Impact of the ESC Cardio-Oncology Guidelines Biomarker Criteria on Incidence of Cancer Therapy-Related Cardiac Dysfunction

Background

The impact of recent consensus definitions of cancer therapy-related cardiac dysfunction (CTRCD) from the European Society of Cardiology cardio-oncology guidelines on the reported incidence of CTRCD has not yet been assessed.

Objectives

The aim of this study was to assess the: 1) cumulative incidence; 2) point prevalence during and after adjuvant therapy; and 3) prognostic value of CTRCD as defined by different asymptomatic CTRCD guideline criteria.

Methods

The cumulative incidence and point prevalence of CTRCD were retrospectively assessed in 118 patients participating in the PRADA (Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy) trial. Asymptomatic CTRCD was assessed using alternative cardiac troponin (cTn) 99th percentile upper reference limits (URLs) to define cTnT and cTnI elevation.

Results

The cumulative incidence of moderate or severe CTRCD was low (1.7%), whereas the cumulative incidence of mild asymptomatic CTRCD was higher and differed markedly according to the biomarker criteria applied, ranging from 49.2% of patients when cTnT greater than the sex-specific 99th percentile URL was used to define cTn elevation to 9.3% when sex-neutral cTnI was used. The point prevalence of CTRCD was highest at the end of anthracycline therapy (47.8%) and was driven primarily by asymptomatic cTn elevation. CTRCD during adjuvant therapy was not prognostic for CTRCD at extended follow-up of 24 months (Q1-Q3: 21-29 months) after randomization.

Conclusions

Mild asymptomatic CTRCD during adjuvant breast cancer therapy was frequent and driven mainly by cTn elevation and was not prognostic of subsequent CTRCD. The incidence of mild, asymptomatic CTRCD differed markedly depending on the cTn assay and whether sex-neutral or sex-dependent URLs were applied. (Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy [PRADA]; NCT01434134).

The Effects of Exercise Training in Patients With Persistent Dyspnea Following Pulmonary Embolism: A Randomized Controlled Trial

BACKGROUND

Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited.

RESEARCH QUESTION

Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea?

STUDY DESIGN AND METHODS

This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72 months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8 weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire).

RESULTS

A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95% CI, 17.7-88.3; P = .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95% CI, -0.09 to 0.00; P = .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention.

INTERPRETATION

In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03405480; URL: www.

CLINICALTRIALS

gov.

Demographic, clinical, and echocardiographic factors associated with residual perfusion defects beyond six months after pulmonary embolism

BACKGROUND

Residual perfusion defects (RPD) after pulmonary embolism (PE) are common.

PRIMARY AIM

This study aimed to determine the prevalence of RPD in a cohort diagnosed with PE 6-72 months earlier, and to determine demographic, clinical, and echocardiographic variables associated with RPD.

METHODS

Patients aged 18-75 years with prior PE, confirmed by computed tomography pulmonary angiography 6-72 months earlier, were included. Participants (N = 286) completed a diagnostic work-up consisting of transthoracic echocardiography and ventilation/perfusion scintigraphy. Demographic, clinical, and echocardiographic characteristics between participants with RPD and those without RPD were explored in univariate analyses using t-test or Mann-Whitney U test. Multiple logistic regression analysis was used to assess the association between selected variables and RPD.

RESULTS

RPD were detected in 72/286 patients (25.2 %, 95 % CI:20.5 %-30.5 %). Greater tricuspid annular plane systolic excursion (TAPSE) (adjusted odds ratio (aOR) 1.10, 95 % CI:1.00-1.21, p = 0.048) at echocardiographic follow-up, greater thrombotic burden at diagnosis, as assessed by mean bilateral proximal extension of the clot (MBPEC) score 3-4 (aOR 2.08, 95 % CI:1.06-4.06, p = 0.032), and unprovoked PE (aOR 2.25, 95 % CI:1.13-4.48, p = 0.021) were independently associated with increased risk of RPD, whereas increased pulmonary artery acceleration time was associated with a lower risk of RPD (aOR 0.72, 95 % CI:0.62-0.83, p < 0.001, per 10 ms). Dyspnoea was not associated with RPD.

CONCLUSION

RPD were common after PE. Reduced pulmonary artery acceleration time and greater TAPSE on echocardiography at follow-up, greater thrombotic burden at diagnosis, and unprovoked PE were associated with RPD.

Recurrent pericarditis

Pericarditis is an important differential diagnosis in patients with chest pain. The two most common causes in the developed world are idiopathic pericarditis and inflammation following cardiac surgery or myocardial infarction. Recurrence of pericarditis affects up to 30 % of patients, half of whom experience multiple episodes, and approximately 10 % develop steroid-dependent and colchicine-refractory pericarditis. Recurrence is due to autoinflammatory processes in the pericardium. Advanced diagnostic imaging and treatment with colchicine and interleukin-1 inhibitors has helped reduce morbidity considerably in recent years. In this clinical review, we summarise up-to-date knowledge about the diagnostic evaluation and treatment of patients with recurrent primary pericarditis.

Left atrial appendage strain predicts subclinical atrial fibrillation in embolic strokes of undetermined source

Aims

Left atrial (LA) strain is promising in prediction of clinical atrial fibrillation (AF) in stroke patients. However, prediction of subclinical AF is critical in patients with embolic strokes of undetermined source (ESUS). The aim of this prospective study was to investigate novel LA and left atrial appendage (LAA) strain markers in prediction of subclinical AF in ESUS patients.

Methods and results

A total of 185 patients with ESUS, mean age 68 ± 13years, 33% female, without diagnosed AF, were included. LAA and LA function by conventional echocardiographic parameters and reservoir strain (Sr), conduit strain (Scd), contraction strain (Sct), and mechanical dispersion (MD) of Sr were assessed with transoesophageal and transthoracic echocardiography. Subclinical AF was detected by insertable cardiac monitors during follow-up. LAA strain was impaired in 60 (32%) patients with subclinical AF compared to those with sinus rhythm: LAA-Sr, 19.2 ± 4.5% vs. 25.6 ± 6.5% (P < 0.001); LAA-Scd, -11.0 ± 3.1% vs. -14.4 ± 4.5% (P < 0.001); and LAA-Sct, -7.9 ± 4.0% vs. -11.2 ± 4% (P < 0.001), respectively, while LAA-MD was increased, 34 ± 24 ms vs. 26 ± 20 ms (P = 0.02). However, there was no significant difference in phasic LA strain or LA-MD. By ROC analyses, LAA-Sr was highly significant in prediction of subclinical AF and showed the best AUC of 0.80 (95% CI 0.73-0.87) with a sensitivity of 80% and a specificity of 73% (P < 0.001). LAA-Sr and LAA-MD were both independent and incremental markers of subclinical AF in ESUS patients.

Conclusion

LAA function by strain and mechanical dispersion predicted subclinical AF in ESUS patients. These novel echocardiographic markers may improve risk stratification in ESUS patients.

Prediction of incident atrial fibrillation with cardiac biomarkers and left atrial volumes

OBJECTIVE

Atrial fibrillation is a common arrhythmia associated with risk of stroke, heart failure and death. We aimed to elucidate the associations of cardiac biomarkers, echocardiographic left atrial volumetric indices and risk of prevalent and incident atrial fibrillation in the general population.

METHODS

We assessed cardiac troponin T (cTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15), maximum (LAVi_max) and minimum (LAVi_min) indexed left atrial volumes and left atrial emptying fraction (LAEF) in subjects born in 1950 participating in the prospective observational cohort, Akershus Cardiac Examination 1950 Study. The Cohorts for Heart and Ageing Research in Genomic Epidemiology for Atrial Fibrillation risk score and sex was used to adjust for residual risk of atrial fibrillation.

RESULTS

Out of 3487 subjects, 157 (4.5%) had prevalent and 123 (3.5%) had incident atrial fibrillation. Echocardiographic left atrial volumes and cardiac biomarkers associated with prevalent atrial fibrillation, but GDF-15 was non-significant in adjusted analysis. Incident atrial fibrillation was predicted by LAVi_max (adjusted HR 1.51, 95% CI 1.30 to 1.75), LAVi_min (adjusted HR 1.52, 95% CI 1.35 to 1.72), LAEF (adjusted HR 1.24, 95% CI 1.04 to 1.48) and NT-proBNP (adjusted HR 1.57, 95% CI 1.32 to 1.85). cTnT and NT-proBNP provided incremental prognostic information to left atrial volumes, but GDF-15 demonstrated no prognostic value for incident atrial fibrillation.

CONCLUSIONS

In the general population, echocardiographic left atrial volumetric indices and NT-proBNP, but not cTnT and GDF-15, associate with prevalent atrial fibrillation and with risk of incident atrial fibrillation. cTnT and NT-proBNP provide incremental prognostic information to echocardiography.

Serial blood pressure measurements, left ventricular remodelling and cardiovascular outcomes

BACKGROUND

Hypertension is a risk factor for the development of cardiovascular disease. Whether serial blood pressure (BP) measurements are more closely associated with subclinical left ventricular (LV) remodelling and better predict risk of cardiovascular events over individual BP measurements are not known.

METHODS

We assessed systolic BP, diastolic BP and pulse pressure at several time points during adulthood in 1333 women and 1211 men participating in the Akershus Cardiac Examination 1950 Study. We defined serial BP measurements as the sum of averaged BPs from adjacent consecutive visits indexed to total exposure time between measurements. We assessed the associations between serial and individual BP measurements and (1) LV structure, function and volumes and (2) incident myocardial infarction, ischemic stroke, heart failure and cardiovascular death.

RESULTS

All indices of higher serial BP measurements were associated with increased indexed LV mass, and the associations were stronger than those of individual BP measurements. Serial diastolic BP pressure was strongly and inversely associated with LV systolic function, while higher serial systolic BP was primarily associated with higher LV volumes. Both serial systolic (incidence rate ratio [IRR] 1.10, 95% CI 1.03 to 1.17) and diastolic BPs (IRR 1.14, 95% CI 1.02 to 1.27) were associated with increased incidence of clinical events.

CONCLUSION

In healthy community dwellers without established cardiovascular disease, different serial BP indices associate strongly with LV remodelling and cardiovascular outcomes. Whether the use of serial BP indices for guiding treatment is superior to individual measurements should be explored in additional prospective studies.

Prediction of anthracycline-induced cardiotoxicity as assessed by global longitudinal strain in women with early breast cancer: insights from the PRADA trial

Background

Early recognition of anthracycline-induced cardiotoxicity is essential to prevent and treat left ventricular dysfunction before permanent damage ensues. Echocardiographic global longitudinal strain (GLS) may be a more sensitive indicator of decline in left ventricular systolic function than measurement left ventricular ejection fraction (LVEF). Many factors have been associated with cardiotoxicity defined by LVEF criteria, but less is known about predictors of early and late cardiotoxicity expressed as GLS.

