Impact of the COVID-19 pandemic on overall percutaneous coronary interventions from the France-PCI registry: Comparative analysis of the years 2019 and 2020

Introduction

In 2020, the coronavirus disease 2019 (COVID-19) pandemic disrupted the health system and a drop in percutaneous coronary interventions (PCI) was observed.

Objective

The objective of this study was to evaluate the impact of the COVID-19 pandemic on a full year of elective and urgent PCIs, from the national France-PCI registry.

Method

The primary endpoint was to compare the number of PCIs performed in 2019 (before the pandemic), and 2020 (during the pandemic).

Results

Between January 1, 2019 and December 31, 2020, in the 20 participating centers, 22,807 consecutive PCIs were included. The total number of PCIs was reduced by −11.5% between 2019 and 2020 (12,102 versus 10,705; P < 0.001), mainly due to a reduction in elective interventions (−21.9%; P < 0.001). There was a significant decrease in PCIs for stable angina (P < 0.001) and silent ischemia (P < 0.001). For urgent PCIs, the decrease was less, mainly driven by a non-ST+ acute coronary syndromes (ACS) reduction (−5.7%; P = 0.01), as well as a decrease of early ST-Elevation myocardial infarctions (STEMIs) < 24 Hours (−7.1%; P = 0.02). There was also a significant increase in the number of late STEMIs > 24H (+23.4%; P = 0.002). Following the decrease in ACS during the first lockdown from March to May 2020, there was an unexpected significant increase in urgent interventions (“rebound effect”) out of step with the rest of the year (P = 0.002) (Fig. 1A). Nevertheless, there was no increase in elective PCIs after the first lockdown in comparison with the rest of the year 2020 (P = 0.67) (Fig. 1B). In 2020, patients were significantly younger (P = 0.001), with less prior history of coronary artery disease (P = 0.001), and prasugrel was more often prescribed after PCIs (P = 0.001). In 2020, the radial approach was more often performed (P = 0.001), as well as an “Ad-hoc” PCI (P = 0.01), and the median fluoroscopy time was lengthened (P < 0.001). For STEMIs < 24H, there was more frequently anterior localizations (P = 0.03), and ground medical transport was the majority (P = 0.03). The time from onset of symptoms to first medical contact was significantly lengthened (P = 0.01), and a non-significant increase in total ischemic time (P = 0.08) was found. Finally, there was no significant increase in intra-hospital cardiovascular events during the pandemic in 2020.

Conclusion

We show an extraordinary reduction in elective and urgent PCIs, as well as a never described paradoxical increase in urgent PCIs after the first lockdown, during the COVID-19 pandemic.

Impact of type 2 diabetes on the incidence of cardiorenal syndromes and on subsequent clinical outcomes: a propensity-matched nationwide analysis

Background

Type 2 diabetes mellitus (T2DM) is a major risk factor for cardiac diseases and renal dysfunction. Whether T2DM increases the risk of cardiorenal syndromes (CRS) subtypes to a similar extent, and whether the risk of deleterious outcomes after CRS is modified by diabetes are poorly known.

Methods

In a nationwide cohort study including 5,123,193 patients seen in French hospitals in 2012 with at least 5 years of follow-up (or dying earlier), we assessed the incidence of CRS subtypes, and then the impact of T2DM in patients with CRS on the risk of death, cardiovascular death, heart failure (HF), myocardial infarction (MI) and end-stage kidney disease (ESKD) during follow-up (27,735,205 person-years). Patients with history of dialysis, kidney transplantation or type 1 DM were excluded of the analysis. We performed 1:1 propensity matching on baseline characteristics including age, sex, risk factors, cardiovascular and non-cardiovascular comorbidities for patients with T2DM or no T2DM. The model by Fine and Gray was used for analyzing the competing risks for clinical events and all-cause death with sub-distribution hazard ratios (sHR).

Results

Among the 5,123,193 patients, 4,605,236 (91.2%) had neither HF nor CKD baseline. Among them, 391,186 (8.1%) had T2DM and 380,581 of them were matched 1:1 with 380,581patients with no T2DM. During follow-up, CRS occurred in 42,375 patients (incidence 0.98%/year): acute, i.e. type 1,3 or 5 CRS n=9,438, 22%; type 2 (cardiorenal) CRS n=21,075, 50%; type 4 (renocardiac) CRS n=11,862, 28%). In multivariable analysis, T2DM was the most powerful predictor of incident CRS (any type, HR: 2.182, 95% CI 2.150–2.214) among all baseline characteristics. The incidence of all-type CRS was higher in matched patients with T2DM (1.30%/year, 95% CI 1.29–1.32) than in those with no T2DM (0.65%/year, 95% CI 0.64–0.66): sHR 1.905 (95% CI 1.867–1.943). The risk of CRS associated with diabetes (vs no diabetes) was higher for type 4 (sHR 2.182, 95% CI 2.098–2.269) than for type 2 (sHR 1.834, 95% CI 1.783–1.887) and for acute (sHR 1.707, 95% CI 1.637–1.780) CRS.

Among the 451,942 patients with HF or CKD at baseline, 26,396 patients had CRS at baseline, among whom 11,355 (43.0%) had diabetes: 8,314 of them were matched 1:1 with 8,314 with CRS and no T2DM. Compared to CRS patients with no diabetes, matched patients with CRS and T2DM had a greater incidence of all-cause death (sHR 1.085, 95% CI 1.048–1.123), cardiovascular death (sHR 1.145, 95% CI 1.080–1.214), ESKD (sHR 1.319, 95% CI 1.223–1.422), hospitalization for HF (sHR 1.119, 95% CI 1.078–1.162) and MI (sHR 1.294, 95% CI 1.139–1.470) during follow-up.

Conclusions

T2DM is a major risk factor for all CRS subtypes, may differently affect the incidence of type 2, type 4 and acute CRS and aggravates the risk of deleterious outcomes after CRS.

Funding Acknowledgement

Type of funding sources: None.

Prognoses of “high-profile” diseases: five-year survival following hospitalization with previous cancer compared to previous heart failure

Background

The prognostic impact of heart failure relative to that of “high-profile” disease states such as cancer within the whole population is poorly known. Some data reported 2 decades ago indicated that heart failure was as “malignant” as many common types of cancer (with the notable exception of lung cancer) and was associated with a comparable number of expected life-years lost. Whether this is also the case in more recent years is unknown.

