Cholesterol remnants distribution in patients admitted for acute coronary syndrome

Background

Cholesterol remnants have been identified as one of leading lipid measurements associated with the incidence of coronary heart diseases. Nonetheless, there is scarce evidence on cholesterol remnants distribution in patients with acute coronary syndrome (ACS).

Methods

We included all consecutive patients admitted for ACS in two different centers. Cholesterol remnants were calculated by the equation: total cholesterol minus low-density lipoprotein cholesterol (LDLc) minus high-density lipoprotein cholesterol (HDLc) and values ≥30 were considered high. Premature ACS was defined in patients presenting with age <55 for men or <65 for women. Correlation weres assessed by linear regression and predictive models were obtained after logistic binary regression.

Results

We included 7,479 patients, mean age 66.68 (13.02), 2,062 (27.57%) women, mean body mass index (BMI) 28.60 (4.64) kg/m2, 2088 (27,92%) with diabetes and 2,726 (36.45%) admitted for ST-elevation ACS. Median (interquartile range) remnants level was 28 mg/dl (21–39) and 3,429 (45.85%) patients had levels ≥30 mg/dl. Significantly higher levels of remnants were observed in patients with diabetes, current smokers, BMI >30 kg/m2, absence of previous cardiovascular disease or premature ACS. No gender differences were observed in remnants level. Age (r: −0.29) and BMI (r: 0.44) were the variables more strongly correlated. As shown in the figures, at any given age, the risk of having cholesterol remnants ≥30 increased with higher BMI.

In-hospital mortality was 3.75% (280 patients). After adjustment by age, gender, previous cardiovascular disease and GRACE score, cholesterol remnants were not associated to higher mortality risk (OR: 0.89 95% CI 0.64–1.10; p=0.21)

Conclusions

Elevated cholesterol remnants is highly prevalent in patients admitted for ACS and their levels inversely correlate with age and positively with body mass index. We propose a risk matrix for estimating the probability of having cholesterol remnants ≥30. Elevated cholesterol remnants were not associated to higher in-hospital mortality risk.

Funding Acknowledgement

Type of funding sources: None.

Baseline profile and results of atrial fibrillation ablation in patients with arrhythmia-induced cardiomyopathy

Background

Atrial fibrillation (AF) is known to trigger a reversible dilated cardiomyopathy referred as arrhythmia-induced CM (AiCM). However, it remains unclear why some patients are more prone to develop AiCM than others and there is scarce information about their clinical outcomes after AF ablation.

Purpose

We ought to find clinical and analytical predictors for the development of AiCM and recovery of LVEF in patients referred for AF ablation.

Methods

A prospective multicenter study of consecutive patients undergoing point-by-point radiofrequency (RF) catheter ablation between September 2016 and November 2021 was conducted. The low voltage areas and left atrial (LA) volume were analyzed offline on high density electroanatomical maps collected prior to RF ablation. Peripheral blood sample for biomarker analysis (Gal-3, FABP4 and sRAGE) were obtained at the time of the procedure.

Results

803 consecutive patients were included, median age was 61 and 240 (30,81%) were women. AF pattern was paroxysmal in 254 (32,60%) and persistent in 534 (68,55%; of whom, long-standing persistent in 113 (14,51%) patients). The median follow-up period was 23.83 months [IQR 9 to 36]. The multivariate analysis revealed LA area, width of QRS segment, persistent AF and chronic kidney disease (CKD) as independent predictors for AiCM. Recurrence-free survival was not different amog both cohorts (Figure 1).

The median increase in LVEF from baseline to the 6-month follow-up visit in patients with AiCM was 16% (CI 14.31–18.47) without changes in the non-AiCM group. The median LVEF previously to CA from patients in the AiCM group was 38% (IQR 30–45%) and after the procedure 57% (IQR 50–60%) [see figure 2].

Conclusions

AiCM is characterized to have a particularly complex pathophysiology not fully understood thus far. Pulmonary vein isolation in patients is safe and suitable for patients that suffered from tachycardiomyopathy. We found that persistent AF and chronic kidney disease play a key role in its development. Neither peripheral blood biomarkers nor left atrial samples showed relevant association with its occurrence.

Funding Acknowledgement

Type of funding sources: None.

Utility of Soluble ST2 biomarker to predict recurrence after electrical cardioversion in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is the more frequent arrhythmia in clinical practice. The ST2S is a biomarker that has demonstrated to be predictor of cardiovascular outcomes in patients with heart failure but there is scarce information of his utility in patients with AF.

Purpose

Considering the characteristics of the ST2S we hypothesize this biomarker could correlate to recurrence in patients with AF and electrical cardioversion (ECV).

Methods

This was an observational and prospective clinical trial. We compared all patients with AF referred for ECV with a control group without AF, from September 1th 2016 to September 30 2019. Clinical, ECG, echocardiographic and ST2S levels were analyzed in both groups at basal, at 3 and 6 months of follow-up in such cases with AF. Patients with inflammatory or allergic diseases, moderate/severe ventricular dysfunction, structural cardiomyopathy, moderate/severe hepatic, renal or respiratory disease were excluded.

Results

We included a total of 94 patients with AF and 40 paired controls. Clinical variables are presented in Table 1. Fifty-eight (61.7%) patients with AF had recurrence at follow-up. There was a significant difference between the ST2S levels at baseline between AF patients (17163.8 pg/mL) and controls (11016.2 pg/mL) (p=0.001). ST2S biomarker levels at 3 and 6 months of follow-up decreased in those patients without AF recurrence as shown in Figure 1. Covariable models were performed and ST2S biomarker levels at 3 months were significant to predict recurrence at 6 months follow-up (Table 2). The calculated cut-point of the biomarker was of 15511.51 pg/ml with a c-value: 0.669.

Conclusions

In our experience ST2S was a useful biomarker to predict recurrence of AF after ECV. Considering the size of the study more studies should be performed to confirm this results.

Funding Acknowledgement

Type of funding sources: None.

A universal electronic consultation programme at the cardiology department after general practitioner referrals to improve healthcare accessibility and outcomes in elderly patients

Background

The on-line healthcare models are an opportunity to improve the accessibility and efficiency in clinical assistance, however, analyses of the effects of outpatient care on healthcare quality, including safety, are limited, particularly in vulnerable populations such as elderly patients 1. The care of elderly patients (generally >80 years) is usually characterized as having more chronic pathologies, particularly more cardiovascular diseases, resulting in having a worse risk profile 2. However, this group is also usually characterized by problems with functionality and dependency that can increase difficulties in moving from their homes to health care centres, particularly in areas of great geographical dispersion such as in our study 3.

The healthcare systems that have integrated electronic clinical records between different assistance levels provide an electronic consultation (e-consultation) as a first step of ambulatory care for all general practitioner (GP) referrals. Healthcare systems that include an e-consultation have already shown favorable health outcomes and reduced displacement of the population served 4,5 and could also improve accessibility to outpatient care, although there are not results to demonstrate its safety in this particular group of high-risk patients.

Purpose

We aimed to assess the accessibility and health outcomes (hospital admissions and mortality) in elderly patients referred to a cardiology department (CD) from primary care after inclusion of an e-consultation in outpatient care.

Methods

We included 9,963 patients >80 years old referred to the CD from January 1st, 2010, to December 31st, 2019. In 2013, we instituted an e-consultation programme (2013–2019) for all primary care referrals to cardiologists that preceded patient in-person consultations when considered. We compared both models (in-person consultation and e-consultation) using I: an interrupted time series regression on delay time, hospital admission, and mortality, II: the accessibility measured as population-adjusted referred rate in both periods, and III: analysing the changes in each municipality in delay time, hospital admission and mortality.

Results

During the e-consult period, the demand of care increased (12.8±4.3% vs 25.5±11.1% per 1,000 inhabitants, p<0.001), delay for care was reduced (−0.094 days; 95% CI [−0.063, −0.140], p<0.001), and age-dependent delay disappeared. After the implementation of e-consults, hospital admission (incidence rate ratio [iRR]: 1.351 [95% CI, 0.787, 2.317], p=0.874), Figure 1, and mortality (iRR: 1.925 [95% CI: 0.889, 4.168], p=0.096) stabilised with a slight downward trend, Figure 2.

Conclusion

Implementation of e-consultations in the outpatient care programme in CD was associated with improved access to cardiology healthcare in elderly patients. After the implementation of the e-consultation, hospital admissions and mortality were stabilised and showed a slight non-significant downward trend.

Funding Acknowledgement

Type of funding sources: None.

Age as a prognostic modifier in anemic patients discharged after acute coronary syndrome

Introduction

The presence of anemia on admission is a poor long-term prognostic factor in patients diagnosed with acute coronary syndrome (ACS). However, it is unknown whether age is a factor modifying the effect of anemia on mortality.

Objective

To determine the effect of age on anemia in terms of long-term mortality in patients admitted for ACS.

Methods

This is an observational study in which we included all patients discharged from cardiology for ACS in two centers from 2003 to 2020. Patients with anemia were classified by hemoglobin values <13 g/dL in men and <12 g/dL in women in the first blood count performed during hospitalization. The interaction between age and anemia was analyzed using the Cox regression model and the chunk test. We analyzed the effect of anemia on mortality using the Cox regression model adjusted for several confounding variables and the interaction with age.

Results

We included 8872 patients diagnosed with ACS, with a mean age of 66.38 (SD ±12.76) years, 27.1% female and 34.3% diagnosed with ST-segment elevation ACS. The mean hemoglobin value was 13.88 (SD ±1.85) g/dL and 20.5% of patients were anemic on admission.

