Cost-effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for the Treatment of Heart Failure With Preserved Ejection Fraction

Importance

Adding a sodium-glucose cotransporter-2 inhibitor (SGLT2-I) to standard-of-care treatment in patients with heart failure with preserved ejection fraction (HFpEF) reduces the risk of a composite outcome of worsening heart failure or cardiovascular mortality, but the cost-effectiveness in US patients with HFpEF is uncertain.

Objective

To evaluate the lifetime cost-effectiveness of standard therapy plus an SGLT2-I compared with standard therapy in individuals with HFpEF.

Design, Setting, and Participants

In this economic evaluation conducted from September 8, 2021, to December 12, 2022, a state-transition Markov model simulated monthly health outcomes and direct medical costs. Input parameters including hospitalization rates, mortality rates, costs, and utilities were extracted from HFpEF trials, published literature, and publicly available data sets. The base-case annual cost of SGLT2-I was $4506. A simulated cohort with similar characteristics as participants of the Empagliflozin in Heart Failure With a Preserved Ejection Fraction (EMPEROR-Preserved) and Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction (DELIVER) trials was used.

Exposures

Standard of care plus SGLT2-I vs standard of care.

Main Outcomes and Measures

The model simulated hospitalizations, urgent care visits, and cardiovascular and noncardiovascular death. Future medical costs and benefits were discounted by 3% per year. Main outcomes were quality-adjusted life-years (QALYs), direct medical costs (2022 US dollars), and incremental cost-effectiveness ratio (ICER) of SGLT2-I therapy from a US health care sector perspective. The ICER of SGLT2-I therapy was evaluated according to the American College of Cardiology/American Heart Association value framework (high value: <$50 000; intermediate value: $50 000 to <$150 000; and low value: ≥$150 000).

Results

The simulated cohort had a mean (SD) age of 71.7 (9.5) years and 6828 of 12 251 participants (55.7%) were male. Standard of care plus SGLT2-I increased quality-adjusted survival by 0.19 QALYs at an increased cost of $26 300 compared with standard of care. The resulting ICER was $141 200 per QALY gained, with 59.1% of 1000 probabilistic iterations indicating intermediate value and 40.9% indicating low value. The ICER was most sensitive to SGLT2-I costs and effect of SGLT2-I therapy on cardiovascular death (eg, increasing to $373 400 per QALY gained if SGLT2-I therapy was assumed to have no effect on mortality).

Conclusions and Relevance

Results of this economic evaluation suggest that at 2022 drug prices, adding an SGLT2-I to standard of care was of intermediate or low economic value compared with standard of care in US adults with HFpEF. Efforts to expand access to SGLT2-I for individuals with HFpEF should be coupled with efforts to lower the cost of SGLT2-I therapy.

Prognostic impact of left ventricular systolic dysfunction in patients with mixed aortic valve disease undergoing aortic valve replacement

BACKGROUND

The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF).

METHODS

We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality.

RESULTS

Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P < .001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P < .001).

CONCLUSIONS

In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population.

Risk of complications after a non-ST segment elevation acute myocardial infarction in a Latin-American cohort: An application of the ACTION ICU score

BACKGROUND

European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (NSTEMI) recommend Intensive Care Unit (ICU) surveillance during the first 24-48 h. Interestingly, the in-hospital mortality of NSTEMI patients has consistently decreased, giving some patients the option to be managed in general hospital wards. The ACTION ICU score has been proposed to identify high-risk patients with NSTEMI and guide the selective risk-based need for ICU care.

OBJECTIVE

To evaluate the usefulness of the ACTION ICU score to predict patients' risk of developing complications requiring ICU care in a Latin-American cohort with NSTEMI.

METHODS

We applied the ACTION ICU score in a retrospective cohort. A composite primary outcome included: cardiorespiratory arrest, shock, high-grade atrio-ventricular block, respiratory failure, stroke, or death. The predictive performance of this model was estimated with a conditional multivariable logistic regression analysis.

RESULTS

Of 1,062 patients with NSTEMI, the primary outcome was present in 75 patients (7.1%), and 1,019 (96%) were admitted to ICU. The most common event was respiratory failure (4.0%), followed by cardiogenic shock (3.7%), and cardiac arrest (1.7%). The presence of heart failure signs or symptoms had the highest association with the primary outcome (OR:2.16; 95%CI:1.61-2.92). The best cut-off point for this population was 3 (complications risk: 4.0%, SEN:96%, SP:15.4%, NPV:98.1%, PPV:7.9%).

