Absence Of Ischemic Heart Disease Research Articles

Safe discharge for patients admitted for lower gastrointestinal bleeding (LGITB): derivation and validation of a novel scoring system

AimBleeding from the lower gastrointestinal tract (LGITB) is a common clinical presentation. Recent guidelines have recommended for incorporation of clinical risk assessment tools in the management for LGITB. We derived and validated a novel clinical scoring system to predict safe discharge after LGITB admission, and compared it to other published scoring systems in current literature.MethodsA retrospective cohort of 798 patients with LGITB from August 2018 to March 2021 was included in the derivation cohort. Multivariate binary logistic regression was performed to identify significant clinical variables predictive of safe discharge. A clinical scoring system was developed based on the results, and validated on a prospective cohort of 312 consecutive patients with LGITB from April 2021 to March 2022. The performance of the novel scoring system was compared to other LGITB clinical risk assessment scores via area under the receiver operating characteristics curve (AUROC) analysis.ResultsVariables predictive of safe discharge included the following; absence of previous LGITB admission, absence of ischemic heart disease, absence of blood on digital rectal examination, absence of dizziness or syncope at presentation and the systolic blood pressure and haemoglobin levels at presentation. The novel score had an AUROC of 0.907. A cut-off point of 4 provided a sensitivity of 41.9%, specificity of 97.5%, positive predictive value of 96.4% and negative predictive value of 51.5% for prediction of safe discharge. The score performs comparably to the Oakland score.ConclusionThe novel LGITB clinical risk score has good predictive performance for safe discharge in patients admitted for LGITB.

Prognostic Value of Different Thresholds for Myocardial Scar Quantification on Cardiac MRI Late Gadolinium Enhancement Images in Patients Receiving Implantable Cardioverter Defibrillators

Purpose To compare the predictive value of different myocardial scar quantification thresholds using cardiac MRI for appropriate implantable cardioverter defibrillator (ICD) shock and mortality. Materials and Methods In this retrospective, two-center observational cohort study, patients with ischemic or nonischemic cardiomyopathy underwent cardiac MRI prior to ICD implantation. Late gadolinium enhancement (LGE) was first determined visually and then quantified by blinded cardiac MRI readers using different SDs above the mean signal of normal myocardium, full-width half-maximum, and manual thresholding. The intermediate signal “gray zone” was calculated as the differences between different SDs. Results Among 374 consecutive eligible patients (mean age, 61 years ± 13 [SD]; mean left ventricular ejection fraction, 32% ± 14; secondary prevention, 62.7%), those with LGE had a higher rate of appropriate ICD shock or death than those without (37.5% vs 26.6%, log-rank P = .04) over a median follow-up of 61 months. In multivariable analysis, none of the thresholds for quantifying scar was a significant predictor of mortality or appropriate ICD shock, while the extent of gray zone was an independent predictor (adjusted hazard ratio per 1 g = 1.025; 95% CI: 1.008, 1.043; P = .005) regardless of the presence or absence of ischemic heart disease (P interaction = .57). Model discrimination was highest for the model incorporating the gray zone (between 2 SD and 4 SD). Conclusion Presence of LGE was associated with a higher rate of appropriate ICD shock or death. Although none of the scar quantification techniques predicted outcomes, the gray zone both in infarct and nonischemic scar was an independent predictor and may refine risk stratification. Keywords: MRI, Scar Quantification, Implantable Cardioverter Defibrillator, Sudden Cardiac Death Supplemental material is available for this article. © RSNA, 2023

A prospective, open-labeled, and randomized trial for assessing safety and clinical utility of gastric biopsies during emergency gastroscopy for patients with bleeding gastric ulcers

