Effect on cholesterol remnants and residual lipid risk with PCSK9 inhibitors: the LIPID-REAL Registry

Background

Monoclonal antibodies that inhibit the proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDLc) by 55%, regardless of baseline treatments. Nonetheless, the effect of other lipid parameters, as cholesterol remnants or, the so-called residual lipid risk, are unknown.

Methods

Multicenter and retrospective registry of patients treated with PCSK9 inhibitors from 14 different hospitals from Spain. Before and on-treatment lipid parameters were recorded. Cholesterol remnants were calculated by the equation: total cholesterol minus LDLc minus HDLc and values ≥30 were considered high. Residual lipid risk was estimated by 1) the estimation of LDL particle size, by the triglycerides/HDLc ratio (TG/HDL) and values <2 were assumed as low and dense LDL particles; 2) total cholesterol/HDLc (TC/HDL) and values >3 were considered high; and; 3) the triglycerides-to-glucose (TG/Gluc) index, obtained as the natural logarithm of (triglycerides * glucose/2)

Results

A total of 652 patients were analyzed, mean age 60.0 (10.5) years and 161 (24.69%) women. Baseline LDLc was 149.2 (49.9) mg/dl, cholesterol remnants 29.9 (20.3) mg/dl, TG/HDL 3.9 (4.1), TC/HDL 4.9 (1.9) and TG/Gluc index 8.9 (0.7). Most patients (92.3%) were on statins; 54.8% with ezetimibe, 8.5% with fibrates.

Evolocumab was initiated in 318 (56.6%) patients; 229 (40.7%) alirocumab 75 mg and 15 (2.7%) alirocumab 150 mg. Median time to second blood determination were 187.5 (IQR 101–242) days. Mean on-treatment LDLc was 67.46 (45.78) mg/dl what represented a 55% reduction. As shown in the figure, significant reduction in cholesterol remnants (p=0.017), TG/HDL ratio (p=0.020), TC/HDL ratio (p<0.001) and TG/Gluc index (p<0.001). The percentage of patients with remnants >30 mg/dl decreased: 34.62% to 30.07 (p<0.01). Significant reductions were also observed in the percentage of patients with TG/HDL >2 (71.25% to 61.98%; p<0.01) or TC/HDL >3 (94.28% to 38.97%; p<0.01)

Conclusions

This multicenter and retrospective registry of real-world patients treated with PCSK9 inhibitors demonstrates a positive effect on cholesterol remnants and lipid-residual risk beyond LDLc reductions.

Funding Acknowledgement

Type of funding sources: None.

Mortality risk in cardiogenic shock depending on aetiology in a Mediterranean cohort. Prognostic accuracy of CardShock vs IABP score: the Shock CAT study

Background

Mortality in cardiogenic shock (CS) remains very high. Several risk scores have been purposed to early stratification, although the CS aetiology could influence in this prediction.

Purpose

The aim is to investigate in-hospital prognosis and mortality risk in CS patients depending on the CS aetiology comparing the prognostic accuracy of CardShock and IABP scores in a Mediterranean cohort.

Method

Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients due to acute coronary syndrome (ACS) and other aetiologies. Data on clinical presentation, biomarkers, management, including mechanical assistance support were analyzed comparing ACS and non-ACS patients. Cardshock and IABP score have been compared to assess 90-days mortality risk in both groups.

Results

A total of 382 CS patients were included, mean age was 65.3 (SD 13.9) years and 75.1% were men. Patient were classified in ACS (n=232, 60.7%) and non-ACS (n=150, 39.3%). In ACS group, 77.6% were STEMI, reperfussion in 84.7% of cases, all with primary angioplasty, 9% developed mechanical complications and 19.4% primary ventricular fibrillation. Main non-ACS aetiologies were severe heart failure (36.2%), malignant arrhythmias (22.1%), valve disease (8.0%) and myocarditis (7.4%). ACS group had less prevalence of women (17.7% vs 36%, p=0.001) and previous myocardial infarction (13.9% vs 24.8%, p=0.007). Mechanical assistance device was implanted more in ACS patients (43.1% vs 16.7%, p<0.001, mainly intraaortic balloon pump (35.6% vs 9.8%, p<0.001) and ECMO (10.7% vs 3%, p=0.01). Both shock risk scores were higher in ACS patients, Cardshock (4.5 vs 4.0, p=0.006) and IABP (2.4 vs 1.9, p=0.005). In-hospital mortality was higher in ACS (37.1 vs 26.7%, p=0.035) although this difference loss the significance at 90-days (40.9 vs 31.8%, p=0.074) and 6-months (45.2 vs 35.8%, p=0.176). Receiver-operating characteristic curves demonstrated that IABP shock score had superior prognostic power for predicting 90-days mortality when compared with Cardshock score in ACS patients (area under the curve -AUC- 0.74 vs 0.66) respectively, p=0.047, although both scores were similar in non-ACS (AUC 0.64 vs 0.62, p=0.693), Figures 1–2.

