Prevalence and implications of exercise pulmonary hypertension in chronic thromboembolic pulmonary disease

Introduction

Recent international statement on chronic thromboembolic pulmonary hypertension proposed the definition of chronic thromboembolic pulmonary disease (CTEPD) and advocated further research regarding its clinical characteristic, natural history, and therapeutic strategy. Exercise pulmonary hypertension (Ex-PH) has been considered a mild degree of pulmonary hypertension (PH) among patients with normal pulmonary hemodynamics at rest. However, the clinical significance of Ex-PH in CTEPD remains unknown.

Purpose

In the patients with CTEPD, we aimed to verify 1) the prevalence and clinical profiles of Ex-PH, 2) effect of BPA on pulmonary vascular response after exercise in Ex-PH, 3) long-term clinical outcomes of conservative management in non-Ex-PH.

Methods

We retrospectively reviewed 26 patients with CTEPD (median age 65 years, 38% male), who underwent cardiopulmonary exercise test with right heart catheterization (CPET-RHC). The definitions of CTEPD are the following 1) pulmonary artery occlusion due to organic thrombus confirmed by imaging studies after ≥3 months of anticoagulation, 2) mPAP<25 mmHg and PAWP≤15 mmHg at rest. PQslope was plotted using multipoint plots. Ex-PH was defined by PQ slope>3.0, and the patients were divided into Ex-PH and non-Ex PH groups. Clinical profiles and long-term outcomes were compared between two groups. The patients in Ex-PH groupunderwent CPET-RHC 6–12 months after balloon pulmonary angioplasty (BPA). In Non-Ex-PH group, serial measurements of echocardiography were performed.

Results

Overall, 5 and 21 patients were categorized as CTEPD with PH (mPAP 21–24mmHg) and without PH (mPAP≤20mmHg), and 14 and 12 were categorized Ex-PH and non-Ex-PH groups, respectively. Although all 5 patients with CTEPD with PH were classified as Ex-PH group (Figure 1), there was no significant difference in baseline hemodynamics at rest between Ex-PH and non-Ex-PH groups (mPAP: 19.5 [18.4–20.6] vs. 17.7 [16.6–18.9] mmHg, PVR: 2.2 [1.7–2.7] vs. 2.3 [1.9–2.8] wood units, P>0.05, respectively). PQ slope was significantly higher in Ex-PH group (4.6 [3.2–6.0] vs. 1.31 [0.2–2.8], p=0.002). There were no differences in respiratory function test, blood gas analysis, and 6-minute walk distance between two groups. There were no major adverse events such as all-cause mortality and hospitalization for PH in overall cohort. Among Ex-PH group, BPA decreased PQslope (4.8 [3.6–6.4] to 2.3 [1.9–3.0], p<0.05). Among no-Ex-PH group, there was no significant change in tricuspid regurgitation pressure gradient (28 [17–33] to 27 [21–36] mmHg, p>0.05) over the 997 [651–1451] days.

Conclusion

Ex-PH was common in patients with CTEPD, and there were no clinical profiles differentiating Ex-PH from non-Ex-PH, except parameters of CPET-RHC. BPA improved an abnormal pulmonary vascular response to exercise in Ex-PH. The conservative management in non-Ex-PH was feasible. Randomized clinical trials will be needed to further investigate this treatment strategy.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Acute coronary syndromes hospitalizations and in-hospital outcomes during and after the lockdown of corona virus disease 19 (COVID-19) pandemic outbreak

Funding Acknowledgements

Type of funding sources: None.

Background

Multiple studies documented an important reduction of acute coronary syndromes (ACS) admissions during the Coronavirus Disease 19 (COVID-19) pandemic. There are few studies regarding the ACS admissions and outcomes during the ongoing pandemic after the initial lockdown.

Purpose

We aimed to study the ACS admissions and in-hospital outcomes during and after the COVID-19 lockdown period.

Methods

A retrograde single-center study was conducted. The data for all admissions were collected from March 9th, (first COVID-19 case) until April 30th, the corresponding period of 2020 total lockdown, for three consecutive years from 2019 to 2021. The control period was considered the year 2019 and the study periods were in 2020 (lockdown) and 2021 (ongoing pandemic). ACS admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA). Incidence rate ratio (IRR [95%CI]) was used to compare all-ACS and subgroups admissions, and risk ratio (RR [95%CI]) to compare the mortality between each study period with the control one.

Results

Were included 550 ACS patients (pts) during 2019, 321 pts during 2020, and 473 pts during 2021 period. The overall-ACS admissions IRR was significantly lower during 2020 lockdown (0.58 [0.44-0.76]), and not significant during 2021 ongoing pandemic (0.86 [0.62-1.18]). During 2020 lockdown, significant reduction for STEMI and UA, the IRR respectively (0.72 [0.56-0.94]) and (0.42 [0.22-0.76]), and not significant during 2021 respectively (0.87 [0.63-1.21]) and (0.86 [0.51-1.46]) were observed. The reduction in NSTEMI admissions was not significant in both periods.

The overall mortality was, importantly increased during the lockdown period (7.45 vs. 3.4 %), RR=2.16 (1.2-3.89). Meanwhile the 2021 mortality was similar (4.2 vs. 3.4%), RR=1.22 (0.66-2.26).

Conclusions

After the initial reduction of admissions in all-ACS, STEMI and UA during the 2020 lockdown period and the increase of all-ACS mortality, the number of admissions and the mortality returned to a similar range during 2021 despite the ongoing COVID-19 pandemic.

Contrast induced nephropathy in interventional cardiology; identification of high-risk patients and its prevention

Funding Acknowledgements

Type of funding sources: None.

Background

CIN is a serious and potentially preventable complication of coronary angiography and/or percutaneous coronary interventions (PCI). The definition of CIN, its incidence and risk factors and therapeutic interventions are not well established .

Purpose

To study incidence and risk factors of CIN in patients undergoing coronary angiography and/or PCI, to investigate high-risk patients with CIN and to evaluate its preventive therapies (Hydration an Acetylcysteine).

Method

This was a prospective trial, in one center with patients undergoing coronary angiography and/or PCI, during 2010-2014. The renal function was evaluated through serum Creatinine (Cr) and GFR (Cockcroft –Gault formula ). CIN was defined as an increase in Creatinine by 25% and/or by 0.5 mg/dL at 48/72 h after the index procedures. Patients with CIN were considered high-risk when Creatinine increased more than 50% and/or by 2 mg/dL, or needing dialysis. We evaluated the major risk factors for CIN such as: Preexisting Renal Lesion (PRL), Age≥65 years, Heart Failure (HF), Diabetes Mellitus (DM), Anemia (Hb < 12 g/dL) and the Quantity of Contrast used. We evaluated the role of hydration with intravenous saline and acetylcysteine (ACC) in the prevention of CIN.

