Euro Heart Survey Research Articles

Retrospective Evaluation of In-Hospital and Thirty-Month Mortality Parameters in Cases of Acute Coronary Syndrome

Objectives: The aim of this study is to retrospectively assess, from the hospital records of patients, the clinical data of patients and the treatment strategies practiced on patients who were diagnosed as Acute Coronary Syndrome (ACS) and hospitalized and treated in the Hospital of Faculty of Medicine to research the effect of these data on occurrence of cardiovascular events and 30 months mortality. 
 Methods: It is a retrospective screening study in which patients hospitalized with the diagnosis of ACS between June 2007 and December 2008 in the Hospital of Faculty of Medicine Cardiology Clinic are evaluated by using patient file information and electronic data recording system information, and by calling patients. In-hospital and long-term follow-up deaths were the endpoints of the study. Statistical analysis was performed using SPSS (Version 15.0).
 Results: 985 patients were included in the study who were diagnosed as ACS, hospitalized and treated in the hospital. The categorization of the patients subjected to the analysis (n:901) according to their diagnosis is as follows: 339 (38%) cases diagnosed as UAP, 206 (23%) cases diagnosed as NSTEMI, and 356 (39%) cases diagnosed as STEMI. 78,4 % of cases were male while 21,6 % were female. It was found that cases with hypertension, hyperlipidemia, obesity risk factor, and with a history of cardiovascular disease fall into the NSTEMI and UAP groups with a larger proportion. Among the groups, the UAP diagnosed cases have the largest and the STEMI diagnosed cases have the smallest ratio of using medicine groups such as beta blocker, calcium-canal blocker, ACE inhibitor, ARB, diuretic, statin, fibrate and nitrate before being hospitalized. In-hospital mortality was frequently encountered with a percentage of 7.6 % in STEMI cases, 2.4 % in NSTEMI cases, and 0.6 % in UAP cases. 30-months of follow-up data were obtained in all diagnosis groups for long-term mortality assessment. 70 (7.8 %) deaths were observed within the follow-up. According to diagnosis groups, death was observed in 22 (6.5 %) of UAP cases, 22 (10.7 %) of NSTEMI cases, and 26 (7.3 %) of STEMI cases. Correlation between long-term survival (30 months) and in-hospital statin usage and statin usage in discharge was not significant (p value respectively 0.1 and 0.16). Correlation between an approximate 30-months-survival and in-hospital ACE inhibitor/ARB inhibitor usage and ACE inhibitor/ARB inhibitor usage during discharge was significant (p = 0.007 and p = 0.004). It is also found that there was a significant correlation between survival in the same period of time and in-hospital beta blocker usage (p = 0.01). There was not a significant correlation between beta blocker usage during discharge and long-term survival (p = 0.779). 
 Conclusion: Results of the unicentral retrospective scanning study which involves 901 ACS diagnosed patients prove to be similar to the ones obtained from GRACE and Euro Heart Survey prospective studies which were carried out in multi-central environment and among outnumbered patients.

