A perspective on muscle phenotyping in musculoskeletal research

Musculoskeletal research should synergistically investigate bone and muscle to inform approaches for maintaining mobility and to avoid bone fractures. The relationship between sarcopenia and osteoporosis, integrated in the term 'osteosarcopenia', is underscored by the close association shown between these two conditions in many studies, whereby one entity emerges as a predictor of the other. In a recent workshop of Working Group (WG) 2 of the EU Cooperation in Science and Technology (COST) Action 'Genomics of MusculoSkeletal traits Translational Network' (GEMSTONE) consortium (CA18139), muscle characterization was highlighted as being important, but currently under-recognized in the musculoskeletal field. Here, we summarize the opinions of the Consortium and research questions around translational and clinical musculoskeletal research, discussing muscle phenotyping in human experimental research and in two animal models: zebrafish and mouse.

Rapid correction of hyperglycemia: A necessity but at what price? A brief report of a patient living with type 1 diabetes

BACKGROUND

The correction and control of chronic hyperglycemia are the management goals of patients living with diabetes. Chronic hyperglycemia is the main factor inducing diabetes-related complications. However, in certain situations, the rapid and intense correction of chronic hyperglycemia can paradoxically favor the onset of microvascular complications.

CASE SUMMARY

In this case report, we describe the case of a 25-year-old woman living with type 1 diabetes since the age of 9 years. Her diabetes was chronic and unstable but without complications. During an unplanned pregnancy, her diabetes was intensely managed with the rapid correction of her hyperglycemia. However, over the following 2 years, she developed numerous degenerative microvascular complications: Charcot neuroarthropathy with multiple joint involvement, severe proliferative diabetic retinopathy, gastroparesis, bladder voiding disorders, and end-stage renal failure requiring hemodialysis.

CONCLUSION

In the literature to date, the occurrence of multiple microvascular complications following the rapid correction of chronic hyperglycemia has been rarely described in the same individual.

Impact of chronic emotions and psychosocial stress on glycemic control in patients with type 1 diabetes. Heterogeneity of glycemic responses, biological mechanisms, and personalized medical treatment

Many studies have clearly established that chronic psychosocial stress may sustainably worsen glycemic control in patients with type 1 diabetes mellitus (T1DMM), thus promoting diabetes complications. Chronic psychosocial stress may be due to: i) the long-term accumulation of stressful life events that require readjustment on the part of the individual (loosing friends, changing schools), and/or ii) exposure to severe chronic stressors (persistent difficulties and adversities of life). Whatever the reason, many studies have clearly established a positive correlation between chronic psychosocial stress and HbA1c levels. However, a small fraction of patients is minimally affected or not affected at all by chronic psychosocial stress. Conversely, positive life events can substantially improve glycemic control. Recent evidence suggests the existence of subpopulations that differ in personality traits, neurohormonal regulatory responses, and food intake behavior (increased or decreased). Better characterization of the clinical and neurohormonal differences between these subpopulations may help develop personalized treatment strategies in the future. In the near future, psychotherapeutic support and automated insulin delivery (AID) could alleviate chronic stress, prevent worsening glycemic control, and ease the burden of diabetes.

Impact of Intensive Glycemic Treatment on Diabetes Complications-A Systematic Review

Diabetes complications can be related to the long duration of the disease or chronic hyperglycemia. The follow-up of diabetic patients is based on the control of chronic hyperglycemia, although this correction, if obtained rapidly in people living with severe chronic hyperglycemia, can paradoxically interfere with the disease or even induce complications. We reviewed the literature describing the impact of the rapid and intense treatment of hyperglycemia on diabetic complications. The literature review showed that worsening complications occurred significantly in diabetic microangiopathy with the onset of specific neuropathy induced by the correction of diabetes. The results for macroangiopathy were somewhat mixed with the intensive and rapid correction of chronic hyperglycemia having a neutral impact on stroke and myocardial infarction but a significant increase in cardiovascular mortality. The management of diabetes has now entered a new era with new therapeutic molecules, such as gliflozin for patients living with type 2 diabetes, or hybrid insulin delivery systems for patients with insulin-treated diabetes. Our manuscript provides evidence in support of these personalized and progressive algorithms for the control of chronic hyperglycemia.

The influence of overweight and obesity in the oral health of a sample of portuguese adults

Background

Overweight and obesity may lead to different problems in various body systems and in the oral cavity. Dental caries and periodontal disease have been related with overweight. The aim of this study was to assess how overweight and obesity have impact on the lifestyle, oral habits and oral pathologies.

Methods

We conducted an observational cross-sectional study where we applied a questionnaire to 140 individuals from Lisbon and Viseu, Portugal., which 70 had a normal Body Mass Index (BMI) (control group) and 70 had an excessive BMI. We also made an oral observation in each individual to record the permanent teeth decayed, missing and filled index (DMFT), the Community Periodontal Index and the oral hygiene status.

Results

From the final sample, 30% of the subjects with overweight brushed their teeth once a day or less, while the majority (62.9%) of the control group brushed twice a day. In the oral examination, 70% had calculus, while in the control group only 22.5% presented calcified plaque. The DMFT was higher among the obesity group in comparison with the control group. Regarding periodontal disease, the participants with overweight need more dental intervention (81.4%) in contrast with the control group (14%).

Conclusions

Most overweight and obese individuals present precarious oral hygiene habits, higher prevalence of dental caries, and worse periods of periodontal health. They are not aware of the repercussions of the association between their cariogenic diet, oral health and overweight.

Key messages

• Oral health behaviors are related with other health conditions, namely obesity and this is a fundamental public health issue.

• Primary preventive strategies should be established having in consideration the oral health status of adults in treatment for obesity and in weight control programs.

Peri-procedural, 30-day and 1 year-outcomes in chronic dialysis patients undergoing transcatheter aortic valve implantation

Background

Patients on chronic dialysis (CD) due to end-stage renal disease (ESRD) with symptomatic severe aortic stenosis eligible for transcatheter aortic valve implantation (TAVI) were excluded from randomized clinical trials. Our study aimed to investigate the outcomes of patients with chronic dialysis who underwent TAVI.

Methods

Single center analysis on prospectively collected data of all consecutive patients who underwent TAVI between January 2011 and December 2020 according to baseline renal function: chronic dialysis group (CD) and control group (CTRL). Procedural, 30-day and 1-year outcomes were assessed. Outcomes were defined in accordance with the VARC-3 criteria.

Results

A total of 875 patients underwent TAVI during the study period, of whom 22 (2.5%) were on chronic dialysis. Patients on CD were younger (median age 80 years, [IQR 73–84] vs 84 years, [IQR 80–87]; p<0.001), more likely to be men [365/863 (42.8%) vs 18/22 (81.8%); p<0.001] and more likely to have peripheral vascular disease [41/853 (4.8%) vs 7/22 (31.8%); p=0.031] and lower body mass index (median 24.1 kg/m2, [IQR 21.5–26.5] vs 26.3 kg/m2, [IQR 23.7–29.3]). Short-term major or life-threatening bleeding were significantly higher in CD patients (odds ratio [95% confidential interval]: 3.67 [1.50–8.96], p 0.005). In contrast, no differences were found regarding rates of vascular complications requiring intervention (OR [95% CI]: 1.35 [0.31–5.90], p=0.662), permanent pacemaker implantation (OR [95% CI]: 0.87 [0.25–2.98], p=1.000) or stroke (OR [95% CI]: 1.51 [0.20–11.64], p=0.504). Importantly, dialysis patients had significantly higher rates of in-hospital, 30-day and 1-year mortality rates (13.6 vs 2.1%, p<0.001; 18.9% vs 2.9, p<0.001 and 26.4% vs 10.7%, p<0.001, respectively). On multivariate analysis, after adjusting for age, gender, relevant co-morbidities, and procedure-related complications, CD remained independently associated with mortality at 1-year. Survival curves during follow up are presented in Figure 1.

Conclusions

Chronic dialysis patients submitted to TAVI had significantly higher rates of short-term life threatening and/or major bleeding, short-term and long-term mortality. Careful selection of patients who would benefit from TAVI among patients with ERDS requiring dialysis is necessary to prevent high rates of postprocedural complications and improve outcomes of this high-risk population.

Funding Acknowledgement

Type of funding sources: None.

Potential impact of replacing SCORE with SCORE-2 on risk classification and statin eligibility – a coronary calcium score correlation study

Background

Recently, the European Society of Cardiology issued new algorithms to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD), along with new age-specific thresholds to classify individuals as low-to-moderate, high, or very-high risk.

The aim of this study was to compare the latest SCORE-2 model with the older SCORE (Systematic COronary Risk Evaluation) in their ability to identify individuals with high coronary artery calcium score (CACS), and assess the relationship between potential eligibility for statin therapy and CACS.

Methods

Individuals 40–69 years old without diabetes or known ASCVD were identified in a single center registry of patients undergoing CACS and coronary CT angiography for suspected coronary artery disease. SCORE and SCORE-2 were calculated and used with each patient's untreated LDL-C values to assess eligibility for statin therapy. High CACS was defined as an Agatston score ≥100.

Results

A total of 389 pts (46% men, mean age 58±8 years) were included, of which 15% (n=60) were active smokers. The mean systolic blood pressure and untreated LDL-C values were 136±17 mmHg and 155±65 mg/dL, respectively.

The proportion of patients classified as low-to-moderate risk, high risk, and very high risk was 93%, 6% and 1% using the SCORE algorithm, and 42%, 44%, and 14% using SCORE-2, respectively. Overall, 218 patients (56%) would have their risk category revised upwards, while no patients would be downgraded.

The median CACS was 5 (IQR 0–71 AU), with 166 patients (43%) having CACS = 0, and 81 (21%) presenting CACS values ≥100.

SCORE and SCORE-2 showed similar discriminative power to identify patients with CACS ≥100 (C-statistic 0.77, 95% CI 0.71–0.82, vs. 0.75, 95% CI 0.69–0.80, P=0.109 for comparison]. The up-reclassification of risk conveyed by SCORE-2 affected patients across all categories of CACS (Fig. 1).