Methods

In a nationwide cohort study including 5,123,193 patients seen in French hospitals in 2012 with at least 5 years of follow-up (or dying earlier), all patients with a first admission to any hospital with heart failure or cancer were identified. We assessed the incidence of all-cause death during follow-up (2,523,627person-years). We analysed the outcome for the most common types of cancer specific to men and women and the results were then age-adjusted in men and in women.

Results

In 2012, 409,210 men had a hospitalisation with heart failure (n=164,601) or cancer (n=244,609). Similarly, 325,410 women were admitted with heart failure (n=127,734), or cancer (n=197,676).

Heart failure was associated with a worse survival rate than urologic cancer in men and a worse survival rate than breast cancer, gynaecologic cancer and gastrointestinal cancer in women (Figure 1). On an age-adjusted basis, cancer was associated with a worse survival than heart failure in men except for urologic cancer (see adjusted hazard ratios in Table 1). Cancer was associated with a worse age-adjusted survival than heart failure in women except for breast cancer.

Conclusion

Heart failure may be as “malignant” as many common types of cancer in men and in women. However, it is possible that the prognosis of HF has improved compared to that of cancer in the 2 last decades since only breast cancer in women and urologic cancer in men had a better prognosis than heart failure in an age-adjusted analysis.

Funding Acknowledgement

Type of funding sources: None.

Prediction of mortality and mode of death in heart failure using multimorbidity and clinical risk score systems: a nationwide analysis

 

Heart failure (HF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Hospital Frailty Risk Score (HFRS). CHA2DS2-VASc score was originally employed as a risk assessment tool for stroke in patients with AF but this comprehensive risk assessment score may help identify HF patients who are at high risk for mortality. We evaluated whether these tools may help to predict mortality and the different modes of death in HF.

Methods

Based on the France nationwide administrative hospital-discharge database, the analysis focused on all patients with HF hospitalized in France in 2012, with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 371,848 consecutive patients hospitalized with HF seen in 2012 and followed until December 2019. Adverse outcomes were investigated during follow-up. CHA2DS2VASc score, CCI and HFRS were calculated for each patient.

Results

Among these 371,848 patients with HF, 220,774 patients died during a follow-up of 4.0±2.8 years (median 4.8) (yearly rate 14.8%, 31.3% cardiovascular and 68.6% non-cardiovascular deaths). Death occurred more often in patients with higher CHA2DS2VASc, CCI and HFRS scores. HFRS was a better predictor of total mortality than CCI and CHA2DS2VASc score (see C-statistics in Table 1). However, the CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and HFRS. By contrast, HFRS was a better predictor of non-cardiovascular mortality than CCI and CHA2DS2VASc score. The optimal predictive performances were better for non-cardiovascular death than for cardiovascular death.

Conclusion

Multimorbidity and frailty assessed with HFRS demonstrated better performances in predicting total mortality and non-cardiovascular mortality than CCI and CHA2DS2VASc score in HF patients. By contrast, CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and HFRS in these patients.

Funding Acknowledgement

Type of funding sources: None.

Immuno-inflammatory response in patients after myocardial infarction and involvement in fibrosis in vitro

Background

Pathophysiology of acute myocardial infarction (AMI) has been described in mice and is based on a three-stage model involving temporal modifications of immune cells and fibroblasts. The acute inflammatory phase is followed by a reparative phase and fibrous scar maturation phase. Purinergic signaling, particularly P2Y11 receptor, has been reported to be involved in the regulation of inflammation after ischemia and could be an actor of resolution of inflammation after AMI.

Purpose

The aims of our study were: (1) to characterize the immune and P2Y11R profiles of AMI patients and (2) to analyze interactions between patients' immune cells and cardiac fibroblasts in vitro.

Methods

We collected peripheral blood mononuclear cells (PBMC) of 182 patients at various times (H0, H4, H24, H48, D3, M1, M6, M12) after reperfused ST-segment elevation AMI, and of 30 healthy donors. Expression level of genes involved in tolerogenicity profile of dendritic cells (HMOX1, STAT3, IDO1), in T cell polarization (CD4, FOXP3, TBX21/GATA3) as well as P2RY11 were evaluated by RT-PCR. P2Y11R expression was analyzed using flow cytometry. PBMC and human cardiac fibroblasts (HCF) were co-cultured during one day (5PBMC/1 HCF) and gene level expression (ACTA2/VIM, COL1A1), phenotype (α-SMA/vimentin) and secretory (soluble collagen) profiles were analyzed by RT-PCR, flow cytometry and Sircol assay.

Results

In the first 48 hours after AMI, the expression level of HMOX1 (fold-change = 8.478 at H48, p&lt;0.0001), STAT3 (2.856 at H0, p=0.0027) and CD4 increased (2.451 at H48, p=0.0052); IDO1 (0.2055 at H24, p&lt;0.0001) and TBX21/GATA3 ratio decreased (0.4498 at H48, p=0.0026); FOXP3 did not vary significantly. In the same time, the expression level of P2RY11 increased (2.124 at H0, p=0.0015) as well as protein expression in T cells (median MFI = 845.5 at H0 vs 229.5 for healthy donors, p=0.0375). In vitro, we observed a non-significant increase of ACTA2/VIM ratio in HCF co-cultured with H24, M1, M6 PBMC; of α-SMA/vimentin with H48, M12 PBMC; of COL1A1 with H24, H48, M12 PBMC; and of soluble collagen in coculture supernatant with M1 PBMC.

Conclusion

Our results suggest that P2Y11R could be involved in evolution of immune response after AMI, and that, in the first 2 days, circulating immune cells have a reparative profile and could participate in the transformation of fibroblast into myofibroblasts.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondation pour la recherche médicale

Effect of cardiorenal syndrome and its different subtypes on incidence of atrial fibrillation in a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorenal syndromes (CRS) are associated with increased risks of all-cause and cardiovascular death, end-stage kidney disease (ESKD), myocardial infarction (MI), heart failure (HF) and ischemic stroke. Whether CRS (and different subtypes of CRS) are more prone to develop atrial fibrillation (AF) is unclear.

Methods

This longitudinal cohort study was based on the national hospitalization database covering hospital care from the entire French population. The analysis focused on those with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 439,787 consecutive patients hospitalized in France in 2012 who had heart failure (HF), chronic kidney disease (CKD) and/or CRS. We estimated incidences of clinical events (including incident AF) during follow-up. Analysis were adjusted for 1) age and sex and 2) all baseline characteristics except cardiac and renal comorbidities.

