Acute and subacute effects of strenuous exercise on platelet aggregation, coagulation and fibrinolysis in patients with stable coronary artery disease

INTRODUCTION

Strenuous exercise may occasionally cause coronary thrombosis with myocardial infarction and sudden cardiac death.

MATERIALS AND METHODS

Patients with stable coronary artery disease (CAD) (n = 164) and healthy individuals (n = 25) performed strenuous exercise on a bicycle ergometer. Blood was drawn at baseline, immediately after exercise and 2 h later. Platelet aggregation was measured with Multiplate® Analyzer. Thrombin generation was determined using a thrombogram and by measuring prothrombin fragment 1 + 2 (F1 + 2). A clot lysis assay was used to investigate fibrinolysis.

RESULTS

From baseline to immediately after exercise, thrombin receptor activating peptide (TRAP)-induced platelet aggregation increased in CAD patients (Δ77 AU × min, 95 % confidence interval (CI): 46;107) and in healthy individuals (Δ153 AU × min, 95%CI: 75;232). Endogenous thrombin potential (ETP) was unaffected by exercise, whilst F1 + 2 increased (Δ17%, 95%CI: 11;24) in CAD patients. Fibrin clot lysis time increased by 9 % (95%CI: 1-17) in CAD patients and by 26 % (95%CI: 8;45) in healthy individuals. When comparing baseline to 2 h post-exercise, TRAP-induced platelet aggregation remained slightly elevated in both CAD patients (Δ53 AU × min, 95%CI: 22;84) and healthy individuals (Δ140 AU × min, 95%CI: 62;219). In contrast, ETP and F1 + 2 decreased in CAD patients (Δ-6 %, 95%CI: -10;-1 and Δ-8 %, 95%CI: -14;-2). Moreover, clot lysis time decreased (Δ-19 %, 95%CI: -27;-11) in patients with CAD and returned to baseline in healthy individuals. All p-values were <0.05.

CONCLUSIONS

Platelet aggregation and F1 + 2 were substantially elevated immediately after exercise in CAD patients, indicating a pro-thrombotic state. After 2 h of recovery, they exhibited a markedly increase in fibrinolysis. Similar results were observed in healthy individuals.

Impact of breast-, gastrointestinal-, and lung cancer on prognosis in patients with first-time pulmonary embolism: A Danish nationwide cohort study

BACKGROUND

Pulmonary embolism (PE) is described as a prognostic factor in patients with cancer however, the prognostic impact of PE remains unknown. This study investigated, the 1-year prognosis following PE in patients with breast-, gastrointestinal-, or lung cancer stratified by cancer status.

METHODS

All Danish patients with first-time PE from 2008 to 2018 were included. Cancer status was categorized as no cancer, history of cancer, non-active cancer and active cancer. Unadjusted and age-stratified 1-year risk of death was estimated using the Kaplan-Meier estimator. Cause of death was reported using the Aalen-Johansen method.

RESULTS

Of 35,679 patients with PE, 18% had a breast-, gastrointestinal-, or lung cancer. Patients with cancer were older compared with no cancer (69.8 years [IQR: 56.2-79.8]). One-year risk of death (95% confidence interval) for active breast-, gastrointestinal-, and lung cancer was 49.5% (44.0%-54.9%), 75.0% (72.5%-77.4%) and 80.1% (78.0%-82.3%) respectively, compared with 18.9% (18.4%-19.3%) for no cancer. Age-stratified analysis revealed no association with increasing age in non-active lung cancer and all active cancers. Further, non-cardiovascular death accounted for an increasing proportion by cancer status (no cancer < history of cancer < non-active cancer < active cancer).

CONCLUSIONS

One-year risk of death was dependent on both cancer type and status; no association with age was found for patients with active cancers. Non-cardiovascular death was leading in non-active and active cancers. Thus, the occurrence of first-time PE could be regarded as a marker of cancer severity for patients with breast-, gastrointestinal-, and lung cancer.

Protocol for a randomised controlled trial comparing warfarin with no oral anticoagulation in patients with atrial fibrillation on chronic dialysis: the Danish Warfarin-Dialysis (DANWARD) trial

INTRODUCTION

Atrial fibrillation is highly prevalent in patients on chronic dialysis. It is unclear whether anticoagulant therapy for stroke prevention is beneficial in these patients. Vitamin K-antagonists (VKA) remain the predominant anticoagulant choice. Importantly, anticoagulation remains inconsistently used and a possible benefit remains untested in randomised clinical trials comparing oral anticoagulation with no treatment in patients on chronic dialysis. The Danish Warfarin-Dialysis (DANWARD) trial aims to investigate the safety and efficacy of VKAs in patients with atrial fibrillation on chronic dialysis. The hypothesis is that VKA treatment compared with no treatment is associated with stroke risk reduction and overall benefit.

METHODS AND ANALYSIS

The DANWARD trial is an investigator-initiated trial at 13 Danish dialysis centres. In an open-label randomised clinical trial study design, a total of 718 patients with atrial fibrillation on chronic dialysis will be randomised in a 1:1 ratio to receive either standard dose VKA targeting an international normalised ratio of 2.0-3.0 or no oral anticoagulation. Principal analyses will compare the risk of a primary efficacy endpoint, stroke or transient ischaemic attack and a primary safety endpoint, major bleeding, in patients allocated to VKA treatment and no treatment, respectively. The first patient was randomised in October 2019. Patients will be followed until 1 year after the inclusion of the last patient.

ETHICS AND DISSEMINATION

The study protocol was approved by the Regional Research Ethics Committee (journal number H-18050839) and the Danish Medicines Agency (case number 2018101877). The trial is conducted in accordance with the Helsinki declaration and standards of Good Clinical Practice. Study results will be disseminated to participating sites, at research conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBERS

NCT03862859, EUDRA-CT 2018-000484-86 and CTIS ID 2022-502500-75-00.

Infrequent transition to direct oral anticoagulants in patients with cancer

INTRODUCTION

Pharmacokinetic drug-drug interactions (DDIs) are challenging aspects of direct oral anticoagulant (DOAC) therapy in patients with cancer. We evaluated the prevalence of potential DOAC/antineoplastic agent DDIs and the one-year cumulative incidence of switching from low-molecular-weight heparin (LMWH) to a DOAC in patients with cancer.

METHODS

Patients with cancer and an indication of LMWH were included from Herlev and Gentofte Hospital, Denmark, in the 2014-2019 period. Follow-up was initiated when the first dose of LMWH was dispensed. Data were obtained from electronic medical records. One-year cumulative incidence of switching from LMWH to DOAC was estimated using the Aalen-Johansen estimator. Potential DDIs were evaluated using a report from the European Heart Rhythm Association (EHRA) and a review by Hellfritzsch et al. RESULTS. A total of 161 patients were included with a median age of 70.8 (interquartile range: 64.2-76.1) years. The one-year cumulative incidence of switching from LMWH to DOAC was 32% (95% confidence intervals: 21-43%) in patients eligible for DOACs. Using the EHRA report, a total of 24% of antineoplastic agents were not identified. This percentage decreased to 8% using data from Hellfritzsch et al. CONCLUSIONS. In patients with cancer, the one-year cumulative incidence of switching from LMWH to DOAC was less-t 35% in patients eligible for DOAC, revealing a potential for improved anticoagulant treatment. Furthermore, contemporary data elaborated on potential DDIs between DOACs/antineoplastic agents.

FUNDING

"Helsefonden" (21-B-0350) and the "Karen Elise Jensens Fonden" (29-4-2021) funded the study.

TRIAL REGISTRATION

Not relevant.

Comparison of important factors to patients recovering from pulmonary embolism and items covered in patient-reported outcome measures: A mixed-methods systematic review

OBJECTIVE

Up to 50 % of patients recovering from pulmonary embolism (PE) experience negative long-term outcomes. Patient-reported outcome measures (PROMs) are important in identifying what matters to patients. We aimed to identify PROMs used in clinical studies and recommended by the International Consortium of Health Outcomes (ICHOM) and compare individual items with factors considered important by patients recovering from PE.

METHODS

This was a convergent mixed-methods systematic review, including quantitative studies, using PROMs and qualitative studies with non-cancer-related PE patients. Items from each PROM and qualitative findings were categorised using an International Classification of Function linking process to allow for integrated synthesis.

RESULTS

A total of 68 studies using 34 different PROMs with 657 items and 13 qualitative studies with 408 findings were included. A total of 104 individual ICF codes were used, and subsequently sorted into 20 distinct categories representing patient concerns. Identified PROMs were found to adequately cover 17/20 categories, including anxiety, fear of bleeding, stress, depression, dizziness/nausea, sleep disturbance, pain, dyspnea, fatigue, activity levels, family and friends, socializing, outlook on life, and medical treatment. PROMs from the ICHOM core set covered the same categories, except for dizziness/nausea.

