Prevalence and Impact of Frailty in Patients ≥70 Years Old with Acute Coronary Syndrome Referred for Coronary Angiography

INTRODUCTION

Elderly patients with acute coronary syndrome (ACS) have a higher risk of adverse cardiovascular events and may be frail but are underrepresented in clinical trials. Previous studies have proposed that frailty assessment is a better tool than chronological age, in assessing older patients' biological age, and may exceed conventional risk scores in predicting the prognosis. Therefore, we wanted to investigate the prevalence and impact on 12-month outcomes of frailty in patients ≥70 years with ACS referred for coronary angiography (CAG).

METHODS

Patients ≥70 years with ACS referred for CAG underwent frailty scoring with the clinical frailty scale (CFS). Patients were divided into three groups depending on their CFS: robust (1-3), vulnerable (4), and frail (5-9) and followed for 12 months.

RESULTS

Of 455 patients, 69 (15%) patients were frail, 79 (17%) were vulnerable, and 307 (68%) were robust. Frail patients were older (frail: 80.9 ± 5.7 years, vulnerable: 78.5 ± 5.5 years, and robust: 76.6 ± 4.9 years, p < 0.001) and less often treated with percutaneous coronary intervention (frail: 56.5%, vulnerable: 53.2%, and robust: 68.6%, p = 0.014). 12-month mortality was higher among frail patients (frail: 24.6%, vulnerable: 21.8%, and robust: 6.2%, p < 0.001). Frailty was associated with a higher mortality after adjustment for age, sex, comorbidities, the Global Registry of Acute Coronary Events (GRACE) score, and revascularisation (HR 2.67, 95% CI 1.30-5.50, p = 0.008). There was no difference between GRACE and CFS in predicting 12-month mortality (p = 0.893).

CONCLUSIONS

Fifteen percent of patients ≥70 years old with ACS referred for CAG are frail. Frail patients have significantly higher 12-month mortality. GRACE and CFS are similar in predicting 12-month mortality.

Troponin dependent 30-day mortality in patients with acute pulmonary embolism

BACKGROUND

Troponin concentrations above upper reference are associated with increased mortality in patients with pulmonary embolism (PE). We aimed to assess whether risk of 30-day mortality increases in a dose-response relationship with concentration of troponin.

METHODS

Using Danish national registries, we identified patients ≥ 18 years of age hospitalized with first-time PE between 2013 and 2018 and available troponin measurements - 1/+1 day from admission. Patients were stratified into quintiles by increasing troponin concentration. Risk of 30-day mortality was assessed performing cumulative mortality curves and Cox regression model comparing the troponin quintiles.

RESULTS

We identified 5,639 PE patients of which 3,278 (58%) had a troponin concentration above upper reference. These patients were older (74 years), 50% male and with heavier comorbidity compared to patients with non-elevated troponin. We found increasing 30-day mortality with increasing troponin concentration (1% in 1st quintile (95% CI 0.5-1.5%), 2% in 2nd quintile (95% CI 1-2.5%), 8% in 3rd quintile (95% CI 5-9%), 11% in 4th quintile (95% CI 9-13%) and 15% in 5th quintile (95% CI 13-16%), confirmed in a Cox model comparing 1st quintile with 2nd quintile (HR 1.09; 95% CI 0.58-2.02), 3rd quintile (HR 3.68; 95% CI 2.20-6.15), 4th quintile (HR 5.51; 95% CI 3.34-9.10) and 5th quintile (HR 8.09; 95% CI 4.95-13.23).

CONCLUSION

30-day mortality was strongly associated with troponin concentration useful for improving risk stratification, treatment strategies and outcomes in PE patients.

Amiodarone attenuates cardiac Rubidium-82 in consecutive PET/CT scans in a rodent model

BACKGROUND

Risk stratification and diagnosis using Rubidium-82 (82Rb) positron emission tomography (PET) is a routine clinical approach in coronary artery disease (CAD). Various drugs are used to treat CAD; however, whether any of them change the uptake of 82Rb in the heart has not been investigated. The aim of this study is to determine whether drugs used in treatment of CAD affect the uptake of 82Rb in the heart in healthy rats.

METHODS

Seventy-seven Sprague-Dawley rats were included in the cross-sectional study. All rats underwent baseline 82Rb PET/CT and divided into eleven groups treated with different drugs. One group was control group (no treatment), eight groups were treated with monotherapy (amiodarone, acetylsalicylic acid (ASA), clopidogrel, ticagrelor, atorvastatin, enalapril, amlodipine, metoprolol succinate), and two groups were treated with polypharmacy (ASA, ticagrelor, atorvastatin, amlodipine or ASA, clopidogrel, atorvastatin, amlodipine). Once a day, they were administered pharmacological therapy through oral gavage, and on day seven, follow-up scanned with 82Rb PET/CT.

RESULTS

In the control group without pharmacological treatment, no difference in the standard uptake value (SUV) ratio between heart and muscle from baseline to follow-up (5.8 vs 7.0, P = .3) was found. The group treated with amiodarone had a significantly reduced SUV ratio from baseline to follow-up (5.8 vs 5.1, P = .008). All other drugs investigated had no difference in SUV ratio from baseline to follow-up.

CONCLUSION

In this study, we showed that drugs normally used to treat CAD do not affect the uptake of 82Rb. However, amiodarone result in a significantly lowered 82Rb uptake, compared to control. This information about amiodarone would probably not change the size assessment of a myocardial perfusion defect in a clinical setting. However, it could change the kinetic parameters when assessing absolute myocardial blood flow in patients treated with amiodarone.

Neuropsychiatric and Cognitive Outcomes in Patients 6 Months After COVID-19 Requiring Hospitalization Compared With Matched Control Patients Hospitalized for Non-COVID-19 Illness

Importance

Prolonged neuropsychiatric and cognitive symptoms are increasingly reported in patients after COVID-19, but studies with well-matched controls are lacking.

Objective

To investigate cognitive impairment, neuropsychiatric diagnoses, and symptoms in survivors of COVID-19 compared with patients hospitalized for non-COVID-19 illness.

Design, Setting, and Participants

This prospective case-control study from a tertiary referral hospital in Copenhagen, Denmark, conducted between July 2020 and July 2021, followed up hospitalized COVID-19 survivors and control patients hospitalized for non-COVID-19 illness, matched for age, sex, and intensive care unit (ICU) status 6 months after symptom onset.

Exposures

Hospitalization for COVID-19.

Main Outcomes and Measures

Participants were investigated with the Mini-International Neuropsychiatric Interview, the Montreal Cognitive Assessment (MoCA), neurologic examination, and a semi-structured interview for subjective symptoms. Primary outcomes were total MoCA score and new onset of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) psychiatric diagnoses. Secondary outcomes included specific psychiatric diagnoses, subjective symptoms, and neurologic examination results. All outcomes were adjusted for age, sex, ICU admission, admission length, and days of follow-up. Secondary outcomes were adjusted for multiple testing.

