The Impact of Educational Materials on Parental Anxiety and Productivity: A Clinical Trial in Pediatric Appendicitis

OBJECTIVES

There is limited literature on how acute appendicitis, the most common acute children's surgical illness, affects the family. We conducted a prospective study to assess the impact of educational materials on parents' anxiety and productivity during the child's illness.

METHODS

A quasi-experimental clinical trial was conducted among parents of children undergoing laparoscopic appendectomy. In Phase I, parents received the standard explanations at diagnosis and throughout the postoperative period. In Phase II, parents also received a comprehensive educational brochure on pediatric appendicitis at diagnosis. The primary outcome, parental preoperative anxiety, was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The secondary outcome, parental productivity, was evaluated through a post-recovery online questionnaire based on the Productivity and Disease Questionnaire (PRODISQ). Baseline characteristics and outcomes were compared between the two cohorts using t-tests, Mann-Whitney, chi-square, or Fischer's exact test as appropriate.

RESULTS

Phases I and II included 67 and 66 families, respectively. Patient demographics and disease severity were similar between both groups. Of the 53 parents (80.3%) in Phase II who answered the postoperative questionnaire, most recommended the booklet (96.2%), as it decreased their stress (78.0%) and enhanced their understanding of appendicitis (94.1%). However, the two groups showed similar preoperative anxiety levels and postoperative productivity loss.

CONCLUSIONS

Educational materials increased satisfaction with surgical care but did not mitigate the high parental preoperative anxiety levels and postoperative productivity loss. Additional research is required to elucidate interventions that may improve these important patient and family-centered outcomes.

TYPE OF STUDY

Non-Randomized Clinical Trial.

LEVEL OF EVIDENCE

II.

Adaptation, Translation, and Validation of a Patient-Reported Experience Measure for Children and Young People for the Canadian Context

BACKGROUND

Patient-reported experience measures (PREMs) evaluate children's and young people's (CYP) perceptions of care. An important PREM developed with and for children was created in London, UK. Given the absence of similar North American instruments, we aimed to adapt, translate, and linguistically validate this instrument for use in a Canadian pediatric outpatient setting.

METHODS

A qualitative design was used, involving CYP and their parents/caregivers. Phase 1 entailed the English survey adaptation using think-aloud testing, revision, and cognitive testing. Phase 2 involved translation into French, revision and back-translation, and cognitive testing. Phase 3 encompassed a cross-validation of the English and French versions of the adapted instrument.

RESULTS

Fifty-five children in 3 age groups (8-11y, 12-13y, 14-16y) participated in creating the Canadian PREM. In Phases 1 and 2, 41 children participated in reviewing and updating specific questions in the instrument, resulting in adjustments and revisions based on their feedback. In Phase 3, 14 bilingual children linguistically validated the PREM instrument.

CONCLUSIONS

This study reports the development of the first Canadian PREM specifically tailored to children. By incorporating the perspectives and preferences of CYP in clinical practice, this approach has the potential to amplify the delivery of patient-centered care for this vulnerable population and ensure that the needs and voices of CYP are acknowledged.

LEVEL OF EVIDENCE

V, Therapeutic.

Assessing the reaction to and efficacy of the Screener drug discovery and development board game as a pedagogical tool in postgraduate courses

Screener, a board game supplemented with online resources, was introduced and distributed by the Brazilian Society of Pharmacology and Experimental Therapeutics to postgraduate programs as an instructional tool for the process of drug discovery and development (DDD). In this study, we provided a comprehensive analysis of five critical aspects for evaluating the quality of educational games, namely: 1) description of the intervention; 2) underlying pedagogical theory; 3) identification of local educational gaps; 4) impact on diverse stakeholders; and 5) elucidation of iterative quality enhancement processes. We also present qualitative and quantitative assessments of the effectiveness of this game in 11 postgraduate courses. We employed the MEEGA+ online survey, comprising thirty-three close-ended unipolar items with 5-point Likert-type response scales, to assess student perceptions of the quality and utility of Screener. Based on 115 responses, the results indicated a highly positive outlook among students. In addition, we performed a preliminary evaluation of learning outcomes in two courses involving 28 students. Pre- and post-quizzes were applied, each consisting of 20 True/False questions directly aligned with the game's content. The analysis revealed significant improvement in students' performance following engagement with the game, with scores rising from 8.4 to 13.3 (P<0.0001, paired t-test) and 9.7 to 12.7 (P<0.0001, paired t-test). These findings underscore the utility of Screener as an enjoyable and effective tool for facilitating a positive learning experience in the DDD process. Notably, the game can also reduce the educational disparities across different regions of our continental country.

Detection of microemboli in patients with acute ischaemic stroke and atrial fibrillation suggests poor functional outcome

INTRODUCTION

We investigated the burden of microembolic signals (MES) in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF), assessing their impact on functional outcomes.

PATIENTS AND METHODS

This multicentre international prospective cohort study involved patients with AIS and either a known or newly diagnosed anticoagulant-naïve AF. All centres utilised the same transcranial Doppler machine for 1-h monitoring with bilateral 2 MHz probes within 24 h of symptom onset. Recordings underwent MES analysis by a blinded central reader. The primary objectives were to ascertain the MES proportion and its association with functional outcomes assessed by the modified Rankin scale (mRS) score at 90 days.

RESULTS

Between September 2019 and May 2021, we enrolled 61 patients, with a median age of 78 years (interquartile range 73-83) and a median stroke severity score of 11 (interquartile range 4-18). MES were observed in 14 patients (23%), predominantly unilateral (12/14, 86%), with a median rate of 6 counts/hour (interquartile range 4-18). MES occurrence was higher post-thrombectomy and among those with elevated brain natriuretic peptide levels (p < 0.05). A worse mRS score of 3-6 was more frequent in patients with MES, occurring in 11/14 (79%), compared to those without MES, 20/47 (43%), with an adjusted odds ratio of 5.04 (95% CI, 1.15-39.4), p = 0.04.

CONCLUSIONS

Nearly a quarter of patients with AIS and AF exhibited silent microembolization after the index event. Detecting MES within 24 h post-stroke (using transcranial Doppler) could signify a marker of poor functional outcomes. Subsequent trials will assess if very early antithrombotic treatment might enhance outcomes in this highly selective group of cardioembolic stroke patients. (Clinicaltrials.gov ID: NCT06018090).

Facing the challenges of air quality and health in a future climate: The Aveiro Region case study

Air pollution and climate change are the most important environmental issues for European citizens. Despite the air quality improvements achieved in recent years, with most pollutants' concentrations below the European Union legislated values, it is necessary to understand whether this will continue in the future due to expected climate changes impacts. In this context, this work tries to answer two main questions: (i) What is the relative contribution of emission source regions/activities to air quality, now and in the future, considering a climate change scenario?; and (ii) What additional policies are needed to support win-win strategies for air quality and climate mitigation and/or adaptation, at urban scale? For that, a climate and air quality modelling system, with source apportionment tools, was applied to the Aveiro Region, in Portugal. Main results show that in the future, due to the implementation of carbon neutrality measures, air quality in the Aveiro Region may improve, with reduction up to 4 μg.m^-3 for particulate matter (PM) concentrations and 22 μg.m^-3 for nitrogen dioxide (NO₂), and consequently, the premature deaths due to air pollution exposure will also decrease. The expected air quality improvement will ensure that, in the future, the limit values of the European Union (EU) Air Quality Directive will not be exceeded, but the same will not happen if the proposed revision of the EU Air Quality Directive is approved. Results also shown that, in the future, industrial sector will be the one with higher relative contribution for PM concentrations and the second one for NO₂. For that sector, additional emission abatement measures were tested, showing that, in the future, it is possible to comply with all the new limit values proposed by the EU.

Emerging microalgae-based biofuels: Technology, life-cycle and scale-up

Microalgae biomass is a versatile feedstock with a variable composition that can be submitted to several conversion routes. Considering the increasing energy demand and the context of third-generation biofuels, algae can fulfill the increasing global demand for energy with the additional benefit of environmental impact mitigation. While biodiesel and biogas are widely consolidated and reviewed, emerging algal-based biofuels such as biohydrogen, biokerosene, and biomethane are cutting-edge technologies in earlier stages of development. In this context, the present study covers their theoretical and practical conversion technologies, environmental hotspots, and cost-effectiveness. Scaling-up considerations are also addressed, mainly through Life Cycle Assessment results and interpretation. Discussions on the current literature for each biofuel directs researchers towards challenges such as optimized pretreatment methods for biohydrogen and optimized catalyst for biokerosene, besides encouraging pilot and industrial scale studies for all biofuels. While presenting studies for larger scales, biomethane still needs continuous operation results to consolidate the technology further. Additionally, environmental improvements on all three routes are discussed in light of life-cycle models, highlighting the ample research opportunities on wastewater-grown microalgae biomass.

Patient experience or patient satisfaction? A systematic review of child- and family-reported experience measures in pediatric surgery

PURPOSE

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important health care quality indicators. PREMs measure patients' perception of the care they have received, differing from satisfaction ratings, which measure their expectations. The use of PREMs in pediatric surgery is limited, prompting this systematic review to assess their characteristics and identify areas for improvement.

METHODS

A search was conducted in eight databases from inception until January 12, 2022, to identify PREMs used with pediatric surgical patients, with no language restrictions. We focused on studies of patient experience but also included studies that assessed satisfaction and sampled experience domains. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool.

RESULTS

Following title and abstract screening of 2633 studies, 51 were included for full-text review, of which 22 were subsequently excluded because they measured only patient satisfaction rather than experience, and 14 were excluded for a range of other reasons. Out of the 15 included studies, questionnaires used in 12 studies were proxy-reported by parents and in 3 by both parents and children; none focused only on the child. Most instruments were developed in-house for each specific study, without patients' involvement in the process, and were not validated.

CONCLUSIONS

Although PROMs are increasingly used in pediatric surgery, PREMs are not yet in use, being typically substituted by satisfaction surveys. Significant efforts are needed to develop and implement PREMs in pediatric surgical care, in order to effectively capture children's and families' voices.

