Concomitant Disease Research Articles

Association of low muscle strength with incident pneumonia in older patients with heart failure.

Patients with heart failure (HF) are at an increased risk of developing pneumonia, leading to a high mortality. A decrease in muscle strength due to aging or concomitant disease may contribute to the development of pneumonia in older adults. We sought to investigate the relationship between low muscle strength and pneumonia incidence in older patients hospitalized for worsening HF. We carried out a sub-analysis of the FRAGILE-HF, a prospective multicenter observational study, including 1266 consecutive older (≥65 years) patients hospitalized with HF (mean age 80.2±7.8 years; 57.4% male; left ventricular ejection fraction 46±17%) and information of incident pneumonia observed after discharge. Patients were followed up for two years post-discharge. A total of 88 patients (7.0%) developed pneumonia after discharge, with an incidence of 42.7 per 1,000 person-years. A total of 893 patients with low muscle strength, defined as handgrip strength <28kg for men and <18kg for women according to international criteria, were more likely to develop pneumonia than those with normal muscle strength (p <0.001; log-rank test). Low muscle strength was a significant predictor of incident pneumonia (adjusted hazard ratio with 95% confidence interval: 2.65 [1.31-5.35], p=0.007). Furthermore, the mortality rates were 43.2% in patients who developed pneumonia and 19.3% in those who did not, indicating a heightened risk of death following the onset of pneumonia (adjusted hazard ratio: 4.25 [2.91-6.19], p<0.001). In older patients hospitalized for HF, low muscle strength was associated with incident pneumonia after discharge.

Abstract 4141497: Left ventricular diastolic function by echocardiography is related to extracellular volume and is an independent predictor of mortality in patients with aortic regurgitation

Background: Cardiac catheterization along with cardiac biopsy studies have shown the presence of abnormally increased left ventricular (LV) chamber stiffness in patients with severe aortic regurgitation (AR) and its significant correlation with interstitial fibrosis. LV diastolic dysfunction (DD) is associated with increased mortality in several patient populations. However, there is a paucity of data on the association of DD with mortality in patients with AR. Hypotheses: 1 - LV DD is related to extracellular volume (ECV), imaging marker of interstitial fibrosis, by cardiac magnetic resonance imaging (CMR) 2 - LV DD by echocardiography is associated with mortality in patients with AR Methods: We studied patients with moderate or greater AR who underwent echocardiographic and CMR imaging within 12 months. We excluded patients with concomitant valve disease, prior valve intervention, cardiomyopathy deemed unrelated to AR, congenital heart disease and terminal conditions. The primary outcome was all-cause death. CMR was used to obtain LV volumes, EF and mass, AR severity, scar extent by delayed hyperenhancement, and ECV. DD was assessed by comprehensive echocardiography. Results: The study included 323 patients. Mean age was 61.9 ± 16.0 years and 22% were female. Median follow-up was 3.8 years, during which 65 patients died and 172 had aortic valve replacement. Median LV EF was 56 (47-65) %, AR volume on CMR was 40 (30-61) mL, and AR fraction was 40 (33-47) %. ECV progressively increased with higher grades of LV DD (Figure 1). Table 1 shows the univariate associations with mortality in the study. On multivariable analysis based on the Lasso variable selection process, Euroscore, Charlson comorbidity index, DD grade, and RAP were associated with total mortality. Conclusion: ECV by CMR progressively increases with higher grades of DD by echocardiography, and DD is independently associated with mortality in patients with AR.

Abstract 4136394: Elucidation of a novel genetic substrate responsible for genetically elusive ring-like arrhythmogenic cardiomyopathy

Background: Arrhythmogenic cardiomyopathy (ACM) is a genetic heart disease characterized by fibrofatty replacement of ventricular myocardium. Arrhythmogenic left ventricular (LV) cardiomyopathy (ALVC) is a phenotypic variant of ACM predominantly involving the LV. Mutations in genes encoding for desmosome proteins and filamin C have been implicated in ALVC, especially in the setting of a ring-like late gadolinium enhancement (LGE) imaging pattern. Objective: To identify the underlying genetic substrate responsible for genetically elusive ring-like ALVC in a patient with seemingly sporadic/recessive disease. Methods: A 38-year-old male was referred for genetic investigation to determine the underlying genetic substrate responsible for his ALVC phenotype. The patient fulfilled both electrocardiographic (low voltage in the limb leads and anterolateral T-wave inversions) and imaging (&gt;1 segment of subepicardial LGE) criteria for ALVC. Additionally, the patient experienced unexplained episodes of tachycardia, shakiness, sweating, and nausea prompting concern for an underlying neuromuscular disease. Genome sequencing (GS) was performed on DNA isolated from the affected patient and both of his unaffected parents. Variants were filtered assuming either a sporadic de novo occurrence or an autosomal recessive inheritance pattern. Results: GS identified compound heterozygous GNPTAB variants in the affected patient. A previously reported maternally derived p.Leu257Leu (c.771G&gt;A) variant involving the last nucleotide of exon 7 of the GNPTAB gene and a novel paternally inherited Lys834fs*5 frame-shift variant were identified. The p.Leu257Leu variant has been reported to cause aberrant splicing and exon skipping of the GNPTAB mRNA transcript. Pathogenic variants in the GNPTAB encoded N-acetylglucosamine-1 (GlcNAc)-phosphotransferase subunits alpha/beta cause mucolipidosis type III, a rare recessive lysosomal storage disease characterized by coarse facial features, developmental delay, short stature, skeletal deformities, and cardiac involvement including valvular thickening and cardiomyopathy. Conclusions: Here, using a genome sequencing trio analysis we identified a compound heterozygous GNPTAB pathogenic variants as the underlying genetic substrate in a patient with ring-like ALVC and concomitant neuromuscular disease manifestation. Genome sequencing may identify the genetic etiology responsible for an otherwise undifferentiated diagnosis of cardiomyopathy.

