In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018

BACKGROUND

The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.

METHODS

Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.

RESULTS

From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70).

CONCLUSION

In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

“Blocked broken heart syndrome”: an unusual case of a complete atrioventricular block complicating a Takotsubo cardiomyopathy

Background

Complete heart block is considered a unique and rare complication of Takotsubo cardiomyopathy, an otherwise self-resolving disease. When this occurs, there is a double clinical dilemma: first to find out which triggered the other and second, to decide whether or not to implant a permanent pacemaker.

Case presentation

We present a case of a 77 years-old female patient, with previous medical history of arterial hypertension, diabetes mellitus, dyslipidemia and bifascicular block known since 2013. She came to the emergency department after recurrent syncopal episodes. At admission a complete heart block was diagnosed, and it was implanted a single chamber temporary pacemaker. The patient remained in disproportional acute decompensated heart failure despite pacemaker implantation. She denied chest pain although referring an episode of self-limiting chest pain 2 days before, after an argument with the family. Blood analysis showed an important rise in NTproBNP and troponin levels. Transthoracic echocardiogram showed a dilated left ventricle with akinesia of apical and mid segments, hyperkinesia of basal segments and severely depressed left ventricle ejection fraction. Coronary angiography showed no significant lesions and the diagnosis of Takotsubo cardiomyopathy was suspected. During the following days, she recovered her own intrinsic rhythm. Electrocardiogram evolved with deep T-wave inversion and prolonged QT interval and transthoracic echocardiogram showed resolution of the previous alterations. Despite complete reversion of rhythm alteration, it was decided to implant a permanent pacemaker.

Conclusions

We describe a rare, life-threatening and often underdiagnosed complication of the stress cardiomyopathy. Furthermore, we performed a literature revision of this rare complication and discussed the therapeutic challenge encountered in such patients.

At the outer edge of STEMI time: even after 12 hours, the clock keeps ticking

Introduction

Although primary percutaneous coronary intervention (pPCI) is not a class I recommendation in all patients (pts) presenting within 12 to 48h of symptom onset (late ST-segment Elevation Myocardial Infarction, STEMI), there is increasing evidence supporting its routine use in this population. Data on long-term clinical outcomes is sparse.

Objective

To evaluate long-term MACE in late-STEMI pts submitted to pPCI and compare with clinical outcomes of early reperfusion groups.

Methods

Retrospective analysis of consecutive pts submitted to pPCI due to STEMI between 2010 and 2015 in a pPCI centre. Included pts were stratified in 5 groups according to symptom-to-balloon time (SBT): <3h; 3–6h; 6–12h; 12–24h; 24–48h. Of a total of 903 pts, 19 pts were excluded due to SBT >48h. Long-term events were established as 5y mortality and 5y-MACE (a composite endpoint of death, re-infarction, heart failure hospital admission and ischemic stroke). The cumulative incidence of long-term outcomes was calculated by the Cox regression analysis and presented according to the Kaplan-Meier method.

Results

Of the 884 pts included in the study, stratification according to SBT was: pPCI<3h (47.4%), pPCI 3–6h (24.9%), pPCI 6–12h (16.5%), pPCI 12–24h (8.0%), and pPCI 24–48h (3.2%). These groups showed no significant difference in terms of demographic characteristics (age, CV risk factors, previous coronary disease or heart failure), clinical severity (systolic arterial pressure, Killip-Kimball class, left ventricle ejection fraction) and angiography findings (multivessel disease, complete revascularization and PCI success). After a median follow-up of 76 (56; 98) months, 5-year mortality was 20.6% (182 pts) and 5-year MACE was 23.3% (206 pts). MACE was associated with increased median SBT: 5.0 (2.0; 9.0) hours vs 4.0 (2.0; 6.5) hours, p<0.001. Of the MACE components, the only that showed a significant association with higher median SBT was mortality: 5.0 (2.0; 10.0) hours vs 4.0 (2.0; 6.0), p<0.001. Differences in long-term outcomes were significant when considering SBT stratified by revascularization time (Figure 1).

Conclusions

As expected, there is a clinical benefit of early reperfusion for long-term cardiovascular events. Within the late-STEMI group, there seems to be a clear distinction between pPCI<24h and >24h, although the clinical benefit of pPCI timing most probably acts a continuum.

Funding Acknowledgement

Type of funding sources: None.

What is there to EAARN with a CRT implantation? Predictive factors of mortality or clinical deterioration in patients receiving cardiac resynchronization therapy based on pre-implant factors

Introduction

Cardiac resynchronization therapy (CRT) in heart failure patients with reduced ejection fraction (HFrEF) and wide QRS complexes has been shown to improve both functional capacity and quality of life, and to decrease hospital admissions and mortality. Mortality in CRT patients has been associated with several pre-implant risk factors and some risk scores, like the EAARN score, have been developed to try and predict mortality and morbidity in this population.

Purpose

Our aim was to assess risk factors for a compositive end-point of admissions for heart failure or cardiovascular death at 5 years, particularly the EAARN SCORE (EF, Age, Atrial Fibrillation (AF), Renal dysfunction, New York Heart Association (NYHA) class IV), in patients with EF <35% and QRS >130ms submitted to CRT implantation.

Methods

We performed a retrospective analysis between 2012 and May of 2019 of all patients admitted for CRT implantation due to HFrEF with EF <35% and QRS >130ms in a single expert centre. Medical records were analysed for clinical, procedural data and outcomes. The predictive accuracy of the score was assessed using the area under curve (AUC) of receiver operating characteristics (ROC) curve. The association between EAARN and the composite end-point at 5-years was analyzed using a Cox regression model.

Results

Of the 134 patients assessed, 101 patients fulfilled all inclusion criteria. The mean age at implantation was 70.2±10 years with a male preponderance (67.2%).

This population was significantly symptomatic, with 35% in NYHA class II, 58% in NYHA class III and 5% in NYHA class IV. Most had an ischemic etiology (74.2%). 75% of patients were considered responders after implantation (NYHA improvement of at least 1 class and/or increase in 10% in EF). A primary composite end-point occurred in 17.8% of patients. The pre-procedure characteristics associated with an event were an ischemic etiology (OR 4.66; CI 95% 1.52–14.24, p<0.05) and pre-procedure EF (OR 0.81; CI 95% 0.81–0.97, p<0.05). The age, sex, NYHA class, presence of AF, renal function, bundle branch block morphology and responder status were non significant. The EAARN Score showed predictive power for the occurrence of an event (OR 1.95; CI 95% 1.13–3.36, p<0.05) and a reasonable discriminative capacity with the ROC curve analysis (figure 1A) demonstrating an AUC of 0.70. The survival analysis (figure 1B) with a Hazard Ratio of 1.88 (CI 95% 1.158–3.058, p<0.05) signifying an increased risk of an event of 88% per EAARN class increase, with the Kaplan Meier curves widening significantly in the different categories of the score.

Conclusions

In patients who implanted a CRT due to HFrEF with EF <35% and QRS >130ms the EAARN score demonstrated a good predictive power and discriminative capacity for admission for heart failure or cardiovascular death at 5 years although it does not account for the etiology which was also a significant factor.

Funding Acknowledgement

Type of funding sources: None.

What are the NEWS in pulmonary embolism risk stratification?

Introduction

The patients with Pulmonary Thromboembolism (PE) stratified as intermediate-high risk with the European Society of Cardiology classification represent an heterogenous population, with the majority having a benign outcome however some evolving in clinical deterioration. Several risk scores have been developed to try and refine the population most at risk but they are deemed sub-optimal.

Purpose

Our aim was to assess the capacity of the National Early Warning Score (NEWS) in predicting a composite end-point of 30-days cardiovascular mortality, rescue thombolysis and/or haemodynamic instability, in a population of intermediate-high risk PE, as compared with other risk evaluation scores as the PESI and SHIeLD scores.

Methods

We performed a retrospective analysis between 2014 and 2019 of all patients admitted for intermediate-high risk PE, in a single expert centre. The patients who underwent fibrinolysis as per clinician discretion (without haemodynamically instability or clinical evidence of clinical deterioration) were excluded. Medical records were analysed for clinical data and outcomes. The predictive accuracy of all scores were assessed using the area under curve (AUC) of receiver operating characteristics (ROC) curve. The association between NEWS and composite end-point at 30-days was analyzed using a Cox regression model.

Results

Of the 1132 patients assessed and admitted with PE, 116 patients fulfilled all inclusion criteria and none of the exclusion criteria and were analysed. The mean age was 69±16 years at time of diagnosis with a female preponderance (62.9%). Most patients were treated with anticoagulation (97.4%), 68% with low molecular weight heparin and the remaining with unfractionated heparin. The average NEWS score was 7±3, the average PESI score was 110±34 and the average SHIeLD score was 14±13. A primary composite end-point occurred in 18 patients (15.5%). The NEWS score showed the greatest predictive power for the occurrence of an event (OR 1.35; 95% CI 1.11–1.64, p=0.003) compared with the SHIeLD score (OR 1.0; 95% CI 1.00–1.07, p=0.035) and the PESI score (OR 1.02; 95% CI 1.00–1.03, p=0.03); it also showed a greatest discriminative capacity with the ROC curve analysis (Figure 1A) demonstrating an AUC of 0.70, vs 0.65 and 0.62 respectively. The survival analysis demonstrated a Hazard Ratio of 1.29 (95% CI 1.10–1.52; p=0.002) signifying a 29% increased risk of an event per each NEWS class increase, with the Kaplan Meier curves widening significantly in the different terciles of the score (Figure 1B).

Conclusions

In PE patients with intermediate-high risk the NEWS score demonstrated a greater predictive power and discriminative capacity than other commonly used risk scores. The NEWS score may help to identify patients in this risk category who might benefit from a reperfusion strategy, but larger studies are needed to confirm this hypothesis.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous coronary intervention in elderly patients with chronic kidney disease and non-ST segment elevation acute coronary syndrome – is it worth it?

 

ESC guidelines recommend revascularization in patients (pts) with chronic kidney disease (CKD) irrespective of age. However, elderly pts are usually underrepresented in the available data on percutaneous coronary intervention (PCI). Thus, the decision on whether to perform PCI in these pts is usually at the discretion of the cardiology team.

Aim

To evaluate the impact of PCI vs conservative approach (CA) in elderly pts (>80 years) with CKD and unstable angina (UA)/non-ST segment elevation myocardial infarction (NSTEMI) who were enrolled in the Portuguese National Registry of Acute Coronary Syndromes. To determine impact of CKD in in-hospital (IH) and long-term outcomes, including MACE (myocardial infarction, stroke and death) and death at 1 year.

