The prevalence of osteopenia and osteoporosis after heart transplantation assessed using CT

OBJECTIVE

Osteoporosis is frequently observed in patients after heart transplantation (HT), although the prevalence long-term post-HT is unknown. Most studies investigating bone mineral density (BD) after HT were performed using dual-energy X-ray absorptiometry. In this study BD, including the prevalence of osteopenia and osteoporosis, was investigated using coronary computed tomography (CCT) long-term post-HT. Moreover, risk factors for abnormal BD were investigated.

METHODS

All first CCT scans between February 2018 and June 2020 used for the annual screening for cardiac allograft vasculopathy were included. Retransplantations and scans with not fully imaged vertebrae were excluded. BD was measured as a mean of the BD of three consecutive thoracic vertebrae and categorized into normal BD, osteopenia or osteoporosis. Binary logistic regression was used to find determinants for an abnormal BD. Linear regression was used to explore determinants for the mean Hounsfield unit (HU) value of the BD.

RESULTS

In total, 140 patients were included (median age 55.2 [42.9-64.9] years, 51 (36%) female). Time between HT and CT scan was 11.0 [7.3-16.1] years. In total, 80 (57%), 43 (31%), and 17 (12%) patients had a normal BD, osteopenia, or osteoporosis, respectively. Osteoporotic fracture or vertebrae fractures was seen in 11 (8%) patients. Determinants for an abnormal BD were recipient age (OR 1.10 (1.06-1.14), p<0.001) and prednisolone use (OR 3.75 (1.27-11.01), p=0.016). In linear regression, left ventricular assist device use pre-HT (p=0.024) and time since HT (p=0.046) were additional BD determinants.

DISCUSSION

Osteopenia and osteoporosis are frequently seen on CCT post-HT. More investigation on appropriate measures to maintain a normal BD in these patients are needed.

Decreased left atrial function in obesity patients without known cardiovascular disease

Obesity is a risk factor for heart failure with preserved ejection fraction (HFpEF). We hypothesized that assessment of left atrial (LA) strain may be useful to reveal precursors of HFpEF in obesity patients. Echocardiograms of obesity patients without known cardiovascular disease who underwent bariatric surgery, and echocardiograms of age- and gender matched controls were analyzed. The echocardiogram was repeated 1 year after bariatric surgery. LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured. 77 Obesity patients were compared with 46 non-obese controls. Obesity patients showed a significantly decreased LA function compared with non-obese individuals (LASr 32.2% ± 8.8% vs. 39.6% ± 10.8%, p < 0.001; LAScd 20.1% ± 7.5% vs. 24.9% ± 8.3%, p = 0.001; LASct 12.1% ± 3.6% vs. 14.5% ± 5.5%, p = 0.005). There was no difference in prevalence of diastolic dysfunction between the obesity group and controls (9.1% vs. 2.2%, p = 0.139). One year after bariatric surgery, LASr improved (32.1% ± 8.9% vs. 34.2% ± 8.7%, p = 0.048). In the multivariable linear regression analysis, BMI was associated with LASr, LAScd, and LASct (β =  - 0.34, CI - 0.54 to - 0.13; β =  - 0.22, CI - 0.38 to - 0.06; β =  - 0.10, CI - 0.20 to - 0.004). Obesity patients without known cardiovascular disease have impairment in all phases of LA function. LA dysfunction in obesity may be an early sign of cardiac disease and may be a predictor for developing HFpEF. LASr improved 1 year after bariatric surgery, indicating potential reversibility of LA function in obesity.

Direct stenting versus stenting after predilatation in STEMI patients with high thrombus burden: a subanalysis from the randomized COMPARE CRUSH trial

Background/Introduction

Direct stenting has been proposed to reduce vessel wall damage and distal embolization in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, studies comparing direct stenting with stenting after predilatation have shown mixed results so far. Patients presenting with high thrombus burden in the culprit lesion represent a subgroup of STEMI patients that may particularly benefit from direct stenting, as high thrombus burden is associated with suboptimal reperfusion and poor clinical outcomes.

Purpose

We sought to determine the efficacy of direct stenting compared with stenting after predilatation in STEMI patients presenting with high thrombus burden.

Methods

The randomized COMPARE CRUSH trial assessed the efficacy of pre-hospital administration of crushed versus integral prasugrel tablets in patients presenting with STEMI planned for primary PCI. We assessed Thrombolysis In Myocardial Infarction (TIMI) flow, corrected TIMI frame count (cTFC) and myocardial blush grade at the end of primary PCI, as well as the occurrence of complete (≥70%) ST-segment resolution 1 hour post-PCI in STEMI patients presenting with high thrombus burden in the culprit lesion (defined as a TIMI thrombus grade ≥3).

Results

A total of 417 STEMI patients were included in the current analysis of which 336 (81%) presented with high thrombus burden on initial angiography with 144 patients (43%) being treated with direct stenting. Patients undergoing direct stenting exhibited significantly lower cTFC post-PCI compared with stenting after predilatation (16 [12–24] vs. 20 [13–29], p=0.02). Moreover, direct stenting patients more frequently exhibited complete ST-segment resolution 1 hour post-PCI compared with stenting after predilatation (72% vs. 59%, OR 1.82 [95% CI, 1.11–2.99], p=0.02). In contrast, we found no differences in the occurrence of TIMI 3 flow (DS 92% vs. 92%, OR 1.02 [0.47–2.22], p=0.97) or myocardial blush grade 3 (DS 63% vs. 54%, OR 1.45 [95% CI, 0.83–2.52], p=0.19) post-PCI between groups.

