Achieve Target Heart Rate Research Articles

Negative long-term prognostic value of stress echocardiography in patients with incomplete revascularization after successful primary PCI

Abstract Background The role of stress echocardiography (SECHO) in a risk stratification of patients with incomplete revascularization after primary percutaneous coronary intervention (pPCI) has not been extensively documented. The Aim The aim of our study was to assess the negative long-term prognostic value of SECHO after successful pPCI and incomplete revascularization of non-culprit lesions. Methods Our study consisted of 194 patients (mean age 59±10years, male 136; 70.1%) successfully treated with pPCI, who performed SECHO according to Bruce protocol in order to assess residual ischemia in coronary artery with non-culprit lesion other than treated vessel. Lesion severity of non-culprit coronary arteries was assessed by quantitative coronary angiography. Duke treadmill score, functional capacity (Metabolic Equivalents - METs), achieved target heart rate (THR), chronotropic incompetence, heart rate recovery (HRR), wall motion score index (WMSI) and ejection fraction were calculated in all patients. Slow HRR was defined as ≤18 beats/min. Median follow up of the patients was 96 ± 32.5 months for the occurrence of all-cause mortality and non-fatal myocardial infarction (MI). Results Out of 194 patients, 38 (19.6%) had positive SECHO test, and 7 patients (3.6%) were lost to follow up so they were excluded from further analysis. During the follow-up period 29 out of 149 patients (18.8%) had an adverse event (20 deaths and 9 non-fatal MI). Negative predictive value of SECHO test was 81.2%. Median time from MI to SECHO test was 8 months. Using the Cox regression analysis, univariate predictors of adverse events were slow HRR (HR 3.750 [95% CI 1.620-8.679], p=0.002), Duke score (HR 0.866 [95% CI 0.755-0.994], p=0.040) and chronotropic incompetence (HR 0.310 [95% CI 0.107-0.895], p=0.030). In the multivariate analysis only the slow HRR remained an independent predictor of adverse events (HR 3.329 [95% CI 1.417-7.825], p=0.006). Using the Kaplan-Meier survival curve we see that the patients with slow HRR had much shorter event-free time (slow HRR 117.2 ± 13.4 months vs normal HRR test 139.4 ± 4.2 months, Log Rank 4.988, p=0.026). (Figure 1.) Conclusion SECHO test has excellent negative long-term prognostic value in patients with incomplete revascularization of non-culprit lesions after successful pPCI while patients with slow HRR have more pronounced risk for the occurrence of adverse events.Figure 1.Kaplan-Meier survival curve

Rate control with Landiolol in atrial tachyarrhythmias and comorbid left ventricular dysfunction: a systematic review and meta-analysis

Abstract Backround Atrial tachyarrhythmias (ATs) are frequently inter-related with heart failure (HF). ATs exacerbate HF, while the existence of chronic HF precipitates the occurrence of ATs. Landiolol, a highly selective and exceptionally-short acting beta-1 blocker has been used in patients with ATs and HF, where evidence on the available treatment options is limited. Purpose In this meta-analysis we intended to assess the clinical effects of rate control with landiolol in patients with ATs and comorbid left ventricular dysfunction, who are not septic or in peri-operative stage. Materials and Methods We systematically searched PubMed, Scopus and WebofScience up to 14 July 2023. Two independent reviewers screened and selected randomized control trials as well as observational studies according to predetermined eligibility criteria. Risk of bias and quality of evidence were assessed according to Cochrane guidelines. Results 2278 articles were initially screened and 11 studies were finally included in this systematic review. In 7 of the eligible studies landiolol was compared with placebo, while in the remaining 4 studies landiolol was investigated in comparison with other antiarrhythmic drugs and specifically digoxin and diltiazem. The total sample size included 1876 patients, 75% of whom were classified into III/IV NYHA class. Landiolol treatment reduced patients’ heart rate by a mean of 42 beats per minute (95% CI: 37-47 bpm) while 3 out of 4 treated patients accomplished targeted heart rate, described as an at least 20% reduction from baseline heart rate and final heart rate less than 110bpm. Compared to patients receiving other antiarrhythmic therapy, patients treated with landiolol had increased odds of achieving target heart rate (OR: 5.32, 95% CI: 2.87-10.05). Referring to landiolol safety, 15% of the treated patients encountered an adverse event, more frequently dose-dependent hypotension. Landiolol was discontinued only in a 6% of the treated patients. No difference in adverse events was identified between landiolol and other antiarrhythmic drugs. Conclusion In this meta-analysis landiolol has achieved satisfactory levels of efficacy and safety regarding rate control in patients with ATs and left ventricular dysfunction.Prisma FlowchartLandiolol efficacy in single-arm studies

Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial.

Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites. 140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,n = 70) or propranolol alone (Gr.B,n = 70). Primary outcome was incidence of bleed at 1year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects. Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1year was lower in Gr.A than B (8.5%vs.27.1%,p-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6mg vs. 76.52 ± 24.4mg; p-0.01) and more patients achieved THR (84.2%vs.55.7%,p-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,p-0.014), diuretic tolerance (80%vs.60%,p-0.047) at higher doses(p-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;p-0.01), plasma renin activity (54.4% from baseline) (p = 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81mmHg(23.5%) vs. 2.61 ± 2.87mmHg(14.5%),p-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,p = 0.013 and 10%vs.15.7%, p = 0.03, respectively). Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.

