The use of cerebral computed tomographic angiography as an ancillary investigation to support a clinical diagnosis of death using neurological criteria: a consensus guideline

This multidisciplinary consensus statement was produced following a recommendation by the Faculty of Intensive Care Medicine to develop a UK guideline for ancillary investigation, when one is required, to support the diagnosis of death using neurological criteria. A multidisciplinary panel reviewed the literature and UK practice in the diagnosis of death using neurological criteria and recommended cerebral CT angiography as the ancillary investigation of choice when death cannot be confirmed by clinical criteria alone. Cerebral CT angiography has been shown to have 100% specificity in supporting a diagnosis of death using neurological criteria and is an investigation available in all acute hospitals in the UK. A standardised technique for performing the investigation is described alongside a reporting template. The panel were unable to make recommendations for ancillary testing in children or patients receiving extracorporeal membrane oxygenation.

Hypertrophic cardiomyopathy and atrial fibrillation: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the European Society of Cardiology

Background

Current guidelines for AF management underline a complex approach to detecting and treating atrial fibrillation (AF). Hypertrophic cardiomyopathy (HCM) is commonly associated with AF.

Purpose

To assess the clinical characteristic and prognosis in patients with HCM and AF.

Methods and results

Overall, 1739 adult patients with HCM (711/40.9% female; median age at diagnosis: 55.5 years) were enrolled in the EURObservational Research Programme – Cardiomyopathy/Myocarditis Long-Term Registry. Baseline clinical characteristics and adverse cardiovascular endpoints at 1-year follow-up were analysed.

Results

At baseline, AF was found in 478 (27.5%) subjects (paroxysmal: 54.7%, persistent: 17.6%, permanent: 27.7%). Newly diagnosed AF was identified during 1-year follow-up in 48 (2.8%) subjects with HCM.

The presence of AF was associated with higher age (59.6±13.8 vs 50.8±16.1, p<0.001); BMI (27.7±5.1 vs 26.6±4.6 kg/m2, p<0.001); more advanced NYHA class (NYHA I/II and III/IV: 75.1 and 24.9 vs 86.2 and 13.8%, p<0.001); more frequent history of diabetes (14.6 vs 8.4%, p<0.001); arterial hypertension 43.4 vs 34.6%, p<0.001); renal impairment (15.4 vs 6.35%, p<0.001); and history of sustained VT (10.8 vs 6.35%, p<0.001). AF patients were characterized by lower left ventricular ejection fraction (LV EF) (59±12 vs 63±11%, P<0.001), left atrium (LA) dilatation (48.9±9.1 vs 42.4±7.7%, p<0.001), increased pulmonary artery systolic pressure (37.8±13.7 vs 29.6±12.6 mmHg, p<0.001), distribution of LV hypertrophy (p=0.032) and more advanced LV diastolic dysfunction (p<0.001).

On multivariate logistic regression analysis, independent predictors of AF in the HCM population were: age at enrolment (OR 1.068, P<0.001); LVEF (OR 0.978, p<0.001); and LA diameter (OR 1.094, p<0.001).

Oral anticoagulation (OAC) was administered in 69.5% of patients with AF (vitamin K antagonist: 48.5%; direct OAC: 21%). ICD was implanted in 26.8% in AF and 16.9% in non-AF subjects (p<0.001). PVI was performed in 9.9% of AF patients only.

The annual incidence of stroke/TIA was higher in AF than in the non-AF population (2.64 vs 0.85%, p=0.009). There was a trend towards increased death from any cause in the AF population (3.39 vs 1.74%, p=0.05). There were no differences in SCD-risk score between AF and non-AF subjects.

Conclusion

The study reveals a high prevalence of AF in patients with HCM that corresponds with more advanced symptoms, increased prevalence of comorbidities, structural and functional heart remodelling along with inadequate anticoagulation and a significant increase in the risk of stroke. The clinical characteristics of HCM-AF patients indicate that the ESC recommended complex AF approach “CC To ABC” is appropriate in this population.

Funding Acknowledgement

Type of funding sources: None.

Influence of sex on cardiovascular outcomes in RBM20 variant carriers

Background

Variants in the RBM20 gene cause dilated cardiomyopathy and may be associated with a poor prognosis.

Objectives

To determine disease penetrance, the risk of adverse events and the influence of sex on outcomes in RBM20 variant carriers.

Methods

Consecutive probands and relatives carrying pathogenic or likely pathogenic RBM20 variants were retrospectively recruited from 12 cardiomyopathy units. The primary endpoint was a composite of malignant ventricular arrhythmia (MVA) and end-stage heart failure (ESHF). MVA and ESHF endpoints were also analysed separately and males and females compared.

Results

Longitudinal follow-up data were available for 163 RBM20 variant carriers (82 male, median age 36.5 years, median follow-up 77.6 months). 10/163 had an MVA event at baseline. 30/153 without baseline MVA (19.6%) reached the primary endpoint with a trend towards worse outcomes in males (p=0.08). 16/153 (10.5%) had new MVA with no difference between males and females (p=0.92). 20/163 (12.2%) developed ESHF (17 males and 3 females; p<0.001).

By the end of follow-up, 114 patients (70%) had either left ventricular systolic dysfunction (LVSD) or had experienced MVA. 22 patients received a first diagnosis of LVSD during follow-up. Disease penetrance in individuals over 40 years of age was 78.5% by last evaluation.

Eleven patients that reached the MVA endpoint had a left ventricular ejection fraction (LVEF) available within 6 months of the event. Median [IQR] contemporary LVEF was 30% [23.75, 40%]. 5/11 patients had a contemporary LVEF >35%. 1/11 had a contemporary LVEF >45% (a female, 1st degree relative presenting with sustained ventricular tachycardia and an LVEF of 65%).

Conclusions

RBM20 variants are highly penetrant. The risk of MVA in male and female RBM20 variant carriers is similar but male sex is strongly associated with ESHF. MVA events occur in patients with LVEF >35%.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Alpha-protein kinase 3 (ALPK3) truncating variants cause an autosomal dominant form of hypertrophic cardiomyopathy

Background

More than half of hypertrophic cardiomyopathy (HCM) remains genetically unsolved. ALPK3 truncating variants (ALPK3tv) have been described as a cause of autosomal recessive cardiomyopathy in a small number of paediatric cases, but the pathogenicity in heterozygosity as a possible cause of autosomal dominant HCM is unknown.

Aims

To determine the frequency of heterozygous ALPK3tv in patients with HCM and to confirm their pathogenicity by means of burden testing in independent cohorts, family co-segregation studies, and functional analysis of an allelic series of ALPK3tv using human embryonic stem cell-cardiomyocytes (hESC-CM). Phenotype was compared with a cohort of 1679 genotyped HCM patients.

