Incidence and impact of venous thromboembolism in hospitalized patients with Crohn-disease

Background

Prevalence of Crohn's disease (CD) is high in North America and in Europe ranging between 100 and 350 patient-cases per 100,000 citizens. CD is characterized by chronic inflammation with a progressive course and is often associated with different intestinal as well as extra-intestinal complications. CD is associated with both, other inflammatory diseases such as ankylosing spondylitis and psoriasis as well as venous thromboembolism (VTE). CD causes an activation of coagulation system, which might be the main reason for an increased risk of thromboembolic complications. Beside previous study results regarding higher VTE risk of patients with CD in comparison to the general population, particularly, data on impact of VTE on survival and risk factors for the occurrence of VTE in CD are sparse.

Purpose

The objectives of our study were to provide evidence about the current and past prevalence of VTE events in hospitalized patients with CD and to investigate the impact of VTE on outcomes of CD patients.

Methods

The German nationwide inpatient sample was screened for patients admitted due to CD (ICD-code K50) (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, own calculations). CD hospitalizations were stratified for VTE and risk factors for VTE and impact of VTE on in-hospital case-fatality rate were investigated.

Results

Overall, 333,975 patients-cases with hospital admissions due to CD were counted in Germany (median age 38.0 [IQR 24.0–52.0] years, 56.0% females) during the observational period between 2005 and 2018. VTE rate increased slightly from 0.6% to 0.7% (β 0.000097 [95% CI 0.000027 to 0.000167], P=0.007) from 2005 to 2018 and with age-decade of life (β 0.0017 [95% CI 0.0016 to 0.0019], P<0.001). In total, 0.7% (n=2,295) of the CD inpatients had an event of VTE. Patients with VTE were in median 12 years older (49.0 [34.0–62.0] vs. 37.0 [24.0–52.0] years, P<0.001) and CD colon-manifestations were more prevalent in those patients (32.0% vs. 27.7%, P<0.001). Age ≥70 years, obesity, colon-involvement, cancer, surgery, thrombophilia, and heart failure were strongly associated with higher risk of VTE in CD patients.

In-hospital death occurred 15-times more often in CD with VTE than without (4.5% vs. 0.3%, P<0.001). VTE was independently associated with substantially increased in-hospital case-fatality rate (OR 9.31 [95% CI 7.54–11.50], P<0.001).

Conclusions

VTE is a life-threatening event in hospitalized CD patients associated with 9.3-fold increased case-fatality rate. Older age, obesity, colon involvement, cancer, surgery, thrombophilia and heart failure were strong risk factors for VTE in patients with CD.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary embolism response team implementation and its clinical value across countries: a scoping review and meta-analysis

Background

Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has been developed to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE), but data on the use and the benefit of PERT are sparse.

Purpose

We aimed to systematically investigate the composition of PERT and its clinical value in clinical routine across different countries.

Methods

We searched PubMed, CENTRAL and Web of Science until January 2022 for full-text, prospective and retrospective observational studies, which included patients with acute PE who were evaluated by a PERT. Eligible articles were designed to either describe the structure and function of PERTs and/or to investigate outcomes related to the implementation of PERT. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and use of advanced therapies.

Results

We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In total, PERT involved a median of 6 (range 2–10) specialties for guiding further diagnostic and treatment modalities. Patients evaluated by a PERT had a mean age of 60 years; of them, 48.7% were females, and 23.5% suffered from malignancy. Right ventricular dysfunction was present in 55% of the patients. In total, 74.5% were classified as intermediate-risk PE and 16% as high-risk PE. In eleven single-arm studies, 1,532 patients with intermediate- and high-risk PE were evaluated by PERT with a mortality rate of 10% and a bleeding rate of 9%. The mean length of stay was 7.3 days and the use of advanced therapy was reported in 30% of all cases. From these, catheter-directed treatment (CDT) was performed in 22% and inferior vena cava filter was inserted in 15%, while systemic thrombolysis was administered in only 6%, surgical thrombectomy in 2% and ECMO in 3% of all cases. When comparing PERT and pre-PERT era no difference in mortality (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.67–1.19, I2=63%) was observed based on nine controlled studies, while mortality tended to be lower when including only intermediate and high-risk patients in the analysis (RR 0.71, 95% CI 045–1.12) (Figure 1). The use of advanced therapies was more common (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay as well as the duration of treatment in intensive care unit was shorter (mean difference −1.6 days and −1.8 days, respectively) in the PERT era.

Conclusion

PERT implementation tended to reduce the mortality rate in patients with intermediate- and high-risk PE and resulted in a shorter in-hospital stay. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends regarding clinical impact of diabetes mellitus on peripheral artery disease

Introduction

Patients with peripheral artery disease (PAD) and Diabetes mellitus (DM) suffer from higher morbidity and mortality rates compared to non-diabetic PAD patients. Huge efforts are made to improve medical care of patients with DM including chronic disease programs.

Purpose

To investigate temporal trends of the clinical burden of DM on PAD patients between the years 2005 and 2019.

Methods

All patients hospitalized due to PAD between 2005 and 2019 in Germany based on the diagnosis related groups [DRG] system were stratified according to presence or absence of DM (source: Federal Statistical Offices of Germany, DRG statistics 2005–2019 and own calculations). Morbidity and mortality of both groups were compared in time trend.

Results

The number of hospitalisations due to PAD increased from 142,778 in the year 2005 to 190,135 in 2019 (β 3956 per year [95% CI 3034–4878], P<0.001). In the same period also the amount of PAD patients with additional diagnosis of DM inclined (2005: 41,609 patients corresponding 29.1% of all PAD patients vs. 2019: 65,302 patients corresponding 34.3% of all PAD patients; β 2019 per year [95% CI 1593–2446], P<0.001). While the portion of patients with type 1 DM decreased during the observational period (β −1.43 [95% CI −1.49 to −1.37]; P<0.001), type 2 DM was progressive (β 2.27 [95% CI 2.23–2.32]; P<0.001). PAD patients with DM suffered from lower rates of pulmonary embolism (β −0.64 [95% CI −0.89 to −0.40]; P<0.001) and intracerebral bleeding (β −0.45 [95% CI −0.94 to 0.04]; P=0.072) in the last years of the investigation period, whereas the amount of patient-cases with pneumonia (β 0.29 [95% CI 0.23–0.35]; P<0.001), shock (β 0.75 [95% CI 0.66–0.84]; P<0.001) and gastrointestinal bleeding (β 0.33 [95% CI 0.20–0.46]; P<0.001) increased. Fortunately, less amputations had to be performed in diabetics over time (amputations regardless of minor or major amputations: β −0.42 [95% CI −0.44 to −0.40]; P<0.001; minor amputations: β −0.03 [95% CI −0.06 to −0.01]; P=0.015; major amputations: β −1.24 [95% CI −1.28 to −11.20]; P<0.001) and in-hospital mortality decreased during the observational-time (2005: 4.7%, 2019: 2.8%; β −0.64 [95% CI −0.69 to −0.59]; P<0.001). Despite the improvement in morbidity and mortality within the investigated time period, diabetics with DM were still associated with increased risk for morbidity and mortality compared to PAD patients without DM.

