Longitudinal outcomes of obeticholic acid therapy in ursodiol-nonresponsive primary biliary cholangitis: Stratifying the impact of add-on fibrates in real-world practice

BACKGROUND

Suboptimal response to ursodeoxycholic acid occurs in 40% of primary biliary cholangitis (PBC) patients, affecting survival. Achieving a deep response (normalisation of alkaline phosphatase [ALP] and bilirubin ≤0.6 upper limit of normal) improves survival. Yet, the long-term effectiveness of second-line treatments remains uncertain.

AIMS

To evaluate the long-term effectiveness of obeticholic acid (OCA) ± fibrates. Focusing on biochemical response (ALP ≤1.67 times the upper limit of normal, with a decrease of at least 15% from baseline and normal bilirubin levels), normalisation of ALP, deep response and biochemical remission (deep response plus aminotransferase normalisation).

METHODS

We conducted a longitudinal, observational, multicentre study involving ursodeoxyccholic acid non-responsive PBC patients (Paris-II criteria) from Spain and Portugal who received OCA ± fibrates.

RESULTS

Of 255 patients, median follow-up was 35.1 months (IQR: 20.2-53). The biochemical response in the whole cohort was 47.2%, 61.4% and 68.6% at 12, 24 and 36 months. GLOBE-PBC and 5-year UK-PBC scores improved (p < 0.001). Triple therapy (ursodeoxycholic acid plus OCA plus fibrates) had significantly higher response rates than dual therapy (p = 0.001), including ALP normalisation, deep response and biochemical remission (p < 0.001). In multivariate analysis, triple therapy remained independently associated with biochemical response (p = 0.024), alkaline phosphatase normalisation, deep response and biochemical remission (p < 0.001). Adverse effects occurred in 41.2% of cases, leading to 18.8% discontinuing OCA. Out of 55 patients with cirrhosis, 12 developed decompensation. All with baseline portal hypertension.

CONCLUSION

Triple therapy was superior in achieving therapeutic goals in UDCA-nonresponsive PBC. Decompensation was linked to pre-existing portal hypertension.

Not all uncivil behaviours are equal: exploring responses to incivility in veterinary practice using vignettes

Workplace incivility is considered a common workplace stressor, linked to a range of adverse impacts such as reduced wellbeing. However, there is a lack of research focused on how targets of incivility respond. The current study addresses that gap by examining responses to incivility within veterinary practice. Veterinarians and veterinary nurses (n = 132) evaluated six scenarios depicting two types of incivility (direct e.g. demeaning comments/indirect, for example, ignoring someone) across three instigators (clients, co-workers, senior colleagues), reporting their perception and appraisal of the uncivil behaviour depicted along with potential responses. Direct incivility was linked to responses such as reciprocation, exit, and support seeking, whereas indirect incivility was associated with affiliative and ignoring responses. Negative appraisal of incivility predicted a higher likelihood of exit, avoidance, support seeking and reporting responses. These findings suggest that incivility targets utilise a broad range of response options and adapt their response dependent on the situation.

Recommendations of the Spanish-Portuguese Internal Medicine services in the fight against climate change and environmental degradation

Facing the severity of the impact of climate change and environmental degradation on human health, 32 Internal Medicine societies, colleges, and associations of 29 Spanish and Portuguese-speaking countries issue a consensus document in which they call for the implication of doctors and all health professionals in the global fight against the causes of these changes. This commitment requires the cooperation of health-related organizations, elaboration and implementation of good environmental sustainability practices, greater awareness of professionals and population, promotion of education and research in this area, increasing climate resilience and environmental sustainability of health systems, combating inequalities and protecting the most vulnerable populations, adopting behaviors that protect the environment, and claiming Internal Medicine as a core specialty for empowerment of the health system to respond to these challenges.

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta-analysis

There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty-one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5-4.0 μg.kg-1 ) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94-1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate-certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0-4.0 μg.kg-1 ) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72-1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate-certainty of evidence). There was no evidence of an effect between remifentanil (2.0-4.0 μg.kg-1 ) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01-13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44-2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low-certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

Excited-State Phase Diagram of a Ferromagnetic Quantum Gas

The ground-state phases of a quantum many-body system are characterized by an order parameter, which changes abruptly at quantum phase transitions when an external control parameter is varied. Interestingly, these concepts may be extended to excited states, for which it is possible to define equivalent excited-state quantum phase transitions. However, the experimental mapping of a phase diagram of excited quantum states has not yet been realized. Here we present the experimental determination of the excited-state phase diagram of an atomic ferromagnetic quantum gas, where, crucially, the excitation energy is one of the control parameters. The obtained phase diagram exemplifies how the extensive Hilbert state of quantum many-body systems can be structured by the measurement of well-defined order parameters.

Balancing client preferences and population-level goals: a qualitative study of the ways in which public health providers and facility administrators interpret and incentivise quality of care in contraceptive counselling in Ethiopia, Mexico and India

Recent work in family planning has shifted from an instrumentalist perspective on quality in contraceptive counselling, which views quality as a means to encourage contraceptive uptake, to privilege quality of care as a valued end in itself. In this context of shifting narratives about quality, it is important to understand how health systems and providers navigate potential conflicts between instrumentalist definitions of quality versus a person-centred definition that considers meeting clients' contraceptive needs and preferences as an important end goal in and of itself. However, we know little about how providers and other health system stakeholders interpret the concept of quality in counselling, and how their experiences with different quality monitoring systems influence their ability to provide person-centred care. This qualitative study draws from 51 in-depth interviews with public healthcare providers and health facility administrators in Ethiopia, Mexico and India. Across all three countries, except for some cases in India, administrators were concerned with encouraging uptake of contraceptives in order to meet local and national level goals on contraceptive uptake and maternal health. In contrast, providers were more concerned with responding to client desires and needs. However, participants across all levels shared the opinion that successful counselling should end with contraceptive uptake. We conclude that the instrumentalist view of quality counselling continues to prevail across all three countries. Our findings suggest that encouraging healthcare providers and administrators to meet even relatively broad targets set by government reinforces an instrumentalist approach, as opposed to an approach that privileges person-centred care.

Effects of forest residue mulching on organic matter and nutrient exports after wildfire in North-Central Portugal

The quick implementation of emergency stabilization measures is vital for minimizing post-fire soil erosion and the associated fertility loss. Mulching has proven to be highly effective in minimizing post-fire soil erosion, however few studies have investigated its impacts on organic matter (OM) and nutrient mobilization from burned forest areas. This study evaluates the effectiveness of forest residue mulching at reducing OM, N and P losses within the sediments after a moderate-severity wildfire over a period of 5 years (Ermida, North-central Portugal). Untreated and mulched plots of ca. 100 m² were bounded with geotextile fabric and sediments were collected from silt fences after a total of 29 periods. During the first five years after the fire, the accumulated OM, N and P exportations in the untreated plots were, respectively, 199, 5.2 and 0.38 g m^-2; and mulch significantly reduced these figures in, respectively, 91 %, 94 % and 95 % (p < 0.05). The overall OM content in the sediments of the untreated plots (45 %) was not different from the OM content of the mulched plots (34 %, p = 0.16). However, the N (8.9 g kg^-1) and P_av contents (0.62 g kg^-1) in the untreated plots were significantly higher than the N (5.6 g kg^-1; p < 0.05) and P_av contents (0.36 g kg^-1; p < 0.05) in the mulched plots. This effect was especially noticeable in the first year after fire. OM and TN contents in the sediments were highly variable throughout the study period, whereas P_av contents declined sharply in the first post-fire rainfall events, maintaining low values afterwards. The main factors driving nutrient exports were ash and litter cover, whereas no significant relationship was observed for OM exports. The present work has shown that forest residues application can be a sustainable strategy for the conservation of soil carbon and nutrients in fire-affected areas.

Flow-status and survival in severe aortic stenosis treated with TAVI – is flow rate superior to stroke volume index?

Background

Low-flow status, currently defined as a stroke volume index (SVi) &lt;35 mL/m2, is an important prognostic predictor for mortality after Transcatheter Aortic Valve Implantation (TAVI) for severe aortic stenosis (SAS). However, transaortic flow rate (FR) – defined as stroke volume divided by left ventricle ejection time - has recently been suggested to be superior to SVi in defining low-flow states, as it reflects more closely valvular resistance, while being independent of body surface area. Low FR is most consistently defined as FR&lt;200 mL/s.

Purpose

Determine the prognostic impact of FR and SVi before TAVI in survival after intervention for SAS.

Methods

A single-centre retrospective database of all TAVI performed between 2011 and 2019 was analyzed, and cases with pre-intervention echocardiograms available were included. Low-flow patients were identified according to basal FR (&lt;200 mL/s) or SVi (&lt;35 mL/m2), and compared with normal-flow cases. The primary endpoint was defined as time to all-cause death or last follow-up. The impact of flow-status (using FR or SVi) in survival was assessed using Kaplan-Meier curves and log-rank test, as well as Cox proportional hazard model adjusted for EuroSCORE II, using FR or SVi either as categorical or continuous variables. A subanalysis further compared patients with preserved and reduced ejection fraction (EF, &lt;52%). p&lt;0.05 was considered statistically significant.

Results

From 657 TAVI performed, 490 (74.6%) cases were included, with a median follow-up of 43 months. From those, 59.6% were defined as low-flow according to FR, and 43.3% using SVi. Low-flow patients, using each parameter, were of higher surgical risk (EuroSCORE II and STS scores), had more advanced NYHA classes, worse estimated creatinine clearance, and suffered more frequently from coronary artery disease. Low-FR patients were also older, and more predominantly female. Atrial fibrillation was more prevalent among low SVi cases. Functional aortic valve area was lower in low-flow patients using both assessments, but low-SVi was also associated with lower transaortic gradients, as well as lower EF before and after TAVI. Regarding all-cause mortality, low-SVi was associated with worse survival [p=0.02, hazard ratio (HR) 1.43 (1.05–1.94)], but not low-FR (p=0.4). However, low-SVi, when adjusted for EuroScore II, was no longer a predictor of all-cause mortality (p=0.08). When considering FR and SVi as continuous variables, a higher SVi (but not FR) was associated with better survival (HR 0.98, p=0.047) in multivariable analysis adjusted for EuroSCORE II. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality.

Conclusions

Low-flow states are common in SAS population treated with TAVI, being frequently associated with worse symptoms and higher procedural risk. Low-SVi, but not low-FR, negatively impacts survival after intervention, representing a marker for prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Aortic valve calcium score: does it correlate with mean transaortic gradient?

Introduction

Aortic valvular calcium score (AVCS) is useful in patients with aortic stenosis for whom echocardiography was not conclusive in grading its severity. Transcatheter aortic valve implantation (TAVI) is an established procedure of treatment in symptomatic severe AS. The burden of aortic valve calcification has been associated with some TAVI related complications (as perivalvular leaks), but at the same time it is well accepted that some degree of calcification is needed to ensure stable anchoring of the prosthesis to the aortic annulus.

