Long-term impact of angiotensin receptor-neprilysin inhibitor based on short-term treatment response in heart failure

AIMS

The long-term effect of angiotensin receptor-neprilysin inhibitor (ARNI) remains uncertain in patients who have experienced improvements in left ventricular (LV) systolic function or significant LV reverse remodelling following a certain period of treatment. It is also unclear how ARNI performs in patients who have not shown these improvements. This study aimed to assess the impact of prolonged ARNI use compared with angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) in patients with and without significant treatment response after 1 year of heart failure (HF) treatment.

METHODS AND RESULTS

The present study enrolled patients with HF with reduced ejection fraction (HFrEF) who were treated with either ARNI or ACEIs/ARBs within 1 year of undergoing index echocardiography. After 1 year of treatment, patients were reclassified into the following groups: (i) patients with HF with improved ejection fraction and persistent HFrEF and (ii) patients with and without LV reverse remodelling based on the follow-up echocardiography. The effect of ARNI versus that of ACEIs/ARBs in each group was assessed from the time of categorizing into new groups using the composite event of all-cause mortality and HF hospitalization. A total of 671 patients with HFrEF (age, 66.4 ± 14.1 years; males, 66.8%) were included, and 133 (19.8%) composite events of death and rehospitalization for HF were observed during the follow-up (median follow-up, 44 [interquartile range, 34-51] months). ARNI had a significantly lower event rate than ACEIs/ARBs in patients with HF with improved ejection fraction (7.0% vs. 30.4%, P = 0.020) and those with persistent HFrEF (17.6% vs. 49.7%, P < 0.001). Irrespective of whether patients exhibited LV reverse remodelling (15.8% vs. 31.1%, P = 0.001) or not (15.0% vs. 54.9%, P < 0.001), ARNIs were associated with a significantly lower event rate than ACEIs/ARBs.

CONCLUSIONS

Regardless of significant treatment response measured by either LVEF or LV reverse remodelling after 1 year of treatment, the extended utilization of ARNI demonstrated a more favourable prognosis than that of ACEIs/ARBs in patients with HFrEF.

Impact of Positron Emission Tomography Viability Imaging: Guided Revascularizations on Clinical Outcomes in Patients With Myocardial Scar on Single-Photon Emission Computed Tomography Scans

BACKGROUND

Positron emission tomography (PET) viability scan is used to determine whether patients with a myocardial scar on single-photon emission computed tomography (SPECT) may need revascularization. However, the clinical utility of revascularization decision-making guided by PET viability imaging has not been proven yet. The purpose of this study was to investigate the impact of PET to determine revascularization on clinical outcomes.

METHODS

Between September 2012 and May 2021, 53 patients (37 males; mean age = 64 ± 11 years) with a myocardial scar on MIBI SPECT who underwent PET viability test were analyzed in this study. The primary outcome was a temporal change in echocardiographic findings. The secondary outcome was all-cause mortality.

RESULTS

Viable myocardium was presented by PET imaging in 29 (54.7%) patients. Revascularization was performed in 26 (49.1%) patients, including 18 (34.0%) with percutaneous coronary intervention (PCI) and 8 (15.1%) with coronary artery bypass grafting. There were significant improvements in echocardiographic findings in the revascularization group and the viable myocardium group. All-cause mortality was significantly lower in the revascularization group than in the medical therapy-alone group (19.2% vs. 44.4%, log-rank P = 0.002) irrespective of viable (21.4% vs. 46.7%, log-rank P = 0.025) or non-viable myocardium (16.7% vs. 41.7%, log-rank P = 0.046). All-cause mortality was significantly lower in the PCI group than in the medical therapy-alone group (11.1% vs. 44.4%, log-rank P < 0.001).

CONCLUSION

Revascularization improved left ventricular systolic function and survival of patients with a myocardial scar on SPECT scans, irrespective of myocardial viability on PET scans.

Bilateral Cardiac Sympathetic Denervation as a Safe Therapeutic Option for Ventricular Arrhythmias

Background

The recurrence of ventricular arrhythmias (VAs) in patients who have already undergone treatment with antiarrhythmic medication, catheter ablation, and the insertion of implantable cardioverter defibrillators is not uncommon. Recent studies have shown that bilateral cardiac sympathetic denervation (BCSD) effectively treats VAs. However, only a limited number of studies have confirmed the safety of BCSD as a viable therapeutic option for VAs.

Methods

This single-center study included 10 patients, who had a median age of 54 years (interquartile range [IQR], 45-65 years) and a median ejection fraction of 58.5% (IQR, 56.2%-60.8%), with VAs who underwent video-assisted BCSD. BCSD was executed as a single-stage surgery for 8 patients, while the remaining 2 patients initially underwent left cardiac sympathetic denervation followed by right cardiac sympathetic denervation. We evaluated postoperative complications, the duration of hospital stays, and VA-related symptoms before and after surgery.

Results

The median hospital stay after surgery was 2 days (IQR, 2-3 days). The median surgical time for BCSD was 113 minutes (IQR, 104-126 minutes). No significant complications occurred during hospitalization or after discharge. During the median follow-up period of 13.5 months (IQR, 10.5-28.0 months) from surgery, no VA-related symptoms were observed in 70% of patients.

Conclusion

The benefits of a short postoperative hospitalization and negligible complications make BCSD a safe, alternative therapeutic option for patients suffering from refractory VAs.

Identification of concealed cardiomyopathy using next-generation sequencing-based genetic testing in Korean patients initially diagnosed with idiopathic ventricular fibrillation

AIMS

Idiopathic ventricular fibrillation (IVF) is a disease in which the cause of ventricular fibrillation cannot be identified despite comprehensive clinical evaluation. This study aimed to investigate the clinical yield and implications of genetic testing for IVF.

METHODS AND RESULTS

This study was based on the multi-centre inherited arrhythmia syndrome registry in South Korea from 2014 to 2017. Next-generation sequencing-based genetic testing was performed that included 174 genes previously linked to cardiovascular disease. A total of 96 patients were clinically diagnosed with IVF. The mean age of the onset was 41.2 ± 12.7 years, and 79 patients were males (82.3%). Of these, 74 underwent genetic testing and four (5.4%) of the IVF probands had pathogenic or likely pathogenic variants (each having one of MYBPC3, MYH7, DSP, and TNNI3). All pathogenic or likely pathogenic variants were located in genes with definite evidence of a cardiomyopathy phenotype, either hypertrophic cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy.

