Clinical Case 15—Warburg effect and pulmonary embolism: a confounding clinical case

Presentation

A 61 year old man with a history of multiple lymph node metastasis of unknown primary cancer was admitted in the Emergency Room with sudden dyspnea preceded by left leg swelling. Physical examination revealed a blood pressure of 91/70mmHg, tachycardia, tachypnea and signs of deep vein thrombosis (DVT).

Diagnosis and management

Blood analysis showed increased serum lactate (SL) (5,5 mmol/L), a slight increase of cardiac enzymes and hypoglycemia, and imagiologic tests showed signs of bilateral pulmonary embolism (PE) and an increase of the right cardiac chambers. The patient was hospitalized with the diagnosis of intermediate-high risk PE. Because the patient presented persistent elevated SL and borderline hypotension, fibrinolysis was performed. However, the patient maintained high SL levels and hypotensive profile. After receiving the lymph node's biopsy result, which pointed towards a follicular lymphoma, the persistent hyperlactatemia, together with the hypoglycemic profile, was interpreted as a consequence of the Warburg Effect. Luckily, the patient didn't had any side effects of the fibrinolytic treatment.

Learning points

Acute high risk PE is marked by the presence of haemodynamic instability at presentation, and the finding of increased SL suggests peripheral hypoperfusion. Systemic thrombolytic therapy is indicated in most of patients with high risk PE. However, there are other causes of hyperlactatemia which the physician must be aware, as it can act as a confounder of PE risk assessment. The Warburg Effect may cause elevated SL in patients with cancer, which in turn are at risk of developing PE.

The HFFI, a new frailty index for assessing long-term outcomes in heart failure

Introduction

Patients hospitalized due to heart failure (HF) compose a heterogeneous population whose prognosis is difficult to forecast. Frailty is a well-recognized prognostic marker in multiple chronic diseases, including HF; however, frailty evaluation is often subjective and standardized and objective prediction models are lacking. We aimed to evaluate if an objective and simple index – Heart Failure Frailty Index (HFFI)– can predict long-term outcomes in this population.

Methods

A retrospective analysis of 258 patients admitted to a Cardiology ward due to HF was performed. The variables albumin, C-reactive protein levels, age and body mass index (BMI) were selected for frailty assessment. After attributing points for each variable, according to odds ratio on univariate analysis, the HFFI was calculated (range 0–8), resulting from the sum of the points attributed to each variable. Kaplan-Meyer and Cox-regression analysis were performed to evaluate HFFI association with 24-month mortality (24MM) and 24-month composite endpoint of rehospitalization or death (24MH).

Results

Mean patient age was 75 (±11) years; 51% were men. 45.7% had atrial fibrillation, 15.9% hat history of acute myocardial infarction, 67.8% had hypertension. Mean LVEF was 47% (±17). A LVEF <40% was present in 40% of patients. 24MM was 11.5% and 24 MH was 58%. Patients were considered frail if they had an HFFI ≥3. Kaplan-Meyer curve analysis revealed a significantly lower median time to 24MM in frail patients, as assessed by HFFI, comparing to non-frail patients (585±33 days vs 697±12 days, mortality rate: 25.4% vs 5.7%, χ2=18.156, p<0.001). There was also a significantly lower median time to 24MH in frail patients (336±34 days vs 449±24 days, combined endpoint rate: 76.1% vs 50.3%, χ2=10.884, p=0.001). Cox regression analysis demonstrated that HFFI independently predicts 24MM (HR: 1.364, p=0.002) and 24MH (HR: 1.106, p=0.035), even after adjustment for other prognostic markers, such as history of atrial fibrillation, previous myocardial infarction, diabetes and natriuretic peptides serum level at index event.

Conclusion

HFFI is a simple and objective frailty index correlated with 24MM and 24MH, being an independent prognostic marker in this population. Its use may help to identify patients with a high risk of mortality or readmission, in need of specialized care.

Funding Acknowledgement

Type of funding sources: None.

An unusual case of stabbing chest pain …literally: a case report

Background

Cardiac surgery is associated with a significant risk of potential postoperative complications. We describe a case of a patient with an unusual late cardiac perforation caused by a needle used to fix temporary epicardial pacing wires to the skin, which slowly migrated across subcutaneous tissues for 2 years following postoperative period.

Case summary

We report a case of middle-aged woman admitted to the cardiac intensive care unit due to suspected acute myocardial infarction. Multimodality imaging revealed the presence of an unusual intracardiac foreign body, located inside the interventricular septum and perforating towards the left atria, complicated by a small intracardiac fistula between septal coronary branches and the right ventricle. Analysis of previous examinations revealed that a needle used to fix temporary epicardial pacing wires to the skin had been left inside the patient, beneath the level of the diaphragm, after cardiac surgery in 2018. This foreign body slowly migrated across the diaphragm, towards the mediastinum, finally lodging inside the heart, after a period of 3 years. The patient was referred to cardiac surgery for foreign body retrieval.

