Trends of mortality rate in patients with congenital heart defects in Germany-analysis of nationwide data of the Federal Statistical Office of Germany

BACKGROUND

Congenital heart defects (CHD) are still associated with an increased morbidity and mortality. The aim of this study was to analyze trends of mortality rates in patients with CHD between 1998 and 2018 in Germany.

METHODS

Data of registered deaths with an underlying diagnosis of CHD were used to evaluate annual mortality between 1998 and 2018. Polynomial regressions were performed to assess annual changes in CHD-associated mortality rates by age groups.

RESULTS

During the 21-year study period, a total of 11,314 deaths were attributed to CHD with 50.9% of deaths in infants (age < 1 year) and 28.2% in neonates (age ≤ 28 days). The most frequent underlying CHDs associated with death were hypoplastic left heart syndrome (n = 1498, 13.2%), left ventricular outflow tract obstruction (n = 1009, 8.9%), atrial septal defects (n = 771, 6.8%), ventricular septal defects (n = 697, 6.2%), and tetralogy of Fallot (n = 673, 5.9%), and others (n = 6666, 58.9%). Among all patients, annual CHD-related mortality rates declined significantly between 1998 and 2010 (p < 0.0001), followed by a significant annual increase until 2018 (p < 0.0001). However, mortality rates in 2018 in all ages were significantly lower than in 1998.

CONCLUSION

Mortality in CHD patients decreased significantly between 1998 and 2010, but a substantial number of deaths still occurred and even significantly increased in the last 3 years of the observation period particularly in neonates and infants. This renewed slight increase in mortality rate during the last years was influenced mainly by high-risk neonates and infants. Assessment of factors influencing the mortality rate trends in association with CHD in Germany is urgently needed. Obligatory nationwide registration of death cases in relation to surgical and catheter interventions in CHD patients is necessary to provide additional valuable data on the outcome of CHD.

Longitudinal outcomes of obeticholic acid therapy in ursodiol-nonresponsive primary biliary cholangitis: Stratifying the impact of add-on fibrates in real-world practice

BACKGROUND

Suboptimal response to ursodeoxycholic acid occurs in 40% of primary biliary cholangitis (PBC) patients, affecting survival. Achieving a deep response (normalisation of alkaline phosphatase [ALP] and bilirubin ≤0.6 upper limit of normal) improves survival. Yet, the long-term effectiveness of second-line treatments remains uncertain.

AIMS

To evaluate the long-term effectiveness of obeticholic acid (OCA) ± fibrates. Focusing on biochemical response (ALP ≤1.67 times the upper limit of normal, with a decrease of at least 15% from baseline and normal bilirubin levels), normalisation of ALP, deep response and biochemical remission (deep response plus aminotransferase normalisation).

METHODS

We conducted a longitudinal, observational, multicentre study involving ursodeoxyccholic acid non-responsive PBC patients (Paris-II criteria) from Spain and Portugal who received OCA ± fibrates.

RESULTS

Of 255 patients, median follow-up was 35.1 months (IQR: 20.2-53). The biochemical response in the whole cohort was 47.2%, 61.4% and 68.6% at 12, 24 and 36 months. GLOBE-PBC and 5-year UK-PBC scores improved (p < 0.001). Triple therapy (ursodeoxycholic acid plus OCA plus fibrates) had significantly higher response rates than dual therapy (p = 0.001), including ALP normalisation, deep response and biochemical remission (p < 0.001). In multivariate analysis, triple therapy remained independently associated with biochemical response (p = 0.024), alkaline phosphatase normalisation, deep response and biochemical remission (p < 0.001). Adverse effects occurred in 41.2% of cases, leading to 18.8% discontinuing OCA. Out of 55 patients with cirrhosis, 12 developed decompensation. All with baseline portal hypertension.

CONCLUSION

Triple therapy was superior in achieving therapeutic goals in UDCA-nonresponsive PBC. Decompensation was linked to pre-existing portal hypertension.

Peri-procedural, 30-day and 1 year-outcomes in chronic dialysis patients undergoing transcatheter aortic valve implantation

Background

Patients on chronic dialysis (CD) due to end-stage renal disease (ESRD) with symptomatic severe aortic stenosis eligible for transcatheter aortic valve implantation (TAVI) were excluded from randomized clinical trials. Our study aimed to investigate the outcomes of patients with chronic dialysis who underwent TAVI.

Methods

Single center analysis on prospectively collected data of all consecutive patients who underwent TAVI between January 2011 and December 2020 according to baseline renal function: chronic dialysis group (CD) and control group (CTRL). Procedural, 30-day and 1-year outcomes were assessed. Outcomes were defined in accordance with the VARC-3 criteria.

Results

A total of 875 patients underwent TAVI during the study period, of whom 22 (2.5%) were on chronic dialysis. Patients on CD were younger (median age 80 years, [IQR 73–84] vs 84 years, [IQR 80–87]; p&lt;0.001), more likely to be men [365/863 (42.8%) vs 18/22 (81.8%); p&lt;0.001] and more likely to have peripheral vascular disease [41/853 (4.8%) vs 7/22 (31.8%); p=0.031] and lower body mass index (median 24.1 kg/m2, [IQR 21.5–26.5] vs 26.3 kg/m2, [IQR 23.7–29.3]). Short-term major or life-threatening bleeding were significantly higher in CD patients (odds ratio [95% confidential interval]: 3.67 [1.50–8.96], p 0.005). In contrast, no differences were found regarding rates of vascular complications requiring intervention (OR [95% CI]: 1.35 [0.31–5.90], p=0.662), permanent pacemaker implantation (OR [95% CI]: 0.87 [0.25–2.98], p=1.000) or stroke (OR [95% CI]: 1.51 [0.20–11.64], p=0.504). Importantly, dialysis patients had significantly higher rates of in-hospital, 30-day and 1-year mortality rates (13.6 vs 2.1%, p&lt;0.001; 18.9% vs 2.9, p&lt;0.001 and 26.4% vs 10.7%, p&lt;0.001, respectively). On multivariate analysis, after adjusting for age, gender, relevant co-morbidities, and procedure-related complications, CD remained independently associated with mortality at 1-year. Survival curves during follow up are presented in Figure 1.

Conclusions

Chronic dialysis patients submitted to TAVI had significantly higher rates of short-term life threatening and/or major bleeding, short-term and long-term mortality. Careful selection of patients who would benefit from TAVI among patients with ERDS requiring dialysis is necessary to prevent high rates of postprocedural complications and improve outcomes of this high-risk population.

Funding Acknowledgement

Type of funding sources: None.

Indexing calcium score of the aortic valve to the annulus area improves the grading of aortic stenosis severity in patients within the grey zone of aortic valve calcification

Introduction

Calcium score of the aortic valve (CaScAoV) is recommended as a supporting tool to assist in the grading of aortic stenosis (AS) severity when echocardiographic assessment is inconclusive. However, a significant proportion of patients have CaScAoV values within a “grey zone” between the “unlikely” and “likely” thresholds. The purpose of this study was to assess the potential usefulness of indexing CaScAoV to the area of the aortic annulus, in order to improve the discriminative power of CaScAoV in this subset of patients.

Methods

Consecutive patients evaluated at a single center TAVI program were retrospectively identified and included in the analysis if cardiac CT and echocardiography were performed within a 6-month timeframe. Those with LVEF &lt;50%, indexed stroke volume &lt;35 ml/m2, rheumatic heart disease, or bicuspid aortic valves were excluded. Severe AS was defined as mean transvalvular gradient ≥40 mmHg. The likelihood of severe AS assessed by CT was categorized according to the guideline-recommended sex-specific CaScAoV thresholds. Patients were considered to be in the “grey zone” if their CaScAoV values were between 800–1200 for women, and between 1600–2000 for men.

Results

A total of 655 patients were included (282 men (43.1%), median age 83 years [IQR 79–86]). AS was considered severe by echocardiographic criteria in 587 patients (89.6%), and moderate in the remainder. Median transvalvular gradient was 49 mmHg (IQR 43–59), and median CaScAoV values were 3329 (IQR 2356–4500) for men, and 1995 (IQR 1462–2781) for women.

Overall, 77 patients (11.7%) had CaScAoV values in the “grey zone”, of which 24 (31.2%) had moderate AS (Figure 1). Patients within this region of uncertainty were no different form the others in terms of age, sex, annulus size and body surface area.

