Diagnosis and Treatment Patterns of Chronic Thromboembolic Pulmonary Hypertension in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia: A Registry Study

BACKGROUND

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) in countries with limited resources have, to date, been poorly represented in registries.

OBJECTIVE

This work assesses the epidemiology, diagnosis, hemodynamic and functional parameters, and treatment of CTEPH in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia.

METHODS

A prospective, cohort, phase IV, observational registry with 3-year follow-up (n = 212) in patients aged ≥ 18 years diagnosed with CTEPH was created. Clinical, hemodynamic, and functional parameters were obtained at an initial visit, follow-up visits, and a final visit at the end of 3 years' observation or end of follow-up. Data were recorded on electronic case report forms. Parameters evaluated included 6-minute walking distance (6MWD), use of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), pulmonary hypertension (PH)-targeted therapy, and survival. All statistical analyses were exploratory and descriptive, and were performed in the overall population.

RESULTS

The most common symptoms were typical of those expected for CTEPH. Almost 90% of patients underwent right heart catheterization at diagnosis or initial study visit. In total, 66 patients (31%) underwent PEA before the initial visit; 95 patients (45%) were considered operable, 115 (54%) were inoperable, and two (1%) had no operability data. Only 26 patients (12%) had been assessed for BPA at their initial visit. PH-targeted therapy was documented at diagnosis for 77 patients (36%), most commonly a phosphodiesterase type 5 inhibitor (23%). Use of PH-targeted therapy increased to 142 patients (67%) at the initial visit, remaining similar after 3 years. Use of riociguat increased from 6% of patients at diagnosis to 38% at 3 years. Between baseline and end of observation, results for patients with paired data showed an increase in 6MWD. Survival at the end of observation was 88%.

CONCLUSIONS

These data highlight the current diagnosis and management of CTEPH in the participating countries. They show that early CTEPH diagnosis remains challenging, and use of off-label PH-targeted therapy is common.

CLINICALTRIALS

gov: NCT02637050; registered December 2015.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

A survey of physician opinions in Russia in the field of pharmacogenetics of cardiovascular disease

Aims: To study the readiness of Russian physicians with experience and younger physicians undergoing clinical residency and postgraduate education to apply pharmacogenetic testing in their clinical practice. Materials & methods: The sociological study involved physicians (n = 378) living in different regions of the Russian Federation, as well as residents and graduate students (n = 185) of the Russian Medical Academy of Continuing Professional Medical Education. The survey consisted of 35 questions, and 23 were created on the online platform of professional surveys, Testograf.ru. Results: Every second respondent was willing to use pharmacogenetic testing in clinical practice to predict the efficacy and safety of medications in patients with cardiovascular disease (p = 0.06). Factors impeding the clinical implementation of pharmacogenetic testing in Russia were identified: physicians' ignorance of pharmacogenetics (p = 0.015), a lack of pharmacogenetic testing in clinical guidelines and treatment standards (p = 0.175) and a lack of economic justification for using pharmacogenetic testing (p = 0.320). Conclusion: Russian physicians have a positive attitude toward pharmacogenetic testing. However, the level of test implementation remains low.

Alpha-protein kinase 3 (ALPK3) truncating variants are a cause of autosomal dominant hypertrophic cardiomyopathy

AIMS

The aim of this study was to determine the frequency of heterozygous truncating ALPK3 variants (ALPK3tv) in patients with hypertrophic cardiomyopathy (HCM) and confirm their pathogenicity using burden testing in independent cohorts and family co-segregation studies.

METHODS AND RESULTS

In a discovery cohort of 770 index patients with HCM, 12 (1.56%) were heterozygous for ALPK3tv [odds ratio(OR) 16.11, 95% confidence interval (CI) 7.94-30.02, P = 8.05e-11] compared to the Genome Aggregation Database (gnomAD) population. In a validation cohort of 2047 HCM probands, 32 (1.56%) carried heterozygous ALPK3tv (OR 16.17, 95% CI 10.31-24.87, P < 2.2e-16, compared to gnomAD). Combined logarithm of odds score in seven families with ALPK3tv was 2.99. In comparison with a cohort of genotyped patients with HCM (n = 1679) with and without pathogenic sarcomere gene variants (SP+ and SP-), ALPK3tv carriers had a higher prevalence of apical/concentric patterns of hypertrophy (60%, P < 0.001) and of a short PR interval (10%, P = 0.009). Age at diagnosis and maximum left ventricular wall thickness were similar to SP- and left ventricular systolic impairment (6%) and non-sustained ventricular tachycardia (31%) at baseline similar to SP+. After 5.3 ± 5.7 years, 4 (9%) patients with ALPK3tv died of heart failure or had cardiac transplantation (log-rank P = 0.012 vs. SP- and P = 0.425 vs. SP+). Imaging and histopathology showed extensive myocardial fibrosis and myocyte vacuolation.