The proportion of patients in whom statin therapy would generally be indicated was higher with the SCORE-2 criteria vs. the SCORE algorithm (61% vs. 29%, respectively, p<0.001). The broadening of potential indication for statin therapy spanned all categories of CACS, including patients with CACS = 0 (Fig. 2).

Conclusion

Even though the discriminative power of SCORE-2 is similar to the older SCORE, the introduction of age-specific thresholds results in the up-reclassification of risk in roughly half of the patients. The application of SCORE-2 will broaden statin eligibility overall, not only in patients with high atherosclerotic burden, but also in those with CACS = 0. These findings support the use of risk modifiers in selected patients to improve the effectiveness of statin therapy.

Funding Acknowledgement

Type of funding sources: None.

Vascular closure device in TAVI with a dedicated endovascular plug-based device – experience from a high-volume tertiary center

Background

Vascular complications at the access site are important adverse events during transcatheter aortic valve implantation (TAVI). Effective, reproducible, and safe closure of large bore arteriotomies remains challenging as management strategies vary among centers and operators. MANTAÒ is a dedicated plug-based vascular closure device (VCD) recently approved for percutaneous access site closure. This study aimed to describe our experience and to determine the safety and effectiveness of MANTAÒ for large bore arteriotomies during transfemoral TAVI.

Methods

Single center retrospective analysis on prospectively collected data of all consecutive patients who underwent transfemoral TAVI from 2018 to 2020. The primary safety outcomes were access-related vascular injury and bleeding complications according to VARC-3 criteria. Technical success was defined as puncture closure obtained with MANTAÒ without the use of unplanned endovascular or surgical intervention. A secondary analysis according to center experience was performed.

Results

Of the 535 patients that underwent transfemoral TAVI during the study period (median age = 84 [IQR 80–87], 39.4% male; median EuroSCORE II of 3.89% [IQR 2.62–5.39]), MANTAÒ VCD was deployed in 320 (59.8%). Overall, 32 (10.0%) patients suffered an access-related vascular injury and 22 (6.6%) had a bleeding complication (Figure 1A). Technical success was achieved in most cases (n=298; 93.1%). 30-day mortality rate was 1.6% (n=5). Since the first deployment in mid-2018, the rates of MANTA-related complications decreased with increasing experience and a steep learning curve effect was noted (Figure 1B).

Conclusions

MANTAÒ was rapidly adopted as the default strategy for vascular access site closure after TAVI at our center. A relatively steep learning was observed, suggesting that few procedures are required to acquire device proficiency. In addition, our results suggest that MANTA Ò can effectively close large bore arteriotomies with a low risk of severe complications.

Funding Acknowledgement

Type of funding sources: None.

Influence of age on the diagnostic value of coronary artery calcium score for ruling out coronary stenosis in symptomatic patients

Background

The 2021 Guideline for the Evaluation of Chest Pain supports the use of coronary artery calcium (CAC) score as a reasonable first-line test to identify patients with a low likelihood of obstructive coronary artery disease (CAD) who may not require additional testing (class IIa, LOE B). However, a recent study from a large cohort of Northern European patients raised concerns about the added diagnostic value of CAC=0 in younger patients. The aim of this study was to assess the influence of age on the value of CAC=0 in symptomatic patients undergoing coronary computed tomography angiography (CCTA).

Methods

We conducted a two-center cross-sectional study assessing symptomatic patients with suspected CAD who underwent CAC score and CCTA. Key exclusion criteria were age <30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Pretest probability of obstructive CAD was calculated based on age, sex and symptom typicality, according to the guideline-recommended method. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The diagnostic likelihood ratios and negative predictive values (NPV) were used to assess the diagnostic value of a CAC score of 0 to rule out obstructive CAD.

Results

A total of 2043 patients (mean age 60±11 years, 60% women) of whom 990 (48.5%) had a CAC score of 0 were included in the analysis. Symptom characteristics were: 38% non-anginal chest pain, 30% atypical angina, 19% dyspnea, and 13% typical chest pain. Overall, the prevalence of obstructive CAD was 12.8% (n=262). Pretest probability of obstructive CAD increased progressively with age, from 6.0% in patients young than 50 years to 20.7% in those 70 years or older. Contrariwise, the prevalence of patients with a CAC score = 0 decreased from 77% in patients younger than 50 years, to 26% in those who where 70 years or older.

The added diagnostic value of a CAC score = 0 was lower in younger patients, with negative likelihood ratios ranging from 0.36 (64% decrease in the likelihood of CAD) in patients younger than 50 years, to 0.09 and 0.10 (∼90% decrease in the likelihood of CAD) in those aged 60–69 years and 70 years or older, respectively – Figure 1.

Despite this, the prevalence of obstructive CAD among patients with a CAC score = 0 was low across all age groups: 2.4% (i.e., NPV = 97.6%) in those younger than 50 years, 3.0% (NPV = 97.0%) among those aged 50–59 years, 1.5% (NPV = 98.5%) in patients between 60 and 69 years, and 2.0% (NPV = 98.0%) among those 70 years or older.

Conclusions

In a cohort of symptomatic patients undergoing CCTA for suspected CAD, the added diagnostic value of a CAC score of zero decreases significantly at younger ages. However, this “diminishing return” of CAC in younger patients if offset by their lower pretest probabilities, yielding high negative predictive values independently of age.

Funding Acknowledgement

Type of funding sources: None.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into “core” DCF and “peri-infarct” GZF zones based on signal intensity (>5 SD, and 2–5 SD above the mean of reference myocardium, respectively).

The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 88 patients (median age 61 years [IQR 54–73], 84% male, median LVEF 30% [IQR 23–36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9–38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4±14.7 g vs. 28.0±15.3 g; P=0.601) but a greater amount of GZF (18.1±9.6 g vs. 11.9±6.7 g; P=0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95% CI: 1.02–1.15; P=0.006), whereas DCF was not (HR: 1.01 per gram; 95% CI: 0.98–1.05; P=0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01–1.12; P=0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9 g, but in only 2 of the 53 patients (3.8%) with GZF <11.9 g – Figure 1.

Conclusions

The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Funding Acknowledgement

Type of funding sources: None.

Use of coronary calcium score to refine the cardiovascular risk classification of the new SCORE2 and SCORE2-OP algorithms in patients undergoing coronary CT angiography

Introduction

Recently, the European Society of Cardiology issued new algorithms (SCORE-2 and SCORE2-OP) to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). CACS has been shown to reclassify a significant proportion of patients when applied on top of several scores, but data on its use with these new algorithms are lacking.

The aim of this study was to assess the risk reassignment that can be attained by using CACS as a risk modifier of the SCORE-2 / SCORE2-OP classification, in patients referred for coronary CT angiography (CCTA).

Methods

Individuals without diabetes or known ASCVD were included in a single center registry of patients undergoing CCTA for suspected coronary artery disease (CAD). The 10-year risk of cardiovascular disease was calculated for each patient using SCORE-2 (ages 40–69) or SCORE2-OP (ages 70–89), and categorised as low-to-moderate, high, or very-high risk, according to guideline-recommended age-specific thresholds. CACS was considered to reclassify risk one level downward if = 0 in high or very-high risk patients, and reclassify risk upward if >100 (or >75th percentile) in those with low-to-moderate risk, or >1000 in those with high-risk.

Results

A total of 529 patients (43% men, mean age 63±10 years) were included, of which 13% (n=69) were active smokers. The mean systolic blood pressure and non-HDL-C values were 137±18 mmHg and 140±37 mg/dL, respectively.

A total of 47 patients (9%) had obstructive CAD on CCTA, classifying them as very-high risk. In the remainder 482 patients without obstructive CAD, the median CACS was 8 (IQR 0–80 AU), with 194 patients (40%) having CACS = 0, and 111 (23%) presenting CACS values ≥100.

The proportion of patients classified as low-to-moderate risk, high risk, and very high risk was 36%, 46% and 19% using the SCORE-2 / SCORE2-OP algorithm.

Using CACS would reclassify 150 patients (31%): 107 patients (22%) downward, and 43 patients (9%) upward. The extent of risk reclassification conveyed by CACS was 33% in patients assessed with SCORE-2, and 25% with SCORE-2 OP (p=0.082). Overall, most of the risk reassignment (42%, n=93) would occur in patients originally classified as high-risk – Fig. 1.

At the time of testing, 32% (n=61) of patients with CACS = 0 were being treated with statins, whereas 52% (n=58) of those with CACS ≥100 were not.

Conclusion

Even when the most recent SCORE-2 / SCORE-2 OP algorithms are used, risk refinement with CACS leads to the reclassification of nearly one third of the patients undergoing CCTA, mostly from downgrading risk. This opportunistic use of CACS may be employed to improve the allocation of primary prevention therapies.

Funding Acknowledgement

Type of funding sources: None.

Implications of the North American 2021 Chest Pain guidelines in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease

Background

The North American 2021 Chest Pain Guidelines recommend not testing stable patients with low pretest likelihood of obstructive coronary artery disease (CAD), defined as pretest probability <15% using contemporary models (Class I recommendation). In selected cases among this subset of patients, coronary artery calcium (CAC) score is considered a “reasonable first-line test” (Class IIa). Despite some supporting evidence, the clinical implications of a widespread adoption of these recommendations remain unclear.

The purpose of this study was to assess the results of three different testing strategies for patients with pretest probability <15%: A) defer testing; B) perform CAC score and withhold further testing if = 0, and proceed to coronary CT angiography (CCTA) if >0; C) perform CCTA in all.

Methods

We conducted a two-center cross-sectional study assessing symptomatic patients with suspected CAD who underwent CAC score and CCTA. Patients with known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea were excluded. Pretest probability of obstructive CAD was calculated based on age, sex and symptom typicality. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA.