Discussion

We describe an unusual case of cardiac perforation caused by a needle used to fix these wires to the skin, which migrated across subcutaneous tissues and finally lodged inside the basal interventricular septum and left atria. Full compliance with standardized surgical care bundles, as well as the implementation of a structured incident reporting system, is of upmost importance to prevent postoperative complications and improve surgical care.

A new ratio with PaO2/FiO2 and pulmonary arterial systolic pressure in the prognosis of intermediate high risk pulmonary embolism

Background

Intermediate high (IH) risk pulmonary embolism (PE) defines a category of patients (P) at increased risk of haemodynamic decompensation. Therefore, it is important to develop tools to identify P who will have an unfavourable outcome. The ratio between arterial oxygen partial pressure (PaO2) to fractional inspired oxygen (FiO2) – P/F ratio - is associated with in-hospital mortality (IHM) in PE. Pulmonary arterial systolic pressure (PASP) is another prognostic factor, related with right ventricular (RV) pressure overload. This study evaluates the usefulness of a new ratio with P/F divided by PASP (P/F:PASP), reflecting both severity of respiratory failure and pressure overload, in the prognosis of P with IH risk PE.

Methods

All P admitted for IH risk PE in an Intensive Cardiac Care Unit (ICCU) for 10 years were included. P/F ratio was calculated with admission blood gas analysis and PASP was obtained with echocardiography at admission in ICCU. P/F:PASP ratio was considered low if inferior to its median. Need for fibrinolysis and IHM were assessed. Follow-up (FU) of 2 years for all-cause mortality was done. Statistical analysis used chi-square and Mann-Whitney U tests, binary logistic regressions and Kaplan-Meier curves.

Results

101 P were studied (mean age 63±17 years; 35.6% male). Mean P/F, PASP and P/F:PSAP were 264±68, 45±15 mmHg and 6.7±3.3, respectively. P/F:PASP was considered low if inferior to 5.9.

There was no difference in age, gender, comorbidities or Pulmonary Embolism Severity Index (PESI) between P with low or high P/F:PASP. However, low P/F:PASP ratio was associated with tachypnea at admission (p=0.034), higher BNP level (p=0.011), right precordial leads T-wave inversion (p=0.029), presence of echocardiographic right ventricle dilation (p=0.002) and lower TAPSE (p=0.002).

Among P who underwent fibrinolysis, 60.4% had low P/F:PASP and 39.6% had high P/F:PASP ratio (χ2=3.32, p=0.05). P/F:PASP ratio was a predictor of fibrinolysis (OR 0.83, 95% CI 0.72–0.96, p=0.011), with lower ratio increasing the probability of fibrinolysis. This result was independent from PESI (OR 0.84, 95% CI 0.72–0.97, p=0.015). P/F:PASP ratio was also a predictor of IHM (OR 0.62, 95% CI 0.38–1, p=0.05).

During FU, there was no difference in mortality between P with low or high P/F:PASP ratio (8.5% vs. 10.4%, respectively; Kaplan-Meier χ2=0.095; p=0.758).

Conclusions

In IH risk PE, low P/F:PASP ratio was associated with analytical, electrocardiographic and echocardiographic risk features. In this study, P/F:PASP ratio was a predictor of short term prognosis, allowing identification of P at higher risk of fibrinolysis and IHM, but it was not useful for long term prognosis, as 2-year mortality was similar between the groups. Therefore, this ratio, as a measure of both respiratory failure and pressure overload, might allow refinement in risk stratification of P with IH risk PE.

Funding Acknowledgement

Type of funding sources: None.

BAUN score, a better predictive model of in-hospital and long-term outcomes in acute heart failure?

Introduction

Patients hospitalized due to acute heart failure (AHF) compose a heterogeneous population whose prognosis is difficult to forecast. Previously, BAUN score has proven to be able to accurately predict in-hospital mortality (IHM) in AHF. We aimed to evaluate BAUN score performance in the prediction of long-term outcomes in this population, comparing it to the recently validated Get With The Guidelines (GWTG) score.

Methods

A retrospective analysis of 1052 patients admitted to a Cardiology ward due to AHF was performed. 268 patients were excluded due to data omission or therapy with sacubitril/valsartan. Using the variables systolic blood pressure, urea, brain natriuretic peptide and sodium at admission, BAUN score was calculated, ranging from 0–28 points. GWTG score was also calculated at the index event. ROC curve analysis was used to compare the predictive value of the two scores for IHM. Kaplan-Meyer and Cox-regression analysis were performed to evaluate BAUN score prediction ability for 24-month mortality (24-MM) and for the composite endpoint of 24-month rehospitalization or death (24-MH).

