Can Pre-Ablation Biomarkers Be Used to Predict Arrhythmia Recurrence after Ablation Index-Guided Atrial Fibrillation Ablation?

BACKGROUND

Ablation Index (AI) software has allowed better atrial fibrillation (AF) ablation results, but recurrence rates remain significant. Specific serum biomarkers have been associated with this recurrence.

OBJECTIVES

To evaluate whether certain biomarkers could be used (either individually or combined) to predict arrhythmia recurrence after AI-guided AF ablation.

METHODS

Prospective multicenter observational study of consecutive patients referred for AF ablation from January 2018 to March 2021. Hemoglobin, brain natriuretic peptide (BNP), C-reactive protein, high sensitivity cardiac troponin I, creatinine clearance, thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were assessed for their ability to predict arrhythmia recurrence during follow-up. Statistical significance was accepted for p values of<0.05.

RESULTS

A total of 593 patients were included - 412 patients with paroxysmal AF and 181 with persistent AF. After a mean follow-up of 24±6 months, overall single-procedure freedom from atrial arrhythmia was 76.4%. Individually, all biomarkers had no or only modest predictive power for recurrence. However, a TSH value >1.8 μUI/mL (HR=1.82 [95% CI, 1.89-2.80], p=0.006) was an independent predictor of arrhythmia recurrence. When assessing TSH, FT4 and BNP values in combination, each additional "abnormal" biomarker value was associated with a lower freedom from arrhythmia recurrence (87.1 % for no biomarker vs. 83.5% for one vs. 75.1% for two vs. 43.3% for three biomarkers, p<0.001). Patients with three "abnormal" biomarkers had a threefold higher risk of AF recurrence compared with no "abnormal" biomarker (HR=2.88 [95% CI, 1.39-5.17], p=0.003).

CONCLUSIONS

When used in combination, abnormal TSH, FT4 and BNP values can be a useful tool for predicting arrhythmia recurrence after AI-guided AF ablation.

Mid-term outcomes after catheter ablation in patients with congenital heart disease

INTRODUCTION

Cardiac arrhythmias are a major concern in patients with CHD. The purpose of this study was to evaluate the long-term outcomes in patients with CHD submitted to catheter ablation.

MATERIALS AND METHODS

Observational retrospective study of patients with CHD referred for catheter ablation from January 2016 to December 2021 in a tertiary referral centre. Acute procedural endpoints and long-term outcomes were assessed.

RESULTS

A total of 44 ablation procedures were performed in 36 CHD patients (55% male, mean age 43 ±3 years). Fifty-four arrhythmias were ablated: 23 cavotricuspid isthmus atrial flutters, 10 atrial re-entrant tachycardias, eight focal atrial tachycardias, eight atrial fibrillations, three atrioventricular re-entrant tachycardias, and two ventricular tachycardias. During a median follow-up time of 37 months (interquartile range 12-51), freedom from arrhythmia recurrence was achieved in 93%, with 1.2 procedures per patient (18% with anti-arrhythmic drugs). There were no adverse events related to catheter ablation. No predictors of recurrence were identified.

CONCLUSION

In patients with CHD, catheter ablation presents a high mid-term efficacy while maintaining a safe profile.

Conservative management of pneumopericardium: A case of unexpected success

A 79-year-old male with severe aortic stenosis was admitted with syncope and cranioencephalic traumatism with major nasal hemorrhage. While being prepared for surgical aortic valve replacement, a high-degree atrioventricular block was detected and a definite pacemaker was implanted.

Ostial vs. wide area circumferential ablation guided by the Ablation Index in paroxysmal atrial fibrillation

AIMS

Pulmonary vein isolation (PVI) guided by the Ablation Index (AI) has shown high acute and mid-term efficacy in the treatment of paroxysmal atrial fibrillation (AF). Previous data before the AI-era had suggested that wide-area circumferential ablation (WACA) was preferable to ostial ablation. However, with the use of AI, we hypothesize that ostial circumferential ablation is non-inferior to WACA and can improve outcomes in paroxysmal AF.

METHODS AND RESULTS

Prospective, multicentre, non-randomized, non-inferiority study of consecutive patients were referred for paroxysmal AF ablation from January 2020 to September 2021. All procedures were performed using the AI software, and patients were separated into two different groups: WACA vs. ostial circumferential ablation. Acute reconnection, procedural data, and 1-year arrhythmia recurrence were assessed. During the enrolment period, 162 patients (64% males, mean age of 60 ± 11 years) fulfilled the study inclusion criteria-81 patients [304 pulmonary vein (PV)] in the WACA group and 81 patients (301 PV) in the ostial group. Acute PV reconnection was identified in 7.9% [95% confidence interval (CI), 4.9-11.1%] of PVs in the WACA group compared with 3.3% (95% CI, 1.8-6.1%) of PVs in the ostial group [P < 0.001 for non-inferiority; adjusted odds ratio 0.51 (95% CI, 0.23-0.83), P = 0.05]. Patients in the WACA group had longer ablation (35 vs. 29 min, P = 0.001) and procedure (121 vs. 102 min, P < 0.001) times. No significant difference in arrhythmia recurrence was seen at 1-year of follow-up [11.1% in WACA vs. 9.9% in ostial, hazard ratio 1.13 (95% CI, 0.44-1.94), P = 0.80 for superiority].

CONCLUSION

In paroxysmal AF patients treated with tailored AI-guided PVI, ostial circumferential ablation is not inferior to WACA with regard to acute PV reconnection, while allowing quicker procedures with less ablation time.

His Bundle Pacing and Left Bundle Branch Area Pacing: Feasibility and Safety

BACKGROUND

There has been increasing interest in pacing methods that provide physiological stimulation, such as His bundle pacing (HBP) or left bundle branch area pacing (LBBAP). Our goal was to assess the feasibility and safety of these techniques.

METHODS

Prospective observational single-center study evaluating 46 patients with indication for a pacemaker that attempted HBP or LBBAP from July 2020 to November 2021. Procedural endpoints and pacing parameters were assessed and compared at implantation and three-month follow-up.

RESULTS

Overall acute procedural success was achieved in 96% of the cases. Successful HBP was achieved in 91% of the patients and all patients for LBBAP. During implantation, HBP patients presented a higher capture threshold (0.80 [0.55-1.53] V vs. 0.70 [0.40-0.90] V, p=0.08) and lower R-wave amplitude (4.0 [2.9-6.2] mV vs 7.8 [5.5-10.5] mV, P=0.001) compared to LBBAP patients. There was no difference between groups, either acutely or at 3-months, regarding paced QRS duration (125±22ms vs 133±16ms, P=0.08; 118±16ms vs. 124±14ms, P=0.19). Although procedural time was similar with both techniques (95 [75-139] min vs. 95 [74-116] min, P=0.79), fluoroscopy time was significantly reduced during LBBAP (8.1 [5.3-13.4] min vs 4.1[3.1-11.3] min, P=0.05). At 3 months of follow-up, the pacing threshold remained with a stable profile in HBP as in LBBAP (1.25 [0.75-2.00] V, P=0.09 and 0.60 [0.50-0.80] V, p=0.78), respectively. The need for re-intervention occurred in 3 (6.5%) HBP cases during follow-up.

CONCLUSION

This first national study demonstrates the feasibility and safety of the HBP and LBBAP in patients with pacemaker indication.

Glycoprotein IIb/IIIa inhibitor use in cardiogenic shock complicating myocardial infarction: The Portuguese Registry of Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES

Cardiogenic shock (CS) complicates 5-10% of cases of myocardial infarction (MI). Whether glycoprotein IIb/IIIa inhibitors (GPIs) are beneficial in these patients is controversial. Our aim is to assess the prognostic impact of GPI use on in-hospital mortality and outcomes in patients with MI and CS undergoing percutaneous coronary intervention (PCI).

METHODS

Between October 2010 and December 2019, 27578 acute coronary syndrome (ACS) patients were included in the multicenter Portuguese Registry of Acute Coronary Syndromes. Of these, 357 with an MI complicated by CS were included in the analysis and grouped based on whether they received GPI therapy (with GPI, n=107 and without GPI, n=250). The primary endpoint was in-hospital mortality. Secondary endpoints included successful PCI and in-hospital reinfarction and major bleeding.

RESULTS

Demographics and cardiovascular risk factors did not differ between groups. ST-elevation MI patients were more likely to receive GPIs (95% vs. 83%, p=0.002). In-hospital mortality was similar between groups (OR 1.80, 95% CI 0.96-3.37). Only age and the use of inotropes or intra-aortic balloon pump were predictors of mortality. Also, no differences between groups were noted for successful PCI (OR 0.33, 95% CI 0.62-4.06), reinfarction (OR 0.77, 95% CI 0.15-3.90), or major bleeding (OR 1.68, 95% CI 0.75-3.74).

CONCLUSION

The use of GPIs in the context of MI with CS did not significantly impact in-hospital outcomes.