CONCLUSIONS

No single PROM covered all aspects assessed as important by the PE population. PROMs recommended in the ICHOM core set cover 16/20 aspects. However, worrisome thoughts, hypervigilance around symptoms, and uncertainty of illness were experienced by patients with PE but were not covered by PROMS.

Myeloperoxidase Inhibition in Heart Failure With Preserved or Mildly Reduced Ejection Fraction: SATELLITE Trial Results

BACKGROUND

Inflammation is a key driver of heart failure with preserved left ventricular ejection fraction. AZD4831 inhibits extracellular myeloperoxidase, decreases inflammation, and improves microvascular function in preclinical disease models.

METHODS AND RESULTS

In this double-blind phase 2a study (Safety and Tolerability Study of AZD4831 in Patients With Heart Failure [SATELLITE]; NCT03756285), patients with symptomatic heart failure, left ventricular ejection fraction of ≥40%, and elevated B-type natriuretic peptides were randomized 2:1 to once-daily oral AZD4831 5 mg or placebo for 90 days. We aimed to assess target engagement (primary end point: myeloperoxidase specific activity) and safety of AZD4831. Owing to coronavirus disease 2019, the study was terminated early after randomizing 41 patients (median age 74.0 years, 53.7% male). Myeloperoxidase activity was decreased by more than 50% from baseline to day 30 and day 90 in the AZD4831 group, with a placebo-adjusted decreased of 75% (95% confidence interval, 48, 88, nominal P < .001). No improvements were noted in secondary or exploratory end points, apart from a trend in Kansas City Cardiomyopathy Questionnaire overall summary score. No deaths or treatment-related serious adverse events occurred. AZD4831 treatment-related adverse events were generalized maculopapular rash, pruritus, and diarrhea (all n = 1).

CONCLUSIONS

AZD4831 inhibited myeloperoxidase and was well tolerated in patients with heart failure and left ventricular ejection fraction of 40% or greater. Efficacy findings were exploratory owing to early termination, but warrant further clinical investigation of AZD4831.

LAY SUMMARY

Few treatments are available for patients with the forms of heart failure known as heart failure with preserved or mildly reduced ejection fraction. Current treatments do not target inflammation, which may play an important role in this condition. We tested a new drug called AZD4831 (mitiperstat), which decreases inflammation by inhibiting the enzyme myeloperoxidase. Among the 41 patients in our clinical trial, AZD4831 had a good safety profile and inhibited myeloperoxidase by the expected amount. Results mean we can conduct further trials to see whether AZD4831 decreases the symptoms of heart failure and improves patients' ability to participate in physical exercise.

Effect of regular exercise training on platelet function in patients with cardiovascular disease and healthy individuals: A systematic review

INTRODUCTION

Regular exercise training is essential in prevention and treatment of cardiovascular disease (CVD), yet the beneficial effects of exercise remain only partly explained. Platelets play a key role in CVD and may be affected by regular exercise training. We aimed to systematically summarise studies investigating the effect of regular exercise training on platelet function in patients with CVD and in healthy individuals.

METHODS

Studies were identified by PubMed, Embase and Web of Science May 16, 2022. We selected studies investigating markers of platelet function in relation to regular exercise training in patients with CVD and in healthy individuals. Regular exercise was defined as exercise training for four weeks or more.

RESULTS

Of the included studies, 11 investigated patients with CVD and 29 were on healthy individuals. Studies were heterogeneous regarding design, study population and methodology, and the results were ambiguous. In total, 52 different markers of platelet function were investigated with platelet aggregation, soluble P-selectin, and thromboxane B2 (TXB2) as the most frequently examined. When evaluating between-group changes after regular exercise, two studies found a reduced platelet aggregation in the exercise group whilst three studies did not find a difference between groups. With respect to TXB2, three studies reported a reduction and two studies an increase in the exercise group. There were no between-group differences in the seven studies examining soluble P-selectin.

CONCLUSION

Regular exercise training has no clear impact on platelet function in patients with CVD or healthy individuals.

PROSPERO REGISTRATION

CRD42022350539.

The angiotensin-converting enzyme I/D polymorphism does not impact training-induced adaptations in exercise capacity in patients with stable coronary artery disease

Systematic exercise training effectively improves exercise capacity in patients with coronary artery disease (CAD), but the magnitude of improvements is highly heterogeneous. We investigated whether this heterogeneity in exercise capacity gains is influenced by the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene. Patients with CAD (n = 169) were randomly assigned to 12 weeks of exercise training or standard care, and 142 patients completed the study. The ACE polymorphism was determined for 128 patients (82% males, 67 ± 9 years). Peak oxygen uptake was measured before and after the 12-week intervention. The ACE I/D polymorphism frequency was n = 48 for D/D homozygotes, n = 61 for I/D heterozygotes and n = 19 for I/I homozygotes. Baseline peak oxygen uptake was 23.3 ± 5.0 ml/kg/min in D/D homozygotes, 22.1 ± 5.3 ml/kg/min in I/D heterozygotes and 23.1 ± 6.0 ml/kg/min in I/I homozygotes, with no statistical differences between genotype groups (P = 0.50). The ACE I/D polymorphism frequency in the exercise group was n = 26 for D/D, n = 21 for I/D and n = 12 for I/I. After exercise training, peak oxygen uptake was increased (P < 0.001) in D/D homozygotes by 2.6 ± 1.7 ml/kg/min, in I/D heterozygotes by 2.7 ± 1.9 ml/kg/min, and in I/I homozygotes by 2.1 ± 1.3 ml/kg/min. However, the improvements were similar between genotype groups (time × genotype, P = 0.55). In conclusion, the ACE I/D polymorphism does not affect baseline exercise capacity or exercise capacity gains in response to 12 weeks of high-intensity exercise training in patients with stable CAD.Clinical trial registration: www.clinicaltrials.gov (NCT04268992).

Small-Area Analysis of Treatment and Clinical Outcomes in Patients with Venous Thromboembolism in Denmark: A Nationwide Cohort Study

OBJECTIVES

 To investigate geographical variation in initiation and extended treatment with anticoagulants and clinical outcomes among patients hospitalized with first-time venous thromboembolism (VTE) in Denmark between 2007 and 2018.

METHODS

 Using nationwide health care registries, we identified all patients with a first-time VTE hospital diagnosis supported by imaging data from 2007 to 2018. Patients were grouped according to residential region (5) and municipality (98) at the time of VTE diagnosis. Cumulative incidence of initiation of and extended (beyond 365 days) anticoagulation treatment as well as clinical outcomes, including recurrent VTE, major bleeding, and all-cause death, were assessed. Sex- and age-adjusted relative risks (RRs) of the outcomes were computed when comparing across individual regions and municipalities. Overall geographic variation was quantified by computing the median RR.

RESULTS

 We identified 66,840 patients with a first-time VTE hospitalization. A difference in initiation of anticoagulation treatment of more than 20 percentage points between regions was observed (range: 51.9-72.4%, median RR: 1.09, 95% confidence interval [CI]: 1.04-1.13). Variation was also observed for extended treatment (range: 34.2-46.9%, median RR: 1.08, 95% CI: 1.02-1.14). The cumulative incidence of recurrent VTE ranged from 3.6 to 5.3% at 1 year (median RR: 1.08, 95% CI: 1.01-1.15). The difference remained after 5 years, and variation was also observed for major bleeding (median RR: 1.09, 95% CI: 1.03-1.15), whereas it appeared smaller for all-cause mortality (median RR: 1.03, 95% CI: 1.01-1.05).

CONCLUSION

 Substantial geographical variation in anticoagulation treatment and clinical outcomes occurs in Denmark. These findings indicate a need for initiatives to ensure uniform high-quality care for all VTE patients.

Prognostic Value of Coronary CT Angiography-derived Fractional Flow Reserve on 3-year Outcomes in Patients with Stable Angina

Background The prognostic value of coronary CT angiography (CTA)-derived fractional flow reserve (FFR) beyond 1-year outcomes and in patients with high levels of coronary artery calcium (CAC) is uncertain. Purpose To assess the prognostic value of coronary CTA-derived FFR test results on 3-year clinical outcomes in patients with coronary stenosis and among a subgroup of patients with high levels of CAC. Materials and Methods This study represents a 3-year follow-up of patients with new-onset stable angina pectoris who were consecutively enrolled in the Assessing Diagnostic Value of Noninvasive CT-FFR in Coronary Care, known as ADVANCE (ClinicalTrials.gov: NCT02499679) registry, between December 2015 and October 2017 at three Danish sites. A high CAC was defined as an Agatston score of at least 400. A lesion-specific coronary CTA-derived FFR value of 2 cm with distal-to-stenosis value at or below 0.80 represented an abnormal test result. The primary end point was a composite of all-cause death and nonfatal spontaneous myocardial infarction. Event rates were estimated using the one-sample binomial model, and relative risk was compared between participants stratified by results of coronary CTA-derived FFR. Results This study included 900 participants: 523 participants with normal results (mean age, 64 years ± 9.6 [SD]; 318 male participants) and 377 with abnormal results from coronary CTA-derived FFR (mean age, 65 years ± 9.6; 264 male participants). The primary end point occurred in 11 of 523 (2.1%) and 25 of 377 (6.6%) participants with normal and abnormal coronary CTA-derived FFR results, respectively (relative risk, 3.1; 95% CI: 1.6, 6.3; P < .001). In participants with high CAC, the primary end point occurred in four of 182 (2.2%) and 19 of 212 (9.0%) participants with normal and abnormal coronary CTA-derived FFR results, respectively (relative risk, 4.1; 95% CI: 1.4, 11.8; P = .001). Conclusion In individuals with stable angina, a normal coronary CTA-derived FFR test result identified participants with a low 3-year risk of all-cause death or nonfatal spontaneous myocardial infarction, both in the overall cohort and in participants with high CAC scores. Clinical trial registration no. NCT02499679 Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Sinitsyn in this issue.

