Intra-hospital variation of gut microbiota product, trimethylamine N-oxide (TMAO) predicts future major adverse cardiovascular events after myocardial infarction

BACKGROUND AND AIMS

Trimethylamine N-oxide (TMAO) has been associated with atherosclerosis and poor outcome. We evaluated the prognostic impact of intra-hospital TMAO variation on patient outcome.

METHODS AND RESULTS

Blood samples from 149 patients with acute myocardial infarction (AMI) were taken on admission and discharge. Plasma TMAO was determined by HPLC-MS. The endpoint was a composite three-point MACE (major adverse cardiovascular events) including all-cause mortality, re-infarction or the heart failure (HF) development. Median TMAO concentration on admission was significantly higher than on discharge, (respectively, 7.81 [3.47 - 19.98] vs 3.45 [2.3 - 4.78] μM,p<0.001). After estimating the 3.45 μM TMAO cut-off with the analysis of continuous hazard ratio, we divided our cohort into two groups. The first group included 75 (50.3%) patients whose TMAO levels remained below or decreased under cut-off (low-low/high-low; LL/HL), while the second group included 74 (49.7%) patients whose TMAO levels remained high or increased above the cut-off during hospitalisation (high-high/low-high; HH/LH). During the median 30-month follow-up, 21.5% patients experienced the composite endpoint. At Kaplan-Meier analysis, a trend of increasing MACE risk was observed in patients in the HH/LH group (p=0.05). At multivariable Cox analysis, patients from HH/LH group had more than two times higher risk of MACE during the follow-up than LL/HL group (HR=2.15 [95% CI, 1.03 - 4.5], p=0.04). Other independent predictors of MACE were older age and worse left ventricular systolic function.

CONCLUSIONS

In patients with AMI, permanently high or increasing TMAO levels during hospitalisation are associated with a higher risk of MACE during long-term follow-up.

Clinical and Prognostic Implications of Right Ventricular Uptake on Bone Scintigraphy in Transthyretin Amyloid Cardiomyopathy

BACKGROUND

The extent of myocardial bone tracer uptake with technetium pyrophosphate, hydroxymethylene diphosphonate, and 3,3-diphosphono-1,2-propanodicarboxylate in transthyretin amyloid cardiomyopathy (ATTR-CM) might reflect cardiac amyloid burden and be associated with outcome.

METHODS

Consecutive patients with ATTR-CM who underwent diagnostic bone tracer scintigraphy with acquisition of whole-body planar and cardiac single-photon emission computed tomography (SPECT) images from the National Amyloidosis Centre and 4 Italian centers were included. Cardiac uptake was defined according to the Perugini classification: 0=absent cardiac uptake; 1=mild uptake less than bone; 2=moderate uptake equal to bone; and 3=high uptake greater than bone. Extent of right ventricular (RV) uptake was defined as focal (basal segment of the RV free wall only) or diffuse (extending beyond basal segment) on the basis of SPECT imaging. The primary outcome was all-cause mortality.

RESULTS

Among 1422 patients with ATTR-CM, RV uptake accompanying left ventricular uptake was identified by SPECT imaging in 100% of cases at diagnosis. Median follow-up in the whole cohort was 34 months (interquartile range, 21 to 50 months), and 494 patients died. By Kaplan-Meier analysis, diffuse RV uptake on SPECT imaging (n=936) was associated with higher all-cause mortality compared with focal (n=486) RV uptake (77.9% versus 22.1%; P<0.001), whereas Perugini grade was not associated with survival (P=0.27 in grade 2 versus grade 3). On multivariable analysis, after adjustment for age at diagnosis (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04]; P<0.001), presence of the p.(V142I) TTR variant (HR, 1.42 [95% CI, 1.20-1.81]; P=0.004), National Amyloidosis Centre stage (each category, P<0.001), stroke volume index (HR, 0.99 [95% CI, 0.97-0.99]; P=0.043), E/e' (HR, 1.02 [95% CI, 1.007-1.03]; P=0.004), right atrial area index (HR, 1.05 [95% CI, 1.02-1.08]; P=0.001), and left ventricular global longitudinal strain (HR, 1.06 [95% CI, 1.03-1.09]; P<0.001), diffuse RV uptake on SPECT imaging (HR, 1.60 [95% CI, 1.26-2.04]; P<0.001) remained an independent predictor of all-cause mortality. The prognostic value of diffuse RV uptake was maintained across each National Amyloidosis Centre stage and in both wild-type and hereditary ATTR-CM (P<0.001 and P=0.02, respectively).

CONCLUSIONS

Diffuse RV uptake of bone tracer on SPECT imaging is associated with poor outcomes in patients with ATTR-CM and is an independent prognostic marker at diagnosis.

Flexible Approaches Based on Multistate Models and Microsimulation to Perform Real-World Cost-Effectiveness Analyses: An Application to Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors

OBJECTIVES

This study aims to show the application of flexible statistical methods in real-world cost-effectiveness analyses applied in the cardiovascular field, focusing specifically on the use of proprotein convertase subtilisin-kexin type 9 inhibitors for hyperlipidemia.

METHODS

The proposed method allowed us to use an electronic health database to emulate a target trial for cost-effectiveness analysis using multistate modeling and microsimulation. We formally established the study design and provided precise definitions of the causal measures of interest while also outlining the assumptions necessary for accurately estimating these measures using the available data. Additionally, we thoroughly considered goodness-of-fit assessments and sensitivity analyses of the decision model, which are crucial to capture the complexity of individuals' healthcare pathway and to enhance the validity of this type of health economic models.

RESULTS

In the disease model, the Markov assumption was found to be inadequate, and a "time-reset" timescale was implemented together with the use of a time-dependent variable to incorporate past hospitalization history. Furthermore, the microsimulation decision model demonstrated a satisfying goodness of fit, as evidenced by the consistent results obtained in the short-term horizon compared with a nonmodel-based approach. Notably, proprotein convertase subtilisin-kexin type 9 inhibitors revealed their favorable cost-effectiveness only in the long-term follow-up, with a minimum willingness to pay of 39 000 Euro/life years gained.

CONCLUSIONS

The approach demonstrated its significant utility in several ways. Unlike nonmodel-based or alternative model-based methods, it enabled to (1) investigate long-term cost-effectiveness comprehensively, (2) use an appropriate disease model that aligns with the specific problem under study, and (3) conduct subgroup-specific cost-effectiveness analyses to gain more targeted insights.

Applicability and performance of heart failure prognostic scores in dilated cardiomyopathy: the real-world experience of an Italian referral center for cardiomyopathies

BACKGROUND

The performance of heart failure (HF) risk models is validated in the general population with HF but in specific aetiological settings, and specifically in dilated cardiomyopathy (DCM), has scarcely been explored. We tested eight of the main prognostic scores used in HF in a large real-world population of patients with DCM.

METHODS

We included 784 consecutive DCM patients enrolled, both inpatients and outpatients, enrolled between January 2000 and December 2017. The risk of 1 and/or 3-year all-cause mortality/heart transplantation/durable left ventricular assist device (LVAD) implantation (D/HTx/LVAD) was estimated in our cohort according to the following risk scores SHFM, 3-CHF, CHARM, MAGGIC, GISSI-HF, MECKI, Barcelona Bio-HF, Krakow score and their accuracy calculated through the receiver operator characteristic (ROC) curve analysis.

RESULTS

During a median follow-up of 5.8 years (Interquartile Range 3.2-7.6 years), 191 patients (20%) died or underwent HTx/LVAD (158 deaths, 30 heart transplantations, and 3 LVAD implantations). The high missing rate allowed to calculated only four prognostic models (MAGGIC, CHARM, 3-CHF and SHFM). All the scores overestimated the rate of D/HTx/LVAD. The prognostic accuracy was suboptimal for MAGGIC (AUC 0.754) and CHARM (AUC 0.720) scores and only modest for 3-CHF (AUC 0.677) and SHFM (AUC 0.667).

CONCLUSIONS

Main prognostic scores for the risk stratification of HF are only partially applicable to real-world patients with DCM. MAGGIC and CHARM scores showed the best accuracy, despite the overestimation of risk. Our findings corroborate the need of specific risk scores for the prognostic stratification of DCM.

CLINICAL PERSPECTIVE

What is new? The present study is the largest analysis in literature which investigate how the main existing heart failure prognostic risk scores performed in a real-world of dilated cardiomyopathy population, both in- and outpatients. What are the clinical implications? DCM is a stand-alone model of heart failure, where the performance of multiple heart failure prognostic scores for the risk stratification is quite limited. The need for contemporary, dedicated prognostic scores in this disease is increasingly evident.

Prognostic value of cardiopulmonary exercise testing repetition during follow-up of clinically stable patients with severe dilated cardiomyopathy. A preliminary study

BACKGROUND

Cardiopulmonary exercise testing (CPET) is a recognized tool for prognostic stratification in patients with dilated cardiomyopathy (DCM). Given the lack of data currently available, the aim of this study was to test the prognostic value of repeating CPET during the follow-up of patients with DCM.

METHODS

This multicenter, retrospective study, analyzed DCM patients who consecutively performed two echocardiographies and CPETs during clinical stability. The study end-point was a composite of death from all causes, heart transplantation, left ventricular assist device implantation, life-threatening ventricular arrhythmias or hospitalization for heart failure.

RESULTS

216 DCM patients were enrolled (52 years, 78% male, NYHA I-II 82%, LVEF 32%, 94% on ACE inhibitors/ARNI, 95% on beta-blockers). The interval between CPETs was 15 months. During a median follow-up of 38 months from the second CPET, 102 (47%) patients experienced the study end-point. Among them, there was stability of echocardiographic values but a significant worsening of functional capacity. Among the 173 patients (80%) who did not show echocardiographic left ventricular reverse remodeling (LVRR), the 1-year prevalence of the study-end point was higher in patients who worsened vs patients who maintained stable their functional capacity at CPET (38 vs. 15% respectively, p-value: 0.001). These results were consistent also when excluding life-threatening ventricular arrhythmias from the composite end-point.

CONCLUSION

In clinically stable DCM patients with important depression of LVEF, the repetition of combined echocardiography and CPET might be recommended. When LVRR fails, 1-year repetition of CPET could identify higher-risk patients.

LDL Cholesterol Variability Impacts the Prognosis of Patients with Chronic Ischemic Heart Disease: A Real-World Italian Experience

Epidemiologic, genetic, and clinical intervention studies have indisputably shown that low-density lipoprotein cholesterol (LDL-C) is causal in the development of atherosclerotic cardiovascular disease (ASCVD). However, LDL-C variability could be related to increased ASCVD risk in patients already treated with statins. The aim of the present retrospective real-life study was to assess the prognostic impact of LDL-C variability on all-cause mortality and cardiovascular hospitalizations in patients with stable cardiovascular artery disease. A total of 3398 patients were enrolled and followed up for a median of 56 months. Considering LDL-C < 70 mg/dL as the therapeutical target, during follow-up, the percentage of patients who achieved this goal raised from 20.7% to 31.9%. In total, 1988 events were recorded, of which 428 were all-cause deaths and 1560 were cardiovascular hospitalizations. At the last medical examination, each increase in LDL-C levels of 20 mg/dL corresponded to a 6% raise in the risk of any event (HR 1.06; 95%CI, 1.03 to 1.09). In conclusion, our real-world study supports the hypothesis that a continuous and progressive downward trend in LDL-C levels is needed to achieve and maintain a cardiovascular benefit, at least in secondary prevention.

