American College Of Cardiology Guidelines Research Articles

An Observational Study on Guideline Mediated Prescribing Pattern in Patients with Acute Decompensated Heart Failure

Introduction: Studies on prescribing patterns are useful investigative instruments for figuring out how drugs function in society. Examining the prescription pattern is a crucial part of gauging the ability of medical professionals to choose a medication that will benefit patients to the fullest. The current study goals were to evaluate, using accepted guidelines, the general medicine department's practice of prescribing in accordance with guidelines in a tertiary care hospital and to assess the inclusion of drugs from essential drug list patients with acute decompensated heart failure. Methodology: Hospital based prospective case observational study was conducted for a period of six months after obtaining the permission from institutional ethical committee. The data was collected and analysed according to the inclusion and exclusion criteria and necessary statistical testing like chi square test and pearson correlation were performed. Results and Discussion: Based on the study, the data of total 100 patients (n=100) were evaluated. Gender distribution of data shows high prevalence rate in males. The most commonly high susceptibility of disease age was found in 40-60 in males and females. The maximum number of patients were hospitalized for 6-7 days, hypertension was the most commonly found precipitating factor. Diuretics were prescribed maximum in the prescription. Out of 650 drugs the maximum number of drugs fall under the category of Anti-hypertensives. Most drugs are given through oral route. The American heart association (AHA) guidelines were assessed for drug prescription using IBM SPSS Statistics. It was depicted that most of the prescriptions were in compliance with the guidelines. Conclusion: The results of our study conclude that prescribing practices were satisfactory according to the American college of cardiology guidelines. Keywords: Prescribing pattern, Guidelines, Acute heart failure, Anti-hypertensives.

Effect of Mineralocorticoid receptor antagonism (MRA) on aldosterone-interleukin 6 axis in heart failure; second opinion. A case-control study

BackgroundIn cases of heart failure characterized by reduced ejection fraction (HFrEF), heightened levels of aldosterone negatively impact the progression of heart failure. Aldosterone exerts its influence through the activation of mineralocorticoid receptors, leading to the subsequent release of IL-6. Recently, the discovery of the role of mineralocorticoid receptor antagonism (MRA) in managing the progression of heart failure, particularly through its effect on IL-6, prompted its inclusion in the American College of Cardiology guidelines. In the years 2019 and 2021, studies elucidated the proinflammatory role of interleukin 6 in the cytokine storm associated with COVID-19, emphasizing the significance of IL-6 inhibitors in controlling this storm. Further research is required to examine the impact of mineralocorticoid receptor antagonism (MRA) on both aldosterone levels and IL-6 release in patients with HFrEF. Additionally, there is a need to assess the effectiveness of current MRA dosages in controlling heart failure with reduced ejection fraction.Patients and methodsA retrospective analysis was conducted on 108 patients with HFrEF diagnosed through echocardiography. The study covered the period from December 2021 to December 2022. All participants underwent blood tests for aldosterone and interleukin 6 using the ELISA test. The patients were categorized based on cardiac compensation status and the specific mineralocorticoid receptor antagonist (MRA) drug regimen they were on.ResultsThere was a notable rise in aldosterone levels and a reduction in serum IL6 observed in 30 patients with Acute Decompensated Heart Failure (ADHF) who were treated with Mineralocorticoid Receptor Antagonists (MRA), as compared to 30 patients with a similar diagnosis who did not receive MRA. Among 24 patients with compensated heart failure using MRA, there was a significant increase in aldosterone levels and a decrease in IL6, in contrast to 24 patients with compensated heart failure who were not on MRA therapy.ConclusionsIn heart failure with reduced ejection fraction (HFrEF), inhibiting mineralocorticoid receptors leads to a reduction in pro-inflammatory IL-6. The action of Mineralocorticoid Receptor Antagonists (MRA) is deemed safe, well-tolerated, and cost-effective when compared to IL-6 inhibitors. There is a need to reevaluate the current MRA regimen with the objective of enhancing its efficacy for optimal reduction in IL-6 and effective control of heart failure progression.