Study population

Elderly pts admitted with UA and NSTEMI, from 2010 until 2021. There were three different groups: Group 1 – eGFR ≥60 ml/min/1.73 m2; Group 2 – eGFR between 30 and 59 ml/min/1.73 m2 and Group 3 – eGFR <30 ml/min/1.73 m2. Pts with ST-segment elevation myocardial infarction and cardiogenic shock were excluded.

Results

A total of 2443 pts, of which 921 (37,7%) were submitted to PCI. 50,2% (n=1126,) were from the group 1, 38,5% (n=941) from group 2 and 11.3% (n=276) from group 3.

Regarding overall population, pts submitted to PCI were mainly male (60,4%) with a mean age of 84±3 years old. They had previous history of PCI (21,6% vs 15,1% p<0.001), less history of heart failure (HF), stroke or dementia (8,5% vs 16,5%; 8,1 vs 13.3% and 2,1 vs 5,9%, p<0.001). At presentation they had more angina (88,8% vs 81,2% p<0.001), less NT-proBNP levels (387 vs 561 p<0.001) and were more frequently in KK class I (75,6% vs 70,2% p=0.004). They developed less HF (21% vs 27%, p<0.001) and MACE (5,7% vs 9,1% p=0.003). Pts in the group 3 were less submitted to PCI (27,5% vs 38,2% vs 39,6% p<0.001) and had more MACE and cardiovascular death when comparing to group 2 and 1 (16,1% vs 8,7% vs 5,3% and 10,5% vs 5,5% vs 2,6% p<0.001 respectively).

Comparing PCI vs CA in each group, there was no difference in IH outcomes between both strategies in group 3. The same was not true for groups 1 and 2, in which PCI seemed to favor overall outcomes (p=0.001 and p=0.015 respectively).

The predictors of IH death and MACE were: age (OR 1.068 p=0.010), dementia (OR 2,376 p=0.015), KK class >1 (OR 2,243, p<0.001), atrial fibrilhation (OR 1.605, p=0.046), not having PCI (OR 0.309, p<0.001), eGFR <30 (OR 3.51, p<0.001) and PCI in pts with eGFR <30 (OR 2.923, p=0.019).

Interestingly, survival analysis showed that pts submitted to PCI in all 3 groups (including group 3) had a longer 1-year survival (p<0.001, p<0.001 and p<0.004).

Conclusions

PCI performance in elderly pts with CKD should be individualized. In our population, especially in group 3, the performance of PCI is associated with a higher IH mortality, however, after surviving hospitalization, these pts seem to have a benefit in 1 year survival.

Funding Acknowledgement

Type of funding sources: None.

Should we stay or should we go: assessment of the need for the implantation of a definite pacemaker in a population of acute coronary syndrome that evolved in advanced atrioventricular block

Introduction

The incidence of advanced atrioventricular block (AVB) secondary to acute coronary syndrome (ACS) has been decreasing in the era of percutaneous revascularization and in most cases is transitory and does not require pacemaker (PM) implantation.

Purpose

Our aim was to assess the characteristics of patients with AVB as a consequence of the ACS and compare those with and without PM implantation, in what regards in-hospital and at 1 year outcomes.

Methods

We performed a retrospective analysis of all patients admitted with AVB secondary to ACS in Portugal between October of 2010 and August of 2021 with data from the Real World Portuguese Registry on Acute Coronary Syndromes (ProACS). Medical records were analysed for demographic, procedural data and outcomes.

Results

Sex hundred and seventy one (671) patients with AVB secondary to ACS were admitted, which corresponded to 2.2% of the total cohort. The mean age was 70±13 with a male preponderance (66%). The ACS was categorized as ST elevation Myocardial Infarction (STEMI) in 76.4%, non-STEMI (NSTEMI) in 22.1%, and unstable angina (UA) in 1.5%. Of the patients admitted with AVB, 8.6% implanted a permanent PM. The was no clinically relevant differences in both groups in what regards to medical priors or medication. Regarding the location of the infarction, an Anterior STEMI was the diagnosis of admission in 36.8% (vs 14.5%; OR 3.45, CI 95% 1.31–9.06, p<0.05) of patients that implanted a PM, and the left descending artery was more frequently the culprit artery, and an Inferior STEMI was the diagnosis of 63.2% (vs 83.7%; OR 0.31, CI 95% 0.12–0.82, p<0.05) of patients and a right coronary artery was more frequently the culprit artery.

The presence of cardiovascular shock and in-hospital death was significantly more frequent in the group that did not implant a PM (OR 0.40; CI 95% 0.17–0.95, p<0.05 and OR 0.33; CI 0.12–0.92, p<0.05 respectively) and the implantation of PM was a negative predictor of in-hospital death (OR 0.28; CI 95% 0.08–0.93, p<0.05).

The follow up at 1 year was performed in two hundred and sixty three (263) patients, 10.6% with an implanted PM. The survival analysis demonstrated increased mortality and a combined end-point of death and readmissions in the population of AVB that did not implant PM compared with a population who did not present with AVB (p<0.05) with the Kaplan Meier curves widening significantly (Figure 1). This difference was not observed compared with an AVB population that implanted PM.

Conclusions

In patients with AVB secondary to ACS, the implantation of a PM might have been withheld in more severe patients, accounting for the increased mortality observed, and this population has worse outcomes at 1 year, leaving open to the hypothesis if either due to a more severe clinical status or the recurrence of AVB.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Normal flow, low gradient aortic stenosis - is LVOT the determinant?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (>40mmHg) and an aortic valve area (AVA ≤1cm2). These patients present with a lower mean gradient (<40mmHg) and area (AVA ≤1cm2). However, the treatment strategies focus on the population with a reduced indexed stroke volume (≤35mL/m2). There is less clarity concerning those with a normal stroke volume. An important determinant of the area and stroke volume is the LVOT diameter, which may have a significant impact in the classification of the severity. There is some literature supporting an expected diameter according to the body surface area.

Purpose

This paper aims to analyse the population with normal flow, low gradient aortic stenosis, as well as compare the impact of the expected LVOT diameter in the classification of patients.

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed as well as echocardiographic variables to properly characterize aortic stenosis.

Results

A total of 79 patients met the criteria for normal flow, low gradient aortic stenosis with a valvular area ≤1cm2.  Mean age was 79.5 ± 8.6 years-old and 38% was male. The mean LVOT diameter was 2.11 ± 0.18 cm which correlated to a mean AVA of 0.88 ± 0.10 cm2. Should the LVOT diameter align with the expected diameter according to the formula [(5,7× BSA +12,1)/10], the mean LVOT diameter would be 2.18 ± 0.11 cm, which correlated to a mean AVA of 0.96 ± 0.22cm2. This represents a statistically significant difference in the value, with the expected diameter being 0.075cm higher than the measured (p = 0.002), which translates in a statistically significant higher AVA (+0.085, p < 0,001). With the above data, 31 (38.8%) patients would have been reclassified as moderate aortic stenosis, according to the recalculated AVA alone. Taking into account the indexed AVA, only 22 (27.8%) patients would be reclassified. 8 other patients (10.1%) would have been reclassified as low flow, low gradient aortic stenosis as the recalculated stroke volume would be lower than 35mL/m2.

Conclusion

This paper reminded us of the importance of an appropriately measured LVOT diameter, and the potential impact in reclassification of valvular heart disease. This is more important when the classification may alter our conduct. Other imaging techniques, such as transoesophageal echocardiogram or CT scan, may obviate the squared error of the LVOT measurement as well as account for the geometry of the LVOT, especially in dubious cases. Abstract Figure.

Is flow better in mL/m2 or mL/s - a practical reflection on aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (>40mmHg) and an aortic valve area (AVA ≤1cm2). There is a population of patients with discordant findings. These patients present with a lower mean gradient (<40mmHg) and area (AVA ≤1cm2).  This states are explained by a low flow (indexed SV ≤35ml/m2). Some studies demonstrated that a flow rate (determined by dividing SV by ejection time) inferior to 200 mL/s is also associated with poor prognosis. Can this be an alternative in stratifying patients with an AVA ≤1cm2?

Purpose

This paper aims to compare flow assessment by the conventional way with flow calculated in ml/s in patients with AVA ≤1cm2

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed for each subgroup as well as echocardiographic variables to properly characterize aortic stenosis.

Results

A total of 118 patients met the criteria for severe aortic stenosis with a valvular area ≤1cm2. This population was made up of 18 patients with severe aortic stenosis low flow, low gradient with depressed ejection fraction and 32 patients with preserved ejection fraction. The other 68 patients represented patients with a normal flow, low gradient aortic stenosis. There is a strong correlation between the variable SVi and Flow Rate (r = 0,796, p < 0,001). A linear regression shows that the flow rate equivalent to a SVi of 35mL/m2 in our sample is 203mL/s, near the value of other studies. 10 (31.3%) patients with severe aortic stenosis low flow, low gradient with preserved ejection fraction, 3 (16.7%) patients with severe aortic stenosis low flow, low gradient with depressed ejection fraction and 53 (77.9%) patients with normal flow, low gradient aortic stenosis would have a flow superior to 200mL/s.

Conclusion

The use of flow rate systematically would downgrade the severity of valvular lesions with possible need for intervention. However, in certain dubious cases its application may identify a subpopulation with need for further study and probable treatment, such as the patients with normal flow, low gradient aortic stenosis. Further studies of this subgroup of patients are warranted to reach any final conclusions. Abstract Figure.

Low gradient aortic stenosis - is survival that different between types and strategies

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (>40mmHg) and an aortic valve area (AVA ≤1cm2). There is a population of patients with discordant findings. These patients present with a lower mean gradient (<40mmHg) and a small area (AVA ≤1cm2). They encompass a population with specific characteristics and rather heterogeneous treatment approach and different prognosis

Purpose

This paper aims to enlighten to the prognosis of the different subpopulation of low gradient aortic stenosis, alone and according to the treatment strategies in a center without surgical ou percutaneous valvular intervention. 

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed for each subgroup as well as echocardiographic variables to properly characterize aortic stenosis and employed strategy and death.

Results

A total of 135 patients met the criteria for severe aortic stenosis with a valvular area ≤1cm2. This population was made up of 19 patients with severe aortic stenosis low flow, low gradient with depressed ejection fraction and 36 patients with preserved ejection fraction. The other 80 patients represented patients with a normal flow, low gradient aortic stenosis. Groups were similar in terms of age, sex, BMI, hypertension, dyslipidaemia, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease and chronic coronary syndrome. In terms of diabetes there was a statistically significant difference (p = 0.019) with a lower prevalence in the group with low flow, low gradient and preserved ejection fraction. There was a statistically significant difference in survival at 24 months between groups (p = 0,004), with a mean survival of 13.6 months, 17.6months and 21 months for low flow low gradient with depressed ejection fraction, low flow low gradient with preserved ejection fraction and normal flow, low gradient patients, respectively. When analysing the treatment strategies, there were also statistically significant differences between the whole population of patients (p = 0.001) and each subgroup (low flow, low gradient with depressed ejection fraction – p <0,001; and normal flow low gradient – p = 0,005), with exception of patients with low flow low gradient and preserved ejection fraction (p = 0,081).