LEVEL OF EVIDENCE

IV.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Source apportionment of air pollution in European urban areas: Lessons from the ClairCity project

Air pollution has become a major threat to human health in the last decades, with an increase of acute air pollution episodes in many cities worldwide. Source apportionment modelling provides valuable information on the contribution from different emission source sectors and source regions to distinct air pollutants concentrations. In this study, the CAMx model, with its PSAT tool, was applied to quantify the contribution of multiple source areas, categories and pollutant types to ambient air pollution, namely to PM and NO₂ concentrations, over six European urban areas: Bristol (United Kingdom), Amsterdam (The Netherlands), Ljubljana (Slovenia), Liguria Region (Italy), Sosnowiec (Poland) and Aveiro Region (Portugal). Results indicate overall higher annual NO₂ and PM concentrations located in the urban centres of the case studies. A comparison between the different areas showed that Liguria is the region with highest NO₂ annual mean concentrations, while Ljubljana, Liguria Region and Sosnowiec are the case studies with the highest PM annual mean concentrations. The annual average contributions denote a major influence from road transport to NO₂ concentrations, with up to 50%, except in Aveiro region, where road transport presents a lower contribution to NO₂ concentrations, and the greatest contributor is the industrial combustion and processes sector with 45%. These results indicate a negligible contribution of the transboundary transport to NO₂ concentrations, highlighting the relevance of local sources, while for PM concentrations the transboundary transport is the major contributor. The results highlight the relevance of long-range transport of PM across Europe. The transboundary transport reduces its importance during winter, when residential and commercial combustion increases its contribution. In the case of the Aveiro region, the industrial combustion and processes sector also plays an important contribution to PM concentrations.

30-day outcomes of P2Y12 inhibitor pretreatment in patients with STEMI submitted to primary PCI – systematic review and meta-analysis

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the cornerstone of antithrombotic therapy in patients with ST-segment elevation myocardial infarction (STEMI). Yet, there is uncertainty surrounding the optimal timing for the initiation of the P2Y12 inhibitor. This study aims to evaluate the effectiveness and safety of P2Y12 pretreatment by means of a systematic review and meta-analysis of studies in primary percutaneous coronary intervention (PCI) in STEMI.

Methods

We performed a systematic search of electronic databases Pubmed, CENTRAL and Scopus until March of 2021. Studies were considered eligible if they were: a) comparing P2Y12 inhibitor upstream administration vs. treatment during PCI; b) patients enrolled for STEMI and submitted to primary PCI. Studies with patients treated with fibrinolysis or medical therapy only were excluded. Major clinical outcomes included 30-day occurrence of all-cause death, definite stent thrombosis and re-infarction. Thrombolysis in myocardial infarction (TIMI) flow-grade pre-PCI and post-PCI, in-hospital cardiogenic shock and major bleeding events were analysed.

Results

Out of 2193 articles, 18 studies were included (1 randomized clinical trial [RCT] and 17 observational studies [non-RCT]), with a total of 76,836 patients, 52,181 in the pretreatment arm. At 30 days, pretreatment was associated with a reduction in definite stent thrombosis (1 RCT & 4 Non-RCT: OR 0.40; 95% CI 0.18–0.90), but no significant reduction in all-cause death (1 RCT & 7 Non-RCT: OR 0.77; 95% CI 0.56–1.04) or re-infacrtion (1 RCT & 4 Non-RCT: OR 0.73; 95% CI 0.49–1.09). Regarding in-hospital outcomes, pretreatment showed a significant reduction in the occurrence of cardiogenic shock (5 Non-RCT: 0.62; 95% CI 0.51–0.79), major bleeding events (1 RCT & 14 Non-RCT: 0.83; 95% CI 0.75–0.92) and in the number of patients with TIMI flow &lt;3 postPCI (1 RCT & 8 Non-RCT: 0.82; 95% CI 0.73–0.93). Pretreatment was not associated with lower number of patients with TIMI flow &lt;3 pre-PCI (1 RCT & 5 Non-RCT: 0.85; 95% CI 0.66–1.09).

Conclusion

Pretreatment with DAPT, including a P2Y12 inhibitor, was associated with lower risk for definite stent thrombosis and cardiogenic shock, but was not associated with lower all-cause death or re-infarction.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of aborted cardiac arrest in patients with acute myocardial infarction

Background

Aborted cardiac arrest (ACA) during the acute ischaemic phase is a relatively frequent but often undervalued complication of acute myocardial infarction (AMI). The aim of this study was to evaluate the clinical and prognostic impact of aborted cardiac arrest in AMI patients and investigate its correlation with infarct size.

Methods

We conducted a single-centre retrospective study enrolling consecutive patients admitted for AMI, from January 2016 to December 2018. ACA was defined as the need for advanced life support measures and defibrillation, either out-of-hospital or in-hospital, up until culprit vessel revascularisation. Infarct size was estimated using peak serum troponin T, impact on left ventricular ejection fraction (LVEF ≤50%) and echocardiographic wall motion index (WMI). Clinical outcomes included cardiogenic shock (SCAI C or more), need for mechanical circulatory support (MCS), major bleeding events (BARC ≥3) during in-hospital phase and all-cause mortality during follow-up.

Results

A total of 571 patients were included (65±13 years old, 72% male). Overall, 237 had anterior STEMI, 39 patients (6,8%) suffered ACA (21 out of hospital), 60 progressed into cardiogenic shock throughout the hospitalisation, 7 needed MCS, and 52 had BARC ≥3 bleeding. During a mean follow-up of 32 months, 96 patients died.

ACA was significantly associated with higher peak serum troponin T (4802 [1950; 9420] vs 2659 [555; 6708] ng/L – p=0.004), higher proportion of patients with reduced or mildly reduced LVEF (60% vs. 36.5%, p=0.018) and higher WMI (1.7 [1.4; 2.3] vs. 1.5 [1.2; 1.8], p=0.016). Moreover, ACA was also associated with higher risk of cardiogenic shock occurrence (64.1% vs. 6.6%, p&lt;0.001 – OR 25.357 (12.115–53.073)), higher need for MCS (7.9% vs 0.8%, p&lt;0.001 – OR 11.271 (2.427–52.343)) and higher incidence of BARC ≥3 bleeding events (28.2% vs. 8.4%, p&lt;0.001 – OR 4.705 (2.185–10.128)) – Table 1.

On univariate Cox regression, ACA showed significant association with all cause death, which remained highly significant after multivariable adjustment (OR 2.431 (1.181; 5.002); p=0.016).

Conclusion

The occurrence of aborted cardiac arrest in patients with AMI was associated with increased morbidity and mortality. This may be driven by a larger area of arrhythmia prone ischemic myocardium.

Funding Acknowledgement

Type of funding sources: None.

Electrocardiographic imaging a valid tool or an inaccurate toy?

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Background and aim

Electrocardiographic imaging (ECGI) is capable of performing an activation map with a single beat. However, previous studies using the epicardial-only system, have suggested a bad accuracy for the assessment of the epicardial breakthrough. Recent systems using endo-epicardial analysis have shown promising results. The aim of this study was to assess the accuracy and reproducibility of two endo-epicardial ECGI systems using different cardiac sources one based on the extracellular-potential, and the other on the equivalent double layer model, respectively the AMYCARD (EP Solutions SA, Switzerland) and VIVO (Catheter Precision, NJ USA) systems.

Methods

We studied 11 consecutive patients referred for ablation of frequent idiopathic premature ventricular contractions at our center that had an ECGI performed using both systems on the same day. The AMYCARD system uses a dense array of body-surface electrocardiograms with up to 224 leads and VIVO uses just the 12-leads ECG. Both systems use a patient-specific heart torso geometry obtained with a CT-scan or cardiac magnetic resonance. The localisation of the PVCs based on ECGI was done using a segmental model with 22 segments on the left ventricle, to include the classical 17 segment model plus the aortic cusps and the papillary muscles, and 12 segments on the right ventricle including 4 on the right ventricular outflow tract (RVOT): (anterior, lateral, right septum and left septum). A perfect match was defined as a predicted location within the same anatomic segment, whereas a near match as a predicted location within the same segment or a contiguous one.

Results

The median (Q1-Q3) number of leads used for the AMYCARD was 131 (118-144). Seven patients underwent ablation and in 4 ablation is pending. The predicted locations and the ablation site are depicted on the Table. We found a perfect match between both systems in 73% (Figure) and near match in 91% of cases. In patients that underwent ablation the systems localised the site of origin of the PVCs within the same segment or the contiguous segment in all patients with VIVO and in six out of seven with AMYCARD.

Conclusions

ECGI is an accurate diagnostic tool with reproducible results regardless the cardiac source used for analysis.

Specialty-related asymmetries in treatment and outcomes of younger patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is the most common arrhythmia and one of the most frequent motives for presentation in the emergency department (ED). However, there are still significant inequalities concerning its treatment.

Purpose

We aimed to assess if management and outcomes of patients with AF differed according to the specialty to which they were referred at hospital discharge.

Methods

We conducted a retrospective single-centre analysis including adult patients admitted to the ED in 2016 with the International Classification of Diseases codes correspondent to AF. Patients older than 75 years and those whose electronic medical file was not accessible were excluded. Patient referral at discharge was not based on any pre-specified criteria but rather performed at the discretion of the physician in the ED.

We divided our sample into 3 groups according to whom the patients were referred at hospital discharge: A) patients referred to an electrophysiologist; B) patients referred to a general cardiologist; and C) those referred to a non-cardiologist (general practitioner or internist).

We assessed patient characteristics, delay to first appointment, treatment strategies as well as stroke and all-cause mortality at 3 years of follow-up.

Results

Of the 372 patients initially screened, 184 were excluded due to age over 75 and 85 patients due to inaccessible medical records, resulting in a final sample of 103 patients with a median age of 65 (58-71) years and median CHA2DS2-VASc of 2 (1-3).

At discharge from the index admission, one third of patients were referred to an electrophysiologist (group A), 41% to a general cardiologist (group B) and the remaining 26% to a non-cardiologist (group C). There were no significant differences in baseline characteristics or type of AF between the groups.

The delay from index hospital admission to the first appointment was superior in groups A and B compared with C (3 and 2 vs 0 months, p=0.050).

Patients referred to an electrophysiologist were more frequently started on a rhythm-control strategy compared with those referred to other physicians (71% vs 38% and 26%, p=0.004). Similarly, significantly more patients in group A underwent catheter ablation (47% vs 12% and 4%, p&lt;0.001), around 2 years after the diagnosis (tendentially earlier than those in group B).

At 3 years follow-up, mortality was higher in group C compared with the other groups (15% vs 0 in group A and 2% in group B, p=0.019). Stroke rates did not differ between groups.