Objective There is no consensus on whether a gastroscopic biopsy is necessary during the emergency treatment of gastrointestinal (GI) diseases such as gastric ulcer bleeding. In this study, we examined the clinical utility and safety of an emergency gastroscopic biopsy for the assessment of gastric ulcer bleeding. Methods We enrolled 150 patients with a single bleeding gastric ulcer after emergency gastroscopy (EG) from April 2020 to April 2022. The patients were randomly divided into the biopsy and no biopsy groups, and they were followed-up until June 2022 to examine whether recurrent gastric ulcer bleeding had occurred. Results Re-bleeding occurred in 15 out of 150 (10%) patients. We diagnosed malignancies in 17 (11.3%) patients and validated 14 (9.3%) of them during the initial gastroscopy procedure. Factors that could predict the occurrence of gastric ulcer re-bleeding with biopsy during EG included an absence of ischemic heart disease (odds ratio [OR] = 0.395, confidence interval [CI]: 0.24–0.65, p ≤ .005), renal disease (OR = 1.74, CI: 0.77–1.59, p ≤ .005), and using warfarin or oral anticoagulants (OR = 11.953, CI: 3.494–39.460, p ≤ .005). No significant differences were observed in 60-day bleeding (p = .077) and the duration of hospitalization (p = .700) between the two groups. Conclusions Patients undergoing biopsy during EG did not exhibit an increased risk of re-bleeding compared with those who did not undergo a biopsy. An early biopsy facilitates an early pathologic diagnosis, early clinical intervention, safe discharge of low-risk patients, and improved outcomes in high-risk patients.

Порівняння впливу фіксованої комбінації периндоприл/амлодипін на ураження органів-мішеней у пацієнтів з артеріальною гіпертензією з ішемічною хворобою серця та без неї (результати дослідження EPHES)

Дослідження EPHES (Evaluation of influence of fixed dose combination Рerindopril/Amlodipine on target organ damage in patients with arterial HypErtension with or without iSchemic heart di­sease — оцінка впливу фіксованої комбінації периндоприл/амлодипін на ураження органів-мішеней у пацієнтів з артеріальною гіпертензією (АГ) з ішемічною хворобою серця (ІХС) та без неї) мало за мету порівняти ефективність фіксованої комбінації (ФК) периндоприл/амлодипін щодо зниження артеріального тиску (АТ) та динаміки вираженості ураження органів-мішеней у хворих на АГ з ІХС та без неї. Матеріали та методи. У дослідження EPHES було включено 60 пацієнтів з АГ віком старше від 30 років: перша група — 30 пацієнтів без ІХС, друга — 30 пацієнтів, які мали ІХС. Строк спостереження становив 12 місяців. Усім пацієнтам у день рандомізації призначали ФК периндоприл/амлодипін у початковій дозі 5/5 мг один раз на добу. При необхідності (АТ > 140/90 мм рт.ст.) дози компонентів ФК збільшували поступово кожні 2 тижні до 10/10 мг, а після 6 тижнів лікування додавався індапамід 1,5 мг. 66,7 та 96,7 % пацієнтів в першій та другій групах відповідно отримували бета-адреноблокатори. Усім пацієнтам проводили: вимірювання маси тіла та зросту, офісних рівнів систолічного АТ (САТ), діастолічного АТ (ДАТ) та частоти серцевих скорочень (ЧСС), добове моніторування АТ, визначення швидкості поширення пульсової хвилі в артеріях еластичного (ШППХе) та м’язового типів, центрального САТ, стандартизованого до ЧСС 75 уд/ хв індексу аугментації (Аіх75), біохімічне дослідження крові, електрокардіографію, ехокардіографію з допплерографією, вимірювання гомілково-плечового індексу, визначення товщини комплексу інтима-­медіа (ТКІМ). Результати. Встановлено, що призначена терапія на основі ФК периндоприл/амлодипін незалежно від наявності або відсутності ІХС ефективно (до цільових рівнів) та безпечно знижувала офісний, середньодобовий, денний, нічний та центральний АТ. При цьому достовірно зменшувалися початково підвищені денна та нічна варіабельність АТ, величина ранкового підйому САТ та частка пацієнтів з добовим профілем АТ типу «нон-дипер», проте ці показники залишалися достовірно більшими у пацієнтів з ІХС на всіх етапах лікування. Хворі з ІХС та без неї не відрізнялися за початковою величиною АІх75, і на фоні призначеної терапії спостерігалося достовірне зменшення цього показника в обох групах, проте у хворих з ІХС це зменшення АІх75 було достовірно меншим, ніж у групі без ІХС, що, імовірно, було пов’язано з більш частим застосуванням бета-блокаторів. Ефективне щодо зниження АТ лікування призводило в обох групах до достовірного зменшення ураження органів-мішеней — покращення пружно-еластичних властивостей аорти та діастолічної функції лівого шлуночка, зменшення рівня альбумінурії, гіпертрофії лівого шлуночка та розміру лівого передсердя. Ступінь зниження ШППХе був достовірно (Р < 0,005) меншим у пацієнтів без ІХС, ніж у групі з ІХС — 2,5 ± 0,2 м/с проти 4,4 ± 0,5 м/с. Окрім того, незважаючи на однаковий ступінь зменшення індексу маси міокарда лівого шлуночка, покращення діастолічної функції лівого шлуночка (збільшення Е/А та зменшення Е/Е’) у групі хворих з ІХС було більшим — на 64,4 та 54,1 % проти 39,8 та 23,2 % відповідно (Р < 0,05 для обох показників). Максимальна величина ТКІМ достовірно зменшилася лише в пацієнтів з ІХС. Терапія не призводила до достовірних змін біохімічних показників та добре переносилася хворими — побічні явища зареєстровані у 2 (6,5 %) в групі без ІХС та у 3 (10 %) у групі з ІХС (Р = НД між групами). Групи достовірно не відрізнялися за динамікою скарг, і серед пацієнтів з ІХС, які мали стенокардію на початку дослідження, значно зменшилася кількість приступів стенокардії за тиждень — з 2,5 ± 0,4 до 1,2 ± 0,2 (Р < 0,01). Висновки. Отже, лікування АГ на основі ФК периндоприл/амлодипін було ефективним щодо зниження АТ та регресу ураження органів-мішеней незалежно від наявності ІХС. Зміни показників, що характеризують ураження органів-мішеней, дещо відрізнялися в пацієнтів з ІХС та без неї, що необхідно враховувати при виборі тактики лікування.