In this subset of patients, indexing CaScAoV to aortic annulus area showed good discriminative power to identify severe AS (AUC 0.69, 95% CI 0.56–0.81, p=0.008). Using previously established thresholds (&gt;300 AU/cm2 for women and &gt;500 AU/cm2 for men), 48 patients (62.3%) were correctly reclassified (net reclassification index of 0.45, p=0.03). These findings were similar for both sexes.

Conclusion

In patients undergoing cardiac CT for known or suspected severe AS with CaScAoV values within the “grey zone”, indexing CaScAoV to the area of the aortic annulus improves the classification of AS severity and may decrease diagnostic uncertainty.

Funding Acknowledgement

Type of funding sources: None.

Value of cardiopulmonary exercise test submaximal parameters in the assessment of aortic stenosis patients

Background

Exercise test is recommended for risk stratification of asymptomatic patients with severe aortic stenosis (AS), although a significant number of patients can't perform a maximal exercise test, increasing the potential value of sub-maximal parameters for the assessment of these patients.

Aim

To assess which parameters could be useful for risk stratification in case of a submaximal Cardiopulmonary Exercise Testing (CPET) in asymptomatic patients with severe AS.

Methods

Retrospective evaluation of adult patients with asymptomatic severe AS, in a single center, who underwent CPET between December 2016 and November 2021. All patients underwent a treadmill CPET using an exercise protocol with progressive increase in workload. Patients were divided in group A (maximal CPET) or group B, respectively, if respiratory exchange ratio (RER) was &gt;1.10 at peak exercise or below this value. Known parameters accessed in a submaximal CPET were evaluated: mean minute ventilation/carbon dioxide production slope (VE/VCO2), VO2 value in first ventilatory threshold (VT1), peak circulatory power, and oxygen uptake efficiency slope (OUES).

Results

CPET was performed in 25 patients with severe asymptomatic AS (80 years ± 7 years, 56% male), median AVA was 0.86 cm2 [IQR 0.65–0.95 cm2] and transaortic pressure gradient was 46 mmHg [IQR 41–55 mmHg]. The most used protocol was a ramp slope. Nineteen patients (76%) didn't reach a RER&gt;1.10 (group B) due to respiratory (26%) or peripheral limitation (53%). Comparing both groups, group B patients showed a shorter duration of exercise of (8±3 min vs. 9±4 min, p=0.422), and a lowest mean peak VO2 (16.3±3.6 vs. 20.5±6.9 ml/kg/min, p=0.207). In our population, bivariate analyses demonstrated that OUES was the only submaximal parameter that could discriminate both groups: Group B patients had the lowest values (1.53 [IQR 1.47–1.70] vs. 1.94 [IQR 1.56–2.11], p=0.042). ROC curve analysis of OUES values revealed an AUC of 0.78 (p=0.042) for maximal CPET prediction. The cut-off point with most sensitivity (S) and specificity (E) obtained using the Youden index (0.62) was 1.9 (S≈67%; E≈95%) (Figure 1).

Conclusions

In our cohort of asymptomatic AS patients, even with submaximal CPET, OUES accurately identify patients with higher degrees of functional limitation. Whether OUES is useful as prognostic marker to the workflow treatment of AS it's worth to be assessed prospectively.

Funding Acknowledgement

Type of funding sources: None.

Cardiopulmonary exercise testing in Fontan patients: unmasking the secret of Super-Fontans

Background

Exercise capacity is usually reduced in Fontan patients, however there is a subset of patients who have normal exercise capacity and better outcomes, the “Super-Fontans”. The aim of this study was to characterize a cohort of Fontan patients undergoing cardiopulmonary exercise testing (CPET) and identify predictors of better functional capacity.

Methods

Single center retrospective analysis of consecutive Fontan patients aged &gt;10 years old who underwent CPET, between March 2018 and May 2021.

Peak respiratory exchange ratio1.05 defined maximal CPET. Peak VO2 (pVO2) as a percentage of its predicted value was used as reference value to stratify patients in tertiles.

Patients in 3rd tertile, with a percentage predicted pVO2 superior to 75%, were considered good-performers.

Blood tests and transthoracic echocardiogram (TTE) were performed on the same day. Additional data were collected from electronic charts.

Results

In total, 49 patients were included (mean age 19±7 years old, 67% male) with intra or extracardiac conduit implanted in mean 12±7 years prior to the CPET.

The most common primary diagnoses were tricuspid/pulmonary atresia (43%), followed by unbalanced complete AV septal defect (14%) and double inlet left ventricle (14%). 12 patients had a systemic right ventricle. All, except 5 patients, had preserved systolic ventricular function and 37% had moderate to severe AV regurgitation.

The majority had normal hemoglobin levels (median 15.6 g/dL), hepatic enzymes (median total bilirubin 0.8 mg/dL), renal function (median creatinine 0.8 mg/dL) and low NT-proBNP (median 122 pg/mL).

All patients had maximal CPET, median %VO2 at VT1 was 57% of peak and mean pVO2 was 66±14% of the predicted. Most patients (69%) showed exercise limitation due to cardiovascular cause, followed by O2 desaturation, present in 22% of CPETs. The age of Fontan completion was not associated with functional capacity (p=0.6).

The good-performer group comprised 13 patients (27%), all in sinus rhythm, of which 10 were physically active. Compared with the remainder, this group had higher VO2 at VT1 (18.7 vs. 14.6, p=0.01) and VO2 at VT2 (25.9 vs. 22.1, p=0.02), both in mL/kg/min. Also, peak heart rate (% predicted) (90 vs. 81, p=0.03) was higher in this subgroup – fig.1. Conversely, differences on TTE parameters (GLS and AV valve regurgitation) and blood biomarkers were not statistically significant. On multivariable analysis, no single variable predicted better functional capacity.

Conclusion

In our Fontan cohort, most patients had reduced exercise capacity, largely due to cardiovascular dysfunction. However, “Super-Fontans” stood out as they had a higher anaerobic threshold illustrating their better physical condition. These findings highlight the role of regular physical activity in Fontan patients as a cornerstone for better functional capacity.

Funding Acknowledgement

Type of funding sources: None.

Potential impact of replacing SCORE with SCORE-2 on risk classification and statin eligibility – a coronary calcium score correlation study

Background

Recently, the European Society of Cardiology issued new algorithms to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD), along with new age-specific thresholds to classify individuals as low-to-moderate, high, or very-high risk.

The aim of this study was to compare the latest SCORE-2 model with the older SCORE (Systematic COronary Risk Evaluation) in their ability to identify individuals with high coronary artery calcium score (CACS), and assess the relationship between potential eligibility for statin therapy and CACS.

Methods

Individuals 40–69 years old without diabetes or known ASCVD were identified in a single center registry of patients undergoing CACS and coronary CT angiography for suspected coronary artery disease. SCORE and SCORE-2 were calculated and used with each patient's untreated LDL-C values to assess eligibility for statin therapy. High CACS was defined as an Agatston score ≥100.

Results

A total of 389 pts (46% men, mean age 58±8 years) were included, of which 15% (n=60) were active smokers. The mean systolic blood pressure and untreated LDL-C values were 136±17 mmHg and 155±65 mg/dL, respectively.

The proportion of patients classified as low-to-moderate risk, high risk, and very high risk was 93%, 6% and 1% using the SCORE algorithm, and 42%, 44%, and 14% using SCORE-2, respectively. Overall, 218 patients (56%) would have their risk category revised upwards, while no patients would be downgraded.

The median CACS was 5 (IQR 0–71 AU), with 166 patients (43%) having CACS = 0, and 81 (21%) presenting CACS values ≥100.

SCORE and SCORE-2 showed similar discriminative power to identify patients with CACS ≥100 (C-statistic 0.77, 95% CI 0.71–0.82, vs. 0.75, 95% CI 0.69–0.80, P=0.109 for comparison]. The up-reclassification of risk conveyed by SCORE-2 affected patients across all categories of CACS (Fig. 1).

The proportion of patients in whom statin therapy would generally be indicated was higher with the SCORE-2 criteria vs. the SCORE algorithm (61% vs. 29%, respectively, p&lt;0.001). The broadening of potential indication for statin therapy spanned all categories of CACS, including patients with CACS = 0 (Fig. 2).

Conclusion

Even though the discriminative power of SCORE-2 is similar to the older SCORE, the introduction of age-specific thresholds results in the up-reclassification of risk in roughly half of the patients. The application of SCORE-2 will broaden statin eligibility overall, not only in patients with high atherosclerotic burden, but also in those with CACS = 0. These findings support the use of risk modifiers in selected patients to improve the effectiveness of statin therapy.

