Prognostic Value of Admission-to-Discharge Change in Integral Congestion Assessment for Predicting Adverse Outcomes in Patients with Decompensated Heart Failure

This study was performed to evaluate the prognostic value of relative changes from admission to discharge (Δ%) of integrated congestion assessment to predict adverse outcomes in patients with irreversible heart failure (HF) during a one-year follow-up. The study included 122 patients (60% males, median age of 69 years) with decompensated HF. Most of the patients (92%) had a history of arterial hypertension, 53.3% had coronary heart disease, and 40.2% had type 2 diabetes mellitus. All patients underwent assessments, including NT-proBNP, lung ultrasound (LUS) B-line score, liver stiffness by transient elastography, and resistance and reactance by bioimpedance vector analysis (BIVA). The assessments were performed at admission and discharge, and a relative change from admission (delta percentage, Δ%) was calculated. Long-term clinical outcomes were assessed by a structured interview conducted 1, 3, 6, and 12 months after discharge. The cut-offs for the occurrence of the endpoint events were Δ% NT-proBNP of ≥ -25, Δ% liver stiffness of ≥ -44, Δ% B-line score on lung ultrasound of ≥ -73, Δ% BIVA resistance of ≤ 18, and Δ% BIVA reactance of ≤ 40. It was revealed that 55% of endpoint events, including 22 (18%) deaths and 33 (27%) readmissions, occurred within a median of 74 days (interquartile range: 33-147). Patients with an endpoint event had significantly worse values of all studied parameters in contrast to patients without it. There was a significant direct association between Δ% NT-proBNP and Δ% B-lines (r=0.18; P=0.04), and a highly reliable inverse association was observed between Δ% liver stiffness and Δ% BIVA reactance (r=-0.4; P<0.001). No significant associations were found between the other parameters. Univariate Cox regression analysis demonstrated the independent prognostic value of all congestion markers under study (NT-proBNP, LUS B-lines, liver stiffness, and BIVA reactance) for predicting the combined endpoint. Multivariate Cox regression analysis confirmed the independent prognostic value in predicting the risk of endpoint event for the following parameters: NT-proBNP (hazard rate [HR] 2.5, P=0.001), liver stiffness (HR 2.3, P=0.012), LUS B-line score (HR 2.2, P=0.008). However, it did not find any significant prognostic value for BIVA resistance and reactance. The relative admission-to-discharge change in the integral assessment of congestion had a prognostic value for predicting the risk of adverse outcomes (all-cause mortality and readmission rate) in patients with decompensated HF during a one-year follow-up.

Similar incidence of over and underdiagnosis of heart failure in hospitalized patients with type 2 diabetes mellitus

Purpose

To assess the incidence of over and underdiagnosis of heart failure (HF) in hospital patients with type 2 diabetes mellitus (T2DM)

Methods

In the single-center prospective study (registry) from 01.08.2018 to 31.01.2019 we included 1008 patients admitted to the city hospital. Key inclusion criteria: a history of T2DM, age ≥40 years. Key exclusion criteria: any other disorders of carbohydrate metabolism, age &lt;40 years, acute coronary syndrome, functionally dependent patients. We assessed the presence of HF in the diagnosis at admission by the following criteria: the presence of HF stage C or D (ACCF/AHA) and at least II NYHA functional class. All patients underwent standard echocardiography and NT-proBNP assessment at 1–3 days after admission. The diagnosis of HF was established by the 2016 ESC HF Guidelines. After the examination, the patients were divided into subgroups: “Confirmed HF” (HF was in the diagnosis, its presence was confirmed), “Unconfirmed HF” (HF was in the diagnosis, its presence was excluded), “First diagnosed HF” (HF was not in the diagnosis, its presence was confirmed) and “Absent of HF” (HF was not in the diagnosis and its presence was excluded). We also analyzed the reasons for admissions in all patients.

Results

The presence of HF in the diagnosis at admission was in 68.8% (n=693) of patients and, accordingly, it was absent in 31.2% (n=315). By the ESC HF Guidelines HF was diagnosed in 68.1% (n=686) and, accordingly, in 31.9% (n=322) it was excluded. The analysis results by the diagnosis at admission are presented in Fig. 1. The analysis of the reasons for admission depending on the HF status is presented in Fig. 2. In 35 patients admitted with HF decompensation the presence of HF was not confirmed and the diagnosis was revised: atrial fibrillation in 11 (31,4%) patients, exacerbation of COPD – 7 (20,0%), pulmonary embolism – 6 (17,1%), pneumonia – 4 (11,4%), kidney diseases – 4 (11,4%), and asthma – 3 (8,7%).