Conclusion

In this group of AF patients, referral to an electrophysiologist at discharge was associated with a higher rate of a rhythm-control strategy, including catheter ablation. In the long-term, those patients showed better survival. These results suggest that, in patients under 75 years, an earlier referral to an electrophysiologist might be beneficial.

Impact of sleep apnea treatment with CPAP on recurrence of atrial fibrillation after catheter ablation

Funding Acknowledgements

Type of funding sources: None. Main funding source(s): None

Background

Sleep apnea, as well as other risk factors such as obesity and high blood pressure, increase the risk of recurrence of atrial fibrillation after catheter ablation. But the true impact of sleep apnea treatment on recurrence of atrial fibrillation is less well defined.

Purpose

Assess the impact of untreated sleep apnea and treatment with CPAP (continuous positive airway pressure) on the risk of atrial fibrillation recurrence in patients undergoing catheter ablation.

Methods

We performed a retrospective analysis of 160 patients undergoing catheter ablation of paroxysmal or persistent atrial fibrillation in our institution, in a period between November of 2015 and November of 2021. We compared two groups: with atrial fibrillation recurrence and without atrial fibrillation recurrence, in a follow-up period of eighteen months. We analysed the clinical characteristics, diagnosis of sleep apnea, treatment with CPAP, echocardiographic findings (indexed volume of left atrium and left ventricular ejection fraction), cardiovascular risk factors and other comorbidities (table 1). Survival analysis of atrial fibrillation recurrence was performed using a Cox Regression analysis (figure 1).

Results

During a mean follow-up time of 22,8 ± 19,9 months, 46 patients (28,8%) had atrial fibrillation recurrence and none died. The recurrence was associated with hypertension, alcohol habits and untreated sleep apnea. Untreated sleep apnea was associated with a 4-fold increased risk of atrial fibrillation recurrence (HR 3,74; 95% CI 1,89-7,42; p &lt;0,001). In patients with sleep apnea (n = 41), CPAP treatment was associated with a 74% decreased risk of recurrence (HR 0,26; 95% CI 0,10-0,72; p = 0,009).

Conclusions

Treatment with CPAP was associated with lower risk of recurrence of atrial fibrillation after catheter ablation in patients with sleep apnea.

Benefit of sleep study in all patients with atrial fibrillation and BMI&gt; 28,0 Kg/m2 before catheter ablation

Funding Acknowledgements

Type of funding sources: None. Main funding source(s): None

Background

Sleep apnea is a known risk factor for atrial fibrillation recurrence after catheter ablation. Despite this, in recent atrial fibrillation guidelines, it is unclear in which patients to test sleep apnea before catheter ablation.

Purpose

Evaluate if body mass index (BMI) has a good discriminative power to predict sleep apnea in patients with atrial fibrillation proposed to catheter ablation.

Methods

We retrospectively studied 160 consecutive patients undergoing catheter ablation of paroxysmal or persistent atrial fibrillation in our institution. We evaluated recurrence of atrial fibrillation after catheter ablation and analysed diagnosis of sleep apnea, body mass index, treatment with CPAP, echocardiographic findings (indexed volume of left atrium and left ventricular ejection fraction), cardiovascular risk factors and other comorbidities and clinical characteristics. Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of body mass index as predictor of sleep apnea. Optimal cut-point value was obtained (Youden index) and patients were divided according to this value.

Results

During a mean follow-up time of 22,8 ± 19,9 months, 46 patients (28,8%) had atrial fibrillation recurrence and none died. The recurrence was associated with hypertension, alcohol habits and untreated sleep apnea (HR 3,74; 95% CI 1,89-7,42; p &lt;0,001). Optimal cut-point value for predicting sleep apnea in patients with atrial fibrillation proposed to catheter ablation was BMI of 28,0 Kg/m2 (AUC 0,733, p = 0,001, 95% CI 0,640-0,827). The group of patients with BMI of 28,0 Kg/m2 had a 4-fold increased risk of sleep apnea (OR 3,95, 95% CI 1,85-8,42, p =0,001) and 2-fold risk of atrial fibrillation recurrence (HR 1,96; 95% CI 1,10-3,51; p = 0,023).

Conclusions

In this group of patients undergoing catheter ablation of atrial fibrillation, a BMI ≥ 28,0 Kg/m2 was independent predictor of sleep apnea and recurrence of atrial fibrillation after catheter ablation. In patients with atrial fibrillation proposed to catheter ablation and BMI ≥ 28,0 Kg/m2 is reasonable to do a sleep study before catheter ablation.

Assessment of activation duration across the right ventricular outflow tract in patients with premature ventricular contractions using noninvasive electrocardiographic mapping: a validation study

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Introduction

Previous studies have reported that wavefront propagation speed across the right ventricular outflow tract (RVOT) can distinguish premature ventricular contractions (PVCs) with a RVOT origin from PVCs with a left ventricular outflow tract (LVOT) origin.

Aim

Validate the non-invasive electrocardiographic mapping (ECGI) for assessment of RVOT activation duration (AD) during PVCs and assess its value as a predictor of the origin of the PVCs.

Methods

We studied 18 consecutive patients, 8 males, median age 55 (35-63) years that underwent ablation of frequent (&gt; 10.000 per 24 h) idiopathic PVCs with inferior axis, that had and an ECGI performed before ablation and the RVOT mapped in PVC. The ECGI was performed with the Amycard system, and invasive mapping was performed with the Carto or Ensite system. Isochronal activation maps of the RVOT in PVC were obtained with the activation direction method (ADM) of the ECGI, and with the Carto and Ensite systems. Total RVOT AD was measured as the time interval between the earliest and the latest activated region. Agreement between the two methods was performed using a Bland-Altman plot and linear regression . The cutoff value of AD to predict PVC origin was calculated with ROC curve.

Results

PVCs originated from the RVOT in 11 (61%) patients. The median (Q1-Q3) RVOT AD measured with ECGI was 54 (39-68) ms and with invasive map 57 (36-70) ms. The agreement between both methods was good with an R2 of 0.747, p&lt;0.0001. Figure displays the Bland-Altman plot (panel A), the linear regression plot (panel B). and two examples of the ECGI isochronal map (panel C). The AD was significantly higher in PVCs from the RVOT vs LVOT, both with ECGI and Carto, respectively 62 (58-73) vs 37 (33-40) ms, p&lt;0.0001 and 68 (60-75) vs 34 (30-40) ms, p&lt;0.0001. The cutoff value of 43 ms for AD measured with ECGI, predicted the origin of the PVCs with a sensitivity and specificity of 100%.

Conclusions

We found good agreement between ECGI and Carto. The AD obtained with ECGI was accurate to predict the origin of the PVCs.

Evolution of Gender Disparities Among Brazilian Surgical, Anesthesia, and Obstetric Providers

INTRODUCTION

Since 2010, most graduating physicians in Brazil have been female, nevertheless gender disparities among surgical specialties still exist. This study aims to explore whether the increase in female physicians has translated to increased female representation among surgical specialties in Brazil.

METHODS

Data on gender, years of practice, and specialty was extracted from Demografia Médica do Brasil, from 2015 to 2020. The percentage of women across 18 surgical, anesthesia, and obstetric (SAO) specialties and the relative increases in female representation during the study period were calculated.

RESULTS

Of the 18 SAO specialties studied, 16 (88%) were predominantly male (>50%). Only obstetrics/gynecology and breast surgery showed a female predominance, with 58% and 52%, respectively. Urology, neurosurgery, and orthopedic surgery and traumatology were the three specialties with the largest presence of men - and the lowest absolute growth in the female workforce from 2015 to 2020.

CONCLUSIONS

In Brazil, where significant gender disparities persist, women are still underrepresented in surgical specialties. Female presence is predominant in surgical specialties dedicated to the care of female patients, while it remains poor in those with male patient dominance. Over the last 5 y, the proportion of women working in SAO specialties has grown, but not as much as in nonsurgical specialties. Future studies should focus on investigating the causes of gender disparities in Brazil to understand and tackle the barriers to pursuing surgical specialties.

Clinical and echocardiographic features of platypnea-orthodeoxia syndrome: a single-centre experience

Funding Acknowledgements

Type of funding sources: None.

Background

Platypnea-orthodeoxia syndrome (POS) is an uncommon condition characterized by dyspnoea and hypoxemia in the upright position that improves with recumbency.1 Possible causes are intracardiac shunt, pulmonary arteriovenous shunt, and V/Q mismatch.1,2 Echocardiography is the cornerstone of POS diagnosis, with special focus on atrial septal defect (ASD) morphology and right-to-left shunt confirmation.3

Purpose

To evaluate the clinical and echocardiographic features of patients presenting with POS due to a cardiac cause.

Methods

We performed a retrospective analysis of patients diagnosed with POS in our centre between 2015 January and 2021 August. Routine blood tests and transthoracic echocardiogram (TTE) were performed in all patients. Demographics, clinical presentation, blood test results, TTE information, and PFO closure procedure details were recorded.

Results

Seven patients were included, 85.7% female (n = 6). The median (IQR) age was 78 (72-85) years. The most prevalent cardiovascular risk factors were hypertension (100%; n = 7) and overweight/obesity (85.7%; n = 6). Two patients (28.6%) had chronic pulmonary disease. The most common symptoms were fatigue and exercise intolerance (n= 5; 71.4%) and the most frequent sign was persistent hypoxemia (n = 7; 100%), although 28.6% (n = 2) patients did not present the typical positional changes in peripheral oxygen saturation. Haemoglobin levels [14.1 (13.3-15.2)] were within the normal range and serum NTproBNP levels [656 (287-1196)] were slightly elevated. Left ventricle function was preserved in all patients; right ventricle morphology and function were normal in 85.7% (n = 6) patients, low probability of pulmonary hypertension in TTE was found in 85.7% (n = 6), and exuberant Eustachian valve was observed in 14.3% (n = 1). All patients presented atrial septal hypermobility, 87.5% (n = 6) meeting atrial septal aneurysm criteria. Patent foramen ovale was found in 85.7% of patients (n = 6) and ostium secundum ASD in 14.3% (n = 1). POS precipitating factors were aortic root dilation (28.6%; n = 2), chest trauma (14.3%; n = 1), right hip arthroplasty (14.3%; n = 1), atrial septal stretching regarding right volume overload (14.3%; n = 1). The underlying mechanism was unknown in 28.6% (n = 2) of patients. ASD closure was performed in 57.1% (n = 4) of patients: 75% (n = 3) showed residual shunt, but clinical improvement was reported by all. No acute complications were described, except for paroxysmal atrial fibrillation (14.3%; n = 1).

