Changing life expectancy in Europe 1990-2019: Global Burden of Disease Study 2019

 

Improvements in life expectancy have slowed in high income countries, with uncertain causes. We assessed the contribution of different causes of death to changes in life expectancy, and changes in population exposure to major risk factors in 16 European Economic Area countries plus the 4 nations of the United Kingdom from 1990-2013 and 2013-2019, using the Global Burden of Disease Study. After decades of steady improvements in life expectancy, all countries experienced smaller annual improvements after 2013. Norway experienced the smallest mean annual rate of change in improvement from pre 2013 to post 2013 of 0.03 years, and Northern Ireland (followed closely by Scotland and England) experienced the largest annual reduction from pre to post 2013 of 0.25 years. The cause of death responsible for the largest reductions in life expectancy improvements after 2013 was cardiovascular disease, followed by neoplasms. The largest reductions in deaths from cardiovascular disease were attributable to seven major risk factors: high LDL cholesterol, tobacco, dietary risks, high fasting plasma glucose, high systolic blood pressure, high body mass index, and low physical activity. The risk factors for deaths from neoplasm were similar. Exposure to tobacco remains a high risk but exposure declined steadily. Exposure to the other risks generally worsened after 2013, particularly for BMI and high fasting plasma glucose. The European countries that had better maintained reductions in deaths from cardiovascular disease and neoplasms also experienced larger improvements in life expectancy. These changes were underpinned by changing exposure to major risks. Policy responses to the slowdown in life expectancy improvements should include reducing population exposure to major risks, including the broader risks from diet and low physical activity, through prevention and addressing the broad social and commercial determinants of health as well as adequate funding for health services.

Key messages

Exploring the millimetre emission in nearby galaxies: Analysis of the edge-on galaxy NGC 891

New observations of the edge-on galaxy NGC 891, at 1.15 and 2mm obtained with the IRAM 30-m telescope and the NIKA2 camera, within the framework of the IMEGIN (Interpreting the Millimetre Emission of Galaxies with IRAM and NIKA2) Large Program, are presented in this work. By using multiwavelength maps (from the mid-IR to the cm wavelengths) we perform SED fitting in order to extract the physical properties of the galaxy on both global and local (~kpc) scales. For the interpretation of the observations we make use of a state-of-the-art SED fitting code, HerBIE (HiERarchical Bayesian Inference for dust Emission). The observations indicate a galaxy morphology, at mm wavelengths, similar to that of the cold dust emission traced by submm observations and to that of the molecular gas. The contribution of the radio emission at the NIKA2 bands is very small (negligible at 1.15 mm and ~ 10% at 2 mm) while it dominates the total energy budget at longer wavelengths (beyond 5 mm). On local scales, the distribution of the free-free emission resembles that of the dust thermal emission while the distribution of the synchrotron emission shows a deficiency along the major axis of the disc of the galaxy.

Dust Emission in Galaxies at Millimeter Wavelengths: Cooling of star forming regions in NGC6946

Interstellar dust plays an important role in the formation of molecular gas and the heating and cooling of the interstellar medium. The spatial distribution of the mm-wavelength dust emission from galaxies is largely unexplored. The NIKA2 Guaranteed Time Project IMEGIN (Interpreting the Millimeter Emission of Galaxies with IRAM and NIKA2) has recently mapped the mm emission in the grand design spiral galaxy NGC6946. By subtracting the contributions from the free-free, synchrotron, and CO line emission, we map the distribution of the pure dust emission at 1:15mm and 2mm. Separating the arm/interarm regions, we find a dominant 2mm emission from interarms indicating the significant role of the general interstellar radiation field in heating the cold dust. Finally, we present maps of the dust mass, temperature, and emissivity index using the Bayesian MCMC modeling of the spectral energy distribution in NGC6946.

Acute pancreatitis in pregnancy: meta-analysis of maternal and fetal outcomes

The impact of acute pancreatitis in pregnancy on maternal and fetal outcomes is unclear. Historical case series document very poor outcomes, with maternal mortality rates of 20 per cent and fetal loss of 50 per cent. However, this is based on outdated clinical practice. This meta-analysis quantified both maternal and fetal outcomes following acute pancreatitis in pregnancy based on the concurrent literature. Maternal and fetal outcomes after acute pancreatitis in pregnancy have improved with advances in the management of pancreatitis.

Myocardial strain by 3D-speckle tracking echocardiography predicts long-term risk of cardiovascular morbidity and mortality in the general population: the Southall And Brent Revisited (SABRE) study

Background

Both left ventricular (LV) ejection fraction (EF) and Global Longitudinal Strain (GLS) by 2D-echocardiography predict mortality and cardiac events, and GLS may be superior to EF. 3D-speckle tracking echocardiography (3D-STE), a recently validated method, allows simultaneous assessment of EF, GLS and principal tangential strain (PTS), but its prognostic utility in the general population is unknown.