Conclusion

Among hospitalized patients with T2DM, there is a similar incidence of over and underdiagnosis of HF. Patients with first diagnosed HF were more likely to be admitted for reasons unrelated to cardiovascular diseases (CVD), most often with hyperglycemia (Fig. 2). Patients with unconfirmed HF – for reasons related to CVD, while the reason for admission in a quarter of patients was HF decompensation (Fig. 2). Despite the availability of examination for HF, the problem of its diagnosis is still relevant.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Effect of antimicrobial therapy on the embolic events in patients with infective endocarditis

Background

Embolic events (EE) are presented in up to 50% of the cases of infective endocarditis (IE). Main approach in prevention of the embolisms is properly timed surgery and antimicrobial therapy. But specific antimicrobial drug to prevent embolic events is not yet established.

Purpose

To analyze effect of a distinct group of an antimicrobials on association with embolic events in patients with IE.

Methods

255 patients with verified IE (DUKE 2009, 2015), hospitalized and treated from January 2010 to January 2020, were included in the study. Patients underwent clinical investigation including physical examination, laboratory and instrumental studies.

Results

About one quarter (27.5%) of the patients had an embolic event after initiation of antimicrobial therapy. Embolism localizations include: brain (30%), lungs (47%), kidneys (20%), spleen (14%), coronary (8%) and peripheral arteries (5.7%). Most common causative agent was Staphylococcus aureus (25.5%). There were no clinical association between a certain group of antimicrobials and embolic outcome (table). However, effectiveness of the first-line antimicrobial, eradication of pathogen and abscence of infection persistence was associated with lower rate of embolism

Conclusion

In correspondence to guidelines adequate antimicrobial therapy (eradication of a pathogen and abscence of infection persistence) is associated with lower thromboembolic risk regardless of certain group of antimicrobials.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): RUDN University Strategic Academic Leadership Program.

POS0217 PULSE WAVE VELOCITY ELEVATION ABOVE INDIVIDUAL REFERENCE VALUES AND AORTIC-BRACHIAL STIFFNESS MISMATCH AS EARLY MARKERS OF ARTERIAL STIFFNESS INCREASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Arterial stiffness (AS) is a known predictor of cardiovascular (CV) disease. The measurement of pulse wave velocity (PWV) is considered to be a gold standard of AS assessment but the recommended threshold of 10 m/s1 may not take into account multiple factors influencing PWV. Use of the proposed individual reference values may help to identify patients with AS increase despite PWV level below this threshold2. The impact of AS on CV outcomes may be mediated by the reversal of the aortic-brachial stiffness (AS gradient)3. One small study in patients with type 2 diabetes has shown that the aortic-brachial stiffness mismatch (hereafter AS mismatch) was an earlier marker of AS than PWV elevation4. Patients with rheumatoid arthritis (RA) have high CV risk and may benefit from early detection of AS increase. Both approaches have not been studied in RA previously

Objectives:

To evaluate the incidence of PWV elevation above individual reference values and the frequency of AS mismatch in RA

Methods:

Study group included 85 patients (pts) with RA (females 77.6%, aged 59.7±14.3 years, HTN 65%, mean DAS-28(CRP) 3.7±1.1) and control group (40 pts matched by gender, age and risk factors). Parameters of AS were measured by applanation tonometry. Individual PWV reference values were assessed2. The AS gradient was calculated as carotid-femoral (cf)PWV/carotid-radial (cr)PWV ratio and its elevation ≥1 was considered as AS mismatch. р<0,05 was considered significant

Results:

In pts with RA with and without history of HTN mean cfPWV was 10.3±3.1 and 7.3±1.5 m/s, respectively, mean AS gradient – 1.4±0.4 and 1.1±0.1 (p<0.001 for trend); in controls – 9.6±1.9 and 6.7±1.4 m/s and 1.3±0.3 and 0.99±0.2, respectively (p<0.001 for trend). cfPWV elevation ≥10 m/s was observed in 34.1% pts with RA and 32.5% of controls: 6.7 and 6.3% of normotensives and 49.1 and 50% of hypertensives, respectively (p>0.05). cfPWV elevation above individual reference values was observed in 41.2% RA pts and 27.5% of controls (p=0.03): in 40% and 6.3% of normotensives (p=0.02) and 41.8% and 41.7% of hypertensives, respectively. After adjustment by age, gender and systolic BP cfPWV elevation above individual reference values in normotensive RA pts was independently associated with BMI (beta=0.39, р=0.02) and dyslipidemia (beta=0.48, р=0.01). The frequency of AS mismatch in RA was significantly higher compared to the controls in both normotensive and hypertensive subgroups: 76.7% vs 43.8% (p=0.03) and 94.5% vs 79.2% (p=0.04), respectively. The same trend was observed in a subgroup with normal cfPWV: AS mismatch was present in RA and controls in 82.1% vs 51.9% (p=0.004) in pts with PWV ≤ 10 m/s and in 82% and 51.7% (p=0.04), respectively in pts with PWV below individual reference values.

