Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

The long-term effect of surgical aortic valve replacement on arterial stiffness and wave reflections

Background

Assessing arterial properties in patients with aortic valve stenosis undergoing surgical aortic valve replacement (SAVR) is difficult, and the results to date have been inconclusive.

Purpose

We sought to investigate how SAVR affects vascular stiffness in the short and long term.

Methods

We included 69 patients (mean age 70.8±8.4 years, 62% men) with severe symptomatic aortic stenosis who underwent SAVR. Arterial stiffness was assessed using the carotid femoral pulse wave velocity (cfPWV) and brachial-ankle pulse wave velocity (baPWV). Measurements in patients with an ankle-brachial index (ABI) <0.9 were excluded from the analysis for baPWV measurments because a low ABI can affect the accuracy of baPWV. Augmentation index corrected for heart rate (Alx@75), central pressures and subendocardial viability ratio (SEVR) were assessed with arterial tonometry. Measurements were conducted at baseline, in the acute phase and 1 year after the operation.

Results

Immediately after SAVR there was an increase in cfPWV (8.04±1.3 m/s vs 8.54±1.6 m/s, p=0.02) that was sustained at 1 year (8.04±1.3 m/s vs 9.42±2.4 m/s, p≤0.001). Similarly, baPWV (n=55) increased in the acute phase (1633±429 cm/s vs 2014±606 cm/s, p<0.001) and persisted 1 year postoperatively (1633±429 cm/s vs 1867±408 cm/s, p<0.001). Post-SAVR we also observed a decrease in Alx@75 (31.02±10% vs 22.73±12%, p≤0.001) that was attenuated 1 year later (31.02±10% vs 26.65±8%, p≤0.001), and an increase in SEVR (136.1±30.4% vs 149.2±37.7%, p=0.01) which remained improved at 1 year (136.1±30.4% vs 147.5±30.4%, p=0.01).

Conclusions

After SAVR the arterial system shows an increase of stiffness in response to the acute relief of the obstruction, which is retained in the long term.

Funding Acknowledgement

Type of funding sources: None.

The natural history of idiopathic chronic large asymptomatic non-inflammatory pericardial effusions

Background/Introduction

Pericardial effusions (PEFs) are a challenging and often troublesome pericardial syndrome. The most recent 2015 ESC guidelines on pericardial diseases recommend drainage in cardiac tamponade or suspected bacterial/ neoplastic etiology (class IC), which should also be considered in large, idiopathic chronic PEFs.

Purpose

In this work we assessed the natural history of asymptomatic, idiopathic, chronic, C-reactive protein (CRP) negative, large PEFs.

Methods

We assessed retrospectively consecutive patients referred to the pericardial unit of our institution with idiopathic (without definite underlying etiology after extensive work-up), chronic (>3 months), large (maximal effusion diameter at end-diastole >2cm), asymptomatic, without evidence of ongoing pericardial inflammation (without CRP elevation or evidence of pericardial inflammation with cardiac magnetic resonance imaging) PEFs. To define the natural history of this condition, only patients with a follow-up of at least 2 years were included. The change in the PEF diameter from the first evaluation to the last follow-up namely: regression (complete or decrease from large to moderate/small), progression with symptoms appearance requiring drainage, or stability over time (defined as variation of PEF diameter <5mm, but still in the range of large), was assessed. Follow-up according to our institutional protocols was performed every 3 months and included clinical examination and focused echocardiography.

Results

Thirty patients fulfilled the inclusion criteria and were analyzed. No patient was receiving anti-inflammatory treatment during follow-up. Nevertheless, 12 patients (40%) had received from their attending physicians a course of anti-inflammatory treatment (non-steroidal anti-inflammatory drugs, glucocorticoids, colchicine and combinations) before enrollment, without or with temporary results. The mean age of this study population was 64.9 (±16.1) years and the mean follow-up was 49.8 (±17.8) months. Women were numerically more often affected compared to men (57% vs. 43%, p=0.465). History of pericarditis was reported in 13% of cases. The mean maximal PEF diameter was 24.5mm (±3.3) and the median disease duration at first evaluation was 15.5 (7–57) months. Concerning outcome, the effusion size remained stable in 24 out of 30 patients (80%), regressed in 4 (13%,) and increased in size requiring drainage due to symptoms onset in the remainder 2 (7%). During follow-up 2 patients (7%) with stable in size effusions died from non-cardiac causes.

Conclusions

According to this study results the outcome of idiopathic, chronic, large, asymptomatic and without evidence of inflammation PEFs is overall favorable. Patients should be reassured about the benign course of this condition but at the same time, advised to seek medical care should symptoms appear, for a timely intervention with pericardial drainage.

Funding Acknowledgement

Type of funding sources: None.

Statins benefit in androgen levels and target organ damage in hypertensive males with erectile dysfunction

Background

Statins may benefit cardiovascular physiology by cholesterol independent or pleiotropic actions. Target organ damage (TOD) amplifies cardiovascular risk in essential hypertension and endogenous testosterone (TT) exhibit vasoprotective effects. Erectile dysfunction (ED) is frequent in hypertensive middle aged men when androgen levels typically fall, impairing thus quality of life.

Purpose

To investigate the effect of statins in TT and TOD in hypertensive middle aged men with ED, independently of cholesterol levels.

Methods

248 hypertensive ED males (mean age: 57 yo) with no history of diabetes mellitus or overt cardiovascular disease enrolled the study. Of those 95 (38%) were on statin therapy for treatment of dyslipidemia. There were all screened for the presence of microalbuminuria, defined as urinary albumin loss 30–300 mg in a 24 h urine volume collection. TT, total cholesterol (Tchol) and low density lipoprotein (LDL) levels were measured on blood samples taken before 09:00 am. All individuals underwent a non invasive evaluation of the carotid-femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) a parameter of wave reflection amplification (Sphygmocor device). ED severity was assessed by the SHIM-5 score (range: 0–25) and higher values indicate a better erectile ability.

Results

In bivariate analysis statin use was positively related to TT (p<0.05 – Figure 1) and negatively to microalbuminuria, Tchol and LDL (p<0.005). Moreover TT was negatively related to PWV, AIx, microalbuminuria (all p<0.005) and positively to the SHIM-5 score (p: 0.003). By linear regression analysis association of TT to statins remained significant after correction for age, BMI, PWV, AIx, Tchol and LDL levels.

Conclusions

Statin therapy benefits endogenous testosterone in hypertensive middle aged men with ED and so lessens TOD and enhances erectile ability independently of cholesterol levels. In such population group pleiotropic effects of statins may help restoring androgen levels, decrease cardiovascular risk and ameliorate quality of life.

Funding Acknowledgement

Type of funding sources: None.

Time-related aortic inflammatory response, as assessed with 18F-FDG PET/CT, in patients hospitalized with severely or critical COVID-19

Aim

Arterial involvement has been implicated in the coronavirus disease of 2019 (COVID-19). Fluorine 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging is a valuable tool for the assessment of aortic inflammation and is a predictor of outcome. We sought to prospectively assess the presence of aortic inflammation and its time-dependent trend in patients with COVID-19.

Methods

Between November 2020 and May 2021, in this pilot, case-control study, we recruited 20 patients with severe or critical COVID-19 (mean age of 59±12 years), while 10 age and sex-matched individuals served as the control group. Aortic inflammation was assessed by measuring 18F-FDG uptake in PET/CT performed 20–120 days post-admission. Global aortic target to background ratio (GLA-TBR) was calculated as the sum of TBRs of ascending and descending aorta, aortic arch, and abdominal aorta divided by 4. Index aortic segment TBR (IAS-TBR) was designated as the aortic segment with the highest TBR.

Results

There was no significant difference in aortic 18F-FDG PET/CT uptake between patients and controls (GLA-TBR: 1.46 [1.40–1.57] vs. 1.43 [1.32–1.70], respectively, p=0.422 and IAS-TBR: 1.60 [1.50–1.67] vs. 1.50 [1.42–1.61], respectively, p=0.155). There was a moderate correlation between aortic TBR values (both GLA and IAS) and time distance from admission to 18F-FDG PET-CT scan (Spearman's rho=−0.528, p=0.017 and Spearman's rho=−0.480, p=0.032, respectively), Figure 1. Patients who were scanned less than or equal to 60 days from admission (n=11) had significantly higher GLA-TBR values compared to patients that were examined more than 60 days post-admission (GLA-TBR: 1.53 [1.42–1.60] vs. 1.40 [1.33–1.45], respectively, p=0.016 and IAS-TBR: 1.64 [1.51–1.74] vs. 1.52 [1.46–1.60], respectively, p=0.038). There was a significant difference in IAS-TBR between patients scanned ≤60 days and controls (1.64 [1.51–1.74] vs. 1.50 [1.41–1.61], p=0.036), Figure 2.

Conclusion

This is the first study suggesting that aortic inflammation, as assessed by 18F-FDG PET/CT imaging, is increased in the early post-COVID phase in patients with severe or critical COVID-19 and largely resolves over time. Our findings may have important implications for the understanding of the course of the disease and for improving our preventive and therapeutic strategies.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of functional syntax score based on quantitative flow ratio

Background/Introduction

The quantitative flow ratio (QFR) based functional Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (FSSQFR) takes into consideration not only the anatomy but also the physiology of coronary arteries.

Purpose

To investigate the prognostic value of the FSSQFR.

Methods

We performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. FSSQFR was counted by summing the individual scores only in ischemia-producing lesions (vessel QFR ≤0.8). Patients were divided into low-, intermediate- and high risk according to SS and FSS with the same cutoff. The primary endpoint was the estimation of the predictive value of FSSQFR for the composite outcome of death, myocardial infarction, ischemia-driven revascularization, stroke, hospitalization for heart failure, and life-threatening arrhythmias.

Results

410 patients were included in this study. Baseline characteristics of the population displayed in Table 1. FSSQFR and SS were estimated for all patients. According to SS, 26.6% of patients were high risk, 36.6% were intermediate risk and 36.8% were low cardiovascular risk. After calculating FSSQFR, risk stratification changed in 10% of the study population, more specifically 21.2%, 36.6%, and 42.2% of patients were classified as high-, intermediate- and low-risk respectively. 5% (n=20) of the patients for whom coronary artery bypass grafting would be recommended according to SS, converted in favor of percutaneous coronary intervention after FSSQFR calculation. After a median 30.2 (25.7–33.7) months follow-up period multivariate regression analysis showed FSSQFR was an independent predictor of primary endpoint after adjustment for age, gender, BMI, and hypertension (adjusted OR: 1.03 [95% CI, 1.01–1.06]; P=0.012). The Kaplan-Meier estimate for the primary endpoint was 15%, 18.7%, and 32.2% in the low, intermediate, and high FSSQFR group, respectively (log-rank P=0.001; Figure 1A) and cardiac death was 2.3%, 8.7%, and 12.6% in the low, intermediate, and high FSSQFR group, respectively (log-rank P=0.003; Figure 1B).

Conclusions

In our study, FSSQFR showed discordance with classical anatomical SS leading to risk re-stratification of patients with coronary disease and possible alternative treatment strategy and also was found to be an independent predictor of higher cardiovascular adverse events.

Funding Acknowledgement

Type of funding sources: None.

Correlation of lipoprotein(a) with parameters of lipid profile and other cardiovascular risk factors in patients with familial combined hyperlipidemia

Background

According to previous studies, Familial Combined Hyperlipidemia (FCH) is related to metabolic syndrome. However, it is unclear whether the presence of increased Lipoprotein (a) [Lp (a)] modifies the characteristics of metabolic syndrome in patients with FCH. Thus, the aim of our study was to identify and compare the components of metabolic syndrome in patients with FCH according to their Lp (a) levels.

Methods

We enrolled 906 patients (592 males, mean age 49±11 years) who fulfilled the FCH criteria, from the outpatient lipid clinic of our hospital.Venous blood samples were obtained for the determination of plasma glucose and lipid profile [i.e., total cholesterol, triglycerides (TG), low and high-lipoprotein cholesterol, (LDL, HDL)], as well as levels of Lp (a). Moreover, information was obtained regarding demographic characteristics and blood pressure (BP) levels. Diagnosis of hypertension was based on BP levels≥140/90 mmHg and metabolic syndrome was defined according to ATP III criteria.