780: 5 MG OF IV VITAMIN K IS SAFE AND EFFECTIVE TO REVERSE LIFE-THREATENING BLEEDS SECONDARY TO WARFARIN

Introduction: Vitamin K is a cofactor in the synthesis of clotting factors. It can be administered to counteract the effects of vitamin K antagonists (e.g., warfarin). The 2020 American College of Cardiology Guidelines recommend 5-10 mg of intravenous (IV) vitamin K for reversal of major bleeding due to warfarin, though the optimal dose of IV vitamin K to rapidly lower the INR to a safe range is unknown. Therefore, the purpose of this study is to compare the guideline-recommend dosing range of 5 mg vs. 10 mg for safety and efficacy. Methods: This single center, retrospective cohort study included patients with life-threatening bleeding secondary to warfarin who received IV vitamin K at Loyola University Medical Center from January 1st, 2014 - July 19, 2022. The primary endpoint of this study is percentage of patients below INR goal ≤1.5 at 24 hours (±12 hours). Secondary endpoints include thromboembolic events and 30-day mortality. This study is IRB approved. Results: Of the 94 patients with life-threatening bleeding, 56 patients met inclusion criteria. Fourteen patients received 5 mg of IV vitamin K and 42 patients received 10 mg. More patients in the 5 mg group had intracranial hemorrhage (85.7% vs. 66.7%). The median baseline INR for the 5 mg group was 2.7 (inner quartile range [IQR] 2-4) vs. 3.3 (2.6-5.8) in the 10 mg group. The primary endpoint of INR goal ≤1.5 within 24 hours of administration was achieved in 85.7% of both dosing groups. A multivariable logistic regression, performed to identify predictive factors of goal INR attainment at 24 hours and adjust for baseline INR found an increase in sequential organ failure assessment score significantly decreased the odds of achieving an INR goal < 1.5 (odds ratio 0.72, 95% confidence interval 0.59-0.89). Two thromboembolic events occurred in the 10 mg group compared to zero in the 5 mg group. Thirty-day mortality was similar between groups. Conclusions: A dose of 5 mg of IV vitamin K is safe and effective in lowering an INR to goal < 1.5 without causing thromboembolic events or significantly increasing mortality.

Clinical Practice Variations in the Management of Ischemia With No Obstructive Coronary Artery Disease.

Background Ischemia with no obstructive coronary artery disease is a condition associated with major adverse cardiovascular outcomes. To date, there are no specific American Heart Association or American College of Cardiology guidelines. The objective of this survey is to better understand the clinical practice and knowledge gaps that exist nationally. Methods and Results Participant-specific links for a survey with 11 questions and 3 reminders were sent between September and October 2020 to the American College of Cardiology CardioSurve Panel. The panel consist of randomly selected cardiologists (n=437) who represent the current profile of the American College of Cardiology US membership. The survey received a 30% response rate. Of the 172 respondents, 130 (76%) indicated that they have treated patients with ischemia with no obstructive coronary artery disease. Although the majority (69%) are generally confident in their ability to manage this condition, 1 of 3 report lack of confidence or are neutral. The American College of Cardiology/American Heart Association Chronic Stable Angina Guidelines are the most commonly used reference for treating ischemia with no obstructive coronary artery disease (81%), with most cardiologists wanting additional clinical guidance, such as randomized controlled trials (61%). More than 4 of 5 cardiologists rarely or never order advanced imaging modalities to assess coronary flow reserve. Approximately 2 of 3 of respondents frequently prescribe statins (68%), aspirin (66%), calcium channel blockers (63%), and β blockers or α/β blockers (55%). However, nearly 70% never prescribe angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Conclusions This survey demonstrates heterogeneity in the management of ischemia with no obstructive coronary artery disease among US cardiologists, identifies support for guideline development, and outlines knowledge gaps for research and education in the therapeutic management of this condition.

Dose-dependent impact of statin therapy intensity on circulating progenitor cells in patients undergoing percutaneous coronary intervention for the treatment of acute versus chronic coronary syndrome