Methods and results

In a discovery cohort of 770 index patients with HCM, 12 (1.56%) were heterozygous for ALPK3tv, odds ratio (OR) 16.01 (95% confidence interval (95% CI): 7.89 to 29.74, p&lt;8.36e-11), compared to the Genome Aggregation Database (gnomAD) population. In a validation cohort of 2047 HCM probands, 32 (1.56%) carried heterozygous ALPK3tv, OR 16.17 (95% CI: 10.31 to 24.87; p&lt;2.2e-16, compared to gnomAD). Combined logarithm of odds score in 7 families with ALPK3tv was 2.99. In comparison with a large cohort of genotyped HCM patients, the phenotype of 51 HCM patients with ALPK3tv (probands and relatives) was characterised by a higher prevalence of apical/concentric patterns of hypertrophy (60%) compared to both sarcomere-positives or negatives (p&lt;0.001 overall), with the age at diagnosis (56±16ys) and maximum wall thickness (18±4mm) similar to sarcomere-negatives and LV systolic impairment at baseline (6%) and non-sustained ventricular tachycardia (31%) similar to sarcomere-positives. Short PR (10%, p=0.009 overall) and extensive fibrosis&gt;15% of LV segments (49%) were distinctive features. During follow-up (5.3±5.7 years), 4 (9%) patients died of heart failure or had cardiac transplantation (p=0.012 vs sarcomere-negatives and p=0.425 vs sarcomere-positives). Analysis of hESC-CM showed that ALPK3 heterozygotes had phenotypic characteristics of HCM, including increased contractile force and delayed membrane repolarization.

Conclusions

Heterozygous ALPK3tv are pathogenic and segregate with a characteristic HCM phenotype.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): MRC UK, UCLH BRC

External validation of the HCM Risk-Kids model for predicting sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). The newly developed HCM Risk-Kids model provides clinicians with individualised estimates of risk. The aim of this study was to externally validate the model in a large independent, multi-centre patient cohort.

Methods

A retrospective, longitudinal cohort of patients diagnosed with HCM aged 1–16 years independent of the HCM-Risk-Kids development and internal validation cohort was studied. Data on HCM Risk-Kids predictor variables (unexplained syncope, non-sustained ventricular tachycardia, maximal left ventricular wall-thickness, left atrial diameter and left ventricular outflow tract gradient) were collected from the time of baseline clinical evaluation. The performance of the HCM Risk-Kids model in predicting risk at 5 years was assessed.

Results

The cohort consisted of 421 patients with a median age at baseline evaluation of 12.3 years (IQR 7.3, 14.4). Over a median total follow up 3.48 years (IQR 1.83, 6.62, range 1 month – 20.7 years). Fourteen patients (3.3%) died and 10 (2.4%) underwent cardiac transplantation. Twenty-three patients (5.4%) met the SCD end-point within 5-years, with an overall incidence rate of 2.03 per 100 patient years (95% CI 1.48–2.78). Model validation showed a Harrell's C-index of 0.745 (95% CI 0.52–0.97) and Uno's C-index 0.714 (95% 0.58–0.85) with a calibration slope of 1.15 (95% 0.51–1.80). Figure 1a describes the agreement between predicted and observed 5-year cumulative proportion of SCD or equivalent events for each tertile of predicted risk in one imputed data set. One hundred and twenty-five (29.7%) patients had a predicted 5-year risk of ≥6%. SCD events occurred in 6 patients (2.0%) with a predicted risk &lt;6% and 17 (13.6%) with a predicted risk ≥6. A 5-year predicted risk threshold of ≥6% identified 17 (73.9%) SCD-events with a corresponding C-statistic of 0.702 (95% CI 0.60–0.81) (Figure 1b).

Conclusions

This study reports the first external validation of the HCM Risk-Kids model in a large and geographically diverse patient population. A 5-year predicted risk of ≥6% identified over 70% of events, confirming that HCM Risk-Kids provides a method for individualised risk predictions and shared decision making in children with HCM. Incorporation of the model into routine clinical care will enable independent prospective model validation and assessment of the effect of its use in clinical practice.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart FoundationMedical Research Council Observed vs predicted risk by tertilesObserved vs predicted by threshold

Standardising clinical outcomes measures for adult clinical trials in Fabry disease: A global Delphi consensus

BACKGROUND

Recent years have witnessed a considerable increase in clinical trials of new investigational agents for Fabry disease (FD). Several trials investigating different agents are currently in progress; however, lack of standardisation results in challenges to interpretation and comparison. To facilitate the standardisation of investigational programs, we have developed a common framework for future clinical trials in FD.

METHODS AND FINDINGS

A broad consensus regarding clinical outcomes and ways to measure them was obtained via the Delphi methodology. 35 FD clinical experts from 4 continents, representing 3389 FD patients, participated in 3 rounds of Delphi procedure. The aim was to reach a consensus regarding clinical trial design, best treatment comparator, clinical outcomes, measurement of those clinical outcomes and inclusion and exclusion criteria. Consensus results of this initiative included: the selection of the adaptative clinical trial as the ideal study design and agalsidase beta as ideal comparator treatment due to its longstanding use in FD. Renal and cardiac outcomes, such as glomerular filtration rate, proteinuria and left ventricular mass index, were prioritised, whereas neurological outcomes including cerebrovascular and white matter lesions were dismissed as a primary or secondary outcome measure. Besides, there was a consensus regarding the importance of patient-related outcomes such as general quality of life, pain, and gastrointestinal symptoms. Also, unity about lysoGb3 and Gb3 tissue deposits as useful surrogate markers of the disease was obtained. The group recognised that cardiac T1 mapping still has potential but requires further development before its widespread introduction in clinical trials. Finally, patients with end-stage renal disease or renal transplant should be excluded unless a particular group for them is created inside the clinical trial.

CONCLUSION

This consensus will help to shape the future of clinical trials in FD. We note that the FDA has, coincidentally, recently published draft guidelines on clinical trials in FD and welcome this contribution.

Myocardial work analysis in screening of familial dilated cardiomyopathy

Introduction

Early detection of affected family relatives of patients with dilated cardiomyopathy (DCM) is essential in order to guide follow up, outcomes and initiate early treatment. Myocardial work analysis is a novel method which integrated strain imaging and blood pressure and has the potential to identify patients with subclinical disease.

Purpose

We analysed myocardial work in family relatives of DCM patients with positive genotype but negative phenotype in order to identify whether myocardial work can identify early changes.

Methods

Seventy-four family relatives of DCM patients attending for screening were examined. All individuals were asymptomatic with either positive (45/74, G+) or negative (29/74, G-) genotype and no echocardiographic evidence of left ventricular dilatation or systolic impairment. Non-invasive myocardial work analysis using two-dimensional (2D) speckle tracking echocardiography was analysed. Global longitudinal strain (GLS) was measured by the same vendor specific software used for myocardial work analysis. Left ventricular (LV) ejection fraction (EF) was measured with the Simpson's biplane method. The peak systolic arm cuff blood pressure (BP) measurement at the time of echocardiography was used for the myocardial work study.

Results

In total we included 74 individuals (37±15 years old, 50.7% women) with mean systolic and diastolic BP of 121.3±14 and 73.2±10 mmHg respectively, mean EF was 58±5% and mean GLS at 18.4±2.5%.

G+ individuals had pathogenic and very likely pathogenic mutations in 8 different genes (TTN, BAG3, DSP, FLNC, LMNA, DMD, RBM20, TPM1). There was no difference in age, systemic hypertension, diabetes or medical treatment between the 2 groups.

No significant difference was found among G+ and G- individuals in mean systolic and diastolic BP (121.2±14.7 vs 121.2±15.2 mmHg), mean EF (57.3±5 vs 59.1±4%), GLS (−18.2±1.5 vs −18.6±2.9%), mean global work index (1818±403 vs 1928±295 mmHg%) and global constructive work (2192±464 vs 2260±318 mmHg%).

