Experimentally Induced Peripheral Venous Congestion Exacerbates Inflammation, Oxidative Stress, and Neurohormonal and Endothelial Cell Activation in Patients With Systolic Heart Failure

BACKGROUND

Venous congestion (VC) is a hallmark of symptomatic heart failure (HF) requiring hospitalization; however, its role in the pathogenesis of HF progression remains unclear. We investigated whether peripheral VC exacerbates inflammation, oxidative stress and neurohormonal and endothelial cell (EC) activation in patients with HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Two matched groups of patients with HFrEF and with no peripheral VC vs without recent HF hospitalization were studied. We modeled peripheral VC by inflating a cuff around the dominant arm, targeting ∼ 30 mmHg increase in venous pressure (venous stress test [VST]). Blood and ECs were sampled before and after 90 minutes of VST. We studied 44 patients (age 53 ± 12 years, 32% female). Circulating endothelin-1, tumor necrosis factor-α, interleukin-6, isoprostane, angiotensin II (ang-2), angiopoietin-2, vascular cell adhesion molecule-1, and CD146 significantly increased after the VST. Enhanced endothelin-1 and angiopoietin-2 responses to the VST were present in patients with vs without recent hospitalization and were prospectively associated with incident HF-related events; 6698 messenger ribonucleic acid (mRNA probe sets were differentially expressed in ECs after VST.

CONCLUSIONS

Experimental VC exacerbates inflammation, oxidative stress, neurohormonal and EC activation and promotes unfavorable transcriptome remodeling in ECs of patients with HFrEF. A distinct biological sensitivity to VC appears to be associated with high risk for HF progression.

Association of cardiometabolic and vascular atherosclerosis phenotypes on non-contrast chest CT with incident heart failure in patients with severe hypercholesterolemia

BACKGROUND

Coronary artery calcium (CAC), thoracic aorta calcification (TAC), non-alcoholic fatty liver disease (NAFLD), and epicardial adipose tissue (EAT) are associated with atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF).

OBJECTIVES

We aimed to determine whether these cardiometabolic and atherosclerotic risk factors identified by non-contrast chest computed tomography (CT) are associated with HF hospitalizations in patients with LDL-C≥ 190 mg/dL.

METHODS

We conducted a retrospective cohort analysis of patients with LDL-C ≥190 mg/dL, aged ≥40 years without established ASCVD or HF, who had a non-contrast chest CT within 3 years of LDL-C measurement. Ordinal CAC, ordinal TAC, EAT, and NAFLD were measured. Kaplan-Meier curves and multivariable Cox regression models were built to ascertain the association with HF hospitalization.

RESULTS

We included 762 patients with median age 60 (53-68) years, 68% (n=520) female, and median LDL-C level of 203 (194-216) mg/dL. Patients were followed for 4.7 (IQR 2.75-6.16) years, and 107 (14%) had a HF hospitalization. Overall, 355 (47%) patients had CAC=0, 210 (28%) had TAC=0, 116 (15%) had NAFLD, and median EAT was 79 mL (49-114). Moderate-Severe CAC (log-rank p<0.001) and TAC (log-rank p=0.006) groups were associated with increased HF hospitalizations. This association persisted when considering myocardial infarction (MI) as a competing risk. NAFLD and EAT volume were not associated with HF.

CONCLUSIONS

In patients without established ASCVD and LDL-C≥190 mg/dL, CAC was independently associated with increased HF hospitalizations while TAC, NAFLD and EAT were not.

Long-Term Mortality in Patients With Severe Hypercholesterolemia Phenotype From a Racial and Ethnically Diverse US Cohort

BACKGROUND

Tools for mortality prediction in patients with the severe hypercholesterolemia phenotype (low-density lipoprotein cholesterol ≥190 mg/dL) are limited and restricted to specific racial and ethnic cohorts. We sought to evaluate the predictors of long-term mortality in a large racially and ethnically diverse US patient cohort with low-density lipoprotein cholesterol ≥190 mg/dL.

METHODS

We conducted a retrospective analysis of all patients with a low-density lipoprotein cholesterol ≥190 mg/dL seeking care at Montefiore from 2010 through 2020. Patients <18 years of age or with previous malignancy were excluded. The primary end point was all-cause mortality. Analyses were stratified by age, sex, and race and ethnicity. Patients were stratified by primary and secondary prevention. Cox regression analyses were used to adjust for demographic, clinical, and treatment variables.