Comparison of discrimination and calibration performance of ECG-based machine learning models for prediction of new-onset atrial fibrillation

BACKGROUND

Machine learning (ML) methods to build prediction models starting from electrocardiogram (ECG) signals are an emerging research field. The aim of the present study is to investigate the performances of two ML approaches based on ECGs for the prediction of new-onset atrial fibrillation (AF), in terms of discrimination, calibration and sample size dependence.

METHODS

We trained two models to predict new-onset AF: a convolutional neural network (CNN), that takes as input the raw ECG signals, and an eXtreme Gradient Boosting model (XGB), that uses the signal's extracted features. A penalized logistic regression model (LR) was used as a benchmark. Discrimination was evaluated with the area under the ROC curve, while calibration with the integrated calibration index. We investigated the dependence of models' performances on the sample size and on class imbalance corrections introduced with random under-sampling.

RESULTS

CNN's discrimination was the most affected by the sample size, outperforming XGB and LR only around n = 10.000 observations. Calibration showed only a small dependence on the sample size for all the models considered. Balancing the training set with random undersampling did not improve discrimination in any of the models. Instead, the main effect of imbalance corrections was to worsen the models' calibration (for CNN, integrated calibration index from 0.014 [0.01, 0.018] to 0.17 [0.16, 0.19]). The sample size emerged as a fundamental point for developing the CNN model, especially in terms of discrimination (AUC = 0.75 [0.73, 0.77] when n = 10.000, AUC = 0.80 [0.79, 0.81] when n = 150.000). The effect of the sample size on the other two models was weaker. Imbalance corrections led to poorly calibrated models, for all the approaches considered, reducing the clinical utility of the models.

CONCLUSIONS

Our results suggest that the choice of approach in the analysis of ECG should be based on the amount of data available, preferring more standard models for small datasets. Moreover, imbalance correction methods should be avoided when developing clinical prediction models, where calibration is crucial.

Association of Tricuspid Regurgitation With Outcome in Acute Heart Failure

BACKGROUND

Tricuspid regurgitation (TR) is common in chronic heart failure (HF) and is associated with negative prognosis. However, evidence on prognostic implications of TR in acute HF is lacking. We sought to investigate the association between TR and mortality and the interaction with pulmonary hypertension (PH) in patients admitted for acute HF.

METHODS

We enrolled 1176 consecutive patients with a primary diagnosis of acute HF and with available noninvasive estimation of TR and pulmonary arterial systolic pressure.

RESULTS

Moderate-severe TR was present in 352 patients (29.9%) and was associated with older age and more comorbidities. The prevalence of PH (ie, pulmonary arterial systolic pressure >40 mm Hg), right ventricular dysfunction, and mitral regurgitation was higher in moderate-severe TR. At 1 year, 184 (15.6%) patients died. Moderate-severe TR was associated with higher 1-year mortality risk after adjustment for other echocardiographic parameters (pulmonary arterial systolic pressure, left ventricle ejection fraction, right ventricular dysfunction, mitral regurgitation, left and right atrial indexed volumes; hazard ratio, 1.718; P=0.009), and the association with outcome was maintained when clinical variables (eg, natriuretic peptides, serum creatinine and urea, systolic blood pressure, atrial fibrillation) were added to the multivariable model (hazard ratio, 1.761; P=0.024). The association between moderate-severe TR and outcome was consistent in patients with versus without PH, with versus without right ventricular dysfunction, and with versus without left ventricle ejection fraction <50%. Patients with coexistent moderate-severe TR and PH had 3-fold higher 1-year mortality risk compared with patients with no TR or PH (hazard ratio, 3.024; P<0.001).

CONCLUSIONS

In patients hospitalized for acute HF, the severity of TR is associated with 1-year survival, regardless of the presence of PH. The coexistence of moderate-severe TR and estimated PH was associated with a further increase in mortality risk. Our data must be interpreted in the context of potential underestimation of pulmonary arterial systolic pressure in patients with severe TR.

398 CARDIAC MAGNETIC RESONANCE PHENOTYPE AND GENOTYPE IN LEFT-SIDED CARDIOMYOPATHIES: CHARACTERIZATION AND CLINICAL OUTCOMES

Background

The combined prognostic role of cardiac magnetic resonance (CMR) and genotype in cardiomyopathies has not been fully investigated. The aim of this study was to identify specific genotype-CMR phenotype correlations in a well-characterized cohort of patients with a spectrum of left-sided cardiomyopathies spanning from arrhythmogenic (ACM) to dilated cardiomyopathy (DCM), and analyze patients’ outcome.

Methods and Results

One-hundred and seventy-four patients with DCM (127) and left sided ACM (47), who underwent a comprehensive evaluation including genetic testing and CMR imaging, were enrolled in this study. The phenotype was classified as DCM or ACM according to current consensus criteria. The primary outcome was a composite of sudden cardiac death/life-threatening ventricular arrhythmias (SCD/MVA). DCM patients showed more frequently pathogenic or likely pathogenic (P/LP) variants of non-arrhythmic genes (34% vs. 7%, p &lt; 0.001), whereas ACM patients reported more frequently P/LP variants of arrhythmic genes (47% vs. 8%, p &lt; 0.001) and non-ischemic free-wall LGE (30% vs. 10%, p = 0.002). After a median follow-up of 92 months (interquartile range 46 - 168), 39 patients (22%) reached the combined endpoint. Carrying a P/LP variant of arrhythmic genes (hazard ratio (HR) 2.2, 95% confidence interval (CI) 1.1 - 4.4, p = 0.024) along with presence of LGE (HR 4.5, 95% CI 1.99 - 11.5, p &lt; 0.001) were independently associated with the study endpoint.

Conclusion

In cohort of well-characterized left sided cardiomyopathies patients spanning from ACM to DCM, a P/LP variant of arrhythmic genes along with presence of LGE were independent predictors of SCD/MVA.

115 DIURETIC DOSE TRAJECTORIES IN DILATED CARDIOMYOPATHY: PROGNOSTIC IMPLICATIONS

Background

For patients with heart failure, prescription of loop diuretics (LD) and higher doses are associated with adverse prognosis. We investigated LD dose trajectories and their associations with outcomes in patients with dilated cardiomyopathy (DCM).

Methods

Associations between outcomes and both furosemide equivalent dose (FED) at enrolment and change in FED in the subsequent 24 months were evaluated. According to FED trajectory, patients were divided in i) dose↑ (FED increase by ≥50% or newly initiated); ii) dose↓ (FED decrease by ≥50%); iii) stable dose (change in FED by &lt;50%); iv) never-users. Primary outcome was all-cause-death/heart transplantation/ventricular-assist-device/heart failure hospitalization. Secondary outcome was all-cause-death/heart transplantation/ventricular-assist-device.

Results

Of 1,131 patients enrolled, 738 (65%) were prescribed LD at baseline. Baseline FED was independently associated with outcome (HR per 20mg increase: 1.12 [95% CI 1.04-1.22, p=0.003]. Of the 908 with information on FED within 24 months from enrolment, 31% were never-users; 29% dose↓; 26% stable dose and 14% dose↑. In adjusted models, compared to never-users, stable dose had a higher risk of primary outcome (HR 2.42 [95% CI: 1.19-4.93], p=0.015), while dose↑ had the worst prognosis (HR 2.76 [95% C.I. 1.27-6.03], p=0.011). The results were consistent for the secondary outcome. Compared to patients who remained on LD, discontinuation of LD (143, 24%) was associated with improved outcome (HR 0.43 [95% C.I. 0.28-0.65], p&lt;0.001).

Conclusions

In a large cohort of patients with DCM, LD use and increasing FED are powerful markers of adverse outcomes. Patients who never require LD have an excellent prognosis.

172 CLINICAL AND PROGNOSTIC IMPLICATIONS OF RV UPTAKE WITH RADIONUCLIDE SCINTIGRAPHY IN TRANSTHYRETIN CARDIAC AMYLOIDOSIS

Aims

The prognostic role of bone tracer uptake in transthyretin cardiac amyloidosis (ATTR-CA) is controversial. The study investigated the potential prognostic significance of biventricular (BiV) uptake in ATTR-CA.

Methods

Consecutive ATTR-CA patients who had cardiac scintigraphy with acquisition of planar and single-photon emission computed tomography (SPECT) images from the National Amyloidosis Centre (NAC) and four Italian centres were included. Planar BiV uptake was defined in presence of right ventricle (RV) uptake and graded in combination with SPECT imaging. The primary outcome was all-cause mortality.

Results

Among 1422 patients with ATTR-CA, BiV uptake was found in 85% of cases on planar scintigraphy and in 100% of cases on SPECT images. During a median follow-up of 39 months, BiV uptake at planar scintigraphy was associated with a higher all-cause mortality compared to isolated LV uptake (40.5% vs 10.7%, p&lt;0.001), whereas the Perugini scale was not (p=0.27 in grade 2 vs 3). At multivariable analysis, RV uptake at planar scintigraphy leading to BiV uptake (HR 2.80, p=0.001), together with higher age at diagnosis (HR 1.03, p=0.001), V122I TTR variant (HR 1.60, p=0.001), NAC ATTR Stage (HR 1.29, p=0.003), E/e’ (HR 1.02, p=0.044), right atrium area index (HR 1.04, p=0.018) and GLS (HR 1.05, p=0.003) were independently associated with all-cause death. At time-dependent ROC curve analysis, the addition of planar BiV uptake to the NAC stage resulted in improved accuracy of the model for prediction of all-cause death (from AUC 0.74 to 0.79; p&lt;0.001).

Conclusions

Planar RV uptake leading to BiV uptake identified ATTR-CA patients with worse outcome, potentially serving as a novel prognostic marker.

207 RE-DEFINING ARRHYTHMOGENIC CARDIOMYOPATHY: CHARACTERIZATION AND LONG-TERM PROGNOSTIC IMPLICATIONS

Background

Arrhythmogenic dilated cardiomyopathy (AR-DCM) combines phenotypical aspects of dilated cardiomyopathy (DCM) and risk of sudden cardiac death (SCD), typical of the arrhythmogenic form (ACM). However, AR-DCM is often ambiguously defined leaving clinicians uncertain on how to identify these high-risk patients.