Results

Overall, 58.2% were male, 67.7% had hypertension, 31.6% had diabetes mellitus and their mean age was 75.3±13.2; 329,154 had isolated HF, 67,939 had isolated CKD, 15,695 had acute concomitant CRS (which could be type 1, 3 or 5 CRS), 15,699 had type 2 CRS (cardiorenal) and 11,300 had type 4 CRS (renocardiac). History of AF was present in 36.4 % of the patients: 39.9% in those with isolated HF, 13.3% in those with isolated CKD, 43.0% in those with concomitant CRS, 57.2% in those with type 2 CRS, 35.3% in those with type 4 CRS (overall p&lt;0.0001).

Incidence and adjusted hazard ratios for of all-cause death, cardiovascular death and incident AF are in Table 1. CRS was associated with a higher risk of death and patients with type 2 CRS had the highest risk of all-cause and cardiovascular mortality. Isolated HF was associated with a higher risk of incident AF than isolated CKD (Table 1). Patients with CRS had higher risk of incident AF than those with isolated HF or isolated CKD. Among patients with CRS, those with concomitant CRS had the numerically highest 5-year risk of incident AF, which was not statistically different than those with type 2 or type 4 CRS in adjusted analysis.

Conclusion

The long-term prognosis of CRS subtypes is poor and may vary, some CRS subtypes being more closely associated with risk of all-cause death and cardiovascular mortality than others. Risk of incident AF is higher in CRS than in isolated HF or isolated CKD and is not statistically different among the various subtypes of CRS.

Cardiovascular events in metabolically healthy obese. A nationwide cohort study

Background

Obesity is a risk factor for cardiovascular disease (CVD) and has been increasing globally over the past 40 years in many countries worldwide. Metabolic abnormalities such as hypertension, dyslipidemia and diabetes mellitus are commonly associated and may mediate some of the deleterious effects of obesity. A subset of obese individuals without obesity-related metabolic abnormalities may be classified as being “metabolically healthy obese” (MHO). We aimed to evaluate the associations among MHO individuals and different types of incident cardiovascular events in a contemporary population at a nationwide level.

Methods

From the national hospitalization discharge database, all patients discharged from French hospitals in 2013 with at least 5 years or follow-up and without a history of major adverse cardiovascular event (myocardial infarction, heart failure [HF], ischemic stroke or cardiovascular death, MACE-HF) or underweight/ malnutrition were identified. They were categorized by phenotypes defined by obesity and 3 metabolic abnormalities (diabetes mellitus, hypertension, and hyperlipidemia). In total, 2,953,816 individuals were included in the analysis, among whom 272,838 (9.5%) were obese. We evaluated incidence rates and hazard ratios for MACE-HF, cardiovascular death, myocardial infarction, ischemic stroke, new-onset HF and new-onset atrial fibrillation (AF). Adjustments were made on age, sex and smoking status at baseline.

Results

During a mean follow-up of 4.9 years, obese individuals with no metabolic abnormalities had a higher risk of MACE-HF (multivariate-adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI]: 1.19–1.24), new-onset HF (HR 1.34, 95% CI 1.31–1.37), and AF (HR 1.33, 95% CI 1.30–1.37) compared with non-obese individuals with 0 metabolic abnormalities. By contrast, risks were not higher for myocardial infarction (HR 0.92, 95% CI 0.87–0.98), ischemic stroke (HR 0.93, 95% CI 0.88–0.98) and cardiovascular death (HR 0.99, 95% CI 0.93–1.04). In the models fully adjusted on all baseline characteristics, obesity was independently associated with a higher risk of MACE-HF events (HR 1.13, 95% CI 1.12–1.14), of new-onset HF (HR 1.19, 95% CI 1.18–1.20) and new-onset AF (HR 1.29, 95% CI 1.28–1.31). This was not the case for the association of obesity with cardiovascular death (HR 0.96, 95% CI 0.94–0.98), myocardial infarction (HR 0.93, 95% CI 0.91–0.95) and ischemic stroke (HR 0.93, 95% CI 0.91–0.96).

Conclusions

Metabolically healthy obese individuals do not have a higher risk of myocardial infarction, ischemic stroke or cardiovascular death than metabolically healthy non-obese individuals. By contrast they have a higher risk of new-onset HF and new onset AF. Even individuals who are non-obese can have metabolic abnormalities and be at high risk of cardiovascular disease events. Our observations suggest that specific studies investigating different aggressive preventive measures in specific subgroups of patients are warranted.

Funding Acknowledgement

Type of funding sources: None.

Antidiabetic drugs use and new-onset atrial fibrillation in patients with diabetes mellitus

Background

Diabetes is one of the most common chronic disorders worldwide and is an important cause of cardiovascular disease. Large studies investigating the risk of atrial fibrillation (AF) in diabetic patients taking different diabetes medications are still missing.

Methods

The analysis was based on the EGB (“Echantillon Généraliste des Bénéficiaires”) database, a 1/97 representative sample of the French nationwide claims and hospitalisation database. A cohort comprising 25,117 adult patients with diabetes and no previous AF seen between 2010 and 2018 was created and followed until December 2018 for incidence of new-onset AF. Among these diabetic patients, 36.0% were treated with metformin, 32.0% were treated with Sulfonylureas, 7.0% were treated with DPP4-inhibitors, 1.6% were treated with GLP1- analogues and 19.6% were treated with insulin. A Cox proportional hazards model was used to determine factors and different oral diabetes medications independently associated with the risk of AF during follow-up.

Results

During a follow-up of 4.8±3.5 years, there were 3,300 patients with new onset AF (yearly rate 2.7%). In multivariable analysis, among baseline characteristics, we found that older age, male sex, hypertension, heart failure, aortic stenosis, chronic kidney disease, anemia and diuretic use were independently associated with a higher risk of new AF. Among diabetes medications included in the multivariable model, use of sulfonylureas was independently associated with a lower risk of AF (HR 0.86, 95% CI 0.80–0.92, p&lt;0.0001 vs no use). By contrast, use of GLP1-analogues (HR 2.27, 95% CI 1.49–3.46, p=0.0001 vs no use), DPP4-inhibitors (HR 1.88, 95% CI 1.59–2.22, p&lt;0.0001 vs no use), metformin (HR 1.09, 95% CI 1.01–1.18, p=0.03 vs no use) and of insulin (HR 1.15, 95% CI 1.05–1.26, p=0.004 vs no use) were independently associated with a higher risk of AF.

Conclusions

Patients with different diabetes medications have significantly different long-term risk of AF. Specifically, sulfonylureas use was associated with a lower risk of incident AF whilst other antidiabetic drugs were associated with a higher risk of AF during follow-up.

Funding Acknowledgement

Type of funding sources: None.