Funding Acknowledgement

Type of funding sources: None.

Vascular closure device in TAVI with a dedicated endovascular plug-based device – experience from a high-volume tertiary center

Background

Vascular complications at the access site are important adverse events during transcatheter aortic valve implantation (TAVI). Effective, reproducible, and safe closure of large bore arteriotomies remains challenging as management strategies vary among centers and operators. MANTAÒ is a dedicated plug-based vascular closure device (VCD) recently approved for percutaneous access site closure. This study aimed to describe our experience and to determine the safety and effectiveness of MANTAÒ for large bore arteriotomies during transfemoral TAVI.

Methods

Single center retrospective analysis on prospectively collected data of all consecutive patients who underwent transfemoral TAVI from 2018 to 2020. The primary safety outcomes were access-related vascular injury and bleeding complications according to VARC-3 criteria. Technical success was defined as puncture closure obtained with MANTAÒ without the use of unplanned endovascular or surgical intervention. A secondary analysis according to center experience was performed.

Results

Of the 535 patients that underwent transfemoral TAVI during the study period (median age = 84 [IQR 80–87], 39.4% male; median EuroSCORE II of 3.89% [IQR 2.62–5.39]), MANTAÒ VCD was deployed in 320 (59.8%). Overall, 32 (10.0%) patients suffered an access-related vascular injury and 22 (6.6%) had a bleeding complication (Figure 1A). Technical success was achieved in most cases (n=298; 93.1%). 30-day mortality rate was 1.6% (n=5). Since the first deployment in mid-2018, the rates of MANTA-related complications decreased with increasing experience and a steep learning curve effect was noted (Figure 1B).

Conclusions

MANTAÒ was rapidly adopted as the default strategy for vascular access site closure after TAVI at our center. A relatively steep learning was observed, suggesting that few procedures are required to acquire device proficiency. In addition, our results suggest that MANTA Ò can effectively close large bore arteriotomies with a low risk of severe complications.

Funding Acknowledgement

Type of funding sources: None.

Severe rheumatic mitral stenosis – analysis of clinical and echocardiographic very long-term outcomes after percutaneous mitral balloon valvuloplasty

Introduction

Mitral balloon valvuloplasty (MBV) is the guideline recommended treatment for symptomatic severe mitral stenosis (MS) with suitable anatomy, but is often deemed transitory. However, data on very-long term echocardiographic follow-up is scarce. The aim of our study was to describe clinical and echocardiographic outcomes in patients previously submitted to MBV for rheumatic MS.

Methods

We conducted a single-centre retrospective study enrolling patients previously submitted to MBV for rheumatic MS from 1990 until 2021. Follow-up was considered until last registered echocardiographic re-evaluation. Patients without electronic health records available were excluded. The primary endpoint was a composite of all-cause death or need of surgery.

Results

A total of 193 patients were included (15.5% male, with a mean age of 52±15 years at the time of MBV, 60.6% with permanent atrial fibrillation). During a mean follow-up of 11±8 years, 87 (45.1%) patients implanted a mitral valve prosthesis, 4 (2.1%) were submitted to surgical mitral valvuloplasty and 30 (15.5%) died without being reinterventioned. Moreover, a total of 23 (11.9%) embolic events were registered – 21 strokes, 1 pulmonary embolism and 1 acute lower limb embolism.

Overall, 133 patients (68.9%) survived more than 5 years, 95 (49.2%) more than 10 years and 56 (26.9%) more than 15 years since MBV without meeting the primary endpoint. The maximum follow-up without intervention was 32 years. Concerning patients submitted to surgery, the mean time from MBV until operation was 9.4±7.3 years (minimum 8 days; maximum 29.3 years).

In regard to echocardiographic long-term outcomes on alive non-operated patients (mean follow-up of 12±9 years), 52.8% remain with mild MS, 91.6% with mild or no mitral regurgitation and 77.6% with mild or no tricuspid regurgitation. Furthermore, only 20.4% have right ventricle dysfunction (defined as a TAPSE &lt;17 mm), 18.3% have pulmonary hypertension (pulmonary artery systolic pressure &gt;45 mmHg), and 6.8% have residual interatrial communication.

Conclusion

MBV is a minimally invasive procedure that has an important benefit in a very significant proportion of patients with rheumatic mitral stenosis, with potential benefit that may last more than three decades without need for another invasive intervention.

Funding Acknowledgement

Type of funding sources: None.

Use of coronary calcium score to refine the cardiovascular risk classification of the new SCORE2 and SCORE2-OP algorithms in patients undergoing coronary CT angiography

Introduction

Recently, the European Society of Cardiology issued new algorithms (SCORE-2 and SCORE2-OP) to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). CACS has been shown to reclassify a significant proportion of patients when applied on top of several scores, but data on its use with these new algorithms are lacking.

The aim of this study was to assess the risk reassignment that can be attained by using CACS as a risk modifier of the SCORE-2 / SCORE2-OP classification, in patients referred for coronary CT angiography (CCTA).

Methods

Individuals without diabetes or known ASCVD were included in a single center registry of patients undergoing CCTA for suspected coronary artery disease (CAD). The 10-year risk of cardiovascular disease was calculated for each patient using SCORE-2 (ages 40–69) or SCORE2-OP (ages 70–89), and categorised as low-to-moderate, high, or very-high risk, according to guideline-recommended age-specific thresholds. CACS was considered to reclassify risk one level downward if = 0 in high or very-high risk patients, and reclassify risk upward if &gt;100 (or &gt;75th percentile) in those with low-to-moderate risk, or &gt;1000 in those with high-risk.

Results

A total of 529 patients (43% men, mean age 63±10 years) were included, of which 13% (n=69) were active smokers. The mean systolic blood pressure and non-HDL-C values were 137±18 mmHg and 140±37 mg/dL, respectively.

A total of 47 patients (9%) had obstructive CAD on CCTA, classifying them as very-high risk. In the remainder 482 patients without obstructive CAD, the median CACS was 8 (IQR 0–80 AU), with 194 patients (40%) having CACS = 0, and 111 (23%) presenting CACS values ≥100.

The proportion of patients classified as low-to-moderate risk, high risk, and very high risk was 36%, 46% and 19% using the SCORE-2 / SCORE2-OP algorithm.

Using CACS would reclassify 150 patients (31%): 107 patients (22%) downward, and 43 patients (9%) upward. The extent of risk reclassification conveyed by CACS was 33% in patients assessed with SCORE-2, and 25% with SCORE-2 OP (p=0.082). Overall, most of the risk reassignment (42%, n=93) would occur in patients originally classified as high-risk – Fig. 1.

At the time of testing, 32% (n=61) of patients with CACS = 0 were being treated with statins, whereas 52% (n=58) of those with CACS ≥100 were not.

Conclusion

Even when the most recent SCORE-2 / SCORE-2 OP algorithms are used, risk refinement with CACS leads to the reclassification of nearly one third of the patients undergoing CCTA, mostly from downgrading risk. This opportunistic use of CACS may be employed to improve the allocation of primary prevention therapies.

Funding Acknowledgement

Type of funding sources: None.

30-day outcomes of P2Y12 inhibitor pretreatment in patients with STEMI submitted to primary PCI – systematic review and meta-analysis

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the cornerstone of antithrombotic therapy in patients with ST-segment elevation myocardial infarction (STEMI). Yet, there is uncertainty surrounding the optimal timing for the initiation of the P2Y12 inhibitor. This study aims to evaluate the effectiveness and safety of P2Y12 pretreatment by means of a systematic review and meta-analysis of studies in primary percutaneous coronary intervention (PCI) in STEMI.

Methods

We performed a systematic search of electronic databases Pubmed, CENTRAL and Scopus until March of 2021. Studies were considered eligible if they were: a) comparing P2Y12 inhibitor upstream administration vs. treatment during PCI; b) patients enrolled for STEMI and submitted to primary PCI. Studies with patients treated with fibrinolysis or medical therapy only were excluded. Major clinical outcomes included 30-day occurrence of all-cause death, definite stent thrombosis and re-infarction. Thrombolysis in myocardial infarction (TIMI) flow-grade pre-PCI and post-PCI, in-hospital cardiogenic shock and major bleeding events were analysed.

