Standards for clinical trials for treating TB

BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Microvascular arterial disease of the brain and the heart: a shared pathogenesis

Microvascular arterial disease in the heart manifest as coronary microvascular dysfunction. This condition causes microvascular angina and is associated increased morbidity and mortality. Microvascular arterial disease in the brain is referred to as cerebrovascular small vessel disease. This is responsible for 45% of dementias and 25% of ischaemic strokes. The heart and brain share similar vascular anatomy and common pathogenic risk factors are associated with the development of both coronary microvascular dysfunction and cerebrovascular small vessel disease. Microvascular disease in the heart and brain also appear to share common multisystem pathophysiological mechanisms. Further studies on diagnostic approaches, epidemiology and development of disease-modifying therapy seem warranted.

Transaortic flow rate to predict short and long term outcomes in individuals with asymptomatic aortic stenosis

Background

Echocardiographic derived transaortic flow rate (TFR), defined as stroke volume over left ventricular ejection time, has been shown to be associated with increased mortality in asymptomatic mild to severe aortic stenosis (AS) and superior to stroke volume index (SVi) in individuals with symptomatic discordant AS undergoing aortic valve replacement. However, TFR has not been explored alongside SVi in asymptomatic moderate to severe AS, who are a group of interest in risk stratifying for early intervention. Moreover, there is no data where TFR is indexed to body surface area (TFRi).

Purpose

We explored the prognostic value of TFR, TFRi and SVi in a homogenous cohort of asymptomatic patients with moderate to severe AS.

Methods

Subjects with asymptomatic moderate to severe AS were prospectively recruited to the Prognostic Importance of Microvascular Dysfunction in asymptomatic patients with AS (PRIMID) study, a multi-centre observational study in the UK conducted between April 2012 and November 2014. All subjects underwent extensive phenotyping with transthoracic echocardiography, bicycle exercise testing and cardiovascular magnetic resonance (CMR) imaging, with blinded core-lab analysis. Patients were followed up in person for a minimum of 12 months, and through health records thereafter. The composite outcome of interest was: cardiovascular mortality, AVR for symptoms and major adverse cardiovascular events (hospitalisation with heart failure, myocardial infarction, syncope and arrhythmia) at one-year and at five years. A cox proportional hazards model was used to calculate a hazard ratio (HR) and 95% confidence intervals (95% CI). Known co-variables associated with the composite outcome were added into the multivariable model.

Results

Overall, 173 individuals were included with a mean age of 66.3—-±13.3 years and 76.4% were male. Most individuals had severe AS (71.1%, n=123). There were 47 (64.4%) primary outcome events at one-year and 110 (63.6%) events at five-years. Age, sex, N-terminal pro brain natriuretic peptide (NT-pro-BNP), peak aortic velocity (AV Vmax), a positive exercise tolerance test (ETT), myocardial perfusion reserve and right ventricular ejection fraction measured on cardiac magnetic resonance were included in the multivariable model in addition to TFR or TFRi or SVi. Decreasing TFR and TFRi remained independently associated with one-year and five-year composite outcome (Figure 1). However, SVi was only associated with the composite outcome at five-years. AV Vmax (HR: 4.36, 95% CI: 2.59, 7.34, p&lt;0.01) and a positive ETT (HR: 1.87, 95% CI: 1.03, 3.37, p=0.04) were independently associated with the primary outcome at one-year.

Conclusion

Both TFR and TFRi have a potential role in risk stratifying asymptomatic patients with AS and identifying those for earlier intervention, and may be superior to SVi. However, further prospectively designed studies are needed before this becomes part of the routine clinical practice.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Independent research from a Post-Doctoral Fellowship supported by the National Institute for Health Research (NIHR-PDF 2011-04-51 Geral P McCann).

Comorbidity and medication use in patients with angina due to a coronary vasomotion disorder

Background

Microvascular angina and vasospastic angina are disorders of coronary vasomotion. The associations between these conditions, comorbidity and medication use in relatively unselected populations is not well described.

Aim

To describe the proportions of patients with concomitant morbidity and related medication use in an international, contemporary, clinical database.

Methods

TriNetX, a global federated health research network with access to anonymized electronical medical records (EMRs) from participating healthcare organizations including academic medical centres, specialty physician practices, and community hospitals, predominantly in the USA was used. The ICD10 code (I20.1) representing “Angina pectoris with documented spasm” was used as a primary search term. ICD10 codes were also used for cardiorenal and metabolic conditions. Medication use was classified as occurring prior to or on the date of the angina episode. The time-period for defining the analysis population was 01.01.2017–31.12.2019. The population age was ≥18 years.

Results

Data were available on 12,200 individuals (mean (SD) age 63 (13) years; 63% female). The % of individuals with a concomitant diagnosis is described in Table 1. Hypertension occurred in almost two thirds of individuals, an anxiety disorder affected more than one quarter and type 2 diabetes and/or obesity occurred in one fifth. Medication use is described in Table 2. Half of patients received a calcium channel blocker therapy. Nitroglycerin, beta-blockers, and isosorbide mononitrate were less commonly used (45%, 45% and 23%, respectively). Most (58%) patients were prescribed an antacid. Half of patients received statin treatment (50% overall; 36% atorvastatin) and insulin (12%) and metformin (9%) were the most commonly prescribed antidiabetic medications.

Conclusions

Angina associated with coronary spasm associates with female sex and cardio-metabolic risk factors. Contemporary pharmacotherapy for diabetes and statins appear to be under-used.

Funding Acknowledgement

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

Improvement in angina pectoris after percutaneous coronary interventions in focal and diffuse coronary artery disease

Objective

To investigate the effect of PCI on patient-reported outcomes in focal and diffuse coronary artery disease (CAD) as defined by the pullback pressure gradient (PPG).

Background

Improvements in fractional flow reserve (FFR) following PCI are associated with freedom from angina. CAD patterns influence the FFR change after stenting. Therefore, CAD patterns might be essential to assess the likelihood of PCI success in terms of angina relief.

Methods

This is a sub-analysis of the TARGET-FFR randomized clinical trial (NCT03259815). The 7-item Seattle Angina Questionnaire (SAQ-7) and EuroQol five-level EQ-5D questionnaire (EQ-5D-5L) were administered at baseline and three months after PCI. The PPG index was calculated from manual pre-PCI FFR pullbacks and the median PPG value was used to define focal and diffuse CAD.