Conclusion

POS diagnosis depends on high clinical suspicion: the most common manifestations are fatigue and persistent hypoxemia. Typical positional changes in oxygen saturation are not present in all patients. Polycythaemia, right chambers dilation, and pulmonary hypertension are not common. Echocardiography is fundamental for diagnosis, allowing right-to-left shunt confirmation and ASD morphology evaluation to outline a successful closure procedure.

Prognostic significance of peak atrial longitudinal strain in patients with functional mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic mitral regurgitation has been shown to promote left atrial (LA) dysfunction and remodeling. However, the significance of LA dysfunction in this setting has not been fully investigated. The aim of our study was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in a cohort of patients with LV systolic dysfunction and functional mitral regurgitation (FMR).

Methods

Patients with at least mild FMR and reduced LVEF (&lt; 50%) under optimized medical therapy who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single-centre. FMR grading was undertaken according to the new 2021 valvular guidelines. PALS was assessed by 2D speckle tracking in apical 4-chamber view (as per EACVI current recommendations). Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters, namely PALS, and all-cause mortality.

Results

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median mitral regurgitant volume was 25mL (IQR: 14 – 34mL). According to the new ESC 2021 valvular guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. Median PALS was 14% (IQR 8 – 20%). The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS (figure 1). On ROC curve analysis, the best PALS cut-off value associated with mortality was &lt; 15%. Kaplan-Meier survival curves according to FMR severity and PALS &gt; or &lt; 15% are depicted in figure 2. PALS remained independently associated with all-cause mortality on multivariable analysis (adjusted hazard ratio [aHR]: 0.94; 95%CI: 0.90 – 0.98; p = 0.004) even after adjustment for several (n = 14) clinical and echocardiographic confounders.

Conclusion

In a cohort of patients with reduced LVEF and functional mitral regurgitation, peak atrial longitudinal strain was associated with all-cause mortality. Abstract Figure 1  Abstract Figure 2

Assessing the impacts of citizen-led policies on emissions, air quality and health

Air pollution is a global challenge, and especially urban areas are particularly affected by acute episodes. Traditional approaches used to mitigate air pollution primarily consider the technical aspects of the problem but not the role of citizen behaviour and day-to-day practices. ClairCity, a Horizon 2020 funded project, created an impact assessment framework considering the role of citizen behaviour to create future scenarios, aiming to improve urban environments and the wellbeing and health of its inhabitants. This framework was applied to six pilot cases: Bristol, Amsterdam, Ljubljana, Sosnowiec, Aveiro Region and Liguria Region, considering three-time horizons: 2025, 2035 and 2050. The scenarios approach includes the Business As Usual (BAU) scenario and a Final Unified Policy Scenarios (FUPS) established by citizens, decision-makers, local planners and stakeholders based on data collected through a citizen and stakeholder co-creation process. Therefore, this paper aims to present the ClairCity outcomes, analysing the quantified impacts of selected measures in terms of emissions, air quality, population exposure, and health. Each case study has established a particular set of measures with different levels of ambition, therefore different levels of success were achieved towards the control and mitigation of their specific air pollution problems. The transport sector was the most addressed by the measures showing substantial improvements for NO₂, already with the BAU scenarios, and overall, even better results when applying the citizen-led FUPS scenarios. In some cases, due to a lack of ambition for the residential and commercial sector, the results were not sufficient to fulfil the WHO guidelines. Overall, it was found in all cities that the co-created scenarios would lead to environmental improvements in terms of air quality and citizens' health compared to the baseline year of 2015. However, in some cases, the health impacts were lower than air quality due to the implementation of the measures not affecting the most densely populated areas. Benefits from the FUPS comparing to the BAU scenario were found to be highest in Amsterdam and Bristol, with further NO₂ and PM10 emission reductions around 10%-16% by 2025 and 19%-28% by 2050, compared to BAU.

Is authorship by women in Brazilian academic surgery increasing? A five-year retrospective analysis

Women remain underrepresented in 80% of Brazilian surgical specialties, however, women representation within the Brazilian academic surgical literature remains unknown. This study aims to evaluate the gender distribution of first and last authors in Brazilian surgical journals. All publications between 2015 and 2019 from the five Brazilian surgical journals with the highest impact factor were reviewed. The first and last authors' names were extracted from each article and a predictive algorithm was used to classify the gender of each author. Authors were further classified by surgical field and geographic region to investigate patterns of female authorship among journals, specialties, and region over the study period. Multivariable logistic regression was then used to identify factors independently associated with female authorship. 1844 articles were analyzed; 23% (426/1844) articles had female first authors, and 20% (348/1748) had female last authors. Acta Cirúrgica Brasileira was observed to have the highest rates for both first and last female authors (37%, 138/371; 26%, 95/370)) and Revista Brasileira de Ortopedia (9%, 48/542; 10%, 54/522) had the lowest rates. Papers with a woman senior author were twice as likely to have a woman first author (OR 1.98, 95% CI 1.51-2.58, p≤0.01). Women's representation in medicine is increasing in Brazil, yet women remain underrepresented as the first and last authors in the Brazilian surgical literature. Our results highlight the importance of senior women mentorship in academic surgery and demonstrate that promoting female surgeon senior authorship through academic and financial support will positively impact the number of female first authors.

Abyssal Benthic Rover, an autonomous vehicle for long-term monitoring of deep-ocean processes

[Figure: see text].

Association of skeletal muscle and cardiovascular risk factors in patients with lower extremity arterial disease

BACKGROUND

Sarcopenia is defined as low muscle mass, with low muscle strength or low physical performance. The skeletal muscle mass (or density) and strength are inversely associated with cardiovascular risk factors. We aim to determine the relationship between skeletal muscle characteristics (strength, mass, area), and cardiovascular risk factors in a population with lower extremity artery disease (LEAD) METHODS: : An observational, prospective study including patients with LEAD was conducted from January 2018 to December 2020. The cardiovascular risk factors and anthropometric measurements were prospectively registered. The skeletal muscle characteristics (area, density/mass and strength) were analysed. The skeletal muscle area and density were quantified with a CT scan. The strength was determined with a Jamar® hydraulic hand dynamometer.

RESULTS

96 patients with LEAD with 67.70± 10.11 years-old were enrolled in the study. The most prevalent cardiovascular risk factor was hypertension, followed by dyslipidemia and diabetes. Patients with diabetes had a lower handgrip strength and skeletal muscle density, when compared with patients without diabetes (strength: 19.67± 9.98 kgf versus 26.79 ± 11.80 kgf, p=0.002 and skeletal muscle density: 10.58 ± 17.61 HU versus 18.17 ± 15.33 HU, p=0.032). There was a trend for the association between the presence of cardiovascular risk factors (hypertension and dyslipidemia) and a decrease in skeletal muscle density and strength (density: hypertension: 13.46 ± 16.74 HU versus 20.38 ± 11.63 HU p=0.055; dyslipidemia: 13.57 ± 17.16 HU versus 17.74 ± 13.00 HU p=0.315; strength- hypertension: 22.55 ± 10.08 kgf versus 27.58 ± 15.11 p= 0.073; dyslipidemia: 22.80 ± 10.52 kgf versus 25.28 ± 13.14 kgf p=0.315). Interestingly, we found that smokers had a favorable skeletal muscle characteristic, which could be explained by the higher prevalence of diabetes in non-smokers.

CONCLUSIONS

The indicators of skeletal muscle dysfunction (strength and density) are associated to the presence of diabetes in patients with LEAD. Therapeutic strategies to improve the skeletal muscle characteristics could have a role in improving LEAD risk factors, particularly diabetes.

Validation of a novel framework defining the acceptable standard of care for heart failure with reduced ejection fraction

Background

In heart failure with reduced ejection fraction (HFrEF), uptitration of neurohormonal antagonists to trial-proven doses shown to reduce mortality is challenging and seldomly achieved in clinical practice. A major reason for underdosing of these agents is the lack of a clear description of what constitutes an acceptable standard of care in HFrEF. To address this limitation, a novel framework for describing the physician adherence to evidence-based treatment was recently proposed. The aim of our study was to evaluate and validate the proposed framework in a real-world population of patients with HFrEF.

Methods

A cohort of patients with HFrEF, defined as left ventricular ejection fraction (LVEF) &lt;40%, under treatment with neurohormonal antagonists for at least 3 months were retrospectively identified at a tertiary hospital's Heart Failure Clinic. Demographic, clinical, echocardiographic and treatment data were assessed. Patients were divided in three strata for each neurohormonal antagonist, according to the proposed framework: Status I – patients receiving target doses or the highest tolerated dose; Status II – use of subtarget doses for reasons unrelated to clinically important intolerance; and Status III – not receiving the drug at any dose. The prognostic value of each strata was assessed for all-cause mortality.

Results

A total of 408 patients (mean age 68±12 years, 78% male, 63% ischemic etiology) were included. The median LVEF was 31% (IQR 25–36) and most patients were in NYHA class II or III [210 (51.5%) and 163 (40%), respectively]. Medical therapy is described in Table 1. During a median follow-up of 3.3 years (IQR 1.4–5.6), 210 patients died. On univariable analysis, achieving Status I of beta-blocker (BB) therapy (HR: 0.50; 95% CI: 0.32–0.81; P=0.004) or ACEi/ARB (HR: 0.56; 95% CI: 0.36–0.86; P=0.012) was associated with reduced all-cause mortality. The mortality of patients in Status II of BB or ACEi/ARB was similar to the mortality of those not receiving the drug (HR for BB: 0.90; 95% CI: 0.53–1.52; P=0.69 and HR for ACEi/ARB: 0.71; 95% CI: 0.42–1.18; P=0.182) – figure 1. Achieving Status I of BB remained independently associated with reduced mortality after adjustment for several clinical and echocardiographic confounders (n=13) (adjusted HR: 0.59; 95% CI: 0.35–0.98; P=0.041).

Conclusions

In this real-world population of patients with HFrEF, the vast majority of patients were in Status I of BB and ACEi/ARB therapy. Achieving Status I of BB therapy seems to be associated with reduced mortality, even after adjustment for several markers of disease severity, highlighting the need for uptitration of medical therapy to maximal tolerated doses according to trial-proven regimens.

