Temporal trends in the treatment and outcomes of patients with acute coronary syndrome according to bleeding risk

Background

High bleeding risk is associated with adverse clinical outcomes in patients with ACS. We aimed to evaluate temporal trends in the treatment and outcomes of ACS patients according to bleeding risk.

Methods

Included were ACS patients enrolled in the ACSIS survey. Bleeding risk was calculated using the CRUSADE score. Patients were divided into 3 groups according to enrolment period: early (2002–2004), mid (2006–2010) and recent (2012–2018). Each group was further divided into 3 sub-groups according to bleeding risk (low, intermediate and high). The primary endpoints were 30-day MACE and 1-year all-cause mortality.

Results

Included were 13,058 ACS patients. Patients at high bleeding risk were more frequently treated with guideline-based medications and coronary revascularization regardless of enrollment period. ACS patients at high bleeding risk had higher rates of 30-day MACE and 1-year all-cause mortality in all enrolment periods. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p<0.001), Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p<0.001), and for patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p<0.001) in low, moderate and high bleeding risk group, respectively. Furthermore, among patients enrolled in early period, 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p<0.001), Among patients enrolled in mid period, 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p<0.001), and for patients enrolled in recent period, 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p<0.001) in low, moderate and high bleeding risk group, respectively. These differences remained significant following a multivariate analysis.

Conclusions

Despite the improvement in the treatment of ACS patients in recent years, high bleeding risk remains a very strong predictor of adverse clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Characteristics of aortic root and vascular anatomy in bicuspid versus tricuspid aortic valve stenosis in patients undergoing transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).

Objectives

This study sought to compare aortic root and ilio-femoral artery characteristics and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVI multicenter registry.

Methods

88 patients with bicuspid AS and 213 matched patients with tricuspid AS were referred for pre-procedural computed tomography (CT) evaluation before TAVI. We performed a detailed assessment of aortic root anatomy: size of the annulus, sinus of Valsalva (SoV), sino-tubular junction (STJ); we also determined the dimensions of aorta, left subclavian, and ilio-femoral arteries.

Results

Patients with bicuspid AS had significantly larger aortic root dimensions, (annulus mean diameter: 25.5±2.9 mm vs. 23.7±2.4 mm, SoV mean diameter: 35.3±4.7 mm vs. 32±4.4mm, STJ mean diameter: 31.5±4.9 mm vs. 27.6±3.5 mm; respectively) than patients with tricuspid AS (P value for all <0.001), even after adjustment for their larger BSA and height. Dimensions of ascending aorta, left subclavian artery, and ilio-femoral arteries were also consistently larger in bicuspid than in tricuspid AS morphology.

Conclusions

Patients with bicuspid AS had significantly larger aortic root dimensions, larger ascending aorta, subclavian artery and ilio-femoral arteries even after adjustment for their BSA and height.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Rabin Medical Center

Differences in valve morphology between patients with bicuspid and tricuspid aortic valve

Background

Bicuspid aortic valve (BAV) patients represent a significant minority of severe aortic stenosis (AS) patients undergoing transcutaneous aortic valve implantation (TAVI). These patients demonstrate anatomic differences compared to tricuspid aortic valve (TAV). Ethnicity is associated with different valve morphologies characterized by Siever's classification.

Purpose

We aim to evaluated the prevalence of BAV subtypes and the differences in valve morphology and aortic root dimensions between BAV and TAV in patients undergoing computed tomography (CT) before TAVI.

Methods

In five Israeli medical centers, 131 patients with BAV and 674 patients with TAV underwent CT angiography. BAV morphology was defined according to the number of commissures and raphe, following Siever's classification. Aortic root dimensions were measured at the level of the aortic annulus, sinus of Valsalva (SOV), and sino-tubular junction (STJ). Finally, Agatston score unit (AU) for valve calcification was evaluated.