Medical therapy for secondary prevention in patients with myocardial infarction with non-obstructive coronary artery disease: long-term outcome of a Portuguese centre

Background

The outcomes of dual anti-platelet therapy (DAPT), β-blocker, renin-angiotensin-aldosterone system (RAAS) inhibitor and statin therapy are unknown in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). The aim of this study was to examine the effects of secondary prevention therapy at discharge on long-term outcomes in MINOCA.

Methods

Patients with MINOCA undergoing early coronary angiography between 2009 and 2016 were extracted from a clinical database. Patients were followed until 2018 for outcome events. All patients with a MINOCA diagnosis and without history of atrial fibrillation were included. A total of 646 consecutive patients were enrolled. The primary end point was major adverse cardiac events (MACE) defined as all-cause mortality, myocardial infarction (MI), stroke, and heart failure (HF). Secondary endpoints comprised all individual endpoints for the composite end-point. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis and Cox regression models.

Results

Mean age was 67.9±13.4 years and 31.6% were women. No patient was lost to follow-up. Mean left ventricular ejection fraction was 47.8±13.1%. At discharge, 87.2%, 82.5% and 79.5% of the patients were on statins, RAAS inhibitors and β-blockers, respectively. The majority (72.8%) were discharged on DAPT. During follow-up (Mdn 59 months), 303 (46.9%) patients experienced a MACE and 208 (33.4%) died. MI occurred in 98 patients (17.8%) and stroke in 31 patients (5.6%). HF admissions were also common (82, 14.9%). The hazard ratio (HR) for major adverse cardiac events was 0.31 (0.23–0.41) in patients on statins, RAAS inhibitors and β-blockers. For patients on DAPT the HR was 0.61 (0.48–0.78). In univariate Cox regression analyses, a reduced risk of MACE was found in patients using combined secondary prevention therapies (HR 0.58, 0.46–0.74). Regarding the individual endpoints, combined secondary prevention therapy reduced the risk of stroke (HR 0.45, 0.22–0.99, P=0.04) but not risk of future MI nor HF admissions. Patients in the combined therapy group had a higher median survival (66 months, IQR 27–82 months) than the group without secondary prevention (34.5 months, IQR 6.8–74 months; P&lt;0.001 of Log Rank test for equality of survivor functions). In a multiple Cox regression analysis including RAAS inhibitors, statins, DAPT and β-blockers in the model, none of these drugs was associated with lower MACE, except for RAAS inhibitors.

Conclusions

The results indicate long-term beneficial effects of treatment with secondary prevention medical therapies in patients with MINOCA. Properly powered randomized clinical trials are warranted.

Funding Acknowledgement

Type of funding sources: None.

Characterization and long-term follow-up of children with brugada syndrome: experience from a tertiary paediatric referral centre

Introduction

Brugada syndrome (BrS) is an autosomal dominant channelopathy, which typically presents in young adults. It can also be diagnosed in children, but data in this age group is scarce.

Purpose

To describe the clinical features, management and long-term follow-up of children with BrS history followed-up in a tertiary paediatric referral centre.

Methods

Single centre retrospective study of consecutive patients with history of BrS, defined as having a BrS positive phenotype (BrS(+)), or a negative phenotype-positive genotype (BrS(−)). They were all followed up in a paediatric heart rhythm clinic. Clinical and demographical data were collected and analysed according to the phenotype.

Results

30 patients were included, with a median age at diagnosis of 7 years (IQR 1–13) and a mean follow-up time of 7±3 years. Sixteen patients were BrS(+), predominantly male (n=13, 81%). 88% (n=14) performed a genetic test, which was positive in 57% (n=8); the most frequent mutation was SCN5A (n=5). Family history of BrS was present in 56% (n=9) and almost one third had family history of sudden cardiac death (SCD). Most of the patients had a type 1 Brugada ECG pattern (n=14) and 2 patients presented a fever and drug induced pattern, respectively. Fourteen patients were BrS(−), mostly female (n=11, 79%) with a loss-of-function mutation in the SCN5A gene (n=10). They all had family members with BrS, mainly from the paternal side, and 43% (n=6) mentioned SCD history. Although most of the patients were asymptomatic, the prevalence of rhythm or conduction disturbances was not infrequent, particularly in BrS(+) patients (n=12, 75%). Also, in this group and during follow-up, 3 patients had documented supraventricular tachyarrhythmias, and 2 patients had syncope episodes, one of which required an implantable cardioverter-defibrillator. No events were reported in the BrS(−) patients. Nine patients (n=9/30, 30%) were hospitalized, 3 due to an arrhythmic event (all in the BrS(+) group). Overall, no sudden cardiac death event was reported during follow-up.

Conclusion

In our study, although the majority of the patients were asymptomatic, the occurrence of arrhythmic events was not negligible, especially in the BrS(+) patients. Despite the significant family history, patients with BrS(−) had no events reported during follow-up. Nevertheless, the management of these patients is not clear cut, and a personalized therapeutic strategy with close follow-up is essential.

Funding Acknowledgement

Type of funding sources: None.

3D printing for left atrial appendage closure: A meta-analysis and systematic review

BACKGROUND

Three-dimensional printing (3D) has emerged as an alternative to imaging to guide left atrial appendage closure (LAAC) device sizing.

AIMS

We assessed the usefulness of 3D printing compared to a standard imaging-only approach for LAAC.

METHODS

We identified studies comparing an imaging-only with a 3D printing approach in LAAC. A fixed-effects meta-analysis was performed targeting a co-primary endpoint of disagreement in device sizing and leaks.

RESULTS

Eight studies that assigned 283 participants to an imaging-only approach and 3D printing approach (145 patients) were included. 3D printing significantly reduced the risk of the co-primary endpoint (risk raio (RR) = 0.19; 95% confidence interval (CI) 0.09-0.37), with consistency across the studies (I2 = 0%). Individually, both device size disagreements [RR 0.13 (95% CI 0.06-0.29), P < 0.001] and leaks [RR 0.24 (95% CI 0.09-0.64) P = 0.004] were reduced under a 3D printing modeling strategy.

CONCLUSION

Compared with an imaging-only strategy, 3D printing is associated with reduction in device size disagreements and leaks.

Inflammation in acute coronary syndrome: prognostic significance

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with acute coronary syndrome (ACS) the acute phase reactant, C-reactive protein (CRP), might be significantly elevated. Several reports suggest that CRP may play a direct pathophysiological role on the development and progression of atherosclerosis, and CRP values correlate with infarct size when measured by magnetic resonance imaging.

Purpose

The aim of the present study was to evaluate the prognostic value of CRP in patients presenting with an ACS.

Methods

Retrospective analysis of 635 consecutively admitted patients due to ACS in a single coronary intensive care unit. CRP levels were measured at admission. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether CRP was an independent predictor of outcome.

Results

In the studied sample, 75% were male. Median age was 69 [interquartile range (IQR) 57–78]. ST-elevation myocardial infarction (STEMI) occurred in 39.6%, non-ST segment elevation myocardial infarction in 44.9% and unstable angina in 15.5% of the patients. Median left ventricular ejection fraction (LVEF) was 48% (IQR 40–55%) and median CRP level at admission 0.7 mg/dL (IQR 0.5–1.9 mg/dL). Regarding important comorbidities and past medical history, 75.9% had hypertension (HTN), 34.0% diabetes, 20.3% chronic kidney disease (CKD), 68.6% dyslipidaemia and 17.3% heart failure (HF). The median follow-up was 34 months (IQR 22–72). In univariate analysis, CRP was significantly associated with all-cause mortality (HR 1.06 per 1 mg/dL increase, 95% CI 1.04–1.08, p&lt;0.001), as was gender, age, LVEF, STEMI and previous history of diabetes, HTN, CKD or HF. In multivariate analysis, CRP remained significantly associated with the primary endpoint (HR 1.02, 95% CI 1.00–1.05, p=0.033), as did age, LVEF and previous history of HF.

Conclusions

In our study, CRP at admission was an independent risk factor for all-cause mortality following an ACS. This finding indicates that inflammation associated with the acute event has a significant impact in the long-term prognosis. More evidence is needed to determine if treating inflammation (and when, in the course of the disease) could result in better outcomes.

Aortic valve intervention for aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis

Aortic stenosis with cardiac amyloidosis (CA-AS) is common in the elderly. We provide an overview and a meta-analysis of outcomes after aortic valve (AV) intervention. The primary end point was all-cause mortality. Weighted pooled analysis showed a non-significant higher risk of death in CA-AS patients following surgical or transcatheter AV replacement. After transcatheter AV replacement, the risk of death in CA-AS patients was comparable to that associated with aortic stenosis alone (risk ratio: 1.23; 95% CI: 0.77-1.96; p = 0.39; I² = 0%). An AV intervention is possibly not futile in CA-AS and should not be denied to patients with this condition.