Results

Out of 2193 articles, 18 studies were included (1 randomized clinical trial [RCT] and 17 observational studies [non-RCT]), with a total of 76,836 patients, 52,181 in the pretreatment arm. At 30 days, pretreatment was associated with a reduction in definite stent thrombosis (1 RCT & 4 Non-RCT: OR 0.40; 95% CI 0.18–0.90), but no significant reduction in all-cause death (1 RCT & 7 Non-RCT: OR 0.77; 95% CI 0.56–1.04) or re-infacrtion (1 RCT & 4 Non-RCT: OR 0.73; 95% CI 0.49–1.09). Regarding in-hospital outcomes, pretreatment showed a significant reduction in the occurrence of cardiogenic shock (5 Non-RCT: 0.62; 95% CI 0.51–0.79), major bleeding events (1 RCT & 14 Non-RCT: 0.83; 95% CI 0.75–0.92) and in the number of patients with TIMI flow &lt;3 postPCI (1 RCT & 8 Non-RCT: 0.82; 95% CI 0.73–0.93). Pretreatment was not associated with lower number of patients with TIMI flow &lt;3 pre-PCI (1 RCT & 5 Non-RCT: 0.85; 95% CI 0.66–1.09).

Conclusion

Pretreatment with DAPT, including a P2Y12 inhibitor, was associated with lower risk for definite stent thrombosis and cardiogenic shock, but was not associated with lower all-cause death or re-infarction.

Funding Acknowledgement

Type of funding sources: None.

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden cardiac death

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the “MADIT-ICD benefit score”, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT &gt;200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8–38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269). In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores &lt;7 (log rank p=0.104).

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036).

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of aborted cardiac arrest in patients with acute myocardial infarction

Background

Aborted cardiac arrest (ACA) during the acute ischaemic phase is a relatively frequent but often undervalued complication of acute myocardial infarction (AMI). The aim of this study was to evaluate the clinical and prognostic impact of aborted cardiac arrest in AMI patients and investigate its correlation with infarct size.

Methods

We conducted a single-centre retrospective study enrolling consecutive patients admitted for AMI, from January 2016 to December 2018. ACA was defined as the need for advanced life support measures and defibrillation, either out-of-hospital or in-hospital, up until culprit vessel revascularisation. Infarct size was estimated using peak serum troponin T, impact on left ventricular ejection fraction (LVEF ≤50%) and echocardiographic wall motion index (WMI). Clinical outcomes included cardiogenic shock (SCAI C or more), need for mechanical circulatory support (MCS), major bleeding events (BARC ≥3) during in-hospital phase and all-cause mortality during follow-up.

Results

A total of 571 patients were included (65±13 years old, 72% male). Overall, 237 had anterior STEMI, 39 patients (6,8%) suffered ACA (21 out of hospital), 60 progressed into cardiogenic shock throughout the hospitalisation, 7 needed MCS, and 52 had BARC ≥3 bleeding. During a mean follow-up of 32 months, 96 patients died.

ACA was significantly associated with higher peak serum troponin T (4802 [1950; 9420] vs 2659 [555; 6708] ng/L – p=0.004), higher proportion of patients with reduced or mildly reduced LVEF (60% vs. 36.5%, p=0.018) and higher WMI (1.7 [1.4; 2.3] vs. 1.5 [1.2; 1.8], p=0.016). Moreover, ACA was also associated with higher risk of cardiogenic shock occurrence (64.1% vs. 6.6%, p&lt;0.001 – OR 25.357 (12.115–53.073)), higher need for MCS (7.9% vs 0.8%, p&lt;0.001 – OR 11.271 (2.427–52.343)) and higher incidence of BARC ≥3 bleeding events (28.2% vs. 8.4%, p&lt;0.001 – OR 4.705 (2.185–10.128)) – Table 1.

On univariate Cox regression, ACA showed significant association with all cause death, which remained highly significant after multivariable adjustment (OR 2.431 (1.181; 5.002); p=0.016).

Conclusion

The occurrence of aborted cardiac arrest in patients with AMI was associated with increased morbidity and mortality. This may be driven by a larger area of arrhythmia prone ischemic myocardium.

Funding Acknowledgement

Type of funding sources: None.

A-17 Effects Of Parental Mental Health On Patient and Parent-Reported Anxiety Symptoms Following Concussion In Adolescents

Purpose: Examine the impact of parental mental health history on patient and patent-reported post-concussion symptoms of anxiety. Methods: Participants included 105 adolescents (42.9% male), 12–18 years old, including concussion patients (n = 72, 3.42 ± 1.7 days post-injury) and age-and-sex matched controls (n = 33). Patients and parents completed the Screen for Child Anxiety Disorders, Parent and Child versions (SCARED-P, SCARED-C) and medical histories. T-tests were used to compare control/concussed responses on the SCARED. Logistic regression (LR) was used to evaluate group predictors, as well as high/low (i.e., &gt;21 PCSS total score) concussion symptom groups at 30 days post-injury. Results: Results indicated that concussed SCARED-C (controls: M = 7.88 SD = 7.55, concussed: M = 13.4 SD = 11.42), (t[103] = −2.53, p = 0.01) and SCARED-P (controls: M = 3.55 SD = 3.62, concussed: M = 6.72 SD = 7.12), (t[103] = −2.42, p &lt; 0.01) scores were higher than controls. SCARED-C/SCARED-P scores were not predictive of high/low symptom report at 30 days post-injury, X2(2, n = 59) = 3.46, p = 0.18. The stepwise LR model was significant, X2(1, n = 105) = 7.34, p = 0.007; SCARED-C scores were predictive of concussion group inclusion, SCARED-P scores were not. In analyses of only patients whose parent reported a mental health history (22/105, 21%), there was no significant difference between control and patients on the SCARED-C, t(20) = −1.82, p = 0.08, or SCARED-P, t(20) = −0.34, p = 0.74. SCARED-C/SCARED-P scores did not predict control/concussion group inclusion, X2(2, n = 22) = 5.04, p = 0.08. Conclusions: SCARED-P/SCARED-C scores effectively differentiated between groups: patients and parents reported higher anxiety symptoms. The inclusion of parents with mental health diagnoses precluded the SCARED from differentiating controls from patients.

A cardiac magnetic resonance myocardial strain patterns analysis in left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recently, a classification with four types of septal longitudinal strain patterns was described using a speckle tracking based strain analysis in echocardiography suggesting pathophysiological continuum of LBBB-induced LV remodeling. Little data exist on feature tracking cardiac magnetic resonance (FT-CMR) in LBBB patients, and whether such patterns could be reproduced in CMR is not established yet.

Purpose

In this study, we aimed to: 1) Assess and reproduce the new strain patterns classification by CMR and 2) Evaluate its association with LV remodeling and myocardial scar in a LBBB cohort.

Methods

Single center registry which included LBBB patients with septal flash (SF) referred to CMR to assess the structural cause of LV dysfunction. LBBB was defined according to Strauss criteria as strict LBBB, non-strict LBBB or nonspecific LV conduction delay.

A semi-automated FT-CMR was used to quantify myocardial strain and detect the four septal longitudinal and radial strain patterns, according to the recent classification (LBBB-1 through LBBB-4) – Figure. Extent of SF was visually scored as mild, moderate, or prominent.

Results

A total of 115 patients were included (mean age 66±11 years; 57% men; 38% with ischemic heart disease). Median duration of QRS was 150± 26ms and majority of the patients (n=90, 78%) were classified as strict LBBB.

In longitudinal strain analyses LBBB-1 was observed in 23 (20%), LBBB-2 in 37 (32.1%), LBBB-3 in 25 (21.7%), and LBBB-4 in 30 (26%) patients. Patients at higher LBBB stages (longitudinal or radial pattern) had more prominent septal flash, greater LV volumes, lower LV ejection fraction and lower absolute global longitudinal, circumferential and radial strain values compared with patients in less advanced stages (p &lt; 0.05 for all) - table.

There was no difference between patterns in clinical characteristics, ischemic etiology, QRS duration and time delay between septal and lateral LV wall.

Late gadolinium enhancement (LGE) was found in 63 patients (54.8%), with a septal location in 34 (29.6%) patients, lateral in 4 (3.5%) patients, septal and lateral in 11 (9.6%) patients. Furthermore, no difference was found for LGE presence, distribution or location between the four strain patterns.

Conclusions

Among patients with LBBB, our study found a good association between longitudinal and radial strain patterns with the degree of LV remodeling and LV dysfunction by FT-CMR analysis. Additionally, myocardial fibrosis didn’t seem to interfere with the staged LBBB classification.