Conclusion:

Patients with RA are characterized by higher frequency of cfPWV elevation above individual reference values compared to controls irrespectively of history of HTN. This method may be more appropriate for AS evaluation than use of standard criteria in this population. AS mismatch in RA pts is highly prevalent and may be considered as an earlier marker of AS than cfPWV elevation. These findings may be used for early detection of vascular ageing in patients with RA.

References:

[1]Williams B, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. J Hypertens 2018;36(10):1953-2041

[2]Reference Values for Arterial Stiffness’ Collaboration. Determinants of pulse wave velocity in healthy people and in the presence of cardiovascular risk factors: ‘establishing normal and reference values’. Eur Heart J. 2010;31(19):2338-50

[3]Yu S, et al. Central Versus Peripheral Artery Stiffening and Cardiovascular Risk. Arterioscler Thromb Vasc Biol. 2020;40(5):1028-1033

[4]Troitskaya, E., et al. Aortic-brachial stiffness mismatch in patients with arterial hypertension and type 2 diabetes mellitus, J Hypertens 2018;36:e191

Disclosure of Interests:

None declared

Young patients with type 1 diabetes mellitus are characterised by high frequency of masked hypertension that is associated with increased arterial stiffness

Background

Hypertension (HTN) is a major risk factor for microvascular complications and cardiovascular disease (CVD) in individuals with type 1 diabetes (T1D). Masked and nocturnal HTN are associated with increased cardio-vascular (CV) risk and may be common in patients with T1D. Increased arterial stiffness (AS) is associated with elevated blood pressure (BP) and vascular complications. Very few studies have analyzed the association between masked HTN and markers of AS in T1D.

Purpose

To evaluate BP phenotypes and their associations with AS and to assess CV risk in young patients with T1D without history of HTN and other known CVD.

Methods

We included 81 patients with T1D without any history of known CVD. Routine clinical and laboratory evaluation was performed. Office BP was measured with a validated oscillometric device. 24-h ABPM was performed using BPLab Vasotens (“Petr Telegin”). Central BP and AS (carotid-femoral pulse wave velocity (cfPWV)) were measured with applanation tonometry. BP phenotypes were analyzed according to the criteria recommended in ESC/ESH 2018 HTN guidelines. CV risk categories were assessed with the global scale of 10-year risk (ESC 2019). P &lt;0.05 was considered significant. Data are presented as median (interquartile range (IQR)).

Results

The study group included 39% males, age 27 (23; 34) years, 24.7 smokers, duration of T1D– 6 (2.8; 11) years, HbA1c – 6.9% (5.6; 7.9%). Brachial BP was 122 (110; 122)/80 (70; 80) mmHg; central BP was 109 (100; 118)/72 (67; 78) mmHg, cfPWV – 6.3 (5.3; 6.7) m/s. High and very high 10-year CV risk was observed in 87.7% of patients. True HTN was observed in 5 (6.2%) patients, masked – in 31 (38.3%), white-coat – in 1 (1.2%), true normotension in 44 (54.3%). Isolated nocturnal HTN was found in 30.7% of patients with office BP &lt;140/90 mmHg. 41% of all patients with clinical normotension had masked HTN and isolated nocturnal HTN was present in 74.2% of them. The most common patterns of diurnal index were non-dipping (63,9%) and night-peaking (16.6%). Patients with masked HTN compared to patients with true normotension were older (31±8.6 vs 26.4±5.5 years, p=0.02), had longer duration of T1D (6 (3; 12.9) vs 4 (0.7; 8) years, p=0.009), higher urine albumin/creatinine ratio (18.5 (11; 29) vs 8 (3; 17) mg/g, p&lt;0.001) and higher cfPWV (7.2 (6.2; 8.2) vs 6.3 (5.8; 6.8) m/s, p=0.002).

Conclusions

Young patients with T1D and clinical normotension are characterized by high frequency of masked HTN (41%) especially isolated nocturnal HTN (74.2%), and high rate of non-dipping. Masked HTN is associated with higher cfPWV and higher albuminuria. This may reflect early vascular changes and potentially lead to further CV risk elevation in this population.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The publication was prepared with the support of the “RUDN University Program 5-100”

THU0126 COMBINATION OF NON-DIPPING PROFILE WITH ELEVATION OF NIGHTTIME SYSTOLIC BLOOD PRESSURE IN PATIENTS WITH RHEUMATOID ARTHRITIS IS ASSOCIATED WITH HIGHER ARTERIAL STIFFNESS AND CARDIOVASCULAR RISK

Background:

Nocturnal hypertension (HTN) and non-dipping profile are important predictors of adverse cardiovascular (CV) outcomes. Their associations with subclinical vascular damage in rheumatoid arthritis (RA) are still a matter of investigation. It was shown that 10-year atherosclerotic CV disease risk (rASCVD) may be more accurate in CV risk prediction in RA than SCORE. Associations of impaired 24-h BP phenotypes with CV risk in RA are not well-studied yet.