CONCLUSION

The ACTION ICU score may be a promising tool to identify the need for ICU care in Latin-American patients with NSTEMI. Furthermore, additional research is needed to evaluate the cost-effectiveness of this strategy.

Myxedema heart disease and non-comatose presentation of myxedema: A case report

Myxedema coma is an emergency that develops from non-diagnosed or severe hypothyroidism and requires early recognition and management. Cardiac manifestations are uncommon and pose a challenge in the recognition of myxedema coma. We present the case of a 76-year-old male with a history of thyroidectomy secondary to a follicular carcinoma, who presented with dyspnea, generalized edema, drowsiness, disorientation, memory loss, and episodic generalized tonic-clonic seizures. Antiepileptic and diuretic treatment for seizures and heart failure exacerbation did not improve the symptoms. Further blood analysis revealed a thyroid-stimulating hormone and free thyroxine of 163 mUL/L and 0.64 ng/dL, respectively. Treatment with intravenous hydrocortisone and levothyroxine led to progressive clinical improvement. Uncommon clinical manifestations such as cardiac and non-specific neurologic symptoms should be considered as manifestations of myxedema coma. A comatose mental status is not a universal manifestation, and milder symptoms should be considered. An adequate assessment, including diagnostic scores and prompt hormonal supplementation prevents fatal consequences.

Cost-Effectiveness of Antibiotic-Eluting Envelope for Prevention of Cardiac Implantable Electronic Device Infections in Heart Failure

BACKGROUND

Use of an antibiotic-eluting envelope (AEE) during cardiac implantable electronic device procedures reduces infection risk but increases procedural costs. We aim to estimate the cost-effectiveness of AEE use during cardiac implantable electronic device procedures among patients with heart failure.

METHODS

A state-transition cohort model of heart failure patients undergoing cardiac implantable electronic device implantation or generator replacement was developed with input parameters estimated from randomized trials, registries, surveys, and claims data. Effectiveness was estimated from the World-Wide Randomized Antibiotic Envelope Infection Prevention Trial. AEE was assumed to cost $953 per unit. The model projected mortality, quality-adjusted life-years, costs, and the incremental cost-effectiveness ratio of AEE use compared with usual care from a US healthcare sector perspective over a lifetime horizon. We assumed a cost-effectiveness threshold of $100 000 per quality-adjusted life-year gained.

RESULTS

Compared with usual care, AEE use in initial implantations produced an incremental cost-effectiveness ratio of $112 000 per quality-adjusted life-year gained (39% probability of being cost-effective). In generator replacement procedures, AEE use produced an incremental cost-effectiveness ratio of $54 000 per quality-adjusted life-year gained (84% probability of being cost-effective). Results were sensitive to the underlying rate of infection, cost of the AEE, and durability of AEE effectiveness.

CONCLUSIONS

Universal AEE use for cardiac implantable electronic device procedures in patients with heart failure with reduced ejection fraction is unlikely to be cost-effective, reinforcing the need for individualized risk assessment to guide uptake of the AEE in clinical practice. Selective use in patients at increased risk of infection, such as those undergoing generator replacement procedures, is more likely to meet health system value benchmarks.

Abstract 10315: Cost-Effectiveness of Bempedoic Acid in Patients with Established Atherosclerotic Cardiovascular Disease

Introduction: Non-statin therapies may improve long-term outcomes in patients with atherosclerotic cardiovascular disease (ASCVD) who experience statin-associated side effects (SASE).

Objective: To examine the cost-effectiveness of a newly approved combination of bempedoic acid and ezetimibe (BAEze) in patients with ASCVD from a U.S. healthcare sector perspective.

Methods: State-transition Markov model of US adults with ASCVD and low-density lipoprotein cholesterol (LDL-C) ≥70mg/dL on maximally tolerated statin and ezetimibe. The study cohort was stratified by concurrent statin use: high-intensity (group1), moderate-/low-intensity (group 2), or no statin due to severe SASE (group 3). The intervention group received BAEze (annual cost $2,447) instead of ezetimibe. We estimated baseline LDL-C from NHANES; relative LDL-C lowering and rate of adverse events from randomized trials; and the relationship between LDL-C lowering and cardiovascular events from meta-analyses of statin trials. The main outcome was lifetime incremental cost-effectiveness ratio (ICER), with a threshold of $100,000 per quality-adjusted-life-year (QALY) gained.