Purpose

We hypothesized that 3D-STE derived LV myocardial strains predict a composite of cardiac endpoints, and that GLS would be a better prognostic marker than EF. We also investigated the utility of PTS compared with GLS and EF.

Methods

A total of 529 individuals (69±6y; 76.6% male) from SABRE study, a UK-based tri-ethnic community cohort, underwent health examinations. The association between 3D-STE EF or multidirectional myocardial strains and a composite cardiac endpoints comprising coronary heart disease (fatal/non-fatal), heart failure hospitalization, new-onset arrhythmia was determined using Cox proportional hazards models with and without adjustment for potential confounders and Harrell's C statistics were calculated. Associations with cardiovascular (CV) mortality was examined as a secondary objective. The incremental value of 3D-STE EF, GLS and PTS in improving CV risk stratification by the established Framingham risk score (FRS) was investigated using a likelihood ratio test on a series of nested Cox proportional hazards models.

Results

During follow-up (median, 8y), there were 56 composite cardiac endpoints and 24 CV deaths. EF and radial strain were negatively associated, while GLS, global circumferential strain and PTS were positively associated with the composite cardiac endpoints in unadjusted models (Table 1). Associations were only marginally affected by adjustment for potential confounders although confidence intervals of the estimate increased slightly (Table 1). There was little difference in the C-statistics for EF, GLS or PTS for the composite cardiac endpoints (Table 1). Associations with CV mortality were generally weaker and only GLS showed some evidence of a positive association with CV mortality in unadjusted and adjusted models (Table 1). Compared to EF and GLS, PTS most improved the predictive value (model fit) of FRS for composite cardiac endpoints (Table 2). None of the measures convincingly improved calibration for CV mortality.

Conclusions

3D-STE-derived LV myocardial strains predicted adverse cardiac events and CV mortality in a multi-ethnic sample of the UK general population. PTS/3D-strain was an independent predictor of cardiac events with some evidence of it being a slightly better predictor than conventional indices of LV function (GLS and EF). Future prospective studies are needed to confirm and extend these findings.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The main SABRE study is supported by the Wellcome Trust and BHF.

913 Near-Peer Teaching for Surgical Foundation Year Doctors During COVID-19 Pandemic

Introduction

Literature has shown near-peer teaching to be an effective method of improving learning. There is little data on surgical teaching initiatives of this kind. Nationally and locally, teaching sessions and courses have been cancelled due to the pandemic. A new surgical lunch-time virtual course was created to fill this gap.

Method

FY1 doctors from University Hospital Wales were invited to participate in a survey exploring the need and topics for surgical teaching. Results were used to create a surgical teaching course. Near-peer, core surgical trainees were recruited to teach. A post-course questionnaire was distributed to FY1 doctors who attended the teaching to assess the success of the course.

Results

15 FY1 doctors completed the initial questionnaire. 33% (5) were currently on a surgical placement. 60% (9) had an upcoming surgical placement. 73% (11) felt they did not have sufficient teaching on surgical specialties during medical school. 93% (14) felt they did not have sufficient teaching on how to manage surgical patients as a FY1. 100% (15) responded they would be interested in surgical teaching delivered by core surgical trainees. Eight topics were suggested, and lunchtime sessions were created. Post-course feedback was completed by 12 FY1 doctors. 88% (10) of respondents found the course ‘extremely useful’ and relevant to their surgical jobs.

Conclusions

There is a demand for surgical teaching for FY1s. Near-peer education designed by FY1s and delivered by CSTs is an effective way for teaching relevant surgical knowledge. Lunch-time virtual teaching is a good way to continue teaching sessions through the pandemic.

Comparison of the prognostic value of stress and rest pulmonary transit time estimation using myocardial perfusion CMR

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Background

Pulmonary transit time (PTT) is a quantitative biomarker of cardiopulmonary status. Rest PTT was previously shown to predict outcomes in specific disease models, but clinical adoption is hindered but challenges in data acquisition. Whether evaluation of PTT during stress encodes incremental prognostic information has not been previously investigated as scale.

Objectives

To compare the prognostic value of stress and rest PTT derived from a fully automated, in-line method of estimation using perfusion CMR, in a large patient cohort.

