COVID-19 and common mental health symptoms in the early phase of the pandemic: An umbrella review of the evidence

BACKGROUND

There remains uncertainty about the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on mental health. This umbrella review provides a comprehensive overview of the association between the pandemic and common mental disorders. We qualitatively summarized evidence from reviews with meta-analyses of individual study-data in the general population, healthcare workers, and specific at-risk populations.

METHODS AND FINDINGS

A systematic search was carried out in 5 databases for peer-reviewed systematic reviews with meta-analyses of prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms during the pandemic published between December 31, 2019 until August 12, 2022. We identified 123 reviews of which 7 provided standardized mean differences (SMDs) either from longitudinal pre- to during pandemic study-data or from cross-sectional study-data compared to matched pre-pandemic data. Methodological quality rated with the Assessment of Multiple Systematic Reviews checklist scores (AMSTAR 2) instrument was generally low to moderate. Small but significant increases of depression, anxiety, and/or general mental health symptoms were reported in the general population, in people with preexisting physical health conditions, and in children (3 reviews; SMDs ranged from 0.11 to 0.28). Mental health and depression symptoms significantly increased during periods of social restrictions (1 review; SMDs of 0.41 and 0.83, respectively) but anxiety symptoms did not (SMD: 0.26). Increases of depression symptoms were generally larger and longer-lasting during the pandemic (3 reviews; SMDs depression ranged from 0.16 to 0.23) than those of anxiety (2 reviews: SMDs 0.12 and 0.18). Females showed a significantly larger increase in anxiety symptoms than males (1 review: SMD 0.15). In healthcare workers, people with preexisting mental disorders, any patient group, children and adolescents, and in students, no significant differences from pre- to during pandemic were found (2 reviews; SMD's ranging from -0.16 to 0.48). In 116 reviews pooled cross-sectional prevalence rates of depression, anxiety, and PTSD symptoms ranged from 9% to 48% across populations. Although heterogeneity between studies was high and largely unexplained, assessment tools and cut-offs used, age, sex or gender, and COVID-19 exposure factors were found to be moderators in some reviews. The major limitations are the inability to quantify and explain the high heterogeneity across reviews included and the shortage of within-person data from multiple longitudinal studies.

CONCLUSIONS

A small but consistent deterioration of mental health and particularly depression during early pandemic and during social restrictions has been found in the general population and in people with chronic somatic disorders. Also, associations between mental health and the pandemic were stronger in females and younger age groups than in others. Explanatory individual-level, COVID-19 exposure, and time-course factors were scarce and showed inconsistencies across reviews. For policy and research, repeated assessments of mental health in population panels including vulnerable individuals are recommended to respond to current and future health crises.

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.

Remote mental health care interventions during the COVID-19 pandemic: An umbrella review

Mitigating the COVID-19 related disruptions in mental health care services is crucial in a time of increased mental health disorders. Numerous reviews have been conducted on the process of implementing technology-based mental health care during the pandemic. The research question of this umbrella review was to examine what the impact of COVID-19 was on access and delivery of mental health services and how mental health services have changed during the pandemic. A systematic search for systematic reviews and meta-analyses was conducted up to August 12, 2022, and 38 systematic reviews were identified. Main disruptions during COVID-19 were reduced access to outpatient mental health care and reduced admissions and earlier discharge from inpatient care. In response, synchronous telemental health tools such as videoconferencing were used to provide remote care similar to pre-COVID care, and to a lesser extent asynchronous virtual mental health tools such as apps. Implementation of synchronous tools were facilitated by time-efficiency and flexibility during the pandemic but there was a lack of accessibility for specific vulnerable populations. Main barriers among practitioners and patients to use digital mental health tools were poor technological literacy, particularly when preexisting inequalities existed, and beliefs about reduced therapeutic alliance particularly in case of severe mental disorders. Absence of organizational support for technological implementation of digital mental health interventions due to inadequate IT infrastructure, lack of funding, as well as lack of privacy and safety, challenged implementation during COVID-19. Reviews were of low to moderate quality, covered heterogeneously designed primary studies and lacked findings of implementation in low- and middle-income countries. These gaps in the evidence were particularly prevalent in studies conducted early in the pandemic. This umbrella review shows that during the COVID-19 pandemic, practitioners and mental health care institutions mainly used synchronous telemental health tools, and to a lesser degree asynchronous tools to enable continued access to mental health care for patients. Numerous barriers to these tools were identified, and call for further improvements. In addition, more high quality research into comparative effectiveness and working mechanisms may improve scalability of mental health care in general and in future infectious disease outbreaks.

Worldwide comparative efficacy of nutraceuticals on lipid profile. an updated systematic review and network meta-analysis

Introduction

In case of patients without indications to statin therapy, those being close to the target and especially with statin intolerance, nutraceuticals might be an additional option of hypercholesterolemia therapy. Despite a large number of nutraceuticals, little is known on their comparative efficacy due to the paucity of head-to-head comparisons. We aimed to assess the lipid-lowering effect of various nutraceuticals by means of network meta-analysis.

Methods

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were carefully searched to identify eligible studies to the meta-analysis. We included parallel or crossover randomized clinical trials (RCT), comparing head-to-head or to placebo/no intervention, the following nutraceuticals: a) artichoke, b) berberine, c) bergamot, d) garlic, e) green tea extract, f) plant sterols and stanols, g) policosanols, h) red yeast rice (RYR), i) silymarin, j) spirulina. We did not include soy protein, fiber, and lupin trials, as unlike other nutraceuticals they are in fact dietary interventions. Due to strikingly inconsistent results of policosanols RCTs carried out in Cuba and other countries, we excluded Cuban trials from main analysis.

Results

From the initially identified 4151 articles we finally included 131 studies. As some studies reported clinically different groups separately, they were split and finally we included 136 records, 134 with data on total cholesterol (TC), 125 with data on low-density cholesterol (LDL-C), 127 that provided information on high-density cholesterol (HDL-c) and 129 that included data regarding triglycerides (TG). Pooled studies covered data for 6755 patients randomized to nutraceutical arms and 6370 randomized to receive placebo/no intervention. For reducing TC bergamot, was identified as the most effective approach (P-score = 1.0) followed by RYR (0.90) and berberine (0.76). For increasing HDL-C, bergamot (0.98), berberine (0.85), and RYR (0.77) were the most effective. While evaluating LDL-C reduction, bergamot (1.00) and RYR (0.90) showed the highest reduction efficacy. Reducing effect of investigated nutraceuticals on TG levels was the highest for bergamot (1.00) and RYR (0.78). Majority of reports regarding Cuban policosanol trials implicated very high effectiveness of those nutraceuticals, which was in contrast to trials conducted in other countries

Conclusions

Bergamot, berberine, and RYR seemed to be most effective nutraceuticals in terms of lipid-lowering efficacy. Alleged high effectiveness of policosanols was not confirmed in our analysis. This analysis might support the physicians and patients' decisions to use only those nutraceuticals of confirmed efficacy.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Silesia, Katowice

The characteristic of acute coronary syndromes of patients with multivessel coronary artery disease in centers with and without cardiac surgery on-site – data from PL-ACS registry

Background

Every year more than 100,000 acute coronary syndromes are diagnosed in Poland. There are 36 cardio-surgical centers and more than 157 catheterization laboratories available in Poland dedicated to treat acute coronary syndromes. MVD patients have a considerable clinically relevant burden of adverse cardiovascular events following ACS.

Purpose

The aim of the study was to analyze the outcomes of acute coronary syndrome (ACS) treatment in Polish patients with the multivessel coronary disease (MVD) in the centers with and without cardiac surgery (CS) on site.

Methods

This was a retrospective analysis (1st January, 2017 to 31st December, 2020) of ACS patients outcomes using data from PL-ACS registry. PL-ACS registry is a polish archive of the ACS patients, which data are obtained from all cardiology and cardiac surgery departments in Poland. The registry is supervised by the Polish Ministry of Health. The following analysis considered only patients with MVD. MVD was defined as the presence of ≥70% diameter stenosis of three or more epicardial coronary arteries. For the purpose of this analysis the MVD patients (n=4618) were divided to two groups: those treated in the centers with the cardiac surgery department on site (CS group, n=595) and those without (non-CS group, n=4023).

Results

Patients in the CS group were elder (70.8 vs. 69.0, p=0.008) as compared to the non-CS group. There were no differences in sex (male 68.6% vs. 67.2%, p=0.49) and BMI (27.5% vs. 27.7%, p=0.12) were between both groups. There was no statistically significant difference between the types of acute coronary syndrome, between CS and non-CS group – [STEMI (34.6% vs 31.1%), NSTEMI (53.6% vs 55.3%), UA (11.8% vs 13.6%), p=0.16]. Patients in the CS group had higher prevalence of renal failure (13.3% vs. 8.8%, p≤0.001) and a more frequent had a history of a past coronary angioplasty (18.9% vs. 14.4%, p=0.005). During the coronary angiography a femoral artery access was more often used in CS group patients (47.1% vs. 15.2%, p<0.001). Percutaneous coronary intervention of MVD was more often performed in the CS group (74.6% vs. 71.0%, p=0.054). In-hospital death (7.6% vs. 4.6%, p=0.002), reinfarction (1.1% vs. 0.1%, p<0.001), hemorrhagic complications (6.4% vs. 1.6%, p<0.001), recurrent target vessel revascularization (1.8% vs. 0.4%, p≤0.001) and pulmonary oedema (3.7% vs. 1.5%, p<0.001) occurred more often in the CS group.

Conclusions

The safety of ACS treatment in MVD patients in centers without CS on site is non-inferior to treatment of such patients in center with CS on site. Interestingly, there were more in-hospital adverse cardiac events observed in ACS MVD patients treated in center with CS on-site. However, in centers with CS on site ACS MVD patients had a higher co-morbidity and were subjected to a higher number of PCIs. It suggests that in general, centers with CS-onsite treat more severe patients as compared to those without CS on-site.

Funding Acknowledgement

Type of funding sources: None.

Dubious effect of the high biventricular paced beats percentage itself on the cardiac resynchronization efficacy in patients with atrial fibrillation. The randomized Pilot-CRAfT Study results

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Cardiology statutory grant

Background

The presence of atrial fibrillation (AF) in cardiac resynchronization therapy (CRT) recipients is common and AF is a marker of poorer CRT response. The negative influence of AF on CRT efficacy is belived to be mediated mainly by the drop of effectively captured biventricular paced beats percentage (BiVp%). According to observational trials, the minimal BiVp associated with better outcomes is 95-98%, however there is lack of randomized trials to confirm this findings.

Purpose

The purpose of the study was to assess the influence of BiVp% itself on the clinical outcomes in the population CRT patients with atrial fibrillation in a prospective, randomized cohort.

Methods

The study included the prospective Pilot-CRAfT study participants that is patients with CRT and permanent or persistent AF lasting for ≥6 months that were randomly assigned to rhythm or rate control strategy. We divided the whole study population according to their BiVp at the 12 month follow-up with two borderline BiVp values (BiVp >98% vs <98% and >95% vs <95%) and analysed the echocardiographic indices, exercise tolerance and quality of life between the prespecified groups.