Predicting the earliest deviation in weight gain in the course towards manifest overweight in offspring exposed to obesity in pregnancy: a longitudinal cohort study

BACKGROUND

Obesity in pregnancy and related early-life factors place the offspring at the highest risk of being overweight. Despite convincing evidence on these associations, there is an unmet public health need to identify "high-risk" offspring by predicting very early deviations in weight gain patterns as a subclinical stage towards overweight. However, data and methods for individual risk prediction are lacking. We aimed to identify those infants exposed to obesity in pregnancy at ages 3 months, 1 year, and 2 years who likely will follow a higher-than-normal body mass index (BMI) growth trajectory towards manifest overweight by developing an early-risk quantification system.

METHODS

This study uses data from the prospective mother-child cohort study Programming of Enhanced Adiposity Risk in CHildhood-Early Screening (PEACHES) comprising 1671 mothers with pre-conception obesity and without (controls) and their offspring. Exposures were pre- and postnatal risks documented in patient-held maternal and child health records. The main outcome was a "higher-than-normal BMI growth pattern" preceding overweight, defined as BMI z-score >1 SD (i.e., World Health Organization [WHO] cut-off "at risk of overweight") at least twice during consecutive offspring growth periods between age 6 months and 5 years. The independent cohort PErinatal Prevention of Obesity (PEPO) comprising 11,730 mother-child pairs recruited close to school entry (around age 6 years) was available for data validation. Cluster analysis and sequential prediction modelling were performed.

RESULTS

Data of 1557 PEACHES mother-child pairs and the validation cohort were analyzed comprising more than 50,000 offspring BMI measurements. More than 1-in-5 offspring exposed to obesity in pregnancy belonged to an upper BMI z-score cluster as a distinct pattern of BMI development (above the cut-off of 1 SD) from the first months of life onwards resulting in preschool overweight/obesity (age 5 years: odds ratio [OR] 16.13; 95% confidence interval [CI] 9.98-26.05). Contributing early-life factors including excessive weight gain (OR 2.08; 95% CI 1.25-3.45) and smoking (OR 1.94; 95% CI 1.27-2.95) in pregnancy were instrumental in predicting a "higher-than-normal BMI growth pattern" at age 3 months and re-evaluating the risk at ages 1 year and 2 years (area under the receiver operating characteristic [AUROC] 0.69-0.79, sensitivity 70.7-76.0%, specificity 64.7-78.1%). External validation of prediction models demonstrated adequate predictive performances.

CONCLUSIONS

We devised a novel sequential strategy of individual prediction and re-evaluation of a higher-than-normal weight gain in "high-risk" infants well before developing overweight to guide decision-making. The strategy holds promise to elaborate interventions in an early preventive manner for integration in systems of well-child care.

Prognostic significance of peak atrial longitudinal strain in patients with functional mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic mitral regurgitation has been shown to promote left atrial (LA) dysfunction and remodeling. However, the significance of LA dysfunction in this setting has not been fully investigated. The aim of our study was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in a cohort of patients with LV systolic dysfunction and functional mitral regurgitation (FMR).

Methods

Patients with at least mild FMR and reduced LVEF (&lt; 50%) under optimized medical therapy who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single-centre. FMR grading was undertaken according to the new 2021 valvular guidelines. PALS was assessed by 2D speckle tracking in apical 4-chamber view (as per EACVI current recommendations). Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters, namely PALS, and all-cause mortality.

Results

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median mitral regurgitant volume was 25mL (IQR: 14 – 34mL). According to the new ESC 2021 valvular guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. Median PALS was 14% (IQR 8 – 20%). The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS (figure 1). On ROC curve analysis, the best PALS cut-off value associated with mortality was &lt; 15%. Kaplan-Meier survival curves according to FMR severity and PALS &gt; or &lt; 15% are depicted in figure 2. PALS remained independently associated with all-cause mortality on multivariable analysis (adjusted hazard ratio [aHR]: 0.94; 95%CI: 0.90 – 0.98; p = 0.004) even after adjustment for several (n = 14) clinical and echocardiographic confounders.

Conclusion

In a cohort of patients with reduced LVEF and functional mitral regurgitation, peak atrial longitudinal strain was associated with all-cause mortality. Abstract Figure 1  Abstract Figure 2

Intraosseous access in neonates is feasible and safe - An analysis of a prospective nationwide surveillance study in Germany

BACKGROUND

This was a prospective surveillance study to investigate reports on the safety and frequency of use of intraosseous (IO) access in neonates.

METHODS

Over a two-year period, paediatric hospitals in Germany were asked to report all cases of IO access to the nationwide Surveillance Unit for Rare Paediatric Diseases (ESPED). Hospitals reporting a case submitted responses via an anonymised electronic questionnaire, providing details on indication, success rate, system used, location, duration to first successful IO access, complications, alternative access attempts and short-term outcome. We present a subset of data for IO use in infants of less than 28 days.

RESULTS

A total of 161 neonates (145 term and 16 preterm born infants) with 206 IO access attempts were reported. In 146 neonates (91%), IO access was successfully established, and success was achieved with the first attempt in 109 neonates (75%). There was no significant impact of gestational age or provider's educational level on success rates. In 71 infants with successful IO access (79%), the estimated duration of placement was less than 3 min. The proximal tibia was the predominant site used. A semiautomatic battery-driven device was used in 162 attempts (88%). The most often applied medications via IO access were crystalloid fluid and adrenaline. Potentially severe complications occurred in 9 patients (6%).

CONCLUSION

Within this surveillance study, IO access in neonates was feasible and safe. IO access is an important alternative for vascular access in neonates.

Is the BNT162b2 COVID-19 vaccine effective in elderly populations? Results from population data from Bavaria, Germany

Background

The efficacy of the BioNTech-Pfizer BNT162b2 vaccination in the elderly (≥80 years) could not be fully assessed in the BioNTech-Pfizer trial due to low numbers in this age group. We aimed to evaluate the effectiveness of the BioNTech-Pfizer (BNT162b2) vaccine to prevent SARS-CoV-2 infection and severe outcomes in octo- and novo-generians in a German state setting.

Methods and findings

A prospective observational study of 708,187 persons aged ≥80 years living in Bavaria, Germany, was conducted between Jan 9 to Apr 11, 2021. We assessed the vaccine effectiveness (VE) for two doses of the BNT162b2 vaccine with respect to SARS-CoV-2 infection and related hospitalisations and mortality. Additionally, differences in VE by age groups ≥80 to ≤89 years and ≥90 years were studied. Analyses were adjusted by sex. By the end of follow-up, 63.8% of the Bavarian population ≥80 years had received one dose, and 52.7% two doses, of the BNT162b2 vaccine. Two doses of the BNT162b2 vaccine lowered the proportion of SARS-CoV-2 infections and related outcomes, resulting in VE estimates of 68.3% (95% confidence interval (CI) 65.5%, 70.9%) for infection, 73.2% (95% CI 65.3%, 79.3%) for hospitalisation, and 85.1% (95% CI 80.0%, 89.0%) for mortality. Sex differences in the risk of COVID-19 outcomes observed among unvaccinated persons disappeared after two BNT162b2 vaccine doses. Overall, the BNT162b2 vaccine was equally effective in octo- and novo-genarians.

Conclusions

Two doses of BioNTech-Pfizer’s BNT162b2 vaccine is highly effective against COVID-19 outcomes in elderly persons.

Incremental prognostic value of worsening renal function parameters in addition to the GRACE score in patients with acute coronary syndrome

Background

Baseline renal function, one of the parameters included in the GRACE score, has prognostic relevance in patients admitted for acute coronary syndrome (ACS).

Purpose

The aim of this study was to compare different worsening renal function (WRF) parameters during hospitalization for ACS and their impact on all-cause mortality. Furthermore, we aimed to assess if these parameters had any incremental prognostic value in addition to the GRACE score.

Methods

We conducted a single-center retrospective study enrolling consecutive patients admitted for ACS from January 2016 to December 2018. Estimation of glomerular filtration rate (eGFR) for each patient was calculated based on the CKD-EPI formula. WRF during hospitalization was assessed by means of: serum creatinine (sCr) elevation ≥0,3mg/dL, duplication of the sCr value or maximum sCr value ≥2,0mg/dL.

Results

A total of 555 patients were included (65±13 years old, 72% male). Overall, 402 (72%) had hypertension, 167 (30%) were diabetic, 88 (16%) had left ventricular ejection fraction &lt;40%. Mean GRACE score was 102.7±29.1 and median sCr at baseline was 0.83 mg/dL [0.70; 0.97]. Median length of hospitalization was 4 days [2; 10] and the mean follow-up of 963 days.