RESULTS

A total of 18 740 patients were included (37% non-Hispanic Black, 30% Hispanic, 12% non-Hispanic White, and 2% non-Hispanic Asian patients). The mean age was 53.9 years, and median follow-up was 5.2 years. Both high-density lipoprotein cholesterol and body mass index extremes were associated with higher mortality in univariate analyses. In adjusted models, higher low-density lipoprotein cholesterol and triglyceride levels were associated with an increased 9-year mortality risk (adjusted hazard ratio [HR], 1.08 [95% CI, 1.05-1.11] and 1.04 [95% CI, 1.02-1.06] per 20-mg/dL increase, respectively). Clinical factors associated with higher mortality included male sex (adjusted HR, 1.31 [95% CI, 1.08-1.58]), older age (adjusted HR, 1.19 per 5-year increase [95% CI, 1.15-1.23]), hypertension (adjusted HR, 2.01 [95% CI, 1.57-2.57]), chronic kidney disease (adjusted HR, 1.68 [95% CI, 1.36-2.09]), diabetes (adjusted HR, 1.79 [95% CI, 1.50-2.15]), heart failure (adjusted HR, 1.51 [95% CI, 1.16-1.95]), myocardial infarction (adjusted HR, 1.41 [95% CI, 1.05-1.90]), and body mass index <20 kg/m2 (adjusted HR, 3.36 [95% CI, 2.29-4.93]). A significant survival benefit was conferred by lipid-lowering therapy (adjusted HR, 0.57 [95% CI, 0.42-0.77]). In the primary prevention group, high-density lipoprotein cholesterol <40 mg/dL was independently associated with higher mortality (adjusted HR, 1.49 [95% CI, 1.06-2.09]). Temporal trend analyses showed a reduction in statin use over time (P<0.001). In the most recent time period (2019-2020), 56% of patients on primary prevention and 85% of those on secondary prevention were on statin therapy.

CONCLUSIONS

In a large, diverse cohort of US patients with the severe hypercholesterolemia phenotype, we identified several patient characteristics associated with increased 9-year all-cause mortality and observed a decrease in statin use over time, in particular for primary prevention. Our results support efforts geared toward early recognition and consistent treatment for patients with severe hypercholesterolemia.

Use of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Cardiac Transplantation: Results of an A Priori Ventless Approach

Primary graft dysfunction (PGD) after cardiac transplantation is a devastating complication with increasing frequency lately in the setting of donation after circulatory death (DCD). Severe PGD is commonly treated with extracorporeal membrane oxygenation (ECMO) using central or peripheral cannulation. We retrospectively reviewed the outcomes of PGD after cardiac transplantation requiring ECMO support at our center from 2015 to 2020, focused on our now preferential approach using peripheral cannulation without a priori venting. During the study period, 255 patients underwent heart transplantation at our center and 26 (10.2%) of them required ECMO for PGD. Of 24 patients cannulated peripherally 19 (79%) were alive at 30 days and 17 (71%) 1 year after transplant; two additional patients underwent central ECMO cannulation due to unfavorable size of femoral vessels and concern for limb ischemia. Successful decannulation with full graft function recovery occurred in 22 of 24 (92%) patients cannulated peripherally. Six of them had an indwelling intra-aortic balloon pump placed before the transplantation. None of the other 18 patients received a ventricular vent. In conclusion, the use of an a priori peripheral and ventless ECMO approach in patients with PGD after heart transplant is an effective strategy associated with high rates of graft recovery and survival.

Predicting Hemodynamic Changes During Intra-Aortic Balloon Pump Support With a Longitudinal Evaluation

The use of intra-aortic balloon pump (IABP) has decreased in recent years due to negative outcome studies in cardiogenic shock complicating acute myocardial infarction, despite its favorable adverse-event profile. Acute hemodynamic response studies have identified potential super-responders with immediate improvements in cardiac index (CI) in heart failure patients. This single-center retrospective study aimed to predict CI and mean arterial pressure (MAP) changes throughout the entire duration of IABP support. The study analyzed 336 patients who received IABP between 2016 and 2022. Linear mixed-effect regression models were used to predict CI and MAP improvement during IABP support. The results showed that CI and MAP increases during the first days of support, and changes during IABP support varied with time and were associated with baseline parameters. Longitudinal CI change was associated with body surface area, baseline CI, baseline pulmonary artery pulsatility index, baseline need for pressors, and diabetes. Longitudinal MAP change was associated with baseline MAP, baseline heart rate, need for pressors, or inotropes. The study recommends considering these parameters when deciding if IABP is the most appropriate form of support for a specific patient. Further prospective studies are needed to validate the findings.

Pulsatility and flow patterns across macro- and microcirculatory arteries of continuous-flow left ventricular assist device patients

BACKGROUND

Reduced arterial pulsatility in continuous-flow left ventricular assist devices (CF-LVAD) patients has been implicated in clinical complications. Consequently, recent improvements in clinical outcomes have been attributed to the "artificial pulse" technology inherent to the HeartMate3 (HM3) LVAD. However, the effect of the "artificial pulse" on arterial flow, transmission of pulsatility into the microcirculation and its association with LVAD pump parameters is not known.

METHODS

The local flow oscillation (pulsatility index, PI) of common carotid arteries (CCAs), middle cerebral arteries (MCAs) and central retinal arteries (CRAs-representing the microcirculation) were quantified by 2D-aligned, angle-corrected Doppler ultrasound in 148 participants: healthy controls, n = 32; heart failure (HF), n = 43; HeartMate II (HMII), n = 32; HM3, n = 41.

RESULTS

In HM3 patients, 2D-Doppler PI in beats with "artificial pulse" and beats with "continuous-flow" was similar to that of HMII patients across the macro- and microcirculation. Additionally, peak systolic velocity did not differ between HM3 and HMII patients. Transmission of PI into the microcirculation was higher in both HM3 (during the beats with "artificial pulse") and in HMII patients compared with HF patients. LVAD pump speed was inversely associated with microvascular PI in HMII and HM3 (HMII, r2 = 0.51, p < 0.0001; HM3 "continuous-flow," r2 = 0.32, p = 0.0009; HM3 "artificial pulse," r2 = 0.23, p = 0.007), while LVAD pump PI was only associated with microcirculatory PI in HMII patients.