Prognosis of diabetes mellitus and timing of heart failure in patients with acute myocardial infarction. An analysis of a French nationwide hospital database

Background

Diabetes mellitus (DM) is a factor of increased mortality in patients with acute myocardial infarction (AMI). DM is also associated with a higher risk of heart failure (HF) in patients with coronary artery disease as in the general population. The aim of the present study was to assess the incidence of HF developing at the acute stage of MI and of HF occurring in the year following hospital discharge, according to presence of DM. We also assessed the association between DM, HF and long-term mortality in this AMI population.

Methods

We used the French administrative hospital-discharge database, including all patients without history of HF admitted for AMI between 2010 and 2019 (n=797,212, mean age 69 years, 66% male). Among them, 520,258 patients (65%) had ST-segment elevation myocardial infarction (STEMI), 276,954 (35%) had non-STEMI, 192,456 patients (24%) had a history of DM. Occurrence of HF during the initial hospital stay was analysed in the whole population. In patients without HF during the index hospitalisation, discharged and alive at day 8 (n=535,813), we collected all hospitalisations for HF occurring during the year after discharge and analysed subsequent long-term mortality in those alive at one year (n=270,534) (length of follow-up 2.0±2.5 years, median 0.9, IQR 0.1–3.5).

Results

Overall, DM patients were older than non-DM patients (71±12 vs 67±15 years) and had more frequent comorbidities. At the acute stage, DM was associated with a higher risk of HF (28.7% vs 20.5% adjusted OR 1.40, 1.38–1.42, p&lt;0.0001). In patients without HF at the acute stage and discharged alive at day 8, DM was associated with a higher risk of being hospitalised with HF in the first year (5.6% vs 2.8%, adjusted HR 1.52, 1.49–1.56, p&lt;0.0001). In patients alive at one year, rates of all-cause death per year during subsequent follow-up were 2.2% in those without DM or HF during the first year (reference), 3.4% in those with DM and no HF during the first year (adjusted HR 1.22, 1.18–1.25, p&lt;0.0001), 7.7% in those without DM and with HF during the first year (adjusted HR 1.92, 1.83–2.02, p&lt;0.0001) and 8.9% in those with DM hospitalised with HF during the first year (adjusted HR 2.23, 2.09–2.37, p&lt;0.0001) (see figure).

Conclusion

After AMI, patients with diabetes are at increased risk of heart failure both at the acute stage and in the year following myocardial infarction, compared with non-diabetic patients. Non-fatal HF developing in the year following discharge is associated with noticeably higher subsequent mortality, and the combination of DM and HF is particularly at risk. Improved management is needed in diabetic patients following an AMI to avoid development of heart failure and its longer-term consequences.

Funding Acknowledgement

Type of funding sources: None.

Prevalences and incidences of cardiovascular and renal diseases in type 1 compared with type 2 diabetes: a nationwide observational study

Background

Type 1 diabetes (T1D) and type 2 diabetes (T2D) increase risks of cardiovascular (CV) and renal disease compared with diabetes-free populations. There are only few studies comparing T1D and T2D for the risk of these clinical events. We examined these issues in a nationwide analysis in France.

Methods

All patients aged ≥18 seen in French hospitals in 2013 with at least 5 years of follow-up were identified and categorized by their diabetes status. A total of 50,623 patients with T1D (age 61.4±18.6, 53% male) and 425,207 patients with T2D (age 68.6±14.3, 55% male) were followed over a mean period of 4.3±2.1 years (median 5.3, interquartile 2.8–5.8 years). Prevalence and event rates of myocardial infarction (MI), heart failure (HF), ischemic stroke, chronic kidney disease (CKD), all-cause death and CV death were assessed with age stratification of 10-year intervals. Cox regression analyses were used to estimate risk with adjustment on sex and age.

Results

The age and sex-adjusted prevalence of CV diseases was higher in T2D for ages above 40 years whereas the adjusted prevalence of CKD was more common in T1D between ages 18 and 69 years and higher in T2D for ages above 80 years.

During 2,033,239 person-years of follow-up, there were 27,497 patients with MIs (yearly rate 1.4%), 24,892 with ischemic strokes (yearly rate 1.2%), 100,769 with incident HF (yearly rate 5.4%), 65,928 with incident CKD (yearly rate 3.4%) and 197,858 deaths (yearly rate 9.7%) including 49,026 CV deaths (yearly rate 2.4%) were recorded. Age and sex-adjusted event rates comparing T1D versus T2D showed that MI risk was increased for ages above 60 (1.2-fold for T1D versus T2D) and HF between ages 18–29 and above 60 years (1.1–1.4-fold). Adjusted risk of ischemic stroke did not markedly differ between T1D and T2D. Risk of incident CKD was 1.1–2.4-fold higher in T1D between ages 18–49 and above 60 years. The all-cause death risk was 1.1-fold higher in T1D at age ≥60 years, the cardiovascular death risk being 1.1-fold higher in T1D between 60 and 69 years.

Conclusions

The adjusted prevalent burden and risk of incident renal disease are greater among patients with T1D compared with T2D patients across most ages. Although the prevalent burden of cardiovascular diseases may be lower in T1D than in T2D, patients with T1D may have a higher risk of incident MI, HF, all-cause death and cardiovascular death at middle-older ages, highlighting their need for improved prevention.

Funding Acknowledgement

Type of funding sources: None.

Trends in all-cause and cardiovascular mortality in patients with acute myocardial infarction: a nationwide analysis over 10 years

Background

The decline in mortality reported during last decades in patients with acute myocardial infarction (AMI) has been attributed mainly to improved use of reperfusion therapy. We sought to determine the trends in all-cause and cardiovascular mortality for patients with AMI seen at a nationwide level in recent years.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. Adverse outcomes including all-cause death and cardiovascular (CV) death were investigated during follow-up.

Results

We used the French administrative hospital-discharge database, including all patients admitted for AMI between 2010 and 2019 (n=797,212, mean age 69 years, 66% male). Among them, 520,258 patients (65%) had ST-segment elevation myocardial infarction (STEMI) and 276,954 (35%) had non-STEMI (NSTEMI). Reperfusion therapy with primary percutaneous coronary intervention increased from 40% in 2010 to 58% in 2019 for patients with STEMI. Revascularization between day 0 and day 8 increased from 38% in 2010 to 49% in 2019 for patients with NSTEMI. At day 30, all-cause death was recorded in 78,826 patients (9.9%), among whom 56,582 (72%) had CV death. The rate of all-cause death and CV death in patients with STEMI and NSTEMI are in the table. Our data showed higher reduction rates in NSTEMI vs STEMI patients regarding both all cause death (−18,4% vs −14,1%) and CV death (−24.21% vs −9.2%).

