CV Mortality Research Articles

Abstract 4144585: Association of renal function with mortality and heart failure hospitalization rates after Transcatheter Mitral Valve Edge to Edge Repair

Background: Transcatheter edge to edge repair (TEER) is an established treatment for patients with symptomatic severe functional MR on optimal medical therapy or severe symptomatic primary MR and high surgical risk. Renal dysfunction is associated with adverse outcomes but the threshold at which risks rise are uncertain. Aim To determine the association of estimated glomerular filtration rate (eGFR) with adverse outcomes in patients undergoing TEER for severe symptomatic mitral regurgitation (MR) in Ontario, Canada. Methods: This was a population-based retrospective cohort study using linked administrative datasets of patients who underwent TEER in Ontario, Canada, between 2011 and 2023. The key exposure was eGFR, which was modeled using restricted cubic splines. Outcomes were 1-year mortality, cardiovascular mortality (CV) and heart failure hospitalization (HF). Cause-specific hazards regression was used to model the association between eGFR and outcomes, utilizing eGFR 30ml/min/1.73m2 as the reference value. Results: We studied 2076 patients, of whom 294 (14.2%) had eGFR <30ml/min/1.73m2 and 841 (40.5%) had eGFR 30-60ml/min/1.73m2. The incidence at one year was 16.8% for all-cause mortality, 11% for CV mortality and 14.2% for HF hospitalizations. The Figure illustrates that the predicted incidence of adverse outcomes increases with lower eGFR, with subtle differences in patterns of change in risk at lower eGFR levels such that all-cause mortality and CV mortality begin to rise rapidly at eGFR values ≤30ml/min/1.73m2, while HF hospitalization increases linearly at eGFR ≤50ml/min/1.73m2. Conclusions: There was a progressive increase in all-cause, CV mortality and HF hospitalization after TEER for patients with lower eGFR, particularly those with values <30 ml/min/1.73m2. This data can inform patient discussions and guide post-procedural follow-up.

Abstract 4145834: Comparison of 30-Day Outcomes of TAVR vs. SAVR in Patients with Prior CABG: A Meta-Analysis

Introduction: Managing severe aortic stenosis in patients with a history of coronary artery bypass grafting (CABG) is challenging. Traditionally, surgical aortic valve replacement (SAVR) was the standard treatment, but transcatheter aortic valve replacement (TAVR) offers a less invasive alternative. This meta-analysis compares the 30-day outcomes of TAVR versus SAVR in patients with prior CABG. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. Studies comparing TAVR and SAVR in patients with prior CABG were included. The primary outcomes were 30-day (cardiovascular) CV mortality, all-cause mortality, stroke, and myocardial infarction. Heterogeneity was assessed using the Chi-squared test and I-squared statistic. P value <0.05 was considered statistically significant. Results: Nine studies with a total of 8,487 patients were included for the 30-day outcomes. The pooled odds ratio (OR) for 30-day CV mortality was 1.00 (95% CI: 0.48-2.06), with no significant difference between TAVR and SAVR (p=0.99). For 30-day all-cause mortality, the pooled OR was 0.75 (95% CI: 0.51-1.10), also showing no significant difference between TAVR and SAVR (p=0.14). The pooled OR for 30-day myocardial infarction was 0.34 (95% CI: 0.09-1.27), indicating no significant difference between TAVR and SAVR (p=0.11). However, the pooled OR for 30-day stroke was 0.67 (95% CI: 0.50-0.90), showing a significantly lower incidence with TAVR compared to SAVR (p=0.007). Detailed results in Figure 1. Conclusion: In patients with a history of CABG, TAVR appears to have comparable 30-day outcomes to SAVR in terms of CV mortality, all-cause mortality, and myocardial infarction. However, TAVR is associated with a significantly lower incidence of 30-day stroke. These findings suggest that TAVR may be a safer option in the short term for this high-risk patient population. Further research is needed to confirm these results in larger, randomized controlled trials.

Abstract 4118402: National Burden, Trends, and Racial Disparities in Cardiovascular Mortality Among Incarcerated Individuals in the United States from 2000-2019