Results

103 patients (51 with focal and 52 with diffuse disease) were analyzed. There were no differences in baseline characteristics between patients with focal and diffuse CAD. Patients with focal disease had larger increases in FFR with PCI than those with diffuse disease (0.30±0.14 units vs 0.19±0.12 units, p&lt;0.001). Patients who underwent PCI to focal CAD had significantly higher SAQ-7 summary scores at follow-up compared to those with diffuse CAD (87.1±20.3 vs. 75.6±24.4, mean difference 11.5 [95% CI 2.8 to 20.3], p=0.01). Following PCI, residual angina was present in 39.8% of all patients but was significantly lower among those with treated focal CAD (27.5% vs 51.9%, p-value=0.020).

Conclusion

Persistent angina after PCI was almost twice as common in patients with diffuse CAD as defined by the pre-PCI PPG. Patients with focal disease reported greater improvement in angina and quality of life with PCI. The likelihood of successful angina relief from PCI can be predicted by the baseline pattern of CAD.

Funding Acknowledgement

Type of funding sources: None.

The Impact of Living with INOCA

Background

There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives.

Purpose

We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis.

Methods

A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5

Results

A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P&lt;0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p&lt;0.0001) (Figure 1).

Conclusions

Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of plasma level of NT-pro BNP in patients with microvascular angina – a report from the international cohort study by COVADIS

Aims

Although the importance of microvascular angina (MVA) has been emerging, prognostic biomarkers for MVA remain to be developed. We thus aimed to examine whether plasma level of N-terminal prohormone of brain natriuretic peptide (NT-pro BNP) could predict the prognosis of MVA patients.

Methods

In the international prospective cohort study of MVA patients by the Coronary Vasomotor Disorders International Study (COVADIS) group, we evaluated the association between plasma level of NT-pro BNP and the incidence of major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina.

Results

We examined a total of 226 MVA patients (M/F 66/160, 61.9±10.2 [SD] years) with both plasma NT-pro BNP levels and echocardiographic data in the COVADIS study. Plasma NT-pro BNP level was elevated (median 94 pg/ml, IQR 45–190) while mean LVEF (69.2±10.9%) and E/e' (10.7±5.2) were almost normal. During follow-up period of a median of 365 days (IQR 365–482), 29 MACEs occurred. ROC curve analysis identified plasma NT-pro BNP level of 78 pg/ml as the optimal cut-off value. Multivariable logistic regression analysis revealed that plasma NT-pro BNP level ≥78 pg/ml significantly correlated with the incidence of MACE (odds ratio (OR) [95% confidence interval (CI)] 3.11 [1.14–8.49], P=0.03). When divided into 2 groups by NT-pro BNP 78 pg/ml, the Kaplan-Meier survival analysis showed a significantly worse prognosis in the group with NT-pro BNP ≥78 (log lank, P=0.03) (Figure).

Conclusions

These results indicate that plasma NT-pro BNP level is a novel prognostic biomarker for MVA patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Japan Heart Foundation

Prevention and early treatment of the long-term physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise-CISCO-21

Background

Coronavirus disease-19 (COVID-19) infection causes persistent health problems such as breathlessness, chest pain and fatigue, and therapies for the prevention and early treatment of post-COVID-19 syndromes are needed. Accordingly, we are investigating the effect of a resistance exercise intervention on exercise capacity and health status following COVID-19 infection.

Methods

A two-arm randomised, controlled clinical trial including 220 adults with a diagnosis of COVID-19 in the preceding 6 months. Participants will be classified according to clinical presentation: Group A, not hospitalised due to COVID but persisting symptoms for at least 4 weeks leading to medical review; Group B, discharged after an admission for COVID and with persistent symptoms for at least 4 weeks; or Group C, convalescing in hospital after an admission for COVID.

Participants will be randomised to usual care or usual care plus a personalised and pragmatic resistance exercise intervention for 12 weeks. The primary outcome is the incremental shuttle walks test (ISWT) 3 months after randomisation with secondary outcomes including spirometry, grip strength, short performance physical battery (SPPB), frailty status, contacts with healthcare professionals, hospitalisation and questionnaires assessing health-related quality of life, physical activity, fatigue and dyspnoea.

Discussion

Ethical approval has been granted by the National Health Service (NHS) West of Scotland Research Ethics Committee (REC) (reference: GN20CA537) and recruitment is ongoing. Trial findings will be disseminated through patient and public forums, scientific conferences and journals.

Trial registration

ClinicialTrials.gov NCT04900961. Prospectively registered on 25 May 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06632-y.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Right ventricular dysfunction in patients with COVID-19 pneumonitis whose lungs are mechanically ventilated: a multicentre prospective cohort study

Cardiovascular complications due to COVID-19, such as right ventricular dysfunction, are common. The combination of acute respiratory distress syndrome, invasive mechanical ventilation, thromboembolic disease and direct myocardial injury creates conditions where right ventricular dysfunction is likely to occur. We undertook a prospective, multicentre cohort study in 10 Scottish intensive care units of patients with COVID-19 pneumonitis whose lungs were mechanically ventilated. Right ventricular dysfunction was defined as the presence of severe right ventricular dilation and interventricular septal flattening. To explore the role of myocardial injury, high-sensitivity troponin and N-terminal pro B-type natriuretic peptide plasma levels were measured in all patients. We recruited 121 patients and 118 (98%) underwent imaging. It was possible to determine the primary outcome in 112 (91%). Severe right ventricular dilation was present in 31 (28%), with interventricular septal flattening present in nine (8%). Right ventricular dysfunction (the combination of these two parameters) was present in seven (6%, 95%CI 3-13%). Thirty-day mortality was 86% in those with right ventricular dysfunction as compared with 45% in those without (p = 0.051). Patients with right ventricular dysfunction were more likely to have: pulmonary thromboembolism (p < 0.001); higher plateau airway pressure (p = 0.048); lower dynamic compliance (p = 0.031); higher plasma N-terminal pro B-type natriuretic peptide levels (p = 0.006); and raised plasma troponin levels (p = 0.048). Our results demonstrate a prevalence of right ventricular dysfunction of 6%, which was associated with increased mortality (86%). Associations were also observed between right ventricular dysfunction and aetiological domains of: acute respiratory distress syndrome; ventilation; thromboembolic disease; and direct myocardial injury, implying a complex multifactorial pathophysiology.

