History Of CAD Research Articles

Abstract 16265: Acute Coronary Syndrome in Patients With Familial Hypercholesterolemia: Incidence, Predictors, and Outcomes

Introduction: Individuals with Familial Hypercholesterolemia (FH) are at high risk for ASCVD events. However, little is known about the incidence, predictors, and outcomes of admissions for acute coronary syndromes (ACS) in this population. Objectives: To describe the in-hospital outcomes, readmission rates, and predictors of recurrent ACS in the FH population. Methods: Utilizing the National Readmission Databases from 10/2016 to 12/2017, we identified individuals with FH (ICD-10 E78.01) admitted with ACS. The primary outcome was in-hospital complications, which was compared using propensity-score matching (PSM 1:3). Multivariate logistic regression was performed to identify the predictors of 30-day readmissions. Results: There were a total of 1,697,513 ACS admissions during the study period (non-FH=1,969,979 and FH=534). Individuals admitted for ACS with FH were younger (median age 57 vs 69), had fewer comorbidities (hypertension, diabetes mellitus, and heart failure), were more likely to present with STEMI (32.8% vs 22.6%; p<0.01) and more likely to undergo multi-vessels revascularization (CABG 12.7% vs 5.9%, p<0.01; multivessel PCI 11.4% vs 7.6%, p<0.01) than patients without FH. After PSM, FH patients more commonly experienced in-hospital VT arrest [11.8% vs 8.0%; p<0.01] and required more frequent mechanical circulatory support [8.6% vs 3.3%; p<0.01]) compared to those without FH. Although FH patients who survived the initial index admission (97.9%) had lower 30-day readmission rates than non-FH patients (9.3% vs 15.1%; p<0.01), readmission was more frequently for cardiovascular disease (81.5% vs 46.5%; p<0.01). Predictors of 30-day readmission were young age, male sex, diabetes, history of CAD, and smoking (p<0.01). Conclusions: Individuals with FH admitted with ACS are younger, have fewer comorbidities, and more frequently present with STEMIs compared to those without FH. FH patients were more likely to suffer in-hospital cardiac complications. These results highlight the high-risk status of ACS and post-ACS care in FH patients.

Abstract 15701: Relationship Between Cardiac Biomarkers and Major Adverse Cardiovascular Events in DECLARE-TIMI 58

Introduction: Biomarkers of hemodynamic stress and myocardial injury are associated with the risk of CV death & heart failure in patients with atherosclerotic vascular disease (ASCVD). Here we explore the association between cardiac biomarkers and ASCVD outcomes in patients with type 2 diabetes (T2DM). Methods: This was a nested biomarker study in DECLARETIMI 58, a randomized, blinded, placebo-controlled trial of dapagliflozin in T2DM and either multiple risk factors (MRF, ~60%) or established ASCVD (~40%). The relationship between baseline NT-proBNP and hsTnT levels (TIMI Biomarker Laboratory, n=14,565) and the composite of myocardial infarction, ischemic stroke, and CV death (MACE), was modeled within the placebo arm using Cox models adjusted for age, sex, race, smoking, baseline eGFR, BMI, T2DM duration, insulin use, history of CAD, MI, ischemic stroke, PAD, HF, dyslipidemia & hypertension. Interaction testing was applied to assess the effect of dapagliflozin according to baseline biomarker value. Results: NT-proBNP and hsTnT were significantly associated with MACE (Adjusted hazard ratio (aHR) per 1-SD in log-transformed biomarker, NT-proBNP: aHR 1.62; hsTnT aHR 1.59). The magnitude of the relationship was similar in patients with ASCVD (NT-proBNP aHR 1.60; hsTnT aHR 1.62) and MRF (NT-proBNP aHR 1.62; hsTnT: aHR 1.51) [Fig A] . Moreover, both biomarkers remained independently associated with MACE when combined in the multivariable model (NT-proBNP aHR 1.46, hsTnT aHR 1.39). The risk of MACE by baseline biomarker level and stratified by treatment arm is shown in Fig B. Conclusions: In patients with T2DM both with and without ASCVD, higher baseline NT-proBNP or hsTnT levels identified patients at increased risk of MACE. The difference in MACE rates between dapagliflozin and placebo tended to be more pronounced in ASCVD patients with higher baseline or NT-proBNP or hsTnT levels.

Abstract 15848: Impact of the Covid-19 Pandemic on D2B Activations in a Single, Tertiary Care, Urban Medical Center in the United States

Introduction: Initial reports suggest that patients may delay seeking medical attention during the Coronavirus Disease 2019 (COVID-19) pandemic. Our aim was to determine if the COVID-19 outbreak is associated with a higher incidence of late presentations for patients with STEMI, greater need for mechanical circulatory support and PCI. Methods: We retrospectively evaluated consecutive patients that presented to a single, academic medical center with acute chest pain and ST-segment elevation on ECG from March 15 through June 17 in years 2019 and 2020. All patients were referred for emergent coronary angiography and the final cohort consisted of 32 patients. Medical records were reviewed to determine time between symptom onset and hospital arrival, need for PCI and/or mechanical circulatory support, total fluoroscopy time and volume of contrast administration during catheterization. Results: There was no significant difference in age, gender, cardiac risk factors or history of CAD between the cohorts that presented in 2019 compared with 2020 (Table 1). The mean time from symptom onset to arrival in the ED was 6.5 ± 8 and 9.2 ± 17 hours in 2019 and 2020 (p=0.55), respectively. PCI was performed during the index catheterization in 5 (50%) and 21 (95%) patients in 2019 and 2020 (p=0.01), respectively. Mean volume of contrast media used per case was 142 ± 65 ml in 2019 and 237 ± 104 ml in 2020 (p=0.017). There was a trend towards greater need for mechanical circulatory support and total fluoroscopy time during cases in 2020 (Table 1). Conclusions: In patients with suspected STEMI during the COVID-19 pandemic, there was a trend towards longer duration between symptom onset and arrival to the ED. More patients presenting with ST-segment elevation required PCI and there was a trend towards greater utilization of mechanical circulatory support. These findings may reflect a decline in access to outpatient services and/or delays in patients seeking care for acute chest pain.