Methods

A retrospective two-center study of patients referred clinically for adenosine stress myocardial perfusion assessment using CMR. Analysis of right and left ventricular cavity arterial input function curves from first pass perfusion was performed automatically, allowing the in-line estimation of both rest and stress PTT. Association with major adverse cardiovascular events (MACE) was evaluated. MACE was defined as a composite outcome of myocardial infarction, stroke, heart failure admission and ventricular tachycardia or appropriate ICD treatment (including ICD shock and/or anti-tachycardia pacing).

Results

985 patients (67% male, median age 62 years (IQR 52,71)) were included, with median left ventricular ejection fraction (LVEF) of 62% (IQR 54-69). Median stress PTT was shorter than rest PTT 6.2 (IQR 5.1, 7.7) seconds versus 7.7 (IQR, 6.4, 9.2) seconds. Stress and rest PTT were highly correlated (r = 0.69; p < 0.001). Stress PTT also correlated with LVEF (r=-0.37), stress MBF (r=-0.31), LVEDVi (r = 0.24), LA area index (r = 0.32) (p < 0.001 for all). Over a median follow-up period of 28.6 (IQR, 22.6 35,7) months, MACE occurred in 61 (6.2%) patients. After adjusting for prognostic factors, both rest and stress PTT, independently predicted MACE, but not all-cause mortality. For every 1xSD (2.39s) increase in rest PTT the adjusted hazard ratio (HR) for MACE was 1.43 (95% CI 1.10-1.85, p = 0.007). The hazard ratio for one standard deviation (2.64s) increase in stress PTT was 1.34 (95% CI 1.048-1.723; p = 0.020) after adjusting for age, LVEF, hypertension, diabetes, sex and presence of LGE

Conclusions

In this 2-center study of 985 patients, we deploy a fully automated method of PTT estimation using perfusion mapping with CMR and show that both stress and rest PTT are independently associated with adverse cardiovascular outcomes. In this patient cohort, there is no clear incremental prognostic value of stress PTT, over its evaluation during rest.

Figure 1. Stress and Rest Pulmonary Transit Time estimation using myocardial perfusion CMR

Figure 2. Event-free survival curves for major adverse cardiovascular events (Heart failure hospitalization, myocardial infarction, stroke and ventricular tachycardia/ICD treatment) according to mean rest PTT (8.05seconds) and mean stress PTT (6.7seconds). Log-rank for both p < 0.05

Sinecatechins ointment as a potential novel treatment for usual type vulval intraepithelial neoplasia: a single-centre double-blind randomised control study

OBJECTIVE

To compare the safety and efficacy of 10% sinecatechins (Veregen® ) ointment against placebo in the treatment of usual type vulvar intraepithelial neoplasia (uVIN).

DESIGN

A Phase II double-blind randomised control trial.

SETTING

A tertiary gynaecological oncology referral centre.

POPULATION

All women diagnosed with primary and recurrent uVIN.

METHODS

Eligible patients were randomised 1:1 to receive either sinecatechins or placebo ointment (applied three times daily for 16 weeks) and were followed up at 2, 4, 8, 16, 32 and 52 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure, recorded at 16 and 32 weeks, was histological response (HR). Secondary outcome measures included clinical (CR) response, toxicity, quality of life and pain scores.

RESULTS

There was no observed difference in HR between the two arms. However, of the 26 patients who were randomised, all 13 patients who received sinecatechins showed either complete (n = 5) or partial (n = 8) CR, when best CR was evaluated. In placebo group, three patients had complete CR, two had partial CR, six had stable disease and two were lost to follow up. Patients in the sinecatechins group showed a statistically significant improvement in best observed CR as compared with the placebo group (P = 0.002). There was no difference in toxicity reported in either group.

CONCLUSION

Although we did not observe a difference in HR between the two treatment arms, we found that 10% sinecatechins application is safe and shows promise in inducing clinical resolution of uVIN lesions and symptom improvement, thus warranting further investigation in a larger multicentre study.

TWEETABLE ABSTRACT

A randomised control study indicating that sinecatechins ointment may be a novel treatment for uVIN.

Pulsatile and resistive systolic loads as determinants of left ventricular remodelling after physical training