CONCLUSION

Next-generation sequencing-based genetic testing identified pathogenic or likely pathogenic variants in 5.4% of patients initially diagnosed with IVF, suggesting that genetic testing with definite evidence genes of cardiomyopathy may enable molecular diagnosis in a minority of patients with IVF. Further clinical evaluation and follow-up of patients with IVF with positive genotypes are needed to unveil concealed phenotypes, such as the pre-clinical phase of cardiomyopathy.

Sex differences in the association between minor nonspecific ST-segment and T-wave abnormalities and coronary artery calcification

BACKGROUND AND AIMS

Although minor nonspecific ST-segment and T-wave abnormalities (NSSTTA) have been associated with adverse cardiovascular outcomes, their relationship with subclinical atherosclerosis remains controversial. Therefore, the associations between electrocardiographic (ECG) abnormalities, including NSSTTA, and coronary artery calcification (CAC) were investigated in this study.

METHODS

This cross-sectional study included 136,461 Korean participants with no known cardiovascular disease or cancer, who underwent a health checkup including ECG and computed tomography to measure the coronary artery calcium score (CACS) by Agatston method between 2010 and 2018. ECG abnormalities were defined in accordance with the Minnesota Code using an automated ECG analysis program. A multinomial logistic regression model was used to calculate prevalence ratios (PRs) with 95% confidence intervals (CI) for each CACS category.

RESULTS

In men, both NSSTTA and major ECG abnormalities were associated with all levels of CACS. The multivariable-adjusted PRs (95% CI) for CACS >400 comparing NSSTTA and major ECG abnormalities to the reference (neither NSSTTA nor major ECG abnormalities) were 1.88 (1.29-2.74) and 1.50 (1.18-1.91), respectively. Women with major ECG abnormalities were more likely to have a CACS of 101-400, the PRs (95% CI) comparing major ECG abnormalities to the reference group was 1.75 (1.18-2.57). NSSTTA were not associated with any CACS level in women.

CONCLUSIONS

NSSTTA and major ECG abnormalities are associated with CAC in men, though NSSTTA were not associated with CAC in women, suggesting that NSSTTA should be considered sex-specific risk factors for coronary artery disease in men, but not in women.

Clinical and Genetic Features of Korean Inherited Arrhythmia Probands

BACKGROUND AND OBJECTIVES

Inherited arrhythmia (IA) is a more common cause of sudden cardiac death in Asian population, but little is known about the genetic background of Asian IA probands. We aimed to investigate the clinical characteristics and analyze the genetic underpinnings of IA in a Korean cohort.

METHODS

This study was conducted in a multicenter cohort of the Korean IA Registry from 2014 to 2017. Genetic testing was performed using a next-generation sequencing panel including 174 causative genes of cardiovascular disease.

RESULTS

Among the 265 IA probands, idiopathic ventricular fibrillation (IVF) and Brugada Syndrome (BrS) was the most prevalent diseases (96 and 95 cases respectively), followed by long QT syndrome (LQTS, n=54). Two-hundred-sixteen probands underwent genetic testing, and 69 probands (31.9%) were detected with genetic variant, with yield of pathogenic or likely pathogenic variant as 6.4%. Left ventricular ejection fraction was significantly lower in genotype positive probands (54.7±11.3 vs. 59.3±9.2%, p=0.005). IVF probands showed highest yield of positive genotype (54.0%), followed by LQTS (23.8%), and BrS (19.5%).

CONCLUSIONS

There were significant differences in clinical characteristics and genetic yields among BrS, LQTS, and IVF. Genetic testing did not provide better yield for BrS and LQTS. On the other hand, in IVF, genetic testing using multiple gene panel might enable the molecular diagnosis of concealed genotype, which may alter future clinical diagnosis and management strategies.

Predictors of stroke or systemic embolism in patients with non-valvular atrial fibrillation with CHA2 DS2 -VASc score of 0

BACKGROUND

Anticoagulant therapy has been important for stroke prevention in patients with atrial fibrillation (AF). However, it was not recommended due to its relatively higher risk of bleeding than its lower risk of stroke in patients with a CHA₂ DS₂ -VASc score of 0.

HYPOTHESIS

This study aimed to evaluate the predictors of stroke in AF patients with very low risk of stroke.

METHODS

Between 1990 and 2020, 542 patients with non-valvular AF (NVAF) with a CHA₂ DS₂ -VASc score of 0 followed up for at least 6 months were enrolled. Patients with only being woman as a risk factor were included as a CHA₂ DS₂ -VASc score of 0 in this study. The primary outcome was stroke or systemic embolism.

RESULTS

The primary outcome rate was 0.78%/year. In Cox hazard model, age of ≥50 years at diagnosis (hazard ratio [HR] 6.710, 95% confidence interval [CI] 1.811-24.860, p = .004), LVEDD of ≥46 mm (HR 4.513, 95% CI 1.038-19.626, p = .045), and non-paroxysmal AF (HR 5.575, 95% CI 1.621-19.175, p = .006) were identified as independent predictors of stroke or systemic embolism. Patients with all three independent predictors had a higher risk of stroke or systemic embolism (4.21%/year), whereas those without did not have a stroke or systemic embolism.