However, we found significant reduction of the global work efficiency (GWE) with a GWE of 94.4±2.7% in the G+ versus 95.9±1.6% in the G- individuals (p 0.02). Moreover, the global wasted work (GWW) was increased in the G+ with a GWW of 111±58 mmHg% versus 82±41 mmHg% in the G- individuals (p 0.03).

Conclusion

DCM gene carriers show, early on, decreased myocardial work efficiency and increased wasted work compared to unaffected family members, which appears to be earlier than other parameters such as EF and GLS. Myocardial work analysis could potentially recognize individuals showing early cardiac involvement and guide closer follow up and early initiation of treatment.

Funding Acknowledgement

Type of funding source: None

Long-term survival with tafamidis in patients with transthyretin amyloid cardiomyopathy

Background

The Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), demonstrated that tafamidis was an effective treatment for patients with transthyretin amyloid cardiomyopathy (ATTR-CM). Tafamidis, at an 80 mg daily dose, was subsequently approved in several countries for the treatment of ATTR-CM. Patients who completed ATTR-ACT were eligible to enroll in an ongoing long-term extension study (LTE) which provides additional data on the long-term efficacy of tafamidis.

Purpose

To assess the long-term benefit of tafamidis in patients with ATTR-CM and to determine median survival times with treatment.

Methods

Patients with ATTR-CM who completed ATTR-ACT (in which they were randomized to tafamidis meglumine 80 mg, 20 mg or placebo for 30 months) could enroll in the ongoing LTE in which patients continued to be treated with the same dose of tafamidis or, if previously treated with placebo, were randomized to tafamidis meglumine 80 mg or 20 mg. Tafamidis free acid 61 mg is a new formulation (bioequivalent to tafamidis meglumine 80 mg) developed for patient convenience and all patients in the LTE transitioned to tafamidis free acid 61 mg as of 1 Aug, 2018. All-cause mortality (with heart transplant or cardiac mechanical assist device [CMAD] implantation counted as death) was assessed using a Cox proportional hazards model (as of 1 Aug, 2019). Patients treated with tafamidis meglumine 80 mg in ATTR-ACT and the LTE who transitioned to tafamidis free acid 61 mg (tafamidis 80/61 mg) were compared with patients treated with placebo in ATTR-ACT who transitioned to tafamidis in the LTE (placebo/tafamidis).

Results

There were a total of 176 tafamidis 80/61 mg patients and 177 placebo/tafamidis patients. Median treatment duration was 51.9 months with tafamidis 80/61 mg and 51.4 months with placebo/tafamidis. With tafamidis 80/61 mg, there were 75 (42.6%) all-cause deaths; consisting of 67 (38.1%) deaths, 6 (3.4%) heart transplants, and 2 (1.1%) CMAD implantations. With placebo/tafamidis, there were 108 (61.0%) all-cause deaths; consisting of 102 (57.6%) deaths and 6 (3.4%) heart transplants. There was a significant reduction of 41.1% in the risk of all-cause mortality with tafamidis 80/61 mg compared with placebo/tafamidis (hazard ratio [95% CI], 0.5888 [0.4370, 0.7931]; P=0.0004). Median survival time with placebo/tafamidis was 35.8 months but was not reached with tafamidis 80/61 mg.

Conclusions

Treatment with tafamidis significantly improves long-term survival in patients with ATTR-CM. The comparatively poorer survival in patients treated with placebo in ATTR-ACT who transitioned to tafamidis in the LTE highlights the importance of early diagnosis and treatment.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This study was sponsored by Pfizer.

Penetrance of hypertrophic cardiomyopathy and outcome in sarcomeric mutation carriers

Background

Predictive genetic screening of the first degree relatives of patients with hypertrophic cardiomyopathy (HCM) caused by sarcomere protein (SP) gene mutations is current standard of care, but there are few data on long-term outcomes in mutation carriers without HCM.

Purpose

To establish the role of sex and genotype in HCM penetrance as well as the rate of major adverse clinical events in SP mutation carriers and following the diagnosis of HCM.

Methods

Retrospective analysis of consecutive adult and paediatric SP mutation carriers identified during family screening and who did not fulfill diagnostic criteria for HCM at first evaluation.

Results

321 individuals from 170 families [median age first evaluation 15.2 years (IQR 7.3–32.6); 153 (47.7%) males] were evaluated. Causal SP genes were: MYBPC3 (n=133 (41.4%)), MYH7 (n=77 (24.0%)), TNNI3 (n=51 (15.9%)), TNNT2 (n=40 (12.5%)), TPM1 (n=9 (2.8%)), MYL2 (n=6 (1.9%)), and ACTC1 (n=1 (0.3%)); 4 (1.3%) carried multiple mutations.

After a median follow up of 7.4 years (IQR 2.5–12.7), 89 (27.7%) patients developed HCM. Disease penetrance at the age of 50 years was 47% (95% CI 38%-56%). One hundred and fifty three (47.7%) individuals underwent cardiac magnetic resonance (CMR) imaging; among those diagnosed with HCM, 22/89 (24.7%) fulfilled criteria on CMR but not echocardiography.

In a multivariable model adjusted for genotype, follow up duration and evaluation with CMR, independent predictors of HCM development were male sex (HR 3.11; CI 1.82–5.32) and abnormal ECG (HR 7.87; CI 4.43–13.97). Patients with MYH7 and multiple mutations were more likely to develop HCM than those with MYBPC3 mutations (HR 2.03; CI 1.04–3.96 and HR 10.13; CI 1.40–72.92, respectively). Disease penetrance was lowest in carriers of TNNI3 mutations (HR 0.13; CI 0.03–0.48).

There were no major adverse events in individuals without HCM. Following the diagnosis of HCM, the combined rate of all-cause death, appropriate defibrillator shock or resuscitated cardiac arrest was 1.1%/year [median follow up 4.0 years (IQR 2.1–8.9)].

Conclusions

Approximately 50% of SP mutation carriers develop HCM by the age of 50 and become prone to disease complications during long-term follow-up. Sex, MYH7 mutations and the presence of an abnormal ECG are associated with a higher risk of disease development. CMR should be employed systematically in long-term screening.

HCM penetrance by sex

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and natural history of PRKAG2 syndrome

Purpose

Mutations in the PRKAG2 gene cause a syndrome characterized by hypertrophic cardiomyopathy, conduction disease and ventricular preexcitation. Only a small number of cases have been reported, and the natural history of the disease is poorly understood. The aim of this study is to describe phenotype and natural history of PRKAG2 mutation in a large multicenter international cohort.

Methods

We retrospectively studied clinical, electrocardiographic and echocardiographic data from 90 individuals with PRKAG2 mutations (53% males, 33±21 years) from 27 centers.

Results

At baseline evaluation, 93% of patients were in NYHA functional class I-II. Maximum left ventricular (LV) wall thickness was 18±8 mm and LV hypertrophy (LVH) was present in 60 (67%) subjects at baseline. LV ejection fraction was 61±12%. Seventeen pactients (19%) had a pacemaker (mean age at implantation 37±15and 16 (18%) had atrial fibrillation (AF) (mean age 41±23 years) and 33% had ventricular preexcitation or had undergone an accessory pathway ablation. After a median follow-up of 6 years (IQR:2.3–13.9), 71% of individuals had LVH, 29% had AF, 21% a de novo pacemaker (mean age at implantation 38±18 years), 14% required admission for heart failure (HF), 8% experienced sudden cardiac death or equivalent, 4% required a heart transplant and 13% died.