Results

In the total population of 906 patients with FCH, 58% (n=524) had metabolic syndrome. We identified a negative correlation between levels of Lp (a) and TG (r=−0.07, p=0.03) and a positive correlation between levels of Lp (a) and HDL (r=0.08, p=0.02). Also, there was a trend towards a negative correlation between levels of Lp (a) and waist circumference (r=−0.6, p=0.06). Moreover, the group of patients with increased Lp (a) levels (≥30mg/dl, n=289, 32%) compared to those with low Lp (a) levels (<30mg/dl, n=616, 68%)had hypertension in a greater percentage (44% vs 36%, p=0.02), lower levels of TG (278±146 vs 302±172 mg/dl, p=0.04), higher levels of HDL (42±11 vs 39±9 mg/dl, p=0.01) and increased levels of LDL (193±55 vs 185±53 mg/dl, p=0.05), while there was no difference in glucose levels (104±24 vs 102±20 mg/dl, p=0.18). In multiple logistic regression analysis increased Lp (a) levels were independent determinants of lower triglycerides levels (<150mg/dl) (OR 0.59, 95% CI 0.36–0.95), after adjustment for confounding factors.

Conclusions

In patients with FCH, increased Lp (a) is related to lower levels of triglycerides, higher levels of HDL, lower waist circumference levels and increased prevalence of hypertension. Thus, it seems that Lp (a) differentiates the expression of metabolic syndrome characteristics in patients with Familial Combined Hyperlipidemia.

Funding Acknowledgement

Type of funding sources: None.

Erectile dysfunction, generalized vascular disease and the long term effects of smoking exposure on arterial properties: time is of the essence

Introduction

Erectile dysfunction (ED) is considered an early manifestation of generalized vascular disease and may precede clinically overt cardiovascular disease (CVD) by 2 to 5 years. We examined macrovascular changes according to time of ED onset and the impact of smoking on the severity of penile vascular damage and large artery wall changes.

Methods

We measured carotid-femoral pulse wave velocity (PWV), carotid intima media thickness (cIMT), augmentation index (AIx) and brachial flow-mediated dilation (FMD) in 378 males with ED (age: 54±7 years). All participants had no clinical manifestations or a history of atherosclerotic disease. They were assessed using the Sexual Health in Men (SHIM)-5 score for ED severity and the penile colour Doppler ultrasonography after intracavernous injection of prostaglandin E1 for measurement of peak systolic velocity (PSV). Low PSV values indicate impaired penile blood inflow and severe vasculogenic ED. ED duration was defined as the time interval between age at diagnosis and study entry.

Results

The study population was divided into three groups according to duration of ED. Group 1: <2 years, Group 2: 2–5 years and Group 3: >5 years. Comparison of various parameters among the three groups using one-way ANOVA or the Kruskal–Wallis test did not demonstrate statistically significant differences in age, prevalence of hypertension, diabetes, smoking, peripheral blood pressure (BP) and metabolic parameters (fasting blood glucose, lipid profile, testosterone levels). Total tobacco cigarette exposure was greater in males with ED duration >5 years (Group 3), compared to Group 2 and 1 patients (23.8 vs 22.5 vs 20.7 pack-years, P<0.01). PWV, AIx and cIMT increased and FMD decreased across the three groups (Figure 1). The three groups had comparable PSV value. We then divided the study population into four subgroups according to tobacco exposure (never smokers; light smokers<20 pack-years, moderate smokers 20–40 pack-years and heavy smokers >40 pack-years). The subgroups have similar age and BP. The three smoking subgroups had significantly higher PWV (P<0.001), AIx (P<0.01), cIMT (P<0.01) and lower FMD (P<0.05) and PSV (P<0.05) compared to never smokers. Post hoc analysis revealed higher PWV, AIx and cIMT and lower FMD in heavy smokers compared to moderate and light smokers (all p<0.05). PSV was similar across the three smoking subgroups.

Conclusions

The study shows that longer ED duration is associated with a more pronounced vascular dysfunction and subclinical vascular wall changes and that heavy tobacco cigarette exposure significantly deteriorates macrovascular parameters. Furthermore there was a significant impairment of penile vasculature even in light smokers. These findings may partly explain why the same process that contribute to CVD may cause earlier ED symptoms and imply that smoking cessation should be a premising non pharmacological intervention in men with ED.

Funding Acknowledgement

Type of funding sources: None.

Deformation analysis in advanced chronic kidney disease: an important prognostic indicator

Background

Chronic kidney disease (CKD) is associated with a higher incidence of cardiovascular manifestations, particularly in patients with advanced renal impairment on long-term dialysis. Cardiac deformation analysis, assessed by speckle tracking echocardiography has been shown to be a significant prognostic index in various specific populations.

Objective

To assess the prognostic value of deformation analysis measurements including both systolic parameters as left ventricular (LV) global longitudinal strain, and diastolic indices as left atrial (LA) strain, in patients with end-stage renal disease.

Methods

We enrolled 67 patients (mean age 62.3±11.8, 65.7% men) with end-stage renal disease. Patients with a confirmed diagnosis of pre/existing cardiac conditions, such as obstructive coronary artery disease, heart failure, severe arrhythmias or severe valvular disease were excluded from the study. A comprehensive transthoracic echocardiography study was performed at baseline. All images were stored digitally and subsequent analysis was performed offline. LV global longitudinal strain (GLS) and LA strain were calculated semi-automatically using dedicated software. The primary endpoints of the study were major adverse cardiovascular events such as all-cause mortality, cardiovascular mortality, myocardial infarction, and hospitalizations for cardiac adverse events. The median follow-up was five years.

Results

The study population had normal or mildly impaired systolic function with a mean LV ejection fraction (EF) of 49.17% (±10.41) while 70% of patients had reduced LV GLS, mean 14.35% (±4.49). Regarding LA parameters, 50% of our cohort had impaired LA strain: mean LA reservoir, LA conduit, and LA contractile reserve were 24.11% (±12.61), 10.56% (±5.88), and 13.60% (±9.15) respectively. The 5-year cumulative event-free survival was 58.2% (±6.7), while 30% of major events occurred in the first 2 years after baseline. Age had a moderate correlation with poor prognosis (p=0.013). Of the echocardiographic parameters LV EF, LV GLS, the conduit phase of LA strain, LA volume and various doppler parameters related to diastolic function, such as mitral E/A ratio and late mitral diastolic velocity A, were found to have a significant negative association with total prognosis (p=0.003, p=0.02, p=0.048, p=0.045, p=0.008, and p=0.017 respectively). Logistic regression analysis showed that of the different echocardiographic parameters LV EF, LV GLS, and the conduit phase of LA strain were significantly associated with the overall prognosis (p=0.009, p=0.007, p=0.05). The conduit element of LA strain was the strongest predictor among them (OR=0.77 p=0.04).

Conclusion

Left ventricular systolic and diastolic dysfunction is a significant prognostic indicator in patients with end stage renal disease. Assessing cardiac mechanics with speckle tracking echocardiography could provide valuable information in this specific population.

Funding Acknowledgement

Type of funding sources: None.

Effect of 1st line treatment on aortic inflammation as assessed by 18 FDG PET/CT in patients with Hodgkin and non-Hodgkin lymphoma

Background

Despite advances in the treatment of oncology patients, therapy-related side effects may lead to premature morbidity among cancer survivors. Inflammatory activation that has been linked to cardiovascular disease is particularly crucial for the pathogenesis of both Hodgkin (HL) and non-Hodgkin lymphoma (NHL).

Objectives

To assess the vascular effects of chemotherapy in patients with HL and NHL by 18-Fluorodeoxyglucose (FDG PET/CT) and to investigate possible interactions with systemic inflammation as assessed by circulating inflammatory markers.

Methods

Between July 2015 and July 2019, sixty-five consecutive patients (37 males, mean age 56±17.8 years) with histologically confirmed new diagnosis of either HL (n=33) or NHL (n=32), were prospectively studied. PET/CT imaging was performed at baseline, at an interim phase and after 1st line treatment. Aortic FDG uptake was assessed by measuring global aortic TBR. Serum interleukin-6 (IL6) and interleukin-1b (IL1b) were measured at each phase for all patients and served as circulating inflammatory markers.

Results

Patients with HL demonstrated significant reduction in aortic TBR after 1st line treatment (aortic TBRbaseline=1.98, aorticTBR3rdscan=1.75, p=0.001, F=8.335), which remained significant after adjustment for 10-year cardiovascular risk (Framingham risk score), dyslipidemia, hypertension and diabetes (p=0.002, F=7.664). In contrast, patients with NHL did not demonstrate a significant aortic inflammation response (aortic TBRbaseline = 2.13, aorticTBR3rd scan=2.015, p=0.596, F=0.527), Figure 1. Regarding inflammatory markers, after 1st line treatment IL6 levels were reduced significantly in both HL and NHL groups (IL6baseline HL=3.25, IL6 post 1st line treatment HL=0.448, p=0.00; IL6baseline NHL=0.475, IL6 post 1st line treatment NHL=0.144, p=0.001); IL1b levels did not change significantly in either group, Table 1.

Conclusions

We demonstrate for the first time that aortic inflammation as assessed by 18-FDG PET-CT is reduced in HL patients after 1st line treatment but not in NHL patients. These findings imply that different pathophysiological pathways and different therapies might affect the arterial bed in different ways in lymphoma patients. Further, a strong potential role of molecular imaging in cardio-oncology emerges, offering valuable information on disease prognosis and progression with a single examination.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Hellenic Society of Hypertension

Smoking promotes vascular damage in apparently healthy men with low testosterone and increased subclinical inflammation

Background

Testosterone deficiency and increased inflammation are both associated with an unfavourable vascular profile. Aim of the study was to examine whether smoking significantly deteriorates the effect of these pathophysiological mechanisms on arterial wall properties.

Methods

Carotid intima media thickness (cIMT) and aortic pulse wave velocity (aPWV) were measured in 87 smokers and 112 aged-matched never smokers (mean age: 49±5 yrs) with no other cardiovascular (CV) risk factors/or manifest CV/atherosclerotic disease. Plasma total testosterone (TT) and high sensitivity reactive protein (hsCRP) levels were measured in the whole study population.

Results

Both smokers and never smokers were divided into four subgroups according to measured low or normal TT levels (low TT<3.5 ng/ml) and high or low hsCRP levels. BMI and LDL-C levels were not different between the subgroups. In smokers the four TT/CRP subgroups had comparable cumulative tobacco smoke exposure. In smokers the low TT/high CRP subgroup had significantly higher aPWV and cIMT compared to the three other subgroups (P<0.01 and P<0.05, respectively by ANOVA, figures A-B) while in never smokers the four TT/CRP subgroups had comparable aPWV and cIMT (all P>0.05, figures C-D). The differences in aPWV and cIMT measurements between TT/CRP subgroups in smokers remained statistically significant after adjustment for age.

Conclusions

The study shows that low TT combined with high CRP are associated with increased carotid IMT and aortic PWV in smokers with no other CV risk factors, while in never smokers the effect of combined low TT and high CRP concentration was not significant. Considering the predictive value of aortic stiffness and carotid thickness, the finding of this study imply interrelationships between tobacco cigarette smoke, subclinical inflammation and low testosterone level regarding changes in arterial wall properties.

Funding Acknowledgement

Type of funding sources: None.

Long-term effects of phosphodiesterase-5 inhibitors on cardiovascular outcomes and death: a systematic review and meta-analysis of cohort studies

Background

Phosphodiesterase type 5 inhibitors (PDE-5i), which are widely used for the treatment of erectile dysfunction, have been found to exhibit systemic vascular benefits by improving endothelial function possibly lowering the risk for cardiovascular events and death.

Purpose

We sought to evaluate the effects of PDE5i on long-term cardiovascular outcomes and mortality.

Methods

A comprehensive search of electronic databases was conducted up to February 28, 2022. Cohort studies comparing PDE5i treatment at any dose with placebo or no treatment and a minimum follow-up duration of 6 months were considered eligible. The outcomes of interest were: (1) major adverse cardiovascular events (MACE) and (2) all-cause mortality. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated.

Results

Eight trials were included (1,152,106 subjects, 8.5% treated with PDE5i). All were males [median age 61.5 years (range 30–72.8)]. The median follow-up duration was 3.8 years (range 2.3–7.5) across the studies. PDE5i use was associated with significant reduction in the composite of MACE [RR 0.79, 95% confidence intervals (CI) 0.69–0.91] (Figure 1). In addition, the analysis of pooled data from 5 studies, after removal of a study with a relatively small sample size, demonstrated that the use of PDE5i was associated with a significantly lower risk of all-cause mortality (RR 0.70, 95% CI 0.53–0.91) (Figure 2). Focusing on patients with a history of coronary artery disease, PDE5i was also found to reduce the risk of all-cause mortality by 15% (RR 0.85, 95% CI 0.74–0.98).