CONCLUSION

The annual stroke or systemic embolism rate in NVAF patients with CHA₂ DS₂ -VASc score of 0 was 0.78%/year, and age at AF diagnosis, LVEDD, and non-paroxysmal AF were independent predictors of stroke or systemic embolism in patients considered to have a very low risk of stroke.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Preoperative cardiac troponin I as a predictor of postoperative cardiac events in patients with end stage renal disease undergoing non-cardiac surgery

We investigated if elevated cardiac troponin I (cTnI) serum levels before non-cardiac surgery were predictors of postoperative cardiac events in patients with end stage renal disease (ESRD) undergoing dialysis. In total, 703 consecutive patients with ESRD undergoing dialysis who underwent non-cardiac surgery were enrolled. Preoperative cTnI serum levels were measured at least once in all patients. The primary endpoint was defined as a composite of cardiac death, myocardial infarction (MI), and pulmonary edema during hospitalization or within 30 days after surgery in patients with a hospitalization longer than 30 days after surgery. Postoperative cardiac events occurred in 48 (6.8%) out of 703 patients (cardiac death 1, MI 18, and pulmonary edema 33). Diabetes mellitus (DM), previous ischemic heart disease, and congestive heart failure were more common in patients with postoperative cardiac events. Peak cTnI serum levels were higher in patients with postoperative cardiac event (180 ± 420 ng/L vs. 80 ± 190 ng/L, p = 0.008), and also elevated peak cTnI levels > 45 ng/L were more common in patients with postoperative cardiac events (66.8% vs. 30.5%, p < 0.001). Multivariate logistic regression analysis showed that DM (odds ratio [OR]  2.509, 95% confidence interval [CI] 1.178-5.345, p = 0.017) and serum peak cTnI levels ≥ 45 ng/L (OR 3.167, 95% CI 1.557-6.444, p = 0.001) were independent predictors for the primary outcome of cardiac death/MI/pulmonary edema. Moreover, cTnI levels ≥ 45 ng/L had an incremental prognostic value to the revised cardiac risk index (RCRI) (Chi-square = 23, p < 0.001), and to the combined RCRI and left ventricular ejection fraction (Chi-square = 12, p = 0.001). Elevated preoperative cTnI levels are predictors of postoperative cardiac events including cardiac death, MI, and pulmonary edema in patients with ESRD undergoing non-cardiac surgery.

Prediction of atrial fibrillation in patients with embolic stroke with undetermined source using electrocardiogram deep learning algorithm and clinical risk factors

Background

Combining the artificial intelligence algorithm with the known clinical risk factors may provide enhanced accuracy for prediction of the hidden atrial fibrillation (AF) in patients with embolic stroke with undetermined source (ESUS).

Purpose

We aimed to develop enhanced prediction models for AF with deep learning algorithm (DLA) and clinical predictors in patients with ESUS. The DLA was created to identify the patients with paroxysmal AF based on their electrocardiograms (ECG) during sinus rhythm.

Methods

We analyzed the 221 patients who underwent insertable cardiac monitor (ICM) for AF detection following ESUS. The DLA was previously developed with sinus rhythm ECGs of 10,605 paroxysmal AF patients and 50,522 non-AF patients. The convolutional neural network was used for the DLA. The primary endpoint was defined as any AF episode lasting over 5 min by ICM. The atrial ectopic burden (AEB) was calculated as the percentage of the number of conducted QRS by atrial ectopy on Holter monitoring.

Results

AF (≥5 min) was detected by ICM in 32 patients (14.5%) during follow-up period of 15.1±8.6 months. AF patients had higher AEB (0.199% vs 0.023%, p&lt;0.001), larger left atrial diameters (LAD, 41.2 mm vs 35.7 mm, p&lt;0.001), and larger left atrial volume index (LAVI, 46.4 ml/m2 vs 32.3 ml/m2, p&lt;0.001) than those without AF. The means of calculated probabilities of AF by DLA were higher in patients with AF than those without AF (63.8% vs 40.2%, p&lt;0.001). In the receiver operating characteristic curve analysis, the areas under the curve (AUC) were the highest in DLA (0.824) followed by AEB (0.784), LAVI (0.780), and LAD (0.768). The multivariable model with AEB, LAVI, and DLA demonstrated excellent prediction accuracy for paroxysmal AF (AUC: 0.902, Figure 1)

Conclusions

In patients with ESUS, the DLA outperformed other clinical risk factors for prediction of AF. Combining DLA with AEB, LAD and LAVI could is a potential useful tool to predict AF in ESUS patients.

Funding Acknowledgement

Type of funding sources: None.

The novel bio-SYNTAX scoring system for predicting the prognosis of patients undergoing percutaneous coronary intervention with left main coronary artery disease

Background

Simple and effective risk models incorporating biomarkers associated with left main coronary artery (LMCA) stenosis are limited. This study aimed to validate the novel Bio-Clinical SYNTAX score (Bio-CSS) incorporating N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with LMCA stenosis.

Methods

Patients who underwent percutaneous coronary intervention (PCI) for LMCA stenosis using a drug-eluting stent (n = 275) were included in the study. We developed the Bio-CSS incorporating NT-proBNP and validated the ability of the Bio-CSS to predict major adverse cardiac events (MACEs) and compared its performance to that of the SYNTAX score (SS) and SS II. The MACEs were defined as death, non-fatal myocardial infarction (MI), and repeat revascularizations.

Results

The Bio-CSS (34.7 ± 18.3 vs. 51.9 ± 28.4, p &lt; 0.001), as well as SS (23.6 ± 7.3 vs. 26.7 ± 8.1, p = 0.003) and SS II (29.4 ± 9.9 vs. 36.1 ± 12.8, p &lt; 0.001), was significantly higher in patients with MACEs. In the Cox proportional hazards model, the log Bio-CSS (hazard ratio 8.31, 95% CI 1.84–37.55) was an independent prognostic factor for MACEs after adjusting for confounding variables. In the receiver operating characteristic curves, the area under the curve of the Bio-CSS was significantly higher compared to those of SS (0.608 vs. 0.706, p = 0.001) and SS II (0.655 vs. 0.706, p = 0.026). Patients were categorized into the three groups based on the tertiles of the Bio-CSS. Patients in the highest tertile of the Bio-CSS had significantly higher MACEs compared to those in the lower two tertiles (log-rank p &lt; 0.001).

Conclusion

In patients who underwent PCI for LMCA stenosis, the novel Bio-CSS improved the discrimination accuracy of established combined scores, such as SS and SS II. The addition of NT-proBNP to the clinical and angiographic findings in the Bio-CSS could potentially provide useful long-term prognostic information in these patients.