Objectives:

To assess dipping patterns and nighttime systolic blood pressure (SBPn) and their associations with arterial stiffness and CV risk assessed by rASCVD in patients with RA.

Methods:

Study group included 90 patients with RA (females 78.7%, age 59.5±14.2 years, HTN 64%, median (med) HTN duration 6.4 years, RA duration – 7.2 years, seropositive RA 66%, mean DAS-28(CRP) 3.8±1.0) and control group (45 patients matched by gender, age and risk factors). All patients with HTN received antihypertensive therapy. Office BP was measured with a validated oscillometric device, 24-hour ABPM was performed with BPLab Vasotens, carotid-femoral PWV was assessed by applanation tonometry. 3 groups were formed after adjustment of dipping state by SBPn: dippers (G1), non-dippers with SBPn<120 mmHg (G2), non-dippers with SBPn≥120 (G3). CV risk in RA group was calculated as 10-year rASCVD. Risk≥7.5% was considered as high. p<0.05 was considered significant.

Results:

Median rASCVD was 6.3%. Rate of BP control was 60% in RA and 66% in the controls (p=0.5). Patients with RA vs controls had higher mean SBPn (124±16 vs 110±8 mmHg, p=0.003), lower diurnal index (DI) (med 3.8 vs 8.1%, p=0.02), higher rate of night HTN (49.6 vs 12.2% (p=0.0002). The RA and control groups didn`t differ by dipping patterns, although RA patients more often had non-dipping profile (DI <10%): 83.9 vs 61.3%, (p=0.02). RA patients with SBPn ≥120 mmHg had higher age (63.7±12.5 vs 52.9±14.5 years), office SBP (143±17 vs 122±13 mmHg), HTN duration (med 5.4 vs 0.5 years), PWV (10.3±3.0 vs 7.9±2.5 m/s) and rASCVD (12 vs 3.4%), p<0.001 for trend. Analysis in hypertensive RA group confirmed significant differences in PWV (11.3±3.1 vs 9.1±3.2 m/s, p=0.02) and rASCVD (med 13.5 vs 10.5%, p=0.045). Patients with DI<10% had higher age (60.9±13.8 vs 54.3±11 years, p=0.04) and rASCVD (med 8.5 vs 3.1%, p=0.02). Patients with rASCVD ≥7.5% compared to <7.5% had higher SBPn (133±11 vs 112±8 mmHg), lower median DI (0 vs 6%), more often had masked HTN (43 vs 16%) and night HTN (48 vs 16%), p<0.01 for trend. SBPn significantly correlated with age (r=0.6), office SBP (r=0.5) and DBP (r=0.4), PWV (r=0.6), rASCVD (r=0.6); non-dipping pattern – with age (r=0.2), and rASCVD (r=0.3). After adjustment by SBPn, no differences were observed between G2 and G3. Patients in G3 vs G1 had higher PWV (10.4±3.1 vs 7.6±1.7 m/s, p=0.004), CRP (med 15.7 vs 7.8 mg/l, p=0.03), rASCVD (med 12.8 vs 3.1%) (p<0.001); in G3 vs G2 – higher PWV (10.8±3.1 vs 8.2±2.3 m/s), rASCVD (med 12.8 vs 2.7%) and ESR (med 45 vs 21 mm/h, p<0.01 for trend).

Conclusion:

Patients with RA had higher incidence of non-dipping pattern and SBPn elevation. Combination of high SBPn and non-dipping was associated with higher arterial stiffness and CV risk – this may be mediated by inflammation. Higher CV risk was associated with masked and night HTN. This may help in defining indications for ABPM in this population.

References:

Hamamoto K. et al. Association of Nocturnal Hypertension With Disease Activity in Rheumatoid Arthritis. Am J Hypertens 2016;29(3):340-7

Ozen G et al. The 2013 ACC/AHA 10-year atherosclerotic cardiovascular disease risk index is better than SCORE and QRisk II in rheumatoid arthritis: is it enough? Rheumatology 2016;55:513 522

Acknowledgments:

The publication was prepared with the support of the “RUDN University program 5-100”.

Disclosure of Interests:

Elena Troitskaya: None declared, Sergei Velmakin: None declared, Svetlana Villevalde Speakers bureau: Servier, Novartis, Boehringer Ingelheim, AstraZeneca, Takeda, Zhanna Kobalava Speakers bureau: Servier, Novartis, Bayer Boehringer Ingelheim, AstraZeneca, Takeda

3329Renal pathologic findings and clinical associations in patients with infective endocarditis

Background

Kidney involvement in infective endocarditis (IE) has a huge contribution in failure of the antimicrobal therapy and in rejection of the surgical treatment. Frequency of kidney lesions is still high and is diagnosed in 50–80% cases intravitaly, and in 91,6% post-mortem.