Abstract 15484: Combined Coronary and Carotid Artery Involvement in a Caucasian Patient With Moyamoya Disease

Introduction: Moyamoya disease (MMD) is a rare, progressive steno-occlusive disease of the intracranial carotid arteries. This is primarily a cerebrovascular disease and is mostly seen in young Japanese patients. We report a case of severe stenosis in the distal left circumflex artery (dLCx) in a non-Japanese patient with previously diagnosed MMD. Case presentation: A 33-year-old Caucasian female with history of MMD and 2 CVAs presented with chest pain for 2 days. Her only medication at home was aspirin. There was no history of hypertension, diabetes mellitus, or tobacco use. There was no family history of early CAD. Physical examination was positive for tachycardia but negative for carotid or femoral bruits. Neurologic examination revealed decreased touch sensation and diminished deep tendon reflexes on the left side. ECG demonstrated tachycardia with T wave inversions in leads III and ST depression in lead II. Acute CVA was ruled out with an MRI. Cardiac troponins were minimally elevated with peak of 0.12 ng/dl. An initial diagnosis of NSTEMI was made; patient was loaded with aspirin, clopidogrel and started on a heparin drip. Cardiac catheterization on the following day revealed single vessel CAD in the dLCx, with 80% stenosis and TIMI flow 2. A drug eluting stent was successfully placed in the dLCx. Angiogram post-stent placement showed optimal angiographic result with TIMI 3 flow. The patient was discharged home on dual antiplatelet therapy, statin, beta-blocker and ACE inhibitor. Discussion: MMD is thought to affect the coronary arteries from fibrous intimal thickening and histopathology of these coronary lesions show a homogenous, soft intimal proliferation with minimum lipid deposition and without substantial inflammatory cell infiltration. Although the combined involvement of carotid and coronary artery stenosis is rare, coronary involvement should be considered as one of the causes of ischemic heart disease in young patients with MMD. To the best of our knowledge, this is the first reported case of combined involvement of carotid and coronary artery stenosis in a Caucasian patient with previously diagnosed MMD. It is imperative to educate patients with MMD about possible CAD so that they seek immediate medical attention if cardiac symptoms occur.

Abstract 12885: Sleepless Nights and Squeamish Days: A Conundrum of Recurrent Myocardial Ischemia

A 63-year old Caucasian female with history of aortic valve replacement and CAD with prior drug-eluting stent placement (DES) to proximal LAD and LCX, presented as a hospital transfer with recurrent episodes of chest pain. Chest discomfort was described as severe chest pressure, radiating to bilateral upper extremities. Episodes were not associated with significant exertion and frequently occurred at night/early morning. Of note, the patient had undergone coronary angiography at the outside hospital, revealing no in-stent restenosis or new coronary lesions. Soon after the patient’s arrival in the CCU, she developed profound chest pressure, accompanied by hypotension, diaphoresis and nausea. Her 12-lead ECG revealed 2-mm ST-elevation in aVR, accompanied by ST-depression in inferior, anterior, and apical leads. Initial high-sensitivity (hs)-troponin T was 26 ng/L. She was given sublingual nitroglycerin and was started on a nitroglycerin and nicardipine infusion, with resolution of symptoms after ~30 minutes, followed by normalization of hs-troponin T. A transthoracic echocardiogram did not reveal focal left ventricular (LV) wall motion abnormalities, mild LV hypertrophy was present. Given the patients’ presentation with no in-stent restenosis or new lesions, frequent episodes of chest pain-not related to exertion with occurrence at nighttime and early morning, her presentation was deemed to be consistent with epicardial coronary vasospasm. Subsequently, the patients’ anti-anginal regimen was uptitrated to include extended-release nitrates, calcium-channel blockade, and I Na blockade. Unfortunately, she continued to have frequent episodes of profound angina, accompanied by hypotension, and significant ischemic ECG changes. This prompted us to pursue bilateral sympathectomy. Subsequently, the patient had resolution of prior symptoms. She was continued on an anti-vasospastic regimen, consisting of extended release nitrates and calcium-channel blockade. This case represents the challenging management of medication-resistant epicardial coronary artery vasospasm. As previously described, sympathectomy remains an effective therapeutic option for management in these difficult and life-threatening situations.