Results

A total of 2259 patients were screened, of which 1385 (61.3%) had pretest probability <15% and were included in the analysis (mean age 57±11 years, 79% women). Symptom characteristics were: 48% non-anginal chest pain, 26% atypical angina, 21% dyspnea, and 5% typical chest pain. Overall, the prevalence of obstructive CAD was 10.3% (n=142). In the 786 patients (56.6%) with a CAC score of 0, 8.5% (n=67) had some degree of CAD [1.9% (n=15) obstructive, and 6.6% (n=52) nonobstructive]. Among those with CAC >0 (n=599), 21.2% (n=127) had obstructive CAD. The results that would be reached with each of the 3 diagnostic strategies are presented in Figure 1. The number of patients needed to scan with strategy B (CAC as gatekeeper) vs. A (no testing) to identify one patient with obstructive CAD was 11, whereas the number needed to scan with strategy C (CCTA for all) vs. strategy B was 91.

Conclusions

Not testing patients with suspected CAD and pretest likelihood <15% would lead to missing obstructive CAD in 1 out of 10 patients. Using CAC as a gatekeeper in this subgroup would decrease the use of CCTA by more than 50%, at the cost of missing obstructive CAD in 1 out of 100 patients. These findings may be used to inform decisions on testing, which will ultimately depend on how much diagnostic uncertainty and missed diagnoses patients and their physicians are willing to accept.

Funding Acknowledgement

Type of funding sources: None.

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden cardiac death

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the “MADIT-ICD benefit score”, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT >200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8–38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269). In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores <7 (log rank p=0.104).

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036).

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

Funding Acknowledgement

Type of funding sources: None.

Transthyretin amyloid cardiomyopathy: a 2-year single-centre experience

Background

Transthyretin Amyloid Cardiomyopathy (ATTR-CM) is an under-diagnosed condition often presenting with Heart Failure (HF). We aimed to assess a cohort of patients with ATTR-CM and HF, focusing on the centre strategies to identify new cases, prognosticate and tailor treatment.

Methods

We conducted an all-comers single-centre prospective registry of consecutive patients with HF due to ATTR-CM followed in our centre from November 2019 to 2021. As per site protocol, diagnosis is established according to the algorithm by Gilmore et al. and all patients are assessed in our HF outpatient clinic at least twice yearly with systematic electronic chart data collection. We evaluated disease-modifying treatment and compliance with the current European Guidelines and CHAD-STOP management. A summary of this program is presented in the central figure.

Results

Overall, 60 patients were included (mean age 83±7 years; 80% male). ATTR-CM was confirmed by the non-invasive algorithm in all but 8 patients, in whom endomyocardial biopsy was positive. Of those undergoing genetic testing (n=30), 7 (23%) presented with the hereditary form of ATTR-CM (4 Val50Met and 3 Val142Ile mutations). The initial presentation was most often HF (n=43), atrial fibrillation (n=9), or “incidental” myocardial uptake on 99mTc-HMDP bone scintigraphy (grade 2) performed for cancer staging (n=5). Beta-blockers were reduced or stopped in 40 (67%) patients, all of whom improved in NYHA class and/or NT-proBNP (>30% reduction) at 1–3 months. Tafamidis 61mg was started in 22 patients and 15 more currently await approval. Those initiated on or referred to tafamidis 61mg (n=37) had less severe HF, as per NYHA (class I-II – 94 vs. 50%, p=0.033) and performance status (e.g. Karnofsky score 80–100 – 79 vs. 21%, p=0.010). Of those already on tafamidis (n=22), NYHA class remained stable or improved in all but 1 patient. In the year following vs. preceding treatment there was 2 vs. 3 total HF hospitalizations. No drug-related severe adverse events were reported. Over a 2-year follow-up, 14 (23.3%) patients died, of whom 1 was on tafamidis (compassionate use for 19 months).

Conclusions

ATTR-CM recognition is improving in our dedicated rare disease program, possibly due to the implementation of several alert pathways. The identification of the disease at an earlier stage allows targeted treatment, compliant with the recommendations. Nonetheless, the rarity of this disease and the required expertise for its optimal management argues in favour of a national strategic plan based on referral centres for ATTR-CM.

Funding Acknowledgement

Type of funding sources: None.

Management of postmenopausal women: Collège National des Gynécologues et Obstétriciens Français (CNGOF) and Groupe d'Etude sur la Ménopause et le Vieillissement (GEMVi) Clinical Practice Guidelines

AIM

The aim of these recommendations is to set forth an individualized approach to the management of early postmenopausal women (i.e., within the first 10 years after natural menopause) covering all aspects of lifestyle and therapeutic management, with or without menopause hormone therapy (MHT).

MATERIALS AND METHODS

Literature review and consensus of French expert opinion. Recommendations were graded according to the HAS methodology and levels of evidence derived from the international literature, except when there was no good-quality evidence.

SUMMARY RECOMMENDATIONS

The beginning of menopause is an ideal time for each woman to evaluate her health status by assessing her bone, cardiovascular, and cancer-related risk factors that may be amplified by postmenopausal estrogen deficiency and by reviewing her lifestyle habits. Improving lifestyle, including nutrition and physical activity, and avoiding risk factors (notably smoking), should be recommended to all women. MHT remains the most effective treatment for vasomotor symptoms but it could be also recommended as first-line treatment for the prevention of osteoporosis in early postmenopausal women at low to moderate risk for fracture. The risks of MHT differ depending on its type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. There is reasonable evidence that using transdermal estradiol in association with micronized progesterone or dydrogesterone may limit both the venous thromboembolic risk associated with oral estrogens and the risk of breast cancer associated with synthetic progestins. Treatment should be individualized to each woman, by using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of its benefit-risk balance. For bothersome genitourinary syndrome of menopause (GSM) symptoms, vaginal treatment with lubricants and moisturizers is recommended as first-line treatment together with low-dose vaginal estrogen therapy, depending on the clinical course. No recommendation of an optimal duration of MHT can be made, but it must take into consideration the initial indication for MHT as well as each woman's benefit-risk balance. Management of gynecological side-effects of MHT is also examined. These recommendations are endorsed by the Groupe d'Etude sur la Ménopause et le Vieillissement hormonal (GEMVI) and the Collège National des Gynécologues-Obstétriciens Français (CNGOF).

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with non-ischemic dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden card

Funding Acknowledgements

Type of funding sources: None.

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the ‘MADIT-ICD benefit score’, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥ 7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT >200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥ 7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8-38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269) – Fig 1A. In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores <7 (log rank p= 0.104) – Fig 1B.

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036) – Fig 1C.

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct "gray zone" of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into "core" DCF and "peri-infarct" GZF zones based on signal intensity (>5 SD, and 2-5 SD above the mean of reference myocardium, respectively).

The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 88 patients (median age 61 years [IQR 54-73], 84% male, median LVEF 30% [IQR 23-36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9-38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4g ± 14.7 vs. 28.0g ± 15.3; P = 0.601) but a greater amount of GZF (18.1g ± 9.6 vs. 11.9g ± 6.7; P = 0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95%CI: 1.02-1.15; P = 0.006), whereas DCF was not (HR: 1.01 per gram; 95%CI: 0.98-1.05; P = 0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01-1.12; P = 0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9g, but in only 2 of the 53 patients (3.8%) with GZF <11.9g – Figure.

Conclusions

The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Benefits of a Supervised Ambulatory Outpatient Program in a Cardiovascular Rehabilitation Unit Prior to a Heart Transplant: A Case Study

Preoperative peak oxygen uptake (V.O2peak) and ventilatory efficiency (V.E/V.CO2slope) are related to the vital prognosis after cardiac transplantation (HTx). The objective of our study was to evaluate the effects of exercise-based cardiac rehabilitation (ECR) program on the preoperative exercise capacity of a HTx candidate. A male patient, aged 50–55 years, with chronic heart failure was placed on the HTx list and performed 12 weeks of intensive ECR (5 sessions-a-week). Our results showed that the cardiac index continuously increased between the onset and the end of ECR (1.40 vs. 2.53 L.min–1.m2). The first 20 sessions of ECR induced a V.O2peak increase (15.0 vs. 19.3 ml.min–1.kg–1, corresponding to 42.0 and 53.0% of its maximal predicted values, respectively). The peak V.O2 plateaued between the 20th and the 40th ECR session (19.3 vs. 19.4 ml.min–1.kg–1) then progressively increased until the 60th ECR session to reach 25.7 ml.min–1.kg–1, i.e., 71.0% of the maximal predicted values. The slope of V.E/V.CO2 showed a biphasic response during the ECR program, with an increase between the onset and the 20th ECR session (58.02 vs. 70.48) and a decrease between the 20th and the 40th ECR session (70.48 vs. 40.94) to reach its minimal value at the 60th ECR session (31.97). After the first 40 sessions of the ECR program, the Seattle Heart Failure Model score predicted median survival time was estimated at 7.2 years. In conclusion, the improvement in exercise capacity and cardiorespiratory function following the ECR helped delay the heart transplant surgery in our patient awaiting heart transplantation.

Prognostic significance of peak atrial longitudinal strain in patients with functional mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic mitral regurgitation has been shown to promote left atrial (LA) dysfunction and remodeling. However, the significance of LA dysfunction in this setting has not been fully investigated. The aim of our study was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in a cohort of patients with LV systolic dysfunction and functional mitral regurgitation (FMR).

Methods

Patients with at least mild FMR and reduced LVEF (< 50%) under optimized medical therapy who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single-centre. FMR grading was undertaken according to the new 2021 valvular guidelines. PALS was assessed by 2D speckle tracking in apical 4-chamber view (as per EACVI current recommendations). Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters, namely PALS, and all-cause mortality.

Results

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median mitral regurgitant volume was 25mL (IQR: 14 – 34mL). According to the new ESC 2021 valvular guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. Median PALS was 14% (IQR 8 – 20%). The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS (figure 1). On ROC curve analysis, the best PALS cut-off value associated with mortality was < 15%. Kaplan-Meier survival curves according to FMR severity and PALS > or < 15% are depicted in figure 2. PALS remained independently associated with all-cause mortality on multivariable analysis (adjusted hazard ratio [aHR]: 0.94; 95%CI: 0.90 – 0.98; p = 0.004) even after adjustment for several (n = 14) clinical and echocardiographic confounders.