CARDIAC PAPILLARY FIBROELASTOMA: A CASE WITH UNPRECEDENTED SPREAD

INTRODUCTION

Papillary fibroelastomas (PFE) are a rare primary cardiac neoplasm, out of which multifocal PFE constitute a small minority of cases. These benign masses are commonly found on valvular surfaces, particularly the aortic valve.

CLINICAL CASE

We present a patient with a history of embolic stroke and intra-cardiac masses. Multimodal imaging revealed multiple nodules with extensive intra-cardiac distribution. All nodules were successfully removed without valve dysfunction.

CONCLUSION

This is a unique case of multiple PFE involving intracardiac cavities as well as all valvular structures.

Computed tomography coronary angiography as the noninvasive in stable coronary artery disease? Long-term outcomes meta-analysis

Aim: To compare outcomes of coronary computed tomography angiography (CCTA) with that of functional testing (FT) in stable coronary artery disease. Methods: We searched PubMed, Embase, and Cochrane for randomized controlled trials (RCTs). A random-effects meta-analysis targeting all-cause death and nonfatal acute coronary syndromes was performed. Results: Eight RCTs enrolling 29,579 patients were included. Pooled relative risk (RR) for the primary end point was similar between CCTA and FT (RR = 0.97; 95% CI: 0.76-1.22). CCTA outperformed FT in nonfatal myocardial infarction (MI) (RR = 0.59; 95% CI: 0.41-0.83) and in downstream testing (OR: 0.47; 95% CI: 0.21-1.01). Conclusion: Updated data of stable coronary artery disease suggests that CCTA improved nonfatal MI and downstream testing.

Bisphosphonates and atrial fibrillation risk: a final word

Background

Bisphosphonates (BPs) are widely prescribed drugs that decrease bone fracture risk in osteoporosis patients. Nevertheless, the class has been associated with a plethora of adverse effects, including incidental atrial fibrillation (AF). This epidemiologic link has, however, been met with skepticism by some authors.

Purpose

To perform a meta-analysis aimed at ascertaining the extent to which BPs might increase the odds of AF.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar, from inception to the first of March, 2021, for randomized controlled trials comparing oral or intravenous BPs with placebo or a no-treatment control, in what concerns AF risk. In order to be included in the quantitative analysis, studies were required to feature a minimum patient follow-up of 6 months. De novo AF diagnoses served as the primary endpoint. Data related to individual BPs were further investigated separately, with respect to this outcome. Study-specific Mantel-Haenszel odds ratios (ORs) were pooled using traditional meta-analytic techniques, under a random-effects model.

Results

42 RCTs, encompassing 52.436 patients (32.071 randomized to BPs), were regarded as eligible for quantitative synthesis. Of note, 2 pooled analyses, one of 4 trials with ibandronate and the other of 6 trials with risedronate, were included. Individual BP representation may be depicted as follows: Alendronate, 23 trials, with 14.599 patients; Risedronate, 7 trials, with 15.350 patients; Zoledronic acid, 7 trials, with 13.059 patients; Ibandronate, 4 trials, with 8.754 patients; and Minedronate, 1 trial, with 674 patients. 748 de novo AF diagnoses were reported, in total. In the main analysis, BPs were not found to be significantly associated with an increase in AF odds (OR 1.10, 95% CI 0.95–1.28, P 0.21, i2 0%). As for individual BPs, Alendronate (OR 1.09, 95% CI 0.82–1.45, P 0.55, i2 0%), Risedronate (OR 0.81, 95% CI 0.35–1.86, P 0.61, i2 31%), Ibandronate (OR 0.89, 95% CI 0.52–1.52, P 0.67) and Minedronate (0 AF events reported, both in the active and in the control group) were also not shown to meaningfully enhance AF risk. On the contrary, Zoledronic acid utilization was associated with a significant, though small, increase in new AF cases (OR 1.29, 95% CI 1.01–1.64, P 0.04, i2 0%).

Conclusion

The professed BP-driven increase in AF odds is not apparent in a fairly populated randomized setting. In fact, a barely significant increment in AF risk seems only to occur with the most potent BP (Zoledronic acid). Therefore, AF development concerns should not refrain doctors from prescribing this highly effective pharmacological class.

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of percutaneous coronary intervention associated blood loss in acute coronary syndrome

Background

Antiplatelet and anticoagulants are one of the mainstay treatment of acute coronary syndrome (ACS), however they are associated with a significant increase of bleeding risk. While anaemia is a recognized predictor of adverse outcomes, it is unknown if a variation of haemoglobin (HB) levels, even without associated anaemia, has the same impact.

Purpose

The aim of this study was to determine the prognostic impact of HB variation after percutaneous coronary intervention (PCI) in ACS patients.

Methods

Retrospective analysis of 822 consecutive patients admitted due to ACS and treated with PCI, in a single coronary intensive care unit. Delta HB – ΔHB – (HB at admission – HB 24 hours after PCI) was calculated. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether ΔHB was independent from other known factors in predicting the outcome.

Results

In the studied sample, 75.4% were male. Mean age was 66.4±13.1. ST-elevation myocardial infarction (STEMI) occurred in 45.5%, non-ST segment elevation myocardial infarction in 42.6% and unstable angina in 11 9% of the studied population. Moderate to severe systolic dysfunction was present in 23.5% of the cases. Regarding comorbidities and past medical history, 76% had hypertension (HTN), 30.3% diabetes, 16.4% chronic kidney disease (CKD), 62.2% dyslipidaemia and 10.5% heart failure (HF). Mean HB at admission was 13.8±1.8 g/dL, mean HB after PCI was 12.9±1.9 g/dL and mean ΔHB was 0.9±1.1 g/dL. The mean follow-up was 51.6±30.6 months. In univariate analysis, ΔHB was significantly associated with all-cause mortality (HR 1.15 per 1 g/dL loss, 95% CI 1.01–1.30, p=0.04), as was HB at admission, HB after PCI, age, sex, diabetes, HTN, dyslipidaemia, CKD and moderate to severe systolic dysfunction. In multivariate analysis, ΔHB remained significantly associated with the endpoint and gained even more statistical power (HR 1.25, 95% CI 1.10–1.43, p&lt;0.01). HB at admission and after PCI, age, CKD and moderate to severe systolic dysfunction were also independent predictors of this outcome.

Conclusions

In our study, irrespective of the admission and discharge HB, ΔHB was associated with more adverse outcomes in patients submitted to PCI. Hence, even patients with a normal HB after PCI have a worse long-term prognosis if a negative variation of HB occurs. This highlights the importance of identifying and optimising all the correctable factors that might lead to an increased bleeding risk.

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

Subsegmental pulmonary embolism: yet another case for being a medical conservative

Background

The advent of multi-detector computed tomographic pulmonary angiography has allowed better assessment of the peripheral pulmonary arteries, thereby increasing the incidence of pulmonary embolism (PE). Even though most patients with PE are treated with anticoagulation, its value in the subsegmental setting (SSPE) has not yet been confirmed.

Purpose

To perform a meta-analysis aimed at ascertaining the extent to which anticoagulation results in a net positive effect in patients with SSPE.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar, from inception to March 2021, for controlled studies addressing the effect of anticoagulation on SSPE patients. Specifically, venous thromboembolism (VTE) recurrence served as the primary efficacy endpoint, whereas clinically significant bleeding represented the primary safety outcome. Furthermore, major bleeding, PE-related and all-cause mortality were also studied, as secondary endpoints. All anticoagulation strategies, namely oral or parenteral, met inclusion criteria. Study-specific odds ratios (ORs) were pooled, under a random-effects model.

Results

1 cross-sectional, 8 retrospective and 4 prospective non-randomized studies, encompassing 82, 641 and 157 patients, respectively, were regarded as eligible for quantitative evaluation. 667 patients (75.8%) were allocated to the anticoagulation arm. The absolute number of events for each outcome may be reported as follows: primary efficacy endpoint, 5; primary safety endpoint, 60; major bleeding, 38; PE-related mortality, 0; all-cause mortality, 25. 7 studies reported their respective outcomes under a prespecified 3-month follow-up period, while only 1 featured cancer patients as its entire sample. As for the primary efficacy endpoint, and despite the surprising adjudication of all its 5 events to the anticoagulated patients, their relative overrepresentation (371 vs. 143 patients) stemmed a non-significant tendency towards a decrease in VTE recurrence in this arm (OR 0.59, 95% CI 0.09–3.81, P 0.58, i2 0%). On the other hand, anticoagulation was associated with a significant increase in clinically significant hemorrhages (OR 2.89, 95% CI 1.07–7.80, P 0.04, i2 0%) and a non-significant propensity towards an increment in major bleeding (OR 2.44, 95% CI 0.79–7.59, P 0.12, i2 0%). Lastly, and even though no events of PE-related mortality were reported, anticoagulation was linked with a meaningful reduction in all-cause mortality (OR 0.31, 95% CI 0.11–0.82, P 0.02, i2 0%).