Abstract 17423: Impact of Hypertriglyceridemia on ST-Elevation Myocardial Infarction Outcomes

Introduction: There has been conflicting data regarding the impact of hypertriglyceridemia (HTG) on STEMI outcomes, including reports of a “lipid paradox” defined as lower event rates in patients with HTG. Therefore, the association between HTG and outcomes in STEMI deserves further investigation especially given the results of REDUCE-IT trial. Methods: A prospective, multicenter database of the Midwest STEMI Consortium was examined. The Midwest STEMI Consortium is a unique association of 4 large STEMI systems of care: Iowa Heart Center, Minneapolis Heart Institute Foundation, Prairie Cardiovascular, and The Christ Hospital. We included all consecutive STEMI patients between age of 40 and 75. Those with missing TG levels were excluded (23%). We compared 3 groups of TG levels: normal (<150 mg/dl), moderate (150 to 499 mg/dl), and severe (>500 mg/dl) for MACE (death, MI, or stroke) and all-cause mortality. Results: Of 6492 consecutive STEMI patients from 03/2003 to 01/2020, 3760 (58%) met inclusion criteria. The mean (SD) age was 59.1 ± 9.2 and male gender was predominant (76%). A little over one-third of the study participants had moderate HTG (35%). Patients with higher TG levels had lower HDL levels and increased rates of history of premature CAD, DM, and HTN (Table). Moderate HTG was not a risk factor for MACE or all-cause mortality. Severe HTG was significantly associated with increased in-hospital (p=0.016) but not 1-year all-cause mortality (p=0.21) (Figure). Conclusions: In STEMI patients, higher TG levels were associated with increased in-hospital but not 1-year all-cause mortality.

Abstract 16160: Invasive Approach for Cocaine Associated Non-ST-Elevation Myocardial Infarction is Associated With Reductions in Major Adverse Cardiac Events and Worsening Emergent Revascularization

Introduction: Impact of an invasive approach in patients with cocaine associated non-ST-elevation myocardial infarction (CANSTEMI) is unknown. Hypothesis: To determine the effects of an invasive approach on patients with CANSTEMI. Methods: Nationwide Readmissions Database (NRD) from years 2016-2017 was utilized for hypothesis. We utilized ICD-10 CM codes I21.4 in primary diagnosis field and F14 in secondary fields to identify CANSTEMI. Coronary angiogram (CA) with or without percutaneous coronary intervention (PCI) was considered an invasive approach. The primary outcome was a composite of major adverse cardiac events (MACE) at one year. Secondary outcomes included all-cause mortality, MI readmission, stroke readmission, and emergent revascularization at one year. Cox-Proportional Hazard regression was used to adjust for demographic and comorbid confounders. Results: A total of 7,372 patients were identified of which 4,332 (58.8%) underwent invasive treatment. Patients with obesity, hyperlipidemia, tobacco use, and a personal and family history of CAD were more likely to undergo an invasive approach. Conversely, patients with CKD stage 3 or more and anemia were less likely to undergo invasive treatment. The primary outcome was significantly reduced with an invasive approach compared to a non-invasive approach. Similarly, all-cause mortality and MI readmission were also significantly reduced with an invasive approach. An invasive approach was associated with increased emergent revascularization compared to a noninvasive approach. On further stratification of an invasive approach, CA and PCI both were individually associated with improved MACE outcomes and PCI only was associated with increased emergent revascularization. Conclusions: In conclusion, an invasive approach with CA with or without PCI for CANSTEMI was associated with reductions in morbidity and mortality. PCI only was associated with an increase in emergent revascularization.

Effect of Management Strategy of ST Elevation Myocardial Infarction Patients Presented with Cardiogenic Shock on Hospital Mortality

Background: Patients with acute myocardial infarction (MI) and shock are at increased risk of mortality, we divided the managing strategies and also sought to determine whether the revascularization strategy of coronary arteries makes difference regarding to mortality.Methods: We prospectively analyzed sixty patients presented by ST elevation myocardial infarction and complicated by cardiogenic shock admitted to National Heart Institute CCU foe one year who had recent history of acute STEMI within 24 hours of onset of symptoms and complicated by cardiogenic shock. They were divided in to two groups: Group1 with cardiogenic shock received thrombolytic. Group2 has PCI with two Subgroups: PCI for only Culprit artery. Another had total revascularization. Hospital mortalities in all shocked patient were studied according to revascularization strategy Results: We included 60 patients with a mean age of 59 years. Females were (36.7%). CA was present in 26.7%. Hospital mortality was 26.7% (16 out of the 60 patients included in the study 50% in group 1 and 20% in culprit only subgroup and only 10% in total revascularization subgroup). After adjustment, higher mortality was in patients with thrombolytic group compared to patients with revascularization. Conclusions:Total revascularization, when the anatomy is favorable, is the better revascularization strategy regarding mortality rather than culprit only revascularization, but the worst outcome and mortality was with patients in thrombolytic group without intervention. Risk factors; Dyslipidemia, DM, history of CAD and LVEF%, Post PCI TIMI flow (< grade III), were all associated with high mortality.

Long term perspective with LBBB: role of stress echocardiography

Abstract Background Previous studies have shown that left bundle branch block (LBBB), as a relatively common electrocardiographic (ECG) abnormality, represents the condition with often non benign and sometimes adverse outcome. Purpose The Aim of our study was to determine the predictive value of a stress echocardiography test in patients with LBBB. Methods Our study population included 189 patients (88 male, 46.6%, mean age 63.08±9.65) with diagnosed left bundle branch block who performed stress echocardiography (SECHO) according to Bruce protocol. Median follow-up of the patients was 56 months (IQR 48–71 months) for the occurrence of cardiovascular death and non-fatal myocardial infarction, repeat revascularization (coronary artery bypass grafting-CABG or percutaneous coronary intervention-PCI). Results Out of 189 patients, 32 (16.9%) patients had positive, while 157 (83.1%) patients had negative SECHO test. During the follow up period 28 patients had major adverse cardiac event: 1 nonfatal myocardial infarction, 6 heart failure hospitalizations, 5 CABGs, 8 PCIs, while 8 patients had cardiac death. Using the Cox regression analysis, univariate predictors of adverse cardiac events were diabetes mellitus (HR 4.530 [95% CI 1.355–15.141], p=0.014), PCI (HR 4.288 [95% [95% CI 2.010–9.144], p&amp;lt;0.001) and positive SECHO test (HR 2.289 [95% CI 1.006–5207], p=0.048). In the multivariate analysis only previous PCI remained independent predictor of adverse events (HR 3.650 [95% CI 1.665–8.003], p=0.001). p=0.048). Using the Kaplan-Meier survival curve the patients with negative SECHO had better outcome compared to patients with positive SECHO (140/160; 87,5% vs 21/29; 72.4%, p=0.035) and much longer event-free time (77.4±1.6 months vs 67.1±5.4 months, Log Rank 4.136, p=0.042) Conclusion Patients with LBBB and negative SEHO test have good prognosis. Patients with history of CAD and diabetes mellitus and LBBB are at increased risk for future events and need periodical reassessment. Funding Acknowledgement Type of funding source: None