CONCLUSIONS

The "artificial pulse" of the HM3 is detectable in the macro- and microcirculation but without creating a significant alteration in PI compared with HMII patients. Increased transmission of pulsatility and the association between pump speed and PI in the microcirculation indicate that the future clinical care of HM3 patients may involve individualized pump settings according to the microcirculatory PI in specific end-organs.

Global Longitudinal Strain Is Associated with Mortality in Patients with Multiple Myeloma

Patients with multiple myeloma (MM) are at a high risk for developing cardiovascular complications. Global longitudinal strain (GLS) can detect early functional impairment before structural abnormalities develop. It remains unknown if reduced GLS is associated with reduced survival in patients with MM. We conducted a retrospective cohort analysis of patients diagnosed with MM between 1 January 2000 and 31 December 2017 at our institution. Patients with a 2D transthoracic echocardiogram completed within 1 year of MM diagnosis, left ventricular ejection fraction (LVEF) greater than 40%, and no history of myocardial infarction prior to MM diagnosis were included. GLS was measured using an artificial-intelligence-powered software (EchoGo Core), with reduced GLS defined as an absolute value of <18%. The primary outcome of interest was overall survival since myeloma diagnosis. Our cohort included 242 patients with a median follow up of 4.28 years. Fifty-two (21.5%) patients had reduced average GLS. Patients with reduced GLS were more likely to have an IVSd ≥ 1.2cm, E/E' > 9.6, LVEF/GLS > 4.1, higher LV mass index, and low-voltage ECG. A Total of 126 (52.1%) deaths occurred during follow-up. Overall survival was lower among patients with reduced GLS (adjusted HR: 1.81, CI: 1.07-3.05).

Amyloidosis-related echo features and mortality in patients with multiple myeloma

Background/Introduction

Patients with multiple myeloma (MM) are at increased risk of developing AL amyloidosis. It was determined by screening fat pad and bone marrow biopsy that 38% MM patients had amyloidosis at time of diagnosis and the majority were asymptomatic (1). However, whether amyloidosis-related echo features in MM affect survival remains unknown (1, 2).

Purpose

The goals of our study are to: 1) characterize prevalence of amyloidosis-related echo features in patients with multiple myeloma, 2) investigate whether decrease in longitudinal strain affect survival outcomes.

Methods

Patients diagnosed with MM between Jan 1, 2000 and Dec 31, 2017 at our institution were identified through Clinical Looking Glass. Those with echo within 1 year after myeloma diagnosis and left ventricular ejection fraction (LVEF) greater than 40% were included. Global longitudinal strain (GLS) and LVEF measurements were done using EchoGo (Ultromics, Oxford, UK). The average of GLS obtained from apical 4-chamber and apical 2-chamber views was used for analysis, with decreased GLS defined as absolute value less than 18%. Statistical analysis was conducted with STATA13, using Chi square test and Kruskal-Wallis for univariable analysis and Cox regression model for survival analysis.

Results

From a total cohort of 909 patients, 252 met inclusion criteria, of which 59 (23.4%) patients had decreased average GLS (see Table 1). Patients' mean age was 63±11 years, 44.8% were male and most were Black (42.7%) and the rest Hispanic (33.3%) and White (7.9%). Median follow up time was 4.25 years. The group with decreased GLS had lower percentage of females (22% vs 51.8%, p&lt;0.01), higher percentage of previous MI (11.9% vs 1.6%, p&lt;0.01) and more prior diagnosis of heart failure (20.3% vs 1.6%, p&lt;0.01).

Among patients with decreased GLS, five-year mortality rate was 63.3% compared to 46.0% in those with preserved GLS (p&lt;0.036). Median survival time was 3.9 years among those with reduced GLS and 4.3 years in those without (see Figure 1; p&lt;0.01). Reduced GLS correlated with decreased survival (HR 1.6, p=0.03) even after adjusting for demographic variables (age, gender, race), history of MI, history of CHF, Charlson comorbidity index, myeloma RISS stage, and LVEF (≥50% vs 40–50%).

Forty-seven (18.6%) patients had end diastolic inter-ventricular septum (IVSd) thickness ≥1.2cm. Median GLS in patients with increased IVSd thickness was 19% compared to 21% in those without (p=0.01). Nine patients had the apical sparing strain pattern for amyloidosis.

Total of 158 patients had bone marrow specimen stained with Congo-red with 7 (4.4%) testing positive. Median GLS was 19% in the group staining positive for Congo-red compared 21% in the group with negative stain (p=0.03).

Conclusions

Decrease in GLS on baseline echo correlates with increased mortality in patients with MM and may be due to subclinical cardiac amyloidosis.

Funding Acknowledgement

Type of funding sources: None.

The analysis of COVID-19 in-hospital mortality: A competing risk approach or a cure model?