Purpose

To assess if there is a correlation between aortic valve calcium score and mean transvalvular gradient 6 months after TAVI – is a higher AVCS correlated with lower mean transaortic gradient after TAVI?

Methods

We performed a single-center, retrospective cohort study including patients who underwent TAVI with a preoperative standardized contrast enhanced MSCT with AVCS available. Clinical and echocardiographic data were collected previously to TAVI (pre-TAVI) and at 6 months follow up (6M-FUP).

Results

A total of 187 patients were included, with 54% female and a mean age of 79.4±9.0 years old. Most patients had tricuspid aortic valve (95.7%); 5 patients had aortic bicuspidy and 3 had aortic valve bioprothesis. Concerning the valve type, 73.3% had new generation prosthesis and the main valve used was the CoreValve Evolut Pro (33.7%). Also, 38,5% needed balloon pre-dilation before TAVI. The mean pre-TAVI aortic transvalvular maximum and mean gradients were 76.5±23.2 mmHg and 48.3±15.5 mmHg, respectively; mean aortic valve area was 0.75±0.16 cm2. The mean AVCS was 2851±1524 AU (Agaston Units); 81.2% of women had AVCS&gt;1300 AU and 74.4% men had AVCS &gt;2000 AU. Comparing transvalvular aortic gradients previously and 6M-FUP after TAVI, there was an average differential of maximum gradient of 61±22 mmHg and of mean gradient of 40±15 mmHg. A negative and weak correlation was found between the AVCS and the maximum gradient (pearson coefficient of −0.181, p=0.02) and between mean gradient at 6M-FUP (pearson coefficient of −0.191, p=0.014).

Discussion and conclusion

AVCS is a significant predictor for death, stroke and perivalvular leaks after TAVI. On the other hand, high AVCS is associated with better seating in the native annulus during deployment. Nevertheless, high AVCS did not strongly correlated with mean transaortic gradient 6 months after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p&lt;0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p&lt;0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous valve commissurotomy in mitral stenosis patients: a 20 years follow-up

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve surgery in the treatment of patients with clinically significant mitral stenosis (MS). Although rheumatic MS incidence has decreased in developed countries, it remains a prevalent healthcare problem in Cardiology clinics

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with and without pulmonary hypertension (PH).

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, mitral valve re-intervention or hospitalization for a cardiovascular cause.

Results

A total of 124 patients were enrolled: 87% were female, with a mean age at the time of repair of 46±11 year-old and a mean follow-up of 20±6 years. Before the procedure, 34% were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%), with a mean MVA improvement of 0.9 cm2 and reduction of 8.5 mmHg in TVG and 9.7 mmHg in pulmonary artery systolic pressure (PASP) after PMC.

During long-term follow-up, 42% of patients were submitted to re-intervention (most of them surgically) and 24% died. In patients non-submitted to re-intervention, TVG and PASP remained similar with early post-procedure evaluation (p=0.109 and p=0.777, respectively), while MVA reduced over time, yet still statistically superior to baseline MVA (1.6 cm2 vs 1.0 cm2, p&lt;0.001). Concerning time-to-event analysis, approximately 80% of patients kept uneventful after 10 years; after 30 years, more than 20% continued MACE-free and approximately 50% were alive. Regarding PH presence at time of PMC, there was no significant difference in MACE events and all-cause mortality between the two groups (Log Rank, p=0,846 and p=0.661, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. After a long-term follow-up patients maintained the reduction in TVG and PASP and a smaller but significative improvement in MVA. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning PH presence.

Funding Acknowledgement

Type of funding sources: None.

Reduced 3D-left atrium ejection fraction predicts development of atrial fibrillation in patients with hypertrophic cardiomyopathy

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM), occurring in approximately 25% of patients, related to left atrial (LA) dilatation and remodeling. HCM patients who develop AF have increased risk of HCM-related death, functional impairment, and stroke. Accurate risk stratification for AF in this population is crucial as contemporary treatments are highly successful.

Purpose

To assess if new echocardiographic parameters can predict the development of AF in HCM patients.

Methods

HCM patients who underwent comprehensive echocardiographic examination during 2011 were followed and checked for “de novo” AF until November 2021. We searched for associations between AF development and novel echocardiographic parameters such as LA Volume index, Left Atrioventricular Coupling Index (LACI, as LAVI/a'), 3D LA volumes and 3D LA ejection fraction (3D-LAEF).

Results

A total of 43 patients were included, with 62.8% male and mean age 56,1±6,2 years old. 55.8% had the septal asymmetric HCM type and mean LV mass was 326±127g. Mean LA diameter and biplane 2D volume was 46±7 mm and 78±37 mL, respectively. 11.6% of patients already had AF. During a median follow-up of 9.4 years, the incidence of “de novo” AF was 31,6%. Within the total 17 patients with AF, 35,2% took warfarin and the remaining direct oral anti-coagulation. No stroke was documented. There were 3 deaths (mortality rate of 7,0%), none from cardiac causes.

No association was found between AF development and LAVI, LACI or 3D LA volumes. We only found a statistically significant difference regarding 3D-LAEF, which was lower in patients who developed AF compared with those without AF (26±12% VS 39±19%, p=0.04).

Binary logistic regression analysis found that reduced 3D-LAEF predicts the development of AF (p=0.019, odds ratio [OR] 2.6, 95% confidence interval [CI] 1.0 to 1.1). The area under a receiver operating characteristic curve using 3D-LAEF as a predictive marker for AF development in HCM patients was 0.743 (p=0.004). When the cut-off value of 3D-LAEF was set at 34,5%, the sensitivity and specificity for AF diagnosis were 66% and 86%, respectively.

Conclusion

In our study, 3D LAEF predicted the development of AF in HCM patients – this may be a useful tool to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Long-term success in percutaneous valve commissurotomy – is Wilkins score over 9 a definitive limit?

Background

Percutaneous valve commissurotomy (PMC) is an established treatment in patients with significative mitral stenosis (MS). Although rheumatic MS incidence has decreased in the last century, it remains a prevalent pathology worldwide. The Wilkins score (WS) is a reference in echocardiographic assessment of MS; a score ≤8 is considered a predictor of treatment success and score between 9 and 11 is a “grey zone” (WGZ) in which doubts persists regarding PMC success.

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with WS ≤8 and patients in WGZ.

Methods

We retrospectively analysed all patients between 1991 and 2008 with significative rheumatic MS undergoing PMC. Data were collected at baseline and during long-term follow-up. M ACE was defined as a composite of all-cause mortality, mitral valve re-intervention or cardiovascular hospitalization.

Results

In our cohort, 124 patients were included. Most were female (87%), mean age at the time of repair was 46±11 year-old and mean follow-up was 20±6 years. Before the procedure, 81% had WS ≤8 and 19% were in WGZ. Both groups had similar baseline characteristics, namely age at first intervention, NYHA class and follow-up time. All patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%). Mean MVA improvement was similar in both groups [0.9 cm2 in WS ≤8 and 0.8 cm2 in WGZ, t(102)=0.173, p=0.863]; there was also no significative difference in TVG and PASP reduction after PMC. During long-term follow-up, re-intervention and mortality occurred in 40% and 23% in WS ≤8 and in 50% and 29% in WGZ, respectively, and none of these differences was statistically significant (p=0.389 and p=0.544, respectively). Concerning time-to-event analysis, approximately 80% of patients kept uneventful and &gt;90% alive after 10 years in both groups and no significant difference in M ACE events and all-cause mortality between WS ≤8 and WGZ was observed (Log Rank, p=0,419 and p=0.950, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS in both WS ≤8 and WS 9–11, with similar MVA improvement. After 10 years, approximately 80% of patients were MACE-free and &gt;90% alive in both groups. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning WS groups.

Funding Acknowledgement

Type of funding sources: None.

Patient delay in acute myocardial infarction: a long journey still ahead

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs &lt;7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.

20 year-follow up of mitral stenosis patients after percutaneous valve commissurotomy: moderate disease of other valves as predictor for re-intervention

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve (MV) surgery in the treatment of patients with clinically significant mitral stenosis (MS). About 40% of patients treated with PMC will require at least one reintervention (either PMC or MVS) along time.

Purpose

To evaluate the long-term results of PMC in patients with rheumatic MS.

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during early and long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, MV re-intervention or cardiovascular hospitalization.

Results

A total of 124 patients were enrolled: 108 (87%) were female, with a mean age at the time of PMC of 46±11 years.

At baseline, 34% patients were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function and 83% presented pulmonary hypertension. Regarding associated valve disease, 46 patients had mild tricuspid regurgitation (TR), 19 mild aortic regurgitation (AR), 14 moderate IT and 5 moderated AR.

Most of the procedures were successful (91%) and without complications (94%), with median improvement in MV area of 0.9 cm2 (IQR 0.5) and median reductions in mean transmitral gradient (MTG) of 6 mmHg (IQR 6) and in pulmonary artery systolic pressure (PASP) of 8 mmHg (IQR 10) early after PMC.

During the mean follow-up of 20±6 years, 52 (42%) of patients had MV re-intervention (86% surgery and 14% re-PMC), 37 (30%) were hospitalized and 30 (24%) died. Concerning time-to-event analysis, approximately 80% of patients kept MACE-free after 10 years; after 30 years, more than 20% continued MACE-uneventful, approximately 50% were alive and about 45% were free from re-intervention.

Considering patients submitted to surgical re-intervention, 9 underwent MV valvuloplasty and the others MV replacement with mechanical (32) or biological prothesis (11). At the same procedure, 23 patients were submitted to tricuspid annuloplasty, 9 to other valve replacement and one to coronary artery bypass graft.

Using Cox regression, we found that the presence of moderate disease of other valves at PMC time was associated with a 2.3-fold greater rate of re-intervention compared to patients with none or mid disease of other valves (HRcrude 2.3; 95% IC 1.221–4.331, p=0.017). After adjusting for the success of the PMC and for mitral regurgitation after PMC, the observed effect remained significant (HRadjusted = 2.7; 95% CI 1.417–5.233, p=0.003).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. Still, about 40% required re-intervention, with moderate disease of other valves as its independent predictor.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

AB0173 MORPHOLOGICAL PARAMETERS ASSESSED BY ULTRASOUND IN QUADRICEPS MUSCLE WERE ASSOCIATED WITH CLINICAL FEATURES, MUSCLE STRENGTH, FUNCTIONAL CAPACITY AND PHYSICAL FUNCTION OF RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) patients usually present extra-articular manifestations (1,2), which affect muscle mass and, consequently, physical function (3). Among the various methods to assess muscle mass we tested muscle morphology by ultrasound (MU) to verify the associations of the quadriceps muscle with clinical features, muscle strength, functional capacity and physical function.

Objectives

To assess the MU of the quadriceps muscle and verify the muscle quality assessed by the pennation angle and its associations with clinical features, muscle strength, functional capacity and physical function in RA patients.

