Valorization of Water Treatment Sludge for Applications in the Construction Industry: A Review

To address the growing global water demand, it is imperative to implement advanced treatment systems and sustainable alternatives for managing the large amount of waste generated during the water purification process, known as water treatment sludge (WTS). Worldwide, researchers and companies are exploring alternatives and methods for the valorization of WTS as a raw material in other processes. It is urgent that all productive sectors, which contribute significantly to greenhouse gas emissions, adopt this management principle to ensure more sustainable production, contributing to the global goal of climate neutrality. Notably, in civil construction, incorporating WTS as a supplementary cementitious material (SCM) shows great promise, considering that the industrial waste currently used for this purpose is increasingly restricted. The use of WTS as a raw material in the cement industry not only contributes to the reduction of the carbon footprint, but also reduces the high waste load still disposed of in landfills. The emerging applications for WTP sludge are reviewed, with emphasis on its valorization in the civil construction as an SCM. The main characteristics of this waste and their impacts on the environment are also addressed.

Green Thermal Aggregates: Influence of the Physical Properties of Recycled Aggregates with Phase Change Materials

Increasing construction and demolition waste (CDW) and the large amount of energy consumption in the building operation process are high-profile issues at present. In the construction industry, recycled aggregated (RA) from CDW can be reutilized in construction, along with green materials, for example, as a road base layer, as aggregate in concrete, etc. Phase change materials (PCM) are often used as building materials due to their good latent heat storage properties. With the use of RA as a matrix to absorb PCM, a thermal performance aggregate can be obtained. This work studied the physical properties of RA from Portugal and combined PCM with RA to prepare a green thermal aggregate through two methodologies using a vacuum and atmospheric pressure. The green aggregate was used in concrete to observe its effect on the compressive strength of concrete. The results showed that the amount of PCM absorbed by the RA mainly depends on the porosity of the matrix material. At the same time, the volume expansion coefficient of PCM was 2.7%, which was not enough to destroy the RA. Ultimately, as the amount of green thermal aggregate increases, the compressive strength of concrete decreases. Green thermal aggregate prepared under vacuum conditions has a greater negative impact on the compressive strength of concrete.

Performance of Eco-Friendly Cement Mortars Incorporating Ceramic Molds Shells and Paraffin Wax

The lost wax foundry industry has been rapidly expanding in recent years, generating a large amount of waste due to the fact that most of the durable goods include castings and the need for dimensional precision castings for specific purposes, such as the automotive and aeronautics sectors. The waste produced by this industry is currently being deposited in landfills because practical applications are not known and cannot be reused in a new production process, and recycling is also a challenge because of the economics of the process. Thus, the main objective of this study consists in the incorporation of the produced wastes by the lost wax casting foundry industry (ceramic molds shells and paraffin wax) as substitutes for natural aggregate in exterior coatings mortars, evaluating their behavior under normal operating conditions and against freeze-thaw actions. The obtained results revealed porosity, flexural strength, and compressive strength adequate under normal operating conditions. The freeze-thaw performance of the mortars with waste incorporation was similar to the mortars developed with natural aggregates. Thus, the potential of the ceramic mold shells and paraffinic waxes utilization in cementitious mortars for the construction sector was demonstrated.

Portuguese Consensus and Recommendations for Acquired Coagulopathic Bleeding Management (CCBM)

We aimed to determine how Portuguese physicians handle major bleeding. We also aim to establish global diagnostic and therapeutic recommendations to be followed in clinical practice by using a step-wise approach of evidence generation. This study followed a three-step process: a steering committee desk review, a Delphi technique, an expert panel meeting. A modified 3-round Delphi including 31 statements was performed. Questions were answered in a five-point Likert-type scale. Consensus threshold was established as a percentage of agreement among participants ≥90% in the first round, and ≥85% in the second and third rounds. The level of consensus achieved by panelists was discussed with the scientific committee (January-2020). Fifty-one physicians participated in the study (compliance rate >90%). Analyzing the three rounds, consensus was reached on 20 items (64.5%) in the first, 4/11 items (36.4%) in the second and 6/7 items (85.7%) in the third. One statement about administration of clotting factor concentrates for bleeding control did not reach consensus. A high level of consensus was reached toward the need for implementing Patient Blood Management strategies in Portuguese hospitals, reduce exposure to allogeneic blood components, to use goal directed therapies for acquired bleeding management, and the need for evaluating blood transfusion indirect costs. A final version with 12 recommendations was built, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Our results provide critically appraised and updated evidence on bleeding coagulopathies management in Portugal. Additional studies, mainly about indirect costs of blood transfusion, are needed.

Searching for the final diagnosis using cardiac magnetic resonance in MINOCA patients

Introduction

In patients with clinical evidence of acute myocardial infarction (AMI), absence of obstructive coronary disease does not imply absence of acute thrombotic process. Thereafter, it can be designated as Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). In these cases, performing Cardiac Magnetic Resonance (CMR) can be essential for establishing a final diagnosis, due to evaluation of the presence and pattern of late enhancement.

Purpose

The aim of this study is to evaluate the diagnostic and prognostic impact of cardiac magnetic resonance in patients with a possible diagnosis of MINOCA.

Methods

A 7-years prospective study in our centre, which included all patients proposed to CMR with a presumptive diagnosis of MINOCA due to acute chest pain, troponin raise and absence of angiographically significant coronary disease (luminal stenosis of <50%). All patients performed functional, anatomical evaluation, as so late gadolinium enhancement search. We analysed clinical characteristics, electrocardiographic presentation, echocardiographic and coronariography results. A presumptive diagnosis was elaborated after coronariography and comparison was made with the definitive one after CMR.

