Serum uric acid levels significantly improve the accuracy of cardiovascular risk score models

Background

This study evaluated the impact of serum uric acid (sUA) on the accuracy of atherosclerotic cardiovascular disease (ASCVD) pooled cohort equations (PCE) model, Systematic Coronary Risk Evaluation score 2 (SCORE2) and SCORE2-Older Persons (OP).

Methods

We evaluated 19,789 asymptomatic self-referred adults aged 40–79 years who were screened annually in a preventive healthcare setting. All subjects were free of cardiovascular disease and diabetes at baseline. sUA levels were expressed as a continuous as well as dichotomous variable (categorized into sex-specific tertiles, with the upper tertiles defined as high sUA). Mortality and cancer data were available for all subjects from nationwide registries. The primary endpoint was the composite of death, acute coronary syndrome and stroke, after excluding subjects diagnosed with lymphatic spread cancer during follow up.

Results

Mean age of study population was 50±8 years and 69% were men. During median follow up of 6 years [2.0–13.1], 1,658 (8%) subjects reached the study endpoint. ASCVD, SCORE2 risk and high sUA were all independently associated with the study endpoint in the multivariable Cox regression model (p<0.001 for all). Continuous net reclassification improvement analysis showed an improvement of 13% in the accuracy of classification when high sUA was added to the PCE and SCORE2 models (p<0.001 for both). sUA remained independently associated with the study endpoint among normal-weight subjects in the SCORE 2 model (HR 1.3, 95% CI 1.1–1.6) but not among overweight individuals (p for interaction = 0.01). Addition of sUA to the models in normal-weight subgroup (N=6,624) resulted in a significant 20% improvement in the model performance for both SCORE2 and ASCVD when sUA was incorporated as dichotomous variable (p<0.001 for ASCVD and p=0.026 for SCORE2 model).

Conclusions

sUA significantly improves classification accuracy of PCE and SCORE 2 models. This effect is especially pronounced among normal weight subjects.

Funding Acknowledgement

Type of funding sources: None.

Decreasing albumin within normal range is associated with increased likelihood of ischemic heart disease

Background

Albumin (ALB) is a known biomarker of frailty, and cardiovascular disease and frailty are interdependent. Epidemiological evidence demonstrates that low serum albumin levels are linked to events of ischemic heart disease (IHD), venous thromboembolism, heart failure, atrial fibrillation, and stroke.

Purpose

We aimed to investigate the association of variations in ALB levels that are within normal range with IHD events among apparently healthy adults.

Methods

A case-control retrospective study of self-referred adults participating in an executive screening program between 2002 and 2017. All subjects were free of IHD and diabetes at baseline and had their ALB documented in each visit. Only subjects with at least two ALB measurements and whose ALB levels were within the normal range at all visits were included. Relationships between ALB trend and occurrence of IHD (acute coronary syndrome or percutaneous coronary intervention) within 2 years from the last visit were investigated.

Results

The final study cohort included 16,386 subjects. Median age was 53 (IQR 45–60), 11,461 (70%) were men. Analysis included a total of 99,127 visits. Median number of visits per subject was 5 (IQR 3–9, median inter-visit time 1.02 years) and median ALB level was 4.4 (IQR 4.2–4.6). IHD within 2 years was diagnosed in 545 (3%) subjects. Of those, only 36 were female and they tended to have lower variations in ALB throughout the years. Hence, we conducted an analysis of the 509 males only, and created an equal-size age-matched cohort of IHD-free subjects. Our analysis demonstrated a progressive and significant decrease in ALB levels among IHD cases, but not among controls (mean decrease of 0.021 g/DL vs. 0.004 g/DL per year, p<0.01; OR [CI] = 0.82 [0.72–0.93]; Figure 1). Similar results were found among subjects with at least 3 or 4 visits (0.015 g/DL vs. 0.006 g/DL per year, p=0.027, and 0.009 g/DL vs. 0.003 g/DL per year, p=0.045, respectively).

Conclusions

Kinetics of ALB within the normal range can identify men at risk for IHD in preventive healthcare screening programs.