Materials/Methods

28 patients with verified IE (DUKE 2009, 2015), hospitalized and treated in clinical hospital from 2010 to 2018, were included in the study. Kidney function was assessed using CKD-EPI formula. Acute kidney injury (AKI) was diagnosed according to current guidelines (KDIGO 2012). Intravital nephrobiopsy was performed in 2 (7,1%) patients, in 26 patients (92,9%) morphological assessment was made on the autopsy tissue specimens. Autopsy material was assessed grossly and microscopically with H&E staining. Morphological changes in kidney were estimated based on standart histological criteria.

Results

Majority of patients with IE (92.9%) had structural changes in kidney tissue: 3 (12%), 16 (64%) and 6 (24%) patients had respectively isolated glomerular, tubular and mixed lesions. Significantly higher is rate of tubular lesion than glomerular (p=0.014). Main pattern in glomerular damage was mesangial proliferation, we didn't found any cases of crescentic GN. Herewith, proliferation was mainly diffuse (87.5%) rather than focal (12.5%). Glomerular damage in subacute IE (>56 days) appears more often than in acute IE (<56 days) (p=0.057 χ2=3.63). When studying the influence of various factors on the involvement of the glomeruli or tubules, no statistically significant group differences were obtained, except for the gram-negative flora as the causative agent, in which the tubules are significantly more likely to be affected (p=0.019)

Morphological diagnosis n (%) Morphological diagnosis n (%) Glomerulonephritis 8 (28.6) Tubulointerstitial nephritis 3 (10.7) Membranoproliferative glomerulonephritis 3 (10.7) Allegrgic tubulointerstitial nephritis 2 (7.2) Mesangioproliferative glomerulonephritis 5 (17.9) Infective tubulointerstitial nephritis 1 (3.6) Extracapillar crescentic glomerulonephritis 0 (0) Kidney abscess 3 (10.7) Acute tubular necrosis 22 (78.6) Kidney infarction 1 (3.6) Acute tubular necrosis (ischaemic) 11 (39.3) Renal artery embolism 1 (3.6) Acute tubular necrosis (toxic) 11 (39.3) Shock kidney 4 (14.3)

Conclusions

A morphological study of patients with IE revealed a wide range of kidney damage, however, the frequency of tubular lesions, mediated by nephrotoxic drugs and hemodynamic disorders significantly exceeds the frequency of immune complex glomerular lesions, as previously thought.

429Impairment in arterial-ventricular coupling and its prognostic value in patients with decompensated heart failure

Objective

The interaction of the left ventricle (LV) with the arterial system, termed ventricular-arterial coupling (VAC), is a central determinant of cardiovascular performance and cardiac energetics. Heart failure (HF) modify the structure and function of LV. The aim of the study was to assess VAC parameters and their prognostic value in patients with different phenotypes of decompensated HF.

Methods

Parameters of VAC were assessed by 2-dimentional echocardiography in 355 patients admitted with decompensated HF (198 male, 72±11 years (M±SD), arterial hypertension 94%, previous myocardial infarction 42%, HF with preserved ejection fraction (HFpEF) 36%, reduced EF (HFrEF) 44%, mid-range EF (HFmrEF) 20%, diabetes 40%, NTproBNP 3763 (1801; 5486) pg/ml, eGFR 51 (41; 64) ml/min/1.73 m2) on the admission. VAC was expressed as the ratio arterial elastance (Ea)/ end-systolic LV elastance (Ees) and was considered optimal at range of 0.6–1.2. Patients received standard therapy (334 (94%) beta-blockers, 312 (88%) iv diuretics, 170 (48%) – iv nitrates, 280 (79%) and 57 (16%) ACEI and ARB, 270 (76%) MRA). Hospital length of stay was 10 (8; 12) days. P<0.05 was considered statistically significant.

Results

The median values of Ea, Ees and VAC were 2.2 (1.7; 2.9) mmHg/ml, 1.8 (1.0; 3.0) mmHg/ml and 1.32 (0.75; 2.21). Impairment of VAC was revealed in 63% of patients: VAC >1.2 – in 55% (predominantly patients with HFrEF), VAC<0.6 – in 8% of patients (all with HFpEF). Normal VAC was observed in 78% of patients with HFpEF, 42% of patients with HFmrEF and only in 1% with HFrEF. There was significant correlation between VAC and levels of NTproBNP (r=0.35), hematocrit (r=−0.29), hemoglobin (r=−0.26), systolic pulmonary artery pressure (sPAP) (r=0.18), diameters of left atrium (r=0.32) and right ventricle (RV) (r=0.32).