Abstract 4135259: Coronary Artery Anomalies Induce Myocardial Ischemia in Hypertrophic Cardiomyopathy

Background: Myocardial ischemia is a frequent finding in hypertrophic cardiomyopathy (HCM) and is often attributed to microvascular disease, extravascular compressive forces, reduced coronary flow reserve, hemodynamic abnormalities, and concomitant atherosclerotic coronary artery disease (CAD). The potential contribution of congenital coronary artery anomaly (CCAA) to myocardial ischemia in HCM has not been systematically explored. Research Question: We aimed to evaluate the spectrum and potential contribution of CCAA to myocardial ischemia in HCM. Methods: From June 1991 to March 2023 a total of 35 CCAA were reported in 29 adults [age 18-87 (47.9±19.9; 59% male; 35% obstructive, 21% apical variant). Clinical data on presence or absence of myocardial ischemia, mode of therapy, and outcomes of the patients were reviewed. Results: The individual CCAAs were graphically reproduced [Figure] and were categorized based on the number of coronary ostia present in the aorta [single ostium (n=11; 38%); 2 ostia (n=13; 45%); 3 ostia (n=4; 14%); 4 ostia (n=1; 3%)]. The anomalous coronary artery was the left main in 6 (17%); left anterior descending in 6 (17%); left circumflex in 8 (23%); right in 14 (40%) or the ramus intermedius in 1 (3%). Two patients (7%) with apical variant HCM also had coronary artery fistulae in a non-anomalous coronary artery. Of all 29 patients who presented, 12 (41%) showed objective evidence of myocardial ischemia and of those, a total of 6 (50%) had an anomalous coronary artery coursing between the great vessels. In addition, 1 of 5 patients with sudden cardiac arrest had a high-risk coronary anomaly. Pharmacologic treatment was offered to 11 (38%) patients and 3 (10%) patients underwent coronary artery surgery (bypass grafting in 2 and unroofing in 1). Septal reduction therapy was performed in 8 (28%). Follow up data was available in 14 patients including 2 of the 3 who underwent surgical correction. Symptomatic improvement was noted in all 14. Conclusion: Congenital coronary artery anomalies may be present in patients with HCM and may contribute to myocardial ischemia. Treatment options depend on the type of anomaly and presence of objective evidence of myocardial ischemia.

Predictors of Selective Serotonin Reuptake Inhibitor Treatment Failure in Persons With Cystic Fibrosis.

Depression and anxiety are common in persons with cystic fibrosis (PwCF). Genetic polymorphisms in CYP2C19 and CYP2D6 are well-established predictors of selective serotonin reuptake inhibitors (SSRIs) treatment failure yet have not been studied specifically in PwCF. The purpose of this study was to determine the rate of SSRI failure in PwCF and to identify factors that predict treatment failure. A retrospective cohort study was conducted of PwCF prescribed an SSRI for depression or anxiety. Potential predictors of SSRI failure were compared between PwCF for SSRI treatment success and failure. When CYP2D6 and CYP2C19 pharmacogenetic (PGx) test results were available, SSRI selection was compared to appropriateness per Clinical PGx Implementation Consortium (CPIC) guideline. PGx results were not available at the time of prescribing. The study included 184 PwCF and 45% experienced SSRI treatment failure. Demographics, concomitant drug-drug interactions, concomitant antidepressant medications, liver disease, and pulmonary function tests were not different between success and failure groups. Only 44 PwCF had PGx results and of these, only nine had actionable genotypes and prescribed an affected SSRI. This cohort had a failure rate of 78% (7 of 9) which was significantly higher compared to 40% (14 of 35) and 45% (83 of 184) in our PGx cohort and total cohort, respectively (p = 0.04; p = 0.04). SSRI failure rate in PwCF is high and consistent with rates of the general population. Greater depression severity and number of SSRIs trialed were seen in the failure group. Pre-emptive PGx testing may improve SSRI success rates in PwCF.