During follow-up (median 1764 days, IQR 694–2439 days) there was an increased risk of all-cause mortality in patients with anemia adjusted for age and other risk factors (sex, renal function, GRACE score, atrial fibrillation, LVEF and previous revascularization), HR 15.5 (CI 5.77–41.75; p>0.005). We found a significant interaction between age and anemia (p<0.01). As represented in the figure, the adjusted risk of mortality decreased at older ages; in patients whose age was >80 anemia was not associated to higher mortality risk. Similar results were observed for cardiovascular mortality, HR 21.36 (CI 6.13–74.43, p>0.005).

Conclusion

Age modifies the risk of mortality in patients discharged after an ACS being the risk of mortality higher in youngest ages and disappearing in octogenearians. There results should be taken under consideration for the treatment and management of ACS patients.

Funding Acknowledgement

Type of funding sources: None.

Echocardiographic phenotype and prognostic value of relative apical sparing of longitudinal strain pattern in severe aortic stenosis with and without cardiac amyloidosis. The AMYTAVI study

Introduction

It is estimated that 15% of patients with AS have concomitant cardiac amyloidosis (CA). Left ventricular (LV) longitudinal strain (LS) pattern with relative apical sparing (RELAPS>1), shown as bright red in the apical segments on the polar map, has been strongly associated with CA. Its presence and its significance in AS is yet to be determined.

Purpose

To determine the prevalence of the RELAPS>1 pattern in patients with severe AS with and without concomitant CA, and to analyze the echocardiographic phenotype associated with this strain pattern and its prognostic value.

Methods

Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: relative apical LS (average apical LS/average basal+mid LS); SAB: (apical-septal/basal-septal LS); EFSR: (LVEF/GLS). After TAVI, a 99Tc-PYP scintigraphy and a proteinogram were performed to screen for CA.

Results

324 patients were included. The mean age was 81 yo, 52% women. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Among those, 111 (46%) presented relative apical sparing (RELAPS>1).

There were no differences in clinical characteristics between patients with RELAPS <1 and >1: similar age, sex, cardiovascular risk factors and funcional class, renal function or NT-proBNP. Among patients with RELAPS>1 there was more frecuently CA with uptake grade 2 and 3 on scintigraphy (15% vs. 4.5%, P=0.006) (Figure 1). RELAPS>1 group showed greater LV hypertrophic remodeling: thicker myocardial wall with smaller ventricular cavity, especially concentric hypertrophy; LVEF and GLS was similar, however, MAPSE and myocardial contraction fraction (MCF) were worse in RELAPS >1 group, and EFSR was significantly higher (4.2 vs 3.9, p=0.002). RELAPS >1 group had smaller aortic valve area (AVA: 0.6 vs 0.7 cm², p=0.045), but similar transvalvular gradients due to lower stroke volume. It had larger atria and less left atrial (LA) fractional emptying, as well as higher prevalence of atrial fibrillation (AF: 41% vs 27%, p=0.03). Right ventricle (RV) size were similar, however, RV function was worse in RELAPS >1 group (TAPSE: 19 vs 21 mm, p=0.003; free Wall LS: −24 vs −27%, p=0.008).

There was no difference in all-cause mortality at 1 year of follow-up between groups (6.4% vs. 6.3%, p=1).

Figure 2 represents the morphological characteristics according to the LS phenotype.

Conclusions

In severe AS, RELAPS >1 is present in almost half of the patients. It is associated with worse cardiac remodeling, as well as higher prevalence of AF. However, it wasn't associated with higher mortality at 1 year. 1 in 7 patients with AS and RELAPS >1 have concomitant ATTR CA grade 2/3.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer

Oleoylethanolamide mitigates cardiac metabolic alterations secondary to obesity induced by high-fat diet in C57/BL6J mice

Background

It is well known that high-fat diet (HFD) feeding causes cardiac inflammation, remodeling, and dysfunction, and that increased fat intake, especially saturated fat, is a major driver of cardiometabolic diseases. Oleoylethanolamide (OEA) is a member of acylethanolamides recognized for its metabolic and anti-inflammatory properties due to the high affinity for different receptors and to its role as a modulator of the endocannabinoid system. OEA effects on the cardiovascular alterations caused by fat overnutrition are still unknown.

Purpose

The aim of this study was to evaluate the impact of OEA treatment on cardiac metabolic changes induced by HFD in obese mice.

Methods

Male C57Bl/6J mice were divided into 3 groups: control group (STD) receiving standard chow diet; mice fed with HFD for 20 weeks; HFD group treated with OEA (HFD+OEA 2,5 mg/kg/die i.p.) from week 12 to week 20.

Results

In HFD mice, OEA treatment reduced body weight measured throughout the experimental period. Before sacrifice, we performed the oral glucose tolerance test (OGTT), where HFD+OEA mice showed an improvement of insulin sensitivity, altered by HFD. HFD feeding led to a significant increase in the production of inflammatory cytokines and chemokines, such as interleukin (IL)-1b, IL-6, the monocyte chemoattractant protein (MCP)1 and the pro-fibrotic marker fibrillin in the cardiac tissue. Conversely, OEA normalized the transcription of the above-mentioned pro-inflammatory mediators in the heart of obese mice. OEA treatment also reduced the gene expressions levels of cardiac fatty acid transporter CD36, that were significantly induced in the heart of HFD-fed mice, and that have been found to be linked to myocardial lipid accumulation. We also evaluated the gene expression levels of the adipokines adiponectin and meteorin-like protein (Metrnl), finding that the increased ventricular expression of both in HFD mice were significantly reduced by OEA. Moreover, OEA treatment induces an increase in AMPK and AKT phosphorylation, whose pathways converge towards the phosphorylation of AS160, a kinase implicated in the translocation of the glucose transporter (GLUT) 4 to the cardiomyocyte membrane, a mechanism involved in the modulation of cardiac glucose metabolism.

Since it has been reported that cardiac autophagy is altered in metabolic disorders like obesity, we also studied the effect of OEA in autophagosome formation, and we determined that cardiac protein levels of LC3II, an autophagosomal membrane marker, are markedly increased by OEA treatment.

Conclusions

Taken together, our results indicate a potential cardioprotective effect of OEA as a molecule able to reduce body weight and body weight gain, to ameliorate glucose disposal improving blood glucose, to restore cardiac metabolic alterations related to obesity, and to decrease proinflammatory and profibrotic markers at cardiac level, induced by HFD.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fondo de Investigationes Sanitarias, Instituto de Salud Carlos III

Plasma miR-451a predicts atrial fibrillation recurrence after pulmonary vein ablation

Background/Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia diagnosed in European countries. Several studies have shown that catheter ablation is a more effective treatment than antiarrhythmic drugs and should be prioritised in symptomatic patients. However, AF recurrence after catheter ablation remains a challenge. MiRNAs have been identified, in recent years, as epigenetic modulators in numerous biological processes, including cardiac electric conduction. MiRNAs can be easily detected in the circulation, making them attractive as potential biomarkers for risk stratification in AF patients.

Purpose

Our purpose is to find a miRNA able to predict the AF recurrence after catheter ablation.

Methods

44 patients submitted to catheter ablation were consecutively recruited and classified based on recurrence after a follow up of 12 to 48 months. Peripheral and left atrium blood samples were collected before catheter ablation. Human Cardiovascular Disease miScript miRNA PCR Arrays were performed to analyse 84 miRNAs altered in cardiovascular disease. Significant miRNAs changes in ΔCt levels were assessed using Two-way ANOVA and post hoc Tukey tests. Simple logistic regression analysis was performed to analyse association to AF recurrence. KEGG pathway enrichment analysis was performed to identify the most enriched targets and pathways involved in AF recurrence.

Results

In our cohort, overall recurrence rate was 47.7%. qPCR expression analysis showed increased levels of miR-328-3p and decreased levels of miR-486-5p in recurrent patients, both in peripheral as well as left atrial blood. Our results also showed decreased levels of miR-let-7b-5p and miR-451a in recurrent patients, but selectively regulated in peripheral and atrial blood, respectively (Figure 1). Simple logistic regression analysis showed a significant association between blood atrial levels of miR-451a and AF recurrence (Figure 2A). KEGG pathway enrichment analysis showed that miR-451a could be involved in epigenetic regulation of myocardial electromechanic integrity (Figure 2B).

Conclusion

Expression analysis of atrial blood miR-451a levels, prior to catheter ablation, could be a good a risk stratifier of recurrence.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): IN607A2019/02. Xunta of Galicia. Grants for the consolidation and structuring of competitive research units in the universities of the Galician University System, in the public research organizations of Galicia and in other entities of the Galician R&D System 2019

Echocardiographic phenotype in severe aortic valve stenosis with and without cardiac amyloidosis: the AMY-TAVI trial

Background

Longitudinal Strain (LS) pattern in cardiac amyloidosis (CA) typically spares the apex of the heart, which is a sensitive and specific finding that can be used to distinguish CA from other causes of left ventricular (LV) hypertrophy. RELAPS >1 suggests with high specificity CA, and shows a bright red in the apical segments of the polar map.

Purpose

To identify differential echocardiographic characteristics of aortic stenosis (AS) with concomitant TTR-CA (AS-CA) compared to AS alone.

Methods

Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: relative apical LS (average apical LS/average basal+mid LS); SAB: (apical-septal/basal-septal LS); EFSR: (LVEF/GLS). After TAVI, a 99Tc-DPD scintigraphy and a proteinogram were performed to screen for CA.

Results

324 patients were included. The mean age was 81 yo, 52% women. 39 (12%) patients presented cardiac uptake on scintigraphy: 14 (4.3%) grade 1; 13 (4%) grade 2, and 11 (3.4%) grade 3. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Echocardiographic characteristics between AS alone and those with grade 1 (AS-DTD1) and grade 2/3 (AS-CA) are shown in Table 1.