The aims of the study were to re-define AR-DCM based on outcome related arrhythmic markers and to test the usefulness of the novel AR-DCM definition in identifying arrhythmogenic genotypes (i.e., LMNA, FLNC, RBM20, and desmosomal genes).

Materials and methods

Consecutive DCM patients with genetic evaluation and Holter ECG monitoring or telemetry in two referral institution were analyzed. The arrhythmic markers tested to define AR-DCM were: SCD or major ventricular arrhythmias (MVA), unexplained syncope, rapid nonsustained ventricular tachycardia (nsTV), ≥1000 premature ventricular contractions/24 hours, or ≥50 ventricular couplets/24 hours. Patients were labeled as Early AR-DCM if criteria were met within 12 months from enrolment. The primary endpoint was a composite of SCD/MVA; the secondary endpoint was a composite of all-cause mortality/heart transplant/LVAD implantation (D/HTx/LVAD).

Results

Among the 743 DCM patients included, 290 had disease-related variants (39%), 94 (30%) of these carried arrhythmogenic genotype. Early AR-DCM was identified in 429 (58%) patients. During a median follow-up of 7.0 [2.2-13.8] years, among arrhythmic markers the occurrence of syncope and/or nsVT within 12 months from enrolment were the only arrhythmic markers independently associated with SCD/MVA (Figure), while the occurrence of early MVA and/or nsTV emerged as the strongest long-term predictors of D/ HTx/LVAD. Family history of MVA was also independently associated with primary and secondary endpoints, and together with MVA, nsTV or unexplained syncope increased the agreement between AR-DCM and arrhythmogenic genotypes in 1 out 2 patients.

Conclusions

A combination of early (i.e., within 1 year from diagnosis) MVA or nsVT or unexplained syncope might be proposed as a clinically useful new definition of AR-DCM, especially if associated to family history of MVA. This definition in fact allows clinicians to anticipates worse long-term arrhythmic and global outcomes, and to accurately identify malignant arrhythmogenic genotypes.

472 PROGNOSTIC VALUE OF CPET REPETITION DURING FOLLOW-UP OF DILATED CARDIOMYOPATHY

Background

although cardiopulmonary exercise testing (CPET) is a recognized tool for prognostic stratification in patients with dilated cardiomyopathy (DCM), there are no data about the prognostic value of its repetition during follow-up in this setting. The aim of this study was to test the prognostic value of repeating CPET during follow-up, among a large cohort of DCM patients.

Methods

in this multicenter, retrospective study, we analyzed DCM patients who consecutively performed at least two CPET during a clinical stable phase of disease. All patients performed CPET and echocardiogram within 10 days. The study end-point was a composite of death from all causes, heart transplantation, implantation of durable left ventricular assist device, life-threatening ventricular arrhythmias or hospitalization for HF.

Results

216 DCM patients were enrolled (52±12 years, 78% male, NYHA I-II 82%, LVEF 32±9%, 94% on ACE inhibitors, 95% on beta-blockers); the duration of the disease at the time of first CPET was 68 months. The interval between the two CPETs was 15 (11;23) months. During a median follow-up of 38 months from the second CPET, 108 (47%) patients went through the end-point. Time-dependent ROC curves revealed that to repeat during a follow-up of 12 months both CPET and echocardiogram gives a more accurate prognostic stratification than basal echocardiography + basal CPET. Despite an higher AUC (0.91 vs 0.85) there were no significant different accuracies (95% CI: 83.6 - 98 vs 75.5–96.5; p-value: 0.2) between the repetition of CPET plus echocardiogram vs. the repetition of the echocardiogram alone. Among patients who experienced the study outcome, there was a substantial stability of echocardiographic values (relative variation of LVEF +2.7%, LVEDV +1.3%) but a significant worsening of functional capacity (relative variation of percentage predicted VO2 peak +6%, p-value: 0.002). Conversely, there were a significant improvement in echocardiographic values and CPET values in events-free patients (LVEF relative variation -8.6% p-value: 0.002; ppVO2 peak relative variation -6.8%, p-value: 0.002).

Conclusion

in a large population of clinically stable DCM patients, the systematic repetition of echocardiography or both CPET and echocardiography showed no significant prognostic impact, in presence of stable or worsened echocardiogram. Nevertheless, when there is a clinical variation of symptoms or a failing in the reverse remodeling process, 1-year repetition of CPET can identify higher risk patients.

Using marginal structural joint models to estimate the effect of a time-varying treatment on recurrent events and survival: An application on arrhythmogenic cardiomyopathy

In many clinical applications to evaluate the effect of a treatment, randomized control trials are difficult to carry out. On the other hand, clinical observational registries are often available and they contain longitudinal data regarding clinical parameters, drug therapies, and outcomes. In the past, much research has addressed causal methods to estimate treatment effects from observational studies. In the context of time-varying treatments, marginal structural models are often used. However, most analyses have focused on binary outcomes or time-to-the-first event analyses. The novelty of our approach is to combine the marginal structural methodology with the case where correlated recurrent events and survival are the outcomes of interest. Our work focuses on solving the nontrivial problem of defining the measures of effect, specifying the model for the time-dependent weights and the model to estimate the outcome, implementing them, and finally estimating the final treatment effects in this life-history setting. Our approach provides a strategy that allows obtaining treatment effect estimates both on the recurrent events and the survival with a clear causal and clinical interpretation. At the same time, the strategy we propose is based on flexible modeling choices such as the use of joint models to capture the correlation within events from the same subject and the specification of time-dependent treatment effects. The clinical problem which motivated our work is the evaluation of the treatment effect of beta-blockers in arrhythmogenic right ventricular cardiomyopathy (ARVC/D), and the dataset comes from the Trieste Heart Muscle Disease Registry.

Natural history and clinical parameters of chemotherapy-induced dilated cardiomyopathy

Background

Chemotherapy-induced dilated cardiomyopathy (CI-DCM) is a well-recognized phenotype of non-ischemic dilated cardiomyopathy (DCM), characterized by poor outcomes. However, a detailed comparison between idiopathic DCM (iDCM) and CI-DCM is still lacking.

Methods

All consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry were analyzed. CI-DCM and iDCM were defined according to current recommendations. The primary study outcome measure was all-mortality death and secondary outcomes were a) a composite of cardiovascular death/heart-transplantation/ventricular-assist-device implantation, and b) major ventricular arrhythmias.

Results

The study included 551 patients (499 iDCM and 52 CI-DCM). At enrolment, compared to iDCM, CI-DCM patients were older (51±14 years vs 58±3 years respectively, p&lt;0.001) and had a higher left ventricular ejection fraction (35%±10 vs 32%±9, p=0.03). Over a median follow-up of 90 months (IQR 54–140 months), CI-DCM patients had a higher incidence of all-cause mortality compared to iDCM (36.5% vs 8.4% in CI-DCM and iDCM respectively, p&lt;0.001), while the incidence of major ventricular arrhythmias was higher in the iDCM group compared to CI-DCM (4% vs 0%, in CI-DCM and iDCM respectively, p=0.03). The risk of the composite outcome was comparable between the two groups (p=0.91). At Cox multivariable analysis, the diagnosis of CI-DCM emerged as independently associated to primary outcome (HR 6.42, 95% CI 2.52–16.31, p&lt;0.001).

Conclusions

In a well-selected DCM cohort, patients with a chemotherapy-induced aetiology had a higher incidence of all-cause mortality compared to iDCM. Conversely, the incidence of life-threatening ventricular arrhythmic events was higher among patients with iDCM.

Funding Acknowledgement

Type of funding sources: None.

Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF

BACKGROUND

Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular ejection fraction (LVEF) relies mostly on late gadolinium enhancement (LGE) characterization. Left ventricular peak global longitudinal strain (LV-GLS) measured by feature tracking analysis might improve prognostication of AM presenting with normal LVEF.

METHODS

Data of patients undergoing cardiac magnetic resonance (CMR) for clinically suspected AM in seven European Centres (2013-2020) were retrospectively analysed. Patients with AM confirmed by CMR and LVEF ≥50% were included. LGE was visually characterized: localized versus. non-localized, subepicardial versus midwall. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including cardiac death, life-threatening arrhythmias, development of heart failure or of LVEF <50%.

RESULTS

Of 389 screened patients, 256 (66%) fulfilled inclusion criteria: median age 36 years, 71% males, median LVEF 60%, median LV-GLS -17.3%. CMR was performed at 4 days from hospitalization. At 27 months, 24 (9%) patients experienced ≥1 ACE (71% developed LVEF <50%). Compared to the others, they had lower median LV-GLS values (-13.9% vs. -17.5%, p = .001). At Kaplan-Meier analysis, impaired LV-GLS (both considered as > -20% or quartiles), non-localized and midwall LGE were associated with ACEs. Patients with LV-GLS ≤-20% did not experience ACEs. LV-GLS remained associated with ACEs after adjustment for non-localized and midwall LGE.

CONCLUSION

In AM presenting with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE characterization, improving risk stratification and representing a rationale for further studies of therapy in this cohort.

Sex differences in natural history of cardiovascular magnetic resonance- and biopsy-proven lymphocytic myocarditis

AIMS

The role of sex in determining the profile and the outcomes of patients with myocarditis is largely unexplored. We evaluated the impact of sex as a modifier factor in the clinical characterization and natural history of patients with definite diagnosis of myocarditis.

METHODS AND RESULTS

We retrospectively analysed a single-centre cohort of consecutive patients with definite diagnosis of myocarditis (i.e. endomyocardial biopsy or cardiac magnetic resonance proven). Specific sub-analyses were performed in cohorts of patients with chest pain, ventricular arrhythmias, and heart failure as different main symptoms at presentation. The primary outcome measure was a composite of all-cause mortality or heart transplantation (HTx). We included 312 patients, of which 211, 68% of the whole population, were males. Despite no clinically relevant differences found at baseline presentation, males had a higher indexed left ventricular end-diastolic volume (62 ± 23 mL/m2 vs. 52 ± 20 mL/m2, P = 0.011 in males vs. females, respectively) at follow-up evaluation. At a median follow-up of 72 months, 36 (17%) males vs. 8 (8%) females experienced death or HTx (P = 0.033). Male sex emerged as predictors of all-cause mortality or HTx in every combination of covariates (HR 2.600; 1.163-5.809; P = 0.020). Results were agreeable regardless of the main symptom of presentation.

CONCLUSIONS

In a large cohort of patients with definite diagnosis of myocarditis, females experienced a more favourable long-term prognosis than males, despite a similar clinical profile at presentation.

Clinical characterization and natural history of chemotherapy-induced dilated cardiomyopathy

AIMS

Chemotherapy-induced dilated cardiomyopathy (CI-DCM) is a well-recognized phenotype of non-ischemic dilated cardiomyopathy (DCM), characterized by poor outcomes. However, a detailed comparison between idiopathic DCM (iDCM) and CI-DCM is still lacking.