Continuous flow left ventricular assist devices do not worsen endothelial function in subjects with chronic heart failure: a pilot study.

AimsTo evaluate endothelial function in subjects with left ventricular assist devices (LVADs), comparing them with subjects with chronic heart failure with reduced ejection fraction on the list for heart transplant (HT) and with HT patients with a normal systolic cardiac function to identify any differences.MethodsWe enrolled 28 subjects with LVAD, 55 subjects with HT, and 42 subjects with heart failure on the transplant list. The subjects underwent a general physical examination, assessment of laboratory blood parameters, and assessment of endothelial function through flow‐mediated dilation (FMD) of brachial artery.ResultsThe three groups were homogeneous as regards age, gender, smoke abuse, C‐reactive protein (CRP) and FMD parameters (P = ns). In LVAD group percentage of FMD change showed an inverse correlation with CRP (rho: −0.5, P: 0.003), a well‐known marker of inflammation and tissue damage.ConclusionsContinuous flow related to LVAD seems to not worsen endothelial function. Endothelial function was not affected by cardiovascular risk factors (hypertension, hypercholesterolaemia, diabetes, obesity, and tobacco habit), by the functional status expressed by New York Heart Association class, by the left ventricular systolic function and by the presence or absence of ischaemic heart disease in all the populations analysed. CRP was the only factor able to influence percentage of FMD change in patient with LVAD, reinforcing the hypothesis that inflammation is the main determinant of endothelial function.

Implantable cardioverter-defibrillator therapy in primary prevention in the elderly

In elderly patients with heart failure and an indication for implantable cardioverter defibrillator (ICD) implantation, the incidence of sudden cardiac death (SCD) increases progressively with age, up to 80-85 years. ICD implantation is a recognized therapy, included in the guidelines for the prevention of SCD in the general population, which is also applied to elderly patients, albeit in an uneven manner, given the lack of robust data in the literature. In fact, the average age of patients included in the main randomized trials on ICDs is about 60 years. All this brings to a series of doubts in this regard, compounded by recent studies that have raised the suspicion of therapeutic futility in the implantation of ICDs in primary prevention in subjects aged ≥70 years, especially in the absence of ischemic heart disease. In the elderly, although the risk of SCD does not vary, the mortality rate for other causes tends progressively to increase with age, as the main consequence of the simultaneous presence of situations such as frailty syndrome and comorbidity. In order to avoid an ageistic attitude, it is therefore necessary to promote randomized controlled trials aimed at a multidimensional evaluation of the elderly patients with an indication for ICD implantation, from which more robust data can be obtained to allow the heart team a selectively targeted evaluation of elderly patients.