Conclusion

Currently available evidence underpins marginal efficacy and safety concerns regarding the use of anticoagulation in SSPE patients, who are expected to experience very low to none PE-related mortality. The association of anticoagulation with lower all-cause death may be attributable to selection bias. Randomized controlled trials are, however, still needed to fully validate this hypothesis.

Funding Acknowledgement

Type of funding sources: None.

Transbasilic Approach for Percutaneous Closure of an Atrial Septal Defect

Atrial septal defect (ASD) closure is indicated in the presence of a significant left-to-right shunt. In the case of an interrupted inferior vena cava (IVC), the standard percutaneous approach can be troublesome. The authors report a case of a 55-year-old female patient with an ostium secundum ASD with a significant left-to-right shunt at rest (Qp/Qs, 1.6). The cardiac computed tomography scan showed an interrupted IVC above the renal veins. To our knowledge, this is the first case in the literature where the transbasilic peripheral vein approach for ASD closure was used.

Chronic kidney disease in acute coronary syndromes: real world data of long-term outcomes

Aim: Patients with chronic kidney disease (CKD) are at increased cardiovascular risk. Methods: Patients with acute coronary syndrome were retrospectively allocated to three groups (stage 3A, stage 3B or stage 4) based on the Kidney Disease Improving Global Outcomes classification formulas: the CKD Epidemiology Collaboration (CKD-EPI; N = 401) and the modification of diet in renal disease (n = 355). The primary end point was all-cause mortality (median follow-up time, 32 months [15-70]). Results: Study results showed decreased median survival was associated with poor renal function for both the CKD-EPI (78 vs 61 vs 40 months, p = 0.014) and modification of diet in renal disease groups (68 vs 57 vs 32 months, p = 0.006). After adjustment, age (OR: 1.07; 95% CI: 1.01-1.14) and pulmonary artery systolic pressure (OR: 1.08; 95% CI: 1.03-1.14), but not estimated glomerular filtration rate, were associated with decreased survival. Conclusion: Study results suggest that poor outcomes after an acute coronary syndrome were associated with comorbidities rather than estimated glomerular filtration rate level.

Coronary computed tomography angiography vs functional testing for stable coronary artery disease: long-term outcomes meta-analysis

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND  The emerging role of coronary computed tomography angiography (CCTA) has been acknowledged in the 2019 Guidelines of the European Society of Cardiology recommending it’s as the initial diagnostic strategy for most patients with suspected stable coronary artery disease (CAD). However, it is unclear how CCTA performs compared with the standard approach of functional testing (FT). We performed an updated meta-analysis to clarify the question, analyzing outcomes beyond one year of follow-up.

METHODS We searched PubMed for studies comparing clinical outcomes with ≥1 year of  follow-up between initial CCTA vs FT strategy in patients with suspected stable CAD. Occurrence of all-cause mortality and non-fatal acute coronary syndrome (ACS) was the combined primary outcome. Secondary outcomes included non-fatal myocardial infarction (MI), the use of longer-term investigations, revascularization procedures and new medication use.

RESULTS A total of 29,579 patients underwent either CCTA (n = 14,457) or FT (n = 15,122) and were followed for a mean of 1.75 years. CCTA was associated with a comparable all-cause mortality and non-fatal ACS to FT (2.64% vs 2.65%; risk ratio [RR], 0.97; 95% CI, 0.76-1.22). However, a 41% reduction in non-fatal MI was evident after CCTA testing (RR 0.59, 95% CI 0.41-0.83; P = 0.003). Compared with FT, patients undergoing CCTA were less likely to downstream additional testing (28.85% vs 33.86%; odds ratio [OR], 0.47, 95%CI 0.21-1.01; P = 0.05) and more prone to pursue coronary revascularization (OR 1.72; 95%CI 1.11-2.66; P = 0.01). Significant heterogeneity for invasive coronary angiography and revascularization was noted. CCTA patients had a non significant increase in new medication use, namely aspirin or statin therapy.

CONCLUSIONS In patients with suspected stable CAD, initial evaluation with CCTA was associated with a long-term 41% decrease in non-fatal MI and 53% reduction in downstream testing. Despite these differences, CCTA strategy was associated with a similar risk of long-term all-cause mortality and non-fatal ACS.

Abstract Figure.

Direct oral anticoagulants versus vitamin-K antagonists for left ventricular thrombus - a systemic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular (LV) thrombus is a current clinical problem. The incidence of systemic embolism (SE) is up to 16% in these patients and international guidelines recommend anticoagulation with vitamin-K antagonists (VKAs). Data on direct oral anticoagulants (DOACs) for LV thrombus is increasing but still with conflicting results.

Methods

We performed a systematic review and meta-analysis of studies assessing the efficacy of DOACs versus VKAs in LV thrombus resolution, SE events and/or stroke and bleedings events. We systematically searched PubMed and Cochrane database for studies comparing DOACs versus VKAs as anticoagulant strategy for LV thrombus. Random-effects meta-analysis was performed.

Results

Four studies were included: n= 727 patients (DOACs group – 243 patients vs VKAs group – 484 patients).  There is a 40% reduction in the odds for achieving thrombus resolution in the group of patients treated with DOACs (pooled OR 0.60; 95% CI 0.43-0.85; I2 =0%; P = 0.003) - Figure 1A. No difference between groups for the odds of SE and/or stroke was observed during follow-up (pooled OR 1.75; 95% CI 0.92-3.35; I2 =0%; P = 0.09) - Figure 1B. Bleedings events were not different between both anticoagulant strategies (pooled OR 0.65; 95% CI 0.30-1.39; I2= 0%, P = 0.26) - Figure 1C.

Conclusion

Although probably with less efficacy for thrombus resolution, the use of DOAC for LV thrombus does not seem to increase the risk of SE and/or stroke or bleedings events compared to VKAs.

Abstract Figure 1 - Pooled analysis (DOAC vs VKA)

Left Ventricular Thrombus Therapy With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review and Meta-Analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) for left ventricular thrombus (LVT) resolution. Direct oral anticoagulants (DOACs) are increasingly evaluated as alternatives to the standard of care in anticoagulation.

METHODS

We performed a systematic review and meta-analysis to assess the use of DOACs vs VKAs for LVT treatment. The occurrence of LVT resolution, systemic embolism (SE) or stroke, and bleeding events were compared during follow-up using random-effects analysis.

RESULTS

The 5 included studies were all observational (a total of 828 patients). Of these, 284 patients (34%) were treated with DOACs, and 544 (66%) treated with VKAs. Thrombus resolution was similar for both methods (pooled odds ratio [OR], 0.91; 95% CI, 0.47-1.75; I ² = 63%; P = .78). The incidence of SE or stroke was also similar (pooled OR, 1.59; 95% CI, 0.85-2.97; I ² = 0%; P = .14). Clinically relevant bleeding incidence was similar for both groups (pooled OR, 0.66; 95% CI, 0.31-1.40; I ² = 0%; P = .28), although all bleeding events were less frequent in the DOAC group (pooled OR, 0.49; 95% CI, 0.26-0.90; I ² = 0%; P = .02).

CONCLUSION

Our systematic review and meta-analysis suggests DOACs were as effective as VKAs for LVT resolution, with a similar risk of systemic embolism/stroke and clinically relevant bleeding. These results, obtained from observational studies, are not definitive and hence randomized controlled trials are needed. Nevertheless, our analysis identifies key experimental features required in future studies.

The prolactine hypothesis for peripartum cardiomyopathy: has it found its feet for good?

Background

Peripartum cardiomyopathy (PPCM) is a rare but serious condition that affects childbearing women. Dopamine agonists (DAs) may represent a specific therapy, potentially facilitating left ventricular recovery, through inhibition of prolactin secretion. However, their therapeutic value in this setting has not been fully demonstrated.

Purpose

To perform a meta-analysis aimed at evaluating the extent to which DAs are able to interfere with the natural history of PPCM.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library, Google Scholar, Scopus and DARE for both randomized controlled trials (RCTs) and observational studies addressing the impact of DAs on main outcomes of PPCM patients, published up until February 1, 2020. Endpoints were those of mortality, recovery from heart failure and, likewise, the degree to which left ventricular ejection fraction (LVEF) was restored. All analyses were conducted under a DA plus optimized medical therapy (OMT) vs. OMT alone design, while results were pooled using traditional meta-analytic techniques, under a random-effects model. Odds ratios (ORs) were computed for the first two outcomes, whereas mean difference (MD) was calculated to quantify LVEF restoration.