Conclusions

PRKAG2 syndrome is a severe, progressive cardiomyopathy characterized by high rates of AF, conduction disease, advanced HF and life-threatening arrhythmias. Outcome is not clearly related to the classical features of preexcitation and severe LVH, which are not always present.

Natural history of PRKAG2 syndrome

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III (ISCIII)

Clinical profiles and incident heart failure in cardiomyopathies: a population-based linked electronic health record cohort study

Background

Cardiomyopathies frequently cause heart failure (HF), however their prevalence in the general population and the natural history of incident HF across the spectrum of cardiomyopathy phenotypes is poorly understood. Improved understanding will help guide rational selection of diagnostic tests and accelerate the recognition of underlying causes of HF.

Purpose

To estimate the prevalence of cardiomyopathies using electronic health records; to compare clinical characteristics between patients with cardiomyopathy phenotypes; and to describe the temporal relationship between diagnosis of cardiomyopathy and incident HF.

Methods

A population-based cohort of patients with cardiomyopathy (n=4058) was provided by the UK Clinical Practice Research Datalink (CPRD) from a denominator sample of ∼9 million individuals. Patients were phenotyped into groups according to ESC criteria: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC) and restrictive cardiomyopathy (RCM). An additional group of transthyretin amyloid cardiomyopathy (ATTR-CM) was reported separately. Point prevalence was estimated for each cardiomyopathy subtype and clinical characteristics defined. An index date at first diagnosis of HF was determined for each patient and the time from/to first diagnosis of cardiomyopathy calculated relative to the index date and presented graphically.

Results

DCM was the most common cardiomyopathy phenotype among women and men with 3.4 and 7.7 cases per 10,000 population, respectively. The 2-fold increase in prevalence among men was consistent across DCM, HCM and RCM; the reverse trend was observed for ARVC which was found in 2.3 per 10,000 women and 1.1 per 10,000 men. At the time of first diagnosis of cardiomyopathy, most patients with ATTR-CM (73.5%), DCM (71.0%) and RCM (71.3%) had pre-existing HF though this proportion fell to 41.0% in ARVC and 31.0% in HCM. In relation to incident HF, a diagnosis of HCM and DCM were recorded earliest at a mean −2.2 years (SE 0.2) and −0.6 years (SE 0.1), respectively. We observed a clustering of diagnoses of RCM (mean −0.2 years, SE 0.4) and ARVC (mean 0.1 years, SE 0.1) around the time of onset of heart failure, whereas a diagnosis of ATTR-CM was first recorded at a mean of 0.9 years (SE 0.2) following the onset of heart failure.

Conclusions

Most diagnoses of ATTR-CM, DCM and RCM were preceded by clinical expression of HF whereas most people with ARVC or HCM developed HF after their cardiomyopathy diagnosis. Our findings in ARVC and HCM suggest a more indolent course with respect to cardiac function or better recognition in an asymptomatic phase. The clustering of a diagnosis of heart failure around the time of diagnosis of cardiomyopathy highlights a need for greater awareness of specific aetiologies of heart failure in routine practice and suggests opportunities for presymptomatic or earlier diagnosis.

Temporality of HF in cardiomyopathies

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Pfizer

The influence of age on the diagnostic yield of genetic testing in dilated cardiomyopathy

Background

Dilated cardiomyopathy (DCM) has an estimated population prevalence of 1/250 and is the underlying diagnosis in a third of heart failure patients. A substantial proportion of patients have familial disease caused by dominant mutations in one of more than 50 genes, but clinical practice guidelines recommend genetic testing in young patients with idiopathic DCM. There is an absence of robust data on the influence of age on the diagnostic yield of genetic testing.

Methods

The study cohort comprised 825 consecutive and unrelated patients (524 male (63.5%)) with DCM who underwent genetic testing from 2015 to 2019. Genetic variants were classified using American College of Medical Genetics (ACMG) criteria. Analyses were stratified by age and sex.

Results

173 (20.1%) patients had a positive genetic test (“pathogenic” or “likely pathogenic” variant); 292 (34.4%) had a variant of unknown significance. Mean age at genetic testing was 49.9±14.4 years. Mean age of patients with a positive test was 47.6±13.6 years. 99 (18.9%) men and 67 (22.3%) women had a positive test (p=0.246).

Mutations in the TTN gene, encoding for titin, accounted for 46.1% of positive results. 13.8% of mutations were in DSP, 8.4% in RBM20, 6% in FLNC, 4.2% in LMNA, 3.6% in BAG3 and 3.6% in MYH7.

There was a trend to declining yield with age (likelihood ratio chi-square p value = 0.047). The yield was 17.2% in the 56–65 year age group and 11.5% above 66 years of age (figure 1).

Conclusions

Approximately 1 in 5 patients with DCM had a positive genetic test. The yield declined in patients over 66 years but remained above 11%, suggesting that genetic testing should not be confined to younger patients with DCM.

Figure 1. Yield of Genetic Testing by Age

Funding Acknowledgement

Type of funding source: None

Genetic counselling and testing of adult patients with cardiomyopathies: insight from the EORP cardiomyopathy and myocarditis registry of the European Society of Cardiology

Introduction

Cardiomyopathies comprise a heterogeneous group of diseases, often of genetic origin.

Purpose

We assessed the current practice of genetic counselling and testing of adult cardiomyopathy patients in the prospective ESC EORP cardiomyopathy registry.

Methods

3 208 adult patients from sixty-nine centres in 18 countries were enrolled. Clinical data on genetic counselling and testing and on the presentation of cardiomyopathies were gathered.

Results

Genetic counselling was performed in 60.8% of all patients (75.4% in hypertrophic (HCM), 39.2% in dilated (DCM), 70.8% in arrhythmogenic right ventricular (ARVC) and 49.2% in restrictive cardiomyopathy (RCM), p&lt;0.001). Comparing European geographical areas, genetic counselling was performed from 42.4% to 83.3% (p&lt;0.001). It was provided by a cardiologist (85.3%), geneticist (15.1%), genetic counsellor (11.3%), or a nurse (7.5%), (p&lt;0.001). Genetic testing was performed in 37.3% of all patients (48.8% in HCM, 18.6% in DCM, 55.6% % in ARVC and 43.6% in RCM, p&lt;0.001). Index patients with genetic testing were younger at diagnosis, had more familial disease, family history of sudden cardiac death or implanted cardioverter defibrillators but less comorbidities than those not tested (p&lt;0.001 for each comparison). At least 1 disease causing variant was found in 41.7% of index patients with genetic testing (43.3% in HCM, 33.3% in DCM, 51.4% in ARVC and 42.9% in RCM, p=0.13).

Conclusion

We report on the practice of genetic counselling and testing in cardiomyopathies in Europe. Genetic counselling and testing were performed in a substantial proportion of patients but less often than recommended by European guidelines, and much less in DCM than in HCM and ARVC, despite evidence for genetic background.

Funding Acknowledgement

Type of funding source: None

The relationship between left ventricular outflow tract gradient and sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

The most common mode of death in childhood hypertrophic cardiomyopathy (HCM) is sudden cardiac death (SCD). Left ventricular outflow tract obstruction (LVOTO) is an established risk factor for SCD in adults with the disease. In contrast, the prognostic implications of LVOTO in childhood disease is unclear, with recent studies suggesting that it may have an inverse relationship with the risk of SCD.