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Barts Cardiovascular Biomedical Research Centre

onbehalf

The Marathon Study Consortium

Introduction

Cardiovascular function depends on the inter-relation between heart and vasculature.  The contribution of aorta and peripheral vessels to the total systolic load of the left ventricle (LV) can be represented respectively by a "pulsatile" and a "resistive" component. We sought to understand their interrelation by exploring how LV remodelling occurred with altered load associated with an external stimulus (training). Methods: 237 untrained healthy male and female subjects volunteering for their first-time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided into 4 groups according to the variation (positive versus null or negative) in Total Arterial Compliance Index (TACi), representing the pulsatile component of the LV load, and in Systemic Vascular Resistance Index (SVRI), representing the resistive component of the LV load. Results: 138runners (age 21-69 years; F: 51%) completed the race. Data are reported for each variable as Δ mean [95% Confidence Interval]. In the whole cohort, training was associated with a small increase in LV mass index (+3g/m2, [0, 6 g/m2]), indexed LV end-diastolic volume (EDVi) (+3ml/m2, [-2, 5 3ml/m2]), in LV mass/LVEDV ratio (+0.02g/ml, [0.00, 0.04 g/ml]) and in TACi (+0.02ml/m2, [0.02, 0.38 ml/m2]). SVRi mildly fell (-43dyn·s/cm2[-103, 17dyn·s/cm2]). TACi increase was associated with LVEDVi increase and no change in LV mass/EDV (eccentric remodelling). On the other hand, both TACi reduction and SVRi increase were associated with increase in LV mass/EDV and no significant change in LVEDVi (concentric remodelling). A similar increase in LV mass was observed in all groups. See Table. Conclusion: Cardiac remodelling observed after mild, medium term, unsupervised training seems to be related to the modifications of aorta and peripheral vessels. In particular, a reduction in pulsatile load seems associated with eccentric LV remodelling, while an increase in both pulsatile and resistive with concentric LV remodelling. Further research is needed to understand the interaction between TACi and SVRi.

Table 1 LV EDVi (ml/m2) LV mass index (g/m2) LV mass/EDV TACi increase (n = 75) +4 [0, 9] +3 [0, 7] 0 [-0.03, 0.03] TACi decrease (n = 62) -1 [-6, 4] +3 [0, 8] 0.04 [0.01, 0.07] SVRi increase (n = 63) 0 [-4,4] +3 [0, 7] +0.03 [0, 0.06] SVRi decrease (n = 73) +3 [-3, 7] +3 [-1, 6] +0.01 [-0.02, 0.04]

Cardiovascular disease recurrence and long-term mortality in a tri-ethnic British cohort: a retrospective study

Background

People of South Asian and of African Caribbean descent have elevated risks of some cardiovascular diseases compared to Europeans. How ethnicity relates to recurrent risk, and explanations for between ethnic group differences in recurrence are unclear. We characterized long-term risk of major adverse cardiovascular event (MACE) and mortality following a non-fatal cardiovascular event in a tri-ethnic British cohort.

Methods

We linked hospital and mortality records of a population-based cohort of South Asian, African Caribbean and European men and women aged 40–69 years with no prior history of cardiovascular disease. We identified index and recurrent cardiovascular events (stroke, transient ischaemic attack, myocardial infarction, or ischaemic heart disease), and mortality from 1988 to 2017. Using multivariable proportional hazards models, we separately calculated the adjusted hazard ratios (HR) of MACE and death following index event. We adjusted for demographics, vascular and lifestyle risk factors. We used interaction terms to evaluate if diabetes or decade of index event modified the association between ethnicity and outcomes.

Results

We included 801 participants with first non-fatal cardiovascular events, 647 coronary and 127 cerebrovascular, of whom 335 (41.8%) were European, 396 (49.5%) South Asian, and 70 (8.7%) African Caribbean. During a mean follow-up of 5.3 years, 537 patients developed MACE and 338 died. Crude incidence rate of MACE was higher in South Asians (135.9 per 1000-person-years) compared to Europeans (117.1) and African Caribbeans (123.6). Higher risk of MACE in South Asian compared to Europeans was eliminated in the adjusted models (HR 0.97, 95% confidence interval 0.77–1.21), whereas their mortality advantage was eliminated when the younger age at index event was accounted for (HR 0.95, 0.72–1.26). African Caribbeans had similar outcomes to Europeans (HR MACE 1.04, 0.74–1.47; and HR death 1.07, 0.70–1.64). There was no modification by diabetes for outcomes, whereas survival following index event improved more in South Asian, than African Caribbean, compared to European over three decades (Pinteraction = 0.04).

Conclusions

Baseline vascular risk factors explained the observed ethnic variation in cardiovascular disease recurrence and long-term mortality, with a relative improvement in survival of minority ethnic groups over time.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): UK Medical Research Council, Wellcome Trust

The wider consequences of obesity: estimated social and economic costs from Mendelian Randomization

Background

Obesity is a key public health issue worldwide. Accurate estimates of its full impacts on health, social, and economic outcomes are required, but are difficult to obtain due to bias from confounding and reverse causality (the impact of social and economic factors on obesity).

