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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.

Deep learning-based plaque quantification from coronary computed tomography angiography: external validation and comparison with intravascular ultrasound

Background

Atherosclerotic plaque quantification from coronary computed tomography angiography (CTA) enables accurate assessment of coronary artery disease burden, progression, and prognosis. However, quantitative plaque analysis is time-consuming and requires high expertise. We sought to develop and externally validate an artificial intelligence (AI)-based deep learning (DL) approach for CTA-derived measures of plaque volume and stenosis severity. We compared the performance of DL to expert readers and the gold standard of intravascular ultrasound (IVUS).

Methods

This was a multicenter study of patients undergoing coronary CTA at 11 sites, with software-based quantitative plaque measurements performed at a per-lesion level by expert readers. AI-based plaque analysis was performed by a DL novel convolutional neural network which automatically segmented the coronary artery wall, lumen, and plaque for the computation of plaque volume and stenosis severity. Using expert measurements as ground truth, the DL algorithm was trained on 887 patients (4,686 lesions). Thereafter, the algorithm was applied to an independent test set of 221 patients (1,234 lesions), which included an external validation cohort of 171 patients from the SCOT-HEART (Scottish Computed Tomography of the Heart) trial as well as 50 patients who underwent IVUS within one month of CTA. We report the performance of AI-based plaque analysis in the independent test set.

Results

Within the external validation cohort, there was excellent agreement between DL and expert reader measurements of total plaque volume (intraclass correlation coefficient [ICC] 0.876), noncalcified plaque volume (ICC 0.869), and percent diameter stenosis (ICC 0.850; all p<0.001). When compared with IVUS, there was excellent agreement for DL total plaque volume (ICC 0.945), total plaque burden (ICC 0.853), minimal luminal area (ICC 0.864), and percent area stenosis (ICC 0.805; all p<0.001); with strong correlation between DL and IVUS for total plaque volume (r=0.915; p<0.001; Figure). The average DL plaque analysis time was 20 seconds per patient, compared with 25–30 minutes taken by experts.

Conclusions

AI-based plaque quantification from coronary CTA using an externally validated DL approach enables rapid measurements of plaque volume and stenosis severity in close agreement with expert readers and IVUS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute, United States

18F-sodium fluoride positron emission tomography-computed tomography in acute aortic syndrome

Background

Acute aortic syndrome is characterised by diseases that disrupt the intima and weaken the aorta. This damaged aorta is prone to aneurysmal dilation and ultimately rupture – a catastrophic event. 18F-sodium fluoride positron emission tomography and computed tomography (PET-CT) is a promising multimodality imaging technique that informs on the pathological state of the aorta. In abdominal aortic aneurysms (a chronic aortic disease), 18F-sodium fluoride PET uptake is associated with aortic expansion and requirement for aortic repair.

Purpose

The aim of this study was to describe aortic 18F-sodium fluoride uptake in patients with acute aortic syndrome for the first time.

Methods

Patients with intramural haematomas, aortic dissections or penetrating aortic ulcers, along with healthy control subjects, underwent contrast-enhanced 18F-sodium fluoride PET-CT. 18F-Sodium fluoride uptake was assessed using standardised uptake values and corrected for background blood pool activity to obtain tissue-to-background ratios (TBR).

Results

Forty-six patients and twenty healthy control subjects were matched for age, gender, body mass index, ischaemic heart disease and diabetes mellitus. Participants with acute aortic syndrome had widespread aortic 18F-sodium fluoride uptake. Radiotracer binding in patients with acute aortic syndrome was substantially greater than healthy subjects (TBR 2.00±0.45 vs 1.36±0.39, p<0.001). Subgroup analysis in patients with untreated type B acute aortic dissection revealed peak radiotracer binding at the site of intimal disruption compared to the proximal reference aorta (TBR [inter-quartile range] 1.61 [1.38–1.88] vs 1.18 [1.08–1.39] respectively; p<0.001).

Radiotracer uptake was highest in patients with penetrating aortic ulcers, followed by aortic dissection and intramural haematomas (TBR (±SD) 2.19±0.55 vs 1.99±0.43 vs 1.71±0.27 respectively; p=0.046). No difference in radiotracer uptake was observed between patients with sub-acute and chronic disease (TBR (±SD) 1.94±0.37 vs 2.04±0.51, p=0.497). 18F-sodium fluoride uptake was similar between Stanford Type A and Type B dissections (TBR (±SD) 1.98±0.49, 2.00±0.44, p=0.851). 18F-Sodium fluoride binding was independent of maximum aortic diameter (R2 = 0.036, p=0.21).

Conclusion

Our preliminary findings suggest that aortic 18F-sodium fluoride uptake is increased in patients with acute aortic syndrome, especially around the site of intimal disruption or penetrating aortic ulcers. This technique appears to identify disease activity that may have clinical applications for assessing prognosis and guiding therapeutic interventions.

18F-NaF PET/CT in Acute Aortic Syndrome

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Thrombus formation on bioprosthetic aortic valves

Background

18F-GP1 is a novel radiotracer with a high affinity for the platelet glycoprotein IIb/IIIa receptor. Subclinical bioprosthetic valve thrombus has been postulated as a trigger for accelerated valve degeneration.