Competing risk analyses have been widely used for the analysis of in-hospital mortality in which hospital discharge is considered as a competing event. The competing risk model assumes that more than one cause of failure is possible, but there is only one outcome of interest and all others serve as competing events. However, hospital discharge and in-hospital death are two outcomes resulting from the same disease process and patients whose disease conditions were stabilized so that inpatient care was no longer needed were discharged. We therefore propose to use cure models, in which hospital discharge is treated as an observed “cure” of the disease. We consider both the mixture cure model and the promotion time cure model and extend the models to allow cure status to be known for those who were discharged from the hospital. An EM algorithm is developed for the mixture cure model. We also show that the competing risk model, which treats hospital discharge as a competing event, is equivalent to a promotion time cure model. Both cure models were examined in simulation studies and were applied to a recent cohort of COVID-19 in-hospital patients with diabetes. The promotion time model shows that statin use improved the overall survival; the mixture cure model shows that while statin use reduced the in-hospital mortality rate among the susceptible, it improved the cure probability only for older but not younger patients. Both cure models show that treatment was more beneficial among older patients.

Visual Coronary and Aortic Calcium Scoring on Chest Computed Tomography Predict Mortality in Patients With Low-Density Lipoprotein-Cholesterol ≥190 mg/dL

BACKGROUND

Current guidelines recommend coronary artery calcium (CAC) scoring for stratification of atherosclerotic cardiovascular disease risk only in patients with borderline to intermediate risk score by the pooled cohort equation with low-density lipoprotein-cholesterol (LDL-C) of 70 to 190 mg/dL. It remains unknown if CAC or thoracic aorta calcification (TAC), detected on routine chest computed tomography, can provide further risk stratification in patients with LDL-C≥190 mg/dL.

METHODS

From a multisite medical center, we retrospectively identified all patients from March 2005 to June 2021 age ≥40 years, without established atherosclerotic cardiovascular disease and LDL-C≥190 mg/dL who had non-gated non-contrast chest computed tomography within 3 years of LDL-C measurement. Ordinal CAC and TAC scores were measured by visual inspection. Kaplan-Meier curves and multivariable Cox-regression models were built to ascertain the association of CAC and TAC scores with all-cause mortality.

RESULTS

We included 811 patients with median age 59 (53-68) years, 262 (32.3%) were male, and LDL-C median level was 203 (194-217) mg/dL. Patients were followed for 6.2 (3.29-9.81) years, and 109 (13.4%) died. Overall, 376 (46.4%) of patients had CAC=0 and 226 (27.9%) had TAC=0. All-cause mortality increased with any CAC and moderate to severe TAC. In a multivariate model, patients with CAC had a significantly higher mortality compared with those without CAC: mild hazard ratio (HR), 1.71 (1.03-2.83), moderate HR, 2.12 (1.14-3.94), and severe HR, 3.49 (1.94-6.27). Patients with moderate TAC (HR, 2.34 [1.19-4.59]) and those with severe TAC (HR, 3.02 [1.36-6.74]) had higher mortality than those without TAC.

CONCLUSIONS

In patients without history of atherosclerotic cardiovascular disease and LDL-C≥190 mg/dL, the presence and severity of CAC and TAC are independently associated with all-cause mortality.

Access to care in patients with pancreatic adenocarcinoma by race/ethnicity in an academic center in the Bronx, NY

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Background: Racial disparities in the overall survival (OS) of patients with pancreatic adenocarcinoma (PDAC) have been previously reported. Large population datasets suggest that Non-Hispanic Blacks (NHB) have decreased OS when compared to non-Hispanic Whites (NHW), and Hispanics. It is unclear whether this is related to biologic features or differences in access to care. This study was aimed to compare time to treatment in a racially-diverse cohort of patients with PDAC in an academic center in the Bronx, NY. Methods: Patients diagnosed with PDAC between 2015 and 2021, available race/ethnicity (NHW, NHB or Hispanic) who received treatment at Montefiore Medical Center were identified. Data including demographics (age, gender, BMI), clinical features (date of diagnosis, presentation [localized/metastatic], tumor location, grade), first-treatment received (surgery or chemotherapy) and outcomes (vital status, date of death) were collected manually. Time to first treatment was compared between racial/ethnic groups using the Kruskal-Wallis test. Results: Of 226 patients diagnosed with PDAC, there were 46 (20.4%), 77 (34.1%) and 103 (45.6%) NHW, NHB and Hispanics respectively. The frequency of metastatic disease was higher in Hispanics and NHB compared to NHW (42.7% vs. 46.7% vs. 22.2%, p = 0.02). Median time to first treatment did not differ significantly among racial/ethnic groups in the overall cohort and stratified by disease presentation. Conclusions: There were no differences in access to care among racial/ethnic groups in this cohort. A higher frequency of metastatic disease at presentation among NHB and Hispanics might be explained by more aggressive biology. Further evaluation of the molecular profile in this cohort is warranted.[Table: see text]

Twenty-four-hour blood pressure and heart rate variability are reduced in patients on left ventricular assist device support

BACKGROUND

Limited data exist on the circadian blood pressure (BP) and heart rate (HR) variations that occur in heart failure (HF) patients on left ventricular assist device (LVAD) support.

METHODS

We prospectively recorded clinic and 24-hour ambulatory BP and HR data in patients on HeartMate II LVAD support. Results were compared to HF patients with ejection fraction ≤30% and controls with no history of cardiovascular disease. Physiologic nocturnal BP and HR dipping was defined as a ≥10% decline compared to daytime values.