TO DRAIN OR NOT TO DRAIN: A THERAPEUTIC CONUNDRUM IN A PATIENT WITH PERICARDIAL TAMPONADE AND EISENMENGER SYNDROME

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: PAH is diagnosed when mean pulmonary artery pressure is greater or equal to 20 mmHg at rest with a pulmonary vascular resistance =3 Wood units. In regions without endemic schistosomiasis, it is commonly idiopathic (1). Eisenmenger syndrome (ES) is the most advanced form of pulmonary arterial hypertension (PAH) and is associated with several congenital heart defects such as ASDS, VSDS etc. CASE PRESENTATION: We present the case of a 30-year-old patient with a past medical history of Trisomy-21, unrestricted ventricular septal defect (VSD) complicated by Eisenmenger Syndrome, PAH (On Treprostinil and Bosentan), chronic hypoxia and Hashimoto's Thyroiditis, who presented from his group home for acute on chronic shortness of breath and fever. Initially, he was hypoxic and hypotensive with signs of severe volume overload on physical exam. Oxygen saturations improved mildly on high flow nasal cannula (HFNC). CT chest and bedside echocardiogram showed a massive pericardial effusion (4.5 cm at the largest point) with tamponade physiology, and pulsus paradoxus (Figure 1,2,3). He was started on vasopressors, inotropes, intravenous prostacyclin and inhaled epoprostenol. Extracorporeal membrane oxygen (ECMO) was planned to stabilize him and drain the effusion, but the family refused ECMO. A Swanz Ganz catheter was placed under fluoroscopic guidance to help guide management but it crossed the VSD and inadvertently ended up in the aorta after which it was removed. After multiple discussions with adult congenital heart disease experts, it was decided that draining the pericardial effusion was not an option given the concern for acute right ventricular failure which could precipitate hemodynamic collapse and cardiac arrest. Another concern was bleeding complications especially bleeding into the pericardial cavity from inadvertently puncturing the multiple collateral vessels that such patients develop. The patient gradually developed increasing vasopressor requirements and eventually passed away. DISCUSSION: A pericardial effusion develops when fluid accumulates between the two layers of pericardium. In PAH, it may develop due to elevated right atrial pressures or underlying connective tissue disease. Its presence in PAH is associated with a significantly increased risk of death and the decision to drain such an effusion remains highly controversial. Multiple studies have reported dismal prognosis of patients who have had such effusions drained (2). The Euro heart survey reported that mortality was particularly high in patients with Eisenmenger's, and they had an increased frequency of major bleeding events as well (2). CONCLUSIONS: Pericardial effusion drainage in patients with pulmonary arterial hypertension is controversial and is associated with poor outcomes. Mortality is particularly high in patients with Eisenmenger's, and a multidisciplinary approach should be utilized to manage such patients. REFERENCE #1: Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2019;53(1):1801913. REFERENCE #2: Engelfriet PM, Duffels MG, Möller T, et al. Pulmonary arterial hypertension in adults born with a heart septal defect: the Euro Heart Survey on adult congenital heart disease. Heart. 2007;93(6):682-687. DISCLOSURES: No relevant relationships by Saad Farooq, source=Web Response No relevant relationships by ELLIOT SULTANIK, source=Web Response No relevant relationships by Guy Weigold, source=Web Response No relevant relationships by Omar Yacob, source=Web Response

Heart Valve Critical Pathway and Heart Valve Clinic: Novel Benchmarks for Modern Management of Valvular Heart Disease.

The growing burden of valvular heart disease in Western countries represents a challenge for the daily clinical practice, especially in the light of the ever-increasing number of therapeutic options. The Euro Heart Survey showed that, among elderly subjects with severe, symptomatic valve dysfunction, surgery is denied for 33% of patients with aortic stenosis and for 50% of patients with mitral regurgitation. Current management (from diagnosis to follow-up) is often fragmented in multiple-sometimes unnecessary-steps. Such a "patchy" approach may translate into a suboptimal management, especially in the geriatric population. New healthcare models exist that can coordinate care, reduce fragmentation, limit costs and, ultimately, improve outcomes: the clinical pathways.

Atrial Fibrillation

Atrial fibrillation (AF) is an abnormal rhythm characterized by chaotic atrial electrical activity resulting in loss of atrial contraction, an irregular and unpredictable heart rate, and a tendency for thrombus formation. The prevalence of AF is estimated at 1 to 2%, but it’s likely higher than that because one-third of patients may have no symptoms and might never seek medical attention. Data suggest that 1 in 4 people over the age of 40 will develop AF in their lifetime. About 10% of patients over age 80 have experienced the arrhythmia, and some estimates predict the prevalence will double in the next 50 years. This chapter discusses the pathophysiology, genetics, diagnosis, classification, and treatment of AF. Figures show atrial fibrillation and coarse atrial fibrillation plus common right atrial flutter. One algorithm is for oral anticoagulation therapy, and a second shows a recommended hierarchical choice of antiarrhythmic therapies versus catheter ablation for recurrent symptomatic atrial fibrillation. Tables list classification, diagnostic evaluation of, clinical consequences of, and conditions often associated with atrial fibrillation. Three scoring systems are included: 1) for congestive heart failure, hypertension, diabetes, stroke, and transient ischemic attack; 2) to assess the risk of bleeding with oral anticoagulation, and 3) data and proportion of patients from the Euro Heart Survey. Other tables include long-term anticoagulation guidelines for atrial fibrillation, intravenous drugs used for acute rate control, oral drugs used for chronic rate control, and antiarrhythmic drugs for conversion of atrial fibrillation and/or maintenance of sinus rhythm. In addition, there’s a summary of randomized trials weighing rate control and rhythm control strategies, plus schemes for categorizing thromboembolism risk. This review contains 4 highly rendered figures, 14 tables, and 129 references.

What should the C ('congestive heart failure') represent in the CHA2 DS2 -VASc score?

What should the C ('congestive heart failure') represent in the CHA2 DS2 -VASc score?