468-P: Nonalcoholic Steatohepatitis Is Associated with Diabetic Cardiomyopathy in Type 2 Diabetes

Background: Abnormalities in cardiac structure and function in type 2 diabetic patients may develop in the absence of ischemic heart disease. These abnormalities are attributed to diabetic cardiomyopathy. Impaired diastolic heart function has been observed in persons with nonalcoholic fatty liver disease (NAFLD) and/or with type 2 diabetes. We investigated the association between liver fibrosis and left ventricular (LV) diastolic dysfunction in type 2 diabetes. Methods: We studied 92 patients with type 2 diabetes (51 men; mean age 62 ± 6 years) who had undergone liver ultrasonography and conventional Doppler echocardiography. Presence of NAFLD and/or advanced liver fibrosis was determined by abdominal ultrasonography and NAFLD fibrosis score (NFS). LV diastolic dysfunction was defined according to transmitral peak early to late ventricular filling (E/A) ratio and deceleration time (DT), using echocardiography. Results: Fifty-four patients (58.7%) had NAFLD. On echocardiography, LVEF was within normal range in both groups, whereas LV mass index (P=0.035) and LA diameter (P=0.021) were significantly greater in the NAFLD patients. The systemic vascular resistance and arterial elasticity were not different. NAFLD patients had lower E/A ratio (P=0.014) and longer DT (P=0.042) than those without steatosis. When NAFLD was stratified by NFS, subjects with advanced liver fibrosis exhibited a higher prevalence of diastolic dysfunction (46.2%, 55.6%, 60.0%; none, simple steatosis, advanced fibrosis, respectively; P for trend = 0.025). In multivariate logistic regression, liver fibrosis was independently associated with diastolic dysfunction (OR=1.46, 95% CI=1.02-2.46, P=0.041) after adjusting for cardiometabolic risk factors. Conclusions: Our data show that in patients with type 2 diabetes and NAFLD, liver fibrosis was associated with LV diastolic dysfunction and may be an independent risk factor for diastolic dysfunction. Disclosure D. Cho: None.

Genetic Arrhythmia Center: Caring for Patients and Families at Risk for Sudden Cardiac Death and Advancing the Understanding of Rare Cardiomyopathies and Channelopathies

Although rare in the general population, genetic arrhythmia syndromes have a significant public health impact due to their contribution to the incidence of sudden cardiac death, particularly in children and young adults. When sudden cardiac death occurs in the absence of ischemic heart disease, a genetic cardiac condition may be suspected and clinical and genetic screening of family members is recommended. The Genetic Arrhythmia Center at the Minneapolis Heart Institute collaborates with local partners in the Sudden Cardiac Arrest network to connect patients and their family members with interdisciplinary care for diagnosis and treatment of these conditions. The most common conditions seen in the Genetic Arrhythmia Center include arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction, long QT syndrome, and Brugada syndrome. In addition to providing clinical care and genetic testing and counseling services, the Genetic Arrhythmia Center is working to advance the scientific understanding of the clinical presentation and natural history of these rare conditions.

Predictors of Recurrent Stroke in Patients with First-Ever Acute Ischemic Stroke: A Prospective Single-Institute Study

As previous research has suggested that recurrent stroke (RS) adversely affects the life of survivors of ischemic stroke (IS), we aimed to assess the relationship between RS and the potential risk factors in patients with first-ever IS. We prospectively studied consecutive patients with first-ever acute ischemic stroke (AIS) who were admitted within the first 7 days of onset to the Acute Stroke Unit at the Guangdong Second Provincial General Hospital between November 2012 and January 2014. We recorded demographic factors, vascular risk factors, previous Rankin scale score, and etiology. The association between stroke recurrence and its risk factors was analyzed by using multivariable Cox regression model. Out of a total of 421 patients, 57 (13.5%) patients experienced RS during the follow-up period. Multivariable Cox regression analysis revealed that smoking [hazard ratio (HR), 2.153; 95% Confidence Interval (CI), 1.263-3.671], high density lipoprotein cholesterol (HDL) (HR, 0.438; 95% CI, 0.211-0.911), housework (HR, 0.488; 95% CI, 0.256-0.933), ischemic heart disease (IHD) (HR, 2.998; 95% CI, 1.281-7.020), daily consumption of fresh fruits (HR, 0.477; 95% CI, 0.278-0.819), and good sleep quality (HR, 0.375; 95% CI, 0.216-0.650) were associated with RS among stroke patients. Our results suggest that healthy lifestyle (high fruit intake, smoking cessation, housework, good sleep quality), higher HDL levels, and absence of IHD were associated with a lower risk of RS in patients with first-ever IS. Funding Statement: This work was partially supported by the Science and Technology Program of Guangzhou, China (201707010436 to ZXH), Guangdong Second Provincial General Hospital Medical Scientific Research Projects (YY2016-005 to ZXH), and Administration of Traditional Chinese Medicine of Guangdong Province, China (20173024 to XTL; 20181012 to ZXH). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: The study protocol was approved by the Ethical Committee of the Guangdong Second Provincial General Hospital.