Methods

Using data from the UK Biobank and ALSPAC, we applied a genetic causal inference approach (Mendelian Randomization, MR) to estimate the impact of body mass index (BMI) on key social and economic outcomes. Because genetic variants are assigned before birth and cannot change, estimates from MR studies are less liable to confounding and reverse causation.

Results

Effects of higher BMI were often larger in MR than conventional (non-genetic) models, suggesting previous studies may have underestimated the impact of BMI. For example, in adolescents, MR models implied a standard deviation increase in BMI led to exam scores around 1/3 of a grade lower in all subjects at age 16, and 8.7% (CI: 1.8% to 16.1%) more school absence. In adults a 5kg/m2 increase in BMI corresponded, among other negative outcomes, to £2,778 less annual household income (CI: £1,864 to £3,693), less chance of owning one's home (-1.6%, CI: -2.4% to -0.8%), and higher chance of being lonely (2.4%, CI: 1.4% to 3.5%). At £21.22 (CI: £14.35 to £28.07) per person per marginal kg/m2 per year, MR estimates for inpatient hospital costs were around 40% higher than conventional estimates.

Conclusions

Findings from causal inference based on genetic variation indicate that high BMI has negative impacts on social and economic outcomes that may be larger than previously estimated. This evidence highlights the potential social and economic value of preventing high BMI across the life course.

Key messages

High BMI has considerable negative impacts not only for health, but for individuals’ education and socioeconomic outcomes, and overall health care costs. Previous attempts to quantify these effects may have underestimated BMI’s full impact.

Foot and ankle service adaptation in response to COVID-19 and beyond

The disruption to healthcare provision as a result of the COVID-19 pandemic has compelled us to streamline healthcare delivery. This has given us an opportunity to implement healthcare technology, reform inter-disciplinary collaboration and ultimately enhance patient care. We discuss some of the advances made by the foot and ankle department at our hospital. These innovations have broad applicability and will hopefully ignite discussion amoung a number of healthcare teams about improving the future care of their patients.

Low volumetric bone density is a risk factor for early complications after spine fusion surgery

This study aims to investigate lumbar spine (LS) volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion.

INTRODUCTION

Lumbar spine (LS) fusion surgery is increasingly performed worldwide. Complications after fusion result in significant morbidity and healthcare costs. Multiple factors, including osteoporosis, have been suggested to contribute to risk of complications and re-operation. However, most studies have used DXA, which is subject to artifact in patients with spine pathology, and none have investigated the relationship between BMD and timing of post-operative complications. This study aims to investigate LS volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion.

METHODS

We evaluated a cohort of 359 patients who had initial LS fusion surgery at our institution, had pre-operative LS CTs and post-operative imaging available for review. Demographic factors, smoking status, vBMD, and details of surgical procedure were related to likelihood and timing of post-operative complications.

RESULTS

Mean age was 60 ± 14 years, vBMD 122 ± 37 g/cm³. Median follow-up was 11 months. Skeletal complications occurred in 47 patients (13%); 34 patients (10%) required re-operation. Low vBMD (directly measured and estimated using HU) and smoking were associated with increased risk of skeletal complications. Each increase in baseline vBMD of 10 g/cm³ decreased the complication hazard and increased the complication-free duration in time-to-event analysis (hazard ratio 0.91, 95% CI 0.83-0.98, p < 0.02).

CONCLUSIONS

Low vBMD was a significant risk factor for early post-operative complications in patients undergoing LS fusion. Prospective studies are needed to confirm these findings and to elucidate the optimal timing for follow-up and strategies for prevention of post-operative complications in this population.

Improved results demonstrated in the 2017 national audit of early syphilis management in the United Kingdom

The revised British Association of Sexual Health and HIV UK guidelines on the management of syphilis were published in 2015 and this audit measures performance against those standards and recommendations. Although not included in the guideline recommendations, an exploratory question on clinics’ HIV testing policy was also included. The audit was conducted over a two-month period in 2017 in genitourinary medicine (GUM) clinics across the UK of cases presenting in 2016. A total of 161 GUM clinics participated, and data were collected for 3017 cases. The standard for adherence to recommended treatment was met (97%, standard: 97%) and almost met for documented pre-treatment syphilis serology (95%, standard: 97%). Even though only 74% of patients had a documented action in relation to informing sexual contacts (standard: 97%), the standard for contacts seen and tested per index case within four weeks was met (0.9, standard: 0.6). Finally, those clinics with a formal policy on HIV testing after a syphilis diagnosis were twice as likely to test after the HIV window period, compared to clinics without a policy; a concurrent HIV diagnosis was made in 75 (3%) patients. More work is required to standardize documented delivery of effective partner notification and a formal policy on HIV testing appears to be effective.