Results: BAEze had an ICER of $188,000/QALY in group 1 (95% UI: 141,500-284,600; cost-effective in 0% of 10,000 probabilistic simulations) and $175,600/QALY (132,700-264,700; cost-effective in 0% simulations) in group 2. In group 3, BAEze produced 0.28 incremental QALYs at a lifetime cost of $25,600, yielding an ICER of $92,600/QALY (66,000-152,100; cost-effective in 59% simulations).

Conclusions: Among US adults with ASCVD, cost-effectiveness of BAEze varies substantially by concurrent statin use, and only meets conventional cost-effectiveness thresholds among patients unable to take a statin due to severe SASE. Our findings argue for the selective use of BAEze among patients with ASCVD and severe SASE but should be updated when more data on long-term effectiveness and safety become available.

Cost-effectiveness of Dapagliflozin for the Treatment of Heart Failure With Reduced Ejection Fraction

Importance

Heart failure with reduced ejection fraction produces substantial morbidity, mortality, and health care costs. Dapagliflozin is the first sodium-glucose cotransporter 2 inhibitor approved for the treatment of heart failure with reduced ejection fraction.

Objective

To examine the cost-effectiveness of adding dapagliflozin to guideline-directed medical therapy for heart failure with reduced ejection fraction in patients with or without diabetes.

Design, Setting, and Participants

This economic evaluation developed and used a Markov cohort model that compared dapagliflozin and guideline-directed medical therapy with guideline-directed medical therapy alone in a hypothetical cohort of US adults with similar clinical characteristics as participants of the Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction (DAPA-HF) trial. Dapagliflozin was assumed to cost $4192 annually. Nonparametric modeling was used to estimate long-term survival. Deterministic and probabilistic sensitivity analyses examined the impact of parameter uncertainty. Data were analyzed between September 2019 and January 2021.

Main Outcomes and Measures

Lifetime incremental cost-effectiveness ratio in 2020 US dollars per quality-adjusted life-year (QALY) gained.

Results

The simulated cohort had a starting age of 66 years, and 41.8% had diabetes at baseline. Median (interquartile range) survival in the guideline-directed medical therapy arm was 6.8 (3.5-11.3) years. Dapagliflozin was projected to add 0.63 (95% uncertainty interval [UI], 0.25-1.15) QALYs at an incremental lifetime cost of $42 800 (95% UI, $37 100-$50 300), for an incremental cost-effectiveness ratio of $68 300 per QALY gained (95% UI, $54 600-$117 600 per QALY gained; cost-effective in 94% of probabilistic simulations at a threshold of $100 000 per QALY gained). Findings were similar in individuals with or without diabetes but were sensitive to drug cost.

Conclusions and Relevance

In this study, adding dapagliflozin to guideline-directed medical therapy was projected to improve long-term clinical outcomes in patients with heart failure with reduced ejection fraction and be cost-effective at current US prices. Scalable strategies for improving uptake of dapagliflozin may improve long-term outcomes in patients with heart failure with reduced ejection fraction.

Left Ventricular Longitudinal Strain in Characterization and Outcome Assessment of Mixed Aortic Valve Disease Phenotypes

OBJECTIVES

The aims of this study were to characterize the interplay between mixed aortic valve disease (MAVD) phenotypes (defined by concomitant severities of aortic stenosis and aortic regurgitation) and left ventricular global longitudinal strain (LV-GLS), and to assess the prognostic utility of LV-GLS in MAVD.

BACKGROUND

Little is known about the way LV-GLS separates MAVD phenotypes and if it is associated with their outcomes.

METHODS

This observational cohort study evaluated 783 consecutive adult patients with left ventricular ejection fraction ≥50% and MAVD, which was defined as coexisting with at least moderate aortic stenosis and at least moderate aortic regurgitation. We measured the conventional echocardiographic variables and average LV-GLS from apical long, 2- and 4-chamber views. The primary endpoint was all-cause mortality.

RESULTS

Mean age of patients was 69 ± 15 years, and 58% were male. Mean LV-GLS was -14.7 ± 2.9%. In total, 458 patients (59%) underwent aortic valve replacement at a median period of 50 days (25th to 75th percentile range: 6 to 560 days). During a median follow-up period of 5.6 years (25th to 75th percentile range: 1.8 to 9.4 years), 391 patients (50%) died. When stratified patients into tertiles according to LV-GLS values, patients with worse LV-GLS had worse outcomes (p < 0.001). LV-GLS was independently associated with mortality (hazard ratio: 1.09; 95% confidential intervals: 1.04 to 1.14; p < 0.001), with the relationship between LV-GLS and mortality being linear.