BackgroundBy low-density lipoprotein (LDL) reduction, statins play an important role in cardiovascular risk modification. Incompletely understood pleiotropic statin effects include vasoprotection that might originate from mobilisation and differentiation of vascular progenitor cells. Data on the potentially differential impact of statin treatment intensity on circulating progenitor cells in patients undergoing percutaneous coronary intervention (PCI) are scarce. This study examines the potential association of different permanent statin treatment regimens on circulating progenitor cells in patients with coronary syndrome.Methods and resultsIn a monocentric prospective all-comers study, 105 consecutive cases scheduled for coronary angiography due to either (A) non-invasive proof of ischemia and chronic coronary syndrome (CCS) or (B) troponin-positive acute coronary syndrome (ACS) were included. According to the 2018 American College of Cardiology Guidelines on Blood Cholesterol, patients were clustered depending on their respective permanent statin treatment regimen in either a high- to moderate-intensity statin treatment (HIST) or a low-intensity statin treatment (LIST) group. Baseline characteristics including LDL levels were comparable. From blood drawn at the time of PCI, peripheral blood mononuclear cells were isolated, cultivated and counted and, by density gradient centrifugation, levels of circulating progenitor cells were determined using fluorescence-activated cell sorting (FACS) analysis. In ACS patients both absolute and relative numbers of circulating early-outgrowth endothelial progenitor cells (EPCs) concurrently were significantly lower in the HIST group as compared to the LIST group. This effect was more pronounced in ACS patients than in CCS patients. Both in ACS and CCS patients, HIST caused a significant reduction of the number of circulating SMPCs.ConclusionsIn patients undergoing PCI, a dose intensity-dependent and LDL level-independent pro-differentiating vasoprotective pleiotropic capacity of statins for EPC and SMPC is demonstrated.

Abstract 11864: Ironing Out the Details: Increasing the Screening of Iron Deficiency in Heart Failure Patients and the Promotion of Intravenous Iron Replacement

Background: The American College of Cardiology (ACC) recommends intravenous iron replacement (IVIR) in patients with iron deficiency (ID) and heart failure with reduced ejection fraction (HFrEF). IVIR, in patients with HFrEF and ID, is associated with improvement in patient symptoms, functional capacity, 6-minute walk distance, and quality of life. Emerging data demonstrates IVIR can reduce hospital admissions for HFrEF. The purpose of this study is to enhance screening of ID in the HFrEF population and IVIR in the inpatient setting. Methods: This is a single-center, retrospective chart review using ICD 10 codes I50.2 and I50.42 to query the diagnosis of HFrEF in admissions from January 2018 to June 2020. Patients with recent major surgery within the last three months, use of erythropoietin stimulating agents, blood transfusions within a six-week time period, a history of cirrhosis, and/or a diagnosis of end stage renal disease receiving IVIR were excluded. ID in HFrEF is defined as ferritin &lt;100 micrograms/L or a ferritin of 100-299 micrograms/L with transferrin saturation of &lt;20%, per ACC guidelines. Further analysis was performed on 150 of 600 admissions pulled. Results: Of the 150 admissions analyzed, 108 of 150 were due to decompensated HFrEF and only 22 of the 150 had iron studies performed during admission. Approximately 15 of 22 patients with iron studies had a diagnosis of ID and only 1 of the 15 patients was initiated on IVIR. Additionally, 22 of the 150 total patients were on oral iron replacement and were not placed on IVIR. Discussion: Work-up of ID in patients with HFrEF is frequently omitted in the inpatient setting. In patients that have been diagnosed with ID, few receive appropriate treatment. There should be increased efforts to identify and administer IVIR to hospitalized patients with HFrEF and ID once their acute decompensation has been stabilized. This study aims to increase usage of HFrEF order sets on admissions by including iron studies within the workflow. The initiative includes administering first doses of IVIR in the hospital with subsequent transition to the outpatient setting, providing patient/provider education, and offering clinical decision support at time of ordering.

Abstract 11879: The Genetic Characteristics Based on Next Generation Sequencing in Patients With Hypertrophic Cardiomyopathy

Objective: This study aimed to explore the genetic epidemiological characteristics in patients with hypertrophic cardiomyopathy (HCM). Methods: We prospectively enrolled 383 unrelated HCM probands who received genetic testing and 3.0 T cardiac MRI examination, including 118 familial HCM and 265 sporadic HCM. The diagnosis of HCM is based on the diagnostic criteria of the American Heart Association and American College of Cardiology guidelines. Patients with familial HCM underwent targeted next generation sequencing including 117 candidate pathogenic genes associated with cardiomyopathies, while sporadic HCM underwent whole-exome sequencing. The genotypic characteristics were analyzed. Results: Among the 383 unrelated Chinese HCM probands, we reported 56 new pathogenic or likely pathogenic gene site mutations, including 3 new rare non-sarcomeric gene mutations and 53 new sarcomeric gene mutations. According to the analysis of genotypic characteristics, it was found that the frequency of rare genes was 3.4%, and the positive rate of sarcomere protein gene detection was 62.4%. Among them, MYH7 and MYBPC3 are the most common pathogenic genes, accounting for 61.9% of sarcomere protein gene mutations. Additionally, in the included HCM population, there was no significant difference in the positive detection rate of sarcomere protein gene between familial HCM and sporadic HCM (66.1% vs 64%, P = 0.7). The proportion of sporadic HCM carrying polygenic mutations was higher than that of familial HCM (11.2% vs. 1.8%, P = 0.003). Conclusion: We reported 56 new gene mutations, which expanded the gene spectrum of HCM. Additionally, the frequency of rare disease genes in the HCM cohort is 3.4%, and the composition ratio of sarcomere protein gene is similar to that of North American or European HCM populations. However, the gene positive rate of sporadic HCM is similar to that of familial HCM, but the composition ratio of genotypes is different.