Results

Out of the 1231 patients enrolled, 804 patients fulfilled the inclusion criteria. The incidence of CIN resulted 14.4%, higher in the group of patients with risk factors for CIN (15.3%) versus without risk factors (9.1%); p=0.05. Risk factors HF (OD: 4.63; CI95%: 2.10-10.05, p<0.001), PRL (OD: 1.57; CI95%: 1.02-2.41, p=0.039) and Age ≥ 65 years (OD: 1.82; CI95%: 1.37-3.73, p=0.038 ) resulted independent risk factors, for CIN whereas Anemia (p=0.171), DM (p=0.502) and the Quantity of contrast used (p=0.479) did not result independent risk factors. Creatinine at 24 hours after the procedure resulted a predictive factor for the development of CIN. (sensitivity 64.7%, specificity 91.7%, positive predictive value 63.5%, negative predictive value 92.1% ). Creatinine > 1.5 mg/dL before the procedure resulted an independent risk factor for CIN, with a higher specificity than eGFR < 60 ml/min. The incidence of patients with CIN at high risk was 3.9% and HF resulted the only independent risk factor in this subgroup of patients (OD:4.49, CI 95%: 2.03-9.95). Intravenous hydration with saline resulted efficient in the prevention of the development of CIN (p=0.029), whereas ACC did not (p=0.485).

Conclusions

The frequency of CIN is higher in the group with risk factors. The HF, PRL, Age≥ 65 years resulted as independent risk factors for, and intravenous hydration with saline was a simple and efficient method for the prevention of CIN. Although our definition of CIN is widely used, the need for a universal definition for CIN is a contemporary need.

The impact of temperature changes on patients with acute coronary syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

There are few studies about changes in temperature as a risk factor instability of atheromatous plaque and Acute Coronary Syndrome (ACS). It is the first study in our country.

Purpose

To evaluate the impact of temperature on patients with Acute Coronary Syndrome.

Methods

This is a retrospective, observational, analytical study conducted in a single-center, in the period January-December 2018. We included patients with the diagnosis of ACS, hospitalized in CCU, who performed emergency coronary angiography. Data were collected retrospectively using patient records from archived files at the Statistics Center. Data on atmospheric parameters, measured at the weather monitoring station, were obtained from the National Meteorological Service database (average daily temperature in each district of the country). The number of inhabitants for the respective districts is taken from the National Institute of Statistics.

Results

The study included 1165 patients. A significant association was found between the number of ACS per day with temperature changes (r=-0.13, p<0.01). The highest number of ACS was in October 10.4%, whereas the lowest number was in January 10.6%, with a significant decreasing trend during May-June and the peak in October (p=0.04). Significant changes in the average monthly values of temperature were accompanied by a statistically significant increase in the number of cases as occurred in March-April and October-November. (p≤0.05) A statistically significant relationship was observed between seasonal changes in temperature with the number of cases with ACS. The autumn season prevails with 27.9% of the total cases, followed by the spring season with 25.6%, the summer season with 24.2%, and the winter season with 22.3%, (p = 0.04). Most cases in the cold period (November-March) occurred on days with statistically significant changes in Temperature.

Conclusion

The study notes an important relationship between seasonal, monthly, and daily changes of temperatures, in relation to the frequency of cases with Acute Coronary Syndrome.

Left ventricular global longitudinal strain is superior to ejection fraction for prognostication in ebstein anomaly

Background

Certain factors such as left ventricular (LV) geometry and loading conditions affect the validity and reliability of LV ejection fraction (LVEF) as a true measure of LV contractility. LV global longitudinal strain (LVGLS) is less sensitive to these factors, and it has superior prognostic performance in patients with acquired heart disease. The purpose of this study was to determine the clinical implications of using LVGLS (instead of LVEF) as the measure of LV systolic function in adults with Ebstein anomaly given the inherent abnormalities of LV geometry and preload in this population.

Methods

Retrospective cohort study of 673 adults with Ebstein anomaly (2003–2018). We hypothesized that LVGLS had a stronger correlation with heart failure indices and transplant-free survival compared to LVEF.

Results

Compared to LVEF, LVGLS had stronger correlations with cardiac index (r=0.46 vs r=0.21, p=0.007), glomerular filtration rate (r=0.57 vs r=0.19, p<0.001), and NT-proBNP (r=−0.64 vs r=−0.41, p=0.01). Of 673 patients, 514 (76%) had normal LV systolic function (LVGLSNormal-LVEFNormal), 87 (13%) had subclinical LV dysfunction (LVGLSLow-LVEFNormal) and 66 (10%) had overt LV dysfunction (LVGLSLow-LVEFLow). Compared to the overt LV dysfunction group, the subclinical LV dysfunction group had similar 10-year transplant-free survival (64% vs 63%, p=0.6), but were less likely to be on heart failure therapy (12% vs 82%, p<0.001). LVGLS (but not LVEF) was the independent predictor of transplant-free survival

Conclusions

LVGLS provided more robust risk stratification and prognostication than LVEF in patients with Ebstein anomaly, and patients with low LVGLS had reduced transplant-free survival regardless of LVEF. The use of LVGLS (rather than LVEF) as the measure of LV systolic function has important clinical implications with regards to initiation of medical and surgical therapies.

Funding Acknowledgement

Type of funding sources: None.

“Target Heart Rate” calculated aiming at zero overlap of mitral E and A waves is useful for prediction of long-term outcome for patients with heart failure and reduced ejection fraction

Background

Lower heart rate (HR) is associated with more favourable long-term outcome in patients with heart failure with reduced ejection fraction (HFrEF). However, an optimal threshold of HR remains unclear. Targeted HR (THR), defined by echocardiographic deceleration time (DCT) to eliminated overlap of E and A waves, may aid in risk stratification of HFrEF patients.

Purpose

In this study, we aimed to clarify the impact of on long-term clinical outcome in patients with HFrEF.

Methods

In the multicenter WET-HF registry, 4000 consecutive patients hospitalized for acute decompensated HF (ADHF) were registered between 2006 and 2017. Among them, the patients with EF ≥40% or a history of atrial fibrillation were excluded. THR was calculated based on their DCT value measured in compensated HF phase during the index admission. The following formula was applied; THR (bpm)=93 - 0.13 × deceleration time (DCT, msec). A total of 876 patients with HFrEF were included in the present analysis (age: 72 [60–81], male: 69%) and the patients were divided into the 2 groups of HR at discharge ≤ THR (L group) and > THR (H group). The primary endpoint (PE) was defined as the composite of all-cause death and ADHF re-admission.

Results

Compared to the H group, the L group showed higher prevalence of males (74% vs. 66%, P=0.025) with higher body mass index (BMI, 23.2 vs. 22.2, P=0.016), hemoglobin (Hb, 12.9 vs. 12.4, P=0.031), albumin (Alb, 3.7 vs. 3.6, P=0.039) and larger left atrial diameter (LAD, 44 mm vs. 41 mm, P=0.002) and tricuspid regurgitation pressure gradient (TRPG, 29 mmHg vs. 27 mmHg, P=0.012). Age, estimated glomerular filtration rate (eGFR), LVEF (29% vs. 30%, P=NS) and E/e' (17.7 vs. 16.8, P=NS) were similar for both groups. At discharge, HR was lower in L group (66 [60–71] bpm vs. 80 [74–86] bpm, P<0.001), albeit there were no significant differences in b-blocker prescription (90% vs. 85%, P=0.069) or its dose (3.75 [1.25–7.25] mg vs. 2.5 [1.25–5] mg, P=0.11).