Conclusion

In a large and systematic nationwide analysis of patients with AMI, the rate of all-cause death and CV death at day 30 decreased from 2010 to 2019, both for those with STEMI and those with NSTEMI. Both death rate reductions were more important in NSTEMI patients despite a lower increase of reperfusion therapy compared to STEMI patients. Earlier diagnosis and management as well as improvement of pharmacological intervention and revascularization strategy may explain this difference.

Funding Acknowledgement

Type of funding sources: None.

Clinical outcomes and death associated with cardiorenal syndromes. A comprehensive nationwide cohort study

Background

Cardiorenal syndromes (CRS) are associated with increased risks of all-cause and cardiovascular death, end-stage kidney disease (ESKD), myocardial infarction (MI), heart failure (HF) and ischemic stroke. Whether subtypes of CRS are more prone to develop specific complications is unclear.

Methods

This longitudinal cohort study was based on the national hospitalisation database covering hospital care from the entire French population. The analysis focused on those with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 385,687 consecutive patients hospitalized in France in 2012 who had heart failure (HF), chronic kidney disease (CKD) and/or CRS. We estimated incidence of cardiovascular and all-cause death, MI, hospitalization for HF, ischemic stroke, ESKD (chronic dialysis or transplantation). Analysis were adjusted for 1) age and sex and 2) all baseline characteristics except cardiac and renal comorbidities.

Results

Overall, 57.7% were male, 67.3% had hypertension, 31.1% had diabetes mellitus and their mean age was 75.3±13.2; 34,217 had isolated CKD, 324,141 had HF, 11,162 had acute concomitant CRS (which could be type 1, 3 or 5 CRS), 12,198 had type 2 CRS and 3,969 had type 4 CRS.

Type 2 CRS was associated with the highest 5-year incidence of all-cause (30.3/100 patient-years [29.7–30.9]) and cardiovascular (10.7 [10.4–11.1]) death and HF (46.9 [45.9–47.9]), type 4 CRS with the highest incidence of MI (2.50 [2.21–2.83]) and patients with acute CRS with the highest incidence of ischemic stroke (2.05 [1.89–2.21]). The incidence of ESKD was 7.43/100 patient-years [6.92–7.99] for type 4 and 6.31 [6.03–6.61] for type 2 CRS, 6.16 [5.88–6.45] for aCRS, 6.00 [5.87–6.14] for CKD and 1.17 [1.15–1.19] for HF.

As compared to CKD, the adjusted risk of ESKD was higher in type 4 (HR: 1.18 [1.10–1.28]) and aCRS (1.07 [1.02–1.13]) and similar for type 2 (HR: 0.99 [0.94–1.04]) CRS. The adjusted risk of all-cause and cardiovascular death and HF was higher in patients with type 2 CRS vs all other groups, and higher in aCRS and 4 CRS than isolated CKD.

Conclusion

The long-term prognosis of CRS subtypes is poor but varies widely, some CRS subtypes being more closely associated with specific complications than others.

Funding Acknowledgement

Type of funding sources: None. All-cause deathCardiovascular death

Incidence of atrial fibrillation in patients with diabetes mellitus: effect of sex, age and type of diabetes in a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Background. There remain uncertainties regarding diabetes mellitus and the incidence of atrial fibrillation (AF), in relation to type of diabetes, and the interactions with sex and age. We investigated whether diabetes confers higher relative rates of AF in women compared to men, and whether these sex-differences depend on type of diabetes and age.

Methods. All patients aged &gt; =18 seen in French hospitals in 2013 with at least 5 years of follow-up without a history of AF were identified and categorized by their diabetes status. We calculated overall and age-dependent incidence rates, hazard ratios, and women-to-men ratios for incidence of AF in patients with type 1 and type 2 diabetes (compared to no diabetes).

Results. In 2,921,407 patients with no history of AF (55% women), 45,389 had prevalent type 1 diabetes and 345,499 had prevalent type 2 diabetes. During 13.5 million person-years of follow-up, 327,012 patients with new-onset AF were identified. The incidence rates (IRs) of AF were higher in type 1 or type 2 diabetic patients than in non-diabetics, and increased with advancing age. Among individuals with diabetes, the absolute rate of AF was higher in men than in women. When comparing individuals with and without diabetes, women had a higher adjusted hazard ratio (HR) of AF than men: adjusted HR 1.32 (95% confidence interval 1.27-1.37) in women vs. 1.12(1.08-1.16) in men for type 1 diabetes, adjusted HR 1.17(1.16-1.19) in women vs. 1.10(1.09-1.12) in men for type 2 diabetes.  The adjusted HRs for women were significantly higher than the adjusted HRs for men as shown with the adjusted women-to-men ratios (adjusted WMR = adjusted HR women compared to adjusted HR men) = 1.18 (95%CI 1.12-1.24) for type 1 diabetes and 1.10 (95%CI 1.08-1.12) for type 2 diabetes. This phenomenon was seen across all ages in men and women with type 1 diabetes and progressively decreased with advancing age.  In type 2 diabetes, this phenomenon was seen after 50 years, increased until 60-65 years and then progressively decreased with advancing age.

Conclusion. Although men have higher absolute rates for incidence of AF, the relative rates of incident AF associated with diabetes are higher in women than in men for both type 1 and type 2 diabetes.

Prediction of mortality and mode of death by clinical risk score systems in 2.6 million patients with atrial fibrillation: a nationwide analysis

 

Atrial fibrillation (AF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict mortality and the different modes of death in AF.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all AF patients treated between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. CHA2DS2VASc score, CCI and CFI were calculated for each patient.

Results

Among 2,641,626 patients with AF, 670,541 patients died during a follow-up of 2.0±2.3 years (median 1.1) (yearly rate 12.6%, 30.3% cardiovascular and 69.7% non-cardiovascular deaths). Death occurred more often in patients with higher CHA2DS2VASc, CCI and CFI scores. CCI was a better predictor of total mortality than CFI and CHA2DS2VASc score (see C-statistics in table); however, the CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI. By contrast, CCI was a better predictor of non-cardiovascular mortality than CFI and CHA2DS2VASc score. The optimal predictive performances were better for non-cardiovascular death than for cardiovascular death.

Conclusion

Multimorbidity assessed with CCI demonstrated better performances in predicting total mortality and non-cardiovascular mortality than CHA2DS2VASc score and Frailty assessed with CFI in AF patients. By contrast, CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI in these patients.