Case report of varicose veins treatment in patient with a prosthetic mitral valve

This clinical case may be of interest in situations where a patient with varicose veins of the lower limbs and concomitant heart disease, who is on long-term anticoagulant therapy and is scheduled to undergo minor surgery, may present the possibility of endovenous laser ablation (EVLA) against the background of warfarin use. Patient, G., 68 years old, with rheumatic combined mitral valve disease (mitral valve replacement in 2019, permanent atrial fibrillation), also had varicose vein disease of the lower limbs. History included acute cerebrovascular accident (19.01.2023). Duplex Ultrasonography Screening (DUS) showed failure of the left great saphenous vein valve. Hypocoagulation was also observed in coagulogram and the risk of bleeding on HAS-BLED score was average. On Caprini score, the risk was very high. Endovenous laser ablation of the large saphenous vein on the left side was performed. During follow-up examinations, there were no signs of bleeding from puncture sites. The target trunk was obliterated in dynamics at DUS. Therefore, it is possible to carry out EVLA of a large subcutaneous vein while taking therapeutic doses of warfarin without switching to bridge therapy. Endovascular laser ablation allowed it to be done with less risk of bleeding and, against the background of taking warfarin, reduced the risk of thrombosis.

Clinical and Radiographic Features of Peri-Implant Medication-Related Osteonecrosis of the Jaw: ARetrospective Study.

This study aimed to analyze the factors affecting the occurrence of peri-implant medication-related osteonecrosis of the jaw (PI-MRONJ) in patients using anti-resorptive drugs (ARDs) on different implant position, inclinations, and types of prosthesis. The data of 75 patients with bone necrosis that progressed around the implant between 2018 and 2022 were retrospectively examined to identify the factors influencing PI-MRONJ. Data, including patient demographics (age, sex, smoking status, concomitant disease, time of ARD therapy, dose of ARDs, and parafunctional habits) and implant-specific information (type of prosthesis, angle of insertion), were extracted from medical and dental records. Tilted implants with an angle ≥ 5.1° relative to the occlusal plane of the prosthesis had a stronger association with PI-MRONJ in comparison to non-tilted implants (inclination was < 5°). Additionally, the boundary of the area of osteonecrosis around the fixture was larger for the splinted implant-supported crowns than for the single implant supported crowns). In patients taking anti-resorptive medications the inclination of the implant was associated with the occurrence of PI-MRONJ. Further studies are required to confirm the clinical findings.

Respiratory manifestations of pediatric granulomatosis with polyangiitis: A 12-year experience from a tertiary care facility.

Pediatric granulomatosis with polyangiitis (GPA) is associated with several pulmonary manifestations. This study aims to describe these manifestations at time of diagnosis and longitudinally at a tertiary-care pediatric hospital. We performed a retrospective chart review of patients with GPA treated at our facility between 1 January 2010 through 31 December 2021. We collected baseline demographics, reported symptoms, imaging findings, pulmonary function tests (PFTs), and laboratory data at time of diagnosis. Data were collected using 6-month observation intervals to follow recurrence of respiratory manifestations, testing during recurrence, and resultant treatment modifications. Of 13 patients treated for GPA during the study period, 12 developed respiratory tract involvement. A total of 87 6-month observation periods were analyzed. At time of diagnosis, 83% (10/12) of subjects reported respiratory symptoms, 92% (11/12) had abnormal chest computed tomography (CT) imaging, and 42% (5/12) had abnormal PFTs. Fewer than half of the patients were seen by pulmonology within 6 months of diagnosis. Eight subjects (75%) had respiratory manifestations during subsequent observation periods. Chest CT or PFTs were obtained in 23/44 (52%) of observations periods with respiratory symptoms, with pulmonary consultation in only 9/44 (20%). This is the first US study to describe respiratory manifestations in pediatric GPA patients longitudinally, finding they are common and frequently recurrent. Our cohort had almost universally abnormal imaging at diagnosis regardless of respiratory symptoms. Early collaboration with pediatric pulmonology in the care of GPA patients may allow rheumatology teams to efficiently evaluate recurrent symptoms and address concomitant lung disease.