Differences in the 2020 ESC Versus 2015 ESC and 2014 ACC/AHA Guidelines on the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation.

We assessed the differences in the 2020 European Society of Cardiology (ESC) versus 2015 ESC and 2014 American College of Cardiology (ACC) guidelines on the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The recent publication of the 2020 ESC has provided a comprehensive series of recommendations on diagnosis and management of patients presenting with NSTE-ACS. However, there are discrepancies between the 2020 ESC versus 2015 ESC and 2014 ACC guidelines, creating uncertainty among clinicians in routine practices. Our investigation provides insights into several domains, including diagnosis, risk stratification, pharmacological treatments, invasive treatment, and special populations. Overall, it seems that the 2020 version of the ESC guideline for the management of NSTE-ACS provides the most evidence-based recommendations for clinicians; although due to the lack of validated investigation across some of the proposed recommendations, further longitudinal multicenter studies are warranted to address the current questions. Diagnostic algorithm in NSTE-ACS. ACC = American College of Cardiology; CABG = coronary artery bypass grafting; CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; CS = cardiogenic shock; ECG = electrocardiography; eGFR = estimated glomerular filtration rate; ESC = European Society of Cardiology; GRACE = Global Registry of Acute Coronary Events; HF = heart failure; LVEF = left ventricular ejection fraction; MPI = myocardial perfusion imaging; MR = mitral regurgitation; NSTE-ACS = non-ST-segment elevation acute coronary syndromes; PCI = percutaneous coronary intervention; TIMI = thrombolysis in myocardial infarction.

The 2020 American Heart Association / American College of Cardiology guidelines for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: What is new?

On 22 December 2020, Circulation published the new American College of Cardiology / American Heart Association guidelines for the diagnosis and treatment of patients with hypertrophic cardiomyopathy. The most important guidelines were those concerning pharmacological and invasive methods of treating symptomatic patients with obstruction of the left ventricular outlet. Considering the most recent clinical studies, the indications for invasive methods of treatment have expanded to include septal myectomy and alcohol septal ablation. A separate section in the guidelines has been devoted to the management of non-obstructive hypertrophic cardiomyopathy with preserved left ventricular ejection fraction. The recommendations for patients with hypertrophic cardiomyopathy with atrial fibrillation, ventricular arrhythmias and severe heart failure have been revised. Received 26 March 2021. Revised 12 May 2021. Accepted 13 May 2021. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and study design: S.A. Budagaev, A.V. Afanasyev, A.V. Bogachev-ProkophievData collection and analysis: S.A. Budagaev, M.A. OvcharovDrafting the article: S.A. Budagaev, A.V. Afanasyev, A.S. ZalesovCritical revision of the article: A.V. Bogachev-ProkophievFinal approval of the version to be published: S.A. Budagaev, A.V. Afanasyev, A.V. Bogachev-Prokophiev, A.S. Zalesov, M.A. Ovcharov

Myocardial work in Stage 1 and 2 hypertensive patients.

Myocardial work (MW) is a novel parameter that can be used in a clinical setting to assess left ventricular (LV) pressures and deformation. We sought to distinguish patterns of global MW index in hypertensive vs. non-hypertensive patients and to look at differences between categories of hypertension. Sixty-five hypertensive patients (mean age 65 ± 13 years; 30 male) and 15 controls (mean age 38 ± 12 years; 7 male) underwent transthoracic echocardiography at rest. Hypertensive patients were subdivided into Stage 1 (n = 32) and Stage 2 (n = 33) hypertension based on 2017 American College of Cardiology guidelines. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, reduced ejection fraction, valvular heart disease, intracardiac shunt, and arrhythmia. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency were estimated from LV pressure-strain loops utilizing proprietary software from speckle-tracking echocardiography. LV systolic and diastolic pressures were estimated using non-invasive brachial artery cuff pressure. Global longitudinal strain and LV ejection fraction were preserved between the groups with no statistically significant difference, whereas there was a statically significant difference between the control and two hypertension groups in GWI (P = 0.01), GCW (P < 0.001), and GWW (P < 0.001). Non-invasive MW analysis allows better understanding of LV response under conditions of increased afterload. MW is an advanced assessment of LV systolic function in hypertension patients, giving a closer look at the relationship between LV pressure and contractility in settings of increased load dependency than LV ejection fraction and global longitudinal strain.