Combined low-dose dobutamine and exercise stress echocardiography: a new hybrid protocol to detect inducible ischaemia.

Myocardial response to stress echocardiography may be elicited physiologically, through exercise, or pharmacologically, often with dobutamine. Both have advantages but also limitations due to reduced exercise capacity or side-effects to stressor agent/lack of closeness to true pathophysiology of ischaemic cascade. We have combined low-dose dobutamine and exercise, creating a 'hybrid' protocol to utilize the advantages of both techniques and limit the drawbacks. The aim of the study was to evaluate its safety and feasibility. In the hybrid protocol, low-dose dobutamine infusion (up to 10 µg/kg/min) is enhanced by supine bicycle exercise at 3-min increments of workload of 25 W to achieve target heart rate (THR). We analysed safety and outcome data for all the patients who underwent this protocol from 2017 to 2022. Out of 835, 727 (87.1%) patients referred for evaluation of ischaemia underwent the hybrid protocol. The median age was 61 years old and 61% (442/727) were men. The median exercise time was 11 (9-13.5) min with a median maximum workload of 100 W (75-125). Out of 727, 670 (92.2%) achieved THR. Atropine was not used. Out of 727, 192 (26.4%) of studies were positive for ischaemia. Out of 122, 102 (83.6%) with positive stress who underwent invasive angiography had significant coronary disease. The incidence of complications was low: 1/727-severe arrhythmia, 5/727 (0.7%) developed a vasovagal episode, and 14/727 (1.9%) had a hypertensive response to exercise. Our findings suggest that this protocol is safe, feasible, and has a high success rate in achieving THR.

PREDICTIVE FACTORS FOR ACHIEVEMENT OF TARGET SYSTOLIC BLOOD PRESSURE AND HEART RATE: SUB-ANALYSIS OF PRIDE STUDY

Objective: To define predictors for achievement of target systolic blood pressure (SBP) and heart rate (HR) in the PRIDE study (NCT03730116). Design and method: It was a 12-week ambispective observational study to assess antihypertensive and antianginal effectiveness of Bisoprolol/ Perindopril (Biso/Per) single-pill combination (SPC) in outpatients with coronary artery disease (CAD), history of myocardial infarction (MI) and arterial hypertension (HTN). This analysis aimed to evaluate predictive values of baseline (BL) demographic and clinical characteristics to achieve target SBP and HR in study population. Results: Of 481 included patients, 154 (32.0%) were female, mean age 61.4 (8.9) years. Prevalence of type 2 diabetes mellitus (T2D) at BL was 24.1%. Proportions of patients with Grade I, II, III or isolated HTN (ISH) and those with controlled HTN (BP< 140/90 mm Hg) at BL were 55.3% (n=266), 10.8% (n=52), 5.0% (n=24), 5.0% (n=24), 23.9% (n=115), correspondingly. Mean duration of HTN and CAD were 12.8 (8.4) and 6.1 (6.3) years. Proportions of patients treated with 2,5/2,5, 5/5, 5/10 and 10/10 mg of Biso/Per SPC at BL were 12.1%, 33.5%, 34.3%, 20.2% correspondingly. Doses were changed in 1.6% of cases by week 12 of observation. At week 12, mean SBP, DBP and HR significantly decreased by 24.9 (16.4), 12.2 (11.0) mm Hg and 14.4 (11.7) bpm, respectively (p< 0.001 for all). Multivariable analyses revealed grade III HTN at BL was the only significant negative predictor for achieving SBP< 140 mm Hg, whereas grade III HTN, CAD with angina of functional class II and older age (more 65 y.o.) were negative predictors for achieving SBP < or equal 130 mm Hg at week 12 of observation. Grade III HTN at or presence of T2D at BL decreased the likelihood of achieving target HR (55-60 bpm), according to the data given in Table 2. Conclusions: Grade III HTN, concomitant T2D and symptomatic angina were negative predictors for achievement of the target SBP and HR in patients with HTN and a history of MI. There were no positive predictors for achievement of the target BP and HR explored.

Online Bayesian optimization of vagus nerve stimulation.

Objective.In bioelectronic medicine, neuromodulation therapies induce neural signals to the brain or organs, modifying their function. Stimulation devices capable of triggering exogenous neural signals using electrical waveforms require a complex and multi-dimensional parameter space to control such waveforms. Determining the best combination of parameters (waveform optimization or dosing) for treating a particular patient's illness is therefore challenging. Comprehensive parameter searching for an optimal stimulation effect is often infeasible in a clinical setting due to the size of the parameter space. Restricting this space, however, may lead to suboptimal therapeutic results, reduced responder rates, and adverse effects.Approach. As an alternative to a full parameter search, we present a flexible machine learning, data acquisition, and processing framework for optimizing neural stimulation parameters, requiring as few steps as possible using Bayesian optimization. This optimization builds a model of the neural and physiological responses to stimulations, enabling it to optimize stimulation parameters and provide estimates of the accuracy of the response model. The vagus nerve (VN) innervates, among other thoracic and visceral organs, the heart, thus controlling heart rate (HR), making it an ideal candidate for demonstrating the effectiveness of our approach.Main results.The efficacy of our optimization approach was first evaluated on simulated neural responses, then applied to VN stimulation intraoperatively in porcine subjects. Optimization converged quickly on parameters achieving target HRs and optimizing neural B-fiber activations despite high intersubject variability.Significance.An optimized stimulation waveform was achieved in real time with far fewer stimulations than required by alternative optimization strategies, thus minimizing exposure to side effects. Uncertainty estimates helped avoiding stimulations outside a safe range. Our approach shows that a complex set of neural stimulation parameters can be optimized in real-time for a patient to achieve a personalized precision dosing.