RESULT

Twenty-nine LVAD patients (age 59 ± 15 years, 76% male, 38% ischemic etiology), 25 HF patients (age 64 ± 13 years, 84% male, 32% ischemic etiology) and 26 controls (age 56 ± 9 years, 62% male) were studied. Normal nocturnal BP dipping was less frequent in LVAD patients (10%) than in HF patients (28%) and controls (62%) and reversed BP dipping (BP increase at night) was more common in LVAD patients (24%), compared to HF (16%) and controls (8%), (p < 0.001, for all comparisons). Physiologic HR reduction was less frequent in LVAD patients (14%), compared to HF (16%) and controls (59%) (p < 0.001, for all comparisons). Among LVAD patients, 36% exhibited sustained hypertension over the 24-hours and 25% had white-coat hypertension.

CONCLUSIONS

Treatment of advanced HF with an LVAD does not restore physiologic circadian variability of BP and HR; additionally, BP was not adequately controlled in more than a third of LVAD patients, and a quarter of them exhibited white-coat hypertension. Future studies are warranted to confirm these findings and investigate prognostic and management implications in this population.

Hospital bed occupancy rate is an independent risk factor for COVID-19 inpatient mortality: a pandemic epicentre cohort study

INTRODUCTION

COVID-19 first struck New York City in the spring of 2020, resulting in an unprecedented strain on our healthcare system and triggering multiple changes in public health policy governing hospital operations as well as therapeutic approaches to COVID-19. We examined inpatient mortality at our centre throughout the course of the pandemic.

METHODS

This is a retrospective chart review of clinical characteristics, treatments and outcome data of all patients admitted with COVID-19 from 1 March 2020 to 28 February 2021. Patients were grouped into 3-month quartiles. Hospital strain was assessed as per cent of occupied beds based on a normal bed capacity of 1491.

RESULTS

Inpatient mortality decreased from 25.0% in spring to 10.8% over the course of the year. During this time, use of remdesivir, steroids and anticoagulants increased; use of hydroxychloroquine and other antibiotics decreased. Daily bed occupancy ranged from 62% to 118%. In a multivariate model with all year's data controlling for demographics, comorbidities and acuity of illness, percentage of bed occupancy was associated with increased 30-day in-hospital mortality of patients with COVID-19 (0.7% mortality increase for each 1% increase in bed occupancy; HR 1.007, CI 1.001 to 1.013, p=0.004) CONCLUSION: Inpatient mortality from COVID-19 was associated with bed occupancy. Early reduction in epicentre hospital bed occupancy to accommodate acutely ill and resource-intensive patients should be a critical component in the strategic planning for future pandemics.

Severity of Functional Mitral Regurgitation on Admission for Acute Decompensated Heart Failure Predicts Long-Term Risk of Rehospitalization and Death

Background

Functional mitral regurgitation (FMR) has emerged as a therapeutic target in patients with chronic heart failure and left ventricular systolic dysfunction. The significance of FMR in acute decompensated heart failure remains obscure. We systematically investigated the prevalence and clinical significance of FMR on admission in patients admitted with acute decompensated heart failure and left ventricular systolic dysfunction.

Methods and Results

The study was a single‐center, retrospective review of patients admitted with acute decompensated heart failure and left ventricular systolic dysfunction between 2012 and 2017. Patients were divided into 3 groups of FMR: none/mild, moderate, and moderate‐to‐severe/severe FMR. The primary outcome was 1‐year post‐discharge all‐cause mortality. We also compared these groups for 6‐month heart failure hospitalization rates. Of 2303 patients, 39% (896) were women. Median left ventricular ejection fraction was 25%. Four hundred and fifty‐three (20%) patients had moderate‐to‐severe/severe FMR, which was independently associated with 1‐year all‐cause mortality. Moderate or worse FMR was found in 1210 (53%) patients and was independently associated with 6‐month heart failure hospitalization. Female sex was independently associated with higher severity of FMR.

Conclusions

More than half of patients hospitalized with acute decompensated heart failure and left ventricular systolic dysfunction had at least moderate FMR, which was associated with increased readmission rates and mortality. Intensified post‐discharge follow‐up should be undertaken to eliminate FMR amenable to pharmacological therapy and enable timely and appropriate intervention for persistent FMR. Further studies are needed to examine sex‐related disparities in FMR.

Incidence of new-onset atrial fibrillation in COVID-19 is associated with increased epicardial adipose tissue

PURPOSE

Coronary artery calcium (CAC) and epicardial adipose tissue (EAT) can predict AF in the general population. We aimed to determine if CAC and EAT measured by computed tomographic (CT) scanning can predict new-onset AF in patients admitted with COVID-19 disease.

METHODS

We performed a retrospective, post hoc analysis of all patients admitted to Montefiore Medical Center with a confirmed COVID-19 diagnosis from March 1st to June 23rd, 2020, who had a non-contrast CT of the chest within 5 years prior to admission. We determined ordinal CAC scores and quantified the EAT volume and examined their relationship with inpatient mortality.

RESULTS

A total of 379 patients were analyzed. There were 16 events of new-onset AF (4.22%). Patients who developed AF during the index admission were more likely to be male (75 vs 47%, p < 0.001) and had higher EAT (129.5 [76.3-197.3] vs 91.0 [60.0-129.0] ml, p = 0.049). There were no differences on age (68 [56-71] vs 68 [58-76] years; p = 0.712), BMI (28.5 [25.3-30.8] vs 26.9 [23.1-31.8] kg/m²; p = 0.283), ordinal CAC score (3 [1-6] vs 2 [0-4]; p = 0.482), or prevalence of diabetes (56.3 vs 60.1%; p = 0.761), hypertension (75.0 vs 87.3%, p = 0.153), or coronary artery disease (50.0 vs 39.4%, p = 0.396). Patients with new-onset AF had worse clinical outcomes (death/intubation/vasopressors) (87.5 vs 44.1%; p = 0.001).