In-hospital mortality was 1.5%. After 6 months of follow-up 72 (20.3%) patients were readmitted with decompensated HF and 42 (11.8%) patients died. Patients with vs without worse prognosis had lower Ea (2.1 (1.7; 2.8) vs 2.3 (1.9; 3.0) mmHg/ml, Ees (1.5 (0.7; 2.5) vs 1.9 (1.0; 3.1) mmHg/ml, systolic blood pressure (130 (115; 150) vs 140 (130; 160) mmHg), higher level NTproBNP (4687 (3277; 6220) vs 3396 (1555; 5052) pg/ml), RV diameter (3,3 (3,0; 3,7) vs 3,0 (2,8; 3,5) cm), p<0.05 for all. There was increased risk of re-hospitalizations with decompensated HF and all-cause death in patients with decrease of Ea <2.2 mmHg/ml (OR 2.5, 95% CI 1.39–4.34, p<0.05), increase sPAP >45 mmHg (OR 3.7, 95% CI 1.74–7.45, p<0.05).

Conclusion

Impairment of VAC was revealed in 63% of patients with decompensated HF. Decrease of arterial elastance <2.2 mmHg/ml and increase of sPAP >45 mmHg are associated with risk of all-cause death and decompensated HF re-admissions in 6 month follow-up.

P5405Clinical and prognostic relevance of increased liver stiffness coupled with abnormal liver function tests in decompensated heart failure

Objective

Recent studies have demonstrated associations of either abnormal liver function tests (LFT) or liver stiffness (LS) increase with negative outcomes in decompensated heart failure (DHF). We aimed to assess incidence, clinical and prognostic relevance of combined increase of LS and LFT in DHF.

Methods

The study included 130 patients (73% male, 68±11 years [M±SD], myocardial infarction 49%, atrial fibrillation 63%, diabetes mellitus 39%, chronic kidney disease 24%, EF 39±14%, EF<40% 54%, NT-proBNP 3601 [1905; 6220] pg/ml, alcohol abuse 26.2%) hospitalized with DHF, in whom levels of alanine transaminase (ALT), aspartate transaminase (AST) and total bilirubin (TB) and LS (using transient elastography) were assessed in the first 48 hours of admission. Patients with previous liver disease or acute hepatitis were excluded. Higher then upper normal limit levels of either AST/ ALT/ TB were considered as LFT increase; LS >5.9 kPa – as abnormal. Outcomes were assessed by phone contacts in 1, 3, 6 and 12 months. Kruskal–Wallis test, Pearson's chi-squared test and Kaplan-Meier survival analysis were used. P<0.05 was considered significant.

Results

Median LS was 11.1 (6.8; 24.5) kPa, median ALT 20.1 (14.9; 30.7) U/l, AST 26 (20; 36.3) U/l, TB 19 (13.2; 27) μmol/l. LS and ALT, AST, TB increase occurred in 79.2 and 15.4, 13.1, 40.8% patients.

Based on combination of LS and LFT increase subjects were divided into 3 groups: without LS and LFT increase (G1, 16.2%), with only LS increase (G2, 33.1%) and both LS and LFT increase (G3, 46.1%). Isolated LFT increase was noted only in 6 (4.6%) patients.

G3 compared to G2 and G1 was characterized by lower EF (33±14 vs 41±13 and 45±11%, p<0.001) and inferior vena cava (IVC) collapsibility (23.3 vs 41.9 and 61.9%, p=0.003), higher IVC diameter (2.4 [2; 2.6] vs 2.2 [2; 2.4] and 2 [1.95; 2.2] cm, p<0.001), right ventricular diameter (3.5 [3.2; 3.9] vs 3.2 [3; 3.6] and 3 [2.9; 3.1] cm, p<0.001), pulmonary artery pressure (56 [45; 66] vs 50 [37; 65] and 40 [33; 49] mmHg, p=0.014), higher rate of tricuspid regurgitation (70 vs 44.2 and 28.6%, p=0.001). Groups did not differ by alcohol abuse rate (p=0.152).

Kaplan–Meier analysis of groups for all-cause death probability showed significant differences (figure): event-free survival for G3 vs G1 and G2 was 64.9 vs 81 and 95% (log rank p=0.011, χ2=6.5 for G3 vs G1; log rank p=0.081, χ2=3.1 for G3 vs G2). HF readmission probability was significantly higher in G3 vs G2 and G1: corresponding event-free survival was 50.9 vs 66.7 and 80% (log rank p=0.012, χ2=6.3 for G3 vs G1; log rank p=0.036, χ2=4.4 for G3 vs G2).

Conclusions

Combination of abnormal LFT and increased LS was observed in 46.1% of DHF patients and was associated with lower EF, more serious right-sided dysfunction and higher probability of negative long-term outcomes.