Efficacy and safety of intravenous beta-blockers in acute atrial fibrillation and flutter is dependent on beta-1 selectivity: a systematic review and meta-analysis of randomised trials

BackgroundIntravenous beta-blockers are commonly used to manage patients with acute atrial fibrillation (AF) and atrial flutter (AFl), but the choice of specific agent is often not evidence-based.MethodsA prospectively-registered systematic review and meta-analysis of randomised trials (PROSPERO: CRD42020204772) to compare the safety and efficacy of intravenous beta-blockers against alternative pharmacological agents.ResultsTwelve trials comparing beta-blockers with diltiazem, digoxin, verapamil, anti-arrhythmic drugs and placebo were included, with variable risk of bias and 1152 participants. With high heterogeneity (I2 = 87%; p < 0.001), there was no difference in the primary outcomes of heart rate reduction (standardised mean difference − 0.65 beats/minute compared to control, 95% CI − 1.63 to 0.32; p = 0.19) or the proportion that achieved target heart rate (risk ratio [RR] 0.85, 95% CI 0.36–1.97; p = 0.70). Conventional selective beta-1 blockers were inferior for target heart rate reduction versus control (RR 0.33, 0.17–0.64; p < 0.001), whereas super-selective beta-1 blockers were superior (RR 1.98, 1.54–2.54; p < 0.001). There was no significant difference between beta-blockers and comparators for secondary outcomes of conversion to sinus rhythm (RR 1.15, 0.90–1.46; p = 0.28), hypotension (RR 1.85, 0.87–3.93; p = 0.11), bradycardia (RR 1.29, 0.25–6.82; p = 0.76) or adverse events leading to drug discontinuation (RR 1.03, 0.49–2.17; p = 0.93). The incidence of hypotension and bradycardia were greater with non-selective beta-blockers (p = 0.031 and p < 0.001).ConclusionsAcross all intravenous beta-blockers, there was no difference with other medications for acute heart rate control in atrial fibrillation and flutter. Efficacy and safety may be improved by choosing beta-blockers with higher beta-1 selectivity.Graphical abstract

Factors affecting treatment adherence in working-age patients with myocardial infarction

Aim of the study was to analyze the factors affecting treatment adherence in working-age patients with myocardial infarction (MI). Material and methods. During hospitalization, data of 150 patients with MI were collected using medical records and questionnaires. Social treatment readiness was assessed using the S.V. Davydov method with the calculation of treatment adherence (TA) score. After 6 months, the vital status, frequency and causes of hospitalizations, intake of the main groups of drugs, achievement of cardiovascular health target, frequency of regular medical check-up and the type of specialist conducting it were analyzed. In conclusion, the factors affecting the TA score were identified, as well as factors related to the achievement of cardiovascular health targets. Results. 6 months after MI, 4 (2.7 %) patients died due to cardiovascular diseases, 24 (16 %) were hospitalized. The inpatient TA score was 5 (4; 8) (median (lower quartile; upper quartile)), in 79 (52.6 %) patients it was low. The adherence of the surviving patients to treatment after six months was high: 142 (97.3 %) were taking disaggregants, 138 (94.5 %) were taking beta-blockers and reninangiotensin-aldosterone system inhibitors, 139 (95.2 %) were taking statins. However, only 56 (69.1 %) patients achieved target levels of low-density lipoproteins (LDL); 118 (80.8 %) patients achieved target levels of blood pressure, 95 (65.1 %) patients achieved target levels of heart rate (HR) at rest. Only about half (56.8 %) of patients with MI had regular medical check-ups, and only 38.5 % visited cardiologist. Patients who did not achieve target levels of LDL and HR had lower baseline TA score (p = 0.038 and p = 0.029, respectively), they showed up to fewer regular medical checkups after MI (p &lt; 0.001). In patients who did not achieve target HR, the indicator of willingness to pay for treatment was low (p = 0.041), and regular medical check-ups were 4.2 more likely to be performed by a paramedic (p = 0.021). High-score TA was associated with the patient`s lack of propensity for social isolation, high social awareness, trust in the therapeutic treatment, willingness to pay for treatment, high sociability, dyslipidemia in history, the absence of passive smoking during the year, undergoing stage 2 of stroke recovery, working at the time of MI or the late age at onset of alcohol consumption. Low TA score was associated with the patient being the resident in the city, Q-wave MI, and a long-term smoking. Conclusions. Among the factors affecting treatment adherence in working-age patients with MI, certain indicators such as medical and social treatment readiness throughout hospitalization, and social, economic and clinical anamnestic characteristics are highlighted. The identification these factors should be implemented in real clinical practice to improve secondary prevention and outpatient follow-up.

