As of December 2019, 71 patients were screened for enrollment in the noninterventional validation phase of this study; 65 patients met the inclusion and exclusion criteria. Of these, 46 patients consented and 19 declined to participate in the study. Only 2 patients de-enrolled from the study and data collection is ongoing for the remaining 44.

Conclusions

This study will provide new and important insights into shoulder physiotherapy adherence, the relationship between adherence and recovery, barriers to better adherence, and methods for addressing them.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17841

The lower trapezius transfer: a systematic review of biomechanical data, techniques, and clinical outcomes

BACKGROUND

Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs.

METHODS

MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated.

RESULTS

Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation.

CONCLUSION

This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.

Local surgical complication rates in patients receiving surgery without immediate post-operative radiation therapy for lower extremity bone metastases

•

161 lower limb reconstruction surgeries for pathological or impending pathological fractures were included in the study.

•

46.6% of patients did not receive radiation within 12 weeks of surgery.

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Among patients not receiving post-operative radiation, 6.7% required a second operation to the index surgical site.

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Among patients not receiving post-operative radiation, 16.0% later received radiation to the index surgical site."?>

Purpose

Pathological metastatic fractures in lower-extremity weight bearing bones often require surgical reconstruction. Post-operative radiation is routinely recommended following surgical reconstruction. This study evaluated the clinical outcomes of patients that undergo surgical fixation of an established or an impending pathologic lower extremity fracture without post-operative radiation.

Materials and methods

A retrospective chart review of patients at Sunnybrook Health Sciences Center between 2007 and 2019 was performed. Descriptive statistical analyses were performed.

Results

A total of 161 surgical reconstruction procedures were identified. Among these cases, 86/161 (53.4%) received post-operative radiation, 75/161 (47%) did not receive post-operative radiation within 12 weeks of their index surgery. Of the 75 patients not receiving post-operative radiation, 40 patients had prior radiation to the surgical site and 35 patients were radiation naïve. 5 patients (6.7%) required a second operation to the index surgical site, with 4 patients (5.3%) requiring a second fixation surgery to stabilize hardware at a median of 6.0 months post-surgery. Post-surgical radiation to the surgical site (at >12 weeks) was administered to 12 patients (16.0%) at a median of 9.1 months post-surgery.

Conclusions

The surgical revision rate was low despite absence of immediate post-operative radiation therapy and was similar to prior reports in patients receiving post-operative radiation.

Acute Fifth Metatarsal Tuberosity Fractures: A Systematic Review of Nonoperative Treatment

OBJECTIVE

Acute metatarsal fractures are a common lower extremity injury. Although surgery may be recommended in specific cases, most are treated nonoperatively. Treatment protocols vary significantly among practitioners, with no consensus on the most efficacious approach. This systematic review aims to identify the effect of treatment protocols on union rate and functional outcome after an acute fifth metatarsal tuberosity fracture.

LITERATURE SURVEY

Multiple databases, including CINAHL, EMBASE, MEDLINE, and the Cochrane CEntral Register of Controlled Trials (CENTRAL) were searched from database inception to March 4, 2018 to identify clinical studies addressing nonoperative management of metatarsal fractures reporting nonunion, pain, and/or length of recovery.

METHODOLOGY

Two reviewers independently completed title, abstract, and full-text screening. Data abstraction was completed in duplicate. Outcome measures and complications were descriptively analyzed.

SYNTHESIS

A total of 1941 studies were eligible for screening. Seven studies (four randomized controlled trials and three prospective cohort studies) satisfied inclusion criteria. This resulted in a total of 388 patient with acute fifth metatarsal tuberosity fractures in 12 different treatment arms, with the most common treatment including plaster casting (7). The mean age was 42 years (27 to 56 years), and the overall nonunion rate was low (1.1%). Four unique functional scores were reported across all studies, and all showed good to excellent short-term results. The overall qualities of studies were moderate, with particular limitations in randomization and concealment allocation.

CONCLUSION

Most acute fifth metatarsal tuberosity fractures heal well, with good-to-excellent functional outcomes with nonoperative treatment, regardless of technique. We recommend a conservative rehabilitation framework, including 2 to 3 weeks of immobilization in a walking cast, followed by gradual increase in activity and strengthening until clinical union is achieved.