CONCLUSION

Increased EAT measured by non-contrast chest CT identifies patients hospitalized with COVID-19 at higher risk of developing new-onset AF. Patients with new-onset AF have worse clinical outcomes.

A History of Heart Failure Is an Independent Risk Factor for Death in Patients Admitted with Coronavirus 19 Disease

Aims: The association between cardiovascular diseases, such as coronary artery disease and hypertension, and worse outcomes in COVID-19 patients has been previously demonstrated. However, the effect of a prior diagnosis of heart failure (HF) with reduced or preserved left ventricular ejection fraction on COVID-19 outcomes has not yet been established. Methods and Results: We retrospectively studied all adult patients with COVID-19 admitted to our institution from March 1st to 2nd May 2020. Patients were grouped based on the presence or absence of HF. We used competing events survival models to examine the association between HF and death, need for intubation, or need for dialysis during hospitalization. Of 4043 patients admitted with COVID-19, 335 patients (8.3%) had a prior diagnosis of HF. Patients with HF were older, had lower body mass index, and a significantly higher burden of co-morbidities compared to patients without HF, yet the two groups presented to the hospital with similar clinical severity and similar markers of systemic inflammation. Patients with HF had a higher cumulative in-hospital mortality compared to patients without HF (49.0% vs. 27.2%, p < 0.001) that remained statistically significant (HR = 1.383, p = 0.001) after adjustment for age, body mass index, and comorbidities, as well as after propensity score matching (HR = 1.528, p = 0.001). Notably, no differences in mortality, need for mechanical ventilation, or renal replacement therapy were observed among HF patients with preserved or reduced ejection fraction. Conclusions: The presence of HF is a risk factor of death, substantially increasing in-hospital mortality in patients admitted with COVID-19.

Coronary artery calcification and epicardial adipose tissue as independent predictors of mortality in COVID-19

Recent epidemiological studies have demonstrated that common cardiovascular risk factors are strongly associated with adverse outcomes in COVID-19. Coronary artery calcium (CAC) and epicardial fat (EAT) have shown to outperform traditional risk factors in predicting cardiovascular events in the general population. We aim to determine if CAC and EAT determined by Computed Tomographic (CT) scanning can predict all-cause mortality in patients admitted with COVID-19 disease. We performed a retrospective, post-hoc analysis of all patients admitted to Montefiore Medical Center with a confirmed COVID-19 diagnosis from March 1st, 2020 to May 2nd, 2020 who had a non-contrast CT of the chest within 5 years prior to admission. We determined ordinal CAC scores and quantified the epicardial (EAT) and thoracic (TAT) fat volume and examined their relationship with inpatient mortality. A total of 493 patients were analyzed. There were 197 deaths (39.95%). Patients who died during the index admission had higher age (72, [64–80] vs 68, [57–76]; p < 0.001), CAC score (3, [0–6] vs 1, [0–4]; p < 0.001) and EAT (107, [70–152] vs 94, [64–129]; p = 0.023). On a competing risk analysis regression model, CAC ≥ 4 and EAT ≥ median (98 ml) were independent predictors of mortality with increased mortality of 63% (p = 0.003) and 43% (p = 0.032), respectively. As a composite, the group with a combination of CAC ≥ 4 and EAT ≥ 98 ml had the highest mortality. CAC and EAT measured from chest CT are strong independent predictors of inpatient mortality from COVID-19 in this high-risk cohort.

SARS-COV-2 infection presenting as ST-elevationmyocardial infarction

We describe a patient presenting with chest discomfort, anterolateral ST elevation, and developing acute cardiogenic shock secondary to SARS-COV-2infection-patient zero presenting to our institution's cardiac catheterization laboratory. The emergent presentation with limited clinical information led to exposure of personnel. The diagnosis was complicated by two negative tests for SARS-COV-2, and high-clinical suspicion from the patient's occupational history led to additional testing in order to confirm the diagnosis.

Complement promotes endothelial von Willebrand factor and angiopoietin-2 release in obstructive sleep apnea

STUDY OBJECTIVE

Obstructive sleep apnea (OSA) is highly prevalent and triples vascular thromboembolic risk. Intermittent hypoxia (IH) during transient cessation of breathing in OSA impairs endothelial protection against complement. Complement activation stimulates the endothelial release of a pro-thrombotic von Willebrand factor (vWF). We investigated whether increased complement activity in OSA promotes the endothelial release of vWF and pro-inflammatory angiopoietin-2. We further investigated whether improving complement protection with statins reverses these changes.

METHODS

Using endothelial cells (ECs) and blood collected from OSA patients (n = 109) and controls (n = 67), we assessed whether altered cellular localization of complement inhibitor CD59 in OSA modulates exocytosis of Weibel-Palade bodies (WPB), secretory granules that store vWF and angiopoietin-2. These interactions were also assessed in vitro in ECs exposed to normoxia or IH with or without recombinant complement C9 and with or without atorvastatin.