Background: Cardiovascular disease is the leading cause of death in the U.S. Mass incarceration is a national public health issue, with the US having the highest incarceration rate in the world. However, there is a paucity of data on cardiovascular mortality among incarcerated individuals, or how the racialization of mass incarceration contributes to cardiovascular health inequities. The aim of this study was to evaluate the burden of cardiovascular mortality, trends in cardiovascular deaths, as well as racial differences in cardiovascular death and receipt of care among those incarcerated in U.S. state prisons from 2001-2019. Methods: We utilized the database “Mortality in Correctional Institutions: ICD-10 Diagnosis Codes for Natural Deaths Occurring in State Prison or Local Jail Custody, 2000-2019” from the United States Bureau of Justice Statistics. This database collects inmate death records from each of the nation’s 50 state prison systems. We extracted all deaths related to cardiovascular causes to evaluate the epidemiology of individuals with cardiovascular death, trends in cardiovascular death rates, and differences between racial groups. Results: From 2000-2019, there were a total of 18227 (28.0%) deaths secondary to cardiovascular causes among those incarcerated in US state prisons. The rate of CV death increased from 71.3 per 100,000 persons in 2001 to 94 per 100,000 persons in 2019. Black individuals who died while incarcerated had higher rates of death related to a cardiovascular cause than White individuals (30.9% vs. 27.8%, p<0.0001). Black individuals had higher rates of death due to ischemic heart disease (23.2% vs 21.9%) and hypertensive-related cardiovascular deaths (3.71% vs. 2.96%) as compared to white counterparts (p<0.001). Black incarcerated individuals who died from a cardiovascular cause were less likely to be evaluated by a medical provider in prison (78.6% vs. 81.9%; p<0.0001), were less likely to have a diagnostic test performed (65.3% vs. 69%, p<0.0001), were less likely to receive medications (68.1% vs 72.6%, p<0.001), as well as treatment other than medications (49.1% vs 52.8%, p <0.0001) for the condition which caused death as compared to White counterparts. Conclusions: Deaths due to cardiovascular causes are high among patients incarcerated in US state prisons. Combined with decarceral efforts to address mass incarceration, strategies to ensure quality and equitable cardiovascular care for this population are needed.

In HF, T2D, CKD, or atherosclerotic CVD, SGLT2 inhibitors reduce HF hospitalizations and CV mortality.

Usman MS, Bhatt DL, Hameed I, et al. Effect of SGLT2 inhibitors on heart failure outcomes and cardiovascular death across the cardiometabolic disease spectrum: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2024;12:447-461. 38768620.

External validation of SCORE2-Diabetes in the Netherlands across various Socioeconomic levels in native-Dutch and non-Dutch populations.

Adults with type 2 diabetes have an increased risk of cardiovascular events (CVE), the world's leading cause of mortality. The SCORE2-Diabetes model is a tool designed to estimate the 10-year risk of CVE specifically in individuals with type 2 diabetes. However, the performance of such models may vary across different demographic and socioeconomic groups, necessitating validation and assessment in diverse populations. This study aims to externally validate SCORE2-Diabetes and assess its performance across various socioeconomic and migration origins in the Netherlands. We selected adults with type 2 diabetes, aged 40-79 years and without previous CVE from the Extramural LUMC Academic Network (ELAN) primary care data cohort from 2007 to 2023. ELAN data were linked with Statistics Netherlands registry data to obtain information about the country of origin and socioeconomic status (SES). CVE was defined as myocardial infarction, stroke, or CV mortality. Non-CV mortality was considered a competing event. Analyses were stratified by sex, Dutch versus other non-Dutch countries of origin, and quintiles of SES. Of the 26,544 included adults with type 2 diabetes, 2,518 developed CVE. SCORE2-Diabetes showed strong predictive accuracy for CVE in the Dutch population (observed-to-expected ratio (OE)=1.000, 95% CI=0.990-1.008 for men, and OE=1.050, 95% CI=1.042-1.057 for women). For non-Dutch individuals, the model underestimated CVE risk (OE=1.121, 95% CI=1.108-1.131 for men, and OE=1.100, 95% CI=1.092-1.111 for women). The model also underestimated the CVE risk (OE>1) in low SES groups and overestimated the risk (OE<1) in high SES groups. Discrimination was moderate across subgroups with c-indices between 0.6 and 0.7. SCORE2-Diabetes accurately predicted the risk of CVE in the Dutch population. However, it underpredicted the risk of CVE in the low SES groups and non-Dutch origins, while overpredicting the risk in high SES men and women. Additional clinical judgment must be considered when using SCORE2-Diabetes for different SES and countries of origin.

Unveiling the heartbeat of hope: exploring cardiovascular morbidity, mortality, and socioeconomic threads in 65,173 Child, Adolescent, and Young Adult (caya) cancer patients