Yoga and Cardiovascular Health Trial (YACHT): a UK-based randomised mechanistic study of a yoga intervention plus usual care versus usual care alone following an acute coronary event

OBJECTIVE

To determine the effects of yoga practice on subclinical cardiovascular measures, risk factors and neuro-endocrine pathways in patients undergoing cardiac rehabilitation (CR) following acute coronary events.

DESIGN

3-month, two-arm (yoga +usual care vs usual care alone) parallel randomised mechanistic study.

SETTING

One general hospital and two primary care CR centres in London. Assessments were conducted at Imperial College London.

PARTICIPANTS

80 participants, aged 35-80 years (68% men, 60% South Asian) referred to CR programmes 2012-2014.

INTERVENTION

A certified yoga teacher conducted yoga classes which included exercises in stretching, breathing, healing imagery and deep relaxation. It was pre-specified that at least 18 yoga classes were attended for inclusion in analysis. Participants and partners in both groups were invited to attend weekly a 6- to 12-week local standard UK National Health Service CR programme.

MAIN OUTCOME MEASURES

(i) Estimated left ventricular filling pressure (E/e'), (ii) distance walked, fatigue and breathlessness in a 6 min walk test, (iii) blood pressure, heart rate and estimated peak VO₂ following a 3 min step-test. Effects on the hypothalamus-pituitary-adrenal axis, autonomic function, body fat, blood lipids and glucose, stress and general health were also explored.

RESULTS

25 participants in the yoga + usual care group and 35 participants in the usual care group completed the study. Following the 3-month intervention period, E/e' was not improved by yoga (E/e': between-group difference: yoga minus usual care:-0.40 (-1.38, 0.58). Exercise testing and secondary outcomes also showed no benefits of yoga.

CONCLUSIONS

In this small UK-based randomised mechanistic study, with 60 completing participants (of whom 25 were in the yoga + usual care group), we found no discernible improvement associated with the addition of a structured 3-month yoga intervention to usual CR care in key cardiovascular and neuroendocrine measures shown to be responsive to yoga in previous mechanistic studies.

TRIAL REGISTRATION NUMBER

NCT01597960; Pre-results.

P2444Comparison of 3D and 2D echocardiography-derived indices of left ventricular function and structure to predict long-term mortality in the general population: Southall And Brent Revisited (SABRE) study

Background

Three-dimensional echocardiography (3DE) may have advantages over two-dimensional echocardiography (2DE) for the assessment of left ventricular (LV) function and structure. However, studies comparing 3DE and 2DE-derived indices in relation to mortality are limited, particularly in the general population.

Purpose

We examined associations between 2DE and 3DE-derived LV ejection fractions (LVEF) and volumes for all-cause mortality in a population-based sample.

Methods

A total of 899 individuals (age, 69.6±6.1 years; 77.5%male) from the SABRE study, a UK-based tri-ethnic community cohort, underwent a comprehensive transthoracic echocardiography examination. 2D LVEF and volumes were calculated, and full-volume 3D LV datasets acquired over 4 sub-volumes were obtained using a matrix-array transducer and were analysed offline using Qlab advanced, v7.0. The associations between both 2D- and 3D-derived LVEF (≥55% vs. <55%), body surface area indexed end-diastolic volume (iEDV) and end-systolic volume (iESV), and all-cause mortality were determined using Cox proportional hazards models. Survival curves were constructed using the Kaplan-Meier method.

Results

Of the 899 individuals, 118 (13.1%) died over a median follow-up period of 8 years to 2018. Kaplan Meier survival estimates (Figure 1 illustrates LVEF) and Cox regression revealed that 2D and 3D LVEF, iEDV and iESV were associated with increased risk of all-cause mortality (LVEF (≥55% vs. <55%), 3DE: HR=0.53 (0.35, 0.80); 2DE: HR=0.51 (0.34, 0.75), iEDV (per 1SD increment), 3DE: HR=1.20 (1.0, 1.41); 2DE: HR=1.19 (1.0–1.41), iESV (per 1SD increment), 3DE: HR=1.27 (1.1, 1.52), 2DE: HR=1.32 (1.15, 0.1.51)). However, 3DE associations tended to be stronger in models adjusted for classical risk factors including age, sex, ethnicity, systolic blood pressure, cholesterol:HDL ratio, body mass index, antihypertensive medications, diabetes, and smoking (LVEF (≥55% vs. <55%), 3DE: HR=0.59 (0.39, 0.90); 2DE: HR=0.69 (0.46, 1.0), iEDV (per 1SD increment), 3DE: HR=1.20 (1.0, 1.41); 2DE: HR=1.10 (0.93, 1.31), iESV (per 1SD increment), 3DE: HR=1.27 (1.1, 1.52), 2DE: HR=1.20 (1.04, 0.1.39)).