RESULTS

Circulating levels of angiopoietin-2 were greater in OSA than controls and levels of vWF cleavage products correlated with OSA severity. In cultured ECs, IH enhanced complement-stimulated angiopoietin-2 and vWF release by reducing EC surface and increasing intracellular expression of complement inhibitor CD59. Intracellular CD59 co-localized with WPB in OSA. IH increased binding of intracellular CD59 to syntaxin-3, which dissociated syntaxin-3 from voltage-sensitive calcium channel Cav1.2, and activated WPB exocytosis in a calcium-dependent manner. Atorvastatin reversed IH-enhanced endothelial release of vWF and angiopoietin-2.

CONCLUSIONS

IH promotes the complement-mediated release of vWF and angiopoietin-2, which may contribute to pro-thrombotic and pro-inflammatory conditions in OSA. Statin reversed these effects, suggesting a potential approach to reduce cardiovascular risk in OSA.

Statin Use and In-Hospital Mortality in Patients With Diabetes Mellitus and COVID-19

Background

Severe coronavirus disease 2019 (COVID‐19) is characterized by a proinflammatory state with high mortality. Statins have anti‐inflammatory effects and may attenuate the severity of COVID‐19.

Methods and Results

An observational study of all consecutive adult patients with COVID‐19 admitted to a single center located in Bronx, New York, was conducted from March 1, 2020, to May 2, 2020. Patients were grouped as those who did and those who did not receive a statin, and in‐hospital mortality was compared by competing events regression. In addition, propensity score matching and inverse probability treatment weighting were used in survival models to examine the association between statin use and death during hospitalization. A total of 4252 patients were admitted with COVID‐19. Diabetes mellitus modified the association between statin use and in‐hospital mortality. Patients with diabetes mellitus on a statin (n=983) were older (69±11 versus 67±14 years; P<0.01), had lower inflammatory markers (C‐reactive protein, 10.2; interquartile range, 4.5–18.4 versus 12.9; interquartile range, 5.9–21.4 mg/dL; P<0.01) and reduced cumulative in‐hospital mortality (24% versus 39%; P<0.01) than those not on a statin (n=1283). No difference in hospital mortality was noted in patients without diabetes mellitus on or off statin (20% versus 21%; P=0.82). Propensity score matching (hazard ratio, 0.88; 95% CI, 0.83–0.94; P<0.01) and inverse probability treatment weighting (HR, 0.88; 95% CI, 0.84–0.92; P<0.01) showed a 12% lower risk of death during hospitalization for statin users than for nonusers.

Conclusions

Statin use was associated with reduced in‐hospital mortality from COVID‐19 in patients with diabetes mellitus. These findings, if validated, may further reemphasize administration of statins to patients with diabetes mellitus during the COVID‐19 era.

THU0127 Estimated cardiovascular risk in a large cohort of rheumatoid arthritis patients from the “Cardiovascular Obesity and Rheumatic DISease (CORDIS)” Study Group of the Italian Society of Rheumatology

Background:

Rheumatoid arthritis (RA) patients present high cardiovascular (CV) morbidity and mortality and EULAR recommends estimating their CV-risk [1]. The Systematic Coronary Risk Evaluation (SCORE) algorithm is suggested if National Guidelines are lack, but few data are available about different strategies.

Objectives:

To estimate the 10-years CV-risk using different algorithms in RA compared to osteoarthritis (OA) patients, as control group.

Methods:

A total of 1467 RA patients (78.3% female; mean age 59.8±11.5 years; mean disease duration 131±109 months), fulfilling the 2010 EULAR/ACR classification criteria, and 342 age and sex matched patients with OA (79.8% female; mean age 58.7±11.5 years) were enrolled in this multicentre cross-sectional study during 2019. Clinical and laboratory data were registered, and individual CV-risk was calculated using: SCORE chart, “Progetto Cuore” model (PCM), QRisk3, Reynolds Risk Scores (RRS) and Expanded Risk Score in RA (ERS-RA), as stated by suitable algorithms. Statistical analysis was performed using the Statistical System Graphpad Instat 8.0 (San Diego, CA-USA).

Results:

In 46 (3%) RA patients a previous CV event was observed. Among traditional CV-risk factors, RA patients presented higher frequency of diabetes (9.9% vs 6.4%; p=0.04) and lower prevalence of dyslipidaemia (21.7% vs 32.5%; p<0.0001) compared to OA patients. Prevalence of hypertension was similar in both groups (40% vs 39.2%). Mean BMI (25.6±4.8 vs 26.6±4.4; p<0.0001) and prevalence of obesity (15% vs 21%; p=0.003) were significantly lower in RA patients. Finally, RA patients were more frequently smokers (20.4% vs 12.5% - p=0.002). 441 (30%) RA patients were in CDAI remission, 998 (68%) patients were on csDMARDs while a biologic agent was used in 617 (42%) patients. About 43% of RA patients were on a mean prednisone-dose of 4.5±3.5 mg/day. The 10-years CV-risk resulted 2 to 3-fold higher in RA compared to OA patients using the different algorithms. The QRisk3 estimated the highest CV risk in our cohort of patients, while the ERS-RA and RRS were significantly higher than PCM and SCORE.