Myeloperoxidase Inhibition Reverses Biomarker Profiles Associated With Clinical Outcomes in HFpEF

BACKGROUND

Systemic microvascular dysfunction and inflammation are postulated to play a pathophysiologic role in heart failure with preserved ejection fraction (HFpEF).

OBJECTIVES

This study aimed to identify biomarker profiles associated with clinical outcomes in HFpEF and investigate how inhibition of the neutrophil-derived reactive oxygen species-producing enzyme, myeloperoxidase, affects these biomarkers.

METHODS

Using supervised principal component analyses, the investigators assessed the associations between baseline plasma proteomic Olink biomarkers and clinical outcomes in 3 independent observational HFpEF cohorts (n = 86, n = 216, and n = 242). These profiles were then compared with the biomarker profiles discriminating patients treated with active drug vs placebo in SATELLITE (Safety and Tolerability Study of AZD4831 in Patients With Heart Failure), a double-blind randomized 3-month trial evaluating safety and tolerability of the myeloperoxidase inhibitor AZD4831 in HFpEF (n = 41). Pathophysiological pathways were inferred from the biomarker profiles by interrogation of the Ingenuity Knowledge database.

RESULTS

TNF-R1, TRAIL-R2, GDF15, U-PAR, and ADM were the top individual biomarkers associated with heart failure hospitalization or death, and FABP4, HGF, RARRES2, CSTB, and FGF23 were associated with lower functional capacity and poorer quality of life. AZD4831 downregulated many markers (most significantly CDCP1, PRELP, CX3CL1, LIFR, VSIG2). There was remarkable consistency among pathways associated with clinical outcomes in the observational HFpEF cohorts, the top canonical pathways being associated with tumor microenvironments, wound healing signaling, and cardiac hypertrophy signaling. These pathways were predicted to be downregulated in AZD4831 relative to placebo-treated patients.

CONCLUSIONS

Biomarker pathways that were most strongly associated with clinical outcomes were also the ones reduced by AZD4831. These results support the further investigation of myeloperoxidase inhibition in HFpEF.

High bleeding risk in all-comers with ST-segment elevation myocardial infarction and use of P2Y12-inhibitiors

Background

Bleeding has an important prognostic impact in patients with ST-segment elevation myocardial infarction (STEMI), yet stratification of bleeding risk to guide dual antiplatelet therapy (DAPT) is not routinely performed in clinical practice.

Purpose

To describe high bleeding risk (HBR) patients according to the PRECISE-DAPT (predicting bleeding complications in patients undergoing stent implantation and subsequent DAPT) score and use of P2Y12-inhibitors.

Methods

This single-centre observational study included consecutive patients with STEMI who were treated with percutaneous coronary intervention (PCI) from 2009–2016. Individual linkage to Danish nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Age, prior bleeding diagnosis, and blood samples before PCI (maximum 30 days before hospitalisation) were used to calculate the PRECISE-DAPT score. A score ≥25 was considered as HBR. Due to 26.7% missing on blood parameters (mainly leucocytes), the maximum and minimum values of the missing parameters and respective imputed PRECISE-DAPT scores were calculated. If both the maximum and minimum score were ≥25 or &lt;25, patients were categorised accordingly, and a maximum score of ≥25 and minimum score of &lt;25 as missing. Differences between continuous (median [interquartile range, IQR]) and categorical variables (frequency [percentage]) were assessed using Wilcoxon rank-sum and χ2-test for patients with vs. without HBR. Cumulative incidence of major bleeding (composite of bleedings leading to hospitalisation) and major adverse cardiovascular events (MACE) (composite of all-cause mortality, recurrent MI, and ischemic stroke) 1 year after PCI were plotted for patients with and without HBR. Number of HBR patients alive and collecting a P2Y12-inhibitor prescription within 30 days from discharge was reported.

Results

We identified 6179 PCI-treated patients with STEMI, of whom 5530 (89.5%) had imputed PRECISE-DAPT scores (Figure 1). A total of 1821 (32.9%) were at HBR, and these were more often female (38.3 vs. 18.2%, p-value&lt;0.001), elderly (median age 75 [IQR 67, 81] vs. 57 years [IQR 51, 64], p-value&lt;0.001), and had more comorbidities (diabetes [16.7 vs. 12.1%], heart failure [16.2 vs. 7.6%], cardiac arrhythmia [24.9 vs. 12.3%], cancer [17.5 vs. 5.7%], and ischemic stroke [8.1 vs. 2.6%], all p-values&lt;0.001) compared with patients not at HBR. One-year cumulative incidence of major bleeding and MACE for patients with and without HBR were plotted (Figure 2). Of the 1431 (78.6%) HBR patients who were alive and claimed a P2Y12-inhibitior prescription 30 days from discharge, 459 (32.1%) were treated with clopidogrel, 672 (46.9%) with ticagrelor, and 300 (21.0%) with prasugrel (Figure 1).

Conclusion

Every third PCI-treated all-comer with STEMI was at HBR according to the PRECISE-DAPT score. HBR patients were more often treated with potent P2Y12-inhibitors (prasugrel or ticagrelor) instead of clopidogrel.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

Prognostic value of FFRCT in patients with stable chest pain – a 3-year follow-up of the ADVANCE-DK registry

Introduction

The short-term safety of using coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) to guide downstream testing after CTA is well documented. Whether the prognostic information provided by FFRCT can be extended to sustained follow-up and to patients with a high degree of coronary artery calcification (CAC) is unknown.

Purpose

To evaluate the association between FFRCT and clinical outcomes in new onset stable symptomatic patients with coronary stenosis up to 3 years after CTA index testing.

Methods

Multicenter 3-year follow-up study of 900 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. The criterium for an abnormal FFRCT test result was an FFRCT value ≤0.80 (2 cm distal to stenosis). High CAC was defined as a CAC score ≥400. The primary endpoint (PE) was a composite of all-cause death and spontaneous myocardial infarction (MI). The secondary endpoint (SE) was a composite of cardiovascular (CV) death and spontaneous MI. Events were adjudicated by an independent clinical committee.

Results

Patient characteristics are given in Table 1. Coronary stenosis ≥50% was present in 750 (83%) patients. In total 36 patients suffered a PE (all-cause death, n=24; MI, n=12) and 22 an SE (CV death, n=10; MI, n=12). An abnormal vs a normal FFRCT test result was associated with an increased risk of the PE and of the SE both overall and in patients with high CAC; PE (all), 6.6% vs 2.1%, relative risk (RR): 3.1; 95% CI: 1.6–6.3, p&lt;0.001, SE (all), 5.0% vs 0.6%, RR: 8.7; 95% CI: non assessable, p&lt;0.001, PE (high CAC), 9.0% vs 2.2%, RR: 4.1; 85% CI: 1.4–11.8, p=0.001, and SE (high CAC), 6.6% vs 0.5%, RR: 12.0; 95% CI: non assessable, p=0.01, respectively, Figure 1. The observed increased risk in patients with an abnormal vs a normal FFRCT test result persisted after adjustment for degree of stenosis by CCTA (&lt; / ≥50%) and amount of CAC (&lt; / ≥400): PE, adjusted RR: 2.5; 95% CI: 1.2–5.2, p=0.02, and SE, adjusted RR: 8.0; 95% CI: 2.1–30.2, p=0.002.

Conclusion

Patients with stable chest pain, stenosis by CTA and a normal FFRCT test result have a low risk of adverse outcomes during 3 years of follow-up. An abnormal FFRCT identifies patients at increased risk of death or spontaneous MI. These associations are consistent in patients with high levels of CAC.

Funding Acknowledgement

Type of funding sources: None.

FFRCT and recurrent symptoms in patients with stable chest pain

Introduction

The major benefit of coronary revascularization when compared with optimal medical treatment (OMT) in patients with stable chest pain (CP) relates to improvement of symptoms and reduction of reinterventions. Non-invasive methods are warranted to discriminate between patients at low and high risk of recurrent CP for subsequent guidance of antianginal treatment (invasive or OMT).