Abstract Background Despite significant progress in managing cancer in children, adolescents, and young adults (CAYAs), persistent complications impact their quality of life with some being severe or life-threatening.(1,2) Long-term outcomes depend on common risk factors for malignancy and cardiovascular diseases (CVD) that overlap, and treatments are known to increase the risk for CVD. (3,4) Healthcare inequality due to socioeconomic status is omnipresent and may significantly impact outcomes. Purpose This study aims to comprehensively cover morbidity, mortality, demographic, and socioeconomic factors among CAYAs and investigate their impact on cardiovascular outcomes. Methods This retrospective matched cohort study included the entire Swedish population under 25 with cancer from 1958 to 2021. The study population was identified from the National Board of Health and Welfare's Cancer Register, with controls paired 1:5 based on age, sex, and residence. Multiple registers provided data on morbidity, mortality, and demographics. Results Covering 63 years, identified 65,173 CAYAs (1.24 million patient-years) and matched with 312,935 controls (7.45 million person-years), a total of 378,108 individuals (74% females). The mean follow-up was 19.5 (SD16.9) years for CAYAs, and 23.8 (16.8) for controls, (p&amp;lt;0.001). At the end of the study, the median age of CAYAs was 33.4 (IQR 27.9) years and controls 39.2 (28.3) (p&amp;lt;0.0001), with an age span of &amp;lt;1-88 years in both groups. CVD was detected in 16.9 % of the CAYAs, representing a 1.21-time elevated risk (95% CI 1.18-1.23, p&amp;lt;0.0001) compared to controls. CAYAs had a higher mortality rate, and 5-years survivors lived a mean of 26.9 years shorter than controls. CV mortality was also increased in CAYAs, (1.9% compared to 0.7% in controls) but at a higher age, although at a mean of 22.8 years younger than their controls. The 5-year survivors were older at CV mortality and lived in mean 6.5 years shorter than controls (p&amp;lt;0.0001). After adjusting for socioeconomic factors, individuals born outside Europe and those with greater sick leave had a higher mortality risk, while education and marriage showed a beneficial association with mortality. (p&amp;lt;0.0001). Interpretation The Rebuc study, spanning six decades, revealed a significantly increased risk of serious complications among young cancer patients in Sweden. Not only do young cancer patient survivors face a significantly higher risk for cardiovascular disease, but the higher mortality risk before middle age also underscores the severity of the health challenges they confront. Furthermore, these young individuals are more susceptible to socioeconomic factors that may adversely affect their survival.

Sex sifferences in lifes essential eight and its association with mortality among adults without known CVD

Abstract Background The American Heart Association’s Life’s Essential 8 (LE8) score is a helpful tool to quantify cardiovascular health (CVH) metrics. Sex differences in relation to LE8 and its association with mortality are not known. Methods The National Health and Nutrition Examination Survey (NHANES) between 2009 and 2018 was utilized to evaluate the prevalence of health metrics included in LE8 among adult patients, stratified by sex. Health metrics were further subdivided into health behaviors (diet, physical activity, nicotine exposure, and sleep) and health factors (body mass index, non–high density lipoprotein cholesterol, blood glucose, and blood pressure). LE8 scores were also evaluated based on age, race/ethnicity, and socioeconomic status. Cox proportional hazard models were used to evaluate the association between the levels of CVH and risk of all-cause and cardiovascular mortality. Results Among 22,761 participants, 52% were female. Overall CVH score was similar in both females and males (65.8 vs. 65.9). Females had higher health factors score (64.3 vs. 63.1, p &amp;lt;0.001) and lower health behaviors score (67.2 vs 68.6, p &amp;lt;0.001). Amongst individual metrics, blood pressure score was higher in females (73.2 vs. 67.7, p &amp;lt;0.001) while males had higher physical activity score (70.6 vs. 54.9, p &amp;lt;0.001). For individuals under 65 years of age, overall CVH and health factors scores were higher in females while in those age 65 or older, males had higher scores. The most prominent sex differences were noted in non-Hispanic Black females who had significantly lower CVH scores than Black males. High or moderate LE8 scores vs. low LE8 scores demonstrated lower all-cause and CV mortality in both sexes (p-interaction 0.98 and 0.9). High or moderate health behaviors scores also demonstrated a significant association with lower all-cause and CV mortality, with the reduction in mortality being more prominent in females (p-interaction 0.01 and 0.03). Conclusions We demonstrate important sex differences in CVH metrics along with notable variations based on age and race/ethnicity. Furthermore, we highlight sex differences in the association of CVH metrics with mortality. These findings underscore the importance of designing and implementing effective strategies for both sexes, aimed at targeting these specific factors.

Detection of biventricular volume increase in overweight and obese by using a novel index of the ideal human - a single center non-contrast-enhanced cardiac CT study

Abstract The bi-ventricular volume (BVV) can be measured from non-contrast-enhanced CT images in patients referred for coronary artery calcium (CAC) scoring. Such determined BVV has been found to correlate with left ventricular mass and to predict increased risk of all-cause and CV mortality in patients with type 2 diabetes mellitus. Currently, no data are available that quantifying the effect of body size on BVV using NCE-CT. We used a new indexing parameter that consisted of two parts: height and the difference between numerical values of height and body surface area (BSA). In the "ideal human", the difference is zero. Any deviation from this value determines the share of body mass regardless of height. Aim We hypothesize that a novel indexation way allows for better discrimination of the increased bi-ventricular volume in overweight and obese patients. Method We retrospectively analyzed the CT data from 2466 patients with CAC scoring over the last 15 years. Among them 1606 women and 860 men with an average age of 64 ± 11 years (range 21-93). The fatless bi-ventricular volume was measured manually using commercial software on a dedicated workstation (Vitrea2). Values of the raw (measured, ml) BVV and BVV normalized for height, BSA, and the novel parameter i.e. [h+ (h-BSA)], were compared in patients taking into account body mass index (BMI) categories of normal weight (25% of patients), overweight (40%) and obese (35%). Results Overall, the measured BVV [ml] was significantly greater in males (414±97) than in females (297±66) (p&amp;lt;0.001). BVV decreased non-linearly from before 40ties to mid-60ties, and then remained nearly stable. In normal-weight males, the measured BVV (370±80ml) was greater than in normal-weight females (279±61ml) (p&amp;lt;0.001). In overweight males, the BVV was 411±89ml; in overweight females, the BVV reached 290±59ml (p&amp;lt;0.001). These differences were non-significantly different from the sample of patients with normal BMI. In obese patients, mean values significantly differed between males and females (442±106 vs 321±71 ml, p&amp;lt;0.001). As the absolute value of the BVV should be interpreted in the context of body habitus, normalization for height, BSA, and the novel index were used. The results of these examinations are given in the figure. Conclusions Commonly used methods of indexing the volumetric parameters of the ventricles, as well as the novel indexing approach showed similar results in patients with normal body weight. The proposed indexation allowed for discriminating the increase in BVV that is easy to overlook in overweight. The use of body surface area for volumetric normalization is misleading as it provides similar values in normal, overweight, and obese patients, and should therefore be avoided. We should consider whether ventricular size standards based on a study population under 50 years of age create reliable conditions for detecting ventricular enlargement at an older age.

