Association of beta-blockers beyond 1 year after myocardial infarction for patients without heart failure or left ventricular systolic dysfunction and cardiovascular outcomes: nationwide cohort study

Background

Beta-blockers (BB) is an established treatment following presentation with myocardial infarction (MI). However, there is uncertainty as to whether BB use beyond the first year of MI has a secondary preventive role in patients without heart failure and/or left ventricular systolic dysfunction (LVSD).

Purpose

To investigate the association between BB treatment beyond one year after MI for patients without heart failure or LVSD and cardiovascular (CV) outcomes.

Methods

We used data from SWEDEHEART, the national Swedish register for coronary heart disease, to identify patients with MI who were hospitalised between 2005 and 2016. Deterministic linkage of individual patient data was performed with the National Patient Register, the Swedish Prescribed Drug Register, and the National Cause of Death Register. Patients with heart failure or LVSD with left ventricular ejection fraction <50% were excluded. Follow-up started at 1 year after hospitalisation with first MI (index date), when patients were allocated into two groups according to BB treatment. Information about BB treatment at index date and during follow-up was obtained from the Swedish National Prescribed Drug Register. The primary outcome was a composite of all-cause mortality, recurrent MI, unscheduled revascularisation or hospitalisation for heart failure. Secondary outcomes comprised the individual components of the composite outcome, CV death and stroke. Comparison of outcomes between the study groups was performed using Cox and Fine-Gray regression models adjusting for relevant clinical factors after propensity-score weighting. In the main intention-to-treat analysis, patients were censored at end of follow-up (31st December 2017), death or at pre-specified outcome, whichever came first. In supplementary per-protocol analysis, patients were, in addition, censored at the time of first BB discontinuation or switch between treatment arms.

Results

A total of 43,618 patients with MI were hospitalised between 2005 and 2016. Of these, 34,253 (78.5%) were prescribed BB and 9,365 (21.5%) were not on BB treatment at index date 1 year following MI. The median age of the population was 64 years, 25.5% were female, and 36.2% had a STEMI. Median follow-up was 4.5 years. In the intention-to-treat analysis, and after multivariable adjustments and propensity score weighting, BB treatment was associated with a similar rate of the composite CV outcome (hazard ratio [HR] 0.99; 95% confidence interval [CI] 0.93–1.04) compared with no BB treatment. A similar finding was observed when censoring for BB discontinuation or treatment switch during follow-up in a per-protocol analysis (HR 0.98; 95% CI 0.98–1.06). Similar associations were observed for all secondary outcomes (Figure 1).

Conclusions

BB treatment beyond one year after MI for patients without heart failure or LVSD is not associated with a different risk of cardiovascular outcomes compared with patients who do not receive BB.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement.

Oral anticoagulant treatment in patients with atrial fibrillation early after valvular intervention: a nationwide cohort study

Background

Treatment with non-vitamin K oral anticoagulants (NOAC) is the first option for primary prevention of ischaemic stroke in patients with atrial fibrillation (AF). However, there is still an evidence gap regarding efficacy and safety of NOAC in patients with AF and severe valvular heart disease undergoing valvular intervention.

Purpose

The aim was to evaluate the efficacy and safety of NOAC or no oral anticoagulant (OAC) treatment versus warfarin during the first 3 months after valvular intervention.

Methods

We used data from the National Quality Register SWEDEHEART and included all patients with AF discharged after surgical valvular intervention with bioprosthesis or valvuloplasty, or transcatheter aortic valve implantation (TAVI) between 2010 and 2016. Outcomes, including the composite of cardiovascular (CV) events (CV death, ischaemic stroke or systemic embolism), major bleeding, and relevant comorbidities and OAC treatment at discharge were collected from the National Patient Register, the Swedish Prescribed Drug Register, and the National Cause of Death Register. The association between exposure (warfarin, NOAC or no OAC) and occurrence of composite CV events and major bleeding was explored using a time-dependent adjusted Cox regression analysis.