Purpose

To evaluate the association between coronary CT angiography (CTA) derived fractional flow reserve (FFRCT), recurrent CP and quality of life (QOL) in patients with new onset stable CP and stenosis by CTA.

Methods

Multicenter cohort 3-year follow-up sub-study of 769 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. An abnormal FFRCT was defined as the lowest in vessel FFRCT value ≤0.80. Patients were classified according to completeness of revascularization by FFRCT: 1) completely revascularized (CR-FFRCT), all coronary arteries with an abnormal FFRCT test result revascularized; 2) incompletely revascularized (IR-FFRCT), ≥1 coronary artery with an abnormal FFRCT test result not revascularized. All patients completed the Seattle Angina Questionnaire (SAQ-7), the EuroQol questionnaire (EQ-5D-5L) and graded (0–100) overall health using the EQ VAS scale at 3-year follow-up. Recurrent CP was defined as CP within the last 4 weeks prior to this follow-up.

Results

Patient characteristics are given in Table 1. At follow-up 23% patients reported recurrent CP. An abnormal vs a normal FFRCT increased the risk of recurrent CP, 27% vs 15%, RR: 1.82; 95% CI: 1.31–2.52, p&lt;0.001. Amongst patients with abnormal FFRCT, revascularization (+/−) was associated to a numerical, but not statistical significantly, reduced risk of recurrent CP, 23% vs 30%, RR: 0.76; 95% CI: 0.56–1.03, p=0.07. IR-FFRCT vs CR-FFRCT had a higher risk for recurrent CP, 31% vs 13%, RR: 2.34; 95% CI: 1.48–3.68, p&lt;0.001, whilst no difference was observed for CR-FFRCT vs normal FFRCT, 13% vs 15%, RR: 0.92; 95% CI: 0.54–1.54, p=0.74. IR-FFRCT vs CR-FFRCT or normal FFRCT, had lower SAQ-7, EQ-5D-5L and EQ-VAS scores, Table 1, all p&lt;0.005. Scores for three selected SAQ-7 domains are shown in Figure 1. Use of antianginal medicine was higher in IR-FFRCT compared to CR-FFRCT and normal FFRCT, mean ± SD: 1.2±0.05 vs 1.0±0.04, p=0.02.

Conclusion

An abnormal FFRCT identifies patients with an increased risk of recurrent CP up to 3 years after index testing. Completeness of revascularization by FFRCT reclassifies patients with abnormal FFRCT into groups with low and high risk for recurrent CP and impaired QOL.

Funding Acknowledgement

Type of funding sources: None.

Completeness of revascularization by FFRCT and prognosis in stable chest pain

Introduction

Major randomized trials of patients with stable chest pain (CP) demonstrated no prognostic benefits of coronary revascularization over optimal medical treatment (OMT). However, in a recent large-scale study, completeness of revascularization was associated with a reduced risk of all-cause death and non-fatal myocardial infarction (MI).

Purpose

To evaluate the association between completeness of revascularization relative to the result of coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) and 3-year prognosis in patients with new onset stable CP and coronary stenosis.

Methods

Multicenter cohort 3-year follow-up sub-study of 900 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. The FFRCT result was abnormal when ≤0.80 (2 cm distal to stenosis). Patients were classified according to completeness of revascularization by FFRCT: 1) completely revascularized (CR-FFRCT), all coronary arteries with an abnormal FFRCT test result revascularized; 2) incompletely revascularized (IR-FFRCT), ≥1 coronary artery with an abnormal FFRCT test result not revascularized. The primary endpoint (PE) was a composite of all-cause death and spontaneous MI. The secondary endpoint (SE) was a composite of cardiovascular (CV) death and spontaneous MI.

Results

Patient characteristics are given in Table 1. In total 36 (4.0%) patients suffered a PE (all-cause death, n=24; MI, n=12) and 22 (2.4%) an SE (CV death, n=10; MI, n=12). Overall, an abnormal vs a normal FFRCT test result was associated with an increased risk of both the PE, 6.6% vs 2.1%, relative risk (RR): 3.1; 95% CI: 1.6–6.3, p&lt;0.001 and of the SE, 5.0% vs 0.6%, RR: 8.7; 95% CI: non assessable, p&lt;0.001. In patients with abnormal FFRCT, revascularization vs no revascularization did not reduce the risk of the PE or the SE (data not shown). Patients with IR-FFRCT vs CR-FFRCT had a numerical, but not statistical significantly, increased risk of the PE, 8.6% vs 4.2%, RR: 2.14; 95% CI: 0.87–5.26, p=0.10), and an increased risk of the SE, 7.1% vs 2.4%, RR: 3.13; 95% CI: 1.02–9.63, p=0.04, Figure 1. In CR-FFRCT versus normal FFRCT no difference in the risk of the PE or the SE was observed, Figure 1. Univariate sensitivity analyses performed in the IR-FFRCT group did not reveal any differences in the risk of the PE or the SE after adjustment for neither statin therapy at follow-up (−/+), baseline risk variables (&lt; / ≥3), amount of CAC (&lt; / ≥400), degree of stenosis by CTA (&lt; / ≥50%) nor referral to ICA (−/+).

Conclusion

In symptomatic patients with coronary stenosis by CTA, incomplete revascularization determined by FFRCT is associated with an increased risk of adverse cardiovascular outcomes compared to complete revascularization.

Funding Acknowledgement

Type of funding sources: None.

Effect of supervised high-intensity interval training on haemostasis in patients with coronary artery disease: a randomised controlled trial

Background

Regular exercise training is recommended for patients with stable coronary artery disease (CAD), because it improves quality of life and reduces cardiovascular mortality and hospital admissions. CAD patients benefit from anti-thrombotic therapy and may have a pro-coagulant condition compared to healthy individuals. Long-term exercise training may reduce platelet aggregation and coagulation and increase fibrinolysis.

Purpose

We aimed to investigate if supervised high-intensity interval training affects haemostasis in patients with stable CAD.

Methods

We randomised stable CAD patients to supervised high-intensity interval training or standard care. High-intensity exercise training was performed on rowing ergometers three times weekly for 12 weeks. Blood samples were obtained in all patients prior to randomisation (baseline) and after 6 and 12 weeks. We evaluated platelet aggregation with the Multiplate® Analyzer, thrombin generation using the Calibrated Automated Thrombogram and fibrinolysis employing an in-house clot lysis assay. Between group differences were evaluated with mixed model analysis using SPSS. According to our sample size calculation, we have a statistical power of 88% to detect a difference of 25% in clot lysis time.

Results

A total of 142 patients with stable CAD (mean age 67±9 years, 83% males) completed the study; 64 in the exercise group and 78 in the control group. The weekly average active training duration was 54 min, and adherence to training was 97%. When comparing the two groups (exercise vs. standard care) from baseline to post intervention, we found no significant changes in ADP-induced platelet aggregation (difference between baseline and 12 weeks (Δ) 11 AU·min, 95% confidence interval (CI): −46–68 in the exercise group and Δ24 AU·min, 95% CI: −28–77 in the standard care group, p=0.52), thrombin generation (endogenous thrombin potential Δ45 nM·min, 95% CI: −77–166 in the exercise group and Δ103 nM·min, 95% CI: −7–212 in the standard care group, p=0.18) or fibrinolysis (50% clot lysis time Δ62 sec, 95% CI: −136–261 in the exercise group and Δ215 sec, 95% CI: 38–391 in the standard care group, p=0.39).

Conclusion

High-intensity interval training did not have major effects on platelet aggregation, thrombin generation nor fibrinolysis in patients with stable CAD.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Aarhus UniversityThe Faroese Health Research Foundation (Sjúkrakassagrunnurin)

Influence of intensive lipid-lowering on CT derived fractional flow reserve in patients with stable chest pain: Rationale and design of the FLOWPROMOTE study

INTRODUCTION

Coronary CT angiography (CTA) derived fractional flow reserve (FFR_CT ) shows high diagnostic performance when compared to invasively measured FFR. Presence and extent of low attenuation plaque density have been shown to be associated with abnormal physiology by measured FFR. Moreover, it is well established that statin therapy reduces the rate of plaque progression and results in morphology alterations underlying atherosclerosis. However, the interplay between lipid lowering treatment, plaque regression, and the coronary physiology has not previously been investigated.

AIM

To test whether lipid lowering therapy is associated with significant improvement in FFR_CT , and whether there is a dose-response relationship between lipid lowering intensity, plaque regression, and coronary flow recovery.

