HFA-PEFF score as a prognostic factor in patients with liver cirrhosis

Introduction

Cardiovascular complications of liver cirrhosis which are frequently referred to as cirrhotic cardiomyopathy (CCM), include high cardiac output, reduced afterload and diastolic dysfunction. However, there are only scarce or even conflicting data about the prognostic significance of CCM. HFA-PEFF score is a diagnostic score for heart failure with preserved ejection fraction (HFpEF), which has prognostic value in HFpEF patients. It has functional, morphological and biomarker domains and the score may vary from 0 to 6. Score of 5 or 6 is diagnostic of HFpEF in symptomatic patients. No study has calculated HFA-PEFF score in cirrhotic patients to date.

Purpose

The purpose of this prospective study was to calculate HFA-PEFF score in cirrhotic patients, correlate it with disease severity and determine its prognostic significance.

Methods

A total number of 92 consecutive cirrhotic outpatients were prospectively examined and 72 fulfilled the inclusion criteria. Patients older than 75 years old or patients with ejection fraction (LVEF) <50%, coronary artery disease, moderate or severe valvular heart disease, atrial fibrillation, ongoing alcohol consumption, hepatocellular carcinoma and poor acoustic window were excluded. In all patients a thorough echocardiographic examination was performed, BNP or NT-pro-BNP levels were measured and subsequently HFA-PEFF score was calculated. MELD score was used to define the severity of cirrhosis. The median follow-up was 20 months and the study end-point was defined as the composite of all-cause death.

Results

Mean age was 58.5±8.3 years, 52 (72.2%) were males, median Meld score was 12.9 (8.5–16.3) and mean LVEF was 61.1±5.4%. HFA-PEFF score was 5 or 6 in 38 (52.8%), 2–4 in 27 (37.5%) and 0 or 1 in 9 (9.7%) patients. According to Spearman's coefficient analysis, HFA-PEFF score was correlated with MELD score (rho=0.566, p<0.001), but not with age, systolic blood pressure (SBP) and heart rate. The survival analysis stratified by the HFA-PEFF score [low, score 0–4 (N=34) vs. high, score 5–6 (N=38)] indicated that the HFA-PEFF score successfully predicted all cause two-year survival (log-rank test p<0.001). According to the Cox-regression proportion hazard models HFA-PEFF score as a continuous variable correlated with six-month, one year and two year survival. When HFA-PEFF was treated as a categorical variable, hazard models were significant for the one and two-year survival. The multivatiate COX regression survival analysis showed that the increased HFA-PEFF score (low: score 0–4, N=34 vs high: score 5–6, N=38) was significantly associated with decreased two-year survival when patient age, gender and MELD score are taken into account [HR=3.659 (1.068–12.536), p=0.039].

Conclusions

HFA-PEFF score is high among patients with liver cirrhosis, especially those with increased disease severity. HFA-PEFF score is associated with survival even when adjusting for the severity of the cirrhosis.

Funding Acknowledgement

Type of funding sources: None.

Bioethanol and biogas production: an alternative valorisation pathway for green waste

Biofuels are a research field of great interest given the environmental benefits they offer over conventional fossil fuels. Nowadays, it is urgent to find ways of utilizing waste in the direction of biofuels production. The aim of this paper was the utilization of green waste (branches, leaves and ligno-cellulosic residues from tree prunings, hedge cuttings and grass clippings) towards biofuels production and specifically towards bioethanol and biogas. The experimental plan that was followed included biogas production through anaerobic digestion and bioethanol production through alcoholic fermentation after the necessary chemical pretreatment (acid or alkaline hydrolysis) prior to enzymatic hydrolysis and fermentation. Based on the results obtained, three valorisation scenarios of green waste were designed and compared in terms of product mass intensity, product yield and energy content of biofuels produced. The optimal results for bioethanol production were 5.22 g/L ethanol, 70.61% saccharification yield and 33.67% ethanol yield with acid pretreatment using H₂SO₄ 3% w/v, 475 μL/g cellulose CellicCtec2 and 10% solids loading. Regarding biogas, the highest biogas production observed was 267.1 mL biogas/g dry substrate resulting from anaerobic digestion of the alkaline stillage. Thus, the production of biofuels from green waste is technically feasible, although it provides moderate efficiencies. However, for a sustainable valorisation of green waste, other techno-economic factors such as the cost of enzymes, chemicals, energy, etc. must be taken into account.

Dobutamine stress echocardiography during covid-19 pandemic: impact on volume and positivity rates in a tertiary hospital

Funding Acknowledgements

Type of funding sources: None.

Introduction

The emergence of coronavirus 2019 infection (covid-19) was accompanied by severe social and economic restrictions and applied significant pressure to the healthcare systems. The first pandemic wave started in March to May 2020 and was characterized by the peak of confinement measures and lockdown application. The second wave started in September and peaked in November to December 2020 and was characterized by improved healthcare organization but significant burden for the hospitals and intensive care units. Dobutamine stress echocardiography (DSE) is used for evaluation of ischemia in patients with known or suspected coronary artery disease.

Purpose

To compare DSE volume and positivity rates between 2019 and 2020 time periods in a department of a public tertiary hospital.

Methods

We retrospectively analysed DSE studies performed in our department in 2020 including the peak of covid-19 restrictions and compared the data to the 2019.

Results

Volume of DSE studies decreased from 1516 in 2019 to 996 in 2020 (-34.3%). The study volume reduction was greater in April (-93.7%) and May (-54.5%) when the covid-19 restrictions were at the peak. Great decreases were also recorded in November (-46.8%) and December (-53.5%) when the second wave of covid-19 disease emerged. Conversely, small increases were recorded in September (7.1%) and October (10.6%) (figure 1). Regarding positivity rates, a statistically non-significant increase was recorded (33.6% vs 34.2% in 2019 and 2020 respectively, p = 0.73). Interestingly a statistically significant increase in positivity levels was recorded during the period March to May 2020 compared to the same period of 2019 (44.7% vs 36.9%, p = 0.029). On the contrary, positivity rates were decreased at the period September to December (27.1% vs 34.2%, p = 0.019) (figure 2).

Conclusions

Volume of DSE studies was significantly reduced in 2020 when compared to 2019 during respective peaks of the pandemic and the accompanying restriction measures. Positivity rates were higher during the first pandemic wave, possibly due to decreased hospital attendance of mildly symptomatic patients in combination with stricter admission criteria at the emergency department. Lower positivity rates during the second pandemic wave possibly reflect an adjustment of both healthcare systems and patients to the new conditions imposed by the covid-19 pandemic. Abstract Figure 1  Abstract Figure 2