Conclusion

The use of PDE5i in men with or without known coronary artery disease was associated with a lower risk of cardiovascular events and overall mortality. This information underlines that PDE5i could provide considerable clinical benefit beyond the treatment of ED and could instigate the conduction of further, large-scale randomized clinical trials.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of discordance between plain coronary angiography and quantitative flow ratio in revascularization guidance

Background/Introduction

Percutaneous coronary intervention (PCI) guided by functional coronary stenosis severity has been associated with less clinical adverse events compared with plain coronary angiography. Quantitative flow ratio (QFR) has proven to be a reliable tool for functional assessment of coronary lesions.

Purpose

To investigate the prognostic role and the extend of disagreement between plain coronary angiography and QFR in guiding the decision to treat a coronary lesion.

Methods

We retrospectively performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. Patients with referral for coronary artery bypass graft surgery after coronary angiography were excluded. We aimed to measure QFR in all vessels of each patient. Patients were divided in two groups according to the concordance or discordance of the two methods. Patients with at least one vessel with QFR value ≥0.80 treated with PCI and/or at least one vessel with QFR value <0.80 not treated with PCI were included in the discordance group. The remaining patients formed the concordance group. Primary endpoint was the composite outcome of cardiovascular death, myocardial infraction and ischemia-driven revascularization.

Results

Overall, we included 549 patients in the study. Concordance between plain coronary angiography and QFR was present in 404 (73.6%) patients, while discordance between the two methods was found in 145 patients (26.4%). Baseline patient characteristics are displayed in Figure 1. Patients in the discordance group were older, with more extended coronary artery disease and higher SYNTAX score. After a median follow-up period of 30.5 (26.4–33.7) months, multivariate regression analysis showed significant higher rate of the composite outcome in the discordance group (OR: 2.975 95% CI 1.782–4.967, p<0.001) (Figure 2).

Conclusion

In our study, discordance between plain coronary angiography and QFR in revascularization guidance was present in approximately one fourth of patients and was found to be a strong independent predictor of higher cardiovascular adverse events.

Funding Acknowledgement

Type of funding sources: None.

Acute effects of COVID-19 vaccination on inflammatory, macrovasular and microvascular biomarkers

Purpose

To fight the COVID-19 pandemic, messenger RNA (mRNA) vaccines were the first to be adopted by vaccination programs worldwide. We sought to investigate the short-term effect of mRNA vaccine administration on endothelial function and arterial stiffness.

Methods

Thirty-two participants (mean age 37±8 years, 20 men) that received the BNT162b2 mRNA COVID-19 vaccine were studied in 3 sessions in a sequence-randomized, sham-controlled, assessor-blinded, cross-over design. Primary outcome was endothelial function assessed by brachial artery flow-mediated dilatation (FMD), and secondary outcomes were aortic stiffness, evaluated with carotid-femoral pulse wave velocity (PWV), microvascular function that was estimated with hyperemic mean blood flow velocity (HMBFV) of the brachial artery, and inflammation measured by high-sensitivity C-reactive protein (hsCRP) and interleukins (hsIL-6 and hsIL-1b) in blood samples. The outcomes were assessed prior to, and at 8h, 24h post the 1st dose of vaccination, and 8h, 24h and 48h post the 2nd.

Results

There was an increase in hsCRP that was apparent at 24h after both the 1st dose (−0.60 [95% Confidence intervals [CI]: −1.60 to −0.20], p=0.013) and the 2nd dose (max median difference at 48h −6.60 [95% CI: −9.80 to −3.40], p<0.001) compared to sham. Similarly, interleukins also increased. The vaccine did not change PWV. FMD remained unchanged during the 1st dose but decreased significantly by 1.5% (95% CI: 0.1% to 2.9%, p=0.037) at 24h post the 2nd dose (Figure). FMD values returned towards baseline at 48h. HMBFV remained unchanged during the 1st dose but at 48h post the 2nd dose was numerically lower than the sham procedure but the difference between the 2 sessions was not statistically significant (max mean difference at 48h 8.6 [95% CI: −0.6 to 17.8], p=0.067).

Conclusions

Our study shows that the mRNA vaccine causes a prominent increase in inflammatory markers, especially after the 2nd dose and a transient deterioration of endothelial function at 24h that returns towards baseline at 48h. These results confirm the short-term cardiovascular safety of the vaccine.

Funding Acknowledgement

Type of funding sources: None.

Effect of long-term testosterone replacement therapy on arterial stiffness and systemic endothelial function in male patients with hypogonadism

Purpose

The study aims at providing the long-term effect of testosterone replacement therapy on systemic endothelial function, aortic stiffness and wave reflections in men with testosterone deficiency (TD).

Methods

This is a randomized single-center double-blind placebo-controlled trial involving 24 men (aged 51±9 years) with erectile dysfunction (ED) and total testosterone (TT) levels below 3.5 ng/ml randomised to receive either intramuscular (i.m) testosterone undecanoate (TU) injections (1000 mg as a single 4 mL i.m. injection at 0, 6, 18, 30 and 42 weeks) or an identical placebo at similar time points. A TU /placebo 2:1 randomization list was generated and patients were centrally assigned to one of the two arms, consecutively. Central blood pressure (BP), augmentation index (AIx), carotid-femoral pulse wave velocity (PWV) and brachial flow mediated dilatation (FMD) were measured at baseline, and at 18, 24, 30 and 44 weeks.

Results

The changes in central systolic BP and pulse pressure were more potent in the TU group compared to placebo group, however the decreases in these parameters were not statistically significant in point-of-time and time and group interaction. Repeated measures ANOVA revealed that the in point-of-time decrease in AIx was statistically significant in the group receiving TU (P=0.029) compared to men receiving placebo (figure). The maximal response in AIx was observed at 18 and 24 weeks (by 4.2% and 5.0%, respectively, all P<0.05). The interaction of time and group was also statistically significant (P=0.012) indicating significant differences between the treatment groups and time. PWV in the TU therapy group decreases during the whole study period, however the in point-of-time change was not statistically significant (P>0.05, figure). In men receiving TU the change in PWV was marginally significant only at 24 weeks (reduction by 0.34 m/s, P=0.05), whereas there were no significant differences in PWV between baseline and all other assessment time points. TU minimally increased brachial FMD up to 24 weeks (increase by 0.15%, P=0.05) from the beginning of therapy and the in point of the time change was not statistically significant (P>0.05, figure).

Conclusion

The 44-week TU i.m therapy was associated with a beneficial sustained effect on central AIx wave reflections thorough the whole study period. PWV decreased, particularly at 24 weeks, however the change in aortic elastic properties during the whole study session was not significant. Systemic endothelial function minimally improved compared to placebo. Given that AIx is an independent marker of cardiovascular disease and predictor of the corresponding risk, these findings have important implications to assess the effect of testosterone replacement interventions on cardiovascular performance and the corresponding risk of patients with ED and TD.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Pharmaceuticals Figure 1. TU vs placebo Aix PWV and FMD changes

Arterial stiffness and valvular calcifications in aortic stenosis: caught between a rock and a hard place

Background/Introduction

Arterial stiffness and aortic hemodynamics are independent predictors of adverse cardiovascular events. Indications for transcatheter aortic valve implantation (TAVI) are expanding and aortic valve calcifications (AVC) are an important prognostic factor of the success of TAVI.

Purpose

We sought to investigate the associations between AVC and aortic vascular function/hemodynamics.

Methods

Fifty-two high-risk patients (mean age 80.4±8.5 years, 27 male) with severe symptomatic aortic stenosis undergoing TAVI were included. Arterial stiffness was estimated through carotid-femoral pulse wave velocity (cfPWV) and brachial-ankle pulse wave velocity (baPWV). Aortic hemodynamics (aortic pressures, aortic augmentation index corrected for heart rate [AIx@75]) were also measured. Measurements were conducted prior to the implantation and at discharge. In all patients, a native and contrast-enhanced multislice cardiac computed tomography were performed pre-interventionally. AVC were then graded semi-quantitatively as follows: grade 1 – no calcification; grade 2 – mildly calcified (small isolated spots); grade 3 – moderately calcified (multiple larger spots); grade 4 – severely calcified (extensive calcification of all cusps).

Results

Group 1 (subjects with none/mild AVC, n=29) did not significantly differ in age, gender and body-mass index compared to group 2 (subjects with moderate/severe AVC, n=23). As far as the traditional cardiovascular risk factors were concerned, only hypertension (p=0.008), coronary artery disease (p=0.016), atrial fibrillation (p=0.075) and insulin-dependent diabetes mellitus (p=0.068) were found to be more prevalent in group 2. Group 2 had significantly higher both cfPWV and baPWV (8.3±1.7 vs 7.2±1.2 m/s and 1750±484 cm/s vs. 2101±590 cm/s with p=0.008 and p=0.022 respectively) compared to Group 1 (Figure 1). Even after adjustment for age, gender and systolic blood pressure, aortic stiffness indices were higher in Group 2 compared to Group 1 (p=0.038 and p=0.048, respectively). There was no statistically significant difference in peripheral or aortic pressures as well as in wave reflections indices between the two groups.

Conclusion

Our study shows that in patients with aortic valve stenosis there is a correlation between increased aortic stiffness and a greater extent of damage of aortic valvular leaflets as well as calcifications.

Funding Acknowledgement

Type of funding sources: None. Figure 1. PWV and aortic valve calcifications

Target organ damage in relation to intensity of cigarette smoking, statin therapy and the endogenous testosterone in middle aged hypertensive men with erectile dysfunction

Background

Target organ damage (TOD) amplifies cardiovascular risk in essential hypertension. Erectile dysfunction (ED) refers to microvascular disease and frequently accompanies the hypertensive middle aged male population. Endogenous testosterone (TT) and statins exhibit vasoprotective effects while cigarette smoking typically relates to an adverse cardiovascular outcome.

Purpose

To investigate TOD in relation to cigarette smoking, statin therapy and TT in essential hypertension middle aged males with ED.

Methods

223 hypertensive ED males (mean age: 59 yo) with no history of diabetes mellitus or overt cardiovascular disease enrolled the study. There were all screened for the presence of microalbuminuria, defined as urinary albumin loss 30 – 300 mg in a 24 h urine volume collection. Among them 96 (43%) were current cigarette smokers. Intensity of smoking referred in terms of packs per year. The presence and severity of ED was assessed by the SHIM-5 score (range 0–25), higher values indicate better erectile ability. All underwent a non invasive evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) a parameter of wave reflection amplification (Sphygmocor device).Moreover left ventricular mass index (LVMI) was assessed by 2D echocardiography (Devereux formula) and intima-media thickness (cIMT) of the common carotid artery by vascular ultrasound imaging. cIMT is a marker of atheromatosis.

Results

Microalbuminuria detected in 89 (40%) patients was positively related to other parameters of TOD such as PWV, cIMT, LVMI (all p<0,005) and smoking habits (p=0,02) and negatively to the SHIM-5 score, TT and statin use (all p<0,01). A notably negative correlation to the intensity of smoking was the SHIM-5 score (p=0,013) and a positive the cIMT (p=0,001). Statins were positively related to TT (p=0,006).In linear regression analysis, relation of packs per year remained significant regarding microalbuminuria and the SHIM-5 after adjustment for age, body mass index, PWV, LVMI, central systolic, diastolic and pulse blood pressure. Similarly, relation of statins, TT and microalbuminuria remained significant after adjustment for age, LVMI, PWV, AIx and smoking status.

Conclusion

Intensive cigarette smoking accelerates silent kidney damage and sabotages erectile performance in hypertensive middle aged men with ED independently of the central hemodynamic load. Statins protect from microvascular kidney damage and the decline of testosterone probably by enhancing endothelial physiology. In such population group, simple and clinically oriented criteria may reveal early diagnosis of target organ damage and guide appropriate life-style modifications and further therapeutic judgments.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Coronary artery disease and familial hypercholesterolaemia patients' eligibility for PCSK-9 inhibitors: who is to benefit from lower ldl thresholds?

Purpose

High and very high cardiovascular risk patients are usually possible candidates for PCSK-9 inhibitors. Coronary artery disease (CAD) and Familial Hypercholesterolaemia (FH) patients belong to this group by definition, according to 2019 recent dyslipidaemia guidelines. The real contribution of each group to potential eligibility for PCSK-9 is to be investigated.