CONCLUSIONS

LV-GLS is associated with all-cause mortality. LV-GLS may be useful for risk stratification in patients with MAVD.

Syncope due to non-sustained episodes of Torsade de Pointes associated to androgen-deprivation therapy use: a case presentation

BACKGROUND

Abiraterone is a medication frequently used for metastatic castrate-resistant prostate cancer. We report a case of non-sustained episodes of TdP associated with severe hypokalemia due to androgen-deprivation therapy. Few case presentations describe this association; the novelty lies in the potentially lethal cardiovascular events among cancer patients receiving hormonal therapy.

CASE PRESENTATION

A 70-year-old male presented with recurrent syncope without prodrome. ECG revealed frequent ventricular ectopy, non-sustained episodes of TdP, and severe hypomagnesemia and hypokalemia. During potassium and magnesium infusion for repletion, the patient underwent temporary transvenous atrial pacing. As part of the work-up, coronary angiography revealed a mild coronary artery disease, and transthoracic echocardiogram showed a moderately depressed ejection fraction. After electrolyte disturbances were corrected, the QT interval normalized, and transvenous pacing was no longer necessary. Abiraterone was discontinued during the admission, and the patient returned to baseline.

CONCLUSIONS

Cancer treatment is complex and requires a multidisciplinary approach. We presented a case of non-sustained TdP associated with androgen-deprivation therapy in an elderly patient with mild coronary artery disease and moderately reduced ejection fraction. Close follow-up and increased awareness are required in patients with hormonal treatment, especially in the setting of other cardiovascular risk factors.

Clinical, metabolic, and molecular genetic characterization of hereditary methemoglobinemia caused by cytochrome b5 reductase deficiency in 30 dogs

Genotype–phenotype correlations of humans and dogs with hereditary methemoglobinemia are not yet well characterized. We determined total hemoglobin and methemoglobin (MetHb) concentrations, cytochrome b₅ reductase (CYB5R) enzyme activities, genotypes, and clinical signs in 30 dogs with persistent cyanosis without cardiopulmonary disease. Erythrocytic CYB5R enzyme activities were low in all dogs assayed. Owner-reported quality of life ranged from subclinical to occasional exertional syncope. Two previously reported and two novel CYB5R3 missense variants were identified among the methemoglobinemic cohort and were predicted to impair enzyme function. Two variants were recurrent: a homozygous Ile194Leu substitution was found in Pomeranians and other small dogs, and a homozygous Arg219Pro change occurred predominately in pit bull terriers. The other two variants were Thr202Ala and Gly76Ser substitutions in single dogs. Of the two common CYB5R3 genotypes, Arg219Pro was associated with a more severe metabolic phenotype. We conclude that CYB5R3 deficiency is the predominate cause of canine hereditary methemoglobinemia. Although this finding is unlikely to alter the clinical approach to hereditary methemoglobinemia in dogs, it demonstrates the possibility of how genotype–phenotype cohort analysis might facilitate precision medicine in the future in veterinary medicine.

Abstract 15981: Cost-effectiveness of Dapagliflozin in Heart Failure With Reduced Ejection Fraction

Introduction: In May 2020, the US FDA approved the use of dapagliflozin, an SGLT2 inhibitor, for the reduction of cardiovascular death and heart failure hospitalization in patients with heart failure with reduced ejection fraction (HFrEF). We examined the cost-effectiveness of adding dapagliflozin to guideline-directed medical therapy (GDMT) in patients with or without diabetes.

Methods: We developed a state-transition Markov model with inputs from the DAPA-HF trial, FDA review documents, published literature, and nationally representative datasets (Panel A). The model was calibrated to event rates observed in DAPA-HF; survival was extrapolated using non-parametric approaches. The main outcomes were quality-adjusted life years (QALYs) and incremental cost effectiveness ratio (ICER) of dapagliflozin + GDMT compared with GDMT alone, from a healthcare sector perspective and a lifetime analytic horizon. We applied a discount rate of 3% per year for future costs and benefits, and assumed a willingness-to-pay threshold of $100,000 per QALY gained. In sensitivity analyses, we examined subgroups with or without diabetes, and varied the cost of dapagliflozin (base case = $6,188 per year). This analysis was independent of the trial sponsor.