Association of lifes essential 8 and mortality among adults with and without CVD

Abstract Background Differences in the American Heart Association’s Life’s Essential 8 (LE8) score and its association with mortality based on the presence of clinically prevalent cardiovascular disease (CVD) has not been assessed previously. Methods Data from the National Health and Nutrition Examination Survey (NHANES) 2009-2018 was utilized to calculate LE8 scores among adult patients, stratified by the presence of existing CVD. Health metrics were further divided into health behaviors and health factors. Scores were also evaluated based on sex, age, race/ethnicity, and socioeconomic status. Cox proportional hazard models were used to evaluate the association between the levels of cardiovascular health (CVH) and risk of all-cause and cardiovascular mortality. Results 25,359 patients were included in the analysis, of which 10.2% had known CVD. Individuals with known CVD had lower overall CVH (55.9 vs. 65.8, p &amp;lt;0.001), health behaviors (60.6 vs. 67.9, p &amp;lt;0.001), and health factors (51.3 vs. 63.8, p &amp;lt;0.001) scores. The lower CVH scores in those with prior CVD persisted after stratification by sex, age, race/ethnicity, and socioeconomic status. When assessing the association of CVH metrics with mortality, for every 10-point increase in LE8 score, there was a significant reduction (17%-27%) in all-cause and CV mortality in those with and without CVD. Conclusions Individuals with known CVD have lower CVH metric scores. Overall, the LE8 score is able to predict future CV outcomes in both individuals with and without CVD and highlights the importance of effective implementation strategies that target health factors and behaviors in primary and secondary prevention populations.

Long-term outcomes in patients with dual pathology aortic stenosis and cardiac amyloidosis referred for valve intervention

Abstract Background The coexistence of aortic stenosis (AS) and cardiac amyloidosis (CA) is common. If treated with transcatheter aortic valve implantation (TAVI), patients with the combined phenotype (AS-CA) have a comparable short term survival to those with lone AS, whereas data on longer term outcomes is currently lacking. Purpose This study aimed to evaluate the clinical outcomes of AS-CA compared to lone AS over a 5-year follow-up. Methods Using a prospective, multicentre, observational, case-control design, we screened consecutive patients with severe AS referred for TAVI for co-existing CA. CA screening included blinded 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) with additional SPECT/CT and light chain assessment prior to intervention. Transthyretin CA (ATTR) was diagnosed by bone scintigraphy and unremarkable light chain assessment, light-chain CA (AL) by endomyocardial biopsy. Mortality (all-cause and cardiovascular [CV]) and hospitalisation for heart failure (HHF) were captured as clinical endpoints. Results 376 patients (83±7 years, 52% female, EuroSCORE-II 4.9±2.9) were recruited, of which 43 (11.4%) had AS-CA (42 ATTR, 1 AL). Compared to lone AS, patients with AS-CA were older with higher cardiac biomarkers (NT-proBNP, high-sensitive Troponin-T) and a higher prevalence of atrial fibrillation. Heart team decision yielded valve replacement in 320 (85%) and conservative management in 56 (15%) patients, without differences between AS-CA and lone AS. Over a median follow-up of 5.4 (Q1: 4.9; Q3: 5.7) years, 230 (61.1%) patients died and 67 (17.8%) experienced HHF (with a total HHF number of 91). AS-CA was associated with higher all-cause mortality (crude HR 1.64, 95%CI 1.15-2.35; log-rank, p=0.006), which remained significant after multivariate adjustment for clinical confounders (EuroSCORE-II, valve replacement; adjusted HR 1.63, 95%CI 1.15-2.32; p=0.006). AS-CA was not associated with CV mortality (log-rank, p=0.18) or time to first HHF (log-rank, p=0.43), but the rate of HHF was significantly higher in AS-CA compared to lone AS (5.7 versus 3.5 per 1,000 patient years, p=0.022). Conclusions Among elderly patients referred for TAVI, long-term outcomes of AS-CA are characterized by higher mortality and a higher rate of heart failure hospitalisations compared to patients with lone AS. Studies evaluating the role of CA-specific treatments are warranted in this population.