Results

The study included 43 CRT patients (97,7% males) aged 68,4 (SD: ±8,3) years with mean BiVp% 82,4% ±9,7% at baseline. The mean baseline left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD) and maximal oxygen uptake (VO2max) were: 30 ±8%, 65 ±8 mm, 14 ±5 mL/(kg*min), respectively. In both of the study arms the BiVp% raised significantly reaching 98,1 ±2,3% and 96,3 ±3,9% in the rhythm control and the rate control arms respectively (P=0,093). As a result the were overall 21 patients with BiVp >98% and 29 patients with BiVp >95% at the end of the study. The BiVp groups >98% vs <98% and >95% vs <95% did not differ as to baseline characteristics and we have not observed any differences in the mean LVEF, mean LVEDD, mean VO2max, and quality of life in the prespecified BiVp% groups at the end of the follow up. Moreover no linear correlations between the BiVp% and LVEF, LVEDD, VO2max values were observed. However, in the rate control group patients with AVNA performed had lower LVEDD at the end of the study (57,7 ±3,0 vs 65,4 ±7,0 p=0,007) and significant decrease in the LVEDD after AVNA was observed (-8,6 95%CI [-14,9; -2,3]).

Conclusions

The BiVp >98% or >95% alone does not seem to warrant good response to cardiac resynchronization in patients with persistent atrial fibrillation as assessed in the prospective randomized cohort. However, performing AVNA in this group of patients may be beneficial in terms of LVEDD decrease.

Comparison of inpatient and outpatient cardiac rehabilitation following myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR) following myocardial infarction (MI) improves prognosis. Models of second phase CR differ across countries. The aim of the study was to compare outcomes in MI survivors participating in outpatient and inpatient CR programmes.

Methods

We included all patients hospitalized due to acute MI in Poland between October 2017 and December 2018 (n=96634). Among them 4411 patients were referred to and commenced outpatient CR, whereas 11626 patients started inpatient CR within 30 days following discharge. All the patients were the subject of prospective follow-up. The primary endpoint was defined as death from any cause.

Results

The mean follow-up was 332.8±128.1 days. Younger age, male sex, and a cancer in the history were related to higher probability, whereas diabetes, heart failure, chronic kidney disease, chronic obstructive pulmonary disease, ST-elevation myocardial infarction, and myocardial revascularization were related to lower probability of participation in the outpatient CR. Participation in outpatient CR was related to the risk of all-cause mortality both in univariable (hazard ratio [95% confidence intervals] 0.37 [0.26-0.51]) and multivariable analysis (0.53 [0.38-0.74]). Participation in the outpatient CR was also related to the lower risk of death or MI or stroke (0.57 [0.48-0.67] and 0.72 [0.61-0.84]) and a lower risk of death or hospitalization due to cardiovascular reasons: 0.78 (0.73-0.84) and 0.85 (0.80-0.91) for the univariable and multivariable analyses respectively. The analysis of propensity score matched groups confirmed the results.

Conclusion

Outpatient CR following MI may be related to improved prognosis compared to the inpatient programme.

Duration of dual antiplatelet therapy and long-term outcomes following drug-eluting balloon or drug-eluting stents for treatment of in-stent restenosis (DAPT-Dragon Registry)

Objectives

The aim of the DAPT-DRAGON registry was to asses long-term outcomes and the length of dual antiplatelet therapy (DAPT) in patients treated with percutaneous coronary intervention (PCI) due to drug-eluting stent in stent restenosis (DES-ISR) with drug-eluting balloons (DEB) or thin-DES.

Background

Data regarding the duration of DAPT in patients with DES-ISR treated with PCI is still undergoing research and observation, and the adequate duration of DAPT in this group of patients is not unambiguously sanctioned.

Methods

Overall, 1,367 consecutive patients with DES-ISR who underwent PCI with DEB or DES, were entered into the multi-center DAPT-DRAGON Registry (Fig. 1). The mean age was 66.7±9 years (70.5% males). The median follow-up was 3.3 years. There were 34.1% patients with chronic coronary syndrome, 35.2% with unstable angina, 2.9% with ST segment elevation myocardial infarction and 27.7% with non-ST segment elevation myocardial infarction (MI). We assessed selected study endpoints according to the duration of DAPT (≤3 vs. >3 months and ≤6 vs. >6 months), before and after propensity score matching (PSM): stroke, target lesion revascularization (TLR), target vessel revascularization (TVR), MI, death and device-oriented composite endpoints (DOCE).

Results

Among predictors of increased DOCE rate before PSM, we demonstrated: PCI with DEB vs. DES (p<0.001), recurrent ISR (p=0.002), treatment with glycoprotein IIb/IIIa inhibitor during PCI (p<0.001), lower left ventricle ejection fraction (p=0.004) and extent of stenosis (p<0.001). Pairwise contrast analysis considering type of PCI (thin-DES vs. DEB) and duration of DAPT (≤6 vs. >6 months) before PSM revealed superiority of thin-DES+DAPT >6 months vs. DEB+DAPT >6 months for DOCE (p<0.001), TVR (p=0.02) and TLR (p=0.01). After PSM analysis, the length of DAPT (≤3 vs. >3 months) had no significant influence on assessed long-term outcomes, while the percentage of stroke free survival was significantly lower in the group of patients with DAPT ≤6 months vs. >6 months (p=0.01; Fig. 2).

Conclusions

Long-term treatment with DAPT (>6 months) in patients with DES-ISR with DES implantation is related to better long-term outcomes in terms of lower rate of DOCE, TVR and TLR compared to PCI with DEB. DAPT >6 months is related to a greater rate of strokes, independently of the type of treatment (thin-DES and DEB) compared to DAPT ≤6 months.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Gender distribution in patients treated with rotablation – analysis of 5,177 percutaneous coronary interventions based on a large national registry from between 2014 and 2020

Background

Patients undergoing percutaneous coronary intervention (PCI) procedures using rotational atherectomy (RA) are a special group of patients characterised by the presence of massive calcifications in the coronary arteries. Due to a significant increase regarding the frequency of these procedures in recent years and the distinctiveness of this narrow group of patients among all patients undergoing PCIs, we have characterised the group according to gender.

Aims

The aim of analysis was to assess the gender percentage share in following years and differences between both groups of Polish patients undergoing PCI with rotational RA between 2014 and 2020.

Methods

Based on the Polish National Registry of Percutaneous Coronary Interventions (ORPKI), we analysed 751,113 patients treated with PCI between 2014 and 2020. Then, we extracted 5,177 (0.7%) treated with PCI and RA, 3,552 of them (68.6%) were males. Selected indices among the two groups were compared using the t-test for continuous variables, the χ2 test or the likelihood-ratio test for nominal variables where appropriate. To compare means of samples in the following years, one-way ANOVA test was used.

Results

The results of the study indicate an upward RA tendency in successive years (p<0.001). Moreover, this tendency and its increase was greater between the years 2016–2019 (Fig. 1). Almost twice as many RA procedures pertain to men, while the percentage share did not undergo a significant change in following years (Fig. 2). The mean age was 72±9 years in the overall group. In the total group, there were 2,873 patients (55.49%) with chronic coronary syndrome, 1,033 (19.95%) with unstable angina, 654 (12.63%) with non-ST segment elevation myocardial infarction (NSTEMI) and 494 (9.54%) with ST segment elevation myocardial infarction (STEMI).

Females were significantly older in comparison to males [75.2±8.3 vs. 70.5±9.2, p<0.001], more often diabetics [613 (37.72%) vs. 1,068 (30.07%), p<0.001], less often smokers [173 (10.6%) vs. 635 (17.9%), p<0.001] and were significantly more often treated due to acute coronary syndrome [780 (48.8%) vs. 1,401 (40.5%), p<0.001]. Considering periprocedural complications among females, there were more cardiac arrests [13 (0.8%) vs. 10 (0.28%), p=0.01] and deaths [11 (0.68%) vs. 6 (0.17%), p=0.006] when compared to males.

Conclusion

The percentage of RA among overall PCIs has been still growing in recent years in Poland. The majority of patients treated with RA are men. Gender distribution did not change significantly among patients treated with PCI and RA during the analysed period of time.

Funding Acknowledgement

Type of funding sources: None.

Long term outcomes of a coordinate care program in patients after myocardial infarction (KOS-MI)

Introduction

Despite significant progress in treatment of myocardial infarction (MI), the annual mortality remains a challenge. Since 2017, The Coordinated Care in Myocardial Infarction Program (KOS-MI) has been introduced in Poland, which guarantees and coordinates patients to achieve complete revascularization, electrotherapy when necessary, cardiac rehabilitation and access to cardiologist for patients after MI.

Purpose

The aim of this study was to assess long term outcomes (3-year follow-up) of patients enrolled in KOS-MI.

Methods

This is a prospective multicenter registry of 1973 consecutive patients with myocardial infarction hospitalized in 4 centers of American Heart of Poland from 11.2017 to 11.2018. Patients which constituted a study group were enrolled in KOS-MI program at discharge. A control group consisted patients who received standard of care. Propensity score matching was utilized for patients baseline characteristic matching and results adjustment. Follow-up was obtained from the National Health Fund registry citizens. Combine endpoint of MACCE consisted of death, MI, stroke and repeated revascularization.

Results

In total 753 patients were enrolled in KOS program and 1173 constituted a control group. More than 90% of patients in both groups underwent PCI. Patients in KOS-MI were mostly men (70% vs. 65%; p<0,05), were younger (65 vs. 68; p<0,05), admitted with STEMI (44,8% vs. 37,5%; p<0,05) with previous history of heart failure (23% vs. 17%; p<0,05). Patients in the control group had more comorbidities: chronic kidney disease (9,8% vs. 4,4%; p<0,05), previous AMI (17,6% vs. 12,6%; p<0,05), prior PCI (15,7% vs. 11%; p<0,05) and atrial fibrillation (11,7% vs. 8,4%; p<0,05). They were more often admitted with NSTEMI (62,5% vs. 55,3%; p<0,05) and acute heart failure (4,7% vs. 2,7%; p<0,05). KOS patients had more often completed revascularization performed (50% vs. 33,4%; p<0,05). Following propensity score matching 576 pairs were matched, and patient baseline characteristic were well balanced in all variables.

In long- term follow-up (mean 2,8±0,27 years) mortality was significantly lower in KOS group (9% vs. 16,3%; p<0,05) and MI similar (10,8% vs. 13,1%; p=0,14). MACCE was higher in the control group (43% vs. 30,2%; p<0,05). Prevalence of hospitalization for HF and repeated revascularization was higher in the control group (14,7% vs. 9,4%; p<0,05 and 27,9% vs. 21%; p<0,05, respectively). After adjustment MACCE remained significantly lower for KOS-MI, whereas there was tendency for lower mortality, hospitalization for HF and repeated revascularizations (Figure 1).

Conclusions

Combination and coordination of unrestricted rehabilitation, complete revascularization, electrotherapy and ambulatory cardiologist care in the KOS-MI program improves long term prognosis in patients after MI.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Impact of COVID-19 pandemics upon pulmonary hypertension patients: insights from BNP-PL national database

Introduction

COVID-19 pandemic has caused not only an increase in overall and cardiovascular mortality, but also hindered access to health care, diagnosis and treatment of diseases other than coronavirus infection.

Aim

Assessment of the impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy of pulmonary hypertension (PH) in Poland, along with an analysis of the incidence and course of COVID-19 among patients (pts) diagnosed with PH, treated under the National Health Fund program, registered in the national BNP-PL database.

Methods

The records of the complete population of Polish pts treated under the National Drug Program of PH (PAH and CTEPH), registered in the national database of BNP-PL, updated on an ongoing basis by all PH centers, were analyzed. The frequency of SARS-CoV-2 infections, the clinical severity of their course and the mortality were reviewed, taking into account the specific therapies used. The basic clinical characteristics of the group of sick and deceased patients were compared to the remaining patients registered in the BNP-PL database. The rate of increase of new diagnoses ended with inclusion in the Drug Program between March and December 2020, compared to the corresponding periods of the previous year, and the change in the treatment profile were compared.