Methods

RA women, age ≥18years and who met 2010 American College of Rheumatology (ACR) criteria were included. Morphological parameters in quadriceps muscle consisted of the pennation angle of rectus femoris (RF), vastus intermedius (VI) and vastus lateralis (VL). RA activity was measured by 28-joint disease activity score (DAS28), muscle strength by handgrip and chair stand tests, functional capacity by health assessment questionnaire (HAQ), and physical function by timed-up-and-go (TUG) test and short physical performance battery (SPPB). Pearson’s or Spearman’s correlation coefficients were explored. The significance level was set at p ≤ 0.05 for all analyzes.

Results

Eighty-one patients were included (age: 58.64±9.52 years old; DAS28: 3.24±1.34). Smaller pennation angle in rectus femoris (RF) were associated with lower handgrip strength (r= 0.224, p=0.044), chair stand test (r= -0.372, p=0.004), HAQ (r= -0.404, p=0.001), SPPB (r= 0.262, p=0.047), as well as higher disease activity by DAS-28 (r= -0.415, p<0.0001) and age (r= -0.290, p=0.009). Smaller pennation angle in vastus intermedius (VI) were associated with worse chair stand (r= -0.281, p=0.033), HAQ (r= -0.302, p=0.015) and higher disease activity by DAS-28 (r= -0.304, p=0.006). Lastly, smaller pennation angle in vastus lateralis (VL) were associated with worse chair stand (r= -0.290, p=0.027), as well as higher DAS-28 (r= -0.237, p=0.033) and age (r= -0.272, p=0.014).

Conclusion

The pennation angles of the quadriceps muscle evaluated by ultrasound (RF, VI and VL muscles) were associated with chair stand test and DAS-28. In addition, the level of disease activity assessed by DAS-28 also appears to be affecting the quadriceps muscle. Finally, MU may be a useful method to evaluate the impact of the disease on skeletal muscle.

References

[1]Summers GD, Deighton CM, Rennie MJ, Booth AH. Rheumatoid cachexia : a clinical perspective. 2008;(April):1124–31.

[2]da Rocha OM, Batista A de AP, Maestá N, Burini RC, Laurindo IMM, Kayser C. Sarcopenia in rheumatoid cachexia: Definition, mechanisms, clinical consequences and potential therapies. Rev Bras Reum. 2009;49, 294–30.

[3]de Santana FS, da Cunha Nascimento D, de Freitas JPM, Miranda RF, Muniz LF, Neto LS, et al. Assessment of functional capacity in patients with rheumatoid arthritis: Implications for recommending exercise. Rev Bras Reumatol. 2014;54(5):378–85.

Table 1.

Associations between the quadriceps muscle morphology by ultrasound (pennation angle) with clinical features, muscle strength, functional capacity and physical function in rheumatoid arthritis patients.

VariablesnComponents of the quadriceps muscleRp-valueAge (y)81RF-0.2900.009VINSNSVL-0.2720.014Disease duration (y)81RFNSNSVINSNSVLNSNSDas-28 (CRP)81RF-0.415<0.0001VI-0.3040.006VL-0.2370.033Handgrip strength test (kg)81RF0.2240.044VINSNSVLNSNSChair stand test (s)58RF-0.3720.004VI-0.2810.033VL-0.2900.027HAQ (score)65RF-0.4040.001VI-0.3020.015VLNSNSTUG test (s)68RFNSNSVINSNSVLNSNSSPPB (score)58RF0.2620.047VINSNSVLNSNS

RF: rectus femoris; VI: vastus intermedius; VL: vastus lateralis; n: number; y: years; s: seconds; kg: kilogram; DAS28: Disease Activity Score 28; CRP: C-reactive protein; TUG: Timed-up-and-go; SPPB: Short Physical Performance Battery; NS: Not significant.

Acknowledgements

We thank the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—CAPES) institution, the Foundation for Research Support of the Rio Grande do Sul State (Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul-FAPERGS), the Research and Events Incentive Fund (Fundo de Incentivo à Pesquisa e Eventos-FIPE) of HCPA and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq).

Disclosure of Interests

None declared

AB0681 The 2-year impact of COVID-19 pandemic on muscle strength and physical performance in patients with systemic sclerosis: a cohort study

Background

Systemic sclerosis (SSc) patients are particularly prone to developing loss of muscle strength and worsening of physical performance due to decreased physical activity1. The lifestyle changes imposed by the SARS-CoV-2 outbreak have increased the incidence of sarcopenia in at-risk individuals2. However, the literature is scarce on the impacts of the COVID-19 pandemic on muscle strength and physical performance of SSc patients.

Objectives

(1) To assess the impact of the COVID-19 pandemic on muscle strength and physical performance of SSc patients and (2) to verify the associations of muscle strength and physical performance with inflammatory markers in a cohort study.

Methods

SSc patients who met the ACR / EULAR 2013 classification criteria were included. Patients followed between 2019 and 2021. Muscle strength was measured by handgrip strength (kg) and sit and stand (SST, seconds) tests. Physical performance was measured by timed up and go (TUG, seconds) and short physical performance battery (SPPB, points). Inflammatory markers were measured by C-reactive protein (CRP). T test for independent samples, Mann-Whitney U test of independent samples and Spearman’s correlation coefficients were explored. The significance level was set at p ≤ 0.05 for all analyses.

Results

Forty SSc patients concluded this study. At baseline, the mean age was 59 ±11.1 years old and the median disease duration was 13.1 (6.4-19.2) years. Patients had a median of 4.5 clinic visits (3.0-6.0) over the 2 years. The majority of patients were women (37, 92.5%). Ten patients (25%) had diffuse cutaneous disease, 30 patients (75%) non-diffuse cutaneous disease [25 patients (62.5%) had limited cutaneous disease, and 5 (12.5%) had sine scleroderma SSc]. The median of CRP was 2.9 (1.2-5.3). The median of handgrip strength was 20.0 (10.3-25.8) kg to the right hand and 19.0 (12.0-22.8) kg to the left hand. The median of SST was 14.4 (11.9-18.7) seconds. The median of TUG was 8.6 (7.7-9.5) seconds and the median of SPPB was 9.8 (9.0-11.0) points. The CRP was positively associated with SST (r=0.3, p=0.047) and TUG (r=0.3, p=0.029), and negatively with SPPB (r=-0.4, p=0.016). After 2 years of follow-up, the patients showed improvement in the left handgrip strength test (p=0.049) and SST (p=0.001). In physical performance, they showed improvement in the TUG test (p=0.005) and SPPB (p=0.001). The CRP was associated positively with TUG (r=0.4, p=0.033), no other associations were found.

Conclusion

Despite the COVID-19 pandemic and the restrictions imposed, in this population of patients with SSc, we did not detect any worsening in muscle strength and physical performance. Some of these parameters of muscle strength and physical performance were associated with the inflammatory marker CRP. More investigations are needed to assess the actual impact and possible associations.

Table 1.

Baseline comparison and after 2 years of patients with SSc

BaselineAfter 2 yearspCRP (mg/L),median (IQR)2.9 (1.2-5.3)2.3 (1.0-5.1)0.361Handgrip (kg),right, median (IQR)20.0 (10.3-25.8)20.5 (14.3-27.0)0.072left, median (IQR)19.0 (12.0-22.8)19.0 (14.0-26.0)0.049*SST (seconds),median (IQR)14.4 (11.9-18.7)11.6 (9.9-13.1)0.001*TUG (seconds),median (IQR)8.6 (7.7-9.5)7.9 (7.1-9.2)0.005*SPPB (points),median (IQR)9.8 (9.0-11.0)11.0 (10.0-12.0)0.001*

SSc: systemic sclerosis; IQR: interquartile range; mg: milligram; L: liter; kg: kilograms grams; TUG: timed and up go; SST: sit and stand test; SPPB: short physical performance battery; PCR: C-reactive protein; and * significant difference of ≤0.05.

References

[1]Zaghlol, Rabab S et al. “Functional Disability Among Systemic Sclerosis Patients: Relation to Disease Characteristics and Quality of Life Parameters.” Current rheumatology reviews, 2021.

[2]Bakaloudi, Dimitra Rafailia et al. “Impact of the first COVID-19 lockdown on body weight: A combined systematic review and a meta-analysis.” Clinical nutrition (Edinburgh, Scotland), 2021.

Disclosure of Interests

None declared

POS0845 ASSESSING FRAILTY IN SYSTEMIC SCLEROSIS: A CROSS-SECTIONAL STUDY COMPARING FRAIL AND EDMONTON FRAILTY SCALES WITH PHYSICAL FRAILTY PHENOTYPE

Background

Systemic sclerosis (SSc) is a chronic disease characterized by autoimmunity, vasculopathy and fibrosis. During the disease course, patients with SSc are prone to accumulate multiple organ damage, increasing their vulnerability to adverse outcomes in comparison with individuals of the same age: a phenomenon called frailty. One of the most used definitions of frailty is the physical frailty phenotype (PFP) by Fried, et al. The PFP consists of 5 components: unintentional weight loss, exhaustion, muscle weakness, slow walking speed, and low physical activity. There is scarce data about frailty in patients with SSc.

Objectives

To study the prevalence and clinical aspects of PFP in a sample of patients with SSc. Also, we aim to investigate the diagnostic accuracy of the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) scale and the Edmonton frailty scale (EFS) using the PFP as the reference standard.

Methods

Cross-sectional study, including patients with SSc according to the 2013 ACR-EULAR classification criteria or the criteria suggested by Le Roy and Medsger for early disease. PFP assessment was according to the original definition, except for physical activity domain, assessed with the International Physical Activity Questionnaire (IPAQ). Patients were classified according to Fried’s criteria in robust (0), pre-frail (1-2), and frail (≥3). FRAIL scale and EFS were also applied to the same individuals. The FRAIL score ranges from 0 to 5 and patients were classified as robust (0), pre-frail (1-2), or frail (≥3). The EFS score ranges from 0–17 and categorizes patients as not frail (0–4), vulnerable (5–6), mild frailty (7–8), moderate frailty (9–10), and severe frailty (≥11). For the diagnostic assessment of FRAIL scale and EFS, we estimated the area under the receiver operating characteristic curve (AUC), considering PFP as the reference standard and dichotomizing the results in frail vs. non-frail.

Results

Between March and December 2019, 82 SSc patients were consecutively included. The mean age and disease duration were 60.4 (±10.6) and 13.4 (±8.2) years, respectively; 91.5% were women, and 19.5% with diffuse cutaneous SSc. The PFP distribution was: 8 (9.8%) robust, 47 (57.3%) pre-frail and 27 (32.9%) frail patients. The PFP domains´ frequencies were: low physical activity in 57 (69.5%), muscle weakness in 41 (50%), exhaustion in 34 (41.5%), unintentional weight loss in 15 (18.3%) and slow walking speed in 8 (9.8%) patients. Using the FRAIL scale, 44 (53.7%) patients were considered pre-frail and 25 (30.5%) frail. According to the EFS, 26 patients (31.7%) were classified as vulnerable and 12 (14.6%) as frail: mild in 6 (7.3%), moderate in 4 (4.9%) and severe in 2 (2.4%). The AUC against PFP was: 0.871 (95% CI 0.789-0.954, p<0.001) for FRAIL scale and 0.870 (95% CI 0.791-0.948, p<0.001) for EFS (Figure 1).