Results

Mean patient age was 77 (±10) years; 51% were men. Mean left ventricle ejection fraction (EF) was 49% (±16.4). An EF<40% was present in 31% of patients. IHM, 24-MM and 24-HM were 6.5%, 17.1% and 57.8%, respectively. Mean BAUN score was 7 (±5.64). Mean GWTG score was 49.7 (±9.8). ROC curve analysis for IHM prediction revealed a better performance of the BAUN score (AUC: 0.738p, <0.001) in comparison with GWTG score (AUC: 0.687, p<0.001). Patients were stratified into subgroups according to BAUN risk score – very-high risk (≥22), high risk (16–21), intermediate risk (5–15) and low risk (<5). Kaplan-Meyer analysis revealed a significant difference in 24-MM according to risk subgroup (very high: 35%, high: 26.7%, intermediate: 19.5%, low risk: 12.7%, χ2=16.304, p=0.001). When stratified by non-reduced or reduced EF (≥40% or <40%), there was still a significant mortality difference in subgroups with reduced (p=0.007) and borderline significant in patients with nonreduced EF (p=0.05). Kaplan-Meyer analysis also revealed a significant difference between subgroup risk for 24-MH (51%; 63.8%; 63.3% and 75%, respectively, for low, intermediate, high and very-high risk, χ2=21.237, p<0.001). Cox regression analysis demonstrated that BAUN score independently predicts 24-MM (HR: 1.056, p=0.043) and 24-MH (HR: 1.033, p=0.048), even after adjustment for other prognostic markers, such as atrial fibrillation, coronary artery disease, previous myocardial infarction, age, EF and GWTG score.

Conclusion

BAUN outperforms GWTG score for IHM prediction in AHF. It also independently predicts 24-MM and 24-MH. Its use may identify patients with high risk of mortality/readmission, in need of specialized care, and those patients with low risk of death, who might be candidates for lenient surveillance.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of relative wall thickness in heart failure with preserved ejection fraction: what is the best method for its calculation?

Background

The HFA-PEFF diagnostic algorithm is a recently published tool to help in the diagnosis of heart failure with preserved ejection fraction (HFpEF). One of the echocardiographic diagnostic criteria is left ventricular (LV) relative wall thickness (RWT), an index of LV concentricity. LV wall thickness can be measured by echocardiography at the posterior wall (PW) and/or the interventricular septum (IVS) in parasternal long axis view. There are three methods of RWT calculation: RWTPW= 2xPW/LV dimension at end diastole (LVDd) – the most used method, RWTIVS = 2 x IVS / LVDd and RWTPW + IVS = (PW + IVS) / LVDd. This study compares the prognostic value of these 3 methods of calculation in patients with acute HFpEF.

Methods

All patients admitted with acute HFpEF in a Cardiology Department during 7 years were included. RWT was considered elevated if superior to its median and was calculated with the 3 formulas. In-hospital mortality (IHM) was evaluated. The primary endpoint (EP) was a composite of all-cause mortality or hospitalization for HF during follow-up of 24 months. Statistical analysis used chi-square and Mann-Whitney U tests, binary logistic regressions, and Kaplan-Meier curves.

Results

478 patients were studied (61.3% female, mean age 79.4±8.3 years). Mean RWTPW, RWTIVS and RWTPW+IVS were 0.46±0.16, 0.50±0.17 and 0.48±0.16, respectively. IHM was 3.4% and primary EP occurred in 57.8%.

High RWTPW was associated with higher LV ejection fraction (LVEF) (p<0.001). Patients with high RWTIVS were older (p=0.044). High RWTPW+IVS was associated with higher left atrial area (p=0.037) and higher LVEF (p=0.002).

There was no statistically significant difference between patients with high and low RWT, calculated using the 3 formulas, in other indices that are commonly used to assess diastolic function, namely in e' and E/e'.

None of the 3 methods of RWT calculation was a predictor of IHM.

Survival analysis showed that patients with high RWTPW had higher incidence of the primary EP (43.2% vs. 16.8%, Kaplan-Meier χ2=5.99; p=0.014), but not patients with high RWTIVS (Kaplan-Meier χ2=0.23; p=0.631) or RWTPW+IVS (Kaplan-Meier χ2=1.92; p=0.166).

RWTPW was a predictor of primary EP (OR 1.81; 95% CI 1.15–2.85; p=0.011) and this result was independent from e' and E/e' (OR 2.96; 95% CI 1.08–8.10; p=0.035).

Conclusion

In this study comparing 3 formulas for calculation of RWT, RWTPW had better risk prediction during follow-up than RWTIVS or RWTPW+IVS. RWTPW was a predictor of all-cause mortality and hospitalization for HF, and was independent from e' and E/e', indexes that are also recommended in HFA-PEFF diagnostic algorithm. Therefore, the formula incorporating PW should be preferred in the evaluation of patients with suspected or diagnosed HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Direct oral anticoagulants compared with vitamin K antagonists for left ventricular thrombi systematic review and meta-analysis

Background

Left ventricular thrombus (LVT) is a serious complication primarily occurring in patients with LV dysfunction following large myocardial infarction. The role of direct oral anticoagulants in this clinical setting remains controversial.

Purpose

To compare DOACs versus vitamin K antagonists (VKA) in LVT treatment.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in February 2020, for interventional or observational studies comparing DOAC with VKA on LVT treatment.