Results

A total of 85 patients were included, 53% were male, with a mean age of 49±20 years old. Clinical history of hypertension was observed in 52% patients, 34% had dyslipidaemia, 8% with diabetes, obesity was present in 21% of patients and smoking habits in 33%. At admission, 47% had ST segment elevation, so emergent coronariography was performed. The mean highest troponin I was 7,54±9,39ng/mL. Late gadolinium enhancement was observed in 50 (59%) of patients. After CMR realization a final diagnosis of MINOCA was made in only 13 patients (15%) and in 51 patients (60%) CMR evaluation allowed a diagnosis modification, with impact on patients' management and prognosis. Of these 51 patients, a definitive diagnosis of myocarditis was seen in 65% of cases, of Takotsubo's myocardiopathy in 27%, and hypertrophic cardiomyopathy in 8%. In 21 (25%) of patients, late gadolinium enhancement was not found. However its absence could exclude type 1 AMI as definitive diagnosis.

Conclusion

CMR is a fundamental technique on MINOCA patients' management. In our population, performing CMR allowed initial diagnosis modification in about two thirds of the cases, with important therapeutic and prognostic implications.

Funding Acknowledgement

Type of funding source: None

Cardiogenic shock without severe left ventricular dysfunction after acute myocardial infarction: population characterization and impact in prognosis

Introduction

Traditionally, severe left ventricular dysfunction is assumed to be the main predictor of CS afte acute myocardial infarction (AMI), however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction.

Purpose

To characterize the population of patients (Pts) with CS after AMI but without severe left ventricular dysfunction (defined as ejection fraction >30%) and assess their impact in mortality.

Methods

From a national multicenter registry, we evaluated 16332 Pts with AMI and ejection fraction (EF) >30%. We considered 2 groups: Group 1 – Pts who developed CS and Group 2 – Pts who didn't developed CS. We registered age, gender, cardiovascular and non-cardiovascular co-morbidities, electrocardiographic presentation and coronary anatomy. We also evaluated the following in-hospital complications: Re-Infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT) atrial fibrillation (AF) and stroke. We compared the in-hospital mortality.

Results

The presence of CS without severe left ventricular dysfunction was observed in 3,2% pts (n=518) with AMI, being CS present at admission in 46,8% of these pts. The mean EF was lower in group 1 pts (44% ± 11 vs 53±11%, p<0,001). Patients in group 1 were older (71±13 vs 65±13 years, p<0,001), more females (38,8% vs 26,6%, p<0,001), had a higher prevalence of previous valvular heart disease (6,1% vs 3,0%, p<0,001), heart failure (10,1% vs 4,8%, p<0,001, peripheral artery disease (7,5% vs 5,3%, p=0,03), chronic kidney disease (9,8% vs 5,4%, p<0,001), chronic pulmonary obstructive disease (9,1% vs 4,9%, p<0,001) and previous stroke (11,0% vs 7,2%, p<0,001). At admission, Group 1 pts had more ST-elevation AMI (72,6% vs 43,0%, p<0,001), more AF (11,4% vs 6,6%, p<0,001) and more right bundle block (9,9%% vs 5,8%, p<0,001). Group 1 patients received less coronary angiography (80,9% vs 88,2%, p<0,00. The presence of multivessel disease (64,3% vs 51,4%, p<0,001), left main disease (12,2% vs 7,2%, p<0,001), left anterior descending disease (72,4% vs 64,3%, p<0,001) and right coronary disease (64,8% vs 55,5%, p<0,001) were more prevalent in Group 1 pts. Group 1 pts had more in-hospital complications: Re-Infarction (4,4% vs 0,9%, p<0,001), AF (23,0% vs 4,3%, p<0,001), mechanical complications (8,9% vs 0,3%, p<0,001), high atrial ventricular block (21,9% vs 2,3%, p<0,001), VT (10,8% vs 1,2%, p<0,001) and major bleeding (8,9% vs 1,3%, p<0,001). In-hospital mortality was also much higher in Group 1 pts (29,5% vs 1,2%, p<0,001).

Conclusions

Cardiogenic shock is present in 3,2% of AMI pts without severe ventricular dysfunction. These pts were older, more frequent female, had higher morbidities and in-hospital complications. Even without severe ventricular dysfunction, cardiogenic shock in these patients was associated with a much higher in-hospital mortality.

Funding Acknowledgement

Type of funding source: None

Modified zwolle score with delta-creatinine: enhancing the safety of early discharge after STEMI

Introduction

The Zwolle score (ZS) is recommended to identify low-risk patients eligible for early discharge after acute ST-segment elevation myocardial infarction (STEMI), but as only one-third of STEMIs have a low ZS, the discharge is often postponed. Creatinine variation (Δ-Cr) also provide prognostic information after STEMI.

Purpose

The authors intend to study the “modified Zwolle Score” (MZS) model, which encompasses Δ-Cr as a variable that may enhance the discriminative power of the standard ZS. The outcome is 30-day mortality, time range that starts right after the ACS.

Methods

This is a retrospective study with data from a national multicentre registry. We have included 3.296 patients with STEMI. Zwolle score was calculated for each patient. It is defined as shown in figure 1.

Δ-Cr was defined as maximum serum creatinine minus admission serum creatinine. A Δ-Cr≥0.3 was assigned 2 points in the Modified Zwolle Score, after interpretation of odds ratio via multivariate analysis.

For prediction quality assessment, we have performed ROC curve analysis with both scoring systems versus 30-day mortality. Regarding survival analysis, we have performed Kaplan-Meier curves with Log-rank analysis. We have also registered complications during hospital stay.