Conclusion

Frailty is prevalent in patients with long-standing SSc, and most of them are considered pre-frail or vulnerable. Low physical activity, muscle weakness and exhaustion are among the most frequent clinical aspects of the frailty phenotype. Both FRAIL scale and EFS showed overlapping diagnostic accuracy against PFP as the reference standard, and FRAIL scale seems to be more feasible than EFS.

References

[1]Rockwood MR, MacDonald E, Sutton E, Rockwood K, Baron M. Frailty index to measure health status in people with systemic sclerosis. J Rheumatol. 2014;41(4):698-705.

[2]Morley JE, Vellas B, Abellan van Kan G, et al. Frailty consensus: a call to action. J Am Med Dir Association. 2014;14(6):392-7.

[3]Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

[4]van Kan GA, Rolland YM, Morley JE, Vellas B. Frailty: Toward a Clinical Definition. J Am Med Dir Assoc. 2008;9(2):71-2.

[5]Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9.

Disclosure of Interests

None declared

Impact of the use of cusp overlap projection technique in the incidence of post-TAVR permanent pacemaker implantation with self-expanding valves

Funding Acknowledgements

Type of funding sources: None.

Introduction

Current rates of new Permanent Pacemaker (PPM) Implantations in the context of Transcatheter Aortic Valve Replacement (TAVR) range from 2-36% and that necessity is related to worse prognosis. The use of self-expanding valves and a lower valve implantation depth are two factors associated with an increased risk of conduction disturbances post-TAVR. Theoretically, cusp overlap implantation technique has the potential to enable a higher valve deployment by eliminating parallax of the delivery catheter.

Aim

To compare the in-hospital incidence of PPM post-TARV using self-expandable valve according to the fluoroscopic guidance technique.

Methods

Retrospective, single-centre study, with evaluation of patients consecutively submitted to TAVR with self-expanding CoreValveTM between July 2020 and December 2021 dichotomized according to the use of cusp overlap implantation technique for fluoroscopic valve implantation guidance.

Results

138 patients were included, predominantly women (57.2%), with a mean age of 78.4±8.0 years old, with severe aortic stenosis of the native valve being the most common indication for TAVI (85.5%). Cusp overlap view technique was applied in 50.7% of the patients (n=70). Frailty and co-morbidities were the most common cause for surgical refusal (54.3%). There was a significantly higher percentage of hypertensive patients (92.9% vs. 77.9%), lower previous aortic valve surgery (2.9% vs. 16.2%) and lower percentage of patients previously medicated with b-blockers in the group of patients in whom was used the cusp overlap technique; there were no other relevant differences related to the baseline characteristics. First degree atrioventricular block was present in 19.6% and complete right bundle block in 13.6% of the patients. Incidence of in-hospital post-TAVR PPM implantation wasn’t significantly different between the two cohorts of patients (cusp overlap vs. standard approach: 24.3% vs. 26.5%, p=0.77) (71.4% implanted in the context of complete heart block). Likewise, there were similar proportions of in-hospital new-onset of complete left bundle branch block (35.8% vs. 37.3%, p=0.86), volume of contrast used (140.6±37.5 mL vs. 145.2±51.5 mL, p=0.12), fluoroscopy time (15.6±8.8 min vs. 19.6±8.9 min, p=0.40) and radiation dose (556.3±320.6 mGy vs. 859.4±531.2 mGy, p=0.06).

Conclusions

This study shows that using the cusp overlap view for self-expanding valve implantation does not seem to achieve a significant reduction in in-hospital PPM implantation rate in comparison with the traditional 3 cusp co-planar fluoroscopic view. A larger and probably randomized clinical trial is needed to confirm these results.

Supraventricular arrhythmias in MINOCA patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

De novo atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS). However, 5-15% of patients (pts) admitted with suspected acute myocardial infarction have no significant lesions on coronary angiography (&gt;50%) (MINOCA). Contrary to initial beliefs, MINOCA is not a benign disease, given that mortality and incidence of adverse events is similar to ACS.

Objective

To evaluate predictors and prognosis of AF in the setting of MINOCA.

Methods

Based on a multicenter retrospective study, data collected from admissions between 2013 and 2020. Pts without data on cardiovascular history or uncompleted clinical data were excluded. We included 7590 pts with non-ST elevation myocardial infarction (NSTEMI). Between those, 1561 (19.2%) were MINOCA. We divided MINOCA pts in 2 groups (G): GA – MINOCA with de novo AF; GB – MINOCA without de novo AF during in-hospital stay.

Results

MINOCA pts’ mean age was 65±13, 62% were male and 2.1% had de novo AF. GA pts were older (76±10 vs 65±13, p&lt;0.001), had higher rates of Killip-Kimball class (KKC) &gt;I (27.8% vs 9.7%, p=0.027) and kidney function impairment (50% vs 10.2%, p&lt;0.001), lower haemoglobin at admission (13±1.5 vs 13.7±1.8, p=0.038), higher rates of diuretics (56.3% vs 17.6%, p&lt;0.001) and amiodarone usage during hospitalization (31.3% vs 3.6%, p&lt;0.001) and higher rates of left ventricle ejection fraction (LVEF)&lt;50% (47.1% vs 19.1%, p=0.009). The Gs were similar regarding gender, times from symptoms to admission, cardiovascular risk factors and past history of heart failure, stroke or ACS, and heart rate and systolic arterial tension at admission. In the global population, older age (p=0.001, OR 1.87, CI 1.23-2.72), KKC&gt;I (p=0.004, OR 1.76, CI 1.19-2.61) and LVEF&lt;50% (p&lt;0.001, OR 2.25, CI 1.5-3.38) were predictors of AF during hospitalization. In MINOCA pts, only older age (p=0.014, OR 4.2, CI 1.34-13.2) and LVEF&lt;50% (p&lt;0.001, OR 7.44, CI 2.17-25.47) were predictors of de novo AF. Regarding 1 year-prognosis, the occurrence of AF in MINOCA pts was associated with worse outcomes, namely 1year-mortality (log rank=0.002) and 1-year all cause readmission (log rank 0.028)

Conclusion

As expected, AF in the setting of MINOCA is associated with poorer prognosis. Pts with older age and LV dysfunction are at higher risk of de novo AF in this population.

Two-Dimensional Supersolid Formation in Dipolar Condensates

Dipolar condensates have recently been coaxed to form the long-sought supersolid phase. While one-dimensional supersolids may be prepared by triggering a roton instability, we find that such a procedure in two dimensions (2D) leads to a loss of both global phase coherence and crystalline order. Unlike in 1D, the 2D roton modes have little in common with the supersolid configuration. We develop a finite-temperature stochastic Gross-Pitaevskii theory that includes beyond-mean-field effects to explore the formation process in 2D and find that evaporative cooling directly into the supersolid phase-hence bypassing the first-order roton instability-can produce a robust supersolid in a circular trap. Importantly, the resulting supersolid is stable at the final nonzero temperature. We then experimentally produce a 2D supersolid in a near-circular trap through such an evaporative procedure. Our work provides insight into the process of supersolid formation in 2D and defines a realistic path to the formation of large two-dimensional supersolid arrays.

Transcatheter aortic valve implantation (balloon-expandable versus self-expandable valves) - what echocardiographic parameters should we evaluted?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) is currently the recommended treatment for aortic stenosis (AS) in high or intermediate-risk or inoperable patients. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the two major types of transcatheter heart valves (TTHV). Despite major diferences, both designs are recomended, however, there are only limited data available for the comparison of newer generation BEV and SEV.

Purpose

Compare echocardiographic and clinical parameters, during 1 year of follow-up of a balloon-expandable (BS) versus self-expanding (SE) transcatheter aortic valve implantantation, with emphasis on the composite endpoits proposed by uptade Valve Academic Researc Consortium (VARC-2).

Methods

Retrospective, comparative study in patients with symptomatic severe AS with a high operative risk, who implanted BEV or SEV between January 2016 and December 2019. All patients underwent echocardiographic study before an after the procedure (on the day , 6 months and 1 year of follow up), clinical data were collected. The following ecocardiographic parameters were evaluated: transvalvular and prosthetic aortic gradientes and paravalvular leak (PVL).

Results

We studied 106 patients (81 ± 8 years, 60% female) with severe AS (mean gradient of 49 ± 12 mmHg), who were threated with BE or SE transcatheter aortic valve. Comparative analysis between BEV vs SEV, showed: there were no statistically significant in mean transprosthetic gradients (9.5 ± 4.8 vs 10 ±6.2; p = 0.49). There were no statistically significant differences between BE and SE valves in the cumulative incidence of death from any cause (21% vs. 28%; p = 0.49), death from cardiovascular causes (3.3% vs. 0%; p= 0.26), all strokes (1.6% vs. 1.6%; p = 0.85), pacemaker implatation (18% vs. 15% p = 0.79); major bleeding (3.3% vs 6.5%; p = 0.18) and renal injury (1.6% vs. 2.1%: p = 0.67). There were statistically significant differences between BE and SE valves in the cumulative incidence of moderate or severe PVL (5% vs. 23.9%; p = 0.009) and repeat hospitalization (11.6% vs. 28%;p = 0.04). Device sucess was achieved in 97 % for BEV vs 91% for SEV (p = 0,39). The early safety at 30 days was observed in 5% for BVE vs. 4.3% for SVE (p = 0.87). The clinical efficacy after 30 days was achieved in 1,6% for BVE vs. 4.3% for SVE (p = 0.03), with higher incidence of moderate or severe PVL. The composite endpoint valve safety occured in 3,3 % for BVE vs 26% for SVE (p &lt; 0,001), with moderate or severe PVL in 23%.

Conclusion(s): In patients with symptomatic severe aortic stenosis who implanted BEV or SEV transcatheter aortic valve there was a significant improvement in the hemodynamic status. The present study suggests that use of SEV was associated with a higher risk of PVL and repeat hospitalization, with a endpoint clinical efficacy after 30 days (4,3%) and time-related valve safety (26%).

Regression of left ventricular mass after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Regression of left ventricular mass (LVM) after transcatheter aortic valve implantation (TAVI) is an important parameter of left ventricular reverse remodeling and is associated with less hospitalizations 1year after TAVI. The association between LVM índex (LVMi) at 6 months and outcome 1 year after TAVI is unclear.

Purpose

Evaluate and compare LVMi, before TAVI and 6 months after, and determine the association between LVMi regression and clinical outcomes at 1-year follow-up.