The Proportion of Women Authors and the Inclusion of Sex and Gender Content Among the American College of Cardiology Clinical Practice Guidelines, 2008-2018.

Background: Sex and gender, two important factors affecting health care, should be routinely taken into consideration in clinical practice. Members of the Sex and Gender Health Collaborative Scholarship Committee reviewed clinical guidelines published by the American College of Cardiology (ACC) from 2008 to 2018 to determine if the number of women authors on the writing committee influenced the presence of sex- and gender-specific content and recommendations in each guideline. Methods: We reviewed 33 ACC clinical guidelines from 2008 to 2018 and determined the number of women authors on the writing committee for each guideline. We then reviewed each guideline to identify specific content on sex and/or gender differences as it pertained to the guideline's subject cardiac condition. Results: The median proportion of women authors among the 33 ACC guidelines was 22.2% (interquartile range 4.4-81.1). Only two guidelines (6%) had writing committees with >50% women authors. Overall, 25 of 33 guidelines (75.8%) contained sex and gender content; however, the depth and detail of the sex and gender content varied widely among guidelines. The proportion of women authors was not associated with the presence of sex- and gender-specific content. Conclusions: Our findings demonstrate continued gender disparities in authorship, and changes should be made to increase the inclusion of women in clinical practice guideline writing committees. We propose selecting a sex and gender champion for guideline writing committees and/or including a specific section on sex- and gender-related content in each guideline to ensure inclusion of sex- and gender-specific recommendations in clinical guidelines.

Variation in Blood Pressure Classification Using 7 Blood Pressure Estimation Protocols Among Adults in Taiwan

Discrepancies in blood pressure (BP) estimates lead to incomparable BP assessment. To determine intraindividual discrepancies in BP estimates and classifications based on different BP estimation protocols. This cross-sectional study was a secondary analysis of data from the May Measurement Month Taiwan in 2017 and 2018, which were cross-sectional survey campaigns at pharmacies nationwide to raise awareness of high BP. Participants were volunteers aged 20 years or older. Analysis was conducted from February 2 to August 7, 2020. Pharmacist-measured sitting BP using oscillometric sphygmomanometers. A total of 7 BP estimation protocols were assessed according to the latest American College of Cardiology (ACC), Chinese Hypertension League (CHL), European Society of Cardiology (ESC), International Society of Hypertension, Japanese Society of Hypertension, and National Institute of Health and Care Excellence (NICE) hypertension guidelines, and the proposed Averaging the Lowest Two systolic readings protocol. According to BP classification schemes of ESC and ACC guidelines, intraindividual discrepancies were identified if classification inconsistencies among 7 BP estimates were present. Of 81 041 participants, 62 647 adults with 3 BP readings were included. The median (interquartile range) age was 59.0 (46.0-69.0) years, and 31 922 (51.5%) were women. The intraindividual maximum mean (SD) differences in systolic/diastolic BP estimates among the seven protocols were 4.8 (4.3)/3.3 (3.1) mm Hg. The highest prevalence of BP of 140/90 mm Hg or higher was by CHL (16 405 participants [26.2%]) and the lowest was by Averaging the Lowest Two (13 996 participants [22.3%]; P < .001); while the highest prevalence of 130/80 mm Hg or higher was by NICE (37 232 participants [59.4%]) and the lowest prevalence was by Averaging the Lowest Two (32 788 participants [52.4%]; P < .001). Compared with the other 6 estimates, Averaging the Lowest Two reclassified 7.3% to 15.8% of participants designated as 140/90 mm Hg or higher to less than 140/90 mm Hg, and 4.9% to 14.1% of those as 130/80 mm Hg or higher to less than 130/80 mm Hg. Intraindividual discrepancies in classifications occurred in 19 815 participants (31.6%) with the ESC classification and 16 401 participants (26.2%) with the ACC BP classification. Classification agreements were the lowest between NICE (κ coefficient, 0.667 [95% CI, 0.662-0.671]) and ESC protocols (κ coefficient, 0.705 [95% CI, 0.701-0.709]). This cross-sectional study of adults in Taiwan found that different BP estimation protocols led to considerable intraindividual discrepancies in BP estimates and classifications. These findings suggest that the Averaging the Lowest Two protocol is less likely to overestimate BP and could serve as a prudent recommendation for BP estimation.