Results: Compared with GDMT alone, adding dapagliflozin produced 0.57 additional QALYs at an incremental cost of $56,650, producing an ICER of $98,700 per QALY gained (Panel B). In subgroup analyses, dapagliflozin produced 0.71 additional QALYs in patients with diabetes at an ICER of $89,100 per QALY gained, and 0.48 additional QALYs in patients without diabetes at an ICER of $108,800 per QALY (Panels C and D). A 9% price reduction (to $5,613 per year) would make dapagliflozin cost-effective in patients without diabetes.

Conclusions: Adding dapagliflozin to GDMT in patients with HFrEF is cost-effective and has the potential to improve long-term outcomes. Scalable strategies to improve access and uptake are urgently required.

Characteristics and Outcomes of Patients With Takotsubo Syndrome: Incremental Prognostic Value of Baseline Left Ventricular Systolic Function

Background

We sought to determine (1) long‐term outcomes in patients presenting with documented Takotsubo syndrome (TS), (2) whether left ventricular global longitudinal strain (LV‐GLS) provides incremental prognostic value, and (3) prognostic cutoffs of LV ejection fraction (LVEF) and LV‐GLS during an acute TS episode.

Methods and Results

We studied 650 patients with TS (aged 66±14 years, 88% women) who were diagnosed clinically and angiographically between 2006 and 2018. Baseline LVEF and LV‐GLS (using velocity vector imaging) were recorded. The primary end point was all‐cause mortality. TS triggers were unknown (34%), emotional (16%), physical (41%), and neurologic (10%). Mean LVEF and LV‐GLS were 36±10% and −11.6±0.4%; in addition, 94% patients had LVEF <52%, and 80% had apical ballooning. No patient had obstructive coronary artery disease. At a median of 2.2 years (interquartile range, 0.7–4.4), 175 (27%) had died (9% in‐hospital deaths). Multivariate Cox survival analysis revealed that higher age (hazard ratio [HR], 1.35), male sex (HR, 1.75), lower baseline LVEF (HR, 1.02), worse LV‐GLS (HR, 1.04), neurologic trigger (HR, 2.66), and physical trigger (HR, 2.64) were associated with mortality, whereas aspirin (HR, 0.70) and β‐blockers (HR, 0.73) improved survival (all P<0.049). The addition of LVEF and LV‐GLS to clinical markers (age, sex, cardiogenic shock at presentation, and peak troponin I) significantly increased log‐likelihood ratios: clinical (−521.48), clinical plus LVEF (−511.32, P<0.001), and clinical plus LVEF and LV‐GLS (−500.68, P<0.001). On penalized spline analysis, LVEF of 38% and LV‐GLS of −10% were cutoffs below which survival was significantly worse.

Conclusions

Patients with TS with a neurologic or physical trigger had significantly worse survival than those without such a trigger, with baseline LVEF and LV‐GLS providing incremental prognostic value.

Contemporary Outcomes of Pulmonary Valve Endocarditis: A 16-Year Single Centre Experience

BACKGROUND

Limited data exist regarding the clinical characteristics and contemporary outcomes of patients with pulmonary valve (PoV) infective endocarditis (IE).

METHODS

This is a retrospective cohort study of patients with a confirmed diagnosis of IE affecting the PoV at our centre between January 2002 and October 2018. Electronic medical records were reviewed to gather the clinical and echocardiographic variables. The population was subdivided according to risk factor profiles: group 1: miscellaneous risk factors; group 2: patients with congenital heart disease (CHD); and group 3: patients who inject drugs (PWID). The primary outcome was all-cause mortality.

RESULTS

Out of 2,124 cases of IE during the study period, 24 (1.1%) patients had PoV IE. The majority of cases of PoV IE occurred in patients with prosthetic valves (54.2%). Coagulase-negative Staphylococci species were the most common micro-organisms. Seventy-five per cent (75%) of the patients required surgical management. The median follow-up was 2.8 years (interquartile range: 0.2-5.3 years). Patients with miscellaneous risk factors were older (p<0.01), and had higher rates of hypertension (p=0.01) and hyperlipidaemia (p=0.04). There was a statistically significant difference in survival between the groups (p=0.03), mainly driven by better outcomes of patients with CHD, compared to those with miscellaneous risk factors.