Results

Fourteen publications were included, nine published studies and five conference abstracts, providing 1899 patients, 490 patients on DOACs and 1409 subjects on VKA. In terms of efficacy, DOAC had a lower LVT resolution for all studies included which reported LVT resolution (pooled OR, 0.73; 95% CI, 0.55–0.98; P=0.04; I2=52%), but sensitivity analysis revealed no difference between anticoagulant strategy (pooled OR, 0.78; 95% CI, 0.57–1.05; P=0.10; I2=59%). In terms of systemic embolism or stroke, DOAC had a similar efficacy (pooled OR, 1.06; 95% CI, 0.69–1.63; P=0.78; I2=30%) compared to VKA. In clinically relevant bleeding events analysis, the anticoagulation strategy did not differ in the odds of bleeding (pooled OR, 0.65; 95% CI, 0.37–1.15 P=0.14; I2=0%), with similar findings in net adverse clinical events analysis (pooled OR, 0.66; 95% CI, 0.35–1.25; I2=54%; P=0.20).

Conclusion

Our pooled data suggests DOACs as a safe approach to LVT, despite inconsistent efficacy on LVT resolution.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the GRACE score, TIMI score and a New Laboratorial Score to predict adverse outcomes in acute coronary syndrome

Introduction

Acute coronary syndrome (ACS) is a clinical entity which includes a heterogeneous group of patients with different outcomes. Risk scores are in this setting a resourceful tool to identify the subset of patients with a worse prognosis, in order to plan therapeutic and surveillance strategies.

Aim

To create a risk score – Laboratory Risk Score (LRS) – which exclusively includes analytical and echocardiographic parameters, as a predictor of adverse outcomes (in-hospital mortality and 1-year mortality), and compare it with other well-known scores: GRACE Score (GS) and TIMI-score (TS).

Methods

A retrospective cohort study was conducted, which included patients admitted in the Cardiology Department with the diagnosis of ACS. In order to calculate the new LRS, the authors attributed the value of 1 to each of the satisfied condition from the following: leucocytes >11,7g/L, hemoglobin <13.3g/dL, red cell distribution width >14%, prothrombinemia <90%, glycaemia at admission >143mg/dL, urea >53.5mg/dL, creatinine >1.16mg/dL, reactive C-protein >1.0mg/dL, maximum troponin >35.0ng/dL, natriuretic brain peptide >416 pg/dL and left ventricular ejection fraction <40%. LRS resulted from the sum of the satisfied conditions.

ROC curves for LRS, GS and TS to predict in-hospital mortality and to predict 1-year mortality were constructed. The statistical analysis was performed in SPSS and Medcalc. p value <0.05 was considered statistically significant.

Results

1714 patients (70.4% male, average age 69±13 years-old) were included in this study. Intra-hospital mortality rate was 6.8% and 1-year mortality rate after de discharge was 4.8%.

The areas under the ROC curves for predicting in-hospital mortality were the following: 0,790 (LRS, p<0,001), 0,793 (GS, p<0.01), 0.817 (TS, p<0.001). For predicting 1-year mortality, the areas under the ROC curves were: 0,715 (LRS, p<0,001), 0,761 (GS, p<0,001), 0.742 (TS, p<0.001). Pairwise comparison of ROC curves showed no significant differences between the scores.

Conclusion

The above-mentioned risk scores, including the new LRS, are obtained with non-invasive and widely available parameters and displayed a good performance in predicting in-hospital and 1-year mortality. Pairwise comparison of ROC curves demonstrated that the new laboratorial score was not inferior predicting adverse outcomes. The SRL is an easily obtained score, that shows a statistical significance in predicting mortality, especially the prediction of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: None.

Global longitudinal strain as a predictor of cardiovascular events and mortality in patients with ischemic heart disease and heart failure with preserved/mid-range ejection fraction

Introduction

Global longitudinal strain (GLS) is considered a more sensitive marker of systolic dysfunction than other measures commonly used in clinical practice, such as left ventricle ejection fraction (EF). Our objective was to evaluate the impact of reduced GLS in death and cardiovascular events in patients hospitalized due to heart failure with mid-range or preserved ejection fraction, with previous history of acute myocardial infarction.

Methods

A retrospective analysis of 170 patients admitted to a Cardiology ward due to acute heart failure (AHF) was performed. Patients with reduced EF (Simpson biplane method - EF<40%) were excluded based on echocardiographic evaluation after AHF stabilization. GLS measured by “speckle tracking” technique was calculated for each patient. Measurements were made by the same operator to minimize interoperator variability. Mann-Whitney U test was used for univariate analysis. Kaplan-Meier survival plots and Cox-regression analysis were performed to assess differences in 12-month mortality (12MM) and in the composite endpoint of cardiovascular event or death (12CVM) at 12 months.