Results

A total of 85 COVID-19 survivors (36 [42%] women; mean [SD] age 56.8 [14] years) after hospitalization and 61 matched control patients with non-COVID-19 illness (27 [44%] women, mean age 59.4 years [SD, 13]) were enrolled. Cognitive status measured by total geometric mean MoCA scores at 6-month follow-up was lower (P = .01) among COVID-19 survivors (26.7; 95% CI, 26.2-27.1) than control patients (27.5; 95% CI, 27.0-27.9). The cognitive status improved substantially (P = .004), from 19.2 (95% CI, 15.2-23.2) at discharge to 26.1 (95% CI, 23.1-29.1) for 15 patients with COVID-19 with MoCA evaluations from hospital discharge. A total of 16 of 85 patients with COVID-19 (19%) and 12 of 61 control patients (20%) had a new-onset psychiatric diagnosis at 6-month follow-up, which was not significantly different (odds ratio, 0.93; 95% CI, 0.39-2.27; P = .87). In fully adjusted models, secondary outcomes were not significantly different, except anosmia, which was more common after COVID-19 (odds ratio, 4.56; 95% CI, 1.52-17.42; P = .006); but no longer when adjusting for multiple testing.

Conclusions and Relevance

In this prospective case-control study, cognitive status at 6 months was worse among survivors of COVID-19, but the overall burden of neuropsychiatric and neurologic signs and symptoms among survivors of COVID-19 requiring hospitalization was comparable with the burden observed among matched survivors hospitalized for non-COVID-19 causes.

Echolucent carotid plaques becomes more echogenic over time - a 3D ultrasound study

OBJECTIVES

We aimed to detect changes in carotid artery atherosclerotic plaque volume and echogenicity over time in patients with an acute thromboembolic event and in patients with chronic atherosclerotic disease, both treated with statin, using a novel 3D ultrasound system.

METHODS

We included two cohorts of patients; 70 patients, naïve to statin treatment, admitted with acute, first-time myocardial infarction (aMI) and 69 patients who had been on statin treatment for a minimum of 6-months with chronic peripheral arterial disease (cPAD). 3D ultrasound examination was performed at baseline and after 3- and 12-months. Plaque volume was quantified in 3D ultrasound plaque acquisitions and echogenicity was assessed using gray-scale median (GSM) and normalized with adventitia as reference.

RESULTS

The aMI group had darker plaques than the cPAD group at baseline (mean GSM: 60.98, standard deviation (SD): 24.09 vs 71.75, SD: 21.55; P=0.006), 3-months (63.64, SD: 20.47 vs 73.44, SD: 20.46; P=0.006) and at 12-months follow-up (59.25, SD: 18.07 vs 71.02, SD: 22.31; P=0.004). The differences were not significant after adjusting for traditional risk factors. Dividing both groups by the median GSM, the darkest half of the aMI group's had an increase in GSM mainly within the first 3-months (10.49, CI95%: 2.45 - 18.53; P=0.012) and hereafter remained unchanged at 12-months follow-up (-0.53, CI95%: -7.28 - 6.22, P=0.875). In the darkest cPAD group GSM also increased within 3-months (8.14, CI95%: 1.85 - 14.32, P=0.012) and hereafter stabilised till 12-months (-2.54, CI95%: -9.62 - 4.53, P=0.475). Plaque volume did not change in the aMI group from baseline (median: 55.41mm³, interquartile range (IQR): 24.24 - 84.31) to 12-months (58.67mm³, IQR: 31.81 - 93.51) (P=0.220) whereas there was a small decrease in the cPAD group from baseline (71.63mm³, IQR: 40.12 - 135.61) to 12-months (67.73mm³, IQR: 31.00 - 122.38) (P=0.026).

CONCLUSION

Assessed with the novel 3D matrix ultrasound system echolucent carotid plaque had increasing GSM within a 3-months period, indicating stabilization of the more vulnerable plaques in aMI and cPAD patients. Plaque volume decreased over 12-months follow-up in long-term statin treated patient with cPAD, but not during the first 12 months statin therapy in patients with aMI.

Pulmonary embolism: Age specific temporal trends in incidence and mortality in Denmark 1999-2018

BACKGROUND

Through the last two decades the prevention, diagnosis and treatment of pulmonary embolism (PE) has evolved along with demographic changes. The influence of these current transformations is important in the assessment of the future burden of PE. We aimed to describe age specific temporal trends in incidence of first-time PE and subsequent mortality.

METHODS

We identified patients ≥18 years of age with a first-time in-hospital diagnosis of PE in Danish national registers. By dividing patients into seven age groups (18-34, 35-44, 45-54, 55-65, 65-74, 75-84, >85 years), age specific incidence and 1-year mortality rates were calculated for four different calendar periods between 1999 and 2018.

RESULTS

From 1999 to 2018 65,478 patients with a first-time PE were identified. PE incidence per 100,000 person years increased during the study period in all age-groups (18-34 years: 10 to 18, 35-44 years: 18 to 35, 45-54: 26 to 63, 55-64 years: 42 to 123, 65-74 years: 92 to 229, 75-84 years: 166 to 383 and >85 years: 155 to 417), p_trend <0.0001 for all. During the study period 1-year mortality rate decreased from 4 to 2 per 10 person years in patients aged 65-74 years and this trend was found in all age groups (p_trend = 0.0001 for all).

CONCLUSION

Despite a decreasing mortality rate, incidence rate of PE increased in Denmark across all age groups from 1999 to 2018, reflecting improved sensitivity of diagnostic methods and changes in the burden of comorbid conditions, all together warranting a continuing need for early prevention of PE.

Importance of Risk Assessment in Timing of Invasive Coronary Evaluation and Treatment of Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome: Insights From the VERDICT Trial

Background The optimal timing of invasive examination and treatment of high-risk patients with non-ST-segment-elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard-care invasive coronary angiography on the risk of all-cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. Methods and Results Patients with clinical suspicion of non-ST-segment-elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48-72 hours) invasive strategy. The primary outcome of the present study was all-cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow-up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16-3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63-1.10]) (P_interaction=0.006). Conclusions In patients with non-ST-segment-elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high-risk and low-risk patients with non-ST-segment-elevation acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02061891.

Room for improvement: initiation of lipid-lowering treatment and achievement of lipid target levels-a Danish registry-based study

AIMS

Prevention of adverse outcomes in individuals with high cholesterol levels may be improved by intensified lipid-lowering treatment (LLT). We studied whether treatment goals of low-density lipoprotein cholesterol (LDL-C) were reached within 1 year from baseline (defined as first LDL-C measurement) in a Danish population.