Funding Acknowledgement

Type of funding sources: None.

Permanent pacemaker implantation post transcatheter aortic valve replacement- the role of pacing burden

Introduction

Previous studies have provided inconsistent results regarding the clinical impact of new permanent pacemaker (PPM) post TAVR. Our aim is to evaluate whether new PPM post TAVR is associated with higher 1-year mortality and/or heart failure hospitalizations and whether pacing burden is related to adverse outcomes.

Results

Overall, 1245 patients underwent TAVR between the years 2008–2019 and were included in our analysis with a median follow up of 2.3 years (IQR 1–4). 191 (15%) had a new PPM implantation during index admission. Compared to patients without PPM those implanted had significantly higher 1-year mortality rate (18% vs 11%, p-0.007) as well has higher combined outcome of mortality and HF hospitalizations. There was no difference in pacing burden between survivors and non survivors in all models examined: first and last clinic visit, maximal pacing during the first-year post implantation and the difference in pacing trend between visits. Older age, peripheral artery disease (PAD) and previous myocardial infarction (MI) were independently associated with mortality or combined outcome of mortality and HF hospitalizations.

Conclusion

New pacemaker implantation post TAVR is associated with higher 1-year mortality and HF hospitalization, however pacing burden isn't associated with adverse clinical course.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 pandemic and admission rates for and management of acute coronary syndromes in Israel

Background

Since the COVID-19 pandemic outbreak several countries have reported a decrease in the number of patients admitted with non-ST elevation myocardial infarction (NSTEMI).

Purpose

We aimed to evaluate admission trend and outcomes of patients with NSTEMI in the COVID-19 era in a nationwide survey.

Methods

A prospective, multicenter, observational, nationwide study involving 13 medical centers across Israel. All NSTEMI patients admitted to intensive cardiac care units (ICCUs) over an 8-week period during the COVID-19 outbreak were compare them with NSTEMI patients admitted 2 years earlier (control period) during the Acute Coronary Syndrome Israeli Survey (ACSIS) 2018.

Results

There were 624 (43%) NSTEMI patients, of them 349 (56%) hospitalized during the COVID-19 era and 275 (44%) during the control period, representing a 27% increase in NSTEMI admission rate during the COVID-19 era. Approximately 76% were male, median age was 67 years (IQR 58–76). There were no differences in baseline characteristics between the two study periods. During the COVID-19 era, more patients arrived at the hospital via an emergency medical system (EMS) compared with the control period (p for trend = 0.005)

Time from symptom onset to hospital admission was longer in the COVID-19 era [687.00 (IQR147–2805) vs. 178.00 (IQR 102- 407), respectively, p-value <0.001]. Nevertheless, time from hospital admission to reperfusion was similar in both groups. Rate of percutaneous coronary intervention was higher in the COVID-19 era group (91.3% vs. 59.7%, respectively, p<0.001). In-hospital mortality rate was similar in both groups (2.3% vs. 4.7%, respectively, p=0.149) as was the 30-day mortality rate (3.7% vs. 5.1%, respectively, p=0.238).

Conclusions

In contrast to previous reports, in Israel, admission rate of NSTEMI was increased during the COVID-19 era. With longer time from symptoms to admission, but with the same time from hospital admission to reperfusion therapy and with similar in-hospital and 30-day mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Acute myocardial infarction in the Covid-19 era: incidence, clinical characteristics and in-hospital outcomes – a multicenter registry

Background

A reduction in acute myocardial infarction (AMI) hospitalizations during the coronavirus pandemic has been previously documented. We aimed to describe the characteristics and in-hospital outcomes of AMI patients during the Covid-19 era compared to a recent previous registry.

Methods

We conducted a prospective, multicenter, observational study involving 13 intensive cardiac care units (ICCUs) to evaluate consecutive AMI patients admitted throughout an 8-week period during the Covid-19 outbreak. Data were compared to the corresponding period in 2018 using an acute coronary syndrome survey conducted in all ICCUs in Israel. The primary end-point was defined as a composite of sustained ventricular arrhythmia, pulmonary congestion, and/or in-hospital mortality.