Results

A total of 127 patients were included. Mean patient age was 64 (±14) years; 72% were men. 48% of patients had history of ST elevation AMI. Mean EF was 54% (±8) and mean GLS was −14.3 (±3.8). Rates of 12MM and 12CV M were 14.2% and 19.3%, respectively. A statistically significant association between 12MM and 12MCV was found in univariate analysis for GLS (p<0.001). Kaplan-Meyer survival plots revealed that a compromised GLS (<−16) was associated with significantly increased 12MM (23% vs 2.5%, X2: 7.999, p=0.005) and 12CVM (26.6% vs 10%, X2: 4.139, p=0.042). When stratified by mid-range vs preserved EF, GLS <−16 was associated with worse outcomes, although the results did not reach statistical significance (p>0.05). However, when considering a severely compromised GLS (<−13), GLS was significantly associated with increased 12MM (52% vs 8.3%, X2: 5.533, p=0.019) and 12CVM (50% vs 8.3%, X2: 4.970, p=0.026), in the subgroup of patients with heart failure with mid-range EF. Cox-regression analysis demonstrated that GLS was independently associated with 12MM (HR: 0.668p, <0.001) and the 12CVM composite endpoint (HR: 0.819, p=0.008), even after adjustment for other important prognostic markers such as chronic kidney disease, pulmonary disease and diabetes, with significant hazard ratio reduction for each positive point increase in GLS.

Conclusion

GLS is an independent predictor of 12MM and 12CVM in patients hospitalized due to AHF, with an EF ≥40% and previous history of acute myocardial infarction. In the subgroup of patients with heart failure with mid-range EF, a severely compromised GLS (<−13) is a strong predictor of 12MM and 12CVM.

Funding Acknowledgement

Type of funding sources: None.

AHFM score, a predictive model of in-hospital and long-term mortality in heart failure

Introduction

Patients hospitalized due to heart failure (HF) constitute a heterogeneous population whose prognosis is difficult to forecast. The purpose of this study was to create a model based on simple bedside recordable echocardiographic, analytical and objective clinical parameters that could accurately predict mortality and/or rehospitalization risk in different stages of HF course.

Methods

A retrospective analysis of 347 patients admitted to a Cardiology ward due to decompensated HF was performed. The echocardiographic variables pulmonary artery systolic pressure (PSAP) and E/e' ratio, and the analytical/clinical variables systolic blood pressure (SBP), urea and brain natriuretic peptide (BNP) were selected for inclusion. Subgroups were created for each variable and an odds ratio (OR) for the risk of in-hospital mortality (IHM) was calculated. A numerical value proportional to the OR was attributed to each subgroup. A score was created, ranging from 0–47 points, corresponding to the sum of the classification attributed to each variable. ROC curve analysis was used to assess predictive value of the score for IHM. Kaplan-Meyer and Cox-regression plots were used to assess mortality (24MM) and the composite endpoint of HF rehospitalization or death at 24 months (24HM).

Results

Mean patient age was 78 (±9) years; 51% were men. Score variable means were - PSAP: 47 (±15) mmHg; E/e': 16.8 (±7.8); SPB: 138 (±31) mmHg; Urea: 71 (±35) mg/dl; BNP: 911 (±995) pg/ml. Mean ejection fraction (EF) was 48% (±16). 35% of patients had EF<40%. IHM, 24MM and 24HM were 3.5%, 17.1% and 63.6%, respectively. A statistically significant association between IHM and PSAP, E/e', BNP, urea and SBP (p<0.05) was found on univariate analysis. ROC curve analysis of AHFM revealed an AUC of 0.785 (p=0.001) for IHM risk prediction. The cut-off point with most sensitivity (S) and specificity (E) obtained using the Youden index (0.4246) was 18 (S≈75%; E≈67%), associated with significant difference in IHM (1.3% vs 7.6%). IHM by score interval was 1.3%, 3.1% and 25%, respectively, for the intervals 0–18, 19–29 and ≥30. ECHO-AHF score <13 predicted in-hospital survival in all patients. Kaplan Meyer survival analysis by subgroup revealed significant differences in 24MM according to AHFM risk category (13.8% vs 21.9% vs 30.8%, respectively, χ 2= 17.217 p<0.001), but not for 24 MH. Cox-regression analysis demonstrated that AHFM score remained a significant independent predictor of 24MM (HR: 1.067, p=0.05), even after adjustment for other variables, such as coronary disease, chronic kidney disease, atrial fibrillation, EF and diabetes.

Conclusion

AHFM score is an accurate model for predicting IHM and long-term risk of HF death. Its use may help to identify patients with high risk of mortality, in need of specialized care, and those with lower risk of death, who might be candidates for early discharge or lenient follow-up.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular noncompaction and EcoScore: prognostic value of a new echographic risk score

Introduction

Left Ventricular Non-Compaction (LVNC) is a rare and underdiagnosed cardiomyopathy, characterized by hypertrabeculation of the left ventricle. This disease is associated with high rates of morbidity and mortality; however, its main adverse prognostic factors are not well established.

Aim

To create a risk score for LVNC based on echocardiographic criteria (EcoScore) to predict the occurrence of adverse events.

Methods

The authors included patients with the diagnosis of LVNC, according to the Jenni Criteria. Clinical and echocardiographic data were evaluated and the occurrence of the following adverse events was reported: hospitalizations due to supraventricular or ventricular tachyarrythmias and heart failure, acute myocardial infarction, stroke, heart transplant and death. The follow-up time was 24 months. ROC curves to predict the occurrence of at least one adverse event were constructed for each echocardiographic parameter. The optimal cut-off obtained from each ROC curve was then used to attribute points (1 point per parameter). The EcoScore resulted from the sum of the obtained points. The authors finally created a ROC curve to predict the occurrence of any adverse event for the EcoScore. The statistical analysis was performed in SPSS. p value <0.05 was considered statistically significant.