METHODS

Investigator driven, prospective, multicenter, randomized study of patients with stable angina, coronary stenosis ≥50% determined by clinically indicated first-line CTA, and FFR_CT  ≤ 0.80 in whom coronary revascularization was deferred. Patients are randomized to standard (atorvastatin 40 mg daily) or intensive (rosuvastatin 40 mg + ezetimibe 10 mg daily) lipid lowering therapy for 18 months. Coronary CTA scans with blinded coronary plaque and FFR_CT analyses will be repeated after 9 and 18 months. The primary endpoint is the 18-month difference in FFR_CT using (1) the FFR_CT value 2 cm distal to stenosis and (2) the lowest distal value in the vessel of interest. A total of 104 patients will be included in the study.

CONCLUSION

The results of this study will provide novel insights into the interplay between lipid lowering, and the pathophysiology in coronary artery disease.

Safety and efficacy of the 5-lipoxygenase-activating protein inhibitor AZD5718 in patients with recent myocardial infarction: The phase 2a FLAVOUR study

BACKGROUND

Leukotrienes are pro-inflammatory vasoactive lipid mediators implicated in the pathophysiology of atherosclerotic cardiovascular disease. We studied the effect of the 5-lipoxygenase-activating protein inhibitor AZD5718 on leukotriene biosynthesis and coronary microvascular function in a single-blind, phase 2a study.

METHODS

Patients 7-28 days after myocardial infarction (±ST elevation), with <50% left anterior descending coronary artery stenosis and Thrombolysis in Myocardial Infarction flow grade ≥ 2 after percutaneous coronary intervention, were randomized 2:1:2 to once-daily AZD5718 200 mg or 50 mg, or placebo, in 4- and 12-week cohorts. Change in urine leukotriene E₄ (uLTE₄) was the primary endpoint, and coronary flow velocity reserve (CFVR; via echocardiography) was the key secondary endpoint.

RESULTS

Of 129 randomized patients, 128 received treatment (200 mg, n = 52; 50 mg, n = 25; placebo, n = 51). Statistically significant reductions in uLTE₄ levels of >80% were observed in both AZD5718 groups versus the placebo group at 4 and 12 weeks. No significant changes in CFVR were observed for AZD5718 versus placebo. Adverse events (AEs) occurred in 12/18, 3/6 and 6/13 patients receiving 200 mg, 50 mg and placebo, respectively, in the 4-week cohort, and in 27/34, 14/19 and 24/38 patients, respectively, in the 12-week cohort. Serious AEs in seven patients receiving AZD5718 and four receiving placebo were not treatment-related, and there were no deaths.

CONCLUSIONS

In patients with recent myocardial infarction, AZD5718 was well tolerated, and leukotriene biosynthesis was dose-dependently inhibited. No significant changes in CFVR were detected.

CLINICALTRIALS

gov identifier: NCT03317002.

Initiation of and persistence with P2Y12 inhibitors in patients with myocardial infarction according to revascularization strategy: a nationwide study

BACKGROUND

We aimed to analyse initiation of and persistence with P2Y12 inhibitors after first-time myocardial infarction (MI).

METHODS AND RESULTS

Using Danish nationwide registries, we identified patients ≥30 years with first-time MI during 1 January 2005-30 June 2016 and subsequent prescriptions of P2Y12 inhibitors. Independent factors related to initiation of and persistence with P2Y12 inhibitors were analysed by multivariable logistic regression and a Cox proportional hazards model. Patients were stratified by revascularization strategy: percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or medical therapy alone (MTA). Overall, 79 597 MI patients were included with 39 172 undergoing PCI, 2619 CABG, and 16 640 MTA, showing initiation of P2Y12 inhibitors of 93.4%, 49.0%, and 51.5%, respectively. Congestive heart failure, cerebrovascular disease, cardiac dysrhythmias, renal failure, previous bleeding, and oral anticoagulants were associated with less initiation of P2Y12 inhibitors. Female sex was associated with less initiation of P2Y12 inhibitors following MTA. MTA, coronary angiography, cerebrovascular disease, diabetes with complications, previous bleeding, antidiabetics, and ticagrelor as P2Y12 inhibitor were associated with non-persistence, whereas female sex, advanced age, and concomitant pharmacotherapy with angiotensin-converting enzyme inhibitors, beta-blockers, statins, oral anticoagulants, and aspirin were associated with high persistence.

CONCLUSION

Initiation of P2Y12 inhibitors in PCI-treated MI patients was high in contrast to those treated with CABG or MTA and patients with certain comorbidities. Further studies on the benefit-risk ratio of P2Y12 inhibitors in CABG-treated or MTA-treated patients and patients with comorbidities after first-time MI are warranted, as is focus on persistence among patients receiving MTA, patients with comorbidities, and users of ticagrelor.

Different perceptions of thorax anatomy and hand placement for chest compressions among healthcare professionals and laypersons: Implications for cardiopulmonary resuscitation

Aim

The European Resuscitation Council guidelines recommend that the hand position for chest compressions is obtained by “placing the heel of your hand in the centre of the chest”. Importantly, guidelines are based on a study on healthcare professionals being extrapolated to laypersons. This study explored whether healthcare professionals and laypersons differ in anatomical knowledge necessary for obtaining the correct hand position for chest compressions and understanding of European Resuscitation Council guideline recommendations in the absence of a demonstration.

Methods

We asked laypersons and healthcare professionals to identify where to place the hands for chest compressions on digital pictures of the chest of a man and a woman. Both groups were asked to identify where to place the hands for chest compressions, the left nipple (positive control), the centre of the chest and to delineate the anterior area of the chest.

Results

In total, 50 laypersons and 50 healthcare professionals were included. Healthcare professionals were significantly better at identifying the correct hand position for chest compressions compared to laypersons (male chest: P = 0.03, female chest: P < 0.0001) and delineating the anterior area of the chest. We found no significant difference between groups when instructed to identify the left nipple nor the centre of the chest (male chest: P = 0.57, female chest: P = 0.50).

Conclusion

Laypersons and healthcare professionals have different perceptions of chest anatomy and where to perform chest compressions suggesting that caution should be taken when extrapolating results from healthcare professionals to laypersons. The ERC 2015 guideline recommendations on hand placement for chest compressions seems understandable by both laypersons and healthcare professionals.

Coronary CT angiography derived FFR in patients with left main disease

The presence of left main coronary artery disease (LMCAD) is associated with an unfavorable clinical outcome. The clinical utility of FFR_CT testing for non-invasive physiological assessment in LMCAD remains largely unknown. In this single center observational study LMCAD patients were retrospectively identified between November 2015 and December 2017. We evaluated the relationship between LMCAD diameter stenosis and downstream FFR_CT values, and the clinical consequences following FFR_CT testing in patients with LMCAD. The composite endpoint (all-cause death, myocardial infarction, unplanned revascularization) was determined over a median follow-up of 1.1 years. LMCAD was registered in 432 of 3202 (13%) patients having coronary CTA. FFR_CT was prescribed in 213 (49%), while 59 (14%) patients were referred directly to invasive angiography or myocardial perfusion imaging. FFR_CT was performed in 195 (45%) patients. LM stenosis severity was inversely related to downstream FFR_CT values. In patients with simple LMCAD with stenosis ≥ 50%, > 80% had FFR_CT > 0.80 in non-diseased proximal and downstream segments (n = 7). No patients with simple LMCAD and FFR_CT > 0.80 (n = 20) suffered an adverse clinical outcome. FFR_CT testing in patients with LMCAD is feasible. LM stenosis severity is inversely related to FFR_CT value. Patients with LMCAD and FFR_CT > 0.80 have favorable clinical outcomes at short-term follow-up. Large-scale studies assessing the clinical utility and safety of deferring invasive catheterization following FFR_CT testing in patients with LMCAD are warranted.

Coronary Flow Velocity Reserve and Myocardial Deformation Predict Long-Term Outcomes in Heart Transplant Recipients

BACKGROUND

After heart transplantation (HTx), invasive coronary angiography is the gold standard for surveillance of cardiac allograft vasculopathy (CAV). Noninvasive CAV surveillance is desirable. The authors examined left ventricular global longitudinal strain (LVGLS) and noninvasive coronary flow velocity reserve (CFVR) related to CAV and prognosis after HTx.

METHODS

Doppler echocardiographic CFVR and LVGLS were evaluated in 98 HTx patients. All-cause mortality and major adverse cardiac events (MACE), including hospitalization for heart failure, cardiovascular death, and significant CAV progression, were recorded.

RESULTS

Median follow-up duration was 3.3 years (range: 1.7-5.4 years). Patients with low CFVR (<2.0; n = 20) showed reduced MACE-free survival (hazard ratio, 4.3; 95% CI, 2.2-8.4; P < .0001) and increased all-cause mortality (hazard ratio: 4.7; 95% CI: 2.0-11.3; P < .0001) compared with patients with high CFVR (≥2.0; n = 78). Worsened LVGLS (≥-15.5%) was also a strong independent predictor of MACE and cardiovascular and all-cause mortality. Combined low CFVR and worsened LVGLS provided incremental prognostic value, even after adjustment for CAV and time since HTx. The prevalence of low CFVR increased significantly with CAV severity, and the prevalence of combined low CFVR and/or worsened LVGLS was high in patients with moderate CAV (86%) and those with severe CAV (83%). The negative predictive value of combined high CFVR and improved LVGLS to rule out significant CAV was 94.5% (95% CI, 86.2%-98.4%), whereas the positive predictive value was 39.0% (95% CI, 25.3%-54.3%). The model had sensitivity of 84.2% (95% CI, 63.6%-95.3%) and specificity of 67.5% (95% CI, 56.6%-77.2%) for one or more abnormal parameters.