Methods

Retrospective, comparative study in patients with symptomatic severe aortic stenosis with a high operative risk, after TAVI. All patients underwent echocardiographic study before TAVI and 6 months of follow-up, the LVMi (by the Devereux formula) was evaluated. Associations between LVMi regression (percent change between baseline and 6 months after TAVI), rehospitalization rate and death at 1 year of follow-up were examined.

Results

We studied 50 patients, 82% with moderade or severe LVMi before TAVI. Comparative analysis between ecocardiography study before and 6 months after TAVI, showed there was statistically significant decrease in LVMi (150,7 ± 38 g/m2 vs 132 ± 36 g/m2; p = 0.03). LVMi moderate or severe (between 130 and 154 g/m2) at 6 months was associated with biggest hospitalization rate (p = 0,03).Comparative analysis between regression of LVMi (before and 6 months after TAVI) and death, showed: decrease of 5% and 10% in LVMi was independently associated with death at 1 year (p = 0,77 vs p = 0,4).

Conclusions

Patients with severe symptomatic aortic stenosis treated with TAVI who had a significant decrease of LVMi after 6 months of follow-up had lower hospitalization rates, but decrease of LVMi is independently associated with death at 1 year of follow-up.

Diagnostic and prognostic contribution of 99mTc-DPD scintigraphy in transthyretin V30M cardiac amyloidosis

Background

Early diagnosis and prognostic stratification of hereditary transthyretin amyloidosis (ATTR) are crucial. Previous findings suggested that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy presents suboptimal accuracy to detect ATTR cardiomyopathy caused by V30M mutation, particularly in patients with onset of symptoms under 50 years of age. Furthermore, its prognostic value has never been evaluated in ATTR caused by this mutation.

Purpose

To assess the diagnostic value of DPD scintigraphy to detect cardiomyopathy in a large cohort of patients with ATTR-V30M mutation and to explore its prognostic value regarding mortality.

Methods

Of the 305 ATTR-V30M mutation carriers followed prospectively and who underwent DPD scintigraphy, 288 individuals [median age 46 (39–56); 49% male] without myocardial thickening attributable to other causes were enrolled in the study. Amyloid cardiomyopathy was defined by septal thickness ≥13mm not attributable to other causes plus at least one of the following criteria: (1) late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) ratio &lt;1.60; (2) electrical heart disease (arrhythmia or cardiac conduction defect); or (3) amyloid infiltration documented in biopsy.

Results

Amyloid cardiomyopathy was identified in 41 (14.2%) patients and 44 (15.3%) individuals presented abnormal cardiac DPD uptake. Individuals with cardiac DPD retention had 27-fold higher likelihood of having amyloid cardiomyopathy (OR: 27.4; 95% CI 11.6–65.0; P&lt;0.001). However, DPD scintigraphy presented suboptimal accuracy to detect ATTR cardiomyopathy (89.9%) with limitations in sensitivity (56.1%), specificity (95.6%), positive predictive value (67.7%) and negative predictive value (92.9%).

During a mean follow-up 33.6±1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with amyloid cardiomyopathy (HR: 14.1; 95% CI 4.9–40.7; P&lt;0.001), 13 times higher in those with abnormal cardiac DPD uptake (HR: 12.59; 95% CI % 4.56–34.72; P&lt;0.001) and 10 times higher in those with H/M MIBG ratio &lt;1.60 (HR: 10.40; 95% CI 2.95–36.69; P&lt;0.001). The prognostic value of ventricular thickness and cardiac DPD uptake was additive: patients without septal thickening and no cardiac DPD retention had excellent prognosis (5-year mortality of 0.75%), while those with septal thickening and/or abnormal DPD retention presented 5-year mortality rates ranging from 39.9 to 53.3%.

Conclusions

DPD scintigraphy is valuable in the evaluation of ATTR-V30M mutation carriers, particularly for prognostic stratification purposes, identifying patients at higher risk of death.

Funding Acknowledgement

Type of funding sources: None.

Single stenting versus double stenting technique in true bifurcation coronary lesions

Introduction

The ideal treatment technique for coronary bifurcation lesions remains unknown. Although single-stenting strategy has been recommended by default, little evidence exists regarding clinical outcomes between single versus double-stenting in current practice.

Purpose

To compare procedural details and clinical outcomes between single vs double-stenting techniques in true bifurcation coronary lesions.

Methods

Retrospective study of all patients (pts) referred for percutaneous coronary intervention (PCI) of true bifurcation lesions between June 2018 and June 2020. Only Medina X,X,1 lesions were included. Pts were split in 2 groups: group 1 (single-stenting) and group 2 (double-stenting). Procedural details and clinical outcomes were assessed. Acute and long-term adverse events included procedural complications (a composite outcome of side branch occlusion, coronary iatrogenic dissection and type 4 acute myocardial infarction (AMI)) and a composite of cardiovascular death, AMI, stroke, re-restenosis and reintervention, respectively.

Results

A total of 118 pts were included, 74,6% male, mean age of 66,4±11 years.

Ninety-five pts (80,5%) were treated with single-stenting (G1) and 23 pts (19,5%) with double-stenting technique (G2). Both groups were well matched regarding baseline characteristics and clinical presentation. T and protrusion (TAP) and minicrush were the most frequent double-stenting techniques (43,5% and 21,7%).

G2 lesions mainly involved the left main (LM) and proximal left anterior descendent artery (LAD) (52,2%) and in G1 mid LAD (34,7%). LM lesions were more common in G2 (26,1% vs 8,4%; p=0,030). G1 had more lesions Medina 1,1,1 (75,8% vs 52,2%; p=0,025) and less Medina 0,1,1 (9,5% vs 30,4%; p=0,015). Proximal optimization technique and kissing balloon occurred more in G2 (p&lt;0,05). G2 had more intravascular ultrasound guided PCI (p=0,046). Femoral access, heparin, contrast and radiation dose, and fluoroscopy time were higher in G2 (p&lt;0,05). Acute adverse composite outcome was similar in both groups (G1 13% vs G2 14,3%; p=0,855).

Median follow-up was similar (G1 16,8±7,9 and G2 19,7±8,8 months; p=0,127). G1 had less occurrence of long-term adverse composite outcome (7,4% vs 26,3%; p=0,032). Excluding interventions in LM, G2 had more significant incidence of acute events (20% vs 2,6%; p=0,028), and higher rate of long-term adverse events (20% vs 4,2%; p=0,056). In interventions of the LM only, no differences were noticed in acute and long-term composite events between groups.

Conclusions

Double-stenting techniques in true coronary bifurcation lesions included more often LM lesions and were complex procedures requiring frequently intracoronary imaging. Although acute adverse events were similar to those of single-stenting, long-term adverse outcomes were more frequent in double-stent group, except for LM lesions.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of coronary angiography after TAVR

Background

The prevalence of coronary artery disease (CAD) is high among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR).

Indications for TAVR are now expanding to younger and lower risk patients. During their lifetime, these patients will be at risk of developing CAD and it is expected an increase in coronary angiography and percutaneous coronary intervention (PCI). Aortic prosthesis, particularly if in supra-annular position, may pose important technical difficulties in coronary re-engagement after TAVR.

Purpose

To evaluate the feasibility to reengage the coronary ostia after TAVR, describe complications and compare technical differences between coronary procedures performed before and after TAVR.

Methods

Retrospective analysis of 714 patients submitted to TAVR from August 2007 to December 2019. Patients who needed coronary angiography after TAVR were selected.

The primary endpoint was the rate of successful coronary ostia cannulation after TAVR, defined by the possibility to selectively cannulate and inject both coronary ostia.

Secondary endpoint was complications associated with coronary catheterization after TAVR.

Results

Among 714 patients, 25 (3.5%) patients were submitted to a total of 28 coronary angiography after TAVR. 14 patients were male (56%), mean age 78.2±6.2 years and 9 (36%) had history of previous coronary revascularization.

From the 28 coronary angiographies (balloon-expandable Edwards-Sapien n=11, 44%; self-expandable CoreValve n=10, 40%; Portico n=2, 8%; Symetis n=2, 8%), 25 (89%) met the primary endpoint. Only three was semiselective (Symetis, CoreValve Evolut R and CoreValve TAVR in TAVR), with impossibility to cannulate both coronary arteries, right coronary artery and left coronary artery, respectively. 13 (46%) patients had also indication for PCI and all were successfully performed (Edwards-Sapien n=4, 31%; CoreValve n=6, 46%; Portico n=2, 15%; Symetis n=1, 8%). The main indications for coronary angiography was chronic coronary syndrome (n=12, 43%) and acute coronary syndrome without ST segment elevation (n=7, 25%). Circumflex artery was the most frequently treated vessel (n=6), followed by left anterior descending artery (n=4), right coronary artery (n=3) and left main (n=2).

There were no complications reported during or post-procedure. Comparing coronary angiographies before and after TAVR, there were no significant differences regarding arterial access site, catheter diameter, fluoroscopy time and quantity of contrast used in coronary angiography.

Conclusion

Although the need for coronary angiography was rare in patients after TAVR, selective diagnostic coronary angiographies were possible in 89% (25/28) and PCI was feasible in all patients in whom it was indicated, without any reported complications.

Further prospective studies are needed to confirm the great feasibility of performing coronary angiography after TAVR.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho

Momentum Entanglement for Atom Interferometry

Compared to light interferometers, the flux in cold-atom interferometers is low and the associated shot noise is large. Sensitivities beyond these limitations require the preparation of entangled atoms in different momentum modes. Here, we demonstrate a source of entangled atoms that is compatible with state-of-the-art interferometers. Entanglement is transferred from the spin degree of freedom of a Bose-Einstein condensate to well-separated momentum modes, witnessed by a squeezing parameter of -3.1(8)  dB. Entanglement-enhanced atom interferometers promise unprecedented sensitivities for quantum gradiometers or gravitational wave detectors.

Atrial Fibrillation in Acute Coronary Syndrome - early onset impact on MACE

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Atrial Fibrillation (AF) complicates approximately 10% of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on ACS patients’ (pts) prognosis.

Objective

To evaluate early onset (≤48h) de novo atrial fibrillation (AF) as predictor of major adverse cardiovascular events (MACE) and in-hospital complications.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 8/01/2019. Pts were divided in two groups: A – early onset de novo AF (EOAF), and B – late onset de novo AF (LOAF). Patients without data on previous cardiovascular history or uncompleted clinical data were excluded. Univariate logistic regression was performed to assess if LOAF in ACS was a predictor of MACE or complications.

