Dealing with COVID-19 Barriers to Care: Digital Platform to support and monitor chronic patients

The Covid-19 pandemic is causing a set of disruptions, especially at the delivery of healthcare services. The pandemic has shown subsidiary health effects like, chronic care, mental health, surgeries, and deadlock in the other diseases’ treatment.

A digital health platform (PrimaryCare@COVID-19) was implemented to be used by primary care physicians, and nurses, to address both chronic care and COVID-19-related patients at home or traveling. It has been piloted in three Health centers at Lisbon Health Region and it could be scale-up to all primary care in Portugal in the near future. This project was funded by the National Science Foundation to address Primary Care consultations and chronic care services shortage. The clinical primary care processes were studied and a digital workflow was defined using Design Science Research Methods.

This project‘s innovative digital platform is already covering several dozens of chronic patients while at home and addressing the communication with COVID-19-related patients.

The health professionals (physicians and nurses) are able to safely and rigorously communicate with chronic patients and prescribe the required medicines, as well as inform them about the COVID-19 measures. In case of patients either on quarantine or in isolation this platform also allows for the monitoring and health evaluation.

This eHealth Digital Platform is an opportunity to manage chronic care during epidemics, allowing to follow-up patients, preventing them from becoming uncontrolled and having to go to emergency. The digital platform uses smart algorithms to deal with both medication interactions and vital signs alerts while monitoring, chronic and COVID-19 infected, patients, allowing health professionals to remotely consult these patients at home/travelers (by default with phone, but also via digital videoconferencing) and manage all health information about patients in a secure way (and following GDPR rules).

Investigation of hospital deaths declared as garbage codes in Belo Horizonte, Brazil, in 2017

Background

Improving the quality of causes of death (COD) is vital for defining adequate public policies. In Brazil, one third of deaths are reported as having a cause that is not useful for public health analysis of cause-of-death data, the so-called garbage codes (GC). The investigation of these deaths is one of the strategies that could improve the quality of mortality statistics in the country.

Methods

For all GCs identified in 2017 in the routine mortality information system from Belo Horizonte city, Brazil, municipal health professionals collected information about the final disease obtained from hospital records or autopsies in a standardized form. A trained physician analyzed this information and filled in a new death certificate (DC). The DC that originally showed a GC as an underlying COD was categorized into GC reclassified when the garbage cause changed to a specific cause after investigation. Causes of death derived from the reclassified GCs were analyzed to assess the impact on the mortality profile before and after the investigation.

Results

In Belo Horizonte, 1,395 deaths out of 3,038 registered as garbage codes were investigated, with a 35% reduction in deaths due to these causes. There was an increase in deaths from ischemic heart diseases, Alzheimer's disease, chronic obstructive pulmonary disease, hemorrhagic and ischemic stroke, and violence.

Conclusions

The investigation of deaths from garbage codes modified the mortality profile and improved its quality, providing direction for more assertive public health policies. Strategies for training physicians to report specific causes of death is another strategy that could improve the quality of mortality data.

Key messages

This study proved to be a feasible strategy in improving the quality of causes of death in mortality statistics and should be incorporated into the surveillance routine activities in Brazil. The evaluation of the GC investigation is an important instrument in helping management of health interventions aiming at better quality of information and more qualified health services.

HIV/AIDS: a 30 year history at the Northern Region of Portugal

Since 1981, when the first cases of human immunodeficiency virus (HIV) infection were diagnosed, the need to monitor what emerged shortly afterwards as an epidemic arose. Portugal was not immune, and over the years different measures have been taken to control the national epidemic. The goal of this research is to contribute to the previous knowledge about the trend of HIV infection at the regional level that allows adequate planning focused on controlling the epidemic. This is an observational, descriptive and cross-sectional study, whose data were anonymized at the source, based on the analysis of cases notified by doctors. The data were analyzed using the software Microsoft® Excel version 16.16.4 and IBM® SPSS® Statistics version 25. To check if there is a proven statistical relationship between the variables, the Chi-Square independence test (X2) was used. The results obtained revealed 14512 accumulated cases, in the different stages of infection, 76.7% of which are male, with a higher incidence between 25-29 years of age. Type HIV-1 covers 97.1% of all cases. From 2013 to 2017 it was observed that 74.2% lived in urban areas. Late diagnosis was found in rural areas, particularly in heterosexual transmission. It was concluded that there are several similarities between data at regional and national levels, such as the occurrence of late diagnosis in the category of heterosexual transmission. Regarding legislative changes, no conclusion can be inferred, although hypotheses were raised that can should be discussed in future studies.