Results

33 patients (48.5% male, age at diagnosis 45.9±21 years) were included in this study. The optimal cut-offs for each parameter obtained from the ROC curves were the following: left ventricle dyastolic diameter >55mm, left atrial diameter >40mm, pulmonary artery systolic pressure >22mmHg and left ventricle ejection fraction <40%. The area under the curve for the EcoScore to predict any adverse event was 0.850 (p=0.017) and an EcoScore >1 had a sensibility of 85.7% and a specificity of 70%.

Conclusion

The EcoScore accurately predicted the occurrence of at least one adverse event in this population. Thus, it could be a good tool in the daily practice to select patients who may benefit from a more aggressive surveillance and treatment.

Funding Acknowledgement

Type of funding sources: None.

NISAR-F SCORE: a simple risk stratification tool for patients implanted with cardiac resynchronization therapy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Individualized estimation of prognosis after cardiac resynchronization therapy (CRT) remains challenging. Outcomes in this group of patients are influenced by multiple factors and a comprehensive and customized approach to estimate prognosis after CRT is lacking

Aims

To develop and validate a simple prognostic score for patients implanted with CRT (NISAR-F score), based on readily available clinical and echocardiographic variables to predict the combined endpoints of death or hospitalization in 24 months.

Methods

A single-centre retrospective study was conducted with inclusion of all consecutive patients who underwent CRT implantation between 2012 and 2019. Follow-up started after CRT implantation and ended upon death, hospitalization or 24 months after study entry. Survival analysis was performed using a multivariate Cox regression model, in order to analyze the effect on survival /hospitalization in 24 months of the following factors: age, gender, NYHA Class III-IV, ischemic heart failure, type 2 diabetes, arterial hypertension, dyslipidemia and ejection fraction < 21%. According to the analysis, points were attributed to each factor. Afterwards, the NISAR-F score was calculated for each patient, summing the points of each variable. The authors finally created ROC curves for the NISAR-F score to predict the occurrence of the combined endpoint in 2 groups of patients: CRT responders (ejection fraction increase of at least 10% after CRT implantation) and CRT non-responders. The statistical analysis was performed in SPSS.

Results

102 patients were included in the study (75.4% male, mean age 68 ± 10.46 years). 10(9.8%) of the patients were re-hospitalized and 8 (7.8%) died during the 24-month follow-up.  After calculating NISAR-F score for each patient, area under ROC curves were obtained. The analysis of the ROC curves allows us to confirm the good performance of the score created [responders group (AUC 0.812) vs non-responders (AUC 0.721)].

Conclusion The NISAR-F score is a useful tool to predict the combined endpoint (mortality and hospitalization in 24 months) after CRT implantation, in both responders and non-responders, revealing good performance of this new and simple score based only on clinical and echocardiographic variables.

The impact of lipid profile in acute coronary syndrome: young patient vs old patient

Funding Acknowledgements

Type of funding sources: None.

Introduction

Several studies have suggested a relationship between dyslipidemia and atherogenesis, which displays a main role in the pathophysiology of Acute Coronary Syndrome (ACS).

Aim

To compare the lipid profile between younger (<55 years) and older (≥55 years) patients admitted due to ACS.

Methods

A single-centre retrospective study was conducted, with inclusion of all consecutive patients admitted in the Cardiology Department due to ACS. Several analytical parameters were evaluated, including total cholesterol (CT), HDL cholesterol (HDL), LDL cholesterol (LDL) and triglycerides (TG) and CT/HDL, LDL/HDL and TG/HDL ratios were calculated. All parameters are presented in mg/dL. Afterwards, comparison of these data between younger (age < 55 years, Group-A) and older (age≥55 years, Group-B) patients was done. Statistical analysis was performed with SPSS and a p value < 0.05 was considered statistically significant.

Results

1168 patients (70.1% male, mean age 69 ±12 years) were included in this study. 15.8% of patients were from Group-A. Mean levels of the analysed parameters were the following: CT 176 ± 55, LDL 111 ± 45, HDL 40 ± 12 and TG 137 ± 102. The following mean ratios were obtained: CT/HDL 4.6 ± 1.9, LDL/HDL 2.9 ± 1.4 and TG/HDL 3.8 ± 3.5. Comparison of the analysed parameters and calculated ratios is exhibited in table 1.

Conclusion

Overall, a worse lipid profile was observed in younger patients. This data reveals the role of dyslipidemia in coronary heart disease, which displays a main role in atherosclerosis at a younger age. This fact highlights the importance of adopting a healthy lifestyle and the adherence to primary and secondary prevention measures of cardiovascular events.