CONCLUSIONS

In a contemporary 16-year series, a high proportion of patients with PoV IE required surgical management. Patients with PoV IE and CHD had better survival, compared to patients with miscellaneous risk factors at a median follow-up of 2.8 years.

Long-Term Outcomes in Patients With Mixed Aortic Valve Disease and Preserved Left Ventricular Ejection Fraction

Background

Concurrent presence of aortic stenosis and aortic regurgitation is termed mixed aortic valve disease (MAVD). Although multiple articles have addressed patients with “isolated” aortic stenosis or aortic regurgitation, the natural history, impact, and outcomes of MAVD are not well defined. Here, we evaluate long‐term outcomes in patients with MAVD and cardiovascular adaptations to chronic MAVD.

Methods and Results

This observational cohort study evaluated 862 adult patients (56.8% male) with preserved left ventricular ejection fraction and at least moderate aortic regurgitation and moderate aortic stenosis. Primary outcome was all‐cause mortality. Subgroup analysis was based on treatment modality (aortic valve replacement [AVR] versus medical management). A regression analysis of longitudinal echocardiographic parameters was performed to assess the natural history of MAVD. Mean age was 68±15 years, and mean left ventricular ejection fraction was 58±5%. At 4.6 years (25th–75th percentile range, 1.0–8.7), 58.6% of patients underwent an AVR and 48.8% patients died. In both unadjusted and adjusted Cox survival analysis, AVR was associated with improved survival (hazard ratio, 0.41; 95% CI, 0.34–0.51, P<0.001). Impact of AVR persisted when stratifying the cohort by symptom status and baseline aortic valve area (log rank, P<0.001 for both) and after propensity‐score matching (hazard ratio, 0.40; 95% CI, 0.32–0.50; P<0.001). In the longitudinal analysis, there were statistically significant changes over time in aortic valve peak gradient (P<0.001) and aortic valve area (P<0.001) and only mild increases in left ventricular end‐diastolic (P<0.007) and ‐systolic (P<0.001) volumes.

Conclusions

MAVD confers a high risk of all‐cause mortality. However, AVR significantly reduces this risk independent of aortic valve area, symptom status, and after controlling for confounding variables.

HEART, TIMI, and GRACE Scores for Prediction of 30-Day Major Adverse Cardiovascular Events in the Era of High-Sensitivity Troponin

Fundamento

Múltiplos sistemas de pontuação têm sido elaborados para calcular o risco de eventos cardiovasculares adversos maiores (MACE) em pacientes com dor no peito. Não há dados que avaliem se o escore HEART tem um desempenho superior a TIMI e GRACE para a predição de MACE, especialmente na era de troponina I de alta sensibilidade e em uma população exclusivamente latino-americana.

Objetivo

Comparar o desempenho dos escores HEART, TIMI e GRACE para a predição de MACE em 30 dias de acompanhamento, em pacientes atendidos com dor no peito no departamento de emergência.

Métodos

Os escores HEART, TIMI e GRACE foram analisados em 519 pacientes com dor no peito no departamento de emergência. O desfecho primário foi a ocorrência de MACE no período de 30 dias. O desempenho do escore HEART foi comparado com o dos escores TIMI e GRACE utilizando o teste de DeLong, considerando estatisticamente significativos os valores de p de 0,05.

Resultados

Um total de 224 pacientes (43%) apresentaram MACE no período de 30 dias. A estatística C para os escores HEART, TIMI e GRACE foi de 0,937, 0,844 e 0,797 respectivamente (p < 0,0001). Uma pontuação de 3 ou menos no escore HEART apresentou uma sensibilidade de 99,5% e um valor preditivo negativo de 99% para classificar pacientes de baixo risco de maneira correta; ambos os valores foram mais elevados do que aqueles obtidos pelos outros escores.

Conclusão

O escore HEART, em um período de 30 dias, prediz eventos cardiovasculares, mais eficazmente, em comparação com os outros escores. Troponinas de alta sensibilidade mantêm a superioridade previamente demonstrada deste escore. Este escore oferece uma identificação mais precisa dos pacientes de baixo risco. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

P1951Serial left ventricular global longitudinal strain and mortality in patients with Takotsubo cardiomyopathy

Background

Recent studies on Takotsubo cardiomyopathy (TC) have challenged the common conception that it is a relatively benign condition with functional recovery observed in the majority of cases. However, it is important to recognize that overt functional recovery might not reflect the true regional recovery, which might have an adverse impact on survival.