Results

In total, 4730 patients with AF and valvular intervention were included. The cohort had a mean age of 75 years, 35.9% were women and mean CHA2DS2-VASc score was 3.3 (Table 1). The proportion of patients treated with warfarin was higher in patients undergoing surgical valve intervention whereas NOAC was more commonly prescribed to patients treated with TAVI. Rates of composite CV events and major bleeding was similar between patients treated with NOAC versus warfarin. No OAC treatment versus warfarin was associated with higher rate of composite CV event, but with no difference with regard to major bleeding (Table 1).

Conclusion

A large proportion of patients with AF undergoing valvular intervention was not treated with OAC despite having a high CHA2DS2-VASc score. Also, patients on no OAC versus warfarin had a higher risk of i CV events in the early phase after valvular intervention. The efficacy and safety of NOAC was similar compared to warfarin during the first 3 months after intervention. Treatment with OAC in patients with AF, irrespective of NOAC or warfarin, was associated with improved clinical outcome early after valve intervention.

Funding Acknowledgement

Type of funding sources: None.

Accuracy of estimating left ventricular ejection fraction in clinical routine. A SWEDEHEART registry validation study

Objective

Patients admitted to Swedish hospitals with myocardial infarction (MI) are reported to the nationwide Swedish registry for MI (SWEDEHEART). During hospital stay an echocardiography is routinely performed, and left ventricular ejection fraction (LVEF) is assessed according to the clinical praxis. LVEF is categorized as normal (>50%) or mild, moderate or severely impaired (40–49%, 30–39% and <30%, respectively) and reported to the registry by the treating center. The purpose of this study was to validate the reported LVEF assessments against independent echocardiography re-evaluation as this has never previously been done.

Methods

A random sample of 130 patient from three different hospitals were included. LVEF re-evaluation was performed by two independent reviewers using the modified biplane Simpson method and their mean LVEF was compared to the SWEDEHEART LVEF. Agreement between reported and re-evaluated LVEF was assessed using Gwet's AC2 statistics.

Results

Analysis showed good agreement between reported and reevaluated LVEF (AC2: 0.76 [95% CI 0.69–0.84]). The LVEF re-evaluations corresponded with registry reported categorized LVEF in 66.0% of cases. In 25.4% of cases the SWEDEHEART LVEF was lower than re-evaluated LVEF. The opposite relation was found in 8.6% of cases (p<0.005).

Conclusion

Independent validation of SWEDEHEART-reported LVEF shows an overall good agreement with the re-evaluated LVEF. However, a tendency to underestimation of LVEF was observed in patients with impaired LV systolic function, in whom the reported assessment of LVEF should be interpreted more cautiously.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Selanders Stiftelse

Association of growth differential factor-15, hs-cardiac troponin T and N-terminal pro-brain natriuretic peptide with coronary artery disease in patients undergoing elective coronary angiography

Background

Although the importance of conventional risk factors is well established, a significant proportion of patients with coronary artery disease (CAD) lack any of these factors and many patients without CAD have one or more of them. Better tools are needed to improve risk stratification of patients.

Purpose

We aimed to investigate the association between plasma levels of growth differentiation factor 15 (GDF-15), a marker of stress and inflammation, high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with the presence of CAD in stable patients referred for elective coronary angiography.

Methods

Plasma levels of the three biomarkers were measured in 252 consecutive patients. Patients with known CAD, acute coronary syndrome, or with chronic inflammatory conditions were excluded. CAD was defined by the presence of at least one lesion causing >50% stenosis. The outcome was defined as an ordinal variable with 3 levels: no CAD, 1- or 2-vessel CAD and 3-vessel or left main CAD.