Abstract 14432: Myocardial Work in Stage I and II Hypertensive Patients

Introduction: Myocardial work is a novel parameter that can be used in a clinic setting to assess left ventricular (LV) pressures and deformation. This study sought to distinguish patterns of global myocardial work index in hypertensive vs. non-hypertensive patients. Methods: Fifty (25 male, mean age 60±14 years) hypertensive patients and 15 (7 male, mean age 38±12 years) control patients underwent transthoracic echocardiography at rest. Hypertensive patients were divided into stage 1 (26 patients) and stage 2 (24 patients) based on the 2017 American College of Cardiology guidelines. We excluded patients with suboptimal image quality for myocardial deformation analysis, reduced ejection fraction (EF), valvular heart disease, and arrhythmia. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were estimated from LV pressure strain loops utilizing proprietary software from speckle-tracking echocardiography. LV systolic and diastolic pressures were estimated using a noninvasive brachial artery cuff. Results: Global longitudinal strain (GLS) and EF were preserved between the two groups with no statistically significant difference whereas there was a statistically significant difference in the GWI (p&lt;0.01), GCW (p=0.03), GWW (p&lt;0.01), and GWE (p=0.03) (Figure and Table). Conclusions: Myocardial work gives us a closer look at the relationship between LV pressure and contractility in settings of increased load dependency whereas LVEF and GLS cannot. We show how myocardial work is an advanced assessment of LV systolic function in hypertensive patients.

Early vs Late Discharge in Low-Risk ST-Elevation Myocardial Infarction Patients Treated With Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

BackgroundFor low-risk patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) the recommended optimal discharge timing is inconsistent in guidelines. The European Society of Cardiology guidelines recommend early discharge within 48–72 h, while the American College of Cardiology guidelines do not recommend a specific discharge strategy. In this systematic review and meta-analysis we compared outcomes with early discharge (≤3 days) versus late discharge (>3 days). MethodsRandomized controlled trials (RCTs) and observational studies were selected after searching MEDLINE and EMBASE database. Meta-analysis was stratified according to study design. Outcomes were reported as random effects risk ratios (RR) with 95% confidence intervals. ResultsSeven RCTs comprising 1780 patients and 4 observational studies comprising 39,288 patients were selected. The RCT-restricted analysis did not demonstrate significant differences in terms of all-cause mortality (RR, 0.97 [0.23–4.05]) and major adverse cardiac events (MACE) (RR, 0.84 [0.56–1.26]). Conversely, observational study restricted analysis showed that early vs late discharge strategy was associated with a reduction in all-cause mortality (RR, 0.40 [0.23–0.71]) and MACE (RR, 0.45 [0.26–0.78]). There were no significant differences in hospital readmissions between early vs late discharge in both RCT or observational study analyses. ConclusionsEarly discharge strategy in appropriately selected low-risk patients with STEMI undergoing PCI is safe and it has the potential to improve cost of care.

Comparing the Attention Score Between American and European Cardiology Guidelines

The American College of Cardiology (ACC) in USA and the European Society of Cardiology (ESC) in Europe have issued around 25 practice cardiology guidelines since 2008. The attention and impact of these guidelines have not been investigated yet. In this study, we aim to compare the attention brought up by ACC and ESC guidelines. Guideline documents were defined as documents published by either the ACC or the ESC, where recommendations with a specific level of evidence are clearly indicated. These documents were posted on their respective websites. For each document, we extracted the attention on blogs, news, social media, and other platforms to calculate a total score known as the Altmetric Attention Score (AAS). Then we compared AAS, citations, and other indices between ACC and ESC guideline documents. A total of 26 US and 24 European cardiology guidelines were released between 2008 and 2018. We found a significant difference in the median AAS between American and European guidelines (p = 0.048). The median AAS for European and for American guidelines were 159 (104.25-392.5) and 79 (24-169.75), respectively. The US Contribution to the AAS was significantly higher than the European in both the European guidelines (p < 0.001, median contribution values were 7.6% vs 3.4%, respectively), and the American guidelines (p = 0.011, median contribution values were 12% vs 7%, respectively). The attention brought up by the European guideline documents was higher than the American guidelines, although most of the attention in both guidelines was contributed to by USA.