METHODS AND RESULTS

All consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry were analysed. CI-DCM and iDCM were defined according to current recommendations. The primary study outcome measure was all-mortality death and secondary outcomes were a) a composite of cardiovascular death/heart-transplantation/ventricular-assist-device implantation, and b) major ventricular arrhythmias. The study included 551 patients (499 iDCM and 52 CI-DCM). At enrolment, compared with iDCM, CI-DCM patients were older (51 ± 14 years vs. 58 ± 3 years, respectively, P < 0.001) and had a higher left ventricular ejection fraction (32% ± 9 vs. 35% ± 10, respectively, P = 0.03). Over a median follow-up of 90 months (IQR 54-140 months), CI-DCM patients had a higher incidence of all-cause mortality compared with iDCM (36.5% vs. 8.4% in CI-DCM and iDCM respectively, P < 0.001), while the incidence of major ventricular arrhythmias was higher in the iDCM group compared with CI-DCM (4% vs. 0%, in CI-DCM and iDCM respectively, P = 0.03). The risk of the composite outcome was comparable between the two groups (P = 0.91). At Cox multivariable analysis, the diagnosis of CI-DCM emerged as independently associated to primary outcome (HR 6.42, 95% C.I. 2.52-16.31, P < 0.001).

CONCLUSIONS

In a well-selected DCM cohort, patients with a chemotherapy-induced aetiology had a higher incidence of all-cause mortality compared with iDCM. Conversely, the incidence of life-threatening ventricular arrhythmic events was higher among patients with iDCM.

P356 PREVALENCE AND PROGNOSTIC IMPACT OF LIPID GOAL ATTAINMENT AND PATIENT ADHERENCE TO LOWERING LIPID TREATMENT: DATA FROM COMMUNITY ITALIAN SETTING

Aims

The aim of the study was to provide real–world data on low–density lipoprotein cholesterol (LDL–C) goal achievement at the time of current 2019 ESC/EAS Guidelines, treatment patterns and patient adherence to lowering lipid treatment (LLT).

Methods and Results

This community–based study identified patients with at least one LDL–C measurement and cardiological evaluation from 01–Jan–2016 to 31–Dec–2018. Patients risk stratification and LDL–C target achievement were assessed according to 2019 EAS/ESC guidelines. To identify the proportion of patients at LDL–C target, only patients with an available LDL–C evaluation after 1 year from baseline were considered (7317 patients, 51% of initial cohort 14317 pts). Of those, 492 pts (7%) presented LDL–C at target. Among them, 187 were at very high risk (4% of very high risk subgroup) and 47 at high risk (3% of high risk subgroup). Statin intolerance was reported in 7,5% of patients (1073 out of 14317). The adherence evaluation was performed in patients having 1–year of follow–up and at least one statin purchase. It was estimated through the Proportion of Days Covered (PDC), defining as adherent patients with a PDC value ≥ 75%. 8332 (58% of initial cohort 14317 pts) met the selection criteria for PDC calculation. Of those, 3346 (40%) patients resulted as adherent (46% and 22% in very high e high CV risk categories). In a multivariable Cox regression model, adjusted for age, sex, risk factors and comorbidities, patients adherence emerged as a protective factor (HR 0.62; 95% CI 0.43–0.89; p = 0,010).

Conclusion

In a real–world setting, the achievement of LDL–C target and patient adherence was suboptimal across different CV risk categories. In a full adjusted survival model, patient adherence was independently associated with a prognosis improvement.

C65 POST–DISCHARGE ARRHYTHMIC RISK STRATIFICATION OF PATIENTS WITH ACUTE MYOCARDITIS AND LIFE–THREATENING VENTRICULAR TACHYARRHYTHMIAS

Aims

The outcomes of patients presenting with acute myocarditis and life–threatening ventricular arrhythmias (LT–VA) are unclear. The aim of this study was to assess the incidence and predictors of recurrent major arrhythmic events (MAEs) after hospital discharge in this patient population.

Methods and Results

We retrospectively analysed 156 patients (median age 44 years; 77% male) discharged with a diagnosis of acute myocarditis and LT–VA from 16 hospitals worldwide. Diagnosis of myocarditis was based on histology or the combination of increased markers of cardiac injury and cardiac magnetic resonance (CMR) Lake Louise criteria. MAEs were defined as the relapse, after discharge, of sudden cardiac death or successfully defibrillated ventricular fibrillation, or sustained ventricular tachycardia (sVT) requiring implantable cardioverter–defibrillator therapy or synchronized external cardioversion. Median follow–up was 23months [first to third quartile (Q1–Q3) 7–60]. Fifty–eight (37.2%) patients experienced MAEs after discharge, at a median of 8 months (Q1–Q3 2.5–24.0 months; 60.3% of MAEs within the first year). At multivariable Cox analysis, variables independently associated with MAEs were presentation with sVT [hazard ratio (HR) 2.90, 95% confidence interval (CI) 1.38–6.11]; late gadolinium enhancement involving ≥2 myocardial segments (HR 4.51, 95% CI 2.39–8.53), and absence of positive short–tau inversion recovery (STIR) (HR 2.59, 95% CI 1.40–4.79) at first CMR.

Conclusions

In this international multicentre study, patients discharged free from HTx or LVAD after an acute myocarditis complicated by LT–VA had a recurrence of MAEs during follow–up of 37.2%, after a median time of 8 months. Initial CMR pattern and sVT at presentation stratify the risk of arrhythmia recurrence.

C67 CARDIOVASCULAR RISK CLASSIFICATION AND LIPID LOWERING TREATMENT PRESCRIPTIONS IN A REAL–WORLD: INSIGHT FROM ITALIAN COMMUNITY COHORT

Background

Lipid lowering treatment (LLT) and LDL–C target across CV risk categories might prompt consideration on further lower LDL–C levels advocated by last EAS/ESC guidelines.

Aim

The aim of the study was to provide current prevalence, clinical characteristics, LLT across different CV risk classes at the time of publication of current ESC/EAS Guidelines. Short–term prognosis was also addressed.

Methods and Results

This community–based study enrolled 6851 patients (mean age 71 years) with an LDL–C measurement and cardiological evaluation from 01–Jan–2018 until 31–Dec–2018. Of those, 4578 (67%) patients were at very high risk, 1494 (22%) at high risk, 420 (6%) at moderate risk, and 359 (5%) at low risk according to EAS/ESC 2019 guidelines. Dyslipidemia was present in three quarter of patients, and 3888 (57%) received LLT. High Efficacy (potency to reduce LDL–C ≥ 50%) LLT was prescribed in 21% of patients (23% and 10% in very high and high risk categories). There was a statistically significant difference between CV categories with respect to demographic, CV risk factors, and comorbidities. Patients at very high risk were more frequently elderly with a high proportion of patients affected by atherosclerotic CVD (ASCVD) and non–cardiac comorbidities. 394 (9%) patients at very high risk and 102 (7%) patients at high risk presented LDL–C at target. Among very high risk patients, 439 (10%) were treated with ezetimibe. At 24 months of follow–up, death occurred in 676 (8%) patients. In survival curves, adjusted for age and comorbidities, an increased risk of death and CV hospitalization was confirmed in the high risk and very high risk categories. Similar trend was confirmed considering composite endpoint of myocardial infarction and stroke.

Conclusion

In a contemporary population the strategy to achieve the ambitious LDL–C target of current Guidelines continue to be largely suboptimal and LLT is widely underused. This underlines the huge unmet need when assessed more aggressive LDL–C target advocated in current EAS/ESC guidelines.

P319 SOMETHING MORE OF SIMPLE CARDIAC CONDUCTION DISORDERS

Background

Cardiac amyloidosis (CA) is an infiltrative disease caused by extracellular deposition of amyloid fibrils. Possible cardiac manifestations include heart failure with preserved ejection fraction (EF), aortic valve stenosis, microvascular coronary artery disease, atrial fibrillation (AF), ventricular arrhythmias, and cardiac conduction disorders (CCD). We report a case of advanced CCD in a patient first diagnosed with wild–type transthyretin amyloidosis (ATTRwt).

Case Report

An 88–year–old man went to Emergency Room for chest pain with minimal elevation of troponin I and increase in NTproBNP. The patient reported a recent syncope with ribs fractures. The medical history showed hypertension, paroxysmal AF, carotid atherosclerosis, vascular encephalopathy and prostate cancer. Troponin I monitoring showed plateau values and there were no clinical signs of heart failure. ECG showed regular sinus rhythm with marked first degree atrioventricular block, right bundle branch block and left anterior fascicular block (Fig. 1A). Cardiac telemetry recorded brief phases of atrioventricular dissociation (AVD). Transthoracic echocardiography showed severe left ventricular concentric hypertrophy (LVCH) with granular–sparkling appearance and preserved EF, reduced global longitudinal strain with apical sparing (Fig. 1B), mitral–aortic valve degeneration and dilation of the ascending aorta. Given the advanced CCD with AVD and the recent syncope, the patient underwent a dual–chamber pacemaker implantation. In consideration of the echocardiographic suspicion of CA, following Gillmore’s diagnostic algorithm (GDA), serum electrophoresis and assay of serum free light chains were performed and resulted normal, while 99mTc–DPD bone scintigraphy was positive for significant radiotracer cardiac uptake (Perugini grade 3) (Fig. 1C). Based on this result, we carried out the search for transthyretin gene mutations which resulted negative, and therefore the diagnosis of ATTRwt was made.

Discussion

Advanced CCD in patients with transthyretin CA are present in about 9.5% of cases at the time of diagnosis, especially in older patients. It is therefore essential, in case of concomitant LVCH, to suspect the presence of CA as the cause of CCD by searching for the disease red flags and following the GDA to non–invasively confirm or exclude the diagnosis of CA. A correct and timely diagnosis of CA makes it possible to treat the disease and its complications, improving the prognosis.

Incidence and Risk Factors for Pacemaker Implantation in Light Chain and Transthyretin Cardiac Amyloidosis

AIMS

The incidence and risk factors of pacemaker (PM) implantation in patients with cardiac amyloidosis (CA) are largely unexplored. We sought to characterise the trends in the incidence of permanent PM and to identify baseline predictors of future PM implantation in light chain (AL) and transthyretin (ATTR) CA.

METHODS AND RESULTS

Consecutive patients with AL and ATTR-CA diagnosed at participating Centres (2017-2020) were included. Clinical data recorded within ±1 month from diagnosis were collected from electronic medical records. The primary study outcome was the need for clinically-indicated PM implantation. Patients with PM (n = 41) and/or permanent defibrillator in situ (n = 13) at CA diagnosis were excluded. The study population consisted of 405 patients: 29.4% AL, 14.6% variant ATTR and 56% wild-type ATTR; 82.5% were males, median age 76 years. During a median follow-up of 33 months (interquartile range 21-46), 36 (8.9%) patients experienced the primary outcome: 10 AL-CA, 2 variant ATTR-CA and 24 wild-type ATTR-CA (p = 0.08 at time-to-event analysis). At multivariable analysis, history of atrial fibrillation (hazard ratio [HR] 3.80, p = 0.002), PR interval (HR 1.013, p = 0.002) and QRS >120 ms (HR 4.7, p = 0.001) on baseline ECG were independently associated with PM implantation. The absence of these 3 factors had a negative predictive value of 92% with an area under the curve of 91.8% at 6 months.