Conclusion

In a cohort of patients with reduced LVEF and functional mitral regurgitation, peak atrial longitudinal strain was associated with all-cause mortality. Abstract Figure 1  Abstract Figure 2

Bone Phenotyping Approaches in Human, Mice and Zebrafish - Expert Overview of the EU Cost Action GEMSTONE ("GEnomics of MusculoSkeletal traits TranslatiOnal NEtwork")

A synoptic overview of scientific methods applied in bone and associated research fields across species has yet to be published. Experts from the EU Cost Action GEMSTONE ("GEnomics of MusculoSkeletal Traits translational Network") Working Group 2 present an overview of the routine techniques as well as clinical and research approaches employed to characterize bone phenotypes in humans and selected animal models (mice and zebrafish) of health and disease. The goal is consolidation of knowledge and a map for future research. This expert paper provides a comprehensive overview of state-of-the-art technologies to investigate bone properties in humans and animals - including their strengths and weaknesses. New research methodologies are outlined and future strategies are discussed to combine phenotypic with rapidly developing -omics data in order to advance musculoskeletal research and move towards "personalised medicine".

Validation of a novel framework defining the acceptable standard of care for heart failure with reduced ejection fraction

Background

In heart failure with reduced ejection fraction (HFrEF), uptitration of neurohormonal antagonists to trial-proven doses shown to reduce mortality is challenging and seldomly achieved in clinical practice. A major reason for underdosing of these agents is the lack of a clear description of what constitutes an acceptable standard of care in HFrEF. To address this limitation, a novel framework for describing the physician adherence to evidence-based treatment was recently proposed. The aim of our study was to evaluate and validate the proposed framework in a real-world population of patients with HFrEF.

Methods

A cohort of patients with HFrEF, defined as left ventricular ejection fraction (LVEF) <40%, under treatment with neurohormonal antagonists for at least 3 months were retrospectively identified at a tertiary hospital's Heart Failure Clinic. Demographic, clinical, echocardiographic and treatment data were assessed. Patients were divided in three strata for each neurohormonal antagonist, according to the proposed framework: Status I – patients receiving target doses or the highest tolerated dose; Status II – use of subtarget doses for reasons unrelated to clinically important intolerance; and Status III – not receiving the drug at any dose. The prognostic value of each strata was assessed for all-cause mortality.

Results

A total of 408 patients (mean age 68±12 years, 78% male, 63% ischemic etiology) were included. The median LVEF was 31% (IQR 25–36) and most patients were in NYHA class II or III [210 (51.5%) and 163 (40%), respectively]. Medical therapy is described in Table 1. During a median follow-up of 3.3 years (IQR 1.4–5.6), 210 patients died. On univariable analysis, achieving Status I of beta-blocker (BB) therapy (HR: 0.50; 95% CI: 0.32–0.81; P=0.004) or ACEi/ARB (HR: 0.56; 95% CI: 0.36–0.86; P=0.012) was associated with reduced all-cause mortality. The mortality of patients in Status II of BB or ACEi/ARB was similar to the mortality of those not receiving the drug (HR for BB: 0.90; 95% CI: 0.53–1.52; P=0.69 and HR for ACEi/ARB: 0.71; 95% CI: 0.42–1.18; P=0.182) – figure 1. Achieving Status I of BB remained independently associated with reduced mortality after adjustment for several clinical and echocardiographic confounders (n=13) (adjusted HR: 0.59; 95% CI: 0.35–0.98; P=0.041).

Conclusions

In this real-world population of patients with HFrEF, the vast majority of patients were in Status I of BB and ACEi/ARB therapy. Achieving Status I of BB therapy seems to be associated with reduced mortality, even after adjustment for several markers of disease severity, highlighting the need for uptitration of medical therapy to maximal tolerated doses according to trial-proven regimens.

Funding Acknowledgement

Type of funding sources: None.

Anomalous origin of the right coronary artery with interarterial course: red flag or innocent bystander?

Aims

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD).

Methods and results

We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Right-ACAOS with IAC patients were analyzed for cardiac symptoms and long-term occurrence of first MACE (SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55±17 years, 64% were male and 11 (39.3%) presented with stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no CV deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel.

Conclusion

Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.

Funding Acknowledgement

Type of funding sources: None.

Incorporating coronary calcification into pretest assessment of the likelihood of coronary artery disease: validation and recalibration of a new diagnostic tool

Background

A new clinical tool was recently proposed to improve the estimation of pre-test probability of obstructive coronary artery disease (CAD) by incorporating coronary artery calcium score (CACS) with clinical risk factors. This new model (Clinical+CACS) showed improved prediction when compared to the method recommended by the 2019 ESC guidelines on chronic coronary syndromes, but was never tested or adjusted for use in our population. The aim of this study was to assess the performance of this new method in a Portuguese cohort of symptomatic patients referred for coronary computed tomography angiography (CCTA), and to recalibrate it if necessary.

Methods

We conducted a two-center cross-sectional study assessing symptomatic patients who underwent CCTA for suspected CAD. Key exclusion criteria were age <30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The Clinical+CACS prediction model was assessed for discrimination and calibration. A logistical recalibration of the model was conducted in a random sample of 50% of the patients and subsequently validated in the other half.

Results

A total of 1910 patients (mean age 60±11 years, 60% women) were included in the analysis. Symptom characteristics were: 39% non-anginal chest pain, 30% atypical angina, 19% dyspnea and 12% typical angina. The observed prevalence of obstructive CAD was 12.9% (n=247). Patients with obstructive CAD were more often male, were significantly older, had higher prevalence of typical angina and cardiovascular risk factors, and higher CACS values. The new Clinical+CACS tool showed greater discriminative power than the ESC 2019 prediction model, with a C-statistic of 0.83 (CI 95% 0.81–0.86) versus 0.67 (CI 95% 0.64–0.71), respectively (p-value for comparison <0.001). Before recalibration, the Clinical+CACS model underestimated the likelihood of CAD in our population across all quartiles of pretest probability (mean relative underestimation of 49%), which was subsequently corrected by the recalibration procedure - Figure.

Conclusions

In a Portuguese cohort of symptomatic patients undergoing CCTA for suspected CAD, the new Clinical+CACS model showed better discrimination power than the 2019 ESC method. The underestimation of the Clinical+CACS model was corrected by recalibrating it for our population. This new tool might prove useful for guiding decisions on the need for further testing.

Funding Acknowledgement

Type of funding sources: None.

The gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than total myocardial fibrosis in patients with previous myocardial infarction

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on the assessment of left ventricular ejection fraction (LVEF), but markers that could refine risk assessment are needed. Total fibrosis mass (TFM) and “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether TFM and GZF can predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling all consecutive patients with previous myocardial infarction undergoing LGE-CMR before implantable cardioverter-defibrillator (ICD) implantation for primary or secondary prevention. TFM and GZF were defined as myocardial tissue with signal-intensities >6 SD and 2–6 SD above the mean of reference myocardium, respectively. The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 55 patients (mean age 62±12 years, 87% male, mean LVEF 30% ± 8%) were included. During a mean follow-up period of 34±15 months, 10 patients reached the primary endpoint (8 appropriate ICD shock, 2 sustained VT or VF). Patients who attained the primary endpoint had similar TFM (28.6g ± 14.5 vs. 23.1g ± 14.5; P=0.283) but larger GZF (25.3g ± 11.0 vs 15.6g ± 7.3; P=0.001). After adjustment for LVEF, GZF remained independently associated with the composite arrhythmic endpoint (adjusted hazard ratio [aHR]: 1.10; 95% CI: 1.03–1.17; P=0.005), whereas TFM did not (aHR: 1.02; 95% CI: 0.98–1.06; P=0.394). Decision tree analysis identified 16.4g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 9 out of the 22 patients (41%) with GZF >16.4g, but in only 1 of the 33 patients (3%) with GZF ≤16.4g – Figure.

Conclusions

The extent of GZF seems to be a better predictor of ventricular arrhythmias than TFM. This LGE-CMR parameter may be useful to identify a subgroup of patients with previous myocardial infarction at an increased risk of life-threatening arrhythmic events.

Funding Acknowledgement

Type of funding sources: None.

Anticipating recurrent ischemic events after an acute coronary syndrome: validation and application of the SMART-REACH score

Background

The SMART-REACH score (SRS) was developed to predict the risk of major adverse cardiovascular events in ambulatory patients with established cardiovascular disease, although it has not been extensively validated. Patients at higher risk of recurrent ischemic events may benefit from novel, more intensive treatment options, and earlier identification of these patients can potentially improve outcomes.

Purpose

We aimed to validate the SRS and evaluate its performance in a population recently admitted with acute coronary syndrome.

Methods

In this single-centre retrospective cohort, we included 320 patients aged 45 to 80 years, who were discharged following admission for an acute coronary syndrome between 2016 and 2018. To calculate the SRS for each patient, we considered clinical data on admission (age, gender, smoking, diabetes, prior history of vascular disease, heart failure or atrial fibrillation), lipid values obtained within the first 24 hours of hospitalization, serum creatinine level at baseline and once the patient was deemed clinically stable, and discharge medication. The outcome of interest was defined as stroke, myocardial infarction or cardiovascular death (MACE) at two years of follow-up. SRS was assessed for discrimination and calibration.

Results

Mean age was 63±9 years, and 240 (75%) were male. There was high prevalence of cardiovascular risk factors: 71% had hypertension, 32% had diabetes mellitus, 42% were active smokers and 25% had previously established cardiovascular disease. The outcome of interest was observed in 38 patients (22 cardiovascular deaths, 6 strokes and 14 myocardial infarctions). SRS showed good discrimination of the estimated MACE risk with overall C-statistic of 0.646 (95% CI, 0.554–0.737, p=0.004) (picture 1) and calibration (p-value for the goodness-of-fit test of 0.544). The global estimated risk of MACE at 2-years was 4.8% (3.8%-6.8%). The expected/ observed ratio was 0.56 for the occurrence MACE (picture 2).