Working in the Woodlands: A mixed methods evaluation of Green Care in First Episode Psychosis

Introduction

Recognition of the essential role of nature-based activities for general wellbeing is expanding. Currently, there is limited evidence of the benefits of green care for those with severe and enduring mental illness, including psychosis.

Objectives

We aim to establish benefits and difficulties encountered during a 10-session green care programme for 18-30 year olds who have experienced first episode of psychosis (FEP) using a mixed methods approach.

Methods

This was a service evaluation of a ’Woodland Group’ of 10 half-day sessions for participants with FEP. Sessions consisted of a welcome and agenda setting, ice-breaking activity, core nature-based activity. Quantitative data for this evaluation was collected through the 15-item Questionnaire on the Process of Recovery (QPR), and a semi-structured intervention experience questionnaire. Qualitative data was collected via a focus group. Thematic analysis was performed by the three co-authors.

Results

4/8 patients showed reliable improvement on QPR outcome measures, 1 showed deterioration and 3 showed no change. Mean QPR scores showed modest increase from average 3.4 (week 1) to 3.8 (week 10). 100% of respondents would recommend this group to others. Thematic analysis identified themes of connection with nature and others, development of a sense of wellbeing and ‘peacefulness’ and new perspectives on psychotic experience.

Conclusions

This small, retrospective evaluation is the first to investigate green care interventions for young people experiencing FEP. Our results reflect the positive informal feedback from participants and supporting staff. Limitations include small sample size, incomplete data, and reliance on patient-reported outcomes. These findings show promise for nature-based activities within EIS.

Disclosure

No significant relationships.

Patients presenting with acute coronary syndromes have unreported coronary artery calcium on historical CT imaging

Introduction

Ischaemic heart disease (IHD) remains the leading cause of mortality globally1. The presence and extent of coronary artery calcification (CAC) is a strong predictor of cardiovascular events, and CAC scoring has been shown to be more predictive of cardiovascular events than other traditional risk assessment scores2.

Incidental coronary calcification can be detected and quantified on non-gated CT chest scans covering the heart in the field of view3. This finding is typically not reported4 and hence an opportunity to optimise cardiovascular risk assessment and treatment is missed.

Purpose

We sought to investigate whether patients presenting to our centre with an acute coronary syndrome (ACS) event had historical CT imaging demonstrating coronary artery calcification.

Methods

We retrospectively reviewed case records for all patients referred to our centre for an invasive coronary angiogram following their first known admission with an ACS event. ACS were defined according to contemporary guidelines from the European Society of Cardiology. We reviewed a 3 month period prior to the COVID-19 pandemic (01/01/2019–31/03/2019). The national imaging database was interrogated to identify previous CT imaging that includes the heart in the field of view. The presence of coronary calcification was confirmed and quantified using an ordinal scoring method previously described3. The clinical radiology reports for the scans were reviewed to determine the frequency of CAC being reported.

Demographic information was collected from our electronic patient record including the presence of risk factors for IHD. Prescribed medication prior to admission was also recorded using the on-admission medicines reconciliation documented in the electronic patient record.

Results

385 patients with first presentation of ACS were identified. 75 (19%) had a prior non-gated CT chest imaging. The most common indication for CT was for investigation of possible malignancy. The mean interval from CT imaging to ACS admission was 36 months.

CAC was present on 67 (89%) scans. The mean ordinal score was 4.04, corresponding to moderate CAC. The distribution of CAC by coronary artery revealed the majority of disease to involve the left anterior descending artery (Table 1). Only 12/67 (18%) of clinical radiology reports mentioned coronary calcification (Figure 1).

Patients with CAC frequently had additional risk factors for IHD. Despite this only 42% were prescribed antiplatelet therapy, and only 45% prescribed a statin.

Conclusions

A significant proportion of ACS admissions have evidence of CAC on historical CT scans. This finding is often not reported and the majority of patients with demonstrated coronary artery disease are not prescribed appropriate preventative therapies. Systematic reporting of this finding may have a significant impact on the prevention of acute cardiovascular events.

Funding Acknowledgement

Type of funding sources: None. Table 1

Effect of low dose intracoronary alteplase on global circumferential strain (myocardial strain CMR substudy from the T-TIME trial)

Background

Microvascular obstruction affects half of patients with ST-segment elevation myocardial infarction (STEMI) and confers an adverse prognosis. Feature-tracking (FT) cardiac magnetic resonance (CMR) allows myocardial strain assessment from standard cine images without the need for specialist sequences. Myocardial strain reflects both systolic and diastolic function allowing the assessment of both global and regional myocardial deformation. Strain recovery is impaired in patients with microvascular obstruction. There is growing evidence to suggest that global circumferential strain may offer incremental value beyond traditional CMR endpoints.

Purpose

We aimed to determine whether a therapeutic strategy involving low-dose intracoronary alteplase improves global circumferential strain in STEMI.

Methods

Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the United Kingdom within 6 hours of STEMI were randomised in a 1:1:1 dose-ranging trial design. Participants were randomly assigned to treatment with placebo (n=151), alteplase 10mg (n=144), or alteplase 20mg (n=145). The primary outcome was the amount of microvascular obstruction (%left ventricular mass) quantified by CMR at 2–7 days. Global circumferential strain was a prespecified secondary endpoint measured at 2–7 days and 3 months. Troponin T AUC was measured at 0, 2, and 24 hours post reperfusion. Patients were followed up to 1 year with all events adjudicated by an independent committee.

Results

Among the 440 patients who were randomised (mean age 60.5 years; 85% male), the primary endpoint was achieved in 396 (90%), all patients were followed up to 1 year for clinical events. The amount (mean, standard deviation) of microvascular obstruction was not different between the groups (2.3% vs. 2.6% vs. 3.5% left ventricular mass); p=0.28. Global circumferential strain was worse in patients receiving alteplase. −23.1% (placebo) vs −20.6 (10mg alteplase) vs −22.0% (20mg alteplase); mean difference for both doses combined vs placebo: 1.8% (95% CI 0.5, 3.2), p=0.009. There were no differences between groups in the other CMR endpoints including LV ejection fraction (LVEF). The area-under-the-curve for troponin T measured in 317 (72%) patients was increased in both treatment groups compared to placebo, mean difference 1.53 (95% CI: 1.16, 2.01), p=0.002. There were no differences in MACE at 1 year; placebo n=16 (10.6%), 10mg alteplase n=22 (15.3%), 20mg alteplase group n=15 (10.3%).