Conclusion

Our analyses brings to our attention a clear difference in prognosis between the subgroups analysed with a worse mean survival at 24 months in patients with low flow, low gradient and depressed ejection fraction. Furthermore, there seems to be a clear impact of treatment strategies in each group of patients and still some margin of improvement especially in patients without a clearly defined treatment strategy. Abstract Figure.  Abstract Figure.

High-risk acute pulmonary embolism in a Portuguese centre: are we doing enough?

Introduction

For high-risk acute Pulmonary Embolism patients (HR-PE pts), reperfusion treatment is imperative to improve mortality. Although systemic thrombolysis (ST) is generally an appropriate first-line therapy, several population-based studies report its underuse. Data on epidemiology, management and outcomes of HR-PE in Portugal is scarce.

Purpose

Estimate the reperfusion rate in HR-PE pts, the reasons for non-reperfusion (NR) and how it influences outcomes.

Methods

Retrospective single-centre registry of consecutive HR-PE pts between 2008–2018, defined by the 2019 ESC guidelines criteria. Independent predictors for NR were assessed by multivariate logistic regression. The cumulative incidence of PE-related mortality at 30 days was calculated according to the Kaplan-Meier method and differences stratified by reperfusion were assessed using the log-rank test.

Results

Of a total of 1955 pts admitted with acute PE, 74 (3.8%) had HD instability at admission (mean age 68±15 years). The majority of pts (68.5%) came from the emergency department while the remaining 31.5% were already hospitalized for other reasons. The total reperfusion rate was 50% - 35pts were submitted to systemic thrombolysis, 1pt to first-line percutaneous embolectomy and 1pt to rescue endovascular treatment. Age was an independent predictor of NR (63±17 vs 73±12, p=0.02) with >75 years representing 15 times the risk of non-treatment (OR 15.5, 95% CI 3.23–74.25, p<0.001). Absolute contraindication for thrombolysis was present in 29.7% (22pts), with recent major surgery (13pts) and recent cerebral event (8pts) as the most common reasons. The presence of an absolute contraindication for systemic thrombolysis was also an independent predictor of NR (66.7% vs 13.6%; OR 13.3, 95% CI 2.51–70.65, p=0.002). Being hospitalized was associated with the presence of absolute contraindications for thrombolysis (68.2% vs 14.0%, p<0.001) and was also an independent predictor of NR (38% vs 77.3%; OR 8.49, 95% CI 1.56–46.11, p=0.013). PE-related death at 30 days was 28.4% (21pts), which was significantly lower in the reperfusion group (17.1% vs 38.9%, p=0.042). At a mean follow-up of 2.5±3.3 years, survival rate was 33.8% (figure 1).

Conclusions

Low reperfusion rate due to contraindications for thrombolysis was associated with high PE-related mortality. This data suggests that it is necessary to implement interventional alternative strategies, at a national level, to improve outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Survival rate according to reperfusion.

Comparison of 2-years follow-up of optimal medical therapy versus balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension

Introduction

Balloon pulmonary angioplasty (BPA) has emerged as a therapeutic option for chronic thromboembolic pulmonary hypertension (CTEPH) considered ineligible for pulmonary endarterectomy (PEA). The initial publications showed very good short-term outcomes for the technique, but there are limited data regarding medium-term outcomes and its comparison with optimal medical treatment (OMT).

Objectives

To evaluate and compare the medium-term outcomes of OMT versus (vs) BPA in inoperable CTEPH.

Methods

Retrospective study of consecutive patients (pts) with CTEPH followed in a referral centre for Pulmonary Hypertension. Selected those pts considered ineligible for PEA and with at least 2 years of follow-up. Comparison between two treatment strategies: OMT alone [maximum tolerated doses of pulmonary vasodilator drugs (PVD), as indicated] vs BPA (pts who completed the program with or without OMT). Endpoint was a composite of all-cause death and unplanned right heart failure admission at 2-year.

Results

From 62 pts, 19 pts were included (11 pts were excluded due to recent diagnosis; 32 were submitted to EAP): mean age 65.0±15.3 years, 89.5% female. At diagnosis, all pts had functional capacity limitation and elevated serum NTproBNP levels (median value 1255.0 pg/mL). Mean pulmonary arterial pressure (mPAP) was 46.2±9.3 mmHg and pulmonary vascular resistance (PVR) 15.3±8.3 Wood units (WU). Concerning treatment, 12 pts (63.2%) underwent OMT alone. These pts had higher NTproBNP levels (2670.0 vs 538.0 pg/mL, p<0.01) and PVR values (19.7±7.6 vs 9.7±5.4 WU, p=0.01) and lower CI (1.6±0.3 vs 2.4±0.5 L/min/m2, p<0.01), at baseline; the remaining basal features didn't differ among groups (Fig.A). At 2-year follow-up, pts submitted to BPA were under PVD in 71.4% of cases with a mean of 1±0.8 drugs per patient and no difference compared to OMT group (83.3%, 1.7±0.9 drugs per patient), although oxygen therapy was higher in medical group (50% vs 0%, p=0.04). A significant overall improvement was observed in BPA group (Table – A): all pts were in functional class I (p<0.01), no one had right ventricular dysfunction (p<0.01) and mPAP decreased to 25.1±6.7 mmHg (p=0.01) and RVP to 2.9±0.8 WU (p=0.01). Inversely, no change was observed in pts under OMT alone (p>0.05 in all, Table – A). Endpoint rate was 31.6% with all adverse events occurring in the OMT group (50% vs 0%, p=0.04). After adjustment by Cox regression, no difference in baseline or follow-up features besides treatment influenced the outcome. Kaplan-Meier analysis (Graphic – B) confirmed significant benefit of BPA in 2-year outcome occurrence (long rank 4.6, p=0.03).

Conclusions

BPA strategy seems to improve medium-term functional capacity, right ventricular function and haemodynamics and decrease oxygen therapy dependence in inoperable CTEPH. Pts under OMT alone have a poor prognosis. These data encourage the development and implementation of the technique for inoperable CTEPH.

Funding Acknowledgement

Type of funding sources: None.

Left atrial appendage velocity as an instrument of predicting atrial fibrillation recurrence after successful catheter ablation – a useful tool?

Introduction

Catheter ablation for the treatment of Atrial Fibrillation (AF) is a modality of treatment in growing expansion. However the sustained long term response in preventing AF recurrence is poor for most patients, namely in those with a dilated left atrium.

Purpose

Our aim was to assess the utility of an echocardiographic parameter for left atrium function, the left atrial appendage velocity (LAAV), in predicting recurrences after catheter ablation.

Methods

We performed a 9 year retrospective analysis of all patients who underwent a successful catheter ablation for the treatment of atrial fibrillation and had a valid pre-procedural transesophagic echocardiogram in a single expert centre. Medical records were analysed for demographic, procedural data and outcomes.

Results

Seventy-three (73) patients fulfilled all inclusion criteria and were analysed. The mean age was 62±11 with a male preponderance (58,7%). The majority of patients (82,7%) had preserved left ventricle ejection fraction. Only 46% of patient had a volumetric assessment of the left atrium dimensions prior to ablation, with slight, moderate and severe dilation of the left atrium in 20%; 8,6% and 28,6% of patients. Of the patients subjected to an AF ablation the average LAAV was 50,6±19 cm/s, with 78% of patients with normal atrial appendage velocities.

Patients with low LAAV (<40cm/s) had a higher proportion of AF recurrences at 3 and 6 months (58,3 vs 12,8% and 89% vs 21,7%; p<0,05 for all) with a linear correlation between the presence of recurrences and LAAV (LAAV of 39,1 vs 57,5 cm/s; p<0,05 OR 0,91 (CI 95% = 0,85–0,97); r2=0,34 at 3 months and LAAV of 43,5 vs 59 cm/s; p=0,01; OR 0,94 (CI 95% = 0,89–0,99); r2=0,24 at 6 months respectively). There was a trend towards association with recurrences at 1 year although it did not reach statistical significance. There was no significant difference in the use of antiarritmic drugs, either prior or post ablation, in both groups. It was not possible to assess the additive predictive value to the left atrium dimensions due to the low percentage of volumetric assessment of left atrium prior to AF ablation.

Conclusions

Patients with low left atrial appendage velocities had a lower long term success rate of catheter ablation, with higher rates of recurrence at 3 and 6 months and a trend towards higher recurrences at 1 year, with linear correlation which hypothesises the use of the left atrial appendage velocity as novel predictive parameter for an integrative model.

Funding Acknowledgement

Type of funding sources: None.

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Introduction

The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks.

Purpose

This study aims to analyze how OHA influences D2B and long-term mortality.

Methods

Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method.

Results

Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p<0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP >5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p<0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2.

Conclusion

OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Contrast-induced nephropathy after staged balloon pulmonary angioplasty: lower risk compared with left-sided cardiac procedures

Introduction

The risk of contrast-induced nephropathy (CIN) after left-sided cardiac procedures is reported as 10–15%. When the ratio of total contrast volume in ml to glomerular filtration rate (GFR) in mL/min (ratio V/GFR) exceeds 3.7, the risk increases significantly. However, there are few reports regarding the risk of CIN in patients (pts) with right-sided cardiac interventions such as balloon pulmonary angioplasty (BPA) and ratio V/GFR is not validated for use in this procedures.

Purpose

To assess the prevalence of CIN in pts with chronic thromboembolic pulmonary disease with or without hypertension (CTEPH/CTED) undergoing BPA.

Methods

Prospective single-centre study that included all BPA sessions performed from 2017 to 2020. Serum creatinine concentration (SC) was measured and the GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) before and 48 hours after each BPA procedure and 6 months after BPA treatment completion. CIN was defined as an increase of ≥25% and/or ≥0.5 mg/dL in SC from the baseline value within 48h of contrast administration.