Supine ergometry induced changes of left ventricular function and pulmonary hypertension have an uneven prognostic relevance for asymptomatic aortic stenosis according to age and gender

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Risk stratification in the asymptomatic severe aortic stenosis (AS) remains a difficult task within the spectrum of its hemodynamic phenotypes, especially on aging demographics. Interplay of left ventricular function and AS hemodynamics may be studied using semisupine bicycle ergometry (SBE). Purpose Purpose of the study was to interrogate the prognostic relevance of SBE based evaluation of LV function and noninvasive hemodynamics in asymptomatic severe AS. Methods Seventy-eight asymptomatic severe AS patients (pts), followed up on valve clinic in a tertiary center (age 65±12 years, female 29), were referred for SBE. AS related cardiac events (independent decision for surgery, NYHA worsening) during a follow up of 33/21 months occurred in 25 pts (64% for age&amp;gt;65 vs 30% for age&amp;lt;65). Workload (Watts) and % achieved target heart rate (%targetHR) were considered surrogates for SBE efficiency. The following parameters (mean±SD) were estimated at rest(R) and SBE (Ex): Biplane LV ejection fraction (EF) and stroke volume (SV), 2D strain (SR), tricuspid peak gradient (TRPG), transmitral E/e, HR, systolic blood pressure (SBP), HR*SBP product and their respective % changes. Results Event group had a decreased SBE efficiency in workload (Watts: 59±16 vs 78±20, p&amp;lt;0.001), similar %target heart rate (73±13 vs 73±9), with differences among the continuous variables only in EFex (59±8 vs 63±7, p = 0.04) and %dLVEF (6±10 vs 12±10, p = 0.02). Categorical classification was performed for inadequate LV functional improvement at SBE, using the absolute cut off for &amp;lt;5% LVEF increase and the &amp;lt;3% for LVSR increase, as well as for an excessive increase in pulmonary hypertension at SBE, using the cut off for TRPG &amp;gt;55mmHg. Respective distribution of cases was similar for age category &amp;gt; or &amp;lt;=65 years (dEX &amp;lt;5: 46% vs 45%, dSR &amp;lt;3: 62% vs 87%, TRPGEx &amp;gt;55mmHg: 38% vs 48%, all p = ns). Kaplan Meier analysis for events using TRPG&amp;gt;55 was significant for females (log rank=3.2, p = 0.06/ figure1). Kaplan Meier analysis for events using dEF≥5 was significant for age &amp;lt;65 years (log rank =4.7, p = 0.03/figure2). LVSR cut off did not provide any difference in outcome. Conclusion SBE induced changes on LV function and pulmonary hypertension have an uneven risk stratification relevance according to age and gender. Dedicated algorithms to gender and age have to be applied for the improvement of prognostication in severe AS based on SBE.

A 3-minute recumbent stepper test in chronic stroke.

Persons with stroke often have difficulty achieving target heart rate (HR) during graded exercise testing (GXT), which is known to limit test sensitivity for detecting clinically relevant cardiac conditions. A novel Recumbent Stepper 3-minute (RS 3Min) "all out" test may increase sensitivity of stress testing after stroke. To determine the feasibility of adding the RS 3Min test after GXT among persons after stroke. A within-participant, nonrandomized, repeated measures design. Rehabilitation research laboratory and cardiovascular stress laboratory PARTICIPANTS: Fifteen participants with chronic stroke (56.7 ± 9.6 years; 6.4 ± 4.3 years post stroke; 8 male). All participants randomly completed (1) a symptom-limited treadmill GXT and (2) a symptom-limited RS GXT followed by RS 3Min critical power test. HR, ratings of perceived exertion, oxygen consumption, respiratory exchange ratio, and power output measured continuously during each test. Blood pressure measured every 2 minutes and or immediately post exercise. P value set at p < .05 from omnibus test for a significant difference among protocols. The RS 3Min test had a significantly higher rate of achieving target HR compared to the RS GXT (9/14 vs 4/14, p=.02) and was not significantly different from the treadmill GXT (9/14 vs 5/14, p=.09). Minimum power output during the RS 3Min was significantly higher than peak power output during the RS GXT (110 ± 41 W vs. 84 ± 22 W, p=.02) with 12/15 participants reaching a VO2 plateau. Although additional studies with randomized designs are needed, a novel RS 3Min "all out" test appears to be a promising method for enhancing test sensitivity in cardiovascular screening after stroke, while providing a potentially valid measure of critical power.

Assessment of Vascular and Valvular Calcification Improves Screening for Coronary Artery Disease Before Liver Transplantation

Coronary artery disease (CAD) is common in patients with cirrhosis who underwent orthotopic liver transplantation (OLT) evaluation and stress echocardiogram (echo) has a low sensitivity in these patients. This study aimed to assess the impact of vascular and valvular calcification on the ability to identify CAD before OLT. We performed a case-control study of 88 patients with and 97 without obstructive CAD who underwent OLT evaluation. All patients had a preoperative stress echo, abdominal computed tomography, and cardiac catheterization. A series of nested logistic regression models of CAD were fit by adding independent variables of vascular (including coronary) calcification, aortic and mitral valve calcification, age, gender, and history of diabetes mellitus requiring insulin to a baseline model of abnormal stress echo. Compared with stress echo alone, identification of the presence or absence of vascular and valvular calcification on routine preoperative computed tomography and echo improved the diagnostic performance for the detection of CAD based on coronary angiogram when combined with stress echo in patients with cirrhosis who underwent OLT evaluation (area under the curve 0.58 vs 0.73, p <0.001), which is even further improved when age, gender, and history of diabetes mellitus requiring insulin are considered (area under the curve 0.58 vs 0.80, p <0.001). Achieving target heart rate (p=0.92) or rate-pressure product >25,000 (p=0.63) did not improve the ability of stress echo to identify CAD. In conclusion, the use of abdominal vascular, coronary artery, and valvular calcification, along with stress echo, improves the ability to identify and rule out obstructive CAD before OLT compared with stress echo alone.