Results

The study cohort comprised 1466 patients, of whom 774 (53%) were hospitalized during the Covid-19 outbreak. Overall, 841 patients were diagnosed with ST-elevation MI (STEMI): 424 (50.4%) during the Covid-19 era and 417 (49.6%) during the parallel period in 2018. No differences were detected in the admission rate of patients between the two study periods. STEMI patients admitted during the Covid-19 period tended to have fewer co-morbidities, but a higher Killip class (p value = 0.03). The median time from symptom onset to reperfusion was extended from 180 minutes (IQR 122–292) in 2018 to 290 minutes (IQR 161–1080, p<0.001) in 2020. Hospitalization during the Covid-19 era was independently associated with an increased risk of the combined endpoint of heart failure, malignant arrhythmia, or death in the multivariable logistic regression model (OR 1.63, 95% CI 1.02–2.65, p value = 0.05).

Conclusion

While the admission rate of AMI and STEMI in Israel remained similar during both the Covid-19 era and the corresponding period in 2018, total ischemic time extended significantly during the Covid-19 period, which translated into a more severe disease status upon hospital admission, and a higher rate of in-hospital adverse events.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by a grant from a Fefer foundation for medical research

Incident cardiovascular events among middle-age men are associated with increased risk of subsequent prostate cancer diagnosis

Introduction

Prostate cancer is the second most common malignancy in men worldwide, but incidence is highly dependent on screening.

Purpose

We aimed to examine whether incident cardiovascular disease (CVD) events are associated with increased risk of future prostate cancer in middle-aged men.

Methods

We evaluated asymptomatic self-referred men who participated in a screening program. All subjects were free of CVD and cancer at baseline. CVD was defined as the composite of acute coronary syndrome, percutaneous coronary intervention, or stroke. Study endpoint was the development of cancer during follow up. Cancer and mortality data were available for all subjects from national registries. Cox regression models were applied with CVD as a time-dependent covariate and death as a competing risk event.

Results

Final study population included 18,282 subjects. Median age was 47 years (Interquartile range [IQR] 41–54). During median follow up time of 12 years (IQR 4–17) 2,047 (11%) subjects developed CVD, 406 (2.2%) developed prostate cancer and 694 (4%) died. Compared with patients who were free of CVD or prostate cancer during follow up, risk of death was 4, 6 and 15 times higher for patients who developed CVD event, prostate cancer, or both during follow up, respectively (p <.001 for all). Time dependent survival analysis showed that subjects who developed CVD during follow up were 60% more likely to develop prostate cancer (95% Confidence Interval [CI] 1.2–2.1, p=.001). However, after multivariable adjustment, this association was no longer significant. Interaction analysis demonstrated that the association of incident CVD with the risk of future cancer diagnosis was age dependent such that in middle-aged men (age≤55 years; N=14,473) incident CVD was associated with a significant 70% increased risk of subsequent cancer diagnosis in multivariable model (95% CI 1.13–2.6, p=.011, p for interaction=.002). Exploratory analysis of men younger than 55 showed that independent association of incident CVD with subsequent cancer diagnosis was different among subjects with normal body mass index (BMI) (≤25 kg/m2) compared with those with increased BMI (HR 0.55; 95% CI [0.22–1.42]; p value=0.23 vs. 1.6; 95% CI [1.007–2.54]; p value=.047; p for interaction=.058, respectively).

Conclusion

Incident CVD is independently associated with increased risk of subsequent prostate cancer diagnosis among men ≤55 years. Routine prostate cancer surveillance should be considered after CVD event in this population.

Funding Acknowledgement

Type of funding sources: None.

Predictors of deterioration in cardiorespiratory fitness among healthy adults: the importance of sex and obesity

Introduction

Cardiorespiratory fitness (CRF) is associated with cardiovascular co-morbidities and is a strong predictor of adverse cardiovascular outcomes. However, data on the natural history of cardiorespiratory fitness among healthy subjects is limited.

