P879Discharge medication and 1-year outcomes in patients with myocardial infarction and nonobstructive coronary artery disease: a nationwide registry-based study

Introduction

Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 5% to 10% of all patients with myocardial infarction. Although these patients are often treated as if they had obstructive coronary artery disease (OCAD), optimal medical therapy for secondary prevention in MINOCA patients have not been prospectively studied. We hypothesize that the same treatment strategy as for OCAD is unlikely to be beneficial in MINOCA patients due to their heterogeneous nature.

Purpose

Characterize and assess the impact of discharge medication on 1-year mortality or hospitalization in patients with MINOCA.

Methods

Retrospective cohort study of consecutive patients with acute myocardial infarction (AMI) recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between 2010 and 1017. All patients who underwent coronary angiography and had no obstructive lesions (defined as <50% diameter stenosis) were included for analysis (n=829, 4.8% of a total of 17213). Patient demographics, clinical characteristics and medication at discharge were analyzed. The association between treatment and outcome was estimated by comparing treated and untreated groups using Cox proportional hazard models. The exposures considered were treatment at discharge with statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs), beta-blockers (BB), aspirin (ASA) or dual antiplatelet therapy (DAPT). The outcomes evaluated were 1-year all-cause mortality and 1-year hospitalization due to cardiovascular disease (CVD)

Results

829 patients (54% male, mean age 65±13 years) were included. 67% had hypertension, 20% diabetes mellitus, 45% hyperlipidemia, 66% were overweight, 23% were current smokers, 5.5% had history of heart failure, 4.3% valvular heart disease, 8% cerebrovascular disease and 4.7% chronic kidney disease. The admission diagnosis was most frequently non-ST elevation MI (79.3%) and mean left ventricular ejection fraction (%) was 56±12. 4 patients died during hospitalization (0.5%). At discharge, aspirin was prescribed in 85.7% patients, clopidogrel in 54.8%, ticagrelor in 7.5%, DAPT in 57.7%, ACEi/ARB in 79.2%, beta-blocker in 69% and statins in 90.2%. 1-year mortality and 1-year CVD hospitalization was 3.8% and 9%, respectively. After adjusting for covariates in Cox regression analysis, we found no association between any medication at discharge and 1-year outcomes.

Conclusion

A high proportion of patients are prescribed antiplatelet therapy, including DAPT. We found no significant 1-year beneficial effect of treatment with statins, ACEi/ARBs, BB, aspirin or DAPT in MINOCA. This may be partially explained by the highly heterogenous population and relative short-term follow-up. In MINOCA patients, treatment should be individualized after an exhaustive diagnostic workup to identify the underlying cause (e.g. CAD with spontaneous autolysis of an intracoronary thrombus, myocarditis or takotsubo syndrome).

P1772Diagnostic accuracy of a novel electrocardiographic criterion for the diagnosis of left ventricular hypertrophy in hypertrophic cardiomyopathy

Introduction

The 12-lead electrocardiogram (ECG) is a fundamental initial diagnostic modality for the early evaluation of a patient suspected of having hypertrophic cardiomyopathy (HCM). ECG criteria for the diagnosis of left ventricular hypertrophy (LVH) typically have low sensitivity and high specificity. Recently, a novel ECG criterion (Peguero-Lo Presti, PLP) with higher sensitivity (62%) and similar specificity (90%) was developed in a cohort of hypertensive patients, but its accuracy in patients with HCM has not been tested. We hypothesized that Peguero-Lo Presti criterion would improve upon the sensitivity of other criteria, while maintaining high specificity, for the diagnosis of LVH in patients for with HCM.