Lipid profile: young vs old patient Group A Group B Total Cholesterol 199 ± 44 170 ± 56 p < 0.001 LDL Cholesterol 128 ± 37 107 ± 46 p < 0.001 HDL Cholesterol 39 ± 10 40 ± 12 p = 0.307 Triglycerides 195 ± 189 125 ± 66 p < 0.001 CT/HDL 5.3 ± 1.5 6.8 ± 2.0 p < 0.001 LDL/HDL 3.4 ± 1.1 2.8 ± 1.4 p < 0.001 TG/HDL 5.6 ± 6.3 3.5 ± 2.5 p < 0.001

The effects of smoking and alcoholism in acute coronary syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction

Several studies have concluded that smoking increases mortality in patients with coronary disease. On the other hand, a J-shaped dose-effect curve has been used to describe the relationship between alcohol and cardiovascular mortality. According to the majority of studies, a moderate intake of alcohol is associated with a decrease in mortality, while an excessive alcohol intake appears to increase mortality.

Aim

To evaluate the effect of smoking and excessive alcohol intake in hospital mortality and 1-year mortality in patients hospitalized due to acute coronary syndrome (ACS).

Methods

A single-centre retrospective study was conducted, with inclusion of all consecutive patients admitted in the Cardiology Department due to ACS. Follow-up started after hospital admission and ended upon hospital death, death within the following 12 months or 12 months after study entry. Patients were divided in two groups: smokers (Group-A) and non-smokers (Group-B), to analyse the effect of smoking in hospital mortality and 1-year mortality. To analyse the effect of excessive alcohol intake, patients were also divided in other two groups: Group-C (excessive drinkers) and Group-D (non-excessive drinkers). Statistical analysis was performed with SPSS and a p value < 0.05 was considered statistically significant.

Results

1120 patients (68.9% male, mean age 69.12 ± 12.67 years) were included in this study. 20.5% were smokers and 3.2% had a previous excessive alcohol intake.

Between Group-A and Group-B, a statistically significant difference was observed in gender (93.1% male in Group-A vs 62.9% male in Group-B, p = 0.002), but not in age (p = 0.116). Hospital mortality rates in Group-A and Group-B were respectively 6.0% and 8.7% (p = 0.191) and 1-year mortality rates were 3.1% vs 5.1% (p = 0.239).

Between Group-C and Group-D, a statistically significant difference was observed in gender (94.4% male in Group-C vs 69.8% male in Group-B, p < 0.001), but not in age (p = 0.730). Hospital mortality rates in Group-C and Group-D were respectively 25% and 9.6% (p = 0.003) and 1-year mortality were 3.8% vs 6.6% (p = 0.577).

Conclusions

Smoking did not have a positive or negative effect in hospital mortality and 1-year mortality. However, excessive alcohol intake was associated with increased hospital mortality in this population.

Dipper pattern in arterial hypertension: is there a correlation with ageing?

Funding Acknowledgements

Type of funding sources: None.

Dipper pattern in arterial hypertension

is there a correlation with aging?

Background

Systemic arterial hypertension is an important cardiovascular risk factor. Non-dipper hypertension is associated with increased cardiovascular morbidity and mortality.

Purpose

Study the effect of aging in the dipper pattern, in patients submitted at 24-Hour Ambulatory Blood Pressure Monitoring.

Methods

Retrospective study based on patients submitted at 24-Hour Ambulatory Blood Pressure Monitoring on the first trimester of 2020. Patients were divided into categories based on percentage of nighttime blood pressure drop: 0% Reverse Dipper, 0-10% Non-Dipper, 10-20% Dipper e >20% Extreme Dipper. The sample was dived into two groups: group A (GA) with age between 18- and 60-years vs group B (GB) with age between 60- and 90-years.

Results

This study included 91 hypertensive patients, whom 46.2% were male and with a mean age of 56 ± 15 years. GA represented 60.4% of study sample, whom 43.6% were male and with a mean age of 46 ± 10 years. In the group B, 50% were male with a mean age of 71 ± 6 years. GB patients had more history of diabetes (7.8% vs 26.5%, p = 0.022). No significant difference was found between the two groups in history of kidney chronic disease, obesity or sleep apnea syndrome. In terms of medical treatment, GB had more prescription of loop diuretics (3.9% vs 22.9%, p = 0.010) and angiotensin-converting enzyme (ACE) inhibitors (58.8% vs 88.6%, p = 0.028). No significant differences were found in the prescription of other hypertension therapies or the use of drug combinations. No significant difference was found in the number of Dippers in both groups (63.6% vs 58.3%, p = 0.386). GB had more reverse dippers (1.8% vs 16.7%, p = 0.014). GA had more extreme dippers (12.7% vs 2.8%, p = 0.024).

Conclusion

There is no difference in the rate of dipper pattern accordingly to age. The prevalence of reverse dippers in older patients was superior, leading to increased risk of cardiovascular events in this group. The younger group had more prevalence of extreme dippers, which, by some authors, can lead to increased risk of a silent cerebrovascular event.

Coexistence of DIPNECH and carotid body paraganglioma: is it just a coincidence?

SUMMARY

We describe the case of a 56 year-old woman with the almost simultaneous appearance of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and a carotid body paraganglioma. Of interest, 6 years earlier, the patient underwent total thyroidectomy due to papillary thyroid carcinoma and, in the meantime, she was submitted to mastectomy to treat an invasive ductal carcinoma of the breast. In order to explain these lesions, an extensive genetic study was performed. Results showed positivity for the presence of the tumor suppressor gene PALB2, whose presence had already been detected in a niece with breast cancer. The patient underwent different procedures to treat the lesions and currently she is symptom-free over 2 years of follow-up.