Results

The sample mean age is 63±14, and it is composed by 76.8% of males. The majority of patients presented Killip Class I (87.3%). The STEMI was anterior in 49.7% of patients and inferior in 49.8% of patients. The mean admission time was 5 days. Intrahospital mortality was 3% and 30-day mortality was 4%.

The mean ZS was 3.1±2.8 points, the mean MZS was 3±2.1 points and the mean Δ-Cr was 0.2±0.6mg/dL.

The ROC curve analysis between ZS and early mortality revealed a c-statistic of 0.810 (CI 0.796–0.823), whereas the ROC curve between MZS and early mortality revealed a c-statistic of 0.853 (95% CI: 0.841–0.865). The ROC curves comparison showed superiority of the MZS c-statistic, with a difference between AUC of 0.043 (p<0.001, 95% CI: 0.024–0.063).

Regarding low-risk patients, 30-day mortality was 3.3% using ZS (0–2 points) and 2.4% using modified ZS (0–2 points). Fifty patients (1.5%) died between 3rd and 10th day after ACS: original ZS low-risk criteria registered 0.09% and modified ZS low-risk criteria 0.06% fatalities. Kappa coefficient for intergroup concordance was good (0.73).

Conclusion

We conclude that by adding Δ-Cr to the standard ZS, a renal function parameter that was lacking in the ZS, its predicting capacity regarding early mortality in patients admitted with STEMI was increased. Comparing both scores, low-risk patients defined by MZS registered less complications, 3–10 day mortality and 30-day mortality than low-risk patients defined by the original ZS. This fact may lead to better distinction of patients who will benefit from early discharge.

Zwolle Score, ROC curves and survival

Funding Acknowledgement

Type of funding source: None

Barriers to exercise among participants of a bariatric surgery program from a Brazilian capital

The aim of this study was to analyze the perceived barriers to exercise and its associated factors among participants of a bariatric surgery program, in a reference hospital, from a Brazilian northeastern capital. Therefore, the Scale of Benefits and Barriers to Exercise (EBBS), which used only the domains related to the dimension of the barriers that evaluate them in four subdimensions (physical effort, environmental, time and family) was applied with 289 patients (49 men and 240 women) with a mean age of 43 years (SD 8.6), who were in the pre (n = 81) or post (n = 208) operative period. It was collected information about their sex, age, weight and height (for BMI calculation), exercise (WHO recommendations were used), and if they had already undergone bariatric surgery. To analyze the associations and estimate the prevalence ratios of the variables in relation to the barriers, Poisson Regression was used. The level of significance was set at 5%. In the general assessment of barriers, it was found that physically active patients (PR = 0.78 95% CI = 0.72-0.83 p < 0.001) have less perception of barriers than inactive ones. In the physical effort and environmental subdimensions, the assets (PR = 0.82 CI95% = 0.76-0.88 p < 0.001 and PR = 0.78 CI95% = 0.73-0.84 p < 0.001, respectively) and those who have already undergone bariatric surgery (PR = 0.88 CI 95% 0.80-0.97 p = 0.014 and PR = 0.88 CI 95% = 0.80-0.96 p = 0.006, respectively) have lower perception of barriers. Those over 42 years of age (PR = 0.88 CI95% 0.81-0.95 p < 0.001) and the active ones (PR = 0.79 CI95% = 0.73-0.85 p < 0.001) have lower perception of barriers of the time sub-dimension. In the family sub-dimension, there was no association between the variables studied and the perception of barriers. It was concluded that being physically inactive, not having undergone bariatric surgery and being under 42 years old is associated with a greater perception of barriers to exercise.

Key messages

The health service can use the findings to track those most likely to use barriers to exercise. The health service can propose personalized physical activities to reduce barriers to exercise.

Interventional Algorithm in Gastrointestinal Bleeding-An Expert Consensus Multimodal Approach Based on a Multidisciplinary Team

The approach to the patient with gastrointestinal bleeding (GIB) can be very complex. A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine worked together to provide the best knowledge and guide clinical practitioners in the real setting of health institutions, characterized by disparate availability of human and technical resources. The authors propose a global and personalized approach according to different clinical scenarios to improve the outcomes of patients with GIB, for whom the reduction of inappropriate transfusions is crucial. The goal of this document is to provide clear and objective guidance through interventional algorithms toward a goal-directed approach according to the clinical situation and supported by the latest available scientific data on GIB management in different settings.

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality

Backgrund

New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance.

Objective

To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction.

Methods

We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant.

Results

We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation.

Conclusion

New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

No man is an island: spatial clustering and access to primary care as possible targets for the development of new community mental health approaches

BACKGROUND

to understand if patients seen at Centro Hospitalar Psiquiátrico de Lisboa (CHPL) live in geographical clusters or randomly throughout the city, as well as determine their access to the psychiatric hospital and primary care facilities (PCF).

METHODS

spatial autocorrelation statistics were performed (queen criterion of contiguity), regarding all patients observed at CHPL in 2017 (at the census subsection level), and considering not only their overall number but also main diagnosis, and admission to the psychiatric ward - voluntary or compulsory. Distance to the hospital and to the closest PCF was measured (for each patient and the variables cited above), and the mean values were compared. Finally, the total number of patients around each PCF was counted, considering specified radius sizes of 656 and 1000 m.

RESULTS

All 5161 patients (509 psychiatric admissions) were geolocated, and statistical significance regarding patient clustering was found for the total number (p-0.0001) and specific group of disorders, namely Schizophrenia and related disorders (p-0.007) and depressive disorders (p-0.0002). Patients who were admitted in a psychiatric ward live farther away from the hospital (p-0.002), with the compulsory admissions (versus voluntary ones) living even farther (p-0.004). Furthermore, defining a radius of 1000 m for each PCF allowed the identification of two PCF with more than 1000 patients, and two others with more than 800.