Conclusion

In patients presenting within 6 hours of STEMI, low-dose intracoronary alteplase compared with placebo did not reduce microvascular obstruction. There was a reduction in global circumferential strain and an increase in Troponin T AUC supporting an increase in myocardial injury early after reperfusion in patients receiving alteplase. There was no differences in MACE at one year suggesting no long-term clinical sequelae.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): T-TIME was supported by grant 12/170/4 from the Efficacy and Mechanism Evaluation (EME) programme of the National Institute for Health Research (NIHR-EME). Boehringer-Ingelheim U.K. Ltd. provided the study drugs (alteplase 10mg, 20mg), matched placebo, and sterile water for injection. Study recruitment flowchartTable- Study endpoints

Role of inpatient coronary CT angiography on clinical decision making during COVID- 19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has had a profound effect on healthcare delivery. Here we describe the effect of repurposing of a research Computed Tomography scanner on clinical care of cardiology patients in an urban academic medical centre which did not have routine access to CCTA prior to the pandemic. 

Patients requiring invasive coronary angiography require transfer to a regional cardiac centre (no ICA available on site).

Purpose

We investigated the effect of CCTA on i) diagnostic certainty ii) avoidance of clinician defined unnecessary invasive angiography in hospitalised patients.

Methods

This was a prospective, longitudinal cohort study involving hospitalized patients admitted to an urban academic medical centre (catchment population 650 000) between March 29 and September 21, 2020. Routinely collected (usual care) data were gathered by clinicians who were members of the usual care medical team and ethics approval or explicit patient consent was not required. High-sensitivity Troponin-I was measured on admission and 3- and 6– hours after if mandated (Abbott Architect TnI assay).

A 320-detector scanner (Aquilon ONE, Canon) was used. Intravenous metoprolol was used where required to control the heart rate (target 60 b.p.m.) and sublingual glyceryl trinitrate will be given to all patients immediately before the scan acquisition.

Results

Forty-three patients underwent inpatient CCTA, mean age: 61 ± 13 years (range 30-88y), 54% female. The presenting complaint was typical chest pain in 28 (65%), atypical chest pain in 10 (23%), and a variety of symptoms in 5 (12%) including palpitations, syncope, breathlessness.

Thirty-six (84%) of patients had a detectable TnI above the 99% centile. Median(IQR) peak TnI was 127 (33-635)ng/L.

CCTA was carried out on average 1 day post request. 

CCTA resulted in an improvement in clinician diagnostic certainty (Initial review: 21% yes, 79% probable, post-CCTA review: 84% yes, 16% probable) in providing a diagnosis.

21 (49%) of invasive coronary angiograms were avoided due to CCTA, whilst an inpatient invasive coronary angiogram (ICA) was performed in 4(9%) due to CCTA demonstrating significant disease, and in 2(%) the ICA was changed from out-patient to in-patient. Three ICA tests were requested as OP due to CCTA findings. CCTA did not overestimate disease severity in this cohort. 

We saved 21 inter hospital transfers for ICA during this time period. 

Using NHS England cost tariffs, a cost saving of &gt;£36,000 was made for using CCTA instead of ICA in these 21 patients who would have required ICA.

Conclusion

Inpatient CCTA resulted in greater clinician diagnostic confidence, avoidance of unnecessary invasive angiograms and a significant cost saving. This also reduced the duration of patient stay, reducing the potential exposure of patients to COVID-19.

Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Aims 

Fractional flow reserve (FFR_CT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFR_CT would improve economic and clinical outcomes compared with standard care.

Methods and results 

Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFR_CT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFR_CT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01).

Conclusion 

A strategy of CTCA with selective FFR_CT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

Validation of the Hamilton Program for Schizophrenia Voices Questionnaire: Associations with emotional distress and wellbeing, and invariance across diagnosis and sex

BACKGROUND

Voice-hearing is a transdiagnostic experience with evident negative effects on patients. Good quality measurement is needed to further elucidate the nature, impact and treatment of voice-hearing experiences across patient groups. The Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) is a brief self-report measure which requires further psychometric evaluation.

METHODS

Using data from a transdiagnostic sample of 401 adult UK patients, the fit of a conceptual HPSVQ measurement model, proposing a separation between physical and emotional voice-hearing characteristics, was tested. A structural model was examined to test associations between voice-hearing, general emotional distress (depression, anxiety, stress) and wellbeing. The invariance of model parameters was examined across diagnosis and sex.

RESULTS

The final measurement model comprised two factors named 'voice severity' and 'voice-related distress'. The former comprised mainly physical voice characteristics and the latter mainly distress and other negative impacts. Structural model results supported voice-related distress as mediating the associations between voice severity and emotional distress and wellbeing. Model parameters were invariant across psychosis versus non-psychosis diagnosis and partially invariant across sex. Females experienced more severe and distressing voices and a more direct association between voice severity and general anxiety was evident.

CONCLUSIONS

The HPSVQ is a useful self-report measure of voice-hearing with some scope for further exploration and refinement. Voice-related distress appears a key mechanism by which voice severity predicts general distress and wellbeing. Whilst our data broadly support interventions targeting voice-related distress for all patients, females may benefit especially from interventions targeting voice severity and strategies for responding.

UK national and regional trends in cardiovascular magnetic resonance usage – the British Society of CMR survey results

Background

CMR is an imaging modality recommended for multiple indications. Access to CMR is a key issue for its clinical use. We surveyed all CMR units in the UK.

Methods

An online survey of CMR units in the UK, with responses analysed by region and compared with population data.

Results

Response rate was 100% (Table). The UK performed a total of 102,886 scans in 2017, and 117,967 in 2018 representing a 1-year 14.7% increase and a 10-year increase of 573% compared to 2008 data (20,597).By head of population in 2018 there were 1,776 CMR scans per million people, with significant variation nationally and regionally, e.g. 4,256 per million in London vs. 396 per million in Wales (Figure). Mean number of scans per unit was 1,404, (range 98–10,000) with wide variation in referral to diagnostic times (mean 45.7 days, range 5–180) (Figure).