Conclusions

Cardiogenic shock due to ACS had higher in-hospital mortality than non-ACS CS, although this difference decreased at 90 days and 6 months. IABP score provided better 90-days mortality risk prediction than CardShock score in ACS patients, but both scores are similar in non-ACS cardiogenic shock.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Clinical impact on treatment and prognosis of advanced cardiac imaging with echocardiography in the acute setting of a COVID-19 infection

Background and objectives

Despite myocardial injury being related to excess mortality in acute COVID-19 infection, its impact on imaging findings remains unclear. This study aimed to characterize transthoracic echocardiographic (TTE) findings in patients admitted with COVID-19 infections and its impact on management and prognosis.

Methods

A prospective observational cohort study was performed among 66 COVID-19 patients who were admitted to a tertiary center between March 1 and May 25, 2020 and underwent TTE. High-sensitivity troponin I (hs-cTnI) data, echocardiographic assessment of right and left ventricular (LV) functional parameters, strain, and myocardial work analysis were obtained.

Results

2025 patients were admitted with COVID-19 and in 200 a complete TTE study was performed. Due to poor image quality, only 66 studies were included in the final analysis. The median age was 62 years (IQR, 55–70) and 59.1% of patients were males. The most common comorbidity was hypertension (47%), followed by smoking history (30.3%), atrial fibrillation (9.1%), and chronic obstructive pulmonary disease (7.9%). More than half of the patients (39, 59%) were admitted to the ICU, and half of them (33, 50%) required invasive mechanical ventilation. TTE was mainly indicated because of concerns for systemic conditions (50%) and evaluation of hemodynamic assessment (30%). Thirty-six patients (54.5%) had an abnormal TTE result and 57% had elevated hs-cTnI levels. The most common cardiac abnormality was LV diastolic dysfunction in 33% of the patients, followed by right ventricular dysfunction (12%) and LV dysfunction (6%) (Figure 1). LV GLS was reduced in 48.5% of the cases. Myocardial work performance indices were all reduced in patients with an abnormal TTE (GWI 30%, GCW 30%, GWW 40%, and GWE 40%), although differences were not significant (P>0.2 for all parameters). Patients with an abnormal TTE were older and presented a higher cardiovascular risk profile. There were no significant differences in the levels of D-dimer, NTproBNP, and hs-cTnI between patients with and without diastolic dysfunction, RV, or LV dysfunction (P>0.3 for all parameters). Using Spearman rank correlation, there was an inverse relationship between hs-cTnI and LV strain and myocardial work analysis. TTE results impacted clinical management in 60 patients, mainly de-escalation of medical treatment (Figure 2). Abnormal TTE results did not impact in-hospital outcomes.

Conclusions

Severe echocardiographic abnormalities are uncommon in hospitalized patients with COVID-19 infections, presenting mostly with subclinical myocardial changes, such as diastolic dysfunction, reduced LV GLS, and myocardial work indices, both associated with high-sensitivity troponin I elevation. An echocardiographic study should be limited to rule out long-term ICU complications or to evaluate hemodynamic instability. Although TTE was a valuable tool for guiding management, it had no significant impact on prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Findings on TTE studies.Figure 2. Changes in management.

Mortality risk in cardiogenic shock: head to head comparision CardShock vs IABP score in a Mediterranean cohort: the Shock CAT study

Background

Mortality in cardiogenic shock (CS) remains very high. Several risk scores have been purposed to early stratification.

Purpose

The aim is to investigate in-hospital prognosis and mortality risk in CS patients comparing the prognostic accuracy of CardShock and IABP scores in a Mediterranean cohort.

Method

Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients due to acute coronary syndrome (ACS) and other aetiologies. Data on clinical presentation, biomarkers, management, including mechanical assistance support were analyzed. Cardshock and IABP score have been compared to assess 90-days mortality risk in a Mediterranean cohort.

Results

A total of 382 CS patients were included, mean age was 65.3 (SD 13.9) years and 75.1% were men. The most common cause of CS was ACS (61%, n=233); of them, 77.6% were STEMI, 9% developed mechanical complications and 19.4% primary ventricular fibrillation. STEMI patients were reperfused in 84.7% of cases, all with primary angioplasty. Main non-ACS aetiologies were severe acute heart failure, malignant arrhythmias and myocarditis. Mechanical assistance device was implanted in one third of patients (n=119), mainly intraaortic balloon pump (26.1%), ECMO in 7.8% and Impella in 4.5%. Average Cardshock score was 4.3 (SD 1.74) and mean IABP score was 2.2 (SD 1.61). In-hospital mortality was 33% (126 patients) and 90-days mortality was 37.3% (141 patients). Receiver-operating characteristic curves demonstrated that IABP shock score had superior prognostic power for predicting 90-days mortality when compared with Cardshock score (area under the curve 0.72 vs 0.66) respectively, p=0.042; Figure 1.