CONCLUSIONS

as patients seem to live in geographical clusters (and considering PCFs with the highest number of them), possible locations for the development of programs regarding mental health treatment and prevention can now be identified.

P840 A surprising outcome

Introduction

infective endocarditis(IE) is a high morbidity and mortality disease, and heart failure,central nervous system embolization and annular abscess account for common complications.Nevertheless,intracardiac fistula is rare and predicts higher mortality and urgency for surgery.

Case

84years old male patient,with an aortic bioprosthesis valve Perimount n23 since 2015,was admitted to internal medicine ward 3months before,due to Enterococcus faecalis bacteremia.at that time,transoesophageal echocardiography(TEE) revealed moderate to severe mitral valve(MV) regurgitation(vena contracta 0.7cm) and trivial tricuspid regurgitation,but did not showed any suggestive images of endocarditis.the patient was treated with 14days of amoxicillin-clavulanate.

On the current presentation,due to fadigue to mild physical activity and fever for 2weeks,he was admitted to cardiology ward for further investigation.blood cultures were positive for the previous agent,so antibiotherapy with ampicillin 12g/day and gentamicin 240mg id was started.TEE revealed thickening of aortic bioprosthesis’ leaflets with preserved systolic opening.aortic valve annulus thickening,mainly near the non-coronary cusp,was evident, without characteristic features of peri-annular abscess.on ventricular side of the prosthesis,there was a vegetation(10.7x10.8mm). a small nodule lesion,coherent with a second vegetation,was present on the MV’s posterior leaflet,without regurgitation’s worsening. a third one was observed on the septal leaflet of the tricuspid valve(7.3x6.5mm),which also caused an increasement in severity of the regurgitation,quantified as moderate.

On the sixth day,the patient presented with right arm paresis,so a brain CT was performed,showing an ischemic lesion on the left middle cerebral artery.Reevaluation,5days later,owing to new neurological changes,showed multiple acute vertebrobasilar embolic strokes.

As a result of poor medical response and embolic strokes,the patient was referred to surgical treatment. however, due to prohibitive surgical risk (euroscore 59%), the patient was refused.

After 6weeks of blood culture driven antibiotherapy,a reevaluation TEE revealed a periprosthetic pseudoaneurysm with small aorta-to-right atrium fistula.no vegetations were found.

Conclusion

rate complication of cardiac fistulae is high,60%of the patients develop heart failure and mortality rate is higher than 40%.although conservative treatment was addressed,after 8months discharge,the patient remains with few heart failure symptoms(NYHA classII).

Indirect evaluation of pit and fissure sealants: A 3D-based method validation

Background

Material and Methods

Results

Conclusions

P260 Left ventricular pseudoaneurysm manifesting as syncope

Introduction

Left ventricular (LV) pseudoaneurysms form when cardiac rupture is contained by adherent pericardium or scar tissue. LV pseudoaneurysm is one of the mechanical complications of myocardial infarctions (MI), particularly inferior wall MI.

Although LV pseudoaneurysms are not common, the diagnosis is difficult and they are prone to rupture. Transthoracic echocardiography is commonly used in clinical practice and is usually sufficient to make the diagnosis of LV pseudoaneurysm. Regardless of treatment, patients with LV pseudoaneurysms had a high mortality rate, especially those who did not undergo surgery.

Description of the clinical case

74 years-old woman, with previous history of hypertension, dyslipidaemia and type 2 diabetes and stable coronary disease. In June 2018 the patient underwent coronary angiography that revealed left main and 3 vessels coronary disease, Cardiac revascularization surgery was proposed that the patient refused. The patient was stable during 6 months. Four days before presenting to emergency department the patient mentioned intermittent pre-cordial pain associated with exertion. At admission day she felt intense pre-cordial pain, accompanied by sudoresis and nausea, relieving with sublingual nitrate. The patient was hemodynamically stable at admission. Electrocardiogram showed sinus rhythm 65 bpm with 2mm ST-elevation of inferior leads. Troponin I was positive 30 ng/dL. Echocardiogram revealed marked hypokinesia of inferior and lateral wall with moderate depression of global systolic function ans presence of slight circumferential pericardial effusion (6mm in diastole on lateral wall)

Emergent coronariography was performed and revealed progression of coronary disease of the right coronary artery with sub-occlusion of the mid segment. Cardiac revascularization surgery was proposed and the patient accepted this time. Echocardiogram was repeated during hospitalization revealed a stable pericardial effusion with reduced dimension comparing to admission. After 3 weeks, while waiting surgery in the ward, the patient was a syncope that resulted in fracture of the distal peroneum. Ecocardiogram was performed and revealed a LV posterior wall pseudoaneurysm through a narrow neck in parasternal long axis view and the presence of large pericardial effusion (Fig 1). The patient was submitted to definitive reparative cardiac surgery with pericardium patch and coronary artery bypass graft from left internal mammary to anterior descending coronary artery. The patient recovered well from the cardiac surgery and at 2 months follow up is alive and without signs of heart failure.

This case illustrates the complexity in the management of patients with LV pseudoaneurysm. These patients require substantial critical care, imaging and surgical expertise.

A high clinical index of suspicion is needed to avoid missing the diagnosis LV pseudoaneurysm and transthoracic echocardiography is essential to establish the diagnosis.

Abstract P260 Figure. Fig 1 - LV pseudoaneurysm

P1722A new predictive score for mortality and cardiogenic shock in patients with ST-elevation myocardial infarction

Introduction

Acute Myocardial Infarction with ST elevation (STEMI) presents a high rate of potentially fatal complications and in-hospital mortality.