Increase of renal resistive index and mineral metabolism disorder in patients with acute coronary syndrome with preserved renal function.

Coronary artery disease is one of the first causes of death in the Western world; for this reason, it is essential to identify new, systemic, non-invasive and low-cost cardiovascular risk markers. The acute coronary syndrome includes ST-Elevation Myocardial Infarction (STEMI) and Non-ST-Elevation Myocardial Infarction (NSTEMI), based on ECG findings. We aimed to evaluate Renal Resistive Index (RRI) as a marker of cardiovascular risk and assess the associations with other cardiovascular risk factors (metabolic indexes, mineral metabolism disorders and endothelial dysfunction and atherosclerosis markers) in STEMI and NSTEMI patients. Clinical, laboratory and instrumental examinations as metabolic and inflammation indexes, markers of atherosclerosis and endothelial dysfunction (renal function, mineral metabolism disorders, inflammation indexes, Intima Media Thickness (IMT), Ankle Brachial Pressure Index, Left Ventricular Mass Index, Relative Wall Thickness) were performed. Eighty-one patients with STEMI and NSTEMI were enrolled. We showed a significant positive correlation between RRI and age (p<0.01), intact parathyroid hormone (p<0.01) and IMT (p<0.01), as well as a significant negative correlation between RRI and body surface area (BSA) (p=0.02), estimated Glomerular Filtration Rate (eGFR) (p<0.01), serum calcium (p<0.01) and 25-hydroxy-vitamin D (p=0.03). Moreover, we found a significant correlation between RRI and male patients (p<0.01), coronary artery disease history (CAD) (p=0.049), hypertension (p=0.025) and left ventricular eccentric hypertrophy (LVEH) (p=0.047). Our study showed an association between RRI and the main traditional and non-traditional cardiovascular risk factors involved in atherosclerosis pathogenesis, such as age, BSA, hypertension, male sex, CAD history, mineral metabolism disorders and LVEH, in patients with preserved renal function. Moreover, we found a significant correlation between RRI and eGFR, suggesting that RRI could be useful in the evaluation of both renal function and progression of renal damage, even in an early stage with a conserved or only slightly reduced kidney function. We also showed a significant correlation with some markers of systemic atherosclerosis such as IMT and LVEH. For a more precise assessment of prognosis and cardiovascular risk in patients with high cardiovascular mortality, we suggest performing a systematic RRI evaluation, considering the non-invasive nature of the procedure, its reproducibility, easy execution, and low costs.

Prevalence of type 2 diabetes with stable coronary artery disease but without prior myocardial infarction or stroke and THEMIS-like patients from the SNDS French nationwide claims database

Abstract Background The THEMIS randomized controlled trial showed that patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), without prior myocardial infarction (MI) or stroke, and who received ticagrelor plus aspirin, had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. The number of patients concerned and their characteristics in current practice are not well known. Purpose To assess the characteristics of CAD-T2DM adults (≥18 years) without prior MI-stroke, and more specifically, of THEMIS-like patients in a real world setting. Methods Cohort within the main scheme of the SNDS (Système National des Données de Santé), the French nationwide claims database, representing about 86% of 66 million people. All CAD-T2DM prevalent patients without prior MI-stroke were identified on January 1st, 2014 (index date) based on a 5-year database history, and followed for two years. The THEMIS-like population included CAD-T2DM patients without prior MI-stroke ≥50 years at index date without renal failure with dialysis, cirrhosis or liver cancer history, as well as no intracranial and gastro-intestinal bleeding for the last 6 months, or anticoagulant or antiplatelet agent 2 months before and after index date. Study prevalence was standardized for the European population for 1,000 adults (‰) using sex and 5-year age classes from Eurostat statistics. Results From the 359,595 CAD-T2DM patients identified in the database, 71.8% had no prior MI-stroke (n=258,260), including 24.9% of THEMIS-like patients (n=64,334). CAD-T2DM without prior MI-stroke and THEMIS-like patients had the same mean age of 72 years, with 68% and 66% men, 26% and 25% with more than 4-year CAD and T2DM history, 79% and 76% of hypertension, 28% and 19% of revascularisation procedure, 19% and 11% of peripheral arterial disease, 16% and 9% of heart failure, and 39% and 32% of diabetes complications, respectively. The table below presents prevalence estimation per 1,000 European adults with differences according to both populations, as well as sex and age-classes. Conclusions The two populations had similar characteristics, although noting some differences in comorbidities. The THEMIS-like prevalence was estimated to 1.50‰ European adults, representing about a quarter of CAD-T2DM patients without prior MI-stroke. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Interferon-gamma inducible protein IP-10 and left ventricular remodelling post-acute myocardial infarction: a longitudinal cardiovascular magnetic resonance imaging substudy of CAPRI clinical trial