Conclusion

STEMI patients presenting with high thrombus burden treated with direct stenting showed improved markers of early myocardial reperfusion compared with patients treated with stenting after predilatation, indicating that a direct stenting strategy may benefit the subgroup of STEMI patients that present with high thrombus burden. Randomized trials are warranted to further investigate whether the potential benefits of direct stenting outweigh potential hazards over the long-term.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Daiichi-Sankyo and Shanghai MicroPort Medical

Diagnostic accuracy of angiography-based vessel fractional flow reserve after chronic coronary total occlusion recanalization

Background

Angiography-Based Vessel FFR (vFFR) demonstrated a strong correlation with invasive fractional flow reserve (FFR) in both a pre- and post-percutaneous coronary intervention (PCI) setting. However, the role of vFFR and its correlation with post-PCI FFR in chronic coronary occlusion (CTO) has not been evaluated yet. We sought to investigate the diagnostic performance of post-PCI vFFR with post-PCI FFR as a reference in patients undergoing successful CTO PCI.

Methods

Between March 2016 and September 2019, a total of 80 patients from the FFR-SEARCH and FFR REACT studies underwent successful CTO recanalization [1,2]). A total of 50 patients (median age 66 (IQR: 56–74) years, 76% were male) were eligible for the analysis. Median FFR was 0.89 (IQR: 0.84–0.94) while median vFFR was 0.91 (IQR: 0.85–0.94). Suboptimal physiological results, defined as FFR and vFFR &lt;0.90, were identified in 26 (52%) and in 21 (42%) patients, respectively. A strong correlation (r=0.79) was found between vFFR and FFR with a mean bias of 0.013±0.051. Receiver-operating characteristics curve analysis revealed an excellent accuracy of vFFR in predicting FFR &lt;0.90 (AUC: 0.97; 95% CI: 0.93–1.00).

Conclusion

vFFR shows a good agreement with FFR and a high diagnostic accuracy for FFR ≤0.90 in patients undergoing successful PCI of a CTO lesion.

Funding Acknowledgement

Type of funding sources: None.

Immediate versus staged revascularisation of non-culprit arteries in patients with acute coronary syndrome: a systematic review and meta-analysis

Although there is robust evidence that revascularisation of non-culprit vessels should be pursued in patients presenting with an acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD), the optimal timing of complete revascularisation remains disputed. In this systematic review and meta-analysis our results suggest that outcomes are comparable for immediate and staged complete revascularisation in patients with ACS and MVD. However, evidence from randomised controlled trials remains scarce and cautious interpretation of these results is recommended. More non-biased evidence is necessary to aid future decision making on the optimal timing of complete revascularisation.

Platelet reactivity and bleeding outcomes in female patients presenting with ST-segment elevation myocardial infarction: a COMPARE CRUSH substudy

Background/Introduction

Females presenting with ST-segment elevation myocardial infarction (STEMI) are characterized by an increased risk of bleeding after primary percutaneous coronary intervention (pPCI) compared with males. The reason for increased bleeding rates is multifactorial, including age, comorbidities, vessel anatomy and possible differences in platelet biology. Data about platelet reactivity levels in females versus males presenting with STEMI is scarce.

Purpose

Investigation of gender-driven variances in platelet reactivity and bleeding outcomes in STEMI patients planned to undergo pPCI.

Methods

The COMPARE CRUSH trial was a randomized multicenter ambulance trial assessing the effect of prehospital administration of P2Y12 inhibitor loading dose with crushed versus integral prasugrel tablets in STEMI patients. We assessed the occurrence of high platelet reactivity (HPR), predictors of HPR at baseline and bleeding outcomes between females and males. Blood samples were analyzed at four prespecified time points using VerifyNow.

Results

The COMPARE CRUSH trial included 633 STEMI patients in the period between November 2017 and March 2020. Females more frequently exhibited HPR at baseline than males (76% vs. 41%, odds ratio (OR), 4.58 [95% CI, 2.52 to 8.32], p&lt;0.01). Moreover, female sex was a strong, independent predictor for HPR at baseline (OR, 4.93 [95% CI, 2.30 to 10.57], p&lt;0.01). HPR rates at other time points were not significantly different between females and males. The risk of bleeding within the first 48 hours was significantly increased in females (OR, 6.02 [95% CI, 2.58 to 14.08], p&lt;0.01), but after adjustment for baseline characteristics this increased risk was no longer statistically significant (OR, 2.61 [95% CI, 0.73 to 9.32], p=0.14).

Conclusion

Female sex is an independent predictor for occurrence of HPR at baseline in STEMI patients. However, females exhibit a stronger platelet inhibition effect by oral P2Y12 inhibitors than males, which may contribute to an increased bleeding risk. A more tailored antiplatelet therapy approach should be considered for female STEMI patients to reduce bleeding risk.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Unrestricted grants from Daiichi-Sankyo and Shanghai MicroPort Medical.