Funding Acknowledgement

Type of funding sources: None.

STEMI with mid-range ejection fraction: a group of intermediate risk not to be forgotten

Background

Reduced left ventricular ejection fraction (LVEF) &lt;40% is an important negative prognostic factor in the setting of ST-elevation acute myocardial infarction (STEMI). On the other hand, data concerning mid-range LVEF (mrEF) post-STEMI are scarce. Consequently, recommendations regarding reassessment of LVEF or administration of neurohormonal medication in this group of patients (pts) are also lacking.

Purpose

To assess the current treatment and prognosis of STEMI with mrEF.

Methods

Retrospective study including all consecutive pts hospitalized for STEMI and submitted to primary percutaneous coronary intervention in a Cardiology centre in 2018. Pts were divided into 3 groups according to LVEF assessed before hospital discharge: preserved EF (pEF: LVEF ≥50%), mid-range EF (mrEF: LVEF 40–49%) and reduced EF (rEF: LVEF &lt;40%). We analysed clinical characteristics, treatment, evolution of LVEF post-STEMI and clinical outcomes - death, myocardial infarction (MI) and hospitalization for heart failure (HF) – of the mrEF group and compared it with pEF.

Results

188 pts with a mean age of 61 years were admitted for STEMI in 2018. The majority (58%, n=109) had pEF; 29% (n=55) had mrEF and 13% (n=24) were in the rEF group. Pts in the mrEF group had similar baseline characteristics to the others. However, compared with pEF, culprit-lesion was more often located in left main or left anterior descending arteries (80% vs 35%, p&lt;0.001) and NT-proBNP levels were higher in mrEF pts (2270 vs 881 pg/mL, p&lt;0.001).

At discharge, all mrEF patients were medicated with a renin-angiotensin-aldosterone blocker and 91% with a beta-blocker.

After a median of 8 months, LVEF improved a mean of 4% (± 9%) in the mrEF group. However, in 12.5% LVEF worsened to &lt;40% (vs 0 in the pEF group, p=0.006).

At a median follow-up of 2.6 years, there was an increase in mortality according to the EF group (pEF 4% vs mrEF 13% vs rEF 48%, log-rank: p&lt;0.001 – fig. 1) with a hazard ratio (adjusted for age) of 3.75 (95% CI 1.1–12.8, p=0.035) for mrEF vs pEF. There was also a non-significant tendency to higher rates of the composite endpoint of MI and hospitalization for HF in the mrEF group vs pEF (8.2% vs 2.9%, p=0.213).

Conclusions

This study confirms previous reports of the worse prognosis of STEMI with mrEF and suggests the existence of a continuum of risk of adverse clinical outcomes according to LVEF. Therefore, this group of intermediate risk might also benefit from neurohormonal medication, which is only specifically recommended for rEF in current STEMI guidelines. It also highlights the importance of a closer follow-up (with reassessment of LVEF) of mrEF pts since a non negligeable proportion ultimately progress to rEF and may require additional medical treatment or even an implantable cardioverter defibrillator. Further research with larger samples is required to identify predictors of worsening LVEF and assess the impact of neurohormonal modulation in this population.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier Survival Analysis

Incremental prognostic value of worsening renal function parameters in addition to the GRACE score in patients with acute coronary syndrome

Background

Baseline renal function, one of the parameters included in the GRACE score, has prognostic relevance in patients admitted for acute coronary syndrome (ACS).

Purpose

The aim of this study was to compare different worsening renal function (WRF) parameters during hospitalization for ACS and their impact on all-cause mortality. Furthermore, we aimed to assess if these parameters had any incremental prognostic value in addition to the GRACE score.

Methods

We conducted a single-center retrospective study enrolling consecutive patients admitted for ACS from January 2016 to December 2018. Estimation of glomerular filtration rate (eGFR) for each patient was calculated based on the CKD-EPI formula. WRF during hospitalization was assessed by means of: serum creatinine (sCr) elevation ≥0,3mg/dL, duplication of the sCr value or maximum sCr value ≥2,0mg/dL.

Results

A total of 555 patients were included (65±13 years old, 72% male). Overall, 402 (72%) had hypertension, 167 (30%) were diabetic, 88 (16%) had left ventricular ejection fraction &lt;40%. Mean GRACE score was 102.7±29.1 and median sCr at baseline was 0.83 mg/dL [0.70; 0.97]. Median length of hospitalization was 4 days [2; 10] and the mean follow-up of 963 days.

Baseline eGFR showed significant correlation with mortality during follow-up (HR 0.742 [95% CI 0.691–0.797] per 10 mL/min/1.73m2 increase in eGRF). Moreover, all WRF parameters showed significant association with all-cause mortality during follow-up on a univariate analysis - p&lt;0,001 (Table 1). Elevation of sCr ≥0,3 mg/dL during hospitalization was the most frequent WRF parameter (210 patients - 38%) and the most sensitive parameter to predict our endpoint, occurring in 56 patients who died during follow-up (sensitivity 66.7%). Both duplication of sCr and absolute sCr ≥2,0mg/dL during hospitalization showed a lower prevalence; however, the majority of patients with one of these findings died during follow-up (51,4% and 68,5%, respectively).

On a multivariate Cox regression analysis, adjusted for the GRACE score, all individual WRF parameters remained independently associated with all-cause mortality during follow up (Table 2).

Conclusion

Worsening renal function has significant prognostic impact in patients admitted for ACS. Identification of these parameters during hospitalization adds significant value to the prognostic stratification of the GRACE score.

Funding Acknowledgement

Type of funding sources: None.

Validation of the CARPREG II risk stratification model and the WHOm scale in pregnant women with heart disease

 

The physiological changes of pregnancy imply a state of haemodynamic stress, which increases the risk of maternal-fetal complications in women with cardiac pathology. Risk stratification models allow clinical decisions to be guided and optimal diagnostic, follow-up and management strategies to be established according to each estimated category in order to reduce adverse outcomes.

Objective

To validate the CARPREG II and WHOm risk prediction models in a population of pregnant women with heart disease.

Materials and methods

Validation and comparison study of a risk prediction model in a prospective cohort of pregnant women with heart disease assessed between 2016 and 2019 by a cardiobstetric team in an average income country. The CARPREG II score was established and patients were classified according to the WHOm risk scale. We assessed cardiovascular and perinatal outcomes and determined the calibration and level of discrimination of these tools.

Results

In a cohort of 328 pregnant women (27±7 years), 33% (n=110) had congenital heart disease, followed by arrhythmias in 30% (n=98), valvular pathologies in 14% (n=46) and cardiomyopathies in 9% (n=29). In 56% of the pregnancies, the route of delivery was caesarean section, 84% of these by obstetric indication. A cardiac event occurred in 15%, with left heart failure (5.3%) and arrhythmias (2.3%) being the most frequent. The frequency of maternal death of cardiac origin during the study was 1.6%. Neonatal outcomes occurred in 37% of gestations (preterm delivery (16%) and low weight for gestational age (8.4%)) and obstetric events in 12.5%: pregnancy-induced hypertension (9%) and postpartum haemorrhage (2.3%).

NYHA functional class III-IV or cyanosis (OR 12 95% CI 3.1 - 46.4) and left ventricular dysfunction (LVEF &lt;55%) (OR 3 95% CI 1 - 10.9) were the most statistically significant risk predictors. Discrimination of both models was adequate (AUC-ROC of 0.74 95% CI 0.64 - 0.84) for the CARPREG II risk index and 0.77 for the WHOm scale (95% CI 0.69 - 0.86) (Figure 2). Calibration is also good in the study population (Hosmer- Lemeshow goodness-of-fit 0.6 and 0.1, respectively). By including in the CARPREG II model the variables ejection fraction and pulmonary artery systolic pressure in their numerical and not dichotomised form, a discrete improvement in the predictive ability of the scale is evident (AUC-ROC 0.81 95% CI 0.71–0.91).

Conclusions

The CARPREG II and WHOm risk stratification models have good ability to discriminate the risk of adverse cardiac outcomes in pregnant women with heart disease and fit our population. To improve the predictive power of CARPREG II, the variables pulmonary hypertension and left ventricular dysfunction could be used numerically and not dichotomised as in the original model.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): San Vicente Foundation University Hospital, Cardio-obstetric Center

Aortic plaques in patients with atrial fibrillation: an often-forgotten risk factor for thromboembolism

Background

CHA2DS2-VASc risk score is the main determinant for maintaining anticoagulation after atrial fibrillation (AF) ablation, irrespective of the procedure outcome. The presence of aortic plaques is included in the score, but isn't regularly assessed previously to AF ablation. This way, risk factors for coronary artery disease (CAD) other than arterial hypertension and diabetes mellitus may influence stroke risk in patients with AF, albeit not being included in the CHA2DS2-VASc score.

Purpose

We sought to evaluate the prevalence of aortic plaques diagnosed during transesophageal echocardiography (TOE) in patients submitted to AF ablation and to assess its determinants and clinical impact on the CHA2DS2-VASc score.

Methods

Retrospective study of patients submitted to AF ablation that performed TOE prior to the procedure, with assessment of aortic plaques. CHA2DS2-VASc risk score was evaluated in the pre-ablation patient evaluation and reassessed after TOE. Demographic, clinical and echocardiographic data, including cardiovascular risk factors, were analyzed. We assessed AF recurrence rate, cerebrovascular events and death during follow-up.

Results

120 patients were submitted to TOE prior to AF ablation from November 2015 to December 2020, mean age 66.6 (±9.55) years, 48% male. In 30 (25%) patients aortic plaques were identified in TOE. Mean CHA2DS2-VASc was 2.2 (±1.47) in pre-ablation evaluation and 2.5 (±1.69) post-TOE, increasing in all patients with aortic plaques and prompting beginning of oral anticoagulation in 5 patients. AF was paroxysmal in 74% and persistent in 26% of patients, mean duration of 6.28 (±3.76) years. Arterial hypertension was present in 79 (66%) of patients, type 2 diabetes mellitus in 24 (20%) and dyslipidemia in 67 (56%). 17 (14%) patients had a prior stroke. During a mean follow-up of 30 (±18.3) months, 32 (27%) patients had AF recurrence and 10 (8%) were submitted to redo procedures. 107 (89%) patients remained under oral anticoagulation, stroke occurred in 1 patient and 2 patients died.