LEARNING POINTS

The presence of two rare neoplasms in a single person should raise the suspicion of a common etiology. To the best of our knowledge, this is the first case that shows the coexistence of DIPNECH and paraganglioma. The contribution of the PALB2 gene in the etiology of these rare neoplasms is a possibility.

Follicle development in cryopreserved bitch ovarian tissue grafted to immunodeficient mouse

The present study evaluated: (1) in vivo follicular development in canine ovarian tissue after slow freezing and xenotransplantation; and (2) the use of erythropoietin (EPO) as an angiogenic factor to optimise the transplantation procedure. Frozen-thawed ovarian tissue from five bitches was grafted into severe combined immunodeficient (SCID) mice (n=47) treated with or without EPO (500 IU kg(-1), once daily for 3 days) (Groups A and B, respectively) and analysed after 0, 1, 8 or 16 weeks. Follicle grade, follicle density, follicle morphology and stromal cells density were assessed by histological analysis, whereas vascularisation of the graft was quantified by immunohistochemistry with anti-α-smooth muscle actin antibody. Despite a massive loss of follicles after grafting, secondary follicle density was higher at 8 and 16 weeks than at 1 week regardless of EPO treatment. EPO significantly improved early follicle morphology and stromal cell density after 8 weeks and blood vessel density at 16 weeks after transplantation (P<0.05). Intact secondary follicles with more than three granulosa cells layers were observed 16 weeks after transplantation. The results suggest that canine ovarian tissue can be successfully preserved by our slow-freezing protocol because the tissue showed follicular growth after xenotransplantation. EPO treatment did not lessen the massive loss of follicles after transplantation.

Hydrogen adsorption onto nickel modified carbon nanotubes

The Hot Filament Chemical Vapour Deposition (HFCVD) method was employed to study hydrogen adsorption on multi-walled carbon nanotubes (MWCNTs) modified by nickel doping. Prior to the nickel doping, effective functionalisation of CNTs was achieved by treating them in HNO3/H2O2 medium. Samples were characterized using Scanning Electron Microscopy (SEM), Energy Dispersive X-ray (EDS), and Fourier Transform Infrared (FTIR) and Raman spectroscopy techniques. SEM analyses revealed the morphology of the samples and the presence of nickel was identified by EDS analyses. Raman analysis revealed the enhancement of defects on the CNTs after the nickel modification. The defects created along with the catalytic activity of nickel supplied more hydrogen access to the CNTs. This was inferred from highest intensity ratio of D and G band (ID/IG) for hydrogen treated samples. However, FTIR spectra did not exhibit any C-H related bands. This confirms that the adsorption of hydrogen onto CNTs is primarily by surface adsorption.

Morphologie folliculaire après cryoconservation du cortex ovarien chez la lapine (Oryctolagus cuniculus)

OBJECTIVE

To compare the effects of two cryoprotective agents (DMSO and 1,2-PROH) used at two concentrations (1,5 and 2 M) on the morphology of small ovarian cortex follicles in doe.

MATERIALS AND METHODS

Ovarian cortexes (n=40) were frozen in TCM199+10% FCS medium added to 1.5 or 2 M of DMSO or 1,2-PROH. Two controls were realized (fresh and frozen without cryoprotectant). The equilibration in cryoprotective solutions before freezing, and the elimination of the cryoprotective agents after thawing, was performed step by step. The effects induced by cryopreservation were evaluated by histological examination.

RESULTS

Fresh ovarian tissue showed 68.6% of intact follicles. After freezing, only 1.5 M of 1,2-PROH preserved 48.0% of normal follicles, with no significant difference compared to the fresh control. The proportion of follicles without morphological defect observed after cryopreservation with DMSO was significantly reduced (respectively 28.8 and 34.8% for 1,5 and 2 M of DMSO).

DISCUSSION AND CONCLUSIONS

Our results suggest that 1,2-PROH is a more effective cryoprotectant than DMSO, for the cryopreservation of doe ovarian cortex. These results differ from those that were obtained for other species, credibly because of a higher fragility of the ovarian tissue of the doe. Nevertheless, this species is an interesting animal model which allows rapid results after cryopreserved ovarian tissue graft.

Simultaneous occurrence of acute myocarditis and reactivated Chagas' disease in a patient with AIDS

Myocarditis is not an uncommon finding in autopsy series of patients with AIDS, although clinically important myocarditis is rarely noted. We describe a 50-year-old woman with AIDS and chronic chagasic megaesophagus, without previous cardiac abnormalities, who experienced reactivation of Chagas' disease, characterized by the finding of Trypanosoma cruzi via direct microscopic examination of the buffy coat, xenodiagnosis, and blood culture; she developed fatal acute myocarditis. Reactivation of Chagas' disease in patients with AIDS has been reported, but in the great majority of cases it has been associated with central nervous system involvement. In areas where Chagas' disease is endemic, reactivation may occur in patients with AIDS.