Decreased left atrial function in morbid obese patients without known cardiac disease

Background

Obesity is an important risk factor for atrial fibrillation and heart failure. However, little is known about the underlying pathophysiology. Left atrial (LA) dysfunction due to diastolic dysfunction and chronic volume overload may play a significant role in morbid obesity.

Purpose

To compare LA function in morbid obese and non-obese individuals, and secondly, to determine whether LA function in morbid obese patients improves one year after bariatric surgery.

Methods

Data of morbid obese patients without known cardiac disease included in the CARdiac Dysfunction In Obesity (CARDIOBESE) study were used. Patients and age- and gender matched non-obese controls underwent transthoracic echocardiography. In the morbid obese patients echocardiography was repeated 1 year after bariatric surgery. LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were analyzed with speckle tracking using dedicated software (TomTecArena, integrated in Sectra IDS7).

Results

64 morbid obese patients were compared with 46 non-obese controls. Obese patients had significantly decreased LA function compared with non-obese individuals (LASr 39.6±10.8% vs 31.3±8.3%, p&lt;0.001; LAScd −24.9±8.3% vs −19.5±7.2%, p&lt;0.001; LASct −14.7±5.3% vs −11.8±3.5%, p=0.002). There was no significant difference in diastolic function between the non-obese and morbid obese group (normal function 38.2% vs 52.7%, intermediate function 3.6% vs 4.5%, dysfunction 0% vs 0.9%, p=0.689). In 47 obese patients LA strain did not improve significantly 1 year after bariatric surgery, although there was a trend of improvement in all phases of LA function (LASr 31.0±8.2% vs 33.1±8.2%, p=0.089; LAScd −19.4±7.1% vs −20.4±6.6%, p=0.349; LASct −11.6±3.3% vs −12.8±5.4%, p=0.151).

Conclusions

Morbid obese patients without known cardiac disease have impairment in all phases of LA function. This subclinical cardiac dysfunction would have remained largely unmasked with assessment of diastolic function according to current guidelines, as shown by the comparable proportion of obese and non-obese individuals with diastolic dysfunction. LA dysfunction in obesity may therefore be an early sign of cardiac disease and a predictor for developing atrial fibrillation and heart failure. LA function did not improve one year after bariatric surgery. Longer follow-up after bariatric surgery may be needed to investigate whether improvement of LA function will occur after a longer period following weight loss surgery.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): BeterKeten Outcomes of the study populationLeft atrial strain outcomes

Prevalence and pathophysiology of subclinical cardiac dysfunction in obesity patients detected by multimodality diagnostics

Background

Obesity doubles the lifetime risk of developing heart failure. Current knowledge on the role of obesity in causing cardiac dysfunction is insufficient for optimal risk stratification.

Purpose

The aim of the study was first to identify the prevalence of subclinical cardiac dysfunction in obesity patients and second to investigate the underlying pathophysiology by comparing obesity patients with and without cardiac dysfunction.

Methods

The CARDIOBESE-study is a cross-sectional multicentre study of 100 obesity patients (BMI ≥35 kg/m2) without known cardiovascular disease, and 50 age- and gender-matched non-obese controls (BMI ≤30 kg/m2). Echocardiography was performed, blood samples were collected and a Holter monitor was affixed. Cardiac dysfunction was defined as either reduced LV ejection fraction, decreased global longitudinal strain (GLS), diastolic dysfunction, sustained supraventricular or (non)sustained ventricular arrhythmia or an increased BNP.

Results

Figure 1a shows the characteristics of the obesity patients and the non-obese controls. 59 obesity patients (48 [42–50] years, 70% female) showed subclinical cardiac dysfunction: 57 patients had decreased GLS, 2 patients with normal GLS had either diastolic dysfunction or increased brain natriuretic peptide. Only 1 non-obese control had diastolic dysfunction, none had another sign of cardiac dysfunction. Figure 1b shows the characteristics of obesity patients with and without cardiac dysfunction. Multivariable logistic analysis identified male gender and SDNN-index, which is a heart rate variability parameter and thereby a measure of autonomic dysfunction, as independent significant risk factors for subclinical cardiac dysfunction in obesity patients.

Conclusions

There was a high prevalence (61%) of subclinical cardiac dysfunction in obesity patients without known cardiovascular disease, which appeared to be best identified by GLS. Subclinical cardiac dysfunction in obesity was linked to autonomic dysfunction and male gender, and not to the presence of traditional cardiac risk factors, inflammation, increased cardiac filling pressure, cardiomyocyte damage or increased left ventricular mass.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stichting BeterKeter

Long-Term Outcome of the Randomized DAPA Trial

Background:

The randomized DAPA trial (Defibrillator After Primary Angioplasty) aimed to evaluate the survival benefit of prophylactic implantable cardioverter defibrillator (ICD) implantation in early selected high-risk patients after primary percutaneous coronary intervention for ST-segment–elevation myocardial infarction.

Methods:

A randomized, multicenter, controlled trial compared ICD versus conventional medical therapy in high-risk patients with primary percutaneous coronary intervention, based on one of the following factors: left ventricular ejection fraction <30% within 4 days after ST-segment–elevation myocardial infarction, primary ventricular fibrillation, Killip class ≥2 or TIMI (Thrombolysis in Myocardial Infarction) flow <3 after percutaneous coronary intervention. ICD was implanted 30 to 60 days after MI. Primary end point was all-cause mortality at 3 years follow-up. The trial prematurely ended after inclusion of 266 patients (38% of the calculated sample size). Additional survival assessment was performed in February 2019 for the primary end point.

