Severity of congenital Long QT Syndrome disease onset and risk of depression, anxiety, and mortality: a nationwide study

Introduction

The congenital Long QT Syndrome (cLQTS) is associated with an increased risk of sudden cardiac death (SCD). Thus, cLQTS patients are susceptible to develop depression or anxiety, both of which have been associated with poor outcomes including risk of mortality.

Aim

We examined if a cLQTS diagnosis and the severity of cLQTS disease onset was associated with an increased risk of depression, anxiety, and all-cause mortality compared with a matched control population.

Methods

Using Danish nationwide registries and inherited cardiac disease clinics, we identified all patients with known cLQTS (1994–2016) who were ≥18 years at the time of diagnosis. The disease onset for cLQTS was identified as asymptomatic, ventricular tachycardia [VT]/ syncope, aborted SCD [aSCD], or unknown (i.e. no available information). After cLQTS diagnosis, we determined the risk of depression (i.e. depression diagnosis or prescription of antidepressants), anxiety (i.e. anxiety diagnosis or prescription of anxiolytics), and mortality using multivariable Cox proportional hazards regression. Patients were followed for three years. An age and gender matched control population was identified (matching 1:4). Competing risk analysis with death as competing risk was used to generate cumulative incidence plots.

Results

Overall, 428 cLQTS patients were identified of which 107/428 (25%) developed depression or anxiety after being diagnosed with cLQTS compared with 285/1712 (16.6%) from the control population (p<0.001). The severity of disease onset was identified for 229/428 (55%) cLQTS patients; 104 (24%) were asymptomatic, 89 (21%) had VT/ syncope, and 36 (8.4%) had aSCD. A graded relationship between the severity of cLQTS disease onset and risk of depression or anxiety was identified (Figure 1). In multivariable models, patients with aSCD as disease onset had a higher risk of developing depression or anxiety compared with asymptomatic cLQTS patients (HR=2.34, CI: 1.03–5.32). Furthermore, previous depression (HR=6.38, CI: 4.80–8.48) and anxiety (HR=4.20, CI: 3.15–5.59) was found as associated risk factors. However, no risk was associated with concurrent treatment with beta-blockers (HR=1.23, CI: 0.90–1.69). During follow-up, 8 cLQTS patients died of which 4 had developed depression or anxiety (50%). No significant association between all-cause mortality and depression or anxiety was found, although numbers were low (P=0.22).

Conclusion

The prevalence of depression and anxiety was high among cLQTS patients after diagnosis. Moreover, a graded relationship between severity of disease onset and risk of depression or anxiety was identified. These findings highlight a need for increased awareness following a cLQTS diagnosis in order to reduce the risk of adverse outcomes.

Cumulative incidence curve

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Fund of Rigshospitalet

P2630Incidence and prognostic impact of new-onset left bundle branch block in patients with heart failure and reduced ejection fraction

Background

Cardiac resynchronization therapy (CRT) improves survival in patients with heart failure, reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). However, little is known about the incidence of LBBB in HFrEF and the risk factors for developing this. We addressed these questions in the PARADIGM-HF and ATMOSPHERE trials.

Methods

We identified 7703 patients with a non-paced rhythm on their baseline ECG, a QRS<130 ms, and at least one follow-up ECG (done at annual visits and end of study). Patients were stratified by baseline QRS duration (≤100 ms - reference; 101–115 ms and 116–129 ms) and followed until development of QRS duration ≥130 ms with a LBBB configuration or latest available ECG. The crude LBBB incidence rate per 100 person-years (py) was identified in the three QRS duration subgroups. Additionally, we examined risk of the primary composite outcome of cardiovascular death or HF hospitalization, and all-cause mortality, in patients with incident LBBB vs. no incident LBBB.

Results

Overall, 313 of 7703 patients (4%) developed LBBB during a mean follow-up of 2.7 years, yielding an incidence rate of 1.5 per 100 py. The rate ranged from 0.9 in those with QRS ≤100 ms to 4.0 per 100 py in patients with QRS 116–129 ms. Other predictors of incident LBBB included male sex, age, lower LVEF, HF duration and absence of AF. The risk of the primary composite endpoint was higher among those who developed incident LBBB vs no incident LBBB; event rates 13.5 vs 10.0 per 100 py, yielding an adjusted HR of 1.43 (1.05–1.96). For all-cause mortality the corresponding rates were 12.6 vs 7.3 per 100 py; HR 1.55 (1.16–2.07) (Table 1).