Predictors of High-Sensitivity Cardiac Troponin T Elevation in Patients with Acute Paroxysmal Supraventricular Tachycardia and Ischemic Heart Disease.

We studied the predictors and patterns of high-sensitivity cardiac troponin T (hs-cTnT) elevation in patients with paroxysmal supraventricular tachycardia (PSVT) in the presence and absence of ischemic heart disease. During calendar year 2013, we enrolled 70 of 72 consecutive adult patients with PSVT who presented at our center within 4 hours after the onset of tachycardia. On the basis of increased hs-cTnT at either of 2 initial measurements, we divided patients into groups (hs-cTnT-positive and hs-cTnT-negative), to study the predictors of enzyme elevation. We then divided the hs-cTnT-positive patients into 2 groups-those with and those without ischemic heart disease-and compared hs-cTnT changes. We observed hs-cTnT elevation in 52 of the 70 patients (74.3%). The hs-cTnT-positive patients were significantly older (P=0.008) and had a significantly higher duration of tachycardia (P=0.01). Older age, the presence of chest pain, lower diastolic blood pressure, and longer duration of tachycardia increased the odds of enzyme elevation. Among patients with elevated hs-cTnT levels, the baseline and maximal hs-cTnT levels were significantly higher in ischemic patients (P=0.01 and P=0.003, respectively). The increase in hs-cTnT seemed to be higher and longer in ischemic patients, although this was not statistically significant (P=0.908). Finally, hs-cTnT did not decrease to baseline levels within 48 hours in either group. We found that hs-cTnT levels increased in all our patients with PSVT, more so in those with ischemic heart disease.

The contributions of fasting and postprandial blood glucose increments to oxidative stress and inflammation in dyslipidemic type 2 diabetic patients with stable ischemic heart disease

Background/objectivesContributions of fasting and postprandial blood glucose increments on level of inflammation and oxidative stress biomarkers in patients with stable ischemic heart disease (IHD) and diabetes mellitus type 2 (T2DM) was evaluated. MethodologyNinety T2DM patients (60 with IHD and 30 without IHD) treated with metformin and/or sulphonylurea were enrolled in cross-sectional nested case–control clinical study. The areas under the six-point daily glucose curve above the fasting glucose concentrations (AUCpp) and over 5.5mmol/L (AUCbg) were calculated to determine postprandial (AUCpp) and fasting (AUCbg-AUCpp) glucose increments. Malondialdehyde (MDA), protein carbonyl group (PCO), fibrinogen, C-reactive protein (hsCRP), leukocyte count and adhesion molecules ICAM-1 and VCAM-1 were determined. ResultsAUCbg-AUCpp 58.2 (95%CI 40.6–75.8) was higher in IHD group compared to non-IHD 36.9 (95%CI 23.5–50.2) mmol*h/L. They had significantly higher ICAM-1 (mean±SD) 72.70±30.6 vs. 60.22±22.6ng/mL and MDA 16.47±4.5 vs. 13.42±4.01μmol/g plasma proteins, but similar PCO, VCAM-1, fibrinogen, hsCRP concentration and leukocyte count. AUCpp positively correlated with MDA (r=0.45) and ICAM-1 (r=0.32) in the presence of IHD, and VCAM-1 (r=0.44) in the absence of IHD. AUCbg-AUCpp positively correlated with PCO (r=0.45) in the absence of IHD. The analysis revealed that AUCpp over turning point of 0mmol*h/L was associated with high MDA and ICAM-1 expression in diabetics with IHD. AUCbg-AUCpp over 30mmol*h/L leads to high oxidative protein modification in diabetics without IHD. ConclusionIn T2DM patients with stable IHD, AUCpp at any point, significantly contributes to increasing of MDA and ICAM-1 expression. Fasting blood glucose increment showed significant correlation with carbonyl content in diabetics without IHD.