Abstract Background Adverse left ventricular (LV) remodelling is associated with development of heart failure and poor outcomes in patients with acute myocardial infarction (AMI). Understanding the immunomodulatory mechanisms of LV remodelling is an essential step for the development of novel therapies. Interferon-γ-inducible protein-10 (IP-10)/CXCL10 is a chemokine involved in the recruitment of activated T cells into sites of tissue inflammation. Although IP-10 was reported to reduce adverse LV remodeling in a preclinical myocardial infarction model, its role in LV remodeling in humans with AMI remains unknown. Purpose To determine the clinical predictive value of serum IP-10 in LV remodeling in patients with ST-segment elevation myocardial infarction (STEMI). Methods This is a substudy of the double-blind, randomised controlled trial “Evaluating the effectiveness of intravenous ciclosporin on reducing reperfusion injury in patients undergoing primary percutaneous coronary intervention” (CAPRI; ClinicalTrials.gov registry number NCT02390674), which enrolled 52 acute STEMI patients. LV remodeling was assessed by cardiovascular magnetic resonance (CMR) imaging and was defined as the 12-week vs. the 3-day post-myocardial infarction change of the left ventricular ejection fraction (ΔLVEF), LV end-diastolic volume (ΔEDV) or LV end-systolic volume (ΔESV). Serum IP-10 was measured before and 5min, 15min, 30min, 90min and 24h after reperfusion by ELISA. Linear regression analysis was used to determine the independent association of IP-10 with the endpoints of the study. Results Serum IP-10 concentration peaked at 30min after reperfusion followed by a 2-fold decrease at the 24h post reperfusion compared to pre-reperfusion levels (P&amp;lt;0.001 for all). Comparison of the 12-week CMR to the baseline CMR imaging revealed that baseline pre-reperfusion as well as 5min, 15min, 30min and 90min, but not 24h, post-reperfusion IP-10 serum levels associated with increased LVEF and decreased ESV at 12-weeks (range correlation coefficient r=[0.35–0.41], P&amp;lt;0.05 with ΔLVEF and r=[−0.33 to −0.44], P&amp;lt;0.05 with ΔESV) indicating that the increase of IP-10 at the acute phase of myocardial infarction confers a cardioprotective role. Multivariable linear regression analysis for ΔLVEF showed that in a model including baseline pre-reperfusion or 5min or 15min or 30min or 90min post-reperfusion IP-10 and age, gender, traditional risk factors (arterial hypertension, body-mass index, hyperlipoproteinemia, diabetes mellitus, smoking, family history of CAD), infarct location, admission high-sensitivity troponin T, door-to-balloon time and ciclosporin treatment, only IP-10 was the independent determinant of ΔLVEF. Conclusions Increased serum IP-10 levels early after reperfusion are associated with reverse LV remodeling in patients with STEMI undergoing primary PCI. The clinical application of IP-10 as a novel biomarker of LV remodeling post-AMI should be further explored and validated. Funding Acknowledgement Type of funding source: None

Clinical prevalence and outcome of cardiovascular events in the first 100 days postallogeneic hematopoietic stem cell transplant.

Recent advances in allogeneic hematopoietic stem cell transplant (HSCT) have allowed us to offer HSCT to older, advanced disease patients with more co-morbidities. Cardiovascular toxicity post-transplant is a major concern due to the increased risk of mortality. Few studies have examined the prevalence of CV events including CAD (MI, angina, PCI, CABG, CHF, arrhythmias), HTN, stroke/TIA, and death in the first 100days post-transplant. We assessed the impact of pretransplant MUGA results in predicting postallogeneic HSCT CV events and overall survival in the first 100days, and whether or not transient anthracycline-induced cardiomyopathy or cumulative anthracycline dose affected overall survival. This retrospective, cohort study included 665 patients with a median age of 52years who underwent HSCT from 2009 to 2015. The most frequent CV event in the first 100days post-HSCT was arrhythmia seen in 2.9% of patients followed up by CHF (12.3%), MI (9%), and angina (8%). Two patients had PCI, and both survived the first 100days. Cardiovascular risk factors predict for a poor MUGA scan but not survival. Higher dose anthracycline pretransplant predicted for a poor outcome. A history of CV disease, MI, or CAD was the most important predictive of CV events, P-value=.00002. 88.6% survived the first 100days. Patients with an EF<50% had a significant likelihood of having a CV event compared to patients with an EF>60% (OR=5.3, 95% CI [1.6-18.1], P=.0219). Cumulative anthracycline dose did not have a significant impact on overall survival.

Prognostic significance of post-stress reduction in left ventricular ejection fraction with adenosine stress in Jordanian patients with normal myocardial perfusion

BackgroundThe significance of post-stress reduction in left ventricular ejection fraction (LVEF) in patients with normal perfusion on adenosine stress/rest imaging remains controversial. MethodsConsecutive patients who underwent 2-day adenosine gated stress/rest 99mTc-sestamibi imaging and had normal perfusion were analyzed. LVEF was quantified at rest and 1 hour post-adenosine. Patients were followed up for hard (cardiac death or nonfatal MI) and soft (coronary revascularization or congestive heart failure) cardiac events for 24.1 ± 11.0 months. ResultsOf 560 patients included in the study, 135 (24.1%) had a post-stress reduction in LVEF of ≥ 5%. Rest LVEF (P < 0.001), known history of CAD (P = 0.01) and transient ischemic dilatation ratio (P = 0.02) were independent predictors of LVEF reduction. Event-free survivals were similar in patients with and without ≥ 5% LVEF reduction (P = 0.8). The unadjusted hazard ratio (95% CI) for cardiac events for ≥ 5% LVEF reduction was 1.09 (0.55-2.15), P = 0.81, while the hazard ratio adjusted for known history of CAD, smoking, post-stress LVEF and peak heart rate was 0.87 (0.44-1.75), P = 0.71. ConclusionsSignificant post-adenosine reduction in LVEF occurs in about one-fourth of patients with normal perfusion but does not confer adverse prognosis compared with patients without such reduction.