Funding Acknowledgement

Type of funding source: None

Bleeding risks with frailty and multimorbidity in patients with atrial fibrillation. A nationwide analysis of 1.4 million subjects

Background

Frailty and multimorbidity are common in patients with atrial fibrillation (AF). The quantifiable frailty phenotype has been validated as predictive of mortality and disability, and patients can be categorised as frail and non-frail using the Claims-based Frailty Index (CFI). The Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and also a strong estimator of mortality. We evaluated whether frailty and multimorbidity are associated with the risk of major bleeding in patients with AF.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients with AF between 2010 and 2019 in France. CCI and CFI were calculated for each patient, and their associated risks of bleeding compared to 4 bleeding risk scores (HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT). The analysis focused on patients with events or with at least one year of follow-up. Predictive abilities of the scores were compared in the whole population, and then separately in the subgroup of elderly patients (&gt;75 yo).

Results

Among 1,372,567 patients with AF, 131,535 major bleeding events were recorded during a follow-up of 3.5±2.1 years (median 3.1, IQR 1.8–4.9) (yearly rate 2.7%). Bleeding occurred more commonly in patients with higher HAS-BLED, ATRIA, CCI and CFI scores. Those with high frailty and multimorbidity had markedly higher yearly incidences of bleeding events of 13.0% and 14.7%, respectively (vs low frailty and multimorbidity: 4.3%% and 4.1%, respectively; p&lt;0.001). The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). In elderly patients (n=853,833), the c-statistics were all lower than in the whole population and were lower for the 4 scores than for the CCI and CFI scores (0.463, 0.473, 0.443, 0.445, 0.622 and 0.620 for HAS-BLED, ATRIA, ORBIT, HEMORR2HAGES, CCI and CFI, respectively).

Conclusion

Multimorbidity and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF.

Funding Acknowledgement

Type of funding source: None

Impact of the timing of coronary revascularization relative to the transcatheter aortic valve implantation procedure: insights from a propensity score analysis based on a nationwide analysis

Background

The significance and the management of coronary artery disease (CAD) are disputed in patients treated by transcatheter aortic valve implantation (TAVI). In the presence of a significant CAD eligible for percutaneous coronary intervention (PCI), the issue of the timing of PCI relative to TAVI is unsettled. To answer this question, the present study aimed at comparing the short-term and long-term outcome in patients treated by staged PCI within a 90-day time interval before or after TAVI.

Methods

Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with TAVI between 2014 and 2018. Patients treated with PCI in the preceding 90 days before the TAVI procedure (pre-TAVI PCI) or subsequent 90 days after the TAVI procedure (post-TAVI PCI) were included. All-cause mortality, cardiovascular mortality, stroke, myocardial infarction and a combined cardiovascular endpoint were assessed at 30 days after the last procedure (short-term) and during the whole follow-up (long-term). Propensity score matching was used for the analysis of outcomes.

Results

8613 patients met the inclusion criteria with a vast majority of pre-TAVI PCI patients (N=8324) as opposed to post-TAVI PCI (N=229). After propensity score matching, 2 groups of 227 patients with comparable characteristics were obtained. At 30 days, no significant difference was observed for any of the outcome tested with the exception of myocardial infarction more frequent in post-TAVI PCI (OR 2.43 [1.17–5.07]). After a mean [SD] follow-up of 459 [569] days, all outcomes were identical between subgroups. The figure below illustrates the Kaplan Meier curve for all-cause mortality.

Conclusions

Our study based on a French nationwide database shows that PCI is performed pre-TAVI in a majority of cases, with no significant impact on outcome. Deferring PCI after TAVI seems safe and may provide an opportunity to make the decision on more objective parameters while the stenosis has been removed (such as FFR or IFR). In any case, the timing of PCI relative to TAVI does not seem to represent a concern and should be decided on an individual basis.

Figure 1

Funding Acknowledgement

Type of funding source: None

LDL-cholesterol decrease by anti-PCSK9 monoclonal antibodies: systematic review, meta-analysis and meta-regression of randomized controlled trials

Background

PCSK9 antibodies are novel potent and expansive lipid lowering agents that demonstrated clinical benefit in high risk patients. We hypothesized that optimization of dose and administration schedule, ideally adapted to the target population, could reduce costs while maintaining the clinical benefit.

Objective

To explore the relationship between LDL-Cholesterol (LDL-C) decrease by anti-PCSK9 monoclonal antibodies and several covariates such as drug dose, administration schedule, baseline LDL-C, population and statins.

Methods

We performed systematic review, meta-analysis and meta-regression of randomized controlled trials that compared alirocumab or evolocumab to placebo or no treatment and reported LDL-C decrease, with a minimum follow-up of 12 weeks and with a sample size of 30 patients or more. Electronic searches of MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov from inception to March 2019. We evaluated the quality of included studies and extracted aggregate data. We used random effect models and multivariate multilevel meta-regression to explore factors influencing LDL-C decrease. All analyses were performed with R.

Results

From 1479 references identified and screened on title/abstract, the full texts of 72 articles were screened. We included 32 studies (31 references.) Anti-PCSK9 mAbs decreased LDL-C by 53%, 95% CI (−56% to −50%), with no significant difference between the two drugs (p=0.07). In univariate meta-regressions, higher baseline LDL-C level, monthly administration, higher percentage of patients with high-dose statins were associated with a lower LDL-C decrease (p&lt;0.0001, p=0.02 and p=0.006 respectively). Drug dose and population did not influence LDL-C decrease in univariate analysis, but with a significant statistical interaction between drug dose and administration schedule (p=0.03). In multivariate meta-regression, LDL-C decrease remained significantly and negatively influenced by baseline LDL-C level

(p&lt;0.0001) and the percentage of patients with high-dose statins (p=0.0009), and was significantly and positively influenced by drug dose (p&lt;0.0001).

Conclusion

Alirocumab and evolocumab showed substantial LDL-C reductions in clinical trials, without significant differences in their biological efficacies. A higher baseline LDL-C, higher intensity of statin co-treatment and a lower dose seemed to negatively influence LDL-C decrease.

Funding Acknowledgement

Type of funding source: None

Risk of ischemic stroke in patients with acute myocardial infarction and new atrial fibrillation: a nationwide analysis

Background

In patients with acute myocardial infarction (AMI), history of atrial fibrillation (AF) and new onset AF during the early phase may be associated with a worse prognosis. Whether both conditions are associated with a similar risk of stroke and should be similarly managed is a matter of debate.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. The adverse outcomes were investigated during follow-up.