Hitting the Target? Achieving Optimal Cardiovascular Intensity for Persons With Spinal Cord Injury And Stroke

<h3>Research Objectives</h3> To investigate the feasibility of achieving the American Physical Therapy Association Locomotor Clinical Practice Guideline's cardiovascular intensity recommendations for persons with acute or sub-acute spinal cord injury (SCI) and acute or sub-acute cerebrovascular accident (CVA). <h3>Design</h3> A retrospective data-analysis from June 2020-June 2022. <h3>Setting</h3> 114 bed inpatient rehabilitation hospital. <h3>Participants</h3> 78 persons with acute/sub-acute spinal cord injury who participated in 253 locomotor sessions and 81 persons with acute/sub-acute stroke who participated in 222 locomotor sessions. <h3>Interventions</h3> Locomotor sessions were 30-60 minutes in duration and aimed to utilize advanced rehabilitation technology in order to achieve target heart rate recommendations within 60-80% heart rate reserve per the American Physical Therapy Association Locomotor Clinical Practice Guideline. <h3>Main Outcome Measures</h3> Average heart rate with activity, average maximum heart rate with activity, average target heart rate, average gait distance (feet), and rating of perceived exertion (RPE). <h3>Results</h3> 22.2% of persons with acute/sub-acute cerebrovascular accident achieved average target heart rate via average maximum heart rate, while 17.9% of persons with SCI achieved average target heart rate via average maximum heart rate. Average RPE was 15 for both SCI and CVA cohorts. Average session walking distance for persons with SCI and CVA were 1,250.95 feet and 1,313.45 feet, respectively. <h3>Conclusions</h3> Achievement of Locomotor Clinical Practice Guideline target heart rate values appear to be more feasible for persons with acute/sub-acute CVA than for SCI, although attainment of target heart rates were low for both groups. Gait distance and perceived exertion levels were similar between groups, although heart rate responses appeared to be different. <h3>Author(s) Disclosures</h3> None.

Supine ergometry for aged population with degenerative mitral regurgitation: evidence for prognostic yield

Abstract Introduction Degenerative mitral regurgitation (MR) has an increased prevalence with aging with risk stratification evolving as a complex scenario. Semisupine bicycle ergometry (SBE) is a currently applied means to interrogate noninvasive hemodynamics. Aim Aim of the study was to interrogate prognostic parameters by SBE in asymptomatic moderate to severe degenerative MR for patients older than 65 years. Patients and methods One hundred seventy-four asymptomatic MR patients (pts), followed up on valve clinic in a tertiary center (age 56/14 female 71), were referred for SBE. MR related cardiac events (surgery, NYHA worsening) during follow up of 34/25 months occurred in 24 pts. Age group &amp;gt;65 had 53 pts (age 71/4 vs 50/13 &amp;lt;0.001, females 36% vs 43%). The following parameters (mean/SD) were estimated at rest (R) and SBE (Ex): Biplane left ventricular (LV) ejection fraction (EF), stroke volume (SV), 2D LV strain (SR), tricuspid peak gradient (TRpg), transmitral E/e, HR, systolic blood pressure (SBP), HR*SBP product and their respective % changes (%d). Results Group &amp;gt;65 during SBE had a decreased workload (Watts: 74/22 vs 89/18, p&amp;lt;0.001), similar % achieved target heart rate (73/11 vs 69/10), with more symptoms (30% vs 16%, p&amp;lt;0.01). Event rate was greater (30% vs 7%, p&amp;lt;0.001). Group aged&amp;gt;65 had differences in SBPR (145/20 vs 132/19, p&amp;lt;0.002), SREx (20/4 vs 21/5, p&amp;lt;0.04), EFEx (64/9 vs 68/6, p&amp;lt;0.01), TRpgR (34/11 vs 27/6, p&amp;lt;0.001), TRPG Ex (55/13 vs 50/10, p&amp;lt;0.02), E/eEx (14/6 vs 11/3, p&amp;lt;0.006), %dSV (0.01/0.23 vs 0.14/0.25, p&amp;lt;0.001) and %dEF (0.12/0.08 vs 0.15/0.11, p&amp;lt;0.03). In stepwise logistic regression analysis for events, E/eEx was the only selected (log exp 0.89, p&amp;lt;0.05). Classification for events by ROC analysis gave a E/eEx cut off 13 (area 0.67, p=0.01) with sensitivity/specificity 50/80%. Kaplan Meier analysis revealed prognostic contribution for E/eEx &amp;gt;13 only in the age &amp;gt;65 (log rank p&amp;lt;0.04, Figure 1). Moreover, symptomatic SBE had a decisive prognostic contribution in the aged cohort (Kaplan-Meier log rank = 0.004, Figure 2). Conclusion SBE may be applied with an efficient performance in the older then 65 years age spectrum, within the context of asymptomatic moderate to severe degenerative MR, providing critical information for risk stratification Funding Acknowledgement Type of funding sources: None.