S3538 Needle Track Seeding in a Patient With Hepatocellular Carcinoma

INTRODUCTION: We present a case of a 56-year-old Caucasian male with a history of CAD, HTN, and HCV who initially presented in 3/2017 with lower extremity edema found to have newly diagnosed systolic heart failure and severe mitral regurgitation. During his workup for CABG and valve repair he was found to have cirrhosis secondary to HCV with hepatocellular carcinoma (HCC) by biopsy. After treatment for HCC the patient later developed recurrence due to needle track seeding. CASE DESCRIPTION/METHODS: After further imaging for his initial presentation of heart failure the patient underwent a CT guided fine needle aspiration and core needle biopsies of newly identified liver lesions in the left hepatic lobe (Figure 1). Pathology was consistent with HCC and the patient had no evidence of metastatic disease at that time. He was not deemed eligible for transplantation and was treated with transarterial chemoembolization (TACE). A surveillance MRI 7 months post-biopsy demonstrated a mass within the right rectus abdominus muscle which was located in the region of a prior biopsy tract (Figure 2). Given concerns for metastatic disease, the lesion was biopsied and histopathology was consistent with HCC. He was treated with cryoablation to the rectus abdominus muscle lesion and selective internal radiation therapy. The lesion was no longer visualized on follow-up imaging obtained four months later (Figure 3). DISCUSSION: Needle track seeding is a known complication with variable rates reported in the literature. More recent studies demonstrate a less than 1% rate of seeding when biopsy is performed alone.1,2 However, the rate is thought to be even lower in cases that use a coaxial biopsy system as was performed in this case. This is an important complication to consider as it may alter treatment; often disqualifying patients from liver transplantation or other curative procedures. For those who are being considered for liver transplantation diagnostic needle biopsies should be avoided if possible.Figure 1.: Axial contrast enhanced CT image in a 56 year old male showing CT guided percutaneous biopsy of a mass in the left hepatic lobe (circle).Figure 2.: Follow-up axial T1 post contrast MR images, 7 months later, showing a hyper-enhancing lesion in the right rectus abdominus muscle.Figure 3.: Axial T1 post contrast MR images of a 56-year-old male showing complete resolution of the soft tissue lesion following cryoablation. Residual tumor is noted in the left hepatic lobe.

ASSESSMENT OF IMPLEMENTING THE COMPASS TRIAL RESULTS IN ROUTINE CLINICAL PRACTICE IN ONTARIO, CANADA: INSIGHTS FROM THE CARDIOVASCULAR HEALTH IN AMBULATORY CARE RESEARCH TEAM (CANHEART) STUDY

The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial showed a decrease in major adverse cardiovascular events (MACE) with low-dose rivaroxaban and aspirin vs aspirin alone in patients with a history of CAD and/or PAD. The aim of this study was to examine a) the applicability of the COMPASS trial’s population and b) potential impact of this strategy on MACE and bleeding outcomes in a North American routine clinical practice context.

S2449 A Rare Case of Acute Liver Failure in Suspected Catastrophic Antiphospholipid Syndrome

INTRODUCTION: Catastrophic antiphospholipid syndrome (CAPS) is a rare syndrome which presents as system wide thrombotic events that leads to eventual multi organ failure. Acute liver failure is less commonly seen in patients with CAPS. We present a rare case of a 48 year old female with suspected CAPS who developed acute liver failure. This patient tested positive for COVID-19 infection, which likely triggered CAPS. CASE DESCRIPTION/METHODS: A 48 year old female with a history of CAD and hypertension presented to the hospital after being found by her husband at home to be unresponsive. She reported a 1 week history of decreased appetite, nausea and vomiting. Labs on admission were significant for: PT 13.9s, BUN 23, Cr 2.16, TB 12.6, DB 9.59, ALP 321, ALT 2480 , AST 3320. Labs three months prior to admission were normal. Hepatitis A and B, EBV serologies, ANA, ASMA, total IgG/IgM levels were negative. Liver doppler was negative for thrombosis. COVID-19 RT-PCR was positive. Her hospital course was complicated by multi organ failure as well as coagulopathy. Arterial doppler of the lower extremities showed an occluded right sided anterior tibial artery. Lupus anticoagulant (LA) antibody was negative however a PTT-LA antibody was positive. Liver biopsy showed extensive non-inflammatory centrilobular necrosis, patchy portal based mononuclear infiltrates suggestive of ischemic or toxic mediated injury secondary to drug or viral infection. Subsequently, she went into acute renal failure requiring hemodialysis and respiratory failure requiring intubation. Given the above findings, she was diagnosed with suspected CAPS. DISCUSSION: CAPS is diagnosed in patients with sudden onset of multiorgan failure with presence of at least one venous, arterial or small vessel thrombosis in any organ with a positive antibody (ie LA , anti- cardiolipin or anti-beta glycoprotein I antibody). PTT-LA antibody has been reported to be a weak reagent for the LA antibody. A positive PTT-LA antibody can imply that symptoms are due to a partial presence of the LA antibody. We found no other cause for her multiorgan failure and given above findings, she was diagnosed with probable CAPS. Although COVID-19 has been shown to cause elevation of liver enzymes in the literature, the degree of liver enzyme elevation as seen in our patient has not been reported.

