Development of a new score to predict left ventricular reverse remodelling in patients with nonischemic cardiomyopathy

Background and purpose

Implantable cardioverter-defibrillator is indicated in patients with dilated non-ischemic cardiomyopathy (DCM) and severely depressed left ventricular ejection fraction (LVEF) after a wait-and-see period of 3–9 months under optimised medical therapy. However, in the first 6 months after the disease debut, around 2% of patients might suffer life-threatening arrhythmias.

The appearance of left ventricular reverse remodelling (LVRR) in patients with DCM is associated with a lower incidence of ventricular tachyarrhythmias. Therefore, it is relevant an early identification of the patients who will experience LVRR during the follow-up.

Our aim was to develop a score to predict the appearance of LVRR in patients with DCM.

Methods

From 2014 to 2021, 201 patients with DCM and LVEF ≤45% were prospectively evaluated in our tertiary care hospital. All patients underwent a transthoracic echocardiogram and 1.5 Tesla scanner cardiac magnetic resonance (MR) as part of the diagnostic workup. LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50% associated with a reduction in left ventricular end-diastolic diameter ≥10%.

Results

The median age of our cohort (n=201) was 61.6 (14.7) years, and 68% were male. Most patients (>90%) were treated with beta-blockers or RASS blockers, and 72% with mineralocorticoid receptor antagonists.

During a mean follow-up period of 37.6 (33.9) months 45% of patients had LVRR.

Patients with LVRR had a lower cardiovascular mortality (3.33 vs 9.59%; p=0.153), lower mortality due to heart failure (0% vs 8.22%; p=0.023), and a lower incidence of ventricular tachyarrhythmias (1.67% vs 19.18%; p=0.001).

Table 1 shows the echocardiographic, MR and clinical characteristics of patients who experienced LVRR.

Variables significantly associated with LVRR in the univariable analysis and considered clinically relevant were included in a multivariable logistic regression analysis. The final model included the presence of right ventricular end systolic volume index (RVESVi) >50 ml/m2 (2 points), left bundle brach block (LBBB) echo pattern (1 point), female gender (1 point) and tachycardiomyopathy/idiopathic/alcoholic/chemotherapy induced cardiomyopathy as the potencial cause of DCM (1 point).

The score showed a good discrimination, with an area under the ROC curve of 0.82 (95% CI 0.69 to 0.94), 84% sensitivity and 80% specificity. The presence of 3 or more points was associated with a high probability to had LVRR (0 points: 1%; 1 points: 17%; 2 points: 38%; 3 points: 64%; 4 points: 84%%; 5 points: 94% and 6 points: 98%) (Figure 1).

Conclusion

A new score with four variables (RVESV, LBBB echo pattern, female gender and tachycardiomyopathy/idiopatic/alcoholic/chemotheapy induced cardiomyopathy as potential cause) accurately predicts the probability of LVRR. Considering patients who experience LVRR have less cardiovascular events, this score may be a helpful tool for patients' risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Hyperaemic and non-hyperaemic pressure indices of coronary stenosis severity in patients with chronic kidney disease

Background

Evidence regarding the use of pressure indices for the assessment of coronary stenoses in patients with chronic kidney disease (CKD) is scarce.

Methods

We assessed the relation between eGFR, FFR and resting Pd/Pa in 1147 consecutive patients (1316 vessels) included in the International Collaboration of Comprehensive Physiologic Assessment Study. We also compared FFR and Pd/Pa against a standardized cut-off of coronary flow reserve (CFR<2.0). Finally, we examined the occurrence of vessel-oriented composite outcome (VOCO: cardiac death, vessel-specific revascularization, vessel-specific myocardial infarction) across negative/positive results of both FFR and CFR in patients with and without CKD.