Articular reductions - how close is close enough? A narrative review

Intra-articular fractures are a unique subset of fractures as they involve a varying extent of damage to cartilage. The impact of this articular fracture causes significant microscopic and macroscopic changes, as well as biomechanical irregularities, which can lead to further cartilage damage, and ultimately cascade down the dreaded path to arthritis. It is generally believed that an anatomic reduction of an articular fracture is the necessary goal of treatment for these injuries, however it yet to be delineated how perfect this reduction has to be. A comprehensive literature review was carried out to create a best available evidence guide to the acceptability of upper extremity and lower extremity articular fracture reductions. Ultimately, a perfect anatomic reduction is the best strategy to minimize abnormal loading and wear patterns, however this should be balanced with the realistic factors of each individual case, such as the level of difficulty, joint involved, surgical timing, and patient activity levels.

Determinants of aspirin resistance in patients with type 2 diabetes

BACKGROUND

Cardiovascular disease is a leading cause of mortality among patients with type 2 diabetes mellitus (T2DM). Numerous patients with T2DM show resistance to aspirin treatment, which may explain the higher rate of major adverse cardiovascular events observed compared with non-diabetes patients, and it has recently been shown that aspirin resistance is mainly related to accelerated platelet turnover with persistent high platelet reactivity (HPR) 24h after last aspirin intake. The mechanism behind HPR is unknown. The aim of this study was to investigate the precise rate and mechanisms associated with HPR in a population of T2DM patients treated with aspirin.

METHODS

Included were 116 consecutive stable T2DM patients who had attended our hospital for their yearly check-up. HPR was assessed 24h after aspirin intake using light transmission aggregometry (LTA) with arachidonic acid (AA) and serum thromboxane B2 (TXB2) measurement. Its relationship with diabetes status, insulin resistance, inflammatory markers and coronary artery disease (CAD) severity, using calcium scores, were investigated.

RESULTS

Using LTA, HPR was found in 27 (23%) patients. There was no significant difference in mean age, gender ratio or cardiovascular risk factors in patients with or without HPR. HPR was significantly related to duration of diabetes and higher fasting glucose levels (but not consistently with HbA_1c), and strongly related to all markers of insulin resistance, especially waist circumference, HOMA-IR, QUICKI and leptin. There was no association between HPR and thrombopoietin or inflammatory markers (IL-6, IL-10, indoleamine 2,3-dioxygenase activity, TNF-α, C-reactive protein), whereas HPR was associated with more severe CAD. Similar results were found with TXB2.

CONCLUSION

Our results reveal that 'aspirin resistance' is frequently found in T2DM, and is strongly related to insulin resistance and severity of CAD, but weakly related to HbA_1c and not at all to inflammatory parameters. This may help to identify those T2DM patients who might benefit from alternative antiplatelet treatments such as twice-daily aspirin and thienopyridines.

Reasons for the Failure of Platelet Function Testing to Adjust Antiplatelet Therapy: Pharmacodynamic Insights From the ARCTIC Study

BACKGROUND

In the ARCTIC trial (Assessment by a Double Randomization of a Conventional Antiplatelet Strategy Versus a Monitoring-Guided Strategy for Drug-Eluting Stent Implantation and of Treatment Interruption Versus Continuation One Year After Stenting), treatment adjustment following platelet function testing failed to improve clinical outcomes. However, high-on-treatment platelet reactivity (HPR) is considered as a predictor of poor ischemic outcome. This prespecified substudy evaluated clinical outcomes according to the residual platelet reactivity status after antiplatelet therapy adjustment.

METHODS

We analyzed the 1213 patients assigned to the monitoring arm of the ARCTIC trial in whom platelet reactivity was evaluated by the VerifyNow P2Y₁₂ test before percutaneous coronary intervention and during the maintenance phase (at 14 days). HPR was defined as platelet reaction unit≥235U. The primary ischemic end point, a composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization and the safety end point of major bleeding were assessed according to the platelet reactivity status.

RESULTS

Before percutaneous coronary intervention, 35.7% of patients displayed HPR (n=419). During the acute phase, between percutaneous coronary intervention and the 14-day platelet function testing, ischemic (adjusted hazard ratio, 0.94 [95% CI, 0.74-1.18]; P=0.58) and safety outcomes (hazard ratio, 1.28 [95% CI, 0.22-7.59]; P=0.78) were similar in HPR and non-HPR patients. During the maintenance phase, the proportion of HPR patients (n=186, 17.4%) decreased by 56%. At 1-year, there was no difference for the ischemic end point (5.9% versus 6.0%; adjusted hazard ratio, 0.79 [95% CI, 0.40-1.58]; P=0.51) and a nonsignificant higher rate of major bleedings (2.7% versus 1.0%, hazard ratio, 2.83 [95% CI, 0.96-8.41]; P=0.06) in HPR versus non-HPR patients.

CONCLUSIONS

The proportion of HPR was halved after platelet function testing and treatment adjustment but without significant ischemic benefit at 1 year. HPR seems more as a modifiable risk marker than a risk factor of ischemic outcome.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00827411.