Key messages

Late diagnosis in rural areas. Late diagnosis in heterosexual transmission.

AB0015 IDENTIFICATION OF KEY GENES TO SUPPORT SYSTEMIC LUPUS ERYTHEMATOSUS, RHEUMATOID ARTHRITIS AND ANKYLOSING SPONDYLITIS DIAGNOSIS BY TRANSCRIPTOMIC APPROACH

Background:

Early diagnosis of inflammatory rheumatic diseases (IRD), as Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA) and axial Spondyloarthritis (axSpA) represents in our days a major clinical challenge. Increasing evidence has determined that early diagnosis, prompt treatment initiation and early achievement of remission are the best predictors of long-term clinical, functional and radiographic outcomes. Therefore, identification of sensitive biomarkers to support an early diagnosis to enable early therapy is of utmost importance [1,2].

Objectives:

This study aims to identify novel genes that may improve the current clinical diagnosis approach for early SLE, RA and axSpA.

Methods:

A cross-sectional study was conducted on 44 participants, 12 with axSpA (according to ASAS criteria), 11 with RA (according to ACR/EULAR criteria for RA), 10 with SLE (according to ACR classification criteria for SLE) and 11 Healthy Controls (HC), gender and age matched. Patients with co-occurrence of other IRD or having received biological therapies were excluded. Peripheral blood samples were collected into PAXgene tubes and stored in -80°C. mRNA profiling by RNA-seq was performed. Unpaired t-tests with multivariate permutation correction were applied to identify differentially expressed genes (DEGs) between patients and HC for each disease and within diseases. Enrichment analysis, Gene ontology (GO) and Kyoto Enrichment of Genes and Genomes (KEGG) analysis were also performed. DEGs that allow to distinguish each disease from HC and between diseases. The top DEGs (axSpA n=2, RA n=2, SLE n=3) identified were confirmed by quantitative RT-PCR.

Results:

For axSpA, genes involved in negative regulation of cytokines by JAK/STAT pathway and in osteoblast differentiation through STAT3 pathway, were confirmed. In SLE, genes involved in trap for immune complexes in peripheral blood and involved in nucleosome regulation, were also confirmed. Regarding RA, no genes were confirmed.

Conclusion:

Our work provides new insights into IRD pathogenesis, and discloses new biomarkers, which may be useful as either predictive biomarkers for diagnosis or therapeutic targets to improve IRD approach.Further validation are needed in different cohorts.

References:

[1]Monti, S. et al. (2015) ‘Rheumatoid arthritis treatment: The earlier the better to prevent joint damage’, RMD Open, 1(Suppl 1), pp. 1–5. doi: 10.1136/rmdopen-2015-000057.

[2]Oglesby, A. et al. (2014) ‘Impact of early versus late systemic lupus erythematosus diagnosis on clinical and economic outcomes.’, Applied health economics and health policy, 12(2), pp. 179–90. doi: 10.1007/s40258-014-0085-x.

Acknowledgments:

To all patients and healthy controls who participated in the study

Disclosure of Interests:

Atlas Mashayekhi Sardoo: None declared, Paul Leo: None declared, Mariana Santos: None declared, Tiago Costa: None declared, Sergio Fernandes Almeida: None declared, Sara Maia: None declared, Vladimir Benes: None declared, Mattew Brown Speakers bureau: MSD, Pfizer, Novartis, Jaime Branco Speakers bureau: Vitoria, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria,

Associations of socioeconomic and health related factors with fall risk on community dwelling older adults from Alentejo

Introduction With the world, population ageing falls become a problem. Portugal follows this tendency, particularly in Alentejo. Ecological models evidence that biological, behaviour and socioeconomic factors explain falls. However, the role of socioeconomic and health-related factors on the risk of falls is not well known.