Results

The analysis included 1704 pts (PAH 1134, CTEPH 570). The incidence of SARS-CoV-2 infections was 3.8% (n=65), including PAH 2.7% (n=46) and CTEPH 3,2% (n=18). 32 patients (49%) required hospitalization. Mortality rate was 28% (18/65) – including 7/18 outside of hospital. Those who died due to COVID-19 were older (mean age 68.4±15.8 vs. 50.8±18.8 yrs; p<0,001), had higher WHO class and more cardiovascular comorbidities (4±2,06 vs. 2,66±1,8; p=0,01) (Table 1). During the pandemic the number of new diagnoses of PH markedly decreased compared to the corresponding period in 2019 (total 150 vs. 203, PAH 90 vs. 123, CTEPH 60 vs. 80, respectively). A significant increase in total mortality was also observed in the PH group (9,72 vs. 5,85%). Moreover, escalation of specific PH therapy decreased significantly (14,7% vs. 21,6%). Incidence of COVID-19 study group was lower than estimated for general Polish adult population (3,8% vs. 6,5%).

Conclusions

COVID-19 pandemic deeply influenced the diagnostic and therapeutic process of pulmonary hypertension by reducing the number of new diagnoses, escalation therapy and increased overall mortality in this population. This may be due in part to the conversion of some PAH centers into hospitals treating patients infected with SARS-CoV-2, as well as to patients' fear of admitting to hospital despite clinical deterioration. Pulmonary hypertension is linked to markedly increased mortality in COVID-19, similarly for PAH and CTEPH. Intriguing finding of lower infection rate may be linked to protective lifestyle or specific therapies.

Funding Acknowledgement

Type of funding sources: None.

Phase I dose-escalation single centre clinical trial to evaluate the safety of infusion of memory T cells as adoptive therapy in COVID-19 (RELEASE)

BACKGROUND

Effective treatments are still needed to reduce the severity of symptoms, time of hospitalization, and mortality of COVID-19. SARS-CoV-2 specific memory T-lymphocytes obtained from convalescent donors recovered can be used as passive cell immunotherapy.

METHODS

Between September and November 2020 a phase 1, dose-escalation, single centre clinical trial was conducted to evaluate the safety and feasibility of the infusion of CD45RA^- memory T cells containing SARS-CoV-2 specific T cells as adoptive cell therapy against moderate/severe cases of COVID-19. Nine participants with pneumonia and/or lymphopenia and with at least one human leukocyte antigen (HLA) match with the donor were infused. The first three subjects received the lowest dose (1 × 10⁵ cells/kg), the next three received the intermediate dose (5 × 10⁵ cells/kg) and the last three received the highest dose (1 × 10⁶ cells/kg) of CD45RA^- memory T cells. Clinicaltrials.gov registration: NCT04578210.

FINDINGS

All participants' clinical status measured by National Early Warning Score (NEWS) and 7-category point ordinal scales showed improvement six days after infusion. No serious adverse events were reported. Inflammatory parameters were stabilised post-infusion and the participants showed lymphocyte recovery two weeks after the procedure. Donor microchimerism was observed at least for three weeks after infusion in all patients.

INTERPRETATION

This study provides preliminary evidence supporting the idea that treatment of COVID-19 patients with moderate/severe symptoms using convalescent CD45RA^- memory T cells is feasible and safe.

FUNDING

Clinical Trial supported by Spanish Clinical Research Network PT17/0017/0013. Co-funded by European Regional Development Fund/European Social Fund. CRIS CANCER Foundation Grant to AP-M and Agencia Valenciana de Innovación Grant AVI-GVA COVID-19-68 to BS.

Last before-death transmission in patients with heart failure and implantable cardioverter-defibrillator followed by remote monitoring - insights from the COMMIT-HF registry

Funding Acknowledgements

Type of funding sources: None.

Background 

Remote monitoring (RM) of cardiac implantable electronic devices (CIED) in patients with heart failure allows to regularly analyze the devices" and patients" conditions. 

Purpose 

The purpose of this study was evaluation of the ultimate transmissions sent before death in patients monitored remotely. 

Methods 

The last transmissions delivered by the devices in patients enrolled into COMMIT-HF Registry (NCT02536443) who died when monitored remotely have been retrospectively analysed. The characteristics and contents of the transmissions and clinical reactions undertaken have been obtained from the RM systems of four major RM providers. 

Results 

Of 1,306 patients with CIEDs who were enrolled at the RM programme in our centre, 267 died and their last transmission occurred less than 90 days before death, of which 133 (49.8%) were scheduled and 134 (50.2%) alert-triggered. The median period between transmission and death was 31 days for scheduled and 8 days for alert-triggered transmissions. The most frequent alert-triggered transmissions were atrial fibrillation/flutter (35.8%) and ventricular tachyarrhythmias (24.6%). A clinical reaction has been undertaken after 9.8% of planned and 67.1% of alert-triggered transmissions and consisted mainly of telephone consultations and referrals for hospital admissions. 

Conclusions 

This is the first analysis of the ultimate transmissions delivered by CIEDs before death. In approximately 50% of patients, the last transmission has been alert-triggered. Hence, an appropriate organization of the RM facility, which should immediately analyse and react to the transmission, seems mandatory to obtain clinical benefit in patients with HF and RM. Causes of alerts and clinical reactionsCause of alertAll alert-triggered transmissions (N = 134)AF/AFL episode, n (%)48 (35.8%)Ventricular tachycardia, n (%)18 (13.4%)Ventricular fibrillation, n (%)15 (11.2%)Biventricular pacing percentage reduction, n (%)15 (11.2%)Others38 (28.3%)Congestion monitor indications, n (%)14 (10.4%)Clinical reactionPlanned transmission (N = 133)Alert-triggered transmission (N = 134)Telephone consultation10 (7.5%)58 (43.2%)Referral to the GP or outpatient specialist clinic visit2 (1.5%)12 (8.9%)Referral for hospital admission1 (0.7%)18 (13.4%)Pharmacotherapy modificationN/A2 (1.5%)Abstract Figure.

Rhythm or rate control strategy in CRT recipients with long-standing persistent atrial fibrillation - preliminary results of the PilotCRAfT study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology in Warsaw Statutory Grant

Background

The presence of atrial fibrillation (AF) in cardiac resynchronization therapy (CRT) recipients is common and AF is a marker of poorer CRT response. The negative influence of AF on CRT efficacy is mediated mainly by the drop of the effectively captured biventricular paced beats percentage (BiVp%) which should exceed 95-98% to warrant good CRT response.  Sinus rhythm (SR) restoration may improve CRT efficacy which in turn may protect AF recurrence. However, there is lack of randomized studies comparing rhythm and rate control strategies in these patients.

Purpose

The purpose of the Pilot-CRAfT study (NCT01850277) was to compare the efficacy of rhythm vs rate control strategy in CRT patients with long-standing persistent or permanent atrial fibrillation.

Methods

The study included patients with CRT and permanent or persistent AF lasting for ≥6 months, resulting in BiVp% <95%, who were randomly assigned to rhythm or rate control strategy. The rhythm control strategy comprised of external electrical cardioversion (EEC). The rate control strategy included pharmacotherapy and atrioventricular node ablation (AVNA) as needed. Both of the study arms received amiodarone. The follow-up lasted 12 months. The primary endpoint was the 12-month BiVp%. The patients underwent ECHO, cardiopulmonary test, quality of live (QoL) and clinical outcomes assessment.  

Results

The study included 43 CRT patients (97,7% males) aged 68,4 (SD: ±8,3) years with mean BiVp% 82,4% ±9,7% at baseline. The mean duration of AF paroxysm was 25 ±19 months. The mean baseline left ventricular ejection fraction (LVEF), left atrium area and maximal oxygen uptake (VO2max) were: 30 ±8%, 33 ±7 cm2, 14 ±5 mL/(kg*min), respectively. The EEC was performed in 19 out of 22 patients assigned to the rhythm control arm. The immediate success rate of EEC was 58%. 42% of  the rhythm control arm patients remained in SR after 12 months. In the rate control group 1 person underwent AVNA and in 1 patient spontaneous SR resumption was observed. After 12 months there was significant BiVp% increase in both the rhythm and the rate control arms (98,1 ±2,3 vs 96,3 ±3,9%, respectively. The BiVp% differences between the groups were not significant (P = 0,093). However, in the per protocol analysis, the rhythm control group had greater LVEF after 12 months as opposed to the rate control arm (36,8% vs 29,9% respectively, P = 0,039). The LVEF raised significantly in the rhythm control group (ΔLVEF 5,0 (95%CI: 1,54; 8,46)). No significant differences between the groups in the VO2max, QoL, clinical and safety end-points were noticed.

Conclusions

Structured follow-up of CRT patients with long-standing persistent or permanent AF leads to significant BiVp% increase exceeding 95%. The rate control strategy did not improve CRT effectivness, irrespective of high BiVp%. However limited in the efficacy, the rhythm control strategy may improve CRT outcome in these patients, resulting in LVEF increase.

Biomarkers associated with poor prognosis in patients with end-stage heart failure

Background

Despite advances in the treatment, end-stage heart failure (HF) is a disease with a severe prognosis, showing an annual mortality rate of 30 to 50%. Due to a poor prognosis in this population of patients, it is necessary to accurately stratify the risk of death, including simple and effective prognostic markers.

Objective

This study aimed to determine biomarkers associated with mortality in patients with end-stage HF.

Material and methods

The study was a prospective analysis of optimally treated patients with end-stage HF, who were hospitalised at the Cardiology Department between 2016 and 2018. At the time of enrollment to the study routine laboratory tests, cardiopulmonary exercise tests, echocardiography and right heart catheterization were performed in all patients. Human Interleukin 33 (IL-33) and IL-1 Receptor Like 1 (IL1RL1) were measured by sandwich enzyme-linked immunosorbent assay (ELISA) with the commercially available kit (Human Il-33 and IL1RL1 ELISA kit, SunRedBio Technology Co, Ltd, Shanghai, China). Plasma concentration of N-terminal brain natriuretic peptide (NT-proBNP) was measured using a commercially available kit (Human NTproBNP ELISA kit, Roche Diagnostics, Mannheim, Germany). The endpoint was all-cause mortality during a one-year follow-up. The Medical University of Silesia's local Institutional Review Board approved the study protocol, and all patients provided informed consent.

Results

The final study group consisted of 282 patients (87.6% males, median age 57.0 years). One-year mortality rate in the analysed population was 28%. In a multivariate analysis, independent risk factors of death included NT-proBNP [Hazard Ratio (HR) 1.056 (95% Confidence Interval (CI): 1.024–1.089); P<0.001], sodium [HR 0.877 (95% CI: 0.815–0.944); p<0.001], IL33 [HR 0.977 (95% CI: 0.965- 0.989); p<0.001] and IL1RL1 [HR 1.015 (95% CI: 1.008–1.023); p<0.001) serum levels.

Conclusions

Our study showed that lower sodium and IL-33 levels, as well as higher NT-proBNP and IL1RL1 levels are associated with an increased risk of death in patients with end-stage HF during a one-year follow-up.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of SIlesia, Katowice, Poland

Strict compliance with ESC therapeutic guidelines after myocardial infarction treated with invasive strategy correlates with improved 18-month outcomes

Background

Despite improved early outcomes in patients (pts) with acute myocardial infarction (MI) in Poland with prevalent strategy of primary angioplasty by radial access, mid- and long-term outcomes are unsatisfactory.