Compared with AS alone, patients with AS-CA had significantly lower transvalvular gradients, although similar AVA, and low flow-low gradient (LF-LG) AS was more prevalent. AS-CA exhibited slightly worse cardiac remodeling (LV mass ind: 202 g/m² vs 176 g/m², p=0.032), and worse diastolic dysfunction, but without significant differences in thickness, diameters or volumes, with similar relative wall thickness (RWT: 0.53 vs. 0.51 mm, p=0.52). LVEF was similar, however myocardial contraction fraction (MCF= stroke volume/myocardial volume) and MAPSE were worse in AS-CA.

GLS, RELAPS, SAB and EFSR were not different, but RELAPS >1 pattern was more prevalent in AS-CA (74% vs 44%, p=0,006) (Figure 1). Mass/strain ratio (RMS) was similar. There were no differences in size and fractional emptying of left atrium, or atrial septum thickness.

Right ventricle (RV) size was similar, as well as conventional function parameters (TAPSE and S'). However, RV LS was worse in AS-CA. Pericardial effusion was more prevalent in AS-CA (25% vs 7.4%, p=0.013).

In the multivariate analysis, predictors of AS-CA were: age (OR: 1,2, p=0,02), BG (OR: 0,2, p=0,01), E/A (OR: 4,7, p=0,02), LV Mass index (OR: 1,02, p=0,04) and RELAPS >1 (OR: 0,12, p=0,01).

Conclusion

Dual pathology of AS-AC is common in older patients referred for TAVI. Although it is more prevalent in patients with AS-CA, RELAPS>1 pattern can be present in almost 50% of patients with severe AS alone, which reduces its value as screening tool for CA in this clinical setting respect to others.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer

Impact of a universal electronic consultation program at the cardiology service of a galician health area on hospital admissions and on the accessibility and equity of healthcare services

Background

The implementation of integrated electronic medical record projects between healthcare levels allows all healthcare professionals access to all the clinical information of patients, which is a key factor in optimizing the management of healthcare resources, facilitating the communication between professionals and avoiding medical acts that do not add value, always from the premise of safety and quality for patients [1]. The benefits that telemedicine models can bring in reducing waiting times and the role they can play in organizing the growing demand for care have been described [2,3]. A matter of concern is the lack of accessibility for patients who live further away from their reference hospital centers, not only from a management point of view but also from a clinical point of view, since they are patients who are usually admitted with more complications and therefore could have a worse prognosis.

Purpose

To assess the impact on accessibility to healthcare provision and hospital admissions of an outpatient care management program that includes an e-consultation through an integrated medical record.

Patients and methods

It was registered the epidemiological and clinical data available from the 41,258 patients referred from January 1, 2010 to December 31, 2019, from Primary Care to the Cardiology Service of a health area, in which all doctors share the same electronic medical record. The municipality where the patients live and the admissions for cardiovascular causes in any hospital service during the first year after consultation in the Cardiology Service was recorded.

Results

After the e-consultation was implemented, the demand for care increased in all municipalities (7.2±2.4 vs 10.1±4.8 rates per 1,000 habitants-year, p&lt;0.001). In general, higher delay times were recorded in the regional hospital area, the furthest patients; the spatial effects also were similar in both periods; however, these differences were lower in the e-consultation period than in the in-person consultation period, Figure 1. Also, during the single act consultation period, we observed a progressive reduction in the delay to cardiology consultation which was markedly reduced after the implementation of the e-consultation. The interrupted time series analysis showed that the number of hospital admissions during the period of the Single Act Consultation has increased at approximately 1.1% per month (RR: 1,011 [IC95%: 1.003–1.018]), and after the implementation of the E-Consultation, this upward trend is stabilized in mean with a constant trend (RR: 1.011*0.989 ∼ 1), Figure 2.

Conclusions

The implementation of an e-consultation in the outpatient management model increases the demand for care and improves accessibility to health care for patients furthest from the referral hospital. After the implementation of the e-consultation, the upward trend of hospital admissions observed during the single act period, was stabilized with a slight downward trend.

Funding Acknowledgement

Type of funding sources: None.

Utility of open window mapping using high-density mapping approach in accessory pathways ablation

Introduction and purpose

We sought to described a new protocol of open window mapping (OW) utilizing high-density mapping in accessory pathways (AP) in CARTO® 3 system. This protocol automatically map conventional electrophysiology criteria for AP location, as shorter local EGM AV interval (extended early meets late tool), earliest local activation time (LAT)and annotation at unipolar signal (wavefront annotation).

Methods

This was a single center, prospective and observational trial of 21 consecutive patients who underwent an AP catheter ablation.

Results

We included 16 men and 5 women, with a mean age of 32.6±17.9 years. The characteristics of AP, including mapping and ablation were described in Table 1. Twelve AP were of left location and 9 in right location. Mapping was performed in anterograde conduction in 17 patients (80.9%), retrograde in 9 patients (42.9%) and orthodromic tachycardia in 7 patients (33.3%). Mean mapping points were 3205±2034, with 29.2 min±12.5 min of mapping. All 21 patients had a successful ablation after OW mapping and mean radiofrequency time until complete AP elimination was 2.76 s.

We present an example of a Left lateral AP OW mapping in antegrade and retrograde conduction in Figure 1, which shows EEML mapping tool, targeting shorter interval EGM AV or VA and color adjust to determine earliest LAT in chamber of exit.

Conclusions

In our experience, automatically mapping of conventional electrophysiology criteria for AP diagnostic is feasible to localize AP insertion, suggesting an increasing in effectiveness of procedure, and reducing mapping time, ablation time and X-ray exposure time. More studies should be performed to corroborate these conclusions.

Funding Acknowledgement

Type of funding sources: None.

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 &lt;2 were assumed as low and dense LDL particles; 2) total cholesterol/HDLc (TC/HDL) and values &gt;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&lt;0.001) and TG/Gluc index (p&lt;0.001). The percentage of patients with remnants &gt;30 mg/dl decreased: 34.62% to 30.07 (p&lt;0.01). Significant reductions were also observed in the percentage of patients with TG/HDL &gt;2 (71.25% to 61.98%; p&lt;0.01) or TC/HDL &gt;3 (94.28% to 38.97%; p&lt;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.

Cardiac sodium/hydrogen exchanger (NHE11) as a novel potential target for SGLT2i in heart failure

Background

Despite the cardiac benefits of sodium/glucose cotransporter 2 inhibitors (SGLT2i), their basic of action remains unclear. Sodium/hydrogen exchanger (NHE) has been proposed as mechanism of action of SGLT2i, but there are controversies related to its function and expression in heart failure (HF).

Purpose

We hypothesized that sodium transported-related molecules could be altered in human HF and they could be modulated through SGLT2i.

Methods

Transcriptome-level differences in genes involved in sodium transport between HF and control (CNT) were investigated in 36 heart samples with RNA-sequencing technology (HF, n=26; CNT, n=10). In addition, NHE11 and NHE1 protein levels were determined in 80 heart samples (HF, n=70; CNT, n=10) by ELISA assay. Furthermore, the effect of empagliflozin on NHE11 mRNA levels in rat left ventricular tissue (n=22) was studied through RT-qPCR.

Results

We observed alterations in several genes involved in sodium transport. Among them the overexpression in SLC9C2 (p=0.005) and SCL9A1 (p=0.020) genes, which encode the NHE11 and NHE1 proteins, respectively. In addition, cardiac protein levels of these molecules were determined. We found a significant increase in the concentration of NHE11 (p=0.042) and NHE1 (p=0.018) in HF. Moreover, NHE11 levels were correlated with left ventricular diameters. Due to the relevance of NHE11 changes observed, we studied the effect of SGLTi on its expression. NHE11 mRNA levels were reduced in rats treated with empagliflozin (p=0.010).

Conclusions

Our findings show alterations in several sodium transport, reinforce the importance of these channels in HF progression. We described upregulation in NHE11 and NHE1 in HF patients, but only NHE11 correlated with cardiac dysfunction. In addition, the most relevant finding is the change observed in the expression of the unknown NHE11 after treatment with empagliflozin. These results propose NHE11 as a potential target of SGLT2i in cardiac tissue.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Carlos III European Regional Development Fund (ERDF)

Empagliflozin treatment differentially modifies visceral and subcutaneous adipose tissue lipidomes and pro-inflammatory cytokines in zucker fatty diabetic rats

 

EMPA-REG OUTCOME (Empagliflozin, Cardiovascular Outcome Event Trial) trial highlighted the relevance of pharmacological inhibition of sodium-glucose cotransporter 2 (SGLT2) for the treatment of patients with type 2 diabetes mellitus (T2DM) and/or cardiovascular disease. Although the pathways through which SGLT2 inhibitors exert a beneficial effect on the cardiovascular system are still unknown, it has been suggested that energy metabolism regulation and a reduction of systemic inflammation could be some of the mechanisms implicated. Available data also suggests that empagliflozin treatment could be able to exert regulatory effects on adipose tissue (AT) depots. The aim of our study was to evaluate the impact of empagliflozin treatment on the lipidome of visceral (VAT) and subcutaneous adipose tissue (SAT) depots in a rat model of obesity and T2DM. Diabetic obese Zucker Fatty (ZDF) rats were treated with 30 mg/kg/day of empagliflozin p.o for 6 weeks. The lipidomes of VAT and SAT depots were analyzed using ultra-high performance liquid chromatography coupled to mass spectrometry. Empagliflozin's effect on pro-inflammatory markers in AT was analyzed by RT-PCR. In VAT, 18 metabolites were significantly altered in empagliflozin-treated rats vs. controls. Nearly all diglycerides tested (13 of 14) were significantly increased in treated rats, as the most notable altered chemical class. Furthermore, 3 oxidized fatty acids (FA) and FA like gadoleic acid and linoleic acid were also significantly increased. In SAT, a total of 14 metabolites were significantly altered. Most of them (13 of 14) were glycerophospholipids. Significantly lower levels of 4 lysophosphatidylethanolamines, 4 lysophosphatidylcholines, and 3 lysophosphatidylinositols and higher levels of 2 phosphatidylcholines were shown. In contrast to VAT, a significant decrease in most of these metabolites was observed in empagliflozin-treated samples. Several ratios of metabolites were also calculated to infer the potential enzyme activities related to lipid metabolism in both VAT and SAT. However, the ratios studied were only statistically significant in VAT of empagliflozin-treated rats vs. control, where the main potential enzyme activities altered were desaturases and elongases. Empagliflozin treatment also reduces the expression of the pro-inflammatory cytokines interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFα) and monocyte-chemotactic protein-1 (MCP-1) in VAT, with no changes in SAT, except for interleukin-13 (IL-13), which also decreases compared to untreated diabetic ZDF rats. In conclusion, empagliflozin increased oxidized FA and diglycerides in VAT and decreased glycerophospholipid levels in SAT. The anti-inflammatory effect of empagliflozin in VAT is not observed in SAT. The effect of empagliflozin on the regulation of the adipose tissue lipidome and inflammatory profile is different depending on the localization of the depots.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim Pharma GmbH and Co

Safety of leadless pacemaker implantation in very eldery patients in a one-center study

Funding Acknowledgements

Type of funding sources: None.