Results:

A total of 266 patients, 78.2% males, with a mean age of 60.8±11.3 years, were enrolled. One hundred thirty-one patients were randomized to the ICD arm and 135 patients to the control arm. All-cause mortality was significant lower in the ICD group (5% versus 13%, hazard ratio, 0.37 [95% CI, 0.15–0.95]) after 3 years follow-up. Appropriate ICD therapy occurred in 9 patients at 3 years follow-up (5 within the first 8 months after implantation). After a median long-term follow-up of 9 years (interquartile range, 3–11), total mortality (18% versus 38%; hazard ratio, 0.58 [95% CI, 0.37–0.91]), and cardiac mortality (hazard ratio, 0.52 [95% CI, 0.28–0.99]) was significant lower in the ICD group. Noncardiac death was not significantly different between groups. Left ventricular ejection fraction increased ≥10% in 46.5% of the patients during follow-up, and the extent of improvement was similar in both study groups.

Conclusions:

In this prematurely terminated and thus underpowered randomized trial, early prophylactic ICD implantation demonstrated lower total and cardiac mortality in patients with high-risk ST-segment–elevation myocardial infarction treated with primary percutaneous coronary intervention.

Registration:

URL: https://www.trialregister.nl ; Unique identifier: Trial NL74 (NTR105).

ST-segment elevation myocardial infarction: Historical perspective and new horizons

After a brief history of the emergence of modern therapy for acute ST-elevation myocardial infarction, we discuss the issues that dominate ongoing studies and are the focus of intense debates. The role of angiography, pharmacotherapy, thrombus aspiration, management of multi-vessel disease, mechanical complications and cardiogenic shock and the quest for myocardial salvage are discussed.

434 Feasibility and reproducibility of parameters of cardiac function and dimension by transthoracic echocardiography in obesity patients

Background

Cardiac disease occurs more frequently in obesity patients. Imaging by transthoracic echocardiography (TTE) can be limited due to poor acoustic windows. An increase of the number of obesity patients who need to undergo TTE is expected.

Purpose

The aim of this study was to evaluate the feasibility, test-retest variability and inter- and intra-observer variability of parameters of cardiac function and dimension by TTE in obesity patients as compared to non-obese controls.

Methods

100 obesity patients (BMI≥35kg/m2) and 50 non-obese controls (BMI &lt; 30kg/m2) without known cardiovascular disease were prospectively enrolled and underwent an echocardiogram. Feasibility of echocardiographic parameters was assessed by categorizing the image quality and by evaluating the availability of the echocardiographic parameters. Intra-observer reproducibility was assessed by one observer on the same echocardiographic loop in 50 patients. A second observer assessed interobserver reproducibility in these patients. In 37 obesity patients and 17 non-obese controls images were obtained by two physicians to investigate test-retest variability.

Results

Image quality was excellent in 11% of the obesity patients as compared to 60% of the non-obese controls. Nevertheless, apart from global longitudinal strain (GLS), all investigated parameters of cardiac function and dimension were available in both groups (Table). GLS was obtainable in 93% of obesity patients versus 98% of non-obese controls (p = 0.20). For the vast majority of parameters inter- and intra-observer variability was comparable between obesity patients and non-obese controls. There were no significant differences between obesity patients and non-obese controls regarding the test-retest variability (Table).

Conclusion

Although non-obese controls on average had better echocardiographic image quality than obesity patients, feasibility of assessment of a broad variety of parameters of cardiac function and dimension was excellent in obesity patients and there were no important differences regarding variability of measurements.

Echocardiographic parameters Available obesity patients (n = 100) Available non-obese controls (n-50) Intra-observer variability obese (n = 50) Intra-observer variability non-obese (n = 25) Inter-observer variability obese (n = 50) Interobeserver variability non-obese (n = 25) Test-retest variability obese (n = 37) Test-rest variability non-obese(n= 17) IVSd 100% 100% 10.6 ± 6.3 6.8 ± 6.3* 10.8 ± 6.9 8.5 ± 4.5 11.1 ± 9.0 10.1 ± 6.4 LVEDD 100% 100% 5.4 ± 4.7 6.7 ± 5.3 5.5 ± 3.7 5.5 ± 3.3 6.7 ± 5.1 6.1 ± 5.2 PWd 100% 100% 12.4 ± 9.0 13.7 ± 9.6 11.5 ± 9.7 9.7 ± 6.7 12.4 ± 9.4 9.8 ± 6.4 E/A ratio 100% 100% 5.9 ± 9.6 2.1 ± 3.0 4.9 ± 5.0 3.8 ± 3.4 8.9 ± 5.7 8.5 ± 5.7 LA-volume index 100% 100% 12.3 ± 7.8 8.7 ± 6.5 11.0 ± 6.9 9.2 ± 4.8 13.6 ± 11.8 10.1 ± 6.3 GLS 93% 98% 6.8 ± 5.2 5.6 ± 4.6 6.4 ± 4.9 5.6 ± 4.6 8.8 ± 7.6 6.9 ± 5.3 Selection of various echocardiographic parameters. *p &lt; 0.05

P936 Early signs of cardiac dysfunction in obesity patients, results of the CARDIOBESE study

Introduction

Obesity is becoming a global epidemic. Current knowledge on early signs of cardiac dysfunction in obesity patients is insufficient. The onset of heart failure in obesity patients cannot be fully explained by the presence of traditional cardiovascular risk factors.