Sex Differences in Long-Term Cardiovascular Outcomes and Mortality After COVID-19 Hospitalization During Alpha, Delta and Omicron Waves

Background: Increased mortality and occurrence of cardiovascular (CV) outcomes during hospitalization and in short-term follow-up for moderate to severe SARS-CoV-2 infection have been associated with male sex, yet data regarding long-term outcomes by sex and COVID-19 variant (Alpha, Delta, and Omicron) are limited. Methods: This prospective study of 4882 patients examines potential differences by sex in the occurrence of primary combined cardiovascular outcomes (CV death, CV hospitalization, myocardial infarction (MI), stroke, pulmonary embolism) as well as secondary outcomes (CV death, cardiovascular hospitalizations, myocardial infarction, stroke, pulmonary embolism) at 18-month follow-up after urgent hospitalization for SARS-CoV-2-associated pneumonia, as well as evaluating for differences during the three COVID-19 waves. Survival rate was analyzed for the entire cohort by sex and SARS-CoV-2 variant and adjusted for age using the multiple Kaplan–Meier method. To compare survival in groups of men and women for each wave, the Gehan–Wilcoxon test was applied with significance p &lt; 0.05. Univariate Cox proportional hazards models were used to search for potential risk factors of CV death at 18-months follow-up separately for men and women in each COVID-19 wave. Results: Men had significantly higher 18-month CV mortality compared to women in the Delta wave (6.13% men vs. 3.62% women, p = 0.017). Although men had higher percentages of all other CV endpoints (excepting pulmonary embolism) at follow-up during the Delta wave, none were significant compared with women, except for the combined CV endpoint (16.87% men vs. 12.61% women, p = 0.017). No significant differences by sex in CV outcomes were seen during the Alpha and Omicron variants. Discrepancies in CV outcomes in demographical data and concomitant disease between the COVID-19 variants of concern existed. Conclusions: Higher male mortality and higher but non-significant incidences of CV outcomes occurred during the Delta wave of the COVID-19 pandemic, with the lowest incidence of CV outcomes observed during the Omicron variant.

Lung cancer and pulmonary tuberculosis: key features of molecular mechanisms of concomitant disease

Lung cancer and pulmonary tuberculosis have long been significant problems for global health, occupying leading positions in terms of morbidity and mortality in both developed and developing countries. Numerous clinical and experimental studies have allowed to get knowledge of the mechanisms of development of these pathological processes individually, the impact of diseases on the macroorganism, and various options of treatment. According to population studies, the interaction between these two processes is undeniable – both active tuberculosis and post-tuberculosis changes are equally risk factors for the development of neoplastic processes, and malignant tumors create favorable conditions and predispositions for the development of mycobacterial infection. However, the mechanisms of interaction between these two diseases in concomitant cases remain opened and insufficiently studied. This literature review provides a detailed description of the variants of lung cancer and pulmonary tuberculosis combinations, the pathophysiological basis of the interaction between infectious and neoplastic processes: modulation of the immune response by M. tuberculosis and lung tumor; oncogenic signaling pathways activated by tuberculosis infection; mechanisms of epithelial-mesenchymal transition in post-tuberculosis scar changes and its role in the formation of so-called "scarcinoma"; the relationship between tumor-mediated and tuberculosis-associated immunosuppression; the role of the PD-1: PD-L signaling pathway, and the influence of modern types of anti-tumor immunotherapy on the course of these pathological processes. The final part of the review presents our own data from experimental studies on the combination of cancer and tuberculosis in a laboratory model, identifying promising directions for further research on this issue.

Pectoralis Major and Abdominis Rectus Musculocutaneous Flap Reconstruction for Sternal Wound Closure in Ectopia Cordis

Summary: Ectopia cordis is a rare congenital condition resulting in extrathoracic positioning of the heart. The severity of presentation may vary with partial or complete displacement through sternal or diaphragmatic defects. Operative management is typically required, but due to the rarity of the condition, no standard exists for optimal closure. Reconstruction techniques can include compound local flap placement including pectoralis major, rectus abdominis, or latissimus dorsi flaps as well as synthetic material placement, autologous bone, and cartilage grafts to correct sternal deformity. This case report outlines the successful utilization of bilateral composite pectoralis major and rectus abdominal musculocutaneous flaps for complex staged closure of a sternal wound after creation of a cavopulmonary anastomosis in a 5-year-old patient with concomitant single-ventricle congenital heart disease. This single-staged closure after cardiac repair was performed without intra- or postoperative complications, and the patient demonstrated satisfactory healing with stable cardiac coverage at follow-up visit. This technique may present as an effective approach in complex sternal wound closure in patients with ectopia cordis.

Atrial fibrillation and multimorbidity: How to choose the perfect direct oral anticoagulant?