Introduction

Leadless pacemakers (LPM) have demonstrated safety in patients with multiple commorbidities. Very elderly patients have multiple commorbidities and are more prone to develop complications in pacemaker implants.

Purpose

We present our experience with LPM in a subgroup of very elderly patients.

Methods

We present a prospective clinical trial that including all consecutive LPM implantation from June 1 2015 to December 25 2021. We divide the patients in two groups according to age: older or younger than 85 y/o. Clinical and electrical, characteristics, as well as related complications and electrical parameters were compared between the two groups according to age.

Results

A total of 300 LPM were implanted and divided in two groups: 231 patients of less than 85 y/o and 69 patients ≥85 y/o. Clinical and electrical characteristics were described in table 1. Mean follow-up was of 36 months. There were 7 complications, all during the implantation procedure and there were no significant differences in complications between both groups . Electrical performance had no differences between the patients and was stable at long-term follow-up. (Figure 2)

Conclusions

There were no significant differences in complications or electrical performance between both groups and LPM were safe at long-term follow-up in very elderly patients with multiple commorbidities.

Feasibility of open window mapping approach in accessory pathways ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction and Objectives

We described a new protocol of open window mapping (OW) in accessory pathways (AP) in CARTO® 3 system. This protocol automatically mapping conventional electrophysiology criteria of AP diagnostic, as shorter local EGM AV interval (extended early meets late tool), earliest local activation time (LAT) and annotation at unipolar signal (wavefront annotation).

Methods

Single center, prospective and observational study of 17 consecutive patients underwent AP catheter ablation.

Results

Mapping was performed in anterograde conduction in 13 patients (76.5%), retrograde in 5 patients(29,4%) and orthodromic tachycardia in 2 patients (11,7%). Mean of numbers of points were 3092±2246, with 30min ± 13min of mapping. Ablation was effective in 17 patients( 100%) and RF time until complete AP elimination was 2.6s. Image 1 show representation of EEML tool, targeting shorter interval EGM AV or VA and color adjust to determine earliest LAT.

Image 1 show representation of EEML tool, targeting shorter interval EGM AV or VA and color adjust to determine earliest LAT.

Conclusions

In our experience, automatically mapping of conventional electrophysiology criteria for AP diagnostic is able to localize AP insertion, suggesting an increasing in effectiveness of procedure, a reducing in mapping time, ablation time and X-ray exposure time.

Differences between Takotsubo and the working diagnosis of myocardial infarction with non-obstructive coronary arteries

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the XXXX1 registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centers (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p&lt;0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p&lt;0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p&lt;0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p&lt;0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in global mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

Compared to the rest of MINOCA, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding sources: None. Central Illustration

Genesis of epicardial adipocytes and its association with progenitor markers, muscarinic receptor type 3 and b-blockers intake in patients with cardiovascular disease

Introduction

Epicardial fat thickness or volume was found to be associated with cardiovascular disease (CVD). Our aim was to study the epicardial adipocyte-progenitors' markers and its association with cholinergic or adrenergic activity in patients with cardiovascular disease.

Materials and methods

We have included epicardial adipose tissue (EAT) biopsies from 29 patients underwent open-heart surgery. From 10 patients (69±5 years old, 31±8 kg/ m2, 40% CAD, 40% HF, 60% AF, 0% T2DM) stromal cells from epicardial and subcutaneous fat were isolated after collagenase activity and cultured for 14 days and then submitted to adipogenesis for next 14 days. Samples from 19 patients (60±9 years old, 29±4 kg/m2, 42% CAD, 37% HF, 32% AF, 32% T2DM, 53% β-blockers) were used for “ex vivo assays”. Explants were split into equal pieces (100 mg), treated with or without acetylcholine (ACh) for 30 min. Afterwards RNA was isolated and cDNA was amplified by real time PCR. We selected adipocytes progenitors (CD36, PREF1, COL1A1), adipocytes markers (ADIPO, FABP4), muscarinic (muscarinic receptor type 2 (CHRM2) and 3 (CHRM2)) and β-adrenergic receptors (ABRD1, ABRD2 and ABRD3). Gene expression was represented regarding ACTB as 2HK/GEN.

Results

The stromal vascular cells (SVC) from subcutaneous fat (SAT) had higher expression levels of CD36, PREF1 and COL1A1 than SVC from epicardial fat (EAT). It explains the higher adipocytes markers after adipogenesis induction in SAT than EAT cells. However, an upregulation of fibroblasts markers was detected on EAT. The levels of CD36 and PREF1 in SVC were associated with higher adipogenesis. Although CHRM2 was higher in EAT than SAT SVC, the adipogenesis induction upregulated only CHRM3 (1.48±0.065 vs 1.42±0.036 a.u.) in EAT cells. Thus, this receptor was associated with adipocytes markers in epicardial fat (r=0.777 for CD36 and r=0.746 for FABP4) and incremented in epicardial fat biopsies from patients who were taken β-blockers (1.61±0.011 n=10 vs 1.54±0.097 a.u. n=9; p=0.05) and modulated by ACh treatment (p=0.05).

Conclusions

Our results showed that CD36 and PREF1 in epicardial SVC are adipocytes progenitors. The higher presence of adipocytes markers is associated with higher levels of muscarinic receptor (CHRM3), which are upregulated in epicardial fat from patients who were taken β-blockers and modulated by cholinergic activity. Because a metabolic and lipolytic dysfunction was associated with CHRM3, the sympathetic modulation might play a role in the epicardial adipocytes genesis. Further studies are needed to understand if this mechanism might improve or not future cardiovascular events.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ISCIII (PFIS2020)

Gender differences low-density lipoprotein cholesterol reduction with PCSK9 inhibitors in real world patients

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, and are supposed to have a homogenous effect. We tested possible gender differences in a large multicenter registry of real-world patients treated with PCSK9 inhibitors.

Methods

Multicentre and retrospective registry of patients treated with PCSK9 inhibitors from 14 different hospitals from Spain. Before and on-treatment LDLc cholesterol was recorded as well as medical treatments, clinical indication and clinical features.

Results

A total of 562 patients were analysed, mean age 60.2 (9.6) years and 79.2% males. Most frequent indication for PCSK9 inhibitor treatment was established cardiovascular disease (CVD) with LDLc &gt;100 mg/dl (58.1%) followed by familial hypercholesterolemia (23.4%) and statin intolerance (18.5%). Indications other than CVD were more frequent in women (53.3% vs. 39.1%; p=0.03). Women were more frequently ezetimibe (67.5% vs. 50.6%; p=0.001) before PCSK9 treatment; although no gender differences in statin use was observed (78.6% vs. 83.6%; p=0.93) in the whole cohort it was significantly lower in patients with coronary heart disease (91.4% vs. 98.9%; p=0.005). Before treatment LDLc was 148.7 (50.1) mg/dl and it was higher women vs. men (160.3 (59.3) vs. 145.6 (47.0); p=0.005). Evolocumab was initiated in 318 (56.6%) patients; 229 (40.7%) alirocumab 75 mg and 15 (2.7%) alirocumab 150 mg. No gender differences in PCSK9 inhibitors drug or dose were observed.

Median time to second blood determination were 187.5 (IQR 101–242) days. Mean on-treatment LDLc was 66.7 (46.4) mg/dl and it was also higher in women vs. men (84.4 (58.6) vs. 61.9 (41.3); p&lt;0.001). Mean LDLc reduction was 54.7% but it was higher in men as compared to women (57.0% vs. 46.1%; p=0.0003). Higher LDLc reductions were also observed in patients with CVD as compared to the other 2 indications (57.1% vs. 47.3%; p=0.002). Moreover, LDLc reduction with PCSK9 inhibitors treatment was also higher in men vs women among patients with CVD (58.9% vs. 48.0%; p=0.04)

Conclusions

This multicentre and retrospective registry of real-world patients treated with PCSK9 inhibitors highlights significant gender differences in LDLc reduction.

Funding Acknowledgement

Type of funding sources: None.

The real-world cost and health resource utilization associated to the CNIC-polypill compared to usual care

Background

Cardiovascular (CV) polypills have been defined as scalable strategies for CV prevention. Nonetheless, their impact on health systems from an economic perspective has been questioned. The NEPTUNO study has evaluated the effectiveness, the healthcare resources utilization (HRU) and the economic impact of the CNIC-polypill - aspirin (ASA) 100mg, atorvastatin (A) 20/40mg and ramipril (R) 2,5/5/10mg – compared to usual care in a real-life clinical setting in Spain.