Conclusions

Even though invasive management with STEMI reperfusion and mechanical assistance devices, cardiogenic shock in-hospital mortality remains 33% in a contemporary Mediterranean cohort. In this population, IABP shock score provided better 90-days mortality risk prediction than CardShock score

Funding Acknowledgement

Type of funding sources: None.

Routine advanced echocardiography in the evaluation of cardiovascular sequelae of COVID19 survivors with elevated cardiovascular biomarkers

Background

COVID19 has been related to elevated CVB and biventricular dysfunction during hospitalization. However, it is unknown whether patients with biomarker elevation exhibit long-lasting abnormalities in cardiac function.

Purpose

To determine, using advanced echocardiography, the prevalence and type of cardiovascular sequelae after COVID19 infection with marked elevation of cardiovascular biomarkers (CVB), and their prognostic implications.

Methods

All patients admitted from March 1st to May 25th, 2020 to a tertiary referral hospital were included. Patients with cardiovascular disease antecedent, death during admission, or the first 30 days after discharge were excluded. Patients with hs-TnI >45 ng/L, NT-proBNP >300 pg/ml, and D-dimer >8000 ng/ml were separated based on each CVB elevation and matched with COVID controls (three biomarkers within the normal range) based on intensive care requirements and age.

Results

From a total of 2025 hospitalized COVID19 patients, 80 patients with significantly elevated CVB and 29 controls were finally included. No differences in baseline characteristics were observed among groups, but elevated CVB patients were sicker. Follow-up echocardiograms showed no differences among groups regarding LVEF or RV diameters, but TAPSE was lower if hs-TnI or D-dimer were elevated. Hs-TnI patients also had lower global myocardial work and global longitudinal strain. The presence of an abnormal echocardiogram was more frequent in the elevated CVB group compared to controls (23.8 vs 10.3%, P=0.123) but mainly associated with mild abnormalities in deformation parameters. Management did not change in any case and no major cardiovascular events except deep vein thrombosis occurred after a median follow-up of 7 months (Figure 1).

Conclusions

Minimal abnormalities in cardiac structure and function are observed in COVID19 survivors without previous cardiovascular diseases who presented a significant CVB rise at admission, with no impact on patient management or short-term prognosis. These results do not support a routine screening program after discharge in this population.

Funding Acknowledgement

Type of funding sources: None.

Iron deficiency is associated with larger infarcts and with adverse remodeling in STEMI patients and reduces myocardial tolerance to ischemia/reperfusion by inhibiting the eNOS/sGC/PKG pathway in mice

Background

Iron deficiency (ID) interferes with the cardioprotective pathway endothelial nitric oxide synthase/soluble guanylate cyclase/protein kinase G (eNOS/sGC/PKG), but its role in acute myocardial infarction remains unclear.

Methods

Patients (n=125) with a first anterior STEMI treated with PCI underwent magnetic resonance imaging in the acute phase and at 6 months. We assessed whether ID (ferritin level <100 μg/L or <300 μg/L if transferrin saturation was <20%) was associated with infarct size acutely or with adverse left ventricular (LV) remodeling (LV end-diastolic volume increase at 6 months >20%, n=105). C57BL6/N mice were fed with standard diet or iron-deficient diet for 4 weeks before undergoing 45-min coronary occlusion/24-h reperfusion.

Results

Patients with ID (43.2%) had larger infarcts (22.8±10.2 vs 16.8±9.8% of LV mass, P=0.002) and more frequent microvascular obstruction (70.0 vs 43.3%, P=0.004) in the initial exam than the rest. They also developed adverse LV remodeling more often (38.6 vs 14.8%, P=0.005), even after adjusting by infarct size and final TIMI flow grade (OR 3.1, 95% CI 1.1–8.6, P=0.027). In mice, ID diet reduced myocardial iron content, serum ferritin and hemoglobin levels without reaching anemic values and without inducing echocardiographic alterations. ID diet reduced myocardial eNOS protein content, its dimeric form, and nitrites/nitrates and cGMP levels. eNOS decrease was associated with reduced HSP90 levels and increased eNOS ubiquitination in correlation with oxidative and nitrosative stress. Weekly iv administration of iron sucrose effectively reverted the ID-diet effects. Infarct size was larger in the ID group than in controls (58.8±3.0 vs. 40.3±3.6%, P=0.03) but was not increased in ID-diet animals treated with iron sucrose (36.3±4.0%) or receiving the sGC activator ataciguat before ischemia (31.0±2.5%).

Conclusions

ID is associated with larger infarcts and with more frequent adverse LV remodeling in patients with STEMI and reduces myocardial tolerance to ischemia/reperfusion in mice by attenuating eNOS/sGC/PKG pathway activity. Iron sucrose treatment and sGC activation reverted these deleterious effects of ID in mice. Iron supplementation might be beneficial in STEMI patients with ID.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIBER-CV. Instituto de Salud Carlos III (PI16/00232), co-financed by the ERDF