Results

FFR increases as renal function worsens (beta −10.5, 95% CI −20.0 to −11.03, p=0.030), a relation that was not seen with resting Pd/Pa (beta −6.14, 95% CI −19.9 to 6.78, p=0.351). Both indices had similar diagnostic accuracies for the detection of a CFR<2.0 in the presence of CKD (AUC 0.629 for FFR vs 0.663 for resting Pd/Pa, p=0.192). However, CKD patients showed a higher proportion of vessels with negative FFR but low CFR (24.5% vs 13.4%, p=0.015).

CFR decreased linearly with deteriorating eGFR, and this was mainly driven by higher resting coronary flow in CKD patients (p=0.026), while hyperaemic coronary flow remained similar (p=0.403). IMR did not change significantly with eGFR (beta −0.02, 95% −0.09 to 0.05, p=0.557).

The incidence of VOCO was higher in patients with CKD and FFR>0.80 when compared to non-CKD patients and FFR>0.80 (12.7% vs 6.90%, p=0.062). Prognosis was worse for those with CKD, negative FFR and CFR<2.0 (20.59% vs. 8.44% in non-CKD, p=0.038).

Conclusions

The assessment of a given coronary stenosis in patients with CKD with either FFR or resting Pd/Pa is equivalent when compared to underlying coronary flow. In CKD, impaired CFR is caused by a state of increased resting flow. The assessment of CFR on top of standard pressure wire examination significantly improves prognostic stratification in CKD patients.

Funding Acknowledgement

Type of funding sources: None.

Assessment of vascular endothelial function in COVID-19 patients

Background

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) uses angiotensin-converting enzyme 2 (ACE2) receptor as a means to enter the host. High density of ACE2 receptor in vascular endothelial cells may explain why vascular complications related to endothelial dysfunction occur in COVID-19. However, in vivo assessment of vascular endothelial function during COVID-19 has not been reported.

Objective

To investigate the vascular endothelial function and its temporal changes in COVID-19 patients.

Methods

In this prospective blinded study, systemic endothelial function was assessed using plethysmography-derived peripheral arterial tonometry (PAT). The reactive hyperemia index (LnRHI), a measure of endothelium-mediated hyperaemia, and the augmentation index, a measure of arterial vascular stiffness, were measured in 102 individuals across three study groups using PAT: group 1 (active infection), constituted by 20 patients hospitalised due to acute COVID-19; group 2 (past infection), constituted by 52 patients who had recovered from COVID-19; and group 3 (controls), constituted by 30 healthcare workers not infected by SARS-CoV-2. Additionally, among group 1, PAT assessment was repeated in 14 patients several weeks after recovery from acute COVID-19. PAT studies were analysed at a blinded fashion with respect to the assigned study group.

Results

Lower resting PAT amplitude was found in acute COVID-19 patients compared to the other groups (ratio of arterial tone signal between hyperemia to resting condition was 1.5 [interquartile range, 1.1] in group 1, 1.3 [0.3] in group 2 and 1.2 [0.3] in group 3, p=0.041). On the contrary, no significant differences between groups were found with respect to the hyperemic PAT amplitude (867.9 [486.1] in group 1, 944.7 [748.1] in group 2 and 819.3 [639.6] in group 3, p=0.444). Due to the lower resting PAT amplitude, there was a paradoxically significantly increased LnRHI during acute COVID-19 compared to past infection and controls (0.73 [0.32] vs. 0.53 [0.31] vs. 0.44 [0.23], respectively; p=0.013) (Figure A). Furthermore, among group 1 patients, LnRHI normalised markedly from acute COVID-19 to past infection stage (0.73 [0.32] vs. 0.49 [0.28], respectively; p=0.005) (Figure B). Augmentation index was significantly higher during acute COVID-19 compared to past COVID-19 and controls (9.6 [19.1] in group 1, 6.97 [18.6] in group 2 and −0.35 [20.53] in group 3; p=0.045 for COVID groups vs. controls).