Objectives To analyse the association of socioeconomic and health-related factors with fall risk on community-dwelling older adults from Alentejo.

Methodology This observational study involved 384 community-dwelling older adults (73.6 ± 6.0 years), the minimal sample size calculated by Open Epi Online program, of whom 40.6% fell at least once in the previous year. Sociodemographic characteristics (age, gender, marital status, schooling, retirement age, living alone and yield) and health-related factors (number of health conditions, cognitive state, fat mass %, physical activity, and depression index) were accessed.

Results Univariate Regression Logistic showed that gender was the only sociodemographic characteristics which significantly explains falls occurrence, in which to be woman increases the likelihood of falling on 96% (OR: 1.96, p < 0.05). As regard health-related factors, results show that for each additional health condition the likelihood of falling increased 17%, for each additional 1% on fat mass this likelihood increased 4%, and for each additional point on depression index this likelihood increased 15.1% (OR: 1.04 to 1.17, p < 0.05).

Conclusion Health-related factors showed to be more preponderant in the occurrence of falls compared to socio-demographic characteristics. Women with more chronic conditions increased fat mass, and high depression index will be the most susceptible to falls. Thus, preventive measures should play particular attention to these persons.

mTOR pathway alterations in chromophobe renal cell carcinoma: Impact on metastasis development and overall survival

712

Background: Chromophobe renal cell carcinoma (chRCC) is a histologically and molecularly distinct class of rare renal cancer representing less than 5% of the kidney tumors. Molecular knowledge of this disease is limited, as well as prognostic factors for relapse if localized disease or response in the metastatic setting. Methods: From our database form different Spanish Hospitals, we identified a series of 89 chRCC with a localized stage and 3 patients stage IV at first diagnoses. We performed an in-depth characterization of mTOR pathway alterations, through targeted NGS and immunohistochemistry (IHC) of phospho-S6, tuberin and PTEN, and determined their impact on metastasis development and overall survival. Mutations in mitochondria and telomere maintenance genes were also assessed. TCGA kidney chromophobe project (KICH, n=64) was used for validation. Results: TP53, mTOR pathway ( MTOR, TSC2 or TSC1), telomere-related genes ( ATRX, TERT promoter or DAXX) and respiratory chain complex I, were mutated in 28%, 16%, 15% (26, 14, 12 of 87) and 15% (14 of 73) of primary tumors. PTEN and FLCN were mutated in four and three patients, respectively, two with bilateral tumors. IHC of phospho-S6 revealed positive staining in 37% of primary tumors (21 of 57), in association with MTOR, TSC2 and TSC1 mutations (P=0.009). Negative PTEN staining in 82% of cases (46 of 56) suggested PTEN loss as a chRCC characteristic, and was mutually exclusive with MTOR, TSC2 or TSC1 mutations (P=0.001). Weak or negative tuberin staining correlated with TSC2 mutations (P=0.02). Regarding metastasis development, TP53 mutations were enriched in malignant tumors (P=0.018), while telomere-related mutations showed a trend in the same direction. mTOR pathway mutations were associated with worse outcome. Overall survival in multivariable analysis adjusting for tumor stage gave a Hazard Ratio of 6.5 (P=0.009) This association was confirmed in TCGA-KICH (HR=11.9, P=0.05). Conclusions: Our study provides new genomic knowledge of chRCC and identifies novel markers of poor survival. Furthermore, we identified patients with mutations in mTOR pathway genes that showed high sensitivity to mTOR inhibitors.

555 Right ventricular longitudinal strain of patients with pulmonary hypertension

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Recently, speckle-tracking echocardiography has emerged as a new tool in the RV assessment. In this study, we aimed to study the value of global longitudinal strain in the RV evaluation of these patients.