Results

76 consecutive BPA sessions were performed in 15 CTEPH/CTED pts: mean age 63.2±14.0 years, 60% female, 86.7% CTEPH, mean of 5.3±1.9 sessions per patient with 4.3±1.9 vessels dilated per session. Mean value of GFR before BPA program was 73.5±26.3 mL/min. All the procedures were performed using low-osmolality contrast agent with a 1:1 dilution ratio with normal saline solution. Pts received 273.0±73.0 mL of contrast per session with a ratio V/GFR 3.7±1.7 mL. SC and GFR did not change significantly within 48h after BPA (+3.1%, p=0.07 and −3.0%, p=0.13, respectively). Ratio V/GFR >3.7 occurred in 44.3% of cases (n=31), but CIN occurred in only 5.3% (n=4) with an increase in SC <0.5 mg/dL but ≥25% in 3 cases (+33% in mean) and ≥0.5 mg/dL in 1 case. None of the pts required renal replacement therapy. Higher SC and lower GFR 48h after BPA were significantly correlated with greater rato V/GFR during procedure (r=0.75, p<0.01 and r=−0.74, p<0.01, respectively) – see figure. But neither higher values of ratio V/GFR (OR 1.43; CI95% 0.84–2.41; p=0.19) nor V/GFR >3.7 (OR 1.28; CI95% 0.17–9.6; p=0.81) were predictors of CIN. GFR before procedure did not influence the contrast volume administered (p=0.901), number of vessels (p=0.63) and segments treated by session (p=0.45). At 6 months follow-up, there was a trend for SC (1.3±0.2 mg/dL vs 1.1±0.2 mg/dL, −15%, p=0.43) and GFR (44.5±8.3 mg/dL vs 53.0±12.6 mg/dL, +16%, p=0.34) improvement in pts with impaired renal function at baseline (GFR<60 mL/min).

Conclusions

These findings suggested that the occurrence of CIN after BPA was low, raising the hypothesis that the influence of contrast agent on renal function could differ in right-sided cardiac interventions. Although the ratio V/GFR may be correlated with the risk of nephropathy, it is necessary to find a new cut-off to predict CIN in BPA pts.

Funding Acknowledgement

Type of funding sources: None.

Reperfusion in high-risk acute pulmonary embolism: can the PESI score predict outcomes?

Introduction

Acute pulmonary embolism (PE) is one of the leading causes of cardiovascular death worldwide. Haemodynamic (HD) instability defines high risk (HR) of early mortality and reperfusion treatment is the standard of care for rapid relieve of right ventricle (RV) overload in these situations. The impact of reperfusion in long-term outcomes is not well established. The PE Severity Index (PESI) score is used to stratify the risk of early death in HD stable patients (pts) and was not validated to predict outcomes in HR-PE.

Purpose

Estimate the prognostic performance of the PESI score in HR-PE and study its possible interaction in acute and long-term outcomes of reperfusion in HR-PE pts.

Methods

Retrospective single-centre study of consecutive HR-PE pts, defined by the 2019 ESC guidelines criteria, between 2008–2018. Logistic regression analysis was performed to test for an interaction between tertiles of the PESI score and reperfusion in early-mortality (during hospitalization and at 30 days) as well as 1-year MACE (a composite of cardiovascular mortality, PE recurrence or chronic thromboembolic pulmonary hypertension).

Results

Of a total of 1955 PE pts, 102 fulfilled the inclusion criteria (72.5% pts initially presented with HD instability with the remaining developing HR-PE after hospital admission). Mean age was 68±15 years and 60% were females. In-hospital and 30-day mortality were 39.6% and 43.0%, respectively. At one-year follow-up, MACE was 55.0%. Mean PESI at the time of HR-PE diagnosis was 200±39 and showed significant differences for in-hospital mortality (189±38 vs 217±34; OR 1.02, 95% CI 1.00–1.03, p<0.001), 30-day mortality (191±38 vs 214±36; OR 1.02, 95% CI 1.00–1.03, p=0.004) and 1y-MACE (186±41 vs 214±32; OR 1.02, 95% CI 1.01–1.03, p<0.001). Total reperfusion rate was 57.8% and was also associated with lower in-hospital mortality (OR 0.45, 95% CI 0.20–1.02; p=0.057), 30-day mortality (OR 0.35, 95% CI 0.15–0.80; p=0.012) and 1y-MACE (OR 0.35, 95% CI 0.15–0.80; p=0.014). The benefit of reperfusion was significantly influenced by the PESI score categorized by tertiles (figure 1).

Conclusions

Although the PESI score stratifies HD stable pts, in this population it was able to predict cardiovascular outcomes in HR-PE pts. Furthermore, it showed a significant interaction with the prognostic impact of reperfusion in early and late cardiovascular outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Interaction between PESI and reperfusion

One-year follow-up of continuous aspiration mechanical thrombectomy for the management of intermediate-high and high-risk pulmonary embolism: what is the line between utility and futility?

Introduction

Percutaneous catheter-directed treatments have emerged at the last decade for the management of acute high- or intermediate-high-risk pulmonary embolism (PE). Good short-term efficacy and safety have been published, but there are limited data regarding medium- to long-term outcomes.

Purpose

This study aimed to evaluate 1-year all-cause mortality of acute high- and intermediate-high-risk PE patients (pts) treated with continuous aspiration mechanical thrombectomy.

Methods

Twenty-nine consecutive pts with acute central PE (mean age 67.2±14.4 years; 72.4% female; 24.1% active cancer; Charlson comorbidity index 4.5±2.1; 82.8% in class>III of original PESI score; 44.8% high-risk PE) were treated with the Indigo Mechanical Thrombectomy System (Penumbra, Inc) between 03/2018 and 03/2020. Clinical success was defined as improvement in hemodynamic and/or oxygenation parameters or pulmonary hypertension or right heart strain at 48 hours after intervention plus survival to hospital discharge. Data regarding severe adverse events potentially related to the procedure, in-hospital and 1-year all-cause mortality were collected.

Results

Clinical success was 75.9%, with a significant improvement in mean paO2/fiO2 ratio (+77.1±103.2; p<0.01), shock index (−0.4±0.4, p<0.01), need for aminergic support (−75.0%, p<0.01), right ventricular function (66.6%, p<0.01) and systolic pulmonary arterial pressure (−10.2±11.5mmHg, p<0.01) at 48 hours after procedure. In-hospital survival rate was 82.8% but severe adverse events potentially related to the procedure occurred in 3 pts (10.3%). One-year follow-up was completed in 93.1% of cases and all-cause mortality rate was 34.5% (n=10 of which half occurred during the index hospital stay). Higher scores of Charlson comorbidity index (5.8±1.9 vs 3.7±1.9, p=0.01) and de novo atrial fibrillation at admission (40% vs 0%, p<0.01) were associated with higher 1-year all-cause mortality occurrence and were identified as 2 independent risk predictors by multivariate Cox regression. Kaplan-Meier curves confirmed its significant influence in 1-year survival free of adverse event (Figure). Time among diagnosis and percutaneous treatment (p=0.99), PESI score (p=0.24) and other clinical, haemodynamic and echocardiographic features did not influence mortality and suggest similarity of the PE severity at baseline. Technical characteristics were also not associated with mortality.

Conclusions

Aspiration thrombectomy for acute high- and intermediate-high-risk PE was feasible with a high clinical success rate. One-year all-cause mortality rate was elevated and predicted by high comorbidity index and de novo atrial fibrillation at admission. This data support the national expansion of this new PE treatment, but probably and as similar to other invasive techniques, we need to take into account comorbidities and avoid futility in multimorbidity pts.

Funding Acknowledgement

Type of funding sources: None.

Complications of balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease according to the classification proposed by the 6th world symposium on pulmonary hypertension

Introduction

Balloon pulmonary angioplasty (BPA) is a complex procedure and not risk free. In an attempt to standardize reports of BPA complications in the several centers, a classification of complications was proposed by the task force on chronic thromboembolic hypertension (CTEPH) in the 6th World Symposium on Pulmonary Hypertension (WSPH).

Purpose

To determine the prevalence of BPA complications according to the classification of 6th WSPH and to identify its predictors.

Methods

Detailed procedural and technical aspects were collected for consecutive patients (pts) with inoperable, residual/recurrent chronic thromboembolic disease, undergoing BPA at a single institution from December/2017 to December/2020. Per procedure logistic regression analysis was used to evaluate the predictive variables for complications.

Results

A total of 76 BPA sessions in 15 pts were performed (mean age 63.2±14.0 years; 60.0% women; 86.7% CTEPH). Mean pulmonary artery pressure and pulmonary vascular resistance before the first BPA session were 33.1±13.3 mmHg and 4.8±3.2 woods unit, respectively (73.3% of pts under vasodilator therapy). Femoral access was used for all pts. Mean vessels treated per procedure were 4.3±1.9 (324 vessels in total). Webs, subtotal occlusions, ring-like stenosis and total occlusions were noted in 215 (66.4%), 58 (17.9%), 31 (9.6%) and 20 (6.2%) treated vessels, respectively. We performed 21 pressure-wire-guided sessions (27.6%). Intravascular imaging was used in 6 procedures (7.9%). Average time of fluoroscopy was 60.3±14.0 minutes and volume of contrast 273.0±73.0 mL per session. Procedure-related adverse events occurred in 25.0% of the interventions (27.6% in the first two years vs 16.7% in the last two). Pulmonary artery vascular injuries were noted in 6 BPA vessels (7.9% per procedure and 1.9% per treated vessel): haemoptysis in all, but perforation was only detected angiographically in 3 of them (balloon inflation was performed for 2 distal perforations, and 1 perforation sealed without any intervention). Vascular dissection in distal lesions occurred in 4 cases (5.3%) with no need of transcatheter or surgical procedures. We had 3 lung injuries, all grade 2. None of the pts required oral intubation or mechanical ventilation. Extra-pulmonary complications were illustrated in table. Importantly, there was no peri-procedural death. The occurrence of vascular or lung injuries was 0% in pressure-wire-guided BPA versus 14.5% in non-guided (p=0.098). Multivariate analysis revealed that age (OR 1.05; CI 1.01–1.10; p=0.030) was the only independent predictor of complications.

Conclusions

In our experience, BPA can be safely performed in inoperable, residual or recurrent CTEPH or CTED pts, with 25% minor procedural-related complications but no major adverse event. Age was the strongest factor related to the occurrence of complications.

Funding Acknowledgement

Type of funding sources: None.

Indirect effects of COVID-19 Pandemic in ST-segment elevation myocardial infarction: insights from a multicentric national survey

Objective

Coronavirus disease 2019 (COVID-19) pandemic may have indirect consequences in ST-segment elevation myocardial infarction (STEMI) outcomes due to difficulties in healthcare access, but also due to reperfusion delays. The objective of this study was to evaluate the performance indicators in STEMI during the early phase of the lockdown following the COVID-19 pandemic.

Methods

The “patient delay” and the “system delay” were evaluated in 312 patients with suspected STEMI, in the period of the first State of Emergency in Portugal, through a survey called “Moment COVID” implemented within 18th March to 2 May 2020, in 18 national centers of Interventional Cardiology where PPCI is carried out 24/7. These patients were compared with a historical cohort of 267 patients from the 5th year after integration of SFL Initiative in Portugal (Moment 2015) in which the same survey was applied. Patients with late presentation of STEMI (>12 hours of symptoms onset) were excluded from this analysis.