Atrial fibrillation is one of the most common tachyarrhythmias, the prevalence of which is steadily increasing due to an increase in the proportion of the elderly population. The presence of a comorbidities in elderly patients with atrial fibrillation, increasing the risk of thromboembolic events, has a significant impact on the clinical strategy of atrial fibrillation, as well as on the choice of therapeutic tactics, especially anticoagulant therapy with proven efficacy and low risk of bleeding. One of the most common concomitant diseases in patients with atrial fibrillation are chronic kidney disease, anemia and coronary artery disease. These comorbidities in patients with atrial fibrillation not only increase the risk of stroke and/or systemic embolism, but are also accompanied by an increased risk of cardiovascular mortality, all causes mortality, and hemorrhagic events. At the same time, according to research data, about half of polymorbid patients with atrial fibrillation do not receive anticoagulant therapy, which indicates a low awareness of physicians about rational pharmacotherapy based on clinical recommendations for this cohort of patients. The drug of choice with the most studied safety profile and a high degree of efficacy in these patients is apixaban from the group of direct oral anticoagulants. Unlike vitamin K antagonists and other representatives of direct oral anticoagulants, apixaban, according to the conducted studies, is associated with a more significant reduction in the risk of thromboembolic events, and most importantly, has a lesser effect on the risks of bleeding in patients, predisposing to hemorrhagic complications, with atrial fibrillationand concomitant coronary artery disease, anemia, chronic kidney disease.

The Association of High Burden Premature Ventricular Contractions with Esophageal/Upper GI Diseases

Six patients in our clinical program who were diagnosed with high burden (&gt;10%) premature ventricular contractions (PVCs) and concomitant significant upper GI disease with no other significant cardiac history demonstrated a significant reduction in the burden of PVCs following surgical or procedural interventions of the upper GI tract (68.34% reduction, p = 0.024). Furthermore, in all cases, the origin of the PVCs was from the base of the right ventricular outflow tract (RVOT). This is the first report in the literature that we are aware of that makes the unique association that we propose a dual mechanism of action of the upper GI and vagally mediated PVCs and through direct, anatomical extrinsic triggering of the right ventricular outflow tract (RVOT) of the heart. These are very preliminary findings that warrant larger clinical and mechanistic studies that if confirmed, may define a new physiologic subset of PVCs for which we propose a new term, “E-PVCs”.

Tricuspid regurgitation in the context of severe concomitant left-sided valvular heart disease: patients characteristics and long-term clinical and interventional outcomes

Abstract Background The clinical features, therapeutical management and outcome of patients with significant tricuspid regurgitation (TR) in the context of multiple valvular disease (VD) are poorly defined. Purpose To assess the characteristics, management and long-term prognosis of a large cohort of patients with multiple VD, focusing on the context of significant TR and concomitant severe mitral or aortic disease. Methods Clinical and echocardiographic data were collected in 1183 patients with ≥moderate TR diagnosed at our centers from January 2012 to June 2020: after propensity score matching for age to create matched cohort with &amp;lt; 10% of absolute difference, 975 patients were included in this study and divided in 4 groups as shown in Figure 1. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization+any valvular intervention. Results Patients with isolated TR (356, 37%) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). TR+ severe MR patients (466, 48%) showed higher rates of concomitant coronary artery disease, NYHA class III/IV symptoms and larger left atrial volumes. The group of TR+ severe AS (131 patients, 13%) was characterized by older age, more comorbidities and lower LVEF. Patients with TR and severe AR (22, 2%) were younger, with larger LV dimensions and higher pulmonary pressures. Overall, in 37(4%) patients tricuspid intervention was performed: no differences were found between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment (p=0.444 and p= 0.624, respectively), while left-valve only surgical treatment was more common among patients with TR and severe MR and left-valve transcatheter treatment among patients with TR and severe AS (both p&amp;lt;0.001). After a median follow-up of 2.8 years, the primary endpoint occured in 374 (38%) of patients, and was significantly more frequent in the group of patients with TR and severe AS (p&amp;lt;0.001, Figure 2). In this group, after multivariate analysis, indexed stroke volume remained independenty associated with ACD (OR 0.96, CI 0.93-0.98, p =0.040). Eventually, the secondary endpoint too was more common in patients with TR and severe AS (p&amp;lt;0.001, Figure 2). Conclusions In the context of significant TR, concomitant severe left-sided VD is common, and each subtype presents with different clinical features and echocardiographic phenotypes; in this scenario, TR was profoundly underteated. Long-term, patients with significant TR+ severe AS have considerable worse prognosis.Figure 1Figure 2

Association between echocardiographic parameters and abnormal spirometry among chronic heart failure patients