Conclusions

Non-invasive assessment of systemic vascular endothelial function with PAT revealed significant differences between subjects with acute COVID-19, past COVID-19 and controls. Lower baseline PAT amplitude and high augmentation index suggest vasoconstriction at rest during the acute phase of COVID-19. These findings open new research opportunities to investigate the prognostic value of PAT in COVID-19 patients.

Funding Acknowledgement

Type of funding sources: None.

Myocardial ischaemia of non-obstructive origin as a cause of new onset anginal chest pain in the long COVID syndrome

Background

New-onset chest pain occurs in around 20% of patients with long COVID syndrome (LCS). Being the vascular endothelium one of the targets of the SARS-CoV-2 virus, we hypothesized that new onset anginal symptoms in LCS could be due to endothelium dysfunction and other non-obstructive causes of myocardial ischaemia.

Methods

We investigated 11 consecutive patients who developed new onset anginal chest pain, suggestive of myocardial ischaemia, after documented SARS-CoV-2 infection. Intracoronary assessment included endothelium-dependent evaluation with acetylcholine testing (Ach), and endothelium-independent assessment with coronary flow reserve (CFR) and microcirculatory resistance (MR). Criteria for positiveness of these tests and medical treatment recommendation were obtained from 2019 ESC guidelines and 2020 EAPCI consensus document on ischaemia with non-obstructive coronary arteries (INOCA).

Results

Mean patient age was 56 years (SD ± 15); 10 (91%) were female. In the acute COVID-19 phase, 4 patients (36%) had had pulmonary infiltrates and 2 (18%) required hospitalization. Conclusive non-invasive tests were obtained in 7 (64%), showing exercise-related myocardial ischaemia in 6 (86%). Coronary angiography ruled out obstructive epicardial stenoses in all the patients. Ach testing revealed abnormal endothelium-dependent responses in 9 (82%) patients: 5 (56%) had epicardial vessel and 4 (44%) microvascular spasm. Endothelium-independent assessment was abnormal in 6 (54%) cases, with abnormal CFR in 2 (33%), abnormal MR in 2 (33) and both abnormal CFR and MR in 2 (33%) patients. The most frequent endotype was combined endothelium dependent- and independent abnormalities (6/9, 67%). Stratified medical treatment according to endotype led to significant improvement in Seattle Angina Scores for angina frequency (+22 points, p=0.013) and a notable trend towards angina stability (+25 points, p=0.093) at a mean follow-up time of 222 days.

Conclusions

Myocardial ischaemia of non-obstructive origin is common in patients with chest pain and LCS. Vasomotor abnormalities related to endothelial dysfunction occurred in 82% of patients, frequently associated to impaired microvascular vasodilation or high microvascular resistance. Stratified medical treatment led to significant improvement in angina stability and frequency.

Funding Acknowledgement

Type of funding sources: None.

Cardiac mechanics as predictors of left ventricular reverse remodelling in patients with dilated non-ischemic cardiomyopathy

Background and purpose

The appearance of left ventricular reverse remodelling (LVRR) is associated with a better prognosis in patients with dilated non-ischemic cardiomyopathy (DCM).

Our aim was to identify cardiac imaging parameters, including speckle tracking by transthoracic echocardiography (TTE) and feature tracking by CMR, associated with LVRR in a prospective cohort of patients with DCM.

Methods

From 2014 to 2021, 182 patients with DCM and left ventricle ejection fraction (LVEF) <40% were prospectively evaluated in our hospital.

LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50%, associated with a reduction in left ventricular end- diastolic diameter ≥10%.

Patients underwent multimodality imaging evaluation including CMR with a 1.5 Tesla scanner, and TTE. Cardiac mechanics, including global longitudinal strain (GLS), strain rate (SR) and mechanical dispersion (MD) were measured.

Results

Median age of our cohort was 62.3 (14.4) years, and 67.7% were male.