The Euro Heart Survey and EURObservational Research Programme (EORP) in atrial fibrillation registries: contribution to epidemiology, clinical management and therapy of atrial fibrillation patients over the last 20years.

Management of atrial fibrillation (AF) may be challenging in clinical practice. Given the complexity of AF patients and the continuous advances in AF clinical management, there is a need for standardized programmes aimed at collecting so-called 'real-world clinical practice data' regarding the epidemiology, diagnostic/therapeutic/management practices and assessing adherence to guidelines. Over the past 20years, the number of registries and surveys based on real-world AF patients has been dramatically increased. In Europe, based on the Euro Heart Survey (EHS) and the EURObservational Research Programme (EORP), a large series of studies based on these prospective, observational, large-scale multicentre registries on AF have been published. This narrative review gives an overview of these two projects on AF led by the European Society of Cardiology, focusing mainly on the contribution that these studies have provided to AF management and patient outcomes. Both the EHS and the EORP registries have collected a large amount of data regarding contemporary clinical practice, and despite some limitations, mainly related to their observational nature, these registries have contributed to our knowledge and clinical management of AF patients.

P193 The value of 12-lead electrocardiogram in secundum atrial defect with pulmonary hypertension

Abstract Background Pulmonary hypertension is a serious complication that can develop in patients with secundum Atrial Septal Defect (ASD) and based on Euro Heart Survey, 24,77% of ASD patients develop PH. The gold-standard for the diagnosis of pulmonary hypertension in ASD is right heart catheterization. However, in low-middle income country like Indonesia, right heart catheterization only available in a few centers while Indonesia is often referred as the world’s largest archipelago. Thus, there is a huge number of undiagnosed and untreated patients with ASD-PH in Indonesia, especially in patients who lives in rural and isolated area. This research was initiated to investigate the diagnostic value of simple 12-lead ECG in the diagnosis of pulmonary hypertension in ASD with the intention to help doctors in isolated area. Method We performed a cross-sectional study analyzing the 12-lead ECG and mean arterial pressure collected from right heart catheterization from 120 patients with secundum ASD aged > 18 years old. The 12-lead ECG collected within 24 hours before RHC procedure. Results We analyzed the ECG and RHC from 60 subjects diagnosed with pulmonary hypertension and 60 subjects without pulmonary hypertension. We found that R in lead V1 + S in lead V6> 12,5 mV, right axis deviation (RAD), and RV strain were independent predictors of pulmonary hypertension in secundum ASD. Based on Receiver Operator Characteristics (ROC), we obtained that R in V1 + S in V6> 12,5 mm, right axis deviation (RAD), and RV strain has an Area Under of Curve (AUC) of 80,8%, 70,5%, and 85,6% respectively. We developed a scoring system and a score of >5 have a sensitivity of 90%, specificity of 84,4%, positive predictive value of 84,4%, negative predictive value of 90%, and accuracy of 87,1%. We also developed a predictor for pulmonary vascular disease (low flow and high resistance PH) to predict wether the defect can be closed. We obtained that R in V6 + S in V6 > 27,5 mm can predict a low flow high resistance pulmonary hypertension in secundum ASD with an AUC of 77,1% (CI 95% 58-96,1%) Conclusion ECG score of 12-lead ECG derived from this study can be used to predict PH in secundum ASD. It may help cardiologists or general practitioners in rural and isolated area to diagnose pulmonary hypertension in ASD and plan the best management for the patients.

New perspectives by imaging modalities for an old illness: Rheumatic mitral stenosis.

Mitral stenosis (MS) is a progressive and devastating disease and most often occurs among young women. Given its considerable prevalence in Mediterranean and Eastern European countries according to the Euro Heart Survey, new imaging modalities are warranted to improve the management of patients with this condition. A wide spectrum of abnormalities occurs involving all parts of this complex structure and causing different grades of MS and/or regurgitation as a consequence of rheumatic affection. Novel imaging modalities significantly improved the assessment of several aspects of this rheumatic destructive process including the morphological alterations of the mitral valve (MV) apparatus, left atrial (LA) function, LA appendage, right and left ventricular (LV) functions, and complications, namely, atrial fibrillation and thromboembolic events. Furthermore, new imaging modalities improved the prediction of outcome of patients who underwent percutaneous balloon mitral comissurotomy and changed the paradigm of patient selection for intervention and risk stratification. The present review aimed to summarize the role of new multimodality, multiparametric imaging approaches to assess the morphological characteristics of the rheumatic MS and its associated complications, and to guide patient management.