A Higher Cardiothoracic Ratio Is Associated with 2-Year Mortality after Hemodialysis Initiation

A high cardiothoracic ratio (CTR) is indicative of a cardiac disorder. However, few reports have revealed an association between the CTR and mortality in patients starting hemodialysis (HD). Methods: Patients with HD initiation (n = 387; mean age, 66.7 ± 12.7 years) were divided into the following three groups according to their CTR at HD initiation: CTR <50%, 50% ≤ CTR < 55%, and CTR ≥55%. Kaplan-Meier analysis was performed to compare 2-year all-cause mortality among these groups. Furthermore, we investigated the factors affecting their 2-year mortality using a Cox proportional hazard regression analysis. Results: Sixty-five patients (17%) died within 2 years after HD initiation. Kaplan-Meier analysis showed that patients with CTR ≥55% had a higher mortality rate than those in the other groups. Cox proportional hazard regression analysis was performed using parameters with p values <0.1 among these three groups [sex, age, presence or absence of ischemic heart disease, hemoglobin levels, serum albumin levels, CTR, body mass index (BMI)] and confounding factors [presence or absence of diabetes mellitus, and estimated glomerular filtration rate (eGFR)]. Age, eGFR, BMI, and CTR ≥55% at HD initiation were identified as factors influencing 2-year mortality. Conclusion: CTR >55% is one of the most important independent factors to affect 2-year all-cause mortality. Thus, confirming the cardiac condition of patients at HD initiation with a CTR >55% may improve their survival.

Increased High-Sensitivity Troponin-T Levels Are Associated with Mortality After Ischemic Stroke.

Biomarkers for diagnosis, treatment, and outcome prediction after stroke are lacking. Therefore, we aimed to evaluate the association between increased serum troponin, stroke severity, and mortality. Unselected patients with acute ischemic stroke assessed for troponin levels were included over the span of 1 year. Risk-factor profile, stroke etiology, stroke severity, and mortality during acute admission were recorded. The study included 212 patients, and 35 had increased troponin levels. Elevated troponin levels were associated with older age (82.1 ± 10.7 vs. 72.2 ± 12.6, p < 0.001), poor kidney function (calculated GFR 58.7 ± 29.8 vs. 82.7 ± 28.4, p < 0.001), and known ischemic heart disease (51.4% vs. 33.9%, p = 0.049). Patients with increased troponin had increased stroke severity on admission (National Institutes of Health Stroke Scale (NIHSS) 16.0 ± 9.4 vs. 10.4 ± 8.0, p < 0.001). This association remained significant after multivariate analysis but was nonlinear. Mortality rates were significantly higher in patients with increased troponin (37.1 vs. 5.6%, p < 0.001). On multivariate analysis, elevated troponin (odds ratio [OR] 22.57, 95% CI 4.4-116.6), absence of ischemic heart disease (OR 10.3, 95% CI 1.8-57.6), and admission NIHSS score (OR 1.59 for every 5 points, 95% CI 1.1-2.4) were associated with mortality. This study indicates that elevated troponin is an independent marker for severe deficits on presentation and for mortality in stroke patients.

Role of antihypertensive drugs in the treatment of migraine

The treatment of migraine depends on the frequency, severity and concomitant diseases. There are several specific drugs developed for migraine prevention in addition to the additive antimigraine effects of some other non-specific drugs. The aim of this literature-based review is to summarize the possible antimigraine properties of different antihypertensive agents (beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, etc.) focusing on the possible side effects (avoidance of beta blockers in the absence of heart disease, possible antiparkinson effect of calcium channel blockers, additive effect of drugs modifying the renin-angiotensin system activity, etc.). Current evidence supports the use of angiotensin converting enzyme inhibitors (mainly lisinopril) and angiotensin receptor blockers (mainly candesartan) for long-term migraine prevention and blood pressure control. Long-term beta-blocker treatment should be avoided in the absence of ischemic heart disease due to possible unfavourable cardiovascular effects.

Association of microalbuminuria with ischemic heart disease in non-diabetic Asian-Indians: A case control study.