METHODS AND RESULTS

Danish registries were used to identify all persons in the Northern Region of Denmark who had LDL-C measured between 1997 and 2012 and who were naïve to LLT. Patients were categorized in LDL-C <5 or ≥5 mmol/L and further subdivided into low, high, and very high predicted cardiovascular (CV) risk as suggested by European guidelines for risk stratification. Initiation of LLT and lipid target levels were assessed after 1 year (3.0, 2.5, and 1.8 mmol/L, respectively). In this study, we examined the intensity of LLT and whether treatment goals were reached. More patients with LDL-C ≥5 mmol/L, regardless of the CV risk, initiated LLT compared with patients who had a very high CV risk and LDL-C <5 mmol/L. In total, 37.7% (n = 32 581) of all patients with a follow-up LDL-C, and 25.1% (n = 3229) of patients with LDL-C ≥5 mmol/L, had achieved their target levels after 1 year. Only 45.2% (n = 4545) of the LDL-C ≥5 mmol/L high-risk patients with a follow-up LDL-C had started LLT 12 months after baseline.

CONCLUSION

Less than half of patients presenting with an LDL-C ≥5 mmol/L start LLT within 1 year, representing a missed opportunity for both primary and secondary prevention of CV disease.

Prognostic Value of Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes

BACKGROUND

Severity and extent of coronary artery disease (CAD) assessed by invasive coronary angiography (ICA) guide treatment and may predict clinical outcome in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS).

OBJECTIVES

This study tested the hypothesis that coronary computed tomography angiography (CTA) is equivalent to ICA for risk assessment in patients with NSTEACS.

METHODS

The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial evaluated timing of treatment in relation to outcome in patients with NSTEACS and included a clinically blinded coronary CTA conducted prior to ICA. Severity of CAD was defined as obstructive (coronary stenosis ≥50%) or nonobstructive. Extent of CAD was defined as high risk (obstructive left main or proximal left anterior descending artery stenosis and/or multivessel disease) or non-high risk. The primary endpoint was a composite of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or heart failure.

RESULTS

Coronary CTA and ICA were conducted in 978 patients. During a median follow-up time of 4.2 years (interquartile range: 2.7 to 5.5 years), the primary endpoint occurred in 208 patients (21.3%). The rate of the primary endpoint was up to 1.7-fold higher in patients with obstructive CAD compared with in patients with nonobstructive CAD as defined by coronary CTA (hazard ratio [HR]: 1.74; 95% confidence interval [CI]: 1.22 to 2.49; p = 0.002) or ICA (HR: 1.54; 95% CI: 1.13 to 2.11; p = 0.007). In patients with high-risk CAD, the rate of the primary endpoint was 1.5-fold higher compared with the rate in those with non-high-risk CAD as defined by coronary CTA (HR: 1.56; 95% CI: 1.18 to 2.07; p = 0.002). A similar trend was noted for ICA (HR: 1.28; 95% CI: 0.98 to 1.69; p = 0.07).

CONCLUSIONS

Coronary CTA is equivalent to ICA for the assessment of long-term risk in patients with NSTEACS. (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes [VERDICT]; NCT02061891).

Usefulness of High Sensitivity Troponin T to Predict Long-Term Left Ventricular Dysfunction After ST-Elevation Myocardial Infarction

Guidelines recommend the use of transthoracic echocardiography (TTE) and clinical scores to risk stratify patients after ST-elevation myocardial infarction (STEMI). High sensitivity troponin T (hs-cTnT) is predictive of outcome after STEMI but the predictive value of hs-cTnT relative to other risk assessment tools has not been established. We aimed to compare the predictive value of hs-cTnT to other risk assessment tools in patients with STEMI. A subset of 578 patients with STEMI were included in this post-hoc study from the Third DANish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction trial. Patients underwent cardiac magnetic resonance imaging (CMR) during index hospitalization as well as TTE at 1 year after their STEMI. The predictive value of hs-cTnT was compared with CKMB, infarct size (IS)/left ventricular ejection fraction (LVEF) assessed with CMR, LVEF assessed at discharge with TTE and the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk-scores. The primary outcome was LV systolic dysfunction defined as LVEF ≤40% after 1 year on TTE. The area under the receiver operating characteristic curve analyses showed no significant difference between hs-cTnT and early CMR-assessed IS or LVEF in predicting subsequent LVEF ≤40%. Area under the curve for hs-cTnT was 0.82, 0.85 for IS (p = 0.22), and 0.87 for LVEF (p = 0.23). For predischarge TTE-assessed LVEF, the value was 0.85 (p = 0.45), 0.63 for creatine kinase-MB (p <0.001), 0.61 for the GRACE score (p <0.001), and 0.70 for the TIMI score (p = 0.02). A peak hs-cTnT value <3,500 ng/L ruled out LVEF ≤40% with probability of 98%. In conclusion, in patients presenting with STEMI undergoing PCI, hs-cTnT level strongly predicted long-term LV dysfunction and could be used as a clinical risk stratification tool to identify patients at high risk of progressing to LV dysfunction due to its general availability and high-predictive accuracy.

Patients with Unstable Atherosclerosis Have More Echolucent Carotid Plaques Compared with Stable Atherosclerotic Patients: A 3-D Ultrasound Study

Using a novel 3-D ultrasound system, we aimed to determine differences in carotid plaque size and echogenicity in two atherosclerotic groups. Seventy patients admitted with acute myocardial infarction (aMI) and 69 patients known with chronic peripheral arterial disease (cPAD) were included. The cPAD group had larger plaque volumes (median: 70.24 mm³, interquartile range [40.12-135.61] vs. 55.41 mm³ [4.24-84.31], p = 0.004), thicker plaques (2.45 mm [1.85-3.25] vs. 1.99 mm [1.55 - 2.64], p = 0.005) and higher gray-scale medians (GSMs) (mean: 71.75, standard deviation: 21.55 vs. 60.99 [24.09], p = 0.006) than the aMI group. After adjustment for traditional risk factors, the difference persisted for thickness and volume. The difference in GSM persisted after adjustment for volume only. Patients with stable atherosclerotic disease had larger and brighter carotid plaques compared with unstable atherosclerotic patients. 3-D ultrasound may prove useful in identifying thromboembolic risk.

Ultrasound-assisted thrombolysis for acute intermediate-high-risk pulmonary embolism

INTRODUCTION

Eustachian tube dysfunction (ETD) may result in hearing loss, chronic otitis and cholesteatoma. With advances in treatment options, the identification of patients with obstructive ETD is becoming increasingly important. The objective of this study was to validate a Danish translation of the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7).

METHODS

All participants underwent tympanometry, otomicroscopy and completed the ETDQ-7. We included 34 ears from patients with obstructive ETD who had abnormal tympanometry curves but no history of cholesteatoma or adhesive otitis. As a control group, 48 otherwise healthy ears with a normal tympanometry curve were included from patients with known sensorineural hearing loss or normal hearing.

RESULTS

A Cronbach's alpha of 0.77 indicated a good internal consistency reliability of the questionnaire. The mean ETDQ-7 score in the obstructive ETD group was 31 versus 13.5 in the control group (p = 0.00). A receiver operating characteristics analysis produced an area under the curve of 94%, showing excellent discriminatory abilities between the groups.