Results

29851 pts had ACS. EOAF occurred in 584 pts (2.0%) and LOAF in 360 pts (1.2%). EOAF were younger (73 ± 13 vs 77 ± 10, p &lt; 0.001) and smokers (21.3% vs 12.1%, p &lt; 0.001). LOAF had higher rates of diabetes mellitus (40.1% vs 30.2%, p &lt; 0.001), angina (30.8% vs 21.4%, p &lt; 0.001), previous ACS (22.5% vs 15.4%, p = 0.006), previous revascularization (percutaneous coronary intervention 14% vs 9.5%, p = 0.032; coronary artery bypass surgery 8.4% vs 3.9%, p = 0.004). ST-segment elevation myocardial infarction (MI) rates were higher in EOAF (56.8% vs 46.9%, p = 0.003) and were admitted directly to the cath lab more often (21.7% vs 13.4%, p = 0.001). Non-ST elevation MI rates were higher in LOAF (44.2% vs 37.7%, p = 0.048). LOAF times from first symptoms to admission were longer (420min vs 183%, p &lt; 0.001), mean brain natriuretic peptide levels were higher (579 vs 447, p = 0.009) and diuretics usage was more frequent (72.8% vs 54.3%, p &lt; 0.001). EOAF had higher rates of heart failure (32.1% vs 17.2%, p &lt; 0.001), atrioventricular block (10.5% vs 7.8%, p = 0.006) and sustained ventricular tachycardia (8.1% vs 3.1%, p = 0.001). LOAF had higher in-hospital mortality (14.2% vs 9.6%, p = 0.031) and longer hospital stay (12 days vs 7 days, p &lt; 0.001). Logistic regression confirmed that EOAF was predictive of in-hospital heart failure (p &lt; 0.001, OR 2.15) and atrioventricular block (p = 0.008, OR 7.46). Regarding 1 year-follow-up, EOAF had poorer prognosis comparing to LOAF (59.3% vs 73.0%, p = 0.018, OR 1.62, CI 1.09-2.42)

Conclusion

EOAF is predictive of MACE, namely heart failure and atrioventricular block, and is associated to poorer prognosis comparing to LOAF.

Cardiac arrest in Acute Coronary Syndrome: predictors and prognosis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Cardiac arrest (CA) is a potential complication of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of CA in the setting of ACS.

Objective

To evaluate predictors and prognosis of CA in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected between 1/10/2010 and 4/09/2019. Patients (pts) without data on previous cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without CA; GB - pts with CA during hospitalization. Logistic regression and survival analysis was performed.

Results

Between 25718 pts with ACS, CA occurred in 651 (2.5%). GB was younger (65 ± 15 vs 67 ± 14, p &lt; 0.001), had higher rates of smoking (35.8% vs 26.4%, p &lt; 0.001), and lower rates of hypertension (62.3% vs 70.9%, p &lt; 0.001), diabetes (25.7% vs 31.7%, p &lt; 0.001), dyslipidaemia (53.8% vs 61.7%, p &lt; 0.001), previous ACS (17.2% vs 20.6%, p = 0.037) and coronary artery bypass grafting (CABG) (1.9% vs 5.1%, p &lt; 0.001). Both groups were similar regarding previous heart failure (p = 0.450) and chronic kidney disease (p = 0.560). GB had shorter times from first symptoms to admission (158min vs 243min, p &lt; 0.001). GA had higher rate of non-ST-elevation myocardial infarction (MI) (78.6% vs 41.4%, p &lt; 0.001), whether GB had higher rates of ST-elevation myocardial infarction (STEMI) (46.7% vs 18.1%, p &lt; 0.001), namely anterior (54.9% vs 46.9%, p &lt; 0.001). GB had lower blood pressure (BP) (122 ± 33 vs 139 ± 28, p &lt; 0.001), higher heart rate (HR) (83 ± 23 vs 77 ± 19, p &lt; 0.001), presented more frequently in Killip-Kimball class (KKC) ≥2 (37.6% vs 14.6%, p &lt; 0.001), in atrial fibrillation (AF) (13.9% vs 7.0%, p &lt; 0.001) and with right bundle block (10.6% vs 5.3%, p &lt; 0.001). GB had higher rates of common trunk culprit lesion (CL) (3.9% vs 1.6%, p &lt; 0.001), anterior descending coronary CL (49% vs 37%, p &lt; 0.001), 1 vessel lesion (53.4% vs 38.5%, p &lt; 0.001), lower CABG rates (4.3% vs 6.3%, p = 0.042), more left ventricle dysfunction (57.7% vs 38.7%, p &lt; 0.001) and needed more frequently mechanical ventilation (35.3% vs 1.1%, p &lt; 0.001), non-invasive ventilation (6.8% vs 1.6%, p &lt; 0.001) and provisory pacemaker (9.4% vs 1.3%, p &lt; 0.001). Logistic regression confirmed that older age (p &lt; 0.001, OR 1.89, CI 1.35-2.64), higher HR (p &lt; 0.029, OR 1.33, CI 1.03-1.71), lower BP (P &lt; 0.001, OR 2.67, CI 1.94-3.68), KKC ≥2 (p &lt; 0.001, OR 2.35, CI 1.84-3.00), AF at admission (p &lt; 0.001, OR 1.84, CI 1.34-2.51), STEMI (p &lt; 0.001, OR 4.08, CI 3.66-6.77), lower left ventricle function (p = 0.009, OR 1.38, CI 1.08-1.75) were predictors of CA. Event-free survival was higher in GA than GB (92.8% vs 83.3%, OR 1.68, p = 0.008, CI 1.41-2.47).

Conclusion

As expected, CA in the setting of ACS is associated with poorer prognosis. Several characteristics of the pts may help to predict the development of CA during hospitalization, allowing earlier identification and prompt treatment.

In-hospital outcomes of sustained ventricular tachycardia in the setting of Acute Coronary Syndrome

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Sustained ventricular tachycardia (SVT) complicates up to 20% of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of SVT.

Objective

To evaluate predictors of early onset (&lt;48h) and late onset (≥48h) SVT.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) were divided in two groups (G): A – pts that presented early onset SVT (ESVT), and B – pts that presented late onset SVT (LSVT). Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. Logistic regression was performed to assess predictors of SVT in ACS.

Results

Between 29851 pts with ACS, 364 (1.2%) presented SVT. ESVT – 251 pts (69%); LSVT – 91 pts (25%). LSVT G was older (74 ± 13 vs 68 ± 14, p = 0.003), was admitted directly to cat lab less frequently (10.1% vs 24.8%, p = 0.003), had longer times from first symptoms to admission (440min vs 261 min, p &lt; 0.001) and had higher rates of previous stroke (14.4% vs 6.8%, p = 0.028). LSVT G had higher rates of non-ST-elevation myocardial infarction (MI) (35.2% vs 23.1%, p = 0.025) and lower rates of ST-elevation MI (53.8% vs 71.7%, p = 0.002), although both G were similar regarding MI location (anterior – p = 0.135, inferior – p = 0.097). LSVT G had higher systolic blood pression (130 ± 33 vs 122 ± 33, p = 0.050), presented more frequently in Killip-Kimball class ≥2 (52.5% vs 35.5%, p = 0.005) and with atrial fibrillation (21.2% vs 12.4%, p = 0.045), and had higher brain-natriuretic peptide (1075 vs 329, p &lt; 0.001). LSVT G was treated more frequently with diuretics (80.0% vs 47.8%, p &lt; 0.001), amiodarone (62.2% vs 48.8%, p = 0.029), digoxin (8.9% vs 2.4%, p = 0.013) and levosimendan (11.1% vs 2.8%, p = 0.004). ESVT G had higher rates of performed coronarography (88.4% vs 79.1%, p = 0.028) but lower rate of 3 vessels disease (58.5% vs 70.8%, p = 0.017). LSVT G had higher rates of severe (&lt;30%) left ventricle dysfunction (32.9% vs 15.4%, p &lt; 0.001) and need to non-invasive ventilation (23.1% vs 6.8%, p &lt; 0.001). Regarding in-hospital complications, ESVT G had higher rates of heart failure (34.7% vs 19.1%, p = 0.006), atrioventricular block (15.7% vs 1.1%, p &lt; 0.001), atrial fibrillation (20.4% vs 7.7%, p = 0.006) and major haemorrhage (5.2% vs 0.0%, p = 0.024). LSVT G had higher rates of in-hospital death (44.4% vs 20.9%, p &lt; 0.001) and in-hospital stay (14 days vs 7 days, p &lt; 0.001). The G were similar regarding re-infarction (p = 0.216), shock (p = 0.179), mechanical complications (p = 1.00), cardiac arrest (p = 0.097) and stroke (0.348) rates. Logistic regression confirmed ESVT was predictive in-hospital heart failure (p = 0.010, OR 2.67) and de novo AF (p = 0.001, OR 5.56), whether LSVT was predictive of in-hospital death (p = 0.002, OR 2.70).

Conclusion

LSVT was associated with higher rates of in-hospital complications, but ESVT was associated with higher in-hospital mortality.

Acute heart failure: does etiology matter?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (pts) with acute heart failure (AHF) are a heterogeneous population. The etiology of the heart disfunction may play a role in prognosis. Risk stratification at admission may help predict in-hospital complications and needs.

Objective

To explore predictors of in-hospital mortality (IHM), post discharge early mortality [1-month mortality (1mM)] and late mortality [1-year mortality (1yM)] and early and late readmission, respectively 1-month readmission (1mRA) and 1-year readmission (1yRA), in our center population, using real-life data.

Methods

Based on a single-center retrospective study, data collected from patients (pts) admitted in the Cardiology department with AHF between 2010 and 2017. Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. The pts were divided in 3 groups: ischemic etiology (IE), valvular etiology (VE) and other etiologies (OE), which included hypertensive and idiopathic cardiomyopathies). Statistical analysis used non-parametric tests and Kaplan-Meyer survival analysis.

Results

We included 300 pts admitted with AHF. Mean age was 67.4 ± 12.6 years old and 72.7% were male. 37.7% had previous history of revascularization procedures, 66.9% had hypertension, 41% were diabetic and 38% had dyslipidaemia. The heart failure was of IE in 45%, VE in 22.7% and of OE in 32.3% of the cases.

There were no significant differences between groups regarding body mass index, Killip-Kimball class, systolic blood pressure at admission, blood tests aspects at admission (namely, creatinine, sodium or urea), inotropes’ usage or need of non-invasive or invasive ventilation. However, IE group had higher percentage of males comparing to VE e OE (83.0% vs 55.9% vs 70.1%, respectively, p &lt; 0.001), higher rates of prior revascularization procedures (68.9%, vs 19.1%, vs 7.2%, p &lt; 0.001) and higher rates of traditional cardiovascular risk factors, namely hypertension (74.1% vs 55.9% vs 57.7%, p = 0.014), diabetes mellitus (48.1% vs 27.9% vs 27.8%, p = 0.002) and dyslipidaemia (48.9% vs 30.9% vs 40.2%, p = 0.022). OE group was younger compared to IE and VE (63.9 ± 13.5 vs 68.9 ± 11.1 vs 69.5 ± 13.0 years old, respectively, p = 0.003). VE group had less left ventricle disfunction comparing to IE and VE groups (left ventricle ejection fraction 40.8 ± 14.1 vs 32.2 ± 9.8 vs 31.6 ± 12.8%, respectively, p &lt; 0.001).