Purpose

The aim of this study was to explore the role of LVOTO and the risk of SCD in childhood HCM.

Methods

A multi-centre, retrospective, longitudinal cohort of 871 children (diagnosed with HCM &lt;16 years of age) was used to explore the relationship between SCD and LVOTO (LVOT gradient ≥30mmHg).

Results

189 patients (23%) had LVOTO, which was mild (30–50mmHg), moderate (50–100mmHg) or severe (&gt;100mmHg) in 58 (6.7%), 98 (11.3%) and 33 (3.8%), respectively. The risk of SCD showed an inverse relation to LVOT gradient severity compared to those with no obstruction: mild HR 1.75 (95% CI 0.89–3.44), moderate HR 1.04 (95% 0.55–1.98), and severe HR 0.7 (0.36–1.35) [figure].On univariable analysis [table] LVOTO was associated with heart failure symptoms (NYHA&gt;1) [p &lt;0.001], maximal wall thickness (MWT) [p &lt;0.001], left atrial (LA) diameter [p &lt;0.001], and future myectomy occurring during follow up [p &lt;0.001]. The inverse relationship observed was not altered by the presence or absence of other traditional risk factors.

Conclusions

LVOTO appears to have a complex relationship with the risk of SCD in childhood HCM, with multiple contributing factors. The pathophysiological mechanisms behind this observation need further exploration, which may be limited by low patient numbers

Cummulative incidence of SCD by LVOTO

Funding Acknowledgement

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

High prevalence of familial and genetic disease in children with cardiomyopathies: baseline paediatric data from the ESC EORP Cardiomyopathy and Myocarditis registry

Background

Previous studies on paediatric cardiomyopathies have provided useful information on their epidemiology and clinical presentation but have been limited by a lack of detailed data on genetic testing and aetiology.

Purpose

The purpose of this study was to examine the frequency of familial and genetic disease among children with cardiomyopathy enrolled in the European Society of Cardiology (ESC) Cardiomyopathy and Myocarditis EORP Long-Term Registry (CMY-LT).

Methods

633 individuals aged &lt;18 years with hypertrophic cardiomyopathy [HCM; n=387 (61%)], dilated cardiomyopathy (DCM; n=205 (33%)], restrictive cardiomyopathy [RCM; n=28 (4%)] and arrhythmogenic right ventricular cardiomyopathy [ARVC; n=11 (2%)] were enrolled by 26 centres from 14 countries. Mean age at diagnosis was 5.2 (±5.4) years and there was a male predominance [n=372 (59%)] across all cardiomyopathy subtypes, with the exception of DCM in those diagnosed &lt;10 years of age (p=0.005). 541 (87%) were probands compared to 83 (13%) first-degree relatives.

Results

Overall, 253 patients (47% of those reported) had familial disease; in those diagnosed between 10 and 18 years of age, familial disease was most frequent in HCM and least frequent in DCM [57 (55%) vs 12 (32%); p=0.046]. Genetic testing was performed in 414 (68%) patients. In those diagnosed &lt;10 years, genetic testing was more frequently performed in HCM [128 (67%) vs 33 (37%) in DCM, 10 (56%) in RCM and 1 (50%) in ARVC; p=0.008]; in those aged 10–18, genetic testing was most frequent in ARVC [n=8 (89%)] followed by HCM [n=81 (69%)], RCM [n=1 (50%)] and DCM [n=22 (46%); p=0.007]. A causative mutation was reported in 250 patients (60%), with a higher yield in those aged 10–18 vs &lt;10 years [77 (69%) vs 172 (57%), p=0.032]. In those &lt;10 years, the prevalence of reported causative mutations was highest in HCM [128 (67%) vs 10 (56%) in RCM, 1 (50%) in ARVC and 33 (37%) in DCM; p&lt;0.001]; in those 10–18 years, there was no significant difference in prevalence of reported causative variants between cardiomyopathy subtypes. Rare disease phenocopies were reported in 171 patients (27%): malformation syndromes [n=75 (12%)]; neuromuscular disorders [n=49 (8%)]; inborn errors of metabolism [n=20 (3%)]; mitochondrial [n=18 (3%)]; and chromosomal [n=15 (2%)]. Phenocopies were reported most frequently in patients &lt;10 years [135 (30%) vs 35 (20%) in those aged 10–18 years; p=0.008], particularly in HCM in those &lt;10 years [n=110 (41%); p&lt;0.001 vs other subtypes] and DCM in those aged 10–18 years [n=18 (38%); p=0.03 vs other subtypes].

Conclusion

This study confirms the heterogeneous aetiology of childhood cardiomyopathies and demonstrate a higher prevalence of familial disease than previously reported in paediatric populations. Genetic testing is performed in a high proportion of patients, with a high yield of reported causative variants.

Funding Acknowledgement

Type of funding source: None

Availability and applicability of cardiac magnetic resonance imaging in diagnosis in cardiomyopathies: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the ESC

Background

Cardiac magnetic resonance (CMR) constitutes a gold standard in the diagnosis of cardiomyopathies. Regardless of CMR advantages, the method is time-consuming, high-cost, with limited availability in some European regions.

Purpose

To assess the availability and applicability of CMR for establishing the diagnosis in different populations of patients with cardiomyopathies.

Methods

Overall, 3208 adult patients with cardiomyopathy (1119 / 34.9% females; median age at diagnosis: 49.0 years): 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM) and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in EURObservational Research Programme (EORP) – Cardiomyopathy/Myocarditis Long-Term Registry were analysed.

Results

CMR scan was performed as a baseline diagnostic method in 29.4% of patients; CMR was a single diagnostic method in 0.9% of patients and in 28.6% of patients CMR was used along with transthoracic echocardiography (TTE). In 67.6% of patients TTE was at the baseline the single diagnostic imaging method. Prevalence of CMR use in different cardiomyopathies was as follows: 20.6% in DCM, 33.8% in HCM, 36.4% in RCM and 51.1% in ARVC (p&lt;0.001). Range of CMR applicability in different European regions was diverse from 0% up to 63.2%.

The population with CMR use was younger, less symptomatic, with decreased prevalence of other cardiovascular risk factors and of associated cardiovascular diseases as compared to the population diagnosed without CMR scanning (p&lt;0.001).

Abnormal CMR results were present in 93.4% of patients with the highest percentage in RCM (95.8%) and HCM (94.9%) followed by DCM (91.5%) and the lowest abnormal CMR scan ratio in ARVC (87.7%) (p=0.030). The majority of CMR examinations comprised the assessment of late gadolinium enhancement (LGE, 93.3% at baseline). Presence of CMR LGE was observed in 69.3% of all patients: 59.1% in DCM, 73.8% in HCM, in 63.9% in ARVC and with the highest prevalence in RCM (83.3%) (p&lt;0.001).

Conclusion

The study reveals real-life data on the low availability and applicability of CMR in adult patients with cardiomyopathies. The analysis shows the advantages of CMR imaging but also identifies the gaps between recommendations and clinical practice. Improvement regarding access, training and reimbursement is necessary to offer CMR to cardiomyopathy patients in accordance with the ESC guidelines.

Funding Acknowledgement

Type of funding source: None

SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

OBJECTIVES

To understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents.