ANGIOSARCOMAS: A TALE OF THE RIGHT ATRIAL RARITY

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary cardiac tumors are quite rare with reported incidence rates of 0.001-0.3%. Angiosarcomas most commonly occur in the head and neck, but also account for the majority of malignant primary cardiac tumors. Presenting symptoms are nonspecific and disease is often advanced at time of diagnosis, making early identification crucial. CASE PRESENTATION: A 65 year-old male with a history of CAD and tobacco use was transferred from an outside hospital with fevers, chest pain, hemoptysis, and respiratory distress. He had been admitted twice in the past two months for dyspnea, chest pain, and fatigue. Prior evaluation included a cardiac echo, which showed a large pericardial effusion. Pericardiocentesis was completed twice, but was non-diagnostic with negative fluid studies. Lung nodules were noted on CT, but thought to be benign and pulmonology had recommended outpatient follow-up. He was thus treated with ibuprofen and colchicine and discharged. On this admission, CXR and CT angiography again showed nodular lung infiltrates and a moderate pericardial effusion, but a new heterogeneous 5.1 x 6.0 x 5.0 cm right atrial mass was also noted. A normocytic anemia (Hgb=8.8) and thrombocytosis (platelets=490) were present with a WBC count of 6.69. Repeat echo showed a large hypoechoic lesion next to the right atrium without effusion. Cardiac MRI demonstrated a 9 cm lobulated lesion along the anterior border of the right atrium, suspicious for a mycotic pseudoaneurysm. The lesion was inseparable from the right coronary artery and two globular thrombi were visualized within the lesion. Pericardial thickening suspicious for loculation/abscess and innumerable pulmonary opacities suspicious for septic emboli were noted. Cardiothoracic surgery was consulted, but preoperative left heart catheterization showed neovascularization of the right atrial mass concerning for cardiac angiosarcoma. Given the high risk of endomyocardial biopsy, biopsy of a lung lesion was completed and confirmed metastatic cardiac angiosarcoma. Treatment and prognosis were reviewed, and the patient elected hospice care. DISCUSSION: Primary cardiac tumors present with non-specific symptoms, including chest pain, shortness of breath, and malaise. TEE is the test of choice with a sensitivity of 97% although CTA or MRI may be necessary. 90% of tumors arise in the right atrium with the most common site of metastasis being the lungs. Treatment is not standardized given the low incidence and lack of randomized trials. Wide resection is the main treatment modality, as primary tumors are generally resistant to chemotherapy and radiation, but surgery with adjuvant therapy is still considered. Despite therapy, outcomes are poor with a median survival of 6 months. CONCLUSIONS: Recognizing a primary cardiac tumor may be difficult as presenting symptoms are non-specific. Echo is the diagnostic modality of choice with the primary treatment being resection. Reference #1: Metastatic Cardiac Angiosarcoma to the Lung, Spine, and Brain: A Case Report and Review of the Literature. Lin CT, Ducis K, Tucker S, Tranmer B. World Neurosurg. 2017 Nov;107:1049.e9-1049.e12. doi: 10.1016/j.wneu.2017.08.023. Epub 2017 Aug 9. Review. PMID: 28803168 Reference #2: Echocardiographic Features of Cardiac Angiosarcomas: The Mayo Clinic Experience (1976-2013). Kupsky DF, Newman DB, Kumar G, Maleszewski JJ, Edwards WD, Klarich KW. Echocardiography. 2016 Feb;33(2):186-92. doi: 10.1111/echo.13060. Epub 2015 Oct 13. PMID: 26460068 Reference #3: Primary malignant tumors of the heart: Outcomes of the surgical treatment. Pacini D, Careddu L, Pantaleo A, Parolari A, Leone O, Daprati A, Gargiulo GD, Di Bartolomeo R. Asian Cardiovasc Thorac Ann. 2015 Jul;23(6):645-51. doi: 10.1177/0218492315573674. Epub 2015 Feb 18. PMID: 25698795 DISCLOSURES: No relevant relationships by Courtney Certain, source=Web Response No relevant relationships by Kim Jordan, source=Web Response No relevant relationships by Craig Sewell, source=Web Response No relevant relationships by Shenali Wickramanayake, source=Web Response