In univariate analysis, age, type 2 diabetes mellitus and dyslipidemia predicted an increase in CHA2DS2-VASc score after TOE (respectively, OR 1.113, 95% CI 1.041–1.190, p-value 0.002; OR 2.907, 95% CI 1.145–7.379, p-value 0.025; and OR 2.442, 95% CI 1.016–5.868, p-value 0.046).

In multivariate analysis, age is the only independent predictor of increased CHA2DS2-VASc score after TOE (OR 1.095, 95% CI 1.013–1.185, p-value 0.023). No risk factor for CAD was independently associated with the presence of aortic plaques (Table 1).

Conclusion

In this population, single CAD risk factors were not independent predictors of aortic plaques. If TOE had not been performed prior to AF ablation, 25% of patients would have had an underestimated CHA2DS2-VASc score and would be off anticoagulation after the procedure, unprotected from thromboembolic events.

Funding Acknowledgement

Type of funding sources: None. Table 1

Left atrial stiffness measured by echocardiography is a stronger predictor of atrial fibrillation recurrence after radiofrequency catheter ablation than left atrial volume

Introduction

Left atrial volume (LAV) is an accepted predictor of atrial fibrillation (AF) recurrence after radiofrequency catheter ablation, stronger than AF duration.

Objective

The aim of this study was to assess the value of left atrial stiffness (LAS) index as a new parameter evaluated by echocardiography to the prediction of AF recurrence after radiofrequency catheter ablation.

Methods

We retrospectively studied consecutive patients with paroxysmal or persistent AF submitted to radiofrequency catheter ablation at our institution between 2017 and 2019. We used transthoracic echocardiography to measure the LAV indexed to body surface area and the LAS index, defined as the ratio between the mitral E/e' (obtained with pulsed Doppler at the tip of the mitral leaflets – E, and tissue Doppler imaging at the mitral annulus – e') and the left atrial strain during the reservoir phase (obtained by speckle tracking echocardiography) [LAS index = (E/e') / LA reservoir strain]. The left ventricular ejection fraction (LVEF) was also evaluated. Patients with poor quality echocardiographic images were excluded. We compared 2 groups of patients, according to the recurrence of AF after the blanking period. We analysed the clinical characteristics and echocardiographic findings. The effect of clinical and echocardiography parameters on AF recurrence was evaluated by univariate and multivariate Cox Regression analysis.

Results

We studied 33 patients, 27 with paroxysmal AF and 6 with persistent AF. Baseline patients' characteristics are presented in Table 1. During a mean follow-up time of 17.9±10.4 months, 7 patients (21%) had AF recurrence, and none died. Patients with AF recurrence had a higher LAS index. After adjusting for confounding variables, only LAS index and LAV were independently associated with AF recurrence (Table 2). Every one unit increase in LAS index was associated with an 11-fold increased risk of AF recurrence (HR 10.86, 95% CI 1.38–85.56; p=0.024), while every one unit increase in LAV index was only associated with a 6% increased risk of AF recurrence (HR 1.06, 95% CI 1.01–1.11, p=0.010).

Conclusion

LAS index evaluated by echocardiography was a much stronger predictor of AF recurrence after radiofrequency catheter ablation than left atrial volume.

Funding Acknowledgement

Type of funding sources: None.

In-depth phenotyping by cardiovascular magnetic resonance uncovering differences between ethnic groups in hypertensive heart disease

Background

Black African/African-Caribbean individuals with hypertension (BH) are at greater risk of heart failure than those of white European ethnicity (WH). The mechanisms underlying this dissimilarity remain poorly understood.

Purpose

To investigate the influence of ethnicity on left ventricular (LV) remodelling using multi-parametric cardiovascular magnetic resonance (CMR).

Methods

BH (n=44), WH (n=38) and healthy-volunteers (HV; n=25, 5 of black ethnicity) underwent comprehensive CMR. The exam included: i) Arterial Stiffness/Afterload pulse-wave-velocity (PWV), aortic elastance (Ea) and systemic vascular resistance (SVR) by phase-contrast velocity-encoding imaging; ii) Ventricular remodelling/Function LV and right ventricular (RV) volumes, mass, ejection fraction (EF), LV peak-filling rate by short-axis cine images; myocardial strains were measured by feature tracking; iii) Left atrial (LA) remodelling/Function volumes and functions by long-axis cine images; iv) Tissue characterisation: extracellular volume by pre/post-contrast T1-mapping and late gadolinium enhancement (LGE) for interstitial and replacement myocardial fibrosis, respectively. Multivariate linear regression models were developed to investigate how LV remodelling associates with ethnicity, arterial afterload, including elastance (Ea) and stiffness [PW], and SVR. Models were adjusted for age, gender, body-mass-index, LV volumes or function and LA volumes.

Results

Subject characteristics are summarised in the Table. PWV and Ea and SVR were greater in hypertensives, particularly in BH, than HV; this was paralleled by higher LV mass, interventricular septum thickness (IVS), LA volumes but lower LV-EF. These findings were confirmed after adjusting for age.

On the Model-1, IVS was associated with Ea (β=0.335, P=0.008) and black ethnicity (β=0.226, P=0.019) but not with SVR or PWV. For each increment of Ea there was a similar increase of IVS in BH and WH (P=0.602 for interaction), however BH had greater IVS than WH at each Ea value (Figure, fully-adjusted Model-1). On Model-2, LV end-diastolic volume was associated with Ea (β=−0.268, P=0.001), SVR (β=−0.319, P=0.019) but not with PWV or ethnicity. However, the inverse relation between LV size and Ea was significantly attenuated in BH (P=0.039 for interaction), (Figure, fully-adjusted Model-2). On model-3, LV-EF was associated with Ea (β=0.223, P=0.009) but not with ethnicity, PWV or SVR. LV-EF reduction for each Ea increment was similar for BH and WH (P=0.597 for interaction).

Conclusion

BH and WH show a distinctive LV remodelling phenotype. BH had a greater susceptibility to hypertrophy and an attenuated reduction of chamber size in response to arterial afterload. Further research to disentangle the genetic and environmental factors underlying these ethnic group-specific differences is utterly required.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Patients with reflex syncope have a higher prevalence of atrial fibrillation than general population which is predicted by the type of the tilt table test response

Introduction

Reflex syncope is the result of an imbalance between the sympathetic and parasympathetic nervous system. The autonomic nervous system has been associated to some forms of atrial fibrillation (AF).

Objective

The aim of this study was to assess the prevalence of AF in patients with reflex syncope and a positive tilt table test and to identify the type of tilt test response in patients with AF in comparison to patients without AF.

Methods

We retrospectively studied consecutive patients that underwent a tilt table test at our institution between 2016 and 2019. We selected those patients with a positive test. Patients with an implanted pacemaker at the time of the tilt test and patients followed in a different institution were excluded. Previous diagnoses of AF episodes were assessed. We analysed the clinical characteristics and the tilt table test results according to previous history of AF.

Results

We studied 49 patients with a positive tilt test. Seven (14.3%) patients had previously diagnosed paroxysmal AF at the time of the tilt table test. Patients with AF were older, had more frequently hypertension, and the tilt test response was more frequently a vasodepressor than mixed or cardioinhibitory response (71.4% vs. 28.6%) (Table). In univariate analysis, age and hypertension were associated with AF, respectively, OR 1.08 (95% CI 1.01–1.17), p=0.034 and OR 10.80 (95% CI 1.19–98.36), p=0.035. A vasodepressor response was also associated with AF (OR 6.25, 95% CI 1.06–36.74, p=0.043).

Conclusions

Patients with reflex syncope and a positive tilt table test had a higher prevalence of AF than the general population. A vasodepressor response was associated with AF as were age and hypertension, demonstrating the possible impact of the autonomic nervous system and the multifactorial nature of AF.

Funding Acknowledgement

Type of funding sources: None.

Anticipating recurrent ischemic events after an acute coronary syndrome: validation and application of the SMART-REACH score

Background

The SMART-REACH score (SRS) was developed to predict the risk of major adverse cardiovascular events in ambulatory patients with established cardiovascular disease, although it has not been extensively validated. Patients at higher risk of recurrent ischemic events may benefit from novel, more intensive treatment options, and earlier identification of these patients can potentially improve outcomes.

Purpose

We aimed to validate the SRS and evaluate its performance in a population recently admitted with acute coronary syndrome.

Methods

In this single-centre retrospective cohort, we included 320 patients aged 45 to 80 years, who were discharged following admission for an acute coronary syndrome between 2016 and 2018. To calculate the SRS for each patient, we considered clinical data on admission (age, gender, smoking, diabetes, prior history of vascular disease, heart failure or atrial fibrillation), lipid values obtained within the first 24 hours of hospitalization, serum creatinine level at baseline and once the patient was deemed clinically stable, and discharge medication. The outcome of interest was defined as stroke, myocardial infarction or cardiovascular death (MACE) at two years of follow-up. SRS was assessed for discrimination and calibration.

Results

Mean age was 63±9 years, and 240 (75%) were male. There was high prevalence of cardiovascular risk factors: 71% had hypertension, 32% had diabetes mellitus, 42% were active smokers and 25% had previously established cardiovascular disease. The outcome of interest was observed in 38 patients (22 cardiovascular deaths, 6 strokes and 14 myocardial infarctions). SRS showed good discrimination of the estimated MACE risk with overall C-statistic of 0.646 (95% CI, 0.554–0.737, p=0.004) (picture 1) and calibration (p-value for the goodness-of-fit test of 0.544). The global estimated risk of MACE at 2-years was 4.8% (3.8%-6.8%). The expected/ observed ratio was 0.56 for the occurrence MACE (picture 2).

Conclusions

Over the first two years after discharge from an acute coronary syndrome, one of every 8 patients developed a potentially fatal recurrent ischemic event. The SRS performed reasonably well in discriminating those at highest risk of MACE, suggesting that this score may help select patients at discharge for ad initium more intensive pharmacological therapy.

Funding Acknowledgement

Type of funding sources: None. ROC curve for the SMART-REACH scoreExpected versus observed MACE

Chronic heart failure in intensive care unit: can we accurately predict the risk?

Background

Severity of disease scoring systems, namely the Simplified Acute Physiology Score (SAPS) and Acute Physiology and Chronic Health Evaluation (APACHE), are widely used to predict mortality in Intensive Care Units (ICU). Yet, neither score includes chronic HF in their model. We aimed to evaluate whether these scores perform well in risk prediction of death of patients previously diagnosed with heart failure (HF).