Impact of different P2Y12 inhibitors in acute coronary syndrome patients with severe chronic kidney disease: insights from the CORALYS registry

Abstract Background The impact of the most potent P2Y12i ticagrelor and prasugrel after acute coronary syndrome in patients with chronic kidney disease (CKD) remains unclear. Most evidence on dual antiplatelet therapy (DAPT) comes from real-world study but is limited to glomerular filtration rate (GFR) under 60 ml/min whereas no data are available regarding patients with severe CKD (stages IV-V) Methods Consecutive patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) and severe CKD defined as GFR under 30 ml/min not on dialysis from the CORALYS (Incidence and Predictors of Heart Failure After Acute Coronary Syndrome) registry were included. Incidence of Net Adverse Clinical Events (NACE) defined as major adverse cardiac events (MACE, a composite of cardiovascular death, myocardial infarction and unplanned revascularizations) in addition to major bleedings (classified as BARC scale 3 to 5) was our primary endpoint. Overall MACE and their single components, all bleedings, major bleedings and hospitalizations for heart failure were the secondary ones. Results Of 14699 patients in the CORALYS registry, 257 presented with severe CKD not on dialysis and had available data on antiplatelet regimen at discharge. Patients were divided into two groups according to the type of P2Y12i prescribed at discharge: 193 (75.1%) were given clopidogrel while 64 (24.9%) with ticagrelor or prasugrel. Our populaiton was predominantly male (153, 59.5%) with an average age 75.8 ± 10.9 years old. Average GFR was 21.8 ± 6.3 ml/min. Over a median follow-up of 459 days, Ticagrelor and Prasugrel were associated to lower rates of NACE compared to Clopidogrel (39.9% vs 25.0%, p=0.036). This was mainly driven by an excess of both CV mortality (31.1% vs 6.3%) and myocardial infarction (20.7% vs 9.4%) reported in the clopidogrel group. No difference was reported regarding overall bleeding events (5.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.81) and major bleedings (1.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.15). At multivariate Cox regression analysis DAPT with Ticagrelor/Prasugrel resulted independently associated with a lower risk of NACE (Adj Hr 0.41, 95%CI 0.23-0.74, p=0.003) whereas left main involvement or multivessel coronary disease led to higher risk of NACE (Adj HR 1.96 95%CI 1.21-3.18, p=0.006) Conclusions In ACS patients treated with PCI with severe CKD ticagrelor and prasugrel were associated to lower risk of NACE, MACE, CV death and myocardial infarction compared to clopidogrel. No significative difference was reported in overall and major bleedings despite a relative increase of major bleedings in the group treated with Ticagrelor or Prasugrel.

Carotid-Femoral pulse wave velocity progression in hypertensive patients is associated with subsequent cardiovascular outcomes

Abstract Background Arterial stiffness (Pulse Wave Velocity - PWV) is associated with CV events and mortality. However, little is known on the relationship of its progression (ΔPWV) over time with CV outcomes. Purpose The aim of our study was to evaluate the relationship between PWV progression and all-cause mortality and CV events in hypertensive subjects. Methods We enrolled 402 consecutive hypertensive outpatients. At baseline anamnestic, clinical, BP, laboratory data and PWV were assessed. We performed a PWV follow-up examination at a median time of 3.7±0.5 years. Patients were subsequently followed for a median time of 10.1 (IQR 9.5 -10.5) years recording all-cause mortality and CV events. Results At baseline the mean age was 53.2±13.0 years, SBP and DBP were 141.8±17.5 and 86.8±10.5 mmHg and PWV was 8.5±1.9 m/s. Despite an improvement in BP control (- 9.2±19.5 and -8.0±12.3 for SBP and DBP respectively), at follow-up the population showed a PWV increase (ΔPWV +0.6±1.9 m/s). Progressors (ΔPWV ≥ 0.5 m/s, 204 patients, 50.7%) had a significantly lower survival probability and higher cumulative incidence of composite events, while no differences were seen for CV events (unadjusted analysis). At cox multivariable analysis neither ΔPWV ≥ 0.5 m/s (progressors) nor ΔPWV (as a spline function) were associated with CV events and with all-cause mortality. However, the association with survival probability and cumulative incidence of CV events, as a composite outcome, was significant (HR = 2.32, 95% CI: 1.33 – 4.04, p=0.003). Conclusions In conclusion, our study shows that PWV progression of at least 0.5 m/s is frequent in hypertensive patients and that it is associated with a significantly higher risk of developing CV events or dying (composite outcome).

Is etiology of severe tricuspid regurgitation related to prognosis?