Clinical indications for CMR were: heart failure 21%, cardiomyopathy 27%, function and viability 22%, stress 24%, vascular disease 5%, valvular 5%, myocarditis/pericardial 10%, paediatric /congenital 10%, others e.g. transplant/masses 4%, with overlap. There were 358 consultants reporting CMR in 2018 (234 (65%) cardiologists and 124 (35%) radiologists). 81% of units had a CMR service for patients with pacemakers and defibrillators.

Conclusion

The survey shows the state of CMR in the UK. The 10-year growth has been remarkable, but there are wide disparities in terms of use, access and wait times with potential implications for clinical care. Action is needed to make access equitable across the UK.

Figure 1

Funding Acknowledgement

Type of funding source: None

Angina, quality of life and prognosis: prospective comparison of patients undergoing invasive management

Background

Angina is associated with impaired quality of life and an adverse prognosis.

Purpose

Prospectively evaluate quality of life and clinical outcomes in patients with angina undergoing invasive coronary angiography according to endotype: symptoms and/or signs of ischaemia and no obstructive coronary artery disease (INOCA) compared to obstructive coronary artery disease subjects managed by medical therapy, revascularization with percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery, respectively.

Methods

We conducted a prospective clinical evaluation of patients with angina undergoing clinically indicated invasive management (NCT03193294). Symptom severity and quality of life were assessed at baseline and repeated after 6 months. Comparisons between treatment groups were based on analysis of covariance general linear models adjusting for baseline score, sex, and cardiovascular risk. INOCA subjects were considered as one diagnostic group and not all subjects had invasive vasoreactivity testing.

Results

391 patients (mean age 62±10 years, 52% female) were enrolled over 12 months and classified into one of four groups: INOCA (N=185; 47%), obstructive CAD treated by PCI (N=126; 32%), obstructive CAD treated by CABG (N=48; 12%) and obstructive CAD managed with medical therapy (N=32; 8%). After adjusting for between group differences and overall risk, INOCA subjects had worse angina and worse treatment response at follow up (21% and 27% reduction in angina score compared to CAD patients revascularized with PCI and CABG respectively). INOCA subjects had numerically lower treatment response than CAD patients managed with medications (6.4 units, −12%; P=0.181). Population baseline mean Seattle Angina Questionnaire (SAQ) frequency score (60±26) and SAQ summary score (52.5±19) were similar between groups. The absolute difference was 6.4 units versus medically managed CAD (95% CI: −3.0 to 15.9; P=0.181), 11.3 units versus the CAD group undergoing PCI (6.1 to 16.5; P&lt;0.001) and 14.3 units versus CABG (6.2 to 22.3; P=0.001). INOCA subjects had overall reduced quality of life (EQ5D index) and increased psychological distress scores versus all CAD groups at 6 months. During longer-term follow-up (median 18 months), 23 (6%) MACE events occurred with no differences between the groups (Kaplan Meier log-rank P=0.890).

Conclusion(s)

Patients with INOCA had more severe angina symptoms reflecting worse quality of life and treatment response at 6 months with similar MACE as CAD subjects even after adjustment for confounding factors. This study highlights the need for evidence-based antianginal therapies and disease-modifying treatments for angina patients regardless of the presence of obstructive coronary disease.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): This work was funded by the British Heart Foundation (PG/17/2532884; RE/13/5/30177; RE/18/6134217)

Low-dose colchicine in patients treated with percutaneous coronary interventions for myocardial infarction in the Colchicine Cardiovascular Outcomes Trial (COLCOT)

Background/Introduction

Experimental and clinical evidence supports the role of inflammation in atherosclerosis and its complications. Colchicine is an orally administered, potent anti-inflammatory medication that was shown to significantly lower the risk of ischemic cardiovascular events compared to placebo among subjects with a recent myocardial infarction (MI) in the main COLCOT trial. Patients treated with percutaneous coronary intervention (PCI) after MI represent an important subpopulation that may derive particularly important benefits from colchicine.

Purpose

To assess the impact of low-dose colchicine on cardiovascular events in subjects treated with PCI for an index MI.

Methods

We performed an international, randomized, double-blind trial involving patients recruited within 30 days after a MI (main COLCOT trial; n=4745). In this trial, patients were eligible if they had a confirmed myocardial infarction within 30 days before enrollment, had completed any planned percutaneous revascularization procedures and were treated medically according to national guidelines that included the intensive use of statins. Subjects were randomly assigned to receive oral colchicine 0.5 mg once daily or matching placebo. Among the entire COLCOT study population, 4408 subjects were treated with PCI for the index MI and form the COLCOT-PCI study population. We analyzed the time to the first positively adjudicated event of the composite of CV death, resuscitated cardiac arrest, acute MI, stroke or urgent hospitalization for angina requiring coronary revascularization (primary endpoint).

Results

In the main COLCOT trial, low-dose colchicine led to a significantly lower risk of the primary endpoint (hazard ratio, 0.77; 95% confidence interval [CI], 0.61 to 0.96; p=0.02). In the COLCOT-PCI subpopulation, low-dose colchicine was associated with a large reduction in the risk of a primary endpoint event (hazard ratio, 0.72; 95% confidence interval [CI], 0.57 to 0.92; p=0.008). The hazard ratios for individual components of the composite primary endpoint were 0.71 (95% CI, 0.37 to 1.33) for death from cardiovascular causes, 0.84 (95% CI, 0.26 to 2.75) for resuscitated cardiac arrest, 0.90 (95% CI, 0.66 to 1.21) for myocardial infarction, 0.25 (95% CI, 0.08 to 0.76) for stroke, and 0.42 (95% CI, 0.25 to 0.71) for urgent hospitalization for angina requiring coronary revascularization.

Conclusion

Low-dose colchicine markedly reduces the risk of ischemic cardiovascular events in patients treated with PCI for their index MI.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Government of Quebec and Canadian Institutes of Health Research

Irish Defence Forces combat medical technician training: experience of a novel university medical school-based programme

AIMS

This study explores the opinions and experiences of Irish Defences Forces' (IDF) graduates from University College Dublin's Diploma in Military Medicine Care (DMMC). It aims to identify which aspects of medical education are relevant for the development of military graduates in the role of Combat Medical Technician (CMT) in future.