MANAGEMENT OF ACUTE CORONARY SYNDROME AND SUBACUTE IN-STENT THROMBOSIS IN SETTING OF FACTOR V LEIDEN MUTATION

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Factor V Leiden (FVL) results from mutation in the F5 gene resulting in hypercoagulable state. Although, venous thromboembolism (VTE) is frequently reported with FVL, cases of arterial thrombosis, especially MI in setting of FVL are rare. CASE PRESENTATION: 55-year-old Caucasian woman, diagnosed with FVL (heterozygous) 3 weeks ago in setting of unprovoked right lower extremity DVT, presented with substernal chest pain radiating to left arm. Past medical history was insignificant. She was up to date on cancer screening. Home medication was recently initiated rivaroxaban. No family history of premature CAD or thrombophilia and no smoking, alcohol, or drug use reported. Of note, the patient presented 1 week prior to this visit with chest pain, peak troponin I of 1.99 ng/ml, without ST changes on EKG. CT arteriogram at that time showed no occlusions, calcified or non-calcified coronary plaques. Echocardiogram at that time was normal. EKG on this visit showed ST-elevations in leads II, III, aVF, V3-V6. Emergent coronary angiography revealed 80% focal mid LAD stenosis due to thrombus, and distal showering of thrombus in the apical region. Left ventriculography showed apical dyskinesis with normal EF. Remaining coronary vessels were 100% patent. She was treated with DES to mid LAD, aspirin, ticagrelor, beta-blocker and statin. Hematology was consulted for possible anticoagulation failure given acute LAD thrombus and recommended heparin to warfarin bridge with INR goal of 2-3. 5 days later, patient had chest pain again and left heart catheterization this time showed subacute in-stent thrombosis, treated with manual aspiration and balloon angioplasty. She was switched to therapeutic enoxaparin and remains asymptomatic to date. DISCUSSION: Hereditary thrombophilias are associated with increased risk of thromboembolic events. Association of FVL with VTE is well established, but its role in arterial thrombotic events is controversial. While the patient received dual anti-platelet therapy following stent implantation, the subacute in-stent thrombosis likely resulted from her underlying hypercoagulable state. We can possibly infer that the dual anti-platelet therapy alone may not be effective for the carriers of FVL. Also, the role of NOACs to prevent coronary artery thrombosis is questionable. Higher INR goal on warfarin or therapeutic doses of LMWH may be necessary to prevent coronary thrombus in setting of FVL. CONCLUSIONS: More studies are needed to establish the role of thrombophilic disorders and coronary artery and stent thrombosis. Higher INR goal on warfarin or therapeutic LMWH may be required to prevent future coronary thrombotic events. In patients with acute or subacute stent thrombosis, hypercoagulable workup should be pursued, and such patients can potentially benefit from anticoagulation therapy on top of dual antiplatelet therapy. Reference #1: J Cardiovasc Med (Hagerstown). 2008;9(4):410–413. DISCLOSURES: No relevant relationships by Mohammad Hamza, source=Web Response No relevant relationships by Usman Naseer, source=Web Response No relevant relationships by Sheikh Raza Shahzad, source=Web Response Speaker/Speaker's Bureau relationship with Amgen Please note: $5001 - $20000 Added 06/01/2020 by Ira Zackon, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Takeda Please note: $1001 - $5000 Added 06/01/2020 by Ira Zackon, source=Web Response, value=Honoraria Consultant relationship with G1 Therapeutics Please note: $1-$1000 Added 06/01/2020 by Ira Zackon, source=Web Response, value=Consulting fee

S3355 Complicated Cholangitis and the Chaos of COVID-19: A Case Report From the Setting of a Community Hospital Facility

INTRODUCTION: We present a case where the evaluation of multiple biliary tract issues were complicated by the patient's underlying cardiac history and may have played a role in the patient's inoculation of the COVID19 virus. CASE DESCRIPTION/METHODS: Patient was an 81 yo Caucasian male with a past medical history of CAD, CABG and mechanical aortic valve on chronic Coumadin therapy, who presented to the ER for intermittent RUQ pain that had been sharp and intermittent for almost a year and loss of appetite. Other pertinent history included a remote history of alcoholism 40 years ago. He was afebrile on admission but was hypotensive and had an initial WBC of 12.01. Initial CT imaging showed numerous gallstones with stones in the CBD as well as pericholecystic fluid and inflammation at the head of the pancreas, thus initial impression was gallstone pancreatitis, acute cholecystitis, and choledocholithiasis. However, given the patient's intital transaminitis, hyperbilirubinemia, leukocytosis, and hypotension, there was also concern for ascending cholangitis. Biliary drain with cholangiogram was performed with biliary fluid cultures growing Serratia sp., α-hemolytic Streptococcus sp, and non-hemolytic Streptococcus sp so IV antibiotics on hospital day 4 were changed to IV ertapenem. Patient's INR was markedly elevated at 7 which prolonged the removal of the biliary drain and given that the stones in the CBD were never actually removed, decision was made on hospital day 8 to replace biliary drain and perform cholangioplasty of distal CBD stricture. As patient's biliary disease stabilized and patient was awaiting rehab placement on the cardiac medical floor, patient's oxygen requirements continued to worsen from nasal cannula to eventual non-rebreather where at that time, COVID19 inflammatory markers were markedly increased and patient was tested positive for the COVID19 virus and went into acute respiratory failure. Patient and his wife made the decision to change patient's code status and he unfortunately passed away while in hospice care on hospital day 14. DISCUSSION: Ascending cholangitis when present on admission should warrant prompt ICU consideration versus a general medical floor. In this case, due to the patient's underlying cardiac history, patient was admitted to the cardiac floor which at the beginning of the COVID19 pandemic was a non-COVID floor with limited PPE, which may have increased the risk of COVID19 exposure to an already immunocompromised patient with a high risk of sepsis.Figure 1.: Initial CT Abd/Pelvis without IV contrast showing cholelithiasis with gallbladder wall thickening and inflammatory pericholecystic fluid and peripancreatic haziness as well as calculi up to 5 mm in CBD consistent with acute cholecystitis, acute pancreatitis, and acute choledocholithiasis.Figure 2.: Organisms seen in biliary fluid culture on hospital day 3. Antibiotic coverage of Meropenem was determined by sensitivities and minimum inhibitory concentration (MIC) as determined by the Infectious Disease department.Figure 3.: Chest X-ray on hospital day 9 showing diffuse scattered perihilar infiltrates as well as a small-moderate left loculated pleural effusion, consistent with COVID19 pneumonia.