Methods

We retrospectively analyzed 215 consecutive patients who underwent cardiac magnetic resonance (CMR) between 2010 and 2018 for suspected HCM. All patients aged 18 years or older, who had CMR-confirmed HCM and an ECG without confounders (complete left or right bundle brunch block or paced ventricular rhythm) were included for analysis (n=88). Left ventricular mass (LVM) index and maximum wall thickness were derived from CMR analysis. The PLP criteria was defined as the sum of the deepest S wave (SD) in any lead and the S wave amplitude of lead V4 (SV4). Cornell voltage (CL) and Sokolow-Lyon (SL) were used for comparison. We randomly selected 88 gender-matched patients who performed an ECG and CMR for other clinical reasons and who had no structural heart disease or LVH for use as controls. The DeLong and McNemar's test were used to compare ROC area under the curve (AUC) and sensitivity and specificity, respectively, between the three criteria.

Results

88 patients with HCM (63% male, mean age 56.7±15 years) were analyzed. The mean maximum wall thickness was 19.9±4.4mm and mean indexed LVM was 89.7±27g/m2. 34 patients (38.6%) had increased indexed LVM and 77 (87.5%) had at least one segment with late gadolinium enhancement (LGE). Discrimination by AUC was highest for PLP (0.85 [95% CI 0.8–0.9]), compared to CL (0.79, p=0.03) and SL (0.73, p=0.02). Using literature cut-offs, the sensitivity of PLP (60% [95% CI 50–70%]) was significantly higher compared to CL (40% [95% CI 30–50%, p<0,001) and SL (41%, [95% CI 31–51%], p=0.01), whilst maintaining high specificity (PLP 96%; CL 98%; SL 94%). After adjusting for LVM, the amount of LGE had a positive correlation with PLP amplitude (Spearman's rho=0.6, coef=2.4, p=0.01), but not Cornell or Sokolow. The sensitivity of PLP was significantly higher than CL and Sokolow in patients with LGE (61% vs 44% vs 43%, p<0.05).

Conclusion

The Peguero-Lo Presti criteria demonstrated higher sensitivity and similar specificity when compared to the Cornell and Sokolow-Lyon criteria for the diagnosis of LVH in a cohort of patients with hypertrophic cardiomyopathy. Therefore, they could become the standard ECG diagnostic criteria in patients suspected of having LVH and HCM.

P1698Age shock index is a simple bedside clinical risk stratification tool in patients with non-ST-segment elevation myocardial infarction

Introduction

Shock index (SI), (heart rate (HR)/systolic blood pressure (SBP)), has been reported to predict worse outcomes in different acute settings. Two derivatives, named modified SI (MSI), defined as HR/mean BP; and Age SI, defined as SI multiplied by age, were later developed, but only the former was tested for short-term outcomes in patients with myocardial infarction (MI). We hypothesize that Age SI may demonstrate higher prognostic accuracy than SI and MSI due to the added prognostic value of age in this population.

Purpose

Compare the prognostic performance of admission age SI, MSI and SI for predicting in-hospital mortality in patients with NSTEMI.

Methods

Retrospective cohort study of consecutive patients admitted to the Cardiology department of a tertiary care hospital with the diagnosis of NSTEMI between October 2010 and September 2018. Very high-risk patients in need of emergent treatment were excluded. Of the initial cohort of 2476 patients, we excluded 5 who presented cardiac arrest before or at hospital admission, 4 with cardiogenic shock, 95 with acute pulmonary oedema, 10 with SBP <80 mmHg, 1 with HR <40bpm and 1 with HR >160bpm. The primary outcome was all-cause in-hospital mortality. The discriminatory capacity of Age SI, MSI, SI for the primary outcome was assed using the ROC-AUC and compared with the DeLong method, and the value with highest Youden-index was considered the optimal cut-off point. Calibration was assessed using the Hosmer-Lemeshow (HL) test and adjustment for confounding variables was performed using logistic regression analysis.