Purpose

This study investigated what are the predictors of deterioration in CRF over time.

Methods

We investigated 36,239 men and women who were annually screened in a tertiary medical center and completed an exercise stress test in all visits, with a total of 175,596 annual visits. Subjects who failed to complete maximal exercise stress test according to the Bruce protocol at their first baseline visit were excluded. In addition, subjects with less than five visits to the center or those who developed ischemic heart disease during follow-up were excluded. Fitness was categorized into age- and sex-specific quintiles (Q) according to Bruce protocol treadmill time. Change in CRF between the first baseline visit and the fifth visit was used to calculate fitness deterioration. The primary study endpoint was defined as the lower sex-specific quintile of change in metabolic equivalents (METS) between visits 1 and 5. Logistic regression models were applied.

Results

Final study population included 10,841 subjects. The mean age of the study population was 49±10 years, the mean BMI was 26±4, and 8107 (75%) were men. Median METS at baseline were 10.8 (IQR 9–12.6) and 11.1 (IQR 9.4–13) at the first and fifth visit, respectively (p<0.001 for METS between visits). Overall, 2189 (20%) subjects met the study endpoint. CFR deterioration was higher among women as compared to men (p=0.023). Out of obesity, hypertension, fasting blood glucose, LDL, and HDL cholesterol, after adjustments for age, sex, and baseline CFR, only obesity was independently associated with fitness deterioration in the multivariate model (OR=1.4 95% CI 1.2–1.5, p<0.001). The association of obesity with fitness deterioration was modified by sex such that the risk of CRF deterioration was more pronounced in women (OR=1.6 95% CI 1.3–2, p<0.001) than in men (OR=1.3 95% CI 1.1–1.4, p<0.001).

Conclusion

Obesity is an independent predictor of future CRF deterioration. The effect of obesity on future CRF deterioration is more pronounced among women as compared to men.

Funding Acknowledgement

Type of funding sources: None.

Incident cardiovascular events among healthy subjects are associated with increased risk of subsequent cancer diagnosis

Introduction

While Cardiovascular disease (CVD) and cancer share common risk factors, data on the temporal association between the occurrence of CVD and cancer is limited.

Purpose

This study investigated the association between incident CVD events future cancer among apparently healthy subjects.

Methods

We evaluated asymptomatic self-referred adults who participated in a screening program. All subjects were free of CVD and cancer at baseline. CVD was defined as the composite of acute coronary syndrome, percutaneous coronary intervention, or stroke. Study endpoint was the development of cancer during follow up. Cancer and mortality data were available for all subjects from national registries. Cox regression models were applied with CVD as a time-dependent covariate and death as a competing risk event.

Results

Final study population included 26,574 subjects. Median age was 46 years (Interquartile range [IQR] 40–53) and 69% were men. During median follow up time of 10 years (IQR 3–16) 2,463 (9%) subjects developed CVD, 2,040 (8%) developed cancer and 869 (3%) died. Most common cancer types were prostate among men (N=406, 2.2%) and breast among women (N=283, 3.4%). Compared with patients who were free of CVD and cancer during follow up, risk of death was 5, 34 and 54 times higher for patients who developed CVD event, cancer, or both during follow up, respectively (p <.001 for all). Time dependent survival analysis showed that subjects who developed CVD during follow up were 50% more likely to develop cancer in a univariate model (95% Confidence Interval [CI] 1.3–1.7, p<.001). Interaction analysis demonstrated that the association of incident CVD with the risk of future cancer diagnosis was age dependent such that in younger subjects (≤52 years; N=19,052) incident CVD was associated with a significant 30% increased risk of subsequent cancer diagnosis (95% CI 1.03–1.67, p=.027) while in older subjects incident CVD was not associated with increased risk of cancer in the multivariable model (p for interaction =.018).

Conclusion

Incident CVD is independently associated with increased risk of subsequent cancer diagnosis among young adults. Active cancer surveillance should be considered among young patients recovering from a CVD event.