Purpose

To detect early signs of cardiac dysfunction in obesity patients without known cardiovascular disease.

Methods

The CARDIOBESE-study is a cross-sectional multicentre study of 100 obesity patients scheduled for bariatric surgery (body mass index (BMI) ≥35 kg/m2) without known cardiovascular disease, and 50 age-matched and gender-matched non-obese controls (BMI ≤30 kg/m2). Speckle tracking echocardiography, biomarkers and Holter monitoring were used to identify parameters that are able to show cardiac dysfunction at a very early stage in obesity patients.

Results

Obesity patients had impaired left ventricular ejection fraction, global longitudinal strain (GLS) and diastolic function parameters (e.g. septal e" velocity, lateral e" velocity, E/e’ and E/A-ratio) as compared to the non-obese controls (Table). C-reactive protein (CRP) and heart rate were increased, whereas heart rate variability (Standard deviation of NN intervals, SDNN) was decreased. Obesity patients were subdivided in patients with impaired (&lt; -17%, n = 56) or normal GLS (n = 36). Comparison between these patients revealed no differences regarding BMI, prevalence of traditional cardiovascular risk factors or CRP value. Nevertheless, patients with abnormal GLS had a higher waist circumference and lower SDNN.

Conclusion

There is a high prevalence of subclinical cardiac dysfunction as measured by GLS in obesity patients (56%), which appears to be related to abdominal fat and decreased heart rate variability and not to BMI, traditional cardiovascular risk factors or CRP.

Non-obese controls (n = 50) Obesity patients (n = 100) p-value Obesity patients with normal GLS (n = 36) Obesity patients with impaired GLS (n = 56) p-value Age (years) 49.2 ± 9.5 47.9 ± 7.6 0.36 47.6 ± 7.1 48.3 ± 7.6 0.68 BMI (kg/m2) 24.9 ± 3.2 42.9 ± 4.1 &lt;0.001 42.7 ± 4.2 42.7 ± 4.1 0.98 Waist circumference (cm) 81.1 ± 10.4 133.1 ± 12.3 &lt;0.001 128.2 ± 11.5 135.2 ± 10.5 0.006 E/A- ratio 1.19 ± 0.26 1.01 ± 0.3 &lt;0.001 1.08 ± 0.2 0.96 ± 0.27 0.048 Septel e" velocity 10.3 ± 9.8 8.1 ± 1.8 0.03 8.2 ± 1.9 7.8 ± 1.7 0.24 E/e" 8.5 ± 2.1 8.9 ± 2.5 0.32 9.5 ± 2.4 8.7 ± 2.5 0.14 CRP (mg/L) 1.9 ± 2.9 8.8 ± 8.8 &lt;0.001 8.5 ± 7.3 9.3 ± 10.1 0.67 SDNN 160.2 ± 35.4 109.4 ± 46.0 &lt;0.001 130.4 ± 48.3 98.9 ± 41.2 0.001 Table: Selection of parameters. Values are means ± SD. SDNN= Standard deviation of NN intervals (heart rate variability)

P1825 Myocardial bridging and coronary artery disease in hypertrophic cardiomyopathy: a matched case control study

Funding Acknowledgements

None.

Introduction

The etiology of chest pain in hypertrophic cardiomyopathy (HCM) is diverse and includes coronary artery disease (CAD) as well as HCM-specific causes. Myocardial bridging (MB) has been associated with HCM, chest pain, and accelerated atherosclerosis. To investigate differences in the presence of MB and CAD, we compared HCM patients with age-, gender- and CAD pre-test probability (PTP)-matched outpatients presenting with chest pain.

Methods

We studied 84 HCM patients who underwent cardiac computed tomography and compared these with 168 matched controls (age 54 ± 11 years, 70% men, PTP 12% [5%–32%]). MB, calcium score, plaque morphology and presence and extent of CAD were assessed for each patient. Linear mixed models were used to assess differences between cases and controls.

Results

Differences between HCM patients and controls are described in the table. In summary, MB was more often seen in HCM patients (50% vs. 25%, p &lt; 0.001), who were also more likely to have &gt;1 segment affected (14% vs. 2%, p &lt; 0.05). In the HCM group, MB was associated with pathogenic mutation status. Calcium score and the presence of obstructive CAD were similar in both groups (9 [0-225] vs. 4 [0-82] and 18% vs. 19%; p &gt; 0.05 for both).

Conclusion

MB was twice as prevalent in the HCM group. However, in a matched analysis, the prevalence and extent of CAD was equal among patients with and without HCM. These finding illustrate that despite a higher prevalence of MB, the prevalence of CAD is similar between groups, also demonstrating satisfactory performance of pre-test risk prediction in HCM patients.