CONCLUSION

In a large cohort of AL and ATTR-CA patients, 8.9% implanted a PM in the 3 years following diagnosis. History of atrial fibrillation, PR >200 ms and QRS >120 ms predicted future PM implantation.

Prevalence and prognostic significance of ischemic late gadolinium enhancement pattern in non-ischemic dilated cardiomyopathy

BACKGROUND

Typical late gadolinium enhancement (LGE) patterns in dilated cardiomyopathy (DCM) include intramyocardial and subepicardial distribution. However, the ischemic pattern of LGE (subendocardial and transmural) has also been reported in DCM without coronary artery disease (CAD), but its correlates and prognostic significance are still not known. On these bases, this study sought to describe the prevalence and prognostic significance of the ischemic LGE pattern in DCM.

METHODS

A total of 611 DCM patients with available cardiac magnetic resonance were retrospectively analyzed. A composite of all-cause-death, major ventricular arrhythmias (MVAs), heart transplantation (HTx) or ventricular assist device (VAD) implantation was the primary outcome of the study. Secondary outcomes were a composite of sudden cardiac death or MVAs and a composite of death for refractory heart failure, HTx or VAD implantation.

RESULTS

Ischemic LGE was found in 7% of DCM patients without significant CAD or history of myocardial infarction, most commonly inferior/inferolateral/anterolateral. Compared to patients with non-ischemic LGE, those with ischemic LGE had higher prevalence of hypertension and atrial fibrillation or flutter. Ischemic LGE was associated with worse long-term outcomes compared to non-ischemic LGE (36% vs 23% risk of primary outcome events at 5 years respectively, P = .006), and remained an independent predictor of primary outcome after adjustment for clinically and statistically significant variables (adjusted hazard ratio 2.059 [1.055-4.015], P = .034 with respect to non-ischemic LGE).

CONCLUSIONS

The ischemic pattern of LGE is not uncommon among DCM patients without CAD and is independently associated with worse long-term outcomes.

Association of Titin Variations With Late-Onset Dilated Cardiomyopathy

IMPORTANCE

Dilated cardiomyopathy (DCM) is frequently caused by genetic factors. Studies identifying deleterious rare variants have predominantly focused on early-onset cases, and little is known about the genetic underpinnings of the growing numbers of patients with DCM who are diagnosed when they are older than 60 years (ie, late-onset DCM).

OBJECTIVE

To investigate the prevalence, type, and prognostic impact of disease-associated rare variants in patients with late-onset DCM.

DESIGN, SETTING, AND PARTICIPANTS

A population of patients with late-onset DCM who had undergone genetic testing in 7 international tertiary referral centers worldwide were enrolled from March 1990 to August 2020. A positive genotype was defined as the presence of pathogenic or likely pathogenic (P/LP) variants.

MAIN OUTCOMES AND MEASURES

The study outcome was all-cause mortality.

RESULTS

A total of 184 patients older than 60 years (103 female [56%]; mean [SD] age, 67 [6] years; mean [SD] left ventricular ejection fraction, 32% [10%]) were studied. Sixty-six patients (36%) were carriers of a P/LP variant. Titin-truncating variants were the most prevalent (present in 46 [25%] of the total population and accounting for 46 [69%] of all genotype-positive patients). During a median (interquartile range) follow-up of 42 (10-115) months, 23 patients (13%) died; 17 (25%) of these were carriers of P/LP variants, while 6 patients (5.1%) were genotype-negative.

CONCLUSIONS AND RELEVANCE

Late-onset DCM might represent a distinct subgroup characterized by and a high genetic variation burden, largely due to titin-truncating variants. Patients with a positive genetic test had higher mortality than genotype-negative patients. These findings support the extended use of genetic testing also in older patients.

Prognostic Significance of Feature-Tracking Right Ventricular Global Longitudinal Strain in Non-ischemic Dilated Cardiomyopathy

Aims: Left ventricular global longitudinal strain (GLS) by cardiac magnetic resonance feature tracking (CMR-FT) analysis has shown an incremental prognostic value compared to classical parameters in non-ischemic dilated cardiomyopathy (NICM). However, less is known about the role of right ventricular (RV) GLS. Our objective was to evaluate the prognostic impact of RV-GLS by CMR-FT analysis in a population of NICM patients.

Methods: In this multicenter study, we examined NICM patients evaluated with a comprehensive CMR-FT study. Major cardiac events (MACEs) were considered as the study primary outcome measure and were defined as a composite of (a) cardiovascular death, (b) cardiac transplant or destination therapy ventricular assist device, (c) hospitalization for life-threatening ventricular arrhythmias or implantable cardiac defibrillator appropriate intervention. Heart failure (HF) related events, including hospitalizations and life-threatening arrhythmia-related events were considered as secondary end-points. Receiver operating time-dependent analysis were used to calculate the possible additional effect of RV-GLS to standard evaluation.

Results: We consecutively enrolled 273 patients. During a median follow-up of 39 months, 41 patients (15%) experienced MACEs. RV-GLS and LV late gadolinium emerged as the strongest prognostic CMR-FT variables: their association provided an estimated 3-year MACEs rate of 29%. The addition of RV-GLS significantly improved the prognostic accuracy in predicting MACEs with respect to the standard evaluation including LGE (areas under the curve from 0.71 [0.66–0.82] to 0.76 [0.66–0.86], p = 0.03). On competing risk analysis, RV-GLS showed a significant ability to reclassify overall both HF-related and life-threatening arrhythmia-related events, regardless of LV and RV ejection fraction.

Conclusions: In NICM patients, RV-GLS showed a significant prognostic role in reclassifying the risk of MACEs, incremental with respect to standard evaluation with standard prognostic parameters.

362 Trends in the use/non-use of guideline-directed medical therapy in non-ischaemic dilated cardiomyopathy with improved ejection fraction

Aims

Guideline-directed medical therapy (GDMT) is associated with significant improvement of left ventricular function in an important fraction of patients with non-ischaemic dilated cardiomyopathy (NICM), and the recent definition of heart failure with improved ejection fraction (HFimpEF) highlights the importance of longitudinal assessment of left ventricular ejection fraction (LVEF); however, little is known about the long-term outcome of GDMT downtitration in patients with NICM who develop HFimpEF. We sought to assess the functional and prognostic impact of GDMT downtitration in this subgroup.

Methods and results

All consecutive NICM patients enrolled from 1991 to 2018 in the Trieste Heart Muscle Disease Registry with baseline LVEF ≤40% and with ≥1 LVEF assessment after baseline were included. ImpEF was defined as a baseline LVEF ≤40%, a ≥ 10 point increase from baseline LVEF, and a second measurement of LVEF &gt;40%. GDMT downtitration was defined as any dose reduction or drug withdrawal of renin-angiotensin system inhibitors (RASi) or beta-blockers (BB). The outcome measures were a loss of impEF criteria, a composite of all-cause death and heart transplantation (ACD/HTx), a composite of HF hospitalization, heart transplantation and left ventricular assist device (HFH/HTx/LVAD), and a composite of sudden death and major ventricular arrhythmias (SD/MVA). The prognostic role of GDMT downtitration was assessed with Kaplan–Meier analysis and curves of cumulative incidence, considering GDMT downtitration, loss of impEF, and the composites of outcome as time-dependent variables. Among 452 NICM patients with impEF, 186 (41.2%) downtitrated GDMT (median time to downtitration 35 months). Loss of impEF criteria occurred in 186 patients (median time to loss of impEF 51 months). While no significant differences in terms of ACD/HTx, HFH/HTx/LVAD, or SD/MVA among those who downtitrated GDMT and those who didn’t were observed, the population that downtitrated GDMT had a higher cumulative incidence of loss of impEF (P &lt; 0.001).

Conclusions

In NICM patients who develop impEF, we observed a ≈ 40% rate of recurrent decline of LVEF. GDMT downtitration seems to be associated with this functional deterioration, although no differences in terms of major cardiovascular outcomes emerged.

85 Diuretics trajectories in dilated cardiomyopathy

Aims

Diuretics in heart failure (HF) are commended to relieve symptoms at lowest dosage effective. Dilated cardiomyopathy (DCM) is a particular HF setting with several variables that may influence disease trajectory. We aimed to assess the long-term use of diuretics in DCM, the possibility of withdrawal and to explore the prognostic correlations.

Methods and results

All consecutive DCM patients enrolled from 1990 to 2018 were considered eligible. All the patients had available the information about the furosemide-equivalent dose at baseline and at follow-up evaluation within 24 months. Patients were categorized in stable (diuretic dose variation &lt;50%), increasers (diuretics dose increase ≥50% or initiation of diuretic therapy), and decreasers (diuretics dose decrease ≥50% or never prescribed diuretics in the 24-months observation period). The prognostic role of the diuretics trajectory group was assessed with Kaplan Meier analysis and with a time-dependent multivariable model. The outcome measure was a composite of all-cause death/heart transplantation/HF hospitalization (ACD/HTx/HFH). 908 patients were included [mean age 50 ± 16, 70% male sex, 24% NYHA class III or IV, mean left ventricular ejection fraction (LVEF) 31 ± 9%, 66% treated with diuretics at baseline]. The furosemide-equivalent dose at enrolment had a linear association with the risk of outcome. Compared to other groups, decreaser patients were younger, had less HF symptoms, higher LVEF and more dilated left atrium. Decreasers had a lower prescription rate of diuretics and less frequent indication to renin-angiotensin inhibitors and mineralocorticoid receptors antagonists. Over a median follow-up of 122 (62–195) months decreasers had the lowest incidence of outcome, followed by stable, while increasers had the worst outcome (P &lt; 0.001). After adjustment for other prognosticators, compared to stable patients, decreasers had a reduced risk of ACD/HTx/HFH [HR: 0.497 (95% CI: 0.337–0.731)] while increasers had the highest risk of adverse outcome [HR: 2.027 (95% CI: 1.254–3.276)]. Similarly, amongst patients taking diuretics at baseline, the diuretics withdrawal was in independent outcome predictor. The only multivariable predictors of diuretics withdrawal were younger age and lower furosemide-equivalent dose at enrolment.

Conclusions

In DCM patients the diuretics dose at baseline is a strong prognosticator. Diuretics dose reduction or its withdrawal provides a prognostic benefit on hard outcome. Diuretics tapering in selected patients should be considered in the short-term follow-up to improve DCM prognosis.