Funding Acknowledgement

Type of funding sources: None.

Incident cardiovascular events and risk of subsequent cancer diagnosis

Background

Cardiovascular disease (CVD) and cancer share common risk factors. This study investigated the association of CVD diagnosis and the risk of future cancer.

Methods

We evaluated asymptomatic self-referred adults aged 40–79 years who participated in a screening program. All subjects were free of CVD and cancer at baseline. CVD was defined as the composite of acute coronary syndrome, percutaneous coronary intervention or stroke. Cancer and mortality data were available for all subjects from national registries. Primary end-point was development of cancer during follow up. Cox regression models were applied with CVD as a time-dependent covariate and death as a competing risk event.

Results

Final study population included 15,486 subjects. Median age was 50 years (Interquartile range [IQR] 44–55) and 72% were men. During median follow up time of 11 years (IQR 6–15) 1,028 (7%) subjects developed CVD, 1,281 (8%) developed cancer and 499 (3%) died. Most common cancer types were prostate among men (N=277, 1.8%) and breast among women (N=187, 1.2%). Time dependent survival analysis showed that subjects who developed CVD during follow up were 60% more likely to develop cancer (95% Confidence Interval [CI] 1.3–1.95, p<0.001). However, after adjustment for known predictors of cancer, the association of incident CVD with cancer diagnosis was no longer significant (p=0.21). Interaction analysis demonstrated that the association of incident CVD with the risk of future cancer diagnosis was age dependent such that in younger subjects (<50 years; N=7,649) incident CVD was associated with a significant 2 fold increased risk of subsequent cancer diagnosis (95% CI 1.2–3.6, p=0.014) while in older subjects incident CVD was not associated with increased risk of cancer in the multivariable model (p for interaction =0.035; Figure 1).

Conclusions

Incident CVD is independently associated with 2-fold increased risk of subsequent cancer diagnosis among young adults. Our analysis underscores the importance of cancer surveillance among young patients following a CVD event.

Figure 1

Funding Acknowledgement

Type of funding source: None

Platelets reactivity as a predictor of the extent of myocardial infarct damage and poor outcomes in STEMI patients undergoing primary PCI

Background

Despite optimized management of STEMI patients including primary PCI (PPCI) and use of novel anti-platelet agents, a substantial proportion still display a large infarct size and microvascular damage. The extent of MI and presence of microvascular damage as determined by cardiac MRI (CMR) are considered as powerful prognostic factors in predicting both early and long-term prognosis in those patients. Platelets reactivity has been implicated in pathogenesis of microvascular and subsequent myocardial damage including distal embolization, microvascular platelets plugging and inflammation.

Methods

We prospectively evaluated 105 consecutive STEMI patients, with no prior MI, who underwent PPCI. Patients underwent 2D-echocardiography within 48 hours of admission and cardiac MRI (CMR) 5±1 day post admission. All Patients were treated with dual antiplatelet agents and blood sample were analyzed for platelets reactivity (PA) at 72 hours post admission, using arachidonic acid (AA) and adenosine diphosphate (ADP) as agonists. Aspirin hypo-responsiveness was defined as AA-PA≥30%, and P2Y12 non-responsiveness as ADP-PA ≥50%. CMR was evaluated for late gadolinium enhancement (LGE) and microvascular obstruction (MVO), which reflects MI size and microvascular damage respectively. Both parameters were quantified as % of the LV mass. Major adverse cardiac events (MACE) were defined as the composite of death, MI, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year post AMI.

Results

AA and ADP inhibition were 22±17, and 34±16 respectively. Aspirin hypo-responsiveness was associated with significantly higher extent of LGE (p=0.04) and MVO (p=0.003). A multivariate logistic regression analysis revealed that AA-PA hypo-responsiveness is an independent predictor of both MI size as reflected in LGE (OR 3.87; 95% CI: 1.47–10.5, p=0.031), and higher extent of microvascular damage as reflected by MVO% of LV mass (OR 3.6; 95% CI: 1.15–10.3, p=0.027). Patients with aspirin hypo-responsiveness were significantly more likely to sustain MACE (36% vs 12%, HR 4.13, 95% CI: 1.52–10.2, p=0.003). As opposed to AA related platelets reactivity, no significant correlation was demonstrated between ADP induced platelets reactivity and either measures of MVO or LGE.