Conclusions

We observed an improvement regarding morbidity and mortality in hospitalized PAD patients with DM in Germany within the investigation period between 2005 and 2019. However, DM remained to be associated with increased morbidity and mortality compared to non-diabetics. Hence, despite the achieved improvements within the period 2005 to 2019, DM still represents an outstanding risk factor for morbidity and mortality in patients with PAD.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 infection and its impact on case-fatality in patients with pulmonary embolism

Background

Although a high prevalence of pulmonary embolism (PE) has been reported as a complication during severe COVID-19 infections in critical ill patients, nationwide data of hospitalized patients with COVID-19 with PE is still limited. Thus, we sought to analyze seasonal trends and predictors of in-hospital case-fatality in patients with COVID-19 and PE in Germany.

Methods

We used the German nationwide inpatient sample to analyze all data on hospitalizations for COVID-19 patients with and without PE in Germany during the year 2020 and to compare changes of PE prevalence to 2019.

Results

We analyzed data of 176,137 hospitalizations because of COVID-19 in 2020. Among those, PE was recorded in 1.9% (n=3,362) of discharge or death certificates. Almost one third of patients with COVID-19 and PE died during the in-hospital course (28.7%). The case-fatality rate increased with patients' age peaking in the 9th life-decade. Regardless of COVID-19, 196,203 inpatients were diagnosed with PE in Germany between 2019 and 2020. The number of PE hospitalizations were widely equally distributed between both years (98,485 vs. 97,718), while the case-fatality rate of all patients with PE was slightly lower in 2019 compared to 2020 (12.7% vs. 13.1%, P<0.001). In contrast, considerable differences in prevalence and case-fatality were demonstrated in 2020 regarding PE patients with and without COVID-19 infection (28.7% vs. 13.1%, P<0.001) (Figure 1). A COVID-19-infection was associated with a 2.8-fold increased risk of case-fatality in patients with PE (OR 2.81, 95% CI 1.66–2.12, P<0.001).

Conclusions

In Germany, the prevalence of PE events complicating hospitalizations was similar in 2019 and 2020. However, the fatality rate among patients with COVID-19-associated PE was substantially higher than that in those without either COVID-19 or PE, indicating an additive prognostic effect of these two conditions.

Funding Acknowledgement

Type of funding sources: None.

Telomere shortening in hypertensive heart disease depends on NOX2-mediated loss of PRDX1 and oxidative DNA damage

Background

Heart failure (HF) coincides with cardiomyocyte telomere shortening. Arterial hypertension is the most prominent risk factor for HF. Both HF and arterial hypertension are associated with dysregulation of the neurohormonal axis and increased ROS. However, how neurohormonal activation is linked to telomere shortening in the pathogenesis of HF is incompletely understood. Further, recent findings suggest that peroxiredoxin 1 (PRDX1) can act as a telomere specific antioxidant.

Methods

To induce hypertensive HF, male C57BL/6J mice were subjected to AngII-infusion, uninephrectomy and high-salt (AngII++) for 5 weeks. Cardiac function was assessed by ultrasound. Mouse adult cardiomocytes (CMs) isolated from C57BL/6J mice and mice lacking the NADPH-oxidase (NOX) 2/gp91phox as well as rat ventricular CM-derived cells (H9C2) were stimulated with AngII. Telomere length was quantified by Q-FISH after staining with a C-rich telomere probe (TelC). DNA/RNA-damage was evaluated after staining for Oxo-8-Gua (8-oxo-7,8-dihydroguanine) and Oxo-8-G (8-oxo-7,8-dihydroguanosine). Superoxide (O2-) was quantified by 2-hydroxyethidium (2-HE) using HPLC analysis. Colocalization of Oxo-8-Gua and TelC was quantified by automated image analysis. (Sub)cellular and tissue expression of gp91phox/Nox2 and PRDX1 was evaluated by ICC/IHC. All image quantification was conducted semiautomatically.

Results

In mice subjected to hypertensive HF, CM telomere shortening correlated significantly with both left ventricular (LV) dilatation and impairment of LV systolic function, paralleled by a significant loss of myocardial PRDX1 and significantly increased myocardial DNA/RNA-damage. Similarly, CMs stimulated with AngII exhibited significant telomere shortening, significant loss of PRDX1 and significantly increased DNA/RNA-damage, together with significantly increased CM superoxide production and significantly increased expression of the superoxide generating enzyme gp91phox/NOX2. Correspondingly, deficiency of gp91phox/NOX2 significantly prevented AngII-induced CM telomere shortening, DNA/RNA-damage and PRDX1-depletion. A similar effect could be observed upon stimulation of CMs with the specific histone deacetylase (HDAC) 6-inhibitor tubastatin, which prevents deacetylation of PRDX1.

Conclusion

We could provide first evidence that in heart failure, ROS originating from increased NOX2-activity leads to depletion of the telomere-targeted antioxidant and repair-protein PRDX1, which results in damage to the telomeric DNA. Both depletion of NOX2 as well as harnessing the intrinsic antioxidant defense by stabilizing PRDX1 via HDAC6-inhibition prevented CM telomere shortening and could be further evaluated as potential therapeutic targets to address heart failure.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry for Education and Research

Trends and risk factors of in-hospital mortality of patients with COVID-19 in Germany

Background

Unselected data of nationwide studies of hospitalized patients with COVID-19 is still sparse, but these data are of outstanding interest not to exceed hospital capacities and to avoid overloading of national health-care systems.

Purpose

Thus, we sought to analyze seasonal/regional trends, predictors of in-hospital case-fatality and mechanical ventilation (MV) in patients with COVID-19 in Germany.

Methods

We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany between January 1st and December 31st in 2020 (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Covid-19-inpatients with MV vs. without MV and survivors vs. non-survivors were compared. Logistic regression models were calculated to investigate associations between patients' characteristics as well as adverse events and i) necessity of MV and ii) in-hospital death.

Results

We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19-infection. Among those, 31,607 (17.9%) died, whereby in-hospital case-fatality grew exponentially with age. Cardiovascular comorbidities were common in hospitalized patients with confirmed COVID-19-infections: Overall, almost half of the patients (46.8%; n=82,480) had arterial hypertension and 25,574 (14.4%) had a diagnosis of coronary artery disease. In 60.7% (n=106,913) of the hospitalizations, pneumonia was reported, 8.6% (n=15,061) had an acute infection of the upper or lower airways other than pneumonia, and 6.6% (n=11,594) suffered from an acute respiratory distress syndrome (ARDS) during hospitalization

Age ≥70 years (OR 5.91, 95% CI 5.70–6.13, P<0.001), pneumonia (OR 4.58, 95% CI 4.42–4.74, P<0.001) and acute respiratory distress syndrome (OR 8.51, 95% CI 8.12–8.92, P<0.001) were strong predictors of in-hospital death. Most COVID-19-patients were treated in hospitals in urban areas (n=92,971) associated with lowest case-fatality (17.5%) as compared to hospitals in suburban (18.3%) or rural areas (18.8%). MV demand was highest in November/December 2020 (32.3%, 20.3%) in patients between 6th and 8th age-decade. In the first age-decade, 78 of 1861 children (4.2%) with COVID-19-infection were treated with MV and five of them died (0.3%).

Conclusion

The results of our study indicate seasonal and regional variations concerning number of COVID-19-patients, necessity of MV and case-fatality in Germany. These findings may help to ensure flexible allocation of intensive care (human) resources, which is essential for managing enormous societal challenges worldwide to avoid overloaded regional health-care systems.