CONCLUSIONS

The ETDQ-7 has previously been validated in English, German, Dutch and Portuguese, demonstrating good clinical relevance. The Danish translation of the ETDQ-7 has produced similar results and may be valuable in diagnosing obstructive ETD and in monitoring the effect of balloon dilation of the Eustachian tube.

FUNDING

none. The study was approved by the Danish Data Protection Agency (VD-2018-33, I-Suite 6229).

P612Multimodal cardiac imaging in patients with suspected ST-elevation myocardial infarction and no obstructive coronary arteries

Background

Patients with suspected ST-elevation myocardial infarction (STEMI) and normal coronary arteries comprise a heterogeneous group with various underlying causes of disease.

Purpose

To study pathophysiology and underlying diagnoses in patients with suspected STEMI and normal coronary arteries using multimodal cardiac imaging.

Methods

We consecutively included patients with suspected STEMI, normal coronary arteries on acute coronary angiography, and elevated troponin T levels at a tertiary heart center (2012–14). Patients were examined with echocardiography, cardiac magnetic resonance imaging, and 13NH3/82Rb and 18F-FDG positron emission tomography within one week from symptom onset.

Results

We included 42 patients (60% male, median age 58 (IQR 50–65) years. Median troponin T levels were 783 (IQR 566–1208) ng/l. Multimodal cardiac imaging findings are presented in Table 1. Multimodal cardiac imaging showed signs of cardiac involvement in all but one patient (98%). Underlying diagnoses were acute myocardial infarction (36%), Takotsubo cardiomyopathy (29%), perimyocarditis (10%), and cardiomyopathy (7%). The diagnosis was unclear in 19% of patients.

Echocardiography   Left ventricular ejection fraction <40%, n (%) 12 (29)   Moderate to severe left ventricular hypertrophy, n (%) 3 (7)   Moderate to severe valvular disease, n (%) 3 (7)   Pericardial effusion, n (%) 5 (12)   Apical thrombus, n (%) 1 (2) Magnetic resonance imaging   Left ventricular end diastolic volume, ml (IQR) 157 (125–185)   Left ventricular end systolic volume, ml (IQR) 75 (63–88)   Left ventricular stroke volume, ml (IQR) 73 (57–93)   Edema, n (%) 38 (91)   Late gadolinium enhancement, n (%) 22 (52) 13NH3/82Rb and 18F-FDG positron emission computer tomography   Myocardial perfusion defect, n (%) 29 (69)   Myocardial perfusion-metabolism mismatch, n (%) 12/30 (40)   Reduced myocardial viability, n (%) 6/30 (20)

Conclusion

The majority of patients with suspected STEMI and normal coronary arteries had signs of cardiac involvement by multimodal cardiac imaging and were diagnosed with cardiac disease.

Acknowledgement/Funding

The Danish Heart Foundation, the A.P. Møller Foundation, the Foundation of Reinholdt W. Jorck and Wife, Rigshospitalet's Research Foundation

P885Cardiovascular events in patients with suspected ST-elevation myocardial infarction and no obstructive coronary artery disease

Background

Patients with suspected ST-elevation myocardial infarction (STEMI) and no obstructive coronary artery disease (CAD) comprise a heterogeneous group with varying prognoses.

Purpose

To evaluate the prognostic value of cardiac troponin T (cTnT) in patients with suspected STEMI and no obstructive CAD.

Methods

Patients with suspected STEMI and no obstructive (<50% diameter stenosis) CAD were consecutively included from 2009–2014. Patients were classified as having normal cTnT, dynamic cTnT elevation, or stationary cTnT elevation. All patients were followed with respect to major adverse cardiovascular events (MACE), cardiovascular readmission, and repeat coronary procedures, until 1 year after discharge.

Results

The study included 502 patients with suspected STEMI and no obstructive CAD: 165 (33%) had normal cTnT, 293 (58%) had dynamic cTnT elevation and 44 (9%) had stationary cTnT elevation. Within one year after admission, 40 (8%) had MACE, 81 (16%) had cardiovascular readmission, and 8 (2%) underwent repeat coronary procedures. The risk of MACE was elevated in patients with stationary cTnT elevation compared with normal cTnT (OR 13.6, 95% CI 2.3–80.2, p=0.004). There was no statistically significant difference between those with dynamic cTnT elevation and normal cTnT (OR 2.9, 95% CI 0.6–14.0, p=0.189). Adding cTnT pattern to a conventional risk model, area under the receiver operating curve for predicting the 1-year risk of MACE improved significantly (80% vs. 85%, p=0.004, Figure 1).

Figure 1

Conclusion

In patients with suspected STEMI and no obstructive CAD, cTnT pattern during acute hospitalization is associated with the 1-year risk of MACE and improves risk prediction for the individual patient.

Acknowledgement/Funding

The Danish Heart Foundation, the A.P. Møller Foundation, the Foundation of Reinholdt W. Jorck and Wife, Rigshospitalet's Research Foundation

4094Microvascular dysfunction in takotsubo syndrome visualized at stress and rest using 82-rubidium PET imaging

Introduction

Takotsubo Syndrome (TTS) is recognized as the acute onset of reversible heart failure, often mimicking acute coronary syndrome with ECG changes and rise in cardiac biomarkers, but with no apparent coronary obstruction. The pathophysiological mechanisms of TTS are not yet fully understood, but it is well established that microvascular dysfunction and constriction plays a crucial role in the pathogenesis of TTS.

Positron emission tomography (PET) using the radioactive tracer Rubidium-82 (Rb-82) is routinely used to asses myocardial perfusion and microvascular function in a wide array of cardiological conditions.

Purpose

The purpose of this study was to evaluate myocardial perfusion and flow reserve in patients with TTS using Rb-82 positron emission tomography (PET) molecular imaging during rest and pharmacologically induced stress, in the acute phase and after 3 months of follow-up.

Methods

A total of 8 patients were diagnosed with TTS due to acute onset of symptoms, rise in cardiac biomarkers, absence of significant coronary obstruction and apical ballooning of the left ventricle. Subsequently the patients underwent Rb-82 PET scan in the acute phase (1–4 days after onset), and again at 3 months of follow-up. Rb-82 PET scans were performed both during resting conditions and during pharmacologically induced stress with infusion of adenosine. Myocardial blood flow (MBF) and total perfusion defect (TPD) were quantified during rest and stress, and the coronary flow reserve (CFR) was calculated. The AHA-17 segment model was used to determine summed rest scores (SRS) and summed stress scores (SSS). Data are presented as means ± SEM

Results

MBF during stress was significantly lower in the acute phase than at 3 months follow-up (2.99±0.35 vs. 3.82±0.19 ml/g/min, P=0.016) as opposed to resting MBF, which did not differ significantly (1.33±0.14 vs. 1.45±0.09 ml/g/min, P=0.309). The CFR of the patients was not significantly different in the acute phase compared to 3 months follow-up (2.33±0.25 vs 2.65±0.12, P=0.11), though 4 of the patients had a CFR <2.0 in the acute phase, which was normalized at follow-up. TPD was significantly lower at follow-up compared to the acute phase at both rest (21.6±5.86 vs. 0.75±0.61%, P=0.009) and stress (25.3±6.01 vs. 1.25±0.31%, P=0.006). SRS (12.6±3.24 vs. 0.75±0.59, P=0.01) and SSS (19.9±3.39 vs. 1.38±0.59, P=0.001) was significantly higher in the acute phase compared to follow-up. At follow up, all values were normalized.