CONCLUSIONS

Heterozygous ALPK3tv are pathogenic and segregate with a characteristic HCM phenotype.

Left ventricular remodelling in a large cohort of strength competitive athletes: not so common and differs by sex

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This research was supported by FMBA of Russia

Background. There are still very limited data about physiological cardiac adaptation in strength athletes. 

Purpose. To describe structural and functional features of left ventricular (LV) in a large cohort of healthy strength athletes.

Methods. A total of 673 Caucasian athletes (weight-lifting, males/females = 238/157, and Martial Arts, males/females = 200/78) competing in Russian National and International level events were recruited within 2010-2017. Data of standard 2D echocardiography (Echo) and comprehensive medical history were analyzed. Data are presented as median (IQR) and compared by nonparametric tests (table). To assess LV geometry all athletes were divided into 6 groups according to 4-tiered classification based on mass index, concentricity and end-diastolic volume (EDV) index of LV (Figure). 

Results. Both absolute and indexed values of LV structural features were higher in males. Females exhibited higher functional parameters. Only 54 (8%) athletes had elevated LV mass (no sex difference), 23 (3.4%) – LV wall ≥ 12mm (only males) and 78 (11.6%) – changes in LV geometry. There was a prevalence of females in eccentric non-dilated LV hypertrophy (LVH) group (p = 0.088), which was previously accepted as a benign pattern of LV remodelling in non-athlete populations. Males had more often concentric types of LV remodelling (36 of 54 athletes). Among dilated types of LVH, there was a prevalence of males (p = 0.070).

Conclusions. LV remodelling is not common in strength athletes and differs by sex with a more favourable profile in females.

Clinical and Echo parameters Total n = 673 males n = 438 females n = 235 males vs females p-value Age, years 20(4) 20(4) 20(5) 0.06 BSA, m&sup2; 1.84(0.39) 1.96(0.39) 1.66(0.25) &lt;0.001 Sports practice, years 10(6) 10(7) 10(6) 0.12 LV EDD, mm 49(6) 50(5) 46(4) &lt;0.001 LV EDD/(BSA)^0.5 35.8(3) 35.9(3) 35.6(3) 0.017 LV EDV, ml 108(38) 118(32) 92(24) &lt;0.001 LV EDV/(BSA)^1.5 42.8(9) 42.9(10) 42.3(9) 0.14 Maximal LV WT, mm 10(1) 10(2) 9(1) &lt;0.001 LV mass/BSA, g/m&sup2; 86(24) 91(22) 75(16) &lt;0.001 LV Concentricity, g/(ml)^0.67 6.9(1.6) 7.4(1.6) 6.2(1.4) &lt;0.001 LV EF, % 60(5) 60(4) 62(4) &lt;0.001 Mitral E velocity, cm/sec 87(19) 85(19) 89(19) &lt;0.001 BSA - body surface area; EDD - end-diastolic dimension; WT - wall thickness

Abstract Figure. Types of LV geometry in athletes

Can left ventricular global function index be a novel marker of unfavorable outcome in patients with acute coronary syndrome

 

Left ventricular (LV) global function index (LVGFI) is a MRI marker of left ventricular remodeling. LVGFI has high predictive significance in young healthy individuals. The aim of the study was to assess prognostic significance in patients with acute coronary syndrome (ACS).