Objective

The purpose of this study was to identify factors associated with cardiotoxicity, defined as absolute GLS &lt;18% (a) after completion of anthracycline treatment and (b) at extended follow up after completion of adjuvant therapy for early breast cancer.

Methods

120 women with early breast cancer undergoing adjuvant treatment with anthracyclines and/or trastuzumab, were included in the PRADA (PRevention of cArdiac Dysfunction during Adjuvant breast cancer) trial and randomized in a 2x2 factorial fashion to concomitant treatment with candesartan cilexetil, metoprolol succinate or matching placebo. Serial measurements of cardiovascular biomarkers (high sensitivity cardiac troponin I (hs-cTnI), B-type natriuretic peptide (BNP) and Galectin-3), cardiovascular magnetic resonance and echocardiography were performed at baseline, after anthracycline treatment and at extended follow-up median 23 months (interquartile range 21–28 months) after initiation of adjuvant therapy for early breast cancer. To identify potential predictors of cardiotoxicity defined by GLS criteria, associations between demographic, clinical, cancer therapy and biochemical and imaging biomarker data were evaluated by logistic regression analysis.

Results

89 patients had GLS measurements performed at baseline, 87 at completed anthracycline therapy and 81 at extended follow-up. An overall decline in absolute GLS of 0.75% was observed at extended follow-up. One patient had absolute GLS &lt;18 prior to anthracycline therapy whereas, 7 out of 87 (8.0%) and 7 out of 81 (8.6%) patients had GLS levels &lt;18 after completion of anthracycline treatment and at extended follow up, respectively. Variables associated with absolute GLS &lt;18% after anthracycline treatment and at extended follow-up are summarized in Tables 1a and 1b.

Conclusion

In this subanalysis of the PRADA trial, higher age, higher hs-cTnI, lower LVEF, lower E' and higher GLS at baseline predicted subsequent reduced systolic function expressed as reduced absolute GLS after anthracycline treatment. Higher age, hypertension, higher body mass index and higher hs-cTnI concentrations predicted absolute GLS &lt;18 at extended follow up. Assessment of cardiac troponin I, cardiac imaging biomarkers and patient age may assist in the identification of patients at risk for developing cardiotoxicity.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by The South-Eastern Norway Regional Health Authority, The University of Oslo, The Extra Foundation for Health and Rehabilitation, The Norwegian Cancer Society, and Akershus University Hospital. Study medications and matching placebos were provided free of charge by AstraZeneca. Reagents for the analysis of high-sensitivity cardiac troponin I on the Architect platform were provided by Abbott Diagnostics.

Exercise-induced pulmonary hypertension assessed by echocardiography in patients with chronic thromboembolic pulmonary disease

Background

Many patients with chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension (PH) at rest suffer from exercise intolerance. Exercise echocardiography, which is a noninvasive examination, may have potential to discover exercise-induced PH in these patients, however, its role is scarcely explored in this population.

Purpose

To determine the occurrence of abnormal pulmonary pressure during rest and by exercise echocardiography in patients with CTEPD.

Methods

In total, 24 patients with CTEPD, all diagnosed after pulmonary embolism, underwent exercise echocardiography with dynamic supine leg exercise using a cycle ergometer. In addition, all participants underwent a modified incremental shuttle walk test (mISWT), pulmonary function tests and measurement of NT pro-BNP. Systolic pulmonary arterial pressure (sPAP) &gt;50 mmHg by echocardiography during exercise was chosen as cutoff to define exercise-induced pulmonary hypertension (EIPH). Left ventricular diastolic dysfunction during stress was defined according to the American Society of Cardiology guidelines from 2016. Mean pulmonary artery pressure was estimated by sPAP measurements using the Chemla formula (0.61 x sPAP + 2 mmHg), and pulmonary vascular resistance (PVR) by the Doppler method (5.19 x TRV2/TVI RVOT − 0.4) proposed by Abbas et al. [1]. Subjects with heart failure with reduced or preserved ejection fraction, significant valvular heart disease, chronic pulmonary disease and chronic thromboembolic pulmonary hypertension were excluded.

Results

11 (46%) of the patients had EIPH at peak exercise (range 50 to 89 mmHg). PVR at peak exercise ranged from 2.6 to 5.9 WU, whereas 10 had PVR &gt;3.0 WU. None had unmasked left ventricular diastolic dysfunction during exercise, resting tricuspid regurgitation peak velocity (TR V max) &gt;3.4m/s, or a high probability of PH at rest. Three patients had TR V max between 2.9 and 3.4m/s or intermediate probability of PH. All patients had normal biventricular systolic function at rest and during exercise (Table 2).

Conclusion

Patients with CTEPD had normal pulmonary pressures at rest. However, approximately half of the patients showed abnormal rise in pulmonary pressure during exercise, which may explain or contribute to the exercise intolerance in these patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Ostfold Hospital Trust

Exercise hemodynamics by echocardiography and right heart catheterization in patients with chronic thromboembolic pulmonary disease

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of pulmonary hypertension (PH). A subclinical form of PH is referred to as exercise-induced pulmonary hypertension (EIPH), and its prevalence in patients with chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension at rest is unknown.

Purpose

To explore the occurrence of exercise-induced pulmonary hypertension (PH) in patients with CTEPD and compare exercise echocardiography with right heart catheterization (RHC).

Methods

In total, 16 patients with CTEPD, all diagnosed after pulmonary embolism, underwent exercise echocardiography and exercise RHC with dynamic supine leg exercise using a cycle ergometer. CTEPH at rest was defined as mean pulmonary artery pressure (mPAP) &gt;20 mmHg and pulmonary vascular resistance (PVR) ≥3WU. EIPH by RHC was defined as mPAP &gt;30 mmHg with total pulmonary resistance (TPR) ≥3 WU. Based on these criteria, our patients with CTEPD are presented by a flow chart (Figure 1). Systolic pulmonary artery pressure by echocardiography was calculated by tricuspid regurgitation peak velocity (TR V max) and the Bernoulli formula: 4 × (TR V)2. The RHC examination followed the exercise echocardiography within 2 hours. Groups were compared with independent sample t-test.

Results

Four patients (25%) were diagnosed with EIPH by exercise RHC. Patients with EIPH had a mean mPAP at peak exercise of 40.5 mmHg (range 38 to 43mmHg) and TPR of 3.7 WU (range 3.0 to 4.3 WU). The same patients also had a higher TR V max at peak exercise during exercise echocardiography compared to the patients without EIPH (Table 2). None of the patients had signs of elevated left-sided filling pressure during exercise by RHC, and none had left ventricular diastolic dysfunction during exercise by echocardiography.

Conclusion

In total, 4 of 16 patients with CTEPD were diagnosed with EIPH. The same four patients also had abnormal pulmonary artery pressure rise during exercise echocardiography and invasive RHC. These findings suggest that exercise echocardiography may be useful for screening patients with CTEPD and suspected EIPH.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Ostfold Hospital Trust

Prediction of incident atrial fibrillation with GDF-15 and echocardiographic left atrial volumes: data from the Akershus cardiac examination 1950 study

Background

Left atrial structural remodeling is associated with the risk of incident atrial fibrillation, but there is uncertainty as to what echocardiographic left atrial indices that best predict incident atrial fibrillation. GDF-15 is a marker of oxidative stress and inflammation that is closely associated with the risk of stroke, bleeding and mortality in patients with atrial fibrillation. There is, however, limited data regarding its relation with left atrial remodeling and incident atrial fibrillation in the general population.

Purpose

To investigate the association between GDF-15 and left atrial volumes, and their prognostic properties for incident atrial fibrillation in a general population cohort.

Methods

The Akershus Cardiac Examination 1950 Study is a population-based cohort of individuals born in 1950. Comprehensive baseline examinations were performed for 3706 study participants in 2012–2015. Left atrial maximum and minimum volumes were measured, indexed to body surface area yielding LAVimax and LAVimin. Left atrial emptying fraction (LAEF) was calculated as ((LAVimax - LAVimin)/LAVimax)x100%. Individuals with known atrial fibrillation at baseline (n=166) were excluded, leaving 3540 included in this analysis. National health registries provided clinical outcome data regarding atrial fibrillation and death from any cause. Incident atrial fibrillation cases were validated by health records. Atrial flutter was included in the outcome definition. The CHARGE-AF risk score for atrial fibrillation was quantified. Prediction of incident atrial fibrillation was assessed by Cox proportional hazards regression models and visualised by Kaplan-Meier plots.

Results

Mean age at baseline was 63.9±0.7 years and 1763 (49.8%) were female. GDF-15 correlated weakly with LAVimax (r=−0.07, p&lt;0.001) and LAVimin (r=−0.05 p=0.007), but not with LAEF (r=−0.01, p=0.61). During a median follow-up of 6.4 years, incident atrial fibrillation occurred in 135 (3.8%) individuals. Subjects who developed atrial fibrillation had larger LAVimax (30.1±8.3 vs. 26.2±6.9 mL/m2; p&lt;0.001), larger LAVimin (17.1±7.1 vs. 14.1±4.7 mL/m2; p&lt;0.001), and lower LAEF (44.3±10.7 vs. 46.3±9.0%; p=0.019). Concentrations of GDF-15 were not significantly different in those who experienced atrial fibrillation (median 850 [670–1107] vs. 790 [630–1020] ng/L; p=0.06). Left atrial volumes and LAEF, but not GDF-15, were associated with incident atrial fibrillation (Table 1 and Figure 1).

Conclusions

In this population-based cohort study, LAVimax, LAVimin, and LAEF predicted incident atrial fibrillation independently of the CHARGE-AF risk score. GDF-15 was not significantly associated with left atrial structural remodeling or with increased risk of incident atrial fibrillation.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Vestre Viken HF, Hospital TrustAkershus University Hospital

Prediction of occult atrial fibrillation in patients after cryptogenic stroke and transient ischaemic attack: PROACTIA

AIMS

Studies with implantable cardiac monitors (ICMs) show that one-third of patients with cryptogenic stroke/transient ischaemic attack (TIA) have episodes of subclinical atrial fibrillation (SCAF) and benefit switching from antiplatelet- to anticoagulant therapy. However, ICMs are costly and resource demanding. We aimed to build a score based on participant's baseline characteristics that could assess individual risk of SCAF.

METHODS AND RESULTS

In a prospective study, 236 eligible patients with a final diagnosis of cryptogenic stroke/TIA had an ICM implantated during the index hospitalization. Pre-specified evaluated variables were: CHA2DS2-VASc, P-wave duration, P-wave morphology, premature atrial beats (PAC)/24 h, supraventricular tachycardia/24 h, left atrial end-systolic volume index (LAVI), Troponin-T, NT-proBNP, and D-dimer. SCAF was detected in 84 patients (36%). All pre-specified variables were significantly associated with SCAF detection in univariate analysis. P-wave duration, followed by PAC/24 h, NT-proBNP, and LAVI, had the largest ratio of SCAF prevalence between its upper and lower quartiles (3.3, vs. 3.2, vs. 3.1 vs. 2.8, respectively). However, in a multivariate analysis, only PAC/24t, P-wave duration, P-wave morphology, and LAVIs remained significant predictors and were included in the PROACTIA score. Subclinical atrial fibrillation prevalence was 75% in the highest vs. 10% in the lowest quartile of the PROACTIA score with a 10-fold higher number of patients with an atrial fibrillation burden >6 h in the highest vs. the lowest quartile.