Results

In “Moment COVID” there was a trend towards a longer “patient delay” (incremental median 20 min; p=0.059) and a significant longer system-delay (incremental median 17 min; p=0.033) compared to the historical cohort of “Moment 2015”. Consequently, times to revascularization tended to be longer (incremental median 26 min; p=0.074). Indeed, in “Moment COVID” patients were less compliant with the times recommended by the European guidelines: door-to-balloon time <60 min was achieved in 47.6% of patients compared to 57.0% (p=0.052) in “Moment 2015” and system-delay <90 min in 13.9% compared to 21.8% (p=0.033).

Conclusion

These results from a multicentric national analysis demonstrated a trend to longer time from symptom onset to request healthcare system assistance and a significantly longer time from first medical contact to revascularization among patients with STEMI during COVID-19 pandemic. This delay for treatment could negatively impact the STEMI prognosis at the long-term.

Funding Acknowledgement

Type of funding sources: None.

Stent-Save a Life international survey on the practice of primary coronary angioplasty during the COVID-19 pandemic

Aims

To evaluate the impact of the COVID-19 pandemic on patient admissions with acute coronary syndromes (ACS) and primary coronary angioplasty (PPCI) in countries participating in the Stent-Save a Life (SSL) global initiative.

Methods and results

We conducted a multicenter, observational survey to collect data on patient admissions for ACS, STEMI and PPCI in the SSL participating countries throughout a period during the COVID-19 outbreak (March and April 2020) compared with the equivalent period in 2019. From the 32 member countries of the SSL global initiative, 17 accepted to participate in the survey (3 from Africa, 5 from Asia, 6 from Europe and 3 from Latin America (LATAM)). We observed a global reduction of 27,5% and 20,0% in admissions with ACS and STEMI respectively. The decrease in PPCI was 26,7% (Figure 1). This trend was observed in all countries except two. In these two countries, the pandemic peaked later than in the other countries.

Conclusions

This survey shows that the COVID-19 outbreak was associated with a significant reduction of hospital admissions for ACS and STEMI as well as a reduction of PPCI, which can be explained by both patient and system related factors.

Funding Acknowledgement

Type of funding sources: None.

Modulation of inflammation by anti-TNF α mAb-dendrimer nanoparticles loaded in tyramine-modified gellan gum hydrogels in a cartilage-on-a-chip model

Rheumatoid arthritis (RA) is an autoimmune and chronic inflammatory disease characterized by joint inflammation. Since the inflammatory condition plays an important role in the disease process, it is important to develop and test new therapeutic approaches that specifically target and treat joint inflammation. In this study, a human 3D inflammatory cartilage-on-a-chip model was established to test the therapeutic efficacy of anti-TNFα mAb-CS/PAMAM dendrimer NPs loaded-Tyramine-Gellan Gum in the treatment of inflammation. The results showed that the proposed therapeutic approach applied to the human monocyte cell line (THP-1) and human chondrogenic primary cells (hCH) cell-based inflammation system revealed an anti-inflammatory capacity that increased over 14 days. It was also possible to observe that Coll type II was highly expressed by inflamed hCH upon the culture with anti-TNF α mAb-CS/PAMAM dendrimer NPs, indicating that the hCH cells were able maintain their biological function. The developed preclinical model allowed us to provide more robust data on the potential therapeutic effect of anti-TNF α mAb-CS/PAMAM dendrimer NPs loaded-Ty-GG hydrogel in a physiologically relevant model.

AB0848 PARTICIPATION OF UNDERGRADUATE MEDICAL STUDENTS AS INVESTIGATORS IN A RHEUMATOLOGIC COHORT: IMPACT ON DEPRESSION, ANXIETY & STRESS SCALE

Background:

Mental health was widely affected during the new coronavirus pandemic. In addition, some measures adopted by most countries in order to contain the virus spread, such as isolation and social distancing, leading to the interruption of routine activities, including partial or complete interruption of face-to-face classes may be associated with increased stress, depression and anxiety among undergraduate medical students (1). From March to September, 2020, the Brazilian Society of Rheumatology carried out the Mario Pinotti II Project (MPII), a prospective, multicenter, observational cohort study designed to monitor the COVID-19 in patients with rheumatic disease on hydroxychloroquine, using periodic telephone calls performed by undergraduate medical students (2).

Objectives:

To compare the mental health status of medical students who were participating from the MPII with theirs colleagues not involved in this project.

Methods:

A web-based survey via google forms platform was developed by a panel composed of undergraduate medical students, rheumatologists, medical school professors, and a psychology professor. It included details on demographic and life habits data and domains regarding depression, anxiety and stress, using the DASS-21 (Depression, Anxiety & Stress Scale), Brazilian version. Data collection occurred from July 20th to August 31st, 2020. Statistical analysis was performed using the SPSS version 20.0. Univariate and multivariate linear regression analysis were performed to verify associations with the DASS-21, defined as dependent variable. A p-value < 0.05 was deemed as significant. This study was approved by the Institutional Research Ethics Committee.

Results:

A total of 684 undergraduate medical students were included in this study, of whom 228 as MPII volunteers (VG) and 456 as control group (CG). Median age was 23 years (IQ 21-24) and the CG was older than the VG (p<0.03). Most of them were white (68.8%) and women (63%). There were no significant differences regarding comorbidities, ethnicity, smoking status, alcohol intake and physical activity. Older age, male gender, participation of MPII study, absence of a worsening in sleep pattern during the pandemic and a lower number of prior comorbidities were associated with lower DASS21 scores, suggesting a better mental health (Table 1).

Conclusion:

Several aspects may be involved with mental health, including increased emotional maturity, gender and sleep pattern. Although with marginal independent association, medical students with participation in the MPII study had better mental health than their student colleagues not engaged with this research. Our data pointed out that voluntary participation in a research project which foresees interaction by telephone contact with rheumatic patients, professors, rheumatologists, and colleagues is associated with better mental health.

References:

[1]Meo SA, Abukhalaf AA, Alomar AA, Sattar K, Klonoff DC. Covid-19 pandemic: Impact of quarantine on medical students’ mental wellbeing and learning behaviors. Pakistan J Med Sci 2020;36(COVID19-S4):S43–8.

[2]Gomides A, Ferreira G, Kakehas A, Lacerda M, Marques C, Paiva E et al. Impact of chronic use of antimalarials on SARS-COV-2 infection in patients with immune-mediated rheumatic diseases: protocol design for a multicentric observational cohort in Brazil. JMIR Research Protocols, 2020.Preprint

Table 1.

Univariate and multivariate analysis of predictors associated to the DASS-21 in undergraduate medical students during the COVID-19 pandemic

Univariate analysisMultivariate analysisVariableB95%CIp-ValueB95%CIp-ValueAge-0.32-0.61 to -0.030.03-0.47-0.81 to -0.130.008Female gender4.883.021 to 6.76<0.001---Stable love relationship-2.49-4.35 to -0.640.008-2.5-4.4 to -0.590.01Number of previous comorbidities reported4.693.71 to 5.68<0.0014.823.73 to 5.92<0.001MP-II volunteering-2.81-4.74 to -0.860.005---Worsening in sleep pattern6.414.62 to 8.20<0.0015.013.07 to 6.96<0.001

Disclosure of Interests:

None declared

POS1252 COVID-19 IN PATIENTS WITH RHEUMATIC DISEASES ON CHRONIC USE OF HYDROXYCHLOROQUINE IN A LARGE BRAZILIAN COHORT – A 24-WEEK PROSPECTIVE STUDY

Background:

The role of chronic use of hydroxychloroquine (HCQ) in rheumatic disease (RD) patients during the SARS-CoV-2 pandemic is still subject of discussion.

Objectives:

To compare the occurrence of COVID-19 and its outcomes between RD patients on HCQ use with individuals from the same household not taking the drug during community viral transmission in an observational prospective multicenter study in Brazil.

Methods:

Participants were enrolled and monitored through 24-week (From March 29th to Sep 30th, 2020) regularly scheduled phone calls performed by trained medical professionals. Epidemiological and demographic data, as well as RD disease activity status and current treatment data, specific information about COVID-19, hospitalization, need for intensive care, and death was recorded in both groups and stored in the Research Electronic Data Capture (REDCap) database. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. The statistical analysis was performed using IBM-SPSS v.20.0 software. Group comparisons were made using the Man-Whitney, Chi-Square and Fisher Exact Test, as well as multivariate regression models adjusted to confounders. Survival curves were performed using Kaplan-Meier analysis.

Results:

A total of 10,427 participants mean age (SD) of 44.04 (14.98) years were enrolled, including 6004 (57.6%) rheumatic disease patients, of whom 70.8% had systemic lupus erythematosus (SLE), 6.7% rheumatoid arthritis (RA), 4% primary Sjögren’s syndrome (pSS), 1.8% mixed connective tissue disease (DMTC), 1% systemic sclerosis (SSc) and others (15.9), including overlap syndromes. In total, 1,132 (10.8%) participants fulfilled criteria for COVID-19, being 6.7% RD patients and 4.1% controls (p=0.002). A recent influenza vaccination had a protective role (p<0.001). Moderate and severe COVID-19 included the need for hospitalization, intensive care, mechanical ventilation or death. Infection severity was not different between groups (p=0.391) (Table 1). After adjustments for multiple confounders, the main risk factors significantly associated with COVID-19 were higher education level (OR=1.29 95%CI 1.05-1.59), being healthcare professionals (OR=1.91; 95%CI 1.45-2.53), presence of two comorbidities (OR=1.31; 95%CI 1.01-1.66) and three or more comorbidities associated (OR=1.69; 95%CI 1.23-2.32). Interestingly, age >=65 years (OR=0.20; 95%CI 0.11-0.34) was negatively associated. Regarding RD, the risk factors associated with COVID-19 diagnosys were SLE (OR= 2.37; 95%CI 1.92-293), SSc (OR=2.25; 95%CI 1.05-4.83) and rituximab use (OR=1.92; 95%CI 1.13-3.26). In addition, age >=65 years (OR=5.47; 95%CI 1.7-19.4) and heart disease (OR=2.60; 95%CI 1.06-6.38) were associated with hospitalization. Seven female RD patients died, six with SLE and one with pSS, and the presence of two or more comorbidities were associated with higher mortality rate.

Conclusion:

Chronic HCQ use did not prevent COVID-19 in RD compared to their household cohabitants. Health care profession, presence of comorbidities LES, SSc and rituximab were identified as main risk factors for COVID-19 and aging and heart disease as higher risk for hospitalization. Our data suggest these outcomes could be considered to manage them in clinical practice.

Table 1.

Frequency and severity of COVID-19 in patients with rheumatic diseases on chronic use of hydroxychloroquine compared to their household controls

COVID-19 outcomesTotal(%)GroupsPPatients(%)Controls (%)DiagnosisNo9256 (89.1)5300 (88.3)3956 (90.2)0.002Yes1132 (10.9)704 (11.7)428 (9.8)SeverityMild1059 (93.6)662 (94.0)397 (92.8)0.391Moderate52 (4.6)32 (4.5)20 (4.7)Severe21 (1.9)10 (1.4)11 (2.6)

HCQ: hydroxychloroquine.