We include into this analysis 2169 patients with ACS (1340 (61.8%) men and 829 (38.2%) women), mean age 64.08±12.601 years. All patients were observed in 2 Russian multicenter observational studies: ORACLE I (ObseRvation after Acute Coronary syndrome for deveLopment of trEatment options) (2004–2007 years) and ORACLE II (NCT04068909) (2014–2019 years). 1886 (87.0%) pts had arterial hypertension, 1539 (71.0%) – history of coronary artery disease, 647 (29.8%) – history of myocardial infarction, 444 (20.5%) - diabetes mellitus. Duration of the follow-up was 1 years after the hospital discharge. Cases of death from any cause, coronary deaths, repeated coronary events (fatal and non-fatal) were recorded. An echocardiographic study was conducted 5–7 days from the time of hospitalization. The LVGFI was defined as LV stroke volume/LV global volume × 100, where LV global volume was the sum of the LV mean cavity volume ((LV end-diastolic volume + LV end-systolic volume)/2) and myocardial volume (LV mass/density).

During the follow-up, 193 deaths were recorded (8.9%), 122 deaths (5.6%) were coronary. In total, repeated coronary events were recorded in 253 (11.7%) patients. Mean LVGFI was 22.64±8.121%. Patients who died during the follow-up were older (73.03±10.936 years and 63.15±12.429 years, p=0.001), had a higher blood glucose level at the admission to the hospital (8.12±3.887 mmol/L and 7.17±3.355 mmol/L, p=0.041), serum creatinine (110.86±53.954 μmol/L and 99.25±30.273 μmol/L, p=0.007), maximum systolic blood pressure (196.3±25.17 mm Hg and 190.3±27.83 mm Hg, p=0.042). Those who died had a lower LVGFI value (19.75±6.77% and 23.01±8.243%, p&lt;0.001). Myocardial mass index, ejection fraction and other left ventricular parameters did not significantly differ between died and alive patients. Among the patients who died, there were higher rate of women, pts with a history of myocardial infarction, heart failure, diabetes. In a multivariate analysis, diabetes mellitus OR1.67 95% CI [1.12–2.51] p=0.012, history of heart failure (1.78 [1.2.-2.59], p=0.003), a history of myocardial infarction (1.47 [1.05–2.05], p=0024), age (1.06 [1.05–1.08], p=0.001) and LVGFI &lt;22% (1.53 [1.08–2.17], p=0.015) were independent predictors of death from any cause. The LVGFI was also independently associated with the risk of coronary death, but not with the risk of all recurring coronary events.

Thus, LVGFI may be useful the marker to assess risk in patients who have experienced an ACS episode.

Funding Acknowledgement

Type of funding source: None

Ticagrelor in Patients with Stable Coronary Disease and Diabetes

BACKGROUND

Patients with stable coronary artery disease and diabetes mellitus who have not had a myocardial infarction or stroke are at high risk for cardiovascular events. Whether adding ticagrelor to aspirin improves outcomes in this population is unclear.

METHODS

In this randomized, double-blind trial, we assigned patients who were 50 years of age or older and who had stable coronary artery disease and type 2 diabetes mellitus to receive either ticagrelor plus aspirin or placebo plus aspirin. Patients with previous myocardial infarction or stroke were excluded. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major bleeding as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria.

RESULTS

A total of 19,220 patients underwent randomization. The median follow-up was 39.9 months. Permanent treatment discontinuation was more frequent with ticagrelor than placebo (34.5% vs. 25.4%). The incidence of ischemic cardiovascular events (the primary efficacy outcome) was lower in the ticagrelor group than in the placebo group (7.7% vs. 8.5%; hazard ratio, 0.90; 95% confidence interval [CI], 0.81 to 0.99; P = 0.04), whereas the incidence of TIMI major bleeding was higher (2.2% vs. 1.0%; hazard ratio, 2.32; 95% CI, 1.82 to 2.94; P<0.001), as was the incidence of intracranial hemorrhage (0.7% vs. 0.5%; hazard ratio, 1.71; 95% CI, 1.18 to 2.48; P = 0.005). There was no significant difference in the incidence of fatal bleeding (0.2% vs. 0.1%; hazard ratio, 1.90; 95% CI, 0.87 to 4.15; P = 0.11). The incidence of an exploratory composite outcome of irreversible harm (death from any cause, myocardial infarction, stroke, fatal bleeding, or intracranial hemorrhage) was similar in the ticagrelor group and the placebo group (10.1% vs. 10.8%; hazard ratio, 0.93; 95% CI, 0.86 to 1.02).