Methods

The NEPTUNO study is a retrospective, non-interventional analysis of an anonymized medical history dataset covering patients contained in the BIG-PAC administrative database in the years 2015–2018. Patients at age ≥18 years with medical history of previous CV disease were allocated in 4 different cohorts according to their therapy: (1) CNIC-polypill (case cohort), (2) identical mono-components (ASA,R,A), (3) equipotent medication and (4) usual care (control cohorts) and were followed for 2 years. To ensure comparability the cohorts a propensity score matching was performed. Direct all-cause HRU, including inpatient stay, outpatient visits, emergency room visits, rehabilitation, testing and medical treatment, were registered. Total direct medical costs were computed based on unit costs (€, 2020) assigned to each HRU item and were expressed on a per patient (PP) basis. Indirect costs where estimated based on registered productivity loss and the interprofessional average salary.

Results

8,946 patients were recruited. After PSM, each of the four study cohorts consisted of 1,614 patients. There was acceptable comparability between the study cohorts (balance). The mean age was 63.3 years and 60.4% were men. Cohort 1 compared with the control cohorts 2, 3 and 4 showed a significant reduction in HRU on a per patient average for all items (table), specifically in visits to primary care (16.6 vs. 18.7, 18.9 and 21.0; p&lt;0.001), visits to specialists (5.0 vs. 6.2, 6.5 and 7.3; p&lt;0.001), percentage of patients hospitalized (16.5% vs. 19.8%, 21.9% and 24.0%; p&lt;0.001) and days of hospitalization (2.3 vs. 3.4, 3.7 and 4.0; p&lt;0.001), respectively. The total cost per patient with the CNIC-Polypill compared to monotherapy, equivalents and other treatments, corrected for covariates (ANCOVA), was significantly lower (€4,668 vs. €5,587, €5,682 and €6,016; p&lt;0.001), representing a 16.5%, 17.8% and 22.4% reduction in total costs, respectively. Differences were also observed in healthcare costs, while in non-healthcare costs (loss of labor productivity) the differences were not significative (table).

Conclusion(s)

The results of our analysis demonstrate that the use of the CNIC-polypill results in a significantly lower HRU compared to control cohorts as well as a significantly lower total cost and direct medical costs. This data could support the sustainability and scalability of the polypill strategy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Unrestricted grant from Ferrer Lab, Spain

Prognostic impact of treatment with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the acute phase and medium-term on COVID-19 infected patients

Introduction

The first case of COVID-19 infection was described in Wuhan, China, in December 20191. Shortly after, cases of limited human-to-human transmission were reported in other countries, which made the WHO declare the outbreak a Public Health Emergency of International Concern (ESPII) on January 30, 20202.

Recent studies suggest that treatment with angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARAB) during acute COVID-19 infection has no effect on mortality3, but it is no evidence regarding the medium-term clinical implication of previous treatment with ACEI/ARAB on the prognosis of patients with COVID-19 infection.

Purpose

The aim of this study is to evaluate the clinical implication of the use of ACEI/ARB in the acute moment and in medium-term follow-up in patients after COVID-19.

Methods

It is a single-centre, retrospective, analytical observational study of cohorts based on all consecutive patients diagnosed with COVID-19 who were admitted during the first wave (March 10th until May 31st), of the pandemic in our health area. Survival analysis of main outcomes (mortality, heart failure, and major acute cardiovascular events [a composite of cardiovascular mortality, myocardial infarction and stroke]) were adjusted by multivariate logistic regression.

Results

Of the total population studied, 447,979 inhabitants, 1,030 (0.23%) were diagnosed with COVID-19 infection, of which 196 (19%) were under treatment with ACEI/ARB at the time of diagnosis. The main results showed that ACEI/ARB treatment (combined and individually) had no effect on mortality (Hazard Ratio [HR]: 1.64, 95% Confidence Interval [CI] 0.98 2.76, p=0.062), heart failure (HR: 0.98, 95% CI 0.53 1.79, p=0.942), thrombotic events (HR: 1.02, 95% CI 0.22 4.83, p=0.98) and major acute cardiovascular events (HR: 0.88, 95% CI 0.48 1.60, p=0.665).

Conclusions

In conclusion, previous treatment with ACEI/ARB in patients with COVID-19 had no effect on the 6-month prognosis, defined as mortality, heart failure, or major acute cardiovascular events.

Withdrawal of ACEI/ARB in patients testing positive for COVID-19 would not be justified, in line with current recommendations of scientific societies and government agencies.

Funding Acknowledgement

Type of funding sources: None.

Leadless pacemaker implant with concomitant atrioventricular node ablation: a single center study with longterm followup

Funding Acknowledgements

Type of funding sources: None.

Introduction

Feasibility of concomitant leadless-pacemaker(LP) implantation plus atrioventricular node ablation(AVNA) is unknown. Moreover, safety issues in the long run are also undetermined. It seems theoretically attractive since it could avoid one additional procedure and catheter could be introduced through the same sheath employed for the LP. On the contrary, risk of dislocation/electrical variations could represent a shortcoming .

Objective

We aim to report 1) feasibility of concomitant AVNA after a LP implantation and 2) long-term outcomes. 

Methods

Single center, prospective and observational study of 243 consecutive patients with an indication for single-chamber pacemaker placement. The implantation procedure was carried out using a femoral approach and conventional technique. Successful implantation was accomplished in 242/243 patients referred for leadless implantation. In one patient, a complete obstruction of the inferior vena cava was documented, and a conventional unicameral pacemaker was implanted.

Results

33 out of  242 patients underwent immediate AV ablation. Mean age was 75.2 ± 8.3 years. Were predominantly females: 25(75.7%) and indication was fast conduction atrial fibrillation(n = 25), atypical flutter or atrial tachycardia (n = 8). Mean acute "R wave" was 11.3mV, threshold of 0.55Vx0.24ms and impedance of 833Ω. Uneventful AV node ablation was performed in all of them immediately after LP implantation. Additional mean fluoroscopic time was 3.0 minutes.

There were no vascular or arrhythmic complications after the implantation. After a mean follow-up of  19.9± 12 months, all patients remained alive without notable event, and electrical parameters remained unchanged.(Figure 1)

Conclusions

Conconmitant AVN ablation after LP implantation seems feasible without remarkable complications in the long run.  In our  experience, this approach appears more comfortable for the patients and less time-consuming than conventional pacemaker implantation with sequential AV node ablation. There were no device macrodislodgements or unexpected device malfunctions in the follow-up period. Abstract Figure. Electrical performance

P1466Leadless pacemaker mid and long term follow-up in a single center-study

Introduction and objectives

Initial results of Leadless pacemakers (LPM) has been promising in worldwide, nevertheless there are still no long term experience published, so the objective of our study was to evaluate electrical parameters at mid  and long term follow-up, describing as well total complications and mortality in a single center-study.

Methods

 

This was a prospective, observational clinical trial that included 183 consecutive patients, with an indication for a single-chamber pacemaker implantation.

Results

 

All successful implantation included a total of 183 patients with a mean age of 79,2 ±6,6 years (range 54-93y/o); 111 (60,6%) were men and more frequent rhythm was permanent atrial fibrillation (160), including those in which a node ablation was performed in the same procedure (22). Clinical and echocardiographyc characteristics are described in table 1.Mean follow-up was of 26 ±10 months including: 64 patient at 24 months, 46 at 36 months and 7 patients at 48 months. Electrical parameters are represented in figure 1, which were stable and flawless at long term follow-up.  Total complications were 3,3%, with only 2 patient requiring surgery for resolution (1,7%), and all were acute during LPM implantation. A total of 17 patients (9,3%) died with no relation to pacemaker. 

Conclusions

In our experience, leadless pacemakers electrical performance continues stable, appropriate at long term follow-up, and no other complications developed.

Baseline Characteristics of Patients Age(years) 79.2 ± 6.6[54-93] Male gender, n (%) 118 (60.6%) Hypertension, n (%) 149 (81.7%) Diabetes mellitus, n (%) 64 (34.9%) COPD, n (%) 33(18.3%) Renal dysfunction, n (%) 30 (16.7%) Valvular disease, n (%) 74 (41.1%) Atrial Fibrillation, n (%) 161 (98.0%) LVEF(%) 60.0 ± 8 OAC, n (%) 123(67.2%) NOAC, n (%) 23 (10.0%)

Abstract Figure. Electrical performance

Obesity-Related Genetic Determinants of Heart Failure Prognosis

PURPOSE

Recent advances in genomics offer a smart option for predicting future risk of disease and prognosis. The objective of this study was to examine the prognostic value in heart failure (HF) patients, of a series of single nucleotide polymorphisms (SNPs).

METHODS

A selection of 192 SNPs found to be related with obesity, body mass index, circulating lipids or cardiovascular diseases were genotyped in 191 patients with HF. Anthropometrical and clinical variables were collected for each patient, and death and readmission by HF were registered as the primary endpoint.

RESULTS

A total of 53 events were registered during a follow-up period of 438 (263-1077) days (median (IQR)). Eight SNPs strongly related to obesity and HF prognosis were selected as possible prognostic variables. From these, rs10189761 and rs737337 variants were independently associated with HF prognosis (HR 2.295 (1.287-4.089, 95% CI); p = 0.005), whereas rs10423928, rs1800437, rs737337 and rs9351814 were related with bad prognosis only in obese patients (HR 2.142 (1.438-3.192, 95% CI); p = 0.00018). Combined scores of the genomic variants were highly predictive of poor prognosis.