Moderate and severe COVID-19 included the need for any of the following: hospitalization, intensive care, mechanical ventilation or death.

Acknowledgements:

To the Brazilian Society of Rheumatology for technical support and rapid nationwide mobilization.

To all the 395 interviewers (medical students and physicians) who collaborated in the study and the participants

To CNPq (Number 403442/2020-6)

Disclosure of Interests:

None declared

Binge eating disorder, emotional eating and night eating syndrome: A comparative study between subjects with normal weight, overweight and obesity

Introduction

Obesity has been associated with certain psychiatric disorders, especially in patients seeking treatment. It is known that obesity is not a psychiatric disorder in itself, however, it should be noted that a significant part of the population has some type of clinical eating disorder.

Objectives

This study aims to assess levels of Binge Eating Disorder, Night Eating Syndrome and Emotional Eating patterns, according to different groups of Body Mass Index categories.

Methods

A sample of 220 subjects, aged between 18 and 81 years old, with an average age of 33 years participated in this study. 140 (63.6%) were female and 80 were male (36.4%) The sample was divided into three comparison groups, according to the Body Mass Index (BMI). The following measures were used: Sociodemographic questionnaire, Binge Eating Scale, Night Eating Habits Questionnaire, and the Emotional Eating Scale.

Results

When comparing the different BMI groups, it was found that obese subjects were the ones that most reported binge eating behavior. Overweight subjects had higher levels of binge eating when compared to normal-weight participants, but this was not true for Night Eating habits. Subjects with normal weight reported more nocturnal eating behavior, followed by obese individuals.

Conclusions

The prevalence of binge eating disorder seems to be more frequent in obese people, tending to increase according to the level of severity of obesity. Normal-weight subjects reported more nocturnal eating behavior, so they may be more likely to develop this syndrome and, consequently, overweight or obesity.

Sexual functioning and high sensory processing sensitivity

Introduction

The concept of Sensory Processing Sensitivity (SPS) was initially introduced by Aron in 1997 and involves complex processing of sensorial information and internal and external sensory stimuli, that is represented as an individual innate difference, as a temperamental property that concerns not only this deep sensorial processing but also to sharper general responsiveness to the environment. Its association with sexual functioning is still to be deeply determined.

Objectives

Through this research we aim to evaluate the levels of High Sensory Processing Sensitivity (HSPS) and to what extent these are related to sexual functioning, in addition to assessing the mediating role of gender in this relationship.

Methods

A total of 1,054 subjects between the ages of 18 and 80 (M age = 29.4; SD age = 11.9) participated in this study. Participants completed a demographic questionnaire, the Portuguese version of The Highly Sensitive Person Scale, and the Portuguese version of the Massachusetts General Hospital – Sexual Functioning Scale. The recruitment of the sample was internet-based.

Results

showed that the Sensitivity Sensory Processing and Sexual Functioning variables are negatively correlated and that there are statistically significant differences in sexual functioning according to gender (t(df)=7.042; p=<.05), males scoring higher; and participants with lower levels of HSPS presented higher levels of sexual functioning (t(df)=3.599; p<.05). Finally, logistic regression showed that Gender is responsible for 6.2% of the total variance of sexual functioning.

Conclusions

When working with highly sensitive people mental health professionals should take into account problems related to their sexual functioning in clinical practice.

Sexual dysfunctions and sexual behaviors of normal weight, overweight and obese sexual minority men

Introduction

With the growing recognition of overweightness and obesity as significant, international public health concerns, the body of research investigating the relationship between body mass index (BMI), sexual health and sexual functioning in sexual minority men is still scarce.

Objectives

The purpose of this study is to assess sexual health determinants (sexual behavior and sexual functioning) in relation to normal weight, overweightness and obesity among gay and bisexual men.

Methods

The survey included four categories of questions/measurements, encompassing sociodemographic information, protected/unprotected sexual behaviors, sexual functioning, and BMI. The survey was conducted online, and recruitment consisted of online notifications (emails and electronic messages), and advertisements sent to LGBT community organizations, mailing lists, and social networks.

Results

The study sample was composed of 741 gay and bisexual men, ranging in age from 21 to 75 years old (M_age=43.30, SD_age=11.37), 62.5% of men self-identified as gay and 37.5% as bisexual. Prevalence of normal weight was 50.3%, of overweight 33.3% and of obesity 16.4%. Hierarchical multiple regression analysis to assess the effects of BMI on sexual health showed that being younger in age, self-identifying as gay, being in a relationship, having longer penises, adopting insertive position in sex and being normal weight were significant predictors of anal receptive sex without condoms, explaining 24.2% of the total variance. Yet, BMI was not predictive of sexual functioning.

Conclusions

These findings highlight the importance of including BMI in sexual behavior models of sexual minority men to better understand BMI’s role in influencing sexual risk.

Online gaming dependency, attention levels and sleep quality among online gamers

Introduction

The persistent and recurrent use of the internet to engage in games, often with other players, which leads to clinically considerable deficits and online dependency still lacks more research support its impact of attentional levels and Sleep Quality.

Objectives

To assess levels of Online Gaming Dependency, its impact on attention levels and quality of sleep among online gamers.

Methods

The following instruments were used: a sociodemographic questionnaire, as well as the Video Game Behavior Assessment Scale (α = .842) and the Portuguese version of Color and Words Stroop Test. The sample consists of 66 individuals, 92.3% male and 7.7% female, with an average age of 23.1 (SD ± 4.07).

Results

Mild levels of online gaming dependency were obtained. Male gamers presented higher motivation to play online games, and higher levels of Stroop interference. Regarding the association between gaming behaviors and quality of sleep, results show that individuals who have difficulty falling asleep show greater motivation to play online games, a greater degree of concern with daily life and a greater frequency of negative behaviors in relation to online gambling.

Conclusions

The results show the importance of an increase in investigations in this area, as well as to the development of psychological assessment instruments and psychological intervention strategies, based on scientific evidence, on the different variables under study, in order to improve the quality of life in of individuals.

Mental health, suicidal behavior and sexual orientation in Portugal

Introduction

Sexual minority individuals consistently report higher rates of mental disorders and suicidal behavior than heterosexuals. However, much of this research is limited to Anglo-Saxon studies and no information on Portuguese reality is available.

Objectives

The purpose of this study is to compare levels of mental functioning and suicidal behavior among heterosexual, bisexual, and homosexual individuals in Portugal.

Methods

Using online surveys, 1140 individuals (62.40% women, Mage = 36.83, SDage = 13.39, 76.4% heterosexual, 9.4% bisexual, and 14.2% gay or lesbian) completed the BSI subscales for depression and anxiety symptoms, as well as the Suicide Behaviors Questionnaire-Revised.

Results

Self-identified bisexual participants presented higher levels of depressive and anxiety symptoms and higher levels of suicidal ideation and likelihood of suicidal behavior than homosexual and heterosexual participants (who scored the lowest); yet, homosexual participants showed higher levels of suicide attempts. Also, depression and anxiety symptoms were strongly and positively correlated with all dimensions of suicidal behavior. Finally, hierarchical multiple regression analysis showed that higher levels of depression and non-heterosexual sexual orientations were significant predictors of suicidal ideation and the likelihood of suicidal behavior.

Conclusions

The present study adds to the evidence that sexual minority individuals are at risk of increased mental health problems and suicidal behavior, compared to heterosexuals, and reiterates the need for local political and legislative efforts to normalize LGB identities, fighting continued institutional heterosexism, interpersonal intolerance. Mental health providers and mental health policymakers need to consider these results if they want to address inequalities in mental health and in suicidality among these minority groups.

Online psychological intervention with LGBT clients in Portugal

Introduction

This is a quasi-experimental and pioneering study in Portugal.

Objectives

(1) to provide assessment materials for symptoms of internalized homophobia, depression, and anxiety targeted at LGBT people; (2) offer support materials for psychotherapeutic work-oriented in the areas of internalized homonegativity, depression, and anxiety; and (3) offer monitoring measures throughout the program to demonstrate changes. It consists of three phases (pre-program evaluation, therapeutic activities and post-program evaluation).

Methods

38 LGBT + individuals participated, average age was 34.15 years, 30 self-identified as male. Measures used for the pre and post-intervention assessment were the sociodemographic questionnaire, the LGBT identity questionnaire, the Rosenberg self-esteem scale, and the BSI-18. Participants were invited to join the program online, through a platform created for this purpose, where ethical aspects were clarified, namely: confidentiality and commitment to adherence. Therapeutic tasks were sent by email or WhatsApp depending on the preference of each participant.

Results

Relevant differences in internalized homophobia, depressive, and anxious symptoms between the pre and post-intervention moments were observed, indicating that the program is effective in changing these symptoms.

Conclusions

The importance of validating this type of program allows reaching “hidden” populations by offering online support that minimizes the effects of sexual stigma on LGBT + populations.

Anxiety, depression and HIV in older gay and bisexual men

Introduction

Negative consequences of social homonegativity and HIV status among older gay and bisexual men in Portugal are still to be documented.

Objectives

This study seeks to evaluate depression and anxiety disparities among older gay and bisexual men, based upon their HIV status.

Methods

This is a quantitative, descriptive, comparative, and cross-sectional study. Responses were collected from a total of 201 men, with 16.9% being HIV positive, 80.6% identifying as homosexual and 13.9% identifying as bisexual. Participants responded to the Rosenberg Self-Esteem Scale, the BSI-18, and the CDRISC-10.

Results

The sample collected revealed moderate levels of depression and anxiety that were below the average observed among the general population. Older gay men showed higher levels of depression when compared to older bisexual men. Self-esteem was negatively correlated with both depression and anxiety while being positively correlated with resilience. In contrast, depression was negatively correlated with resilience and, conversely, positively correlated with anxiety. Furthermore, anxiety was negatively correlated with resilience. Multiple linear regression models explain 33% of the general variation of depressive symptoms and 25% of the variation of symptoms of anxiety. Regarding comparisons based on HIV status, no statistically significant differences were found between HIV-positive and HIV-negative men.

Conclusions

This study offers a pioneering contribution to the literature on aging and mental health among older sexual minorities in Portugal, giving a voice to older HIV-positive and HIV-negative GBM in Portugal, in order to gain a better understanding of the barriers and obstacles that they face throughout the aging process.

Predictors of the presence of septal late gadolinium enhancement in follow-up cardiac magnetic resonance imaging and its relation to acute myocarditis prognosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Acute myocarditis (AM) is generally a self-limited and benign disease. However, a minority of patients (pts) present or develop adverse outcomes. It has been proposed that the presence of late gadolinium enhancement (LGE) in the septum is associated with worse prognosis. Also, the presence of LGE without oedema in follow-up cardiac magnetic resonance imaging (CMR) seems to reflect more permanent lesions.