Results

Median age was 63 years (56–71), and 35% of patients were females. Among conventional risk factors, hypertension was the most prevalent (70%), followed by hyperlipidemia (69%), smoking (42%), diabetes (33%) and family history of CAD (32%). Of the 252 patients enrolled, 153 (61%) had no CAD, 81 (32%) 1- or 2-vessel CAD, and 18 (7%) 3-vessel or left main CAD. Plasma levels of GDF-15, hs-cTnT and NT-proBNP in each of the 3 groups of CAD are summarized in table 1. In unadjusted ordinal logistic regression analysis, GDF-15 and hs-cTnT were statistically significantly associated with the presence and extent of CAD, while NT-proBNP was not (table 1). However, in a multivariable analysis including age, sex and traditional risk factors, the association of GDF-15 and hs-cTnT with angiographic CAD was attenuated and no longer statistically significant. Age, male sex, family history of premature CAD and the presence of hyperlipidemia, were independent predictors of the presence and extent of CAD (table 2).

Conclusion

In stable patients referred for coronary angiography, plasma levels of GDF-15 and hs-cTnT could predict the presence of CAD when evaluated separately. However, that association was attenuated by clinical characteristics.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Roche Diagnostics International LtdForrenstrasse 26343 RotkreuzSwitzerland Table 1Table 2

1107 Supplementing Orthopaedic Education outside of the Medical Curriculum: The Utility of a 1-Day Orthopaedic Revision Course for Medical Undergraduates

Introduction

Orthopaedic undergraduate education is both minimal and variable across UK medical schools. Furthermore, the clinical skills required to treat musculoskeletal injuries have been found inadequate by several studies assessing UK medical graduates.

Method

Orthopaedic revision courses organized by the student surgical society consisted of lectures and workshops covering clinical orthopaedic knowledge and skills required for university assessments. Five identical courses were run between December 2017 and December 2019 following the completion of fourth year’s musculoskeletal clinical block. Course tutors ranged from foundation year doctors (57%) to orthopaedic consultants and trainees (43%). An anonymous feedback form was handed out at each event and 5-point Likert scale questioning assessed participant perceptions prior to and following the course.

Results

This course led to a significant mean increase in students’ perceived knowledge levels with an average increase of 0.96 (19.2%) across all clinical examinations and lectures (p < 0.01). Tutor grade did not affect mean participant self-reported value of station, with stations taught by consultants and surgical trainees showing similar results to stations taught by FY doctors (p = 0.776).

Conclusions

The feedback revealed significant increases in student self-reported knowledge levels while poor pre-course scores reported might suggest inadequate coverage of orthopaedics in the undergraduate curriculum. The similarity in results when assessing the quality of tutorship suggests that FY doctors can be equally as valuable teaching tools for such courses as surgical trainees and consultants. These results suggest 1-day orthopaedic revision courses of this format can be highly beneficial in supplementing the undergraduate curriculum.

Associations between psychosocial burden and prognostic biomarkers in patients with stable coronary heart disease – a STABILITY substudy

Background

Psychosocial burden is associated with increased risk of cardiovascular (CV) events in patients with stable coronary heart disease (CHD). The underlying mechanisms linking psychosocial burden and CHD are unclear and might be explained by studying biomarkers known to be associated with CV risk.

Methods

15,608 patients in the STABILITY trial completed a questionnaire on to what extent they were feeling down, had loss of interest, experienced financial stress and if they were living alone. Levels of high-sensitivity (hs) C-reactive protein (hs-CRP), interleukin-6 (IL-6), hs-troponin T (hs-TnT) and N-terminal pro-B type natriuretic peptide (NT-proBNP) were assessed at baseline. Associations between levels of psychosocial burden (sometimes, often/always vs. never/rarely) and biomarkers were evaluated in a linear model where geometric mean ratio of the log-transformed biomarker were calculated.

Results

Adjusted associations (age, gender and established CV risk factors) are presented in the table.