Methodology

This is a single-center retrospective cohort of patients admitted to an ICU in 2019. Those whose admission lasted &lt;24 hours were excluded from analysis. The SAPS II and APACHE II scores were calculated using data from the first 24 hours of ICU admission, imputing the worst variable obtained within this timeframe. HF was defined according to the ESC recommendations. In order to assess the performance of the scores, Receiver Operating Characteristic (ROC) Curves were used to predict the risk of death in ICU in HF compared to the non-HF population.

Results

A total of 267 patients were hospitalized in ICU for a period over 24 hours in 2019 (mean age 67±16 years; 58.8% males; 21.7% with chronic HF; 33.7% admitted for sepsis). Compared to patients without HF, those with chronic HF were older (74±13 vs. 65±16 years; p&lt;0.001) and had higher risk scores (mean SAPS II: 43.2±21.7 vs. 56.5±20.7; p&lt;0.001; mean APACHE II: 19.8±10.0 vs. 25.1±10.0; p&lt;0.001). Moreover, these patients were at higher risk of meaningful events during hospitalization (e.g. acute kidney injury: 38.0 vs. 66.1%; p&lt;0.001; shock at any time: 52.4 vs. 67.8%; p=0.036). Furthermore, patients with HF had a trend towards higher mortality rates in ICU (17.3 vs. 28.8%; p=0.051) and a significantly higher death in overall hospitalization (30.8 vs. 45.8%; p=0.032). ROC curves performed well in predicting the risk of ICU death regardless of HF (SAPS II – AUC 0.78 vs. 0.81; p=0.36; APACHE II – AUC 0.75 vs. 0.78; p=0.37).

Conclusion

Approximately 1 in every 4 patients admitted to the ICU had chronic HF. Traditional risk scoring systems (SAPS II and APACHE II) performed well regardless of HF. While these results are reassuring as far as risk stratification accuracy is concerned, HF patients remained at a higher risk for worse outcomes. Therefore, prognostic tools with a therapeutic clinical applicability are urgently needed to improve the outcome of this population.

Funding Acknowledgement

Type of funding sources: None.

Predictors of patient and system delay for primary percutaneous coronary intervention

Background

The delay times of the patient and the system for primary percutaneous coronary intervention (p-PCI) have a determining impact on the prognosis of patients with acute myocardial infarction with ST segment elevation (STEMI).

Purpose

To identify the predictors of patient and system delay for p-PCI in the period of 2020 at a reference hospital for p-PCI.

Methods

Patients submitted to p-PCI in the period from March to September 2020 were included and compared with the same period in 2019. We analyzed the differences between the two groups regarding the patient's delay times, time from the onset of symptoms to the first medical contact (FCM) and the system (time from the first contact with the health system to p-ICP). Data collection of the patient's previous history, coronary intervention performed and post-PCI follow-up was performed using the electronic patient record. Univariate analysis and logistic regression models from multivariate analysis were used to determine the predictors of “patient delay” and “system delay” and adjusted for confounding factors. The analysis was performed with a significance level of 5%.

Results

We included in the study 255 patients who underwent p-PCI, of which 122 in the period from 2020 and 133 in the period from 2019. Regarding the characteristics of the population, there were no significant differences between the two periods. Regarding the patient's delay time, there were no statistically significant differences. The variable first medical contact with a non p-PCI center was the only variable associated with system delay&gt;90 minutes in the multivariate analysis, OR (6.18: 95% CI, 1.91–20), p=0.002. There was a statistically significant association between the period of 2020 (pandemic period) and total ischemia time, but with a negative effect, dependent variable adjusted for confounding factors [adjusted OR: −0.10; 95% CI: −107.61 to −5.57; p=0.03].

Conclusion

In this study, the patient's admission to a non p-PCI centers was identified as the only predictor of longer delay until p-PCI (system delay). However, these results should serve as a contribution to decision making in order to mitigate risks, regardless of any associated catastrophe and eventually alert the population not to neglect the symptoms suspected of acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: None.

Rapid atrial fibrillation increases cardiac biomarkers: decision to perform coronary angiography based on novel high-sensitivity Troponin I peak

Funding Acknowledgements

Type of funding sources: None.

Background

Since January 2018 the availability of high sensitivity Troponin I (hsTnI) has improved ischemia diagnosis. In patients with rapid atrial fibrillation (AF), the decision to undergo coronary angiography is usually due to elevated cardiac biomarkers. However, evidence to support the rentability of this approach is sparse.

Purpose

Evaluate if hsTnI in patients with rapid AF and elevated cardiac biomarkers has a good discriminative power to predict a positive coronary angiography.

Methods

We retrospectively studied consecutive patients admitted to the emergency department (ED) between January 2018 and December 2019 with rapid AF that underwent coronary angiography and had multiple hsTnI values obtained. We analysed risk factors, initial and peak hsTnI, time from ED admission to peak hsTnI and ST-T segment abnormalities (ST depression and/or T wave inversion). We evaluated the presence of significant coronary artery stenosis with the need of revascularization at coronary angiography. Univariable and multivariable analysis was performed to obtain the Odds Ratio (OR, 95% CI, p-value) for significant coronary artery disease (CAD).

Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of peak hsTnI as predictor of a positive coronary angiography. Optimal cut-point value was obtained (Youden index) and patients were divided according to this value.

Results

From 1407 patients admitted to the ED with rapid AF, 30 patients, 60% male, median age 74 (IQR 61.25-80.75) years, were submitted to coronary angiography. Significant coronary artery stenosis was present in 17 (57%) patients.

Age, ST-T segment abnormalities and peak hsTnI were predictors of significant CAD, respectively 1.203, 1.064-1.361, 0.003; 25.00, 3.522-177.477, 0.001; and 1.000, 1.000-1.001, 0.015.

Optimal cut-point value for predicting the presence of significant coronary artery stenosis at coronary angiography was a peak hsTnI of 359 pg/mL (AUC 0.869, p-value 0.001, 95% CI 0.742-0.995). The two groups with hsTnI &lt; 359 and hsTnI &gt;359 differed in age and ST-T segment abnormalities (see Table).

After adjustment, peak hsTnI &gt;359 pg/mL was the only independent predictor of significant CAD (23.894, 1.310-435.669, 0.032).

Conclusion

In this group of patients with rapid AF, peak hsTnI &gt;359 pg/mL was the only independent predictor of significant coronary artery disease. Therefore, those patients should undergo coronary angiography. Abstract Figure.

Optimal percentage of biventricular pacing to obtain CRT response: how high is high enough

Funding Acknowledgements

Type of funding sources: None.

Background

The greatest benefit with cardiac resynchronization therapy (CRT) is achieved when biventricular pacing (BivP) percentage (%) is close to 100%. However, in some patients that goal can be challenging to obtain.

Purpose

Determine whether a lower BivP% could lead to similar CRT response and events, as compared with patients with BivP% &gt;98%.

Methods

Patients with CRT followed up in a remote-monitoring network were retrospectively analyzed. BivP% was assessed and response to CRT was defined as an absolute increase in left ventricle ejection fraction (LVEF) &gt;5% or a relative increase in LVEF &gt;15%.

Low BivP% was defined as &lt;98%. Clinical, echocardiographic data and all-cause death during follow-up were evaluated. ROC curve and AUC were obtained to determine the discriminative power of BivP% as predictor of CRT response. Optimal cut-point value was obtained and patients were divided according to this value. Kaplan-Meyer survival function was used to compare survival in the different groups and the Log-rank test was used for comparison between the groups.

Results

88 patients, 76% male, median age 73.5 (IQR 65.75-79.25) years were included. A CRT-D was implanted in 69%. Etiology was ischemic in 44%. 93% were under beta-blockers. Median LVEF before CRT was 27% (IQR 20.25-32). 

44 patients (50%) had low BivP% (median 91%, IQR 96-99), 55% due to atrial fibrillation and 52% due to frequent premature ventricular complexes. After optimization of medical therapy, device programming and/or interventional procedures, we obtained a BivP &gt;98% in 26 out of the 44 patients (59%). However, in 18 patients (20%) BivP% was &lt;98% (median 95, IQR 92.25-96). 66% patients were CRT responders. Median follow-up was 36 (IQR 23.75-84) months. During follow-up, all-cause mortality was 27% (24 patients).

Optimal cut-point value for predicting CRT response was 91% BivP% (AUC 0.644, p-value 0.047, 95% CI 0.496-0.792). The characteristics of the two groups didn’t differ significantly (Table).

Survival was significantly higher in patients with BivP% &gt;91% (Log-rank 3.667, p-value 0.050) – Figure.

Conclusion

In this population, BivP% &gt;91% was sufficient to achieve CRT-response and was associated with a better survival. BivP% &lt;91%(n = 4)BivP% &gt;91%(n = 84)p-valueAge in years, median (IQR)72.50 (70.50-73.75)74.00 (65.00-80.00)0.666CRT-D, n (%)3 (75.0)58 (69.0)0.999Ischemic cardiopathy, n (%)3 (75.0)35 (41.7)0.311LVEF before CRT, median (IQR)27 (19-39)27 (20-32)0.795Beta-blockers, n (%)4 (100.0)78 (95.1)0.999Abstract Figure.

Clinical impact of transoesophageal echocardiography in acute brain ischaemia: who should we select?

Funding Acknowledgements

Type of funding sources: None.

Background

Stroke is a prevalent disease and is still the leading cause of death in Portugal. Transoesophageal echocardiography (TOE) is a sensitive test often performed to detect embolic sources. However, since its most common findings such as patent foramen ovale (PFO) and atheroma plaques do not necessarily mandate a change in treatment, there is still debate over its clinical impact in the context of brain ischaemia (BI) and which patients (pts) should be submitted to it. 

Purpose

To assess the clinical impact of TOE following BI and to identify clinical and diagnostic testing results that could help predict which pts benefit from it.

Methods

A retrospective study was conducted including all pts submitted to TOE in our hospital after acute BI in 2018 and 2019. Clinical and testing data (brain, vascular and cardiac imaging and 24h-Holter monitoring) was analysed and compared between 2 groups: the pts who had findings in TOE compatible with a source of embolism which resulted in a change in treatment ("relevant TOE" group) vs all other pts who had no such findings or whose findings did not result in change in treatment ("others"). Predictors of relevant TOE were also analysed.