The Relationship Between the Critical Shoulder Angle and the Incidence of Chronic, Full-Thickness Rotator Cuff Tears and Outcomes After Rotator Cuff Repair: A Systematic Review

PURPOSE

To summarize the available evidence and examine the relationship between the critical shoulder angle (CSA) and (1) the incidence of chronic full-thickness rotator cuff tears (RCTs) and (2) outcomes after rotator cuff repair (RCR).

METHODS

A comprehensive search of MEDLINE, Embase, and CINAHL was completed. Comparative studies were included and the influence of the CSA on either the incidence of chronic, full-thickness RCTs, or outcomes following RCR was evaluated. Demographic variables and outcomes were collected.

RESULTS

Seven comparative studies analyzed the influence of the CSA on the incidence of chronic, full-thickness RCTs (the control group constituted patients with a normal rotator cuff). High heterogeneity limited pooling of studies, but the majority concluded that a greater CSA significantly increased the likelihood of a chronic, full-thickness RCT. Conversely, 5 comparative studies analyzed the influence of CSA on outcomes following RCR, and although a greater CSA was associated with a greater re-tear rate, the majority reported that CSA did not significantly influence postoperative functional outcomes, including patient-reported outcome measures (PROMs), range of motion (ROM), and strength.

CONCLUSIONS

Based on the available evidence, there appears to be a relationship between a greater CSA and the presence of a chronic, full-thickness RCT. Furthermore, a greater CSA may be associated with a greater re-tear rate following RCR; however, CSA does not appear to influence functional outcomes following RCR. Despite these observations, the available evidence is of poor quality, and the clinical utility and role of the CSA in the diagnosis and surgical management of a chronic, full-thickness RCT remains in question.

LEVEL OF EVIDENCE

Level IV: Systematic review of Level II-IV studies.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

P2489What are the main determinants of an increase in bnp level in asymptomatic diabetic patients without known cardiac disease?

Background

Diabetes mellitus is associated with a high risk of heart failure. The predictors of futures heart failure events in diabetic patients are not clearly understood. BNP measurement can be used as a surrogate endpoint for the diagnosis of heart failure. We investigated the determinants of an increase in BNP level in a large cohort of asymptomatic diabetic patients without known cardiac disease

Methods

This prospective study included consecutive stable diabetic (type 1 or 2) patients coming for yearly check-up between March 2015 and July 2018 in the university center for the study of diabetes and its complications. Patients with an history of cardiac disease (coronary artery disease, atrial fibrillation, cardiomyopathy, previous heart failure ...) were excluded. All patients had a complete clinical exam, blood pressure measurement (3 consecutive times – mean of 2 lasts measurements), ECG, and blood sample including HbA1C, risk factors assessment, renal function (CKD-EPI) and BNP measurement. Data are presented as mean±SD or median - Spearman's rank and multivariate regression were used for analysis.

Results

3743 patients (mean age 57±14 y.o. – 57% male – 78% / 18% / 4% of type 2, type 1 or other type of diabetes respectively – Mean duration of diabetes 17 [1–63] y. – 44% treated with insulin) were studied. Mean±SD / median [min-max] BNP level was 25±39 / 12 [4–737] ng/L. BNP was <20 / 21–35 / 36–50 / 51–100 / 101–400 / >400 ng/L in 69 / 15 / 6 / 7 / 3 / 0.1% of the population respectively. The parameters most correlated with BNP level in type 1 and type 2 diabetes were age, duration of diabetes, renal function, HbA1C, and pulsed pressure. For multivariate analysis, renal function was removed of the model as it was highly correlated with age (r=−0.68). Multivariate analysis demonstrated that in type 1 diabetes, high BNP level was linked to age (p<0.001), pulsed pressure (p<0.001), duration of diabetes (p=0.003) and HbA1C (p=0.02). In type 2 diabetes, high BNP level was linked to age (p<0.0001), pulsed pressure (p<0.0001), duration of diabetes (p=0.005) but not HbA1C (p=0.09). Interestingly the type of treatment (mainly insulin treatment) was not independently related to an increase in BNP level.

Conclusion

Age, pulsed pressure and duration of diabetes are the main determinants of an increased level of BNP in asymptomatic diabetic patients without any history of cardiac disease. This result could help to select a population who could benefit to a more extensive follow up concerning heart failure.

P4569Differential prognostic impact of blood glucose levels at the acute stage of myocardial infarction according to HbA1c. The FAST-MI programme

Background

Hyperglycemia is a well-known prognostic marker in patients with acute myocardial infarction (AMI), associated with higher mortality compared with normoglycemia. Whether the prognostic impact of glycemic status at the acute stage of AMI is similar in patients with chronic dysglycemia has not been extensively explored.