Methods

We collected clinical, laboratory, echocardiographic and right heart catheterization (RHC) data from consecutive patients referred to an expert tertiary care referral centre from 12/2016 to 11/2018. Global RV systolic peak longitudinal strain (RVS) and RV free wall peak longitudinal strain (RVFWS) (mean of the basal, mid- and apical-segments) were measured by speckle-tracking technique with Echo-Pac software from GE Healthcare®.

Results

Of the 97 included patients, 76% were female. The mean age was 65 ± 15 years. Most patients were in NYHA class II. Median time between TTE and RHC was 70 days [IQR 34 - 184]. Group 2 PH was the most frequent aetiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

Both strain parameters significantly correlated with other echocardiographic parameters such as TAPSE, FAC, Tricuspid S wave, RV diastolic diameter, eccentricity index (EI), systolic pulmonary artery pressure (SPAP), pulmonary acceleration time and presence of RV outflow tract notching. Strain parameters were also associated with pulmonary artery pressures and pulmonary vascular resistance (PVR) measured by RHC. Strain parameters did not correlate with PECP (p > 0.05).

In multivariate analysis, RV global longitudinal strain predicted invasive mean pulmonary artery pressure and PVR independently of TAPSE and FAC (β=1.38, p < 0.001). RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02, AUC 0.72) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51, AUC 0.78). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

RV global and free wall longitudinal strain significantly correlate with other echocardiographic parameters of RV structure and function and with invasive pulmonary artery pressures and PVR.

Abstract 555 Figure.

P1725 An easily dismissed suspect

Funding Acknowledgements

None

Introduction

Constrictive pericarditis (CP) is a rare etiology of heart failure. Is a chronic inflammatory process, characterized by scarring, fibrosis and pericardial calcification. Several etiologies can be associated with CP, namely infectious, idiopathy and post-surgical. In some cases, CP can extend to the myocardium and/or lead to cardiac dysfunction.

Case Report

58 years old woman, active smoking, referred to the emergency room for tachycardia on a routine electrocardiogram. History of 5 months of fatigue and dyspnea to ordinary activities, with progressive aggravation in the last month, associated with weight loss and episodic palpitations. Upon the physical examination presented jugular vein engorgement and peripheral edema. Admission electrocardiogram with atrial flutter at 150 of ventricular frequencies, without other findings. Thoracic radiography without variation (tenues pericardium enhancement), abdominal echography with moderate ascites. Blood work showed elevated liver enzymes, BNP of 230pg/ml, exclusion of infectious tuberculosis and autoimmune panel with isolated positive rheumatoid factor. Transthoracic echocardiography (TTE) at the emergency room show a non-dilated and global left ventricle hypokinesia, with reduced left ventricular ejection fraction (LVEF) and dilatation of the mitral valve ring in the genesis of moderate mitral regurgitation. Anticongestive and antiarrhythmic therapy started with rhythm conversion and clinical improve. Thoracic computed tomography scan reveals an extensive pericardial calcification. 2 months later TTE reveal a preserved LVEF, pericardial calcification, moderate mitral regurgitation, grade III diastolic dysfunction, respiration-related ventricular septal shift, increased of the mitral E-wave velocity with an E/A of 2.76, the peak mitral E-wave decreases 36% with the inspiration, dilated inferior vena cava without respiratory variation. Cardiac magnetic resonance imaging exposes a septal bounce and pericardial calcification, suggestive signs of constrictive pericarditis. The patient waits for cardiac catheterization for confirmation, being with anticoagulation, ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonist medication, remaining in NYHA class I.

Discussion

Clinical suspicion of CP is key for its identification, since there is not a specific clinical manifestation and generally patients presented heart failure symptoms. Echocardiography is best tool for a clinical physician evaluate heart failure etiologies, and can be used with higher sensitivity and specificity associated to the correct criteria to the diagnosis of CP. Pericardiectomy is the standard treatment, however the moment of its performance is not well established, since patients can remain in NYHA class I several years and the surgical procedure have higher mortality rates.