Methods

We enrolled 1892 inpatients prospectively for 12 months, diagnosed either with chronic CAD or with acute coronary syndrome (ACS). In order to test eligibility for PCSK-9 inhibitors, three different LDL thresholds were used in our model for very high and high risk groups: 55mg/dl and 70mg/dl, 70mg/dl and 100mg/dl, 100mg/dl and 130mg/dl, as recommended by the 2019 and 2016 ESC/EAS Guidelines for Dyslipidaemia and the National Health Care system, respectively. A proprietary software was developed and eligibility was determined by using patient clinical information and different criteria. Dutch Lipid Clinic Network criteria were used to determine heterozygous FH population.

Results

The eligible percentage for the three classifications was 18.6%, 7.7% and 1.8%, in the total CAD population respectively. Definite/ probable FH percentages among our population were 4.8%, 3.4%, 1.4%, respectively. Solely CAD eligible population was 13.8%, 4.3% and 0.4% respectively. The increase of the eligible percentages toward more recent guidelines was mostly attributed to the increasing number of coronary patients who become eligible as our criteria become stricter while the percentage of the eligible CAD/FH population only slightly increases.

Conclusions

FH is a significant cardiovascular risk factor but stricter criteria and LDL thresholds, favour solely CAD patients. Using real-world data and an adjustable model, we provide a realistic estimation of PCSK-9 eligibility among CAD patients.

Funding Acknowledgement

Type of funding sources: None. Subgroup analysis of eligible population

Low testosterone accelerates vascular damage in hypertensive smokers with more than a 20-pack-year smoking history

Purpose

Testosterone deficiency and cigarette smoking are both associated with increased cardiovascular (CV) mortality risk. Aim of the study is to investigate the impact of low testosterone level on vascular function and structure changes related to cumulative tobacco smoke exposure in patients with arterial hypertension.

Methods

Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV) and carotid intima media thickness (cIMT) were measured in 263 hypertensive males divided into 4 age-matched groups according to pack-years of smoking as never smokers (0.0 pack-years), light smokers (0.1–20.0 pack-years), moderate smokers (20.1–40.0 pack-years), and heavy smokers (>40 pack-years). Plasma total testosterone (TT) levels were measured in all patients.

Results

PWV and cIMT progressively increased from never smokers and light smokers to moderate and heavy smokers (overall P<0.001 and P<0.01 respectively). The hypertensive males of each smoking group were further classified according to measured low or normal TT levels (low TT<3.5 ng/ml). Figure shows mean PWV and cIMT of the smoking/TT groups. Systolic and diastolic BP was higher in patients with TD compared to subjects with normal TT in moderate and severe heavy smokers (all P<0.05) and similar in light and never smokers. LDL-C levels were comparable between men with TD and normal TT across the four smoking groups. The difference in aortic PWV between TD and normal TT shows a progressive increase from light to moderate and heavy smokers. Similarly, the difference in cIMT between TD and normal TT is also positively correlated with cumulative tobacco exposure. All associations remained statistically significant even after adjustment for BP differences.

Conclusions

The deficiency in TT levels accelerates vascular wall damage of large arteries among hypertensive smokers with more than 20 pack-years tobacco exposure. Considering the predictive value of vascular biomarkers, the findings of this study imply the possibility that the measurement of baseline testosterone level could be an unfavourable marker of smoking-related cardiovascular risk among moderate and heavy smokers with arterial hypertension.

Funding Acknowledgement

Type of funding sources: None. TT, tobacco smoke exposure, PWV and IMT

Myocardial tissue phenotyping by radiomic features of native T1 maps and machine learning enhances disease detection and classification

Background

Myocardial T1 mapping by cardiac magnetic resonance (CMR) is a useful technique to detect diffuse myocardial fibrosis, but a major limitation of T1 mapping is the significant overlap in native T1 values between health and disease.

Purpose

We explored whether radiomic features from T1 maps could enhance the diagnostic value of T1 mapping in distinguishing health from disease and classifying cardiac disease phenotypes.

Methods

In a total of 149 patients (n=30 with no evidence of heart disease, n=30 with LVH of various etiologies, n=61 with hypertrophic cardiomyopathy (HCM) and n=28 with cardiac amyloidosis) undergoing a CMR scan for various indications were included in this study. In addition to measuring native myocardial T1 values from T1 maps, we extracted a total of 843 radiomic features of myocardial texture and explored their value in disease classification.

Results

We first demonstrated that T1 mapping images are a rich source of extractable, quantifiable data. The first three principal components of the T1 radiomics were significantly and distinctively correlated with cardiac disease type. Unsupervised hierarchical clustering of the population by myocardial T1 radiomics was significantly associated with myocardial disease type (chi2=55.98, p<0.0001). After machine learning for feature selection, training with internal validation and external testing, a model of T1 radiomics had good diagnostic performance (AUC 0.753) for multinomial classification of disease phenotype (normal vs. LVH vs. HCM vs. amyloid). A subset of seven radiomic features outperformed mean native T1 values for classification between myocardial health vs. disease and HCM phenocopies (for normal: T1 AUC 0.549 vs. radiomics AUC 0.888, for LVH: T1 AUC 0.645 vs. radiomics AUC 0.790, for HCM T1 AUC 0.541 vs. radiomics AUC 0.638 and for amyloid T1 AUC 0.769 vs. radiomics AUC 0.840).

Conclusions

We have shown that specific imaging patterns in myocardial native T1 maps are linked to features of cardiac disease and we have provided for the first-time evidence that radiomic phenotyping can be used to enhance the diagnostic yield of native T1 mapping for myocardial disease detection and classification.

Funding Acknowledgement

Type of funding sources: None.

Arterial stiffness improves with effective chemotherapy in patients with lymphoma

Introduction

Arterial stiffness independently predicts cardiovascular risk and has been associated with the presence of inflammation. Chemotherapy-induced cardiac dysfunction is a major contributor to adverse morbidity and mortality rates in cancer patients. There is extensive literature describing the cardiotoxic effects of anti-cancer treatment on left ventricular systolic function, that may be the result of direct effects of the cancer treatment on heart function, or due to an indirect acceleration of atherosclerosis. However there is only little evidence regarding chemotherapy effects on arterial elastic properties. The gold standard for measuring arterial stiffness is carotid femoral pulse wave velocity (cfPWV) and it is calculated as a function of transit time and distance of the pulse wave derived from the carotid and femoral arteries.

Purpose

Our aim was to investigate the effect of chemotherapy in aortic stiffness in patients with lymphoma, a malignancy with known high metabolic burden.

Methods

Sixty-six patients (22 male, mean age 56 years) with Hodgkin (n=34) or non-Hodgkin lymphoma (n=32) were enrolled in the study. Patients with Hodgkin Lymphoma underwent therapy with Doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). The interim of their treatment was set at 1 to 3 days prior to initiating the 3rd chemotherapy cycle. Patients with non Hodgkin Lymphoma underwent therapy with cyclophosphamide, doxorubicin, vincristine, and prednisone+rituximab (R-CHOP). Blood pressure (BP) and carotid-femoral pulse wave velocity (c-f PWV) were measured at baseline, interim and after completion of chemotherapy.

Results

Changes in systolic and diastolic BP from baseline, to interim phase and 6 weeks post therapy were insignificant (decrease by 3.87±1.37 mmHg p-0.277 and 3.05±0.92 mmHg p-0.422 respectively). Figure illustrates c-f PWV changes from baseline to interim and 6 weeks after completion of chemotherapy. As figure shows, c-f PWV progressively decreased at the interim phase and at 6–8 weeks after chemotherapy completion (by 0.37±0.14 m/s), (overall P-0.010, by ANOVA) The progressive decrease in c-f PWV remained statistically significant after adjustment for age, systolic BP and diabetes (F=5.173, P-0.009). Patients' baseline characteristics are demonstrated in table 1.

Conclusion

Carotid-Femoral PWV decreased at 6–8 weeks post chemotherapy in patients with lymphoma, suggesting that aortic elastic properties improve with chemotherapy in these patients. Considering that aortic stiffness increases due to systemic inflammation and that lymphomas are increased metabolic burden tumors, the significant improvement in arterial stiffness implies that the presence of inflammation caused by the malignancy may play a significant role in the arterial stiffness progression.

Funding Acknowledgement

Type of funding sources: None.

Renal biomarkers reflect overall hypertensive organ damage: “one organ to rule them all”

Background/Introduction

Hypertension is associated with higher cardiovascular risk as well as several markers of subclinical target organ damage (TOD). Albumin to creatinine ratio (ACR) in urine has been recognized as an independent risk factor for cardiovascular events.

Purpose

We hypothesized that there is a relationship between ACR and markers of TOD in never-treated hypertensives.

Methods

We enrolled 924 consecutive essential hypertensives (mean age 53±12 years, 486 males) without known cardiovascular disease (CVD). Markers of subclinical TOD [left ventricular mass index (LVMI), pulse wave velocity (PWV), ankle-brachial index (ABI) and estimated glomerular filtration rate (eGFR)] were evaluated in all patients. LVMI was assessed echocardiographically using the Devereux formula. Carotid-femoral PWV was estimated with the Complior device. eGFR was calculated by the Cockcroft-Gault formula. ABI was calculated by dividing the highest ankle systolic blood pressure by the highest brachial systolic blood pressure.

Results

ACR exhibited significant association with LVMI (r=0.277, p<0.001, Figure), PWV (r=0.277, p<0.001) ABI (r=−0.078, p=0.018) and eGFR (r=−0.100, p=0.002). In further analysis, ACR was associated with TOD as suggested by the 2018 European Guidelines for Hypertension [left ventricular hypertrophy (LVMI>115 g/m2 in men and >95 g/m2 in women), increased PWV (PWV>10m/s), decreased ABI (ABI<0.9) and decreased renal function (eGFR<60ml/min)]. Specifically, ACR exhibited significant association with the number of TOD and this association was independent of age and gender (p<0.05).

Conclusions

Our findings support the close relationship between ACR and TOD in hypertension, as well as, the predictive ability of ACR for TOD.

Funding Acknowledgement

Type of funding sources: None. Association between LVMI and ACR

Discordance between plain coronary angiography and quantitative flow ratio in revascularization guidance

Background/Introduction

Functional coronary stenosis severity has been associated with less clinical adverse events compared with plain invasive coronary angiography in guiding revascularization. Quantitative flow ratio (QFR) has proven to be a reliable tool of functional assessment of coronary lesions.

Purpose

To investigate the level of agreement between plain coronary angiography and QFR in guiding the decision to treat a coronary lesion.

Methods

We retrospectively performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. Patients with referral for coronary artery bypass graft surgery were excluded. We aimed to measure QFR in all vessels of each patient. All vessels with calculated QFR were divided into four groups based on whether percutaneous coronary intervention (PCI) was performed and on the QFR result with a cut-off point <0.8 indicating revascularization: Group A (PCI+, QFR <0.8); group B (PCI−, QFR >0.8); group C (PCI+, QFR >0.8); group D (PCI−, QFR <0.8) (Figure 1).

Results

We identified 785 patients with available coronary angiography satisfying the technical requirements of QFR software. QFR measurement in at least one vessel was feasible in 546 patients (70%). Mean age was 65.6 (±10.9) and 80% of patients were male. Acute coronary syndrome was the indication for coronary angiography in 36% of the cohort. QFR was calculated in 1193 vessels (∼51% of total vessels). In particular, QFR analysis was feasible in 448 (57%) left anterior descending (LAD), 457 (58%) left circumflex (LCX), and 288 (37%) right coronary arteries (RCA) coronary arteries. The most common reason for inability to calculate QFR was the absence of appropriate projections (30% of the missing cases). A mismatch in treatment strategy between coronary angiography and QFR result was detected in 151 (12.7%) vessels. In 78 (6.6%) cases PCI was performed while QFR was measured above 0.8 (group C). In 73 (6.1%) cases PCI was not performed while QFR was measured below 0.8 (Group D) (Figure 1). Among mismatch cases LAD was more likely to fall within group D whereas RCA was more often related with group C.

Conclusion

Discordance between plain coronary angiography and quantitative flow ratio regarding the decision to perform or to defer PCI was found in a relatively high proportion among patients undergoing coronary angiography. Prognostic evidence is warranted to determine the clinical significance of the mismatch between the two methods.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Exercise capacity benefit in relation to endogenous testosterone, coronary and central vascular physiology, and the Mediterranean regime in hypertensive males with erectile dysfunction

Background

The Mediterranean diet (Med-diet) benefits cardiovascular health, and erectile dysfunction (ED) often coexists in the hypertensive aging male population were endogenous testosterone (TT) typically declines. Coronary flow reserve (CFR) displays the ability of the coronary circulation to increase flow. Wave reflection amplification as expressed by augmentation index (AIx) exhibits a vital parameter of central vascular stiffness.