Conclusion:

Our study demonstrates a higher estimated CV-risk in RA compared to OA patients. The commonly used algorithms to estimate CV-risk in clinical practice perform differently, evaluating different traditional CV-risk factors and disease specific characteristic, as for QRisk3 or ERS-RA. Rheumatologist should impact on both traditional and RA related modifiable CV-risk factors.

References:

[1]Agca R, et al. Ann Rheum Dis 2017;76:17–28.

Disclosure of Interests:

Fabio Cacciapaglia Speakers bureau: BMS; Roche; Pfizer; Abbvie, Matteo Piga: None declared, Gianluca Erre: None declared, Andreina Manfredi: None declared, Elena Bartoloni Bocci: None declared, Garifallia Sakellariou Speakers bureau: Abbvie, Novartis, MSD, Ombretta Viapiana: None declared, Sergio Colella: None declared, Anna Abbruzzese: None declared, Martina Dessì: None declared, Caterina Vacchi: None declared, Floriana Castagna: None declared, Giacomo Cafaro: None declared, Bianca Lucia Palermo: None declared, Alessandro GIollo: None declared, Marco Fornaro: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fabiola Atzeni: None declared

P231 Cardiac metastasis mimicking a myocardial infarction

We present the case of a 79 years old male patient affected by a lung squamous cell carcinoma (T4 N0 M1a) diagnosed in december 2018 with a 5x5 cm mass in the inferior lobe of the left lung close to the pericardium and a second 5 cm mass in the apical lobe of the right lung. TT echocardiography at that time was normal. Treatment with gemcitabine was scheduled with slight progression of the disease at the CT scan control in april 2019 when initial invasion of the left inferior pulmonary vein was detected. An ECG performed during routine control revealed the presence of q waves and ST segment elevation in the inferior leads. The patient was asymptomatic about the heart but the blood tests revealed a slight increase of HS Troponin I. We decided to repeat the TT echo, which showed the presence of a rounded mobile mass of about 3x2.5 cm in the left atrium close to the upper left pulmonary vein and another formation of about 5x2 cm infiltrating the inferior wall of the left ventricle that appeared akynetic. Both metastatic and thrombotic origins were debated and anticoagulant therapy with LMWH was started. We chose to perform a TE echocardiography, which confirmed the presence of the rounded mass in the left atrium, enlarged as compared to the TT evaluation. At the 3D reconstruction, it appeared to come from the left inferior pulmonary vein, completely occluding it, and expanding to the left superior vein, narrowing but not closing its orifice. The mass was well delimitated, disomogenous and vacuolated, thus confirming its likely neoplastic origin. From the trans-gastric view, we confirmed the large infiltration of the inferior wall of the left ventricle. General conditions of the patients quickly deteriorated and he experienced an ischemic stroke. At the TT echo re-evaluation the mass in the left atrium was greatly reduced as compared to the previous control. Cardiac metastases are a rare and frequently clinically silent occurrence; However, in a minority of cases they may present with ECG alterations such as ST-T segment modifications. In neoplastic patients an ischaemic ECG pattern not following its typical progression, without typical symptoms of ischaemia should rise the suspicion of a cardiac metastasis. In our case the abnormalities could be caused by a loss of viable myocardium secondary to the infiltrating mass or by a compression of the right coronary artery. In this context the echocardiography, both TT and especially TE, is a valuable tool that allow to recognize the real cause of these abnormalities and provides useful informations that enable to distinguish neoplastic mass from a thrombus. The ischaemic stroke was probably due to an embolization of the mass from the left atrium, as confirmed by its important reduction at the last echo control.

Abstract P231 Figure. ECG abnormalities and TE echo alteration

Prognostic implications of serial outpatient blood pressure measurements in patients with an axial continuous-flow left ventricular assist device

BACKGROUND

Elevated blood pressure (BP) has been linked to adverse events during left ventricular assist device support. In this study we investigated the association between outpatient BP and stroke or suspected pump thrombosis among HeartMate II (HMII) recipients.

METHODS

We retrospectively studied 220 HMII patients. Serial outpatient BP measurements were averaged. Patients were categorized by: (1) mean arterial pressure (MAP), high (>90 mm Hg) vs intermediate (80 mm Hg ≤ MAP ≤ 90 mm Hg) vs low (<80 mm Hg); (2) systolic BP (SBP), high (≥101 mm Hg, median) vs low; and (3) pulse pressure (PP), high (≥22 mm Hg, median) vs low. To assess visit-to-visit BP variability, patients were divided in quartiles of standard deviation of MAP and SBP. The primary end-point was the composite of stroke or suspected pump thrombosis.

RESULTS

The risk for the primary end-point was increased in the high MAP group (adjusted hazard ratio [HR] 2.75, 95% confidence interval [CI] 1.49 to 5.05, vs intermediate MAP; and 6.73, 1.9 to 23.9, vs low MAP). MAP had higher predictive value for the primary end-point compared with SBP (p = 0.05). Patients with high SBP had a higher rate of stroke (HR 2.8, 95% CI 1.09 to 7.17, vs low SBP). The combination of high SBP and low PP was associated with the highest risk for stroke. The lowest quartile of visit-to-visit MAP variability was associated with the highest risk for the primary end-point.

CONCLUSIONS

Elevated outpatient BP is associated with increased risk for stroke or suspected pump thrombosis in HMII recipients. Reduced PP and low visit-to-visit BP variability may confer additional risk.