Results

 Of the 87 pts (mean age of 57 and maximum of 83) included in the study, 51 (59%) had findings compatible with a potential source of embolism in TOE, PFO being the most common (n = 42). In only half of them did these findings result in a change in treatment (the relevant TOE group: n = 25; 29% of the overall population).

Age and other baseline characteristics did not significantly differ between groups. Pts with a relevant TOE presented more often with visual-field defects (32% vs 10%, p = 0.020) and were more likely to have visible acute lesions on brain imaging (96% vs 76%, p = 0.032) compared with the others. There was also a borderline significant association between the presence of infarct in the territory of the superior cerebellar artery and a relevant TOE (p = 0.054). On the contrary, the presence of significant lesions in extracranial arteries was negatively associated with a relevant TOE (p = 0.016).

Considering the whole population, there were no transthoracic echocardiography (TTE) predictors of a relevant TOE but when analysing only younger patients (age &lt; 50), the presence of any abnormality in TTE became associated with a relevant TOE (OR 8.5, CI 1.1-63.9; p = 0.044). We found no predictors of relevant TOE in 24h-Holter results.

Conclusions

TOE commonly identified potential sources of brain embolism, which proved relevant in half the cases. In the impossibility of submitting all BI patients to TOE, this study suggests that brain and vascular imaging rather than age or other baseline characteristics may be useful in predicting a relevant result. Moreover, TTE does not seem to be an adequate screening method to select patients for TOE, except possibly in younger patients. Studies with larger samples are needed to confirm these results.

Exercise end-tidal carbon dioxide pressure: a new prognostic marker after acute myocardial infarction?

Funding Acknowledgements

Type of funding sources: None.

Background

Although several cardiopulmonary exercise testing (CPET) parameters have already proved to predict prognosis, there is increasing interest in finding variables that do not require maximal effort. End-tidal carbon dioxide pressure (PETCO2), an indirect indicator of cardiac output, is one of such variables. Studies in heart failure populations already suggest its role as a prognostic factor. However, data concerning other populations are still scarce.

Purpose

To assess the association between exercise PETCO2, cardiac biomarkers and systolic function following acute myocardial infarction (AMI) and to evaluate its potential prognostic role in this population.

Methods

A retrospective single-centre analysis was conducted including patients who underwent symptom-limited CPET early after AMI. We assessed PETCO2 at baseline (PETCO2-B), at anaerobic threshold (PETCO2-AT) and at peak exercise and calculated the difference between PETCO2-AT and PETCO2-B (PETCO2-difference). We analysed their association with B-natriuretic peptide (BNP), maximal troponin after AMI as well as with left ventricular ejection fraction (LVEF) 1 year after.

Results

We included 40 patients with a mean age of 56 years (87.5% male), assessed with CPET a median of 3 months after AMI (80% of which were ST-elevation myocardial infarctions). Average respiratory exchange ratio was 1,1 with 48% of patients not reaching maximal effort. Mean PETCO2-AT was 37mmHg, with a mean increase from baseline of 6mmHg (PETCO2-difference). There was a significant positive correlation between all the PETCO2 variables measured and BNP values at time of AMI and on follow-up (best correlation for PETCO2-AT with BNP at AMI hospitalization, r = 0.608, p &lt; 0.001). Maximal troponin was not correlated with PETCO2. Both PETCO2-AT and PETCO2-difference were significantly and positively correlated with LVEF 1-year post-AMI (r = 0.421, p = 0.040 and r = 0.511, p = 0.011, respectively).

Conclusion

PETCO2-AT and PETCO2-difference are both correlated with BNP, an established prognostic marker, and with medium-term systolic function after AMI, suggesting their potential prognostic role in this population. Further studies with larger samples are required to confirm the results of this pilot study and assess PETCO2 as a definite predictor of prognosis after AMI.

Acute coronary syndrome in COVID-19 times: could it be business as usual?

Funding Acknowledgements

Type of funding sources: None.

Background

In an attempt to cope with the COVID-19 pandemic, several measures of social distancing and reorganization of health care systems have been adopted. In Portugal, these included suspending elective clinical activity and a temporary national lockdown. Data from multiple centres, including central hospitals in Portugal, has shown a reduction in hospital admissions for acute coronary syndrome (ACS) during the COVID-19 outbreak. Fear of going to the hospital and physical inactivity have been pointed as possible explanations.

Purpose

to assess the impact of this pandemic and the measures taken against it on the pattern of admissions and treatment of patients with ACS in a district hospital. 

Methods

A single-centre retrospective study was conducted in the Cardiology Department of a Portuguese district hospital, capable of performing 24h percutaneous coronary intervention. We analyzed the admissions for ACS during the peak of the first COVID-19 outbreak in Portugal (16th of March to 3rd of May 2020, coinciding with the suspension of elective activity) and compared it with two control periods: one immediately preceding the study period (27th of January to 15th of March - 2020 control) and one exactly one year before (16th of March to 3rd of May 2019 - 2019 control).

Results

During the 7 weeks of the first COVID-19 outbreak, 46 patients were hospitalized for ACS in our department, while 54 had been admitted during the 2020 control period and 40 in the 2019 control period, with a mean of 7 admissions/week (vs 8 and 6, respectively; p > 0.05). There were no significant differences between the study group and both controls regarding basal characteristics. Their presentation did not differ: the majority of patients (57%) was admitted for ST-elevation myocardial infarction and median time from symptom onset to admission to the emergency room was 3 hours, with 4% of patients presenting in Killip class ≥III (p > 0.05 for all). We also found no significant differences in the treatment administered nor in the outcomes (96% submitted to coronary angiography, median length of hospitalization of 4 days and in-hospital mortality rate of 2%, p > 0.05 for all). 

Conclusions

Our study suggests that the reduction in admissions for ACS during the COVID-19 outbreak is not universal. Additionally, severity at presentation, treatment administered and outcomes did not seem to differ. The relatively low prevalence of COVID-19 in our hospital"s region might be the cause, since people might fear and refrain less from going to the hospital. Larger studies with other centres in low-prevalence regions are needed to confirm this hypothesis.

How changing climate may influence air pollution control strategies for 2030?

Air pollution is a global threat leading to large impacts on human health and ecosystems. In Europe, air quality remains poor in many areas, despite reductions in emissions and ambient concentrations. Air pollution and climate change are the biggest environmental concerns for Europeans, implying concerted and integrated actions to tackle them. The revised 2016 European National Emission Ceilings Directive (NECD) enforces Member States to implement strategies, based on emission reduction measures, aimed to comply with targets by 2030 and achieve European Union (EU) and World Health Organization air quality objectives for environment and health protection. Despite those strategies are designed for 2030, the influence of climate change on air quality is not accounted for. In this sense, the purpose of this paper is the evaluation of the climate change impact on future air quality, taking into consideration emission reduction measures. The WRF-CAMx air quality modelling system was applied over Europe for one year selected as representative of a short-term changing climate (around 2030), and compared to a base case year, to estimate to what extent the climate variables by themselves could positively or negatively influence air quality. Results indicate that meteorological conditions may be decisive for the air quality state in the future. Differences between future and present simulations pointed to a global decrease of ozone levels in the future; increases and decreases in particulate matter and nitrogen dioxide concentrations over different seasons and European regions. This work is intended to contribute to a better understanding of the influence of climate variables on air quality improvement strategies as an additional support to European environmental authorities in developing the National Air Pollution Control Programmes in the scope of NECD.

Left atrial functional assessment and mortality in patients with severe aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe. Both symptoms and systolic dysfunction can appear late in the course of the disease, being often synonym of irreversible damage to the myocardium when found. Thus, there is a necessity to find other sensitive markers present at an earlier stage of the disease. 

Purpose

Our primary aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.

Methods

We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated all 3 left atrial (LA) functional phases (reservoir, conduit and pump) by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and own patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.

Results

After exclusion criteria, a total of 451 patients were included in the analysis (aged 74 ±11years, 54% male) and were followed during a median period of 73 months (interquartile range 44.5). A total of 55.8% of patients underwent AVR and 45,5% of patients registered the primary outcome. Left atrial emptying fraction (LAEF) was the best LA functional parameter in discriminating primary outcome (AUC 0.840, p &lt; 0.001), even when compared to left ventricular ejection fraction, aortic valve area, aortic mean pressure gradient and aortic Vmax. Patients in the lower tercile of LAEF were older, had greater comorbidities, had greater AS severity, with greater degree of diastolic disfunction. After adjustment for clinical and demographic variables, cumulative survival of patients with LAEF &lt;37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (adjusted HR 19.04, 95% CI 8.30-43.67, P &lt; 0.001 and adjusted HR 4.09, 95% CI 1.85-9.06, P = 0.001). Survival was also higher in patients with LAEF 37 to 53% when compared to patients with LAEF &lt;37% (adjusted HR 0.22, 95% CI 0.13-0.37, P &lt; 0.001). All associations remained true after adjustment for AVR (LAEF &lt;37% versus LAEF 37 to 53% and LAEF ≥54%, respectively, adjusted HR 3.97, 95% CI 1.80-8.78, P = 0.001 and adjusted HR 13.95, 95% CI 5.98-32.54, P &lt; 0.001, respectively)

Conclusion(s) In patients with a first diagnosis of severe AS in hospital setting, LA function assessed by volumetric parameters is an independent predictor of all-cause mortality. Compared to classical severity parameters, different LA functional parameters were found to be more potent predictors of death. These data can be useful in clinical practice for risk stratification and therefore for decision of timing for AVR.

Abstract Figure. Survival of patients stratified by group

Landscape-scaled strategies can outperform Lévy random searches

Information on the relevant global scales of the search space, even if partial, should conceivably enhance the performance of random searches. Here we show numerically and analytically that the paradigmatic uninformed optimal Lévy searches can be outperformed by informed multiple-scale random searches in one (1D) and two (2D) dimensions, even when the knowledge about the relevant landscape scales is incomplete. We show in the low-density nondestructive regime that the optimal efficiency of biexponential searches that incorporate all key scales of the 1D landscape of size L decays asymptotically as η_{opt}∼1/sqrt[L], overcoming the result η_{opt}∼1/(sqrt[L]lnL) of optimal Lévy searches. We further characterize the level of limited information the searcher can have on these scales. We obtain the phase diagram of bi- and triexponential searches in 1D and 2D. Remarkably, even for a certain degree of lack of information, partially informed searches can still outperform optimal Lévy searches. We discuss our results in connection with the foraging problem.