Spacecraft sample collection and subsurface excavation of asteroid (101955) Bennu

Carbonaceous asteroids, such as (101955) Bennu, preserve material from the early Solar System, including volatile compounds and organic molecules. We report spacecraft imaging and spectral data collected during and after retrieval of a sample from Bennu’s surface. The sampling event mobilized rocks and dust into a debris plume, excavating a 9-m-long elliptical crater. This exposed material that is darker, spectrally redder, and more abundant in fine particulates than the original surface. The bulk density of the displaced subsurface material was 500–700 kg per cubic meter, about half that of the whole asteroid. Particulates that landed on instrument optics spectrally resemble aqueously altered carbonaceous meteorites. The spacecraft stored 250 ± 101 g of material, which will be delivered to Earth in 2023.

Impact of the COVID-19 Pandemic on Patient Delay and Clinical Outcomes for Patients With Acute Myocardial Infarction

BACKGROUND

It has been known that the fear of contagion during the coronavirus disease 2019 (COVID-19) creates time delays with subsequent impact on mortality in patients with acute myocardial infarction (AMI). However, difference of time delay and clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI between the COVID-19 pandemic and pre-pandemic era has not been fully investigated yet in Korea. The aim of this study was to investigate the impact of COVID-19 pandemic on time delays and clinical outcome in patients with STEMI or non-STEMI compared to the same period years prior.

METHODS

A total of 598 patients with STEMI (n = 195) or non-STEMI (n = 403) who underwent coronary angiography during the COVID-19 pandemic (February 1 to April 30, 2020) and pre-pandemic era (February 1 to April 30, 2017, 2018, and 2019) were analyzed in this study. Main outcomes were the incidence of time delay, cardiac arrest, and in-hospital death.

RESULTS

There was 13.5% reduction in the number of patients hospitalized with AMI during the pandemic compared to pre-pandemic era. In patients with STEMI, door to balloon time tended to be longer during the pandemic compared to pre-pandemic era (55.7 ± 12.6 minutes vs. 60.8 ± 13.0 minutes, P = 0.08). There were no significant differences in cardiac arrest (15.6% vs. 10.4%, P = 0.397) and in-hospital mortality (15.6% vs. 10.4%, P = 0.397) between pre-pandemic and the pandemic era. In patients with non-STEMI, symptom to door time was significantly longer (310.0 ± 346.2 minutes vs. 511.5 ± 635.7 minutes, P = 0.038) and the incidence of cardiac arrest (0.9% vs. 3.5%, P = 0.017) and in-hospital mortality (0.3% vs. 2.3%, P = 0.045) was significantly greater during the pandemic compared to pre-pandemic era. Among medications, angiotensin converting enzyme inhibitors/angiotensin type 2 receptor blockers (ACE-I/ARBs) were underused in STEMI (64.6% vs. 45.8%, P = 0.021) and non-STEMI (67.8% vs. 57.0%, P = 0.061) during the pandemic.

CONCLUSION

During the COVID-19 pandemic, there has been a considerable reduction in hospital admissions for AMI, time delay, and underuse of ACE-I/ARBs for the management of AMI, and this might be closely associated with the excess death in Korea.

Pebbles and sand on asteroid (162173) Ryugu: In situ observation and particles returned to Earth

The Hayabusa2 spacecraft investigated the C-type (carbonaceous) asteroid (162173) Ryugu. The mission performed two landing operations to collect samples of surface and subsurface material, the latter exposed by an artificial impact. We present images of the second touchdown site, finding that ejecta from the impact crater was present at the sample location. Surface pebbles at both landing sites show morphological variations ranging from rugged to smooth, similar to Ryugu's boulders, and shapes from quasi-spherical to flattened. The samples were returned to Earth on 6 December 2020. We describe the morphology of >5 grams of returned pebbles and sand. Their diverse color, shape, and structure are consistent with the observed materials of Ryugu; we conclude that they are a representative sample of the asteroid.

Electrocardiographic Manifestations in Patients with COVID-19: Daegu in South Korea

As COVID-19 spreads worldwide, cardiac injury in patients infected with COVID-19 becomes a significant concern. Thus, this study investigates the impact of several electrocardiogram parameters and disease severity in COVID-19 patients. The deceased patients showed increased dispersion of QTc and Tpe-c compared with surviving patients (78.2±41.1 vs. 40.8±24.6 ms and 60.2±37.3 vs 40.8±24.5 ms, both p<0.05). The QTc dispersion of more than 56.1 ms could predict the mortality in multivariate analysis (Odd ratio 8.06, 95% Confidence Interval 2.843–25.750). A prolonged QTc dispersion could be an independent predictable factor of mortality.

Background and Objectives

As the coronavirus disease 2019 (COVID-19) spreads worldwide, cardiac injury in patients infected with COVID-19 becomes a significant concern. Thus, this study investigates the impact of several electrocardiogram (ECG) parameters and disease severity in COVID-19 patients.

Methods

Seven medical centers in Daegu admitted 822 patients with COVID-19 between February and April 2020. This study examined 267 patients among them who underwent an ECG test and evaluated their biochemical parameters like C-reactive protein (CRP), log N-terminal pro-B-type Natriuretic Peptide (NT-proBNP), cardiac enzyme, and ECG parameters (heart rate, PR interval, QRS interval, T inversion, QT interval, and Tpe [the interval between peak to end in a T wave]).

Results

Those patients were divided into 3 groups of mild (100 patients), moderate (89 patients), and severe (78 patients) according to clinical severity score. The level of CRP, log NT-proBNP, and creatinine kinase-myocardial band were significantly increased in severe patients. Meanwhile, severe patients exhibited prolonged QT intervals (QTc) and Tpe (Tpe-c) compared to mild or moderate patients. Moreover, deceased patients (58; 21.7%) showed increased dispersion of QTc and Tpe-c compared with surviving patients (78.2±41.1 vs. 40.8±24.6 ms and 60.2±37.3 vs. 40.8±24.5 ms, both p<0.05, respectively). The QTc dispersion of more than 56.1 ms could predict the mortality in multivariate analysis (odd ratio, 11.55; 95% confidence interval, 3.746–42.306).

Conclusions

COVID-19 infections could involve cardiac injuries, especially cardiac repolarization abnormalities. A prolonged QTc dispersion could be an independent predictable factor of mortality.