Aims and methods

Using data from the nationwide French FAST-MI cohorts (2005, 2010 and 2015), we analysed the association between glycemia at entry and 30-day death, according to HbA1c level. From the 13,130 patients included, 5,452 had both glycemia and HbA1c assessed at entry. Of those, 1173 (21.5%) had an HbA1c ≥7%.

Results

In patients with HbA1c <7%, LVEF was inversely correlated with glycemic levels (55±11% for glycemia <100, 52±11% for glycemia 100–140, 50±12% for glycemia 140–160 and 49±12% for glycemia >180 mg/dl); a graded association between admission glycemia and 30-day mortality was observed, ranging from 0.7% in normoglycemic patients to 6.3% in patients with admission glycemia >180 mg/dl. In contrast, in patients with HbA1c ≥7%, LVEF was not correlated with glycemia (<100 mg/dl: 49±14%, >180 mg/dl 49±12%), and mortality was the highest in patients with normoglycemia (9.2%) and the lowest in patients with glycemia between 140 and 180 mg/dl (3.1%) (Figure). In multivariate analyses adjusting for baseline characteristics and early management, normoglycemia was associated with a decreased risk of 30-day mortality in patients with HbA1c <7% (HR 0.27, 95% confidence interval 0.10–0.73, P=0.01), while it was associated with a two-fold increase in mortality in patients with HbA1c ≥7% (HR 2.49, 95% confidence interval 1.02–6.09, P=0.046).

Figure 1. 30-day death

Conclusion

In AMI patients with high HbA1c levels on admission, normoglycemia is associated with higher early mortality than hyperglycemia. In contrast, a graded correlation is observed between admission glycemia and early mortality in patients with HbA1c <7%. Management of glycemia at the acute stage of MI might require different measures according to the initial HbA1c level.

Acknowledgement/Funding

Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, Pfizer, Sanofi, Servier

P1694Sex is not an independent predictor of ischemic outcomes or bleeding in NSTEMI patients undergoing percutaneous coronary intervention. Insights from the TAO trial

Background

There is uncertainty regarding whether female sex is an independent predictor of adverse outcomes in acute coronary syndromes (ACS).

Purpose

We sought to describe and compare ischemic and bleeding outcomes between men and women with Non–ST-segment–Elevation (NSTE) ACS enrolled in the large Treatment of Acute coronary syndromes with Otamixaban (TAO) trial in which antithrombotic treatment was standardized and a systematic invasive approach was performed.

Methods

The TAO trial randomized moderate to high-risk NSTE-ACS patients with diagnostic coronary angiography planned in the first 72 hours to heparin plus eptifibatide versus otamixaban. This post-hoc analysis describes ischemic (all-cause death, new myocardial infarction, stent thrombosis within 180 days of randomization) and bleeding outcomes (TIMI major and minor bleeding within 30 days of randomization) according to sex.

Results

Of 13,229 patients with NSTE-ACS randomized in 55 countries, 3,980 (30.1%) were female and 9,249 (69.9%) were male. Mean age was 64.8±11.0 and 60.7±11.1 years, respectively. The prevalence of diabetes (34.0% vs. 25.8%), hypertension (80.8% vs. 67.0%), and hypercholesterolemia (55.9% vs. 52.2%) was higher among women compared with men but current smoking (21.5% vs. 38.7%) and history of previous MI were more frequent in males (15.5% vs. 20.7%).

Females experienced a higher incidence of both ischemic outcomes (10.2% vs. 9.1%; OR=1.15; 95% CI, 1.01–1.30; p=0.034) and bleeding events (4.1% vs. 3.4%; OR=1.23; 95% CI, 1.02–1.49; p=0.029). Bleeding risk and CV death were particularly increased in women younger than 50 years, compared to males of the same age, at 5.5% vs. 1.4% (OR=4.00; 95% CI, 2.13–7.69; p=0.034) and 1.7% vs. 0.5% (OR=4.35; 95% CI, 1.02–20.00; p=0.02), respectively. No difference in either outcome was found between women and men between 50 and 80 years old. Above 80 years, women experienced a lower rate of bleeding (3.9% vs. 7.8%; OR=0.47; 95% CI, 0.23–0.88; p=0.024) but a similar rate of in ischemic events (16.0% vs. 17.2%; OR=0.92; 95% CI, 0.63–1.33; p=0.67).