Challenging the definition of hypertension in pregnancy: a retrospective cohort study

In routine antenatal care, blood pressure is used as a screening tool for preeclampsia and its associated adverse outcomes. As such women with a blood pressure greater than 140/90 mm Hg undergo further investigation and closer follow-up, whereas those with lower blood pressures receive no additional care. In the nonpregnant setting, the American College of Cardiology now endorses lower hypertensive thresholds and it remains unclear whether these lower thresholds should also be considered in pregnancy. (1) To examine the association between lower blood pressure thresholds (as per the American College of Cardiology guidelines) and pregnancy outcomes and (2) to determine whether there is a continuous relationship between blood pressure and pregnancy outcomes and identify the point of a change at which blood pressure is associated with an increased risk of such outcomes. This was a retrospective study of singleton pregnancies at Monash Health, Australia. Data were obtained with regards to maternal characteristics and blood pressure measurements at varying gestational ages. Blood pressures were then categorized as (1) mean arterial pressure and (2) normal, elevated, stage 1 and stage 2 hypertension, as per the American College of Cardiology guidelines. Multivariable regression analysis was performed to identify associations between blood pressure categories and pregnancy outcomes. This study included 18,243 singleton pregnancies. We demonstrated a positive dose-response relationship between mean arterial pressure and the development of preeclampsia in later pregnancy. Across all gestational ages, the risk of preeclampsia was greater in those with "elevated blood pressure" and "stage 1 hypertension" in comparison with the normotensive group (adjusted risk ratio; 2.45, 95% confidence interval, 1.74-3.44 and adjusted risk ratio, 6.60; 95% confidence interval, 4.98-8.73 respectively, at 34-36 weeks' gestation). There was also an association between stage 1 hypertension, preterm birth, and adverse perinatal outcomes. This study demonstrated that preeclampsia and the associated adverse outcomes are not exclusive to those with blood pressures greater than 140/90 mm Hg. As such, those with prehypertensive blood pressures may also benefit from closer monitoring. Further research is essential to determine whether lowering the blood pressure threshold in pregnancy would improve detection and outcomes.

A010 Transposition of the Great Arteries in the 3DHB Region

Transposition of the great arteries (TGA) is a complex congenital heart problem that requires regular monitoring in Adult Congenital Heart Disease (ACHD) clinics. We wanted to assess the demographics of our patients, their outcomes, and their follow up, compared to international monitoring guidelines. We retrospectively collected data for patients >16 years old with TGA in the 3DHB region, utilising the electronic health record. We recorded demographics and outcomes and the frequency of monitoring, from 2010 to 2019, compared with monitoring recommendations from the 2018 American College of Cardiology Guidelines (ACC) for management of ACHD. 52 adults were identified with TGA. The mean age was 29 years (range 17 to 56), with 16 (31%) female. 46 had D-TGA, with 34 having an arterial switch (ASO), 10 an atrial switch, and 2 a Rastelli procedure as their initial surgery. 6 women had a total of 9 successful pregnancies. In assessing the adequacy of monitoring, patients were seen by a cardiologist within the recommended time frame 62% of the time. The ACC ACHD imaging frequency guidelines were met 50% of the time. However, exercise testing in TGA with ASO (6%) and holter monitoring in D-TGA with atrial switch (0%), were significantly underperformed. Patients with TGA within 3DHB have demographic features similar to other cohorts. The monitoring of our patients is deficient in a number of areas and the information will allow us to address these deficiencies and adjust our follow up accordingly.

A multicenter, randomized, double-blind, controlled study to evaluate the efficacy and safety of dantrolene on ventricular arrhythmia as well as mortality and morbidity in patients with chronic heart failure (SHO-IN trial): rationale and design