Funding Acknowledgement

Type of funding sources: None.

Impact of prediabetes and type 2 diabetes mellitus on cardiac function in the general population

Introduction

Prediabetes and type 2 diabetes mellitus (T2DM) are risk factors for heart failure (HF). The association of prediabetes and T2DM to different forms of functional left ventricular impairment and their impact on clinical outcome in the general population needs to be further investigated. In this context, little is known about the prevalences of prediabetes and different HF subtypes in the general population, especially in Europe.

Purpose

To investigate the prevalence and clinical impact of prediabetes and type 2 diabetes mellitus (T2DM) on functional cardiac disorder (FCD).

Methods

The participants of the Gutenberg Health Study sample (15,010 subjects, 35–74 years) were stratified in individuals with euglycaemia, prediabetes and T2DM based on clinical information and HbA1c level. FCD included asymptomatic systolic and diastolic dysfunction, symptomatic systolic and diastolic heart failure, asymptomatic diastolic dysfunction and preserved left ventricular ejection fraction (EF), asymptomatic diastolic dysfunction and reduced EF, asymptomatic preserved diastole and reduced EF, symptomatic heart failure with preserved EF (HFpEF) and symptomatic heart failure with reduced EF HFrEF). Using structured follow-up clinical outcome was assessed.

Results

Overall, 14,870 individuals were included in the present analysis. Among them, 9,426 individuals were categorized in the euglycaemia group, 4,128 participants had prediabetes and in 1,316 individuals T2DM was present. Prevalence of FCD increased from euglycaemia (19.6%) over prediabetes (33.3%) to T2DM (46.8%, p&lt;0.0001). Prevalence of symptomatic HF was increased in patients with T2DM (euglycaemia 2.8%, prediabetes 5.9%, T2DM 11.9%). T2DM was associated with reduced EF (β −0.63, 95% CI −0.99 to −0.26, P=0.00088) and elevated E/E' (β 0.08, 95% CI 0.06 to 0.10, P&lt;0.0001), whereas prediabetes was associated to elevated E/E' (β 0.02, 95% CI 0.01 to 0.03, P=0.0029). Prediabetes and T2DM revealed increased prevalences of FCD (13%, 18%), asymptomatic diastolic dysfunction with preserved EF (prediabetes: 14%, T2DM: 11%), symptomatic heart failure (prediabetes: 46%, T2DM: 70%) and HFpEF (prediabetes: 49%, T2DM: 82%). With prediabetes and T2DM all-cause mortality was elevated in presence and absence of FCD, only T2DM was also a risk factor for cardiovascular mortality with and without FCD. Within a 5-years follow-up, T2DM was an independent risk factor for the development of FCD, asymptomatic diastolic dysfunction with reduced ejection fraction, symptomatic heart failure and HFrEF. Prediabetes was not an independent risk factor for FCD.

Conclusions

In the general population, a high prevalence of asymptomatic FCD is present. Coexisting FCD and prediabetes as well as T2DM result in increased mortality elucidating the need for early detection and prevention of DM development, especially with regard to numerous asymptomatic people concerned. T2DM, but not prediabetes, is a risk factor for incident FCD.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The Gutenberg Health Study is supported by the government of Rheinland-Pfalz (`Stiftung Rheinland-Pfalz für Innovation'), the research programmes `Wissen schafft Zukunft' and the Centre forTranslational Vascular Biology (CTVB) of the Johannes Gutenberg-University of Mainz, Germany, and its contract with Boehringer Ingelheim and Philips Medical Systems including an unrestricted grant forthe Gutenberg Health Study. P.S.W. and J.H.P. are funded by the Federal Ministry of Education and Research (BMBF 01EO1503). P.S.W. and T.M. are principal investigators of the German Center for Cardiovascular Research (DZHK). P.S.W. is principal investigator of the DIASyM research core (BMBF 161L0217A).

Psoriasis and its impact on the clinical outcome of patients with pulmonary embolism

Background

Venous thromboembolism (VTE) is common and associated with high morbidity and mortality. Although chronic inflammation was not categorized as a traditional risk factor for VTE, chronic inflammation might increase the risk to develop VTE events.

While studies confirmed an increased cardiovascular morbidity and mortality in psoriatic patients, data regarding the influence of psoriasis on patients' cardiovascular profile and on prognosis of patients with pulmonary embolism (PE) are sparse.

Purpose

We aimed to investigate the impact of psoriasis on prognosis of PE patients.

Methods

Hospitalized PE patients were stratified for psoriasis and the impact of psoriasis on outcome was investigated in the German nationwide inpatient sample of the years 2005–2017 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2017, own calculations).

Results

Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0–80.0] years) were recorded in Germany 2005–2017. Among these, 3,145 patients were additionally coded with psoriasis (0.3%). Psoriatic PE patients were younger (68.0 [57.0–76.0] vs. 72.0 [60.0–80.0] years, P&lt;0.001) and more often male (64.1% vs. 46.3%, P&lt;0.001). The prevalence of VTE risk factors, traditional cardiovascular risk factors and cardiovascular comorbidities was higher in psoriatic than in non-psoriatic individuals: All investigated traditional cardiovascular risk factors such as essential arterial hypertension (49.8% vs. 43.1%, P&lt;0.001), diabetes mellitus (24.4% vs. 18.7%, P&lt;0.001), hyperlipidaemia (14.1% vs. 12.0%, P&lt;0.001), as well as obesity (19.6% vs. 9.6%, P&lt;0.001) and atherosclerotic comorbidities like coronary artery disease (15.2% vs. 13.8%, P=0.022) and peripheral artery disease (3.6% vs. 2.9%, P=0.010) were more prevalent in PE patients with psoriasis.

Psoriatic PE patients showed a lower in-hospital case-fatality rate (11.1% vs. 16.0%, P&lt;0.001), confirmed by logistic regressions showing an independent association of psoriasis with reduced case-fatality rate (OR 0.73 [95% CI 0.65–0.82], P&lt;0.001), despite higher prevalence of pneumonia (24.8% vs. 23.2%, P=0.029). Psoriasis was an independent predictor for gastro-intestinal bleeding (OR 1.35 [95% CI 1.04–1.75], P=0.023) and transfusion of blood constituents (OR 1.23 [95% CI 1.11–1.36], P&lt;0.001).

Conclusions

Overall, only a minority (0.3%) of all PE cases were coded additionally with psoriasis. PE patients with psoriasis were hospitalized in median four years earlier than those without. Although psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile in PE patients, our data demonstrate a lower in-hospital mortality rate in psoriatic PE, which might be mainly driven by younger age. Our findings may improve the clinical management of these patients and contribute evidence for relevant systemic manifestation of psoriasis.

Funding Acknowledgement

Type of funding sources: None.

Impact of diabetes mellitus on long-term survival after transcatheter mitral valve edge-to-edge repair

Introduction

Diabetes mellitus (DM) represents a notable risk factor after surgical and interventional procedures but data on the influence of DM on long-term survival after Transcatheter Edge-to-edge Repair (TEER) for Mitral valve Regurgitation (MR) are sparse.

Purpose

To compare the outcome of patients with and without DM after TEER.