Dynamic changes of left atrial function during supine ergometry: evidence for interplay with left ventricular function and dynamic changes of pulmonary pressure

Abstract Introduction Despite the pivotal role of left atrial (LA) function in a variety of cardiac pathologies, it has been studied mainly at rest. Aim Aim of the study was to assess the effect of semisupine exercise ergometry (Ex) on LA function, by volumetric and strain parameters and to interrogate relationships with left ventricular (LV) function and noninvasive hemodynamics. Patients and methods Eighty-two patients (female 26, age: mean/SD 61/15) referred for Ex were studied. The following parameters were estimated by 2 D echo: LV systolic (LVvolsyst) and diastolic (LVvoldiast) volume, ejection fraction (LVEF), stroke volume (LVsv), LA minimum (LAvolmin) and maximal volume (LAvolmax), LA emptying fraction [LAEF), LA reservoir volume (LAvolres = LAvolmax − LAvolmin), LA reservoir fraction (LAresFR = LAvolres/LVsv), LA conduit volume (LAcondvol = LVsv − LAvolres) and LA conduit fraction (LAcondFR = LAcondvol/LVsv). LV strain (LVSR) and LA strain (LASR) were estimated by 2D analysis. Peak tricuspid gradient (TRpg) was also estimated. Parameters were measured at rest R and Ex and the respective % changes (%d) were calculated. Results SBE performance was efficient with a % achieved target heart rate 73/9 and workload Watts 96/21. Systolic blood pressure increased from 139/53 to 179/31. Parameters with significant change during Ex are in the table (all p&amp;lt;0.001). LVSRr and LVEFr were both related inversely with LAvolresR (r=−0.39/p=0.001 and r=−0.24/p=0.05) and LAresFRr (r=−0.34/p=0.001 and r=−0.25/p=0.04). LVEFr was related inversely with LAcondRFr r=−0.24/p=0.04). LVSR was related inversely with LAvolresEx (r=−0.43/p=0.001). LVSREx was related inversely with LAvolresR (r=−0.24/p=0.04) and LAcondRFr (r=−0.25/p=0.04). The %dLVSR was related inversely with LAEFr (r=−0.25/p=0.04). The %dLVEF was related inversely with LAresFREx (r=−0.27/p=0.03) and LAcondRFr (r=−0.27/p=0.03). The % increase in TRpg during SBE was positively related with LAresFREx r=0.30/p=0.04 and inversely with LAcondFREx (r=−0.30/p=0.04) (Figure 1). Conclusion SBE induces LA dynamic changes in a spectrum of volumetric and strain indices. Dynamic changes of LV are related with reservoir and conduit LA function. LA reservoir and conduit function during SBE are related with the induced dynamic changes of pulmonary pressure, thus further supporting the clinical relevance of the respective evaluation. Funding Acknowledgement Type of funding sources: None.

Effect of cardiac rehabilitation on intensity of physical activity according to type of surgery and Eurscore II after open heart surgery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients after open heart surgery require cardiac rehabilitation (CR), as reconstructive surgery reduces the quality of life. A perioperative EuroSCORE II score is used for assessment of risk of worse outcomes after surgery. Few is known whether CR is feasible in patients undergoing open heart surgery with moderate and high risk Euroscore II and whether the intensity of physical activity (PA) varies according to the type of heart surgery. Objective To evaluate effect of CR on perceived intensity of PA and target heart rate in patients who underwent open heart surgery and different EurSCORE II scale. Methods The retrospective cohort study included 104 patients who underwent open heart surgery and stage 2 CR: group 1- 64 patients with coronary artery bypass surgery (CABG), group 2 - 40 patients with valvular heart disease (VHD) surgery. We evaluated following parameters: subjective assessment of PA intensity on the Borg scale and objective assessment on the achievement of the training heart rate before and after CR. The perioperative risk of worse outcomes was assessed using EuroSCORE II scale. Results According to the EuroSCORE II scale: 1st group patients were at: -low risk -21%, moderate risk -68%, high risk -11% and 2nd group - low risk 29%, moderate risk 54%, and high risk 17%. None of patients had adverse effects of CR. In the first group, the subjective assessment on the Borg scale before CR was slightly higher than in the second group: -2.43 ± 0.09 points vs. 2.22 ± 0.11 points before CR. At the end of the CR, there was a significant increase (p&amp;lt;0.05) in perception of intensity of PA in both groups - the 1st group –4.37 ± 0.06 points and in 2nd group - 4.35 ± 0.07 points. Target heart rate before CR did not differ between groups: group 1 - 75 ± 5.7 beats per minute and group 2 - 89 ± 7.7 beats per minute (p=0.552): after CR there was a significant decrease in heart rate: group 1 - 55 ± 2.2 bpm, group 2 - 61 ± 3.2 bpm (p =.0012). Conclusion 1. CR increases significantly intensity of physical activity in pts after open heart surgery 2. Though the VHD surgery pts might have lower intensity of PA before CR, the intensity of PA after CR did not differ between CABG and VHD surgeries, increasing in both groups. 3. Patients with moderate and high EurSCORE II risk comprised 80 and 69% of patients in our cohort, none of them experienced adverse effect of CR and had improvement of PA and achieved target heart rate.