CONCLUSION

The PROACTIA score can identify patients with cryptogenic stroke/TIA at risk of subsequent SCAF detection. The large difference in SCAF prevalence between groups may provide a basis for future tailored therapy.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registration: ClinicalTrials.gov; NCT02725944.

Impact of Blood Pressure in the Early 40s on Left Atrial Volumes in the Mid-60s: Data From the ACE 1950 Study

Background

Echocardiographic measures of left atrial volumes are powerful predictors of cardiovascular events and important for assessing diastolic dysfunction. Despite this, there is limited knowledge of factors influencing left atrial remodeling. In particular, the impact of blood pressure in those in their early 40s on left atrial volumes later in life has not been sufficiently elucidated.

Methods and Results

We linked data from individuals born in 1950 who participated in the Age 40 Program, and the ACE (Akershus Cardiac Examination) 1950 Study. We divided the study population into quartiles of systolic blood pressure in their early 40s and assessed the proportion of individuals with an enlarged left atrium in their mid‐60s. The associations between blood pressure and left atrial volumes were assessed in linear regression analyses. Of the 2591 individuals included in this study, 1302 (50.3%) were women, and the mean age in the Age 40 Program was 40.1±0.3 years. Systolic blood pressure was 128.1±13.6 mm Hg and diastolic blood pressure was 78.3±9.5 mm Hg. Mean age in the ACE 1950 Study was 64.0±0.6 years. The proportion of individuals with an enlarged left atrium increased across the quartiles of systolic blood pressure (P=0.001). Systolic blood pressure was independently associated with left atrial volumes; the end‐systolic volume was 0.09 mL (95% CI, 0.04–0.14 mL) larger per 1‐mm Hg higher systolic blood pressure.

Conclusions

Our findings suggest that increased blood pressure in those in their early 40s is relevant for left atrial remodeling later in life.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01555411.

Effects of sildenafil on symptoms and exercise capacity for heart failure with reduced ejection fraction and pulmonary hypertension (The SilHF study): A randomised placebo-controlled multicentre trial

Aims

Pulmonary hypertension (PHT) may complicate heart failure with reduced ejection fraction (HFrEF) and is associated with a substantial symptom burden and poor prognosis. Sildenafil, a phosphodiesterase‐5 (PDE‐5) inhibitor, might have beneficial effects on pulmonary haemodynamics, cardiac function and exercise capacity in HFrEF and PHT. The aim of this study was to determine the safety, tolerability, and efficacy of sildenafil in patients with HFrEF and indirect evidence of PHT.

Methods and results

The Sildenafil in Heart Failure (SilHF) trial was an investigator‐led, randomized, multinational trial in which patients with HFrEF and a pulmonary artery systolic pressure (PASP) ≥40 mmHg by echocardiography were randomly assigned in a 2:1 ratio to receive sildenafil (up to 40 mg three times/day) or placebo. The co‐primary endpoints were improvement in patient global assessment by visual analogue scale and in the 6‐min walk test at 24 weeks. The planned sample size was 210 participants but, due to problems with supplying sildenafil/placebo and recruitment, only 69 patients (11 women, median age 68 (interquartile range [IQR] 62–74) years, median left ventricular ejection fraction 29% (IQR 24–35), median PASP 45 (IQR 42–55) mmHg) were included. Compared to placebo, sildenafil did not improve symptoms, quality of life, PASP or walk test distance. Sildenafil was generally well tolerated, but those assigned to sildenafil had numerically more serious adverse events (33% vs. 21%).

Conclusion

Compared to placebo, sildenafil did not improve symptoms, quality of life or exercise capacity in patients with HFrEF and PHT.

Cardiovascular phenotype of long-term anabolic-androgenic steroid abusers compared with strength-trained athletes

Introduction

Abuse of anabolic‐androgenic steroids (AAS) has been linked to a variety of different cardiovascular (CV) side effects, but still the clinical effects of AAS abuse on CV risk are not clear. The aim of this study was to assess the CV phenotype of a large cohort of men with long‐term AAS use compared with strength‐trained athletes without AAS use.

Methods

Fifty one strength‐trained men with ≥3 years of AAS use was compared with twenty one strength‐trained competing athletes. We verified substance abuse and non‐abuse by blood and urine analyses. The participants underwent comprehensive CV evaluation including laboratory analyses, 12‐lead ECG with measurement of QT dispersion, exercise ECG, 24 h ECG with analyses of heart rate variability, signal averaged ECG, basic transthoracic echocardiography, and coronary computed tomography angiography (CCTA).

Results

Hemoglobin levels and hematocrit were higher among the AAS users compared with non‐users (16.8 vs. 15.0 g/dl, and 0.50% vs. 0.44%, respectively, both p < 0.01) and HDL cholesterol significantly lower (0.69 vs. 1.25 mmol/L, p < 0.01). Maximal exercise capacity was 270 and 280 W in the AAS and the non‐user group, respectively (p = 0.04). Echocardiography showed thicker intraventricular septum and left ventricular (LV) posterior wall among AAS users (p < 0.01 for both), while LV ejection fraction was lower (50 vs. 54%, p = 0.02). Seven AAS users (17%) had evidence of coronary artery disease on CCTA. There were no differences in ECG measures between the groups.

Conclusions

A divergent CV phenotype dominated by increased CV risk, accelerated coronary artery disease, and concentric myocardial hypertrophy was revealed among the AAS users.

Associations between cardiovascular risk factors, biomarkers, and left ventricular mechanical dispersion: insights from the ACE 1950 Study

Aims

Mechanical dispersion measures left ventricular contraction heterogeneity and is associated with the risk of sudden cardiac death. However, the associations between mechanical dispersion and cardiovascular risk factors in early mid-life, and established biomarkers of sub-clinical myocardial injury and dysfunction are not known. We aimed to examine this in the general population.

Methods and results

During 2012–15, we included 2527 Norwegian individuals from the general population born in 1950, with measurements of mechanical dispersion by 2D speckle tracking echocardiography and concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) available. Mechanical dispersion was calculated as the standard deviation of the contraction duration of 17 strain segments. We assessed the associations between mechanical dispersion, concentrations of hs-cTnT and NT-proBNP, and cardiovascular risk factors collected at a national health screening survey two decades earlier. At echocardiography baseline, median age was 64 (interquartile range 63.5–64.5) years, 49.8% were women, 59.1% had hypertension, and 5.9% reported established coronary artery disease. Median mechanical dispersion was 38.0 (29.5–47.0) ms, median hs-cTnT concentration 6 (4–8) ng/L, and the median NT-proBNP concentration 54 (34–93) ng/L. Mechanical dispersion was associated with both hs-cTnT and NT-proBNP concentrations in multivariable models adjusted for clinical and echocardiographic variables. High body mass index, serum triglyceride concentrations, and low resting heart rate at Age 40 were independently associated with increased mechanical dispersion two decades later.

Conclusion

Established risk factors at Age 40 are associated with mechanical dispersion two decades later, and mechanical dispersion is cross-sectionally associated with biomarkers of subclinical myocardial injury and dysfunction.

Left atrial appendage structure predicts thromboembolic risk in 185 patients with crytogenic stroke/TIA without history of AF

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Akerhus University Hospital Dept. of Cardiology

Background

Cryptogenic stroke/TIA (CS) is supposed to be associated with intracardiac thrombus formation and left atrial (LA) structure, in particular thrombus formation in left atrial appendage (LAA). However, there is little evidence if thromboembolic risk is associated with LAA morphology in patients with CS.

Purpose

We aimed to investigate, if different LAA morphology types may predict thromboembolic risk in patients with CS.

Methods

In this prospective study (mean follow-up 859 ± 226 days), 185 patients with CS (mean age 68 ±13 years, 33% female) without history of AF were included. All patients underwent complete transesophageal echocardiography in sinus rhythm after index CS (mean 5 ± 3days). Occurrence of LAA thrombus, sludge or spontaneous echo contrast (SEC) were defined as thromboembolic risk and LAA structure was evaluated by 2D and 3D transesophageal echocardiography. Multilobate LAA was defined as LAA with  &gt; 1 lobes.

Results

Of the 185 included patients, LAA type chicken wing was found in 79 (43%), type windsock in 64 (35%), type cactus in 35 (19%) and type cauliflower in 7 (4%). Thrombus formation occurred in 29/185 (16%), LAA sludge in 112/185 (61%), and LAA SEC in 74/185 (40%), which is increased compared to data in the general population. We found SEC in sludge in 65/112 (58%), SEC in thrombus in 18/29 (62%) and sludge in thrombus in 27/29 (93%). SEC and sludge were significantly associated with thrombus formation, (p &lt; 0.001 and p &lt; 0.01, respectively). Finally, thromboembolic risk occurred in 123 (67%) of all patients with CS. Moreover, LAA type chicken wing was significantly associated with thromboembolic risk (p &lt; 0.01), while all other LAA types were not. Multilobate LAA occurred in 115 (62%) of all patients and predicted thromboembolic risk vs. non-lobated LAA (p= 0.04). In a multivariate analysis LAA type chicken wing and multilobate LAA were independently predictors of thromboembolic risk, figure 1.

Conclusions

Patients with cryptogenic stroke/TIA without history of AF showed increased thromboembolic risk, and SEC and sludge were significantly associated with LAA thrombus formation. Only LAA type chicken wing and multilobate LAA predicted independently thromboembolic risk in this study. Abstract Figure.

Cardiovascular risk associated with long-term anabolic-androgenic steroid abuse: an observational study from Norway

Background

The use of anabolic-androgenic steroids (AAS) has become highly prevalent among recreational weightlifters. Numerous case reports have suggested an association between AAS use and a vast range of different cardiovascular diseases, including sudden cardiac death (SCD) and coronary artery disease (CAD). Few clinical studies have evaluated the risk of SCD and the prevalence of CAD in individuals with long-term AAS use.

Purpose

To evaluate the risk of ventricular arrhythmias and the prevalence of CAD among men with long-term AAS use.

Methods

Strength-trained men with at least three years of cumulative AAS use were recruited from recreational gyms. The control group consisted of strength-trained competing athletes who self-reported never using any performance enhancing drugs (non-users). AAS use was verified by sophisticated blood and urine analyses. Study participants went through a comprehensive cardiovascular evaluation including exercise ECG, 24 h ECG, heart rate variability (HRV) measures, signal averaged ECG (SAECG) and QT dispersion (QTd). Coronary computed tomography angiography (CCTA) was performed in AAS users. Not all participants had all tests.