Methods

Retrospective monocentric assessment of patients after successful treatment of MR by TEER (exclusion of combined forms of transcatheter repair) between 06/2010 and 03/2018. Patients were stratified for DM at baseline and observed regarding mortality during follow-up. Cox regression analyses were performed for survival analyses.

Results

627 patients (47.0% females, 88.2% aged ≥70 years) and among these 174 subjects with DM (27.3%) were included with a median follow-up period of 486 days [IQR 157–916 days]). Within the investigation period, 20 patients (3.2%) were lost to follow-up. Patients with DM more often presented severe comorbidities like obesity (27.3% vs. 9.2%, p&lt;0.001), arterial hypertension (91.4% vs. 83.7%, p=0.013), renal insufficiency (63.8% vs. 43.9%, p&lt;0.001), coronary artery disease (77.0% vs. 59.8%, p&lt;0.001) or peripheral artery disease (14.4% vs. 8.4%, p=0.026) and had a higher median logistic Euroscore I (29.4% [20.0/43.0] vs. 25.0% [16.7/36.6], p=0.001) as well as reduced systolic function (LVEF 35% [30/50] vs. 45% [30/55], p&lt;0.001). No statistical differences in short- and long-term survival were detected between patients with and without DM (in-hospital mortality 1.7 vs. 2.6%, p=0.771; at 30-days 5.0 vs. 6.0%, p=0.842, 1-year 28.7 vs. 25.0%, p=0.419, 3-years 49.2 vs. 44.1%, p=0.554, 5-years 69.0 vs. 68.3%, p=0.497). By calculating cox regression analyses, DM was not predictive for a higher mortality, even after adjustment for other risk factors (HR 1-year 1.17 [95% CI 0.80–1.71], p=0.419; HR long-term 1.13 [95% CI 0.86–1.49], p=0.373) in the total cohort, as well as after stratification for the underlying mitral valve pathology (functional MR: 1-year HR 0.99 [95% CI 0.01–1.62], p=0.969, long-term HR 0.903 [95% CI 0.63–1.29, p=0.571; primary MR: 1-year HR 1.48 [95% CI 0.66–3.35, p=0.344, long-term HR1.66 [95% CI 0.89–3.09], p=0.110).

Conclusions

Even though DM-patients presented with a more vulnerable clinical profile, no relevant differences in short- and long-term mortality after TEER for MR were found. Although being factored in most common risk scores, DM could not be associated with an adverse prognosis after transcatheter therapy of MR.

Funding Acknowledgement

Type of funding sources: None.

Case fatality rate and fatal bleeding complication in patients with pulmonary embolism and patent foramen ovale

Objectives

In patients with acute pulmonary embolism (PE), right atrial pressure is elevated, which increases risk for right-to-left shunt when patent foramen ovale (PFO) is present and thus potentially increases risk for paradoxical embolism. Little is known about the clinical outcome of patients with PE and concomitant PFO.

Methods

We analysed data on patient characteristics, treatments and in-hospital outcomes for all PE patients (ICD-code I26) with concomitant presence of PFO in Germany 2005–2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations).

Results

Between January 2005 and December 2018, 1,174,235 patients with acute PE (53.5% females) were included in this analysis; of those, 5,486 (0.5%) had a concomitant diagnosis of PFO. Trends analysis demonstrating an increasing frequency of diagnosed PE with additional PFO from 2005 (n=299) to 2018 (n=556; p&lt;0.001). While patients with PE and PFO presented more often with signs of haemodynamic compromise such RV dysfunction (37.6% vs. 28.5%) or shock (7.1% vs. 3.9%) as well as paradox arterial emboli (47.8% vs. 3.2%) or intracerebral bleeding (3.3% vs. 0.6%), PE patients with PFO died less often compared to PE patients without PFO (11.1% vs. 15.8%). Patients with PE and PFO were younger (65 [IQR 52–75] vs. 72 [60–80]; P&lt;0.001) and were more often treated invasively with a reperfusion treatment approach like embolectomy (10.2% vs. 4.2%) or systemic thrombolysis (5.0% vs 0.1%). A multivariate logistic regression analysis revealed a 27.6-fold increased risk for paradox arterial emboli (OR, 27.6 [95% CI 26.1–29.1]; p&lt;0.001) and a 3.9-fold increased risk for intracerebral bleeding events (OR, 3.9 [95% CI 3.3–4.54]; p&lt;0.001) for patients with PE and concomitant PFO. In normotensive patients with RVD and PFO, embolectomy were not associated to affect the rate of intracerebral bleeding events (OR, 0.8 [95% CI 0.2–2.6]; p=0.720) compared to conventional non-reperfusion treatment; instead of systemic thrombolysis, which is associated with a higher risk of intracerebral bleeding (OR, 3.5 [95% CI 1.8–6.59]; p&lt;0.001) compared to conventional non-reperfusion treatment.

Conclusion

Patients with acute PE and the concomitant presence of PFO are associated with a high risk for paradox arterial emboli and intracranial bleeding events. Especially in normotensive patients, the use of systemic thrombolysis should be considered with cautious. Thus, our findings may improve the clinical management of patients with PE and PFO.

Funding Acknowledgement

Type of funding sources: None.

Long-term outcomes with new generation prostheses in patients undergoing transcatheter aortic valve implantation

Background

Transcatheter Aortic Valve Implantation (TAVI) is today the first option for older patients with aortic valve stenosis (AS) at intermediate or high risk for surgery. Constant development of bioprosthetic valves and delivery systems have reduced complications and improved outcomes over the years. The 3rd generation Edwards Sapien 3 Valve (S3) and the 2nd generation Medtronic Evolut R Valve (ER) are currently the most frequently used worldwide. There is a paucity of published data regarding long term outcomes in these new generation TAVI patients.

Methods and results

In our retrospective, single-center analysis we included patients with severe Aortic Stenosis who underwent transfemoral TAVI with a new generation prosthesis between 2014 and 2016. Peri- and postprocedural outcomes of these patients were analyzed according to the VARC-2 criteria.

The study population consisted of 359 patients (mean patient age 82±7 years, 47% male, mean EuroSCORE II 8.0±8). The S3 group included 215 patients, the ER group 144 patients. Median follow-up period was 3.8 years (IQR 3.3 to 4.4 years, maximum follow-up in living patients 5.1 years).

Device Success rates where equal in both groups (93.0% vs. 92.4%, p=0.812). We report a 30-day mortality of 2.8% in the S3 group, 2.1% in the ER group, respectively (p=0.674). There was no difference in stroke rate, conversion to open heart surgery, major vascular complications, life-threatening or disabling bleeding or myocardial infarction. Implantation of a new permanent pacemaker was lower in the S3 group (S3: 27.4% vs. ER: 44.5%, p=0.002). While prosthesis mean gradients where higher in the S3 group (12.0 mmHg vs. 8.2 mmHg, p&lt;0.001), there was a tendency to less paravalvular leaks (PVL ≥2: 1% vs. 3.6%, p=0.088).

All-Cause Mortality up to 5 years did not show a difference between both patient groups (mean survival S3 3.5 years, ER 3.3 years, p=0.895). Independent predictors of death where impaired left ventricular function (HR 1.61, p=0.007), chronic kidney injury (HR 1.55, p=0.032), peripheral artery disease (HR 2.10, p=0.003), malignant tumor (HR 2.40, p&lt;0.001) and periprocedural stroke (HR 3.95, p=0.007).