Conclusions

Over the first two years after discharge from an acute coronary syndrome, one of every 8 patients developed a potentially fatal recurrent ischemic event. The SRS performed reasonably well in discriminating those at highest risk of MACE, suggesting that this score may help select patients at discharge for ad initium more intensive pharmacological therapy.

Funding Acknowledgement

Type of funding sources: None. ROC curve for the SMART-REACH scoreExpected versus observed MACE

Chronic heart failure in intensive care unit: can we accurately predict the risk?

Background

Severity of disease scoring systems, namely the Simplified Acute Physiology Score (SAPS) and Acute Physiology and Chronic Health Evaluation (APACHE), are widely used to predict mortality in Intensive Care Units (ICU). Yet, neither score includes chronic HF in their model. We aimed to evaluate whether these scores perform well in risk prediction of death of patients previously diagnosed with heart failure (HF).

Methodology

This is a single-center retrospective cohort of patients admitted to an ICU in 2019. Those whose admission lasted <24 hours were excluded from analysis. The SAPS II and APACHE II scores were calculated using data from the first 24 hours of ICU admission, imputing the worst variable obtained within this timeframe. HF was defined according to the ESC recommendations. In order to assess the performance of the scores, Receiver Operating Characteristic (ROC) Curves were used to predict the risk of death in ICU in HF compared to the non-HF population.

Results

A total of 267 patients were hospitalized in ICU for a period over 24 hours in 2019 (mean age 67±16 years; 58.8% males; 21.7% with chronic HF; 33.7% admitted for sepsis). Compared to patients without HF, those with chronic HF were older (74±13 vs. 65±16 years; p<0.001) and had higher risk scores (mean SAPS II: 43.2±21.7 vs. 56.5±20.7; p<0.001; mean APACHE II: 19.8±10.0 vs. 25.1±10.0; p<0.001). Moreover, these patients were at higher risk of meaningful events during hospitalization (e.g. acute kidney injury: 38.0 vs. 66.1%; p<0.001; shock at any time: 52.4 vs. 67.8%; p=0.036). Furthermore, patients with HF had a trend towards higher mortality rates in ICU (17.3 vs. 28.8%; p=0.051) and a significantly higher death in overall hospitalization (30.8 vs. 45.8%; p=0.032). ROC curves performed well in predicting the risk of ICU death regardless of HF (SAPS II – AUC 0.78 vs. 0.81; p=0.36; APACHE II – AUC 0.75 vs. 0.78; p=0.37).

Conclusion

Approximately 1 in every 4 patients admitted to the ICU had chronic HF. Traditional risk scoring systems (SAPS II and APACHE II) performed well regardless of HF. While these results are reassuring as far as risk stratification accuracy is concerned, HF patients remained at a higher risk for worse outcomes. Therefore, prognostic tools with a therapeutic clinical applicability are urgently needed to improve the outcome of this population.

Funding Acknowledgement

Type of funding sources: None.

Long-term durability of transcatheter aortic valve replacement: outcomes from a contemporary cohort from a tertiary reference center at 5-years and beyond

Background and aim

Long-term data on the durability of transcatheter heart valves is scarce. This is of particular interest as indications expand to younger and lower surgical risk patients. We sought to assess the incidence of long-term structural valve dysfunction (SVD) and bioprosthetic valve failure (BVF) in a cohort of patients with TAVR who reached at least 5-year follow-up, as compared to surgical aortic valve replacement (SAVR), performed within the same time-frame at the same institution.

Methods and results

Consecutive patients with at least 5-year available follow-up, who underwent TAVR between November 2008 to December 2015 in a tertiary single center, were included. From a group of 246 patients undergoing TAVR, 126 had available follow-up data (age at implantation: 83.0 [77.8–87.0] years; EuroScore II: 4.54 [2.60–6.29]%; follow-up: 5.94 [5.06–7.67] years). First generation Corevalve® and Sapien® prosthesis were implanted in 56% and 38% patients, respectively.

SVD and BVF were defined according to the new consensus statement from the EAPCI endorsed by the ESC and the EACTS. Mean transaortic pressure gradients decreased from 53.2±1.3 mmHg (pre-TAVR) to 10.4±0.4 mmHg (at discharge or up to one-year after TAVR, p<0.001), and there was a small non-significant increase at the fifth-year and the last available follow-up (11.2±0.6 mmHg; 14.7±1.8 mmHg, respectively). Moderate and severe SVD were reported in 12 and 4 patients, respectively (8-year cumulative incidence function to SVD: 2.67%; 95% CI, 2.12–3.89). Of these 8 had BVF, 7 of them with hospitalization for acute heart failure. A total of 4 patients died and none required reintervention (redo TAVR or SAVR). BVF for non-SVD were observed in 4 patients (2 subclinic thrombosis successfully treated with anticoagulation and 2 paravalvular regurgitation due to endocarditis).

As comparator, from a cohort of 587 patients submitted to biological SAVR, 247 (age 75.0 [70.0–79.0] years; EuroScore II 1.43 [1.06–2.17]%) had available long-term follow-up (6.89 [6.08–8.19] years). Moderate and severe SVD were reported in 42 and 3 patients, respectively (8-year cumulative incidence function to SVD: 3.13%; 95% CI, 2.45–4.21). These events were clinically relevant (BVF) in 19 of them: 8 performed TAVR valve-in-valve procedures and 3 redo SAVR. At the fifth-year of follow-up the incidence of SVD was not statistically different between TAVR (8%) and SAVR (15%), with a p for comparison of 0.137.

Conclusions

In our population of patients with symptomatic severe aortic stenosis treated with first-generation percutaneous bioprostheses, TAVR was associated with a low incidence of BVF and SVD at the long-term follow-up. These outcomes seem indistinct from those occurring in patients submitted to conventional SAVR

Funding Acknowledgement

Type of funding sources: None. KM curve reporting probability of SVD

Coronary artery calcium score to predict coronary CT angiography interpretability: an old problem revisited

Funding Acknowledgements

Type of funding sources: None.

Introduction

Clinical guidelines recommend against the use of coronary computed tomography angiography (CCTA) in patients with heavy calcification due to interpretability concerns, but no specific approach or threshold is provided. Recently, alternative methods have been proposed as more reliable predictors of CCTA interpretability than the classic coronary artery calcium score (CACS).  The purpose this study was to compare the performance of different measures of coronary calcification as predictors of CCTA interpretability.

Methods

We conducted a retrospective analysis of consecutive patients undergoing CACS and CCTA between 2018 and 2020. The key exclusion criteria were known coronary artery disease, CACS of zero, and presence of non-assessable coronary lesions for reasons other than calcification (movement/gating artifacts or vessel diameter < 2mm). CCTA studies were considered non-interpretable if the main reader considered one or more coronary lesions non-assessable due to calcification. Three different measures of coronary calcification were compared using ROC curve analysis: 1) total CACS; 2) CACS-to-lesion ratio (total CACS divided by the number of calcified plaques); and 3) calcium score of the most calcified plaque. Decision-tree analysis was performed to identify the algorithm that best predicts CCTA interpretability.

Results

A total of 432 patients (191 women, mean age 64 ± 11 years) were included. Overall, 31 patients (7.2%) had a non-interpretable CCTA due to calcification. Patients with non-interpretable CCTA had higher CACS (median 589 vs. 50 AU, p < 0.001), higher CACS-to-lesion ratio (median 43 vs. 14 AU/lesion, p < 0.001), and higher score of the most calcified plaque (median 445 vs. 43 AU, p < 0.001). Among the 3 methods, CACS showed the highest discriminative power to predict a non-interpretable CCTA (C-statistic 0.93, 95%CI 0.89-0.95, p < 0.001) - Figure.

Decision-tree analysis identified a single-variable algorithm (CACS value ≤ 515 AU) as the best discriminator of CCTA interpretability: 396 of the 409 patients (97%) with CACS ≤ 515 AU had an interpretable CCTA, whereas only 5 of the 23 patients (22%) with CACS > 515 AU had an interpretable test, yielding a total of 96% correct predictions.

Conclusions

The recently proposed and more complex measures of coronary calcification seem unable to outperform total CACS as a predictor of CCTA interpretability. A simple CACS cutoff-value around 500 AU remains the best discriminator for this purpose.

Anomalous origin of the right coronary artery with interarterial course: red flag or innocent bystander?

Funding Acknowledgements

Type of funding sources: None.

Background

Anomalous origin of the right coronary artery (right ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomographic angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. This study sought to examine the prevalence, anatomical characteristics and outcomes of right ACAOS with IAC in patients undergoing CCTA for all-indications.

Methods

We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital between January 2012 and December 2020. Right ACAOS patients with IAC were analyzed for cardiac symptoms (anginal chest pain, syncope, aborted SCD) and long-term outcomes were evaluated for myocardial infarction, ischemic test results, revascularization procedures and all-cause or cardiovascular (CV) mortality. CCTAs were reviewed for proposed high-risk features (ie., take-off angle, length and severity of proximal narrowing, intramural course, interarterial length) and concomitant coronary artery disease (CAD). Association between high-risk features was analyzed. Long-term outcomes were evaluated.

Results

Among 10,928 patients referred for CCTA during the study period, we identified 28 patients (0.3% prevalence) with right ACAOS and IAC. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented cardiac symptoms. During a median follow-up of 44.1 ± 31.8 months, there were no CV deaths and only 1 patient (3.65%) underwent surgical revascularization. Baseline characteristics and CCTA findings are presented in figure 1.

Conclusion

Right ACAOS and IAC is an uncommon finding, with an observed prevalence of 0.3%. CCTA provides excellent anatomical characterization of anomalous vessels, including suggested high-risk features. In a population of asymptomatic patients who survived this condition well into adulthood, the risk of events was very low and medical follow up might be a reasonable option.