Results

2 RCTs, 2 prospective cohort, 1 prospective case-control and 2 retrospective cohort studies, encompassing 452 patients, were regarded as eligible for quantitative evaluation. 180 patients were allocated to the DA arm, which was mostly represented by bromocriptine; in fact, only 1 study, including 24 patients, specified cabergolin utilization. Overall, 5 papers including 295 patients reported 42 deaths, whereas 5 papers comprising 305 patients detailed 220 heart failure recoveries, thus unveiling that LVEF restoration was the norm. The addition of a DA to OMT provided no signal of a survival benefit (OR 0.71, 95% CI 0.27–1.87, p=0.49, i2=27%). On the other hand, the incorporation of a DA into the therapeutic regimen narrowly missed significance for the heart failure recovery endpoint (OR 2.68, 95% CI 0.98–7.31, p=0.05, i2=56%). Furthermore, DAs were demonstrated to incrementally improve LVEF by 15% (MD 15.00, 95% CI 10.24–19.76, p&lt;0.00001, i2=77%). Adverse events, including thromboembolic ones, were rare, though adjunct anticoagulation was broadly reported.

Conclusion

In PPCM patients, the addition of a DA to OMT seems to be both effective at incrementally improving LVEF and safe, even though not reaching survival benefit status. These findings appear to corroborate the so-called prolactin hypothesis for PPCM pathophysiology.

Funding Acknowledgement

Type of funding source: None

Statins for venous thromboembolism prevention: old dog, new tricks

Background

Statins are highly effective in preventing major acute cardiovascular events in the setting of atherosclerotic arterial disease. On the other hand, given their antithrombotic and anti-inflammatory properties, statins may also attenuate patients' odds of developing venous thromboembolism (VTE). However, clinical studies have yielded variable estimates of this effect.

Purpose

To perform a meta-analysis designed to evaluate the extent to which statin use influences the rate of subsequent VTE events.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for both randomized controlled trials (RCTs) and observational studies addressing the association between statins and VTE risk, published up until December 1, 2019. Manually reviewed references and key investigators interaction via e-mail correspondence were also data sources. RCTs comparing the effects of statin therapy with those of a placebo or no treatment were included, while interventional studies appraising different lipid-lowering pharmacological strategies were not. Observational studies encompassed both cohort and case-control designs. The primary endpoints were general VTE, deep vein thrombosis or pulmonary embolism. Patients with cancer, heart failure and chronic kidney disease (CKD) were further investigated separately. Study-specific relative risks (RRs) were pooled using generic inverse variance outcome meta-analytic technique with a random-effects model.

Results

23 RCTs comprising 118.464 participants, 12 cohort studies encompassing 2.881.184 patients and 9 case-control studies including 354.367 patients were regarded as eligible for quantitative evaluation. Specifically, 5 observational studies comprising 9.656 cancer patients, 3 studies encompassing 9.693 heart failure patients and 4 studies including 4.353 CKD patients were gathered. In RCTs, statin therapy was proven slightly superior to placebo or no treatment in lowering VTE incidence (RR 0.85, 95% CI 0.73–0.99, p=0.04, i2=14%). Observational studies were found to corroborate this effect, with statin treatment resulting in VTE risk reduction overall (RR 0.72, 95% CI 0.64–0.81, p&lt;0.001, i2=84%) and in both cohort (RR 0.86, 95% CI 0.83–0.90, p&lt;0.001, i2=85%) and case-control (RR 0.68, 95% CI 0.57–0.82, p&lt;0.001, i2=80%) designs. This positive effect held true in cancer patients (RR 0.56, 95% CI 0.33–0.95, p=0.03, i2=78%), but not in those with heart failure (RR 0.7, 95% CI 0.42–1.16, p=0.17, i2=2%) and CKD (RR 1.04, 95% CI 0.67–1.60, p=0.87, i2=0%).

Conclusion

Currently available evidence suggests that statins significantly reduce patients' odds of developing VTE. Given their favorable safety profile and low cost, statin treatment should now be considered in high-risk individuals, particularly in those with cancer.

Funding Acknowledgement

Type of funding source: None

Provisional versus 2-stent strategies for coronary bifurcations: is a bird in the hand worth two in the bush?

Background

Among all subsets of coronary artery lesions, bifurcations stand out due to high incidence, demanding percutaneous interventions (PCIs) and poor outcomes. Amid the different PCI strategies, the provisional (PS) approach is generally recommended over 2-stent (TS) techniques, but this paradigm has been challenged.

Purpose

To compare PS with TS for PCI of coronary bifurcation lesions, concerning procedural aspects and both immediate and long-term patient outcomes.

Methods

Retrospective study encompassing patients consecutively referred to a tertiary interventional cardiology unit for coronary angiography, who were found to have at least 1 native bifurcation lesion. According to operator experience and angiographic features, patients were managed with PS or/(and) TS. Procedural aspects regarding radiological variables, angiographic success and immediate complications were reviewed, as were in-hospital outcomes. Besides, clinical follow-up, by clinic appointment or telephone calling, was performed targeting stent failure, target vessel revascularization (TVR), acute coronary syndromes (ACS), heart failure and mortality.

Results

From January 2010 to June 2017, 404 patients with 433 bifurcation lesions were included. Median age was 70 (62–77) years and 25.3% were female. Median follow-up was 2 (1–3) years. Chronic angina was the dominant PCI context (61.3%) with 9.7% presenting with ST-segment elevation myocardial infarction (MI). Medina class 1,1,1 was documented in 54.1% and 64.9% of lesions were hailed as true bifurcations. 303 patients underwent PS, whereas 67 were managed with TS, with TAP (43.3%) and mini-crush (34.3%) as the leading techniques. True bifurcations were more frequently approached with TS (p&lt;0.001), whereas PCI context did not influence procedure selection. Fluoroscopy time (p&lt;0.001), radiation dose (p=0.003) and contrast volume (p=0.009) were higher in the TS subgroup. OCT guidance (p=0.039) was also more common with TS. Angiographic success was uniformly high (95.1% for PS and 97% for TS), while procedural complications, including iatrogenic coronary dissections (7.4%, mostly minor) and slow-reflow (3.5%), were homogenously low. Acute kidney injury and type 4a MI occurred in 14.5% and 32.3%, respectively, also with no difference between groups. As for long-term outcomes, stent failure, encompassing both stent thrombosis (1 event) and restenosis (4.2%), occurred more often with TS (p=0.046), with ACS events (9.5%) following the same trend (p=0.08). In turn, rates of TVR (12.5%), heart failure hospitalization (6.2%) and mortality, regardless of its cardiovascular nature, were similar.

Conclusion

PS outperforms TS during follow-up, particularly due to lower stent failure odds. Thus, this study further supports the concept of PS as the standard approach for coronary bifurcation lesions.

Funding Acknowledgement

Type of funding source: None

Gender in non- ST elevation myocardial infarction and unstable angina: is there any equality?

Background

Historically, women (W) with acute coronary syndrome (ACS) have worse outcomes compared with men (M). This fact may occur due to gender-specific differences in the presentation and management of patients (P), which were mainly observed in studies dealing with ST-segment elevation infarction (STEMI). There seems to be a gap of knowledge in gender-specific differences in non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA).

Purpose

Assess gender-specific differences in presentation, treatment and outcomes in NSTEMI and UA patients.

Methods

A retrospective cohort study from consecutive ACS patients enrolled in a multicentre national registry from October 2010 to December 2018 was conducted, identifying 11394 P admitted with NSTEMI or UA. Demographic, clinical and treatment variables were compared between male gender and female gender P.

A Cox multivariate regression was performed to evaluate predictor factors of stablished endpoints: mortality at 1-year (1y) and cardiovascular (CV) hospitalization at 1-year.

Results

A total 11394 P were included, 8145 M (71.5%) and 3249 W (28.5%), mean age of 68±13. W, comparing with M, had higher age (72±12 vs 66±13, p=0.001), higher prevalence of hypertension (85% vs 72%, p=0.001) and diabetes (41% vs 34%, p=0.001) and longer time from symptoms to hospital admission (360 minutes vs 297 minutes, p=0.001). Chest pain was less frequent as first symptom in W (85.6% vs 91.3%, p=0.001). In medical treatment, W had higher chance of not having administration of a loading dose of P2Y12 inhibitor (22.1% vs 18.1, p=0.001) and of being medicated with clopidogrel (85.7% vs 82.1%, p=0.002). At discharge, W were less frequently medicated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (82.6% vs 84.4, p=0.028). Coronary angiography was less frequently performed in W (77.3% vs 85.7%, p=0.001). Coronary artery disease was less frequently found in the female gender (12.4% vs 4.8%, p=0.001).

In-hospital mortality was higher in W (2.9% vs 2.1%), but in the multivariate analysis the female gender was not an independent predictor of in-hospital mortality (OR 1.05 [0.67- 1.65], p=0.823). 1-year mortality was higher in W (9.2% vs 7.3%) and 1-year CV hospitalization was higher in M (16.8% vs 14.4%). After adjusting for covariates in Cox regression analysis, difference was still significant for mortality (HR= 1.274 [1.038 - 1.564], p=0.02) and hospitalization (HR = 0.852 [0.726- 0.998], p=0.047).

Conclusion

In this NSTEMI and UA cohort, there are important gender-specific differences in comorbidities, diagnosis, management and outcomes. Gender was an independent predictor of 1-year mortality and 1-year CV hospitalization, but not an independent predictor for in-hospital mortality.