In the survival analysis, the L group showed a significantly lower rate of PE (P=0.03), whereas there was no significant difference in the incidence of PE between the patients with HR at discharge ≥70 bpm and <70 bpm (P=NS).

Multivariate Cox hazard analysis showed that HR at discharge ≤ THR was an independent predictor of PE (hazard ratio 0.67 [0.46–0.97], P=0.037), even after adjusting for confounding factors including age, sex, BMI, Hb, Alb, and b-blocker prescription, whereas HR at discharge <70 bpm was not (hazard ratio 0.94 [0.65–1.33], P=0.71).

Conclusion

THR was associated with long-term outcomes in patients with HFrEF after acute decompensation, suggesting that it may aid in tailored treatment for HR reduction in these patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prognostic implications of left heart diastolic dysfunction in adults with coarctation of aorta

Background

Left atrial dysfunction (LAD) and left ventricular diastolic dysfunction (LVDD) has been described in patients with coarctation of aorta (COA). However, it is unknown whether LA function and LV diastolic function indices can be used for prognostication in this population. The purpose of this study was to determine whether LAD and LVDD were associated with mortality in adults with COA. We hypothesized that LA and LV diastolic function indices will predict transplant-free survival in COA patients.

Methods

Retrospective study of COA patients (age ≥18) at Mayo Clinic (2000–2018). LVDD was determined using the 2016 guidelines for LVDD assessment, and LAD was assessed using LA reservoir strain.

Results

Of 721 patients, LV diastolic function could be determined in 635 (88%), while 86 (12%) were classified as indeterminate diastolic function. Of 635 patients, 414 (65%) had no LVDD, while 146 (23%), 53 (8%), and 22 (4%) had grade I/II/III LVDD respectively. The mean LA reservoir strain was −39±11%, and patients were divided into quartiles: top quartile (reference group), mild LAD, moderate LAD, and severe LAD.

Of 635 patients, 49 died and 4 underwent heart transplant. On multivariate analysis, Grade III diastolic dysfunction (but not Grade I and II) was associated with mortality as compared to normal diastolic function. On the other hand, there was an incremental risk of mortality across LA strain quartiles: mild LAD (HR 1.16, 1.04–2.06), moderate LAD (HR 1.75, 1.27–3.58), and severe LAD (HR 3.49, 1.88–7.16). Of the 86 patients with indeterminate diastolic function, LAD was associated with a lower 5-year transplant-free survival as compared to normal LA function (83% vs 91%, p=0.06).

Conclusions

LAD (but not LVDD) was associated with incremental risk of mortality, and thus can be used for prognostication in all patients including those with indeterminate diastolic function. Although the current study did not identify a consistent relationship between LVDD severity classifications and mortality among COA patients, it does not imply that LVDD is benign. Rather it suggests that the conventional criteria for LVDD severity classifications may not be generalizable to every disease subgroup

Funding Acknowledgement

Type of funding sources: None.

Persistent hypertension and left ventricular hypertrophy after repair of native coarctation of aorta in adults

Background

There are limited data about outcomes after repair of native coarctation of aorta (COA) in adulthood. The purpose of this study was to describe the procedural outcomes, hemodynamic improvement, regression of LV hypertrophy and cardiovascular events in adults undergoing repair of native COA.

Methods

The primary outcomes were procedural complications, re-interventions, and hemodynamic improvement (residual COA gradient <20 mmHg) after COA repair. The secondary outcomes were improvement in the severity of hypertension, regression of left ventricular mass index (LVMI), and incidence of cardiovascular events (atrial fibrillation, heart failure hospitalization, and cardiovascular death) after COA repair. Clinical and imaging indices were assessed pre-intervention, and at 1-year (Y1) and 3-years (Y3) post-intervention.

Results

A total of 172 patients (age 38 [27–48]) underwent COA repair (surgical 161; transcatheter 11). There were no procedural deaths, and all patients had residual COA gradient <20 mmHg. One patients that received transcatheter stent therapy required re-dilation of stent at 12 months post-intervention. There as a reduction in the prevalence of patients requiring anti-hypertensive therapy from 73% (pre-intervention) to 59% and 64% at Y1 and Y3 respectively. However, 72% and 69% of the patients still had systolic blood pressure >130 mmHg (stage 1 and 2 hypertension) at Y1 and Y3 respectively. As compared to patients without hypertension at Y1, patients with stage 1 and stage 2 hypertension had less robust LVMI regression (% change in LVMI 12±5% vs 9±6% vs 5±3%, p<0.001). Hypertension (HR 1.16, 1.05–1.27) and LVMI regression (HR 0.86, 0.81–0.90) were independently associated with cardiovascular events.

Conclusions

Persistent hypertension was common after repair of native COA in adults. Hypertension (including stage 1 hypertension) was associated with suboptimal regression of LVMI and cardiovascular events. These results are concerning, and highlight the importance of early COA diagnosis and repair, and optimal medical therapy for hypertension after COA repair.

Funding Acknowledgement

Type of funding sources: None.

Paradoxical increase in ambulatory systolic blood pressure in coarctation of aorta as compared to idiopathic hypertension

Background

The relationship between office vs ambulatory blood pressure (BP) indices is well-studied in patients with idiopathic hypertension, and based on these data, it is known that average 24-hour ambulatory BP is typically lower than office BP. However, emerging data show that office systolic BP (SBP) underestimates arterial afterload in patients with coarctation of aorta (COA), and minimal increase in stroke volume during low intensity exercise results in exaggerated rise in SBP as compared to those with idiopathic hypertension. We hypothesized that COA patients will have higher ambulatory SBP and a higher prevalence of masked hypertension compared to patients with idiopathic hypertension.

Methods

Case-control study of 118 COA patients and 118 patients with idiopathic hypertension matched by age, sex, body mass index and office SBP.

Results

Although both groups had similar office SBP (132±17 mmHg) by design, the COA group had paradoxical increases in 24-hour ambulatory SBP (135±14 vs 126±13, p<0.001) and daytime ambulatory SBP (142±16 vs 130±13, p<0.001), and less nocturnal dipping (−3±5 vs −9±4, p<0.001). The COA group also had a higher prevalence of masked hypertension (36 [31%] vs 14 [12%], p<0.001), and worse arterial function indices.

Conclusion

These findings underscore the potential limitations of relying on office SBP for screening/monitoring of hypertension in COA and potential pitfalls in extrapolating idiopathic hypertension guidelines recommendations to the treatment of COA. It also provides rationale for further studies to determine if pharmacologic BP interventions guided by ambulatory BP data will improve clinical outcomes in the COA population.

Funding Acknowledgement

Type of funding sources: None.

Outcomes of ST elevation myocardial infarction (STEMI) hospitalizations during corona virus disease 19 (COVID 19) era

Funding Acknowledgements

Type of funding sources: None.

Multiple studies reports a reduction of STEMI hospitalizations rates during COVID 19 pandemic outbreak. Contradictory STEMI complications rates are reported during COVID 19 pandemic regarding case fatalities rates, cardiogenic shock, life threatening arrhythmias and others.

Purpose. To evaluate the impact of the COVID 19 outbreak on STEMI patient outcomes and complication rates in country with low COVID 19 incidence and mortality and without changes in Cardiology hospital services.