Incorporating coronary calcification into pretest assessment of the likelihood of coronary artery disease: validation and recalibration of a new diagnostic tool

Funding Acknowledgements

Type of funding sources: None.

Background

A new clinical tool was recently proposed to improve the estimation of pre-test probability of obstructive coronary artery disease (CAD) by incorporating coronary artery calcium score (CACS) with clinical risk factors. This new model (Clinical + CACS) showed improved prediction when compared to the method recommended by the 2019 ESC guidelines on chronic coronary syndromes, but was never tested or adjusted for use in our population. The aim of this study was to assess the performance of this new method in a Portuguese cohort of symptomatic patients referred for coronary computed tomography angiography (CCTA), and to recalibrate it if necessary.

Methods

We conducted a two-center cross-sectional study assessing symptomatic patients who underwent CCTA for suspected CAD. Key exclusion criteria were age < 30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The Clinical + CACS prediction model was assessed for discrimination and calibration. A logistical recalibration of the model was conducted in a random sample of 50% of the patients and subsequently validated in the other half.

Results

A total of 1910 patients (mean age 60 ± 11 years, 60% women) were included in the analysis. Symptom characteristics were: 39% non-anginal chest pain, 30% atypical angina, 19% dyspnea and 12% typical angina. The observed prevalence of obstructive CAD was 12.9% (n = 247). Patients with obstructive CAD were more often male, were significantly older, had higher prevalence of typical angina and cardiovascular risk factors, and higher CACS values. The new Clinical + CACS tool showed greater discriminative power than the ESC 2019 prediction model, with a C-statistic of 0.83 (CI 95% 0.81-0.86) versus 0.67 (CI 95% 0.64-0.71), respectively (p-value for comparison < 0.001). Before recalibration, the Clinical + CACS model underestimated the likelihood of CAD in our population across all quartiles of pretest probability (mean relative underestimation of 49%), which was subsequently corrected by the recalibration procedure - Figure.

Conclusions

In a Portuguese cohort of symptomatic patients undergoing CCTA for suspected CAD, the new Clinical + CACS model showed better discrimination power than the 2019 ESC method. The underestimation of the Clinical + CACS model was corrected by recalibrating it for our population. This new tool might prove useful for guiding decisions on the need for further testing.

Patients undergoing invasive coronary angiography after a positive single-photon emission computed tomography or a positive stress cardiac magnetic resonance - What to expect at the cath lab

Funding Acknowledgements

Type of funding sources: None.

Background

 Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). However, there are few data on whether or not this remains true in routine clinical practice.

The aim of this study was to assess the clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after a positive stress CMR or positive SPECT, and to compare their positive predictive value with published results from the CE-MARC trial.

Methods

In this retrospective tertiary-center analysis, we included 429 patients (mean age 67 ± 10 years, 28% women, 42% diabetic) undergoing ICA between January 2016 and December 2020, after a positive stress CMR or positive SPECT. Regarding stress test, an adenosine protocol was performed in all stress CMR and in 76.4% (n = 272) of stress SPECT. 

Stress test results, including ischemia location and severity, were classified as reported by their primary readers. Patients with missing data on key variables, and those in whom microvascular disease was considered likely in the original stress test report were excluded. Obstructive CAD was defined as any coronary artery stenosis ≥ 50% in a vessel compatible with the ischemic territory on stress testing.

Results

Out of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ regarding age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p = 0.046). Overall, 320 patients (75%) had obstructive CAD on ICA. The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p = 0.385). There were also no significant differences in the prevalence of left main or 3-vessel disease (9.0% vs. 9.6%, p = 0.871, and 19.7% vs. 23.3% p = 0.483, respectively). Revascularization was performed or planned in 59.3% of patients in the SPECT group, and 52.1% of those in the stress CMR group (p = 0.255). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial (Figure), and would increase to 88.1% and 89.4% for SPECT and stress CMR, respectively, if patients reported as having only mild ischemia were excluded.

Conclusion

In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial.

Solid-Phase Extraction Embedded Dialysis (SPEED), an Innovative Procedure for the Investigation of Microbial Specialized Metabolites

Solid-phase extraction embedded dialysis (SPEED technology) is an innovative procedure developed to physically separate in-situ, during the cultivation, the mycelium of filament forming microorganisms, such as actinomycetes and fungi, and the XAD-16 resin used to trap the secreted specialized metabolites. SPEED consists of an external nylon cloth and an internal dialysis tube containing the XAD resin. The dialysis barrier selects the molecular weight of the trapped compounds, and prevents the aggregation of biomass or macromolecules on the XAD beads. The external nylon promotes the formation of a microbial biofilm, making SPEED a biofilm supported cultivation process. SPEED technology was applied to the marine Streptomyces albidoflavus 19-S21, isolated from a core of a submerged Kopara sampled at 20 m from the border of a saltwater pond. The chemical space of this strain was investigated effectively using a dereplication strategy based on molecular networking and in-depth chemical analysis. The results highlight the impact of culture support on the molecular profile of Streptomyces albidoflavus 19-S21 secondary metabolites.

Elastase inhibitory activity of secondary metabolites from the fungus Virgaria nigra CF-231658

Three known compounds were isolated from Virgaria nigra CF-231658; 2,7-dihydroxy naphthalene (1), virgaricin B (2) and virgaricin (3). The isolated compounds was obtained from liquid-state and agar-supported fermentation using Amberlite XAD-16 solid-phase extraction during the cultivation step. Their structures were elucidated on the basis of 1D and 2D NMR as well as HRMS spectroscopic analyses. The isolated compounds were examined for their ability to inhibit elastase using normal human diploid fibroblasts. Compound 2 displayed the most potent activity with 76.7 ± 2.12% inhibition of the enzyme activity at 5 μM concentration.

Calcium score of the aortic valve as a predictor of aortic stenosis severity

Funding Acknowledgements

Type of funding sources: None.

Background

The calcium score of the aortic valve (CaScAoV) is now recommended as a supporting tool to assist in the grading of aortic stenosis (AS) severity when echocardiographic assessment is inconclusive. However, the proposed CaScAoV cut-offs for considering severe AS "unlikely", "likely", or "very likely" have never been validated in Portuguese cohorts.

Aim

The purpose of this study was to assess the performance of the proposed CaScAoV cut-offs in identifying patients with severe aortic stenosis.

Methods

A total of 513 consecutive patients (median age 83 years [IQR 79–87], 38% males) evaluated at a single-centre TAVI-programme between Jan/2016 and Nov/2019 were retrospectively identified. Only patients with an ECG-gated cardiac computed tomography (CT) and a transthoracic echocardiography performed within a 6-month time-frame were included. Main exclusion criteria were left ventricular ejection fraction < 50%, indexed stroke volume < 35 ml/m2, previous valve surgery and

bicuspid aortic disease. CaScAoV was measured according to the Agatston method (Agatston units – AU). As previously reported, the likelihood of aortic stenosis as assessed by CT was categorized as: "very likely" (>3000 AU for men, >1600 AU for women); "likely" (>2000 AU for men, >1200 AU for women) ; or unlikely (<1600 AU for men, <800 AU for women). Diagnostic tests performance measures were calculated for each category. Separate analyses were performed for each gender.

Results

Severe AS (mean gradient ≥ 40 mmHg) was present in 422 patients (overall 82.3%: 83.1% in females and 80.8% in males), with a median transvalvular gradient of 49 mmHg (IQR 42 – 60).

Overall, the discriminative ability of the CaScAoV to distinguish severe from non-severe AS was higher in men when compared with women (c-statistic 0.86 [95%CI 0.80 – 0.93] vs. 0.72 [95%CI 0.64 – 0.80], p for comparison < 0.001). In males, the "very likely" cut-off had a sensitivity of 71% (95%CI 63 – 78%), a specificity of 81% (95%CI 65 – 92%), a positive predictive value (PPV) of 94% (95%CI 89 – 97%) and a negative predictive value (NPV) of 40% (95%CI 33 – 46%) for the diagnosis of severe AS. Conversely, in women the sensitivity was 75% (95%CI 69 – 80%), specificity was 57% (95%CI 43 – 71%), PPV was 90% (95%CI 86 – 92%) and NPV was 32% (95%CI 25 – 39%).

On the other end of the spectrum, the "unlikely" cut-off showed poor performance in dismissing severe AS, particularly in females – NPV of 43% (95%CI 25-63%) in women vs. 83% (95%CI 63-93%) in men.

Conclusion

In our population, the discriminative power of CaScAoV for identifying patients with severe AS was lower than in previously published cohorts, particularly in females. While very high CaScAoV is strongly supportive of severe AS, caution should be employed when interpreting low CaScAoV values in women, since the recommended cut-off value does not allow the safe exclusion of severe aortic stenosis.

Abstract Figure. Waterfall chart of individuals CaScAoV

Adapting the concepts of proportionate and disproportionate functional mitral regurgitation to clinical practice

Funding Acknowledgements

Type of funding sources: None.

Background

  Despite its theoretical appeal, the concept of Proportionate and Disproportionate FMR has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority over currently established ways of grading FMR.

Objectives

This study sought to evaluate the prognostic value of a new and individualized method of assessing Functional Mitral Regurgitation (FMR) Proportionality.

Methods

Patients with at least mild FMR and reduced left ventricular ejection fraction (< 50%) under optimal guideline-directed medical therapy were retrospectively identified at a single-center. To determine FMR proportionality status, we used a novel approach where two simple equations establish an individual cut-off of regurgitant volume/effective regurgitant orifice area, categorizing the study population into non-severe, proportionate and disproportionate FMR (Figure 1). The primary endpoint was all-cause mortality.