Prognostic value of novel neutrophil-to-hemoglobin and lymphocyte score in patients with acute myocardial infarction

We developed and assessed whether a novel neutrophil-to-hemoglobin and lymphocyte (NHL) score would improve the ability to predict clinical outcome compared with neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) in acute myocardial infarction (AMI). We examined 13,072 AMI patients from the Korean AMI Registry–National Institute of Health database. NHL score was calculated as follows: NHL score (U) = N/(Hb × L), where N, Hb, and L are baseline blood neutrophil, hemoglobin, and lymphocyte count. The primary outcome was the occurrence of major adverse cerebrocardiovascular events (MACCEs) at 2 years. The NLR, SII, and NHL score were independent predictors of 2-year MACCEs. The area under the curve of the NHL score (0.637) for predicting 2-year MACCEs was significantly higher compared with those of SII (0.589) and NLR (0.607). The NHL score significantly improved the reclassification and integrated discrimination compared with NLR ( p < 0.0001) and SII ( p < 0.0001). A high NHL score (≥ 0.35 U) was an independent predictor of 2-year MACCEs (adjusted hazard ratio, 1.41; 95% confidence interval, 1.29–1.55; p < 0.001). The NHL score could be a novel model for predicting long-term MACCEs in patients with AMI.

Effectiveness of a new cardiac risk scoring model reclassified by QRS fragmentation as a predictor of postoperative cardiac event in patients with severe renal dysfunction

Background

It is difficult to evaluate the risk of patients with severe renal dysfunction before surgery due to various limitations despite high postoperative cardiac events. This study aimed to investigate the value of a newly reclassified Revised Cardiac Risk Index (RCRI) that incorporates QRS fragmentation (fQRS) as a predictor of postoperative cardiac events in patients with severe renal dysfunction.

Methods

Among the patients with severe renal dysfunction, 256 consecutive patients who underwent both a nuclear stress test and noncardiac surgery were evaluated. We reclassified RCRI as fragmented RCRI (FRCRI) by integrating fQRS on electrocardiography. We defined postoperative major adverse cardiac event (MACE) as a composite of cardiac death, nonfatal myocardial infarction, and pulmonary edema.

Results

Twenty-eight patients (10.9%) developed postoperative MACE, and this was significantly frequent in patients with myocardial perfusion defect (41.4% vs. 28.0%, p = 0.031). fQRS was observed 84 (32.8%) patients, and it was proven to be an independent predictor of postoperative MACE after adjusting for the RCRI (odds ratio 3.279, 95% confidence interval (CI) 1.419–7.580, p = 0.005). Moreover, fQRS had an incremental prognostic value for the RCRI (chi-square = 7.8, p = 0.005), and to the combination of RCRI and age (chi-square = 9.1, p = 0.003). The area under curve for predicting postoperative MACE significantly increased from 0.612 for RCRI to 0.667 for FRCRI (p = 0.027) and 23 patients (32.4%) originally classified as RCRI 2 were reclassified as FRCRI 3.

Conclusions

A newly reclassified FRCRI that incorporates fQRS, is a valuable predictor of postoperative MACE in patients with severe renal dysfunction undergoing noncardiac surgery.

Prognostic impact of chromogranin A in patients with acute heart failure

Background

Chromogranin A (CgA) levels have been reported to predict mortality in patients with heart failure. However, information on the prognostic value and clinical availability of CgA is limited. We compared the prognostic value of CgA to that of previously proven natriuretic peptide biomarkers in patients with acute heart failure.

Methods

We retrospectively evaluated 272 patients (mean age, 68.5±15.6 years; 62.9% male) who underwent CgA test in the acute stage of heart failure hospitalization between June 2017 and June 2018. The median follow-up period was 348 days. Prognosis was assessed using the composite events of 1-year death and heart failure hospitalization.

Results

In-hospital mortality rate during index admission was 7.0% (n=19). During the 1-year follow-up, a composite event rate was observed in 12.1% (n=33) of the patients. The areas under the receiver-operating characteristic curves for predicting 1-year adverse events were 0.737 and 0.697 for N-terminal pro-B-type natriuretic peptide (NT-proBNP) and CgA, respectively. During follow-up, patients with high CgA levels (>158 pmol/L) had worse outcomes than those with low CgA levels (≤158 pmol/L) (85.2% vs. 58.6%, p<0.001). When stratifying the patients into four subgroups based on CgA and NT-proBNP levels, patients with high NT-proBNP and high CgA had the worst outcome. CgA had an incremental prognostic value when added to the combination of NT-proBNP and clinically relevant risk factors.

Conclusion

The prognostic power of CgA was comparable to that of NT-proBNP in patients with acute heart failure. The combination of CgA and NT-proBNP can improve prognosis prediction in these patients.

N-terminal pro-brain natriuretic peptide and coronary collateral formation in patients undergoing primary percutaneous coronary intervention

There is insufficient information on the relationship between the N-terminal pro-brain natriuretic peptide (NT-proBNP) level and collateral circulation (CC) formation after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction. We analyzed 857 patients who underwent primary PCI. The serum NT-proBNP levels were measured on the day of admission, and the CC was scored according to Rentrop’s classification. Log-transformed NT-proBNP levels were significantly higher in patients with good CC compared to those with poor CC (6.13 ± 2.01 pg/mL versus 5.48 ± 1.97 pg/mL, p < 0.001). The optimum cutoff value of log NT-proBNP for predicting CC was 6.04 pg/mL. Log NT-proBNP ≥ 6.04 pg/mL (odds ratio 2.23; 95% confidence interval 1.51–3.30; p < 0.001) was an independent predictor of good CC. CC development was higher in patients with a pre-TIMI flow of 0 or 1 than those with a pre-TIMI flow of 2 or 3 (22.6% versus 8.8%, p = 0.001). The incidence of left ventricular (LV) dysfunction (< 50%) was greater in patients with a pre-TIMI flow of 0 or 1 (49.8% versus 35.5%, p < 0.001). The release of NT-proBNP was greater in patients with LV dysfunction (34.3% versus 15.6%, p < 0.001). The incidence of good CC was greater in patients with log NT-proBNP levels ≥ 6.04 pg/ml (16.8% versus 26.2%, p = 0.003). The association between NT-proBNP and collateral formation was not influenced by pre-TIMI flow and LV function. NT-proBNP appears to reflect the degree of collateral formation in the early phase of STEMI and might have a new role as a useful surrogate biomarker for collateral formation in patients undergoing primary PCI.