METHODS

A validated Clinical Learning Environment Score tool was adapted and incorporated into an online survey. This was sent electronically to 71 graduates. Responses were anonymous.

RESULTS

38 (54%) graduates responded. Student feedback was positive regarding teaching and clinical placements in the DMMC. In total 16 (42%) students reported use of their new skills in their daily work. Of the 9 (24%) deployed overseas, all used their new skills. Emergency and occupational health skills were used more frequently, while advanced skills were used rarely.

CONCLUSION

An increased emphasis on frequently used skills should be considered. Links to healthcare services would be of benefit to graduates in skills maintenance. Key advanced skills, such as intravenous cannulation and advanced airway management are rarely used but mechanisms to maintain them will improve the relevance of the programme to the CMT role. A change in how the IDF acknowledges qualifications may support more graduates in advancing and maintaining their career in the military medical workforce.

P2707Invasive coronary physiology during primary percutaneous coronary intervention in patients treated with intracoronary alteplase or placebo: the double-blind T-TIME physiology substudy

Background

Impaired microcirculatory reperfusion worsens prognosis post-primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Intracoronary (IC) alteplase targets persisting thrombus post-reperfusion & distal embolisation. In the T-TIME trial microvascular obstruction on cardiac magnetic resonance (CMR) did not differ with IC alteplase vs placebo.

Purpose

To prospectively determine if index of microcirculatory resistance (IMR) is lower & coronary flow reserve (CFR) or resistive reserve ratio (RRR) are higher (improved) with IC alteplase, & to provide mechanistic insights.

Methods

A pre-planned substudy of the main protocol. From 2016–2017, STEMI patients from 3 UK hospitals ≤6 hrs ischaemic time were randomised in a 1:1:1 dose-ranging, double-blind design. Following standard care reperfusion, alteplase (10 or 20mg) or placebo was infused over 5–10 mins proximal to the culprit lesion pre-stenting. IMR (primary outcome), CFR & RRR (secondary outcomes) were measured in the culprit artery post-PCI. Physiology results were obscured from clinicians acquiring the data, to maintain blinding. CMR was performed 2 days & 3 months post-STEMI. Subgroup analyses were prespecified including by ischaemic time (<2 hours, 2–4 hrs, >4 hrs) & IMR threshold >32.

Results

In 144 patients (mean age 59 yrs, 80% male), IMR, CFR or RRR post-PCI did not differ with alteplase vs placebo (Table). Patients with ischaemic time <2 hrs had a dose related increase in CFR (placebo 1.2 [IQR 1.1–1.7], alteplase 10mg 1.4 [IQR 1.0–1.8], alteplase 20mg 2.0 [IQR 1.8–2.3] p=0.01 for interaction) & RRR (placebo 1.5 [IQR 1.3–1.9], alteplase 10mg 1.6 [1.1–2.2], alteplase 20mg 2.2 [2.0–2.6], p=0.03 for interaction). In subjects with post-PCI IMR>32, % ST-resolution at 60 mins was worse with alteplase 10mg vs placebo (23.1±53.9 vs 50.9±31.5) & in those with IMR≤32% ST-resolution at 60 mins was better with alteplase 20mg vs placebo (68.0±30.7 vs 39.1±43.2), p=0.002 for interaction. The CMR findings in the substudy & overall trial populations were consistent.

Main results Placebo Alteplase 10mg Alteplase 20mg (n=53) (n=41) (n=50) IMR, median (IQR) 33.0 (17.0–57.0) 22.0 (17.0–42.0) 37.0 (20.0–57.8) p=0.15 p=0.78 CFR, median (IQR) 1.3 (1.1–1.8) 1.4 (1.1–1.9) 1.5 (1.1–2.0) p=0.92 p=0.74 RRR, median (IQR) 1.6 (1.3–2.2) 1.6 (1.4–2.6) 1.8 (1.3–2.4) p=0.69 p=0.81 P-values for comparison of alteplase with placebo.

Conclusions

In acute STEMI with ischaemic time ≤6 hrs, IMR, CFR or RRR post-PCI did not differ with alteplase vs placebo. In those with shorter ischaemic times (<2 hrs) CFR & RRR, but not IMR, were improved with alteplase. We observed interactions between alteplase dose, ischaemic time & mechanisms of effect.

Acknowledgement/Funding

Dr Maznyczka is funded by a fellowship from the British Heart Foundation (FS/16/74/32573). T-TIME was funded by grant 12/170/4 from NIHR-EME

127Prevalence of coronary artery disease and coronary microvascular dysfunction in heart failure with preserved ejection fraction

Background/Introduction

The prevalence of epicardial coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) have not been studied systematically in an unselected cohort of patients with heart failure and preserved ejection fraction (HFpEF). Both types of coronary disease may play an important role in the pathophysiology and prognosis of HFpEF.

Methods

This prospective multi-centre observational study enrolled near-consecutive patients hospitalized with HFpEF. Patients underwent invasive coronary angiography. Where possible, patients also had guidewire-based assessment of fractional flow reserve, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) performed, followed by vasoreactivity testing with intracoronary acetylcholine.

Results

A total of 75 patients underwent invasive coronary angiography. Guidewire-based assessment of FFR/CFR/IMR was performed in 62 patients, and vasoreactivity testing was possible in 41 patients. Obstructive epicardial CAD was identified in 38 patients (51%). CMD (defined as a CFR <2.0 and/or IMR ≥25) was present in 66% of patients assessed and was similarly prevalent in those with and without obstructive epicardial disease (62% vs. 69%, p 0.52). During vasoreactivity testing, 24% of those assessed had evidence of coronary microvascular endothelial dysfunction. Patients with obstructive CAD were more often male (63% vs. 38%, p 0.028), and had a history of CAD (50% vs. 19%, p 0.005), diabetes mellitus (63% vs. 41%, p 0.05), and a higher E/e' on echocardiography (median 14.4 vs. 12.3, p 0.044) than those without obstructive coronary disease. Patients with CMD had higher B-type natriuretic peptide levels (median 569 vs. 197 pg/ml, p 0.036) than those without microvascular dysfunction.