Results

A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Disproportionate FMR was present in 109 patients (19%) with a median EROA of 26 mm2 (IQR 22-31) and a median RegVol of 40 ml (IQR 34-48), proportionate FMR in 148 patients (26%) with a median EROA of 16mm2 (IQR 12-21) and a median RegVol of 26 ml (IQR 19-32). During a median follow-up of 3.8 years (interquartile range: 1.8 to 6.2 years) there were 254 deaths (44%). The unadjusted mortality incidence per 100 persons-year rose as the degree of FMR disproportionality worsened. On multivariable analysis, disproportionate FMR remained independently associated with all-cause mortality (adjusted hazard ratio: 1.785; 95% confidence interval [CI]: 1.249 to 2.550; P = 0.001). The FMR proportionality concept showed greater discriminative power (C-statistic 0.639; 95% CI: 0.597 to 0.680) than the American (C-statistic 0.588; 95% CI: 0.550 to 0.626; P for comparison = .001) and European guidelines (C-statistic 0.563; 95% CI: 0.534 to 0.591; P for comparison < .001). It was also able to increase the net reclassification index (0.167 [P < 0.001] and 0.084 [P = 0.001], respectively).

Conclusions

A new, simplified and individualized method of assessing FMR Proportionality showed that disproportionate FMR is independently associated with all-cause mortality. This approach seems to outperform the risk stratification of current guidelines.

Abstract Figure 1

Regurgitant volume to left ventricular end-diastolic volume ratio: another step to risk stratification in patients with secondary mitral regurgitation?

Funding Acknowledgements

Type of funding sources: None.

Background

 Quantitative evaluation of secondary mitral valve regurgitation (MR) remains an important yet challenging step in the evaluation of this entity. Its severity can be underestimated when using the proximal isovelocity surface area (PISA) method, which does not take left ventricular (LV) volume into account. Normalizing mitral regurgitant volume (Rvol) for the LV end-diastolic volume (EDV) might overcome this key limitation. This study aimed to investigate the prognostic implication of Rvol/EDV ratio in patients with secondary MR.

Methods

 Patients with at least mild secondary MR and reduced left ventricular ejection fraction (<50%) under optimal guidelines-directed medical therapy were retrospectively identified at a single-center. The cohort was divided into terciles according to the RVol/EDV ratio. The primary endpoint was all-cause mortality.

Results

 A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Median measures of secondary MR were EROA 14 mm2 (IQR 8-22) and RegVol 23 ml (12-34). During a median follow-up of 3.8 years (interquartile range 1.8 to 6.2 years) there were 254 deaths (44%). The unadjusted mortality incidence increases across terciles distribution. Patients at the 2nd and 3rd terciles of the RVol/EDV ratio showed significantly higher mortality when compared to those at the 1st one (baseline reference) (figure 1). After multivariable analysis, terciles of the Rvol/EDV ratio remained independently associated with increased all-cause mortality (considering the 1st tercile as the reference; adjusted HR for the 2nd tercile 1.46 [95% CI 1.05- 2.02]  p = 0.023; adjusted HR for 3rd tercile 1.56 [95% CI 1.09 – 2.22], p = 0.015).

Conclusion

 In patients with secondary MR, Rvol/EDV ratio is independently associated with all-cause mortality. However, the appropriate cut-off to determine any kind of clinical decision remains to be determined.

Abstract Figure.

External validation of the unifying concept for the quantitative assessment of secondary mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

  A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation (SMR) was recently proposed in order to provide a solution for the ongoing guideline controversy. However, these data were derived from a single center cohort and lacks external validation. We aimed to validate the proposed algorithm in a different patient population.

Methods

Patients with at least mild SMR and reduced left ventricular ejection fraction (< 50%) under optimal guideline-directed medical therapy were retrospectively identified at a single-center. The cohort was stratified in low-risk (effective regurgitant orifice area [EROA] < 20 mm2 and regurgitant volume [RegVol] < 30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml) and high-risk (EROA ≥ 30 mm2 and RegVol ≥ 45ml) according to the defined risk-based thresholds tailored to the pathophysiological concept of SMR. In the intermediate-risk group, patients were further stratified on the basis of the hemodynamic severity of SMR, into intermediate low-risk and intermediate high-risk (regurgitant fraction < 50% or ≥ 50%, respectively). The primary endpoint was all-cause mortality.

Results

A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Median measures of SMR severity were EROA of 14 mm2 (IQR 8-22) and RegVol of 23 ml (12-34). During a median follow-up of 3.8 years (interquartile range: 1.8 to 6.2 years) there were 254 deaths (44%). The mortality at 6-years was 38.9% for the low-risk group, 30.7% for the intermediate low-risk, 64.9% in the intermediate high-risk and 63.2% in the high-risk group. On multivariable analysis, the defined thresholds of risk for SMR severity remained independently associated with all-cause mortality (adjusted hazard ratio: 1.164; 95% confidence interval [CI]: 1.020 to 1.327; P = 0.024). The unifying concept showed similar discriminative power (C-statistic 0.588; 95% CI: 0.540 to 0.635) to the American (C-statistic 0.588; 95% CI: 0.541 to 0.635; P for comparison = 1) and European guidelines (C-statistic 0.563; 95% CI: 0.515 to 0.610; P for comparison = 0.458), but it was able to increase the net reclassification index (0.143 [P < .001] and 0.026 [P = .025], respectively).

Conclusions

In this cohort of patients with SMR and LVEF <50%, the proposed unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac proved to be associated with an increased risk of all-cause mortality and could improve risk prediction of current guidelines.

Abstract Figure.

Vascular closure devices in TAVI: MANTA versus ProGlide in a propensity-matched population

Background

Vascular complications increase morbidity and mortality in transcatheter aortic valve implantation (TAVI). A collagen plug-based closure device - MANTA® was recently introduced as an alternative to the suture-mediated ProGlide® vascular closure device (VCD). Data regarding the efficacy and safety comparing both VCD is scarce. The present study sought to compare the effectiveness of both devices.

Methods

Single center retrospective analysis on prospectively collected data of 300 consecutive patients who underwent TAVI using MANTA® or ProGlide® since 2018. A 1:1 propensity-score matched population derived by a multivariate logistic regression model based on age, sex, body mass index, pre-procedural haemoglobin, EuroSCORE II, main access calcification and the sheath-to-artery ratio. The primary endpoint was the composite of major or life-threatening bleeding (VARC-2 definition), femoral artery stenosis/dissection, pseudoaneurysm and need for endovascular/surgical bailout intervention.

Results

The propensity score matching resulted in 129 matched pairs. The median age was 84 years old [IQR 80–87], 42% males with a median EuroSCOREII of 4.29% [IQR 3.05–6.24].

There were no differences in the primary endpoint between MANTA ® and ProGlide® cohorts (3.9% vs 7.8%, p=0.287, respectively). The rates of the primary endpoint with the MANTA® device decreased with center experience, with relatively steep learning curve effect concerning device success.

Major or life-threatening bleeding (3.1% vs 5.4%, p=0.540) and pseudoaneurysm (0.8% vs 2.3%, p=0.622) occurred less frequently in MANTA® cohort, but the differences did not reach statistical significance. Endovascular (stent or balloon) or surgical rescue intervention (9.3% vs 5.4%, p=0.341) and femoral artery stenosis/dissection (6.2% vs 3.1%, p=0.376), were also similar rates. In ProGlide® cohort, to achieve VCD success (without primary endpoint events), 15.5% needed more than 2 devices, significantly different from MANTA ® (p<0,001).

Conclusions

In patients undergoing transfemoral TAVI, the MANTA® VCD showed a similar efficacy and safety compared to the ProGlide® device and it reduced significantly the need of additional VCDs for completion of hemostasis. These results were obtained despite a clear learning curve associated with MANTA.

Funding Acknowledgement

Type of funding source: None

Lung water quantification by cardiac magnetic resonance imaging: a novel prognostic tool in hf

Background

Cardiac magnetic resonance (CMR) imaging has recently been proposed to quantify lung water density (LWD, %) non-invasively. Given that pulmonary congestion plays a key role in the pathophysiology of Heart Failure (HF), we designed a study to assess the prognostic significance of a simplified LWD measure in patients with HF and reduced left ventricular ejection fraction (LVEF).

Methods

We conducted a single-center retrospective study of consecutive patients with HF and LVEF <50% who underwent CMR on a 1.5T scanner. Those with severe interstitial lung disease or chronic liver disease were excluded. All measurements were performed in a parasagittal plane at the right midclavicular line on a standard HASTE sequence, which is widely available in all CMR studies. As previously reported, LWD was determined by the lung-to-liver signal ratio multiplied by 0.7. A cohort of 102 healthy controls was used to derive the upper limit of normal (mean ± 2SD) of the LWD (21.2%). The primary endpoint was a composite of all-cause death or HF hospitalization.

Results

A total of 290 HF patients (mean age 64±12 years, 74.8% male, 56.2% of ischemic etiology) with a mean LVEF of 34±10% were included. LWD measurement took on average 35±4 seconds and showed excellent inter-observer agreement (intra-class correlation coefficient >0.90). LWD was increased in 65 (22.4%) patients. Compared to those with normal LWD, the former were more symptomatic (NYHA ≥III: 29.2% vs. 1.8%; p=0.017) and had higher median NT-proBNP [1973 (IQR: 809–3766) vs 802 (IQR: 355–2157pg/mL); p<0.001]. During a median followup of 21 months (IQR: 13–29), 20 (6.9%) patients died and 40 (13.8%) had at least one HF hospitalization. In multivariate analysis, LVEF (HR per 1%: 0.96; CI-95%: 0.93–0.99; p=0.024), creatinine (HR per 1mg/dL: 2.43; CI-95%: 1.25–4.71; p=0.009) and LWD (HR per 1%: 1.06; CI-95%: 1.01–1.12; p=0.013) were independent predictors of the primary endpoint. The findings were mainly driven by an association between LWD and HF hospitalization (HR per 1%: 1.08; CI-95%: 1.03–1.13; p=0.002).

Conclusions

A CMR-derived method for LWD quantification independently predicts an increased risk of death or HF hospitalization in HF patients with LVEF <50%. Our results support LWD measurement as a simple, reproducible and widely available method, further adding to the prognostic role of CMR in this population.