Derivation and validation of a combined in-hospital mortality and bleeding risk model in acute myocardial infarction

Background

In the potent new antiplatelet era, it is important issue how to balance the ischemic risk and the bleeding risk. However, previous risk models have been developed separately for in-hospital mortality and major bleeding risk. Therefore, we aimed to develop and validate a novel combined model to predict the combined risk of in-hospital mortality and major bleeding at the same time for initial decision making in patients with acute myocardial infarction (AMI).

Methods

Variables from the Korean Acute Myocardial Infarction Registry (KAMIR) - National Institute of Health (NIH) database were used to derive (n = 8955) and validate (n = 3838) a multivariate logistic regression model. Major adverse cardiovascular events (MACEs) were defined as in-hospital death and major bleeding.

Results

Seven factors were associated with MACE in the model: age, Killip class, systolic blood pressure, heart rate, serum glucose, glomerular filtration rate, and initial diagnosis. The risk model discriminated well in the derivation (c-static = 0.80) and validation (c-static = 0.80) cohorts. The KAMIR-NIH risk score was developed from the model and corresponded well with observed MACEs: very low risk (0.9%), low risk (1.7%), moderate risk (4.2%), high risk (8.6%), and very high risk (23.3%). In patients with MACEs, a KAMIR-NIH risk score ≤ 10 was associated with high bleeding risk, whereas a KAMIR-NIH risk score > 10 was associated with high in-hospital mortality.

Conclusion

The KAMIR-NIH in-hospital MACEs model using baseline variables stratifies comprehensive risk for in-hospital mortality and major bleeding, and is useful for guiding initial decision making.

Engineered ionizable lipid nanoparticles for targeted delivery of RNA therapeutics into different types of cells in the liver

Ionizable lipid nanoparticles (LNPs) have been widely used for in vivo delivery of RNA therapeutics into the liver. However, a main challenge remains to develop LNP formulations for selective delivery of RNA into certain types of liver cells, such as hepatocytes and liver sinusoidal endothelial cells (LSECs). Here, we report the engineered LNPs for the targeted delivery of RNA into hepatocytes and LSECs. The effects of particle size and polyethylene glycol-lipid content in the LNPs were evaluated for the hepatocyte-specific delivery of mRNA by ApoE-mediated cellular uptake through low-density lipoprotein receptors. Targeted delivery of RNA to LSECs was further investigated using active ligands. Incorporation of mannose allowed the selective delivery of RNA to LSECs, while minimizing the unwanted cellular uptake by hepatocytes. These results demonstrate that engineered LNPs have great potential for the cell type-specific delivery of RNA into the liver and other tissues.

Impact of Cardiovascular Risk Factors and Cardiovascular Diseases on Outcomes in Patients Hospitalized with COVID-19 in Daegu Metropolitan City

BACKGROUND

Data regarding the association between preexisting cardiovascular risk factors (CVRFs) and cardiovascular diseases (CVDs) and the outcomes of patients requiring hospitalization for coronavirus disease 2019 (COVID-19) are limited. Therefore, the aim of this study was to investigate the impact of preexisting CVRFs or CVDs on the outcomes of patients with COVID-19 hospitalized in a Korean healthcare system.

METHODS

Patients with COVID-19 admitted to 10 hospitals in Daegu Metropolitan City, Korea, were examined. All sequentially hospitalized patients between February 15, 2020, and April 24, 2020, were enrolled in this study. All patients were confirmed to have COVID-19 based on the positive results on the polymerase chain reaction testing of nasopharyngeal samples. Clinical outcomes during hospitalization, such as requiring intensive care and invasive mechanical ventilation (MV) and death, were evaluated. Moreover, data on baseline comorbidities such as a history of diabetes, hypertension, dyslipidemia, current smoking, heart failure, coronary artery disease, cerebrovascular accidents, and other chronic cardiac diseases were obtained.

RESULTS

Of all the patients enrolled, 954 (42.0%) had preexisting CVRFs or CVDs. Among the CVRFs, the most common were hypertension (28.8%) and diabetes mellitus (17.0%). The prevalence rates of preexisting CVRFs or CVDs increased with age (P < 0.001). The number of patients requiring intensive care (P < 0.001) and invasive MV (P < 0.001) increased with age. The in-hospital death rate increased with age (P < 0.001). Patients requiring intensive care (5.3% vs. 1.6%; P < 0.001) and invasive MV (4.3% vs. 1.7%; P < 0.001) were significantly greater in patients with preexisting CVRFs or CVDs. In-hospital mortality (12.9% vs. 3.1%; P < 0.001) was significantly higher in patients with preexisting CVRFs or CVDs. Among the CVRFs, diabetes mellitus and hypertension were associated with increased requirement of intensive care and invasive MV and in-hospital death. Among the known CVDs, coronary artery disease and congestive heart failure were associated with invasive MV and in-hospital death. In multivariate analysis, preexisting CVRFs or CVDs (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.07-3.01; P = 0.027) were independent predictors of in-hospital death after adjusting for confounding variables. Among individual preexisting CVRF or CVD components, diabetes mellitus (OR, 2.43; 95% CI, 1.51-3.90; P < 0.001) and congestive heart failure (OR, 2.43; 95% CI, 1.06-5.87; P = 0.049) were independent predictors of in-hospital death.

CONCLUSION

Based on the findings of this study, the patients with confirmed COVID-19 with preexisting CVRFs or CVDs had worse clinical outcomes. Caution is required in dealing with these patients at triage.

Developing a predictive model for distinguishing invasive nail unit melanoma from nail unit melanoma in situ

BACKGROUND

Clinical information that distinguishes invasive nail unit melanoma from nail unit melanoma in situ before surgery would aid physicians in the decision-making process and estimating prognosis. However, limited information is available on the detailed demographic and dermoscopic features of invasive nail unit melanoma and nail unit melanoma in situ for differential diagnosis.