Abstract Objective Our aim was to assess the prognostic role of the etiology tricuspid valve disease in patients with severe tricuspid regurgitation (TR). Methods Multicenter, observational, and prospective registry in which all patients with severe TR have been consecutively collected within a 6-month period and followed up for one year. Results A total of 1247 patients with severe TR [mean age: 76.7±10.5 years, 876 women (70.2%)] were included: 810 (64.9%) met criteria for severe TR, 301 (24.1%) massive TR, and 136 (11%) torrential TR. The most frequent etiology was functional TR secondary to left-heart disease in 621 patients (49.9%) followed by "atriogenic" TR in 247 (19.8%). TR etiology distribution is described in Figure 1. Death due to refractory HF occurred in 9,2% of patients, hospitalization for HF in 20,8%, and 12,3% underwent TR interventions. In the univariate and multivariate analysis, age, impaired renal function, previous HF admission, and massive and torrential TR were associated with an increased risk of HF hospitalization and cardiovascular mortality. Global (p=0,476) and cardiovascular mortality (p=0,138) rates were similar when comparing different TR etiologies (Figure 2). Conclusion Severe TR is associated with high rates of CV mortality and new HF admission. These findings are and independent from TR etiology.

A new right-heart failure staging system in patients with severe tricuspid regurgitation. Prognostic implications

Abstract Objective Our aim was to describe a new right-heart failure (RHF) staging system in patients with severe tricuspid regurgitation (TR). Methods Multicenter, observational, and prospective registry in which all patients with severe TR have been consecutively collected within a 6-month period, classified according to their clinical condition and right ventricular status, and followed up for one year. Results A total of 1247 patients with severe TR [mean age: 76.7±10.5 years, 876 women (70.2%)] were included: 810 (64.9%) met criteria for severe TR, 301 (24.1%) massive TR, and 136 (11%) torrential TR. A new RHF staging was proposed depending on clinical condition, RV dilation and RV systolic dysfunction (Table). The largest group of patients had a normal right ventricle with signs/symptoms of RHF (41%). Death due to refractory HF occurred in 9,2% of patients, hospitalization for HF in 20,8%, and 12,3% underwent TR interventions. In the multivariate analysis the predictors of CV mortality were age, impaired renal function, previous HF admission, massive and torrential TR and Stages III and IV of the new right-heart failure staging system (figure). Conclusion The new RHF staging system accurately stratifies patients with severe TR into prognostic categories.

The cardiovascular polypill strategy (acetyl salicylic acid, atorvastatin, ramipril) as baseline treatment after a cardiovascular event supported by compelling evidence: a global expert consensus

Abstract Background The SECURE trial demonstrated that the CV-polypill strategy (acetylsalicylic acid [ASA]+atorvastatin+ramipril) reduces CV mortality by 33% in patients with acute myocardial infarction (MI) compared to standard care over 3 years (median). The 2023 ACS ESC Guidelines recommend the polypill strategy to improve outcomes and treatment adherence. The CV-polypill inclusion in the 2023 World Health Organization's essential medicines list signifies its effective and affordable response to a global secondary prevention healthcare requirement. Purpose To reach consensus among medical experts from various countries regarding key implementation aspects of the CV-polypill strategy (ASA+atorvastatin+ramipril) as baseline preventive treatment after a CV event (CVe) in routine clinical practice. Methods A two-round modified Delphi method was employed. A questionnaire consisting of 30 evidence-based statements was developed and validated with input from 8 distinguished cardiologists. The Delphi panel, 50 physicians from 19 countries across Europe, Latin America, and Asia, used a three-point Likert scale to establish their agreement and perceived importance of the statements. Consensus was reached when ≥80% agreed or deemed statements 'very important' or 'important. Statements without consensus in the first round underwent refinement based on evidence and panellists’ feedback in the second round. Persistent disagreements were resolved in a face-to-face meeting with experts. Descriptive statistics were applied. Results 38/50 panellists participated in round 1, and 37/50 in round 2. 31/38 were cardiologists. 28/38 routinely prescribed the CV-polypill strategy. 97.4% of panellists believed that the 24% relative risk reduction in major CVe over 3 years (median), attained with the CV-polypill strategy (ASA+atorvastatin+ramipril) compared to standard care could replicate in clinical practice while maintaining equal safety (97.4%). Unanimous consensus (100%) supported initiating the CV-polypill strategy as baseline preventive treatment upon hospital discharge or at first follow-up. Its efficacy and safety were also acknowledged for stroke (94.7%), peripheral artery disease (92.1%), and both genders (84.2%). 89.5% supported CV-polypill affordability for preventing CHD events and strokes. Algorithms for initiation (97.3%) and transition (97.4%) to the CV-polypill strategy from cardioprotective drugs, considering patient preferences (97.5%), were confirmed. A unanimous consensus (100%) affirmed the positive impact of the simplified CV-polypill treatment on patient satisfaction, with 94.7% recognizing its convenience (Figure 1). Conclusions Skilled medical experts across continents reached consensus on critical implementation aspects and strongly endorse the early use of the CV-polypill strategy (ASA+atorvastatin+ramipril). This adoption aims to reduce CVD recurrence, improve prognosis, and potentially enhance affordability in CVD treatment after a CVe.Consensus on CV polypill implementation