Objective

To test the predictive capacity for Cardiogenic Shock (CS) and In-hospital Mortality (MIH) of a new risk score in patients (Pts) with STEMI.

Population and methods

Evaluated 5765 Pts with STEMI without CS at admission. The new score, was derived by previous studies in this population, and was calculated according to the following criteria: age ≥65 years (1 point), heart rate ≥100bpm (2 points), systolic blood pressure <100mmHg (2 points), blood glucose at admission above 180 mg/dL (1 point) and creatinine at admission >1.5mg/dL (2 points). The population was divided into three subgroups: group A low score (0–2 points), group B intermediate score (3–5 points) and group C score (6–8 points). The endpoints defined were CS during hospitalization, in-hospital mortality and combined end-point of MIH and CS. The relationship between each of the possible scores (from 0 to 8) and the various end-points was determined, and the sensitivity and specificity of the score as a predictor of MIH and CS was defined as the area under the ROC curve (ASC).

Results

After the application of the score, 3 subgroups were obtained: group A with 4819 Pts (83,6%), group B with 884 Pts (15,3%) and group C 62 Pts (1,1%). Patients of group C had a higher MIH (Group C: 45,2% vs B: 11,4% vs A: 2,0%, p<0,001), higher CS (C: 29,5% vs B: 12,0% vs A: 2,3%, p<0,001) and a higher combined end-point of MIH and CC (C: 53,2% vs B: 17,8% vs A: 3,4%, p<0,001) during hospitalization. The proposed score revealed a high predictive capacity of MIH (ASC 0,802, 95% CI 0,775–0,830, p=0,001), of CS (ASC 0,763, 95% CI 0,731–0,795, p=0,001) and for the combined endpoint (MIH and CC) ASC 0,781, 95% CI 0,756–0,806, p=0,001). The logistic regression models showed that Pts with a high score (group C) presented a 41-fold higher risk of MIH (OR 41,3; p<0,001) and 18-fold higher CS (OR 18,0; p<0.001) than patients with low score (group A). It was also found that the risk associated with an increase in one point score unit was 100% (OR 2,0 p<0.001) for MIH and 82% (OR 1,82, p<0,001) for CS.

Conclusion

This new score, with the use of practical and friendly variables, demonstrated a high predictive capacity of MIH and CS.

P2265Cardiogenic shock without severe left ventricular dysfunction after ST-elevation acute myocardial infarction: population characterization and impact in prognosis

Background

The presence of cardiogenic shock (CS) after ST-elevation acute myocardial infarction (STEMI) is associated with a high mortality. Traditionally, severe left ventricular dysfunction is assumed to be the main predictor of CS, however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction.

Purpose

To characterize the population of patients (Pts) with CS after STEMI but without severe left ventricular dysfunction and assess their impact in mortality.

Methods

From a national multicenter registry, we evaluated 7181 Pts with STEMI and ejection fraction (EF) >30%, and excluded all pts with STEMI and an EF<30%. We considered 2 groups: Group 1 – Pts who developed CS and Group 2 - Pts who didn't developed CS. We registered age, gender, cardiovascular and non-cardiovascular co-morbidities, electrocardiographic presentation, vital signs at admission, reperfusion strategies, reperfusion times and coronary anatomy. We evaluated the following in-hospital complications: Re-Infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT) atrial fibrillation (AF) and stroke. We compared the in-hospital mortality.

Results

The presence of CS without severe left ventricular dysfunction was observed in 5,2% pts (n=376), being CS present at admission in 51,2% of these pts. The mean EF was lower in group 1 pts (44% ± 11 vs 51±11%, p<0,001). Patients in group 1 were older (70±14 vs 63±13 years, p<0,001), more females (39,4% vs 23,3%, p<0,001), had a higher prevalence of previous valvular heart disease (2,7% vs 1,0%, p=0,005), heart failure (4,8% vs 1,4%, p<0,001, peripheral artery disease (5,5% vs 2,9%, p=0,004), chronic kidney disease (6,4% vs 2,7%, p<0,001) and chronic pulmonary obstructive disease (8,2% vs 3,1%, p<0,001). At admission, Group 1 pts had more atrial fibrillation (10,4% vs 4,4%, p<0,001) and received less reperfusion (77,7% vs 83,0%, p=0,008), without differences in the type of reperfusion or times to reperfusion. The presence of multivessel disease (60,0% vs 45,7%, p<0,001) and left main disease (6,6% vs 2,4%, p<0,001) were more prevalent in Group 1 pts. Group 1 pts had more in-hospital complications: Re-Infarction (3,5% vs 0,7%, p<0,001), AF (22,1% vs 5,0%, p<0,001), mechanical complications (9,6% vs 0,5%, p<0,001), high atrial ventricular block (26,7% vs 3,7%, p<0,001), VT (10,6% vs 1,9%, p<0,001), stroke (1,9% vs 0,6%, p=0,01) and major bleeding (10,4% vs 1,5%, p<0,001). In-hospital mortality was much higher in Group 1 pts (26,6% vs 1,4%, p<0,001).

Conclusions

Cardiogenic shock is present in 5,2% of STEMI pts without severe ventricular dysfunction. These pts were older, more frequent female, had higher morbidities and in-hospital complications. Even without severe ventricular dysfunction, cardiogenic shock in these patients was associated with much higher in-hospital mortality.

P1764Quality criteria for STEMI care - a national perspective

Introduction

The definition of quality criteria in health care is essential to implement structural organization strategies that ensure that patients (P) receive the best care according to the most updated recommendations available at the time they are treated. Quality indicators have recently been defined with regard to the approach and treatment of STEMI in the European Guidelines published in 2017.