Purpose

To investigate the possible benefits of the Med-diet in exercise capacity, central physiology, CFR and erectile ability in relation to endogenous TT in the middle aged male hypertensive population with ED.

Methods

250 hypertensive males (mean age 56 yo) with ED enrolled the study. All underwent a treadmill stress test (Bruce protocol). Exercise capacity was validated as metabolic equivalents (METs). We measured separately the CFR of the left anterior descending artery by an adenosine protocol (max dose 140μg/kg/min over 6 minutes). PW Doppler measurements were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥2 are considered as non-ischemic response, higher values indicate microvascular coronary integrity. TT was measured on blood samples taken before 09:00 am. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Finally, central pulse pressure (cPP) and AIx were noninvasively estimated as parameters of central hemodynamic load and wave reflection amplification (Sphygmocor device).

Results

In bivariate analysis METs were positively associated to the Med-diet, CFR, TT and the SHIM-5 score (all p<0,005) and negatively to the AIx and cPP (both p<0,025). There was also positive association of the Med-diet to the CFR, TT and the SHIM-5 score (p<0,02) and negative to the AIx and cPP (p<0,025). By linear regression analysis association of METs to TT, CFR and Med-diet remained significant after adjustment for age, BMI, diabetes mellitus, use of statins and smoking status (p<0,005). We further subdivide our population according to the TT threshold of hypogonadism (≤3 ng/ml). Hypogonadism patients exhibit a lower exercise capacity comparing to the normal TT group (picture).

Conclusion

The Med-diet regime benefits exercise tolerance and erectile performance in hypertensive males with ED by enhancing endogenous testosterone and so coronary and central vascular physiology. We strongly recommend this culinary preference promoting thus vascular health and the sense of well being.

Funding Acknowledgement

Type of funding sources: None.

“Stifflammation” in hypertension is a predictor of future cardiovascular hospitalizations

Background/Introduction

Hypertension is associated with increased cardiovascular risk, inflammation and arterial stiffness.

Purpose

We sought to investigate the role of inflammation and arterial stiffness in the prognosis of cardiovascular hospitalizations in hypertensive patients over an extended follow-up.

Methods

One hundred and seventy-three patients (mean age 52.5±13.2 years, 57% males) untreated hypertensives at baseline without cardiovascular disease, were included in the study. Arterial stiffness was assessed with carotid-femoral pulse wave velocity (PWV). High-sensitivity C-reactive protein (hsCRP) was measured in venous blood samples. Other markers of subclinical organ damage [left ventricular mass index (LVMI) by echocardiography and estimated glomerular filtration rate (eGFR)] were also evaluated in all patients.

Results

During 13.6±0.4 years of follow-up, forty-four patients (25.4%) patients were admitted in hospital due to cardiovascular causes. In multivariable logistic regression analysis, only higher hsCRP (Odds Ratio [OR] = 3.34, 95% Confidence intervals [CI]: 1.22–9.51, P=0.02) and increased PWV (OR = 1.48, 95% Confidence intervals [CI]: 1.03–2.12, P=0.036) were associated with higher risk of cardiovascular hospitalizations, which was independent of age, gender, systolic blood pressure, LVMI and presence of diabetes. In further analysis, receiver operating characteristic (ROC) curves were generated to evaluate the ability of hsCRP and PWV to discriminate subjects with cardiovascular hospitalization. The area under the curve (AUC) and 95% CIs of the ROC curves were AUC=0.69 (95% CI: 0.59–0.78, p<0.001) for hsCRP and AUC=0.74 (95% CI: 0.65–0.83, P<0.001) for PWV (Figure).

Conclusions

Our study shows the independent complimentary prognostic role of inflammation and arterial stiffness in the prognosis of hypertensives even in studies with extended follow-up.

Funding Acknowledgement

Type of funding sources: None. ROC curves for the prediction of outcome

Development of a risk-score for pericarditis recurrence in patients with a first episode of acute pericarditis

Background/Introduction

Currently we remain uncertain about which patients are at increased risk for recurrent pericarditis.

Purpose

We developed a risk score for pericarditis recurrence in patients with acute pericarditis.

Methods

We prospectively recruited 262 patients with acute pericarditis. Patients' demographics, clinical, imaging and laboratory data at presentation, were collected. Patients were followed-up for a median of 51 months (interquartile range 21–71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The performance of the final model was assessed by the c-index and model's calibration and the optimism corrected c-index were evaluated after 10-fold cross-validation.

Results

We identified six independent predictors for pericarditis recurrence i.e., age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids, and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725–0.842), while the optimism corrected c-index after cross-validation was 0.752. Based on these variables we developed a risk score point system for recurrence (0–22 points) with equally good performance (c-index 0.740, 95% CI 0.677–0.803). Patients with a low score (0–7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence (Figure 1). The score was predictive of recurrence among most patient subgroups.

Conclusions

A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Conservative management of acute coronary syndromes in chronic kidney disease patients: a deadly sin

Background/Introduction

Chronic kidney disease (CKD) is associated with worse prognosis in acute coronary syndromes (ACS).

Purpose

We sought to investigate the prognostic effect of non-invasive management of ACS in CKD patients in a tertiary University Hospital.

Methods

Two hundred and one patients (mean age 66.5±13.6 years, 150 males) admitted to our Hospital with ACS from 2016–2017 were included in the study. Patients were followed for a median of 2 years post the index event. CKD was defined by an estimated glomerular filtration rate (eGFR) <60 ml/min/m2, as assessed by the Modification of Diet in Renal Disease (MDRD) equation. We grouped patients into four groups according to their CKD status and whether they underwent coronary angiography or not. The primary outcome was all-cause death and secondary outcomes were cardiovascular and non-cardiovascular death.

Results

The majority of patients (n=120, 60%) presented with non-ST elevation ACS (NSTE-ACS), whereas 81 patients as ST-elevation myocardial infarction (STEMI) (40%). Fifty-four patients (27%) were identified as CKD patients (of whom 5 were on dialysis). Overall, 29 patients (14.4%) did not undergo coronary angiography. Patients at a higher age and with CKD were more likely to not undergo angiography. Thirty-seven (18.4%) died during follow-up (25 non-cardiovascular deaths and 12 cardiovascular deaths). Patients with conservative treatment and CKD had the worse prognosis (Hazard ratio [HR] =11.00, 95% Confidence intervals [CI] 4.00 to 30.24, p<0.001) followed by non-CKD patients with conservative treatment (HR=4.37, 95% CI 1.20 to 15.90, p=0.025) compared to non-CKD patients treated invasively (reference group) after adjusting for age, gender, STEMI/NSTE-ACS diagnosis (Figure). Results were similar for non-cardiovascular death, whereas regarding cardiovascular death only the group with CKD and conservative treatment had a lower survival compared to the reference group (HR=26.5, 95% CI 2.9 to 241.7, p=0.004)

Conclusions

Patients with ACS and CKD are less likely to receive invasive management and have higher mortality from both cardiovascular and non-cardiovascular causes than patients without CKD. Conservative management of ACS was associated with higher long-term mortality versus invasive management in all patients, regardless of CKD status.

Funding Acknowledgement

Type of funding sources: None.

Treatment with a fixed dose combination for cardiovascular disease-more than a health benefit?

Background

Despite the proven benefits of cardiovascular disease medication, adherence to treatment remains poor. Fixed-dose combinations (FDC) have been proposed as a measure to enhance adherence.

Objective

To assess compliance to treatment with an FDC, consisting of acetylsalicylic acid, atorvastatin and ramipril, and to gauge its impact on cardiovascular risk factors.

Methods

This was a prospective, multicenter, observational, phase 4 study conducted for 6 months in Greece. 1444 participants (67% males, mean age 63.7 years old) that were prescribed the FDC for primary or secondary prevention were included in the analysis. Descriptive statistical analysis was performed to analyze clinical, sociodemographic and safety parameters.

Results

Approximately equal number of participants was recruited in the primary and secondary prevention group. The majority of patients were overweight and hypertensive. Dosing compliance was 88.6% at 3 months and 86.8% at 6 months. Adherence to treatment was 99.1% at 3 months and 97.6% at 6 months. Statistically significant changes at 6 months compared to baseline were documented in systolic/diastolic blood pressure of 15.7/7.5 mmHg and LDL-c of 32.6 mg/dl, in both CVD and non-CVD participants and in total population as well. The total 10-year risk for CV events was reduced by 34.1% at 6 months. Only 1.2% of the participants reported an adverse event and 0.8% an adverse event reaction.

Conclusions

Among patients with or without CVD, the use of acetylsalicylic acid, atorvastatin and ramipril FDC resulted in good medication adherence at 6 months and statistically significant improvements in blood pressure, total cholesterol and LDL levels.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Galenica SA

Pericardiocentesis vs conservative management in patients with asymptomatic, chronic, large, idiopathic, C-reactive negative pericardial effusion

Background/Introduction

Pericardial effusion (PE) prognosis largely depends on the underlying etiology.

Purpose

We sought to assess the outcome of patients with asymptomatic, chronic (>3 months), large (diastolic echo-free space >2 cm), idiopathic (without apparent etiology), C-reactive protein (CRP) negative PE, undergoing either pericardiocentesis or conservative management.

Methods

A total of n=61 patients aged 66.8±15.6 years (women n=32, 53%) were enrolled in this study. Patients were treated by pericardiocentesis (n=39) or conservatively (n=22) at the discretion of treating physician and personal preference. The median follow-up was 24 months (interquartile range: 15 to 36).

Results

Among those patients undergoing pericardiocentesis, PE re-accumulation (any) occurred in 30 cases (76.9%) with large re-accumulation occurring in 41% of patients. Patients with re-accumulation had higher baseline maximum PE diameter (30±1.5mm vs. 25±1.5mm, p=0.02). In patients managed conservatively effusion size remained overall stable in 17 cases (77%), regressed in 3 cases (14%) and increased leading to near or overt tamponade in 2 cases (9,1%). Complicated course occurred in 5 cases (12.8%) of patients undergoing pericardiocentesis [4 cases of cardiac tamponade (10.2%) and 1 recurrent pericarditis] and in 2 conservatively treated patients (cardiac tamponade). Notably, pericardiocentesis was not helpful in establishing new diagnoses and guide treatment. The complications free survival rate was not significantly different between patients undergoing pericardiocentesis and those treated conservatively (long rank chi2=0.504, p=0.478) (Figure 1).

Conclusions

In conclusion, in asymptomatic patients with chronic, large, hemodynamically irrelevant, CRP negative, idiopathic PE, conservative management seems a more reasonable approach in most cases.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Tobacco cigarette smoking accelerates impairment of aortic elastic properties in middle-aged patients with high normal blood pressure

Background

The impact of smoking on atherosclerosis progression is greater in patients with arterial hypertension. High blood pressure (BP) is a major determinant of increased aortic stiffness which is an independent predictor of cardiovascular events. Aim of this study was to examine whether there are differences between office BP categorization and aortic stiffness on the basis of smoking status.

Methods

We measured carotid-femoral pulse wave (PWV) in 185 men (mean age: 55±10 years) who were not receiving antihypertensive medications and they had no history of diabetes and cardiovascular disease. The cohort was divided into three groups according to office systolic BP (SBP) and diastolic BP (DBP): normal (SBP <130 and DBP <85 mmHg, n=79), high normal (130≤SBP<140 or DBP 85≤DBP<90mmHg, n=42), and hypertension (SBP≥140 or DBP≥90mmHg, n=64).

Results

The three groups had similar age and metabolic parameters (body mass index, fasting blood glucose and LDL-C). PWV progressively increased from normotensive to high normal BP, and to hypertensive patients (7.8±1.4 vs 8.2±1.4 vs 8.6±1.6 m/s, respectively, overall P<0.01). Then we subdivided the three office BP groups into subgroups according to smoking status. Figure shows PWV of the three groups stratified by smoking status. The three subgroups of smokers had similar tobacco exposure (40 pack-years). There were not statistically significant differences between smokers and non smokers in each office BP category with regard to age and metabolic parameters. In separate analysis, among individuals with either normal BP the association of smoking status with PWV level was not significant. However, in hypertensive patients but also in patients with high normal BP, smoking status was significantly correlated with PWV (all P<0.01). Furthermore, the differences in mean PWV between smokers with high normal BP and patients with hypertension were not statistically significant reflecting a detrimental effect of smoking on aortic stiffness among males with high normal BP.