Table 1. Risk of outcomes according to incident LBBB during follow-up No. events Crude rate per 100py Adjusted* HR (95% CI) HF hospitalization or CV death   No incident LBBB 2145 10.0 (9.6–10.4) 1.00 (ref.)   Incident LBBB 43 13.5 (10.0–18.2) 1.43 (1.05–1.96) All-cause mortality   No incident LBBB 1662 7.3 (6.9–7.6) 1.00 (ref.)   Incident LBBB 48 12.6 (9.5–16.7) 1.55 (1.16–2.07)

Conclusion

Among patients with HFrEF, the annual incidence of new-onset LBBB (and a potential indication for CRT), was around 1.5%, ranging from 1% in those with QRS duration below 100 ms to 4% in those with QRS 116–129 ms. Incident LBBB was associated with a much higher risk of adverse outcomes, highlighting the importance of repeat ECG monitoring in patients with HFrEF.

Acknowledgement/Funding

Novartis

P2487Echocardiography and NT-ProBNP both provide independent and improved prediction of prognosis in a type 1 diabetes population without heart disease and with preserved ejection fraction

Background

Cardiovascular disease is the most common comorbidity in type 1 diabetes (T1D). Current guidelines, however, do not include routine echocardiography or cardiac biomarkers in T1D.

Objectives

To investigate if echocardiography and NT-proBNP provide incremental prognostic information in individuals with T1D without heart disease and with preserved left ventricular ejection fraction (LVEF).

Methods

A prospective cohort of individuals with T1D without heart disease and with preserved LVEF (≥45%) from the outpatient clinic were included. Follow-up was performed through Danish national registers. The association between E/e', a marker of diastolic function, from echocardiography and NT-proBNP with major adverse cardiovascular events (MACE) was tested. MACE was defined as death from all-causes, acute coronary syndromes, cardiac revascularization, incident heart failure, or stroke. Additionally, the incremental prognostic value when adding E/e' and NT-proBNP to the clinical Steno T1D Risk Engine score (including age, sex, duration of diabetes, systolic blood pressure, LDL, HbA1c, presence of albuminuria (micro-or macroalbuminuria), eGFR, smoking status, and physical activity [low, medium, high]), was examined. Follow-up was 100% complete.

Results

Of 964 individuals (mean (SD)) age 49.7 (14.5) years, 51% men, HbA1c 66 (14) mmol/mol, BMI 25.6 (4.0) kg/m2, and diabetes duration 26.1 (14.5) years), 121 (12.6%) experienced MACE during 7.5 years of follow-up. In the full multivariable model, E/e' significantly and independently predicted MACE: (HR (95%)) E/'e <8 (n=639) vs. 8–12 (n=248): 2.00 (1.23; 3.25), p=0.005, E/'e <8 vs E/e'≥12 (n=77): 3.36 (1.8; 6.1), p<0.001. Also, NT-proBNP significantly predicted outcome: NT-proBNP <150 pg/ml (n=435) vs. 150–450 pg/ml (n=386): 1.52 (0.9; 2.5), p=0.11, NT-proBNP <150 pg/ml vs NT-proBNP >450 pg/ml (n=143): 2.78 (1.6; 4.9), p<0.001. Adding both (log)E/e' and (log)NT-proBNP to the Steno T1D Risk Engine score significantly and incrementally improved risk prediction: Harrell's C-index: Steno T1D Risk Engine (AUC 0.783 (0.747; 0.818)) vs. Steno T1D Risk Engine + (log)E/e' (AUC 0.805 (0.773; 0.837)): p<0.001 and Steno T1D Risk Engine + (log)E/e' + (log) NT-proBNP (AUC 0.816 (0.783; 0.848)): p=0.002. The risk of MACE by groups of E/e' and NT-proBNP is shown in the figure.