Funding Acknowledgement

Type of funding source: None

Parenteral anticoagulation in non-ST segment elevation acute coronary syndromes: which option to pick?

Background

According to the 2015 European Society of Cardiology's non-ST segment elevation acute coronary syndrome (NSTE-ACS) clinical practice guideline, fondaparinux is the parenteral anticoagulant with the most favorable efficacy/safety profile. Thus, it is recommended over enoxaparin, for instance, in that setting. However, its use and performance in a contemporary portuguese cohort has not been fully described.

Purpose

To assess fondaparinux utilization degree and to compare its in-hospital efficacy and safety profiles with those of enoxaparin, in a contemporary portuguese cohort of NSTE-ACS patients.

Methods

Patients consecutively admitted with NSTE-ACS, between October 2010 and January 2019, were retrospectively identified from a national registry of acute coronary syndromes and were further divided in two groups, as per parenteral anticoagulation strategy (fondaparinux vs. enoxaparin). Key exclusion criteria were specific contraindications to both agents, recent hemorrhagic stroke and indications for anticoagulation other than ACS. The primary efficacy endpoint was a composite of in-hospital reinfarction and mortality, whereas the primary safety endpoint was moderate-to-severe bleeding, as defined by the GUSTO criteria.

Results

A total of 5843 NSTE-ACS patients (mean age 65±13 years, 72.4% males) were included. Of these, 89.2% had a myocardial infarction, while the remaining 10.8% were diagnosed with unstable angina. The most frequent cardiovascular comorbidities were hypertension (71.3%), dyslipidemia (63.0%) and diabetes mellitus (31.7%). Fondaparinux was the anticoagulant of choice in 27.5% of patients, whereas the remainder were treated with enoxaparin. Compared with patients receiving enoxaparin, those in the fondaparinux group were younger, had less hypertension or diabetes mellitus and exhibited a less severe presentation; nonetheless, they had more often a previous history of coronary artery disease or hemorrhagic events. An invasive approach in terms of revascularization was adopted in 87.7% of the cohort (79.1% in the fondaparinux group vs. 90.9% in the enoxaparin group, p<0.001). The primary efficacy and safety endpoints occurred in 2.4% and 4.7% of patients, respectively. After adjustment for relevant covariates, the use of fondaparinux was independently associated with a lower rate of both the primary efficacy (OR 0.56 [0.32–0.95], p=0.034) and the primary safety endpoints (OR 0.37 [0.23–0.59], p<0.001).

Conclusion

In a contemporary portuguese cohort of NSTE-ACS patients, fondaparinux was underused but still independently associated with a lower risk of both a composite of in-hospital reinfarction or mortality event and major hemorrhage.

Funding Acknowledgement

Type of funding source: None

Pre-test probability of obstructive coronary artery disease in the new guidelines: too much, too little or just enough?

Background

Previous 2013 ESC guidelines recommended the use of the Modified Diamond-Forrester method to assess the pre-test probability (PTP) of obstructive coronary artery disease (CAD). The 2019 ESC Chronic Coronary Syndrome guidelines updated this recommendation with a major downgrade in PTP. The aim of this study was to compare the performance of these two methods in patients with stable chest pain undergoing coronary computed tomography angiography (CCTA) for suspected CAD.

Methods

We performed a retrospective analysis on prospectively collected data from a cohort of consecutive patients undergoing CCTA for suspected CAD from October 2016 to 2019. Key exclusion criteria were age <30 years-old, known CAD, suspected acute coronary syndrome or symptoms other than chest pain. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. Whenever invasive coronary angiography (ICA) was subsequently performed, patients were reclassified if luminal stenosis was <50%. The two PTP prediction models were assessed for calibration and discrimination.

Results

A total of 320 patients (median age 63 years [IQR 53–70], 59% women) were included. Chest pain characteristics were: 48% atypical angina, 38% non-anginal chest pain, 14% typical angina. The observed prevalence of obstructive CAD was 16.3% (n=52). Patients with obstructive CAD were more often male, were significantly older and had a higher prevalence of typical angina and cardiovascular risk factors (except for family history of CAD). On average, individual PTP was 22.1% lower in the new guidelines. The 2013 prediction model significantly overestimated the likelihood of obstructive CAD (mean PTP 37.3% vs 16.3%; relative overestimation of 130%, p-value for miscalibration 0.005). The updated 2019 method showed good calibration for predicting the likelihood of obstructive CAD (mean PTP 15.2% vs 16.3%; relative underestimation of 6.5%, p-value for miscalibration 0.712). The two approaches showed similar discriminative power, with a C-statistics of 0.730 and 0.735 for the 2013 and 2019 methods, respectively (p-value for comparison 0.933). Stratification by gender produced similar results.

Conclusions

In patients with stable chest pain undergoing CCTA, the updated 2019 prediction model allows for a more precise estimation of pre-test probabilities of obstructive CAD than the previous model. Adoption of this new score may improve disease prediction and change the downstream diagnostic pathway in a significant proportion of cases.

Graph 1

Funding Acknowledgement

Type of funding source: None

Disproportionate functional mitral regurgitation: clinical validation of a new conceptual framework

Background

Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR.

Methods

Patients with at least mild FMR and reduced LVEF (<50%) who underwent transthoracic echocardiography between 2010 and 2014 were retrospectively identified in our laboratory database. Optimal medical therapy (including cardiac resynchronization when indicated) for ≥3 months was a prerequisite for inclusion. Hemodynamically significant FMR was defined as regurgitant fraction >50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the haemodynamic burden of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF <30% and 30–49%).

Results

A total of 289 patients (median age 69 years [IQR 60–77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm2 (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: <10mL: 41%; 10–20mL: 18%; 20–30mL: 15% and >30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p<0.001).

During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF <30% subgroup, age (HR 1.05 per year [1.02–1.08]; p<0.001), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.042) and TAPSE (HR 0.92 per mm [0.86–0.99]; p=0.030) were independent predictors of mortality. In the LVEF 30–49% subgroup, age (HR 1.05 per year [1.02–1.08]; p=0.003), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.020) and disproportionate FMR (HR 1.02 per mL [1.01–1.03]; p=0.01) were independently associated with increased mortality.

Conclusions

Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF<30%, where the degree of biventricular dysfunction seems to outweigh all other echocardiographic parameters, leaving FMR as a bystander.

Figure 1

Funding Acknowledgement

Type of funding source: None

Respiratory support in COPD patients after acute exacerbation with monitoring the quality of support (Rescue2-monitor): an open-label, prospective randomized, controlled, superiority clinical trial comparing hospital- versus home-based acute non-invasive ventilation for patients with hypercapnic chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is expected to be the 3rd leading cause of death worldwide by 2020. Despite improvements in survival by using acute non-invasive ventilation (NIV) to treat patients with exacerbations of COPD complicated by acute hypercapnic respiratory failure (AHRF), these patients are at high risk of readmission and further life-threatening events, including death. Recent studies suggested that NIV at home can reduce readmissions, but in a small proportion of patients, and with a high level of expertise. Other studies, however, do not show any benefit of home NIV. This could be related to the fact that respiratory failure in patients with stable COPD and their response to mechanical ventilation are influenced by several pathophysiological factors which frequently coexist in the same patient to varying degrees. These pathophysiological factors might influence the success of home NIV in stable COPD, thus long-term NIV specifically adapted to a patient's "phenotype" is likely to improve prognosis, reduce readmission to hospital, and prevent death. In view of this conundrum, Rescue2-monitor (R2M), an open-label, prospective randomized, controlled study performed in patients with hypercapnic COPD post-AHRF, will investigate the impact of the quality of nocturnal NIV on the readmission-free survival. The primary objective is to show that any of 3 home NIV strategies ("rescue," "non-targeted," and "targeted") will improve readmission-free survival in comparison to no-home NIV. The "targeted" group of patients will receive a treatment with personalized (targeted) ventilation settings and extensive monitoring. Furthermore, the influence of comorbidities typical for COPD patients, such as cardiac insufficiency, OSA, or associated asthma, on ventilation outcomes will be taken into consideration and reasons for non-inclusion of patients will be recorded in order to evaluate the percentage of ventilated COPD patients that are screening failures. ClinicalTrials.gov NCT03890224 . Registered on March 26, 2019.

Food safety in canteens: a public health programme in Aveiro region (Portugal) in 2018 and 2019

Background

Each year, 23 million people get ill from unsafe food in Europe. Food safety refers to the absence or safe acceptable levels of hazards in food that may harm the health of consumers. The Public Health Unit of Baixo Vouga Primary Healthcare Cluster (Aveiro region) developed a programme to identify hazards and promote implementation of corrective measures in community canteens that serve children and elderly. It has three fields of action: qualitative evaluation of the installation and operating conditions, based on the legislation; microbiological surveillance of food and utensils; training of food handlers and managers. This study aims to describe the results of such programme in 2018 and 2019.

Methods

This cross-sectional study used data from qualitative evaluation and microbiological results for a descriptive analysis. Additionally, an assess of the compliance of the critical points was performed to identify the main barriers in achieving the proposed targets.

Results

From a total of 420 registered canteens, 211 and 294 were evaluated in 2018 and 2019, respectively. For these years, only 87 (41.2%) and 124 (33.3%) fully complied with all critical points. The main problems were the lack of non-manual activation system in wash basins and faucets and inadequately instructed food handlers about required hygiene measures. Microbiological surveillance results of 371 and 393 samples had a proportion of satisfactory or acceptable results of: 93.5% and 91.3% for the main dish; 56.1% and 46.6% for the salads and 82.4% and 79.8% for the utensils. Coliform bacteria were the most common agent.

Conclusions

The compliances with critical points were low, accounting for the fact they are legislation-based. The microbiological results were worst for the salads' samples. Deviations give us hints of what should be reinforced. Education of the food handlers and consulting with companies to improve procedures and equipment could be of great use.

Key messages

Community canteens’ compliances with legislated criteria were low. This programme is useful in identifying vulnerabilities and may lead to the implementation of corrective measures.