Objective

The authors intend to characterize the level of care provided to P with STEMI inserted into a national multicenter registry since 2011 in order to establish a relationship with international recommendations.

Population and methods

Descriptive study based on a national multicenter registry. A total of 2051 P admitted to the hospital with the diagnosis of STEMI were included, 1266 P for the year 2011 and 785 P for the year 2016.

Results

The P of the year 2011 and 2016 presented similar age (64±14 vs 63±13). There was a higher percentage of P admitted by STEMI fast track managed care system in 2016 (36.9% vs 22.2%, p<0,001) and less from the Emergency Department (31.6% vs 56.8%; p<0,001). Regarding the transport to the Hospital, there was an increase in patients transported by prehospital medical teams (28% vs 21%; p<0,001) and less by own means (35.7% vs 45.6%; p<0,001). Regarding in-hospital therapy, it was found that in 2016 more patients received loading doses of P2Y12 inhibitors – Clopidogrel (78.1% vs 70.3% P<0,001) and Ticagrelor (54.7% vs 0.7% P<0,001). In post-discharge therapy, there was also a slight improvement in care in 2016, with more P being treated with P2Y12 inhibitor (96.2% vs 92.4%; p=0.03) and beta-blocker (84.4% vs 78.7%; p<0,001). Regarding the type of reperfusion, there was an increase in angioplasty (95.5% vs 92.2%; p<0,001) and a decrease in fibrinolysis (4.5% vs 7.8%; p=0.03) in 2016. There was a slight worsening of the prehospital delay in 2016 (median 163min vs 120min) and an improvement in door to reperfusion time (median 60min vs 70min). There was also an increase in angioplasties performed in 2016 (87.1% vs 85.1%; p<0,001) as well as an increase in the percentage of left ventricular function evaluation before discharge (98.2% vs 93.9%; p<0,001).

Conclusion

The results presented demonstrate a slight improvement in the quality of the care provided to STEMI P. However, there are areas for improvement, in accordance with international recommendations, in particular with regard to reperfusion times.

P1720Survival analysis in a population of patients with cardiogenic shock after acute myocardial infarction: characterization of the population and identification of mortality predictors

Introduction

The presence of cardiogenic shock (CC) after acute myocardial infarction (AMI) is associated with high mortality.

Purpose

To compare the clinical characteristics, cardiac and non-cardiac complications among survivors and non-survivors of CC after AMI in order to identify predictors of in-hospital mortality.

Population and methods

An observational study involving 467 patients (P) with CC after AMI included in a national multicenter registry. Considered 2 groups: Group 1 - P with CC who died (n=190) and Group 2 - P with CC who survived (n=277). We recorded age, gender, personal history, coronary angiography and angioplasty performed, in-hospital therapy and ejection fraction, cardiac complications (Re-infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia) and non-cardiac complications [acute renal injury (ARI), major bleeding and stroke]. Multivariate analysis was performed to identify predictors of in-hospital mortality.

Results

Mortality in patients with CC after AMI was 40.6%. Group 1 P were older (77±10 vs 68±13 years, p<0.001), presented higher prevalence of diabetes mellitus (41.8% vs 28.2%, p=0.003), previous AMI (23.8% vs. 12%, p<0.001) 7%, p=0.002), previous angor (31.9% vs 14.1%, p=0.001), heart failure (18.6% vs 8.7%, p=0.002) and peripheral arterial disease (11.8% vs 6.2%, p=0.03). There were fewer coronary angiographies (64.2% vs 87.7%, p<0.001), with no difference in the number or type of vessels with lesions in both groups, as well as inotropic therapy. With the exception of mechanical complications, more prevalent in group 1 (12.6% vs 5.4%, p=0.006), there were no differences in the prevalence of the remaining cardiac complications. Among the non-cardiac complications considered, only the presence of ARI was more prevalent in Group 1 (72.1% vs 37.5%, p<0.001). After multivariate analysis the presence of age>75 years [OR: 2.21 (CI: 1.39–3.51)], previous angor [OR: 1.91 (CI: 1.09–2.92)], LRA [OR: 3.14 (CI: 4.0–7.04)] and mechanical complications [OR: 3.82 (CI: 2.39–6.10] were independent predictors of in-hospital mortality of P with CC post-AMI.

Conclusions

Mortality in patients with CC after AMI remains high. Age>75 years, prior angor, ARI and mechanical complications are independent predictors of in-hospital mortality in P with CC post-AMI.

P603Cardiac Magnetic Resonance evaluation and risk stratification of patients with unexplained or suspected arrhythmias

Introduction

The etiological diagnosis of cardiac arrhythmias is often difficult. Cardiac Magnetic Resonance (CMR) is the gold standard exam for anatomical and functional cardiac evaluation and it may be indicated in patients with ventricular arrhythmias when echocardiography does not provide an accurate assessment of left and right ventricles (LV, RV).

Purpose

The aim of this study was to determine the impact of CMR in the diagnosis and stratification of arrhythmic risk in patients with confirmed or suspected arrhythmias, as well as to describe the changes observed.

Methods

We performed a prospective registry over a 5-year period of all the patients with arrhythmias who underwent CMR for diagnostic and risk stratification purposes. We followed a protocol to evaluate both anatomically and functionally the ventricles and to look for the presence of late gadolinium enhancement (LGE).