P1289 Echocardiograhic prediction of pulmonary arterial capacitance in patients with heart failure with preserved ejection fraction

Background

Pulmonary arterial capacitance (PAC) has emerged as one of the strongest hemodynamic predictors of adverse outcomes in a wide spectrum of cardiovascular diseases, including pulmonary hypertension in heart failure with preserved ejection fraction (HFpEF-PH). We aimed to study non-invasive surrogates for PAC using transthoracic echocardiography in this population.

Methods

We retrospectively evaluated consecutive patients referred to an expert tertiary care referral centre from December 2016 to November 2018. Transthoracic echocardiography (TTE) was performed within 1 year of right heart catheterization (RHC). Echo-Pac software from GE Healthcare® was used to perform echocardiographic analysis. PAC was calculated dividing right ventricular stroke volume by pulmonary arterial pulse (systolic – diastolic) pressure, measured by RHC.

Results

Of the 105 enrolled patients, 43 were had HFpEF-PH. Among these, 72% were female and mean age was 68.9 ± 11.2 years. Median time between TTE and RHC was 68 (IQR 34 – 191) days. Most patients were in NYHA class II (60.5%) and class III (34.9%). Fifty eight percent of the patients had history of paroxysmal or permanent atrial fibrillation. This population presented borderline parameters of right ventricle (RV) systolic dysfunction: fractional area change (FAC) 35.3 ± 9.2%, tricuspid annular plane systolic excursion (TAPSE) 18.3 ± 5.1 mm, tricuspid S’ wave 10.4 ± 2.9 and RV global longitudinal strain -15.5 ± 4.0. Regarding invasive assessment, this population presented mean pulmonary artery pressures of 38.8 ± 13.9 mmHg, pulmonary artery wedge pressure of 21.6 ± 6.4 mmHg, pulmonary vascular resistance of 3.9 ± 2.7 Wood and median PAC of 0.13 (IQR 0.09 – 0.19) ml/mmHg. The TAPSE / Pulmonary arterial systolic pressure (PASP) ratio and the Right ventricular outflow track velocity time integral (RVOT VTI) / PASP ratio were the parameters that best correlated with PAC (r = 0.69, p = 0.002 for both parameters) (table 1). These parameters were obtainable in the majority of patients (31/43). Blant-Altman analysis revealed good agreement between these measures and PAC with a mean difference of - 0.17 (CI -0.21 - -0.13) for RVOT VTI / PASP ratio and -0.23 (CI -0.28 - -0.18) for TAPSE /PASP ratio.

Conclusion

In a HFpEF – PH population, TAPSE / PASP and RVOT VTI / PASP are easily obtainable in most patients and significantly correlate with PAC.

Abstract P1289 Figure.

P1505 Echocardiographic assessment of different pulmonary hypertension groups

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Different etiology groups might have different echocardiographic phenotypes. In this study, we aimed to study echocardiographic characterization of the different PH groups and its ability to predict pulmonary vascular disease severity.

Methods

We collected echocardiographic and right heart catheterization (RHC) data from 97 (75% female, age 65 ± 15 years) consecutive patients referred to an expert tertiary care referral PH centre from 12/2016 to 11/2018. Echocardiographic analysis was performed using Echo-Pac software from GE Healthcare®. Group 3 and 5 were not included in the group comparison analysis due to few patients included.

Results

Group 2 PH was the most frequent etiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population as a whole showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

PH group 1 had a significantly lower FAC (26 ± 4%, p = 0.0025), higher eccentricity index (IE) (1.5 ± 0.1, p = 0.01), and more frequently RV outflow tract (RVOT) notching than other groups (62%, p = 0.012). Group 4 presented an intermedium echocardiographic phenotype between group 1 and 2, and showed more abnormal strain values than the other groups. Group 2 had fewer patients in sinus rhythm (atrial fibrillation in 34% of patients, p = 0.02), presented a thicker interventricular septum (11.3 ± 1.8, p = 0.014), a higher FAC (35 ± 3%, p = 0.0025), higher E mitral wave velocity (72 ± 6 cm/s, p < 0.001) and E/E’ ratio (12.7 ± 10.2, p = 0.006), and larger left (45 ± 3 cm3/m3, p < 0.01) and right atria (25 ± 2 cm2, p = 0.03).