Sinus rhythm restoration as an independent predictor of left ventricular ejection fraction improvement in patients with the first hospitalization for heart failure and reduced ejection fraction

Abstract Background and Purpose Tachycardiomyopathy (TCM) is prevalent in heart failure with reduced ejection fraction (HFrEF). Despite its significance, a comprehensive understanding of its evolutionary trajectory and prognosis remains limited. This study aims to investigate the prognosis and left ventricular ejection fraction (LVEF) trajectory in patients with TCM compared to other etiologies within a cohort initially admitted for "de novo" HFrEF (LVEF &amp;lt; 40%). Methods A prospective registry was conducted across two University Hospitals, incorporating patients hospitalized with a diagnosis of HFrEF. The study encompassed 370 patients admitted between March 2021 and October 2023, with a median follow-up of 15 months (IQR 7-22). Two distinct groups were delineated based on etiology (TCM vs other etiologies). Within the TCM cohort, subgroups were established concerning LVEF improvement, following the criteria outlined in the "Universal Definition and Classification of Heart Failure" report. Categorical variables were presented as absolute frequencies and percentages, analyzed using the chi-square test. Continuous variables were expressed as mean +/- SD and compared through Student's t-test or Mann-Whitney U test. Hazard functions were estimated using the Kaplan-Meier method. Data analysis was executed using SPSS Statistics. Results In our cohort, both TCM and other etiologies groups exhibited improved LVEF post-neurohumoral blockage titration. Nonetheless, the TCM cohort demonstrated notably higher LVEF (49.1% vs. 43.5%, p = 0.005) [Figure 1]. Moreover, overall mortality, cardiovascular mortality, and the composite of CV mortality and hospitalizations for CV causes were notably lower in the TCM group compared to other etiologies [Figure 2]. Among TCM patients, those with improved LVEF during follow-up were younger (66 vs. 72), with no differences in treatment at discharge or after neurohumoral blockage titration. While achieving sinus rhythm before discharge did not correlate with LVEF improvement, attaining sinus rhythm during follow-up (at titration completion) significantly correlated with LVEF improvement [Table 1]. Multivariate analysis revealed that sinus rhythm restoration after up-titration emerged as an independent predictor of LVEF improvement, irrespective of sinus rhythm restoration at discharge or the attainment of quadruple therapy during follow-up, among other variables (Table 2). Conclusions Among patients initially admitted for "de novo" HFrEF, TCM presents a potentially more favorable clinical trajectory compared to other HF causes, showcasing reduced total and cardiovascular mortality, as well as combined cardiovascular mortality and hospitalizations for cardiovascular causes. Notably, in this patient subset, sinus rhythm restoration during follow-up emerged as an independent predictor of improved LVEF, irrespective of pre-discharge sinus rhythm restoration or adherence to comprehensive four-pillar HF management.

Prediction of incident major adverse cardiac events in patients starting haemodialysis for end stage kidney disease, using clinical laboratory cardiac biomarkers - a real world analysis.

Abstract Background and Aims Despite its many advantages, haemodialysis (HD) is associated with increased cardiovascular mortality and morbidity, with some studies reporting 48% higher mortality within 2 years of starting HD. Cardiac biomarkers provide insight into cardiac structure and function, including myocyte stress, inflammation and fibrosis. We aimed to investigate the prognostic significance of routine cardiac biomarkers (troponin and natriuretic peptides) in the prediction of incident major adverse cardiac events (MACE) within 5 years if commencing HD. Methods A retrospective cohort study was performed using electronic medical records from a global federated research network from the US. The network was searched on 26th February 2023. The cohorts commenced HD post-diagnosis of end-stage kidney disease. Data censoring for MACE was invoked prior to the index event of HD. Cardiac biomarkers were the first reported result within 3 months of starting HD. Cohorts were grouped according to biomarker-specific thresholds and 1:1 propensity-score matched for age, gender and co-morbidities (hypertension, diabetes mellitus and smoking status). Logistical regression produced odds ratios with 95%CI for 5-year incident MACE. MACE was defined, a priori, as a composite of ischaemic heart disease, angina pectoris, acute myocardial infarction, heart failure, AF, stroke and all-cause mortality. All statistical analysis was performed on the online platform. Results The results are shown Tables 1(Troponin I and BNP alone) and 2 (Combined Troponin I and BNP). Results that reached statistical significance (p&amp;lt;0.05) are shown. Conclusion Routinely available cardiac biomarkers can predict MACE and cardiac outcomes in incident HD, although results differ between markers of myocyte injury (troponin) and stress (BNP). A combined approach may prove most beneficial. The results suggest the clinical need for CV mortality and morbidity risk profiling in incident dialysis using a combination of clinical and laboratory variables and the need for prospective validation.Table 1Table 2

Association between QT prolongation and cardiovascular mortality in cancer patients