Conclusion

Psychosocial burden in patients with stable CHD was independently associated with elevated biomarkers. The underlying association is likely to be complex and involve multiple pathways.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The STABILITY study was funded by GlaxoSmithKline. Roche Diagnostics, Rotkreuz, Switzerland, supported the research by providing the GDF-15 assay free of charge.

BCG as a game-changer to prevent the infection and severity of COVID-19 pandemic?

The impact of COVID-19 is changing with country wise and depend on universal immunization policies. COVID-19 badly affects countries that did not have universal immunization policies or having them only for the selective population of countries (highly prominent population) like Italy, USA, UK, Netherland, etc. Universal immunization of BCG can provide great protection against the COVID-19 infection because the BCG vaccine gives broad protection against respiratory infections. BCG vaccine induces expressions of the gene that are involved in the antiviral innate immune response against viral infections with long-term maintenance of BCG vaccine-induced cellular immunity. COVID-19 cases are reported very much less in the countries with universal BCG vaccination policies such as India, Afghanistan, Nepal, Bhutan, Bangladesh, Israel, Japan, etc. as compared to without BCG implemented countries such as the USA, Italy, Spain, Canada, UK, etc. BCG vaccine provides protection for 50–60 years of immunization, so the elderly population needs to be revaccinated with BCG. Several countries started clinical trials of the BCG vaccine for health care workers and elderly people. BCG can be uses as a prophylactic treatment until the availability of the COVID-19 vaccine.

Duration and method of tissue storage alters placental morphology - implications for clinical and research practice

We assessed whether placental morphology is affected by placental storage before fixation. Fresh tissue from uncomplicated pregnancies (n = 10) was fixed immediately and further samples were stored dry, in PBS or culture medium for 24, 48 or 72 h at 4 °C. Placental morphology quantified using image analysis software found no difference in syncytial nuclear aggregates, cytokeratin 7, CD45 or Ki67 immunostaining irrespective of duration or mode of storage. The number of blood vessels per villus (CD31) was reduced in all conditions after 72 h (p < 0.05). Distal villous hypoplasia increased after 72 h (p < 0.05). Ideally, storage time should be minimised to ≤48 h prior to morphological or qualitative analysis.

A case of confined placental mosaicism with double trisomy associated with stillbirth

We present a case of stillbirth in which the fetus was well grown and karyotypically normal, but the placenta was morphologically abnormal and had confined placental mosaicism (CPM) for a double trisomy of chromosomes 12 and 15. A compilation of published cases of CPM reveals that whilst approximately 80% of pregnancies progress normally, there is an association with abnormal placental morphology, intrauterine growth restriction, fetal abnormalities and stillbirth. This case highlights the potential adverse effects of CPM and the benefit of placental examination in determining the cause of stillbirth.

Inflammatory BCG adenitis associated with immune reconstitution following allogeneic haematopoietic stem cell transplant in infancy

We describe four cases of a localized, granulomatous reaction to BCG including ipsilateral painful, suppurative lymphadenopathy associated with donor immune reconstitution following allogeneic haematopoietic stem cell transplant performed in infancy and preceded by uneventful, routine BCG immunisation. The management of the inflammatory disease in these cases with surgery, antimycobacterial chemotherapy and steroids, is discussed.

Role of anaerobes in acute pelvic inflammatory disease

Pouch of Douglas aspirates were collected from 50 women with history and examination suggestive of acute pelvic inflammatory disease (PID) and 20 healthy women admitted for tubal ligation served as control. A total of 57 microorganisms were isolated from 37 patients out of 50 in study group. Of 37 positive cultures 21(56.7%) were monomicrobial and 16(43.2%) were polymicrobial. Most common symptom in study group was lower abdominal pain (90%), vaginal discharge (70%) and irregular bleeding (40%) and 30% patients had history of intrauterine contraceptive device (IUCD) implantation. The predominant aerobic isolates were Escherichia coli, Coagulase Negative Staphylococcus (CONS), Staphylococcus aureus, Klebsiella pneumoniae while common anaerobes were Bacteroides fragilis, Prevotella melaninogenica, Fusobacterium nucleatum and Peptostreptococcus spp. Our study shows that cefotaxime, cefuroxime and gentamicin may be used for gram negative aerobic bacilli; cloxacillin, cephaloridine and erythromycin for aerobic gram positive cocci and amikacin and ceftazidime for Pseudomonas aeruginosa. Thus for optimum therapy of acute PID it is beneficial to keep in mind major conceptual changes and therapeutic realities that have influenced current understanding of acute PID and have affected the choice of therapy.