Results

A total of 78 patients were included, of which 65% were male and a mean age of 46±17 years-old was observed. The indications for CMR evaluation of patients with confirmed or suspected arrhythmias were as follows: 33% (n=26) of the patients had very frequent premature ventricular complexes (PVC), 23% (n=18) had sustained ventricular tachycardia (VT), 17% (n=13) suspected structural heart disease with high arrhythmic potential, 12% (n=9) unexplained recurrent syncope, 6% (n=5) supraventricular tachycardia, 5% (n=4) non-sustained VT and 4% (n=3) aborted sudden cardiac death. Depressed ventricular ejection fraction (<50%) was present in 9% (n=7) for the LV and in 14% (n=11)for the RV. Dilation of the LV was found in 24% of the patients (n=19, mean LV volume: 115±4ml/m2) and RV dilation was present in only 1 patient who had right ventricle arrhythmogenic dysplasia (RVAD) (RV volume: 152ml/m2). Cardiac synchronization artifacts due to the presence of very frequent PVC compromised the calculation of v volumes in only 4% (n=3) of the patients. In total, 6% (n=5) had interventricular septum hypertrophy (mean 15±6g/m2), 10% (n=8) had a slight prolapse of the anterior leaflet of the mitral valve and 19% (n=15) had a dilated left auricle. LGE was present in 13% (n=10) and slight pericardium effusion was detected in 12% (n=9). CMR was considered normal in 65% (n=51), in 15% (n=12) we found nonspecific changes deserving follow-up and in 20% (n=15) it was possible to establish a diagnosis which was previously unknown: 5% (n=4) had hypertrophic cardiomyopathy, 4% (n=3) LV non-compaction, 4% (n=3) a myocarditis sequelae, 3% (n=2) RVAD, 3% (n=2) a myocardial infarction scar and 1 had non-ischemic dilated cardiomyopathy.

Conclusions

CMR is a technique with high spatial resolution, feasible and safe, which allowed an increase in diagnosis in 20% of the patients, thus contributing to the risk stratification of our study population with suspected high arrhythmic potential when the first-line complementary exams were inconclusive.

Left main and/or three-vessel disease in patients with non-ST-segment elevation myocardial infarction and low-risk GRACE score: Prevalence, clinical outcomes and predictors

INTRODUCTION

A low-risk GRACE score identifies patients with a lower incidence of major cardiac events, however it can erroneously classify patients with severe coronary artery disease as low-risk. We assessed the prevalence, clinical outcomes and predictors of left main and/or three-vessel disease (LM/3VD) in non-ST-elevation acute myocardial infarction (NSTEMI) patients with a GRACE score of ≤108 at admission.

METHODS

Using data from the Portuguese Registry on Acute Coronary Syndromes, 1196 patients with NSTEMI and a GRACE score of ≤108 who underwent coronary angiography were studied. Independent predictors of LM/3VD and its impact on in-hospital complications and one-year mortality were retrospectively analyzed.

RESULTS

LM/3VD was present in 18.2% of patients. Its prevalence was higher in males and associated with hypertension, diabetes, previous myocardial infarction, heart failure and peripheral arterial disease (PAD). Although there were no differences in in-hospital complications, these patients had higher mortality (0.9 vs. 0.0%) and more major adverse cardiac and cerebrovascular events (MACCE) (4.1 vs. 2.5%, p=0.172), and higher one-year mortality (2.4 vs. 0.5%, p=0.005). Independent predictors of LM/3VD were age (OR 1.03; 95% CI 1.01-1.0, p=0.003), male gender (OR 2.56; 95% CI 1.56-4.17, p<0.001), heart rate (1.02; 95% CI 1.01-1.03, p<0.001), PAD (OR 3.21; 95% CI 1.47-7.00, p<0.001) and heart failure (OR 3.38; 95% CI 1.02-11.15, p=0.046).

CONCLUSIONS

LM/3VD was found in one in five patients. These patients had a tendency for higher in-hospital mortality and more MACCE, and higher one-year mortality. Simple clinical variables could help predict this severe coronary anatomy.

Survival Predictors in Liver Transplantation: Time-Varying Effect of Red Blood Cell Transfusion

BACKGROUND

Many attempts have been undertaken to better predict outcome after liver transplantation. The aim of this study was to identify the pre- and intraoperative variables that may influence the survival after liver transplantation, at a single institution.

METHODS

Anesthetic records from 543 consecutive patients who underwent liver transplantation from June 2006 to June 2014 were reviewed in this retrospective study. Patients undergoing retransplantation were excluded from the analysis, as were patients with familial amyloid polyneuropathy. Preoperative variables studied were age, sex, Model for End-Stage Liver Disease score, primary diagnosis, cold ischemia time, preoperative international normalized ratio, serum albumin, and and hemoglobin levels. Intraoperative variables included were norepinephrine consumption, blood loss, red blood cell transfusion, and surgical time. Variables significant in the univariate analysis with a P value of <.2 were included in a multivariate Cox regression model.

RESULTS

Only red blood cell transfusion (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.04-1.29) and female sex (HR, 1.71; 95% CI, 1.10-2.65) were identified as significant independent predictors for survival after liver transplantation. Because of proportionality assumption violation, the multivariate Cox regression model was subsequently upgraded by adding a time-varying interaction between red blood cell transfusion and time since liver transplantation. As a result, we found that at 3 months after liver transplantation, the rate of dying increased 14% (95% CI, 2%-26%) for each unit transfused, and at 6 months it increased 12% (95% CI, 0.3%-24%).

CONCLUSIONS

Red blood cell transfusion ceased to influence survival from 1 year onward.