Abstract Background A significant proportion (10-40%) of heart failure (HF) patients have concomitant pulmonary disease which have negative effects on cardiovascular outcome of patients. Because of the similarities in symptoms between HF and pulmonary disease, the prevalence of concomitant pulmonary disease may be underestimated. Early detection manage accordingly may improve outcomes of HF patients. We aimed to study clinical and echocardiographic parameters identifying HF patients with concomitant pulmonary disease. Methods This cross-sectional study included adults (age≥18 years) who were diagnosed with HF. The echocardiogram, arterial blood gas and pulmonary function test (PFT) were performed. The patients were classified into normal and abnormal (obstructive and restrictive) PFT patterns. The primary outcome was the association between echocardiographic parameters and abnormal PFT. The receiver operating characteristic (ROC) curve was performed to evaluate diagnostic performance of echocardiographic parameter in detecting abnormal PFT. Results A total of 57 patients was enrolled, of which 32 patients (56.14%) had normal PFT, 14 patients (24.56%) had obstructive PFT, and 11 patients (19.30%) had restrictive PFT. The clinical characteristics were not different between groups. ROC curve demonstrated that only left atrial volume index (LAVI) and main pulmonary artery (MPA) diameter had significant diagnostic accuracy to predict abnormal PFT with AUC of 0.72 (95%CI 0.57-0.87) and 0.66 (95%CI 0.51-0.80) respectively. Using combination of LAVI (cutoff 40mm2/m2) and MPA diameter (cutoff 22.0 mm) had a sensitivity of 95.7% (95%CI 78.05-99.89%) and specificity of 41.94% (95%CI 24.55-60.92%) in detection patients with abnormal PFT. Conclusion Almost half of HF had concomitant abnormal PFT. The combination of LAVI and MPA diameter can identify patients with abnormal PFT with high negative predictive value and should be considered as screening parameters in HF patients.

Clinical profile and outcomes of patients with chronic kidney disease on chronic hemodialysis hospitalized for acute coronary syndrome in a tertiary public hospital in the Philippines

Abstract Introduction Acute coronary syndrome (ACS) and end-stage renal disease (ESRD) are both prevalent globally. Of the many risk factors for ACS, chronic kidney disease (CKD) remains to be of great concern because the interplay of cardiac and renal disease is inherently complicated. Cardiovascular mortality rates are 10-30 times higher in the ESRD population. The risk for cardiovascular disease in CKD extends beyond the traditional risk factors. Purpose The guidelines for ACS may not be applicable to the ESRD population because the landmark ACS trials mostly excluded ESRD patients. Due to the gaps in knowledge regarding ACS in ESRD, our study sought to explore the clinical profile and outcomes of these patients in the our institution. Methods We did a retrospective cohort study among ESRD patients presenting with ACS in our institution from May 2021 to November 2023. The data was analyzed using univariate and bivariate statistics using PRISM software. Results A total of 48 patients with ESRD were admitted for ACS in this study - 8 with STEMI and 40 with NSTEMI. The mean age was 61 years old and 33 (68.8%) were male. The average length of hospital stay was 12 days. The most common comorbidities were hypertension (91.7%), heart failure (83.3%), and diabetes mellitus (60.4%). The most common cause of ESRD in our cohort is concomitant hypertensive and diabetic kidney disease (45.8%) with an average length of hemodialysis at 31 months. The most common chief complaints were chest pain (39.6%), dyspnea (29.2%), and decreased sensorium (10.4%). On admission, 18 (37.5%) presented with systolic BP &amp;gt;160mmHg, 7 (14.6%) presented with shock, and 4 (8.3%) presented with cardiac arrest. On electrocardiogram, 21 (43.8%) had left ventricular hypertrophy while 34 (70.8%) had cardiomegaly on chest radiography. On two-dimensional echocardiogram, the average left ventricular ejection fraction was 46% and 27 (90%) had segmental wall motion abnormalities. The most common angiographic finding was 3-vessel coronary artery disease (50%). Only 5 patients (10.4%) had an LDL-C greater than 55mg/dL. Among those with STEMI, 6 (75%) presented with Kilip II or more. While among those with NSTEMI, 27 (67.5%) had a TIMI risk score &amp;gt;2. Almost all patients received dual-antiplatelet therapy, high dose statin, and beta-blocker. The mortality rate was 43.8% with acute coronary syndrome being the most common cause of death. Conclusion Our study did not show significant associated predictors of mortality possibly due to the low sample size. Despite this, our study portrays that patients admitted for ACS with ESRD present with higher risk features reflected by derangement in vital signs, abnormal laboratories, significant imaging abnormalities, high prognostication scores, and high in-hospital morbidity.Predictors of Mortality

Invasive testing leads to significantly altered (surgical) management strategy in coronary anomalies with interarterial course: 3 year interim analysis of MuSCAT