Objective

We hypothesized that strict implementation of secondary prevention ESC guidelines in post-infarction management may be related with improved mid-term clinical outcomes

Methods

We compared 18-month outcomes of pts treated for MI with primary invasive strategy in a tertiary university hospital (NSTEMI 470/47%, or STEMI 535/53%; N=1005; Gr-L) with similar subset from national databases AMI-PL and PL-ACS (N=117307; NSTEMI 50966/43%, STEMI 64078/57%; Gr-Pol). Females represented 38.5% / 35.7% of Gr-L/Gr-Pol and mean age was 66.1±11.5 vs 65.8±11.9% (NS). The center implemented a strict policy of optimization prognosis-modifying prescriptions at discharge according to ESC guidelines. Endpoints over 18-month follow-up were defined as total mortality and combined clinical endpoint (death, stroke, recurrent MI, recurrent revascularization).

Results

30-days survival was comparable between Gr-L and national cohort. Key medicationrates were significantly higher for Gr-L vs most recent national estimates: renin-angiotensin blockers: 94% vs 79%, statins: 98% vs 75%, beta-blockers 95% vs 85%; ASA: 99% vs 94.5%, P2Y12 inhibitors 100% vs 83%. Rehabilitation was completed in 32% and 51% (after NSTEMI/STEMI) with national average around 20% - all differences p<0.05. Long-term mortality rate (overall 10.6% vs 14.5%, p=0.0005) and composite outcome rate was significantly improved in Gr-L – details shown in the table.

Conclusions

Outcomes of MI patients in primary PCI era are related to optimized medical therapy and rehabilitation planned at discharge. Our study does not prove causality but indicates on strong association of strict compliance with ESC guidelines and improved 18-month outcomes including overall survival.

Funding Acknowledgement

Type of funding source: None

Factors associated with the cardiac allograft vasculopathy after heart transplantation

Introduction

Cardiac allograft vasculopathy (CAV) is a major threat to long-term survival after heart transplantation (HT). The frequency of CAV is estimated to be 8% at 1 year after HT, 30% at the 5-year follow-up, and as high as 50% within 10 years after the procedure. Therefore, it is necessary to select those factors that are closely associated with the presence of CAV and facilitate the proper, fast and minimally invasive diagnosis of this disease.

Purpose

The aim of this study was determine risk factors associated with CAV detection in patients after HT.

Material and methods

We analyzed 299 consecutive patients after HT who underwent routine visits in our institution between 2015 and 2017. During the visit, echocardiography, routine coronary angiography, laboratory tests and immunosuppressive drug serum concentrations were performed in all patients. In addition, 10 ml of peripheral blood was collected to determine human interleukin 33 (IL-33) and IL-1 Receptor Like 1 (IL1RL1). IL-33 and IL1RL1 concentrations were measured by sandwich enzyme-linked immunosorbent assay (ELISA) with the commercially available kit. The diagnosis of CAV was based on the results of coronary angiography and defined according to the current International Society for Heart and Lung Transplantation (ISHLT) criteria.The Medical University Local Institutional Review Board approved the study protocol, and all patients provided informed consent.

Results

Patients' median age was 59.00 (45.00–66.00) years, and 74.2% were men. The median time from HT to study inclusion was 9.03 (6.02–13.01) years. The frequency of CAV according to the ISHLT criteria in the analysed population was 47.5%. At the time of enrolment all patients were receiving immunosuppressive therapy with calcineurin inhibitor and mycophenolate mofetil, and were free from acute rejection (diagnosed either by echocardiography or biopsy), clinical signs of infection or symptoms of acute heart failure. Multivariate analysis using logistic regression confirmed that IL-33 OR 0.958 (0.944–0.972), p<0.0001 as well as IL1RL1 OR 1.061 (1.040–1.083), p<0.0001) serum concentrations, donor age OR 1.046 (1.009–1.085) p=0.015, left ventricular diastolic dimension OR 1.081 (1.016–1.149) p=0.015, and time from HT to blood collection OR 1.256 (1.151–1.371), p<0.0001 were independent factors of CAV detection.

Conclusions

Lower IL-33 and higher IL1RL1 serum concentrations, as well as donor age, left ventricular diastolic dimension and time from HT to blood collection are independently associated with CAV. This study provides non-invasive, low-cost, and simple indicators for CAV detection.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia, Katowice, Poland

Infarct-related artery and long-term mortality following recurrent ST-elevation myocardial infarction; insights from a Polish nationwide registry

Background

Recurrent ST-elevation myocardial infarction (rSTEMI) occurs either as an acute thrombotic event in the same (target-vessel, TV-STEMI) or different vessel (non-target, nonTV-STEMI) compared with the first infarction. Little is known about the frequency of rSTEMI in the era of primary percutaneous coronary intervention (PCI) and about the impact of the infarct-related artery (IRA) on long-term prognosis.

Purpose

We hypothesized that long-term mortality after rSTEMI varies according to IRA (either same or different compared with first STEMI).

Methods

We retrospectively analysed data from the Polish Registry of Acute Coronary Syndromes (PL-ACS) and identified survivors of first STEMI treated with PCI who experienced rSTEMI and were discharged home. We divided rSTEMI into TV-STEMI and nonTV-STEMI group. We compared baseline clinical, angiographic and procedural characteristics and utilized propensity score matching to adjust for baseline differences. 1-, 3- and 5-year all-cause mortality was obtained from the Polish National Health Fund. Categorical variables were presented as counts and percentages and compared using Chi2 test. Continuous variables were presented as medians and interquartile ranges and compared using Mann-Whitney test. The registry was approved by local Ethics Committee and meets the conditions of the Declaration of Helsinki

Results

Between January 2003 and August 2019 a total of 3517 patients (mean age 62.9 years, 75% male) had rSTEMI, of whom 1941 (55%) had TV- and 1576 (45%) had nonTV-STEMI after 615 (77, 1683) days since first infarction (Figure 1). Patients with nonTV-STEMI had higher BMI (27.2 vs 26.8 kg/m2, p=0.03), more hypertension (76.9 vs. 73.5%, p=0.02) and atrial fibrillation (4.7 vs. 3.3%, p=0.04), but had lower left ventricular ejection fraction (43 [35,50] vs. 45 [38,50], p<0.001) compared with TV-STEMI. On coronary angiography nonTV-STEMI had more frequently TIMI flow ≥1 (44.9 vs. 28.0%, p<0.001), multivessel disease (51.8 vs. 41.1%, p=0.003), culprit lesion located in circumflex artery (15.2 vs. 4.8, p<0.001) and more frequently underwent stenting (88.4 vs. 76.1%, p<0.001) compared with TV-STEMI. There was no difference in unadjusted 1-, 3- and 5-year mortality between nonTV-STEMI and TV-STEMI group (14.9 vs. 14.7%, p=0.9; 23.4 vs. 24.2%, p=0.64 and 29.6 vs. 32.9%, p=0.1 respectively). The propensity-score matching of 825 patients with TV- and 826 patients with nonTV STEMI suppressed all baseline differences, but adjusted mortality remained similar between study groups (Figure 1).

Conclusion

While patients with recurrent nonTV-STEMI have different clinical and angiographic characteristics compared with TV-STEMI, the long-term mortality in these groups is similar.

Figure 1

Funding Acknowledgement

Type of funding source: None

Managed care improves prognosis in AMI patients irrespectively of the hospital setting. Data from the MAnaged Care for Acute Myocardial Infarction Survivors (MACAMIS) Programme

Background

In 2017 a nation-wide system of managed care for MI survivors comprising acute treatment of MI, cardiac rehabilitation and cardiac ambulatory care within one year following MI was implemented in Poland. The managed care programme (MCP) was proved to be related to lower risk of all-cause death. The goal of the analysis was to assess the effectiveness of MCP in patients discharged from university, district, municipal and non-public hospitals.

Methods

The database of survivors of acute MI discharged from hospital from October 1, 2017 to December 31, 2018 was analyzed. Patients who died within 10 days after discharge were excluded from the analysis. The primary end-point was defined as death from any cause. Propensity-Score Matching using nearest neighbor matching was used to form comparable groups of patients participating and not participating in the MCP. The Cox proportional hazard regression analysis was used to assess the relation between MCP and the overall mortality.

Results

MCP was implemented in the first stage in 48 hospitals spread around the country (about 34% of all hospitals treating acute MI patients in Poland). Among them 14 were university, 20 district, 8 municipal and 6 nonpublic hospitals. Out of 34064 patients discharged from hospitals with MCP implemented 10404 patients (30.5%) participated in MCP. They were matched with 10404 patients not participating in the MCP. About 24% of the analyzed patients were discharged from university hospitals, 42% from district hospitals, 20% from nonpublic, 14% from municipal and other hospitals. During 326.3±134.8 days of follow-up 1062 patients died (4.4% vs. 6.5% of patients participating and not participating in the MCP; p<0.001). Hazard ratios related to MCP of patients hospitalized in each hospital categories are presented in the table.

Conclusion

The implemented in Poland nation-wide system of managed care for MI survivors is related to improved survival in all hospital settings.

Funding Acknowledgement

Type of funding source: None

Coronary sinus oxidative stress markers allow for accurate assessment of the prognosis in patients with advanced heart failure awaiting transplantation

Background

Oxidative stress is a cause of cardiac diseases and contribute to apoptosis, cardiac remodeling, cardiac growth and repair. The end-stage heart failure (HF) is associated with ischemia-reperfusion, increased neurohumoral activity, cytokine stimulation and presence of inflammatory cells. Above factors are stimuli which generate free radicals and can induce oxidative stress in the heart and cause damage to essential myocardial structures and function. However, the role of oxidative stress in end-stage HF has not been fully understood.

Purpose

This study aimed to evaluate the prognostic value of the oxidative stress markers in ambulatory patients with end-stage HF awaiting heart transplantation (HT) during a 1.5 year follow-up period.

Method

The study was a prospective analysis of 85 optimally treated adult patients with end-stage HF, who were added to the HT waiting list at the Cardiology Department between 2015 and 2016. At the time of enrollment to the study routine laboratory tests, cardiopulmonary exercise test, echocardiography, spirometry and right heart catheterization were performed in all patients. During right heart catheterization, 10 ml of coronary sinus blood was additionally collected to determine total oxidant status (TOS) and total antioxidant capacity (TAC) levels. TOS and TAC were measured by Erel's method. The endpoint was all-cause mortality during a 1.5 years follow-up. The Medical University of Silesia's local Institutional Review Board approved the study protocol, and all patients provided informed consent.

Results

Median age of the patients was 53.0 (43.0–56.0) years and 90.6% of them were male. During the observation period, the mortality rate was 40%. The area under the receiver operating characteristics (ROC) curves indicated an acceptable discriminatory power of TAC (AUC: 0.780 [CI: 0.677–0.883]; sensitivity 56%, and specificity 90%); and excellent power of TOS (AUC: 0.9530 [CI: 0.9279–0.9781]; sensitivity 88%, and specificity 94%) for 1.5 years mortality. Patients with a low TAC level (≤1.10) had a significantly worse 1.5-year survival compared to the group with a high TAC level (>1.10) (1.5 year survival: 20.8% versus 75.4%; (long rank p<0.001). Similarly, patients with a high TOS level (≥3.11) had a significantly worse survival compared to the group with a low TOS level (<3.11) (1.5- year survival: 9.1% versus 92.3%; p<0.001).