PH groups 1 and 4 had higher Pulmonary Vascular Resistance (PVR) and Pulmonary Mean Arterial Pressure (PMAP) values than group 2, which significantly correlated with echocardiographic RV function parameters as TAPSE, FAC, RV global strain and IE. In PH group 2, eccentricity index was the only predictor of PVR (β=4.1, p = 0.018). In this population, a left atria volume < 32.7 cm3/m2 (OR 4.25, CI 1.71 - 10.55) and a E/e’ ratio < 12 (OR 4.72, CI 2.05 - 10.87) predicted PECP < 15 mmHg. RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

Different PH groups present mild echocardiographic differences between them. PH group 1 presented with more echocardiographic signs of RV disfunction, and PH group 2 had higher FAC, E/E’ and larger right and left atria. RV function parameters predicted PVR in PH groups 1 and 4, and EI was the only predictor of PVR in PH group 2.

Abstract P1505 Figure.

P631 A misleading EKG and the saviour echo

Introduction

Floating right heart thrombi (in transit from the legs to the pulmonary arteries) are a severe form of venous thromboembolism, with a high early mortality rate without treatment. Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism.

Case Report

Woman, 76 years old. Previous medical history of hypertension, dyslipidaemia, mitral valve repair and hypothyroidism. Recent admission in our cardiology department with de diagnosis of NSTEMI. She performed an echocardiogram that revealed only an enlarged left atrium, with no other changes. EKG only revealed inversion of T waves in V2-V4 with posterior normalization during hospital stay. She underwent to coronary angiography and right dominance without any coronary lesions was showed. The presence of a fistula, with a badly defined route, was also pointed in the coronary angio.

One month after this episode she was admitted again in our emergency department due to onset of dyspnoea and productive cough. The physical examination showed SatO2: 90%; BP: 95/53 mmHg; HR: 100 bpm; Respiratory rate: 27 cpm; Apyretic (36,9ºC). Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination. EKG revealed a sinus tachycardia, HR 122 bpm, with ST elevation in aVR and ST depression in DI, DII, aVL and V2-V6. Presence of S wave in DI and Q wave in DIII. While the EKG was being performed the patient presented a sudden cardiovascular deterioration (with blood pressure (BP: 67/35mmHg) drop and appearance of chest pain). We performed an arterial-blood gas test that revealed: pH7,16; pCO2 26,5; pO78,7; Potassium 4; Sodium 138; lactates 8,8. With these findings we decided to perform an echocardiogram to identify a possible cause for the shock. The echo showed right dilated chambers (with D-shape in parasternal short axis) with dilated IVC. We also point out the presence of a mobile intra-cardiac mass at the level of right atrium, suggestive of thrombus.

We assumed the presence of obstructive shock in the context of pulmonary embolism. Thrombolysis was performed with clinical improvement of the patient. Medical therapy was optimized and heparin was initiated after the patient finished alteplase perfusion.

During hospital stay the patients didn’t have any other cardiovascular complication and went home after 7 days in hospital. A venous doppler was performed before hospital discharge and it revealed the presence of a deep venous thrombosis at the level of right femoral vein.

Conclusion

The authors presented a didactic clinical case where the EKG mislead us to a possible Acute Coronary Syndrome involving the left main artery. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.

P629 An uncommon cause for a frequent problem

Case Report

Man, 52 years old. Active smoker and with previous peptic ulcer history. Admitted to our emergency department due to sudden onset of confusion and incoherent speech. The physical examination showed only a Glasgow Coma Scale of 9 and the presence of expressive aphasia. Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination.