Figure 1

Conclusion

In individuals with T1D without heart disease and with preserved LVEF, E/e' and NT-proBNP significantly improved risk prediction of cardiovascular events beyond clinical risk factors alone. Echocardiography and NT-proBNP could have a role in clinical care.

P4668Risk of valvular heart disease in bromocriptine-treated women with hyperprolactinaemic disorders

Background

Systematic echocardiographic screening is currently recommended for patients with hyperprolactinemic disorders treated with dopamine agonists, due to a perceived risk of cardiac valve regurgitation as observed in patients with Parkinson's disease. The dopamine agonist bromocriptine is used frequently in hyperprolactinemia patients, but its relation to cardiac valve disease remain uncertain.

Purpose

To determine the incidence of valvular heart disease in bromocriptine-treated women with hyperprolactinaemic disorders compared with matched controls from background population.

Methods

In nationwide Danish registries, we identified patients with hyperprolactinaemic disorders treated with bromocriptine between 1995–2017. Patients were matched 1:5 with population controls based on age and sex using incidence density sampling. We estimated the risk of valvular heart disease defined as admission and/or outpatient clinic visits. Incidence rates, cumulative incidence curve and adjusted cox-proportional hazard models were used to assess outcomes.

Results

A total of 23883 female bromocriptine users and 119415 controls were included. Median age was 29.9 years (Q1-Q3 26.4–33.8). Both groups had few comorbidities, 218 (0.9%) patients and 787 (0.7%) controls with hypertension, 160 (0.7%) patients and 629 (0.5%) controls with diabetes, 408 (1.7%) patients and 1305 (1.1%) controls were beta-blocker users. During a mean follow-up of 19 years 106 (0.44%) patients and 416 (0.35%) controls were diagnosed with valvular heart disease. Incidence rates were 0.254 per 1000 patient years (PY) in bromocriptine users (95% CI 0.21–0.31) and 0.198 per 1000 PY in the control cohort (95% CI 0.18–0.22). Overall, the cumulative incidence of valvular heart disease was 0.6% (95% CI 0.48–0.73) among patients and 0.5% (95% CI 0.4–0.51) among controls; P=0.03 (figure 1a). In adjusted analysis bromocriptine users still had a significant higher risk of valvular heart disease (hazard ratio=1.32, 95% CI 1.06–1.64, P=0.01).

Incidence of valvular heart disease

Conclusion

The use of bromocriptine in younger and otherwise healthy women with hyperprolactinaemic disorders, were associated with a low absolute risk of cardiac valve disease. Still risk was approximately 30% higher compared with age- and sex matched controls. Our study suggests a low clinical yield of echocardiographic screening in this patient population.

Acknowledgement/Funding

Internal grant, Copenhagen University Hospital Rigshospitalet

P3812The economic burden of heart failure in Denmark from 1998 to 2016

Background

Heart failure (HF) imposes a large burden on the individual as well as society and the aim of this study was to investigate the economic burden attributed to direct and indirect costs of patients with HF before, at, and after time of diagnosis.

Methods

Using Danish nationwide registries we identified all patients >18 years with a first-time diagnosis of HF from 1998–2016 and matched them 1:1 with a control group from the background population on age, gender, marital status, and educational level. The economic analysis of the total costs after diagnosis was based on direct costs including hospitalization, procedures, medication, and indirect costs including social welfare and lost productivity to estimate the annual cost of HF.

Results

We included a total of 176,067 HF patients with a median age of 76 years, and 55% were male. Patients with HF incurred an average of €17,039 in sum of total annual direct (€11,926) and indirect (€5,113) health-care costs peaking at year of diagnosis compared to €5,936 in the control group with the majorityattributable to inpatient admissions. The total annual net costs including social transfer after index HF were €11,957 higher in patients with HF compared to controls and the economic consequences increased markedly 2 years prior to the diagnosis of HF (Figure 1).

Conclusion

Patients with HF impose significantly higher total annual health-care costs compared to a matched control group with findings evident more than 2 years prior to HF diagnosis

Acknowledgement/Funding

Novartis