Purpose

To determine the feasibility of 18F-GP1 positron-emission tomography-computed tomography (PET-CT) for the detection of subclinical bioprosthetic aortic valve thrombus.

Methods

(i) Explanted degenerated aortic valve prostheses underwent histology and imaging. (ii) In a prospective observational study, patients with bioprosthetic aortic valve replacement (AVR) underwent echocardiography and 18F-GP1 PET-CT. Valves were assessed for hypoattenuating leaflet thickening (HALT), hypo-attenuation affection leaflet motion (HAM) and GP1 uptake.

Results

(i) GP1 correlated with thrombus on explanted valves (Figure). (ii) The first 6 patients (Table) were asymptomatic and had normally functioning surgical bioprostheses on echocardiography. At a median of 166 (range 122–189) days post-AVR, no patients had HALT or HAM on CT. There was avid focal GP1 uptake on the leaflets of all 6 patients which appeared most prominent along the leaflet edges (Figure). Only one patient had focal uptake in the valve frame, remote from the leaflets. In a separate cohort undergoing 18F-GP1 PET-CT for other conditions, there was no uptake on normal, native aortic valves (n=8).

Conclusion

For the first time, we demonstrate that 18F-GP1 PET-CT is a highly sensitive method of assessing platelet activation on bioprosthetic aortic valves. Despite the absence of CT evidence, early thrombus appeared to be a universal finding on recently implanted valve prostheses. The biological and clinical implications of subclinical bioprosthetic aortic valve thrombus have yet to be established.

GP1 uptake in AVR

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Pericoronary adipose tissue density is associated with clinical disease activity in Takayasu arteritis and coronary arterial inflammation measured by 68Ga-DOTATATE PET in atherosclerosis

Background

Coronary artery disease (CAD) is an under-recognized complication of intense arterial inflammation in Takayasu arteritis (TAK). While pericoronary adipose tissue (PCAT) density is associated with arterial inflammation in CAD patients, this relationship has not previously been studied in TAK patients, nor directly compared with coronary arterial inflammation measured by 68Ga-DOTATATE positron emission tomography (PET).

Purpose

To compare PCAT density with clinical, biochemical and molecular imaging markers of inflammation in TAK and CAD patients.

Methods

PCAT density was quantified from computed tomography coronary angiography (CTCA) around each of the 17 coronary segments in patients with: (1) TAK and CAD, (2) atherosclerotic CAD, and (3) age and gender-matched healthy controls, using semi-automated software (Autoplaque). In TAK patients, PCAT density was compared to the Indian Takayasu Clinical Activity Score (ITAS) and high-sensitivity C-reactive protein (CRP). In CAD patients, PCAT density was compared to local arterial inflammation measured by coronary motion-frozen 68Ga-DOTATATE PET using image registration software (FusionQuant), and systemic (aortic) inflammation using 18F-fluorodeoxyglucose (FDG) PET. Data was acquired either during routine clinical care or prior research that established 68Ga-DOTATATE as an experimental marker of arterial inflammation that binds macrophage somatostatin receptor-2 in atherosclerotic plaques (NCT02021188).

Results

60 patients were included (TAK, n=20; CAD, n=20; healthy, n=20). Non-calcified plaque burden (TAK: 95.2%; CAD: 90.4%, p<0.0001) and CRP (TAK: 25.2 ±SD 16.1 mg/L; CAD: 2.5 ±SD 1.7 mg/L, p=0.04) were greater in TAK than CAD patients.

PCAT density varied significantly among the three groups (median [IQR] TAK: −72.9 [−81.2 to -66.1] Hounsfield unit [HU]; CAD: −79.9 [−88.0 to −72.2]; healthy: −83.8 [−90.1 to −75.8] HU, p<0.0001). Figure: box-plot showing the distribution of PCAT values by group, with corresponding representative multiplanar reconstructed and cross-sectional CTCA images with surrounding PCAT density displayed by color table in left anterior descending arteries.

PCAT density was significantly associated with ITAS (r=0.61, p=0.004) and CRP (r=0.43, p=0.03) in TAK patients, and coronary 68Ga-DOTATATE maximum tissue-to-blood ratio (r=0.31, p<0.001) in CAD patients. PCAT density was not associated with aortic 18F-FDG uptake in CAD patients, nor subcutaneous (pre-sternal) adipose tissue density in either disease group. No significant patient-level confounders were identified using linear mixed-effects regression modelling.

Conclusion

PCAT density measured by CTCA is greater in TAK than CAD patients, and is associated with clinical and biochemical markers of disease activity in TAK, and coronary arterial inflammation measured by 68Ga-DOTATATE PET in CAD. PCAT could be a useful, easy to measure marker of coronary inflammation and disease activity in both TAK and CAD.