Investigations showed a normal EKG, chest X-Ray and arterial-blood gas test. Blood test showed only the presence of thrombocytopenia, leucocytosis and renal disfunction. Brain CT revealed left-sided thalamic lacunar lesion. We assumed an ischemic stroke and admitted the patient in our emergency department. Neurological deterioration in the first 24h. A new brain CT was performed and showed multiple lesions in the middle cerebral artery territory. The echocardiogram was performed and showed the presence of multiples vegetations in both mitral leaflets with moderate to severe mitral regurgitation associated. We assume an ischemic stroke in the context of possible infective endocarditis. Medical therapy was optimized and empirical antimicrobial therapy was started (ampicillin + gentamicin + flucoxacillin).

The patient never had fever during hospital stay. Duke criteria with only 1 major criteria. Persistent negative microbiological cultures with decreasing inflammatory parameters. Blood tests revealed a progressive increase level of INR (2-4) and renal function deterioration. Patient began with massive episodes of diarrhea and sudden decrease of haemoglobin level (sudden reduction of 3g/dl). Endoscopic studies were performed and multiple ischemic lesions of embolic etiology and small vessel disease had been described. Serology test revealed a positive IgG for Mycoplasma pneumoniae. Autoimmune lab tests showed positivity for lupus anticoagulant, anticardiolipin and anti–beta-2 glycoprotein I.

We discussed the clinical case with our autoimmune experts team and the diagnosis of Systemic Lupus Erythematosus + Antiphospholipid Syndrome + Libman-Sacks Endocarditis was assumed. The patient started immunosuppressive therapy (Azathioprine + Mycophenolate Mofetil + Prednisolone).

Despite the used therapy the size of vegetation persisted and mitral regurgitation didn’t improve.

In this context, the patient was presented to our cardiac surgery team and underwent surgical intervention (vegetation removal + mitral valve repair). Evaluation one year after surgery revealed progressive functional and echocardiographic improvement.

Conclusion

The authors presented a didactic clinical case where valvular surgery was required thanks to a hemodynamically significant valvular dysfunction and embolic events.

Salt reduction in bread: Is it enough? Preliminary results of a HIA in Portugal

Issue

Health Impact Assessment (HIA) is a methodology that aims at assessing the impact of policies in health. A pilot HIA is in progress to kick off the implementation of this methodology in Portugal with the support of the World Health Organization (WHO). In this context, the impact of a nation-wide policy that intends to achieve a maximum of 1 g of salt/100 gr in bread is under assessment.

Description of the issue

In 2017, Portugal approved a protocol between the industry and other stakeholders to gradually decrease the amount of salt in bread, as this is the main source of salt intake. The purpose of this study was to assess the impact in blood pressure from current (1.4 gr) to 1 g (29% reduction) of salt in bread. Data from two different surveys regarding blood pressure and salt intake was gathered. We estimated the decrease in blood pressure with respect to current average values according to sex, age, education and region.

Results

It is expected that a reduction of 29% in salt intake through bread contributes to a general decrease in systolic pressure for normotensive people (from 120.4mmHg to 120.0mmHg, p = 0.85) and hypertensive people (from 151.0mmHg to 150.1mmHg, p = 0.68), although not statistically significant. Older hypertensive individuals (65 to 75 years) are the group with the largest benefit (152.8mmHg to 152.0mmHg) but no statistical difference was found. Disaggregation by sex, region and education also didn’t show any statistical difference.

Lessons

The impact in blood pressure from a 29% reduction in salt intake from bread seems very small. We found no statistical significance between the current and expected values in blood pressure either for total or group stratification. The absence of statistical effect might be due to sample size as our sources only allowed us to work with aggregated data.

Key messages

Quality and access to data is needed to assess impact of policies. to increase effects in blood pressure either salt reduction from bread must be larger or a wider range of products should be considered.

Knowledge and Attitude towards the Gradual Reduction of Salt in Bread – an Online Survey

Background

Bread is one of the main sources of salt intake in Portugal. Based on this evidence, a protocol signed between national Health Sector and the Associations of Industrial Bakeries, in 2017, established gradually decrease salt in bread until 2021. This measure also targets schools’ available bread, this should not exceed 1g salt, to end of 2018. A pilot Health Impact Assessment (HIA) aims to assess the potential impact on salt reduction in bread on the eating habits of children (6-18 years) and their families.