Abstract Introduction Diagnostic work-up of patients with an anomalous aortic origin of a coronary artery (AAOCA) includes an anatomical and functional assessment. The approach to functional evaluation currently varies widely and mainly includes noninvasive assessment. Intracoronary hemodynamic assessment can potentially enhance risk assessment for myocardial ischemia and sudden cardiac death and guide management of AAOCA patients. Hence, this study aims to evaluate invasive detection of ischemia on top of the standard of care diagnostic work-up for interarterial or intraseptal AAOCA and the impact on patient management. We report the first clinical outcomes. Methods In this multicenter prospective cohort study on AAOCA, all consecutive patients of 16 years and older with AAOCA with a newly diagnosed interarterial or intraseptal course in whom diagnostic work-up according to the protocol of the MuSCAT trial was performed between January 2021 and January 2024, were included for analysis. Exclusion comprised incomplete diagnostic evaluation, hemodynamically significant concomitant congenital heart disease or obstructive coronary artery disease in the AAOCA effluence. The work-up included invasive ischemia testing using fractional flow reserve (FFR) and or instantaneous wave-free ratio (iFR)/resting full-cycle ratio (RFR) at baseline and during pharmacological stress using adenosine, adrenaline and dobutamine. Results Fifty-eight patients (50% female, median age at AAOCA diagnosis 51.5 years (IQR 44.0-59.0)) were included, Table 1. The right coronary artery was anomalous in 88%, 93% patients had an interarterial and 69% an intramural course. Non-invasive ischemia detection was positive in 12%, negative in 84% and inconclusive in 4%. Invasive hemodynamic assessment was positive for ischemia in 22%, negative in 74% and inconclusive in 3%. Class of recommendation for surgery based on ESC guidelines was I or IIa in 28% patients and IIb, III or unclassified in 72%. Invasive hemodynamic assessment changed the treatment decision in 24% of the patients; 50% with initially recommended surgical treatment and 14% with initially a conservative treatment adjudication, Figure 1. Median follow-up after initial diagnosis was 20 [IQR 10-28] months and in 56% of all patients who completed 6 months follow-up the initial symptoms alleviated. One (2%) patient underwent a percutaneous re-intervention of the operated AAOCA. Conclusions This national prospective study of invasive hemodynamic assessment in patients with AAOCA showed clinically significant impact on the adjustment of initial management strategy in 24% of the patients. No cardiac death of myocardial infarction in the AAOCA supply area occurred during follow-up. Analysis of the complete follow-up of the MuSCAT trial can further substantiate the role of additional invasive functional imaging in AAOCA.

Demographics and clinical outcomes of flow-gradient patterns of aortic stenosis: an analysis of the CURRENT AS Registry-2

Abstract Background Low-gradient (LG) severe aortic stenosis (AS) has not been fully characterized compared with high-gradient (HG) AS. Methods Among 3369 patients with severe AS enrolled in the CURRENT AS Registry-2, the current study population consisted of 3363 patients with data on left ventricular ejection fraction (LVEF) after excluding patients with LG AS without indexed stroke volume data. Patients were divided into 4 groups (LG AS with reduced LVEF: N=285, paradoxical low-flow low-gradient [LFLG] AS: N=220, normal-flow low-gradient [NFLG] AS: N=872, and HG AS: N=1986). Results Compared to HG AS, LG AS with reduced LVEF more often had cardiovascular comorbidities, advanced cardiac damage stages, and frailty with less extensive aortic valve (AV) calcification by computed tomography (CT), and paradoxical LFLG AS more often had atrial fibrillation, concomitant valvular disease, advanced cardiac damage stages, and frailty with less extensive AV calcification, while NFLG AS were less often symptomatic, and had comparable cardiac damage stages, and frailty with less extensive AV calcification. Patients with the 3 types of LG AS less often underwent surgical or transcatheter aortic valve replacement than those with HG AS (cumulative 3-year incidence: LG AS with reduced LVEF: 64.5%, paradoxical LFLG AS: 59.1%, NFLG AS: 54.2%, and HG AS: 87.3%, P&amp;lt;0.001). Cumulative 3-year incidence of death or heart failure hospitalization was much higher in patients with LG AS with reduced LVEF and paradoxical LFLG AS than in those with HG AS (cumulative 3-year incidence: LG AS with reduced LVEF: 65.9%, paradoxical LFLG: 51.1%, NFLG: 35.5%, and HG: 30.5%, P&amp;lt;0.001). After adjusting confounders, LG AS with reduced LVEF and paradoxical LFLG AS compared with HG AS were independently associated with higher risk for death or heart failure hospitalization (HR: 1.82, 95%CI: 1.49-2.23, P&amp;lt;0.001; HR 1.43, 95%CI: 1.13-1.82, P=0.003, respectively), but not NFLG AS (HR 1.03, 95%CI: 0.88-1.21, P=0.68). Conclusions Aortic stenosis might be less severe in LG AS than in HG AS when assessed by the CT calcium score of the aortic valve, and each of the 3 hemodynamic types of LG AS had distinct clinical, and echocardiographic characteristics as well as clinical outcomes that were different from HG AS.Different patterns of severe AS

The risk factors for in-stent restenosis following drug-eluting stent implantation in end-stage renal disease patients receiving renal replacement therapy