OBJECTIVE

This study aimed to investigate the demographic data and dermoscopic features of invasive nail unit melanoma and nail unit melanoma in situ and establish a predictive model for differentiating these two forms of nail unit melanoma.

METHODS

A retrospective observational study of ninety-seven patients diagnosed with nail unit melanoma (59 in situ and 38 invasive cases) in four healthcare centres in South Korea (three tertiary referral hospitals and one second referral hospital) from March 2014 to December 2019.

RESULTS

A multivariable analysis revealed that ulcer (odds ratio = 21.6, confidence interval = 2.1-219.8, P = 0.009), total melanonychia (odds ratio = 17.6, confidence interval = 3.0-104.0, P = 0.002), nail plate destruction (odds ratio = 10.9, confidence interval = 2.0-59.4, P = 0.006) and polychromia (odds ratio = 5.3, confidence interval = 1.36-20.57, P = 0.016) were distinctive dermoscopic features of invasive nail unit melanoma. A predictive model with scores ranging from 0 to 6 points demonstrated a reliable diagnostic value (C-statistic = 0.902) in differentiating invasive nail unit melanoma from nail unit melanoma in situ.

CONCLUSIONS

Invasive nail unit melanoma and nail unit melanoma in situ have different dermoscopic features. A predictive model based on morphologic dermoscopic features could aid in differentiating invasive nail unit melanoma from nail unit melanoma in situ.

Incremental Predictive Value of Plasma Renin Activity as a Prognostic Biomarker in Patients with Heart Failure

BACKGROUND

The association of N-terminal pro-B type natriuretic peptide (NT-proBNP) and plasma renin activity (PRA) for the prognosis of the patients with acute heart failure (HF) has not been fully investigated. This study aimed to determine the association between NT-proBNP and PRA and to investigate the incremental value of PRA to NT-proBNP for predicting long term prognosis in patients with acute HF.

METHODS

Three hundred and ninety-six patients (mean age, 64.7 ± 15.9 years; 46.5% female) presenting with acute HF were enrolled between December 2004 and July 2013. Patients with newly diagnosed HF as well as patients with acute exacerbated chronic HF were included. The prognosis was assessed with the composite event of all-cause mortality and readmission for HF during a 2-year follow-up period.

RESULTS

The etiology of HF was ischemic in 116 (29.3%) patients. In a Cox proportional hazards model, log-transformed PRA (hazard ratio [HR], 1.205; P = 0.007) was an independent predictor of the composite outcome of all-cause mortality and readmission for HF in addition to age (HR, 1.032; P = 0.001), white blood cell (WBC) count (HR, 1.103; P < 0.001), and left ventricular ejection fraction (LVEF) (HR, 0.978; P = 0.013). Adding PRA to age, sex, LVEF, and NT-proBNP significantly improved the prediction for the composite outcome of all-cause mortality and readmission for HF, as shown by the net reclassification improvement (0.47; P < 0.001) and integrated discrimination improvement (0.10; P < 0.001).

CONCLUSION

PRA could provide incremental predictive value to NT-proBNP for predicting long term prognosis in patients with acute HF.

Perioperative outcomes of interrupted anticoagulation in patients with non-valvular atrial fibrillation undergoing non-cardiac surgery

Background

This study aimed to investigate the incidences of and risk factors for perioperative events following anticoagulant discontinuation in patients with non-valvular atrial fibrillation (NVAF) undergoing non-cardiac surgery.

Methods

A total of 216 consecutive patients who underwent cardiac consultation for suspending perioperative anticoagulants were enrolled. A perioperative event was defined as a composite of thromboembolism and major bleeding.

Results

The mean anticoagulant discontinuation duration was 5.7 (±4.2) days and was significantly longer in the warfarin group (p<0.001). Four perioperative thromboembolic (1.9%; three strokes and one systemic embolization) and three major bleeding events (1.4%) were observed. The high CHA₂DS₂-VASc and HAS-BLED scores and a prolonged preoperative anticoagulant discontinuation duration (4.4±2.1 vs. 2.9±1.8 days; p=0.028) were associated with perioperative events, whereas the anticoagulant type (non-vitamin K antagonist oral anticoagulants or warfarin) was not. The best cut-off levels of the HAS-BLED and CHA₂DS₂-VASc scores were 3.5 and 2.5, respectively, and the preoperative anticoagulant discontinuation duration for predicting perioperative events was 2.5 days. Significant differences in the perioperative event rates were observed among the four risk groups categorized according to the sum of these values: risk 0, 0%; risk 1, 0%; risk 2, 5.9%; and risk 3, 50.0% (p<0.001). Multivariate logistic regression analysis showed that the HAS-BLED score was an independent predictor for perioperative events.

Conclusion

Thromboembolic events and major bleeding are not uncommon during perioperative anticoagulant discontinuation in patients with NVAF, and interrupted anticoagulation strategies are needed to minimize these.

A Case of COVID-19 with Acute Myocardial Infarction and Cardiogenic Shock

A 60-year-old male patient with coronavirus disease-2019 showed new onset ST-segment elevation in V1-V2 leads on electrocardiogram and cardiac enzyme elevation in intensive care unit. He had a history of type 2 diabetes mellitus, hypertension, and dyslipidemia. He was receiving mechanical ventilation and veno-venous extracorporeal membrane oxygenation treatment for severe hypoxia. Two-D echocardiogram showed regional wall motion abnormalities. We performed primary percutaneous coronary intervention for acute myocardial infarction complicating cardiogenic shock under hemodynamic support. He expired on the 16th day of admission because of cardiogenic shock and multi-organ failure. Active surveillance and intensive treatment strategy are important for saving lives of COVID-19 patients with acute myocardial infarction.

OP0202 STRESS-ACTIVATED MIR-204 GOVERNS SENESCENT PHENOTYPES OF CHONDROCYTES TO PROMOTE OSTEOARTHRITIS DEVELOPMENT

Background:

A progressive loss of cartilage matrix leads to the development of osteoarthritis (OA). Matrix homeostasis is disturbed in OA cartilage as the result of reduced production of cartilage-specific matrix and increased secretion of catabolic mediators by chondrocytes. Chondrocyte senescence is a crucial cellular event contributing to such imbalance in matrix metabolism during OA development.