Exercise-Induced Ventricular Ectopy and Cardiovascular Mortality in Asymptomatic Individuals

BackgroundThe prognosis of exercise-induced premature ventricular contractions (PVCs) in asymptomatic individuals is unclear. ObjectivesThis study sought to investigate whether high-grade PVCs during stress testing predict mortality in asymptomatic individuals. MethodsA cohort of 5,486 asymptomatic individuals who took part in the Lipid Research Clinics prospective cohort had baseline interview, physical examination, blood tests, and underwent Bruce protocol treadmill testing. Adjusted Cox survival models evaluated the association of exercise-induced high-grade PVCs (defined as either frequent (>10 per minute), multifocal, R-on-T type, or ≥2 PVCs in a row) with all-cause and cardiovascular mortality. ResultsMean baseline age was 45.4 ± 10.8 years; 42% were women. During a mean follow-up of 20.2 ± 3.9 years, 840 deaths occurred, including 311 cardiovascular deaths. High-grade PVCs occurred during exercise in 1.8% of individuals, during recovery in 2.4%, and during both in 0.8%. After adjusting for age, sex, diabetes, hypertension, lipids, smoking, body mass index, and family history of premature coronary disease, high-grade PVCs during recovery were associated with cardiovascular mortality (hazard ratio [HR]: 1.82; 95% CI: 1.19-2.79; P = 0.006), which remained significant after further adjusting for exercise duration, heart rate recovery, achieving target heart rate, and ST-segment depression (HR: 1.68; 95% CI: 1.09-2.60; P = 0.020). Results were similar by clinical subgroups. High-grade PVCs occurring during the exercise phase were not associated with increased risk. Recovery PVCs did not improve 20-year cardiovascular mortality risk discrimination beyond clinical variables. ConclusionsHigh-grade PVCs occurring during recovery were associated with long-term risk of cardiovascular mortality in asymptomatic individuals, whereas PVCs occurring only during exercise were not associated with increased risk.

Abstract 12849: Invasive Assessment of Hemodynamic Effect of Ivabradine in Post ST Segment Elevation Myocardial Infarction Associated Sinus Tachycardia

Introduction: Post MI tachycardia is associated with increase in cardiac morbidity and mortality. We aimed to assess efficacy and safety of ivabradine to control heart rate in post MI tachycardia patients in whom beta-blockers were intolerant. Hypothesis: We hypothesized that ivabradine in post MI tachycardia patients effectively control heart rate without deteriorating effects on hemodynamics. Methods: STEMI patients with sinus tachycardia (heart rate &gt;120/min) who had intolerance to beta blocker were enrolled. Important exclusions were cardiogenic shock, second /third-degree atrioventricular block, Killip class III/ IV. Patient’s invasive hemodynamic parameters such as MAP (Mean Arterial Pressure), iSV (indexed Stroke Volume), CVP (Central Venous Pressure), cardiac output and cardiac index were measured with help of Edwards LifeSciences Flotrac monitor. Patients received ivabradine till heart rate control (&lt;100/min.) was achieved. The primary objectives were to study ivabradine efficacy to achieve target heart rate, and its effects on hemodynamic parameters and secondary objectives were to assess any adverse events. Results: Mean age was 52.7 ± 9.8 years and 29 (81%) were male. At enrolment, mean heart rate, MAP, iSV and CVP was 128.92±3.3bpm, 87.31±10.46mmHg, 28.19±7.85ml/m 2 , 6.35±2.61 mmHg respectively. At target heart rate ≤1oo/min (mean 96.57±5.29bpm), MAP, iSV and CVP were 82.71±13.70 mmHg (P=0.559), 1.11±6.33ml/m 2 (P=0.087) and 7.7±2.54 mmHg (P=0.122) showed no significant changes. However, cardiac output and cardiac index dropped to 5.22± 1.00 L/min (P=0.005) and 2.96±0.60 L/min/m 2 (P=0.005) but within physiological limits. None of the patient reported hypotension, arrhythmia, heart failure or in-hospital mortality. Conclusions: Invasive hemodynamic evaluation showed oral ivabradine is effective and safe alternative to control heart rate in uncomplicated post MI sinus tachycardia patients who had intolerance to beta-blockers.

Efficacy and safety of intravenous beta-blockers in acute atrial fibrillation and flutter is dependent on beta-1 selectivity: a systematic review and meta-analysis of randomised trials