Conclusions

In patients undergoing PPCI for STEMI, platelets reactivity in response to AA is an independent predictor of the extent of both myocardial and microvascular damage. Aspirin hypo-responsiveness is associated with higher rate of adverse events during 1-year follow-up.

Funding Acknowledgement

Type of funding source: None

The extent of pericardial involvement evaluated by cardiac MRI in patients with ST-Segment elevation myocardial infarction: predictors and outcomes

Background

The clinical diagnosis of peri-myocardial infarction pericarditis declined dramatically in the era of primary PCI and novel antiplatelet agents. However, recent data documents the presence of pericardial effusion in substantial proportion of acute MI patients, while recent randomized trial showed that anti-inflammatory drugs seem to improve cardiovascular outcomes, although the mechanism of the benefit remains uncertain.

Methods

We prospectively evaluated 187 consecutive patients, without known prior coronary disease, who underwent primary PCI for STEMI. All patients underwent cardiac MRI (CMR) on day 5±1 post admission. CMR was performed using a 1.5 T (n=101) and 3 T (n=86) scanners. Delayed enhancement (DE) and microvascular obstruction (MVO) were quantified as % of the left ventricular mass (LV). The presence of DE and MVO was recorded according to the AHA segments model. DE was also qualitatively assessed for the degree of transmurality in each segment. CMR pericarditis was defined as evidence of pericardial enhancement on DE images. The presence of pericardial effusion was also documented. Pericarditis extent was expressed as the number of pericardial segments with increased DE. Major adverse cardiac events were defined as the composite of death, recurrent myocardial infarction, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year following STEMI.

Results

Pericardial effusion was found in 94 patients (50%) and enhancement of the pericardium on DE images in 120 patients (65%). In contrary, a clinical diagnosis of peri-myocardial infarction pericarditis was documented and anti-inflammatory therapy was initiated only in three patients (1%). A significant positive correlation was demonstrated between pericardial involvement and either quantitative or qualitative assessment of DE (p<0.001, r=0.34) and MVO (p<0.001, r=0.282). DE transmurality (per segment) was associated with both location of pericardial involvement and its extent (p<0.001). A multivariate logistic regression analysis revealed that DE extent and MVO were independent predictors of pericardial involvement (OR 1.07; CI 95% 1.06–1.13, p=0.02 and OR 1.29; CI 95% 1.01–1.64, p=0.04 for DE and MVO respectively). Additional parameters that were associated with CMR diagnosis of pericarditis included higher maximal CRP levels and proximal coronary lesions. The 1-year incidence of major adverse events was similar in patients with or without CMR-defined pericarditis.

Conclusions

In contrast to the low rate of clinically diagnosed pericarditis, CMR documented pericardial involvement in more than 65% of STEMI patients. This finding is independently associated with the extent and degree and location of myocardial damage.

Funding Acknowledgement

Type of funding source: None

The usefulness of coronary artery calcium score to rule out obstructive coronary artery disease before transcatheter aortic valve replacement

Introduction

Coronary clearance in patients undergoing TAVR is performed by invasive coronary angiography (ICA) or computed tomography angiography (CTA). We aimed to investigate whether CTA-derived low coronary calcium (CAC) score may rule out obstructive coronary artery disease (CAD) in these patients.

Methods

We included 232 consecutive patients with severe aortic stenosis (mean age 80±8; 50% female) who underwent both pre-TAVR CTA and ICA between 2012–2019. Obstructive CAD was defined as a >50% in left main or >70% in the 3 main epicardial vessels. Patients with prior coronary stents or bypass grafts were excluded. CAC score was calculated by Agatston method. Receiver operating characteristic (ROC) was applied to establish the CAC threshold for obstructive CAD, and adjustment for age, gender, diabetes and renal failure was applied.