Discussion

We present a comparison of the new-generation aortic valve prostheses Edwards Sapien 3 and Medtronic Evolut R concerning long-term as well as periprocedural outcomes. The analyzed cohort consisted of patients at intermediate to high surgical risk. Yet, 30-day mortality was very low both in S3 and ER patients. Device success and periprocedural outcomes in both groups were comparable and are in line with previous studies using VARC-2 definitions.

Conclusion

New generation TAVI valves offer an excellent implant and outcome success rate compared to early transcatheter Aortic valve replacement. Long-term survival was independent of prostheses choice and mainly attributed to pre- and intraprocedural comorbidities and complications.

All-Cause Mortality (Kaplan-Meier)

Funding Acknowledgement

Type of funding source: None

Impact of tricuspid valve regurgitation severity and its secondary reduction on long-term survival after transcatheter mitral valve edge-to-edge repair

Background

Mitral valve regurgitation (MR) is a frequent heart valve disorder affecting 1–2% of the humans in the general population and over 10% of the individuals older than 75 years. While a symptomatic and prognostic benefit of transcatheter edge-to-edge repair for MR (TMVR) was reported, data regarding long-term outcome as well as influence of concomitant tricuspid regurgitation (TR) are sparse.

Purpose

We aimed to investigate the impact of periinterventional development of TR on survival of patients undergoing interventional edge-to-edge repair for MR in a large retrospective monocentric study.

Methods

We retrospectively analyzed survival of patients successfully treated with isolated edge-to-edge repair for MR from 06/2010–03/2018 (exclusion of combined forms of TMVR) in our center. Baseline, periprocedural as well as follow-up data were gathered. Concomitant TR was evaluated at baseline and after 30 days and categorized from grades 0 (no TR) to grade III (severe TR). We analyzed the influence of severe vs. non-severe TR on 30-day, 1-year and long-term survival.

Results

Overall, 627 consecutive patients (47.0% female, 57.4% functional MR) were enrolled. Median follow-up time was 462 days [IQR 142–945]. Survival status was available in 96.7%. Survival rates were 97.6% at discharge, 75.7% after 1, 54.5% after 3, 37.6% after 5 and 21.7% after 7 years.

TR at baseline (examination results were available in 92.3%) was categorized as severe TR in 25.6%, medium TR in 33.3%, mild TR in 35.1% and no TR in 6.0%. TR at 1 month (examination results were available in 81.1%) was severe in 16.7%, medium in 30.2%, mild in 45.6% and no TR was found in 7.4%; improvement by at least 1 TR-grade was documented in 33.6% of the patients.

While a severe (compared to non-severe) TR at baseline did not affect the 30-day mortality (7.4% vs. 5.2%, p=0.354), 1-year survival was substantially impaired in those patients (36.5% vs. 23.0%, p=0.012). Accordingly, severe TR was not associated with 30d-mortality (as evaluated by univariate Cox regression, p=0.340), but with 1-year survival (HR 1.78, 95% CI 1.19–2.65, p=0.005) and showed a trend towards impaired long-term survival (HR 1.30, 95% CI 0.96–1.76, p=0.089).

While residual severe TR at one month did not influence 1-year-mortality significantly (p=0.478), improvement of TR demonstrated a trend to better survival after the first year (86.9 vs. 81.0%, p=0.208) confirmed in the Cox regression analysis (HR 0.66, 95% CI 0.36–1.22, p=0.188).

Conclusions

In this large retrospective monocentric study with a long-term follow-up-period of &gt;7 years after edge-to-edge therapy for MR, we demonstrated that severe TR at the time of the intervention had an impact on 1-year-survival. Furthermore, a missing periinterventional improvement of TR was shown to be unfavorable regarding the long-term survival of these patients.

Funding Acknowledgement

Type of funding source: None

Venous thromboembolism in patients hospitalized for knee and hip joint replacement surgery

Background

Venous thromboembolism (VTE) is a frequent acute cardiovascular disease, leading to significant morbidity and mortality worldwide. Major trauma, surgery, immobilisation and joint replacements are major provoking factors for VTE. In particular, patients undergoing knee and hip joint replacement surgery are at high risk of developing VTE perioperatively, even in the era of established pharmacological thromboprophylaxis. Without thromboprophylaxis, as many as 20–60% of patients may develop perioperative VTE.

Purpose

As recent studies indicate an increasing number of total knee and hip replacement surgeries in European countries and the United States, aims of our study were to investigate a) total burden and temporal trends of VTE complications following knee (KJR) and hip joint replacement (HJR) in Germany 2005–2016 and to identify b) predictors of VTE during hospitalization.

Methods

In an analysis of the nationwide German inpatient sample, we included all hospitalized patients with elective primary KJR and HJR in Germany between 2005 and 2016 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2016, own calculations). We analyzed temporal trends of surgical procedure, mortality, and VTE, and identified predictors of VTE.

Results

A total of 1,804,496 hospitalized patients underwent KJR (65.1% women, 53.4% aged ≥70 years) and 1,885,839 received HJR (59.1% women, 51.4% ≥70 years). VTE was documented in 23,297 (1.3% of total) KJR patients and in 11,554 HJR patients (0.6%).

The number of primary KJR (129,832 in 2005 to 167,881 in 2016 [β-(slope)-estimate 1978 per year; 95% CI 1951 to 2004, P&lt;0.001]) and primary HJR (145,223 in 2005 to 171,421 in 2016 [β-estimate 1818 per year; 95% CI 1083 to 2553, P&lt;0.001]) increased during this twelve-year period.

In-hospital VTE decreased from 1.9% to 0.9% (β-estimate −0.77 [95% CI: −0.81 to −0.72], P&lt;0.001) after KJR and from 0.9% to 0.5% (β-estimate −0.71 (95% CI: −0.77 to −0.65), P&lt;0.001) after HJR. In parallel, in-hospital death rate dropped from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate −0.44 [95% CI: −0.59 to −0.30], P&lt;0.001) after KJR and from 0.33% to 0.29% (β-estimate −0.11 (95% CI: −0.20 to −0.02), P=0.018) after HJR.

Infections during hospitalization were associated with a higher VTE risk. VTE events were associated with in-hospital death in KJR (OR 20.86 [95% CI: 18.78–23.15], P&lt;0.001) and HJR (OR 15.19 [95% CI: 14.19–16.86], P&lt;0.001) independently from age, sex and comorbidities.

Conclusions

While total numbers of KJR and HJR interventions increased in Germany between 2005 and 2016, the rate of VTE decreased substantially. VTE complications were associated with 15-to 21-fold increase of in-hospital case-fatality rate. Perioperative infections increased the risk for VTE substantially.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503), institutional grant for the Center for Thrombosis and Hemostasis. The authors are responsible for the contents of this publication.

3-Dimensional assessment of tricuspid annular geometry after percutaneous edge-to-edge repair in patients with severe tricuspid regurgitation

Background

Transcatheter tricuspid valve repair (TTVR) using edge-to-edge leaflet therapy (E2E) has evolved as a feasible therapy to treating severe tricuspid regurgitation (TR). The TRILUMINATE trial using the new TriClip NT has shown promising clinical and functional improvements. However, the 3rd generation MitraClip XTr (Abbott Structural Heart, Santa Clara, CA, USA) has a broad off-label experience in the European Union to address tricuspid TR with wider gaps. There is insufficient data on the secondary effects of E2E on tricuspid annular geometry. The aim of this study was to address this lack of knowledge by evaluating the acute effects of E2E using the MitraClip XTr.