Funding Acknowledgement

Type of funding source: None

Acute coronary syndromes in chronic kidney disease patients: the good, the bad or the ugly?

Background

Patients with chronic kidney disease (CKD) are at increased risk of composite cardiovascular (CV) events and all-cause mortality. However, current aggressiveness of therapeutic strategies may minimize the course of the disease.

Aim

To assess the prognostic impact of optimized medical treatment in a CKD population with acute coronary syndrome (ACS).

Methods

355 ACS patients admitted to a single coronary care with CKD who were discharged from hospital were included. Those with end-stage renal disease were excluded. Three groups were created based on the KDIGO classification: Group A (Stage 3A, eGFR [estimated glomerular filtration rate] 45–59mL/min/1.73 m2) N=190; Group B (Stage 3B, eGFR 30–44mL/min/1.73 m2) N=113; and Group C (Stage 3B, eGFR 15–29mL/min/1.73 m2) N=52. The primary endpoint was long-term all-cause mortality. Kaplan-Meyer survival curves and Cox regression were done. The median of follow-up was 32 (IQ 15–70) months.

Results

Groups were similar regarding demographics, CV risk factors, ACS type, heart failure diagnosis, left ventricular (LV) systolic function, peak troponin, multivessel disease, treatment option (PCI, CABG or OMT) and medical therapy at discharge. More advance renal failure patients had a higher prevalence of diabetes mellitus (DM), a lower haemoglobin, a higher NT-proBNP and were less likely to receive ACE inhibitors/angiotensin II antagonist at discharge. 170 patients met the primary outcome. Kaplan-Meyer curves showed decreased survival with worse renal function (Group A 68% vs Group B 57% vs Group C 37%, Log Rank P=0.006 – Figure 1). After adjustment for age, DM, haemoglobin, NT-proBNP, LV systolic function and ACE inhibitors/angiotensin II antagonist at discharge, eGFR was not associated with increased death (HR 1.00, 95% CI 0.98–1.01). In this model, only age (HR 1.04, 95% CI 1.01–1.07), haemoglobin (HR 0.86, 95% CI 0.979–0.94), Nt-proBNP (HR 1.00, 95% CI 1.00–1.00) and impaired LV function (LV ejection fraction 40–49%: HR 2.95, 95% CI 1.89–4.81; LV ejection fraction &lt;40%: HR 2.15, 95% CI 1.44–3.21) remained associated with the outcome.

Conclusion

The worse outcome attributed to CKD after an ACS seems to be related not the eGFR itself but to associated comorbidities such as age, anaemia, fluid overload and impaired LV function. The fact that some of these comorbidities may be altered by intensive therapy indicates that CKD patients should also be candidates to optimized medical treatment.

Funding Acknowledgement

Type of funding source: None

Moment of truth for aspirin use in variant angina: a meta-analysis

Background

Aspirin has been a mainstay of antiplatelet therapy for coronary artery disease (CAD). However, in the context of variant angina (VA), high-dose aspirin was reported to exacerbate coronary spasms. Consequently, the value of traditional low-dose aspirin in VA, especially if not associated with atherosclerotic CAD, may be disputed.

Purpose

To perform a meta-analysis aimed at evaluating the extent to which low-dose aspirin therapy influences cardiovascular (CV) prognosis in VA.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for studies addressing the long-term impact of low-dose aspirin on main CV outcomes of VA patients, published up until February 1, 2020. The primary endpoint was all-cause mortality, whereas secondary endpoints included CV mortality, acute coronary syndrome (ACS) events, revascularization procedures and hospital admissions for angina. The subgroup of patients with no significant epicardial CAD was further investigated separately, underneath similar outcomes. Study-specific odds ratios (ORs) were pooled using traditional meta-analytic techniques, under a random-effects model.

Results

One prospective multicenter and two retrospective single-center studies, encompassing 1652 and 1164 patients, respectively, were regarded as eligible for quantitative evaluation. Median follow-up ranged between 12 and 52.1 months. 1284 patients were allocated to the aspirin arm and 2770 had no epicardial CAD. Absolute number of events for each endpoint may be reported as follows: all-cause mortality, 33; CV mortality, 11; ACS, 57; revascularization, 14; hospital admission for angina, 218. Aspirin was not found to reduce neither all-cause mortality (OR 0.78, 95% CI 0.38–1.58, p=0.49, i2=0%), nor CV mortality (OR 0.98, 95% CI 0.30–3.25, p=0.98, i2=0%), nor ACS events (OR 1.44, 95% CI 0.51–4.10, p=0.49, i2=47%), nor revascularization procedures (OR 2.06, 95% CI 0.63–6.75, p=0.23, i2=0%), nor hospital admissions for angina (OR 1.60, 95% CI 0.67–3.80, p=0.29, i2=86%). Likewise, this comprehensively neutral effect held true in those with VA and no significant atherosclerotic CAD (OR 1.04, 95% CI 0.28–3.92, p=0.95, i2=0%, for CV mortality; OR 1.29, 95% CI 0.19–8.94, p=0.79, i2=33%, for revascularization; OR 1.73, 95% CI 0.81–3.73, p=0.16, i2=75%, for hospital admission for angina).

Conclusion

Even though scarce, currently available evidence suggests that low-dose aspirin is not effective in shrinking major adverse cardiovascular events in VA patients, particularly in those with no epicardial CAD. On the other hand, lower doses of aspirin may avoid the menace of clinically significant coronary spasms.

Funding Acknowledgement

Type of funding source: None

Global longitudinal strain and chronic kidney disease prognostic impact on acute coronary syndrome

Background

Impaired left ventricular ejection fraction (LVEF) and chronic kidney disease (CKD) have been associated with poorer outcomes in acute coronary syndrome (ACS). Increasing evidence on global left ventricular longitudinal strain (GLS) suggests superiority over left ventricular ejection fraction (LVEF) in risk stratification.

Methods

This study was based on a retrospective analysis of consecutive patients admitted to a Coronary Care Unit between 2009 and 2016. Baseline characteristics and echocardiographic parameters, including LVEF, were assessed. For each patient, a two-dimensional speckle tracking of the left ventricle was assessed and average GLS was calculated using 2, 3 and 4-chamber views. Blood creatinine was measured during hospital stay and used to estimate glomerular filtration rate (GFR) with Modification of Diet in Renal Disease (MDRD) equation. A cox regression analysis was performed to determine mortality prediction value of average GLS, LVEF and GFR in this population. Receiver operating characteristic (ROC) curve analysis was conducted and area under the curve (AUC) was estimated.

Results

A total of 85 patients (66.7±12.7 years old; 78.8% males) were enrolled. LVEF mean was 49.4±9.8% and average GLS was −16.0±4.0%. GFR median was 80.0±48.9 ml/min/1.73m2. In cox regression analysis, worse average GLS was associated with greater mortality (HR 0.721; 95% CI 0.599–0.867; P=0.001). GFR was inversely related to death (HR 0.967; 95% CI 0.944–0.991, P=0.008). In cox regression analysis using average GLS and GFR as covariates, both proved to be independent predictors of mortality (for average GLS, HR 0.748; 95% CI 0.610–0.918, P=0.005; for GFR, HR 0.974; 95% CI 0.949–0.999; P=0.044). The AUC of average GLS to predict mortality was 0.78 (P&lt;0.001, sensitivity 50.7% and specificity 100%) and for average GLS and GFR combined was 0.85 (P&lt;0.001, sensitivity 84.0% and specificity 77.8%). Although LVEF proved to be a mortality predictor, the AUC obtained by ROC curve analysis was inferior to average GLS, with statistical significance (P=0.043).

Conclusions

GLS and CKD proved to be independent predictors of mortality in ACS patients. GLS showed superiority when compared to LVEF in risk stratification and in the future it might replace LVEF. The model combining GLS and GFR emphasized the increased risk of CKD patients and how they should be seen as high-risk patients.

ROC curve analysis

Funding Acknowledgement

Type of funding source: None

Isolated apical perfusion defect in SPECT-CT scans, is there any prognostic value?

Background

Myocardial perfusion imaging (MPI) plays a significant role in diagnostic and therapeutic decision making in coronary artery disease (CAD). An isolated apical defect in the 17th segment in SPECT/CT scans is a common finding, sometimes attributed to the apical thinning phenomenon. However, the clinical significance of apical thinning or other isolated apical defects is unknown.

Purpose

The purpose of this study is to assess the prognostic impact of an isolated apical perfusion defect (17th segment) in patients (P) with suspicion of significant CAD.

Methods

A cohort of 612 consecutive P that underwent a MPI test with a SPECT/CT scanner, between January 2017 and December 2017, in a single nuclear medicine centre, was included in this retrospective study.

The inclusion criteria for this study were either a normal perfusion exam (group 1 – G1) or only an isolated apical defect in the 17th segment, either reversible suggesting ischemia (group 2 – G2) or fixed suggesting necrosis (group 3 – G3). Images with and without attenuation correction were analysed. Mean follow-up was 29±4 months.