CONCLUSIONS

SNPs rs10189761 and rs737337 were identified, for the first time, as independent predictors of major clinical outcomes in patients with HF. The data suggests an additive predictive value of these SNPs for a HF prognosis. In particular for obese patients, SNPs rs10423928, rs1800437, rs737337 and rs9351814 were related with a bad prognosis. Combined scores weighting the risk of each genomic variant could effect interesting new tools to stratify the prognostic risk of HF patients.

P1223Attributable risk proportion of uncontrolled low-density lipoprotein cholesterol in recurrent acute coronary syndromes

Background

Coronary heart disease is chronic condition that usually has recurrent events. Risk factors for incident coronary heart disease are well known conditions related to recurrences have not been clearly outlined. Attributable risk proportion (ARP) refers to the proportion of incident cases in subjects exposed to risk factors that are attributable to that risk factor so we analysed ARP in wide cohort of patients admitted for an acute coronary syndrome (ACS).

Methods

Cross-sectional analysis of all patients admitted in two hospitals between January 2006 and December 2016. ARP was calculated by the equation: prevalence in exposed – (prevalence in exposed/odds ratio). LDL uncontrolled was codified as >70 mg/dl in patients with previous cardiovascular disease; >100 mg/dl in patients with diabetes without previous cardiovascular disease or; >155 mg/dl in patients without cardiovascular disease.

Results

We included 7,518 patients, mean age 66.9 (12.9) years, 72.5% males, median GRACE score 143.2 (40.3) and 35.3% STEMI. Previous coronary heart disease total was present in 2,032 (23.2%) patients and they had statistically higher mean age (70.6±11.11 vs. 65.8±13.3), prevalence of diabetes (37.9% vs. 25.3%) and hypertension (72.9% vs. 53.3%) and lower smoking habit (15.5% vs. 30.9%). LDLc was lower in patients with previous coronary heart disease (90.3±33.8 vs. 111.7±38.1; p<0.01), as well as HDLc (33.5±14.29 vs. 35.9±35.5; p<0.01) and haemoglobin (13.5±3.7 vs. 14.0±2.4; p<0.01). Uncontrolled LDLc was present in 83.4% of the patients with previous coronary heart disease, in contrast to the 28.7% of patients without previous coronary heart disease; this resulted in an ARP of 13.8%. The ARP for diabetes and hypertension were 1.6% and 1.4%, respectively.

Conclusions

The proportion of attributable risk of uncontrolled LDL on recurrent ACS is 13.8% and, therefore, 1 out of every 7 recurrent ACS could be prevented by an accurate LDLc control.

P3494Dapagliflozin reduced lactate release by epicardial adipose tissue from CAD patients: switch from fatty acids to glucose aerobic oxidation

Background

Dapagliflozin, a sodium-glucose co-transporter 2 inhibitor, improves the glucose uptake by epicardial adipose tissue (EAT). However, its metabolic pathways are still unknown. Our aim was to clarify the EAT glucose-lipid metabolism from patients with and without coronary artery disease (CAD).

Methods

Paired subcutaneous (SAT) and EAT biopsies from 49 patients undergoing heart surgery were cultured and treated with or without dapa at 10 or 100 μM for 6 hours. Glucose, lactate and oxygen were analyzed on supernatants by colorimetric or fluorescence assays. Glycolytic, lipolytic, glyceroneogenic and lipogenic genes or protein expression levels were determined on fat tissues by RT-qPCR or western blot, respectively.

Results

Glyceroneogenic and lipid metabolism-involved genes were higher expressed in SAT than in EAT. Dapa reduced their expression in SAT but not in EAT. Lipid-droplet protein levels, perilipin (PLN A) and hormone-sensitive lipase (HSL), were reduced in EAT. Mitochondrial biogenesis-related gene PGC1α was upregulated (p<0.05). Despite this drug improved glucose utilization, it reduced lactate release and oxygen consumption in both fat pads. After classifying patients according presence/absence of CAD, we observed a greater release of lactate by EAT in patients with CAD (3.22±2.40 mM) that was remarkably reduced after dapagliflozin treatment at 10 μM (2.17±1.53 mM, p<0.01) and 100 μM (2.45±2.11 mM, p<0.001).

Clinical characteristics regarding CAD presence (n=49) Non CAD patients (n=26) CAD patients (n=23) p value Gender (male) (n/%) 14/54 20/87 0.010* Age (years) 73±9 67±12 0.026* BMI (kg/m2) 29.±4 30±4 0.377 HTA (n/%) 21/80.8 17/73.9 0.578 T2DM (n/%) 12/46 9/39 0.629 HF (n/%) 2/8 6/26 0.096 L-Lactate (mM) 2±1.1 3.2±2.4 0.029* Glucose (mg/dL) 65±15 62±22 0.539 Oxygen (RFU) 47±9 46±14 0.899 CAD: Coronary artery disease, BMI: Body mass index, HTA: arterial hypertension, T2DM: Diabetes mellitus type 2, HF: Heart failure, RFU: relative fluorescence units.

Lactate in CAD

Conclusions

Dapagliflozin reduced the anaerobic glycolytic pathway, lowering the released lactate by EAT, overall in patients with CAD. This effect suggests a protective metabolic role since high lactate was found to be a marker of poor outcomes in HF patients.

Acknowledgement/Funding

Astrazeneca

P4734Electron microscopy reveals evidence of perinuclear clustering of mitochondria in cardiac biopsy proven allograft rejection

Background

Despite improved efficacy of immunosuppression therapy, allograft rejection continues to be a significant risk, especially early after transplantation. Endomyocardial biopsy (EMB) is the standard tool with a recognized role in the surveillance of posttransplant cardiac rejection and is based on optical microscopy analysis. However, this method presents technical limitations.

Purpose

In this work we focus on the analysis of new ultrastructural findings in cardiac biopsy specimens.

Methods

This study include heart transplanted patients from a single center who were referred for EMB as a scheduled routine screening. Participants were divided into 2 groups: patients transplanted without allograft rejection (n=5), and patients with biopsy-proven allograft rejection (n=5). Rejection episodes were assessed according to the International Society for Heart and Lung Transplantation (ISHLT) consensus report.

Results

We detected by electronic microscopy a significative increase in the number of mitochondria (p<0.0001) and dense bodies in the rejection group (p<0.05). But the most significative finding was the presence of local accumulations of mitochondria close to the nuclear envelope, pressing and shaping the morphology of this membrane in all rejection samples. We found these perinuclear clustering of mitochondria in a 68±27% of the total cardiac nucleus observed from rejection samples. We not observed this phenomenon in non-rejection samples, thus reflecting an excellent sensitivity and specificity.

Perinuclear clustering of mitochondria

Conclusion

We observed by electron microscopy a specific phenomenon, perinuclear clustering of mitochondria, in endomyocardial biopsies from patients with cardiac rejection that affects to the architecture of the nuclear membrane. This ultrastructural approach might complement and improve the diagnosis of rejection.

Acknowledgement/Funding

National Institute of Health [PI16/01627, PI17/01925, PI17/01232], “Consorcio Centro de Investigaciόn Biomédica en Red, M.P.”, and FEDER

P2620PIONEER-HF criteria ready for the prime time? Data from REDINSCOR II registry

Background

New treatment strategies are needed to improve the prognosis in acute heart failure (AHF), recently PIONEER-HF results have been published showing in a selected group of patients a potential use of sacubitril/valsartan with safety in this scenario

Purpose

To evaluate the impact of PIONEER-HF potential indication in daily practice after AHF hospitalization at discharge

Methods

We included a subgroup of 909 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry with the complete data for this analysis. In the trial left ventricular ejection fraction (LVEF) ≤40% and natriuretic peptides at admission with values of NT-ProBNP≥1600 pg/ml were needed to be included. The clinical and analytic stability at discharge to safely start sacubitril/valsartan was considered as MDRD estimated Glomerular Filtration Rate≥30 mL/min/1.73 m2, Systolic Blood Pressure ≥100 mmHg and Potassium ≤5.2 mmol/L.

Results

The mean age was 72.1±12.01 years. Of these, 373 (38.8%) were female, 734 (76,6%) were hypertensive, 462 (48.2%) had diabetes and 282 (29.9%) coronary artery disease. At admission atrial fibrillation was found in 403 patients (40.1%) and 409 (45%) had reduced LVEF. The mean levels of NT-ProBNP 7259.4±9437.1 pg/ml. In this group of patients, the in-hospital mortality was 28 (2.9%) and the 1 year follow up mortality was 197 (20.5%) and the heart failure rehospitalizations in 1 year were 303 (31,5%). In table 1 the percentage of patients that fulfil the needed criteria for the application of PIONEER HF is shown. In our registry 235 patients (25.9%) could be potential users of sacubitril/valsartan after the acute phase of hospitalization

Table 1 Elements to stablish indication Number of patients (%) NT-ProBNP ≥1600 pg/ml at admission 730 (80.3%) MDRD estimated GFR ≥30 mL/min/1.73 m2 at discharge 798 (87.8%) Systolic Blood Pressure ≥100 mmHg at discharge 755 (83.1%) Serum Potassium ≤5.2 mmol/L at discharge 856 (94.2%) Clinical and analytic stability at discharge 636 (70%) Left ventricular ejection fraction ≤40% 409 (45%) PIONEER HF Criteria 235 (25.9%) GFR: Glomerular Filtration Rate.

Conclusions

In our cohort of AHF patients around 1 out 4 could be treated with sacubitril/valsartan at discharge if we apply the PIONEER HF criteria in a contemporary setting, this finding could have potential implications in the prognosis and current costs of care in a population with high morbidity and mortality.

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and FEDER

P658CHA2DS2-VASc score calibration in anticoagulated vs non-anticoagulated patients in a healthcare area

Introduction

Atrial fibrillation (AF) is a highly prevalent heart disease, affecting a significant proportion of patients over 65 years old. The CHA2DS2-VASc score predicts 1 year risk of a thromboembolic (TE) event and is well validated against several populations. However, calibration may vary if there is subgroup heterogeneity.