Objective

We sought to assess baseline and follow-up left ventricular function characteristics and their impact on longer-term mortality in patients presenting with documented Takotsubo cardiomyopathy (TC) at a tertiary centre.

Methods

339 patients (66±14 years, 88% women) presented to our centre between 2006 and 2018 with acute anginal symptoms and were subsequently diagnosed with TC following clinical and angiographic evaluation. All patients returned for a follow-up evaluation including transthoracic echocardiography (TTE). Baseline and follow-up (3–6 months after TC diagnosis) LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS using velocity vector imaging) were recorded on TTE. The primary endpoint was longer-term mortality.

Results

Hypertension, dyslipidaemia, and diabetes were present in 71%, 56%, and 26% of patients. Baseline mean troponin I peak, LVEF and LV-GLS were 0.9±7 ng/ml, 36±9%, and 11±3%; respectively. 94% had baseline LVEF<50%, 272 (80%) had apical ballooning, and 94% had LV-GLS worse than −18%. No patient had angiographically obstructive coronary artery disease. At 3–6 months follow-up, mean LVEF, and LV-GLS improved to 57±9% and 16±3%, respectively. 87% of patients had LVEF >50%, but in 70% LV-GLS remained worse than −18%. After 3.3±3 years, 72 patients (21%) died. On multivariable Cox survival analysis (adjusted for age, gender, baseline troponin peak and follow up LVEF), follow up LV-GLS was independently associated with longer-term mortality (hazard ratio 1.12 [95% confidence interval 1.05, 1.20], p<0.001). Significantly more patients with follow up LV-GLS worse than −18% died vs. those with LV-GLS better than −18% (57/237 [24%] vs. 15/102 [15%], log-rank statistic p-value 0.01, Kaplan-Meier figure 1).

Kaplan-Meier curve of freedom from death

Conclusions

In this large single-centre study of patients with documented TC (majority women), 87% recovered LVEF at 3–6 months, but in 70% LV-GLS remained worse than −18%, which was independently associated with higher longer-term mortality.

Características clínicas y microbiológicas de pacientes con neutropenia febril en un hospital universitario

Objetivo: Describir las características clínicas, demográficas, frecuencia, tipo de aislamientos microbiológicos y resistencia a los antimicrobianos de pacientes con neoplasias hematológicas que presentaron como complicación neutropenia febril en el Hospital Universitario de San IgnacioMétodos: Estudio descriptivo observacional, se tomaron datos de historias clínicas de los pacientes adultos hospitalizados en la Unidad de Hematología y Trasplante de Médula Ósea, que cumplieron criterios de neutropenia febril entre enero de 2013 y diciembre de 2014Resultados: se recolectaron 345 episodios de neutropenia febril, correspondientes a 193 pacientes. Se documentó foco infeccioso en el 68,1% de los episodios, con aislamiento microbiológico en el 62.9% de los episodios, con predominio de bacilos gram negativos, en 63,7% de los casos, seguido por los cocos gram positivos en 27,9% y hongos en 4,9%. En cuanto a los mecanismos de resistencia, en los aislamientos Escherichia coli y Klebsiella peumoniae se encontró producción de Beta Lactamasas de Espectro Extendido (BLEEs) en 17,5 y 13,8%; Carbapenemasas tipo KPC en 1,25 y 2,8% respectivamente. En cuanto a Staphylococcus aureus, se encontró resistencia a meticilina en 6,8% de los aislamientos. Mortalidad asociada a infección en 16,5% de los casos.Conclusión: En pacientes con Neoplasias Hematológicas con neutropenia febril post quimioterapia en el Hospital Universitario de San Ignacio encontramos alta probabilidad de documentación de foco infeccioso, con predominio de microorganismos gram negativos, especialmente enterobacterias; con comportamiento similar en pacientes post trasplante de precursores hematopoyéticos.