Methods

We retrospectively analyzed the imaging data of procedures using the MitraClip XTr to treat severe symptomatic TR at our Institution in 2018. Tricuspid annular geometry was assessed before and immediately after clip implantation by 3D TEE analysis of biplane and manual and automated volume data.

Results

During 2018, 69 patients were treated for severe TR using a transcatheter approach. In 61 patients, E2E was used, in 58 patients the MitraClip XTr was utilized (Pascal: n=3, Edwards Lifesciences, Irvine, CA, USA). Mean age was 79.0 years ± 6.4. Percutaneous TTVR using the MitraClip XTr significantly decreased the diastolic septal-lateral diameter (S/L: 4.1±0.7cm vs. 3.6±0.7cm; p&lt;0.001), annulus area (14.9±6.7 vs. 12.8±6.2 cm2; p&lt;0.001) and annulus perimeter (14.7±25.0 vs. 13.8±24.4 cm; p&lt;0.001) whereas the diastolic anterior-posterior diameter was not significantly affected (A/P: 4.5±1cm vs. 4.4±0.8cm; p=0,45).

Conclusions

Percutaneous TTVR using MitraClip XTr showed significant changes in TV annulus geometry by focal perimeter and area reduction. This highlights a new mechanism of E2E therapy through indirectly adressing the dilated annulus in patients with severe TR.

Annulus geometry by TOE, 3D- and autoMPR

Funding Acknowledgement

Type of funding source: None

In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism

Background and purpose

Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated or has failed. We investigated baseline characteristics and in-hospital outcomes of patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort.

Methods

Data from hospitalizations with PE between 2005 and 2016 were collected by the Federal Office of Statistics (Statistisches Bundesamt) in Germany and included in this analysis. Patients with PE who underwent CDT were compared with patients receiving systemic thrombolysis, and those without thromboytic or other reperfusion treatment.

Results

We analyzed data from 978,094 hospitalized patients with PE. Of these, 41,903 (4.3%) patients received thrombolytic treatment (systemic thrombolysis in 4.2%, CDT in 0.1%). Among PE patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis (OR, 0.29, 95% CI 0.13–0.66, P=0.003). No intracranial bleeding occurred among PE patients with shock who received CDT. Among haemodynamically stable PE patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis (OR, 0.52 [95% CI 0.38–0.70]; P&lt;0.001) or no thrombolytic treatment (0.45 [95% CI 0.33–0.62]; P&lt;0.001).

Conclusion

In the German nationwide inpatient cohort, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Time trends of pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension

Background and purpose

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered as a rare but severe complication after acute pulmonary embolism (PE) and is potentially curable by pulmonary endarterectomy (PEA). We aimed to evaluate, over an 11-year period, time trends of in-hospital outcomes of PEA in CTEPH patients in the German nationwide inpatient sample.

Methods and results

We analyzed data on the characteristics, comorbidities, treatments and in-hospital outcomes for all CTEPH patients treated with PEA in Germany between 2006 and 2016. Overall, 1,398 inpatients were included. The annual number of PEA increased from 67 in 2006 to 194 in 2016 (β 0.69 [95% CI 0.51 to 0.86]; p&lt;0.001) in parallel with a significant decrease of in-hospital mortality (10.9% in 2008 to 1.5% in 2016; β −1.85 [95% CI: −2.46 to −1.24]; p&lt;0.001). Patients' characteristics shifted slightly towards older age and higher prevalence of chronic renal insufficiency and obesity over time, whereas duration of hospital stay decreased over time. Independent predictors of in-hospital mortality were age and right heart failure, and in-hospital complications such as ischemic stroke and bleeding events.

Conclusions

The number of CTEPH patients treated with PEA increased markedly in Germany between 2006 and 2016, in parallel with a decrease of in-hospital mortality. Our findings may suggest that the perioperative management of PEA and the general patients' selection have improved over time and might draw more attention to predictors for in-hospital mortality for CTEPH patients hospitalized for PEA.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Disturbed glucose metabolism and left ventricular geometry in the general population – results from the Gutenberg health study

Background

Prediabetes and type 2 diabetes mellitus (T2DM) have been demonstrated to alter left ventricular geometry and promote left ventricular (LV) hypertrophy (LVH). However, the impact of impaired glucose metabolism on cardiac structure is still not completely understood and controversially discussed.

Purpose

To investigate the impact of prediabetes and T2DM on left ventricular geometry and their potential interaction with LVH in the prediction of survival.

Methods

Data from the Gutenberg Health Study (N=15,010) – a population-based study with highly standardized phenotyping – were analysed. Information was obtained from computer-assisted personal interviews, medical-technical examinations, laboratory measurements in fasting state and echocardiography according to standard operating procedures with detailed quality control. Individuals with other types of diabetes or hyperinsulinemia were excluded from analysis. Study participants aged 35 to 74 years were categorized according to long-term glucose state (HbA1c) into euglycemia, prediabetes and T2DM. LV geometry was assessed according to current guideline recommendations. Multivariable regression analyses were performed to evaluate the association between glucose state and measures of left ventricular geometry. Survival analyses were carried out to assess the prognostic impact dependent on the presence of LVH.

Results

The analysis sample comprised 14,852 individuals aged 55.0±11.1 years (49.5% females). The prevalence of LVH was 10.2% (n=1,227) in euglycaemia, 17.2% in prediabetes and 23.8% in T2DM. Similarly, concentric and eccentric hypertrophy had the highest prevalence in T2DM (13.1% and 10.8%, respectively), followed by prediabetes (9.6% and 8.2%) and euglycaemia (5.7% and 4.5%). In multivariable regression analysis with adjustment for age, sex, traditional cardiovascular risk factors (CVRF), C-reactive protein and LV function, T2DM had a higher impact on relative wall thickness (β: 0.0135 [0.0087; 0.0182]; P&lt;0.0001) and LV mass (β: 5.46 [4.89; 6.03]; P&lt;0.0001) than prediabetes (β-estimaterelative wall thickness 0.00145 [−0.0031; 0.006]; P=0.53; β-estimateLV mass 2.73 [2.19; 3.28]; P&lt;0.0001) compared to euglycemia. During a median follow-up of 9.0 [interquartile range 7.7; 10.4] years, prediabetes did not predict all-cause mortality independent of age, sex and CVRF in Cox regression analysis in individuals without LVH (hazard ratio (HR) 1.15 [0.90; 1.46]; P=0.27) or those with LVH (HR 1.46 [0.97; 2.18]; P=0.069). In comparison, T2DM was a strong and independent predictor of mortality both in absence (HR 1.59 [1.29; 1.96]; P&lt;0.0001) and presence of LVH (HR 2.67 [1.94; 3.66]; P&lt;0.0001).

Conclusions

Although cardiac geometry is altered both in presence of prediabetes and T2DM, only T2DM is a strong predictor of premature mortality in the general population. This merits consideration for future preventive strategies to decrease the burden of cardiovascular disease.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The study was supported by the Federal Ministry of Education and Research (BMBF), the government of Rheinland-Pfalz and the Center for Translational Vascular Biology (CTVB) of the Johannes Gutenberg-University of Mainz, Germany.