Baseline eGFR showed significant correlation with mortality during follow-up (HR 0.742 [95% CI 0.691–0.797] per 10 mL/min/1.73m2 increase in eGRF). Moreover, all WRF parameters showed significant association with all-cause mortality during follow-up on a univariate analysis - p&lt;0,001 (Table 1). Elevation of sCr ≥0,3 mg/dL during hospitalization was the most frequent WRF parameter (210 patients - 38%) and the most sensitive parameter to predict our endpoint, occurring in 56 patients who died during follow-up (sensitivity 66.7%). Both duplication of sCr and absolute sCr ≥2,0mg/dL during hospitalization showed a lower prevalence; however, the majority of patients with one of these findings died during follow-up (51,4% and 68,5%, respectively).

On a multivariate Cox regression analysis, adjusted for the GRACE score, all individual WRF parameters remained independently associated with all-cause mortality during follow up (Table 2).

Conclusion

Worsening renal function has significant prognostic impact in patients admitted for ACS. Identification of these parameters during hospitalization adds significant value to the prognostic stratification of the GRACE score.

Funding Acknowledgement

Type of funding sources: None.

The timing and mechanism of high-grade AV block post-TAVI: knowing your enemy

Background

Complete atrioventricular block (AVB) requiring permanent pacemaker implantation (PPMI) is still a major limitation of transcatheter aortic valve implantation (TAVI) procedures. Although right-bundle branch block (RBBB), membranous septum (MS) length and self-expandable prothesis are recognizable risk factors, their predictability to PPMI is far from satisfactory. While some patients develop persistent intra-procedure high-grade AVB (H-AVB), others present much later with severe bradycardia.

Purpose

This study aims to describe and compare the characteristics of patients who develop AVB during or after TAVI.

Methods

Single centre prospective registry of 506 consecutive patients submitted to TAVI with no previous pacemaker between 2017 and 2020. Post-procedure PPMI (up to 30 days after discharge) was studied and divided into two groups according to the development of persistent intra-procedure H-AVB (Group A) or post procedure H-AVB (Group B). Baseline ECG, computed tomography and TAVI-related characteristics were analyzed.

Results

A total of 88 patients (17,3%), aging 83±6 years, 36.4% male, underwent post-TAVI PPMI (6 after discharge). Previous conduction disturbances were present in 50 (56.8%) patients and 25 (28.4%) had RBBB. 83% were submitted to self-expandable TAVI. Forty-two patients (47.7%) had persistent intra-procedure H-AVB (Group A) whereas 52.3% had post-procedure H-AVB (Group B). In patients with persistent intra procedure H-AVB previous RBBB was significantly more frequent (45.2%, n=19) when compared to patients with post-procedure H-AVB (13%, n=6; p=0.001). Contrarily, AF and previous left-bundle branch block (LBBB) were more likely in Group B. No difference in valvular calcification, MS length, prosthesis type or implantation technique was noted (picture 1). In the group with post-procedure H-AVB, 21.7% had transient AVB during TAVI and all developed de novo LBBB or first-degree AVB post-TAVI. Among these, 33 patients (71.7%) developed delayed H-AVB (&gt;48h post-procedure) while the remaining presented earlier.

Conclusions

In patients with PPMI post-TAVI, those with persistent intra-procedure H-AVB had higher rates of previous RBBB, while those with post-procedure H-AVB frequently had a normal baseline ECG. Anatomical and procedural characteristics did not differ between groups. Further studies are needed to confirm these results.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery calcium score to predict coronary CT angiography interpretability. An old problem revisited

Introduction

Clinical guidelines recommend against the use of coronary computed tomography angiography (CCTA) in patients with heavy calcification due to interpretability concerns, but no specific approach or threshold is provided. Recently, alternative methods have been proposed as more reliable predictors of CCTA interpretability than the classic coronary artery calcium score (CACS). The purpose this study was to compare the performance of different measures of coronary calcification as predictors of CCTA interpretability.

Methods

We conducted a retrospective analysis of consecutive patients undergoing CACS and CCTA between 2018 and 2020. The key exclusion criteria were known coronary artery disease, CACS of zero, and presence of non-assessable coronary lesions for reasons other than calcification (movement/gating artifacts or vessel diameter &lt;2mm). CCTA studies were considered non-interpretable if the main reader considered one or more coronary lesions non-assessable due to calcification. Three different measures of coronary calcification were compared using ROC curve analysis: 1) total CACS; 2) CACS-to-lesion ratio (total CACS divided by the number of calcified plaques); and 3) calcium score of the most calcified plaque. Decision-tree analysis was performed to identify the algorithm that best predicts CCTA interpretability.

Results

A total of 432 patients (191 women, mean age 64±11 years) were included. Overall, 31 patients (7.2%) had a non-interpretable CCTA due to calcification. Patients with non-interpretable CCTA had higher CACS (median 589 vs. 50 AU, p&lt;0.001), higher CACS-to-lesion ratio (median 43 vs. 14 AU/lesion, p&lt;0.001), and higher score of the most calcified plaque (median 445 vs. 43 AU, p&lt;0.001). Among the 3 methods, CACS showed the highest discriminative power to predict a non-interpretable CCTA (C-statistic 0.93, 95% CI 0.89–0.95, p&lt;0.001) – Figure 1.

Decision-tree analysis identified a single-variable algorithm (CACS value ≤515 AU) as the best discriminator of CCTA interpretability: 396 of the 409 patients (97%) with CACS ≤515 AU had an interpretable CCTA, whereas only 5 of the 23 patients (22%) with CACS &gt;515 AU had an interpretable test, yielding a total of 96% correct predictions.

Conclusions

The recently proposed and more complex measures of coronary calcification seem unable to outperform total CACS as a predictor of CCTA interpretability. A simple CACS cutoff-value around 500 AU remains the best discriminator for this purpose.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Anticipating recurrent ischemic events after an acute coronary syndrome: validation and application of the SMART-REACH score

Background

The SMART-REACH score (SRS) was developed to predict the risk of major adverse cardiovascular events in ambulatory patients with established cardiovascular disease, although it has not been extensively validated. Patients at higher risk of recurrent ischemic events may benefit from novel, more intensive treatment options, and earlier identification of these patients can potentially improve outcomes.

Purpose

We aimed to validate the SRS and evaluate its performance in a population recently admitted with acute coronary syndrome.

Methods

In this single-centre retrospective cohort, we included 320 patients aged 45 to 80 years, who were discharged following admission for an acute coronary syndrome between 2016 and 2018. To calculate the SRS for each patient, we considered clinical data on admission (age, gender, smoking, diabetes, prior history of vascular disease, heart failure or atrial fibrillation), lipid values obtained within the first 24 hours of hospitalization, serum creatinine level at baseline and once the patient was deemed clinically stable, and discharge medication. The outcome of interest was defined as stroke, myocardial infarction or cardiovascular death (MACE) at two years of follow-up. SRS was assessed for discrimination and calibration.

Results

Mean age was 63±9 years, and 240 (75%) were male. There was high prevalence of cardiovascular risk factors: 71% had hypertension, 32% had diabetes mellitus, 42% were active smokers and 25% had previously established cardiovascular disease. The outcome of interest was observed in 38 patients (22 cardiovascular deaths, 6 strokes and 14 myocardial infarctions). SRS showed good discrimination of the estimated MACE risk with overall C-statistic of 0.646 (95% CI, 0.554–0.737, p=0.004) (picture 1) and calibration (p-value for the goodness-of-fit test of 0.544). The global estimated risk of MACE at 2-years was 4.8% (3.8%-6.8%). The expected/ observed ratio was 0.56 for the occurrence MACE (picture 2).

Conclusions

Over the first two years after discharge from an acute coronary syndrome, one of every 8 patients developed a potentially fatal recurrent ischemic event. The SRS performed reasonably well in discriminating those at highest risk of MACE, suggesting that this score may help select patients at discharge for ad initium more intensive pharmacological therapy.

Funding Acknowledgement

Type of funding sources: None. ROC curve for the SMART-REACH scoreExpected versus observed MACE

Coronary artery calcium score to predict coronary CT angiography interpretability: an old problem revisited

Funding Acknowledgements

Type of funding sources: None.