BackgroundLeakage of Ca2+ from the sarcoplasmic reticulum (SR) is a critical contributing factor to heart failure pathophysiology. Therefore, reducing SR Ca2+ leaks may provide significant additive benefits when used in combination with conventional therapies. Dantrolene, a drug routinely used to treat malignant hyperthermia, also stabilizes the cardiac isoform of the release channel (RyR2), thus decreasing SR Ca2+ leaks. The purpose of this study is to evaluate the effect of chronic administration of dantrolene on heart failure and lethal arrhythmia in patients with chronic heart failure and reduced ejection fraction in a multicenter, randomized, double-blind, controlled study. MethodsPatients with chronic heart failure who had functional status of New York Heart Association class II and III and a left ventricular ejection fraction <40% were treated according to the Japanese Circulation Society, the European Society of Cardiology, and the American Heart Association/the American College of Cardiology guidelines for diagnosis and treatment of acute and chronic heart failure. Patients were randomized and divided into two groups in a double-blind fashion: dantrolene group and placebo group (target sample size: 300 cases). These drugs were administered for 96 weeks. The primary endpoint is cardiovascular death, first hospitalization for exacerbation of heart failure, or lethal arrhythmia [ventricular tachycardia (VT) storm, sustained VT, ventricular fibrillation] for 2 years after starting administration of dantrolene 1 cap (25mg) three times daily (if not tolerable, two times daily) or matching placebo. ResultsThis paper presents the rationale and trial design of the study. Recruitment for the study started on 8 December 2017. ConclusionsThe results of this trial will clarify the efficacy and safety of dantrolene for ventricular arrhythmia, as well as mortality and morbidity in patients with chronic heart failure and reduced ejection fraction during guideline-directed medical treatment.

Comparison of Apolipoprotein B and Low Density Lipoprotein Cholesterol As Atherosclerotic Cardiovascular Risk Factors

Many large-scale studies have reported that current American Heart Association and American College of Cardiology guidelines overestimate Atherosclerotic Cardiovascular Disease (ASCVD) risk by 75% - 150%. People, who achieve low density lipoprotein (LDL) target with active statin therapy, still remain at a residual risk for cardiovascular disease and have high levels of apolipoprotein B (ApoB). The goal of this retrospective case-control study was to compare LDL and ApoB as predictors of ASCVD. Centers for Disease Control and Prevention9s National Health and Examination Survey (NHANES) data from the 2013-2014 was the data source for this study. Around 5,768 subjects participated in the study and 1522 participants met the study criteria. Of these, 162 (Male = 93, Female = 69 ) were cases (subjects with ASCVD) and 1,360 (Male = 629, Female = 731) were controls (subjects without ASCVD). Chi-square test, correlation coefficient, and logistic regression were used to analyze data. P-value of 0.05). Logistic regression results indicated that cases were 3 times more likely to have an increased LDL value but not likely to have an increased ApoB when compared to controls. The study concluded that LDL is an independent predictor of ASCVD and is a better marker than ApoB.

P1684Elevated serum uric acid associated with hypertension in healthy individuals

Abstract Background Elevated serum uric acid (SUA) induces endothelial dysfunction and is associated with hypertension according to the traditional definition of hypertension. The impact of a divergent definition of hypertension between contemporary guidelines is unclear. Purpose We conducted the present study to investigate the association between SUA and new-onset hypertension according to contemporary blood pressure guidelines. Methods We enrolled 10,537 healthy individuals aged more than 30 years, who routinely underwent an annual health exam with office blood pressure records at our hospital in 2016; of them, 7,349 individuals repeated the exam in 2017. The individuals with hypertension at baseline were excluded, and the rest of the study population were divided into the European Society of Cardiology (ESC) cohort and the American College of Cardiology (ACC) cohort. According to the ESC guideline, hypertension was defined as office BP ≥140/90 mm Hg, whereas ACC guidelines defined hypertension as blood pressure ≥130/80 mm Hg. Hyperuricemia (HUA) is defined as an SUA level of ≥7 mg/dl in men and ≥6 mg/dl in women. Results The study population consisted of 6,378 individuals in the ESC cohort and 4,330 individuals in the ACC cohort. The HUA group was predominantly male and older than the normouricemic group and had a greater ratio of alcohol intake and histories of gout, and greater values of laboratory cardiometabolic biomarker values. The incidence of hypertension was 5.8% in the ESC cohort and 19% in the ACC cohort. Incident hypertension was significantly greater in the HUA vs. normouricemic group (8.6% vs. 4.7%, P&lt;0.001 for ESC and 25.5% vs. 16.9%, P&lt;0.001 for ACC). In multivariate logistic regression analyses, each increment of SUA was associated with increased risks of incident hypertension after age, gender, body mass index, blood pressure at baseline, fasting glucose were adjusted (OR: 1.160, 95% CI: 1.056–1.274, P=0.002 for ESC and OR: 1.120, 95% CI: 1.040–1.207, P=0.031 for ACC). Incidence of hypertension Conclusion Elevated SUA was associated with incident hypertension in healthy individuals from Taiwan regarding various contemporary blood pressure guidelines. Future studies might investigate the effect of urate-lowering therapy on lowering blood pressure. Acknowledgement/Funding TSGH 108-14