P4478Noise pollution exacerbates the development of arterial hypertension via additive oxidative stress and impairment of NO signaling

Background

Environmental noise pollution has been identified as a cardiovascular risk and is characterized by moderate hypertension, endothelial dysfunction, increased oxidative stress, and inflammation. We have gained insights into the mechanism by which these consequences occur by exposing mice lacking the critical NADPH oxidase subunit gp91phox to aircraft noise. Mice were protected from the effects of aircraft noise exposure. NADPH oxidase is believed to be the mediator by which angiotensin II increases oxidative stress, making investigation into the additive effect of noise and hypertension an important subject in modern cardiovascular health research.

Methods and results

C57Bl/6J mice were implanted with subcutaneous osmotic mini-pumps, delivering a moderate dose of 0.5mg/kg/d of angiotensin II for 7 days. Immediately following the implantation, half the mice were exposed to aircraft noise for 7 days at a maximum sound pressure level of 85 dB(A) and a mean sound pressure level of 72 dB(A), a level at which hearing loss does not occur*. Non-invasive blood pressure measurements revealed an additive increase in blood pressure in noise-exposed hypertensive mice. Following sacrifice, endothelial dysfunction was evaluated through isometric tension recordings of 3mm aortic ring segments. These recordings support the blood pressure measurements and indicate a more serious impairment in acetylcholine-induced vasorelaxation in hypertensive mice exposed to noise than the hypertensive or noise only controls. Whole blood stimulated with phorbol 12,13-dibutyrate (PDBu) or zymosan A showed an additive increase in oxidative burst in in noise-exposed hypertensive mice. Dihydroethidium (DHE) staining was used to assess the presence of vascular and cerebral oxidative stress, showing similar additive effects in mice with hypertension plus noise exposure. High performance liquid chromatography (HPLC) measurement of 2-hydroxyethidium further confirmed additive increase of oxidative stress in the aorta and brain. Western blot analysis of aortic tissue revealed highest levels of gp91phox in mice with hypertension plus noise exposure and indicated a decrease in the ratio of P-eNOSSer1177:eNOS as well as a decrease in the ratio of eNOS dimer:monomer, exposing eNOS uncoupling as a potential pathomechanism for endothelial dysfunction and gp91phox as a source for the oxidative stress.Ongoing immunohistochemical and flow cytometric investigations will characterize the role of immune cells in these adverse effects.

Conclusion

Herein, we present novel data demonstrating additive noise-induced cardiovascular consequences on developing hypertension. Noise has previously been established as a cardiovascular risk factor, but the effects have not been determined in pre-existing or developing cardiovascular disease. Our results show a cumulative effect between noise exposure and hypertension and forge an important link between environmental stressors and cardiovascular health.

Acknowledgement/Funding

Boehringer Ingelheim Foundation

P4476Cardiovascular benefits of GLP-1 (liraglutide) treatment in experimental arterial hypertension are mediated by the endothelial GLP-1 receptor

Objective

The LEADER trial demonstrated that glucagon-like peptide-1 (GLP-1) analogs like Liraglutide (Lira) reduce the risk of cardiovascular events in T2DM, an effect beyond glycemic control. A detailed evaluation of the precise mechanisms underlying the cardiovascular protective effects of GLP-1 has been hampered by the fact that the GLP-1 receptor is expressed on different cell types in the vasculature including platelets, neuronal, endothelial and inflammatory cells. We used endothelial and myeloid cell-specific knockout mice of the GLP-1 receptor (GLP-1r) in an angiotensin-II (ATII)-induced model of hypertension. The aim of the recent study was to investigate the cardioprotective effects of GLP-1 in ATII-induced arterial hypertension and to characterize the cell-specific contribution of GLP-1r signaling.

Methods

Arterial hypertension was induced by s.c. ATII administration (0.5mg/kg/d; 7 days) in WT (C57/BL6J) as well as endothelial and myeloid cell-specific GLP-1r knockout mice (Cdh5crexGLP-1rfl/fl and LysMcrexGLP-1rfl/fl mice). Animals were treated with Lira (2x30μg/d; 7 days). Blood pressure was measured by tail-cuff. Vascular function was tested by isometric tension recording. Aortic and cardiac tissue was used for Western blotting, qRT-PCR, FACS, IHC and HPLC to determine the extent of inflammation, oxidative stress and fibrosis. ELISA was used to determine GLP-1 and insulin levels in plasma.

Results

Endogenous GLP-1 (7–36 and 9–36) was reduced in hypertensive animals. Lira ameliorated blood pressure and improved endothelial dysfunction, vascular oxidative stress and inflammation caused by ATII, in both WT and myeloid cell-specific GLP-1r knockout mice. Hypertension led to infiltration of inflammatory monocytes (Ly6G-Ly6Chigh) and neutrophils (Ly6G+Ly6C+) into the vascular wall, which was prevented by Lira. In accordance, Lira suppressed vascular oxidative stress and mRNA expression of iNOS, CD11b and Nox2. Endothelial NO synthase (eNOS) was S-glutathionylated with ATII treatment indicating uncoupled eNOS. Thus, aortic NO levels were reduced, all of which was restored by Lira. Furthermore, vascular fibrosis and cardiac hypertrophy were tremendously reduced by GLP-1. Interestingly, all of these beneficial cardiovascular effects of GLP-1 were abolished in endothelial cell-specific GLP-1r knockout mice.

Conclusion

We show that Lira reduces blood pressure and improves vascular function, fibrosis and cardiac hypertrophy in experimental arterial hypertension in mice. Mechanistically, Lira prevents the infiltration of inflammatory cells to the vascular wall, leading to reduced oxidative stress and improved NO bioavailability. Beneficial effects of GLP-1 are mediated by the GLP-1r expressed on endothelial and not myeloid cells. With the present study we provide a mechanistic approach to explain the cardioprotective effects of GLP-1 analogs like Lira, for which the endothelial GLP-1 receptor is indispensable.

Acknowledgement/Funding

Deutsche Forschungsgesellschaft (DFG), Bundesministerium für Bildung und Forschung (BMBF)

P2653Seasonal variations of myocardial infarction and sex-specific differences in Germany

Background

Ischemic heart disease (IHD) is the most common cause of death with an increasing frequency worldwide. It accounts for approximately 20% of all deaths in Europe and the United States of America. Approximately 1/3 of the IHD patients present with sudden cardiac death. The acute presentation of IHD myocardial infarction (MI) is a life-threatening, serious health problem, which causes substantially morbidity and mortality. It is well established that the onset of MI follows a circadian and seasonal periodicity. Seasonal variation regarding the incidence and the short-term mortality of acute MI was frequently reported, but data about sex-specific differences are sparse.

Purpose

Thus, our objectives were to investigate seasonal variations of myocardial infarction.

Methods

We analyzed the impact of seasons on incidence and in-hospital mortality of patients with acute MI in Germany from 2005 to 2015. We included all MI patients (ICD code I21) with an acute MI (, but not those MI patients with a recurrent event in the first 28 days after a previous MI (ICD code I22)), who were hospitalized in Germany between 2005 and 2015, in this analysis (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2015, own calculations).