Conclusion

Smoking has an unfavorable effect on aortic elastic properties in men with high normal BP. The smokers with high normal BP have PWV comparable to that of hypertensive patients. This finding imply that smoking cessation should be a premising non pharmacological intervention in men with high-normal BP and increased aortic stiffness who are considered to be at a higher cardiovascular risk.

Funding Acknowledgement

Type of funding sources: None. Smoking, BP categories and PWV

Low testosterone is associated with increased risk of major adverse cardiovascular events in smokers with erectile dysfunction

Purpose

Tobacco cigarette smoking and decreased concentrations of testosterone are major risk factors of erectile dysfunction (ED) and independent predictors of cardiovascular disease (CVD). We investigated, whether testosterone deficiency has a complementary predictive value for CVD events in smokers with ED.

Methods

A cohort of 398 men with ED and without known atherosclerotic CVD (mean age: 55±10 years) were followed for the occurrence of major adverse cardiovascular events (MACE), (CVD death, coronary artery disease, stroke). Total testosterone (TT) levels were measured in all patients.

Results

Among the study population, 205 (52%) were smokers. During a mean follow-up of 6 years (range: 1–11 years), 30 (7.5%) patients demonstrated a MACE. Baseline TT levels were significantly lower and prevalence of smoking was higher in the CV-event group than the event-free survival group (P<0.01 and P<0.05, respectively). Kaplan–Meier analysis showed that patients with low TT (≤4.0 ng/mL) had a worse prognosis than patients with TT >4.0 ng/mL (log rank: 6.52, P=0.011), and that smokers had a greater risk of adverse events than never smokers (log rank: 4.42, P=0.04). We then stratified all patients into four groups, on the basis of smoking status (current/never smokers) and low or high TT (≤ or >4.0 ng/mL) and cardiac event-free survival curves were constructed by Kaplan–Meier analysis (figure). The event-free rate in smokers with low TT is significantly lower than that of smokers with low TT or never smokers with normal TT (log rank: 11.3, P=0.02). Smokers with low TT had an almost 4-fold higher risk of MACEs compared to never smokers with normal TT (adjusted hazard ratio: 3.91; P=0.030).

Conclusion

Cigarette smoking combined with low TT concentration is associated with a shorter event-free period compared with either smoking or testosterone deficiency alone. The measurement of testosterone concentration may be useful to further stratify the risk of ED smokers without known CVD.

Funding Acknowledgement

Type of funding sources: None. Smoking testosterone deficiency and MACE

Aortic systolic blood pressure predicts periprocedural myocardial injury after transcatheter aortic valve implantation

Background/Introduction

Periprocedural myocardial injury (PPMI) is a complication of transcatheter aortic valve implantation (TAVI) associated with worse outcome. Central (aortic) systolic blood pressure (SBP) is an independent predictor of cardiovascular events.

Purpose

We sought to investigate the effect of TAVI on peripheral and central hemodynamics, as well as the predictive ability of brachial and aortic SBP for PPMI.

Methods

We enrolled 70 patients (mean age 79.9±8.7 years, 50% males) with severe symptomatic aortic valve stenosis (AVS) undergoing TAVI. Brachial pressures were measured with an oscillometric device and central pressures were assessed by arterial tonometry at baseline and after the procedure at discharge. PPMI was identified based on Valve Academic Research Consortium (VARC-2) criteria. Biomarkers for MI (cardiac troponin and creatinine kinase MB) were analyzed and signs and symptoms according to VARC-2 criteria were collected from clinical records. Stepwise multivariable regression analysis was performed for the prediction of PPMI.

Results

According to VARC-2 definition, 38 (54%) patients had PPMI. In stepwise multivariable regression analysis, brachial SBP at baseline was not predictive of PPMI (p=0.07) after adjusting for age, sex and history of coronary artery disease. On the contrary, aortic SBP predicted PPMI even after adjustment for the abovementioned confounders (Odds ratio [OR]=1.032, 95% Confidence Interval [CI] 1.004–1.061, p=0.026). Interestingly, both SBP and aortic SBP were higher at discharge in patients with PPMI compared to patients without PPMI after adjustment (p=0.021 and p=0.006, respectively). On the contrary, the periprocedural changes of aortic SBP and SBP were not different between patients with PPMI and without PPMI.

Conclusions

Aortic SBP, as assessed by tonometry, is an independent predictor stronger than brachial SBP for PPMI in AVS patients treated with TAVI. This finding suggests the possible clinical role of aortic pressures as a risk stratification tool for PPMI prior to TAVI, as well as, warrants further investigation on their role as therapeutic targets to decrease the incidence of PPMI.

Funding Acknowledgement

Type of funding sources: None.

Short-term health-related quality of life in patients with ischaemic stroke after PFO closure

Funding Acknowledgements

Type of funding sources: None.

Introduction/Purpose: Patent foramen ovale (PFO) is common in asymptomatic adults and is associated with cryptogenic stroke (CS). We sought to evaluate the impact of PFO closure in health-related quality of life (HRQoL) in PFO patients with CS. 

Method

In this pilot study, 19 patients (mean age 47 ± 7.7; 13 male) who underwent PFO closure at our center were invited to a short-term clinical follow up (mean follow-up period 6-10 months). All patients had suffered an ischaemic stroke and their disability level was assessed using the Modified Rankin Scale (MRS, no significant disability 63%). HRQoL was assessed using the 36-Item Short Form Survey (SF-36) and the European Quality of Life-5 Dimensions Questionnaire (EQ-5D) preoperatively and at follow-up. 

Results

Both SF36 and EQ-5D scores improved after the operation as shown by the self-rating scores (20,67% and 40,52% higher scores, respectively). Patients with major mobility problems were more likely to be current smokers (r = 0.481) and those who had lower scores on the MRS scale (r=-0.571) rated higher their scale diagram.  The categories of energy/fatigue (r = 0.459; p = 0.048), social functioning (r = 0.547; p = 0.015) and pain (r = 0.550; p = 0.015) were positively correlated with physical function. Finally, there was a positive correlation between role limitations due to emotional problems and energy/fatigue (r = 0,519; p = 0.023), and between energy/fatigue and emotional well-being (r = 0.519; p = 0,023).

Conclusions

The results of our study indicate that shortly after PFO, subjects perceive improvements in their QoL. However, it seems that poorly rated physical function was more common in active smokers, and affects patients" social life and their emotional state. Health care professionals should encourage these patients to participate in rehabilitation and psychological support programs postoperatively.

Prognostic value of vascular inflammation biomarkers over clinical risk factors for cardiovascular risk : a meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Measurement of vascular inflammation biomarkers is supported for estimation of residual inflammatory risk and cardiovascular risk stratification, but to date there is no systematic assessment of the added value of such biomarkers in predicting cardiovascular events and their comparative performance.

Methods

We systematically searched in MEDLINE published literature before Apr 14, 2020 for prospective cohort studies assessing the prognostic value of common biomarkers of vascular inflammation in stable patients with or without cardiovascular disease. The primary outcome was the difference in the c-index (Δ[c-index]) of the best clinical model with the use of inflammatory biomarkers for the prediction of the composite endpoint of major adverse cardiovascular events (MACEs) and mortality. The secondary outcome was the Δ[c-index] for MACEs only. We calculated I² to test heterogeneity. We used random-effects modelling for the meta-analyses to assess the primary and secondary outcome.

Results

We identified 92,507 studies in MEDLINE after duplicates were removed, of which 90,882 (96%) studies were excluded after screening the titles and abstracts, and 1,507 (93%) of the 1,625 remaining studies were excluded after assessment of the full texts. We included 93 (6%) studies in our quantitative evaluation, in which 351,628 individuals participated. The combination of high-risk plaque features and Fat attenuation Index (FAI) by CCTA was associated with the highest prognostic value i.e. Δ[c-index] for the composite endpoint per biomarker type (A). In meta-analysis, both plasma and imaging biomarkers of vascular inflammation offered incremental prognostic value for the primary outcome (pooled estimate for Δ[c-index]% 2.9, 95%CI 2.1-3.6, B) and for MACEs only (pooled estimate for Δ[c-index]% 2.9, 95%CI 2.1-3.8). The prognostic value of imaging biomarkers significantly surpassed that of plasma biomarkers for the primary outcome (Δ[c-index]% 11.3, 95%CI 8.3-14.3 vs. 1.4, 95%CI 0.9-1.8 respectively, p = 1.7x10-10, C). Notably, biomarkers of vascular inflammation offered higher incremental prognostic value in studies with a shorter duration of follow-up (i.e. <5 years), in primary CHD prevention setting and lower cardiovascular risk populations i.e. (studies with <5% cumulative event incidence, D)

Conclusions

The combination of HRP features and FAI by CCTA imaging had the highest prognostic value for cardiovascular events among plasma or imaging biomarkers of vascular inflammation. CCTA imaging to detect residual inflammatory risk and the vulnerable patient at risk for events is a rational approach to improve risk stratification and prognostication.

Abstract Figure.

Central pulse load and coronary flow benefit in relation to endogenous testosterone and the Mediterranean regime in hypertensive males with erectile dysfunction

Background

Central pulse pressure (cPP) is an important parameter of target organ damage (TOD) in essential hypertension. Coronary flow reserve (CFR) displays the ability of both macro and microcirculation to augment flow to the myocardium while endogenous total testosterone (TT) exhibits vasodilator effects. The Mediterranean diet (Med-diet) benefits cardiovascular health and erectile dysfunction (ED) often coexists with the decline of endogenous testosterone in the aging male population.

Purpose

To investigate the possible benefits of the Med-diet in central PP, CFR and erectile ability in relation to endogenous TT in the primary hypertensive population with ED.

Methods

247 male hypertensive patients (mean age 57 yo) with ED enrolled the study. Significant coronary artery disease was formerly excluded by a dobutamine stess echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140 μg/kg/min over 6 minutes). Measurements by the PW Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥2 are considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Finally, cPP and augmentation index (AIx) were estimated as parameters of central hemodynamic load and wave reflection amplification respectively (sphygmocor device).

Results

In bivariate analysis Med-diet was favorably related to CFR (p=0.24, r=0.48), TT (p=0.01, r=0.57) and the SHIM-5 score (p=0.01, r=0.45). On the contrary, it was negatively related to cPP (p=0.15, r=−0.60) and AIx (p=0.31, r=−0.45). CFR was strongly related to TT (p=0.001, r=0.8) and the SHIM-5 score (p=0.01, r=0.41). By multiple linear regression analysis the relation of CFR, SHIM-5 and Med-diet score remained significant after adjustment for age, BMI, systolic arterial blood pressure and smoking habits. We further subdivide our population according to the mean Med-diet value (26) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=153, 62%) there were still positive relation with the CFR, TT and SHIM-5 score as well as negative correlation to cPP and AIx (p=0.04).

Conclusion

In essential hypertensive males with erectile dysfunction the Med-diet regime lessens central pulse pressure while enhancing coronary flow, testosterone levels and so peripheral vascular physiology. We strongly recommend this dietary pattern as a life-style option and strategic component of holistic therapeutic approach.

Funding Acknowledgement

Type of funding source: None

Aortic stiffness and incident diabetes: the hard, bittersweet truth

Background/Introduction

Aortic stiffness increases with advancing age and is a major risk factor for age-related morbidity and mortality. Aortic stiffness and glycaemic dysregulation are related; however, temporal relationships between aortic stiffness and incidence of diabetes have not been fully delineated.

Purpose

We sought to investigate the role of arterial stiffness in the prediction of incident diabetes.

Methods

376 untreated hypertensive patients (mean age 52.6±12.5 years, 201 males) without known cardiovascular disease and without known history of diabetes, were included in the study. Markers of subclinical organ damage [carotid-femoral pulse wave velocity (PWV) and estimated glomerular filtration rate (eGFR)] were evaluated in all patients. eGFR was estimated using the Cockcroft-Gault formula. Hemoglobin A1c (HbA1c) and blood glucose were measured in venous blood samples. Patients were prospectively followed-up, for incidence of diabetes as defined by the American Diabetes Association criteria.