The groups showed no significant differences regarding IHM (IE 5.2% vs VE 8.8% vs OE 2.1%, p = 0.146), 1mRA (IE 8.1&, VE 7.4%, OE 3.1%, p = 0.276) or 1yRA (IE 55.6%, VE 54.4%, OE 47.4%, p = 0.449). However, VE group had higher rates of 1mM (VE 13.2% vs IE 8.9% vs OE 3.1%, p = 0.05) and 1yM compared to IE and OE (33.8% vs 30.4% vs 17.5%, respectively, p = 0.34). These aspects are represented in Kaplan Meier survival curves.

Conclusion

In our population, the etiology of heart failure was predictor of early and late post-discharge mortality but not readmission.

Predictors of early and late re-hospitalization and mortality in non-ST elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Introduction

Regarding prognosis, acute coronary syndromes (ACS) are heterogeneous. Non-ST elevation myocardial infarction (NSTEMI) is a subtype of ACS. In-hospital (IH) and post-hospitalization (PH) risk stratification is crucial.

Objective

To identify predictors of IH and PH mortality (early and late), as well as predictors of early and late re-admission (RA) in our center population suffering NSTEMI, using real-life data.

Methods

Based on a single-center retrospective study, data collected from admissions between 1/01/2018 and 11/12/2019. Patients (pts) who survived the ACS and were discharged from the hospital were included. Concerning prognosis, we assessed 1-month M and RA (1mM and 1mRA), 6-month M and RA (6mM and 6mRA), 1-year M and RA (1yM and 1yRA).

Results

268 pts with ACS, 59.7% were males and mean age was 66.4 ± 12.5 years old. NSTEMI was the diagnosis in 66.4% and ST elevation myocardial infarction (STEMI) in 31%. Mean creatinine was 1.2 ± 1ml/min, mean sodium was 138 ± 3mmol/L, mean blood urea nitrogen (BUN) was 21 ± 12mg/dL and mean haemoglobin (Hb) was 13.6 ± 1.9g/dL. 88.2% of the pts presented in Killip-Kimball class (KKC) 1, 5.7% in KKC 2, 5.7% in KKC 3 and 0.4% in KKC IV; furthermore, 4.1% of the pts presented de novo AF. Concerning coronary artery disease, 250 were submitted to coronary angiography – 18.8% had no lesions or non-significant lesions (stenosis &lt;50%), 34.8% had one significant lesion, 23.2% had 2 significant lesions and 23.2% had 3 or more. Regarding left ventricle (LV) function, 70.5% of the pts had no LV dysfunction, 15.7% had mild LV impairment (LVI), 9.3% moderate LVI and 4.5% had severe LVI. 8.4% of the patients experienced IH complications, such as auriculoventricular block, heart failure, ventricular tachycardia, stroke, cardiorespiratory arrest and major haemorrhage, during hospitalization. 1mM rate was 1.9% and 1yM rate was 7.8%.

KKC (p = 0.001), BUN (p = 0.007), LV function (p= 0.001) and de novo AF (p = 0.46) were predictors of 1mM. Age (p = 0.004), KKC (p = 0.031), BUN (p = 0.002), sodium (p = 0.037), creatinine (p = 0.001), Hb (p = 0.003), LV function (p &lt; 0.001), de novo AF (p &lt; 0.001) and occurrence of IH complications (p &lt; 0.001) were predictors of 1yM. Age (p = 0.010), male gender (p = 0.19), Hb (p = 0.031), de novo AF (p &lt; 0.001) and occurrence of IH complications (p = 0.001) were predictors of 1mRA. Age (p = 0.004), smoking (p = 0.040), hypertension (p = 0.040), glycemia at admission (p = 0.031), Hb (p = 0.004), LV function (p = 0.019), de novo AF (p &lt; 0.001) and occurrence of IH complications (p &lt; 0.001) were predictors of 1yRA.

Conclusion

This study suggests that de novo AF and occurrence of IH complications are very important prognosis factors regarding early and late mortality and readmission rates.

Acute Coronary Syndrome - reinfarction predictors and outcomes

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Reinfarction (RI) is a potential complication of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of RI in the setting of ACS.

Objective

To evaluate predictors and prognosis of RI in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) without data on previous cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without RI; GB - pts with RI during hospitalization. Logistic regression and survival analysis were performed.

Results

Between 25718 pts with ACS, RI occurred in 223 (0.87%). Regarding epidemiological factors and past history, GB was older (70 ± 12 vs 67 ± 14, p &lt; 0.001), had higher rates of hypertension (77.4% vs 70.6%, p = 0.028), previous stroke (12.1% vs 7.2%, p = 0.005), peripheric arterial disease (10.0% vs 5.5%, p = 0.004) and chronic obstructive pulmonary disease (8.6% vs 4.4%, p = 0.003). GB had higher rates of non-ST-elevation myocardial infarction (MI) (54.3% vs 45.9%, p = 0.012) and GA had higher rates of ST-elevation MI (42.4% vs 35.9%, p = 0.049). The groups were similar regarding blood pressure (p = 0.285), heart rate (p = 0.796) and Killip-Kimball class at admission, but GB had higher levels of brain natriuretic peptide (392 vs 180, p = 0.005). GB had higher rates of multivessel disease (62.8% vs 51.6%, p = 0.002), left ventricle dysfunction (50.0% vs 39.1%, p = 0.002), higher needs of mechanical ventilation (6.3% and vs 1.9%, p &lt; 0.001) non-invasive ventilation (5.4% vs 1.7%, p &lt; 0.001). Logistic regression confirmed that peripheric arterial disease (p = 0.011, OR 1.93, CI 1.17-3.19), multivessel disease (p = 0.003, OR 1.69, CI 1.20-2.39) and lower left ventricle function (p &lt; 0.001, OR 2.42, CI 1.69-3.47) were predictors of RI in the setting of ACS. Event-free survival was similar between groups (p = 0.399).

Conclusion

RI in the setting of ACS was associated multivessel disease and left ventricle disfunction, however, 1-year prognosis was similar to pts who didn’t suffer RI.

Acute heart failure: is ACTION-ICU useful?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (pts) with acute heart failure (AHF) are a heterogeneous population. Risk stratification at admission may help predict in-hospital complications and needs. ACTION ICU score is validated to estimate the risk of complications requiring ICU care in non-ST elevation acute coronary syndromes.

Objective

To validate ACTION-ICU score in AHF as predictor of in-hospital M (IHM), post discharge early M [1-month mortality (1mM)] and 1-month readmission (1mRA), in our center population, using real-life data.

Methods

Based on a single-center retrospective study, data collected from pts admitted in the Cardiology department with AHF between 2010 and 2017. Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. Statistical analysis used non-parametric tests, logistic regression analysis and ROC curve analysis.

Results

We included 300 pts admitted with AHF. Mean age was 67.4 ± 12.6 years old and 72.7% were male. 37.7% had previous history of revascularization procedures, 66.9% had hypertension, 41% were diabetic and 38% had dyslipidaemia. Mean heart rate was 95.5 ± 27.5bpm, mean systolic blood pressure (SBP) was 131.2 ± 37.0mmHg, mean urea level at admission was 68.8 ± 40.7mg/dL, mean sodium was 137.6 ± 4.7mmol/L, mean glomerular filtration rate (GFR) was 57.1 ± 23.5ml/min. 35.3% were admitted in Killip-Kimball class (KKC) 4. Mean ACTION-ICU score was 10.4 ± 2.3. Inotropes’ usage was necessary in 32.7% of the pts, 11.3% of the pts needed non-invasive ventilation (NIV), 8% needed invasive ventilation (IV). IHM rate was 5% and 1mM was 8%. 6.3% of the pts were readmitted 1 month after discharge.

Older age (p &lt; 0.001), lower SBP (p = 0,035), presenting in KKC 4 (p &lt; 0.001, OR 8.13) and need of inotropes (p &lt; 0.001) were predictors of IHM in our population. Older age (OR 1.06, p = 0.002, CI 1.02-1.10), lower SBP (OR 1.01, p = 0.05, CI 1.00-1.02) and lower left ventricle ejection fraction (LVEF) (OR 1.06, p &lt; 0.001, CI 1.03-1.09) were predictors of need of NIV. None of the studied variables were predictive of need of IV. LVEF (OR 0.924, p &lt; 0.001, CI 0.899-0.949), lower SBP (OR 0.80, p &lt; 0.001, CI 0.971-0.988), higher urea (OR 1.01, p &lt; 0.001, CI 1.005-1.018) and lower sodium (OR 0.92, p = 0.002, CI 0.873-0.971) were predictors inotropes’ usage.

ACTION-ICU was able to predict IHM (OR 1.51, p = 0.02, CI 1.158-1.977), 1mM (OR 1.45, p = 0.002, CI 1.15-1.81) and inotropes’ usage (OR 1.22, p = 0.002, CI 1.08-1.39), but not 1mRA, the need of IV or NIV.

ROC curve analysis revealed ACTION-ICU performs well when predicting IHM (Area under curve (AUC) 0.729, confidence interval (CI) 0.59-0.87), inotropes’ usage (AUC 0.619, CI 0.54-0.70) and 1mM (AUC 0.705, CI 0.58-0.84).

Conclusion

In our population, ACTION-ICU score was able to predict IHM, 1mM and inotropes’s usage.

Acute heart failure: predicting early in-hospital outcomes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (P) with acute heart failure (AHF) are a heterogeneous population. Risk stratification at admission may help predict in-hospital complications and needs. The Get With The Guidelines Heart Failure score (GWTG-HF) predicts in-hospital mortality (M) of P admitted with AHF. ACTION ICU score is validated to estimate the risk of complications requiring ICU care in non-ST elevation acute coronary syndromes.

Objective

To validate ACTION-ICU score in AHF and to compare ACTION-ICU to GWTG-HF as predictors of in-hospital M (IHM), early M [1-month mortality (1mM)] and 1-month readmission (1mRA), using real-life data.

Methods

Based on a single-center retrospective study, data collected from P admitted in the Cardiology department with AHF between 2010 and 2017. P without data on previous cardiovascular history or uncompleted clinical data were excluded. Statistical analysis used chi-square, non-parametric tests, logistic regression analysis and ROC curve analysis.

Results

Among the 300 P admitted with AHF included, mean age was 67.4 ± 12.6 years old and 72.7% were male. Systolic blood pressure (SBP) was 131.2 ± 37.0mmHg, glomerular filtration rate (GFR) was 57.1 ± 23.5ml/min. 35.3% were admitted in Killip-Kimball class (KKC) 4. ACTION-ICU score was 10.4 ± 2.3 and GWTG-HF was 41.7 ± 9.6. Inotropes’ usage was necessary in 32.7% of the P, 11.3% of the P needed non-invasive ventilation (NIV), 8% needed invasive ventilation (IV). IHM rate was 5% and 1mM was 8%. 6.3% of the P were readmitted 1 month after discharge.