METHODS

An outbreak investigation involving 394 residents and 70 staff, was carried out in 4 nursing homes affected by COVID-19 outbreaks in central London. Two point-prevalence surveys were performed one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing.

RESULTS

Overall, 26% (95% CI 22-31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70-336) compared with previous years. Systematic testing identified 40% (95% CI 35-46) of residents as positive for SARS-CoV-2, and of these 43% (95% CI 34-52) were asymptomatic and 18% (95% CI 11-24) had only atypical symptoms; 4% (95% CI -1 to 9) of asymptomatic staff also tested positive.

CONCLUSIONS

The SARS-CoV-2 outbreak in four UK nursing homes was associated with very high infection and mortality rates. Many residents developed either atypical or had no discernible symptoms. A number of asymptomatic staff members also tested positive, suggesting a role for regular screening of both residents and staff in mitigating future outbreaks.

Element Specificity of Transient Extreme Ultraviolet Magnetic Dichroism

In this work we combine theory and experiment to study transient magnetic circular dichroism (TRMCD) in the extreme ultraviolet spectral range in bulk Co and CoPt. We use the ab initio method of real-time time-dependent density functional theory to simulate the magnetization dynamics in the presence of short laser pulses. From this we demonstrate how TRMCD may be calculated using an approximation to the excited-state linear response. We apply this approximation to Co and CoPt and show computationally that element-specific dynamics of the local spin moments can be extracted from the TRMCD in the extreme ultraviolet energy range, as is commonly assumed. We then compare our theoretical prediction for the TRMCD for CoPt with experimental measurement and find excellent agreement at many different frequencies including the M_{23} edge of Co and N_{67} and O_{23} edges of Pt.

Environment and Health: Official knowledge and lay response

Key messages

Formulation of official knowledge and reception of issued messages by lay residents in an area of high deprivation and compromised environment. Factors influencing perception, and adoption, of health messages which may impact on health and well-being in a local population.

1169Interim analysis of data from a long-term, extension trial of tafamidis meglumine in patients with transthyretin amyloid cardiomyopathy

Background

Transthyretin amyloid cardiomyopathy (ATTR-CM), is an underdiagnosed, fatal disease caused by the deposition of transthyretin amyloid fibrils in the heart leading to heart failure. The Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), an international, multi-center, double-blind, placebo-controlled, randomized study, demonstrated the efficacy and safety of tafamidis treatment for patients with ATTR-CM due to variant (ATTRm) or wild-type (ATTRwt) TTR.

Purpose

This is a pooled analysis of data from ATTR-ACT and interim data from the ongoing, long-term, extension study to evaluate longer term data on the efficacy of tafamidis in patients with ATTR-CM.

Methods

Patients who completed ATTR-ACT (which had a duration of 30 months) were eligible to be enrolled in a long-term, extension study in which patients either continued to receive tafamidis meglumine at the same dose (the tafamidis/tafamidis [T/T] group) or, for patients previously treated with placebo, were randomised (in a 1:2 ratio) to tafamidis meglumine 20 mg or 80 mg (the placebo/tafamidis [P/T] group) for up to 60 months. The primary efficacy outcome was all-cause mortality. This analysis combined data from the completed ATTR-ACT with interim data from the extension study (cut-off date: 15 Feb, 2018), and included patients treated with tafamidis meglumine across the two studies with a median follow up of 36 months.

Results

All-cause mortality was significantly lower in the T/T group (n=264; 88 events, 33.3%) compared with the P/T group (n=177; 88 events, 50.3%); hazard ratio (95% CI), 0.64 (0.47, 0.85); P=0.001. In the subgroup of ATTRwt patients, all-cause mortality was significantly reduced in the T/T group (55/201; 27.4%) compared with the P/T group (60/134; 44.8%); 0.64 (0.44, 0.92); P=0.002. In the 106 (24.0%) ATTRm patients, there was a trend towards a reduction in all-cause mortality in the T/T group (33/63; 52.4%) compared with the P/T group (29/43; 67.4%); 0.66 (0.39, 1.09); P=0.17. In patients who were NYHA Class I or II at baseline, all-cause mortality was significantly reduced in the T/T group (38/186; 20.4%) compared with the P/T group (45/114; 39.5%); 0.49 (0.32, 0.75); P=0.001. In those patients with more severe symptoms at baseline (NYHA Class III), there were fewer deaths in the T/T group (50/78; 64.1%) compared with the P/T group (44/63; 69.8%); 0.80 (0.53, 1.21), but this difference was not statistically significant (P=0.50).

Conclusions

In ATTR-ACT, tafamidis was shown to significantly improve survival, functional capacity, and quality of life in patients with ATTR-CM. This pooled analysis with data from the ongoing extension study further supports the efficacy of tafamidis in patients over a longer period of time and the importance of early diagnosis and treatment.

Acknowledgement/Funding

This study was sponsored by Pfizer.

5164New risk prediction score for life-threatening ventricular tachyarrhythmias in laminopathies

Background

An accurate estimation of the risk of life-threatening (LT) ventricular tachyarrhythmia (VTA) in patients with LMNA mutations is crucial to select candidates for implantable cardioverter defibrillator (ICD) implantation.

Methods

We included 839 adult patients with LMNA mutations, including 660 from a French nationwide registry in the development sample, and 179 from other countries, referred to 5 tertiary centers for cardiomyopathies, in the validation sample. LTVTA was defined as a) sudden cardiac death or b) ICD-treated or hemodynamically unstable VTA. The prognostic model was derived using Fine-Gray's regression model. The net reclassification was compared with current clinical practice guidelines. The results are presented as means (standard deviation) or medians [interquartile range].

Results

We included 444 patients 40.6 (14.1) years of age in the derivation sample and 145 patients 38.2 (15.0) years in the validation sample, of whom 86 (19.3%) and 34 (23.4%) suffered LTVTA over 3.6 [1.0–7.2] and 5.1 [2.0–9.3] years of follow-up, respectively. Predictors of LTVTA in the derivation sample were: male sex, non-missense LMNA mutation, 1st degree and higher atrioventricular block, non-sustained ventricular tachycardia, and left ventricular ejection fraction. In the derivation sample, C-index (95% CI) of the model was 0.776 (0.711–0.842). In the external validation sample, the C-index was 0.800 (0.642–0.959) and calibration slope 1.082 (95% CI, 0.643–1.522). A 5-year estimated risk threshold ≥7% predicted 96.2% of LTVTA and net reclassified 28.8% of patients with LTVTA compared with the guidelines-based approach.

Conclusions

Compared to the current standard of care, this risk prediction model for LTVTA in laminopathies facilitated significantly the choice of ICD candidates.

Acknowledgement/Funding

AFM Téléthon

P6234The relationship of alcohol consumption with risk factors of coronary heart disease and the intake of macro- and micro-nutrients in Japanese: the INTERLIPID study

Background

Many studies have reported the J-shaped relationship between alcohol consumption and coronary heart disease (CHD) risk; therefore, light-drinkers is generally recognized to be associated with the lower risk of CHD. However, the mechanisms of lower risk for CHD in light-drinkers are still unclear. Alcohol drinking status is likely to be associated with not only CHD risk factors but also dietary intake. Nevertheless, few studies report these relationships in detail.

Purpose

The purpose of this study is to evaluate the relationships of alcohol drinking status with CHD classical risk factors and the intake of macro- and micro- nutrients in Japanese.