Results

Among 797,212 patients with STEMI or NSTEMI, 146,922 (18.4%) had history of AF, and 11,824 (1.5%) had new AF diagnosed between day 1 and day 30 after AMI. Patients with new AF were older and had more comorbidities than those with no AF but were younger and had less comorbidities than those with history of AF. Both groups with history of AF or new AF had less frequent STEMI and anterior MI, less frequent use of percutaneous coronary intervention but more frequent HF at the acute phase than patients with no AF. During follow-up (mean [SD] 1.8 [2.4] years, median [interquartile range] 0.7 [0.1–3.1] years), 163,845 deaths and 20,168 ischemic strokes were recorded.

Using Cox multivariable analysis, compared to patients with no AF, history of AF was associated with a higher risk of death during follow-up (adjusted hazard ratio HR 1.06 95% CI 1.05–1.08) while this was not the case for patients with new AF (adjusted HR 0.98 95% CI 0.95–1.02). By contrast, both history of AF and new AF were associated with a higher risk of ischemic stroke during follow-up compared to patients with no AF: adjusted hazard ratio HR 1.29 95% CI 1.25–1.34 for history of AF, adjusted HR 1.72 95% CI 1.59–1.85 for new AF. New AF was associated with a higher risk of ischemic stroke than history of AF (adjusted HR 1.38 95% CI 1.27–1.49).

Conclusion

In a large and systematic nationwide analysis, AF first recorded in the first 30 days after AMI was associated with an increased risk of ischemic stroke. Specific management should be considered in order to improve outcomes in these patients after AMI.

Funding Acknowledgement

Type of funding source: None

Outcomes in patients with acute myocardial infarction and a history of illicit drug use: a nationwide analysis

Background

Several reports suggest that illicit drug use may be a major cause of acute myocardial infarction (AMI) independently of smoking habits, and associated with a poorer prognosis.

Purpose

We sought to determine the frequency of history of illicit drug use in an AMI population and its impact on short- and mid-term prognosis.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2018 in France. We identified patients with history of illicit drug use and the adverse outcomes were investigated during follow-up.

Results

Among 797,212 patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI (mean age 69 years, 66% male), 3827 patients (0.5%) had a known history of illicit drug use (cannabis, cocaine or opioid). Patients with illicit drug use were younger and had less comorbidities. They presented more frequently with STEMI and anterior localization compared to those with no history of illicit drug use. In univariate analysis, patients with illicit drug use had lower short-term mortality rates compared to those without history of illicit drug use: 4.9% vs 10.1% at one month (p&lt;0.0001), respectively. However, this might be attributed to a younger age at the time of presentation. Using logistic multivariable analysis with adjustment on age, gender, other cardiovascular and non-cardiovascular comorbidities, type and localisation of MI and procedures of revascularization, history of illicit drug use was associated with a non-significant higher risk of death at one year (adjusted odds ratio OR 1.12 95% CI 0.98–1.29). This trend was supported by a significantly higher risk of death at one year in patients with a history of opioid use (OR 1.27 95% CI 1.04–1.29, p=0.01).

Conclusion

In a large and systematic nationwide analysis of patients with AMI, history of illicit drug use was associated with a non-significant higher overall odds of mortality, which was significant among those with opioid use.

Funding Acknowledgement

Type of funding source: None

Relationship of aging and incident comorbidities to stroke risk in 594,169 Patients with atrial fibrillation: a nationwide analysis

Background

When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities. This study hypothesized that the “Delta CHA2DS2-VASc score”, which reflects the change in score between baseline and follow-up, may be predictive of ischemic stroke compared with the baseline or follow-up assessments of the CHA2DS2-VASc score.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all patients treated with AF between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. A total of 594,169 patients with AF who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc score was defined as the change/difference between the baseline and follow-up CHA2DS2-VASc scores. During 1,290,721 person-years, 19,492 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analysed and compared.

Results

The mean baseline CHA2DS2-VASc score was 1.69, which increased to 2.33 during the follow-up, with a mean Delta CHA2DS2-VASc score of 0.64. The CHA2DS2-VASc score increased in 39.8% of patients. Among 19,492 patients who experienced ischemic stroke, 66.0% had a Delta CHA2DS2-VASc score ≥1 compared with only 38.9% in patients without ischemic stroke, and 5,811 (29.8%) patients had ≥2 new-onset comorbidity, the most common being hypertension. The follow-up CHA2DS2-VASc score and Delta CHA2DS2-VASc score were significant predictors of ischemic stroke (C-index 0.670 95% CI 0.667–0.674 and 0.637 95% CI 634–641 respectively) that performed better than baseline CHA2DS2-VASc score (C-index 0.613 95% CI 0.609–0.616, p&lt;0.0001 for DeLong test).

Conclusions

In this AF cohort, we found that stroke risk (CHA2DS2-VASc score) was non-static, and that many patients developed ≥1 new stroke risk factor(s) before presentation with ischemic stroke. The follow-up CHA2DS2-VASc score and its change (ie Delta CHA2DS2-VASc, reflecting the change in stroke risk profile between baseline and follow-up) were better predictors of ischemic stroke than relying on the baseline CHA2DS2-VASc score. This emphasises how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities, and regular re-assessment of risk is needed.

Funding Acknowledgement

Type of funding source: None

P1870Predicting mortality and mode of death by clinical score systems for patients with atrial fibrillation

Methods

All patients with AF seen in an academic institution were identified and followed up for mortality. CHA2DS2VASc score, CCI and CFI were calculated for each patient. Predictive abilities of the scores were compared using the c-statistic.

Results

Among 8962 consecutive patients with AF, 1294 patients died during a follow-up of 929±1082 days (median 456), (yearly rate 5.5%) and 97% of causes of death were identified (54% cardiovascular and 43% non-cardiovascular). Death occurred more often in patients with higher CHA2DS2VASc scores, CCI and CFI. CFI was a better predictor of total mortality than CCI and CHA2DS2VASc score (table). CFI was also a better predictor of cardiovascular mortality than CCI and CHA2DS2VASc score. Finally, CFI was also a better predictor of non-cardiovascular mortality than CCI and CHA2DS2VASc score. The predictive performances of the 3 tools were better for cardiovascular death than for non-cardiovascular death.