Figure 1

Conclusion

These results supports the evidence that TTS is partly caused by microvascular dysfunction and constriction during the acute phase. Further studies are needed to uncover the exact mechanisms behind.

Publisher Correction: Protein-altering variants associated with body mass index implicate pathways that control energy intake and expenditure in obesity

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Cardiogenic Shock After Arterial Y-Graft Coronary Bypass Surgery Secondary to Critical Stenoses of the Left Subclavian and Left Main Coronary Arteries

We present a case of a 62-year-old man who was in cardiogenic shock. He had a history of coronary artery bypass grafting 4 years previously, with left internal mammary radial artery Y-grafting to a left dominant coronary circulation. Critical stenoses of the left main coronary and left subclavian arteries were seen at angiography. An occluded abdominal aorta precluded the use of mechanical circulatory support. The patient underwent high-risk stenting of the left subclavian artery with a successful outcome. The case highlights the unresolved issue of screening for subclavian stenoses in patients being considered for revascularization with arterial Y-grafting.

Intensive versus conventional blood pressure monitoring in a general practice population. The Blood Pressure Reduction in Danish General Practice trial: a randomized controlled parallel group trial

OBJECTIVE

To compare the effect of a conventional to an intensive blood pressure monitoring regimen on blood pressure in hypertensive patients in the general practice setting.

DESIGN

Randomized controlled parallel group trial with 12-month follow-up.

SETTING

One hundred and ten general practices in all regions of Denmark.

PARTICIPANTS

One thousand forty-eight patients with essential hypertension.

INTERVENTION

Conventional blood pressure monitoring ('usual group') continued usual ad hoc blood pressure monitoring by office blood pressure measurements, while intensive blood pressure monitoring ('intensive group') supplemented this with frequent home blood pressure monitoring and 24-hour ambulatory blood pressure monitoring.

PRIMARY OUTCOME MEASURES

Mean day- and night-time systolic and diastolic 24-hour ambulatory blood pressure.

SECONDARY OUTCOME MEASURES

Change in systolic and diastolic office blood pressure and change in cardiovascular risk profile.

RESULTS

Of the patients, 515 (49%) were allocated to the usual group, and 533 (51%) to the intensive group. The reductions in day- and night-time 24-hour ambulatory blood pressure were similar (usual group: 4.6 ± 13.5/2.8 ± 82 mmHg; intensive group: 5.6 ± 13.0/3.5 ± 8.2 mmHg; P = 0.27/P = 0.20). Cardiovascular risk scores were reduced in both groups at follow-up, but more so in the intensive than in the usual group (P = 0.02).

CONCLUSION

An intensive blood pressure monitoring strategy led to a similar blood pressure reduction to conventional monitoring. However, the intensive strategy appeared to improve patients' cardiovascular risk profile through other effects than a reduction of blood pressure.

TRIAL REGISTRATION

Clinical Trials NCT00244660.

Subacute cardiac rubidium-82 positron emission tomography (82Rb-PET) to assess myocardial area at risk, final infarct size, and myocardial salvage after STEMI

BACKGROUND

Determining infarct size and myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) is important when assessing the efficacy of new reperfusion strategies. We investigated whether rest 82Rb-PET myocardial perfusion imaging can estimate area at risk, final infarct size, and myocardial salvage index when compared to cardiac SPECT and magnetic resonance (CMR).

METHODS

Twelve STEMI patients were injected with 99mTc-Sestamibi intravenously immediate prior to reperfusion. SPECT, 82Rb-PET, and CMR imaging were performed post-reperfusion and at a 3-month follow-up. An automated algorithm determined area at risk, final infarct size, and hence myocardial salvage index.

RESULTS

SPECT, CMR, and PET were performed 2.2 ± 0.5, 34 ± 8.5, and 32 ± 24.4 h after reperfusion, respectively. Mean (± SD) area at risk were 35.2 ± 16.6%, 34.7 ± 11.3%, and 28.1 ± 16.1% of the left ventricle (LV) in SPECT, CMR, and PET, respectively, P = 0.04 for difference. Mean final infarct size estimates were 12.3 ± 15.4%, 13.7 ± 10.4%, and 11.9 ± 14.6% of the LV in SPECT, CMR, and PET imaging, respectively, P = .72. Myocardial salvage indices were 0.64 ± 0.33 (SPECT), 0.65 ± 0.20 (CMR), and 0.63 ± 0.28 (PET), (P = .78).

CONCLUSIONS

82Rb-PET underestimates area at risk in patients with STEMI when compared to SPECT and CMR. However, our findings suggest that PET imaging seems feasible when assessing the clinical important parameters of final infarct size and myocardial salvage index, although with great variability, in a selected STEMI population with large infarcts. These findings should be confirmed in a larger population.

Publisher Correction: Protein-altering variants associated with body mass index implicate pathways that control energy intake and expenditure in obesity

In the version of this article originally published, one of the two authors with the name Wei Zhao was omitted from the author list and the affiliations for both authors were assigned to the single Wei Zhao in the author list. In addition, the ORCID for Wei Zhao (Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA) was incorrectly assigned to author Wei Zhou. The errors have been corrected in the HTML and PDF versions of the article.

Publisher Correction: Protein-altering variants associated with body mass index implicate pathways that control energy intake and expenditure in obesity

In the published version of this paper, the name of author Emanuele Di Angelantonio was misspelled. This error has now been corrected in the HTML and PDF versions of the article.

Protein-altering variants associated with body mass index implicate pathways that control energy intake and expenditure in obesity

Genome-wide association studies (GWAS) have identified >250 loci for body mass index (BMI), implicating pathways related to neuronal biology. Most GWAS loci represent clusters of common, noncoding variants from which pinpointing causal genes remains challenging. Here we combined data from 718,734 individuals to discover rare and low-frequency (minor allele frequency (MAF) < 5%) coding variants associated with BMI. We identified 14 coding variants in 13 genes, of which 8 variants were in genes (ZBTB7B, ACHE, RAPGEF3, RAB21, ZFHX3, ENTPD6, ZFR2 and ZNF169) newly implicated in human obesity, 2 variants were in genes (MC4R and KSR2) previously observed to be mutated in extreme obesity and 2 variants were in GIPR. The effect sizes of rare variants are ~10 times larger than those of common variants, with the largest effect observed in carriers of an MC4R mutation introducing a stop codon (p.Tyr35Ter, MAF = 0.01%), who weighed ~7 kg more than non-carriers. Pathway analyses based on the variants associated with BMI confirm enrichment of neuronal genes and provide new evidence for adipocyte and energy expenditure biology, widening the potential of genetically supported therapeutic targets in obesity.