PCAT density is greater in TAK than CAD

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Wellcome Trust

Electrocardiographic abnormalities in a patient with subarachnoid haemorrhage

A 69-year-old woman presented after collapsing. She denied chest pain, breathlessness or headache. She was afebrile and vital signs were unremarkable. She was confused but the remaining physical examination was unremarkable. Routine blood tests were unremarkable. Cardiac enzymes were raised with a troponin I of 0.54. ECG showed Q waves in leads V1-V3 and widespread T wave inversion in leads II, III, aVF and V1-V6. Acute coronary syndrome (ACS) was suspected and antiplatelet treatment started. The following day her confusion worsened. Further review of the ECG found extensive changes unexplained by occlusion of a single artery suggesting extra-cardiac pathology. An urgent CT head was arranged and revealed subarachnoid haemorrhage. ACS treatment was stopped and she was transferred to neurosurgery where her right posterior communicating artery aneurysm was coiled. Fortunately her recovery was uneventful and she was discharged home with no neurological impairment.

Anxiety and cardiovascular symptoms: the modulating role of insomnia

BACKGROUND

Anxiety and insomnia are associated with cardiovascular (CV) symptoms. We assessed whether the relation between anxiety and CV symptoms is modulated by insomnia.

METHODS

Independently living women (n = 1,440; mean age = 59.36 +/- 6.53 years) were recruited by cluster sampling technique. We obtained data on demographic characteristics, health beliefs, access to health care, CV symptoms, sleep, stress and anxiety levels.

RESULTS

Overall, 56% of the sample reported insomnia; 46% reported CV symptoms, and 54% were highly anxious. There was a greater likelihood for highly anxious women and those experiencing insomnia to report CV symptoms (r(s) = 0.31* and r(s) = 0.32*, respectively). In logistic regression analysis, the adjusted odds ratios for reporting CV symptoms were 1.39 for patients with insomnia and 2.79 for those with anxiety. With control for insomnia, we observed a 3-fold reduction in the magnitude of the association between anxiety and CV symptoms (r(p) = 0.09*). Stepwise adjustments for sociodemographic factors, CV risk markers, and factors anchoring health beliefs and access to health care showed lesser impact on the relationships. With simultaneous control for those covariates, the correlation was r(p) = 0.13*; * p < 0.01.

CONCLUSION

The association of CV symptoms with anxiety is partly accounted for by insomnia.

Fulvestrant in advanced breast cancer following following failure of tamoxifen and a third generation aromatase inhibitor

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Background: Endocrine therapy is a key modality in the management of estrogen receptor positive metastatic breast cancer. Fulvestrant (ICI 182,780) is an estrogen receptor downregulator. It has previously been shown to be as effective as anastrozole in patients who had previously progressed on tamoxifen. Methods: A retrospective study was carried out of metastatic breast cancer patients treated at Charing Cross Hospital between 2002–2005 who had received fulvestrant following treatment failure with tamoxifen and a third generation aromatase inhibitor. All patients were postmenopausal and received fulvestrant 250mg IM every 28 days. Measurable disease was assessed by response evaluation criteria in solid tumors (RECIST). Results: A total of 45 patients were identified with a median age of 60 (range 36 to 90). The ER status was known in 95% (n=43) of patients and was positive in all cases, it was unknown in 2% (n=2). At the time of commencing fulvestrant, 96% (n=43) had metastatic disease and 4% (n=2) locally advanced disease. All patients had received at least 2 lines of prior endocrine therapy (including adjuvant therapy), at time of starting fulvestrant the median number of prior regimens was 3 (range 3–5). Fulvestrant was administered for a median of 4 months (range 1 to 20 months), with 4 patients currently still receiving therapy as of 1 November 2006. Of the 45 patients, 2.2% (n=1) achieved a partial response, while 31% (n=14) achieved stable disease for at least 6 months. Thus, 33.3% (n=15) obtained clinical benefit (defined as PR or SD for at least 6 months). The response rates based on line of therapy will be presented. Of the 45 patients, 41 were evaluable for survival data. The median survival of the remaining patients from the start of fulvestrant therapy was 9 months (range 1 to 48 months). Of the 44 patients, 14% (n=6) remain alive. The treatment was well tolerated and toxicity data will be presented. Conclusions: Fulvestrant is well tolerated and is efficacious as treatment for advanced breast cancer that has failed tamoxifen and a third generation aromatase inhibitors.

No significant financial relationships to disclose.

Glaucoma in the black population: a problem of blindness

Glaucoma is the leading cause of blindness in blacks. Black patients usually present to the ophthalmologist with more extensive optic nerve damage as compared with whites, and the disease process follows a malignant course even after intervention is initiated. Consequent to a greater amount of iris pigmentation, blacks require medications in higher concentrations to receive significant lowering of intraocular pressure. Patients with darker, thicker irides are more prone to have subacute angle-closure glaucoma, which requires gonioscopy and the recognition of subtle details that may be difficult to interpret. If medical therapy fails, the results of noninvasive surgical intervention, such as argon laser trabeculoplasty, and traditional surgical intervention, such as trabeculectomy, have a much lower success rate in the black population when compared with studies of the general population.It is essential that the primary physician be aware of the early signs and risk factors for glaucoma, which are herein outlined in detail. Only through early recognition, proper referral, and aggressive treatment can the incidence of blindness secondary to glaucoma be decreased.