Introduction

Clinical guidelines recommend against the use of coronary computed tomography angiography (CCTA) in patients with heavy calcification due to interpretability concerns, but no specific approach or threshold is provided. Recently, alternative methods have been proposed as more reliable predictors of CCTA interpretability than the classic coronary artery calcium score (CACS).  The purpose this study was to compare the performance of different measures of coronary calcification as predictors of CCTA interpretability.

Methods

We conducted a retrospective analysis of consecutive patients undergoing CACS and CCTA between 2018 and 2020. The key exclusion criteria were known coronary artery disease, CACS of zero, and presence of non-assessable coronary lesions for reasons other than calcification (movement/gating artifacts or vessel diameter &lt; 2mm). CCTA studies were considered non-interpretable if the main reader considered one or more coronary lesions non-assessable due to calcification. Three different measures of coronary calcification were compared using ROC curve analysis: 1) total CACS; 2) CACS-to-lesion ratio (total CACS divided by the number of calcified plaques); and 3) calcium score of the most calcified plaque. Decision-tree analysis was performed to identify the algorithm that best predicts CCTA interpretability.

Results

A total of 432 patients (191 women, mean age 64 ± 11 years) were included. Overall, 31 patients (7.2%) had a non-interpretable CCTA due to calcification. Patients with non-interpretable CCTA had higher CACS (median 589 vs. 50 AU, p &lt; 0.001), higher CACS-to-lesion ratio (median 43 vs. 14 AU/lesion, p &lt; 0.001), and higher score of the most calcified plaque (median 445 vs. 43 AU, p &lt; 0.001). Among the 3 methods, CACS showed the highest discriminative power to predict a non-interpretable CCTA (C-statistic 0.93, 95%CI 0.89-0.95, p &lt; 0.001) - Figure.

Decision-tree analysis identified a single-variable algorithm (CACS value ≤ 515 AU) as the best discriminator of CCTA interpretability: 396 of the 409 patients (97%) with CACS ≤ 515 AU had an interpretable CCTA, whereas only 5 of the 23 patients (22%) with CACS &gt; 515 AU had an interpretable test, yielding a total of 96% correct predictions.

Conclusions

The recently proposed and more complex measures of coronary calcification seem unable to outperform total CACS as a predictor of CCTA interpretability. A simple CACS cutoff-value around 500 AU remains the best discriminator for this purpose.

Rabdomiólise em militares: uma missão de reconhecimento para prevenção

O treinamento físico regular faz parte do cotidiano militar, com intuito de aprimorar competências físicas essenciais para tarefas de combate. No entanto, quando executado de forma extenuante ou desenvolvido em condições climáticas adversas pode ocasionar o desenvolvimento da rabdomiólise por esforço físico. A rabdomiólise por esforço físico é definida como uma síndrome decorrente da necrose das células musculares, com sintomas variáveis, como dor muscular, fraqueza e aumento plasmático de enzimas musculares. A severidade da rabdomiólise por esforço físico varia individualmente, porém, pode se tornar clinicamente relevante, contribuindo para a hospitalização, insuficiência renal aguda, incapacidade permanente ou óbito. Sendo assim, o objetivo desta revisão narrativa é apresentar possíveis causas e fatores de risco para rabdomiólise, discutir sua fisiopatologia, seus possíveis diagnósticos e suas principais complicações, enfatizando o contexto militar.

Whey protein supplementation in muscle hypertrophy

Introduction The nutritional intake in the context of a hypertrophy training can affect body composition, the increase of muscle mass and strength. Whey protein seems to promote a reduction in body fat, improve hypertrophy, and other potential health benefits. This protein is one of the highest quality proteins due to its amino acid content (especially leucine) and to the rapid digestibility. Whey protein consumption has a robust ability to stimulate muscle protein synthesis. There are 3 types of whey protein: controlled, insulated and hydrolysed.

Objectives The goal of this research is verifying the efficacy of the use of whey protein supplementation in athletes seeking muscle strength and mass gain.

Methodology *

We analysed scientific articles from 2014 to 2019, based on Pubmed and Google scholar. Keywords such as whey protein, supplement, hypertrophy, muscle mass and nutrition were used.

Results From scientific research, six articles were analysed. Thus, it is estimated the analysis of 13 men under the age of 18 years and under 30 years of age. Only men with a percentage of fat mass less than or equal to 23% were selected. Two groups were created: the control group that consumed carbohydrate supplements and the experimental group that consumed 36g/day whey protein. Both groups performed 3 sessions/week of resistance training, and the used dose of protein derived from the diet was 1.4g/Kg/day. Both groups experienced gains in strength, 1 maxi (RM) and fat-free mass (FFM). However, the experimental group had an extra 9% and 27% in 1RM and FFM respectively compared to the control group.

Conclusion In short, supplementation with whey protein contributes to the increase of muscle mass and strength in athletes whose training (frequency, volume and duration) and diet are suitable for this purpose.

Late-pregnancy dysglycemia in obese pregnancies after negative testing for gestational diabetes and risk of future childhood overweight: An interim analysis from a longitudinal mother-child cohort study

BACKGROUND

Maternal pre-conception obesity is a strong risk factor for childhood overweight. However, prenatal mechanisms and their effects in susceptible gestational periods that contribute to this risk are not well understood. We aimed to assess the impact of late-pregnancy dysglycemia in obese pregnancies with negative testing for gestational diabetes mellitus (GDM) on long-term mother-child outcomes.

METHODS AND FINDINGS

The prospective cohort study Programming of Enhanced Adiposity Risk in Childhood-Early Screening (PEACHES) (n = 1,671) enrolled obese and normal weight mothers from August 2010 to December 2015 with trimester-specific data on glucose metabolism including GDM status at the end of the second trimester and maternal glycated hemoglobin (HbA1c) at delivery as a marker for late-pregnancy dysglycemia (HbA1c ≥ 5.7% [39 mmol/mol]). We assessed offspring short- and long-term outcomes up to 4 years, and maternal glucose metabolism 3.5 years postpartum. Multivariable linear and log-binomial regression with effects presented as mean increments (Δ) or relative risks (RRs) with 95% confidence intervals (CIs) were used to examine the association between late-pregnancy dysglycemia and outcomes. Linear mixed-effects models were used to study the longitudinal development of offspring body mass index (BMI) z-scores. The contribution of late-pregnancy dysglycemia to the association between maternal pre-conception obesity and offspring BMI was estimated using mediation analysis. In all, 898 mother-child pairs were included in this unplanned interim analysis. Among obese mothers with negative testing for GDM (n = 448), those with late-pregnancy dysglycemia (n = 135, 30.1%) had higher proportions of excessive total gestational weight gain (GWG), excessive third-trimester GWG, and offspring with large-for-gestational-age birth weight than those without. Besides higher birth weight (Δ 192 g, 95% CI 100-284) and cord-blood C-peptide concentration (Δ 0.10 ng/ml, 95% CI 0.02-0.17), offspring of these women had greater weight gain during early childhood (Δ BMI z-score per year 0.18, 95% CI 0.06-0.30, n = 262) and higher BMI z-score at 4 years (Δ 0.58, 95% CI 0.18-0.99, n = 43) than offspring of the obese, GDM-negative mothers with normal HbA1c values at delivery. Late-pregnancy dysglycemia in GDM-negative mothers accounted for about one-quarter of the association of maternal obesity with offspring BMI at age 4 years (n = 151). In contrast, childhood BMI z-scores were not affected by a diagnosis of GDM in obese pregnancies (GDM-positive: 0.58, 95% CI 0.36-0.79, versus GDM-negative: 0.62, 95% CI 0.44-0.79). One mechanism triggering late-pregnancy dysglycemia in obese, GDM-negative mothers was related to excessive third-trimester weight gain (RR 1.72, 95% CI 1.12-2.65). Furthermore, in the maternal population, we found a 4-fold (RR 4.01, 95% CI 1.97-8.17) increased risk of future prediabetes or diabetes if obese, GDM-negative women had a high versus normal HbA1c at delivery (absolute risk: 43.2% versus 10.5%). There is a potential for misclassification bias as the predominantly used GDM test procedure changed over the enrollment period. Further studies are required to validate the findings and elucidate the possible third-trimester factors contributing to future mother-child health status.