Conclusion

TAC with acceptable prognostic power and TOS with excellent prognostic power allows assessment of the prognosis in end-stage HF during a 1.5 year follow-up period.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia, Katowice, Poland

Copeptin, albumin and routine inflammatory markers are predictors of one-year mortality in patients with advanced heart failure underwent cardiac transplantation evaluation

Introduction

Despite significant advances in the prevention and treatment of heart failure (HF), the prognosis for patients with advanced stage of the disease is still poor. Therefore, a better understanding of the underlying HF pathophysiological mechanisms is crucial to improve prognosis in patients with advanced HF. One important research area is the role of inflammation in the pathophysiology of HF.

Purpose

This study aimed to investigate factors associated with mortality in HF patients with particular emphasis placed on inflammatory markers.

Methods

This is a prospective analysis of 282 optimally treated HF patients hospitalised in Cardiology Department between 2016 and 2018 for heart transplantation (HT) evaluation. Patients with contraindications to HT were excluded from the study. At the baseline echocardiography, routine laboratory tests, an ergospirometric exercise test, and right heart catheterisation were performed in all patients. In addition, 10 ml of peripheral blood was collected to determine inflammatory biomarkers. Human procalcitonin and copeptin concentrations were measured by the sandwich enzyme-linked immunosorbent assay (ELISA) with the commercially available kit. A highly sensitive latex-based immunoassay was used to detect plasma C-reactive protein (CRP) using the COBAS Integra 70 analyzer. The end-point of the study was all-cause mortality during one-year follow-up. The study protocol was approved by the Local Ethics Committee of our medical university. All patients provided informed, voluntary consent to participate in the study.

Results

The median age of patients was 57 (51–60) and 87.6% of them were male. A total of 79 (28%) patients died during a one-year follow-up. Multivariate analysis of the Cox proportional hazard model confirmed that procalcitonin [hazard ratio (HR) 1.003 (1.002–1.003), p<0.001], high sensitivity C-reactive protein (CRP) [HR 1.109 (1.039–1.183), p<0.002], copeptin [HR 1.109 (1.019–1.207), p<0.02] and albumin [HR 0.925 (0.873–0.979), p<0.01] serum concentrations, as well as Erythrocyte Sedimentation Rate (ESR) [HR 1.031 (1.001–1.063) p<0.05] were associated with mortality during a one-year follow-up.

Conclusions

Our study demonstrated that higher procalcitonin, CRP and copeptin serum concentrations as well as higher ESR and lower albumin serum concentrations are independently associated with reduced survival in patients with advanced HF.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia

Valsartan improves left ventricle contractility and prevents its remodeling in patients with dual chamber pacemaker

Introduction

Permanent right ventricle pacing leads to left ventricle dyssynchrony, systolic dysfunction, remodeling, and symptomatic heart failure in the long run. Valsartan is well known for its preventive anti-remodeling function in the post infarction heart remodeling.

Objectives

To assess the effect of valsartan on left ventricle contractility, measured as global longitudinal stain, and its remodeling in patients with second and third degree atrioventricular block with first-time implantation of dual chamber pacemaker.

Methods

This was a randomized, double-blind, placebo controlled single center study. One hundred eligible patients were assigned in a 1:1:1 fashion to receive placebo, valsartan 80mg or 160mg once daily, respectively. Echocardiographic assessment of left ventricle geometry, its systolic and diastolic function was performed at baseline and at twelve months. Global longitudinal strain (GLS) was measured off-line with EchoPac software. One patient from placebo group suffered stroke. We present the baseline date for 100 enrolled patients and follow-up data for 88 patients who have completed the study. Data in valsartan arms are pooled in one group.

Results

Results are presented in table. Data are presented as mean and standard deviation.

Valsartan alleviates diastolic dysfunction, left ventricle dilation and protects from loss of systolic function.

Conclusion

Valsartan has protective effect of left ventricle contractile function and remodeling. It may be useful in prevention of pacing induced heart failure. (ClinicalTrials Identifier NCT01805804)

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Medical University of Silesia

Klotho protein, albumin level, left ventricular and left atrium dimensions are independently associated with moderate and severe cardiac allograft vasculopathy in heart transplant recipients

Background

Cardiac allograft vasculopathy (CAV) is one of the main risk factors influencing graft loss and patients survival. An important element of monitoring the patient after heart transplantation (HT) is the assessment of non-invasive indicators associated with the occurrence and progression of CAV. Therefore, new noninvasive sensitive and specific tools are necessary for detecting CAV early, which may result in the modification of immunosuppressive therapy, increase in statin doses, and intensive treatment of CAV-related comorbidities.

Purpose

The aim of the study was to research for factors associated with occurrence of moderate to severe CAV in heart transplant recipients.

Methods

Our analysis included consecutive adult patients after HT with CAV who underwent routine visits in our institution between 2015–2017. Exclusion criteria included history of kidney diseases, hepatitis B and C, autoimmune diseases, chronic pancreatitis or thyroid diseases, and cerebrovascular accidents. During each visit, all patients underwent echocardiography, laboratory tests, immunosuppressive drugs serum concentration analyses, and coronary angiographies. In addition, Klotho protein concentration was measured in all patients using sandwich enzyme-linked immunosorbent assay (ELISA) with the commercially available kit. Coronary angiographies of all patients enrolled to the study were reviewed by two independent interventional cardiologists to accurately classify coronary artery lesions according to International Society for Heart and Lung Transplantation (ISHLT) guidelines. Then, patients were divided into a group with mild CAV (1) and moderate to severe CAV (2/3). The local institutional review board of the Medical University of Silesia approved the study protocol, and all patients provided informed consent.

Results

The final group consisted of 141 patients with CAV. The age of the patients was 60.0 (53.0–66.0) and 77.5% of them were male. The median time from HT to include in the study was 11.6 (8.5–15.0) years. The frequency of CAV 2/3 in the analysed population was 36.6%. All included patients received optimal immunosuppressive therapy consisting of a calcineurin inhibitor (tacrolimus or cyclosporin) and mycophenolate mofetil. Multivariate analysis of logistic regression showed that Klotho protein (OR = 0.719 [0.598–0.866], p<0.001), albumin (OR=0.790 [0.686–0.910] p<0.001), left ventricular diastolic dimension (OR =1.135 [1.054–1.222], p<0.001), and left atrium dimension (OR=1.058 [1.013–1.106] p=0.012) were independent factors of CAV 2/3 presence.

Conclusions

Lower Klotho and albumin levels, as well as left ventricular and left atrium dimensions are the independent factors of moderate to severe CAV presence.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): MEdical University of Silesia, Katowice, Poland

Exhaled air analysis for pulmonary arterial hypertension fingerprints identification

Background

Pulmonary arterial hypertension (PAH) is a rare disease which is often diagnosed in the late phase as its symptoms are non-specific and there is a lack of screening tests. Therefore, there is a strong need for identifying of its biomarkers.

Aim

To identify the biomarkers for PAH in the exhaled breath and in the serum.

Methods

The breath phase of all the patients was collected on the highly porous aseptic material by the use of special patented holder PL 232911. The collected air was then examined with gas chromatography mass spectrometry (GC/MS). For the control of the obtained results plasma of all the patients was examined by the use of Ultra High Performance Liquid Chromatography (UHPLC). A group of 10 patients (2 men, 8 women, mean age 60.4±10.9 years, BMI 27.6±6.0 kg/m2) with diagnosed PAH as well as the group of 10 healthy persons (6 men, 4 women, mean age 35±11 years, BMI 25.6±6.0 kg/m2) were enrolled into the study.

Results

The obtained spectral and chromatographic results clearly presents the qualitative and quantitative QA/QC sensitivity to the metabolites changes in the patient's breath. The identification of changes in ratio of the whole spectra of biomarkers can allow to obtain a multi-dimensional pathways for PAH diagnostics fig. 1. The chromatography data from patients suffering from PAH have been processed by the aid of signal processing toolbox in MATLAB. Only the peaks of the prominence of at least 10000 (experimentally established) have been taken under consideration. The prominence of a peak measures how much the peak stands out due to its intrinsic height and its location relative to other peaks. Next, for the each found peak the arguments of the two neighboring local minima, have been determined and the integration range for calculating the area under the each peak have been established. The ratio of the area under the significant peak to its prominence have been applied for further analysis.

Conclusions

Based on our preliminary results it seems that our method is specific and sensitive in the range of selected bio-fingerprints in patients with PAH. If confirmed on larger population the molecular level breath analysis can be used as a screening test as well as complementary diagnostic method in PAH to the standard clinical practice.

Figure 1. The chromatograms of representative spectra for patients suffering from PAH (red), control (blue) with distinguished significant peaks (presented in the magnification according to their prominence). On the right side, there are the graphical presentation (area/prominence for peaks) of arbitrary chosen patient, but with reference to the original data and for two data approximations obtained by the DWT, which are important in the case of weak separated peaks.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Silesia in Katowice

Managed care improves prognosis in acute myocardial infarction survivors. Data from the MAnaged Care for Acute Myocardial Infarction Survivors (MACAMIS) Programme

Background

Mortality following acute myocardial infarction (MI) remains high despite progress in pharmacotherapy and interventional treatment. In 2017 a nation-wide system of managed care for MI survivors comprising a continuum of acute treatment of MI, staged revascularization, cardiac rehabilitation, cardiac electrotherapy and cardiac ambulatory care within one year following MI was implemented in Poland. The managed care programme (MCP) includes also the quality of care assessment based on clinical measures (e.g. cardiovascular risk factors control) as well as on the rate of minor and major cardiovascular events. The goal of the analysis was to assess the overall mortality of MI survivors participating and not participating in the MCP.

Methods

The database of survivors of acute MI discharged from hospital from October 1, 2017 to December 31, 2018 was analyzed. Patients who died within 10 days after discharge were excluded from the analysis. The primary end-point was defined as death from any cause. Propensity-Score Matching (PSM) using nearest neighbor matching was used to form comparable groups of patients participating and not participating in the MCP. The Cox proportional hazard regression analysis was used to assess the relation between MCP and the overall mortality.

Results

MCP was implemented in the first stage in 48 hospitals spread around the country (about 34% of all hospitals treating acute MI patients in Poland). Out of 87739 analyzed patients (age: 68.1±11.9 years; 55581 men and 32158 women) 34064 were hospitalized in hospitals with MCP implemented. Altogether 10404 patients (11.9% of the whole cohort; 30.5% of those hospitalized in hospitals with MCP implemented) participated in MCP. They were matched with 10404 patients not participating in the MCP. During 324.8±140.5 days of follow-up 7413 patients died. One-year mortality was lower in patients participating in the MCP both when we analyzed the whole cohort (4.4% vs. 9.5%; p<0.001) as well as when we limited the analysis to the PSM groups (4.4% vs. 6.5%; p<0.001, figure 1). MCP was related to the overall mortality in univariate (HR 0.43 [0.39–0.48]) as well as in multivariate analysis (0.64 [0.57–0.71]) in the whole cohort as well as in the PSM cohort (HR 0.63 [0.56–0.72] and 0.64 [0.56–0.72] for the univariate and multivariate analysis respectively). When we limited the analysis to hospitals in which MCP was implemented one-year mortality was 4.3% vs. 6.3% (p<0.001) whereas univariate HR was 0.51 (0.44–0.60) and multivariate HR 0.52 (0.44–0.61).

Conclusion

The implemented in Poland nation-wide system of managed care for MI survivors is related to improved survival. Therefore, the Ministry of Health plans to implement the programme in all cardiac centers in Poland.

Funding Acknowledgement

Type of funding source: None

Patient survival after acute myocardial infarction treated with primary percutaneous coronary intervention within the left main coronary artery according to time of admission

Background

Previously published studies assessing the time effect of primary percutaneous intervention (PCI) on long-term clinical outcomes in an overall group of patients with acute coronary syndromes has been widely investigated. It has been suggested that night-time admission may negatively influence long-term overall mortality. Patients treated within the left main coronary artery (LMCA) belong a narrow group of high-risk procedures that require an operator and a team with high skills.