Exome-wide association study of plasma lipids in >300,000 individuals

We screened variants on an exome-focused genotyping array in >300,000 participants (replication in >280,000 participants) and identified 444 independent variants in 250 loci significantly associated with total cholesterol (TC), high-density-lipoprotein cholesterol (HDL-C), low-density-lipoprotein cholesterol (LDL-C), and/or triglycerides (TG). At two loci (JAK2 and A1CF), experimental analysis in mice showed lipid changes consistent with the human data. We also found that: (i) beta-thalassemia trait carriers displayed lower TC and were protected from coronary artery disease (CAD); (ii) excluding the CETP locus, there was not a predictable relationship between plasma HDL-C and risk for age-related macular degeneration; (iii) only some mechanisms of lowering LDL-C appeared to increase risk for type 2 diabetes (T2D); and (iv) TG-lowering alleles involved in hepatic production of TG-rich lipoproteins (TM6SF2 and PNPLA3) tracked with higher liver fat, higher risk for T2D, and lower risk for CAD, whereas TG-lowering alleles involved in peripheral lipolysis (LPL and ANGPTL4) had no effect on liver fat but decreased risks for both T2D and CAD.

Rare and low-frequency coding variants alter human adult height

Height is a highly heritable, classic polygenic trait with approximately 700 common associated variants identified through genome-wide association studies so far. Here, we report 83 height-associated coding variants with lower minor-allele frequencies (in the range of 0.1-4.8%) and effects of up to 2 centimetres per allele (such as those in IHH, STC2, AR and CRISPLD2), greater than ten times the average effect of common variants. In functional follow-up studies, rare height-increasing alleles of STC2 (giving an increase of 1-2 centimetres per allele) compromised proteolytic inhibition of PAPP-A and increased cleavage of IGFBP-4 in vitro, resulting in higher bioavailability of insulin-like growth factors. These 83 height-associated variants overlap genes that are mutated in monogenic growth disorders and highlight new biological candidates (such as ADAMTS3, IL11RA and NOX4) and pathways (such as proteoglycan and glycosaminoglycan synthesis) involved in growth. Our results demonstrate that sufficiently large sample sizes can uncover rare and low-frequency variants of moderate-to-large effect associated with polygenic human phenotypes, and that these variants implicate relevant genes and pathways.

The 4th Report of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy

The 4th Report provides a brief review of publications focused on the electrocardiographic diagnosis of left ventricular hypertrophy published during the period of 2010 to 2016 by the members of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy. The Working Group recommended that ECG research and clinical attention be redirected from the estimation of LVM to the identification of electrical remodeling, to better understanding the sequence of events connecting electrical remodeling to outcomes. The need for a re-definition of terms and for a new paradigm is also stressed.

[Takotsubo cardiomyopathy is an acute cardiac syndrome induced by stress]

Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome, characterized by transient left ventricular dysfunction often following a stressful event in post-menopausal women. Symptoms are indistinguishable from myocardial infarction. However, TTC patients do not have a culprit lesion on acute angiography, and regional akinesia is not limited to a single vascular territory. As opposed to other cardiomyopathies TTC is completely reversible, albeit with a 5% mortality rate as well as a 10% re-occurrence rate. This article summarizes the current knowledge about aetiology, diagnostics and treatment.

Neuroticism, depression and anxiety in takotsubo cardiomyopathy

Background

Takotsubo cardiomypathy (TTC) causes acute reversible heart failure. Prior studies have indicated that the syndrome is associated with traits such as social inhibition, chronic psychological stress, and anxio-depressive disorders. The objective of this study was to further characterize key psychological/psychopathological traits of patients with TTC.

Methods

A survey of three groups was conducted: I) Female post-recovery TTC patients admitted between October 1^st 2009 and December 10^th 2014, II) Age, gender and geographically matched ST-elevation myocardial infarction (STEMI) patients, and III) Age, gender and geographically matched individuals from the background population. The following questionnaires were used in the survey: the WHO-5 Well-Being Index, Eysenck’s Neuroticism Scale, the Major Depression Inventory, and the anxiety subscale of Symptoms Checklist (SCL-90).

Results

In total, 173 of 230 invitees (75 %) participated in the study. In comparison to the background controls, TTC patients reported significantly less well-being, more neuroticism, more depression, and more anxiety. The levels of well-being, depression and neuroticism were comparable between TTC and STEMI patients, but the level of anxiety was higher in the TTC patients. There was a negative correlation between the time since TTC admission and the total scores on the psychopathology rating scales.

Conclusions

Patients with TTC reported significantly higher anxiety levels compared to both STEMI patients and background controls. However, unlike the STEMI patients, the TTC patients appeared to improve psychologically during the post-recovery phase. This may be a consolation for TTC patients in acute psychological distress.

Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial

BACKGROUND

Despite successful treatment of the culprit artery lesion by primary percutaneous coronary intervention (PCI) with stent implantation, thrombotic embolisation occurs in some cases, which impairs the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). We aimed to assess the clinical outcomes of deferred stent implantation versus standard PCI in patients with STEMI.

METHODS

We did this open-label, randomised controlled trial at four primary PCI centres in Denmark. Eligible patients (aged >18 years) had acute onset symptoms lasting 12 h or less, and ST-segment elevation of 0·1 mV or more in at least two or more contiguous electrocardiographic leads or newly developed left bundle branch block. Patients were randomly assigned (1:1), via an electronic web-based system with permuted block sizes of two to six, to receive either standard primary PCI with immediate stent implantation or deferred stent implantation 48 h after the index procedure if a stabilised flow could be obtained in the infarct-related artery. The primary endpoint was a composite of all-cause mortality, hospital admission for heart failure, recurrent infarction, and any unplanned revascularisation of the target vessel within 2 years' follow-up. Patients, investigators, and treating clinicians were not masked to treatment allocation. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01435408.

FINDINGS

Between March 1, 2011, and Feb 28, 2014, we randomly assigned 1215 patients to receive either standard PCI (n=612) or deferred stent implantation (n=603). Median follow-up time was 42 months (IQR 33-49). Events comprising the primary endpoint occurred in 109 (18%) patients who had standard PCI and in 105 (17%) patients who had deferred stent implantation (hazard ratio 0·99, 95% CI 0·76-1·29; p=0·92). Procedure-related myocardial infarction, bleeding requiring transfusion or surgery, contrast-induced nephopathy, or stroke occurred in 28 (5%) patients in the conventional PCI group versus 27 (4%) patients in the deferred stent implantation group, with no significant differences between groups.

INTERPRETATION

In patients with STEMI, routine deferred stent implantation did not reduce the occurrence of death, heart failure, myocardial infarction, or repeat revascularisation compared with conventional PCI. Results from ongoing randomised trials might shed further light on the concept of deferred stenting in this patient population.