Assessment of CAD by CT HCM group(n = 84) Control group (n = 168) p-value Agatston score 9 [0-225] 4 [0-82] 0.22 No. of pts with score* 0.07 0-399 31 (89%) 149 (91%) &gt;400 8 (11%) 15 (9%) Obstructive CAD 15 (18%) 32 (19%) 0.82 No. of pts with MB 42 (50%) 42 (25%) &lt;0.001 No. of vessels with MB &lt;0.001 1 34 (40%) 39 (23%) 2 8 (10%) 3 (2%) No. of pts with &gt;1 segment with MB 12 (14%) 4 (2%) &lt;0.001 Abbreviations CAD = Coronary artery disease, MB = Myocardial bridging, pts = patients *Only measured in 73/84 HCM patients and in 164/168 control patients

P954Value of a single bolus erythopoetin in STEMI patients treated with the Genous endothelial progenitor cell capture stent

Background

The Endothelial Progenitor Cell (EPC) stent was designed to capture circulating EPCs and promote early stent re-endothelization. Erythropoietin (EPO) stimulates mobilization of EPC from the bone marrow. Combination of EPO and the EPC stent in the setting of ST-segment elevation myocardial infarction (STEMI) has never been investigated.

Methods

STEMI patients enrolled in the HEBE-III trial were randomized to a single bolus of EPO or No-EPO after implantation of the EPC capture stent. Late lumen loss (LLL) was determined at 9-month angiographic follow-up. Clinical data was collected at 30 days and 12 months.

Results

196 patients were randomized to EPO (n=100) or No-EPO (n=96). No significant difference in baseline characteristics was observed between the two groups. A significant reduction in angiographic LLL was observed with EPO (0.43±0.57mm) as compared to No-EPO (0.74±0.63mm) (p=0.011). At 12 months follow up, no difference with regard to death or re- infarction was observed in both groups, whereas significant reduction in the need for target vessel revacularization for the EPO versus No-EPO was observed with rates of 7.1% and 19.1% respectively (p=0.013).

Angiographic and clinical results EPO (n=39) No-EPO (n=45) P-value Angiography   Lume late loss 0.43±0.57 0.74±0.63 0.011 12 months clinical   Death 0 0 ns   Re infarction 0 1 (2.2%) ns   Additional PCI 4 (10.3%) 17 (37.8%) 0.004   CABG 2 (5.1%) 2 (4.4%) ns   CVA 0 0 ns   Bleeding 3 (7.7%) 4 (8.9%) ns ns = not significant; CVA = cerebrovascular accident; CABG = coronary bypass graft; PCI = percutaneous coronary intervention.

Conclusion

In STEMI patients treated with EPC capture stent, additional EPO can further improve angiographic LLL

Sex differences in characteristics and outcome in acute coronary syndrome patients in the Netherlands

Background

Sex differences in acute coronary syndrome (ACS) have been reported, but little is known about the situation in the Netherlands.

Methods

This registry is a merge of available data on ACS patients in the electronic data capture systems of 11 centres with 24/7 interventional cardiology services. We included patients >18 years undergoing a cardiac catheterisation between 2010–2012. We evaluated sex differences in clinical and procedural characteristics and 1‑year mortality.

Results

A total of 29,265 ACS patients (8,720 women and 20,545 men) were registered. Women were on average 4.5 years older (68.5 vs 63.0 years, p < 0.001) and had a higher prevalence of hypertension (62.7 vs 49.8%, p < 0.001) and insulin-dependent diabetes mellitus (9.6 vs 6.8%, p < 0.001) than men. Women less often presented with ST-elevation myocardial infarction (43.7% vs 47.6%, p < 0.001) and appeared to have less extensive coronary artery disease than men. Women less often underwent coronary angiography by radial access (52.5 vs 55.9%, p < 0.001). One-year mortality was higher in women than in men (7.3% and 5.6%, p < 0.001). More specific, the relationship between sex and mortality was age-dependent and showed higher mortality in women ≤71 years, but lower mortality in older women compared with men (p-interaction <0.001).

Conclusion

We found differences in clinical and procedural characteristics and outcome between women and men admitted for ACS, which are in line with other Western countries. The limitations of our registry, based on existing local databases, can be overcome by the use of the prospective Netherlands Heart Registry that is currently in development.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-1271-0) contains supplementary material, which is available to authorized users.

One-year efficacy and safety of routine prasugrel in patients with acute coronary syndromes treated with percutaneous coronary intervention: results of the prospective rijnmond collective cardiology research study

Objective

To investigate 1‑year outcomes with routine prasugrel treatment after acute coronary syndrome (ACS) in a large-scale registry.

Methods

The Rijnmond Collective Cardiology Research registry is a prospective, observational study that enrolled 4,258 consecutive ACS patients treated with percutaneous coronary intervention (PCI) with 1‑year follow-up. Patients received prasugrel as first-choice antiplatelet agent, except for increased bleeding risk patients in which clopidogrel was recommended. Events were validated by an independent clinical endpoint committee.

Results

A total number of 2,677 patients received prasugrel at discharge after the index event. Eighty-one percent of the target population was on prasugrel treatment at hospital discharge. At 1 year, the primary endpoint, a composite of all-cause mortality and myocardial infarction, occurred in 2.4% of patients receiving prasugrel. All-cause mortality occurred in 1.0%, myocardial infarction in 1.5%, target-vessel revascularisation in 3.1%, stent thrombosis in 0.6%, and stroke in 0.5% of the patients treated with prasugrel. Thrombolysis in Myocardial Infarction defined major bleeding episodes not related to coronary artery bypass grafting were observed in 1.4% of patients receiving prasugrel.