Selected baseline characteristics No obstructive CAD (n=37) Obstructive CAD (n=38) p-value No CMD (n=21) CMD (n=41) p-value Age (mean, years) 72 73 0.4 74 72 0.41 Female, n (%) 23 (62%) 14 (37%) 0.028 11 (52%) 22 (54%) 0.92 CAD history, n (%) 7 (19%) 19 (50%) 0.005 7 (33%) 12 (29%) 0.74 Diabetes mellitus, n (%) 15 (41%) 24 (63%) 0.05 11 (52%) 22 (54%) 0.92 BNP (median, pg/ml) 323 315 0.9 197 569 0.036 Ejection fraction (median, %) 59 58 0.35 60 56 0.064 E/e' (median) 12.3 14.4 0.044 14.2 12.4 0.74

Study flow diagram

Conclusion

Both epicardial CAD and CMD are common in HFpEF and each may be a therapeutic target in this condition. Although it has been hypothesized that CMD may be due to endothelial dysfunction, our findings suggest that CMD is predominantly due to structural abnormalities in HFpEF.

Acknowledgement/Funding

Chief Scientist Office

6030Effects of adjunctive treatment with low-dose alteplase during primary percutaneous coronary intervention according to ischaemic time

Background

Microvascular obstruction affects half of patients with acute ST-segment elevation myocardial infarction and confers an adverse prognosis.

Purpose

We aimed to determine whether the efficacy and safety of a therapeutic strategy involving low-dose intra-coronary alteplase infused early after coronary reperfusion associates with ischaemic time.

Methods

We conducted a prospective, multicentre, parallel group, 1:1:1 randomised, dose-ranging trial in patients undergoing primary percutaneous coronary intervention. Ischaemic time, defined as the time from symptom onset to coronary reperfusion, was a pre-specified sub-group of interest. Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the UK were enrolled with follow up to 3 months. Patients with acute myocardial infarction due to occlusion of a major coronary artery presenting ≤6 hours from symptom onset were randomly assigned to treatment with placebo, alteplase 10mg or alteplase 20mg. The primary outcome was the amount of microvascular obstruction disclosed by cardiac magnetic resonance imaging at 2–7 days. Secondary outcomes included infarct size, myocardial haemorrhage, left ventricular ejection fraction, and troponin T area-under-the curve.

Results

440 patients were randomized (figure), the primary endpoint was achieved in 396 (90%), seventeen (3.9%) withdrew and all other patients were followed up to 3 months. In the primary analysis, the amount of microvascular obstruction did not differ between the groups. Their ischaemic times were: ≤2 hours, n=98; ≥2–<4 hours, n=215; and ≥4–6 hours, n=83.

In patients with an ischaemic time ≥4 hours, treatment with alteplase (10 mg, n=26; 20 mg, n=30) was associated with a dose dependent increase in the amount (mean) of microvascular obstruction (% left ventricular mass) compared to placebo (n=27) 1.14 vs. 3.11 vs. 5.20; mean difference on square root scale 0.81 (95% CI 0.21, 1.42), p=0.009. The interaction test between ischaemic time and treatment (active vs. placebo) was not statistically significant p=0.06, however when the interaction was assessed for a trend across treatment groups this did reach statistical significance, p=0.018.

Furthermore, a higher proportion of patients presenting ≥4–6 hours treated with 20 mg of alteplase had myocardial haemorrhage (59.3%) compared to the placebo group (28.0%), odds ratio 3.81 (95% CI 1.19, 12.25), p=0.025. The amount of haemorrhage was also greater; estimated mean difference 3.49 (95% CI 1.22, 5.75), p=0.0026. No between-treatment group differences for myocardial haemorrhage were observed in patients presenting with shorter ischaemic times.

Study flow diagram

Conclusions

In patients presenting with an ischaemic time ≥4 hours, adjunctive treatment with low-dose intra-coronary alteplase during primary PCI was associated with increases in microvascular obstruction and myocardial haemorrhage. The mechanism may involve haemorrhagic transformation within the infarct core.

Acknowledgement/Funding

NIHR EME programme (reference: 12/170/45); British Heart Foundation (BHF reference FS/16/74/32573)

249High-sensitivity cardiac troponin and the universal definition of myocardial infarction: a randomised controlled trial

Background

The Universal Definition of Myocardial Infarction recommends the 99th centile diagnostic threshold using a high-sensitivity cardiac troponin (hs-cTn) assay and the classification of patients by the etiology of myocardial injury. Whether implementation of this definition improves risk stratification, treatment or outcomes is unknown.

Methods

In a stepped-wedge cluster randomized controlled trial, we implemented a high-sensitivity troponin assay and the recommendations of the Universal Definition in 48,282 consecutive patients with suspected acute coronary syndrome across ten hospitals. In a pre-specified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death, and secondary outcome of non-cardiovascular death at one year across diagnostic categories as per the Fourth Universal Definition. We applied competing risks methodology in all analyses, using a cumulative incidence function and determining the cause-specific hazard ratio (csHR) for competing outcomes.

Results

Cardiac troponin concentrations were elevated in 21.5% (10,360/48,282) of all trial participants. Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4,471), type 2 myocardial infarction by 22% (205/916), acute myocardial injury by 36% (443/1,233) and chronic myocardial injury by 43% (389/898). The risk and rate of the primary outcome was highest in those with type 1 myocardial infarction, whereas the risk and rate of non-cardiovascular death was highest in those with acute myocardial injury (Table, Figure). Despite increases in anti-platelet therapy and coronary revascularization after implementation, the primary outcome was unchanged in patients with type 1 myocardial infarction (csHR 1.00, 95% CI 0.82 to 1.21), or in any other category.

Adjusted csHR for competing outcomes Myocardial infarction or cardiovascular death Non-cardiovascular death Adjusted csHR (95% CI) Adjusted csHR (95% CI) Type 1 myocardial infarction 5.64 (5.12 to 6.22) 0.83 (0.72 to 0.96) Type 2 myocardial infarction 3.50 (2.94 to 4.15) 1.72 (1.44 to 2.06) Acute myocardial injury 4.38 (3.80 to 5.05) 2.65 (2.33 to 3.00) Chronic myocardial injury 3.88 (3.31 to 4.55) 2.06 (1.77 to 2.40) Cox regression models adjusted for age, sex, diabetes, ischaemic heart disease, season, days since trial onset and site of recruitment (as a random effect).