CONCLUSIONS

In HTx patients with severe CAV, a higher prevalence of low CFVR and worsened LVGLS was observed. Both measurements were strong independent predictors of MACE and all-cause mortality in HTx patients. Combined CFVR and LVGLS provided incremental prognostic value and showed an excellent ability to rule out significant CAV and may be considered as part of routine CAV surveillance of HTx patients.

Reduction of Myocardial Infarction and All-Cause Mortality Associated to Statins in Patients Without Obstructive CAD

OBJECTIVE

The aim of this work was to evaluate the prognostic impact of statin therapy in symptomatic patients without obstructive CAD.

BACKGROUND

Information on the prognostic impact of post-coronary computed tomographic angiography (CTA) statin use in patients with no or nonobstructive coronary artery disease (CAD) is sparse.

METHODS

Patients undergoing CTA with suspected CAD in western Denmark from 2008 to 2017 with <50% coronary stenoses were identified. Information on post-CTA use of statin therapy and cardiovascular events were obtained from national registries.

RESULTS

The study included 33,552 patients, median aged 56 years, 58% female, with no (n = 19,669) or nonobstructive (n = 13,883) CAD and a median follow-up of 3.5 years. The absolute risk of the combined end point of myocardial infarction (MI) or all-cause mortality was directly associated with the CAD burden with an event rate/1,000 patient-years of 4.13 (95% CI: 3.69-4.61) in no, 7.74 (95% CI: 6.88-8.71) in mild (coronary artery calcium score [CACS] 0-99), 13.72 (95% CI: 11.61-16.23) in moderate (CACS 100-399), and 32.47 (95% CI: 26.25-40.16) in severe (CACS ≥400) nonobstructive CAD. Statin therapy was associated with a multivariable adjusted HR for MI and death of 0.52 (95% CI: 0.36-0.75) in no, 0.44 (95% CI: 0.32-0.62) in mild, 0.51 (95% CI: 0.34-0.75) in moderate, and 0.52 (95% CI: 0.32-0.86) in severe nonobstructive CAD. The estimated numbers needed to treat to prevent the primary end point were 92 (95% CI: 61-182) in no, 36 (95% CI: 26-58) in mild, 24 (95% CI: 15-61) in moderate, and 13 (95% CI: 7-86) in severe nonobstructive CAD. Residual confounding may persist, but not to an extent explaining all of the observed risk reduction associated with statin treatment.

CONCLUSIONS

The risk of MI and all-cause mortality in patients without obstructive CAD is directly associated with the CAD burden. Statin therapy is associated with a reduction of MI and all-cause death across the spectrum of CAD, however, the absolute benefit of treatment is directionally proportional with the CAD burden.

Effectiveness and safety of oral anticoagulation treatment beyond 1 year after venous thromboembolism in patients at intermediate recurrence risk

Effectiveness and safety of long-term anticoagulation treatment are uncertain in venous thromboembolism (VTE) patients at intermediate risk of recurrence. We examined the association between treatment beyond 1 year and outcomes in a Danish nationwide register-based study. VTE patients at intermediate risk of recurrence, that is, non-cancer patients with a first-time unprovoked VTE, who started oral anticoagulation treatment within 30 days and were alive 365 days after the index VTE were included and followed between 2007 and 2015. Exposure was extended (>365 days) or intermediate (91-365 days) treatment. Analyses were done using Cox regression on a propensity score weighted population. We included 18 609 patients with 7232 (38.9%) receiving extended treatment. Mean duration of follow-up was 2.6 years. Compared with intermediate treatment, treatment beyond 365 days was associated with a lower weighted risk of recurrent VTE (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.49-0.65) and all-cause mortality (HR 0.81, 95% CI 0.72-0.90) and an increased risk of major bleeding (HR 1.87, 95% CI 1.58-2.22). In conclusion, extended anticoagulation treatment (predominantly warfarin) beyond 1 year was in real-life settings associated with a lower risk of recurrent VTE and all-cause mortality among VTE patients with an intermediate risk of recurrence. However, an increased bleeding risk should be considered.

Low-dose aspirin for primary and secondary prevention of cardiovascular events in Denmark 1998-2018

Randomised controlled trials have shown a neutral or even unfavourable risk–benefit balance of aspirin for primary prevention of cardiovascular events. Using Danish nationwide registries, we investigated aspirin use and associated risks during the past two decades (1998–2018). We linked individual patient data on repeated aspirin redemptions with registered hospital ICD-10 diagnoses of atherosclerotic cardiovascular disease and bleedings. The prevalence of aspirin use among 1.1 million Danish adults fluctuated over the 20-year study period peaking in 2008 with 8.5% (5.4% primary prevention) and dropping to 5.1% (3.1% primary prevention) in 2018. Aspirin use showed strong age dependency, and 21% of individuals > 80 years were treated with aspirin for primary prevention in 2018. Medication adding to bleeding risk was used concurrently by 21% of all aspirin users in 2018. The incidence of major bleedings were similar with primary and secondary prevention aspirin use and highest in elderly (2 per 100 patient years among individuals > 80 years in 2018). In conclusion, low-dose aspirin use for primary prevention of cardiovascular events remains prevalent. The widespread use of aspirin, especially among older adults, and substantial concomitant use of medications adding to bleeding risk warrant increased focus on discontinuation of inappropriate aspirin use.

Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure

Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.

Real-world use of cardioprotective glucose-lowering drugs in patients with type 2 diabetes and cardiovascular disease: A Danish nationwide cohort study, 2012 to 2019

AIMS

To investigate temporal trends in time to initiation of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide 1 analogues (cardioprotective glucose-lowering drugs [GLDs]) in patients with a new dual diagnosis of type 2 diabetes (T2DM) and cardiovascular disease (CVD).

MATERIALS AND METHODS

In a cohort study, we identified patients with a new dual diagnosis of T2DM and CVD using linked healthcare data from nationwide registries on drug prescriptions and diagnosis codes. For each calendar year between 2012 and 2018, we examined time to initiation and cumulative user proportions (CUPs) for cardioprotective GLD use 1 and 2 years after the dual diagnosis.

RESULTS

Among all individuals living in Denmark in the period 2012 to 2018, 41 733 patients with a new dual diagnosis of T2DM and CVD were identified (median [interquartile range] age 71 [64-79] years, 61% male, and 57% with CVD as the latest diagnosis). Incidence curve slopes and 1- and 2-year CUPs for cardioprotective GLDs increased during the study period (1-year CUP 4.0%, 95% confidence interval [CI] 3.6-4.5) in 2012 to 14.7, 95% CI 13.7-15.7, in 2018; 2-year CUP 5.5, 95% CI 5.0-6.1, in 2012 to 16.7, 95% CI 15.8-17.7, in 2017). T2DM patients with CVD as the second (latest) diagnosis had higher 1-year CUPs than CVD patients with T2DM as the latest diagnosis: 2012: 7.0 (95% CI 6.2-8.0) versus 1.4 (95% CI 1.0-1.8); 2018: 18.1 (95% CI 16.8-19.6) versus 10.0 (95% CI 8.8-11.3).

CONCLUSIONS

In patients with T2DM and CVD, the incidence of cardioprotective GLD initiation increased between 2012 and 2018, however, within 2 years of dual diagnosis, it remained low.

Efficacy and Safety of Oral Anticoagulants in Patients with Systolic Heart Failure in Sinus Rhythm: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Cohort Studies

Introduction  There is conflicting evidence on the risk–benefit ratio of oral anticoagulants (OAC) in heart failure (HF) patients without atrial fibrillation. We aimed to evaluate the efficacy and safety of OAC in HF patients in sinus rhythm.

Methods  A systematic literature search was conducted using PubMed and Embase. We included randomized controlled trials (RCT) and cohort studies, comparing OAC with antiplatelet or no treatment/placebo in patients with HF. Outcomes evaluated were stroke, myocardial infarction (MI), all-cause mortality, and major bleeding.