Context:Microalbuminuria is a known indicator of atherosclerosis and its association with ischemic heart disease (IHD) has been extensively studied in the diabetic population. The significance of urine microalbumin in non-diabetics, however, is yet to be elucidated.Aim:To determine whether an independent association exists between microalbuminuria and IHD in non-diabetic Asian-Indians, and the level of microalbuminuria predictive of concomitant IHD.Materials and Methods:A cross-sectional case-control study was conducted between July 2009 and June 2011. Non-diabetic patients undergoing evaluation for IHD were divided into cases and controls, based on the presence or absence of IHD, respectively. Fifty cases and 50 controls were included, and matched by age, sex, smoking habit, hypertension and body-mass index (BMI). Fasting blood glucose (FBG), fasting lipid profile, and urine microalbumin were recorded for all patients.Results:Mean fasting glucose, mean low density lipoprotein (LDL)-cholesterol and mean urine microalbumin were all significantly higher in cases compared to controls. Urine microalbumin was independently associated with IHD, and microalbumin greater than 12.6 mg/g was predictive of IHD (OR: 13.5; 95% CI, 4.6–39.9; P < 0.001).Conclusion:Urine microalbumin is independently associated with IHD in non-diabetics and levels greater than 12.6 mg/g are predictive of IHD.

Therapeutic potential of HDL in cardioprotection and tissue repair.

Epidemiological studies support a strong association between high-density lipoprotein (HDL) cholesterol levels and heart failure incidence. Experimental evidence from different angles supports the view that low HDL is unlikely an innocent bystander in the development of heart failure. HDL exerts direct cardioprotective effects, which are mediated via its interactions with the myocardium and more specifically with cardiomyocytes. HDL may improve cardiac function in several ways. Firstly, HDL may protect the heart against ischaemia/reperfusion injury resulting in a reduction of infarct size and thus in myocardial salvage. Secondly, HDL can improve cardiac function in the absence of ischaemic heart disease as illustrated by beneficial effects conferred by these lipoproteins in diabetic cardiomyopathy. Thirdly, HDL may improve cardiac function by reducing infarct expansion and by attenuating ventricular remodelling post-myocardial infarction. These different mechanisms are substantiated by in vitro, ex vivo, and in vivo intervention studies that applied treatment with native HDL, treatment with reconstituted HDL, or human apo A-I gene transfer. The effect of human apo A-I gene transfer on infarct expansion and ventricular remodelling post-myocardial infarction illustrates the beneficial effects of HDL on tissue repair. The role of HDL in tissue repair is further underpinned by the potent effects of these lipoproteins on endothelial progenitor cell number, function, and incorporation, which may in particular be relevant under conditions of high endothelial cell turnover. Furthermore, topical HDL therapy enhances cutaneous wound healing in different models. In conclusion, the development of HDL-targeted interventions in these strategically chosen therapeutic areas is supported by a strong clinical rationale and significant preclinical data.

P1-336 Validation of NHS hospital admission records for ischaemic heart disease in the million women study

IntroductionThe Million Women Study is a large longitudinal UK study of women's health. Between 1996 and 2001, 1.3 million women mostly aged 50–64 years were recruited through NHS breast screening...

Dissecting the substrate for sudden cardiac death in the absence of ischemic heart disease

d v v Sudden cardiac death (SCD) remains an enormous clinical problem, accounting for approximately 400,000 cases annually in the United States alone. Current strategies for redicting and preventing SCD focus on the primary preention of cardiovascular diseases and their associated seuelae and the identification of high-risk individuals with schemic and nonischemic cardiomyopathy. When high-risk atients are identified, appropriate medical therapy and rophylactic placement of an implantable cardioverter-debrillator (ICD) have been proven to reduce SCD and total ortality. The majority of sudden deaths occur in low-risk ndividuals with relatively preserved left ventricular funcion that do not meet criteria for ICD placement. Although he event rate of such patients is relatively low, they account or the greatest absolute number of SCD cases because the umber of patients at risk is much larger. In addition, many CD cases represent the first manifestation of cardiac disase, which greatly complicates any preventive strategy. Careful studies of the clinical characteristics and cardiac athology of SCD victims are a critical prerequisite for aining a better understanding of the potential mechanisms f SCD and formulating new preventive strategies. The ajority of SCD cases are due to coronary artery disease, ither in the form of acute coronary syndromes or chronic schemic heart disease with prior myocardial infarction. Much less is known about the substrate for SCD in the absence of ischemic heart disease. One of the major difficulties with studies of SCD victims is that autopsies are not routinely obtained in most countries, which limits the ability to draw definitive conclusions regarding the prevalence of various forms of cardiac pathology. In the present issue of HeartRhythm, Hookana et al report a study of 2,661 consecutive victims of SCD in the province of Oulu in northern Finland. A major strength of this study is that autopsies are mandatory in Finland whenever SCD is not due to a known disease, the deceased has not been treated by a physician during the patient’s last illness, or death is otherwise unex-