BackgroundCancer patients’ vulnerability to QT prolongation contradicts certain anti-cancer drug usage. Until now, the QT prolongation’s impact on CV mortality in cancer patients remains unclear, potentially biasing therapeutic decisions.MethodsThis retrospective observational cohort included adult cancer patients with an electrocardiogram (ECG) performed in a tertiary hospital in Taiwan. The first performed ECGs after cancer diagnosis (n = 59,568) were analyzed. The corrected QT intervals by Bazett (QTcB), Fridericia (QTcFri), and Framingham (QTcFra) formulae were used to predict the 90-day and one-year CV mortality according to the Taiwan death registry.ResultsThe AUC of QTcB (90 days: 0.70, 1 year: 0.68) for predicting CV mortality was better than QTcFri and QTcFra (90 days: 0.63 and 0.50, 1 year: 0.65 and 0.56). Using the restricted cubic spline regression model adjusted by age and comorbidities, QTcB increased a significant but trivial risk of CV mortality at 90 days (hazard ratio, 1.007, P = 0.02) and one year (1.006, P < 0.01). Compared to those with QTcB < 500ms, the patients with QTcB ≥ 500ms were older and had more comorbidities and mortalities within one year. The incidence of sudden death and ventricular arrhythmias was only 0.2%. After adjusting for comorbidities, QTcB was neither associated with 90-day nor one-year CV mortality. In the patients already with QTcB ≥ 500ms, the patients receiving the unexpected uses of QT-prolonging drugs were not associated with higher one-year CV mortality than those without (P = 0.14).ConclusionsRather than a prolonged QT interval per se, comorbidities contributed to CV mortality and irreversible outcomes in cancer patients.

7184 Type 2 Diabetes As An Independent Risk Factor For Increased Incidence Of Cardiovascular Events In Patient With Nonalcoholic Fatty Liver Disease

Abstract Disclosure: E. Roh: None. K. Son: None. H. Jung: None. J. Huh: None. S. Lee: None. S. Ihm: None. K. Han: None. J. Kang: None. Background: Although coexistence of type 2 diabetes (T2DM) and non-alcoholic fatty liver disease (NAFLD) has been linked to unfavorable metabolic profile and an increasing cardiovascular risk, the impact of T2DM on the risk of developing CVD within the context of NAFLD remains unclear. This study aimed to investigate long-term CVD outcomes in patients with NAFLD according to glycemic status using nationwide cohort of Korean adults. Methods: This retrospective, longitudinal study included 1,057,775 patients with NAFLD, who had participated in the national health screening in 2009 and were followed up until 2020. The baseline glycemic status was divided into three categories [normal fasting glucose (NFG), impaired fasting glucose (IFG) and T2DM]. Cox proportional hazards models were used to assess the association of glycemic status with incident CVD. Results: During a median follow-up period of 10.3 years, 26,491 cases of MI, 55,791 cases of stroke, and 11,147 cases of CV death were identified. After adjusting for possible covariates, participants with T2DM had a higher risk of CVD, with hazard ratios of 1.394 (95% CI 1.351−1.439) for MI and 1.391 (95% CI 1.362−1.420) for stroke, and 1.457 (95% CI 1.392−1.524) for CV mortality, compared to those with NFG. The increased risk of CVD attributable to T2DM was more profound among individuals with fewer conventional CVD risk factos, including younger age, not obese, and the absence of hypertension. Conclusions: These results suggest that the identification of T2DM in individuals of NAFLD may help the prediction of future progression of CVD. Presentation: 6/3/2024

Heart rate response and recovery in cycle exercise testing - normal values and association with mortality.

Chronotropic incompetence and impaired heart rate (HR) recovery are related to mortality. Guidelines lack specific reference values for HR recovery. We defined normal values and studied blunted HR response and recovery, and mortality risk. We included 9,917 subjects (45% females) aged 18-85 years who performed a cycle exercise test. We defined normal values for peak HR, HR reserve, and HR recovery at 1 and 2 minutes (HRR1 and HRR2) based on individuals apparently healthy (N=2,242). Associations between blunted HR indices (<5th percentile) and mortality over a median follow-up of 8.6 years were analysed using Cox regression and competing risk analysis. All HR indices were age-dependent and independent predictors of all-cause and CV mortality. The 5th percentiles of HR reserve, HRR1, and HRR2 correlated weakly with existing reference values. HR recovery variables were the strongest predictors of all-cause mortality (HRR1, hazard ratio 1.70 [95% confidence interval, 1.49-1.94] and HRR2, 1.57 [1.37-1.79]), including in subjects with normal exercise capacity (HRR1, 1.96 [1.61-2.39] and HRR2, 1.76 [1.46-2.12]). Combining HR indices appeared to increase the risk of all-cause (HRR1 and HRR2, 1.96 [1.68-2.29] and peak HR and HRR1, 1.87 [1.56-2.23]) and CV mortality, although no specific combination was superior for predicting CV mortality. All HR variables were age-dependent and associated with all-cause and CV mortality. Blunted HR recovery variables were the strongest predictors of all-cause mortality, even in subjects with normal exercise capacity. Combined blunted HR indices appeared to add prognostic value.