Results  Five RCTs and three cohort studies were included. OAC was associated with a reduced risk of ischemic stroke when compared with no treatment/placebo (odds ratio [OR] = 0.67, 95% confidence interval [CI]: [0.47, 0.94]) and antiplatelet therapy (OR = 0.55, 95% CI: [0.37, 0.81]). No significant reduction was found in MI, when OAC was compared with no treatment/placebo (OR = 0.82, 95% CI: [0.63, 1.07]) or antiplatelet therapy (OR = 1.04, 95% CI: [0.60, 1.81]). The all-cause mortality analysis showed no significant reduction when comparing OAC with no treatment/placebo (OR = 0.99, 95% CI: [0.87, 1.12]) or antiplatelet therapy (OR = 1.00, 95% CI: [0.86, 1.16]). The nonsignificant effect of OAC on all-cause mortality was supported by a meta-analysis of the three cohort studies (OR = 1.02, 95% CI: [0.75, 1.38]). Patients treated with OAC had a significantly higher risk of major bleeding than patients receiving antiplatelet therapy (OR = 2.16, 95% CI: [1.55, 3.00]) and a numerically higher risk when compared with no treatment/placebo (OR = 2.38, 95% CI: [0.87, 6.49]).

Conclusion  The present study does not support the routine use of OAC in patients with HF in sinus rhythm.

Design and rationale of FLAVOUR: A phase IIa efficacy study of the 5-lipoxygenase activating protein antagonist AZD5718 in patients with recent myocardial infarction

Patients with coronary artery disease remain at increased risk of recurrent life-threatening cardiovascular events even after adequate guideline-based treatment of conventional risk factors, including blood lipid levels. Inflammation is a critical pathway in the pathogenesis of atherosclerosis and is independently associated with risk of recurrent cardiovascular events. Leukotrienes are potent pro-inflammatory and vasoactive mediators synthesized by leukocytes in atherosclerotic lesions. AZD5718 is a novel antagonist of 5-lipoxygenase activating protein that suppresses leukotriene biosynthesis. FLAVOUR is a phase IIa efficacy and safety study of AZD5718 in patients with myocardial infarction 1-4 weeks before randomization. Stenosis of the left anterior descending coronary artery after percutaneous intervention must be <50%, and Thrombolysis In Myocardial Infarction flow grade must be ≥ 2. Enrolled participants receive standard care plus oral AZD5718 200 mg, 50 mg, or placebo once daily for up to 12 weeks (extended from 4 weeks by protocol amendment). The planned sample size is 100 participants randomized to 12 weeks' treatment. Change in urine leukotriene E4 levels is the primary efficacy outcome. FLAVOUR also aims to evaluate whether AZD5718 can improve coronary microvascular function, as measured by transthoracic colour Doppler-assisted coronary flow velocity reserve. Centrally pretrained study sonographers use standardized protocols and equipment. Additional outcomes include assessment of comprehensive echocardiographic parameters (including coronary flow, global strain, early diastolic strain rate and left ventricular ejection fraction), arterial stiffness, biomarkers, health-related quality of life, and safety. Specific anti-inflammatory therapies may represent novel promising treatments to reduce residual risk in patients with coronary artery disease. By combining primary pharmacodynamic and secondary cardiovascular surrogate efficacy outcomes, FLAVOUR aims to investigate the mechanistic basis and potential benefits of AZD5718 treatment in patients with coronary artery disease.

Platelet aggregation and response to aspirin therapy in cardiac allograft vasculopathy

BACKGROUND

Long-term survival after heart transplantation (HTx) is compromised by cardiac allograft vasculopathy (CAV) characterized by coronary macro- and microvascular disease. The pathogenesis of CAV is unclear and may involve coronary thrombosis. We investigated whether HTx patients with CAV had higher platelet aggregation and turnover than HTx patients without CAV and healthy controls. Furthermore, we investigated the anti-platelet effect of low-dose aspirin in HTx patients.

METHODS

We included 57 patients who had undergone HTx (median 8.3 years from HTx) and 57 healthy controls. Platelet aggregation was measured on-aspirin and off-aspirin using impedance aggregometry with adenosine diphosphate (ADP) and arachidonic acid (AA). We evaluated platelet turnover by flow cytometry, CAV burden by coronary angiography and echocardiography, and microvascular function by echocardiographic coronary flow velocity reserve (CFVR).

RESULTS

Off-aspirin, HTx patients with CAV (n = 21) had higher ADP-induced platelet aggregation than healthy controls (p < 0.01) and HTx patients without CAV (n = 36) (p < 0.05). Aspirin treatment reduced AA-induced platelet aggregation in both HTx groups, but HTx patients with CAV had higher platelet aggregation on-aspirin than HTx patients without CAV (p < 0.05). Platelet turnover did not differ between HTx patients with CAV and HTx patients without CAV (p > 0.34). HTx patients with lower CFVR values had higher platelet aggregation than HTx patients with higher CFVR values (p < 0.05).

CONCLUSIONS

Off-aspirin, platelet aggregation was higher in HTx patients with CAV than in HTx patients without CAV and healthy controls. On-aspirin, platelet aggregation was higher in HTx patients with CAV than in HTx patients without CAV. Aspirin monotherapy may not provide sufficient platelet inhibition in HTx patients with CAV.

Imbalance between Fibrin Clot Formation and Fibrinolysis Predicts Cardiovascular Events in Patients with Stable Coronary Artery Disease

BACKGROUND

 Despite long-term antiplatelet therapy with aspirin, recurrent cardiovascular events remain common in patients with coronary artery disease (CAD).

OBJECTIVE

 We aimed to determine whether fibrin network characteristics are predictive of vascular events in patients with stable CAD treated with aspirin monotherapy.

METHODS

 We included 786 patients with angiographically documented CAD and either prior myocardial infarction, type 2 diabetes mellitus, or both. Median follow-up time was 3 years. At inclusion, fibrin clot properties were evaluated using a turbidimetric assay and the following clot parameters were studied: (1) maximum absorbance, a measure of clot density and fiber thickness; (2) lysis time, assessing fibrinolysis potential; and (3) area under the curve (AUC), a measure of clot formation and lysis. The primary endpoint was the composite of nonfatal myocardial infarction, ischemic stroke, and cardiovascular death. Hazard ratios (HRs) were estimated using multivariable Cox proportional hazards regression.

RESULTS

 A total of 70 primary endpoints occurred. The primary endpoint occurred more frequently in CAD patients with increased clot AUC (crude HR for first vs. fourth quartile: 2.4 [95% confidence interval 1.2-4.6], p = 0.01). This finding remained significant after adjusting for potential confounders (adjusted HR: 2.4 [1.2-4.8], p = 0.01). Neither clot maximum absorbance nor lysis time showed significant association with future vascular events (adjusted HR for maximum absorbance 1.8 [0.9-3.7]; p = 0.09) and lysis time (1.6 [0.8-3.0]; p = 0.18).

CONCLUSION

 We demonstrate that increased clot AUC predicts future cardiovascular events in stable CAD patients receiving aspirin monotherapy.

P4792Dabigatran versus vitamin K antagonists in patients with atrial fibrillation and valvular heart disease

Background

Atrial fibrillation (AF) and valvular heart disease (VHD) are both associated with an increased risk of stroke. Outside post-hoc analyses of randomized controlled trials, knowledge on the effectiveness and safety of dabigatran in patients with AF and VHD is scarce.

Objectives

To compare the risk of all-cause mortality, stroke, and bleeding in patients with AF and VHD treated with dabigatran or a vitamin K antagonist (VKA).

Methods

All Danish residents are provided a unique personal identification number enabling cross-linking of data from Danish nationwide registries. We identified all patients with AF and VHD initiating treatment with dabigatran or VKA between the 22nd of August 2011 and the 31st of December 2014. We defined VHD as aortic stenosis/regurgitation, mitral regurgitation, bioprosthetic heart valves, mitral-, and aortic valve repair. Outcomes were all-cause mortality, stroke, and bleeding. 2-year standardized absolute risks were calculated from cause-specific Cox regression models with death as competing risk.

Results

In total, 599 (27.3%) and 1,596 (72.7%) patients initiated treatment with dabigatran and VKA. The 2-year standardized absolute risk of all-cause mortality (95% CI) for VKA was 27.6% (25.1% to 30.1%) and 25.4% (21.8% to 29.0%) for dabigatran with a corresponding absolute risk difference of −2.2% (−6.3% to 1.9%) (Figure 1). The 2-year standardized absolute risk of stroke for VKA was 3.4% (2.3% to 4.5%) and 3.9% (2.2% to 5.5%) for dabigatran with a corresponding absolute risk difference of 0.5% (−1.6% to 2.5%). Lastly, the 2-year standardized absolute risk of bleeding for VKA was 8.2% (6.6% to 9.7%) and 7.6% (5.1% to 10.1%) for dabigatran with a corresponding absolute risk difference of −0.5% (−3.4% to 2.4%).

Figure 1

Conclusions

In this nationwide cohort study, we found no significant difference in the risk of all-cause mortality, stroke, or bleeding in patients with AF and VHD when comparing VKA to dabigatran.