418 Titin mutations and female sex characterize dilated cardiomyopathy in the elderly

Aims

Dilated cardiomyopathy (DCM) is frequently caused by genetic factors. Studies identifying deleterious rare variants have predominantly focused on early-onset cases, and little is known about the genetic underpinnings of the growing numbers of patients with DCM who are diagnosed after 60 years of age (i.e. late-onset DCM). The aim is to investigate the prevalence, type, and prognostic impact of disease-associated rare variants in late-onset DCM patients.

Methods and results

We analysed a population of late-onset DCM patients who had undergone genetic testing in seven international tertiary referral centres worldwide. A positive genotype was defined as the presence of ‘pathogenic’ or ‘likely pathogenic’ (P/LP) variants. The study outcome was all-cause mortality. 184 patients over age 60 years (56% females, mean age 67 ± 6 years, mean left ventricular ejection fraction 32 ± 10%) were studied. Sixty-six patients (36%) were carriers of a P/LP variant. Titin truncating variants (TTNtv) were the most prevalent (present in 25% of the total population and accounting for 69% of all genotype-positive patients). During a median follow-up of 42 months (interquartile range: 10–115), 23 patients (13%) died; 17 of these (25%) were carriers of P/LP variants while six patients (5.1%) were genotype-negative (P &lt; 0.001).

Conclusions

In the largest series worldwide, to date, of patients with late-onset DCM, we found a high prevalence of female sex and a high genetic mutation burden, largely due to TTNtv. Patients with a positive genetic test had higher mortality than genotype-negative patients. These findings support the extended use of genetic testing also in the elderly.

86 STEMI and multivessel disease: medical therapy amplifies the benefit of complete myocardial revascularization

Aims

Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularization strategies. However, the potential predictors of outcomes on top of different revascularization strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularization strategies and the potential impact of medical therapy.

Methods and results

Using a propensity score approach, the impact of two treatment strategies was analysed—staged non-culprit revascularization group vs. culprit-lesion-only percutaneous coronary intervention (PCI) group—on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularization. Moreover, models were further adjusted for medication at discharge. Among 1385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21–65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularization group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24–0.82; P = 0.01), lower CVD (HR, 0.34; 95% CI, 0.14–0.82; P = 0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24–0.86; P = 0.02). Use of renin–angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27–0.95; P = 0.03), and both renin–angiotensin inhibitors (HR, 0.52; 95% CI, 0.32–0.86; P = 0.01) and beta blockers (HR, 0.48; 95% CI, 0.29–0.79; P = 0.01) were associated with lower all-cause death.

Conclusions

In a real-word STEMI population with multivessel disease, staged non-culprit revascularization was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularization and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularization.

379 Contemporary use of guideline directed medical therapy in dilated cardiomyopathy: therapeutic optimization and prognostic benefits

Aims

Therapy with antineurohormonal drugs at target doses has a prognostic benefits in heart failure with reduced ejection fraction. Dilated cardiomyopathy (DCM) represents a particular setting where the possible benefit of target doses of antineurohormonal drugs is unexplored.

Methods and results

All patients enrolled from 1/1/1992 to 1/3/2020 in the Trieste Muscle Heart Disease register affected by DCM with data on the dosage of therapy available both enrollment and at follow-up visit (i.e., 6–12 month) were included. The population was divided according to the percentage of recommended dose prescribed (0–49%, 50–99%, 100%) of both renin-angiotensin system inhibitors (RASi) and beta blockers (BB). A composite of death/heart transplant/hospitalization for heart failure was considered as the primary endpoint; a composite of sudden cardiac death/major ventricular arrythmias/defibrillator intervention was evaluated as a secondary endpoint. Prognostic associations were explored with uni- and multivariate analyses, Cox regressions, Kaplan–Meier, cumulative incidence curves and propensity score matching. 826 patients were included. At baseline 789 (96%) were taking a RASi and 627 (76%) a BB. The target dose of RASi was prescribed in 29% and 36% of patients at enrolment and at follow-up visit, respectively. The percentage of patients taking the maximum recommended dose of BB was 10% at baseline and 17% after optimization. Predictors of reaching target dose for RASi were BMI &lt; 25 kg/m2, male sex [HR: 1.798 (95% CI: 1.073–3.012), P = 0.026] and higher systolic blood pressure [HR per mmHg 1.038 (95% CI: 1.025–1.051), P &lt; 0.001]. Target dose predictors of BB were age [HR per year 0.527 (95% CI: 0.347–0.802), P = 0.003] and highest systolic blood pressure [HR per mmHg 1.024 (95% CI: 1.013–1.035), P &lt; 0.001]. After adjustment target dose of RASi or BB did not show a significant association with the risk of primary outcome occurrence compared to those taking less than 50% (P = 0.550 for RASi and P = 0.921 for BB). The incidence of arrhythmic events was significantly lower in patients taking 100% of recommended dose of BB compared to those taking less than 50% (P = 0.009), after adjustment for confounders. The target dose of RASi was not associated with an arrhythmic events risk change (P = 0.688).

Conclusions

In DCM a significant number of patients do not tolerate maximal therapy doses, mainly due to hypotension. The achievement of the target dose of RASi and BB, after adjustment for confounders had a neutral effect on the incidence of heart failure-related events. Uptitration of BB to the recommended dose has a strong protective effect on arrhythmic events.

73 Prevalence and prognostic significance of ischaemic late gadolinium enhancement pattern in non-ischaemic dilated cardiomyopathy

Aims

Typical late gadolinium enhancement (LGE) patterns in dilated cardiomyopathy (DCM) include intramyocardial and subepicardial distribution. However, the ischaemic pattern of LGE (subendocardial and transmural) has also been reported in DCM without coronary artery disease (CAD), but its correlates and prognostic significance are still not known. On these bases, this study sought to describe the prevalence and prognostic significance of the ischaemic LGE pattern in DCM.

Methods and results

611 DCM patients with available cardiac magnetic resonance were retrospectively analysed. A composite of all-cause-death, major ventricular arrhythmias (MVAs), heart transplantation (HTx) or ventricular assist device (VAD) implantation was the primary outcome of the study. Secondary outcomes were a composite of sudden cardiac death or MVAs and a composite of death for refractory heart failure, HTx or VAD implantation. Ischaemic LGE was found in 7% of DCM patients without significant CAD or history of myocardial infarction, most commonly inferior/inferolateral/anterolateral. Compared to patients with non-ischaemic LGE, those with ischaemic LGE had higher prevalence of hypertension and atrial fibrillation or flutter. Ischaemic LGE was associated with worse long-term outcomes compared to non-ischaemic LGE (36% vs. 23% risk of primary outcome events at 5 years, respectively, P = 0.006), and remained an independent predictor of primary outcome after adjustment for clinically and statistically significant variables [adjusted hazard ratio 2.059 (1.055–4.015), P = 0.034 with respect to non-ischaemic LGE].

Conclusions

The ischaemic pattern of LGE is not uncommon among DCM patients without CAD and is independently associated with worse long-term outcomes.

146 Prognostic significance of unexplained left ventricular hypertrophy in patients undergoing carpal tunnel surgery

Aims

Carpal tunnel (CT) syndrome is a recognized red-flag of cardiac amyloidosis (CA) and increased cardiovascular (CV) morbidity. We designed this study to characterize the CV profile of patients with CT syndrome at the time of first surgery and to identify high-risk presentations.

Methods and results

We retrospectively reviewed 643 patients who underwent CT surgery between 2007 and 2019. Of them, 130 patients (77 years, 45% males, LVEF 62%) with available CV characterization within ±12 months from CT surgery were included. Abnormal loading conditions causing cardiac hypertrophy (LVH) were investigated to distinguish explained LVH (Ex-LVH) from unexplained LVH (Un-LVH). The primary outcome of the study was all-cause mortality. The secondary outcome measures were the occurrence of (i) new-onset heart failure (HF) or worsening HF requiring hospitalization (HHF) or (ii) pacemaker implantation. New-onset HF was defined as the development of HF signs and symptoms requiring an unplanned cardiologic examination or hospitalization. Median follow-up was 63 months [interquartile range (IQR): 30–95]. LVH was found in 65 (50%) patients, 33% of them presented Un-LVH. Compared to the others, Un-LVH patients were older (77, 75 vs. 70 years in Un-LVH, Ex-LVH, and non-LVH, respectively; P = 0.002), had higher rates of ECG-echo discrepancy (70%, 14.3% and 1.6%, respectively; P &lt; 0.001) and of echocardiographic findings of CA (24%, 7%, and 0%, P &lt; 0.001). Among Un-LVH patients, 9 (43%) experienced death and 7 (33%) developed HF at 3.8 and 2.4 years from CT surgery, respectively. Compared to the others, death and HF development rates were higher in Un-LVH patients both at unadjusted (P = 0.01 and P = 0.02, respectively) and adjusted analysis for age, gender, and renal insufficiency (P = 0.00038 and P = 0.050, respectively).

Conclusions

At the time of CT surgery, Un-LVH was found in more than 30% of patients with LVH and 24% of them showed echocardiographic features suggesting an underdiagnosed CA. Un-LVH was associated with higher all-cause mortality and HF development.

303 Longitudinal arrhythmic risk assessment based on ejection fraction in patients with recent-onset non-ischaemic dilated cardiomyopathy

Aims

Practice guidelines suggest implantable cardioverter defibrillators (ICD) in patients with left ventricular ejection fraction (LVEF) ≤35% despite 3–6 months of guideline-directed medical therapy (GDMT). It remains unclear whether this strategy is appropriate for patients with dilated cardiomyopathy (DCM), who can experience reverse ventricular remodelling for up to 24 months after initiation of GDMT. We sought to assess the longitudinal dynamic relationship between LVEF ≤35% and arrhythmic risk in patients with recent onset non-ischaemic DCM under GDMT.

Methods and results

We performed a competitive risk analysis on patients with recent onset DCM (≤6 months) and recent initiation of GDMT (≤3 months), consecutively enrolled in a longitudinal registry. We assessed risk of major ventricular arrhythmic events or sudden cardiac death (MVAs/SCD) in relationship to LVEF ≤35% at enrollment, 6-months and 24-months post initiation of GDMT. 544 patients met inclusion criteria. LVEF ≤35% identified patients with increased risk of MVAs/SCD starting from 24-months after initiation of GDMT (hazards ratio: 2.126, 95% confidence interval: 1.065–4.245, P = 0.03). However, LVEF ≤35% at presentation or at 6 months post enrollment did not have prognostic significance. 67% of patients with LVEF ≤35% at 6 months after initiation of GDMT improved their LVEF to &gt; 35% by 24 months. This late LVEF improvement correlated with a lower arrhythmic risk (P = 0.012) and was preceded by a reduction of LV dimensions in the first 6 months of GDMT.

Conclusions

In patients with DCM, risk stratification based on LVEF ≤35% is effective after 2 years of GDMT, but not after 6 months.

423 Prevalence and prognostic significance of atrial arrhythmias in arrhythmogenic cardiomyopathy

Aims

Limited data are available concerning atrial arrhythmias (AA) role in arrhythmogenic cardiomyopathy (AC). The aim of the present study was to assess the prevalence and incidence of AA in a large cohort of AC patients and to evaluate its association with clinical outcomes.