Most patients (>90%) were treated with beta-blockers or RASS blockers, and 67% with mineralocorticoid receptor antagonists. 30% had cardiac resynchronization therapy (CRT) and 37% had ICD as primary prevention. Mean LVEF was 31.3%. During a mean follow-up period of 35.9 (35.4) months, 38.3% of patients had LVRR.

Age and gender distribution were similar in both groups. Regarding cardiovascular risk factors and pharmacological treatment, no differences were found between patients with and without LVRR. Baseline CRT therapy was not associated with LVRR (22.6% vs 34.7%; p=0.249). However, there was a trend towards higher LVRR in those who received CRT during follow-up 18.8% vs 0%; p=0.069).

Patients who experienced LVRR had lower basal LVEF (23.4% vs 29%; p<0.008), as well as poorer RV function, including lower RVEF (40.5% vs 51%; p=0.006) and lower TAPSE (16 mm vs 19 mm; p=0.021). Regarding cardiac mechanics, those patients with lower GLS (−9% vs −12%; p=0.001), and higher MD (73 mm vs 55 mm; p=0,050) had LVRR more frequently during follow-up. The presence of a left bundle branch block (LBBB) contraction pattern by strain was associated with higher rate of LVRR (83.3% vs 30.4%; p=0.011). The burden of fibrosis measured by LGE with CMR was not associated with LVRR (14% vs 12%; p=NS).

Patients with LVRR had a lower cardiovascular mortality (3.3 vs 14.3%; p=0.117), lower mortality due to heart failure (0% vs 12.2%; p=0.046), less heart failure hospitalizations (20% vs 46.9%; p=0.016), and a lower incidence of ventricular tachyarrhythmias (3.3% vs 18.4%; p=0.051).

Conclusions

LVRR in patients with DCM receiving optimized medical therapy is associated with a better prognosis. Imaging parameters, including a lower basal LVEF, RVEF, GLS and higher MD, as well as LBBB echo pattern, were associated with a higher frequency of LVRR, and might help to identify patients who could benefit from CRT/and may be helpful to stratify patients's risk.

Funding Acknowledgement

Type of funding sources: None.

P3741Incidence and outcomes of delirium in patients undergoing transcatheter aortic valve replacement

Introduction and objective

Delirium is a frequent problem in the intensive care unit (ICU), often underdiagnosed, and is associated with increased mortality. We sought to evaluate the incidence and implact on prognosis of delirium in patients admitted to ICU after transcatheter aortic valve replacemente (TAVR).

Methods

We included 294 patients admitted to ICU from February 2013 to December 2017 after transfemoral aortic valve implantation. Incidence of delirium was assessed using DSM-IV diagnostic criteria. Risk factors were evaluated, as well as overall mortality and incidence of hospital readmissions.

Results

The mean clinical follow-up was 526 days. Delirium was diagnosed in 60 patients (20.4%). In most cases (78.3%), it occurred in the first 24 hours after the procedure. Age, cognitive impairment and peripheral artery disease were risk factors for the development of Delirum, without finding differences by sex, cardiovascular risk factors (except dyslipidemia) or the usual treatment with benzodiazepines or neuroleptics. Severe bleeding during the procedure was also associated with a higher incidence, but no risk augmentation was seen with the use of general anaesthesia, the urgency of the procedure, use of a transient pacemaker for more than 24 hours after the intervention or the development of a peripheral vascular complication during admission (both related to patient immobility).

The development of Delirium was associated with longer hospital stay (10.8 vs 7.9 days, p=0.004) and with higher mortality (38.8% vs 20.4%, p=0.007). No differences were found in hospital readmissions during follow-up (54.3% vs 48.2%, p=0.453).

Conclusion

Delirium is a frequent complication after TAVR. Age, cognitive impairment and peripheral arteriy disease were risk factors for its development, but no factors that determine patient immobility, use of general anesthesia or the urgency of the procedure. Delirum after TAVR is associated with longer in-hospital stay and with higher mortality.