Methods

Study participants were 1,090 Japanese men and women aged 40–59 years from The INTERLIPID study excepted for 55 individuals who had missing data (n=26) and were past-drinkers (n=29). Alcohol consumption was assessed with two 7-day alcohol records, and average ethanol intake (per week) was calculated. Participants were classified into following 4 groups: non-drinkers (0g/week), light-drinkers (<100 g/week), moderate-drinkers (100–299 g/week), and heavy-drinkers (≥300 g/week). Serum LDL and HDL cholesterol, blood pressure (BP), the prevalence of hypertension and dyslipidemia, and smoking status were assessed as CHD risk factors. The intake of energy and macro- and micro-nutrients were evaluated from the four-timed in-depth 24-hr dietary recalls. Nutrient intake densities were calculated per total energy intake without alcohol. The analysis of variance and chi-squared test were used to evaluate the relations of alcohol status with CHD risk factors and nutrient intake.

Results

Serum HDL cholesterol levels increased and LDL cholesterol levels decreased with increasing alcohol consumption. Systolic and diastolic BP increased with increasing alcohol consumption. J-shaped relationships with alcohol consumption were observed for the proportion of current smoker, number of cigarettes, and the prevalence of hypertension; that is, light-drinkers was lowest among all groups. The prevalence of dyslipidemia was the highest in non-drinkers, and decreased with increasing alcohol consumption. In heavy-drinkers, total energy (kcal/day) was the highest, but energy intake without alcohol (kcal/day) was the lowest. For macronutrients, the intake of carbohydrate (%kcal) decreased, and the intakes of total and animal protein (%kcal) increased with increasing alcohol consumption. The intakes of total cholesterol (mg/1000kcal) and sodium (mg/1000kcal) increased, and total fiber (g/1000kcal) decreased with increasing alcohol consumption. These associations were similar in men and women.

Conclusions

Alcohol consumption was related with not only CHD classical risk factors but also the intake of macro- and micro-nutrients. Non-drinkers had a higher proportion of some CHD risk factors than light-drinkers. These results might influence on J-shaped relationship between alcohol consumption and CHD risk.

Acknowledgement/Funding

1: Ministry of Education, Science, Sports, and Culture of Japan, 2: National Institutes of Health, Bethesda, MD, USA

Interprofessional training for the delivery of community health services in Mexico: the experience of Partners in Health

Interprofessional training in health is scarce in Mexico. Partners in Health (CES in Spanish), is the branch of an international civil society organization that provides health services to poor and rural populations. CES runs a set of ten health centers in Chiapas, Mexico, in partnership with the local Ministry of Health. A key component of the provision strategy is to train healthcare providers, mainly medical and nursing students in their final year of training, to create healthcare teams that work together while fostering their individual capacities. CES offers a diploma on Global Health and Social Medicine, where medical and nursing students -also called pasantes- interact to discuss jointly the effects of global and social determinants of health in local communities, as well as specific clinical topics. A qualitative study including interviews and nonparticipant observations was undertaken to identify initial achievements and challenges of the experience. CES has achieved important benefits related to teamwork as well as clinical capacities of individuals as healthcare providers. However, challenges have emerged: differences in social origin, personal development expectations, professional identity and institutional roles hinder team cohesion. Consequently, CES has introduced adjustments to reduce the negative impact of these differences. Although the training model needs further development, the possibility of transferring some of its good practices to non-CES scenarios should be seriously considered by health authorities.

Bayesian spatial modelling for quasi-experimental designs: An interrupted time series study of the opening of Municipal Waste Incinerators in relation to infant mortality and sex ratio

BACKGROUND

There is limited evidence on potential health risks from Municipal Waste Incinerators (MWIs), and previous studies on birth outcomes show inconsistent results. Here, we evaluate whether the opening of MWIs is associated with infant mortality and sex ratio in the surrounding areas, extending the Interrupted Time Series (ITS) methodological approach to account for spatial dependencies at the small area level.

METHODS

We specified a Bayesian hierarchical model to investigate the annual risks of infant mortality and sex-ratio (female relative to male) within 10 km of eight MWIs in England and Wales, during the period 1996-2012. We included comparative areas matched one-to-one of similar size and area characteristics.

RESULTS

During the study period, infant mortality rates decreased overall by 2.5% per year in England. The opening of an incinerator in the MWI area was associated with -8 deaths per 100,000 infants (95% CI -62, 40) and with a difference in sex ratio of -0.004 (95% CI -0.02, 0.01), comparing the period after opening with that before, corrected for before-after trends in the comparator areas.

CONCLUSION

Our method is suitable for the analysis of quasi-experimental time series studies in the presence of spatial structure and when there are global time trends in the outcome variable. Based on our approach, we do not find evidence of an association of MWI opening with changes in risks of infant mortality or sex ratio in comparison with control areas.

Real time scissor correction in TD-DFT

We demonstrate how the scissor correction to the optical band gap, common in linear-response time-dependent density functional theory (TD-DFT), may be extended to the domain of real-time TD-DFT. This requires modifying both the eigenvalues and momentum matrix elements of the underlying basis set. It provides a simple and computationally economical approach for calculating accurate electron dynamics in solids. We demonstrate the importance of this correction for prototypical semiconductors, diamond and silicon, where the energy absorption in both the linear and non-linear regimes is examined. We also show that for a particular system, ZnSe, using the adiabatic local density approximation together with a scissor correction can be advantageous over other approximations, as the underlying quasi-particle band structure is more accurate.

Competing Spin Transfer and Dissipation at Co/Cu(001) Interfaces on Femtosecond Timescales

By combining interface-sensitive nonlinear magneto-optical experiments with femtosecond time resolution and ab initio time-dependent density functional theory, we show that optically excited spin dynamics at Co/Cu(001) interfaces proceeds via spin-dependent charge transfer and back transfer between Co and Cu. This ultrafast spin transfer competes with dissipation of spin angular momentum mediated by spin-orbit coupling already on sub 100 fs timescales. We thereby identify the fundamental microscopic processes during laser-induced spin transfer at a model interface for technologically relevant ferromagnetic heterostructures.

Factor V Leiden and Thermolabile Methylenetetrahydrofolate Reductase in Extreme Old Age

Both factor V Leiden and the C677T methylenetetrahydrofolate reductase (MTHFR) gene mutation are associated with premature vascular disease, and yet are found at surprisingly high allele frequencies in European populations, 2.7% and 35% respectively. We have investigated the prevalence of these mutations in 87 UK residents over the age of ninety, to look for any evidence of their association with premature death.

Five factor V Leiden heterozygotes were found, giving an allele frequency of 2.9%, similar to that in the general UK population. The frequency of the thermolabile C677T MTHFR mutation was 36% with 11% homozygotes, again similar to that in the UK population; these genotypes are in Hardy-Weinberg equilibrium, suggesting that there is not strong selection against the homozygous state. One person was both heterozygous for factor V Leiden and homozygous for the C677T mutation. This study suggests that neither factor V Leiden nor thermolabile MTHFR are risk factors for premature death.