Figure 1. Kaplan-Meier curves.

Conclusions

In this population-based study, both 2DE and 3DE-derived indices of LV structure and function were associated with all-cause mortality independently of classical risk factors, with some indication that strengths of association were greater for 3DE-derived indices.

Acknowledgement/Funding

SABRE is funded by BHF, Diabetes UK, the MRC and the Wellcome Trust. LA holds a scholarship grant from Imam Abdulrahman Bin Faisal University, SA

6070Association of blood pressure measures with brain structure and function: the Southall and Brent REvisited (SABRE) study

Background

In our rapidly ageing society, dementia and neurocognitive decline are significant global public health problems. Blood pressure (BP), an established cardiovascular risk factor, has been extensively studied with respect to brain structure and function; however, findings across the literature differ depending on the BP component in consideration, and the use of brachial rather than central BP.

Purpose

We set out to assess associations between detailed measures of brain structure and function with comprehensive measures of central and peripheral BP. Furthermore, we performed comprehensive mediation analyses on the associations to investigate potential micro and macro vascular mediatory pathways.

Methods

A community-based sample of 1438 individuals (69.7±6.2 years) from a tri-ethnic cohort. underwent vascular, cognitive and MRI based structural brain measures. BP measures included central (cSBP (Pulsecor)) and peripheral systolic BP (pSBP), diastolic BP (DBP), brachial (bPP) and central pulse pressure (cPP), and mean arterial pressure (MAP). Cognitive assessments comprised tests which explored global/overall function (CSID), executive function and memory. For brain structure, hippocampal brain volume was our key measure. Potential macro- and microvascular mediators included: arterial stiffness (cfPWV), carotid intima-media thickness, retinopathy, white matter hyperintensities and infarcts. Multivariable regression analyses were used to assess associations of BP components with cognitive function scores and brain volumes, adjusted for age, sex and ethnicity as well as macro- and microvascular risk factors. Multiple imputation was performed to account for missing data.

Results

After adjusting for age, sex and ethnicity, both cSBP and pSBP were negatively associated with memory (data are β±SE (z-score) −0.014±0.006, p=0.04), while DBP was positively associated with hippocampal volume (0.006±0.003, p=0.03). cPP was negatively associated with memory (−0.020±0.009, p=0.03), executive function (−0.018±0.006, p=0.002) and hippocampal volume (−0.007±0.003, p=0.005), while bPP was negatively associated with CSID (−0.008±0.004, p=0.04), memory (−0.020±0.008, p=0.02), executive function (−0.016±0.005, p=0.002) and hippocampal volume (−0.006±0.002, p=0.007). There was a stronger association between both PP measures and brain structure and function than with the other BP components, especially MAP. There was little difference in association between cPP and bPP measures with brain structure and function. Furthermore, these associations do not appear to be mediated by either macro- or microvascular disease.

Conclusion

These results suggest that there is a direct association between increased PP and a decline in brain structure and function. This implies that older patients with suboptimal PP control may be at increased risk of developing cognitive impairment and that measuring PP offers mechanistic information above and beyond conventional BP measures.

Acknowledgement/Funding

Wellcome Trust, British Heart Foundation

P909Echocardiographic Assessment of Left Ventricular Function in Patients with Aortic Stenosis and the short-term effects after intervention

Introduction

Aortic stenosis (AS) is the most prevalent form of acquired valvular heart disease, it affects ∼2% of people aged over 75. Series of compensatory mechanisms occur, in order for LV to adapt to high pressure overload. Aortic valve replacement has been the mainstay AS treatment either surgically or percutaneously. The evaluation of myocardial strains after Transcatheter Aortic Valve Implantation (TAVI) and Surgical Aortic Valve Replacement (SAVR) is still underexplored and there is no single study to date scouting the difference between TAVI and SAVR.

Aim

To assess the impact of unloading LV after TAVI and SAVR on LV remodelling.

Methods

In this prospective study, we have recruited 111 patients (75±11 years, 63% were females) with varying degrees of aortic stenosis. Of the 111 patients, 43 patients and 11 patients underwent TAVI and SAVR respectively between November 2017 and May 2018. Demographics, clinical and echocardiographic measurements along with speckle tracking parameters were recorded for all participants and again 4±2 weeks after intervention.