Left ventricular basal inferior pseudoaneurysm and left atrial dissection after myocardial infarction: Case report

Left atrial dissection is a rare entity, mostly occurring after mitral valve surgery, with only a few cases described after myocardial infarction. The authors report a case of a 60-year-old man who presented with an inferior myocardial infarction, complicated with pseudoaneurysm of basal segment of left ventricular inferior wall, which expanded through the mitral ring to left atria, causing left atrial free wall dissection. The left ventriculo-atrial communication through the pseudoaneurysm caused major para-mitral regurgitation and the development of acute heart failure. Good clinical outcome was achieved with stabilization of acute heart failure with high-dose diuretic therapy and delayed cardiac surgery with closure of left ventriculo-atrial communication.

Perioperative Predictors of Survival After Liver Transplantation for Familial Amyloid Polyneuropathy in a Portuguese Center

BACKGROUND

Liver transplantation (LT) has been the treatment of choice to halt the progression of familial amyloid polyneuropathy (FAP). Few studies have identified prognostic factors for post-LT survival in FAP. Our aim was to assess survival rate and to identify independent factors for survival after LT.

METHODS

This retrospective cohort study of FAP patients transplanted for the first time analyzed 116 transplantations from 2006 to 2014. The median follow-up period was 45.5 months.

RESULTS

The overall survival rates at 1 month, 1 year, and 5 years were 89%, 82% and 79%, respectively. On multivariate analysis, only number of red blood cell (RBC) units transfused during surgery, operation time, and body mass index were independent prognostic factors for patient survival. Only 30% of patients were transfused during surgery, and, in these, each RBC unit transfused increased mortality by 53%. The operation time increased mortality by 20% for every 15 minutes of surgery.

CONCLUSIONS

This study suggests that operation time and RBC transfused are predominant factors affecting post-LT survival in our FAP patients.

Complications of Percutaneous Endoscopic Gastrostomy in Dogs and Cats Receiving Corticosteroid Treatment

BACKGROUND

Corticosteroid treatment is commonly required in veterinary patients for treatment of inflammatory, immune-mediated, neurologic, and neoplastic diseases, which also may require assisted enteral nutrition via percutaneous endoscopic gastrostomy (PEG).

OBJECTIVE

To evaluate complications associated with PEG use in dogs and cats receiving corticosteroid treatment.

ANIMALS

Forty-two animals were included in the study: 12 dogs and 2 cats in the steroid group and 26 dogs and 2 cats in the control group.

METHODS

Medical records, between January 2006 and March 2015, were reviewed. Patients were included if the PEG tube was in use for at least 24 hours and if complete medical records were available. Patients were assigned to the control group if they were not treated with corticosteroids during PEG use or to the steroid group if they had received corticosteroids during PEG tube use. Complications were classified as minor, moderate, and major in severity. Maximum severity complication rate was compared between groups.

RESULTS

The general prevalence of complications was found to be similar between groups (P = .306), but in the steroid group, 43% of the cases developed a major severity complication compared with 18% of the control group (P = .054).

CONCLUSION AND CLINICAL IMPORTANCE

Owners of dogs and cats receiving corticosteroids, in which PEG is planned, should be counseled about possible complications beyond those associated with PEG tube usage alone.

Interventional Algorithms for the Control of Coagulopathic Bleeding in Surgical, Trauma, and Postpartum Settings: Recommendations From the Share Network Group

Several clinical settings are associated with specific coagulopathies that predispose to uncontrolled bleeding. With the growing concern about the need for optimizing transfusion practices and improving treatment of the bleeding patient, a group of 9 Portuguese specialists (Share Network Group) was created to discuss and develop algorithms for the clinical evaluation and control of coagulopathic bleeding in the following perioperative clinical settings: surgery, trauma, and postpartum hemorrhage. The 3 algorithms developed by the group were presented at the VIII National Congress of the Associação Portuguesa de Imuno-hemoterapia in October 2013. They aim to provide a structured approach for clinicians to rapidly diagnose the status of coagulopathy in order to achieve an earlier and more effective bleeding control, reduce transfusion requirements, and improve patient outcomes. The group highlights the importance of communication between different specialties involved in the care of bleeding patients in order to achieve better results.

Symmetric Dimethylarginine Assay Validation, Stability, and Evaluation as a Marker for the Early Detection of Chronic Kidney Disease in Dogs

BACKGROUND

Symmetric dimethylarginine (SDMA) is a small molecule formed by methylation of arginine, and released into blood during protein degradation. SDMA is primarily eliminated by renal excretion and is a promising endogenous marker of glomerular filtration rate (GFR).

OBJECTIVES

To validate an assay for SDMA measurement, determine stability of SDMA in blood, and compare SDMA with serum creatinine concentration (sCr) and GFR for early detection of decreasing kidney function in dogs with chronic kidney disease (CKD).

ANIMALS

Eight male dogs affected with X-linked hereditary nephropathy and 4 unaffected male littermates.

METHODS

Prospective study validating SDMA measurement using liquid chromatography-mass spectrometry, assessing stability of SDMA in serum and plasma, and serially determining sCr, SDMA, and GFR (using iohexol clearance) in dogs during progression from preclinical disease to end-stage renal failure. Correlations were determined using linear regression. Timepoints at which sCr, SDMA, and GFR identified decreased renal function were compared using defined cutoffs, trending in an individual dog, and comparison with unaffected littermates.

RESULTS

Symmetric dimethylarginine was highly stable in serum and plasma, and the assay demonstrated excellent analytical performance. In unaffected dogs, SDMA remained unchanged whereas in affected dogs, SDMA increased during disease progression, correlating strongly with an increase in sCr (r = 0.95) and decrease in GFR (r = -0.95). Although trending improved sCr's sensitivity, SDMA identified, on average, <20% decrease in GFR, which was earlier than sCr using any comparison method.

CONCLUSIONS AND CLINICAL IMPORTANCE

Symmetric dimethylarginine is useful for both early identification and monitoring of decreased renal function in dogs with CKD.