Purpose

The aim of the presented study was to assess the relationship between the time of pPCI (day- vs. night-time) and overall mortality among patients treated due to AMI within the LMCA.

Methods

This observational study was performed on 443,805 patients hospitalised due to non-ST segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI). Patients were prospectively enrolled between January 2006 and December 2018 in the ongoing Polish Registry of Acute Coronary Syndromes (PL-ACS). From the overall group of patients, the authors selected 5,404 patients treated within the LMCA. After taking exclusion criteria into consideration, the patients were divided according to time of PCI treatment: daytime hours (7:00 a.m.-10:59 p.m.) – 2,809 patients and night-time hours (11:00 p.m. - 6.59 a.m.) – 473 patients.

Results

Patients treated during night-time and daytime did not differ significantly in age (70.79 [61.52–79.73] vs. 69.73 [60.8–78.82] years, p=0.13) or gender – males (67.6% vs. 67.0%, p=0.79). Patients treated during daytime presented with significantly higher rate of STEMIs (67.2% vs. 49.9%) and lower rate of NSTEMIs (32.8% vs. 50.1%) in comparison to those treated during night-time (p<0.001). The 30-day and 12-month overall mortality rates were significantly greater among patients treated during night-time hours (20.3% vs. 14.9%, p=0.003) and (31.7% vs. 26.2%, p=0.001). Kaplan-Maier survival curves confirmed this relationship (p=0.001). Multiple regression analysis did not confirm that the time of pPCI (day- vs. night-time) is significantly related to survival (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 0.96–1.55, p=0.099). However, significance was achieved for the left ventricle ejection fraction (HR: 0.95; 95% CI: 0.94–0.95, p<0.001), systolic blood pressure on admission (HR: 0.995; 95% CI: 0.991–0.998, p=0.005), age (HR: 1.04; 95% CI: 1.03–1.05, p<0.001), the use of intra-aortic balloon counterpulsation (HR: 1.04; 95% CI: 1.03–1.05, p<0.001) and diagnosed peripheral artery disease (HR: 1.55; 95% CI: 1.2–2.01, p<0.001).

Conclusions

The time of pPCI (day- vs. night-time) in patients with AMI and treated within the LMCA is related to the overall 30-day and 12-month survival which is poorer in those treated during the night-time. However, this relationship was not confirmed by multiple regression analysis and was not found to be significant among other stronger predictors.

Funding Acknowledgement

Type of funding source: None

Coronary sinus catalase and ceruloplasmin levels predict all-cause mortality in patients with end-stage heart failure awaiting heart transplantation

 

Background, As a consequence of the worldwide increase in life expectancy and due to significant progress in the pharmacological and interventional treatment of heart failure (HF), the proportion of patients that reach an advanced phase of disease is steadily growing. Hence, more and more numerous group of patients is qualified to the heart transplantation (HT), whereas the number of potential heart donors has remained invariable since years. It contributes to deepening in disproportion between the demand for organs which can possibly be transplanted and number of patients awaiting on the HT list. Therefore, accurate identification of patients who are most likely to benefit from HT is imperative due to an organ shortage and perioperative complications.

Purpose

The aim of this study was to identify the factors associated with reduced survival during a 1.5-year follow-up in patients with end-stage HF awating HT.

Method

We propectively analysed 85 adult patients with end-stage HF, who were accepted for HT at our institution between 2015 and 2016. During right heart catheterization, 10 ml of coronary sinus blood was additionally collected to determine the panel of oxidative stress markers. Oxidative-antioxidant balance markers included glutathione reductase (GR), glutathione peroxidase (GPx), glutathione transferase (GST), superoxide dismutase (SOD) and its mitochondrial isoenzyme (MnSOD) and cytoplasmic (Cu/ZnSOD), catalase (CAT), malondialdehyde (MDA), hydroperoxides lipid (LPH), lipofuscin (LPS), sulfhydryl groups (SH-), ceruloplasmin (CR). The study protocol was approved by the ethics committee of the Medical University of Silesia in Katowice. The endpoint of the study was mortality from any cause during a 1.5 years follow-up.

Results

The median age of the patients was 53.0 (43.0–56.0) years and 90.6% of them were male. All included patients were treated optimally in accordance with the guidelines of the European Society of Cardiology. Mortality rate during the follow-up period was 40%. Multivariate logistic regression analysis showed that ceruloplasmin (odds ratio [OR] = 0.745 [0.565–0.981], p=0.0363), catalase (OR = 0.950 [0.915–0.98], p=0.0076), as well as high creatinine levels (OR = 1.071 [1.002–1.144], p=0.0422) were risk factors for death during 1.5 year follow-up.

Conclusions

Coronary sinus lower ceruloplasmin and catalase levels, as well as higher creatinine level are independently associated with death during 1.5 year follow-up.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of SIlesia, Katowice, POland

Coronary sinus fetuin and sodium levels are independently associated with all-cause mortality in patients awaiting heart transplantation

Background

Risk stratification is a critical component of selection process of the patients with end-stage heart failure (HF) who are considered for heart transplantation (HT). Due to the constantly increasing number of the patients placed on the transplant waiting lists and a global shortage of organs available for HT, the key issue becomes an accurate risk stratification of death and proper organ allocation to these patients who will benefit the most from this form of treatment.

Purpose

The aim of this study was to identify the factors associated with mortality during a 1.5-year follow-up in patients with end-stage HF awaiting HT.

Methods

We prospectively analysed 72 patients with advanced HF awaiting HT at our institution between 2015 and 2016. At the time of inclusion in the study routine laboratory tests, cardiopulmonary exercise test, echocardiography, and right heart catheterisation were performed in all patients. During right heart catheterisation, 10 ml of coronary sinus blood was collected. Fetuin serum concentration was measured by the sandwich enzyme-linked immunosorbent assay (ELISA) with the commercially available kit.The end-point was defined as all-cause mortality during a 1.5 years follow-up. Our medical university local Institutional Review Board approved the study protocol, and all patients provided informed consent. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Results

Patients' median age was 53.00 (46.00–58.00) years, and 91.7% were men. During the 1.5-year follow-up, 31 (43.1%) patients died. The area under the receiver operating characteristic curve indicated a good discriminatory power of fetuin (AUC: 0.917 [95% CI: 0.858–0.977]). The cut-off point for fetuin (<632.36) had a sensitivity of 87% and a specificity of 83%. Patients with a lower fetuin level had a significantly worse 1.5-year survival compared to the group with a higher fetuin level (20.6% versus 89.5%; (long rank p<0.001). Fetuin OR 0.990 (0.986–0.996); p<0.001) and plasma sodium levels (OR, 0.640 [0.464–0.882]; p<0.001) were independent predictors of death during 1.5-year follow-up period.

Conclusions

Our study demonstrated that a low coronary sinus fetuin and peripheral blood sodium levels are associated with mortality patients with advanced HF accepted for HT. In addition, fetuin level, with excellent prognostic strength, allows for the risk stratification of death in analysed group of patients.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia

P429The efficacy of electrical cardioversion of long-standing persistent or permanent atrial fibrillation in cardiac resynchronization therapy recipients

Funding Acknowledgements

Institute of Cardiology statutory grant (grant no.: 2.30/VII/13)

Background

Atrial fibrillation (AF) and heart failure (HF) often co-exist and influence each other. The presence of AF is often regarded as a marker of HF severity.  Moreover, AF in cardiac resynchronization therapy (CRT) recipients hinders the CRT effectiveness in HF treatment by the reduction of the percentage of biventricular paced beats (BiVp%). Sinus rhythm (SR) restoration makes CRT more effective in HF treatment which may protect AF recurrence.

Purpose

To establish the effectiveness of electrical external cardioversion (EEC) in CRT patients with long-standing persistent AF or permanent, pre-treated with amiodarone.

Methods

The population of the study comprised of the Pilot-CRAfT study participants (NCT01850277), that is patients with CRT, long-standing persistent or considered as permanent AF and BiVp ≤ 95% who were randomly assigned to the "rhythm control" or the "rate control" strategy. The inclusion criteria included an AF paroxysm lasting at least 6 months. Both treatment arms received amiodarone beginning with the loading dose. Subsequently, patients assigned to the rhythm control strategy underwent electrical cardioversion. Rate control strategy included pharmacotherapy and atrioventricular node ablation, as needed. The follow up visit was performed 3 months after the enrolment visit. The EEC effectiveness, an AF recurrence within the 3 month period, BiVp% changes, the EEC parameters  and the EEC related complications were analysed.

Results

Out of 48 participants enrolled in the Pilot-CRAfT study, 25 patients were assigned to the rhythm control arm. The mean age of the rhythm control arm patients was 69,5 years , the mean left ventricular ejection fraction was 30,6% , the mean left atrium diameter was 53 mm and the median duration of persistent AF was 16 months. SR was obtained in 12 out of 20 (60%) patients who underwent the EEC . On the 3 month visit 8 patients remained in SR (40%). In patients with an AF paroxysm lasting less than 1 year the success rate was 100% vs 50% in the AF lasting 1 year at least (p = 0,11 ). After 3 months, SR remained in 100% vs 25% of patients, respectively (p =0,015.).  The effectiveness of anterior-posterior EEC electrodes placement was 20% and it was 71% for the anterior-lateral patch location . The EEC resulted in significant BiVp% rise - also in the whole intention-to-treat (ITT) group:  88,58%  before the EEC vs 96,68% after the EEC  (p = 0,002). No severe adverse events of the EEC were observed.

Conclusions

The electrical cardioversion of persistent atrial fibrillation lasting more than 6 months in patients with severe HF and treated with CRT is characterised by modest success rate, even after the amiodarone pre-treatment. However, the ECC ensures significant rise in BiVp% close to 97%, even in the whole EEC group based on the ITT principle. The AF paroxysm duration <1 year and the anterior-posterior patch placement may ensure better EEC efficacy in this group of patients.

P3396Identification of patients at extremely-high cardiovascular risk within a very-high risk population from the TERCET Registry

Background

The latest guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) introduced a new “ultra-high risk” category of patients, for whom a low-density lipoprotein cholesterol (LDL-C) level <55 mg/dL (1.4 mmol/L) is advised.

Purpose

Based on the above, we aimed to identify the proportion of patients, who are at ultra-high/extremely-high cardiovascular (CV) risk.

Method

Finally, we analyzed the data of 19,781 consecutive patients included in theHyperlipidaemia Therapy in the tERtiary Cardiological cEnTer (TERCET) Registry admitted to the Polish tertiary cardiovascular centre between 2006 and 2018. Among them, there were 7,319 patients admitted with ACS: 3,085 due to ST-segment elevation myocardial infarction (STEMI), 2,256 due to non-ST-segment elevation myocardial infarction (NSTEMI), and 1,978 due to unstable angina (UA), as well as 12,462 due to stable angina (SA). According to the European Society of Cardiology (ESC), all patients included in the Registry are at very high CV risk. All of the patients included in the registry underwent coronary angiography during the hospital stay. On the basis of the multivariate analysis, we aimed at determining the subgroup of the patients with the most unfavourable 12-month outcomes and therefore to indicate the risk factors responsible for extremely-high CV risk.