Methods

A questionnaire is being performed to assess the effect of this measure. The first version was designed by a panel of 11 experts (content validity), following the plain text principles. A external specialist revised it for facial validity. A pilot was tested. Thereafter, a REDCap online survey of “Knowledge and Attitude towards the Gradual Reduction of Salt in Bread” questionnaire was finalized. The target group is the parents or guardians of children and young persons, of School Clusters in the south of Portugal.

Results

Final online survey totalizes 33 items, divided into four blocks: 1.Knowledge and General literacy data, 2.Domestic Consumption, 3.Scholar consumption and 4.Sociodemographic. An adult responsible for the child/young person should answer the survey. Access is possible through a REDCap link, using computers available in the School Cluster, or other manner suitable for the purpose.

Conclusions

This survey will contribute to the identification of modifiable behaviors related with salt intake. Such evidence may eventually provide the opportunity for new strategies in this area.

Key messages

Health Impact Assessment as a procedure to assess the effects of measures and policies on human health. Questionnaires are a rapid tool to access perceptions, attitudes and knowledge.

P1659Evolution of level of evidence c recommendations in European Society of Cardiology clinical practice guidelines on heart failure

Background

Over the past two decades, the European Society of Cardiology (ESC) Clinical Practice Guidelines (CPG) on Heart Failure has increasingly become a familiar part of Cardiology practice and are used worldwide. By creating objective standards, CPG provides a mechanism to assess decision-making and straightforward references for clinicians. Level of Evidence C recommendations are based on expert consensus and/or small retrospective studies and registries with limited and non-representative populations evaluated. The resulting directives need to be proven with better quality data to assess its true benefits.

Purpose

The purpose of our study was to describe and evaluate the evolution of Level of Evidence C recommendations of ESC CPG on Heart Failure and to provide a quality assessment of its benefits in the following years.

Methods

In this retrospective observational Case-Control study, we identified and collected all Level of Evidence C recommendations in five consecutive published documents of ESC CPG in the years 2001, 2005, 2008, 2012 and 2016. Each identified recommendation was classified between two major groups: Diagnostic and Complementary Exams (group 1) and Therapeutics and Interventions (group 2) and was followed up in the following documents. Primary outcomes were classified as: (1) Upgrade to Level of Evidence A or B [Upgrade], (2) Elimination or disproven benefit/harm [Downgrade] and (3) Maintenance or minor reformulation with unchanged benefit/harm [Maintenance]. We applied a Kaplan-Meyer survival analysis to estimate the probability of Upgrade or Downgrade in each group.

Results

A total of 239 different Level of Evidence C recommendations were submitted to the final analysis, 22.6% (n=54) in group 1 and 77.4% (n=185) in group 2. On follow-up, 35.2% (n=76) of recommendations were upgraded, 29.6% (n=64) were downgraded and 35.2% (n=76) were maintained. Regarding outcomes, the downgrade of recommendations occurred predominantly in group 2 (94.4%). Considering all the eliminated recommendations, 60.9% took place on the next following published ESC CPG document. Likewise, 60.5% of upgraded recommendations also occurred on the next following published ESC CPG document. The probability of upgrade or downgrade in the next following document was 52.8%, predominantly in the Therapeutics and Interventions group (37.5% vs 57.9%, p=0.012).

Figure 1

Conclusions

Level of Evidence C recommendations constitutes an important asset of ESC CPG on Heart Failure as they are usually updated on new treatment options and are developed by experts in the specific topic. However, the probability of elimination due to disproven benefit or potential harm was high (29.6%), particularly regarding therapeutics and interventions (94%). Since a significant fraction of Level of Evidence C recommendations remains unchanged on the following document (35%), the need for high-quality data, specifically regarding therapeutic interventions, is warranted.

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

Background

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

Purpose

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

Material and methods

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

Results

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

Conclusions

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