Results

We included 51 AAS users and 21 non-users. Median age (25th-75th percentile) was 33 (29–37) years in the user group and 33 (29–42) years in the non-user group. Forty-eight (94%) of the users had been using AAS for five years or more. Characteristics are presented in the table. AAS users had significantly lower HDL values compared to non-users (p&lt;0.001). No signs of ischemia or arrhythmias were detected during exercise ECG, however maximal exercise capacity was lower than in the control group and also compared to age-standardized values. A considerable, but statistically non-significant reduction was seen in overall HRV estimated as the standard deviation of the RR intervals for normal sinus beats (SDNN) (p=0.05). No difference was seen regarding left ventricular late potentials or QTd (table). Eight (19%) of the forty-two AAS users undergoing CCTA had at least a mild degree of CAD, and four of them three-vessel disease.

Conclusion

No ECG-findings indicated an increased risk of ventricular arrhythmias among the long-term AAS users. However, their maximal exercise capacity was lower than in controls, and one fifth of the long-term AAS users had verified CAD on CT coronary angiography.

Funding Acknowledgement

Type of funding sources: None. Table 1

Left atrial appendage function by strain predicts subclinical atrial fibrillation in patients with cryptogenic stroke/TIA

Background

Left atrial (LA) function by strain has shown to be promising to predict clinical atrial fibrillation (AF) in patients with cryptogenic stroke/TIA. However, there is little knowledge, if this novel method may prospectively predict subclinical AF (SCAF) and moreover, if left atrial appendage (LAA) function by strain and mechanical dispersion may be more sensitive to improve prediction of SCAF.

Purpose

The aim of the present study was to investigate if LA and LAA function by strain could improve the prediction of SCAF in patients at risk.

Methods

In this prospective study (mean follow-up 859±226 days), 185 patients with cryptogenic stroke/TIA, mean age 68±13 years, 33% female and no history of clinical AF or SCAF, were included. All participants underwent 2D and 3D transesophageal and transthoracic echocardiography in sinus rhythm after index cryptogenic stroke/TIA (mean 5±3days). LAA and LA functions by phasic strain, including reservoir strain (Sr), conduit strain (Scd) and contraction strain (Sct) and mechanical dispersion of Sr were assessed. SCAF episodes were detected by cardiac monitoring during follow up (mean 257±273 days).

Results

LAA function by strain was decreased in those with SCAF (60/32% of all patients) compared to those without: Sr: 19.2±4.5% vs. 25.6±6.5% (p&lt;0.001), Scd: −11.0±3.1% vs. −14.4±4.5% (p&lt;0.001), Sct: −7.9±4.0% vs. −11.2±4% (p&lt;0.001), respectively, while mechanical dispersion by Sr strain was increased, 34±24ms vs. 26±20ms (p=0.02). However, LA function by strain and mechanical dispersion did not differ in patients with SCAF compared to patients without. By ROC analyses, LAA strain and mechanical dispersion were highly significant in prediction of SCAF. LAA reservoir strain showed the best AUC of 0.80 (95% CI 0.73–0.87) with a cut-off value of 22.2%, sensitivity of 80%, and specificity of 73%, p&lt;0.001. (Figure)

Conclusions

For the first time, we showed, that left atrial appendage function by strain and mechanical dispersion predicts SCAF, as opposed to left atrial function. Left atrial appendage function by strain may be useful in risk prediction in patients at considerable AF risk.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Akershus University Hospital, Oslo/Lørenskog, Norway

B-Type Natriuretic Peptide Is Associated with Indices of Left Ventricular Dysfunction in Healthy Subjects from the General Population: The Akershus Cardiac Examination 1950 Study

BACKGROUND

Concentrations of B-type natriuretic peptide (BNP) reflect myocardial distension and stress, and are associated with poor prognosis in patients with cardiovascular disease. Accordingly, we hypothesized that concentrations of BNP would be associated with indices of adverse left ventricular (LV) remodeling and early stages of LV systolic and diastolic dysfunction in healthy participants from the general population.

METHODS

We measured BNP in 1757 women and 1677 men free from known coronary heart disease participating in the prospective observational Akershus Cardiac Examination 1950 Study. All study participants underwent extensive cardiovascular phenotyping at baseline, including detailed echocardiography with assessment of indexed LV mass (LVMI), diastolic [tissue Doppler e', E/e' ratio, indexed left atrial volume (LAVI), maximal tricuspid regurgitation velocity (TRVmax), and E/A ratio], and systolic [global longitudinal strain (GLS) and LV ejection fraction (LVEF)] function.

RESULTS

Study participants with the highest BNP concentrations had higher GLS, LVMI, e', E/e' ratio, LAVI, TRVmax, and E/A ratio. In adjusted analyses, both GLS and LVEF exhibited significant nonlinear associations with BNP, with reduced LV systolic function observed in both the low and high concentration range of BNP.

CONCLUSIONS

In healthy participants recruited from the general population, concentrations of BNP exhibit nonlinear associations with LV systolic function, and both low and high concentrations are associated with reduced LV systolic function. This supports the notion that natriuretic peptides are beneficial and elicit cardioprotective effects, and may have important implications for the interpretation of BNP measurements in the general population.

Left ventricular mechanical dispersion in a general population: Data from the Akershus Cardiac Examination 1950 study

AIMS

Increased left ventricular mechanical dispersion by 2D speckle tracking echocardiography predicts ventricular arrhythmias in ischaemic heart disease and heart failure. However, little is known about mechanical dispersion in the general population. We aimed to study mechanical dispersion in the general population and in diseases associated with increased risk of cardiovascular disease.

METHODS AND RESULTS

The present cross-sectional study consists of 2529 subjects born in 1950 included in the Akershus Cardiac Examination (ACE) 1950 study. Global longitudinal strain (GLS) was assessed from 17 strain segments, and mechanical dispersion calculated as the standard deviation of contraction duration of all segments. The cohort was divided according to the median value of mechanical dispersion, and multivariable linear regression models were performed with mechanical dispersion as the dependent variable. The prevalence of coronary artery disease (CAD), hypertension, obesity, and diabetes (P < 0.01 for all) was significantly higher in subjects with supra-median mechanical dispersion. In a multivariable clinical model, CAD (B = 7.05), hypertension (B = 4.15; both P < 0.001), diabetes (B = 3.39), and obesity (B = 1.89; both P < 0.05) were independently associated with increasing mechanical dispersion. When echocardiographic indices were added to the multivariable model, CAD (B = 4.38; P < 0.01) and hypertension (B = 2.86; P < 0.001) remained significant in addition to peak early diastolic tissue velocity e' (B = -2.00), GLS (B = 1.68), and ejection fraction (B = 0.22; P < 0.001 for all).

CONCLUSION

In a general middle-aged population, prevalent CAD and hypertension were associated with increasing mechanical dispersion, possibly indicating elevated risk of fatal arrhythmias and sudden cardiac death. Albeit weaker, systolic and diastolic dysfunction, were also associated with increasing mechanical dispersion.

Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy (PRADA): Extended Follow-Up of a 2×2 Factorial, Randomized, Placebo-Controlled, Double-Blind Clinical Trial of Candesartan and Metoprolol

BACKGROUND

Adjuvant breast cancer therapy containing anthracyclines with or without anti-human epidermal growth factor receptor-2 antibodies and radiotherapy is associated with cancer treatment-related cardiac dysfunction. In the PRADA trial (Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy), concomitant treatment with the angiotensin receptor blocker candesartan attenuated the reduction in left ventricular ejection fraction (LVEF) in women receiving treatment for breast cancer, whereas the β-blocker metoprolol attenuated the increase in cardiac troponins. This study aimed to assess the long-term effects of candesartan and metoprolol or their combination to prevent a reduction in cardiac function and myocardial injury.

METHODS

In this 2×2 factorial, randomized, placebo-controlled, double-blind, single-center trial, patients with early breast cancer were assigned to concomitant treatment with candesartan cilexetil, metoprolol succinate, or matching placebos. Target doses were 32 and 100 mg, respectively. Study drugs were discontinued after adjuvant therapy. All 120 validly randomized patients were included in the intention-to-treat analysis. The primary outcome measure was change in LVEF assessed by cardiovascular magnetic resonance imaging from baseline to extended follow-up. Secondary outcome measures included changes in left ventricular volumes, echocardiographic peak global longitudinal strain, and circulating cardiac troponin concentrations.

RESULTS

A small decline in LVEF but no significant between-group differences were observed from baseline to extended follow-up, at a median of 23 months (interquartile range, 21 to 28 months) after randomization (candesartan, 1.7% [95% CI, 0.5 to 2.8]; no candesartan, 1.8% [95% CI, 0.6 to 3.0]; metoprolol, 1.6% [95% CI, 0.4 to 2.7]; no metoprolol, 1.9% [95% CI, 0.7 to 3.0]). Candesartan treatment during adjuvant therapy was associated with a significant reduction in left ventricular end-diastolic volume compared with the noncandesartan group (P=0.021) and attenuated decline in global longitudinal strain (P=0.046) at 2 years. No between-group differences in change in cardiac troponin I and T concentrations were observed.

CONCLUSIONS

Anthracycline-containing adjuvant therapy for early breast cancer was associated with a decline in LVEF during extended follow-up. Candesartan during adjuvant therapy did not prevent reduction in LVEF at 2 years, but was associated with modest reduction in left ventricular end-diastolic volume and preserved global longitudinal strain. These results suggest that a broadly administered cardioprotective approach may not be required in most patients with early breast cancer without preexisting cardiovascular disease. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01434134.

Diagnostic Thresholds for Pre-Diabetes Mellitus and Diabetes Mellitus and Subclinical Cardiac Disease in the General Population: Data From the ACE 1950 Study

Background Diabetes mellitus (DM) is associated with left ventricular remodeling and incident heart failure, but the association between glycated hemoglobin A1c (HbA1c) and subclinical cardiac disease is not established. We aimed to determine the associations between HbA1c and (1) echocardiographic measures of left ventricular structure and function, and (2) cardiovascular biomarkers: cardiac troponin T, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and CRP (C-reactive protein). Methods and Results Participants (n=3688) born in 1950 from the population-based ACE (Akershus Cardiac Examination) 1950 Study were classified as DM (HbA1c≥6.5% or self-reported DM), pre-DM (HbA1c 5.7%-6.5%), and no-DM (HbA1c<5.7%). DM, pre-DM, and no-DM were classified in 380 (10%), 1630 (44%), and 1678 (46%) participants, respectively. Mean age was 63.9±0.7 years, mean body mass index was 27.2±4.4 kg/m², and 49% were women. Higher HbA1c was associated with worse left ventricular systolic (ejection fraction and global longitudinal strain) and diastolic (E/e'-ratio) function, myocardial injury (cardiac troponin T), inflammation (CRP), and impaired neurohormonal homeostasis (NT-proBNP) (P<0.001 in unadjusted and P<0.01 in adjusted analysis for all). The associations between HbA1c and cardiovascular biomarkers were independent of the echocardiographic variables, and vice versa. Associations were nonlinear (P<0.05 for nonlinearity) and appeared stronger in the pre-DM range of HbA1c than the no-DM and DM range. Conclusions HbA1c was associated with indexes of subclinical cardiovascular disease, and this was more pronounced in pre-DM. Our results suggest that cardiovascular preventive measures should be considered also in subjects with hyperglycemia and HbA1c below the established DM cutoff. Registration clinicaltrials.gov. Identifier: NCT01555411.