Results

During a median 13.5 years follow-up, forty-six patients (12.2%) patients were diagnosed with diabetes. In multivariable logistic regression analysis, only higher PWV (Odds Ratio [OR] = 1.271, 95% Confidence intervals [CI]: 1.002–1.612, P=0.048) was associated with higher risk of incident diabetes, which was independent of age, sex, pulse pressure, HbA1c, fasting blood glucose and eGFR. In further analysis, receiver operating characteristic (ROC) curves were generated to evaluate the ability of PWV to discriminate subjects with diabetes. The area under the curve (AUC) and 95% CIs of the ROC curve was AUC=0.66 (95% CI: 0.58–0.74, P=0.001) for PWV (Figure 1).

Conclusions

In our cohort, higher aortic stiffness was associated with higher risk of incident diabetes.

Figure 1. ROC curve for the prediction of diabetes

Funding Acknowledgement

Type of funding source: None

Hydroxychloroquine for colchicine-resistant glucocorticoid-dependent idiopathic recurrent pericarditis: an observational prospective study

Background

Glucocorticoid (GC)-dependent, colchicine-resistant idiopathic recurrent pericarditis (IRP) remains a clinical challenge. We assessed for the first time the efficacy and safety of hydroxychloroquine (HCQ) in IRP.

Methods

This is a single center, post hoc analysis of prospectively collected data of 15 patients with refractory to standard therapy (colchicine plus either GC or anakinra) IRP (≥3 recurrences, disease duration ≥12 months and inability to wean off treatment) treated with HCQ (400 mg/day). These patients were matched 1:1 for age, sex, and treatment type to IRP patients receiving standard-of-care treatment (control group, n=15). Pericarditis recurrence, the time and C-reactive protein (CRP) levels at 1st flare, the % of patients able to achieve a ≥50% reduction of baseline GC dose and the % reduction of GC dose were compared between groups.

Results

Almost all patients (n=29) but one in the HCQ group (14/15) relapsed during follow-up. However, HCQ treatment was associated with an increased median time of flare-free survival (increase by 4 weeks compared to controls) and reduced hazard ratio for flare in survival analysis (HR=0.36, 95% CI 0.16–0.77, p=0.009). HCQ was also associated with a higher proportion of patients obtaining a ≥50% dose reduction of GCs (33.3% vs. 0% in the control group, p=0.037) and reduced GC dose (HCQ: −43.5% vs. control: −4.5%, p<0.001). There were no signficant differences in CRP levels at flare between groups (p=0.615).

Conclusions

In this prospective study, HCQ use was associated with a GC-sparing effect and an increased flare-free survival period in patients with colchicine resistant GC-dependent IRP.

Funding Acknowledgement

Type of funding source: None

The new LDL-C target <55 mg/dL is achieved by less than 40% of very high risk patients with familial hypercholesterolaemia despite receiving PCSK9 inhibitors: real world data

Background

The recently published ESC/EAS guidelines for the management of dyslipidaemias have lowered the low-density lipoprotein cholesterol (LDL-C) target in the very high risk patients below 55 mg/dL.

Purpose

To examine how achievable is this target in very high risk patients receiving a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) on top of lipid-lowering treatment (LLT).

Methods

The cohort comprised 158 patients who attended the lipid clinic of 3 hospitals in Greece and started treatment with PCSK9i. Patients were requested to attend the lipid clinic 3 months after the initiation of PCSK9i.

Results

Ninety percent of patients had heterozygous familial hypercholesterolaemia (heFH) and 75% had cardiovascular disease (CVD). One hundred forty patients were classified as very high risk because they had either cardiovascular disease (CVD) or heFH with an additional risk factor for whom a target <55 mg/dL is currently recommended. Of those very high risk patients, 105 (75%) were given PCSK9i due to failure to achieve LDL-C targets despite maximum LLT (high intensity statin at maximum tolerated dose + ezetimibe) while in the rest of cases the indication was statin intolerance. The mean reduction of LDL-C at 3 months was 56.2%. Among 105 very high risk patients (all had heFH), LDL-C below 55 mg/dL was achieved by 37.1% while the previously LDL-C target <70 mg/dL was achieved by 60% (Figure 1).

Conclusions

The new LDL-C target <55 mg/dL is achieved by <40% of very high risk patients with heFH despite receiving triple LLT, i.e. PCSK9i + statin + ezetimibe. This therapeutic gap suggests that there is still need for more effective LLT in very high risk heFH patients to maximize their clinical benefit.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effect of smoking cessation with varenicline on blood pressure control in hypertensive patients

Purpose

The interaction between smoking and blood pressure (BP) is complex. Despite the strong association between cigarette smoking and cardiovascular disease (CVD) risk, there is paucity about the effect of pharmacotherapies for treating tobacco dependence on BP in already established arterial hypertension. Varenicline has been shown to be an effective and well-tolerated pharmaceutical intervention for smoking cessation. Aim of the study was to investigate the improvement in BP control in smokers with a diagnosis of hypertension who quit or reduced substantially their tobacco consumption by using varenicline and the association of nicotine dependence with BP changes.

Methods

A total of 89 (mean age:48±7, 52 males) regular smokers (28±9 pack-years) with a diagnosis of hypertension and on anti-hypertensive drugs were studied. All patients received low-intensity counseling and pharmacotherapy with varenicline (1 mg twice daily) for 12 weeks. Point prevalence smoking abstinence was defined by self-report of complete abstinence in the 7 days before the 12 week clinic visit (end of therapy). Office BP was measured at baseline and each follow-up visit (4 and 12 weeks) office BP. The Fagerström Test for Nicotine Dependence (FTND) was used for assessing nicotine dependence. High nicotine dependence (ND) was defined as a FTND score ≥6.

Results

At 12 weeks, 60 (67%) patients were abstinent from smoking and 14 (16%) were non-abstainers who reduced daily consumption to 50% of baseline. The mean time interval between the initiation of treatment with varenicline and smoking abstinence was 1.8±0.6 weeks. There were not significant differences in age, baseline BP level, severity of nicotine dependence and total cigarette consumption (pack-years) between the two groups. Systolic BP (SBP) and diastolic BP (DBP) decreased significantly in abstainers (by 7.2 and 5.5 mmHg at 12 weeks, P<0.01 and P<0.05, respectively) while the decrease in BP level in non-abstainers was minimal. Among patients with sustained tobacco abstinence, 18 were highly ND and 42 had mild and moderate ND. The two ND groups had similar age and BP levels at baseline. Changes in SBP and DBP from baseline in smokers with arterial hypertension between the two ND groups are illustrated in Figure. The observed reductions in SBP and DBP were significant (P<0.05, both for SBP and DBP) when comparing the high ND group to the mild/moderate ND group at 12 weeks. No severe adverse reactions were reported with varenicline use throughout the entire follow-up duration.

Conclusion

Varenicline may help smokers with arterial hypertension under antihypertensive therapy to remain abstinent from tobacco cigarette smoking. A novel and important message of this study is also the substantial improvements in office SBP and DBP in highly nicotine dependent sustained tobacco abstainers.

ND-BP changes after varenicline therapy

Funding Acknowledgement

Type of funding source: None

Combined effect of cigarette smoking and prediabetes on structural and functional changes of large arteries

Purpose

Smoking is a major risk factor for cardiovascular disease and prediabetes is associated with excess risks for adverse cardiovascular outcomes and death. Aim of this study was to explore whether smoking and prediabetes exert a synergistic unfavourable effect on functional and structural parameters of large arteries.

Methods

We measured carotid-femoral pulse wave velocity (cfPWV), augmentation index (AIx) and carotid intima media thickness (cIMT) in 407 individuals without known atherosclerotic disease (mean age: 52±8 years) categorized into four age-matched groups according to glucose metabolic and smoking status: Smokers with diabetes (n=68), Smokers with prediabetes (n=87), Non-smokers with prediabetes (n=98) and Non- smokers with normal fasting blood glucose (FBG) (n=154). Prediabetes was defined as impaired fasting glucose (100–125 mg/dL), impaired glucose tolerance (2-hour glucose level of 140–199 mg/dL during an oral glucose tolerance test), or glycosylated hemoglobin (HbA1c) level of 5.7% to 6.4%. High sensitivity C-reactive protein (hsCRP) was measured in all patients.

Results

Systolic pressure, pulse pressure were increased and hsCRP levels were higher in smokers with diabetes compared to the three other groups (overall P<0.05, P<0.01 and P<0.05, respectively, ANOVA). The cumulative tobacco exposure (measured in pack-years) was similar between smokers with diabetes and smokers with prediabetes (45 pack-years). Figure 1 shows cfPWV, AIx and cIMT of the four groups. Interestingly, smokers with diabetes and smokers with prediabetes have similar mean cfPWV and cIMT and significantly higher values compared to non-smokers with prediabetes and non-smokers with normal FBG. The associations remained statistically significant even after adjusting for systolic pressure and hsCRP level. AIx was not different between the four study groups.

Conclusion

The combination of prediabetes and smoking is associated with higher cfPWV and cIMT values compared to prediabetes alone. The smokers with impaired glucose regulation have functional and structural alterations of large arteries similar to that of smokers with established diabetes. Considering the risk for developing prediabetes in relation to smoking status and the number of cigarettes smoked daily and the independent predictive value of assessing vascular changes in large arteries, the present findings may have important clinical and prognostic implications.

Figure 1. Smoking, prediabetes and vascular changes

Funding Acknowledgement

Type of funding source: None

The effects of chemotherapy on arterial inflammation assessed by 18 FDG PET-CT in patients with Lymphoma

Introduction

Anti-cancer treatment can lead to increased cardiovascular morbidity among lymphoma survivors. This may be the result of direct effect of treatment on heart function, or indirect acceleration of atherosclerosis. 18F-fluorodeoxyglucose (FDG) uptake is a sensitive and robust marker for assessment of atherosclerotic inflammation.

Purpose

To investigate the effects of chemotherapy on arterial inflammation using FDG-PET CT in patients with lymphoma.

Methods

Fifty nine (mean age 58±17 years) patients with Hodgkin (n=39) or non-Hodgkin lymphomas (n=20) underwent 18FDG PET-CT imaging at baseline, interim and after completion of chemotherapy as part of their routine protocol. Arterial inflammation was assessed by arterial target to background ratio (TBR) of the aortic wall along the entire aorta. The index vessel TBR (the vessel with the higher value at baseline) was used for assessment of arterial inflammation. Patients with Hodgkin Lymphomas (HL) underwent therapy with Doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). The interim of their treatment was set at 1 to 3 days prior to initiating the 3rd chemotherapy cycle. Patients with non Hodgkin Lymphomas (NHL) underwent therapy with cyclophosphamide, doxorubicin, vincristine, and prednisone+rituximab (R-CHOP). The interim of their treatment was set at 2 weeks post the 4th chemotherapy cycle. All patients we reassessed 6 weeks after chemotherapy completion.

Results

There were no differences in age and atherosclerotic risk factors (hypertension, diabetes, dyslipidemia and smoking), between the two groups (all P>0.05). Similarly, there were no differences in mean (±SD) index vessel TBR between HL and NHL patients (2.4±0.7 vs 2.7±0.9, respectively, P=0.65). In the whole study population the index vessel TBR progressively decreased after the end of therapy (by 0.53±0.11, from baseline to 6 weeks following the end of therapies) (F=10.94, P<0.001, ANOVA). The index vessel TBR decreased in both HL and NHL patients at 6 weeks after therapy compared to baseline level (all P<0.01, ANOVA, figure). The decrease at the interim scan was more pronounced in NHL compared to HL patients, however at 6 weeks after chemotherapy completion the index vessel TBR decreased further in patients with HL, while it increased slightly compared to interim levels in NHL patients (figure 1).

Conclusion

Arterial inflammation is reduced during and post-chemotherapy in patients with lymphoma. The index vessel TBR changes at the interim phase and 6 weeks after therapy completion indicate a different effect of specific treatment regimes in arterial inflammation between HL and NHL patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Exploring functional and structural vascular changes in obesity: are metabolically healthy obese individuals really healthy?

Purpose

Aim of the study is to compare vascular function and structure parameters among middle-aged men with differences in body mass index (BMI) and metabolic status and to investigate whether obese individuals with a normal metabolic profile have a unhealthy vascular profile.

Methods

We measured carotid-femoral pulse wave velocity (cfPWV), carotid intima media thickness (cIMT) and brachial flow-mediated dilation (bFMD) in 141 obese (BMI≥30 kg/m2) and in 176 aged-matched men with normal BMI (<25 kg/m2) individuals. All participants had no clinical manifestations or a history of atherosclerotic disease. High sensitivity C-reactive protein (hsCRP) and total testosterone (TT) were measured in all patients.