Results

CAC scores range was 3.5–5200 (median = 1028). Eighty-eight patients (38%) had obstructive CAD. ROC curves showed high negative predictive value (NPV) for LAD - CAC score 280, NPV 95%; LCX - CAC score 320, NPV 93%; and RCA - CAC score 347, NPV 90% (figure). Binary logistic regression confirmed CAC score cutoffs per vessel as an independent predictor of obstructive CAD [LAD (OR 3.9, CI 1.1–14, p-0.033); CX (OR 5.7, CI 2.4–12, p<0.001); RCA (OR-5.6, CI 2.5–12, p<0.001)].

Conclusion

CAC score per-vessel can be useful to rule out obstructive CAD in patients with severe aortic stenosis undergoing TAVR. Using specific CAC cut offs can identify patients who may omit ICA

CAC per vessel

Funding Acknowledgement

Type of funding source: None

Right atrium to pulmonary capillary wedge pressure ratio is associated with right ventricular failure and mortality after left ventricular assist device surgery

Introduction

Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. We investigated the role of right atrium to pulmonary capillary wedge pressure (RA/PCWP) ratio as a preoperative predictor of postoperative RVF after LVAD surgery.

Methods

A retrospective analysis of all consecutive patients who received continuous-flow LVADs (HeartMate 2, 3, and HVAD) between August 2012 and May 2018 in a single tertiary center. INTERMACS profile 1 patients were excluded. RA/PCWP ratio was calculated for the entire cohort and divided into quartiles (Q). Patients were stratified into high (Q4) vs. low (Q1–3) RA/PCWP ratio. The primary end point was the composite of in hospital mortality and RVF (defined as the need for a right ventricular assist device or inotrope dependence for >7 days). The secondary endpoint was readmission within 14 days after discharge.

Results

The study cohort consisted of 59 patients (15 patients in the high RA/PCWP group and 44 patients in the low RA/PCWP group) with a median follow-up of 21 months (Interquartile range 14–31). The mean age was 56±11 years and the majority of patients were male (88%). Patients were classified as INTERMACS profile 2 (34%), 3 (19%) or 4 (47%).

Preoperative clinical, laboratory, and echocardiographic parameters were similar in both groups except for a larger proportion of patients with a dilated right ventricle and above moderate tricuspid regurgitation in the high compared to the low RA/PCWP group (73% vs. 29%; P=0.006 and 40% vs. 2%; P=0.001, respectively). Overall, 7 patients (12%) developed the primary end-point and 9 patients (15%) developed the secondary end-point.

Univariate analysis demonstrated that high RA/PCWP is associated with both primary and secondary end-points (odds ratio [OR], 7.6; 95% confidence interval [CI] 1.2–47.2, P=0.029 and OR, 6.25; 95% CI 1.3–28.5, P=0.018, respectively). On multivariable analysis, the association remained significant after adjustment for INTERMACS score (OR, 10.6; 95% CI 1.4–80.9, P=0.022 and OR, 7.9; 95% CI 1.5–42.2, P=0.015, respectively).

Using receiver operating characteristic curve (ROC) derived cut-points, RA/PCWP >0.57 provided 67% sensitivity and 79% specificity (C-statistic = 0.73) for the prediction of in hospital mortality and RVF and 56% sensitivity and 84% specificity (C-statistic = 0.69) for the prediction of readmissions within 14 days after discharge. In comparison, in our cohort using ROC-derived cut points, pulmonary artery pulsatility index, an established RVF predictor, of less than 1.84 provided 40% sensitivity and 20% specificity (C-statistic = 0.3) for the prediction of inhospital death and RVF.

Conclusion

RA/PCWP ratio may help to identify patients at high risk of developing adverse clinical outcomes, including RVF and mortality, after LVAD surgery.

Funding Acknowledgement

Type of funding source: None

P626Higher fitness is associated with improved survival among cancer patients

Background

Cardio-respiratory fitness (CRF) is a known predictor of cardiovascular morbidity and mortality. However, data on the association of CRF with survival following a diagnosis of cancer is limited.