Results

Type 0 accounted for 27% (36/131), Type IA for 63% (82/131), Type IC for 9% (12/131), and Type 2 for 1% (1/131). Calcium score in BAV patients was significantly higher compared to TAV patients, 4000±1897 vs. 2152±1216 AU; respectively (P<0.001). Distance from the annulus to the left main coronary artery was greater in BAV patients compared to TAV (13.8±3.6 mm vs. 12.8±2.8 mm; respectively, P<0.001), similar distance from annulus to right coronary artery was observed in BAV and TAV patients (16.7±3.7 mm vs. 15±3 mm; respectively, P<0.001). Aortic annulus perimeter was greater in BAV than TAV patients (79.3±11mm vs. 73±8.7mm, respectively, P<0.001), as well as SOV perimeter (35.7±4.5mm vs. 32±3.7mm, respectively, P<0.001), and STJ perimeter (32.3±5mm vs. 27±3.3 mm; respectively, P<0.001).

Conclusion

In Israel, AS patients showed more frequently type 1A BAV. BAV patients have larger aortic root dimensions and higher calcium burden than TAV patients.

Funding Acknowledgement

Type of funding source: None

P6160Long term prognosis of intramural course of coronary arteries in patients with hypertrophic cardiomyopathy assessed by coronary CT angiography

Background

The prognostic value of an intramural course of the coronary arteries detected by coronary CTA in patients with hypertrophic cardiomyopathy (HCM) is not well-known.

Purpose

To evaluate in patients with HCM, who were referred for coronary computed tomography angiography (CTA), whether an intramural course of a coronary artery is associated with a worse outcome compared to HCM patients without an intramural course of the coronary arteries.

Methods

The study population consisted of 92 patients with HCM who were referred for coronary CTA and who did not have obstructive CAD. During follow-up, the occurrence of unstable angina pectoris that required hospitalization, myocardial infarction, and all-cause mortality was evaluated (i.e. adverse cardiac events).

Results

Using coronary CTA, 57 patients (62%) had an intramural course of coronary arteries. Patients with HCM were followed over 5.5±3.5 years. The composite of adverse cardiac events occurred in 17/57 (29.8%) patients with, and 11 out of 35 (31.4%) patients without intramural course (P=0.87). The event rate of unstable angina pectoris requiring hospitalization (28.1% vs. 22.9%), myocardial infarction (1.8% vs. 8.6%), and all case mortality (0.0% vs. 0.0%) was similar in patients with and without an intramural course.

Conclusion

Intramural course of coronary arteries in patients with HCM was frequently observed by coronary CTA, but it was not associated with worse cardiovascular clinical outcome.

P3378Differences in valve morphology and aortopathy between patients with bicuspid and tricuspid aortic valves: a Computed Tomography Study

Background

Transcatheter aortic valve implantation (TAVI) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of differences in valve morphology and aortic root dimensions in patients with BAV in comparison to patients with tricuspid aortic valve (TAV) is important for the spread of TAVI in patients with BAV.

Purpose

The present study evaluated the prevalence of BAV subtypes and the differences in valve morphology and aortic root dimensions between BAV and TAV in patients undergoing computed tomography (CT) before TAVI.

Methods

In five medical centers in Israel, 104 patients (69±13.5 years) with BAV and 105 patients (81±8.22 years) with TAV underwent CT angiography. BAV morphology was defined according to the number of commissures and raphe following Siever's classification. Functional BAV was defined as 3 cusps with focal fusion of 1, 2, or 3 commissures. Aortic root dimensions were measured at the level of the aortic annulus, sinus of Valsalva (SOV), sino-tubular junction (STJ), and ascending aorta (AA). Membranous septum (MS) length was measured in coronal view. The volume and agatston score of aortic valve calcification were evaluated.

Results

Type 0 account for 22% (23/104), type IA for 58% (60/104), Type IC for 9% (9/104), functional BAV for 11% (12/104). Type IB and II were not found in the studied population. As compared with TAV, patients with BAV have significantly larger aortic annulus area, SOV area, STJ area and AA Area; however, the ellipticity index of aortic annulus, SOV, STJ, and AA were similar. MS length was significantly smaller in patients with BAV compared to patients with TAV (6.4±2.3 mm vs. 8.1±2.7mm; retrospectively; P<0.001) and the volume of aortic valve calcifications was significantly higher in BAV compared to TAV patients: 2.3±1.6 ml3 vs. 1.4±1.2 ml3 retrospectively; P=0.003).

Conclusions

In Israel, patients with BAV showed more frequently type 1A BAV. BAV patients have larger aortic root dimensions than patients with TAV without difference in regard to the ellipticity index. MS length was smaller and the amount of aortic leaflet calcifications was higher in patients with BAV. These findings may have important impact on procedural outcome.