Abstract Background Intravenous (IV) beta-blockers are commonly used to manage patients with acute atrial fibrillation (AF) and atrial flutter (AFl). Important pharmacodynamic differences exist amongst beta-blockers, and the choice of beta-blocker or other therapy is often not evidence-based. Purpose Systematic review and meta-analysis of randomised controlled trials (RCTs) in the setting of acute AF/AFl to assess the efficacy and safety of IV beta-blockers against other pharmacological interventions (diltiazem, verapamil, digoxin, anti-arrhythmic drugs or placebo). Methods Prospectively registered (PROSPERO: CRD42020204772). MEDLINE, EMBASE and Cochrane Register were searched from inception to August 2020. The primary outcomes were reduction in heart rate and proportion of patients achieving study-defined target heart rate. Secondary outcomes included conversion to sinus rhythm and incidence of adverse events. Beta-blockers were divided according to beta-1 adrenoreceptor selectivity. Meta-analysis was performed to calculate risk ratios (RR) and standardised mean differences (SMD) using random-effects, and fixed-effects within beta-1 subgroups. Results From 5974 studies, 12 RCTs were included with variable risk of bias, encompassing 1152 participants with mean age 62 years, 38% women and baseline heart rate 137 beats/minute. With high heterogeneity (I2=87%; p&amp;lt;0.001), there was no difference in the reduction in heart rate between beta-blockers and comparators (SMD −0.65, 95% CI −1.63–0.21; p=0.19), and no difference in the proportion that achieved target heart rate (RR 0.85, 95% CI 0.36–1.97; p=0.70). Analysis by beta-1 selectivity demonstrated that conventional beta-1 blockers (metoprolol, esmolol) were inferior for target heart rate reduction (RR 0.33, 95% CI 0.17–0.64; p=0.001), whereas super-selective agents (landiolol) were superior (RR 1.98, 95% CI 1.54–2.54; p&amp;lt;0.001). There was no difference in the rate of conversion to sinus rhythm between beta-blockers and comparators (RR 1.15, 95% CI 0.92–1.44; p=0.21). Adverse events were similar in both groups overall, with no significant difference in hypotension (RR 1.74, 95% CI 0.85–3.58; p=0.13), bradycardia (RR 0.86, 95% CI 0.19–3.81; p=0.153) or events leading to drug discontinuation (RR 1.16, 95% CI 0.26–5.15; p=0.84). Assessment by beta-1 selectivity showed that hypotension and bradycardia were more frequent with non-selective beta-blockers (sotalol) than comparators (RR 4.57, 95% CI 1.92–10.85; p=0.001 and 5.97, 95% CI 1.34–26.57; p=0.019). Conclusion There is no difference between IV beta-blockers overall and other medications for the control of acute AF/AFl, although better efficacy was shown for beta-blockers with higher beta-1 selectivity. IV beta-blockers were as safe as comparator agents, with the exception of non-selective beta-blockers. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Independent systematic review commissioned by Amomed Pharma. Target heart rate and hypotension events

Exercise tolerance and quality of life in patients with known or suspected coronary artery disease.

Coronary artery disease (CAD) is known to impact on patients' physical and mental health. The relationship between performance on treadmill exercise tolerance test (ETT) and health-related quality of life (HRQL)has never been specifically investigated in the setting of CAD. Consecutive patients undergoing an ETT with the Bruce protocol during a diagnostic workup for CAD (n = 1,631, age 55 ± 12years) were evaluated. Exercise-related indices were recorded. Detailed information on cardiovascular risk factors and past medical history were obtained. HRQLwas assessed with the use of the validated 36-Item Short Form Survey (SF-36) questionnaire. Increasing age and the presence of cardiovascular risk factors and comorbidities correlated with lower scores on the physical and mental health component of SF-36(all P < 0.05). Subjects with arrhythmias during exercise and slow recovery of systolic blood pressure had lower scores on the physical health indices or the Social Role Functioning component (P < 0.05). Achieved target heart rate and good exercise tolerance were independently associated with better scores of the physical and mental health domains of SF-36 and overall HRQLscores (β = 0.05 for target HR and PCS-36, β = 1.86 and β = 1.66 per increasing stage of exercise tolerance and PCS-36 and MCS-36, respectively, P < 0.001 for all associations). Ischemic ECG changes were associated with worse scores on Physical Functioning (β = - 3.2, P = 0.02) and Bodily Pain (β = - 4.55, P = 0.026). ETT parameters are associated with HRQL indices in patients evaluated for possible CAD. Physical conditioning may increase patient well-being and could serve as a complementary target in conjunction with cardiovascular drug therapy.

Speeding up beta-blockade prior to coronary CT angiography: can we predict the dose of intravenous metoprolol required to achieve target heart rate in a given patient?

To evaluate the use and safety of intravenous (IV) metoprolol in a cohort of patients undergoing coronary computed tomographic angiography (CCTA) at a university hospital, and in particular, to establish if the minimum dose required to achieve the target heart rate (HR) in a given patient can be predicted from the baseline HR. Patients undergoing CCTA at a tertiary centre between January 2015 and May 2018, with baseline HR ≥60 bpm requiring IV metoprolol, were identified retrospectively from the database. Patients with a contraindication to beta-blockade or an indication for CCTA other than coronary disease were excluded. HR at baseline and at the time of scanning were recorded, together with the total dose of IV metoprolol administered. Of 625 patients identified, 330 (52.8%) achieved HR ≤60 with IV metoprolol. Patients who achieved target HR had lower baseline HR. They received a lower radiation exposure due to tight prospective gating and a lower tube voltage. The lower quartile dose of metoprolol administered was 5 mg for patients with baseline HR <65 beats per minute (bpm), but 10 mg for HR 65-74 bpm, and ≥20 mg for higher HRs. There were no cases of symptomatic bradycardia/hypotension. Patients with a resting HR of ≥60 bpm can reasonably be given an initial minimum dose of 5-20 mg metoprolol IV before CCTA, with additional doses as required.