Methods. Was conducted a retrograde study collecting data for STEMI hospitalizations, revascularization procedures and case fatalities and other complications from March 9th 2020 (first COVID 19 case in our country) to April 30th (period of total lockdown) compared with the same period of 2019 in our center. Incidence rate ratio (IRR) was used to compare STEMI admissions and revascularization procedures and risk ratio (RR) to compare case fatality rate and other complications rate.

Results

Hospital admissions for STEMI declined during 2020 (COVID 19 period) from a total of 217 patients in 2019 to 155 patients hospitalization in 2020 representing IRR 0.72 (p = 0.009). Reduction were observed in the number of primary PCI from 168 procedures in 2019 to 113 in 2020 (IRR 0.67 p = 0.001). Symptom onset to our ICU (including regional transportation) was significantly higher in 2020 than in 2019 (939.97 ± 1122 versus 436.15 ± 383 minutes p <0.0001) The STEMI case fatality was importantly increased during pandemic outbreak (13.55%) compared to 2019 (8.3%) (RR= 1.63 p = 0.001), but a similar a primary PCI-STEMI case fatality 6.2% versus 5.95%. Also an increase was observed for cardiogenic shock (IRR =1.75 p = 0.003).

Results; Hospitalizations and related invazive revascularization procedures for STEMI significantly reduced during COVID 19 pandemic. We identified a substantial increase of STEMI case fatalities and cardiogenic shock during pandemic outbreak. Delayed timely reperfusion by primary PCI has an important impact on infarct related mortality.

Impact of coronavirus disease 19 (COVID 19) pandemic on acute coronary syndrome (ACS) hospitalizations, and related invasive procedures

Funding Acknowledgements

Type of funding sources: None.

Background

  Reports from countries affected by the COVID 19 pandemic demonstrate a reduction in ACS hospitalizations and invasive procedures.

Purpose

We aimed to investigate the impact of the COVID 19 pandemic on ACS patient hospitalizations and related invasive procedures in a country with low COVID 19 incidence and without changes in Cardiology hospital services.

Methods

We conducted a retrograde study collecting data for ACS hospitalizations including ST elevation myocardial infarction (STEMI), non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) and related invasive and revascularization procedures from March 9th 2020 (first COVID 19 case in our country) to April 30th (period of total lockdown) compared with the same period of 2019 in our center.

Results

Hospital admissions for ACS declined during 2020 (COVID 19 period) from a total of 550 patients in 2019 to 321 patients hospitalization in 2020 representing a 41.6% reduction (p &lt; 0.001). The reduction was observed for all types of ACS, the greatest reduction was for UA 58% (p &lt; 0.001) followed by NSTEMI 32% (p &lt; 0.001) and for STEMI 28% reduction (p &lt; 0.009). Compared to 2019 the proportion of patients presented with STEMI was higher in 2020 (48.6% vs 39.5% p = 0.01) and lower with UA (43.3% vs 31.5% p = 0.0002)

Reduction was observed also in coronary angiography by 43% (p &lt; 0.001) and in percutaneous coronary interventions with 42% (p &lt; 0.001). Compared to 2019 the proportion of patients with 3 vessels coronary disease(CAD)and left main (LM) was higher during COVID 19 pandemic,  respectively 33% vs 40% p = 0.032 and 8% vs 13% p = 0.046

Conclusions

Hospitalizations and related invasive procedures for ACS significantly dropped during COVID 19 pandemic.  Patients admitted to hospital during pandemic presented more with STEMI and had more 3 vessels CAD and LM. Measures should be taken to ensure patients for the safety of health services and encouraged not to neglect cardiac consultations and treatments.

Leg raise can detect exercise-induced pulmonary arterial wedge pressure elevation

Background

Exercise-induced elevation of pulmonary arterial wedge pressure (PAWP) may show preclinical or exercise-induced left ventricular diastolic dysfunction. Invasive hemodynamic assessment during provocative maneuvers, like exercise and volume challenge, in these patients allows greater sensitivity to diagnose or exclude HFpEF. The aim of this study was to examine how the leg raise, which is a simple way to increase preload, can detect exercise-induced PAWP elevation.

Methods

Four hundred seventy-nine patients (60±14y.o, mean pulmonary arterial pressure (PAP) 19mmHg, PAWP 8mmHg, CTEPH /IPAH/CTD-PH/SOB unknown reason: 357/56/38/28pts) with near-normal PAP and normal PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter. Exercise-induced elevation in PAWP of over 20mmHg was defined as exercise-induced elevation group.

Results

ΔPAWP (after leg raise - rest) in the exercise-induced elevation group was significantly higher (6.0±4.1 vs. 2.7±3.9mmHg, p&lt;0.001, in the older (age≥60y.o) group (n=276); 3.4±3.5 vs. 1.9±3.4mmHg, p&lt;0.001, in the younger (age&lt;60y.o) group (n=203)) than that in the non-elevation group after legs raise for cycle ergometer exercise. The area under the ROC curve for ΔPAWP was 0.72 (95% CI: 0.65–0.78) in the older and 0.64 (95% CI: 0.53–0.75) in the younger. In the older, the cut-off value for detect exercise-induced PAWP elevation of ΔPAWP was 4mmHg, with 72% sensitivity and 58% specificity. On the other hand, in the younger, the cut-off value was 3mmHg, with 69% sensitivity and 59% specificity.

Conclusion

Leg raise can easily detect occult left ventricular diastolic dysfunction.

Funding Acknowledgement

Type of funding source: None

Prognostic value of a normal Artificial Intelligence applicative response in subjects with stable chest pain. From the ARTICA co-operative registry

Background

An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has already been used at point of care with efficacy for evaluating subjects with stable chest pain (SCP) and it has been proved to correctly identify absence of significant coronary artery disease (CAD) versus standard care approach (SD) without known prognostic implication yet.

Purpose

The aim is to determine the prognostic value of “no testing/Follow up” AI DSS response in a referral population evaluated for SCP.

Methods

From 2016 to 2019, an AI DSS ESC guidelines based applicative was used on 1.291 subjects with SCP to determine testing appropriateness compared with human specialist standard evaluation. 590 of them, 332 males, mean age 62±11 years deemed to be completely negative – by “no testing/follow up” response - were evaluated. The negative response was defined and confirmed by a normal Coronary Tomography Angiography scan executed in all these subjects. Mean follow-up was 3.46±1.76 years. Two groups based on pre-test likelihood of having CAD were analyzed – low and intermediate. No subjects with high pre-test likelihood were present. The primary endpoint was cumulative incidence of cardiovascular death, hospitalizations for acute coronary syndrome and coronary revascularizations.

Results

The primary endpoints classification is displayed in the Table. The unadjusted hazard ratio for primary endpoint was 3.84 (95% CI 0.32–8.68, p=0.009) in patients with intermediate compared to those with low pre-test likelihood of CAD. Moreover, the “no testing and Follow up” response showed an incremental prognostic value over conventional risk factors (χ2=7, P=0.022) and over a combination of conventional factors and ST-T changes (χ2=9, P=0.014).

Conclusions

In an outpatient population without known CAD evaluated for chest pain, after the administration of AI DSS, a “No tests/Follow up” confers an excellent prognosis regardless of the ESC SCORE Charts and rest ECG abnormalities. These preliminary data confirms the safety of ARTICA AI DSS use in subjects with stable chest pain.