Purpose

To evaluate the association between CRF in a large cohort of asymptomatic adults and a probability of survival after subsequent cancer diagnosis.

Methods

We evaluated asymptomatic self-referred adults aged 40–79 years who were screened annually at a tertiary medical center. All subjects were free of cardiovascular disease and cancer at baseline and completed maximal exercise stress test according to the Bruce protocol. Fitness was categorized into age- and sex-specific quintiles (Q) according to Bruce protocol treadmill time with Q1-Q2 defined as low fitness and Q3-Q5 as higher fitness. Cancer data was available from a national cancer registry. The primary end point was all-cause mortality.

Results

Final study population in included 15,800 subjects. Mean age was 51±8 years and 72% were men. During median follow up of 13 years (IQR 7–16) 1,312 (8%) subjects developed cancer and 486 (3%) died. Most common cancer types were prostate in 302 (23%) and breast cancer in 189 (14%) patients. No difference was found in distribution of major cancer types between different fitness categories. Univariate Cox regression with cancer as a time dependent covariate showed that subjects who developed cancer during follow up were 19 times more likely to die (95% CI 15.5–22.5, p<0.001). Kaplan Meier analysis showed that the cumulative probability of death from the time of cancer diagnosis was significantly lower among high fitness patients (34% ± 4% vs. 25% ± 3%, p Log rank = 0.008; Figure 1). Multivariate interaction analysis with cancer as a time dependent covariate showed that cancer-related risk of death was fitness-dependent, such that in the lower fitness group cancer was associated with 18 folds increased risk of death (95% CI: 13.5–23) whereas among high fitness group the risk of death was lower (HR=13; 95% CI: 10–17; p for interaction = 0.048).

Conclusions

Low CRF is associated with worse survival among subjects diagnosed as having cancer during follow up. These findings support the effectiveness of fitness assessment in preventive health care settings.

P4650Sex differences in clinical presentation and in hospital outcomes among myocarditis and peri-myocarditis patients

Background

Data are scarce regarding sex differences among patients with myocarditis and peri-myocarditis. Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to myocarditis and peri-myocarditis.

Methods and results

We analyzed data of 322 consecutive patients between January 2007 and October 2017 who were hospitalized with the diagnosis of myocarditis or peri-myocarditis at our medical center. Eighty-four percent of the patients were males. Both males as well as females had similar rates of chronic medical conditions. However, males were more likely to present with ST elevation (75% vs. 44%. P<0.001) as well as PR depression in ECG compared to women and have higher admission troponin levels (7.6±11 vs. 2.3±4, P<0.001). Women were older (45±17 vs. 36±14, P<0.001) and tended to present with a rather normal ECG. There were no differences in the incidence of in-hospital mortality or the need for escalation therapy between male and female patients. However, males were more likely to have ventricular arrhythmias (7% vs. 0%, P=0.05). no differences in long term mortality were observed among males and females.

Variable Male (N=272) Female (N=50) P-value Age 36±14 45±17 <0.001 Cardiology Department 243 (90%) 39 (78%) 0.03 Dyspnea 63 (23%) 22 (44%) 0.002 Pericardial chest pain 94 (35%) 20 (40%) 0.52 Admission SBP (mmhg) 122±16 116±16 0.02 Admission HR (b/min) 82±16 89±21 0.04 Normal ECG 37 (14%) 12 (24%) 0.06 ST elevation 204 (75%) 22 (44%) <0.001 LVEF <50% 215 (80%) 45 (90%) 0.08 LGE 176 (88%) 20 (69%) 0.009 Albumin 4±0.3 3.6±0.4 <0.001 Troponin admission 7.6±11 2.3±4 <0.001

Conclusions

Male patients, which constitute the majority of patients. Admitted with myocarditis are younger, with higher troponin levels at admission, are more likely to present with ST elevation, and have a higher rate of ventricular arrythmias when compared to women. However, there are no differences in early as well as long term mortality rates between men and women.