FUNDING

Danish Agency for Science, Technology and Innovation, and Danish Council for Strategic Research.

Increased Remnant Cholesterol Explains Part of Residual Risk of All-Cause Mortality in 5414 Patients with Ischemic Heart Disease

BACKGROUND

Increased concentrations of remnant cholesterol are causally associated with increased risk of ischemic heart disease. We tested the hypothesis that increased remnant cholesterol is a risk factor for all-cause mortality in patients with ischemic heart disease.

METHODS

We included 5414 Danish patients diagnosed with ischemic heart disease. Patients on statins were not excluded. Calculated remnant cholesterol was nonfasting total cholesterol minus LDL and HDL cholesterol. During 35836 person-years of follow-up, 1319 patients died.

RESULTS

We examined both calculated and directly measured remnant cholesterol; importantly, however, measured remnant cholesterol made up only 9% of calculated remnant cholesterol at nonfasting triglyceride concentrations <1 mmol/L (89 mg/dL) and only 43% at triglycerides >5 mmol/L (443 mg/dL). Multivariable-adjusted hazard ratios for all-cause mortality compared with patients with calculated remnant cholesterol concentrations in the 0 to 60th percentiles were 1.2 (95% CI, 1.1-1.4) for patients in the 61st to 80th percentiles, 1.3 (1.1-1.5) for the 81st to 90th percentiles, 1.5 (1.1-1.8) for the 91st to 95th percentiles, and 1.6 (1.2-2.0) for patients in the 96th to 100th percentiles (trend, P < 0.001). Corresponding values for measured remnant cholesterol were 1.0 (0.8-1.1), 1.2 (1.0-1.4), 1.1 (0.9-1.5), and 1.3 (1.1-1.7) (trend, P = 0.006), and for measured LDL cholesterol 1.0 (0.9-1.1), 1.0 (0.8-1.2), 1.0 (0.8-1.3), and 1.1 (0.8-1.4) (trend, P = 0.88). Cumulative survival was reduced in patients with calculated remnant cholesterol ≥1 mmol/L (39 mg/dL) vs <1 mmol/L [log-rank, P = 9 × 10(-6); hazard ratio 1.3 (1.2-1.5)], but not in patients with measured LDL cholesterol ≥3 mmol/L (116 mg/dL) vs <3 mmol/L [P = 0.76; hazard ratio 1.0 (0.9-1.1)].

CONCLUSIONS

Increased concentrations of both calculated and measured remnant cholesterol were associated with increased all-cause mortality in patients with ischemic heart disease, which was not the case for increased concentrations of measured LDL cholesterol. This suggests that increased concentrations of remnant cholesterol explain part of the residual risk of all-cause mortality in patients with ischemic heart disease.

A mismatch index based on the difference between measured left ventricular ejection fraction and that estimated by infarct size at three months following reperfused acute myocardial infarction

BACKGROUND AND AIM

The reduction of left ventricular ejection fraction (LVEF) following ST-segment elevation myocardial infarction (STEMI) is a result of infarcted myocardium and may involve dysfunctional but viable myocardium. An index that may quantitatively determine whether LVEF is reduced beyond the expected value when considering only infarct size (IS) has previously been presented based on cardiac magnetic resonance (CMR). The purpose of this study was to introduce the index based on the electrocardiogram (ECG) and compare indices based on ECG and CMR.

METHOD AND RESULTS

In 55 patients ECG and CMR were obtained 3 months after STEMI treated with primary percutaneous coronary intervention. Significant, however moderate inverse relationships were found between measured LVEF and IS. Based on IS and LVEF an IS estimated LVEF was derived and an MI-LVEF mismatch index was calculated as the difference between measured LVEF and IS estimated LVEF. In 41 (74.5%) of the patients there was agreement between the ECG and CMR indices in regards to categorizing indices as >10 or ≤ 10 and generally no significant difference was detected, mean difference of 1.26 percentage points (p = 0.53).

CONCLUSION

The study found an overall good agreement between MI-LVEF mismatch indices based on ECG and CMR. The MI-LVEF mismatch index may serve as a tool to identify patients with potentially reversible dysfunctional but viable myocardium, but future studies including both ECG and CMR are needed.

Simvastatin effects on skeletal muscle: relation to decreased mitochondrial function and glucose intolerance

OBJECTIVES

Glucose tolerance and skeletal muscle coenzyme Q(10) (Q(10)) content, mitochondrial density, and mitochondrial oxidative phosphorylation (OXPHOS) capacity were measured in simvastatin-treated patients (n = 10) and in well-matched control subjects (n = 9).

BACKGROUND

A prevalent side effect of statin therapy is muscle pain, and yet the basic mechanism behind it remains unknown. We hypothesize that a statin-induced reduction in muscle Q(10) may attenuate mitochondrial OXPHOS capacity, which may be an underlying mechanism.

METHODS

Plasma glucose and insulin concentrations were measured during an oral glucose tolerance test. Mitochondrial OXPHOS capacity was measured in permeabilized muscle fibers by high-resolution respirometry in a cross-sectional design. Mitochondrial content (estimated by citrate synthase [CS] activity, cardiolipin content, and voltage-dependent anion channel [VDAC] content) as well as Q(10) content was determined.

RESULTS

Simvastatin-treated patients had an impaired glucose tolerance and displayed a decreased insulin sensitivity index. Regarding mitochondrial studies, Q(10) content was reduced (p = 0.05), whereas mitochondrial content was similar between the groups. OXPHOS capacity was comparable between groups when complex I- and complex II-linked substrates were used alone, but when complex I + II-linked substrates were used (eliciting convergent electron input into the Q intersection [maximal ex vivo OXPHOS capacity]), a decreased (p < 0.01) capacity was observed in the patients compared with the control subjects.

CONCLUSIONS

These simvastatin-treated patients were glucose intolerant. A decreased Q(10) content was accompanied by a decreased maximal OXPHOS capacity in the simvastatin-treated patients. It is plausible that this finding partly explains the muscle pain and exercise intolerance that many patients experience with their statin treatment.

Does long‐term losartan‐ vs atenolol‐based antihypertensive treatment influence collagen markers differently in hypertensive patients? A LIFE substudy

BACKGROUND

The aim of this study was to investigate the effects of losartan- vs atenolol-based antihypertensive treatment on circulating collagen markers beyond the initial blood pressure (BP) reduction.

METHODS

In 204 patients with hypertension and left ventricular (LV) hypertrophy we measured serum concentration of carboxy-terminal telopeptide of type I procollagen (ICTP), carboxy-terminal propeptide of type I procollagen (PICP), amino-terminal propeptide of type III procollagen (PIIINP), amino-terminal propeptide of type I procollagen (PINP) and LV mass by echocardiography at baseline and annually during 4 years of losartan- or atenolol-based antihypertensive treatment; 185 patients completed the study.