Objectives:

We sought to identify a previously unknown, senescence-associated signaling pathway in chondrocytes linked to major OA cartilage manifestations such as PG loss and cartilage degeneration.

Methods:

We particularly aimed to screen miRNAs whose inhibition could effectively modulate senescent phenotypes of chondrocytes to treat OA. We investigated the regulatory mechanisms of miR-204 under various stress-eliciting stimuli in primary cultured human and mouse chondrocytes. We examined the in vivo effects of miR-204 overexpression and its antagonism in surgically induced OA mouse models. DMM surgery was used to induce posttraumatic OA in 12-week-old mice. Small RNAs were delivered to mouse knee joints by intra-articular injection. Various OA manifestations including cartilage destruction, subchondral bone sclerosis, osteophyte maturity, and synovial inflammation in mice were histologically inspected.

Results:

We identify miR-204 as a senescence-associated microRNA (miRNA) which is markedly upregulated in OA cartilage. The upregulated miR-204 simultaneously targets multiple components of the sulfated proteoglycan (PG) biosynthesis pathway, effectively shutting down PG anabolism. Ectopic expression of the miR-204 in joints triggers spontaneous cartilage loss and OA development, whereas inhibition of miR-204 ameliorates experimental OA, with concomitant recovery of PG synthesis and suppression of inflammatory senescence-associated secretory phenotype (SASP) factors in cartilage

Conclusion:

we unravel a stress-activated senescence pathway that underlies disrupted matrix homeostasis in OA cartilage.

References:

[1]O. H. Jeon, C. Kim, R.-M. Laberge, M. Demaria, S. Rathod, A. P. Vasserot, J. W. Chung, D. H. Kim, Y. Poon, N. David, D. J. Baker, J. M. van Deursen, J. Campisi, J. H. Elisseeff, Local clearance of senescent cells attenuates the development of post-traumatic osteoarthritis and creates a pro-regenerative environment. Nat. Med. 23, 775–781 (2017)

Disclosure of Interests:

None declared

AB0080 A SYSTEM-LEVEL APPROACH IDENTIFIES A CRITICAL REGULATOR OF CHONDROSARCOMA PROGRESSION

Background:

Chondrosarcomas are cartilaginous tumors that constitute one-third of skeletal system cancers. Chondrosarcomas are capable of transitioning to highly metastatic and treatment-refractory states, resulting in significant patient mortality. However, the molecular events accompanying this behavior remain unknown.

Objectives:

We aimed to uncover the molecular pathway underlying such tumor progression that confers a higher malignancy to chondrosarcoma.

Methods:

We conducted unsupervised gene co-expression network analyses using transcriptomes of patients with chondrosarcoma and extracted a characteristic transcription network underlying chondrosarcoma malignancy. By implementing a system-level upstream analysis of this gene network, we identified the transcriptional factor as a key regulator governing chondrosarcoma progression. We unraveled the functional roles of the identified factor in promoting tumor growth and metastasis of chondrosarcomas in the context of their unique microenvironments.

Results:

By conducting system-level upstream analysis, we identified a factor as a transcriptional regulator that governs the malignancy gene module. The identified factor was upregulated in chondrosarcoma biopsies associated with a high histological grade and conferred chondrosarcoma cells invasiveness and tumor-initiating capacity. In an orthotopic xenograft mouse model, the identified factor modulated local outgrowth and pulmonary metastasis of chondrosarcoma. Pharmacological inhibition of the identified factor in conjunction with the chemotherapy agents such as cisplatin or doxorubicin synergistically enhanced chondrosarcoma cell apoptosis and abolished malignant phenotypes of chondrosarcoma in mice.

Conclusion:

Our study provides a proof of concept evidence that inhibiting the identified factor suppresses progression of chondrosarcoma and improves the efficacy of chemotherapy in cellular and pre-clinical levels. Taken together, we believe that our findings provide novel molecular insights for the development of new anti-cancer therapies to target chondrosarcomas.

References:

[1]Gelderblom H, et al. The clinical approach towards chondrosarcoma. Oncologist 13, 320-329 (2008)

Disclosure of Interests:

None declared

0622 In-Depth Surveillance of Central Sleep Apnea in Patients with Stable Heart Failure

Introduction

Central sleep apnea (CSA) is unique sleep breathing phenotype in patients with advanced chronic heart failure (HF) and portend poor prognosis. The prevalence of CSA in HF patients under contemporary therapy is uncertain.

Methods

We reviewed consecutive HF patients on optimal medical therapy who underwent clinically indicated diagnostic in-lab polysomnography at a single academic center. Age, sex and BMI matched patients without HF were selected from sleep clinic as a control. Patients with atrial fibrillation were excluded from this study. Apnea subtypes were determined after careful scoring and confirmation by sleep physicians. ‘Any CSA’ was defined by central apnea index (CAI) &gt;5 and &gt;1/hr. ‘True CSA’ was defined if met both CAI≥5/hr and &gt; obstructive apnea index (OAI). Obstructive sleep apnea (OSA) was defined if apnea hypopnea index &gt;15 and OAI&gt;CAI. Multivariate analysis was performed using logistic regression adjusting for age, sex, HF and systolic dysfunction as appropriate.

Results

In patients with HF (N=95, mean age 59, female: 50%), CSA was low and was comparable to control group (N=94) (HF vs. Non-HF; CSA: 5.3 vs. 4.3%, P=NS; Any CSA 14.7 vs. 17%, P=NS). Only 3 patients with HF had true CSA. In contrast, OSA was common in both groups regardless of obesity status (52.3 vs. 55.3%). In patients with HF, Cheyne Stokes respiration was more frequent in patients with Any CSA vs. without Any CSA (13.3 vs. 3.8%, p=0.04). In multivariate analysis, presence of OSA, but not HF, was associated with Any CSA in entire cohort (Any CSA OR: 3.1 [1.3, 8.1], p=0.02). In patients with HF, male sex was associated with Any CSA (OR: 5.3 [1.1, 40.8], p=0.05). Exclusion of patients with high BMI did not change the results.

Conclusion

CSA was rare in patients with stable HF on contemporary optimal medical therapy.

Support

None