Prediction of mode of death ROC area (95% C) p vs CHA2DS2VASc/Charlson Total mortality CHA2DS2VASc 0.651 (0.636–0.665) – / 0.0001 CHARLSON (CCI) 0.687 (0.672–0.702) 0.0001 / – Frailty index (CFI) 0.714 (0.700–0.729) <0.0001 / <0.0001 Cardiovascular death CHA2DS2VASc 0.673 (0.654–0.692) – / 0.004 CHARLSON (CCI) 0.707 (0.688–0.726) 0.004 / – Frailty index (CFI) 0.737 (0.719–0.756) <0.0001 / <0.0001 Non cardiovascular death CHA2DS2VASc 0.590 (0.567–0.612) – / 0.0008 CHARLSON (CCI) 0.637 (0.614–0.659) 0.0008 / – Frailty index (CFI) 0.650 (0.628–0.672) <0.0001 / 0.008

Conclusion

Frailty assessed with CFI demonstrated better performances in predicting total mortality, cardiovascular mortality and non-cardiovascular mortality than CHA2DS2VASc score and Charlson comorbidity index in AF patients. Identifying the risk of non-cardiovascular death with simple tools remains a more difficult challenge in these patients.

4070Clinical impact of mitral regurgitation before or following transcatheter aortic valve replacement in patients with aortic stenosis: a nationwide multivariable analysis

Methods

Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients with aortic stenosis treated with transfemoral TAVR in France between 2008 and 2018. Cox regression was used for the analysis of predictors of events during follow-up.

Results

A total of 47,872 patients with transfemoral TAVR were included in the analysis (mean age 83±7 years). Moderate/severe MR was present at baseline (MRb) in 9.5% of the patients. Few patients (1.6%) revealed moderate/severe MR post-TAVR (MRpt). Mean follow-up was 1.31±1.61 years. MRb was associated with an increased cardiovascular mortality (Hazard ratio 1.29, 95% CI 1.20–1.39) and total mortality (Hazard ratio 1.15, 95% CI 1.10–1.21). However, MRb was not an independent predictor in multivariable analysis, neither for cardiovascular mortality (adjusted HR 1.06, 95% CI 0.98–1.14) nor for total mortality (adjusted HR 1.01, 95% CI 0.96–1.07). MRpt was not a predictor of cardiovascular or total mortality. Older age, male sex, history of pulmonary edema/cardiogenic shock, atrial fibrillation, myocardial infarction, diabetes, renal failure, liver disease, pulmonary disease, previous cancer and anemia at baseline independently predicted mortality during follow-up. All of them (but history of cancer) were also independent predictor of cardiovascular death.

Conclusion

Baseline MR was associated with increased cardiovascular and totality mortality following TAVR but was not an independent predictor of any of them. By contrast, several other predictors of cardiovascular and total mortality were identified. This suggests that MR should not be directly considered to establish the strategy for TAVR decision or for avoiding TAVR-related futility.

P1794Futility risk model development and validation among patients with aortic stenosis treated with transcatheter aortic valve replacement

Methods

Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients with aortic stenosis treated with transfemoral TAVR in France between 2008 and 2018. Multivariate logistic regression was used to select the risk factors of early all-cause death in first year after TAVR procedure (considered as futility) for the overall population. Score points were assigned to each risk factor using the β coefficient. Internal validation was performed by a bootstrap method. Calibration was assessed with the Hosmer-Lemeshow goodness of fit test and accuracy with the C-statistic.

Results

A total of 47,872 patients with transfemoral TAVR were included in the analysis (mean age 83±7 years). Mean follow-up was 1.31±1.61 years and 9,338 deaths were recorded (yearly rate 14.9%), among which 4,562 (49%) occurred in first year after TAVR procedure. The final logistic regression model included older age, male sex, history of hospital stay with heart failure, history of acute pulmonary oedema, atrial fibrillation, previous stroke, vascular disease, diabetes, renal disease, liver disease, pulmonary disease, anemia, history of cancer, metastasis and denutrition,. The area under the curve (AUC) for the score was 0.696 (95% CI 0.688–0.704). This score outperformed frailty index and Charlson comorbidity index for identifying futility. AUC was 0.677 (95% CI 0.669–0.86) for internal validation. The Hosmer–Lemeshow goodness of fit test had a p-value of 0.10 suggesting that the model was accurate. We further divided the model into 4 groups with 5%, 12%, 19% and 30% futility, respectively. The low-risk group consisted of 60% of the patients and the high-risk group consisted of 4% of these patients.

Conclusion

This futility prediction score established from a large nationwide cohort of patients treated with TAVR may provide a relevant insight for optimizing healthcare decision. It may facilitate identification of patients who, despite an apparently successful procedure, have risk of death that may outweigh the benefit of an anticipated TAVR.

P4748HASBLED score, frailty index or comorbidity index for bleeding risk assessment in patients with atrial fibrillation?

Background

Charlson comorbidity index (CCI) is a tool to measure comorbid disease status and a strong estimator of mortality. The quantifiable frailty phenotype has also been validated as predictive of mortality and disability. Claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict the risk of bleeding in patients with atrial fibrillation (AF).

Methods

All patients with AF seen in an academic institution were identified and followed up for mortality, stroke and bleeding events. HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT scores, CCI and CFI were calculated for each patient. Hazard ratios were calculated and predictive abilities of the scores were compared using the c-statistic in the whole population and then separately in elderly patients (>75 yo).

Results

Among 8962 patients with AF, 274 major bleeding events were recorded during a follow-up of 874±1054 days. Bleeding occurred more commonly in patients with higher bleeding risk scores, CCI and CFI. The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). Results were similar whether patients were treated with OAC or no OAC. In elderly patients, the c-statistics were all lower and were not significantly different for the 4 scores, CCI and CFI scores (0.594, 0,572, 0.595, 0.594, 0.616 and 0.591 for HAS-BLED, HEMORR2HAGES, ATRIA, ORBIT, CCI and CFI, respectively).

Predictive values for major bleeding ROC Area 95% Conf. Interval P value vs CCI/CFI HASBLED 0.588 0.555–0.621 0.002/0.003 HEMORR2HAGES 0.564 0.531–0.598 <0.0001/<0.0001 ATRIA 0.559 0.522–0.595 <0.0001/<0.0001 ORBIT 0.577 0.542–0.612 0.0002/0.0003 Charlson, CCI 0.652 0.619–0.684 –/0.58 Frailty index, CFI 0.648 0.615–0.681 0.58/–

Conclusion

Comorbidities and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF, although all c-indexes were broadly similar. The 4 bleeding risk scores, CCI and CFI showed lower performance in predicting bleeding within elderly patients in whom they all performed equally to predict bleeding events. Given their simplicity and similar performances, the user-friendly bleeding risk scores remain attractive tools for the estimation of bleeding risk in elderly patients with AF.