After adjustment for age, body weight, diabetes mellitus, prior PCI, serum creatinine, presenting systolic blood pressure, elevated biomarker at presentation, heart failure, the risk of ischemic (OR=1.03; 95% CI, 0.89–1.18; p=0.71) and bleeding events (OR=1.05; 95% CI, 0.85–1.33; p=0.65) were similar between men and women.

Conclusions

In this large international randomized trial of NSTE-ACS with standardized invasive management, women (particularly those younger than 50 years) experienced higher risks of ischemic and bleeding events than men, but the difference was not sustained after adjustment. In this population, sex was not an independent predictor of adverse outcomes in NSTE-ACS. The type of ACS (NSTE-ACS) and routine invasive management in women and men may explain this absence of difference.

Acknowledgement/Funding

The TAO trial was sponsored and funded by SANOFI. The present analysis was supported by the RHU iVASC grant “#ANR-16-RHUS-00010”

101Characterization of the calcium component of vulnerable coronary plaque in patients with NSTEMI: prospective comparison between coronary CT and optical coherence tomography

Background

Acute Coronary Syndrome (ACS) remains a leading cause of mortality worldwide with a high risk of recurrence. Apart culprit plaques, the presence of vulnerable plaques could be associated with the occurrence of future cardiac events and need to adapt treatments. Several studies have demonstrated a role for Coronary Computed Tomographic Angiography (CCTA) to predict the vulnerability of the plaque but with limited analysis of its calcium component. Recent works suggest a role for calcification in this vulnerability.

To our knowledge, no studies have been performed to assess if the study of the calcium component of plaques with CCTA can help to predict vulnerability in non-ST elevation myocardial infarction (NSTEMI).

Purpose

To assess if the CCTA study of the calcium component of plaques can help to predict plaque vulnerability defined by intracoronary OCT analysis in patients with non-ST elevation myocardial infarction (NSTEMI).

Methods

Monocentric prospective study of consecutive patients referred for NSTEMI with elevated high-sensitivity cardiac troponin I level (hs-TnI>50 ng/ml) from January to October 2018. CCTA was systematically performed before coronary angiography to assess the presence of CAD. When CCTA demonstrated significant lesions, coronary angiography was performed within 24 hours associated with systematic OCT study of three coronary arteries. Apart culprit plaques, vulnerable plaques were defined in OCT by a fibrous screed thickness <65 microns. Calcified plaques were analysed with CT and then classified into 3 groups: vulnerable culprit plaque (VCP), vulnerable non-culprit plaque (VNCP) and stable plaque (SP).

Results

Of 1478 patients with chest pain, 257 (17%) had NSTEMI with high level of hs-TnI. From this 257 NSTEMI patients, 44 (17%) were without known CAD and among these, 33 (75%) had received coronary angiography with 29 (66% - mean age 59±13 years, 73% men) having coronary anatomy compatible with OCT assessment. A total of 123 calcified plaques were identified. Among them, OCT allowed to identify 77 (63%) SP and 47 calcified vulnerable plaques; 28 (23%) VNCP and 19 (15%) VCP. After CCTA analysis of the calcium component, predictive factors of plaque vulnerability were identified: longer calcification length (p<0.001), larger calcification volume (p<0.001), lower calcium mass (p=0.003), higher single plaque Agatston score (p<0.001), lower sphericity index (p=0.001), more spotty calcifications (p=0.001), as well as more intimal position in the wall (p<0.001). No significant differences were observed comparing VNCP and VCP (Figure).

OCT and “Virtual Histology” CT

Conclusion

CCTA study of the calcium component of plaque allows to identify predictors of plaque vulnerability defined by OCT in patients with NSTEMI.

[Myalgia and statins: Separating the true from the false]

In therapeutic trials, the incidence of adverse muscle effects under statin is low, exceptional for some authors,<5% for others. In observational studies, however, this incidence is much higher, up to 20% of patients. These adverse effects are drug-dependent and dose-dependent. It is often complex to distinguish between a real adverse effect and a nocebo effect. Causality is more likely if the symptoms are symmetrical and affect the large muscle masses dependent on the large joints, occur within one month of the introduction of the statin and disappear quickly, within a few weeks after discontinuation of treatment. It seems important not to waste time trying to convince the patient that the alleged muscle symptoms are unrelated to statin therapy. In these patients with suspected statin intolerance, therapeutic impasse is rare and there is a need to attempt dosage reductions, experiment different statins or even prescribe other cholesterol-lowering agents.

Surgical repair versus conservative treatment and subacromial decompression for the treatment of rotator cuff tears

Aims

The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff.

Materials and Methods

PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results

Six studies were included. Surgical repair resulted in a statistically significantly better Constant–Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair.

Conclusion

The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the ‘success rate’ of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100–1106.