Abstract Background Chronic renal disease is a recognized risk factor for in-stent restenosis (ISR) following percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). However, the specific risk of ISR among individuals with end-stage renal disease (ESRD) remains unclear or insufficiently studied. Purpose It is imperative to identify the risk factors associated with ISR among patients with ESRD and coronary artery disease following the implantation of DES. This identification is crucial for generating evidence-based strategies aimed at preventing ISR. Methods ESRD patients undergoing renal replacement therapy with concomitant coronary artery disease who underwent PCI with their initial DES implantation at our hospital between January 2013 and December 2022 were included in the study cohort. Clinical data, laboratory test results, and PCI specifics were compared between patients with and without ISR. Univariate and multivariate analyses utilizing Cox proportional hazard regression were employed to identify independent risk factors for DES-ISR. Results Among the 321 patients with ESRD who underwent PCI with DES implantation, totaling 874.5 patient-years of follow-up, 53 cases of ISR occurred during this period, yielding an incidence rate of 6.1 per 100 patient-years. Several baseline characteristics, angiographic findings, and procedural details were found to elevate the risk of ISR significantly. These included underlying diabetes mellitus, peripheral artery disease (PAD), high serum parathyroid hormone levels, LDL-C levels, acute coronary syndrome as the clinical presentation, the presence of triple vessel disease, duration of dual antiplatelet therapy less than 1 year, target lesion involving the left main (LM) or left anterior descending (LAD) artery, target vessel size less than 3 mm, ostial lesion, bifurcation lesion, number of stents implanted equal to or more than 3, and stent size less than 3 mm. In the multivariate Cox proportional hazard model, bifurcation lesion (HR 14.70, 95% CI 4.66-46.38), PCI of LM or LAD (HR 5.29, 95% CI 1.14-24.60), target vessel size less than 3 mm (HR 4.10, 95% CI 1.77-9.50), PAD (HR 3.92, 95% CI 1.52-10.08), and ostial lesion (HR 2.92, 95% CI 1.16-7.38) were identified as independent risk factors for ISR (all p-values &amp;lt; 0.05). Conclusions Among ESRD patients with coronary artery disease, bifurcation lesion, PCI involving the LM or LAD, target vessel size less than 3 mm, PAD, and ostial lesion are identified as independent risk factors for ISR. These findings hold significance in enhancing risk stratification and decision-making concerning treatment planning for this population.Univariate analysis risk factors for ISR

Characteristics and outcomes of patients with moderate multivalvular disease in the context of tricuspid regurgitation

Abstract Background The clinical features and the long-term prognosis of patients with moderate tricuspid regurgitation (TR) in the context of concomitant moderate left-sided valvular disease (VD) are poorly characterized. Purpose This study sought to describe the characteristics and the outcomes of patients with combined moderate TR and moderate mitral or aortic VD. Methods Baseline clinical and follow-up data were collected from 2110 patients with moderate TR in combination with a moderate left-sided VD diagnosed at our centers from January 2012 to July 2020; the final cohort was divided in 4 groups as shown in Figure 1. The primary endpoint was all-cause death; secondary EP was the first occurrence of heart failure (HF) hospitalization. Results Group 1 patients (1529, 72.5%) had the highest prevalence of chronic kidney disease (897, 66%) and lowest left ventricular systolic function (LVEF &amp;lt;50%, 298, 21%), as detailed in Table 1. Coronary artery disease was most prevalent in Group 2 patients (43, 41%), which also presented with the lowest average Charlson Index scores (3.95±1.87) and most prevalent dyspnea symptoms (44, 41%). Group 3 patients (41, 1.9%) were the oldest (82±7 years), had the highest rate of comorbidities (mean Charlson score 5.2±1.6), atrial fibrillation (20, 54%) and pulmonary hypertension (17, 46%). Eventually, Group 4 patients (422, 20%) were the youngest (74±13 years), more commonly female (279, 66%) and with the highest right ventricular dysfunction rate (TAPSE &amp;lt; 17 mm, 114, 40%). After a median follow-up of 2.1 years, the primary endpoint occurred in 895 (42.4%) patients, with a significantly higher incidence in Group 3 patients (p&amp;lt;0.001) (Figure 1). The secondary endpoint occurred in 316 (15.0%) patients and, similarly, significantly more frequently in Group 3 patients (p=0.01). Subgroup analysis for the primary and secondary endpoint in patients with preserved ejection fraction (LVEF &amp;gt; 50%) confirmed the results of the primary analysis, with Group 3 as the cohort with the most adverse outcomes. Conclusions Patients with significant TR frequently exhibit concurrent left-sided VD, identifying distinct patient subgroups with varying clinical profiles. Notably, TR combined with moderate AS is associated with the most severe clinical presentation and the poorest long-term prognosis, even in patients with preserved LVEF.Figure 1.