Localization of estrogen receptor beta protein expression in adult human bone

Evidence suggests that the newly described estrogen receptor beta (ER-beta) may be important for estrogen (17beta-estradiol) action on the skeleton, but its cellular localization in adult human bone requires clarification. We addressed this by using indirect immunoperoxidase with a novel affinity purified polyclonal antibody to human ER-beta, raised to hinge domain (D) sequences from the human receptor. Bone was demineralized in 20% EDTA and all biopsy specimens were formalin-fixed and wax-embedded. Vigorous retrieval was essential for ER-beta detection. In sections (5 microm) of benign prostate hyperplasia, used as positive control, clear nuclear immunoreactivity was seen in glandular epithelial cells, with a 1:500 dilution of ER-beta40. For bone sections, optimal antibody dilutions were 1:100-1:250. We found that in normal bone (from graft operations), in fracture callus from both men and women (>25 years old), pagetic bone, osteophytes, and secondary hyperparathyroid bone, all from older patients, ER-beta was expressed clearly in osteoclast nuclei, with little cytoplasmic immunoreactivity. Nuclear immunoreactivity was still prominent in osteoclasts, with antibody diluted 1:500, although it faded in other cells. Osteoblasts, in areas of active bone formation or bone remodeling, also expressed ER-beta, as did some osteocytes. However, hypertrophic chondrocytes were negative, unlike mesenchymal cells, adjacent to the osteogenesis. Megakaryocytes and some capillary blood vessels cells were receptor positive. All ER-beta expression was blocked totally by preincubation of antibody with antigen. We conclude that ER-beta is expressed in cells of osteoblast lineage and in osteoclasts. The latter appear relatively abundant in this receptor and this might provide a means for direct action of estrogen on osteoclasts.

Changes in collateral ventilation with increased vascular pressure and edema formation

To test the hypothesis that development of hemodynamic edema results in decreased collateral ventilation, we rapidly volume-expanded anesthetized dogs with volumes equivalent to 10 (n = 5) and 15% (n = 5) of body weight. We measured collateral resistance (Rcoll), pulmonary arterial pressure, and left ventricular end-diastolic pressure before, during, and for 1-2 h after the infusion. Lungs were subsequently processed for microscopic examination and measurement of extravascular lung water content. During the infusion, Rcoll increased modestly independent of the fluid-infusion rate or the rate of increase in vascular pressures. After the infusion, Rcoll continued to increase to maximum levels 2-33 times base line even though pressures decreased dramatically. At the end of the experiment, Rcoll returned to base line in one dog and was 3-15 times base line in the other dogs. These changes bore no relationship to the severity of edema formation. Until alveolar flooding occurs, accumulation of lung interstitial fluid and changes in collateral ventilation appear to be coincident events rather than causally related variables.

Effects on body position and cholinergic blockade on mechanics of collateral ventilation

We studied the effects of position and cholinergic blockade on the mechanics of collateral ventilation in anesthetized paralyzed dogs. Resistance to collateral flow (Rcoll) is higher when an obstructed segment is dependent than when it is nondependent. Decreases of Rcoll in response to the local infusion of low oxygen mixtures are greater in dependent regions. We conclude that 1) changes in position affect Rcoll directly through local changes in lung volume related to the gradient of pleural pressure; 2) responses of collateral channels to local concentrations of CO2 and O2 are determined by ventilation perfusion relationships, which vary at different heights in the lung; and 3) resting cholinergic tone in the anesthetized dog varies at different heights in the lung.