Results

2359 patients were included [mean age 66±13 years; 1732 (73.4%) men], of whom 40 (1.7%) died during hospitalization. Discrimination by ROC-AUC was highest for Age SI (0.78 [95% CI 0.71–0.86)], compared to MSI (0.69 [95% CI 0.61–0.78]) and SI (0.69 [95% CI 0.61–0.78)], p<0.01 for comparison. All indexes demonstrated adequate calibration (HL: Age SI 7.4; MSI 4.5; SI 6.4; p>0.5). The optimal cut-off for Age SI was 40, which was present in 684 patients (29%) and had 75% sensitivity, 72% specificity, 4.5% positive and 99.5% negative predictive value (NPV) for in-hospital mortality (4.4% vs 0.6%, p<0.001). After adjusting for covariates, an Age SI higher than 40 was associated with increased in-hospital mortality (adjusted OR 3.2, 95% IC 1.06–9.55), p=0.039).

Mortality and Age Shock Index

Conclusion

Age SI demonstrated better discriminatory capacity and equal calibration, compared to SI and MSI for in-hospital mortality. An age SI higher than 40 was associated with a 3-fold increased risk of in-hospital death. This cut-off demonstrated excellent negative predictive value (99.5%) and may allow very early risk assessment in patients with non-ST-segment elevation MI (NSTEMI), before laboratorial values are available for GRACE calculation. This may guide initial therapy and help select the most appropriate initial site of care.

3036Identifying low-risk patients eligible for early discharge after ST-segment elevation myocardial infarction

Introduction

Early discharge after ST-segment elevation myocardial infarction (STEMI) should be considered in low-risk patients after successful percutaneous coronary intervention (PCI) to reduce healthcare costs and improve resource utilization. The Zwolle criteria is recommended by current guidelines for the identification of low-risk patients but a new score, the FASTEST score, has recently demonstrated to add prognostic value over Zwolle score in small and unicentric studies.

Purpose

Assess if FASTEST score could better identify low-risk patients compared to Zwolle in a contemporary nationwide cohort of patients with STEMI who underwent primary PCI and complete revascularization.

Methods

Multicentric observational study of consecutive patients with ACS recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between October 2010 and January 2019. Patients who underwent primary PCI and received complete revascularization were included, and those with missing data for score calculation were excluded. The FASTEST score awards 1 point for each: femoral access, age>65, LVEF<50, TIMI<3; creatinine >1.5 mg/dl; stenosis of the left main coronary artery; and Killip≥2. The Zwolle score was calculated for comparison. The rate of hospital mortality and a composite of serious adverse events (heart failure, cardiogenic shock, re-infarction, mechanical complication, ventricular arrhythmia and major hemorrhage) was compared between low-risk patients as classified by FASTEST (score=0) or Zwolle (score≤3). One-year mortality and cardiovascular rehospitalization was compared between the two groups.

Results

We included 3322 patients (77.4% male, mean age 62±13 years, 49.5% with anterior STEMI). The FASTEST score identified 855 (25.8%) and Zwolle 2353 (70.7%) low-risk patients. Discrimination by AUC for hospital mortality was 0.92 (95% CI 0.91–0.93) for FASTEST score, significantly higher than Zwolle (0.83 (95% CI 0.82–0.84), p<0.001 for comparison) (Fig.1). Overall hospital mortality was 2.8%. 1 patient died in low-risk FASTEST compared to 24 (1%) in low-risk Zwolle (p=0.01). Low-risk Zwolle patients were more likely to suffer serious hospital adverse events compared with FASTEST score low-risk (19.5% vs 8.5%, p<0.001).

At one-year, 1384 patients had follow-up data. Mortality was significantly lower in low-risk FASTEST than Zwolle (1.5% vs 4.6%, p<0.001) and a tendency for less cardiovascular rehospitalization was also noted (5.4% vs 7.5%, p=0.08).

Figure 1. ROC-AUC for hospital mortality

Conclusion

Approximately one in every four patients were classified as low-risk according to FASTEST score, in contrast with 70% for Zwolle score. Low-risk FASTEST score patients exhibited significantly less hospital mortality (1 patient), hospital serious adverse events and 1-year mortality compared with low-risk Zwolle patients. FASTEST score demonstrated better discriminatory capacity for hospital mortality than Zwolle score and its use for risk stratification should be preferred.