Phenotype and biochemical heterogeneity in late onset Fabry disease defined by N215S mutation

BACKGROUND

Fabry disease (FD) results from X-linked inheritance of a mutation in the GLA gene, encoding for alpha galactosidase A, and is characterized by heterogeneous clinical manifestations. Two phenotypes have been described "Classic" and "late onset" which cannot be predicted exclusively by genotype. The latter has been considered an attenuated form of the disease often affecting a single organ system commonly the heart. Recent studies have demonstrated that cardiac outcomes are similar in patients with classic and late onset mutations. In this study we investigate the relationship between clinical heterogeneity and plasma lyso-Gb3 in a large single centre cohort of N215S patients and compare this to patients with other mutations.

METHODS

In this single-centre, retrospective, cross-sectional study we analysed a cohort of 251 FD patients: 84 N215S mutation (37 males) and 167 non-N215S mutations (58 males). The Mainz severity score index (MSSI) was used as an index of overall disease severity. Cardiac function and morphology were assessed by electrocardiogram and echocardiogram. Left ventricular mass was calculated using the Devereux formula and the left ventricular mass index (LVMI) calculated to adjust for height (g/m2.7). The presence of white matter lesions was assessed by cerebral MRI or computed tomography (CT). GFR was measured by radio-isotope (chromium-EDTA) method and adjusted for patient height (ml/min/m2.7), and urinary protein quantification was undertaken by 24 hour urine collection. Plasma globotriaosylsphingosine (lyso-Gb3) was analysed prior to ERT in 84 patients.

RESULTS

N215S patients showed later symptom onset (males: p< 0.0001, females: p<0.03), later development of left ventricular hypertrophy (LVH) (median survival without LVH: 41 (non-N215S) vs. 64 (N215S) years, p< 0.0001), later development of proteinuria (median survival without proteinuria 43 (non-N215S) vs 71 years (N215S), p< 0.0001), later occurrence of cerebrovascular events (stroke/ Transient Ischaemic Attacks (TIA); median survival without stroke: 74 years (non-N215S) vs. not reached (N215S), p< 0.02), later decline in renal function to GFR <60 ml/min/1.73m2 (median survival: 56 (non-N215S) vs. 72 (N215S) years, p< 0.01), and greater overall survival (median survival 81 (N215S) vs. 66 (non-N215S) years, p< 0.0006). Lyso-Gb3 was found to be less elevated in N215S compared to non-N215S male and female patients. However, the N215S population eventually reached an overall severity measured by MSSI comparable to the non-N215S without equivalent elevation of lyso-Gb3 (means: 6.7 vs. 74.3 nmol/L, p < 0.001). In addition, N215S patients showed strong correlations between lyso-Gb3 levels and LVMI, GFR, and MSSI. These associations became stronger when we investigated individuals' life time exposure to lyso-Gb3 (calculated as [lyso-Gb3]*age): MSSI (r2 = 0.88, p< 0.0001), LVMI (r2 = 0.59, p< 0.005), and GFR (r2 = 0.75, p = 0.0001).

CONCLUSION

These results demonstrate that the N215S mutation results in a late onset phenotype involving the heart and other organs. Correlations between clinical manifestations and plasma lyso-Gb3 variations in this group suggest a Fabry-relevant disease mechanism for the heterogeneity observed in this group.

Spin Flips versus Spin Transport in Nonthermal Electrons Excited by Ultrashort Optical Pulses in Transition Metals

A joint theoretical and experimental investigation is performed to understand the underlying physics of laser-induced demagnetization in Ni and Co films with varying thicknesses excited by 10 fs optical pulses. Experimentally, the dynamics of spins is studied by determining the time-dependent amplitude of the Voigt vector, retrieved from a full set of magnetic and nonmagnetic quantities performed on both sides of films, with absolute time reference. Theoretically, ab initio calculations are performed using time-dependent density functional theory. Overall, we demonstrate that spin-orbit induced spin flips are the most significant contributors with superdiffusive spin transport, which assumes only that the transport of majority spins without spin flips induced by scattering does not apply in Ni. In Co it plays a significant role during the first ∼20  fs only. Our study highlights the material dependent nature of the demagnetization during the process of thermalization of nonequilibrium spins.

Ultrafast demagnetization in bulk versus thin films: an ab initio study

We report ab initio simulations of the quantum dynamics of electronic charge and spins when subjected to intense laser pulses. By performing these purely electron-dynamics calculations for a thin film and for the bulk of Ni, we conclude that formation of surfaces has a dramatic influence of amplifying the laser induced demagnetization. The reason for this amplification is enhanced spin-currents on the surface of the thin films. We show that the underlying physics of demagnetization for bulk is dominated by spin-flips induced by spin-orbit coupling. In the case of thin films, the dominant cause of demagnetization is a combination of the flow of spin-currents and spin-flips. Furthermore, a comparison of our results with experimental data shows that below  ∼120 fs processes of demagnetization are entirely dominated by purely electronic processes followed by which dissipative effects like the Elliott-Yafet mechanism start to contribute significantly.

Prevalence of vitamin D deficiency and association with metabolic syndrome in a Qatari population

OBJECTIVES

Despite long hours of sunlight in Qatar and other regions of the Middle East, vitamin D deficiency has been rising. In parallel, the prevalence of metabolic syndrome has also been increasing in Qatar. Vitamin D levels have been associated with metabolic syndrome but the data are inconsistent and no studies have addressed these inter-relationships in a Middle Eastern population where the prevalence of these conditions is high. The objective is to investigate the prevalence of vitamin D deficiency and its association with metabolic syndrome and its components in the Qatar Biobank population.

METHODS

A cross-sectional study of 1205 participants (702 women and 503 men) from the Qatar Biobank, comprising Qataris and non-Qataris between the ages of 18 and 80 years, was used to perform multivariate linear regression analyses to examine the association between metabolic syndrome and prevalence of vitamin D deficiency (defined as <20 ng ml-1 serum vitamin D levels) adjusting for age, sex, ethnicity, season of blood collection, physical activity and education. Odds ratios and 95% confidence intervals were calculated for all analyses.

RESULTS

Approximately 64% of participants were vitamin D deficient (<20 ng ml-1) with more men being deficient (68.6%) than women (61.3%). Serum vitamin D was 8% lower in individuals with metabolic syndrome (RR: 0.92, 95%CI: 0.87-0.98, P-value: 0.01) compared to individuals without metabolic syndrome. Waist circumference and HDL as well as high triglyceride levels were also significantly positively associated with vitamin D deficiency. No association was found between the other components of metabolic syndrome or diabetes and the presence of vitamin D deficiency.

CONCLUSIONS

Vitamin D deficiency is prevalent in this Qatari population. Presence of metabolic syndrome was associated with presence of vitamin D deficiency. Future prospective studies need to be conducted to investigate the potential for causality.

International scale implementation of the CNOSSOS-EU road traffic noise prediction model for epidemiological studies

The EU-FP7-funded BioSHaRE project is using individual-level data pooled from several national cohort studies in Europe to investigate the relationship of road traffic noise and health. The detailed input data (land cover and traffic characteristics) required for noise exposure modelling are not always available over whole countries while data that are comparable in spatial resolution between different countries is needed for harmonised exposure assessment. Here, we assess the feasibility using the CNOSSOS-EU road traffic noise prediction model with coarser input data in terms of model performance. Starting with a model using the highest resolution datasets, we progressively introduced lower resolution data over five further model runs and compared noise level estimates to measurements. We conclude that a low resolution noise model should provide adequate performance for exposure ranking (Spearman's rank = 0.75; p < 0.001), but with relatively large errors in predicted noise levels (RMSE = 4.46 dB(A)).