Cumulative incidence and number at risk

Conclusions

Implementation of the recommendations of the Universal Definition identified patients with different risks of future cardiovascular and non-cardiovascular events, but did not improve outcomes. Greater understanding of the underlying mechanisms and effective strategies for the investigation and treatment of patients with myocardial injury and infarction are required if we are to improve outcomes.

Acknowledgement/Funding

British Heart Foundation

Survey of screening methods, rates and policies for the detection of carbapenemase-producing Enterobacteriaceae in English hospitals

Multi-drug-resistant Gram-negative bacteria are of major clinical concern. The increasing prevalence of carbapenemase-producing Enterobacteriaceae (CPE), resistant to all beta-lactams including carbapenems and able to colonize the large intestine, represents a key threat. Rapid, accurate detection of intestinal CPE colonization is critical to minimize transmission, and hence reduce costly, difficult-to-treat CPE infections. There is currently no 'gold standard' CPE detection method. A survey of diagnostic laboratories in England found considerable heterogeneity in diagnostic CPE testing methods and procedures.

The effects of remote ischaemic preconditioning on coronary artery function in patients with stable coronary artery disease

Background

Remote ischaemic preconditioning (RIPC) is a cardioprotective intervention invoking intermittent periods of ischaemia in a tissue or organ remote from the heart. The mechanisms of this effect are incompletely understood. We hypothesised that RIPC might enhance coronary vasodilatation by an endothelium-dependent mechanism.

Methods

We performed a prospective, randomised, sham-controlled, blinded clinical trial. Patients with stable coronary artery disease (CAD) undergoing elective invasive management were prospectively enrolled, and randomised to RIPC or sham (1:1) prior to angiography. Endothelial-dependent vasodilator function was assessed in a non-target coronary artery with intracoronary infusion of incremental acetylcholine doses (10^− 6, 10^− 5, 10^− 4 mol/l). Venous blood was sampled pre- and post-RIPC or sham, and analysed for circulating markers of endothelial function. Coronary luminal diameter was assessed by quantitative coronary angiography. The primary outcome was the between-group difference in the mean percentage change in coronary luminal diameter following the maximal acetylcholine dose (Clinicaltrials.gov identifier: NCT02666235).

Results

75 patients were enrolled. Following angiography, 60 patients (mean ± SD age 57.5 ± 8.5 years; 80% male) were eligible and completed the protocol (n = 30 RIPC, n = 30 sham). The mean percentage change in coronary luminal diameter was − 13.3 ± 22.3% and − 2.0 ± 17.2% in the sham and RIPC groups respectively (difference 11.32%, 95%CI: 1.2– 21.4, p = 0.032). This remained significant when age and sex were included as covariates (difference 11.01%, 95%CI: 1.01– 21.0, p = 0.035). There were no between-group differences in endothelial-independent vasodilation, ECG parameters or circulating markers of endothelial function.

Conclusions

RIPC attenuates the extent of vasoconstriction induced by intracoronary acetylcholine infusion. This endothelium-dependent mechanism may contribute to the cardioprotective effects of RIPC.

Prognostic significance of anaemia in patients with heart failure with preserved and reduced ejection fraction: results from the MAGGIC individual patient data meta-analysis

BACKGROUND

Anaemia is common among patients with heart failure (HF) and is an important prognostic marker.

AIM

We sought to determine the prognostic importance of anaemia in a large multinational pooled dataset of prospectively enrolled HF patients, with the specific aim to determine the prognostic role of anaemia in HF with preserved and reduced ejection fraction (HF-PEF and HF-REF, respectively).

DESIGN

Individual person data meta-analysis.

METHODS

Patients with haemoglobin (Hb) data from the MAGGIC dataset were used. Anaemia was defined as Hb < 120 g/l in women and <130 g/l in men. HF-PEF was defined as EF ≥ 50%; HF-REF was EF < 50%. Cox proportional hazard modelling, with adjustment for clinically relevant variables, was undertaken to investigate factors associated with 3-year all-cause mortality.

RESULTS

Thirteen thousand two hundred and ninety-five patients with HF from 19 studies (9887 with HF-REF and 3408 with HF-PEF). The prevalence of anaemia was similar among those with HF-REF and HF-PEF (42.8 and 41.6% respectively). Compared with patients with normal Hb values, those with anaemia were older, were more likely to have diabetes, ischaemic aetiology, New York Heart Association class IV symptoms, lower estimated glomerular filtration rate and were more likely to be taking diuretic and less likely to be taking a beta-blocker. Patients with anaemia had higher all-cause mortality (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 1.25-1.51), independent of EF group: aHR 1.67 (1.39-1.99) in HF-PEF and aHR 2.49 (2.13-2.90) in HF-REF.

CONCLUSIONS

Anaemia is an adverse prognostic factor in HF irrespective of EF. The prognostic importance of anaemia was greatest in patients with HF-REF.

The relevance of professionals' attachment style, expectations and job attitudes for therapeutic relationships with young people who experience psychosis

BACKGROUND

Therapeutic relationships are a central component of community treatment for psychosis and thought to influence clinical and social outcomes, yet there is limited research regarding the potential influence of professional characteristics on positive therapeutic relationships in community care. It was hypothesised that professionals' relating style and attitudes toward their work might be important, and thus this exploratory study modelled associations between these characteristics and therapeutic relationships developed in community psychosis treatment.

METHODS

Dyads of professionals and young patients with psychosis rated their therapeutic relationships with each other. Professionals also completed measures of attachment style, therapeutic optimism, outcome expectancy, and job attitudes regarding working with psychosis.

RESULTS

Professionals' anxious attachment predicted less positive professional therapeutic relationship ratings. In exploratory directed path analysis, data also supported indirect effects, whereby anxious professional attachment predicts less positive therapeutic relationships through reduced professional therapeutic optimism and less positive job attitudes.

CONCLUSIONS

Professional anxious attachment style is directly associated with the therapeutic relationship in psychosis, and indirectly associated through therapeutic optimism and job attitudes. Thus, intervening in professional characteristics could offer an opportunity to limit the impact of insecure attachment on therapeutic relationships in psychosis.