Results

Pre-TAVI LV-GLS mean was −10.8±3.5% and after implantation of aortic prosthesis immediate improvement of the myocardial deformation to −13.98±2.9% was observed after one month of the intervention, mean difference of −3.16% following procedure. There was an evidence of significant improvement in LV-GRS after TAVI (44.86±12.9% to 49.77±10.8%, P value= 0.047). Per contra, when comparing pre and post TAVI LV-GCS, no statistical evidence was noted. However, a difference of −2.4% in GCS following the intervention might be clinically important, but no previous evidence can support this. This is attributed to the poor reproducibility and yet not available standardisation.

Table 1 Variables TAVI (n=43) SAVR (n=11) P value† Pre Post P* value Pre Post P* value GLS (%) −10.82±3.5 −13.98±2.9 <0.001 −12.75±4.3 −16.1±2 0.021 0.152 GCS (%) −30.1±8.1 −32.49±9.2 0.134 −27±9.8 −33.9±4.69 0.063 0.062 GRS (%) 44.86±12.9 49.77±10.8 0.047 36.6±13.3 44.97±4.9 0.074 0.058 Data are expressed as mean ± SD. Comparisons were performed using paired Student's t tests. *Pre and post intervention. †Post TAVI vs. post SAVR. Comparison done using unpaired t test of the differences.

Conclusion

Significant improvement was evident in myocardial deformation parameters – in particular GLS – after weeks of the intervention demonstrating a strong evidence of reversed remodelling following SAVR and TAVI.

Kyphomelic dysplasia, Pierre Robin Sequence and pregnant

We present the anaesthetic management of a parturient with kyphomelic dysplasia and Pierre Robin Sequence who underwent elective caesarean delivery. Potential anaesthetic issues and management strategies are discussed.

In Vivo Platelet Activation Following Myocardial Infarction and Acute Coronary Ischaemia

Forty-seven patients presenting with acute chest pain had in vivo platelet activity assessed by measuring plasma levels of the platelet-specific protein beta thromboglobulin (BTG), and by screening for the presence of circulating platelet aggregates. Nineteen patients with transmural myocardial infarction (MI), 21 patients with acute coronary ischaemia (CI), and 7 patients with non-cardiac chest pain (NCCP) were investigated in a serial study and compared with a normal control group. The means of all BTG determinations in the MI (34, ± SD = 21-57) and CI (33, ± SD = 19-57) groups were significantly higher than those in the NCCP group (24, ± SD = 17-34; p Ã0.01) and normal subjects (22,5, ± SD = 14-37; p Ã0.001). There was no difference in BTG between those with MI or CI, nor between the NCCP group and normal subjects. Raised numbers of circulating platelet aggregates could not be detected in either MI or CI. The mean BTG levels in both MI and CI patients were significantly raised, compared to normal subjects, on the first day of admission to hospital and remained so on each of the subsequent nine days. Neither heparin plus warfarin nor sulphinpyrazone had any significant effect in lowering BTG levels. 15/40 patients (37.5%) following MI and CI had repeatedly raised BTG levels throughout the study period, and it is suggested that these patients represent an “at risk” group that may benefit from anti-platelet therapy in secondary prevention studies.

Age modification of the relationship between C-reactive protein and fatigue: findings from Understanding Society (UKHLS)

BACKGROUND

Systemic inflammation may play a role in the development of idiopathic fatigue, that is, fatigue not explained by infections or diagnosed chronic illness, but this relationship has never been investigated in community studies including the entire adult age span. We examine the association of the inflammatory marker C-reactive protein (CRP) and fatigue assessed annually in a 3-year outcome period for UK adults aged 16-98.

METHODS

Multilevel models were used to track fatigue 7, 19, and 31 months after CRP measurement, in 10 606 UK individuals. Models accounted for baseline fatigue, demographics, health conditions diagnosed at baseline and during follow-up, adiposity, and psychological distress. Sensitivity analyses considered factors including smoking, sub-clinical disease (blood pressure, anaemia, glycated haemoglobin), medications, ethnicity, and alcohol consumption.

RESULTS

Fatigue and CRP increased with age, and women had higher values than men. CRP was associated with future self-reported fatigue, but only for the oldest participants. Thus, in those aged 61-98 years, high CRP (>3 mg/L) independently predicted greater fatigue 7, 19, and 31 months after CRP measurement [odds ratio for new-onset fatigue after 7 months: 1.88, 95% confidence interval (CI) 1.21-2.92; 19 months: 2.25, CI 1.46-3.49; 31 months: 1.65, CI 1.07-2.54]. No significant longitudinal associations were seen for younger participants.

CONCLUSIONS

Our findings support previously described CRP-fatigue associations in older individuals. However, there are clear age modifications in these associations, which may reflect a contribution of unmeasured sub-clinical disease of limited relevance to younger individuals. Further work is necessary to clarify intervening processes linking CRP and fatigue in older individuals.