P2759Value of biomarkers (urinary KIM-1, NGAL, albumin, serum Cys C) for predicting renal lesions and prognosis in patients with infective endocarditis

Background

Infective endocarditis (IE) is frequently complicated by kidney damage of various pathogenesis. The essential differences in pathophysiological mechanisms of kidney lesions (glomerular and tubular damage, mixed mechanisms) create different therapeutical targets. Nowadays these mechanisms are only possible to differentiate with the use of nephrobiopsy or autopsy. Non-invasive methods to assess the genesis of kidney damage are eagerly wanted. It is possible that kidney biomarkers may be such method.

Materials and methods

209 patients with verified IE (DUKE 2009, 2015), hospitalized and treated in city clinical hospital named after V.V. Vinogradov in Moscow from January 2010 to June 2018, were included in the study. Kidney function was assessed using CKD-EPI formula. Acute kidney injury (AKI) and acute kidney disease (AKD) were diagnosed according to current guidelines (KDIGO 2012) and the work group consensus (ADQI 16 Workgroup 2017). Serum creatinine decrease on ≥26,5 mcmol/L in 48 hours after the hospitalization was counted as early-onset AKI. Patients with serum creatinine elevation on ≥26,5 mcmol/L in 48 hours during the hospitalization were diagnosed with late-onset AKI. Biomarkers were assessed at the admission. Cystatin C level was assessed in serum; neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule 1 (KIM-1), albumin levels were assessed in urine.

Results

Kidney damage biomarkers' levels were analyzed in 65 patients with IE. Patients with kidney dysfunction (n=45) comparing to ones without AKI (n=20) had higher mean value of all kidney biomarkers, however, the significant difference was established only for cystatin C. (1.9 vs 1.3 mg/l respectively; p<0.001). Patients with early-onset AKI (n=11) next to patients without AKI had significantly higher cystatin C value at admission (1.9 vs 1.3 mg/l respectively; p=0,0186). In similar manner patients with late-onset had had significantly higher cystatin C value at admission (1.9 vs 1.3 mg/l respectively; p=0,002). Cystatin C appeared to be an independent AKI predictor with threshold value 1.35 mg/l (OR 14.0; 95% CI 1.74–112.2; p=0.013), and also cystatin C was an independent predictor of the in-hospital mortality with threshold 1.87 mg/l (OR 3.16; 95% CI 1.25–7.99; p=0.006). After analysis of patients with AKD it was established that they had significantly higher levels of cystatin C (1.7 vs 1.3 mg/l respectively; p=0.035) and NGAL (19 vs 1.9 ng/ml; p=0.05) in comparison with patients without AKD. Albumin and KIM-1 didn't show significant associations.

Conclusions

The results of a study allow to consider serum cystatin C as AKI marker, AKI predictor and in-hospital mortality predictor in patients with IE, and urinal NGAL and serum cystatin C may be considered as AKD markers.

P2485Cardiac abnormalities and vascular damage in young adults with type 1 diabetes mellitus: incidence and associations with kidney dysfunction

Background

In contrast to type 2 diabetes mellitus (DM), cardiac and vascular abnormalities in type 1 DM (T1DM) are not well investigated. We aimed to evaluate occurrence of cardiac remodeling, arterial stiffness and blood pressure (BP) phenotypes in T1DM patients.

Methods

The cross-sectional study consecutively included T1DM patients 18–44 y.o. without known CVD, in whom 24-hour monitoring of peripheral and central BP (ABPM) with BPLab Vasotens, applanation tonometry and conventional and speckle tracking echo were performed. BP phenotypes were determined according to current guidelines, PWV and CBP - according to individual reference values. Presence of systolic dysfunction was defined as global longitudinal strain (GLS) <20%, left ventricular hypertrophy (LVH) as LV myocardial mass index (LVMI) >95/>115 g/m2 for women/men, LV remodeling (LVR) as RWT ≥0.43. P<0.05 was considered significant.

Results

A total of 125 patients with T1DM (mean age 29,2±7,6 years, 60% male, median duration of DM 6,9 [2; 11] years, HbA1c 9.9 [6; 12] %, mean BMI 23±3 kg/m2, smoking 39%, median GFR 100 [86; 117] ml/min/1.73 m2, GFR <60 ml/min/1.73 m2 – in 8.8%, median albuminuria 19 [8; 24] mg/g (moderate and high albuminuria in 14.6% and 2.2%) were investigated.

According to office BP and ABPM hypertension (HTN) was diagnosed in 28% patients (true and masked in 4.8 and 23.2%, respectively) and true normotension in 72%.

Isolated nocturnal HTN was observed in 14.4%. Majority of the patients were dippers (51.2%), non-dippers and night-peakers profiles were registered in and 43.2% and 5.6%, respectively. Central SBP and PWV elevation were observed in 17.6% and 57.6% (PWV >10 m/s - only in 2.4%). Cardiac abnormalities were revealed in 72.4% of patients: GLS<20%, LVH, LVR and diastolic dysfunction (DD) in 71.2, 12, 39.2 and 16.8% patients, respectively. Isolated GLS <20% was detected in 30%, combination of GLS<20% with LVH (or LVR) and DD in 47.2%.