Purpose

The aim of this study was to determine if the presence of septal LGE in acute-phase CMR was associated with higher extent of disease in follow-up CMR and if initial laboratory tests help to predict the evolution to more permanent lesions.

Methods

Prospective single-centre study of pts admitted with AM diagnosed according to clinical findings, troponin T elevation and CMR criteria (Lake Louise), since 1/2013. Selection of those who underwent acute-phase (CMR-I) and follow-up CMR (CMR-II).

Results

Of 88 pts admitted with AM, 46 fulfilled our inclusion criteria: median age 31 ± 13 years, 85% males. CMR-I was performed at 6 ± 5days and LGE was present in 43 pts (93.5%). CMR-II was performed at 8 ± 4.3 months and 29 pts (63%) improved the number of LGE-positive segments, 10 pts (21.8%) had stable disease and 7 pts (15.2%) worsened CMR findings. Septal-LGE was detected in 10 pts (21.7%) in CMR-I and in 6 pts (13.0%) in CMR-II. Logistic regression analysis identified septal-LGE in CMR-I as a predictor of higher extent of LGE in CMR-II (OR 1.4, 95%CI 1.1-1.9, p = 0.020). Although median values of maximum high-sensitivity troponin and reactive-C protein (RCP) were not associated with septal LGE in CMR-I, increasing values of such tests were univariate predictors of a higher likelihood of septal involvement in CMR-II: maximum troponin (886 vs 1852ng/L; OR 1.00, 95%CI 1.00-1.00 p = 0.017) and RCP (4.2 vs 13.9mg/dL; OR 1.17, 95%CI 1.04-1.33, p = 0.012). After multivariate analysis, RCP was the independent predictor of septal LGE in CMR-II (AUC 80.8, 0.97-0.91, p = 0.012). RCP cut-off value &gt;10.2mg/dL identified patients with septal LGE in CMR-II with a sensitivity and specificity of 83.3% and 85.0%, respectively. The presence of cardiovascular risk factors, clinical presentation and B-type natriuretic peptide values were not predictors of septal LGE in either CMR. In a mean clinical follow-up of 757 ± 476days, no patient died, 3 pts (6.5%) developed new-onset heart failure (NYHA class II functional symptoms) and 2 pts (4.3%) developed ventricular arrhythmias. Due to a small number of adverse events, neither laboratory tests nor LGE septal pattern predicted adverse outcomes.

Conclusions

In this population, septal LGE pattern was able to predict higher extent of LGE in follow-up CMR. Increased cardiac biomarkers and inflammatory proteins in the acute setting were also associated with septal involvement in follow-up and can potentially help to establish the risk of adverse events for patients admitted with acute myocarditis.

Assessment of the CHA2DS2-VASc score in predicting ischemic stroke and death in patients with acute myocardial infarction without atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

onbehalf

on behalf of the investigators of the Portuguese Registry of Acute Coronary Syndromes

Introduction

The CHA2DS2-VASc score is used in clinical practice to stratify the risk of stroke in patients (pts) with atrial fibrillation (AF). Its usefulness in the population of pts with acute myocardial infarction without AF is not well known.

Objectives

To investigate whether CHA2DS2-VASc predicts ischemic stroke and death during hospital stay in pts with acute myocardial infarction without known AF. To determine independent predictors of ischemic stroke in this population.

Methods

A multicentre, retrospective study was performed during 01/10/2010-04/09/2019 period, and included all pts admitted due to acute myocardial infarction. Pts with previous AF, AF rhythm in the electrocardiogram at admission or AF during hospital stay were excluded. Statistical analysis with Kaplan-Mayer and Cox regression was applied.

Results

Of 29851 pts admitted with acute myocardial infarction, were included in our study 19218 pts (74% male, mean age of 65 ± 14 years). 

During hospital stay, 78 (0.4%) pts had an ischemic stroke and 462 (2.4%) pts died. 

The event-free survival analysis showed significant differences according to the CHA2DS2-VASc score at admission (log rank test p = 0.015 for ischemic stroke; log rank test p &lt; 0.001 for in-hospital mortality). (Figure) 

The CHA2DS2-VASc score demonstrated a good predictive accuracy for in-hospital mortality (area under the ROC curve 0.69; 95% CI 0.67-0.72; p &lt; 0.001). The area under the ROC curve indicates that the CHA2DS2-VASc score performed modestly for ischemic stroke (0.62; 95% CI 0.56-0.68; p &lt; 0.001). 

In univariate analysis, the factors that were positively associated with ischemic stroke during hospital stay were CHA2DS2-VASc, absence of previous therapy with statin, time between cardiac symptoms and hospital admission, absence of chest pain, Killip-Kimball class, cardiorespiratory arrest, complete left ventricular block and left ventricle ejection fraction &lt;50% (p &lt; 0.05). 

After multivariate analysis, CHA2DS2-VASc≥3 (HR 2.25; 95% CI 1.37-3.71; p = 0.001), absence of chest pain (HR 3.17; CI 1.44-6.14, p &lt; 0.001) and previous therapy with statin (HR 0.39; 95% CI 0.22-0.67; p = 0.001) were independent predictors of ischemic stroke.

Conclusion

 Among patients with acute myocardial infarction without known atrial fibrillation, the CHA2DS2-VASc score was associated with risk of ischemic stroke and death during hospital stay. This score may be useful for estimating the risk of stroke and in-hospital mortality in these population without known atrial fibrillation.

Abstract Figure.

Haemodynamic assessment of right ventricular overload in pulmonary hypertension: old parameters still fit better than new ones

Introduction

Right ventricular (RV) adaptation to the increased pulmonary load is a key determinant of outcomes in pulmonary hypertension (PH). Pulmonary vascular resistance (PVR) is widely recognized as haemodynamic measure of RV overload. Cardiac filling pressure (CFP), RV stroke work (RVSW), pulmonary artery (PA) compliance and PA pulsatility index (PAPi) are emerging as new haemodynamic parameters to assess RV function.

Aims

To assess the predictive value of CFP, RVSW, PA compliance and PAPi in PH and to compare it with standard haemodynamic parameters.

Methods

Retrospective study including all consecutive right heart catheterizations performed from April/2009 to October/2019 in a PH referral centre. Procedures presenting PH were selected [mean pulmonary arterial pressure (mPAP) &gt;20 mmHg, according to the new definition of the 6st World Symposium on PH]. CFP was calculated as [right atrial pressure (RAP) − pulmonary capillary wedge pressure], value &gt;0.63 associated with RV failure; RVSW as CO / [(heart rate × (mPAP-RAP) × 0.0136], value &lt;15; PA compliance [SV / pulmonary arterial systolic pressure (PASP) − pulmonary arterial diastolic pressure (PADP)], value &lt;2.5]; PAPi [(PSAP − PDAP) / RAP, value &lt;1.85]. Multivariate logistic regression was used to identify predictors of all-cause mortality. Receiver operating characteristic (ROC) curves and area under curve (AUC) were used to assess discrimination power.

Results

From a total of 569 procedures, 470 fulfilled PH criteria: mean age 57.9±16.0 years, 67.7% female, 35.5% performed under pulmonary vasodilator therapy. Pre-capillary PH was diagnosed in 71.9% of cases. Chronic thromboembolic PH was the most common subtype (34.4%). Concerning standard haemodynamic parameters: mPAP was 39.0±12.0 mmHg, mean RAP 8.0±5.0 mmHg, mean RVP 7.5±5.0 uWood and CI 2.5±0.8 L/min/m2. Median value of CFP was 0.6 (IQR 0.4–0.8), RVSW 15.2 (IQR 9.7–25.0), PA compliance 2.1 (IQR 0.9–2.9) and PAPi 5.3 (IQR 3.2–8.5). All-cause mortality rate was 22.8%. Patients experiencing adverse events had lower values of cardiac index (2.3±0.6 vs 2.6±0.8 L/min/m2, p&lt;0.01), RVSW (11.2 vs 16.7, p&lt;0.01) and PA compliance (2.2 vs 2.9, p&lt;0.01) and higher values of PVR (10.0±5.5 versus 6.8±4.6 uWood, p&lt;0.01) and mean RAP (9.9±6.1 versus 7.4±4.5, p&lt;0.01). Multivariate logistic regression identified 2 independent predictors of adverse events: mean RAP (OR 1.08, 95% CI 1.02–1.13, p&lt;0.01) and PVR (OR 1.11, 95% CI 1.06–1.17, p&lt;0.01). According to the ROC curves, new haemodynamic parameters did not have acceptable discrimination power to adverse events occurrence (figure).

Conclusions

In this study, new haemodynamic parameters to assess RV overload in PH were not independent predictors of adverse events as opposite to standard haemodynamic parameters. Further studies are needed to clarify their predictive value, as it has major implications for understanding the arterial load in diseases of the pulmonary circulation.

Funding Acknowledgement

Type of funding source: None

The 90s are the new 70s: approach to nonagenarian patients with myocardial infarction: data from the Real World Portuguese Registry on Acute Coronary Syndromes (ProACS)

Introduction

The approach to Acute Coronary Syndromes is based on robust high quality evidence, currently systematized in European endorsed guidelines. However most trials that support such guidelines excluded or included a small percentage of the very elderly, namely nonagenarian patients, and the clinical decision in this age range is subjected to high interpersonal and inter-hospital variability.

Purpose

Our aim was to assess the approach to nonagenarian patients with Acute Coronary Syndromes (ACS), in what regards the choice of percutaneous coronary intervention or conservative management and determine in-hospital and at 1 year outcomes.

Methods

We performed a 9 year retrospective analysis of all patients with age equal or greater than ninety (90) admitted with ACS in Portugal. Medical records were analysed for demographic, procedural data and outcomes.

Results

Seven hundred and fourteen (714) nonagenarian patients were admitted with ACS, which corresponded to 2.4% of the total cohort. The mean age was 92±2 with a female preponderance (58.7%). There was a high rate of cardiovascular risk factor with hypertension in 81.3%; Dyslipidemia in 46.1% Diabetes Mellitus in 23.4%; and other comorbidities with 21% of prior ACS, 14.4% with Heart Failure, 11% with cerebrovascular events and 15.4% with chronic kidney failure.

The ACS was categorized as ST elevation Myocardial Infarction (STEMI) in 43.9%, non- STEMI (NSTEMI) in 45.8%, and unstable angina (UA) in 2%.