The chi square test was used for categorical variables, and analysis of variance for continuous variables. Binary logistic regression was used to control for confounding.

Results

A total of 612 P were included (57% male sex, mean age of 69±10) and divided in G1 (n=494, 80.7%), G2 (n=62, 10%) and G3 (n=56, 9.2%). P in G3 had higher body mass index (31±7, p=0.028) and higher prevalence of dyslipidemia (84%, p=0.001), while P in G1 had lower ejection fraction at rest (54±15, p=0.001). There was no association between the presence of isolated apical defect and all- cause mortality (G1 = 7.3% vs G2 = 6.5% vs G3 = 5.4%, p=0.851). There was a statistically significant difference between groups in the referral for coronary angiography in the bivariate analysis (G1 = 7.9% vs G2 = 35.5% vs G3 = 10.7%, p=0.001), but this association did not remain when accounted for potential confounders (angina, ejection fraction, previous CAD and diabetes) – OR=3.94, 95% CI: [0.968–16.093], p=0.056.

In those P that underwent coronary angiography, there was no statistically significant difference between the 3 groups in revascularization of significant CAD (G1 = 38.5% vs G2 = 36.4% vs G3 = 50%, p=0.830). During the follow-up time, 11 P of group 1 suffered an acute coronary syndrome (ACS), but there were no events in group 2 or 3.

Conclusion

Isolated apical myocardial defect on a SPECT/CT exam has no association with all-cause mortality in this patients. There is no significant difference in referral for coronary angiography or need for coronary revascularization between P with normal exams and P with isolated apical defects.

Funding Acknowledgement

Type of funding source: None

Ranolazine as you have never seen it before: an antiarrhythmic for atrial fibrillation

Background

Currently available pharmacological options for rhythm control in atrial fibrillation (AF) are overshadowed by suboptimal efficacy and both frequent and potentially severe adverse events. Recent studies have added evidence to the hypothesis that ranolazine might exert antiarrhythmic effects, particularly in atrial tachyarrhythmias.

Purpose

To perform a systematic review with meta-analysis in order to ascertain the potential role of ranolazine in the management of AF.

Methods

We systematically searched MEDLINE, Embase and Scopus for randomized controlled trials (RCTs) and cohort studies addressing the association between ranolazine and AF outcomes, published up until December 1, 2019. The primary endpoint was incidence of AF, which was evaluated under a ranolazine versus placebo design. In this regard, patients in the setting of postcardiac surgery were further investigated separately. Secondary endpoints included AF cardioversion outcomes, which were addressed through comparison between ranolazine plus amiodarone and amiodarone alone for proportional efficacy and temporal requirements (time-to-cardioversion). The latter analysis was also undertaken in a dose-sensitive fashion (≤1000mg vs. 1500mg of ranolazine). Tertiary endpoints covered AF burden and episodes, in paroxysmal AF patients, and safety outcomes, namely death, QTc interval prolongation and hypotension. Study-specific odds ratios (ORs) were pooled using meta-analytic techniques with a random-effects model.

Results

A total of 10 RCTs comprising 8.109 participants and 3 cohort studies encompassing 37.112 patients were regarded as eligible for evaluation. Ranolazine was found to attenuate patients' odds of developing AF (OR 0.53, 95% CI: 0.41–0.69, p&lt;0.001, i2=58%). This effect held true, with an even larger effect size, in the context of post-cardiac surgery (OR 0.34, 95% CI: 0.16–0.72, p=0.005, i2=64%). Ranolazine increased the chances of successful AF cardioversion when added to amiodarone over amiodarone alone (OR 6.67, 95% CI: 1.49–29.89, p=0.01, i2=76%), while significantly reducing time-to-cardioversion [SMD 9.54h, 95% CI: −13.3–5.75, p&lt;0.001, i2=99%]. Interestingly, cardioversion was faster with ≤1000mg of ranolazine (SMD −13.16h, 95% CI: −15.07–11.25, p&lt;0.001, i2=95%) than with 1500mg (SMD −3.57h, 95% CI: −5.06–2.08, p&lt;0.001, i2=23%). In paroxysmal AF, ranolazine was also proved to significantly reduce both AF burden and episodes. There were no safety signals regarding mortality odds, QTc interval prolongation (mostly clinically insignificant) and hypotension (mostly transitory).

Conclusion

Current evidence suggests that ranolazine provides an effective and safe option for a chemical rhythm control strategy in AF management, a field in which medical breakthroughs are desperately needed.

Funding Acknowledgement

Type of funding source: None

Global longitudinal strain in chronic asymptomatic aortic regurgitation: systematic review

Chronic aortic regurgitation (AR) patients typically remain asymptomatic for a long time. Left ventricular mechanics, namely global longitudinal strain (GLS), has been associated with outcomes in AR patients. The authors conducted a systematic review to summarize and appraise GLS impact on mortality, the need for aortic valve replacement (AVR) and disease progression in AR patients. A literature search was performed using these key terms 'aortic regurgitation' and 'longitudinal strain' looking at all randomized and nonrandomized studies conducted on chronic aortic regurgitation. The search yielded six observational studies published from 2011 and 2018 with a total of 1571 patients with moderate to severe chronic AR. Only two studies included all-cause mortality as their endpoint. The other studies looked at the association between GLS with AVR and disease progression. The mean follow-up period was 4.2 years. We noted a great variability of clinical, methodological and/or statistical origin. Thus, meta-analytic portion of our study was limited. Despite a relevant heterogeneity, an impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value in risk stratification and decision-making.

Valvular Disease Begets Valvular Disease

In acute severe aortic regurgitation, an inversion of pressure gradient from the left ventricle to the left atrium causes the classical sign of end-diastolic mitral regurgitation. Here we present a case of mid-diastolic mitral regurgitation in a 51-year-old man with severe aortic regurgitation secondary to infective endocarditis. (Level of Difficulty: Beginner.)

P1092Syncope in the emergency department: can 24-hour holter monitoring be of any help?

Background 

Syncope is a very common reason for presenting to the emergency department (ED). The existence of a telemetry unit is crucial but it is not the reality in some hospitals. In order to avoid unnecessary ward admission, 24-hour Holter (24HH) monitoring could be useful to help with the diagnosis (when the arrhythmic etiology is suspected and the symptoms are frequent enough) and also be important to safely discharge a patient. 

Purpose 

The purpose of this study is to evaluate the diagnostic performance of 24HH monitoring, during a syncope episode in the ER, and to compare the readmission rates between patients with normal and abnormal not diagnostic 24HH monitoring. 

Methods 

A cohort study of consecutive patients (P) who were monitored with 24HH in one hospital in the ED, between January 2015 and December 2017, were included. All the 24HH results were seen by a senior cardiologist and divided in three groups: A - normal, B - abnormal Holter study unlikely to explain syncope and C- Holter study considered to be diagnostic. 

Groups A and B were compared using chi-square independence test to evaluate association between the result of the 24HH and readmission rates at 30 days and 1 year, as well as mortality and device implantation at 1 year. Multivariate logistic regression was used to look for other confounders. 

Results 

A total of 111 P were included in this study. Mean age was 75 ± 14 years old, with 55.6% male patients. 

A previous emergency episode with syncope was present in 56.9% of P. The mortality at one-year follow-up was 11.9%. The 24HH was considered diagnostic in 25.2% of P (28 P), with 18.9% of all the P with necessity of pacemaker (PM) implantation. In the patients with a non-diagnostic 24HH, 6,4% implanted a loop recorder before discharge. 

Group B patients had a higher 30-day readmission rate to the ED when compared with group A (OR = 4.050 CI 95 [1.13 – 14.497], p = 0.033), but no difference in one-year readmission rate (p= 0.065). There was no difference in one-year mortality between the two groups (p= 0.731) or in one-year implantation of pacemaker (p= 0.431). 

Conclusion 

The use of 24HH in the ED could be a valuable tool in the diagnosis of rhythm disorders that cause syncope.  An abnormal non diagnostic result can still be a predictor of 30-day readmission to the ED with similar complaints.

P1433Prevalence and location of residual leaks following percutaneous left atrial appendage occlusion: the importance of 3D transesophageal echocardiography

Background

The left atrial appendage (LAA) shape and size are very variable, and incomplete appendage closure or persistent leaks around the device are common following device placement. Limited studies reported the rate of peri-device leaks (PDL) after percutaneous left atrial appendage closure, and the impact of 3D transesophageal echocardiography (3D-TEE) on the detection of those leaks.

Aim

To describe the rate and location of leaks 1 month after percutaneous closure of the LAA, with and without the use of 3D-TEE.

Methods

A cohort study of consecutive patients (P) who were submitted to a percutaneous LAA closure with success in one interventional cardiology centre, between May 2010 and October 2018, were included. Clinical and echocardiography data were recorded and analysed. Two groups were created: Group A (GA) included patients until August 2015 submitted to 2D TEE on follow up (N= 48) versus Group B (GB), which was composed of patients submitted to 3D-TEE after August 2015 (N= 76).