Patients with vs without HTN were characterized by higher PWV (7.8±1.5 vs 6.9±1.2, p<0.001), LVMI (89.9 [75; 96] vs 71.5 [64; 77] p<0.001), incidence of DD (29.6 vs 12.2%, p=0.03), LVH (28 vs 6%, p=0.002), trend towards higher rate of central SBP increase (32.7% vs 17.4%, p=0.08), lower incidence of LVR (26 vs 44%, p=0.002) and similar GLS (p=0.16).

Groups with vs without nocturnal HTN did not differ by PWV, central SBP, GLS and LVMI. PWV increase was associated only with higher LVMI (88.2 [69; 95] vs 77.6 [68; 83], p=0.042).

Correlations (p<0.05) with albuminuria were observed for GLS (r=−0.26), DD (r=0.22) and non-dipping state (r=−0.34). GFR correlated (p<0.05) with GLS (r=−0.32) and PWV (r=−0.32).

Conclusion

Incidence of prognostically unfavourable phenotypes of HTN, cardiac remodeling and arterial stiffness (even in patients without HTN) were relatively high in T1DM population. GLS and non-dipping state correlated with albuminuria, GLS and PWV with GFR

P2755Acute kidney injury risk calculator in patients with infective endocarditis

Background

Kidney involvement in IE has a huge contribution in failure of the treatment. Frequency of kidney lesions is still high. There are several risk calculators for prognosing embolic events, perioperational mortality, 6-month mortality, but there is none for prognosing kidney events in IE.

Materials/Methods

209 patients with verified IE (DUKE 2009, 2015), hospitalized from 2010 to 2018, were included in the study. Kidney function was assessed using CKD-EPI formula. AKI was diagnosed according to current guidelines (KDIGO 2012). Clinical, hematological and echocardiographic features were analysed to look for predictors of AKI. To create a simple risk calculator independent predictors obtained from log-regression analysis were used. The risk formula was derived using the coefficients: Pr(Y) = 1/[1 + exp(−XB)] where Pr(Y) = prognosed risk of AKI, XB = coef1*predictor1 + ... + logit-regression constant.

Results

AKI was presented in 66% cases and mainly was I (41%) and III (37%) stages. Predictors for AKI were established: MRSA OR 8.0 (95% CI 1.01–68.48; p=0.054), emergence or worsening of the HF sympthoms OR 2.83 (95% CI 1.27–6.32; p=0.011), gentamycin OR 2.71 (95% CI 1.33–5.53, p=0.006), history of CAD OR 2.35 (95% CI 1.05–5.27) p=0.038, WBC at admission >11.5x109/l OR 1.07 (95% CI 1.01–1.13), duration of hospitalization >20.7 days OR 1.03 (95% CI 1.01–1.05) p=0.005, C-reactive protein >90 mg/l OR 1.01 (95% CI 1.01–1.02) p=0.001.

Simple risk calculator Coef OR Indicator MRSA 2.0755 8 0 Emergence or worsening of the heart failure sympthoms 1.04041 2.83 0 Gentamycin 0.3640833 2.71 1 History of coronary artery disease 0.8542633 2.35 1 White blood count at admission 0.0691979 1.07 13 Duration of hospitalization 0.0308953 1.03 2 C-reactive protein 0.0075288 1.01 180 Constant −3.275098 0.0378132 Logit 0.259795900 P 0.564586119 Scaling parameter 100 Points 56 Result 56

Conclusions

A simple risk calculator for AKI is developed for patients with IE.

P829The impact of APOC3 and APOE gene polymorphisms on response to statin therapy in acute myocardial infarction

Background and aim

Many genetic studies have been reported about the association between APOE, APOC3 gene polymorphisms and response to statin therapy in myocardial infarction, but results remain controversial. The aim of this study was to investigate the association between SNP rs7412 (APOE), rs2854117 (APOC3), rs2854116 (APOC3) and lipid-lowering effect of atorvastatin and rosuvastatin in patients with myocardial infarction.

Methods

Polymorphism of genes APOE (rs7412), APOC3 (rs2854117 and rs2854116) was determened. Lipid profile was determined on admission and after 1 year of treatment.

Results

78 patients with myocardial infarction treated with maximal tolerated dose of atorvastatin or rosuvastatin were included. More pronounced reduction of lipid levels was associated with of T allele of rs7412 (APOE), p<0,05. ANOVA demonstrated greater low-density lipoprotein and total cholesterol decrease in patients with combination of genes CT/TT (rs7412, APOE) and CC (rs2854117, APOC3) genotypes, CT/TT (rs7412, APOE) and CT (rs2854116, APOC3) genotypes.

Conclusion

The genetic variants of APOC3 and APOE are useful markers and can be use to predict response to lipid-lowering therapy with statin in myocardial infarction.