Conclusions

In routine practice, a tailored approach of prasugrel prescription in ACS patients undergoing PCI, resulted in low ischaemic and low bleeding rates up to 1 year post PCI.

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1126-0) contains supplementary material, which is available to authorized users.

MR-based source localization for MR-guided HDR brachytherapy

For the purpose of MR-guided high-dose-rate (HDR) brachytherapy, a method for real-time localization of an HDR brachytherapy source was developed, which requires high spatial and temporal resolutions. MR-based localization of an HDR source serves two main aims. First, it enables real-time treatment verification by determination of the HDR source positions during treatment. Second, when using a dummy source, MR-based source localization provides an automatic detection of the source dwell positions after catheter insertion, allowing elimination of the catheter reconstruction procedure. Localization of the HDR source was conducted by simulation of the MR artifacts, followed by a phase correlation localization algorithm applied to the MR images and the simulated images, to determine the position of the HDR source in the MR images. To increase the temporal resolution of the MR acquisition, the spatial resolution was decreased, and a subpixel localization operation was introduced. Furthermore, parallel imaging (sensitivity encoding) was applied to further decrease the MR scan time. The localization method was validated by a comparison with CT, and the accuracy and precision were investigated. The results demonstrated that the described method could be used to determine the HDR source position with a high accuracy (0.4-0.6 mm) and a high precision (⩽0.1 mm), at high temporal resolutions (0.15-1.2 s per slice). This would enable real-time treatment verification as well as an automatic detection of the source dwell positions.

Clinical Characteristics and Management of Coronary Artery Perforations: A Single-Center 11-Year Experience and Practical Overview

Background

Coronary artery perforation (CAP) is a potentially lethal complication of percutaneous coronary intervention. We report on the incidence, clinical characteristics, and management of iatrogenic coronary perforations based on an 11‐year single‐center experience.

Methods and Results

From February 9, 2005, through November 20, 2016, 150 CAP cases were identified from our percutaneous coronary intervention database of 21 212 procedures (0.71%). Mean age of CAP patients was 66±11 years, and 62.7% were male. Treated lesion type was B2/C in 94.6%, and 31.3% were chronic total occlusions. Nonworkhorse guidewires were applied in 74.3%. CAP types were Ellis type I in 2.9%, Ellis type II in 40.4%, Ellis type III in 54.8%, and Ellis type III cavity spilling in 1.9%. CAP treatment was conservative (including prolonged balloon inflation) in 73.3%. Covered stents, coiling, and fat embolization were used in 24.0%, 0.7%, and 2.0%, respectively. Pericardiocentesis for tamponade was required for 72 patients (48.0%), of whom 28 were initially unrecognized. Twelve patients (12.7%) required emergency cardiac surgery to alleviate tamponade. Periprocedural myocardial infarction occurred in 34.0%, and in‐hospital all‐cause mortality was 8.0%. All‐cause mortality accrued to 10.7% at 30 days and 17.8% at 1 year.

Conclusions

CAP is a rare complication of percutaneous coronary intervention, but morbidity and mortality are considerable. Early recognition and adequate management are of paramount importance.

[Angioplasty not always the answer in stable angina]

The number of percutaneous coronary interventions (PCIs) has more than doubled in the Netherlands over the past 15 years. In part, this is due to an increase in PCI for stable angina, and it is questionable whether this is justified since recently published trials, including the Courage study, show that there is no survival benefit of PCI for stable angina. This paper discusses the treatment of stable angina, the importance of optimal medical treatment, and the indication for PCI in selected patients.

The impact of gender on long-term mortality in patients with multivessel disease after primary percutaneous coronary intervention

Background

Gender and complete revascularisation are known to affect mortality. The objective of this study was to analyse a gender difference in mortality with respect to complete revascularisation for multivessel disease after primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) patients.

Method

In a prospective consecutive cohort of 1472 patients presenting with STEMI for PPCI, between January 2006 and January 2010, 832 patients with multivessel disease were analysed. The primary outcome was long-term mortality.

Results

Median follow-up was 3.3 ± 1.2 years. Complete revascularisation was performed less in females than in males (30 vs. 38 %; p = 0.04). At PPCI, women (27 %, n = 221) were ± 10 years older (p = 0.001), had more hypertension, renal failure and symptoms of heart failure (all p < 0.01). Cumulative long-term mortality with incomplete revascularisation was higher in females (F: 30 vs. M: 15 %, p = 0.01). After adjustment for baseline characteristics, complete revascularisation (0.84; 95 % CI 0.54–1.32) and gender (1.11; 95 % CI 0.73–1.69) lost significance. Also the gender-by-complete revascularisation interaction was not significant at long term. In women, age under 60 years independently predicted higher mortality (HR 10.09; 95 % CI 3.08–33.08; p < 0.001).

Conclusion

In STEMI patients with multivessel disease at PPCI, women under the age of 60 years had higher mortality, but in women older than 60 years comorbidity impacted the outcome of revascularisation strategy in the long term.