CONCLUSIONS

Findings from this interim analysis suggest that offspring of obese mothers treated because of a diagnosis of GDM appeared to have a better BMI outcome in childhood than those of obese mothers who-following negative GDM testing-remained untreated in the last trimester and developed dysglycemia. Late-pregnancy dysglycemia related to uncontrolled weight gain may contribute to the development of child overweight and maternal diabetes. Our data suggest that negative GDM testing in obese pregnancies is not an "all-clear signal" and should not lead to reduced attention and risk awareness of physicians and obese women. Effective strategies are needed to maintain third-trimester glycemic and weight gain control among otherwise healthy obese pregnant women.

A simple method for identification of misreporting of energy intake from infancy to school age: Results from a longitudinal study

BACKGROUND & AIMS

Misreporting is a major source of reporting bias in nutritional surveys. It can affect the analysis of associations between diet and disease. Although various methods have been proposed to identify misreporting, their application to infants and young children is difficult. We identify misreporting of energy intake in infants and young children and propose a simplified approach.

METHODS

1199 children were enrolled in the Childhood Obesity Programme (CHOP) based in 5 European countries (Belgium, Germany, Italy, Poland and Spain) with repeated measurements of 3-day weighed food protocol and anthropometric indices at 10 time points between ages 1-96 months. Individual cut-offs for the ratio of reported energy intake and estimated energy requirement were calculated to identify misreporters. Misreporting was studied according to age, gender, BMI z-scores and country.

RESULTS

We identified a higher proportion of over-reporters (18.9%) as compared to under-reporters (10.6%). The proportion of over-reporting was higher among infants while under-reporting was more prevalent in school-aged children. Under-reporting was higher in boys (12.0%) and in obese/over-weight children (36.3%). Mean values for upper and lower cut-offs for the ratio of reported energy intake and estimated energy requirement in children ≤12 months were 0.80 and 1.20, and 0.75 and 1.25 for children >12 months, respectively. Using these fixed (mean) values, 90.4% (kappa statistic: 0.78) of all misreporters could be identified.

CONCLUSIONS

Despite intensive measures to obtain habitual intake of children, an essential proportion of nutritional reports were found to be implausible. Both over- and under-reporting should be carefully analysed, even in studies on infants. Fixed cut-offs can be applied to identify misreporting if no individual variation in energy intake can be calculated.

CLINICAL TRIAL REGISTRY

This trial was registered at https://clinicaltrials.gov/show/NCT00338689.

Trends, seasonality and forecasts of pulmonary tuberculosis in Portugal

SETTING

Tuberculosis (TB) is a global public health concern. Surveillance programmes present invaluable epidemiological information regarding its temporal evolution, particularly for pulmonary tuberculosis (PTB), the most common form of TB and the one that presents the greatest challenge in public health.

OBJECTIVES

To characterise, model and predict monthly incidence rates for PTB in Portugal disaggregated by high/low-incidence areas, sex and age groups.

DESIGN

PTB monthly incidence rates were estimated based on PTB cases diagnosed in 2000-2010, disaggregated by population and geographic characteristics. Seasonal-trend LOESS (STL) decomposition was employed to model trend and seasonality. Seasonal autoregressive integrated moving average (SARIMA) models were fit to characterise series behaviour and forecast PTB monthly incidence rates.

RESULTS

Overall, the time series showed a downward trend in and seasonality of PTB diagnosis, with a peak in March and a trough in December. The mean seasonal amplitude was consistently higher in high-incidence areas, in males and in adults aged 25-54 years. SARIMA models were found to adequately fit and forecast the time series, thus predicting trend and seasonal persistence.

CONCLUSIONS

STL and SARIMA findings concurred and were accurate. Endemic PTB seems to be slowly declining and case diagnosis is likely seasonal, which can be expected to persist if past conditions continue.

Peroxiredoxin 2, glutathione peroxidase, and catalase in the cytosol and membrane of erythrocytes under H2O2-induced oxidative stress

Erythrocytes are continuously exposed to risk of oxidative injury due to oxidant oxygen species. To prevent damage, they have antioxidant agents namely, catalase (Cat), glutathione peroxidase (GPx), and peroxiredoxin 2 (Prx2). Our aim was to contribute to a better understanding of the interplay between Prx2, Cat, and GPx under H2O2-induced oxidative stress, by studying their changes in the red blood cell cytosol and membrane, in different conditions. These three enzymes were quantified by immunoblotting. Malondialdehyde, that is, lipoperoxidation (LPO) in the erythrocyte membrane, and membrane-bound hemoglobin (MBH) were evaluated, as markers of oxidative stress. We also studied the erythrocyte membrane protein profile, to estimate how oxidative stress affects the membrane protein structure. We showed that under increasing H2O2 concentrations, inhibition of the three enzymes with or without metHb formation lead to the binding of Prx2 and GPx (but not Cat) to the erythrocyte membrane. Prx2 was detected mainly in its oxidized form and the linkage of metHb to the membrane seems to compete with the binding of Prx2. Catalase played a major role in protecting erythrocytes from high exogenous flux of H2O2, since whenever Cat was active there were no significant changes in any of the studied parameters. When only Cat was inhibited, Prx2 and GPx were unable to prevent H2O2-induced oxidative stress resulting in increasing MBH and membrane LPO. Additionally, the inhibition of one or more of these enzymes induced changes in the anchor/linker proteins of the junctional complexes of the membrane cytoskeleton-lipid bilayer, which might lead to membrane destabilization.

Discovering the infectome of human endothelial cells challenged with Aspergillus fumigatus applying a mass spectrometry label-free approach

Blood vessel invasion is a key feature of invasive aspergillosis. This angioinvasion process contributes to tissue thrombosis, which can impair the access of leukocytes and antifungal drugs to the site of infection. It has been demonstrated that human umbilical vein endothelial cells (HUVECs) are activated and assume a prothrombotic phenotype following contact with Aspergillus fumigatus hyphae or germlings, a process that is independent of fungus viability. However, the molecular mechanisms by which this pathogen can activate endothelial cells, together with the endothelial pathways that are involved in this process, remain unknown. Using a label-free approach by High Definition Mass Spectrometry (HDMS(E)), differentially expressed proteins were identified during HUVEC-A. fumigatus interaction. Among these, 89 proteins were determined to be up- or down-regulated, and another 409 proteins were exclusive to one experimental condition: the HUVEC control or HUVEC:AF interaction. The in silico predictions provided a general view of which biological processes and/or pathways were regulated during HUVEC:AF interaction, and they mainly included cell signaling, immune response and hemostasis pathways. This work describes the first global proteomic analysis of HUVECs following interaction with A. fumigatus germlings, the fungus morphotype that represents the first step of invasion and dissemination within the host.

BIOLOGICAL SIGNIFICANCE

A. fumigatus causes the main opportunistic invasive fungal infection related to neutropenic hematologic patients. One of the key steps during the establishment of invasive aspergillosis is angioinvasion but the mechanism associated with the interaction of A. fumigatus with the vascular endothelium remains unknown. The identification of up- and down-regulated proteins expressed by human endothelial cells in response to the fungus infection can contribute to reveal the mechanism of endothelial response and, to understand the physiopathology of this high mortality disease. This article is part of a Special Issue entitled: Trends in Microbial Proteomics.

Chromosomal, epigenetic and microRNA-mediated inactivation of LRP1B, a modulator of the extracellular environment of thyroid cancer cells

The low-density lipoprotein receptor-related protein (LRP1B), encoding an endocytic LDL-family receptor, is among the 10 most significantly deleted genes across 3312 human cancer specimens. However, currently the apparently crucial role of this lipoprotein receptor in carcinogenesis is not clear. Here we show that LRP1B inactivation (by chromosomal, epigenetic and microRNA (miR)-mediated mechanisms) results in changes to the tumor environment that confer cancer cells an increased growth and invasive capacity. LRP1B displays frequent DNA copy number loss and CpG island methylation, resulting in mRNA underexpression. By using CpG island reporters methylated in vitro, we found that DNA methylation disrupts a functional binding site for the histone-acetyltransferase p300 located at intron 1. We identified and validated an miR targeting LRP1B (miR-548a-5p), which is overexpressed in cancer cell lines as a result of 8q22 DNA gains. Restoration of LRP1B impaired in vitro and in vivo tumor growth, inhibited cell invasion and led to a reduction of matrix metalloproteinase 2 in the extracellular medium. We emphasized the role of an endocytic receptor acting as a tumor suppressor by modulating the extracellular environment composition in a way that constrains the invasive behavior of the cancer cells.

[Difficult endotracheal intubation in a patient with right aortic arch: clinical report]

Congenital aortic arch abnormalities are usually rare in the adult. We report the case of difficult endotracheal intubation in a patient with a right aortic arch.