Two hundred and sixty-eight (268), 37.8% of the cohort, were submitted to percutaneous coronary intervention (PCI), mainly due to STEMI (68.3%). This cohort were composed of patients with less comorbidities (statistically significant less valvular heart disease, heart failure, peripherical artery disease and dementia although more oncological diseases). There was no difference in the severity of ACS, as categorized by the Kilip Kimbal (KK) classification, mechanical complication or depressed ejection fraction between the 2 groups. (p&gt;0.05 for all)

There was a statistically significant increase of advanced atrioventricular block (10.6 vs 4.4%; p 0.002; Logistic regression OR 3.12; IC95 [1.37–7.15], p 0.007) and major bleeding (1.8 vs 5.5%; p 0.008; Logistic regression OR 3.36; IC95 [1.36–8.32] p 0.009) in the PCI group. There was no difference in in-hospital re-infarction, cardiac arrest, stroke or death. (p&gt;0.05 for all)

The follow up at 1 year was performed in two hundred and fifty-six (256) patients, 30.9% submitted to PCI. Although the survival analysis demonstrated a trend towards improvement in 1-year survival and cardiovascular readmissions in the intervention group, it did not reach statistical significance. (p&gt;0.05 for all)

Conclusions

PCI was performed in about a third of nonagenarians presenting with ACS. Our cohort demonstrated a greater rate of in-hospital complications without a significant in-hospital or at 1 year clinical benefit.

Funding Acknowledgement

Type of funding source: None

Prevalence and prognostic value of right ventricular dysfunction in hypertrophic cardiomyopathy

Introduction

Hypertrophic cardiomyopathy (HCM) is the main cause of sudden cardiac death in the young and a cause of heart failure and death at any age. Nevertheless, adverse long-term outcomes are not easy to predict.

Objectives

To assess the prevalence, predictors and prognostic value of right ventricular (RV) dysfunction in patients (pts) with HCM.

Methods

Retrospective single-center study of consecutive pts with HCM evaluated in a specialized medical appointment. Selected those submitted to cardiac magnetic resonance imaging (MRI) as the gold-standard for RV function assessment. The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, ventricular arrhythmias with hemodynamic instability and unplanned heart failure admission.

Results

Were included 112 pts (mean age at first appointment 57±15 years, 63% male). Septal asymmetric phenotype was the most frequent (75%), with a mean septal wall thickness of 18±4 mm. Late gadolinium enhancement was observed in 82%, mostly intramyocardial (67%) and in joint points (47%).

RV dysfunction was detected in 6 pts (5.4%) and RV free wall hypertrophy in 3 pts (2.7%); no patient presented RV dilation.

Factors associated with RV dysfunction were left atria area (HR 1.07/unit, 95% CI 1.01–1.12, p=0.02), left ventricular ejection fraction (HR 0.91/unit, 95% CI 0.86–0.97, p=0.02) and the presence of left ventricle wall motion abnormalities (HR 7, 95% CI 1.3–38, p=0.03) in cardiac MRI.

During a mean follow-up of 60±31 months, the combined primary endpoint occurred in 15 pts (13%), significantly more in pts with RV dysfunction (HR 5.1, 95% CI 1.1–24, p=0.038) (graphic 1). Patients with RV dysfunction also presented more atrial fibrillation / flutter episodes during follow-up (HR 6.4, 95% CI 2.1–20, p=0.001).

Conclusions

Although not common, right ventricular dysfunction was associated with a higher rate of cardiovascular events. These results support a potential role of right ventricular function in the risk stratification of patients with hypertrophic cardiomyopathy.

Figure 1

Funding Acknowledgement

Type of funding source: None

Thermodilution vs indirect fick cardiac output measurement in clinical practice: insights from a tertiary centre

Introduction

Thermodilution (TD) and indirect Fick (IF) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches concerning agreement and comparative prognostic value as applied in medical practice.

Purpose

To assess agreement between TD and IF methods and to compare how well these methods predict mortality.

Methods

Retrospective cohort study including all consecutive right heart catheterizations performed in a referral pulmonary hypertension (PH) centre from 2010 to 2018. Cardiac index (CI) was calculated by indexed CO to body surface area. PH was classified according to the new definition of the 6st World Symposium on Pulmonary Hypertension 2018 [mean pulmonary arterial pressure (mPAP) &gt;20 mmHg]. Patients with cardiac or extra-cardiac shunts or significant (moderate to severe or severe) tricuspid regurgitation were excluded. All-cause mortality over 1 year after right heart catheterization was recorded. Logistic regression was used to identify predictors of the adverse event.

Results

From a total of 569 procedures, 424 fulfilled the inclusion criteria: mean age 56.7±15.4 years, 67.3% female. Haemodynamic parameters were diagnosed of PH in 86.2% of cases: mPAP 35.3±15.3 mmHg, 83.6% pre-capillary subtype, 42.9% belonging to group 4 (chronic thromboembolic pulmonary hypertension) and 26.6% to group 1 (pulmonary arterial hypertension). Mean values of CO and CI were, respectively, 4.5±2.8 L/min and 2.5±0.8 L/min/m2 measured by TD and 4.6±2.4 L/min and 2.6±1.3 L/min/m2 measured by IF method. There was a median difference (IF minus TD) of - 0.03 / min to CO and - 0.05 L/min/m2 to CI but both meausres correlated only modestly (r=0.6 to TD and r=0.5 to IF). One-year all-cause mortality rate was 5.4% (median time to death was 50.5 days). Lower values of CO and CI assessed by TD were significantly associated with all-cause mortality occurrence (CO TD: 4.5±1.3 L/min versus 3.6±1.0 L/min, p&lt;0.01; CI TD: 2.6±0.7 L/min/m2 versus 2.1±0.4 L/min/m2, p&lt;0.01). No association was observed between CO (p=0.31) and CI (p=0.42) measured by IF method and the adverse event. Logistic regression identified 2 independent predictors of all-cause mortality: TD CO (OR 0.55, 95% CI 0.38–0.79, p&lt;0.01) and TD CI (OR 0.34, 95% CI 0.17–0.67, p&lt;0.01). Similar results were obtained when patients diagnosed with PH were independently analyzed.

Conclusions

There is only modest agreement between TD and IF CO and CI estimates. Despite being more time-consuming, TD measurements were predictors of all-cause mortality and present a highest prognostic value. These findings favored their used over IF in clinical practice.

Funding Acknowledgement

Type of funding source: None

Influence of land use and host species on parasite richness, prevalence and co-infection patterns

Tropical forests are experiencing increasing impacts from a multitude of anthropogenic activities such as logging and conversion to agricultural use. These perturbations are expected to have strong impacts on ecological interactions and on the transmission dynamics of infectious diseases. To date, no clear picture of the effects of deforestation on vector-borne disease transmission has emerged. This is associated with the challenge of studying complex systems where many vertebrate hosts and vectors co-exist. To overcome this problem, we focused on an innately simplified system - a small oceanic island (São Tomé, Gulf of Guinea). We analyzed the impacts of human land-use on host-parasite interactions by sampling the bird community (1735 samples from 30 species) in natural and anthropogenic land use at different elevations, and screened individuals for haemosporidian parasites from three genera (Plasmodium, Haemoproteus, Leucocytozoon). Overall, Plasmodium had the highest richness but the lowest prevalence, while Leucocytozoon diversity was the lowest despite having the highest prevalence. Interestingly, co-infections (i.e. intra-host diversity) involved primarily Leucocytozoon lineages (95%). We also found marked differences between bird species and habitats. Some bird species showed low prevalence but harbored high diversity of parasites, while others showed high prevalence but were infected with fewer lineages. These infection dynamics are most likely driven by host specificity of parasites and intrinsic characteristics of hosts. In addition, Plasmodium was more abundant in disturbed habitats and at lower elevations, while Leucocytozoon was more prevalent in forest areas and at higher elevations. These results likely reflect the ecological requirements of their vectors: mosquitoes and black flies, respectively.

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

A nonsense variant in the KRT14 gene in a domestic shorthair cat with epidermolysis bullosa simplex

Epidermolysis bullosa simplex (EBS) is a hereditary blistering disease affecting the skin and mucous membranes. It has been reported in humans, cattle, buffaloes and dogs, but so far not in cats. In humans, EBS is most frequently caused by variants in the KRT5 or KRT14 genes. Here, we report a case of feline epidermolysis bullosa simplex and describe the causative genetic variant. An 11-month-old male domestic shorthair cat presented with a history of sloughed paw pads and ulcerations in the oral cavity and inner aspect of the pinnae, starting a few weeks after birth. Clinical and histopathological findings suggested a congenital blistering disease with a split formation within the basal cell layer of the epidermis and oral mucous epithelium. The genetic investigation revealed a homozygous nonsense variant in the KRT14 gene (c.979C>T, p.Gln327*). Immunohistochemistry showed a complete absence of keratin 14 staining in all epithelia present in the biopsy. To the best of our knowledge, this is the first report of feline EBS, and the first report of a spontaneous pathogenic KRT14 variant in a non-human species. The homozygous genotype in the affected cat suggests an autosomal recessive mode of inheritance.

P694 Late shunt closure: is it the only cause of pulmonary hypertension after surgical repair?

Introduction

Atrial septal defects (ASD) may be a cause of pulmonary hypertension (PH) specially when they are only detected in adulthood. Sinus venosus type ASD are rare, with an estimated prevalence of 4-11%, and frequently they are associated with anomalous venous return of the right superior pulmonary vein (RSPV). Surgical closure is safe and effective, and it is associated with normal life expectancy when performed before age 25; the risk of PH is higher in untreated defects or late closure.

Clinical case

The authors present the case of a 74-years old female patient with previous diagnosis of a sinus venosus type ASD. Closure of the shunt and correction of venous return was performed when the patient was 36. Follow up in the following years was normal, and the patient was discharged from the congenital surgical center. The patient was referred to our PH unit due to symptomatic PH for etiological investigation (PSAP of 70 mmHg in transthoracic echocardiogram). After excluding PH related to left heart disease and lung disease, the most likely cause was pulmonary arterial hypertension due to late closure of left to right shunt, but complete investigation was performed. A transesophageal echocardiogram showed dilatation of right heart chambers and a communication of 36 mm at the high atrial septum between the RSPV and superior vena cava entrance with spontaneous left to right shunt. A severe dilation of coronary sinus (maximal dimension 33.4mm) suggestive of persistent left superior vena cava (PLSVC) was also found. A cardiac magnetic resonance was performed showing dilated right chambers, abnormal drainage of right superior pulmonary vein to right atrium, a dilated coronary sinus with a PLSVC and Qp/Qs 1.7. Right heart catheterization showed a mean pulmonary artery pressure of 25 mmHg with normal pulmonary vascular resistance (2.4 UWood) suggesting that the intracardiac shunt is the responsible for the PH with reversible pulmonary vascular disease. The patient was proposed to surgical repair.

Conclusion

The authors present a rare clinical case of an undiagnosed persisting sinus venous ASD after surgical repair. Failure of shunt closure led to the development of PH, emphasizing the need to maintain lifelong follow up of these patients in specialized centers.

Abstract P694 Figure.