P4600Intraventricular conduction disturbance and ventricular paced rhythms in patients with acute coronary syndromes

Introduction

Left or right bundle branch block (LBBB or RBBB) and ventricular paced rhythms (PM) difficult the diagnosis and often delay adequate treatment in patients with acute coronary syndromes (ACS). In the past few years, guidelines have placed a greater emphasis on the need for considering urgent revascularization in these patients.

Purpose

Evaluate initial revascularization strategy and short-term prognostic impact of LBBB, RBBB and PM in patients with ACS.

Methods

Multicentric observational study of consecutive patients with ACS recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between October 2010 and January 2019. Patients were categorized according to the ECG at admission: LBBB, RBBB, PM and normal QRS morphology. Patients with missing data on the ECG or the primary outcome were excluded. Demographic, clinical data and in-hospital outcomes were analyzed. The association between LBBB, RBBB, PM and in-hospital adverse outcomes was assessed using a logistic regression model. The primary and secondary outcomes were in-hospital mortality and a composite of in-hospital adverse events (heart failure, re-infarction or cardiac arrest), respectively.

Results

Of the original cohort, 18314 (94.3%) patients were included (mean age 66±13 years, 73.2% male): 243 (1.3%) had PM, 846 (4.6%) had LBBB, 1195 (6.5%) had RBBB and 16030 (87.5%) had normal QRS. Patients with abnormal QRS were significantly older, had more comorbidities, were less frequently diagnosed as ST-elevation MI (LBBB 18%; RBBB 35.1%; PM 7.8%; Normal 44.2%, p<0.001) and considered for urgent reperfusion (LBBB 13%; RBBB 33.6%; PM 5.8%; Normal 41.6%, p<0.001). Among patients who underwent non-urgent coronary angiography, the finding of an occluded culprit coronary artery was not higher compared to patients with normal QRS (Normal 15.2% vs LBBB 14.3%; RBBB 17.4%; PM 11.4%, p>0.05 for difference).

Overall in-hospital mortality was 3.4% (LBBB 6.6%; RBBB 8.1%; PM 5.3%; Normal 3.4%; p<0.001) and the composite endpoint of in-hospital adverse events was 17.4% (LBBB 35.6%; RBBB 27.3%; PM 23.5%; Normal 15.6%, p<0.001). After adjusting for cofounding variables, and using normal QRS as reference, only RBBB was shown to be significantly associated with increased in-hospital mortality (OR 1.94; 95% CI 1.43–2.66), p<0.001); and both RBBB (OR 1.75; 95% CI 1.5–2, p<0.001) and LBBB (OR 1.8; 95% CI 1.4–2.3, p<0.001), but not PM, were significantly associated with the composite endpoint of heart failure, re-infarction or cardiac arrest.

Conclusion

Compared to patients with normal QRS, those with LBBB, RBBB or PM less often undergo urgent revascularization and have higher rates of in-hospital adverse outcomes. In multivariate analysis, RBBB patients are almost two times more likely to die compared to those with normal QRS. LBBB and RBBB were independently associated with increased rates of in-hospital adverse events. PM was not associated with worse in-hospital outcomes.

Simultaneous occurrence of advanced neuroblastoma and acute myeloid leukemia

The authors report the case of a 4-year-old boy with a diagnosis of stage IV neuroblastoma (NB), who had been treated with 6 cycles of cyclophosphamide, doxorubicin, cisplatin, and etoposide for 12 months. The patient reached partial remission and presented a diagnosis of acute myelomonocytic leukemia (M4 AML), confirmed by immunophenotyping. After 2 months of therapy for leukemia, the child died with both malignancies in activity. A necropsy histologically confirmed the simultaneity of the two diseases. The authors review the possibilities of this association. The review leads to the conclusion that AML can occur as a secondary malignancy after the onset of the neuroblastoma, or be suggested by a misdiagnosis. The simultaneous occurrence of both as described here is not, however, found in the literature, to the best of the authors' knowledge.