Pulmonary and cardiac variables associated with persistent dyspnea after pulmonary embolism

INTRODUCTION

Persistent dyspnea is common in follow-up after pulmonary embolism (PE), but the underlying mechanisms are poorly understood.

MATERIAL AND METHODS

This cross-sectional study included subjects aged 18-75 years with confirmed PE by computed tomography pulmonary angiography (CTPA) 6-72 months earlier. A total of 180 participants underwent clinical examination, incremental shuttle walk test, laboratory tests, transthoracic echocardiography, pulmonary function tests and ventilation/perfusion scintigraphy. In further analysis, we divided participants into two groups; "dyspnea" or "no dyspnea", based on interview and questionnaires at inclusion. The association of cardiac and pulmonary variables with persistent dyspnea was assessed using multiple logistic regression analysis.

RESULTS

In total, 44% (95% CI: 39%-51%) of the participants reported persistent dyspnea after PE. Age (adjusted odds ratio (aOR) 0.93 per year, 95% CI: 0.90-0.97, P = 0.001), body mass index (BMI) (aOR 1.14 per kg/m², 95% CI: 1.04-1.25, P = 0.004), recurrent venous thromboembolism (VTE) (aOR 3.69, 95% CI: 1.45-9.38, P = 0.006) and diffusion capacity of the lung for carbon monoxide (DLCO) (aOR 0.95 per increase of 1%, 95% CI: 0.92-0.98, P = 0.001) were independently associated with persistent dyspnea.

CONCLUSIONS

Persistent dyspnea was prevalent after PE. Age, BMI and recurrent VTE were independently associated with dyspnea. Apart from reduced DLCO, no other cardiac or pulmonary variables were associated with persistent dyspnea.

Pulmonary rehabilitation to improve physical capacity, dyspnea, and quality of life following pulmonary embolism (the PeRehab study): study protocol for a two-center randomized controlled trial

BACKGROUND

Recently, a large group of patients with persistent dyspnea, poor physical capacity, and reduced health-related quality of life (HRQoL) following pulmonary embolism (PE) has been identified and clustered under the name "post pulmonary embolism syndrome" (PPS). These patients seem good candidates for pulmonary rehabilitation. The aim of the study is to explore whether a pulmonary rehabilitation program can improve physical capacity, dyspnea, and HRQoL in PPS patients.

METHODS

A two-center randomized controlled trial (RCT) is being performed at Østfold Hospital and Akershus University Hospital in Norway. Patients with PPS are 1:1 randomized into an intervention or a control group. The intervention consists of a supervised, outpatient rehabilitation program twice weekly (1 h) for 8 weeks provided by experienced physiotherapists. The intervention involves individually adapted exercises based on existing pulmonary rehabilitation programs (relaxation, interval, and resistance training), and an educational session including topics such as normal anatomy and physiology of the respiratory and circulatory system, information on PE/PPS, breathing strategies, and benefits of exercise/physical activity. Patients randomized to the control group receive usual care without specific instructions to exercise. Participants in the intervention and control groups will be compared based on assessments conducted at baseline, 12 weeks, and 36 weeks after inclusion using the incremental shuttle walk test (primary outcome) and endurance shuttle walk test (exercise capacity), Sensewear activity monitor (daily physical activity), the modified Medical Research Council scale, the Shortness of Breath Questionnaire (dyspnea), and EQ-5D-5L and the Pulmonary Embolism Quality of Life Questionnaire (HRQoL). Recruitment of 190 patients is currently ongoing.

DISCUSSION

Results from this study may provide a currently untreated group of PPS patients with an effective treatment resulting in reduced symptoms of dyspnea, improved exercise capacity, and better HRQoL following PE.

TRIAL REGISTRATION

Clinical Trials NCT03405480 . Registered prospectively on September 2017. Protocol version 1 (from original protocol September 2017). The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 1).

PRediction and detection of Occult Atrial fibrillation in patients after acute Cryptogenic stroke and Transient Ischemic Attack (PROACTIA)

Background

Studies with implantable cardiac rhythm monitors (ICRM) have shown that a 1/3 of patients with cryptogenic stroke/transitory ischemic attack (TIA) have episodes of subclinical atrial fibrillation (SCAF) as one of the potential risk factor for cerebral embolism. However, ICRM are costly and resource demanding.

Purpose

The PROACTIA study seeks to test a pre-specified scoring system to assess individual risk of SCAF in order to offer tailored therapy to patients after cryptogenic stroke/TIA.

Methods

Patients admitted with first time cryptogenic stroke or TIA were eligible for the study and underwent blood sampling, cerebral CT/MRI, carotid Doppler ultrasound, ECG, 24h-HolterECG, transthoracic transesophageal echocardiography, registration of medical history and implantation of ICRM during the index hospitalization

The scoring system was composed of variables that have previously been found associated with AF occurrence: CHA2DS2-VASc, P-wave duration (P-dur), premature atrial contractions (PAC)/24h, supraventricular runs (SVR)/24h, left atrial end-systolic volume index (LAVI), and the biomarkers TnT, NT-proBNP and D-dimer.

Data are presented as median (inter quartile range).

Results

Within 25 months, 434 patients screened and 251 patients were included in the present study and had an ICRM implanted. Eleven patients were later excluded yielding a study cohort of 176 patients with cerebral infarction and 61 with TIA that were followed for 833 (633–1028) days. AF was detected in 36%. It took 113 (25–336) days to detect AF, and 5 (2–14) days from AF-detection to initiation of NOAC. All variables were significantly increased in AF patients: no-AF vs AF: CHADS-VASC: 4 (3–5) vs 5 (4–6)*, LAVI mL/m2: 35 (28–40) vs 40 (35–50)**, PAC/24h: 69 (29–211) vs 347 (59–1917)**, SVR / 24-h: 1 (0–3) vs 3 (1–17)**, P-dur ms: 100 (100–120) vs 120 (100–120)**, D-dimer mg/L: 0,3 (0,2–0,6) vs 0,5 (0,3–0,9)**, TnT ng/L: 10 (7–16) vs 15 (9–27)**, NT-proBNP ng/L: 103 (49–283) vs 245 (102–774)**. *p&lt;0.01, **p&lt;0.001.

Multivariate analysis yielded the following model: −8.524 + 0.057*LAVI (p&lt;0.001) + 0.035*P-dur (p&lt;0.001) + 0.873*LogPAC/24h (p&lt;0.001). ROC analysis using leave-one-out cross validation: AUC=0.77. Applying the model to our population, it would identify a high-risk group (&gt;80% true positive) consisting of 17 true positive and 4 false positive, and a low-risk group (&lt;5% false negative) consisting of 17 true negative and 1 false negative.

Conclusions

ICRM detected SCAF in 36% of cryptogenic stroke/TIA patients within 27 months. LAVI, PAC/24h and P-duration were strong independent predictors of SCAF enabling a meaningful risk stratification that can be used for tailoring therapy in cryptogenic stroke/TIA patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Stiftelsen Dam

Biomarkers in patients with cryptogenic stroke/TIA and subclinical atrial fibrillation

Background

A large proportion of patients with cryptogenic stroke or transitory ischemic attack (TIA) have underlying subclinical atrial fibrillation (SCAF) detected on follow up. It is not clear whether SCAF is the underlying primary entity in the pathogenesis of stroke in these patients, or merely a marker of atrial myopathy associated with left atrial remodeling, fibrosis and inflammation.

Purpose

As a hypothesis generating study, we investigated a panel of selected biomarkers involved in fibrosis, inflammation, and thrombosis: growth differentiation factor 15 (GDF-15), transforming growth factor b (TGFb), galectin-3, soluble suppressor of tumorgenicity2 (sST2), von Willebrand factor (vWF), Tissue metalloprotease1 (TIMP1), Matrix metalloprotease9 (MMP9), Emmprin, Interleukin6 (IL6), C-reactive protein (CRP), Tissue factor (TF), Plasminogen activator inhibitor (PAI1), and their relation to the occurrence of SCAF during follow-up in patients after cryptogenic stroke or TIA. We hypothized that biomarker levels were increased in patients with subclinical AF.

Methods

236 patients, median age 71 years (range 21–94) of which 38% were women, with their first cryptogenic stroke or TIA were included 2–4 days after the index event and followed with an Implantable Cardiac Rhythm Monitor for &gt;1 year. Echocardiography and blood sampling were performed at inclusion. ELISA methods were used.

Results

SCAF occurred in 84 patients (36%). Only GDF-15 was significantly increased in AF- vs no-AF patients: 1010 pg/mL (inter quartile range: 814–1416) vs 860 pg/mL (inter quartile range: 622–1197) (p=0.018), and correlated with the number of premature atrial contractions (PAC)/24h (by Holter ECG during index hospitalization) (rs=0.314, p&lt;0.001) and AF-burden during follow-up (rs=0.149, p=0.022). Furthermore, there was a significant trend across quartiles of GDF-15 for having AF, and patients in the three highest quartiles (Q2–4) compared with Q1 had an odd ratio of having AF of 2.16 (95% CI 1.10–4.25), adjusted for sex and body mass index. The significance, however, was lost when adjusting for age, which correlated significantly to GDF-15 (rs=0.283; p&lt;0.001). ROC curve analyses showed an AUC of 0.593 (0.52–0.68) for GDF-15 compared to 0.617 (0.54–0.69) for age. GDF-15 was also associated with co-morbidities such as hypertension (p&lt;0.001), diabetes (p&lt;0.001), and vascular disease (p&lt;0.001).

Conclusion

In patients with a cryptogenic stroke or TIA experiencing SCAF during follow up, only levels of GDF-15 were elevated and correlated with PAC/24h and AF-burden. However, GDF-15 was highly related to age and co-morbidities and did not add significantly to the prediction of AF in a multivariate analysis.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Stiftelsen Dam, Norwegian Atrial Fibrillation Research Network

Markers of subclinical cardiac disease associate with thresholds for pre-diabetes and diabetes in the general population: data from the ACE 1950 Study

Background

Diabetes mellitus (DM) is associated with increased risk of left ventricular (LV) remodeling and incident heart failure. However, the associations between dysglycemia and subclinical cardiac disease in middle-aged subjects recruited from the general population are not established.