Results

According to the results of the multivariate analysis performed with stepwise backward regression, we identified the following risk factors: LVEF<40% (odds ratio [OR]=3.51, 95% CI: 2.87–4.29), prior stroke (OR=2.28, 95% CI: 1.65–3.01), diabetic nephropathy (OR=2.16, 95% CI: 1.68–2.77), age>75 years (OR=1.84, 95% CI: 1.33–2.55), atrial fibrillation (OR=1.81, 95% CI: 1.45–2.25), acute MI at admission (OR=1.56, 95% CI: 1.26–1.95), multivessel CAD (OR=1.40, 95% CI: 1.15–1.72), prior MI (OR=1.31, 95% CI: 1.07–1.60) and lower body-mass index (OR=1.02 per 1 kg/m2+ less, 95% CI: 1.00–1.04) that might help to define the group of very high risk patients, who should be considered as of extremely-high cardiovascular risk (all p<0.05). The aggregate summary of risk factors associated with “ultra-high” risk is presented in the attached Figure.

Multivariate analysis results

Conclusions

To our best knowledge, the presented study is the first such an analysis conducted on such a large population of very-high cardiovascular risk patients gathered in the registry of secondary cardiovascular prevention. In very-high cardiovascular risk patients, potential risk factors were identified that might help to establish the group of individuals at extremely high CV risk what contributes to higher 12-month mortality.

Acknowledgement/Funding

None

P6333Therapy-induced weight gain is associated with higher appendicular muscle mass in patients with heart failure

Background

The catabolic predominance in acute heart failure (HF) leads to significant weight loss. The low body weight before HF (preHF) and the loss during its natural course, both are risk factors of sarcopenia and worse clinical outcome in HF. Modern therapy can inhibit or even reverse catabolism resulting in oedema-free weight gain. It is unknown if therapy-induced weight gain can protect against low appendicular skeletal muscle mass (ASM) – the key prerequisite of sarcopenia.

Aims

We intended to assess whether therapy-induced oedema-free weight gain protects against low ASM.

Material and methods

In 802 patients with HF (age: 52±10 years 13% women, LVEF: 24±7%, NYHA: 2.6±0.7), we analysed weight changes from preHF to minimal oedema-free weight during HF (minHF), and then weight occurring after removal of all reversible factors aggravating HF with optimisation of therapy (indexHF). At index date we performed dual X-ray densitometry (DXA) calculating ASM as the sum of lean mass within the legs and arms adjusted to body size. The low ASM was defined as ≤7 and 6 kg/m2 in men and women respectively. The catabolic (C) and anabolic (A) components of weight change ware calculated based of formulas: C=100*(minHF-preHF)/preHF, A=100*(indexHF-minHF)/minHF. Using logistic regression we estimated the risk of low ASM after adjustment for potential confounders.

Results

The median C and A were −11.7% and 3.3% respectively. The low ASM was found in 230 (28.7%) patients. In multivariable model comprising age, gender, weight preHF, C and A, the odds for low as compared to normal ASM are shown in table 1.

Odds ratio ± 95% CI Normal ASM Low ASM Gender (man v. women) 1.0 0.87 (0.81–0.94), p=0.0002 Weight preHF (per 1 kg/m2 increase) 1.0 0.85 (0.83–0.87), p<0.0001 Age (per 5 years increase) 1.0 1.05 (1.02–1.08), p=0.0003 C (per 1% increment) 1.0 1.05 (1.04–1.06), p<0.0001 A (per 1% increment) 1.0 0.98 (0.97–0.99), p<0.0001

Conclusions

In HF higher body weight preHF and oedema-free weight gain decreases the risk of low ASM independently of age, gender and weight loss.

P820The prevalence and management of familial hypercholesterolemia in patients with acute coronary syndrome in Poland: results of the TERCET Registry

Background

Prevalence of familial hypercholesterolemia (FH) is high among patients with CAD. However, data on FH among ACS patients are still scarce. Therefore, we aimed to assess the prevalence, lipid-lowering therapy and short- and long-term outcomes in FH patients with ACS.

Methods

We finally included 19,781 consecutive patients from the Hyperlipidaemia Therapy in the tERtiary Cardiological cEnTer (TERCET) Registry for years 2006–2018, including 7,319 patients with ACS: 3,085 with STEMI, 2,256 with NSTEMI, and 1,978 due to unstable angina (UA) (stable CAD group [n=12,462] was treated as a reference). FH diagnosis was based on Dutch Lipid Clinic Network (DLCN) score.

Results

The overall occurrence of probable/definite FH and possible FH were 1.2% and 13.7% respectively. In ACS patients 1.6% had probable/definite FH and 17.0% possible FH. The highest occurrence of FH was observed in STEMI subgroup, where 20.6% of the patients had ≥3 points according to the DLCN criteria. In patients with definite/probable FH, 98.1% were administered statins at discharge (including 57.5% prescribed intensive statin therapy in comparison to only

23.7% in non-FH patients). Patients with definite/probable FH had higher in-hospital and 30-day mortality than patients without FH (3.5% vs 1.2%, p=0.0046 and 4.4% vs 1.7%, p=0.024, respectively). However, no significant differences in investigated outcomes were observed between the FH groups in the 12-month and 36-month follow-up.

The number of patients with FH

Conclusion

The prevalence of FH (definite/probable/possible) in the Polish very high-risk population is even 14.9% and is significantly higher in patients with ACS than in patients with stable CAD. High intensive lipid lowering therapy, including the combination therapy allows improving long-term outcomes in patients with FH.

P3760Temporal trends in stroke prevalence and its associations with changing patterns of antithrombotic regimens in patients with atrial fibrillation and a wide spectrum of coronary artery disease

Introduction

Much of the morbidity and mortality associated with atrial fibrillation (AF) is due to cerebrovascular thrombo-embolic complications such as ischemic stroke. Antithrombotic therapy is the fundamental treatment for many cardiovascular conditions, e.g. coronary artery disease (CAD), AF, and stroke to prevent thrombotic complications and death, but many patients have both CAD and AF. Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor has proven most effective in patients with recent myocardial infarction (MI) or after percutaneous coronary intervention (PCI), whereas for AF, oral anticoagulation (OAC) is most effective, with lesser efficacy but similar bleeding using DAPT. We investigated temporal trends in stroke prevalence and its associations with changing patterns of antithrombotic regimens in patients with non-valvular AF and a wide spectrum of co-incident CAD.

Methods

The Silesian TRiplE Antithrombotic Therapy (TREAT) Registry enrolled 14,873 patients with CAD from 2006 to 2014: 9,379 with stable CAD (SCAD), 1,460 with unstable angina (UA), 1,760 with NSTEMI and 2,328 with STEMI. We compared temporal trends in clinical features, an incidence of clinical events and patterns of antithrombotic regimens.

Results

2,194 of 14,873 patients (14.6%) had AF, including 74.1% with SCAD, 7.7% with UA, 10.1% with NSTEMI and 8.1% with STEMI. The AF prevalence increased from 11.2% in 2006 to 17.2% in 2014 which may be attributed to increasing age from 62.7 in 2006 to 67.8 in 2014. Overall, there was an increasing use of OAC therapy alone or with SAPT or DAPT from 46–50% in 2006–7 to 77–86%% in 2013–14. There was a steady increase in utilization of TREAT, and OAC ± SAPT throughout the study period (Panel A): after PCI there was a substantial increase in TREAT with a steady decline in DAPT (Panel B). The stroke rates declined throughout the study period from 3.3% in 2004 through a peak of 4.9% in 2011 to 1.1% in 2014. Conversely, bleeding rates increased from 6.0% to 10.5%.

Conclusions

There has been an increase followed by a progressive decline in stroke rate despite increasing age and AF prevalence in patients with both CAD and AF. This phenomenon is associated with a significant increase in the proportion of AF patients receiving guideline-recommended OAC therapy, driven by a steady increase in the utilization of triple antithrombotic therapy in patients following ACS or stent implantation and increase in OAC monotherapy in patients without ACS or stent implantation. This positive effect on stroke incidence is offset by increased bleeding risk, necessitating a closer look at the duration of triple therapy for ACS or PCI, and the long-term requirement for additional antiplatelet treatment in uncomplicated CAD.

P4510Impact of secondary tricuspid regurgitation on survival in heart failure - insights from COMMIT-HF registry

Background

Functional tricuspid regurgitation (fTR) is common in left sided heart disease, especially in patients with concomitant left-sided valvular diseases and can lead to functional impairment and reduced survival. However, the impact of fTR on survival in chronic heart failure with reduced left ventricular ejection fraction (HFrEF) without severe left valvular diseases (LVD) is not fully established. The aim of the present study was to observe if moderate to severe fTR may influence the survival in patients with HFrEF without severe LVD.

Methods

We have analyzed a large single-center registry (n=2731) of HFrEF patients treated in a large-volume cardiovascular center between 2009–2015. After exclusion of patients with severe aortic and mitral valve disease we have included 2435 patients with HFrEF (left ventricular ejection fraction (LVEF) ≤35%). Functional moderate to severe tricuspid regurgitation without severe left valvular diseases was present in 465 patients. Twelve -month vital status was available for the whole patient population. Univariate and multivariate Cox proportional hazard regression models were performed to evaluate the relationship between moderate to severe fTR and mortality in the study group.

Results

Comparison of clinical data of fTR and non-fTR in HFrEF patients revealed some significant differences (age 63.3±12.9 vs 61.3±12.4, p=0.002; female sex 25.8% vs 17,9%, p<0.001; chronic kidney disease stage III-V 45.3 vs 26.6%, p=0.001; atrial fibrillation 52.4% vs 28.5%, p<0.001). Twelve-month all-cause mortality was over 2-fold higher in the fTR group (21.2% vs 8.1%, p<0.001). There were no significant differences with regard to the medical treatment, implantable defibrillator or cardiac resynchronization therapy. The presence of fTR was identified as an independent echocardiographic factor impaired 12-month all-cause survival (HR 1.59, CI 1.2- 2.09, p<0.001, figure 1)

Conclusion

Apart from the LVEF, the presence of moderate to severe fTR may predict 12-month all-cause mortality in patients with HFrEF.

Acknowledgement/Funding

None

P956Management of coronary artery disease in elderly patients with ischemic heart failure and reduced ejection fraction - insights from the COMMIT-HF study

Background

Heart failure (HF) is one of the most important global health problems in developed and ageing societies. Coronary artery disease (CAD) is the most common etiologic factor, related to poor outcomes. Data on CAD management in HF is scarce, especially when addressing subpopulations often omitted in randomized trials, such as the elderly.

Purpose

With a large cohort of HF patients (n=2730) we have decided to assess the clinical profile, treatment modalities and outcomes in elderly patients undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed a large single-center all-comer registry of HF patients (left ventricular ejection fraction LVEF≤35%) treated in a large-volume cardiovascular center (2009–2015). Acute coronary syndromes on admission were excluded. Patients with ischemic etiology were selected for further analysis (n=1703) and subsequently divided into the elderly (≥75 y.o., n=346) and young (<75 y.o., n=1357) subgroups.

Results

The elderly group had understandably a worse clinical profile (mean age 79,1±3,5 vs 61,2±8,2, p<0,001; male 75,2 vs 85,4%, p<0,001; NYHA III & IV 60,3 vs 49,6%, p=0,07; diabetes 50,3 vs 44,9%, p=0,07; AF 35,8 vs 22,0%; p≤0,001; anemia 52,6 vs 36,7%, p<0,001; chronic kidney disease stage III-V 54,1 vs 28,9%, p<0,001; severe mitral insufficiency 13,3 vs 8,7%, p=0,01; history of myocardial infarction 68,8 vs 67,4%, p=0,62).ICD or CRT-D were implanted less frequently in the elderly (56,1 vs 68,5%; p<0,001). Echo analysis revealed significantly better LVEF (27,95,3± vs 25,9±6,0%, p<0,001) and less ventricular dilation (LVEDV 159±61 vs 205±82 ml, p<0,001).