A morphologic study of the influx of neutrophils into dog lung alveoli after lavage with sterile saline

The appearance of neutrophils in the alveoli of the lung is a common result of pulmonary infection, although the route of neutrophil migration across the alveolar wall has not been demonstrated in normal animals. Recently, however, several methods of stimulating the influx of neutrophils into alveoli have been developed. In the present study, the lung wash model was used to attract large numbers of neutrophils into the airways in order to identify the site of influx of alveolar neutrophils. The combined use of scanning and transmission electron microscopy has made it possible to visualize the migration of neutrophils from the capillaries, through the interstitial spaces, and through the epithelium at the junctions between Type I and Type II cells.

Size of the pool of alveolar neutrophils in normal rabbit lungs

Morphometric methods and two unique characteristics of neutrophils enabled us to measure the size of the pool of neutrophils in alveoli of rabbit lungs. Rabbit lungs contained an estimated 6.11 x 10(4) alveolar neutrophils/g wet wt of lungs, and 9.57 x 10(5) alveolar neutrophils/rabbit. Lung lavage was successful in removing an average of 42.2% of the neutrophils in the air containing spaces of the lungs. An average of 2.5 +/- 3.5 (SD)% of the cells in the lung washes were neutrophils, but an average of 10.23 +/- 5.0 (SD)% of the cells that were free in the alveolus were neutrophils. Studies of the interaction of alveolar macrophages and neutrophils in vitro showed that neither cell phagocytoses or destroys the other in significant quantities; however, alveolar macrophages containing neutrophils have been observed.

Collateral ventilation in man

To determine whether collateral ventilation (defined as the ventilation of alveolar structures through passages or channels that bypass the normal airways) changes with age or emphysema, we compared the mechanics of collateral ventilation in seven young normal subjects, three old normal subjects and five patients with emphysema. In supine normal subjects at the end of a quiet expiration, resistance to airflow was greater through collateral channels than through bronchi and bronchioles. In emphysema, airways resistance could exceed collateral resistance, causing air to flow preferentially through collateral pathways. We conclude that high collateral resistance minimizes collateral airflow in supine normal subjects. When peripheral airways become obstructed or obliterated in emphysema, collateral channels may provide for more even distribution of ventilation.

Effect of transpulmonary and vascular pressures on rate of pulmonary edema formation

The effect of transpulmonary pressure (Ptp) on rate of extravascular fluid accumulation in isolated canine left lower lobes perfused at constant vascular pressures was investigated. Changes in rate of extravascular fluid accumulation were estimated by changes in rate of slow weight gain. Mean inflow pressure (Ppa) was constant at 34 cmH2O. Mean outflow pressure (Ppv) was constant at either 27.2 cmH2O or 13.6 cmH2O. When increasing Ptp is associated with a derecruitment of vascular beds as the lung changes from predominantly zone III toward zone II, or zone I, there is a decrease in rate of weight gain. When increasing Ptp is not associated with a derecruitment of vascular beds, it is impossible on the basis of these experiments to predict the change in rate of weight gain.

Airway responses to methacholine in allergic and nonallergic subjects

After inhalation challenge with methacholine, bronchoconstrictor responses were produced in allergic subjects with asthma and hay fever as well as nonallergic subjects. Our results indicate that allergic persons possess a greater pulmonary responsiveness to inhalation of this parasympathomimetic agent than nonallergic subjects; however, patterns of response were different in the 2 types of allergic subjects, those with asthma and those with hay fever. Whereas both types of allergic subjects responded with changes in specific airway conductance when nonallergic subjects did not, only asthmatic subjects differed from nonallergic subjects when comparisons of spirometry were made. These data suggest that there is hypersensitivity of both central and peripheral airways in asthmatics and in the larger central airways of nonasthmatic allergic subjects.