Methods and results

We retrospectively analysed 115 patients with definite diagnosis of ARVC, according to 2010 Task Force Criteria, enrolled in the Trieste Heart Muscle Disease Registry. Subjects were further classified into two phenotypic variants, based on ventricular involvement: right-dominant and biventricular form. Uni- and multivariable, extended Kaplan-Meier and cumulative incidence function analysis were performed, as appropriate, for the primary composite endpoint of death and heart transplant (HTx) and for the two distinct secondary endpoints of: (i) death, HTx and first heart failure (HF) hospitalization; (ii) first major ventricular arrhythmias (MVA). Mean age of patients at the time of enrollment was 39 ± 16 years and 80% were male. 73 patients (63%) had a right-dominant form, while 42 (37%) presented a biventricular involvement. AA occurred in the 26% of our study population at baseline or during a median follow-up of 214 months (IQR: 105–311), with a non-significant trend in higher cumulative incidence of AA in patients with biventricular form. At baseline, patients experiencing AA were older (44 ± 18 vs. 37 ± 15 years, P = 0.044) and had larger atrial dimensions, in particular of the right atrium (RA) (23, IQR: 19–27 vs. 18, IQR: 15–25 cm2, P &lt; 0.007). AA emerged as independently associated to death/HTx (HR 2.68, 95% CI: 1.02–7.05, P = 0.046) along with NYHA class &gt;2 (HR: 7.08, 95% CI: 2.50–20.1, P &lt; 0.001) and RA area (HR: 1.05, 95% CI: 1.01–1.09, P = 0.011). Consistently, AA were also independently associated with the secondary endpoint of death/HTx/HF hospitalization (HR: 2.50, 95% CI: 1.06–5.88, P = 0.036), together with NYHA &gt;2, the presence of biventricular involvement, higher RA and left atrium area. Finally, AA did not emerge as independently correlated to MVA during follow-up.

Conclusions

This observational long-term study suggests that AA were common in patients with AC and were independently associated with poor outcomes, mostly related to HF events. A prompt identification throughout the follow-up of AA appears relevant in improving the clinical management of AC patients.

100 Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF

Aims

Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular (LV) ejection fraction (EF) relies mostly on late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) imaging. In this specific AM population, LV peak global longitudinal strain (LV-GLS) measured by feature tracking (FT) analysis might provide further prognostic information.

Methods and results

Data of patients undergoing CMR for clinically suspected AM in seven European Centres, between January 2013 and August 2020, were retrospectively analysed. Those patients fulfilling CMR Lake Louise Criteria (LLC) for the diagnosis of AM and presenting with normal LVEF (≥50%) were included. Patients presenting with heart failure (HF) or significant arrhythmic events, LVEF &lt;50% or haemodynamic instability were excluded. CMR-LGE extent (localized vs. diffuse), localization (subepicardial vs. mid-wall), and distribution (anteroseptal vs. inferolateral) were visually assessed. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including a composite of cardiac death, development of heart failure, life-threatening arrhythmias, or development of LVEF &lt;50%. In patients experiencing more than one event, the first one was considered for the outcome analysis. Of 389 patients with clinically suspected AM, 256 (66%) had confirmed AM with LVEF ≥50% and were included. Median age was 36 years, 71% were males, median LVEF was 60%, and median LV-GLS −17.3%. CMR was performed at a median time of 4 (IQR: 2–12) days from hospital admission. At a median follow-up of 27 months, 24 (9%) patients experienced at least one ACE with development of LVEF &lt;50% accounting for 17 [71%]. Compared to the others, patients experiencing ACEs had lower median LV-GLS values at baseline (−13.9% vs. −17.5%, P = 0.001). At Kaplan–Meier analysis, impaired LV-GLS (both considered as &gt;-20% or quartiles), diffuse and mid-wall LGE were associated with a significantly higher rate of ACEs. LV-GLS remained independently associated with ACEs after adjustment for diffuse or mid-wall LGE as covariate at bivariable analysis.

Conclusions

In AM with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE, improving risk stratification and providing a rationale for further studies of therapy in this cohort.

125 Sex differences in myocarditis natural history

Aims

The role of sex in determining the profile and the outcomes of patients with myocarditis is widely unexplored. Our study seeks to evaluate the impact of sex as a modifier factor in the clinical characterization and natural history of patients with definite diagnosis of myocarditis.

Methods and results

We retrospectively analysed a single-centre cohort of consecutive patients with definite diagnosis (i.e., endomyocardial biopsy or cardiac magnetic resonance proven) of myocarditis. A sub-analysis was performed after division of population according to the main symptom of presentation (i.e., chest pain, ventricular arrhythmias, and heart failure). Clinical and echocardiographic data were evaluated at diagnosis and at last available evaluation (i.e., median of 30 months). The study outcome measure was a composite of all-cause mortality or heart transplantation. We enrolled 312 patients (187; 60% presenting with chest pain; 19; 6% with ventricular arrhythmias; 106; 34% with heart failure). Most of patients (211, 68% of the whole population) were males, consistently in the three modes of presentation. Despite no clinically relevant differences were found at baseline presentation, males presented a larger indexed left ventricular end-diastolic volume (LVEDVi) (62 ± 23 vs. 52 ± 20, P = 0.011 in males vs. females respectively) at follow-up evaluation. At a median follow-up of 62 months, 36 (17%) males vs. females experienced death or heart transplantation (Log-rank P = 0.037). At multivariable Cox analysis, male sex emerged as a predictor of mortality (HR: 2.358; 1.044–5.322; P = 0.039 and left ventricular ejection fraction (LVEF) &lt; 50% (HR: 8.169; 1.226–54.425; P = 0.030)]. Results were consistent in patients presenting with heart failure and chest pain, while arrhythmic group was too small to be reliably interpreted.

Conclusions

In a large cohort of patients with definite diagnosis of myocarditis, females experienced a more favorable long-term prognosis than male, despite a similar clinical profile at baseline.

In vivo antimicrobial activity of 0.6% povidone-iodine eye drops in patients undergoing intravitreal injections: a prospective study

To investigate the antimicrobial activity of a preservative-free 0.6% povidone-iodine eye drop as an antiseptic procedure in decreasing the conjunctival bacterial load in eyes scheduled for intravitreal treatment and to compare its efficacy to the untreated fellow eye used as the control group. Prospective cohort analysis in which 208 patients received preservative-free 0.6% povidone-iodine eye drops three times a day for three days before intravitreal injection. Before and after the prophylactic treatment, a conjunctival swab was collected from both the study eye and the untreated contralateral eye, used as control. The swab was inoculated on different culture media and the colony-forming units were counted. Bacteria and fungi were identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Treatment with 0.6% povidone-iodine eye drops significantly reduced the conjunctival bacterial load from baseline (p < 0.001 for blood agar and p < 0.001 for chocolate agar) with an eradication rate of 80%. The most commonly isolated pathogen at each time-point and in both groups was coagulase-negative Staphylococci, isolated in 84% of the positive cultures. The study provides evidence about the effectiveness of 0.6% povidone-iodine eye drops treatment in reducing the conjunctival bacterial load in eyes scheduled for intravitreal treatment.

Supraventricular Tachycardia Causing Left Ventricular Dysfunction

There is limited evidence on characterization and natural history of supraventricular tachycardia (SVT)-induced left ventricular (LV) dysfunction. The aim of this work was to characterize clinical features and long-term evolution of SVT-induced LV dysfunction. Patients consecutively admitted with sustained SVT and heart rate >100 bpm as the only known cause of a new onset LV systolic dysfunction (i.e., LV ejection fraction [EF] <50%) were analyzed. Patients were then revaluated periodically. Recovered LVEF (i.e., ≥50%) and a composite of death, heart transplant or first episode of major ventricular arrhythmias were evaluated as study end-points. We enrolled 83 patients. After SVT therapy, 56 (67%) showed a recovered LVEF at the last follow-up of median 54 (interquartile range 36 to 87) months. Seventeen (30%) of those patients had a temporary new drop in LVEF during follow-up associated to high-rate SVT relapse. At presentation, patients with recovered LVEF were younger (52 vs 67 years respectively, p <0.001) and had higher LVEF (34% vs 27% respectively, p = 0.005) compared to non-recovered LVEF patients. Finally, 4% of recovered LVEF patients vs 26% of nonrecovered LVEF patients experienced death/heart transplant/major ventricular arrhythmias during follow-up (p = 0.004). In conclusion, after almost 5 years of follow-up, two-thirds of patients with high-rate SVT causing a newly diagnosed LV systolic dysfunction recovered and maintained normal LV function after SVT control, with a subsequent benign outcome. Long term individual surveillance is required in those patients, as arrhythmic recurrences and new drops in LVEF are common in the long term.

Prognostic significance of unexplained left ventricular hypertrophy in patients undergoing carpal tunnel surgery

Aims

Carpal tunnel (CT) syndrome is a recognized red‐flag of cardiac amyloidosis (CA) and increased cardiovascular (CV) morbidity. We designed this study to characterize the CV profile of patients with CT syndrome at the time of first surgery and to identify high‐risk presentations.

Methods and results

We retrospectively reviewed 643 patients who underwent CT surgery between 2007 and 2019. Of them, 130 patients (77 years, 45% male patients, left ventricular ejection fraction 62%) with available CV characterization within ±12 months from CT surgery were included. Abnormal loading conditions causing cardiac left ventricular hypertrophy (LVH) were investigated to distinguish explained LVH (Ex‐LVH) from unexplained LVH (Un‐LVH). LVH was found in 66 (51%) patients, 33% of them presented Un‐LVH. Compared with the others, Un‐LVH patients were older (77 and 75 vs. 70 years in Un‐LVH, Ex‐LVH, and non‐LVH, respectively; P = 0.002), had higher rates of electrocardiogram‐echo discrepancy (70%, 14.3%, and 1.6%, respectively; P < 0.001) and of echocardiographic findings of CA (24%, 7%, and 0%, P < 0.001). Among Un‐LVH patients, 9 (43%) experienced death and 7 (33%) developed heart failure (HF) at 3.8 and 2.4 years from CT surgery, respectively. Compared with the others, death and HF development rates were higher in Un‐LVH patients both at unadjusted (P = 0.01 and P = 0.02, respectively) and adjusted analysis for age, gender, and renal insufficiency (P = 0.00038 and P = 0.050, respectively).

Conclusions

At the time of CT surgery, Un‐LVH was found in more than 30% of patients with LVH, and 24% of them showed echocardiographic features suggesting an underdiagnosed CA. Un‐LVH was associated with higher all‐cause mortality and HF development.