CONCLUSIONS

In patients with stable coronary artery disease and diabetes without a history of myocardial infarction or stroke, those who received ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. (Funded by AstraZeneca; THEMIS ClinicalTrials.gov number, NCT01991795.).

P4633The frequency of mutations in patients with familial hypercholesterolemia who underwent acute coronary syndrome and patients with stable ischemic heart disease

Introduction

Familial hypercholesterolemia (FH) is the most common genetically inherited disease in the world, which leads to a significant increase in blood cholesterol and an increased risk of early atherosclerosis and, consequently, an increase in mortality from ischemic heart disease (IHD). The actual prevalence of genetic variants causing FH in every population remains unknown.

Purpose

To compare the frequency of mutations in patients with FH who underwent acute coronary syndrome (ACS) and patients with stable IHD.

Material and methods

We included 120 patients (male-79, female-41) who had a clinical diagnosis of FH based on the Dutch Lipid Clinic Network (DLCN) score and Simon Broome criteria. The men and women included in the study were ≤55 and ≤60 years of age, respectively. 40 of them were patients with ACS; the remaining 80 were patients with stable IHD. Genetic studies were performed using a multiple approach based on targeted Next Generation Sequencing (NGS) in the Health in code and the ReadSense laboratories.

Results

Variants of the three “classic” genes implicated in FH were detected in 46 patients (38,3%). The frequency of mutations was detected in 32.5% of cases, and in patients with stable IHD in 41.25% of cases (p=0.35). In the group of participants with stable IHD, a mutation in the LDLR gene was obtained in 85% of cases; mutations in the APOB, PCSK9 genes were detected in 15% of cases. The same rate of mutations in the APOB and LDLR genes (38.5% each) was detected in patients with ACS. One patient had a mutation in the PCSK9 gene. In two patients there were mutations at once in two genes responsible for the development of FH: in one case, mutations were determined in the APOB and LDLR genes, in the other - LDLR and PCSK9. All patients who carried variants of the studied genes were heterozygous.

Patients with clinically established FH had mutations in other genes involved in lipid metabolism, such as APOE, which turned to be mutant in 20 participants (16,6%). This variant defines the apoE4 isoform (also called ε4 allele), which is one of the three common genetic isoforms (apoE2, apoE3, and apoE4) of the APOE gene. It has been shown that the choice of apoE4 isoform have TC and LDL levels and increased risk of cardiovascular events related to atherosclerosis. Two patients had LPA mutations. This variant is a genetic polymorphism that has been previously published in association with elevated lipoprotein (a) (Lp(a)) levels and increased risk of IHD. Three patients were found to have ABCG8 mutations thought to be associated with sitosterolemia: two were pathogenic and another one of uncertain significance.

Conclusion

Thus, the frequency of mutations in patients with FH does not depend on the presence or absence of ACS. Both groups of patients are patients of a very high risk of developing both primary and repeated cardiovascular events.

P1748TNF and ANXA2 gene polymorphism associated with outcome and coronary angiography features in patients with early acute coronary syndrome

Background

Genetic predisposition makes a considerable contribution to premature acute coronary syndrome (ACS) development. Tumour necrosis factor (TNF) is an important proinflammatory cytokine influencing intravascular inflammation. Annexin A2 (ANXA2) is an endogenous PCSK9 inhibitor. Higher LDL level is associated with AA genotype of ANXA2 gene SNP rs17845226.

Aim

The aim of the study was to elucidate the association of TNF and ANXA2 gene polymorphism with coronary angiography features and outcome in patients (pts) with early ACS.

Methods

We analyzed data from two prospective observational trials (2004–2007; 2014–2016) - 672 pts (498 men and 174 women) with premature ACS (men≤55, women≤60 years of age). Coronary angiography (CAG) data were analyzed in 225 pts. Genotyping of SNP rs1800629 of TNF (502 pts) and rs17845226 of ANXA2 gene (235 pts) was performed by RT-PCR with allele-specific primers. The primary endpoint was calculated as a combination of all-cause mortality, recurrent ACS, stroke, and peripheral vascular disease. We also analyzed recurrent coronary events (CE) (coronary deaths & recurrent ACS). The mean follow-up time: 414±347.6 days.