Results

The two BMI groups were subdivided into subgroups according to presence/absence of abnormal metabolic profile (presence of major cardiovascular risk factors): Metabolically unhealthy obese (MeUO, n=114), metabolically healthy obese (MeHO, n=27), metabolically unhealthy with normal BMI (MeUN, n=122) and metabolically healthy with normal BMI individuals (MeHN, n=54). The four subgroups had similar age. Figure 1 shows the mean cIMT (left plot), cfPWV (middle plot) and bFMD (right plot) of the four subgroups. Carotid IMT and cfPWV is higher and bFMD is lower in metabolically unhealthy compared to individuals with a normal metabolic profile in both patients with obesity and subjects with normal BMI. Interestingly, the MeNO patients had significantly lower cIMT (P<0.05) and cfPWV (P<0.01) and higher bFMD (P<0.01) level compared to MeUN individuals. However, as figure shows all measured vascular parameters were significantly impaired in MeNO patients compared to those of MeHN individuals. MeHO patients had comparable hsCRP and TT levels to those of MeUO and MeUN individuals denoting increased inflammatory activation and endogenous androgen deficiency.

Conclusions

MeHO which is a obesity phenotype that has created lot of debate is associated with a better vascular profile compared to MeUN status, however patients with MeHO have more impaired vascular function and structure parameters than MeHN individuals. This finding implies that even in the absence of overt metabolic aberrations, the MeHO profile may be associated with endothelial dysfunction, increased aortic stiffness and thickness of the carotid arterial wall.

Figure 1. BMI, metabolic status and vascular changes

Funding Acknowledgement

Type of funding source: None

Association between office blood pressure, antihypertensive medication use and male sexual dysfunction: a penile Doppler study

Background

Arterial hypertension is associated with an almost two-fold increase in the likelihood of having an abnormal penile blood flow. Recent evidence supports the independent of age and blood pressure (BP) level predictive value of severe penile arterial insufficiency for adverse cardiovascular events.

Purpose

Aim of this study is to quantify the association between BP level and severity of penile vascular disease and to examine the potential for differences in effect of BP lowering medication use on the associations between BP level and penile vascular damage.

Methods

We measured penile peak systolic velocity (PSV) in 356 consecutive men with erectile dysfunction (ED) and without a history of diabetes and cardiovascular disease; The cohort was divided according to office systolic BP (SBP) and diastolic BP in three BP categories: normal (SBP <130 and DBP <85 mmHg, n=117), high normal (130≤SBP<140 or DBP 85≤DBP<90mmHg, n=91), and hypertension (SBP≥140 or DBP≥90mmHg, n=148). 164 (46%) patients of the whole study population were treated with antihypertensive medications. Low PSV values after intracavernous injection of prostanglandin E1 indicate impaired penile blood inflow and severe vasculogenic ED.

Results

Figure shows PSV measurements of the three office BP categories subdivided according to use of antihypertensive therapy. Treated and untreated hypertensive patients had similar mean PSV. Interestingly, the mean PSV of men with high normal BP not receiving antihypertensive drugs was significantly higher compared to PSV of men with high normal BP under therapy and significantly lower compared to PSV of normotensive males without therapy (all P<0.05). Among males not receiving antihypertensive medications there was a progressive decrease in PSV values from normal BP, to high normal BP and to hypertension (P=0.01, after adjustment for age), while among males under antihypertension therapy, the three BP categories had similar PSV level (P=0.54 after adjustment for age) (figure).

Conclusion

The inverse associations observed between hypertension status and penile arterial insufficiency in men not taking antihypertensive medication were attenuated or disappeared among men reporting antihypertensive medication use reflecting a medication effect or structural effects of longstanding hypertension on the penile vasculature.

BP level, hypertension therapy and PSV

Funding Acknowledgement

Type of funding source: None

A predictive model of pcsk-9 inhibitors eligibility in coronary and dyslipidemic patients

Purpose

Dyslipidemia is a major cardiovascular risk factor and treatment is mostly based on statins and ezetimibe. PCSK-9 inhibitors are monoclonal antibodies that reduce LDL-c levels and have shown significant reduction of cardiovascular risk in high risk patients. Data regarding potential eligibility for PCSK-9, is limited especially when referring to the recent guidelines.

Methods

Eligibility was calculated using a proprietary adjustable software, which stores data and patient information and thus by using different criteria it can determine potential candidates for PCSK-9 inhibitors. For this purpose, 2000 patients were enrolled prospectively. Our study population was comprised of inpatients diagnosed either with acute coronary syndromes (ACS) or with chronic coronary disease (cCAD) and outpatients from Lipids' Clinic (OLC) (n=407, n=1087, n=506, respectively). In order to test eligibility, three different LDL thresholds were used in our model for high and very high risk groups: a) 70mg/dl and 55mg/dl, respectively, as recommended by the recently updated 2019 ESC/EAS Guidelines for Dyslipidaemia b) 100mg/dl and 70mg/dl, respectively, as recommended by the 2016 ESC/EAS Guidelines for Dyslipidaemias and c) 130mg/dl and 100mg/dl respectively, as mandated by our National Health Care system but also applicable in other countries.

Results

The eligible percentages for the three thresholds were 18.85%, 9.75% and 2.15%, in the total population (TP) respectively and it varied according to clinical status. Subgroup analysis of eligible population revealed the trends in each group (Figure 1). The increase toward more recent guidelines was mostly attributed to the increasing number of coronary patients who become eligible as our criteria become stricter.

Conclusions

Our predictive model provides a realistic estimation of PCSK-9 inhibitors potential eligibility in coronary and dyslipidaemic patients and thus it can become a useful tool for the use of PCSK-9 in health care systems.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen Hellas LTD

The long-term impact of transcatheter aortic valve implantation on arterial stiffness and central hemodynamics

Background/Introduction

The study of arterial properties in patients with aortic valve stenosis who undergo transcatheter aortic valve implantation (TAVI) remains challenging and results so far seem equivocal.

Purpose

We sought to investigate the acute and long-term effect of TAVI on arterial stiffness and wave reflections opting for a global approach.

Methods

We enrolled 90 patients (mean age 80.2±8.1 years, 50% males) with severe symptomatic aortic stenosis undergoing TAVI. Arterial stiffness was assessed by both carotid-femoral and brachial-ankle pulse wave velocity (cfPWV and baPWV). Augmentation index corrected for heart rate (AIx@75), an index of wave reflections, and central pressures were assessed with arterial tonometry. Measurements were conducted at baseline, after the procedure and at 1 year.

Results

Immediately post-TAVI there was a statistically significant increase in arterial stiffness (7.5±1.5 m/s vs 8.4±1.9 m/s, p=0.001 for cfPWV and 1,773±459 cm/s vs 2,383±645 cm/s, p<0.001 for baPWV) despite no change in systolic blood pressure. At 1-year follow-up, TAVI was still associated with an increase in arterial stiffness compared to pre-TAVI (7.5±1.5 m/s vs 8.7±1.7 m/s, p<0.001 for cfPWV and 1,773±459 cm/s vs 2,286±575 cm/s, p<0.001 for baPWV) but not to post-TAVI values. We also observed a decrease in AIx@75 (32.2±12.9% vs 27.9±8.4%, p=0.016) post-TAVI that was attenuated at 1 year (32.2±12.9% vs 29.8±9.1%, p=0.38).

Conclusions

Our study shows that after TAVI the arterial system exhibits an increase of stiffness in response to the acute relief of the obstruction, which is retained in the long term. Our findings further elucidate the immediate and long-term hemodynamic changes of TAVI to the aorta that may entail prognostic role in this growing population.

Change of vascular biomarkers post-TAVI

Funding Acknowledgement

Type of funding source: None

Body mass index, silent coronary artery disease and the impact of adopting healthy lifestyle and sexual performance on the risk of major adverse cardiovascular events in erectile dysfunction patients

Background

Erectile dysfunction (ED) is associated with a higher prevalence of risk factors such as hypertension and diabetes and it is an independent predictor of major adverse cardiovascular events (MACE). ED is a common problem in men with obesity.

Purpose

The aim of this study is to investigate the association of overweight and obesity with asymptomatic coronary artery disease and the impact of lifestyle interventions on MACE risk in men suffering from ED.

Methods

A total of 614 patients (55±9 y/o) with ED and without known cardiovascular disease (CVD) underwent dobutamine stress echocardiography (and coronary angiography in patients with positive stress echocardiography for myocardial ischemia) to reveal occult coronary artery disease (CAD). In all patients C-reactive protein (CRP) and total testosterone (TT) were measured at entry. After this evaluation and management of concomitant traditional risk factors they were advised to adopt the recommended strategies for healthy lifestyle and improvement of sexual activity.

Results

The whole population was divided into three groups according to body mass index (BMI) at entry (normal: 18–25.5 kg/m2, n=132; overweight:25.5–29.9 kg/m2, n=295; and obesity: >29.9kg/m2, n=187). There were no statistically significant differences in age, blood pressure (BP) level and smoking prevalence between the three groups. Obese ED patients had significantly lower TT and higher CRP compared to overweight and normal BMI patients (overall P<0.001 and P<0.01, respectively). The prevalence of angiographically documented CAD was not different between obese and overweight patients and it was significantly higher compared to that of subjects with normal BMI (13.8% vs 14.5% vs 7.2%, respectively, overall P<0.05). In the whole study population, a total of 43 (7%) MACE occurred during a mean follow-up of 6.7 years after adopting a healthy lifestyle and improvement in sexual life. Interestingly, overweight status at baseline was associated with a higher MACE prevalence and the overall difference between the three BMI groups at entry was statistically significant (Mantel log-rank test: 8.65; P=0.0014) (Figure 1). Furthermore, in a Cox proportional hazard model overweight at entry (3.14, CI: 1.49–7.87, P<0.01), TT level (0.72; CI 0.56–0.97, P<0.01) and the use of phosphodiesterase-5 (PDE-5) inhibitors (0.83; CI 0.67–0.97, P<0.05) were independent predictors of MACE.

Conclusion

Overweight and obese ED patients have similar prevalence of asymptomatic CAD, however the overweight profile at baseline appears to have a significantly higher MACE risk compared to obesity at follow-up after adopting a healthy lifestyle and improving sexual life with PDE-5 inhibitors. The paradox finding warrants further investigation.

Figure 1. BMI categories and MACE risk

Funding Acknowledgement

Type of funding source: None

Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece

Objectives

The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures.

Study design

This is a retrospective observational study.

Methods

Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected.

Results

A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre–COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), −59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), −54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), −60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05).

Conclusion

Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

•

The coronavirus disease 2019 (COVID-19) outbreak has led to an unprecedented health system overload.

•

The restrictive measures in Greece resulted in a low number of COVID-19 cases.

•

Hospital visits and cardiovascular events have diminished after implementation of restrictive measures.

•

Acute coronary syndromes reduced by approximately 55%, despite limited incidence of COVID-19.

•

The multifactorial etiology of this finding should be thoroughly investigated.

Cardiotoxic Profile and Arterial Stiffness of Adjuvant Chemotherapy for Colorectal Cancer

Background and Purpose

Even though new cancer therapies have improved the overall survival, in some cases they have been associated with adverse effects, including increased cardiotoxicity. The purpose of the present study was to assess the cardiovascular effects of adjuvant chemotherapy for colorectal cancer and mainly the impact on arterial stiffness indices.

Material and Methods

A total of 70 patients with non-metastatic colorectal cancer who were treated either with FOLFOX (n=16) or with XELOX (n=54) adjuvant chemotherapy were included in the study. All patients were subjected to full cardiovascular evaluation at the beginning and the end of chemotherapy. Arterial stiffness was assessed by means of pulse wave velocity (PWV) and augmentation index (Aix) and full laboratory examinations were conducted prior to, and soon after, the termination of chemotherapy.

Results

Patients exhibited significantly higher levels of carotid-radial PWV, carotid femoral RWV and Aix post-chemotherapy (p<0.001); these findings remained significant when examined separately in each treatment subgroup (FOLFOX, XELOX). The observed changes were independent of treatment regimen and baseline patient characteristics. Univariate regression analyses showed that baseline PWVc-r and PWVc-f were the only factors associated with PWVc-r and PWVc-f change, while Aix change was independent of its baseline value.

Conclusion

There is a clear burden in arterial stiffness indices post-adjuvant chemotherapy for colorectal cancer in both chemotherapy groups. This is a finding of important clinical significance, however more prospective studies are required in order to encode the possible mechanisms involved.

Periodontitis and Cardiovascular Diseases. Consensus Report

Background

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

Material and Methods

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations.

Results and Conclusions

The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.