256Heart transplant recipients with cardiac allograft vasculopathy have increased platelet aggregation before and after low-dose aspirin therapy

Background

Following heart transplantation (HTx), long-term survival is reduced mainly due to development of a specific form of coronary artery disease, coronary allograft vasculopathy (CAV). Using optical coherence tomography to visualize the coronary artery wall, we have recently shown that layered fibrotic plaques resembling organized clots are the dominant plaque component in CAV. Thus, thrombosis is suggested as a possible mechanism contributing to development and progression of CAV. Aspirin is widely used after HTx despite limited evidence and lack of specific guidelines. The antiplatelet effect of aspirin has not been thoroughly examined in HTx-patients.

Purpose

To investigate baseline platelet aggregation and the antiplatelet effect of aspirin in HTx-patients with and without CAV.

Methods

We included 68 HTx-patients (median 8.6 years from HTx). In 66 patients taking 75 mg aspirin for a minimum of 7 days, platelet aggregation was measured in whole blood using impedance aggregometry with the following agonists: Adenosine diphosphate (ADP) stimulating ADP-receptors and arachidonic acid (AA) for monitoring of aspirin treatment. Aspirin compliance was confirmed by measuring serum-thromboxane B2. Platelet aggregation prior to aspirin therapy was measured in 59 patients as it was not considered clinically safe to interrupt ongoing aspirin treatment for one week prior to blood sampling in 9 patients mainly due to previous coronary stenting. CAV burden was determined by coronary angiography and echocardiography based on international classification. Patients were divided into two groups; no CAV (n=37) and CAV (n=29).

Results

In HTx-patients not treated with aspirin, we found significantly increased ADP-induced platelet aggregation in patients with CAV vs. patients without CAV (904 (95% CI 813–995) vs. 786 (95% CI 728–843) AU*min, P=0.02). Baseline AA-induced aggregation was also higher in patients with CAV vs. patients without CAV, though non-significant (994 (95% CI 907–1081) vs. 905 (95% CI 839–972) AU*min, P=0.10). Even though aspirin reduced AA-induced platelet aggregation in both groups, patients with CAV had significantly increased AA-induced platelet aggregation compared with patients without CAV on aspirin treatment (380 (95% CI 295–465) vs. 286 (95% CI 239–334) AU*min, P=0.04) (Fig. 1).

Conclusions

HTx-patients with CAV have increased platelet aggregation before and after aspirin treatment compared with HTx-patients without CAV. Aspirin monotherapy may not provide sufficient platelet inhibition in HTx-patients with CAV.

Acknowledgement/Funding

Aarhus University (PhD-salary)

Differential vascular effects of aspirin in people with Type 2 diabetes without cardiovascular disease and matched controls without diabetes

AIM

We investigated whether the effect of low-dose aspirin on endothelium-dependent vasodilation and arterial stiffness in people with Type 2 diabetes is different from a matched control group. We examined acute and chronic effects, and effects over the 24h dosing interval.

METHODS

In an open-label parallel group intervention study, we included 21 participants with Type 2 diabetes and 21 age- and sex-matched controls. Endothelium-dependent vasodilation was assessed as the reactive hyperaemia index (lnRHI) measured by peripheral arterial tonometry (EndoPAT^® ). Arterial stiffness was assessed as pulse wave velocity (PWV) measured by applanation tonometry (SphygmoCor^® ). Measurements were performed prior to aspirin intake and 1h after aspirin administration (75 mg). Participants were then treated for 6 days, and measurements were repeated at 24 h and 1 h after aspirin intake.

RESULTS

Baseline lnRHI did not differ between groups. The controls had an immediate increase in lnRHI after the first aspirin tablet. This was not observed in participants with diabetes (difference between groups; P < 0.05). After 1 week, both groups demonstrated increased lnRHI compared with baseline (P < 0.01). In participants with diabetes, lnRHI was significantly lower 24 h after aspirin administration compared with 1 h after administration (P < 0.05). This difference was not observed in controls (P = 0.84, difference between groups; P = 0.12). The effect on PWV did not differ between groups.

CONCLUSION

Aspirin had a reduced immediate effect on endothelium-dependent vasodilation in participants with diabetes. Both groups had improved endothelial function after 1 week of treatment. Further, the effect of aspirin on endothelial function may be declining during a 24 h dosing interval in people with Type 2 diabetes. (Clinical Trial Registry No: 2016-000515-32).

Effect of remote ischaemic conditioning on platelet aggregation and platelet turnover

Remote ischaemic conditioning (RIC) is a new beneficial treatment for patients with ST-elevation myocardial infarction. RIC may inhibit thrombus formation and, therefore, we investigated whether RIC affects platelet aggregation and turnover. 30 healthy male volunteers were subjected to intervention on day 1 (sham intervention, no aspirin), day 2 (RIC, no aspirin), and day 16 (RIC, treated 7 days with aspirin 75 mg/day). RIC was performed as four cycles of 5 min interchangeable inflation and deflation using an automated cuff. Blood samples were collected 5 min before, as well as 5 and 45 min after RIC. Platelet aggregation was measured by Multiplate® using collagen (COLtest), adenosine diphosphate (ADPtest), and arachidonic acid (ASPItest) as agonists. Platelet turnover was evaluated by flow cytometry. Serum thromboxane B₂ was determined by ELISA to confirm aspirin compliance. We found no significant change in platelet aggregation at visit 1 (COLtest: p = 0.32; ADPtest: p = 0.24; ASPItest: p = 0.07), visit 2, except for ADP-induced platelet aggregation evaluated 5 min after RIC (COLtest: p = 0.39; ADPtest: p = 0.02; ASPItest: p = 0.39), or visit 3 (COLtest: p = 0.48; ADPtest: p = 0.61; ASPItest: p = 0.90). Platelet turnover was not influenced by RIC, neither on nor off aspirin (all p-values > 0.07). (1) RIC did not affect platelet aggregation in healthy young men. (2) RIC did not affect platelet turnover in healthy young men. (3) Aspirin did not influence the effect of RIC on platelet aggregation and turnover. (4) Future studies exploring the effect of RIC on platelet aggregation and turnover in patients with ischaemic heart disease are warranted.

Rationale and design of the worldwide prospective multicenter registry on radiation dose estimates of cardiac CT angiography in daily practice in 2017 (PROTECTION VI)

BACKGROUND

Cardiac computed tomography angiography (cardiac CTA) is an increasingly used versatile imaging method to evaluate coronary and cardiac morphology. Owing to improvements in technology, image quality has continuously improved over the last 10-20 years. At the same time, numerous non-randomized and randomized studies have been performed to reduce the associated radiation exposure. Currently, it is unclear if the advances in technology and knowledge about radiation reduction translated into reduced levels of cardiac CTA radiation dose in daily clinical practice as well as a wide utilization of dose-saving strategies.

METHODS

The PROTECTION VI study is a multicenter, prospective, worldwide registry designed to evaluate radiation dose exposure, utilization of dose-saving strategies and diagnostic image quality during cardiac CTA in current daily practice. Assessment of image quality will be addressed by the evaluation of diagnostic image quality at the local study site and the calculation of quantitative image quality parameters in an imaging core laboratory. Above 4000 patients will be enrolled from approximately 70 sites in Europe, North America, South America, Asia and Australia. The study will analyze median radiation dose levels, image quality, frequency of use and efficacy of algorithms for dose reduction, and patient and study-related predictors associated with radiation dose.

CONCLUSIONS

The PROTECTION VI study is designed to provide a reliable estimate of current radiation dose for cardiac CTA and to assess the potential for additional dose reductions.

Platelet function testing and prediction of procedural bleeding risk

The essential role of platelets in haemostasis underlies the relationship between platelet function and spontaneous or procedure-related bleeding, which has important prognostic implications. Although not routinely undertaken, platelet function testing offers the potential to tailor antiplatelet therapy for individual patients. However, uncertainties remain about how well platelet function testing may predict haemostasis and guide management of bleeding risk. Studies of aspirin, P2Y12 inhibitors and other antiplatelet drugs clearly demonstrate how inhibition of platelet function increases bleeding risk. More potent antiplatelet drugs are associated with higher bleeding rates, consistent with the levels of platelet inhibition achieved by these drugs. Studies of patients treated with clopidogrel, which is associated with wide inter-individual variation in antiplatelet effect, suggest that platelet function testing may predict bleeding risk related to coronary artery bypass grafting (CABG) surgery and potentially guide the timing of surgery following discontinuation of clopidogrel. Similarly, some studies have demonstrated a relationship between clopidogrel response and bleeding in patients undergoing percutaneous coronary intervention (PCI), although other studies have not supported this. Carriage of the *17 allele of cytochrome P450 2C19, which is associated with gain of function and enhanced response to clopidogrel, seems to be associated with increased bleeding risk, although studies showing lack of apparent effect of loss-of-function alleles provide contradictory evidence. Further large studies are needed to guide best practice in the application of platelet function testing in the clinical management of patients treated with antiplatelet drugs in order to optimise individual care.