STEMI time delays: a clinical perspective : Editorial comment on the article by Verweij et al

STEMI time delays have been introduced as a performance indicator or marker of quality of care. As they are only one part of a very complex medical process, one should be aware of concomitant issues that may be overlooked or even be more important with regard to clinical outcome of STEMI patients. In this overview we try to summarise the most important ones.

[Developments in percutaneous coronary intervention and coronary stents]

In The Netherlands, more than 30.000 patients undergo a percutaneous coronary intervention every year, during which a coronary stent implantation will be performed in 90% of the cases. It is estimated that more than 5 million coronary stent implantations will be performed worldwide this year. While these numbers are impressive, however, coronary stents still have as a limitation the possibility of stent thrombosis. This has been and is an important stimulus for the development of both coronary stents, from a bare metal stent via a drug eluting stent to the present-day development of bio-absorbable stents, and anti-platelet drugs,from acenocoumarol to thieropyridines. The possibility of shortening the period of use of this powerful medication by developing new kinds of non-thrombogenic stents would, for example, make it possible to achieve significant reductions in subsequent bleeding during (dental) procedures.

Preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy : A case series with acute refractory cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation and optimised medical strategy

Cardiogenic shock continues to be a life-threatening condition carrying a high mortality and morbidity, where the prognosis remains poor despite intensive modern treatment modalities. In recent years, mainly technical improvements have led to a more widespread use of short- and long-term mechanical circulatory support, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and left ventricular assist devices (LVADs). Currently, LVADs are indispensable as 'bridge' to cardiac recovery, heart transplantation (HTX), and/or as destination therapy Importantly, both LVADs and HTX put a vast burden on financial resources, besides significant short- and long-term risks of morbidity and mortality. These considerations underscore the importance of optimal timing and appropriate patient selection for LVAD therapy, avoiding as much as possible an unfortunate and costly clinical path. In this report, we present a series of three cases with acute refractory cardiogenic shock ('crash and burn', INTERMACS profile 1) successfully treated by ECMO and early optimal medical therapy preventing a certain path towards LVAD and/or HTX, for which they were initially referred. This conservative approach in INTERMACS profile one patients warrants very early introduction of adequate medical heart failure therapy under the umbrella of a combination of short-term mechanical circulatory and inotropic support by phosphodiesterase inhibitors. Therefore, this novel combined medical-mechanical approach could have important clinical implications for this extremely challenging patient category, as it may avoid an unnecessary and costly clinical path towards LVAD and/or heart transplantation.

Adoption of prasugrel into routine practice: rationale and design of the Rijnmond Collective Cardiology Research (CCR) study in percutaneous coronary intervention for acute coronary syndromes

Background

Platelet inhibition is crucial in reducing both short- and long-term atherothrombotic risks in patients with acute coronary syndromes (ACS) managed with percutaneous coronary intervention (PCI). Based on randomised trials, recent recommendations in the current guidelines include the endorsement of prasugrel as a first-choice adenosine diphosphate receptor inhibitor. Yet, there is limited experience with the use of prasugrel in routine practice.

Methods

The Rijnmond Collective Cardiology Research (CCR) registry is a prospective, observational study that will follow-up 4000 PCI-treated ACS patients in the larger region of Rotterdam, the Netherlands. Based on recently implemented hospital protocols, all patients will receive prasugrel as first-choice antiplatelet agent, unless contraindicated, in accordance with European guidelines, and will be followed for up to 1 year post-discharge for longitudinal assessment of outcomes and bleeding events. This registry exemplifies a collaborative study design that employs a regional PCI registry platform and provides feedback to participating sites regarding their practice patterns, thereby supporting and promoting improvement of quality of care.

Conclusion

The CCR registry will evaluate the adoption of prasugrel into routine clinical practice and thus, will provide important evidence with regard to the benefits and risks of real-world utilisation of prasugrel as antiplatelet therapy in PCI-treated ACS patients.

Current discharge management of acute coronary syndromes: data from the Rijnmond Collective Cardiology Research (CCR) study

Background

Medical discharge management of acute coronary syndromes (ACS) remains suboptimal outside randomised trials and constitutes an essential quality benchmark for ACS. We sought to evaluate the rates of key guideline-recommended pharmacological agents after ACS and characteristics associated with optimal treatment at discharge.

Methods

The Rijnmond Collective Cardiology Research (CCR) registry is an ongoing prospective, observational study in the Netherlands that aims to enrol 4000 patients with ACS. We examined discharge and 1-month follow-up medication use among the first 1000 patients enrolled in the CCR registry. Logistic regression was performed to identify patient and hospital characteristics associated with collective guideline-recommended pharmacotherapy at hospital discharge.

Results

At discharge, 94 % of patients received aspirin, 100 % thienopyridines, 80 % angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers, 87 % β-blockers, 96 % statins, and 65 % the combination of all 5 agents. ST-segment elevation myocardial infarction, hypertension, hypercholesterolaemia, and enrolment in an interventional centre were positive independent predictors of 5-drug combination therapy at discharge. Negative independent predictors were unstable angina and advanced age.

Conclusion

Current data from the CCR registry reflect a high quality of care for ACS discharge management in the Rotterdam-Rijnmond region. However, potential still remains for further optimisation.