Results

A total of 124 P had an in-hospital admission for LAA closure, with control TEE 1 month after the procedure. Mean age was 73 ± 7 years old, with 62.9% male patients. The procedure was guided by TEE (52%) or intra cardiac echocardiography (ICE) (48%).Transeptal puncture was preferred (95% of the procedures). The most used device was Amulet (62%) vs ACP (23%) and Watchman (15%).

In the follow up TEE, 20% of patients had only 1 leak and 2% had 2 leaks. Of the detected leaks,31% were considered minor (&lt; 1 mm), 35% moderate (1-3 mm) and 34% major (&gt; 3 mm). Patients with leaks had a larger LAA diameter (22 ± 4 mm vs. 17 ± 3 mm, P = 0.01).

Of the detected leaks, 50% were located in the superior portion of the device, 23% were located in the inferior portion, 8% in the posterior portion and 8% in the lateral portion.

In GA the rate of leaks was 14% vs 24.5% in GB, with differences also when specified the size of the leak –  minor (GA 2% vs GB 8.8%), moderate (GA 8% vs GB 8.1%) and major (GA 4% vs GB 7.6%).

Conclusion

The use of 3D echocardiography, 1 month after successful percutaneous LAA closure, augmented the rate of detection of device leaks. It remains to be studied the clinical impact of this finding.

P1391 Global longitudinal strain in chronic asymptomatic aortic regurgitation: a meta-analysis

OBJECTIVES

To assess GLS impact on mortality and need for aortic valve replacement (AVR) or symptom development in chronic asymptomatic AR patients and preserved left ventricular ejection fraction (LVEF).

METHODS A literature search was performed according with these key terms "aortic regurgitation" and "longitudinal strain." The primary endpoint was all-cause mortality. Secondary end-points were: a composite of all-cause mortality, need for AVR or symptom development; and only AVR plus symptom development. Data was pooled using random-effects meta-analysis models. Pooled Hazard Ratio (HR) was performed using its log transformation and inverse variances as weights were then calculated for each study .

RESULTS Six studies were included, with a total of 1,571 asymptomatic patients with at least moderate AR and preserved LVEF. There were 996 events (death, AVR, symptom development) reported during follow-up. Pooled adjusted mortality HR tended to be higher for patients with worse GLS (1.14 [0.96–1.35], P = 0.13, I2 51%). GLS performed better in predicting AVR or symptom development (mean difference -0.72 [-1.29, -0.15], P = 0.01, I2 88%), with an estimated HR of 1.36 ([1.01–1.84], P = 0.04, I2 65%).

CONCLUSIONS In asymptomatic chronic moderate to severe AR patients, impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value on risk stratification as well as on decision-making.

Abstract P1391 Figure 1

571 Echo-Omics to estimate prognosis after an acute myocardial infarction: which one to pic?

BACKGROUND

Simple and reproducible echocardiographic parameters are still the cornerstone of daily clinical practice. These data provides important information for the evaluation of patients with ST-segment elevation myocardial infarction (STEMI). The identification of prognostic echocardiographic parameters in STEMI would help in risk stratification.

PURPOSE

To evaluate the discriminatory capacity of echocardiographic parameters after a STEMI.

METHODS

Single centre retrospective observational study of 303 patients with STEMI who survived hospital stay and had a complete echocardiographic evaluation. The following ecocardiographic parameters were collected at discharge: left ventricular (LV) systolic and diastolic volumes; septal and posterior wall thickness; LV ejection fraction (LVEF); left atrial (LA) diameter; estimated systolic pulmonary artery pressure (SPAP). One year and long-term all cause mortality were analyzed.

RESULTS

For the patients enrolled (71% males, 64.6 ± 14.1 years old), peak troponin I was 99.1 ± 126.5 ng/mL; mean GRACE score was 153.6 ± 38.8 points and mean LVEF was 46.2 ± 11.2%. One year mortality was 8.3% and during a median 73 months follow-up, 25.1% patients were deceased. After adjustment for echocardiographic variables in a Cox regression model, SPAP (HR 1.07, 95%CI 1.02-1.12, P = 0.007) and septal thickness (HR 1.36, 95%CI 1.08-1.73, P = 0.01) were both independently associated with one year mortality. A Kaplan-Meier survival methodology using stratified SPAP and septal thickness showed a trend of different event rate (log rank P = 0.003 and P = 0.035, respectively), with a gradation of cumulative risk for all-cause mortality, with a sharp increase at &gt;40mmHg and &gt;11mm, respectively. Regarding longterm follow-up, only increased SPAP proved to be an independent predictor of mortality (HR 1.04, 95%CI 1.01-1.08, P = 0.016). The difference in favor of an SPAP &lt;33mmHg (sensitivity 86.67% and specificity 54.1%) was seen early after the STEMI event and maintained at each interim analysis (log rank P = 0.002). Upon the visual analysis of the cubic spline curves, patients with SPAP &lt; ± 30mmHg had a good long-term survival. No association of LV volumes or LVEF was noted for both one year and long-term mortality.

CONCLUSION

Classic echocardiographic parameters still have a role to estimate prognosis after STEMI. Estimated SPAP had the greatest discriminatory capabilities, surpassing left ventricular ejection fraction!

Abstract 571 FIGURE 1

Percutaneous Occlusion of Paravalvular Aortic Leaks: A Single-Center Experience Focused on Intracardiac Echocardiography

OBJECTIVES

To describe our initial experience with an intracardiac echocardiography (ICE) for guidance of aortic percutaneous paravalvular leak occlusion (PPVLO) and to assess the outcomes after aortic PPVLO.

BACKGROUND

PPVLO has emerged as an alternative to cardiac surgery for patients with symptomatic PVLs. ICE is an appealing alternative to transesophageal echocardiography (TEE) for guidance of percutaneous structural interventions, but experience with ICE for PPVLO guidance is limited.

METHODS

We performed a retrospective analysis of all aortic PPVLOs performed in our center. The primary endpoints were technical and procedural success. Secondary endpoints included procedure-related complications, mortality, hospital admission due to heart failure, and improvement in New York Heart Association (NYHA) functional class.

RESULTS

Ten aortic PPVLOs were included. ICE was used to guide 40% of the aortic PPVLOs. Median follow-up was 22 months (interquartile range, 3-33 months). Mortality was 22% and hospital admission due to heart failure was 33%. Technical and procedural success rates were 90% and 80%, respectively. Median NYHA class improved significantly after the procedure (P<.01). Success was achieved in all ICE cases without any procedure-related complications.

CONCLUSION

In our initial experience with an ICE-guided approach for aortic PPVLO, technical and procedural success were achieved and there were no procedure-related complications.

P1589Thiazides and skin cancer risk: should we be worried?

Introduction

Diuretic thiazides represent a first-line therapeutic option for arterial hypertension. However, this drug class is regarded as having photosensitizing properties, and, as such, may act as a carcinogen, by triggering phototoxic reactions. Whether or not its long-term use increases skin malignancy risk remains unclear.

Purpose

To examine a possible association between thiazide usage and the risk of skin cancer, namely basal cell carcinoma, squamous cell carcinoma and malignant melanoma.

Methods

MEDLINE, EMBASE, Cochrane Library and Google Scholar databases were comprehensively searched, from inception to the first of February of 2019, for observational studies mentioning thiazide diuretic usage and incidence or prevalence of cutaneous basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Literature review, study selection and appraisal, including methodological quality assessment, and data extraction were independently led by two investigators. Meta-analysis was conducted using generic inverse variance outcome and, due to heterogeneity of the original studies, a random effects model. Confounder-adjusted summary relative risk (RR), with 95% confidence interval (CI), was pooled.

Results

Ten studies met eligibility criteria. Of these, six had a case-control design and the remaining were cohort studies. Overall, 7,079,530 patients were included; 125,946 were diagnosed with basal cell carcinoma, 21,775 with squamous cell carcinoma and 31,191 with malignant melanoma. One study encompassed only squamous cell carcinoma of the lip. In five articles, individual thiazides employed were not addressed, whereas three embraced solely hydrochlorothiazide and other two exclusively bendroflumethiazide. Thiazides were found to be associated with increased risk of basal cell carcinoma (six studies, RR=1.05, 95% CI=1.01–1.10, p=0.02, i2=62%), squamous cell carcinoma (seven studies, RR=1.35, 95% CI=1.05–1.74, p=0.02, i2=92%) and malignant melanoma (six studies, RR=1.17, 95% CI 1.11–1.23, p<0.ehz748.03491, i2=0%).

Conclusion

Risk of all three major forms of skin malignancy is heightened in thiazide diuretic users. Increased awareness and education, especially for those who are at high risk and under the form of intense solar irradiation avoidance, are warranted for both patients and healthcare providers.