Results

The nationwide sample comprised 3,008,188 hospitalizations of patients with MI (2005–2015). The annual incidence was 334.7 per 100.000 population. Incidence inclined from 316.3 to 341.6 per 100.000 population per year (β 0.17 [0.10 to 0.24], P<0.001), while in-hospital mortality rate decreased from 14.1% to 11.3% (β −0.29 [−0.30 to −0.28, P<0.001). Overall, 377,028 (12.5%) patients died in-hospital.

Seasonal variation of both incidence and in-hospital mortality were of substantial magnitude. Seasonal incidence (86.1 vs. 79.0 per 100.000 population per year, P<0.001) and in-hospital mortality (13.2% vs. 12.1%, P<0.001) were higher in the winter than in the summer saeson. Risk to die in winter was elevated (OR 1.080 (95% CI 1.069–1.091), P<0.001) compared to summer season independently of sex, age and comorbidities. Reperfusion treatment with drug eluting stents and coronary artery bypass graft were more often used in summer.

We observed sex-specific differences regarding the seasonal variation of in-hospital mortality: males showed lowest mortality in summer, while females during fall. Low temperature dependency of mortality seems more pronounced in males.

Conclusions

Incidence of acute MI increased 2005–2015, while in-hospital mortality rate decreased. Seasonal variations of incidence and in-hospital mortality were of substantial magnitude with lowest incidence and lowest mortality in the summer season. Additionally, we observed sex-specific differences regarding the seasonal variation of the in-hospital mortality.

Acknowledgement/Funding

This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503)

P717Glucagon-like peptide 1 (GLP-1) improves endothelial dysfunction and vascular inflammation in polymicrobial sepsis induced by cecal ligation and puncture (CLP)

Objective

Sepsis causes severe hypotension, accompanied by high mortality in the setting of septic shock. LEADER, SUSTAIN-6 and other clinical trials revealed cardioprotective and anti-inflammatory properties of GLP-1 analogs like Liraglutide (Lira). We already demonstrated improved survival by amelioration of disseminated intravasal coagulation (DIC) in lipopolysaccharide (LPS)-induced endotoxemia by inhibition of the GLP-1 degrading enzyme dipeptidylpeptidase-4 (DPP-4). With the present study we aim to investigate the mechanism of protective effects of the GLP-1 analog Lira and the DPP4 inhibitor Linagliptin (Lina) in the clinically relevant sepsis model cecal ligation and puncture (CLP).

Methods

C57/BL6j and endothelial cell-specific GLP-1 receptor knockout mice (Cdh5crexGLP-1rfl/flmice) were used and sepsis was induced by cecal ligation and puncture (CLP). DPP4 inhibitor (Lina, 5mg/kg/d; 3 days) and GLP-1 analog (Lira, 200μg/kg/d; 3 days) were applied subcutaneously. Aortic vascular function was tested by isometric tension recording. Aorta and heart tissue was used for Western blotting, dot blot and qRT-PCR. Endogenous GLP-1 (7–36 and 9–36) and insulin was determined by ELISA. Blood samples were collected for examination of cell count, oxidative stress and glucose levels.

Results

Body temperature was increased by CLP and normalized by Lina and Lira. Sham- and Lira- but not Lina-treated septic mice showed low blood glucose levels compared to healthy controls. Acetylcholine-induced (endothelium-dependent) vascular relaxation in aorta was impaired by CLP. This was accompanied by vascular inflammation and elevation of IL-6, iNOS, ICAM-1, and TNF-alpha mRNA levels in aortic tissue. Vascular, cardiac and whole blood oxidative stress were increased by CLP. Furthermore, we detected higher levels of IL-6, 3-nitrotyrosine (3-NT) and 4-hydroxynonenal (4-NHE) in plasma of CLP animals. Lina and Lira reduced oxidative stress and vascular inflammation, which was accompanied by improved endothelial function. In addition, CLP treatment in endothelial specific knockout mice of the GLP-1r strongly induced mortality compared to WT mice, with the effect being strongest in the Lira-treated group.

Conclusion

The present study demonstrates that Lina (DPP4 inhibitor) and the GLP-1 analog Lira ameliorate sepsis-induced endothelial dysfunction by reduction of vascular inflammation and oxidative stress. Clinical trials like LEADER and SUSTAIN-6 proved that GLP-1 analogs like Lira have cardioprotective effects in T2DM patients. The present study, performed in a clinically relevant model of polymicrobial sepsis, reveals that the known cardioprotective effects of GLP-1 might be translated to other diseases which affect the cardiovascular system like sepsis, underlining the potent anti-inflammatory effects of GLP-1 analogs.

Area at risk and viability after myocardial ischemia and reperfusion can be determined by contrast-enhanced cardiac magnetic resonance imaging

BACKGROUND/AIMS

Clinical differentiation between infarcted and viable myocardium in the ischemic area at risk is controversial. We investigated the potential of contrast-enhanced cardiac magnetic resonance imaging (ceCMRI) in determining the area at risk 24 h after ischemia.

METHODS

Myocardial ischemia was induced by percutaneous coronary intervention of the left anterior descending coronary artery in pigs. Coronary occlusion time was 30 min in group A, which caused little myocardial infarction and 45 min in group B, which led to irreversible damage. 24 h after reperfusion ceCMRI was performed at 2 and 15 min after administration of gadolinium-diethylenetriamine pentaacetic acid. The area at risk was determined by intravenous injection of Evans blue and myocardial viability by triphenyltetrazolium-chloride staining.

RESULTS

The signal-intense areas at 2 and 15 min after contrast administration matched the area at risk in groups A and B. Nonviable myocardium in group A was overestimated (14-15%) while good agreement was present in group B.

CONCLUSION

The area at risk of reperfused ischemic myocardium can be determined by ceCMRI 24 h after coronary recanalization. This type of information might have relevant clinical implications in the treatment and stratification of patients with acute coronary syndrome in particular after surgical interventions.

Activated thrombin activatable fibrinolysis inhibitor levels are associated with the risk of cardiovascular death in patients with coronary artery disease: the AtheroGene study

BACKGROUND

Thrombin activatable fibrinolysis inhibitor (TAFI) attenuates fibrinolysis. Results on the association between TAFI levels and the risk of coronary artery disease (CAD) are inconsistent.

OBJECTIVES

We investigated the association between TAFI levels and the risk of cardiovascular events in CAD.

PATIENTS/METHODS

1668 individuals with angiographically proven CAD at baseline were followed for a median of 2.3 years, as part of the prospective AtheroGene cohort. Fifty-six deaths from cardiovascular (CV) causes and 35 non-fatal CV events were observed.

RESULTS

At baseline, three TAFI measurements were available: one evaluating the total amount of TAFI (t-TAFI), one measuring the TAFIa/TAFIai amount, and the last the released activated peptide (TAFI-AP). TAFIa/TAFIai levels were associated with increased risk of CV death [hazard ratio (HR) for one tertile increase, 2.38 (1.56-3.63); P < 10(-4)]. This association remained significant after adjustment for conventional risk factors, CRP levels, white blood count and markers of thrombin generation and fibrinolysis [HR = 1.69 (1.07-2.67); P = 0.01]. In addition, CPB2 gene polymorphisms explained 12%, 6%, and 3% of t-TAFI, TAFIa/TAFIai and TAFI-AP levels, respectively, but none was associated with CV events.

CONCLUSIONS

The amount of activated TAFI, measured by TAFIa/TAFIai ELISA, but not of the t-TAFI is independently associated with the risk of CV death.