Funding Acknowledgement

Type of funding source: None

Comparison of pulmonary vascular resistance and pulmonary artery compliance during exercise between IPAH and CTEPH with normal pulmonary artery pressure

Background

Pulmonary vascular resistance (PVR) and pulmonary artery compliance (PAC) are inversely related. However, the little is known about dynamics during exercise by disease difference. The aim of this study was to reveal the relationships of PVR and PAC during exercise between idiopathic pulmonary arterial hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH) patients.

Methods

Sixty-two IPAH patients (45±9 y.o) and 359 CTEPH patients (63±13 y.o) with normal mean PAP and PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter.

Results

There were no differences between baseline mean PAP and PAWP in 2 groups, however, cardiac output, SaO2 and SvO2 were lower in CTEPH group. Lower PAC (2.9±1.1 vs. 3.7±1.7 ml/mmHg, p&lt;0.001) and higher PVR (2.3±1.0 vs. 1.9±1.0 wood.unit, p=0.016) were observed in CTEPH group. These trends were also seen at peak exercise. PVR-PAC relationship in CTEPH group was leftward shift compared with IPAH group (Figure 1).

Conclusion

Resting and exercise PVR and PAC in CTEPH patients were worse than those in IPAH patients who had normal PAP and PAWP at rest.

Figure 1

Funding Acknowledgement

Type of funding source: None

Usefulness of peripheral-pressure-directed balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

Background

Balloon pulmonary angioplasty (BPA) in expert center may be considered in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are technically non-operable for pulmonary endarterectomy. BPA based on objective quantitative methods has not been established. The endpoint at BPA sessions has not been clarified yet.

Objectives

The purpose of this study was to investigate the usefulness of BPA according to peripheral pressure measured by pressure wire or catheter.

Methods

This study included consecutive 143 CTEPH who underwent cardiopulmonary exercise test with right heart catheterization after BPA. All patients were divided into 2 groups such as angio-guided (n=47) group or pressure-guidedgroup (n=96). In pressure-guided group, the pulmonary arterial pressure (PAP) proximal and distal to the target lesion and the ratio of the 2 pressures were measured by the pressure wire or catheter. the endpoint was determined to when the pressure ratio of distal to proximal pressures was &gt;0.7 to 0.8 finally. The dilation was stopped when the distal mean PAP after each dilation reached 35 mm Hg and when the baseline mean PAP was &gt;35 mm Hg. Changes of hemodynamic parameters such as PAP and pulmonary vascular resistance (PVR) from baseline, and mean PAP and PVR at peak oxygen consumption, and pulmonary arterial pressure – cardiac output (PA-CO) slope were compared between two groups. All data except changes of hemodynamics from baseline were expressed by median [25th percentile-75th percentile]. Changes of hemodynamics from baseline were expressed by average [95% confidence interval]

Results

The median age and male were 66 [56–72] years old and 35. There were no significant differences in number of sessions and dilated vessels between two groups (Angio-guided group vs. Pressure-guided group: 4 [3–6] vs. 4 [3–5], P&gt;0.05; 19 [12–22] vs. 17 [13–22], P&gt;0.05). Changes of PAP and PVR from baseline in pressure-guided group was significantly higher than in angio-guided groups (Angio-guided group vs. Pressure-guided group; ΔPAP: −19 [−20 to −17] vs. −20 [−21 to −20], P&gt;0.05; ΔPVR: −6.0 [−6.3 to −5.7] vs. −6.6 [−6.8 to −6.3], P&lt;0.01). Mean PAP and PVR at peak oxygen consumption (VO2) and PA-CO slope in pressure-guided group were significantly lower than in angio-guided group (Angio-guided group vs. Pressure-guided group; PAP at VO2: 43 [36–50] vs. 39 [34–43], P&lt;0.05; PVR at VO2: 2.7 [1.9–4.5] vs. 2.2 [1.6–2.9], P&lt;0.01; PA-CO slope: 3.8 [2.1–5.2] vs. 2.9 [1.9–4.0], P&lt;0.05).

Conclusions

Peripheral-pressure-directed BPA can improve hemodynamics at rest and exercise more effectively.

Funding Acknowledgement

Type of funding source: None

P1698 Mitral valve endocarditis in hypertrophic obstructive cardiomyopathy

Introduction

Endocarditis complicating hypertrophic cardiomyopathy (HCM) is not commonly reported but occurs almost universally in patients showing evidence of outflow tract obstruction. The estimated cumulative 10 year probability of developing endocarditis in obstructive HCM is &lt; 5%. We report a rare case of mitral valve endocarditis in a young man with hypertrophic obstructive cardiomyopathy.

Case report

A 45 years old man was admitted to the emergency room after a 7 days history of weakness, thoracic discomfort, short of breath, cough and temperature up to 40 °C. He was treated with oral antibiotics in ambulatory setting, but symptoms persisted. He had no previous history of hypertension or known heart disease, family history of coronary heart disease and excessive smoker. On clinical examination, the patient was afebrile with a harsh systolic murmur. Initial blood tests showed normal inflammatory markers (C reactive protein 0.2 mg/l and fibrinogen 202 mg/dL) and normal blood sample. An ECG showed major left ventricular hypertrophy and abnormal lateral repolarisation. Transthoracic echocardiography showed localized septal hypertrophy (2.4 cm) and systolic anterior motion of the anterior mitral leaflet. Continuous wave Doppler ultrasound in the left ventricular cavity and outflow tract, had given a maximal predicted gradient of 73 mmHg. There was suspicion of vegetation on the anterior mitral valve leaflet and mitral regurgitation was quantified as moderate. Transoesophageal echocardiography confirmed the presence of vegetation on the anterior mitral valve leaflet, posterior leaflet prolapse and moderate mitral regurgitation. We found normal coronary arteries on coronary angio-CT. Treatment with intravenous antibiotics was initiated and the case was discussed with a microbiologist and a cardiothoracic surgeon.

Discussion

Infective endocarditis is a rare complication of hypertrophic cardiomyopathy (HCM). It is clear from morphological studies that systolic anterior motion of the anterior mitral valve leaflet is relevant to the pathogenesis of endocarditis. Pathogenesis of infective endocarditis in obstructive HCM can be explained by endocardium damage of the mitral or aortic valve, consequence of turbulence of blood flow during ejection and of the contact between the mitral anterior leaflet and the septum during systole as well as mitral regurgitation. Antibiotic therapy is the mainstay of the treatment. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Surgical procedure may consist of valve replacement or repair, and some authors reported relieve of outflow tract obstruction after mitral valve replacement which may be explained by the removal of systolic anterior motion of the mitral valve. Valve surgery combined with septal myectomy seems logical but requires great expertise and carries a higher operative mortality

Abstract P1698 Figure.