Results

Mean age was 48.6±5.8 (M), 52.7±6.3 (F) years. 298 (44.3%) pts had STEMI, 362 (53.9%) pts – history of CAD, 500 (74.4%) – arterial hypertension, 32 (4.8%) – history of stroke, 81 (12.1%) – diabetes mellitus, 241 (37.1%) – heart failure (HF). The genotype distribution did not differ from the expected Hardy–Weinberg equilibrium: GG/AG/AA=0.557/0.191/0.006 (χ2=3.34, p=0.07) for TNF and CC/AC/AA=0.86/0.136/0.004 (χ2=0.05, p=0.82) for ANXA2. Carriers of allele A of TNF gene SNP had higher frequency of no significant coronary lesion (17.6% vs 5.9%; p=0.021) and NSTEMI (69.5% vs 50.8%, p<0.001). Carriers of allele A of ANXA2 gene SNP had higher frequency of coronary calcinosis (39.3% vs 19.6%; p=0.019) and HF (39.4% vs 22.3%, p=0.034). Carriers of A allele of TNF had higher frequency of CE (30.5% vs 19.5%, p=0.01, log-rank χ2=7.29, p=0.007). HF (OR, 2.686; 95% CI, 1.769–4.077; p<0.001), creatinine level (OR, 1.009; 95% CI, 1.001–1.017; p=0.025) and carrying of A allele of TNF gene SNP (OR, 1.836; 95% CI, 1.163–2.898; p=0.007) and STEMI at admission (OR, 1.009; 95% CI, 1.001–1.017; p=0.025) were independent predictors of any unfavorable outcome and CE in a multivariable Cox regression model. LAD and left main coronary artery involvement (OR, 1.836; 95% CI, 1.163–2.898; p=0.007) was an independent predictor of any unfavorable outcome. Identified relationship was independent of invasive treatment of ACS.

Conclusion

Thus, in patients with early ACS TNF mediated inflammation is associated with NSTEMI, no significant coronary lesion and could play a significant role in the development of unfavourable outcome. Carrying of A allele of ANXA2 gene may accelerate coronary atherosclerosis in these patients and is associated with HF.

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

Aims 

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

Methods and results 

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

Conclusion 

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

Emergency care of patients receiving non-vitamin K antagonist oral anticoagulants

Non-vitamin K antagonist oral anticoagulants (NOACs), which inhibit thrombin (dabigatran) and factor Xa (rivaroxaban, apixaban, edoxaban) have been introduced in several clinical indications. Although NOACs have a favourable benefit-risk profile and can be used without routine laboratory monitoring, they are associated-as any anticoagulant-with a risk of bleeding. In addition, treatment may need to be interrupted in patients who need surgery or other procedures. The objective of this article, developed by a multidisciplinary panel of experts in thrombosis and haemostasis, is to provide an update on the management of NOAC-treated patients who experience a bleeding episode or require an urgent procedure. Recent advances in the development of targeted reversal agents are expected to help streamline the management of NOAC-treated patients in whom rapid reversal of anticoagulation is required.

Late Silent Stent Abscess

BACKGROUND

Coronary stent infections in general and stent abscesses (SAs) in particular are rare but often deadly complications. Most SAs manifest with fever and chest pain within 30 days after intervention and require antibiotics and stent removal.

CASE REPORT

A 45-year-old man with second ST elevated myocardial infarction and cardiogenic shock was admitted to a hospital that had no cardiac catheterization laboratory. The patient underwent fibrinolytic therapy with alteplase but died 1 h later. His medical history revealed posterior myocardial infarction 7 years before, which had been successfully treated with a bare metal stent of the right coronary artery. The post-discharge observation had been unremarkable with no evidence of ischaemia or infection but gross non-compliance. Autopsy revealed complete closure of the left main coronary artery and a surprise additional finding, namely SA; the stented portion of the artery was enveloped by an abscess, and purulent material completely occluded the stent, which was floating in pus. Impressions: Since coronary angioplasty is so common, the incidence of late silent SA is probably higher than expected, especially considering that there is often a lack of clinical manifestations. Clinicians should be cognizant of this complication. More attention may be required to assess the condition of existing stents during repeated interventions. Gross non-compliance and/or early withdrawal from dual anti-platelet therapy may be directly responsible for the development of silent delayed SA.