Purpose

To compare the CHA2DS2-VASc score calibration, in patients with or without anticoagulation (AC) in a real population of AF patients in our healthcare area.

Methods

Patients with an episode with atrial fibrillation/flutter were selected from a general population in a healthcare area (383,000 subjects), with 21/12/2013 as a cut-off date. Patients with valve disease, anticoagulation or antiplatelet therapy were identified.

The CHA2DS2-VASc score was calculated as stipulated in the European Society of Cardiology guidelines. A CHA2DS2-VASc score of 0 is considered to be low risk for TE events (0% at 1 year), score of 1 intermediate risk (0.6% rate at 1 year), and greater than 1 high risk (3% rate at 1 year).

Quantitative variables are presented as mean and standard deviation (SD). Categorical variables were presented as frequencies and percentages. A logistic regression was fitted to predict 1-year risk TE outcomes with CHA2DS2-VASc as the only covariate. Model calibration was assessed using the predicted versus actual probabilities of TE events. All analyses were performed using R v.3.4 (R Core Team, Vienna, Austria) with the packages rms and ggplot2.

Results

CHA2DS2-VASc was calculated in 7990 patients with AF. A total of 1824 patients were excluded either due to valvular disease (846) or due to previous antiplatelet treatment (1047). From them, 143 patients were excluded for an incomplete follow-up time (<1 year).

As of December 31, 2015, 67 stroke cases had been notified from 6023 patients (1.1%) (Table 1). Mortality rate was 181 (3%) at 1 year.

Patients presented overall low risks of stroke with a poor score calibration. Higher scores presented risks that were lower than predicted by CHA2DS2-VASc. Event rate at 1 year was similar regardless of the AC regime at the initial date, and also similar to a previous cohort of anticoagulated patients (Lip et al.). This similarity may indicate confounding by later AC therapy initiation, before the final assessment date.

Table 1. Comparison of thromboembolic event rates in several studies % (No-AC) % (AC) % Lip 2010 % Poli 2011 % Friberg 2012 % Okumura 2014 0.01 0.01 0.02 4.5 4.5 1 AC: anticoagulation.

CHA2DS2VASc score calibration

Conclusion

Higher CHA2DS2-VASc scores are not associated to higher risks of stroke in our healthcare area, in patients with non-valvular AF and without antiplatelet therapy.

P1927A European randomised controlled trial for m-health guided cardiac rehabilitation in the elderly; results of the EU-CaRE RCT study

Introduction

Knowledge about effectiveness of cardiac rehabilitation (CR) in the elderly is limited. Participation rates in supervised CR are consistently lower in the elderly and innovative interventions are needed. The EU has granted a CR study project; a randomised controlled trial conducted in 5 European countries, investigating the effectiveness of mobile telemonitoring guided CR (mCR) in elderly cardiac patients who declined regular CR.

Methods

Patients ≥65 years with indication for CR who declined regular CR were eligible for inclusion. Patients were randomised between regular care (without CR) and a 6-month mCR programme: dedicated programmed smartphone, heartrate monitoring (target HR zones) and coaching. The primary endpoint is the difference in VO2peak between 6-months follow-up and baseline.

Results

Between 2015 and 2018 179 patients were included. Baseline characteristics between groups (table 1) did not differ significantly, except for hypertension. The difference in VO2peak was significantly better in the mCR group (table 1). After correction (mixed linear model) for baseline VO2 peak (fixed factor) and centre (random factor) this difference remained significant. Mean number of registered activity sessions was 4.79 (95% CI; 4.07–5.50) per patient per week.

Table 1. Baseline and primary outcome parameters Baseline Control Programme (n=90) mCR Programme (n=89) P-value Gender (m/f) 76/14 69/20 0.238 Age (mean±SD) 73.57±5.46 72.38±5.37 0.121 Diabetes 15 (16.7%) 23 (25.8%) 0.133 Hypertension 60 (66.7%) 73 (82.0%) 0.019* Hypercholesteremia 71 (78.3%) 74 (83.1%) 0.468 Normal LV-function 48/89 (53.9%) 53/89 (59.6%) 0.497 Index event (CABG/Valve/PCI/none) 0.735   Cardiac history prior to index event 48/89 (53.9%) 53/89 (59.6%) 0.702   Non cardiac comorbidity 40 (44.4%) 44 (49.4%) 0.503 Results   Baseline VO2peak (ml/kg/min) (95% CI) 19.83 (18.65–21.01) 18.78 (18.67–19.89) 0.191   Delta VO2peak at 6 months (ml/kg/min) (95% CI) 0.20 4 (−0.34–0.83) 1.62 (0.86–2.39) 0.005*   Corrected delta VO2peak at 6 months (ml/kg/min) 0.50 (−1.04–2.04) 1.65 (0.11–3.2) 0.015* *Significant.

Conclusions

The application of mCR in elderly patients who declined regular CR results in a better physical condition after 6 months. Compliance to mCR was excellent.

Acknowledgement/Funding

European Union's Horizon 2020 research and innovation programme under grant agreement number 634439, and funding from the Swiss Government.

P4535Discharge treatment with ACE inhibitor/ARB after a heart failure hospitalization is associated with a better prognosis irrespectively of left ventricular ejection fraction

Background

Medical therapy could improve the prognosis of real-life patients discharged after a heart failure (HF) hospitalization.

Purpose

We aimed to determine the impact of discharge HF treatment on mortality and readmissions in different left ventricular ejection fraction (LVEF) groups.

Methods

Multicentre prospective registry in 20 Spanish hospitals. Patients were enrolled after a HF hospitalization.

Results

A total of 1831 patients were included (583 [31.8%] HF with reduced ejection fraction [HFrEF]; 227 [12.4%] HF with midrange ejection fraction [HFmrEF]; 610 [33.3%] HF with preserved ejection fraction [HFpEF], and 411 [22.4%] with unknown LVEF. Angiotensin-converting enzyme (ACE) inhibitors/Angiotensin II receptor blockers (ARB) at discharge were independently associated with a reduction in: i) all-cause mortality: hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.41–0.74, P<0.001, with a similar effect in the four groups; ii) mortality due to refractory HF HR 0.45, 95% CI 0.29–0.64, P<0.001, with a similar effect in the three groups with known LVEF; iii) mortality/HF admissions (HR 0.61; 95% CI: 0.50–0.74), more evident in HFrEF (HR 0.54; 95% CI: 0.38–0.78) compared to HRmEF (HR 0.64; 95% CI 0.40–1.02), orHFpEF (HR 0.70; 95% CI 0.53–0.92).Inpatients with HFrEFtriple therapy (ACE inhibitor/ARB+ betablocker+ mineralocorticoid receptor antagonist) was associated with the lowest mortality risk (HR 0.21; 95% CI: 0.08–0.57, P=0.002) compared to patients that received none of these drugs.

Events according to the number of drugs – HFrEF (n=583) 0 (n=14) 1 (n=98) 2 (n=160) 3 (n=294) P Death or heart failure readmissions 10 (71.4) 58 (59.2) 66 (41.3) 106 (36.1) <0.001 All-cause mortality 9 (64.3) 28 (28.6) 31 (19.4) 36 (12.2) <0.001 Mortality due to refractory heart failure 7 (50.0) 14 (14.3) 17 (10.6) 17 (5.8) <0.001 – HFmrEF (n=227) 0 (n=18) 1 (n=57) 2 (n=81) 3 (n=65) P Death or heart failure readmissions 9 (50.0) 35 (61.4) 34 (42.0) 25 (38.5) 0.057 All-cause mortality 5 (27.8) 18 (31.6) 15 (18.5) 11 (16.9) 0.191 Mortality due to refractory heart failure 3 (16.7) 7 (12.3) 7 (8.6) 4 (6.2) 0.475 – HFpEF (n=610) 0 (n=61) 1 (n=242) 2 (n=219) 3 (n=69) P Death or heart failure readmissions 32 (52.5) 97 (40.1) 89 (40.6) 20 (29.0) 0.057 All-cause mortality 20 (32.8) 41 (16.9) 32 (14.6) 10 (14.5) 0.017 Mortality due to refractory heart failure 11 (18.0) 18 (7.4) 13 (5.9) 4 (5.8) 0.041 Outcomes according to the number of medications at discharge.

Kaplan-Meier Curves for study outcomes

Conclusions

Discharge treatment with ACE inhibitor/ARB after a HF hospitalization is associated with a reduction in all-cause and refractory HF mortality, irrespectively of LVEF.

P6554Utility of accelerometer programmation in leadless pacemaker regardind location. CARDIOCHUS registry

Background

Real-world data reinforce positive results in different implant locations of leadless pacemaker (LPM). LPM have special characteristics regarding accelerometer programmation.

Purpose

The purpose of the study was to describe our experience with LPM different implantation location and its programmation according the vector accelerometer.

Methods

We performed a prospective observational one center study including all patients with LPM implantation within 3 years (June 2015-December 2018). Location of deployment was classified as apicalseptal, midseptal or right ventricle outflow tract (RVOT). Vector programmation was performed from the second visit in patients with acceptable mobility and heart rate below 80 bpm, with the abbreviated protocol recommended by the brand. Clinical evaluation according to vector programmed was performed 3 to 6 months later.

Results

We include a total of 144 LPM, and exercise test was performed in 86 patients. There were 86 men (59.7%) with a mean age of 79.1±6.9 years-old (54 to 89). Location of deployment was distributed as follows: 32.4% in apicalseptal, 54.5% in midseptal and 13.1% in RVOT. Vector 1 was the more frequent programmation, specially in apicalseptal position. Correlation between location and vector of programmation could not be predicted (p=0.2381), but there was a non-significant tendency (p=0.08) between patients with LPM in RVOT location and Vector 3 programmation. Table 1 and Figure 1.