Coronary angiography was performed frequently in both groups (78,6 vs 74,9%, p=0,15). Significant lesions were observed in 73,5 and 65,0% of cases respectively (p=0,008). The elderly were insignificantly less frequently qualified for CABG (9,0 vs 12,5%, p=0,17). Proportion of patients qualified for medical management of CAD was similar (23,5 vs 20,7%, p=0,40). PCI was performed frequently in both groups (59,5 vs 57,9%, p=0,69), often as multi-vessel procedures (34,4 vs 32,4%, p=0,67). There was a trend towards more complete revascularization in the younger patients (50,0 vs 59,5%, p=0,06). 12-month all-cause mortality was significantly higher in the elderly (20,3 vs 7,8%, p<0,001). Periprocedural compilications were very low and comparable (bleeding and/or need for transfusion, stroke and myocardial infarction). PCI itself was not a factor influencing long term outcomes (HR 0,75, 95% CI 0,51–1,1, p=0,15). Cox regression analysis revealed that prior stroke, ejection fraction, ICD and beta-blockers were the factors influencing survival (figure 1).

Conclusions

The analysis shows that PCI is a viable treatment option in the elderly population and when indicated can be performed safely, with good short and long term results. Interventions such as ICD implantation or optimal medical therapy of HF should always be considered.

Acknowledgement/Funding

None

P1699Non-ST segment elevation miocardial infarction (NSTEMI) vs. Unstable angina (UA) in young women aged < 45 years - differences in symptomatology, clinical course, treatment and prognosis

Background

Almost 50% of all ACS in young women are NSTEMI and UA. Due to the type of ACS we observed differences in the symptomatology, treatment and outcomes. The aim was to evaluate the differences in the clinical course and prognosis in young women aged ≤45 years with NSTEMI vs. UA.

Methods

We compared 1143 women aged ≤45y.o. with acute cardiac syndromes: 51% NSTEMI, 49% UA from the PL-ACS registry between 2007 - 2014.

Results

Chest pain was predominant in both group, with a higher incidence in NSTEMI group (91.7% vs. 84.7, p=0.0002). UA group was older (42y.o. vs. 41y.o p=0.003), more often presents atypical symptoms (8.0% vs. 1.5%, p<0,0001) mostly with dyspnea (3.9%vs. 1.7%, p=0.025). During NSTEMI more often occurred pre-hospital cardiac arrest (2.9% vs. 0.8%, p=0.0031). There was no difference between groups in general condition at admission expressed by Killip class. Onset-to-intervention time was longer in UA group (41.8 vs. 30.3 hour p=0.0053) resulted from longer door-to-intervention time only (3.3 vs. 1.5 hour, p<0.0001). In NSTEMI group more often the culprit artery was circumflex (17.1% vs. 9.3% p=0.0004) and diagonal branch (4.4% vs. 1.5%, p=0.0095) with a higher number of total occlusions (pre-procedural TIMI 0: 27.8% vs. 15.6% p=0,0023). Number of PCI was also higher in this group (50.9% vs. 36.1%, p<0.0001) without differences in completed revascularizations. In UA group in stent restenosis was found more often (2.8% vs. 1.5%, p=0.026). Drug eluting stents (DES) were often used in UA group (60.2% vs. 49.6% p=0.027). There were no difference in the incidence of PCI complications. We observed a lower usage of clopidogrel, GP IIb/IIIa inhibitors and parenteral anticoagulant in UA group during hospitalization (for all p<0.0001). Ejection fraction LVEF was higher in UA group (56% vs. 54% p=0.0026) at discharge. The 30-day and 1 year prognosis in both group was low with no statistical difference (Table 1).

Table 1. Mortality rate in studied group NSTEMI group (N=580) UA group (N=563) P 30-day mortality 1.60% 0.70% 0.1799 6-month mortality 2.20% 0.90% 0.0662 One year mortality 3.10% 1.60% 0.0940

Conclusions

Clinical course of ACS in young women is different regardless of the type of ACS (NSTEMI/UA) however with no difference in mortality rate. Typical symptoms increases the probability of unstable angina (UA) 2.8 times (p=0.0003). In the UA group, ACS was rarely related to circumflex and diagonal branch with more frequent in-stent restenosis. PCI delay in patients with UA results from a longer door-to-ballon time.

P3400Definition of extremely high cardiovascular risk in patients after acute myocardial infarction - Data from the TERCET Registry

Background

The latest guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) introduced a new “ultra-high risk” category of patients, for whom a low-density lipoprotein cholesterol (LDL-C) level <55 mg/dL (1.4 mmol/L) is advised.

Purpose

Therefore we aimed at identification of the risk factors in patients after acute myocardial infarction (MI), which increased the risk most, and might help to define the group of individuals at extremely high cardiovascular (CV) risk.

Methods

We analyzed consecutive patients included in the TERCET Registry admitted to the Polish tertiary cardiovascular centre due to MI between 2006 and 2018. According to the guidelines of the European Society of Cardiology (ESC), all patients included in the analysis are considered as of very high CV risk. All patients included in the registry underwent coronary angiography during the hospital stay. On the basis of multivariate analysis, we determined the subgroup of patients with the most unfavourable 12-month outcome (all-cause mortality).

Results

Finally, 4,562 patients admitted due to STEMI or NSTEMI and discharged from our centre were included in the analysis. According to the results of multivariate analysis performed with stepwise backward regression model, the following risk factors in patients after MI: LVEF<35% (odds ratio [OR]=3.83, 95% confidence interval [CI]: 3.14–4.67), age>75 years (OR=1.91, 95% CI: 1.55–2.35), lack of PCI of culprit vessel (OR=1.66, 95% CI: 1.26–2.20), multivessel CAD (OR=1.60, 95% CI: 1.30–1.99), atrial fibrillation (OR=1.53, 95% CI: 1.21–1.94), diabetes mellitus (OR=1.34, 95% CI: 1.11–1.64), increased LDL-C level (OR=1.09 per 1 mmol/L, 95% CI: 1.01–1.19) and increased creatinine level (OR=1.04 per 10 μmol/L, 95% CI: 1.04–1.05), might help to define the group of patients at extremely-high cardiovascular risk (all p<0.05). The aggregate summary of risk factors associated with extremely high risk is presented in the attached Figure.

Next, the effect of the combination of the aforementioned risk factors will be investigated, and SCORE applied for patients in secondary prevention after MI will be prepared.

Multivariate analysis results

Conclusions

To our knowledge, the presented study is the first such an analysis conducted on the population of patients after myocardial infarction gathered in the registry of secondary cardiovascular prevention. In patients after MI, potential risk factors were identified that might help to define the group of patients at ultra-high/extremely-high risk, what might contribute to significantly higher 12-month mortality.

Acknowledgement/Funding

None

P5368The prevalence and management of familial hypercholesterolemia in patients with acute coronary syndrome in Poland: results of the TERCET registry

Background

Prevalence of familial hypercholesterolemia (FH) is high among patients with coronary artery disease (CAD). However, data on FH among patients with acute coronary syndrome (ACS) are still scarce.

Purpose

Therefore, we aimed to assess the prevalence, lipid-lowering therapy and short- and long-term outcomes in patients with FH among patients with ACS.

Methods

We finally included 19,582 consecutive patients from the Hyperlipidaemia Therapy in the tERtiary Cardiological cEnTer (TERCET) Registry for years 2006–2018. Among them, there were 7,319 patients admitted with ACS: 3,085 due to ST-segment elevation acute coronary syndrome (STEMI), 2,256 due to NSTEMI, and 1,978 due to unstable angina (UA). Stable CAD [sCAD] group n=12,462 that was treated as a reference one. Based on the personal and familial history of premature cardiovascular disease and low-density lipoprotein cholesterol (LDL-C) concentration, the Dutch Lipid Clinic Network (DLCN) algorithm was used for FH diagnosis.

Results

At the time of hospitalization, the overall occurrence of probable/definite FH and possible FH were 1.2% and 13.5% respectively. In patients with ACS, 1.6% had probable/definite FH and 17.0% possible FH. The highest occurrence of FH was observed in STEMI subgroup, where 20.6% of the patients had ≥3 points according to the DLCN criteria. There were significant differences in hypolipemic treatment between the FH subpopulations. In patients with definite/probable FH 92.3% and 91.5% were administered statins at discharge, respectively (including 52.9% prescribed intensive statin therapy). Patients with definite and probable FH had higher 30-day mortality than patients without FH (8.2% and 3.8% vs 2.0%, respectively; p=0.0052). However, no significant differences were observed between the FH groups in the 12-, 36- and 60-month follow-up (Figure). Propensity-score matching analysis showed that definite/probable FH patients had significantly higher all-cause mortality at the 36- and 60-month follow-up in comparison to non-FH subjects (11.4% vs 4.8% and 19.2% vs 7.2%, respectively; p≤0.021 for both).

Outcomes depending on DCLN FH diagnosis.

Conclusions

The prevalence of FH according to the DLCN criteria in the Polish very high-risk population is even 14.7% and is significantly higher in patients with ACS than in patients with sCAD. Among patients included in the Registry, the occurrence of FH rises to 20.6% in the STEMI subgroup, and to 17.2% in the NSTEMI subgroup. Propensity-score matching analysis confirmed that FH itself is a cause of increased all-cause mortality in the long-term follow-up.

Acknowledgement/Funding

None

P1743Assessment of quality of care of patients with ST-segment elevation myocardial infarction in Poland

Introduction

2017 ESC Guidelines for the management of ST-elevation myocardial infarction (STEMI) patients have called for the assessment of the quality of care to establish measurable quality indicators in order to ensure that every patient with STEMI receives the best possible care. We investigated the quality indicators of health care services in Poland provided to STEMI patients.

Methods

The Polish Registry of Acute Coronary Syndromes (PL-ACS) is an ongoing, nationwide, multicenter, prospective, observational study of consecutively hospitalized patients with the whole spectrum of ACS in Poland. For the purpose of assessing quality indicators, we included 8,279 patients from the PL-ACS Registry hospitalized with STEMI between January 1 and December 31, 2018.

Results

All emergency medical services (EMS) are equipped with ECG/defibrillators. 408 of 8,279 patients (4.9%) arrived at PCI center by self-transport, 4,791 patients (57.9%) patients arrived at PCI center by direct EMS transport, and 2,900 patients (37.2%) were transferred from non-PCI facilities. Whilst 95.1% of STEMI patients arriving in the first 12 hours received reperfusion therapy, the rates of timely reperfusion were much lower (ranging from 39.4% to 55.0% for various STEMI pathways). 7,807 patients (94.3%) underwent PCI as a mode of primary reperfusion strategy. The median left ventricular ejection fraction (LVEF) was 46% and was assessed before discharge in 86.0% of patients. 489 of 8,279 patients (5.9%) died during hospital stay. Optimal medical therapy is prescribed in 50–85% of patients depending on various clinical settings. Only one in two STEMI patient is enrolled in a cardiac rehabilitation program at discharge. No patient-reported outcomes were recorded in the PL-ACS Registry.

Figure 1

Conclusions

The results of this study identified areas of healthcare systems that require solid improvement. These include prehospital ECG decision strategy, direct transport to PCI center, timely reperfusion, guidelines-based medical therapy (in particular in patients with heart failure), referral to cardiac rehabilitation/secondary prevention programs. More importantly, we recognized an urgent need for the initiation of recording quality indicators associated with patient-reported outcomes.