Purpose

To assess the associations of dysglycemia and diagnostic DM thresholds with indices of subclinical cardiac injury and dysfunction in the general population.

Methods

We included participants born in 1950 from the Akershus Cardiac Examination 1950 Study with available biomarker measurements (n=3,688). We used regression models and restricted cubic splines (knots selected from lowest Akaike Information Criterion) to assess the association between glycated hemoglobin A1c (HbA1c) and cardiac troponin T (cTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), C-reactive protein (CRP), and echocardiographic parameters. We classified participants with self-reported diagnosis of DM or HbA1c ≥6.5% (48 mmol/L) as DM, participants with HbA1c 5.7–6.5% as pre-DM, and participants with HbA1c &lt;5.7% (39 mmol/mol) as no-DM.

Results

Mean age was 63.9±0.7 years, mean body mass index (BMI) 27.2±4.4 kg/m2, and 1,795 participants (49%) were women. DM was classified in 380 participants (10%), pre-DM in 1,630 participants (44%) and no-DM in 1,678 participants (46%). Increasing HbA1c concentrations were associated with younger age, male sex, obesity, hypercholesterolemia, hypertension, and established coronary artery disease in adjusted analyses. In models adjusted for age, sex, BMI, smoking, hypertension, atrial fibrillation, coronary artery disease and renal function, greater HbA1c was associated with increasing logcTnT and logCRP concentrations, decreasing logNT-proBNP concentrations and worse global longitudinal strain and E/e' (p&lt;0.001 for all). LV mass index was not associated with HbA1c in adjusted models (p=0.23). All five associations were non-linear in the total study population (p&lt;0.001 for non-linearity for all) with robust, linear associations in the pre-DM range of HbA1c, also in adjusted models, and attenuated associations in the no-DM and DM range (Figure 1).

Conclusion

We found robust, linear associations between HbA1c and indices of subclinical cardiac injury and dysfunction among participants classified as pre-DM, while associations were more attenuated among participants with DM. Preventive measures for cardiovascular disease should be considered also in patients with dysglycemia and HbA1c below the established cutoff for DM.

Figure 1. P-values for overall trend

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Akserhus University Hospital

Cardiac Troponin I and T Are Associated with Left Ventricular Function and Structure: Data from the Akershus Cardiac Examination 1950 Study

Background

Concentrations of cardiac troponin I (cTnI) and T (cTnT) are associated with clinical cardiac outcomes, but do not correlate closely in subjects recruited from the general population. Accordingly, we hypothesized that cTnI and cTnT concentrations would be influenced by different cardiovascular (CV) and non-CV risk factors and reflect different CV phenotypes.

Methods

We measured cTnI and cTnT with last generation assays in 1236 women and 1157 men with no known CV disease participating in the prospective observational Akershus Cardiac Examination 1950 Study. All study participants underwent extensive CV phenotyping at baseline, including detailed echocardiography.

Results

Concentrations of cTnI were measurable in 60.3% and cTnT in 72.5% of study participants (P &lt; 0.001), and correlated moderately (r = 0.53; P &lt; 0.001). cTnI was more strongly associated with male sex (P = 0.018), higher education (P &lt; 0.001), history of hypertension (P &lt; 0.001), and age (P &lt; 0.001), whereas cTnT was more strongly associated with eGFR (P = 0.015). Both cTnI and cTnT were inversely associated with global longitudinal strain and positively associated with LV mass index (LVMI) in analyses adjusted for CV risk factors. The association between cTnI and LVMI was stronger than the association between cTnT and LVMI (P = 0.035). Concentrations of cTnI improved diagnostic accuracy for LV hypertrophy when added to established CV risk factors, but concentrations of cTnT did not improve these models further.

Conclusions

In a large community-based cohort examined with extensive echocardiography, concentrations of cTnI and cTnT are associated with subclinical LV hypertrophy and dysfunction. Concentrations of cTnI appear superior to cTnT in predicting subclinical LV hypertrophy.

Sex differences and higher upper normal limits for left atrial end-systolic volume in individuals in their mid-60s: data from the ACE 1950 Study

Aims

The current study aimed to describe normal values of left atrial (LA) volumes and LA emptying fraction (LAEF) in a large sample in their mid-60s from the general population and to explore sex differences.

Methods and results

In the Akershus Cardiac Examination (ACE) 1950 Study, body surface area-indexed LA maximum (LAVimax) and minimum (LAVimin) volumes and LAEF were measured in 3489 individuals aged 63.9 ± 0.6 years from the general population. A healthy group of 832 individuals was defined. Data are presented as mean ± standard deviation (SD) and a normal range of mean ± 2 SD. T-tests were used for comparisons. In the healthy group, mean LAVimax was 25.5 ± 6.2 mL/m2 and the normal range was 13.1–37.9 mL/m2. Men had significantly larger body surface area-indexed volumes than women, but there was no difference in LAEF. The mean LAVimax for healthy men was 26.4 ± 6.5 mL/m2, for healthy women 24.9 ± 5.8 mL/m2 (P &lt; 0.001) and the upper normal limits were 39.4 and 36.5 mL/m2, respectively. In the healthy group, 13.0% of all men and 5.4% of all women had LAVimax above the current upper normal limit of 34 mL/m2.

Conclusion

A large proportion of healthy individuals, in particular men, had LAVimax &gt;34 mL/m2. Our findings suggest that the recommended cut-off may be too low at the age of 65 years and above and that sex-specific cut-offs should be considered.

P958 Back to basis? Feasibility of standard and novel echocardiographic measurements after breast cancer surgery

Background

It is recommended that breast cancer patients should undergo cardiac follow-up during chemotherapy, with clinical assessment and echocardiogram. Standard measurements are robust and reproducible, but novel echocardiography methods as global longitudinal strain (GLS) and three-dimensional (3D) echocardiography are recommended due to their superior sensitivity. These methods require high-quality images. Breast cancer surgery may lead to reduced echocardiographic image quality in this population, in addition to age, obesity and smoking.

Purpose

We wanted to explore the feasibility of standard and novel echo methods in an unselected breast cancer population.

Methods

The present study included consecutive, unselected patients referred to baseline echocardiogram at the cardio oncology outpatient clinic in a large university hospital prior to start of adjuvant chemotherapy. Data on surgery, smoking habits, age and body mass index were collected. Feasibility was defined as the presence or absence to carry out meaningful measurements of left ventricular (LV) systolic function, from standard mitral annular plane systolic excursion (MAPSE) and two-dimensional LV ejection fraction (EF), to novel GLS and 3D LVEF. Multivariable logistic regression was performed to assess the impact of relevant variables on image quality.

Results

116 female patients were included. 21 % of these patients had insufficient images for novel analyses. Left sided breast implant (OR 5,77; P 0,04), age (OR 3,89; P 0,02) and daily smoking (OR 3,57; P 0,03) were found to be independently associated with insufficient image quality. Standard analyses like two-dimensional EF and MAPSE were obtainable in 99 and 97 % of the examinations, respectively.

Conclusion

One of five in a postoperative breast cancer population cannot undergo follow-up using novel, sensitive echocardiographic measurements. Standard measurements, however, are obtainable in almost all patients. It is therefore important that these measurements are included in cardiac follow-up during chemotherapy.

558 Prevalence of diastolic dysfunction according to EACVI/ASE guidelines from 2009 and 2016 in a 63-65 years old general population cohort-Data from the ACE 1950 study

Funding Acknowledgements

Akershus University Hospital and Vestre Viken Hospital Trust

OnBehalf

ACE 1950

Background

Large surveys have previously reported a prevalence of left ventricular diastolic dysfunction (DD) between 20- and 30 % in individuals above 60 years of age. The new DD guidelines from 2016, however, have emphasized the presence of increased left ventricular filling pressure, and may result in a stricter definition of DD.

Purpose

The aim of the present study was to compare the prevalence of DD using 2009 and 2016 EACVI/ASE criteria and to identify clinical correlates of DD.

Methods

The present cross-sectional substudy consisted of 3706 indivuduals born in 1950 included in the Akershus Cardiac Examination (ACE1950) 1950 study. Comprehensive baseline cardiovascular examination was performed, including ultrasound imaging utilizing echocardiographic indices for diagnosing DD according to both the 2009 and 2016 criteria.

Results

Complete echocardiographic data were available in 3464 (93.5%) individuals. Mean age was 63.9 ± 0.7 years, and 49% were women. 11% had diabetes mellitus and 23% were obese (BMI &gt;30). In the total cohort, 19.8% (685/3464) fulfilled the 2009 criteria for diastolic dysfunction. Of these, 7.9% (n = 273) had grade 1; 8.7% (n = 303) grade 2 and 3.1% (n = 109) grade 3 diastolic dysfunction. Only 2.0% (71/3464) of the total cohort were classified with DD according to the 2016 criteria. In individuals with known diabetes the prevalence of DD was 22% and in obese this number was 28.9% using the 2009 criteria.

Conclusions

Diastolic dysfunction is present in 1 in 5 of 63-65 years old norwegians, and higher in the obese and those with diabetes, according to the 2009 criteria. However, the prevalence was dramatically lower by applying the 2016 criteria. LV filling pressure can be looked upon as dynamic and be normalized by unloading, and therefore possibly mask DD in some individuals.

P1270 Systolic blood pressure at age 40 is associated with left atrial volumes at age 64

Funding Acknowledgements

Vestre Viken Hospital Trust

Background

Left atrial (LA) enlargement is associated with elevated blood pressure (BP) and with cardiovascular morbidity and mortality. In the assessment of LA size, echocardiographic guidelines recommend the use of LA end-systolic volume (LAVmax). LA end-diastolic volume (LAVmin) and LA emptying fraction (LAEF) may add valuable information in risk assessment. The knowledge of early adulthood BP and its association to LA volumes and LAEF later in life is limited.

Purpose

To explore the association between systolic BP at age 40 and LA volumes and LAEF at age 64.

Methods

We linked data from subjects who had participated in both a nationwide cardiovascular screening survey (1990-1991) at the age of 40, and the Akershus Cardiac Examination (ACE) 1950 Study (2012-2015) at the age of 64 (n = 2,597). In the ACE 1950 Study, LAVmax and LAVmin were measured with echocardiography according to the summation of discs method. LAEF was calculated as (LAVmax-LAVmin/LAVmax)x100%. The association between systolic BP at age 40 and LA volumes and LAEF at age 64 was assessed in univariate and multivariate linear regression analyses.

Results

Systolic BP at age 40 was associated with LAVmax and LAVmin but not with LAEF at age 64. In our multivariate model, a 10 mm Hg higher systolic BP at age 40 was associated with a 0.9 ml greater LA end-systolic volume and a 0.5 ml greater LA end-diastolic volume at age 64.

Conclusion

Early adulthood systolic BP is associated with LA volumes 24 years later in life.