Table 1. Micra Location and Activity Vector Apicalseptal Midseptal RVOT P Value Test Vector 39 (84.8%) 40 (58.5%) 7 (46.7%) NS Vector 1 22 (56.4%) 26 (65.0%) 2 (28.6%) NS Vector 2 8 (20.5%) 4 (10.0%) 1 (14.3%) NS Vector 3 9 (23.1%) 10 (25.0%) 4 (57.1%) 0.08

Figure 1

Conclusions

In our series, Vector 1 was the predominant accelerometer programmation specially in apicalseptal LPM position and Vector 3 in RVOT position.

P6549Conventional single lead ventricular pacemaker against leadless pacemaker system in real-world patients: prospective one center study. CARDIOCHUS Registry

Background

As more experience is obtained with leadless pacemakers systems (LPM), a great group of patients is considered for its implantation. There are issues that cannot be completely avoided with conventional transvenous pacemaker (VVI-PM) such as infectious or pocket related complications in which LPM are clearly superior.

Purpose

The aim of the study was to compare the clinical and device performance between LPM and VVIPM in the same period of time in a “real-world” population.

Methods

We performed a prospective, observational, one center study, including all patients with a single chamber pacemaker implantation within 3 years (June 2015-December 2018) and its mid-term follow-up. All clinical, electrical and echocardiographic characteristics, as well as implantation characteristics and complications, were described.

Results

We included a total of 339 patients with transvenous pacemakers, 195 patients with VVI-PM and 144 LPM. There were no significant differences in mortality between both groups during the follow-up (12,3±10 months), Figure 1. Although there were no significant differences in major complications (P-value 0,54), the number of total complications was lower in the LPM group (P-value 0,01) at the expense of fewer minor ones (P-value 0,02), Table 1.

Table 1. Complications TVP (195) LPM (144) P value Major complications 11 (5.6%) 6 (4.2%) 0.54 Minor complications 10 (5.1%) 0 (0.0%) 0.01 Total Complications 21 (10.7%) 6 (4,2%) 0.02

Figure 1

Conclusions

In our study, during the med-term follow-up, there were no significant differences in terms of mortality and the major complications between LMP and VVI-PM. Although, the number of minor complications were less with the LMP.

P2513Offer and participation in different European cardiac rehabilitation programs in the elderly after ACS or coronary revascularization. The EU-CaRE study

Background

Cardiac rehabilitation programs (CRP) are strongly recommended after acute coronary syndrome (ACS) or coronary revascularization (PCI or CABG), but actual offer and participation among elderly patients (age ≥65) have not been well characterised.

Purpose

To analyse current offer and participation rates in different European CRP in elderly patients.

Methods

Data from elderly patients recruited for CRP, after ACS, PCI or CABG, in centres from seven European countries participating in the EU-CaRE study (NTR5306), were analysed.

Results

3471 patients were screened, of whom 80.9% (n=2806) were offered participation and 68.0% of these (n=1908) agreed to participate in a CRP.

Outpatient CRP were offered to 73–92% of screened patients. Among reasons for not offering the program were contraindications and geographical conditions. Patients who were not offered were mainly older, with worse cardiovascular risk profile and comorbidities. In the multivariable analysis main variables related with offering in Copenhagen were age (OR=0.92, CI95% 0.87–0.98), gender (male, OR=2.42, CI95% 1.10–5.31) and previous CABG (OR=0.12, CI95% 0.04–0.36). In Bern, age (OR=0.89, CI95% 0.85–0.93), ACS (OR=1.85, CI95% 1.01–3.54) and smoking status (OR=0.47, CI95% 0.24–0.93). In Zwolle, age (OR=0.89, CI95% 0.91–0.97), CABG (OR=4.34, CI95% 1.37->10), smoking status (OR=0.23, CI95% 0.06–1.11), diabetes mellitus (OR=0.33, CI95% 0.13–0.91) and comorbidities (i.e. obstructive pulmonary disease). In Santiago, age (OR=0.83, CI95% 0.73–0.91), index event PCI (OR=14.21, CI95% 3.68->10) and rheumatoid arthritis.

The ratio of participation among those who were offered the program varied from 46% to 94% (46% to 67% in outpatients' programs). Main reasons for not participating were patients considered that it was not useful (366, 10.5%), travel distance (205, 5.8%), transport difficulties (134, 3.8%) and exercises on own initiative (70, 2.0%). In a center-specific analysis we performed predictive models of participation. In Copenhagen (AUC=0.69) the main variables predicting participation were age (OR=0.99, CI95% 0.96–1.03), not living alone (OR=1.53, CI95% 0.96–2.42), CABG (OR=2.69, CI95% 1.51–4.80) and comorbidities. In Bern (AUC=0.81), age (OR=0.92, CI95% 0.89–0.95), ACS (OR=3.99, CI95% 2.56–6.20) and peripheral artery disease. In Zwolle (AUC=0.71), age (OR=0.94, CI95% 0.91–0.98), employment status (OR=0.28, CI95% 0.13–0.60), CABG (OR=3.62, CI95% 2.28–5.77) and previous ACS (OR=0.58, CI95% 0.35–0.95). In Santiago (AUC=0.85), age (OR=0.95, CI95% 0.90–0.99), rural habitat (OR=0.58, CI95% 0.32–1.04), valvulopathy (OR=0.33, CI95% 0.14–0.79) and the index intervention PCI.

Conclusions

Knowing reasons (travel distance, usefulness of the program understood by patient) and variables (age, living alone or in rural area) that determine if CRP is offered and whether or not patients participate will help redesign CRP to better adapt to actual needs of an elderly European population.

Acknowledgement/Funding

This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement number 634439

P4464Significative role of edoxaban on endotelial cell functions

Background

Edoxaban is a new oral anticoagulant with factor X activated (FXa) inhibition properties. It is approved for the prevention of ictus and embolism in patients with atrial fibrillation and for the treatment of venous thrombosis and lung embolism. However, little is known about its effects on endothelial cell functions.

Objectives

To study the edoxaban effects on key endothelial functions as proliferation, wound-healing, angiogenesis and peripheral blood mononuclear cells (PBMCs) adhesion.

Methods

Human umbilical endothelial cells (HUVECs) were obtained from donated umbilical cords after signed informed consent of the mothers. Cell proliferation and viability were measured by a real-time cell analyzer by noninvasive electrical impedance monitoring. Migration was study in wound-healing assays. Angiogenesis was measured after 16 hours of HUVECs' seeding in a three dimensional matrix and PBMCs adhesion to HUVECs' monolayers was assessed in the presence or in the absence of edoxaban and/or FXa. Measurements on each assay was compared between control conditions and edoxaban's or FXa's treatments and between treatments with FXa and the combination of FXa and edoxaban.

Results

Edoxaban (1 Nm – 1 μm) was a safe, non-toxic molecule for HUVECs. It significantly promoted HUVECs' growth at concentrations between 10–500 Nm, been the maximal response at 100 nM. The proliferative effect of edoxaban 100 nM was also observed in the presence of FXa 9 nM, which also induced proliferation by itself. In spite of this proliferative effect, edoxaban (50–100 nM) did not increased healing (cells' migration) after a wound, but counteracted the healing effects of FXa 9 nM. Edoxaban (100–500 nM) alone did not influence angiogenesis, but partially restore the anti-angiogenic effect of FXa on HUVECs. Finally, and very interestingly, edoxaban (50–500 nM) significantly inhibited PBMCs adhesion to endothelial cells' monolayers, and even blocked the FXa (50 nM)- and tumor necrosis factor (TNF; 10μg/ml)-induced adhesion.

PBMCs adhesion to endothelial cells

Conclusions

Edoxaban is a safe and proliferative-inducer drug in endothelial cells in vitro. It counteracts the anti-angiogenic and pro-migratory effects of FXa on HUVECs, but more importantly, edoxaban significantly reduced PBMCs adhesion to endothelial cells monolayers in comparison to control experiments and compared to stimulated cells, independently of the pro-inflammatory drug used.

Acknowledgement/Funding

Daiichi-Sankyo España S.A.U.

P6361Prognostic value of discharge heart rate in acute heart failure patients: more relevant in atrial fibrillation?

Background

The prognostic impact of heart rate (HR) in acute heart failure (AHF) patients is not well known especially in atrial fibrillation (AF) patients.

Purpose

The aim of the study was to evaluate the impact of admission HR, discharge HR, HR difference (HRD) (admission- discharge) in AHF patients with sinus rhythm (SR) or AF on long- term outcomes.

Methods

We included 1398 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentric, prospective registry. Logistic regression models were used to estimate the association between admission HR, discharge HR and HR difference and one- year all-cause mortality and HF readmission.

Results

The mean age of the study population was 72±12 years. Of these, 594 (42.4%) were female, 655 (77.8%) were hypertensive and 655 (46.8%) had diabetes. Among all included patients, 745 (53.2%) had sinus rhythm and 653 (46.7%) had atrial fibrillation. Only discharge HR was associated with one-year all-cause mortality (Relative risk (RR)= 1.182, confidence interval (CI) 95% 1.024–1.366, p=0.022) in SR. In AF patients discharge HR was associated with one-year all-cause mortality (RR= 1.276, CI 95% 1.115–1.459, p≤0.001). We did not observe a prognostic effect of admission HR or HRD on long-term outcomes in both groups. This relationship is not dependent on left ventricular ejection fraction (Figure 1)

Effect of post-discharge heart rate

Conclusions

In AHF patients lower discharge HR, neither the admission nor the difference, is associated with better long-term outcomes especially in AF patients

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and the Fondo Europeo de