P1701 Biatrial thrombus detection in a patient with atrial paroxysmal fibrillation and asymptomatic massive pulmonary embolism

Introduction

Computed tomography (CT) is a noninvasive test for detection of LA and LAA thrombus.Although the transesophageal echocardiogram is the gold standart method, it can have rare but potential life threatening complications.Case report:A 62 y.o woman presented to the ER complaining of palpitations started less then 12h ago with no chest pain or dispnea.She was diagnosed with high rate paroxysmal atrial fibrillation (HR∼120/min).The ECG showed AF with no specific changes,the troponin I (TPI) level was negative and a TTE revealed a dilated left atria.The other lab results were within normal range(TBC and blood chemistry).Her past medical history included hypertension and diabetes type 2 for 10 years and 6 months respectively both on regular treatment and obesity.Also 2 months ago she was diagnosed with Hashimoto thyroiditis and close monitoring of TSH was recommended but no treatment.Subsequently,LMWH (enoxaparin) and amiodarone loading dose for cardioversion were started.After 24h the pt was still in AF,with a controlled heart rate and no complains.However ECG changes were noticed (evolutive T negative waves in leads D1,D2,aVL,V3-V6).A D-Dimer was requested and came back negative,O2 saturation was 97%.The asymptomatic pt was transferred to the Cardiology ward for further evaluation.TPI remained negative.Due to the cardiac risk factors and the ECG changes it was decided to perfom a coronary angiography which resulted normal.An electrical cardioversion was considered.Both TEE and pulmonary angio CT were requested prior.Because of the ECG changes the CT was performed first and showed central and peripheric bilateral pulmonary artery clots present also in both the left and right atrial auricles.Due to the massive thromboembolism(PE) unfractioned heparin was immediately started (aPTT 50-70s).A new TTE showed a PAP of 50 mmHg.Approximately 10h after the heparin infusion,the pt became hypotensive and started complaining of dyspnea,tachypnea,cough,pleuritic pain and fever(high temperature 39.5-40ᵒC).Considering the deteriorating conditions she was consulted by a cardiac surgery team and it was decided to perform an emergency surgical pulmonary embolectomy despite the high risk.Within 24h,the pt underwent a surgical embolectomy of the right and left pulmonary branches after incision of the pulmonary artery, as well as a clot embolectomy of the right and left atria auricles (confirmed by intraoperatory TEE).She was put on an iv heparin regimen and recovered well.She was discharged 2 weeks later in good condition,with a PAP of 40 mmHg,on acenocoumarol with persistent AF.1.5 years later she is in NYHA class I,in sinus rhythm taking rivaroxaban 20 mg/d.Discussion: Biatrial thrombus detection in both atrial auricles is rare as well as in this case a massive PE without a stroke.CT can be used as an alternative modality for detecting thrombus in selected high risk patients because it shows a good diagnostic accuracy with high sensitivity and specificity.

Abstract P1701 Figure. Biatrial clots on CT and removed ones

P1460 Atrial myxoma with atypical location in an asymptomatic patient

Introduction

Primary cardiac tumours are rare. Most of them are benign, among which myxomas are the most common. Usually they occur in the left atrium (75%) but there are cases of right atrial myxomas. The majority of patients with atrial myxoma present with one or more symptoms of clinical triad of embolic events, intracardiac obstruction, or nonspecific manifestations. We report a rare case of cardiac myxoma arising from the right atrium as an accidental finding during routine medical checkup.

Case report

A 52 years-old woman was admitted to ambulatory care for a general checkup. At presentation, her heart rate was 82 bpm, regular and blood pressure was 150/90 mmHg. Other investigative results were normal. Her ECG showed normal sinus rhythm. She was sent for a routine echocardiography to judge for further treatment of the arterial hypertension. Transthoracic echocardiogram showed normal left ventricular ejection fraction. There was a mobile echogenic mass of nearly 6 cm2 in the right atrium, prolapsing through the tricuspid valve with mild tricuspid regurgitation without causing obstruction and protruding into the inferior vena cava (IVC). The transesophageal echocardiographic examination confirmed the presence of a mobile multilobular mass in the right atrial free wall close to the IVC origin.

A total body angio-CT scan showed an intraatrial mass measuring approximately 5 × 4 cm, without infiltration of the adjacent structures, suggesting the diagnosis of myxoma. Coronary angiography revealed normal coronary arteries. The patient underwent median sternotomy under general anesthesia. The tumor was completely excised through a right atriotomy. The resected mass was sent for histological assessment which confirmed the diagnosis of myxoma.

Discussion

RA myxomas usually originate in the fossa ovalis or base of the interatrial septum, but in this case, the myxoma was implanted in the atrial inferior vena cava junction. Myxomas are usually polypoid and pedunculated tumors (approximately 83% of cases). In this report, our patient had a solitary, pedunculated mass with polypoid areas and a lobulated surface. Echocardiography remains the best diagnostic method for locating and assessing the extent of myxomas and for detecting their recurrence, with a sensitivity of up to 100%. However, transthoracic echocardiogram may not identify tumors smaller than 5 mm in diameter, and a transesophageal echocardiogram is required when there is suspicion of a very small tumor. In this case, an echocardiogram suggested the hypothesis of RA myxoma, which was confirmed by a histopathological exam. Myxomas are friable with high chance of systemic or pulmonary embolization depending on tumour location. Early diagnosis and timely surgical resection is the treatment of choice to prevent possible fatal consequences such as sudden death.

Abstract P1460 Figure. Right Atrial Myxoma

P839Lifetime cost-effectiveness of diagnostic artificial intelligence tool for evaluating individuals with stable chest pain. The co-operative ARTICA registry database

Background

Non-invasive cardiac imaging testing has been often favored as an initial test for symptomatic patients with at least intermediate pre-test likelihood (pt-lk) of obstructive CAD. Despite this condition, uncertainty remains regarding the optimal testing strategies. It is known that intelligence applied with automatic decision support system (AI DSS) is able to correctly identify absence of significant CAD versus standard care (SD) in patients with stable chest pain (SCP). No evidence of long-term cost-effectiveness about AI DSS has been published in this setting.

Purpose

The aim is to determine the cost-effectiveness of AI DSS when applied to individuals without known CAD presenting with stable chest pain syndrome.

Methods

1725 subjects, 982 males, age 61±12 years, with SCP were referred for clinical evaluation by human standard care (SD) and AI DSS administration during same day visit on a 2 years period. Exercise treadmill test (ETT), coronary tomographic angiography (CTA), invasive coronary angiography (ICA), stress echocardiography (SE)/gated myocardial perfusion scintigraphy (gMPS) and follow up/no tests (FNT) alone and combined strategies were analyzed. For the post-diagnosis follow up period of 16±3 months, we employed a Markov model based on 1-year cycle to account for outcomes for those correctly diagnosed with CAD. All subjects performed CTA to verify presence of CAD. CAD was defined as ≥70% stenosis in at least one major epicardial coronary artery vessels. Monte Carlo simulation was performed to derive mean values for costs and QALYs at different CAD prevalence of 15%, 50% and 80%.

Results

Data from ARTICA registry about lifelong costs based upon different diagnostic strategies in subjects with 15%, 50% and 80% CAD pt-lk are shown in Table.