Effectiveness of anti-vascular endothelial growth factors in neovascular age-related macular degeneration and variables associated with visual acuity outcomes: Results from the EAGLE study

Objective

To assess the overall effectiveness of anti-vascular endothelial growth factor (VEGF) therapy in treatment-naïve patients with neovascular age-related macular degeneration (nAMD) in a clinical practice setting.

Study design

EAGLE was a retrospective, 2-year, cohort observational, multicenter study conducted in Italy that analyzed secondary data of treatment-naïve patients with nAMD. The primary endpoint evaluated the mean annualized number of anti-VEGF injections at Years 1 and 2. The main secondary endpoints analyzed the mean change in visual acuity (VA) from baseline and variables associated with visual outcomes at Years 1 and 2.

Results

Of the 752 patients enrolled, 745 (99.07%) received the first dose of anti-VEGF in 2016. Overall, 429 (57.05%) and 335 (44.5%) patients completed the 1- and 2-year follow-ups, respectively. At baseline, mean (standard deviation, SD) age was 75.6 (8.8) years and the mean (SD) VA was 53.43 (22.8) letters. The mean (SD) number of injections performed over the 2 years was 8.2 (4.1) resulting in a mean (SD) change in VA of 2.45 (19.36) (P = 0.0005) letters at Year 1 and −1.34 (20.85) (P = 0.3984) letters at Year 2. Linear regression models showed that age, baseline VA, number of injections, and early fluid resolution were the variables independently associated with visual outcomes at Years 1 and 2.

Conclusions

The EAGLE study analyzed the routine clinical practice management of patients with nAMD in Italy. The study suggested that visual outcomes in clinical practice may be improved with earlier diagnosis, higher number of injections, and accurate fluid resolution targeting during treatment induction.

STEMI and Multivessel Disease: Medical Therapy Amplifies the Benefit of Complete Myocardial Revascularisation

BACKGROUND

Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularisation strategies. However, the potential predictors of outcomes on top of different revascularisation strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularisation strategies and the potential impact of medical therapy.

METHODS

Using a propensity score approach, the impact of two treatment strategies was analysed -staged non-culprit revascularisation group vs culprit-lesion-only percutaneous coronary intervention (PCI) group -- on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularisation. Moreover, models were further adjusted for medication at discharge.

RESULTS

Among 1,385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21-65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularisation group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24-0.82; p=0.01), lower CVD (HR, 0.34; 95% CI, 0.14-0.82; p=0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24-0.86; p=0.02). Use of renin-angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27-0.95; p=0.03), and both renin-angiotensin inhibitors (HR, 0.52; 95% CI, 0.32-0.86; p=0.01) and beta blockers (HR, 0.48; 95% CI, 0.29-0.79; p=0.01) were associated with lower all-cause death.

CONCLUSIONS

In a real-word STEMI population with multivessel disease, staged non-culprit revascularisation was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularisation and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularisation.

Impact on clinical outcomes of right ventricular response to percutaneous correction of secondary mitral regurgitation

AIMS

In patients with heart failure and reduced ejection fraction (HFrEF) and secondary mitral regurgitation (SMR), impaired right ventricular function (RVF) may negatively influence the prognosis. Percutaneous mitral valve repair (pMVR) can promote the recovery of RVF. We sought to characterize the response of the right ventricle to pMVR in HFrEF with SMR and to assess the association between improved RVF after pMVR and outcomes.

METHODS AND RESULTS

Overall, 221 patients with HFrEF and SMR ≥3+ successfully treated with pMVR in four tertiary care centres for heart failure were included. Improved RVF was defined as Δ right ventricular fractional area change (ΔRVFAC) ≥5% at early follow-up (median time 4 months). The primary endpoint was a composite of death/heart transplantation (D/HT). Mean age was 69 ± 11 years, mean left ventricular ejection fraction was 31 ± 8% and mean RVFAC was 34 ± 9%. ΔRVFAC ≥5% occurred in 88 patients (40%) and was independent of the measures of left ventricular reverse remodelling. During a median follow-up of 29 months (interquartile range 12-46), 81 patients (37%) reached the primary endpoint. After adjustment for other significant covariates, ΔRVFAC ≥5% was significantly associated with lower risk of D/HT (hazard ratio 0.52, 95% confidence interval 0.29-0.94, P = 0.030). In the secondary outcome analysis exploring the risk of heart failure hospitalizations, ΔRVFAC ≥5% confirmed the prognostic association with the endpoint.

CONCLUSIONS

In patients with HFrEF and SMR, about 40% of patients improved RVF after pMVR. RVF improvement was associated with better long-term survival free from HT and lower risk of heart failure hospitalization.

Interpretability of time-series deep learning models: A study in cardiovascular patients admitted to Intensive care unit

Interpretability is fundamental in healthcare problems and the lack of it in deep learning models is currently the major barrier in the usage of such powerful algorithms in the field. The study describes the implementation of an attention layer for Long Short-Term Memory (LSTM) neural network that provides a useful picture on the influence of the several input variables included in the model. A cohort of 10,616 patients with cardiovascular diseases is selected from the MIMIC III dataset, an openly available database of electronic health records (EHRs) including all patients admitted to an ICU at Boston's Medical Centre. For each patient, we consider a 10-length sequence of 1-hour windows in which 48 clinical parameters are extracted to predict the occurrence of death in the next 7 days. Inspired from the recent developments in the field of attention mechanisms for sequential data, we implement a recurrent neural network with LSTM cells incorporating an attention mechanism to identify features driving model's decisions over time. The performance of the LSTM model, measured in terms of AUC, is 0.790 (SD = 0.015). Regard our primary objective, i.e. model interpretability, we investigate the role of attention weights. We find good correspondence with driving predictors of a transparent model (r = 0.611, 95% CI [0.395, 0.763]). Moreover, most influential features identified at the cohort-level emerge as known risk factors in the clinical context. Despite the limitations of study dataset, this work brings further evidence of the potential of attention mechanisms in making deep learning model more interpretable and suggests the application of this strategy for the sequential analysis of EHRs.

Post-discharge arrhythmic risk stratification of patients with acute myocarditis and life-threatening ventricular tachyarrhythmias

AIMS

The outcomes of patients presenting with acute myocarditis and life-threatening ventricular arrhythmias (LT-VA) are unclear. The aim of this study was to assess the incidence and predictors of recurrent major arrhythmic events (MAEs) after hospital discharge in this patient population.

METHODS AND RESULTS

We retrospectively analysed 156 patients (median age 44 years; 77% male) discharged with a diagnosis of acute myocarditis and LT-VA from 16 hospitals worldwide. Diagnosis of myocarditis was based on histology or the combination of increased markers of cardiac injury and cardiac magnetic resonance (CMR) Lake Louise criteria. MAEs were defined as the relapse, after discharge, of sudden cardiac death or successfully defibrillated ventricular fibrillation, or sustained ventricular tachycardia (sVT) requiring implantable cardioverter-defibrillator therapy or synchronized external cardioversion. Median follow-up was 23 months [first to third quartile (Q1-Q3) 7-60]. Fifty-eight (37.2%) patients experienced MAEs after discharge, at a median of 8 months (Q1-Q3 2.5-24.0 months; 60.3% of MAEs within the first year). At multivariable Cox analysis, variables independently associated with MAEs were presentation with sVT [hazard ratio (HR) 2.90, 95% confidence interval (CI) 1.38-6.11]; late gadolinium enhancement involving ≥2 myocardial segments (HR 4.51, 95% CI 2.39-8.53), and absence of positive short-tau inversion recovery (STIR) (HR 2.59, 95% CI 1.40-4.79) at first CMR.

CONCLUSIONS

Among patients discharged with a diagnosis of myocarditis and LT-VA, 37.2% had recurrences of MAEs during follow-up. Initial CMR pattern and sVT at presentation stratify the risk of arrhythmia recurrence.

Antiarrhythmic therapy and risk of cumulative ventricular arrhythmias in arrhythmogenic right ventricle cardiomyopathy

OBJECTIVES

The aim of our study was to investigate the benefit of antiarrhythmic drugs (AAD) - beta-blockers, sotalol or amiodarone - in a cohort of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) patients with long-term longitudinal follow up.

BACKGROUND

AAD are prescribed in ARVC to prevent ventricular arrhythmias and control symptoms. However, there are no controlled clinical trials and knowledges regarding the efficacy of AAD in ARVC are limited.

METHODS

The study population included 123 patients with definite diagnosis of ARVC and ≥ 2 clinical evaluations. The primary outcome was a composite of sudden cardiac death (SCD)/recurrent major ventricular arrythmias (MVA): sudden cardiac arrest, sustained ventricular tachycardia (VT) and appropriate implantable cardioverter defibrillator interventions, including recurrent events in patients with >1 MVA. Time to first event (SCD or MVA) was considered as secondary composite endpoint.

RESULTS

Sixteen patients were taking AAD at baseline and 75 started at least one AAD during a median follow-up of 132 months [61-255]. A total of 37 patients experienced ≥1 MVA with a total count of 83 recurrent MVA. After adoption of a propensity score analysis, no AAD were associated with lower risk of recurrent MVA. However, if dosage of AAD was considered, beta-blockers at >50% target dose were associated with a significant reduction in the risk of MVA compared to patients not taking beta-blockers (HR 0.10, 95% CI 0.02-0.46, p = 0.004).

CONCLUSIONS

In a large cohort of ARVC patients with a long-term follow-up, only beta-blockers administrated at >50% target dose were associated with lower risk of SCD/recurrent MVA.

Impact on clinical outcomes of right ventricular response to percutaneous correction of secondary mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular function (RVF) is a strong determinant of prognosis in patients with reduced ejection fraction heart failure (HFrEF) and secondary mitral regurgitation (SMR). Percutaneous mitral valve repair (pMVR) can promote the recovery of RVF.

Purpose. We sought to characterize the RV response to pMVR in HFrEF with SMR and to assess the influence of improved RVF after pMVR in this specific setting of patients.

Methods. We included all the patients with HFrEF and SMR≥3+ successfully treated with pMVR between April 2012 and January 2020 in two tertiary care centers for HF. Improved RVF was defined as DRVFAC≥5% at early follow-up (median time 4 months). The primary endpoint was a composite of death/heart transplant (D/HT).  

Results. In total, 110 patients were included. Mean age was 67 ± 12 years, mean LVEF was 31 ± 8% and mean RVFAC was 31 ± 10%. DRVFAC≥5% occurred in 54 (49%) patients and was independent from the measures of left ventricle recovery. During a median follow-up of 36 months (IQR 19-52), 40 patients (36%) died or were transplanted.  After adjustment for other significant covariates, DRVFAC≥5% was significantly associated with lower risk of D/HT (HR 0.49, 95% CI 0.24 – 0.98 p &lt; 0.042) along with M2+ at follow-up (HR 0.36; 95% CI 0.17-0.74 p 0.005).

Conclusions. In patients with HFrEF and SMR, the improvement of RVF is frequent after pMVR and is associated with better long-term survival free from HT.

Abstract Figure.