Table. Association of systolic blood pressure at age 40 to left atrial (LA) volumes and LAEF at age 64 Univariate Multivariate* Dependent variable B (95% CI) p-value B (95% CI) p-value LAVmax (ml) 2.4 (2.0, 2.9) &lt;0.001 0.9 (0.4, 1.4) 0.001 LAVmin (ml) 1.5 (1.1, 1.8) &lt;0.001 0.5 (0.1, 0.9) 0.015 LAEF (%) -0.01 (-0.3, 0.3) 0.938 0.2 (-0.2, 0.5) 0.294 *Adjusted for gender, body mass index, smoking, resting heart rate and antihypertensive treatment, all assessed at age 40. B (95% CI), regression coefficient for systolic blood pressure (per 10 mm Hg) with 95% confidence interval; LAVmax, LA end-systolic volume; LAVmin LA end-diastolic volume; LAEF, LA emptying fraction

103 Normal values and gender differences of left atrial volumes

Funding Acknowledgements

Vestre Viken Hospital Trust

Background

Left atrial (LA) enlargement is associated with cardiovascular morbidity and mortality. Echocardiographic guidelines recommend body surface area (BSA) indexed LA end-systolic volume (LAVimax) in the assessment of LA size with an upper normal limit of 34 ml/m² for both genders and all age groups. LA end-diastolic volume (LAVimin) and LA emptying fraction (LAEF) may add valuable information in risk assessment, but there are limited data on normal values.

Purpose

To add knowledge and explore gender differences of LA volumetric measures.

Methods

In The Akershus Cardiac Examination 1950 Study, all inhabitants of Akershus County, Norway, born in 1950 were invited. In 3,489 individuals LAVmax and LAVmin were measured with echocardiography according to the summation of discs method and indexed to BSA. LAEF was calculated. A healthy group was defined by excluding those with heart failure, atrial fibrillation, coronary artery disease, stroke, hypertension, diabetes, chronic obstructive pulmonary disease, body mass index &gt; 30kg/m², eGFR &lt; 60 ml/min/1.73 m², left ventricular ejection fraction &lt; 50%, E/e’&gt;14 and E/A &gt; 2.0. Data are presented as mean ± standard deviation (SD) and a normal range of mean ± 2SD. T-tests were used for comparisons.

Results

In 840 healthy individuals, aged 63.8 ± 0.6 years, mean LAVimax was 25.6 ± 6.3 ml/m² and the normal range was 13.0-38.2 ml/m². Men had significantly larger volumes than women.

Conclusion

We present LA volumes and LAEF in a large cohort from the general population at age 64. The upper normal limit of LAVimax in 840 healthy individuals was 38 ml/m². Men had larger LA volumes than women, contrary to most previous studies. Thus, 13% of the healthy men in our cohort would be defined with an enlarged atrium with the current cut-off value at 34 ml/m².

Table. Left atrial (LA) volumes and LAEF Total (mean ± SD) Total (2SD range) Male (mean ± SD) Female (mean ± SD) P-value (male vs. female) All participants (n = 3489) LAVimax (ml/m&sup2;) 26.8 ± 7.6 11.6-42.0 27.9 ± 8.1 25.6 ± 6.8 &lt;0.001 LAVimin (ml/m&sup2;) 14.7 ± 5.8 3.1-26.3 15.5 ± 6.5 13.9 ± 4.9 &lt;0.001 LAEF (%) 45.6 ± 9.7 26.2-65.0 45.3 ± 10.2 45.9 ± 9.2 0.07 Healthy group (n = 840) LAVimax (ml/m&sup2;) 25.6 ± 6.3 13.0-38.2 26.6 ± 6.7 24.9 ± 5.8 &lt;0.001 LAVimin (ml/m&sup2;) 13.7 ± 4.3 5.1-22.3 14.1 ± 4.6 13.3 ± 3.9 0.008 LAEF (%) 46.8 ± 8.8 29.2-64.4 47.0 ± 9.1 46.5 ± 8.4 0.37 LAVimax, LA end-systolic volume, body surface area (BSA)-indexed; LAVimin, LA end-diastolic volume, BSA-indexed; LAEF, LA emptying fraction; SD, standard deviation

P3433Growth differentiation factor 15 predicts subclinical left ventricular dysfunction: Data from the Akershus Cardiac Examination 1950 Study

Background

Growth differentiation factor 15 (GDF-15) is upregulated in response to both acute and chronic cardiac injury, and concentrations of GDF-15 are increased in acute myocardial infarction and acute heart failure. Associations between GDF-15, left ventricular structure and preclinical stages of left ventricular dysfunction in the general population remain unclear.

Methods

We measured GDF-15 in 1237 women and 1158 men participating in the prospective observational Akershus Cardiac Examination (ACE) 1950 Study, which included community dwellers aged 63–65 residing in Akershus county, Norway. All study participants were free from known coronary heart disease and underwent extensive cardiovascular phenotyping at baseline, including detailed echocardiography. Regression models were constructed on global longitudinal strain (GLS), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF), and adjusted for demographics, established cardiovascular risk factors, hs-cTnT and NT-proBNP.

Results

Concentrations of GDF-15 were measurable in 98.1% of study participants, and were positively associated with male sex, age, BMI, current smoking, diabetes mellitus, as well as concentrations C-reactive protein, hs-cTnT and NT-proBNP. Higher education, alcohol consumption, eGFR and concentrations of total cholesterol were all associated with lower concentrations of GDF-15. Concentrations of lnGDF-15 were significantly associated with GLS (B −0.44 [95% CI −0.70 to −0.18]; Figure) and LVEF (B 0.72 [95% CI 0.14–1.29]), but not LVMI (Table).

Table 1. Associations between GDF-15 and indices of left ventricular structure and function. Model 1 Model 2 Model 3 B (95% CI)   GLS (n=2395) 0.17 (−0.07 to 0.42) −0.04 (−0.28 to 0.20) −0.44 (−0.70 to −0.18)   LVEF (n=2383) 0.01 (−0.52 to 0.54) 0.21 (−0.31 to 0.73) 0.72 (0.14 to 1.29)   LVMI (n=2371) 2.00 (0.32 to 3.68) −0.37 (−1.98 to 1.24) −0.42 (−2.16 to 1.33) OR (95% CI)   GLS (n=2395) 1.35 (0.98 to 1.87) 1.28 (0.92 to 1.78) 0.81 (0.56 to 1.17)   LVEF (n=2383) 1.04 (0.75 to 1.44) 0.88 (0.62 to 1.24) 0.73 (0.50 to 1.07)   LVMI (n=2371) 1.27 (0.91 to 1.76) 1.12 (0.79 to 1.57) 1.11 (0.75 to 1.64) Linear regression models constructed on continuous levels of GLS, LVMI and LVEF. Logistic regression models constructed on the upper sex specific deciles of GLS and LVMI, and on the lower sex specific decile of LVEF. GDF-15, hs-cTnT and NT-proBNP were all transformed by the natural logarithm. Model 1, unadjusted. Model 2, adjusted for sex, age and study site. Model 3, adjusted for sex, age, study site, BMI, eGFR, total and HDL cholesterol, CRP, higher education, hypertension, diabetes mellitus, statin use, current smoking, alcohol consumption, hs-cTnT and NT-proBNP.

Figure 1

Conclusion

Concentrations of GDF-15 are inversely associated with GLS, a highly sensitive index of subclinical myocardial dysfunction. In healthy subjects free from known cardiovascular disease, GDF-15 appears protective and promotes beneficial cardiac function.

P2766Increased right ventricular burden in patients with chronic thromboembolic disease

Introduction

Patients with chronic thromboembolic disease (CTED) have residual perfusion defects after pulmonary embolism (PE) but not increased pulmonary artery (PA) pressure. These patients suffer from functional limitation and have a higher risk of venous thromboembolism recurrence.

Purpose

In this study we wanted to explore if CTED patients had signs of increased PA pressure and right heart burden by echocardiography

Methods

Inclusion criteria were history of PE, age 18–75 years and PE diagnosed 6–72 months prior to inclusion. Patients with left ventricular systolic or diastolic heart failure, valvular disease, chronic pulmonary disease and chronic thromboembolic pulmonary hypertension were excluded. All patients underwent echocardiography with standard and novel methods and ventilation/perfusion (VQ)-scan. The echocardiographic examinations were blinded to the result of the VQ-scan. VQ-scan were analyzed according to the European Association of Nuclear Medicine-criteria, and deemed either positive or negative. Data are presented as mean ± SD or median ± IQR as appropriate. Independent sample t-test or Mann-Whitney U test was used for the primary statistical analysis. Multiple linear regression was used to adjust for age, BMI and systolic blood pressure.

Results

Conclusion

Patients with CTED after PE have increased PA pressure and impaired RV systolic and diastolic function compared to those without residual perfusion defects. These findings indicate that CTED patients should be more thoroughly followed up.

Effect of candesartan and metoprolol on myocardial tissue composition during anthracycline treatment: the PRADA trial

Aims

Anthracycline treatment may cause myocyte loss and expansion of the myocardial extracellular volume (ECV) fraction by oedema and fibrosis. We tested the hypotheses that adjuvant treatment for early breast cancer with the anthracycline epirubicin is dose dependently associated with increased ECV fraction and total ECV, as well as reduced total myocardial cellular volume, and that these changes could be prevented by concomitant angiotensin or beta-adrenergic blockade.

Methods and results

PRevention of cArdiac Dysfunction during Adjuvant breast cancer therapy (PRADA) was a 2 × 2 factorial, placebo-controlled, double-blinded trial of candesartan and metoprolol. Sixty-nine women had valid ECV measurements. ECV fraction, total ECV, and total cellular volume were measured by cardiovascular magnetic resonance before and at the completion of anthracycline therapy. ECV fraction increased from 27.5 ± 2.7% to 28.6 ± 2.9% (P = 0.002). A cumulative doxorubicin equivalent dose of 268 mg/m2 was associated with greater increase in ECV fraction than doses <268 mg/m2 (mean change 3.4% [95% confidence interval (CI) 1.2, 5.5] vs. 0.7% [95% CI 0.0, 1.5], P = 0.006), as well as greater increase in total ECV (1.9 mL [95% CI 0.4, 3.5] vs. 0.1 mL [95% CI -0.6, 0.8], P = 0.04). In patients receiving candesartan, total cellular volume decreased (-3.5 mL [95% CI - 4.7, -2.2], P < 0.001) while in patients not receiving candesartan, it remained unchanged (P = 0.45; between group difference P = 0.003).

Conclusions

Anthracycline therapy is associated with dose-dependent increase in ECV fraction and total ECV. Concomitant treatment with candesartan reduces left ventricular total cellular volume.

Exercise capacity in COPD patients with exercise-induced pulmonary hypertension

Background

Pulmonary hypertension (PH) in patients with COPD is associated with reduced exercise capacity. A subgroup of COPD patients has normal mean pulmonary artery pressure (mPAP) at rest, but develops high mPAP relative to cardiac output (CO) during exercise, a condition we refer to as exercise-induced pulmonary hypertension (EIPH). We hypothesized that COPD patients with EIPH could be identified by cardiopulmonary exercise test (CPET) and that these patients have lower exercise capacity and more abnormal CPET parameters compared to COPD patients with normal hemodynamic exercise response.