Lifelong costs related to strategies FNT (€) ETT-SE/gMPS-ICA (€) SE/gMPS-ICA (€) CTA-ICA (€) CTA-SE/gMPS-ICA pt-lk CAD 15% AI DSS 350 8,250 8,850 10,450 11,020 SD 1,015 11,100 12,715 12.215 12,215 pt-lk CAD 50% AI DSS 1,610 17,375 19,540 20,410 20,110 SD 1,855 19,650 21,340 22,950 22,115 pt-lk CAD 80% AI DSS 2,910 28,210 30,875 31,215 31,765 CD 4,110 32,715 34,815 35,755 35,660

Conclusion

Data from ARTICA registry demonstrate that automatic use of AI DSS result in improved costs and enhanced effectiveness when compared with human SD in subjects with stable chest pain.

P2461The presence of L wave was associated with non-invasively estimated left atrial stiffness in heart failure patients

Background

The mid-diastolic L wave is recorded as mid-diastolic mitral forward flow with conventional Doppler echocardiography. L wave is occasionally detected in heart failure (HF) patients but its mechanism of occurrence is still unknown. It is hypothesized that L wave was induced by a positive atrioventricular gradient caused by left atrial filling via pulmonary veins, and the magnitude of the L wave is augmented by increasing ventricular stiffness. We speculate that also Left atrium (LA) function will relate with the presence of L wave because the L wave flow occurs passing LA. LA function has been known to have reservoir, booster pump and conduit function. It is reported that LA conduit function related to LA stiffness. The aim of this study is to clarify the association between LA functions and presence of L wave in HF patients.

Methods and results

Eighty two patients who admitted to our hospital for HF were enrolled in this study. We performed echocardiography before discharge. LA speckle-tracking strain was analyzed by an external software program using apical 4 chamber view. Reservoir function was measured as peak strain value at end systole, and booster pump function was measured as the value of atrial contraction. Conduit function was calculated as the difference of the peak value at end systole and atrial contraction. There were 23 patients who had L wave before discharge and 59 patients without L wave. Transmitral E wave (E) and left atrial volume index (LAVI) were higher in patients with L wave than in those without L wave. LA reservoir strain was not different in two groups, but poster pump strain was lower and conduit strain was higher in patients with L wave than those without. LA reservoir strain and booster pump strain weakly correlated with A wave velocity (r=0.39 p=0.004, r=46 p=0.001) and LAVI (r=−0.23 p=0.0383, r=−0.31 p=0.005), but conduit strain had no correlation with A wave (r=0.12 p=0.26) and LAVI (r=−0.04 p=0.67). In multivariate regression analysis for the presence of L wave with A wave velocity, LAVI and LA conduit strain, LA conduit strain remained independent predictors of the presence of L wave (HR 1.12 95% CI 1.04–1.23; p=0.004).

Conclusion

LA conduit function was not correlated with conventional echo parameters of LA function (A wave velocity and LAVI). The presence of L wave was associated with LA conduit strain.

P6466Novel index with combined echocardiographic parameter and CT parameter (pPAT) is useful for screening pulmonary hypertension in Systemic Sclerosis Patients

Background

Systemic sclerosis (SSc) patients with pulmonary arterial hypertension (PAH) had poor survival rate. Usual index of estimating PH is tricuspid regurgitate jet pressure gradient (TRPG). Accurate assessment of PAH is important for the management of SSc patients. However, estimated mean pulmonary arterial pressure (mPAP) using TRPG by echocardiography does not always reflect actual mPAP by right heart catheterization (RHC) in SSc patients. On the other hand, recent reports have shown that rPA, a ratio of diameter of pulmonary artery to ascending aorta (PA/Ao) calculated by computed tomography (CT), was associated with mPAP. However, both index are not sufficient for evaluation of PH. We hypothesized that the product of TRPG and rPA (pPAT) could estimate mPAP of SSc patients more accurately than TRPG or rPA.

Purpose

We investigated the usefulness of the product of TRPG and rPA for detecting actual mPAP in SSc patients.

Methods

Thirty-six SSc patients who suspected PH were enrolled retrospectively. We defined PH as resting mPAP from RHC of >25 mmHg. We measured both a widest pulmonary artery diameter and an adjacent ascending aorta diameter at the same level of the bifurcation of the main pulmonary artery using CT images.

Results

The average age was 67 years old and average mPAP by RHC was 24.7 mmHg. Mean TRPG and mean rPA were 35.1 mmHg and 1.06, respectively. Furthermore, mean pPAT was 37.9. We found pPAT had a stronger correlation with actual mPAP (r=0.848, p<0.001) than TRPG (r=0.754, p<0.001) or rPA (r=0.584, p<0.001). On ROC analysis, pPAT predicted PH with high accuracy for a cut-off of 33.1. In order to evaluate the usefulness of pPAT, we compared false-negative patients between two cutoff values of TRPG 34 mmHg described in ESC guideline and pPAT 33.1. Among the patients with TRPG <34mmHg, 4 patients (18%) had PH. In contrast, when screening PH using pPAT, the diagnosis of PH was missed in only one patient.

Figure 1

Conclusion

The product of TRPG and PA/Ao (pPAT) could be a novel and useful noninvasive index for identifying PH in SSc patients.

P5974Prognostic value of global tangential strain by three-dimensional echocardiography heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy

Background

In the current clinical guidelines, cardiac resynchronization therapy (CRT) is recommended in heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms as Class I indication. In terms of HF patients with intermediate ECG criteria, prediction for benefit of CRT is still controversial in routine echocardiography.

Purpose

The aim was to assess whether three-dimensional (3D) echocardiographic indexes of global LV function at baseline has a prognostic value following CRT implantation in patients who fulfilled with intermediate ECG criteria.

Methods

We studied 62 HF patients who fulfilled with the indication criteria of CRT implantation according to current the clinical guidelines. In addition to routine two-dimensional echo, 3D echo dataset was acquired for determination of 3D global tangential strain (GTS) and 3D global longitudinal strain (GLS). We tracked predefined unfavorable outcomes for 3 years after CRT implantation: death, hospitalization due to worsening HF.

Results

LBBB with QRS width ≥150ms was evident in 26 of 62 patients (aged 68±11 years with 160±26 ms of QRS duration and 29±7% of LV ejection fraction), and the other 36 patients only fulfilled intermediate ECG criteria (QRS width 120–149ms or non-LBBB). Unfavorable events occurred in 21 patients (34%). The median GTS was −15.4%. Although GLS was not predictive, GTS greater than −15.4% had high probability of unfavorable outcomes over 3 years (Log-rank, p<0.05). There is no difference in the probability of unfavorable outcomes between LBBB and intermediate ECG criteria. Baseline GTS in patients with intermediate ECG criteria was associated with unfavorable outcomes: −12.6±2.6% vs. −17.3±3.8% (p<0.05). Outcome was better in the intermediate ECG criteria patients with GTS ≤−15.4% than in those with LBBB and in those with intermediate ECG criteria patients with GTS >−15.4% (Log-rank: p<0.05, p<0.0001, respectively).

Conclusions

Baseline GTS by 3D echocardiography is useful for predicting outcome over 3 years after CRT implantation regardless of the ECG criteria for CRT indication.

P5490Sex-related differences in intrahospital outcome of patients undergoing PCI

Background

Cardiovascular diseases remain the number one cause of mortality in the world despite modern scientific and therapeutic advancement. Gender difference pathophysiology, treatment and outcome have been hypothesized and studied. Whether there are sex differences in the outcome after PCI remains controversial.