Older age (p &lt; 0.001), lower SBP (p = 0,035) and need of inotropes (p &lt; 0.001) were predictors of IHM in our population. As expected, patients presenting in KKC 4 had higher IHM (OR 8.13, p &lt; 0.001). Older age (OR 1.06, p = 0.002, CI 1.02-1.10), lower SBP (OR 1.01, p = 0.05, CI 1.00-1.02) and lower left ventricle ejection fraction (LVEF) (OR 1.06, p &lt; 0.001, CI 1.03-1.09) were predictors of need of NIV. None of the variables were predictive of IV. LVEF (OR 0.924, p &lt; 0.001, CI 0.899-0.949), lower SBP (OR 0.80, p &lt; 0.001, CI 0.971-0.988), higher urea (OR 1.01, p &lt; 0.001, CI 1.005-1.018) and lower sodium (OR 0.92, p = 0.002, CI 0.873-0.971) were predictors of inotropes’ usage.

Logistic regression showed that GWTG-HF predicted IHM (OR 1.12, p &lt; 0.001, CI 1.05-1.19), 1mM (OR 1.10, p = 1.10, CI 1.04-1.16) and inotropes’s usage (OR 1.06, p &lt; 0.001, CI 1.03-1.10), however it was not predictive of 1mRA, need of IV or NIV. Similarly, ACTION-ICU predicted IHM (OR 1.51, p = 0.02, CI 1.158-1.977), 1mM (OR 1.45, p = 0.002, CI 1.15-1.81) and inotropes’ usage (OR 1.22, p = 0.002, CI 1.08-1.39), but not 1mRA, the need of IV or NIV. ROC curve analysis revealed that GWTG-HF score performed better than ACTION-ICU regarding IHM (AUC 0.774, CI 0.46-0-90 vs AUC 0.731, CI 0.59-0.88) and 1mM (AUC 0.727, CI 0.60-0.85 vs AUC 0.707, CI 0.58-0.84).

Conclusion

In our population, both scores were able to predict IHM, 1mM and inotropes’s usage.

Stroke in acute coronary syndrome: predictors and prognosis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Stroke is a potential complication of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of stroke in the setting of ACS.

Objective

To evaluate predictors and prognosis of stroke in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) without data on previous cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without stroke; GB - pts with stroke during hospitalization. Logistic regression was performed to assess predictors of stroke in ACS. Survival analysis was evaluated through Kaplan Meier curve.

Results

Population – 25711 pts with ACS, CA occurred in 154 (0.6%). Regarding epidemiological factors and past history, GB was older (72 ± 12 vs 67 ± 14, p &lt; 0.001), had higher rates of females (53.2% vs 27.5%, p &lt; 0.001), diabetes (43.9% vs 31.5%, p &lt; 0.001), previous stroke (13.3% vs 7.2%, p = 0.004), peripheric arterial disease (9.2% vs 5.5%, p = 0.044) and dementia (6.8% vs 1.7%, p &lt; 0.001), and had lower rates of smoking (16.6% vs 26.7%, p = 0.005), dyslipidaemia (53.5% vs 61.6%, p = 0.047) and previous ACS (12.7% vs 20.6%, p = 0.017. GB had longer times from first symptoms to admission (340min vs 240min, p = 0.011). The groups were similar regarding diagnosis, namely non-ST-elevation myocardial infarction (MI) (p = 0.345) and ST-elevation MI (p = 0.541). GB had higher heart rate (HR) (84 ± 24 vs 77 ± 19, p = 0.001), presented more frequently in Killip-Kimball class (KKC) ≥2 (28.0% vs 15.1%, p &lt; 0.001), in atrial fibrillation (AF) (16.4% vs 7.1%, p &lt; 0.001) and with higher brain-natriuretic peptide levels (545 vs 180, p &lt; 0.001). The groups were similar regarding culprit lesion and number of lesions. GB had more left ventricle (&lt;50%) dysfunction (51.4% vs 39.1%, p &lt; 0.001) and needed more frequently mechanical ventilation (10.4% vs 1.9%, p &lt; 0.001) and provisory pacemaker (8.4% vs 1.5%, p &lt; 0.001).

Logistic regression confirmed that older age (p = 0.018, OR 1.69, CI 1.10-2.60), female gender (p &lt; 0.001, OR 2.09, CI 1.38-3.15), diabetes (p = 0.002, OR 1.91, CI 1.27-2.86), dementia (p = 0.047, OR 2.13, CI 1.01-4.50), AF (p = 0.024, OR 1.87, CI 1.09-3.21) and lower left ventricle function (p = 0.002, OR 2.01, CI 1.29-3.15) were predictors of stroke in the setting of ACS. Event-free survival was higher in GA than GB (79.9% vs 70.5%, OR 1.58, p &lt; 0.001, CI 1.36-1.83).

Conclusion

As expected, stroke in the setting of ACS is associated with poorer prognosis. Several characteristics of the pts may help to predict the occurrence of stroke during hospitalizations, therefore allowing an earlier identification and prompt treatment.

Heart failure in Acute Coronary Syndrome: predictors and prognosis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the Investigators of " Portuguese Registry of ACS "

Introduction

Heart failure (HF) is a frequent complication of acute coronary syndromes (ACS). Therefore, it is important to access its impact on prognosis and identify patients (pts) with higher risk of HF.

Objective

To evaluate predictors and prognosis of HF in the setting of ACS.

Methods

Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Pts without data on cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without HF; GB - pts with HF during hospitalization.

Results

HF occurred in 4003 (15.6%) out of 25718 pts with ACS. GB was older (74 ± 12 vs 65 ± 13, p &lt; 0.001), had more females (36.3% vs 26.2%, p &lt; 0.001), had higher rates of arterial hypertension (78.4% vs 69.3%, p &lt; 0.001), dyslipidaemia (64.4% vs 61.1%. p &lt; 0.001), previous ACS (25.6% vs 19.7%, p &lt; 0.001,), previous HF (16.4% vs 4.1%, p &lt; 0.001), previous stroke (11.9% vs 6.4%, p &lt; 0.001), chronic kidney disease (CKD) (17.1% vs 5.5%, p &lt; 0.001), chronic obstructive pulmonary disease (COPD) (7.8% vs 3.8%, p &lt; 0.001) and longer times from first symptoms to admission (268min vs 238min, p &lt; 0.001). GA had higher rate of smokers (28.4% vs 16.2%, p &lt; 0.001) and higher rate of non-ST-elevation myocardial infarction (MI) (46.5% vs 43.0%, p &lt; 0.001). GB had higher rates of ST-elevation MI (STEMI) (49.2% vs 41.1%, p &lt; 0.001), namely anterior STEMI (58.1% vs 44.9%, p &lt; 0.001). GB had lower blood pressure (130 ± 32 vs 140 ± 28, p &lt; 0.001), higher heart rate (86 ± 23 vs 76 ± 18, p &lt; 0.001), Killip-Kimball class (KKC) ≥2 (63.2% vs 6.7%, p &lt; 0.001), atrial fibrillation (AF) (15.4% vs 5.7%, p &lt; 0.001), left bundle branch block (7.5% vs 3.1%, p &lt; 0.001) and were previously treated with diuretics (39.1% vs 22.1%, p &lt; 0.001), amiodarone (2.2% vs 1.4%, p &lt; 0.001) and digoxin (2.8% vs 0.7%, p &lt; 0.001). GB had higher rates of multivessel disease (66.0% vs 49.5%, p &lt; 0.001) and planned coronary artery bypass grafting (7.3% vs 6.0%, p &lt; 0.001), reduced left ventricle function (72.3% vs 33.4%, p &lt; 0.001) and needed more frequently mechanical ventilation (8.2% vs 0.9%, p &lt; 0.001), non-invasive ventilation (8.7% vs 0.5%, p &lt; 0.001) and provisory pacemaker (4.5% vs 1.0%, p &lt; 0.001). Logistic regression confirmed females (p &lt; 0.001, OR 1.42, CI 1.29-1.58), diabetes (p &lt; 0.001, OR 1.43, CI 1.30-1.58), previous ACS (p &lt; 0.001, OR 1.27, CI 1.10-1.47), previous stroke (p &lt; 0.001, OR 1.35, CI 1.16-1.57), CKD (p &lt; 0.001, OR 1.76, CI 1.50-2.05), COPD (p &lt; 0.001, OR 2.15, CI 1.82-2.54), previous usage of amiodarone (p = 0.041, OR 1.35, CI 1.01-1.81) and digoxin (p &lt; 0.001, OR 2.30, CI 1.70-3.16), and multivessel disease (p &lt; 0.001, OR 1.64, CI 1.67-2.32) were predictors of HF in the setting of ACS. Event-free survival was higher in GA than GB (79.5% vs 58.1%, OR 2.3, p &lt; 0.001, CI 2.09-2.56).

Conclusion

As expected, HF in the setting of ACS is associated with poorer prognosis. Several features may help predict the HF occurrence during hospitalizations, allowing an earlier treatment.

Quantum Droplets of Dipolar Mixtures

Recently achieved two-component dipolar Bose-Einstein condensates open exciting possibilities for the study of mixtures of ultradilute quantum liquids. While nondipolar self-bound (without external confinement) mixtures are necessarily miscible with an approximately fixed ratio between the two densities, the density ratio for the dipolar case is free. Therefore, self-bound dipolar mixtures present qualitatively novel and much richer physics, characterized by three possible ground-state phases: miscible, symmetric immiscible, and asymmetric immiscible, which may in principle occur at any population imbalance. Self-bound immiscible droplets are possible due to mutual nonlocal intercomponent attraction, which results in the formation of a droplet molecule. Moreover, our analysis of the impurity regime shows that quantum fluctuations in the majority component crucially modify the miscibility of impurities. Our work opens intriguing perspectives for the exploration of spinor physics in ultradilute liquids, which should resemble to some extent that of ^{4}He-^{3}He droplets and impurity-doped helium droplets.

CHEMOMETRIC STRATEGY FOR OPTIMIZATION OF AN ACID DECOMPOSITION METHOD TO DETERMINE THE MINERAL COMPOSITION IN ALMOND PULP (Terminalia catappa Linn.)

In this work, multivariate optimization techniques were applied to develop an acid digestion procedure in digester block using “cold finger” as reflux system to determine minerals in almond pulp samples by inductively coupled plasma optical emission spectrometry. Two-level full factorial design and Box-Behnken design were applied to evaluate and optimize the factors involved in the acid digestion process. In both experimental designs, Function D and Function MR multiple responses were used to establish the method condition for all analytes and with greater digestion efficiency. Two apple and spinach leaves certified reference materials were analyzed to confirm the proposed method accuracy. The digestion efficiency was evaluated by residual carbon content which showed 1.32-1.77% range. The concentration values found for each element in almond pulp collected in Salvador, Bahia, Brazil in mg 100 g-1 were: 3.08 (Ca), 0.209 (Cu), 0.407 (Fe), 356 (K), 21.5 (Mg), 0.096 (Mn), 34.4 (P) and 0.289 (Zn). The developed method was simple and efficient for almond pulp mineral composition evaluation. This unconventional fruit has nutritional relevance with future application for new food recipes and pharmaceutical products formulation.