Methods

Ninety-three stable outpatients with COPD underwent right heart catheterization with the measurement of mPAP, CO, and capillary wedge pressure at rest and during supine exercise. Resting mPAP <25 mmHg with ΔmPAP/ΔCO slope above or below 3 mmHg/L/min were defined as COPD-EIPH and COPD-normal, respectively. Pulmonary function tests and CPET with arterial blood gases were performed. Linear mixed models were fitted to estimate differences between the groups with adjustment for gender, age, and airflow obstruction.

Results

EIPH was observed in 45% of the study population. Maximal workload was lower in COPD-EIPH compared to COPD-normal, whereas other CPET measurements at peak exercise in % predicted values were similar between the two groups. After adjustment for gender, age, and airflow obstruction, patients with COPD-EIPH showed significantly greater increase in oxygen uptake, ventilation, respiratory frequency, heart rate, and lactate with increasing work load, as well as more reduction in pH compared to those with normal hemodynamic responses.

Conclusion

COPD-EIPH could not be discriminated from COPD-normal by CPET. However, COPD-EIPH experienced a higher cost of exercise in terms of higher oxygen uptake, ventilation, respiratory frequency, heart rate, and lactate for a given increase in workload compared to COPD-normal.

Prevalence of atrial fibrillation and cardiovascular risk factors in a 63-65 years old general population cohort: the Akershus Cardiac Examination (ACE) 1950 Study

OBJECTIVES

To investigate the sex-specific prevalence of atrial fibrillation (AF), including subclinical AF found by screening in a general population aged 63-65 years. The prevalence of cardiovascular risk factors and their association with AF will also be investigated.

DESIGN

Cross-sectional analysis of an observational, prospective, longitudinal, population-based cohort study.

SETTING

General population in Akershus county, Norway.

PARTICIPANTS

Women and men born in 1950. We included 3706 of 5827 eligible individuals (63.6%); 48.8% were women.

METHODS

All participants underwent extensive cardiovascular examinations, including 12-lead ECG. History of AF and other cardiovascular diseases were self-reported. Subsequent validation of all reported or detected AF diagnoses was performed.

RESULTS

Mean age was 63.9±0.7 years. Prevalence of ECG-verified AF was 4.5% (women 2.4%, men 6.4%; p<0.001), including screen-detected AF in 0.3% (women 0.1%, men 0.6%; p<0.01). Hypertension was found in 62.0% (women 57.8%, men 66.0%; p<0.001). Overweight or obesity was found in 67.6% (women 59.8%, men 74.9%; p<0.001). By multivariate logistic regression, risk factors associated with AF were height (OR 1.67 per 10 cm; 95% CI 1.26 to 2.22; p<0.001), weight (OR 1.15 per 10 kg; 95% CI 1.01 to 1.30; p=0.03), hypertension (OR 2.49; 95% CI 1.61 to 3.86; p<0.001), heart failure (OR 3.51; 95% CI 1.71 to 7.24; p=0.001), reduced estimated glomerular filtration rate (OR 2.56; 95% CI 1.42 to 4.60; p<0.01) and at least one first-degree relative with AF (OR 2.32; 95% CI 1.63 to 3.31; p<0.001), whereas male sex was not significantly associated (OR 1.00; 95% CI 0.59 to 1.68; p=0.99).

CONCLUSION

In this cohort from the general population aged 63-65 years, we found a higher prevalence of known AF than previously reported below the age of 65 years. The additional yield of single time point screening for AF was low. Body size and comorbidity may explain most of the sex difference in AF prevalence at this age.

TRIAL REGISTRATION NUMBER

NCT01555411; Results.

Cardiopulmonary exercise test and PaO2 in evaluation of pulmonary hypertension in COPD

Background

Exercise tolerance decreases as COPD progresses. Pulmonary hypertension (PH) is common in COPD and may reduce performance further. COPD patients with and without PH could potentially be identified by cardiopulmonary exercise test (CPET). However, results from previous studies are diverging, and a unified conclusion is missing. We hypothesized that CPET combined with arterial blood gases is useful to discriminate between COPD outpatients with and without PH.

Methods

In total, 93 COPD patients were prospectively included. Pulmonary function tests, right heart catheterization, and CPET with blood gases were performed. The patients were divided, by mean pulmonary artery pressure, into COPD-noPH (<25 mmHg) and COPD-PH (≥25 mmHg) groups. Linear mixed models (LMMs) were fitted to estimate differences when repeated measurements during the course of exercise were considered and adjusted for gender, age, and airway obstruction.

Results

Ventilatory and/or hypoxemic limitation was the dominant cause of exercise termination. In LMM analyses, significant differences between COPD-noPH and COPD-PH were observed for PaO₂, SaO₂, PaCO₂, ventilation, respiratory frequency, and heart rate. PaO₂ <61 mmHg (8.1 kPa) during unloaded pedaling, the only load level achieved by all the patients, predicted PH with a sensitivity of 86% and a specificity of 78%.

Conclusion

During CPET, low exercise performance and PaO₂ strongly indicated PH in COPD patients.

Neurohormonal Blockade and Circulating Cardiovascular Biomarkers During Anthracycline Therapy in Breast Cancer Patients: Results From the PRADA (Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy) Study

BACKGROUND

Anthracyclines are associated with cardiotoxic effects. Cardiovascular biomarkers may reflect myocardial injury, dysfunction, inflammation, and fibrosis and may precede and predict the development of left ventricular impairment. The aim of this study was to assess: (1) longitudinal change in circulating cardiovascular biomarkers, (2) the effect of metoprolol succinate and candesartan cilexetil on the biomarker response, and (3) the associations between on-treatment changes in biomarker concentrations and subsequent left ventricular dysfunction in patients with early breast cancer receiving anthracyclines.

METHODS AND RESULTS

This report encompasses 121 women included in the 2×2 factorial, placebo-controlled, double-blind PRADA (Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy) trial with metoprolol and candesartan given concomitantly with anticancer therapy containing the anthracycline, epirubicin (total cumulative dose, 240-400 mg/m²). Cardiovascular magnetic resonance, echocardiography images, and circulating levels of biomarkers were obtained before and after anthracycline treatment. Cardiac troponins I and T, B-type natriuretic peptide, N-terminal pro-B-type natriuretic peptide, C-reactive protein, and galectin-3 increased during anthracycline therapy (all P<0.05). The troponin response was attenuated by metoprolol (P<0.05), but not candesartan. There was no association between change in biomarker concentrations and change in cardiac function during anthracycline therapy.

CONCLUSIONS

Treatment with contemporary anthracycline doses for early breast cancer is associated with increase in circulating cardiovascular biomarkers. This increase is, however, not associated with early decline in ventricular function. Beta-blockade may attenuate early myocardial injury, but whether this attenuation translates into reduced risk of developing ventricular dysfunction in the long term remains unclear.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrial.gov. Unique identifier: NCT01434134.

Long-term peritoneal port-catheter in a patient with cardiac ascites

A peritoneal port-catheter was inserted in a 70-year-old man because of repeated paracentesis due to cardiac ascites. Instead of frequent hospital admissions, the patient could drain his ascites at home, which dramatically improved his quality of life and enabled him to perform his daily activities.

Left ventricular biomechanics in professional football players

Chronic exercise induces adaptive changes of left ventricular (LV) ejection and filling capacities which may be detected by novel speckle-tracking echocardiography (STE) and tissue Doppler imaging (TDI)-based techniques. A total of 103 consecutive male elite Norwegian soccer players and 46 age-matched healthy controls underwent echocardiography at rest. STE was used to assess LV torsional mechanics and LV systolic longitudinal strain (LS). Diastolic function was evaluated by trans-mitral blood flow, mitral annular velocities by TDI, and LV inflow propagation velocity by color M-mode. Despite similar global LS, players displayed lower basal wall and higher apical wall LS values vs controls, resulting in an incremental base-to-apex gradient of LS. Color M-mode and TDI-derived data were similar in both groups. Peak systolic twist rate (TWR) was significantly lower in players (86.4±2.8 vs controls 101.9±5.2 deg/s, P<.01). Diastolic untwisting rate (UTWR) was higher in players (-124.5±4.2 vs -106.9±6.7 deg/s) and peaked earlier during the cardiac cycle (112.7±0.8 vs 117.4±2.4% of systole duration, both P<.05). Untwisting/twisting ratio (-1.48±0.05 vs -1.11±0.08; P<.001) and untwisting performance (=UTR/TW; -9.25±0.34 vs -7.38±0.40 s^-1 , P<.01) were increased in players. Augmented diastolic wall strain (DWS), a novel measure of LV compliance in players, was associated with improved myocardial mechanical efficiency. The described myocardial biomechanics may underlie augmented exertional cardiac function in athletes and may have a potential role to characterize athlete's heart by itself or to distinguish it from hypertensive or hypertrophic cardiomyopathy.

Mechanisms of ECG signs in chronic obstructive pulmonary disease

OBJECTIVE

Patients with chronic obstructive pulmonary disease (COPD) often have abnormal ECGs. Our aim was to separate the effects on ECG by airway obstruction, emphysema and right ventricular (RV) afterload in patients with COPD.

METHODS

A cross-sectional study was performed on 101 patients with COPD without left heart disease and 32 healthy age-matched controls. Body mass index (BMI) was measured, and pulmonary function tests, ECG, echocardiography and right heart catheterisation (only patients) were performed. Variables were grouped into (1) airway obstruction by FEV% (percentage of forced expiratory volume)_predicted, (2) emphysema by residual volume/total lung capacity and residual volume (percent of predicted) and (3) RV afterload by mean pulmonary pressure, artery compliance, vascular resistance and RV wall thickness.

RESULTS

In multivariate regression analysis, emphysema correlated negatively to R+S amplitudes in horizontal and frontal leads, RV/left ventricle (LV) end-diastolic volume ratio to horizontal amplitudes and BMI negatively to frontal amplitudes. Increased airway obstruction, RV afterload and BMI correlated with horizontal QRS-axis clockwise rotation. Airway obstruction, RV afterload, RV/LV end-diastolic volume ratio and BMI correlated to the Sokolow-Lyon Index for RV, and RV afterload negatively to Sokolow-LyonIndex for LV. Several classical ECG changes could, however, not be ascribed to specific mechanisms.

CONCLUSIONS

In COPD, the various pathophysiological mechanisms modify the ECG differently. Increased airway obstruction and RV afterload mainly increase the Sokolow-Lyon Index for RV mass and associate with clockwise rotation of the horizontal QRS-axis, whereas emphysema reduces the QRS amplitudes. BMI is an equally important determinant for the majority of the ECG changes.