Discharge to a Skilled Nursing Facility and Subsequent Clinical Outcomes Among Older Patients Hospitalized for Heart Failure

Heart failure (HF) is the leading cause of hospitalization among older Americans. Subsequent discharge to skilled nursing facilities (SNF) is not well described. We performed an observational analysis of Medicare beneficiaries ≥65 years of age, discharged alive to SNF or home after ≥3-day hospitalization for HF in 2005 and 2006 within the Get With The Guidelines-HF Program. Among 15 459 patients from 149 hospitals, 24.1% were discharged to an SNF, 22.3% to home with home health service, and 53.6% to home with self-care. SNF use varied significantly among hospitals (median, 10.2% versus 33.9% in low versus high tertiles), with rates highest in the Northeast. Patient factors associated with discharge to SNF included longer length of stay, advanced age, female sex, hypotension, higher ejection fraction, absence of ischemic heart disease, and a variety of comorbidities. Performance measures were modestly lower for patients discharged to SNF. Unadjusted absolute event rates were higher at 30 days (death, 14.4% versus 4.1%; rehospitalization, 27.0% versus 23.5%) and 1 year (death, 53.5% versus 29.1%; rehospitalization, 76.1% versus 72.2%) after discharge to SNF versus home, respectively (P<0.0001 for all). After adjustment for measured patient characteristics, discharge to SNF remained associated with increased death (hazard ratio, 1.76; 95% confidence interval, 1.66 to 1.87) and rehospitalization (hazard ratio, 1.08; 95% confidence interval, 1.03 to 1.14). Discharge to SNF is common among Medicare patients hospitalized for HF, and these patients face substantial risk for adverse events, with more than half dead within 1 year. These findings highlight the need to better characterize this unique patient population and understand the SNF care they receive.

Non-invasive Quantification of Myocardial Fibrosis in Diabetic Cardiomyopathy: T1 Mapping or Integrated Backscatter?

Purpose: Interstitial fibrosis is believed to be one of several contributors to diabeticcardiomyopathy (DCM), manifesting as myocardial dysfunction in the absenceof ischemic heart disease in subjects with type 2 diabetes (T2DM). Myocardialultrasound reflectivity is proportionate to fibrosis, but use of the pericardiumas a frame of reference (calibrated integrated backscatter, cIB) may be limitedby signal saturation. Recently, diffuse fibrosis has been shown to be inverselyproportionate to T1 time on post-contrast T1 mapping using cardiac magneticresonance imaging. We sought to compare the association of cIB and T1 timewith DCM.Methods: Demographic, anthropometric, hemodynamic and biochemical datawere measured in 107 apparently healthy, asymptomatic subjects with T2DM (65men, 60±9 years). LV dysfunction (LVD) was sought on resting echo (early diastolictissue velocity [Em] < 1SD from mean for age). Ischemia was excludedby exercise echo. Standard 2D and color TDI measures (tissue velocity, strainand strain rate) were acquired in apical long axis views. Calibrated integratedbackscatter (cIB) was calculated from a parasternal long axis view. Tonometricaortic pulse wave velocity (APWV) was used to determine arterial stiffness. T1mapping was performed in those with LVD and matched controls.Results: LVD was identified in 23 subjects (28%) who also demonstrated significantlypoorer diabetic control (HbA1c 8.2±2.0 vs 7.3±1.4 mmol/L) but no relationshipwith cIB. T1 mapping was performed in 26 subjects (17 men, 60±10years) comprising 20 with LVD and 6 controls. Em was independently associatedwith age (β=-0.76 p<0.001), body mass index [BMI] (β=-0.65, p<0.001), strain(β=0.51, p=0.003) and post-contrast T1 time (β=0.36, p=0.04) [model R Square =0.63] but not cIB. Post-contrast T1 time was independently associated with insulinresistance (HOMA-IR β=-0.63, p=0.016) [model R Square = 0.38] but not withcIB, APWV, BMI or low density lipoprotein (LDL). The only independent correlateof cIB was APWV (β=0.59, p=0.009) [model R Square = 0.39] and not HOMA-IR,BMI or LDL.Conclusions: Quantitative tissue characterisation of fibrosis (T1 time) was independentlyassociated with subclinical DCM, in addition to systolic dysfunction(strain), age and BMI. The association of T1 mapping with insulin resistance contrastswith the link between cIB and arterial stiffness, suggesting potential differencesbetween fibrosis in DCM and hypertension.