RESULTS

Beyond the first year of treatment systolic and diastolic BP, LV mass index (LVMI) as well as collagen markers did not change significantly and were equal in the two treatment groups. Changes in PICP during first year of treatment were related to subsequent changes in LV mass index after 2 and 3 years of treatment (r=0.28 and r=0.29, both p<0.05) in patients randomized to losartan, but not atenolol.

CONCLUSION

Long-term losartan- vs atenolol-based antihypertensive treatment did not influence collagen markers differently, making a BP-independent effect of losartan on collagen markers unlikely. However, initial reduction in circulating PICP may predict later regression of LV hypertrophy during losartan-based antihypertensive treatment.

Increased systolic ambulatory blood pressure and microalbuminuria in treated and non‐treated hypertensive smokers

OBJECTIVE

The primary aim of the present study was to evaluate the impact of smoking status on both clinic and ambulatory blood pressure (BP) and heart rate (HR) by using 24-h ambulatory BP monitoring in treated and non-treated hypertensive smokers and non-smokers. A secondary aim was to evaluate the interrelations between BP, smoking status and microalbuminuria.

DESIGN

Five hundred and eighty treated and non-treated hypertensive smokers and non-smokers were consecutively recruited. The patients were divided into groups of non-smokers (n = 414) and smokers (n = 166). We were able to match 115 smokers with 230 non-smokers with regard to clinic BP, gender and age.

METHODS

Microalbuminuria (albumin/creatinine ratio on morning spot urine sample), sitting clinic BP (mercury sphygmomanometry) and ambulatory BP (A&D TM 2421) were measured.

RESULTS

In the matched group we found a significant difference in ambulatory systolic and diastolic daytime BP between smokers and non-smokers (146.5 +/- 15.0/90.6 +/- 9.7 mmHg vs 142.3 +/- 12.6/89.0 +/- 9.0 mmHg). The smokers had significantly higher log albumin/creatinine ratio (0.51 +/- 0.93 vs 0.19 +/- 0.87). These results were found to be valid for treated as well as untreated patients. In both the matched and unmatched groups, the smokers had significantly higher HR.

CONCLUSION

The higher daytime BP and HR as well as microalbuminuria in smokers may contribute to their increased cardiovascular risk. Furthermore, the higher ambulatory BP in smokers implicates that these patients tend to be underdiagnosed and undertreated if only clinic BP is used.

[Pharmacological hypertension therapy]

Drug therapy in uncomplicated hypertension can be initiated with either ACE-inhibitors, angiotensin II receptor antagonists, calcium channel blockers or thiazides. In younger patients, the first three classes are preferable. Beta-blockers are first-line drugs for hypertension in patients with cardiac comorbidity. Initial combination therapy is indicated in high-risk patients where blood pressure reduction of > 20/10 mmHg is desired. Resistant hypertension generally calls for an increment in diuretic dosage and/or addition of a potassium-sparing diuretic.

Opposite effects of losartan and atenolol on natriuretic peptides in patients with hypertension and left ventricular hypertrophy: a LIFE substudy

BACKGROUND

Secretion of natriuretic peptides is related to cardiac wall stress and influenced by the renin-angiotensin system. Therefore, we investigated the influence of blood pressure (BP) reduction with losartan versus atenolol on N-terminal pro-atrial natriuretic peptide (Nt-proANP) and N-terminal pro-brain natriuretic peptide (Nt-proBNP).

METHODS

In 183 patients with hypertension and electrocardiographic left ventricular (LV) hypertrophy, enrolled in the LIFE Study, we measured BP and serum Nt-proANP and Nt-proBNP by immunoassay after 2 weeks of placebo treatment and after 1, 2, 4, 6, 12, 24, 36 and 48 months of randomized treatment with losartan- or atenolol-based antihypertensive regimens.

RESULTS

There was no significant difference in BP at any time point between the two treatment groups. In patients treated with losartan, median Nt-proANP decreased gradually throughout the study, reaching significance after 6 months of treatment (1125-1060 pmol/l, P < 0.001), and Nt-proBNP decreased within the first month (24.7-18.7 pmol/l, P < 0.01) and stayed reduced throughout the study. During losartan-based antihypertensive treatment, Nt-proANP and Nt-proBNP as a percentage of baseline values were correlated to reductions in systolic BP (r = 0.11, P < 0.01 and r = 0.10, P = 0.01) and diastolic BP (r = 0.17, P < 0.001 and r = 0.07, P = 0.09). In atenolol-treated patients, Nt-proANP (1100-1640 pmol/l, P < 0.001) and Nt-proBNP (20.0-37.7 pmol/l, P < 0.001) increased during the first month, and remained elevated throughout the study. During atenolol-based antihypertensive treatment, changes in Nt-proANP (r = -0.16, P < 0.001) and Nt-proBNP (r = -0.07, P = 0.08) were negatively related to change in heart rate.

CONCLUSION

Nt-proANP and Nt-proBNP were reduced in parallel with BP in losartan-treated patients whereas they increased in parallel with decreased heart rate in atenolol-treated patients.

Markers of collagen synthesis is related to blood pressure and vascular hypertrophy: a LIFE substudy

Cardiac fibrosis and high levels of circulating collagen markers has been associated with left ventricular (LV) hypertrophy. However, the relationship to vascular hypertrophy and blood pressure (BP) load is unclear. In 204 patients with essential hypertension and electrocardiographic LV hypertrophy, we measured sitting BP, serum collagen type I carboxy-terminal telopeptide (ICTP) reflecting degradation, procollagen type I carboxy-terminal propeptide (PICP) reflecting synthesis and LV mass by echocardiography after 2 weeks of placebo treatment and after 1 year of antihypertensive treatment with a losartan- or an atenolol-based regimen. Furthermore, we measured intima-media thickness of the common carotid arteries (IMT), minimal forearm vascular resistance (MFVR) by plethysmography and ambulatory 24-h BP in around half of the patients. At baseline, PICP/ICTP was positively related to IMT (r=0.24, P<0.05), MFVR(men) (r=0.35, P<0.01), 24-h systolic BP (r=0.24, P<0.05) and 24-h diastolic BP (r=0.22, P<0.05), but not to LV mass. After 1 year of treatment with reduction in systolic BP (175+/-15 vs 151+/-17 mmHg, P<0.001) and diastolic BP (99+/-8 vs 88+/-9 mmHg, P<0.001), ICTP was unchanged (3.7+/-1.4 vs 3.8+/-1.4 microg/l, NS) while PICP (121+/-39 vs 102+/-29 microg/l, P<0.001) decreased. The reduction in PICP/ICTP was related to the reduction in sitting diastolic BP (r=0.31, P<0.01) and regression of IMT (r=0.37, P<0.05) in patients receiving atenolol and to reduction in heart rate in patients receiving losartan (r=0.30, P<0.01). In conclusion, collagen markers reflecting net synthesis of type I collagen were positively related to vascular hypertrophy and BP load, suggesting that collagen synthesis in the vascular wall is increased in relation to high haemodynamic load in a reversible manner.