High Incidence of Sleep-Related Breathing Disorders in Children with Down Syndrome Referred to a High-Altitude Sleep Laboratory

Aims: The aim of the study was to assess the incidence of sleep-related breathing disorders (SRBD) in children with Down Syndrome (DS) living at high altitude. Methods: A retrospective descriptive study was conducted on 53 children with DS who underwent polysomnography (PSG) at San Ignacio University Hospital (2640 m/8660 ft above sea level) from 2009 to 2016. Data were extracted from official PSG reports and analyzed using measures of central tendency and dispersion, frequency calculation, ranges, and confidence intervals. Associations were examined using t-test, chi-square test, and analysis of variance test. Results: Obstructive sleep apnea (OSA) was present in 90.5% of children. Central sleep apnea was evident in 11.3%. Periodic breathing was seen in 15.1% of patients. Snoring was able to predict OSA with a sensitivity of 61.7%, a specificity of 100%, and negative predictive value of 25%. Conclusion: Children with DS who live at high altitude have a high incidence of SRBD. Our findings show a higher incidence of SRBD than previously reported in the population with DS. Furthermore, snoring was not sensitive enough to predict OSA. This high risk of SRBD may increase the risk of other comorbid conditions seen in the population with DS. Our results support the need for routine PSG screening independent of symptoms such as snoring status.

Cardiogenic shock as the first manifestation of large vessel vasculitis in a young patient: case report

Background

Cardiogenic shock secondary to coronary involvement in large vessel vasculitis (LVV) is an unsuspected finding, even more, when no other vascular territories are compromised and when it constitutes the initial clinical manifestation. This case report illustrates a case in which a complete diagnostic study uncovered this aetiology.

Case summary

A 33-year-old woman with cough and chest pain who was diagnosed with acute bronchitis returned with worsening dyspnoea, chest pain, and developed cardiogenic shock. The initial differential diagnoses included myocarditis and takotsubo cardiomyopathy (TCM) owing to a positive troponin I, and echocardiogram with left ventricular dilation, dyskinesia in mid-ventricular and apical segments, systolic dysfunction, and functional mitral regurgitation. A cardiac magnetic resonance showed contractility abnormalities resembling the pattern of TCM but lacked the characteristic myocardial oedema. Subsequently, a coronary angiography expected to result without obstructions showed a critical narrowing of the left main coronary artery. Surgical management consisted of a pericardium patch grafted in the stenotic ostium to restore adequate perfusion. The surgical specimens were sent to the pathology laboratory that reported findings compatible with LVV. Four days after the surgical intervention the patient was discharged alive with a complete recovery of left ventricular systolic function.

Discussion

Chest pain symptoms in a young woman, could be caused by multiple entities, and an ischaemic aetiology from a non-atherosclerotic origin should be kept in mind. A complete study with coronary angiography is crucial to rule out an ischaemic cause even in low-risk groups for atherosclerotic coronary heart disease.

Functional Changes in Acute Eosinophilic Myocarditis Due to Chemotherapy With Ibrutinib

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Different types of myocardium infiltration can lead to similar manifestations.

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Differentiating CA is important as it often carries dismal prognosis if not treated.

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EM due to ibrutinib mimicked CA.

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Ibrutinib discontinuation led to functional and structural normalization.

Conditional reprogramming of pediatric airway epithelial cells: A new human model to investigate early-life respiratory disorders

BACKGROUND

Airway epithelial cells (AEC) are quite difficult to access in newborns and infants. It is critically important to develop robust life-extended models to conduct translational studies in this age group. We propose the use of a recently described cell culture technology (conditionally reprogrammed cells-CRC) to generate continuous primary cell cultures from nasal and bronchial AEC of young children.

METHODS

We collected nasal and/or bronchial AEC from a total of 23 subjects of different ages including newborns/infants/toddlers (0-2 years; N = 9), school-age children (4-11 years; N = 6), and a group of adolescent/adult donors (N = 8). For CRC generation, we used conditioned medium from mitotically inactivated 3T3 fibroblasts and Rho-associated kinase (ROCK) inhibitor (Y-27632). Antiviral immune responses were studied using 25 key antiviral genes and protein production of type III epithelial interferon (IFN λ1) after double-stranded (ds) RNA exposure.

RESULTS

CRC derived from primary AEC of neonates/infants and young children exhibited: (i) augmented proliferative capacity and life extension, (ii) preserved airway epithelial phenotype after multiple passages, (iii) robust immune responses characterized by the expression of innate antiviral genes and parallel nasal/bronchial production of IFN λ1 after exposure to dsRNA, and (iv) induction of airway epithelial inflammatory and remodeling responses to dsRNA (eg, CXCL8 and MMP9).

CONCLUSION

Conditional reprogramming of AEC from young children is a feasible and powerful translational approach to investigate early-life airway epithelial immune responses in humans.