Aim of the study

We undertook this study to assess whether there are sex-related differences in intrahospital outcome of patients undergoing percutaneous coronary intervention.

Materials and methods

This is a prospective observational study. We enrolled consecutively all patients undergoing PCI in UHC “Mother Theresa” from April to October 2018 and were followed in the 1st Clinic of Cardiology. Data for 352 patients were collected, 261 males and 91 females. We excluded from the study patients that could not be followed.

Results

Women were older (5.27; 95% CI: 2.98–7.6; p<0.001), had more hypertension (p≤0.001), Diabetes Mellitus (p≤0.001), while men were more likely to be smokers (p≤0.001). Female sex had a higher unadjusted mortality rate (5.5% vs. 1.5%, p=0.039) which vanished after adjustments for age, co-morbidities and procedural or infarct related complications (p=0.237). The age-group with the highest mortality rate was that of 61–70 years. Women had more procedure related complications like inguinal hematomas (p=0.02), pseudo aneurisms (p=0.005) and contrast induced nephropathy (p=0.021). Female gender was associated with more severe peri-procedural arrhythmias in the setting of AMI (p=0.039). Total hospital stay was longer for women (p=0.001), after elective PCI (p=0.01) and after primary PCI (p=0.007). After multivariate analysis and adjustment, female gender remained an independent factor for prolonged hospitalization.

Conclusion

Female sex seems to have a tendency for higher mortality even after losing its significance after multivariate adjustments. Females get more myocardial infarction and procedural related complications and have longer hospital stays than men.

P5245Cost-saving diagnosis approach by artificial intelligence tool in patients with suspected coronary artery disease. The co-operative ARTICA registry database

Background

Although coronary tomographic angiography (CTA) has shown promise as a “gatekeeper” to invasive coronary angiography (ICA) in longitudinal cohort studies, it remains unknown whether the strategy of direct initial performance of CTA is cost-effective when compared with selected exercise treadmill testing (ETT) +/− functional cardiac imaging strategies in patients with suspected coronary artery disease (CAD). An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has been used at point of care for evaluating subjects with stable chest pain (SCP).

Purpose

The objective was to verify the cost-saving effect of the robotic AI DSS vs direct CTA by human standard care (SD) for diagnosing CAD in subjects presenting with SCP.

Methods

From October 2016 over three hospitals, 1017 subjects, 620 males, age 62±11 years, with clinically SCP being referred for CTA by SD received also a same day pre-scan AI DSS administration. All patients did not demonstrate significant CAD at CTA. CTA/ICA, or exercise treadmill test (ETT)/ stress echocardiography (SE), gated myocardial perfusion scintigraphy (gMPS) or Follow up/No tests (FNT) strategies by AI DSS were analyzed and compared to direct CTA SD. Pre-test likelihood (pt-lk) of CAD consider clinical risk factors into the model. Sensitivity and specificity of non-invasive diagnostic tests within our model were based upon a bivariate analysis of data from published multicenter trials. Costs of procedures were calculated by the sum of technical and professional components. Probabilistic sensitivity analysis was conducted to assess the impact of uncertainty in model parameters.

Results

The direct approach used performing direct CTA strategy by SD in all subjects costed 406.800 €. Costs of each procedure and distribution of AI DSS outputs are shown in the Table. Across the range of pt-lk of CAD, total costs of AI DSS strategy resulted 146.030€ with −65% vs SD approach.

AI DSS tests distribution and costs pt-lk (pt/%) FNT (0€) ETT (90€) SE (350€) Stress gated MPS (750€) CCTA (400€) ICA (3.000€) High (29/2.8) 0 0 1 2 0 26 Int (371/36.5) 259 5 51 48 7 1 Low (612/60.7) 595 2 2 0 13 0 Total costs (€) 0 630 18,900.00 37,500.00 8,000.00 81,000.00

Conclusion

These results from ARTICA registry seem to demonstrate that AI DSS is extremely cost-saving in subjects with stable chest pain across the whole range of pt-lk of CAD.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Analysis of the factors affecting the formation of the microbiome associated with chronic osteomyelitis of the jaw

Chronic osteomyelitis of the jaw (COMJ) is one of the most intractable diseases among head and neck infections. Antimicrobial agents are routinely administered for COMJ without sufficient bacterial information, resulting in frequent treatment failures. To improve our knowledge of the bacterial aetiology of COMJ and to assist in the development of effective treatments, we performed a comprehensive analysis of the microbiome. Sixteen patients with four clinical types of COMJ (four with suppurative osteomyelitis, three with osteoradionecrosis of the jaw, four with primary chronic osteomyelitis, and five with bisphosphonate-related osteonecrosis of the jaw) were enrolled in this study. Bone samples were subjected to bacterial community comparisons by 16S rRNA gene pyrosequencing. As a result, we clarified that COMJ was caused by a far greater range of bacterial species (12 phyla and 163 genera) than previously reported. Moreover, the bacterial structures in COMJ changed dramatically with disease stage and the condition of the affected bone. Multiple correlation analyses revealed that sequestration and bone exposure could affect the community structure. On the basis of these factors, we reclassified COMJ into three clinical stages: I, inflamed or sclerotic bone without exposure; II, sequestrum without exposure; and III, exposed sequestrum. In stage II, the bacterial diversity was significantly lower, and the anaerobe genera Fusobacterium, Tannerella (formerly Bacteroides) and Porphyromonas were more abundant, than observed during other stages. Because these bacteria habitually reside in any clinical stage, they were considered to constitute the core microbiome of COMJ. Targeting these bacteria should lead to the development of effective preventive measures and cures.

Financial loss in pyramid savings schemes, downward social mobility and acute coronary syndrome in transitional Albania

OBJECTIVE

Extensive financial losses caused by the collapse of pyramid savings schemes led to the 1997 turmoil in Albania. The authors' aim was to assess the association of financial loss and social mobility with acute coronary syndrome (ACS) 6-9 years after the precipitous collapse.

METHODS

A population-based case-control study was conducted in Tirana, the Albanian capital, in 2003-6. 467 non-fatal consecutive ACS patients were recruited (370 men aged 59.1 (SD 8.7) years and 97 women 63.3 (SD 7.1) years, 88% response). The control group comprised 469 men (53.1 (SD 10.4) years) and 268 women (54.0 (SD 10.9) years, 69% response). Information on the absolute financial loss (in US$), relative loss and subjective social mobility was obtained by a structured interviewer-administered questionnaire. Associations of financial loss and social mobility with ACS were assessed by multivariable-adjusted logistic regression.

RESULTS

Financial loss in pyramid scams was frequent in both ACS patients (55%) and controls (41%). Downward subjective social mobility was noted in 31% of patients and 12% of controls. Upon adjustment for sociodemographic and socioeconomic characteristics and conventional coronary risk factors, ACS was associated with both financial loss (OR 1.9, 95% CI 1.4 to 2.6) and downward social mobility (OR 2.2, 95% CI 1.4 to 3.3). Although the association with financial loss was partly mediated through subjective social mobility, both maintained independent associations with ACS.

CONCLUSIONS

In the wake of a nationwide catastrophic collapse of savings that led to losses totalling about 40% of the Albanian gross domestic product, the authors detected apparent long-term deleterious health effects of financial loss and downward intragenerational subjective social mobility.