TGF-β Signaling Promotes Tissue Formation during Cardiac Valve Regeneration in Adult Zebrafish

Cardiac valve disease can lead to severe cardiac dysfunction and is thus a frequent cause of morbidity and mortality. Its main treatment is valve replacement, which is currently greatly limited by the poor recellularization and tissue formation potential of the implanted valves. As we still lack suitable animal models to identify modulators of these processes, here we used adult zebrafish and found that, upon valve decellularization, they initiate a rapid regenerative program that leads to the formation of new functional valves. After injury, endothelial and kidney marrow-derived cells undergo cell cycle re-entry and differentiate into new extracellular matrix-secreting valve cells. The TGF-β signaling pathway promotes the regenerative process by enhancing progenitor cell proliferation as well as valve cell differentiation. These findings reveal a key role for TGF-β signaling in cardiac valve regeneration and establish the zebrafish as a model to identify and test factors promoting cardiac valve recellularization and growth.

The "Heart Valve Clinic" Pathway for the Management of Frail Patients With Valvular Heart Disease: From "One for All" to "All for One".

Valvular heart disease (VHD) is frequently diagnosed in old patients with clinical evidence of heart failure. This elderly population typically presents a high prevalence of frailty and comorbidities, which are associated with increased operative risk for surgical and percutaneous procedures. Recently, the Euro Heart Survey reported a clear gap between treatment guidelines and their application in the "real world". A more realistic approach to the treatment of older VHD patients treatment, mostly if associated with heart failure, is advocated. A multidisciplinary approach, as obtained with the Heart Valve Clinic methodology (intended to put the patient in the "center" of the scene and the specialists "around him"), has been applied in a group of 79 patients, aged >70 years, with symptomatic VHD, divided in 2 groups according to their frailty status (58 robust and 21 frail). No in-hospital mortality and no difference in late mortality and complications were observed. Infections were more frequent (14.3 vs. 1.7 %; P = 0.02) in frail patients. In patients with postoperative complications, serum levels of interleukin 6 (67.6 vs. 49.6; P = 0.01) and of CAF (C-terminal agrin fragment) as sarcopenia marker (67.9 vs. 62.0; P = 0.04) were higher than that in uncomplicated patients. This study was designed to determine the outcomes of the multidimensional geriatric assessment in the management of older patients with heart failure eligible for heart valve surgery. Geriatric assessment and measurement of inflammatory and sarcopenia markers may represent valid tools for a more realistic evaluation of elderly patients with VHD.

DIAGNOSTIC PITFALLS IN THE ASSESSMENT OF MULTIVALVULAR DISEASE

Multivalvular disease (MVD) is observed in 20% of patients with native valves per the EuroHeart Survey. Concurrent aortic and mitral valve disease is the most common MVD and when present, warrants careful evaluation given the implications for dual valve intervention. A 76-year-old female was

Incidence and outcome of peri-procedural cardiogenic shock: results from the international Euro Heart Survey PCI registry.

There is a large body of literature on acute myocardial infarction complicated by cardiogenic shock. However, very little is known about patients who are initially haemodynamically stable and develop cardiogenic shock during percutaneous coronary intervention. A total of 47,407 consecutive patients were prospectively enrolled in the PCI Registry of the Euro Heart Survey Programme. We analysed interventions with peri-procedural complications that were classified as 'shock induced by procedure' on the case report form. Clinical and procedural characteristics as well as hospital outcomes of haemodynamically stable patients who developed cardiogenic shock during percutaneous coronary intervention were evaluated. Patients with haemodynamic instability at presentation prior to intervention were excluded. A total of 68 patients (0.2%) developed cardiogenic shock as a complication of percutaneous coronary intervention. The majority of cases comprised acute coronary syndrome (60.3%) with complex lesions (93.1%). Most patients had multi-vessel disease (82.1%) and an ejection fraction less than 40% (58.1%). In the multivariate analysis, left main disease (odds ratio (OR) 9.51), ST-segment elevation myocardial infarction (OR 5.31) and multi-vessel disease without left main involvement (OR 3.32) were the strongest independent predictors of peri-procedural cardiogenic shock. Among these patients procedural success was low (66.1%) and in-hospital mortality was very high (39.7%). In this real-world registry the rate of haemodynamically stable patients who developed cardiogenic shock during percutaneous coronary intervention was very low. Patients at a priori high risk were more likely to be affected by this complication. The in-hospital mortality rate of these patients was very high.

Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: A comparison between EORP-AF pilot and EHS-AF registries

BackgroundIn 2002, the European Society of Cardiology conducted the Euro Heart Survey (EHS), while in 2014concluded 1-year follow-up of the EURObservational Research Programme AF (EORP-AF) Pilot Registry. MethodsWe analysed differences in clinical profiles, therapeutic approaches and outcomes between these two cohorts after propensity score matching (PSM). ResultsAfter PSM, 5206 patients were analysed. In EORP-AF there were more elderly patients than EHS (p < .001). EORP-AF patients were more burdened with cardiovascular (CV) and non-CV comorbidities, with a higher proportion of patients with high thromboembolic risk. EORP-AF patients used more oral-anticoagulant (OAC) (p < .001).At 1-year follow-up EORP-AF patients had lower risk for thromboembolic and CV events, readmission for AF and other CV reasons (all p < .001), showing conversely a higher risk for CV death (p = .015). Kaplan-Meier curves showed that EORP-AF patients had higher risk for CV death (p < .0001) and all-cause death (p = .0019). Cox regression confirmed that EORP-AF patients were at higher risk for CV death (p = .021). ConclusionsWe found significant changes in AF epidemiology over a decade in Europe, with older patients, more burdened with comorbidities. A greater use of OAC was found. Despite a reduction in risk for thromboembolic events, a high risk of CV-related death was still evident.

Effect of Systemic Hypertension With Versus Without Left Ventricular Hypertrophy on the Progression of Atrial Fibrillation (from the Euro Heart Survey)

Hypertension is a risk factor for both progression of atrial fibrillation (AF) and development of AF-related complications, that is major adverse cardiac and cerebrovascular events (MACCE). It is unknown whether left ventricular hypertrophy (LVH) as a consequence of hypertension is also a risk factor for both these end points. We aimed to assess this in low-risk AF patients, also assessing gender-related differences. We included 799 patients from the Euro Heart Survey with nonvalvular AF and a baseline echocardiogram. Patients with and without hypertension were included. End points after 1 year were occurrence of AF progression, that is paroxysmal AF becoming persistent and/or permanent AF, and MACCE. Echocardiographic LVH was present in 33% of 379 hypertensive patients. AF progression after 1 year occurred in 10.2% of 373 patients with rhythm follow-up. In hypertensive patients with LVH, AF progression occurred more frequently as compared with hypertensive patients without LVH (23.3% vs 8.8%, p = 0.011). In hypertensive AF patients, LVH was the most important multivariably adjusted determinant of AF progression on multivariable logistic regression (odds ratio 4.84, 95% confidence interval 1.70 to 13.78, p = 0.003). This effect was only seen in male patients (27.5% vs 5.8%, p = 0.002), while in female hypertensive patients, no differences were found in AF progression rates regarding the presence or absence of LVH (15.2% vs 15.0%, p = 0.999). No differences were seen in MACCE for hypertensive patients with and without LVH. In conclusion, in men with hypertension, LVH is associated with AF progression. This association seems to be absent in hypertensive women.

Management of Acute Coronary Syndromes

Management of Acute Coronary Syndromes

Guerra F, et al. Symptomatic atrial fibrillation and risk of cardiovascular events: data from the Euro Heart Survey.

Guerra F, et al. Symptomatic atrial fibrillation and risk of cardiovascular events: data from the Euro Heart Survey.

5769Changes in thromboembolic risk profile and antithrombotic therapy use over a decade: a comparison of Euro Heart Survey on AF and EURObservational research programme AF pilot registry

5769Changes in thromboembolic risk profile and antithrombotic therapy use over a decade: a comparison of Euro Heart Survey on AF and EURObservational research programme AF pilot registry

The influence of progression of atrial fibrillation on quality of life: a report from the Euro Heart Survey.

Progression of atrial fibrillation (AF) from paroxysmal to persistent forms is an active field of research. The influence of AF progression on health related quality of life (HRQoL) is currently unknown. We aimed to assess the influence of AF progression on HRQoL, and whether this association is mediated through symptoms, treatment, and major adverse events. In the Euro Heart Survey, 967 patients were included with paroxysmal AF who filled out EuroQoL-5D at baseline and at 1 year follow-up. Those who progressed (n = 132, 13.6%) developed more problems during follow-up than those who did not, on all EuroQoL-5D domains (increase in problems on mobility 20.5% vs. 11.4%; self-care 12.9% vs. 6.2%; usual activities 23.5% vs. 14.0%; pain/discomfort 20.5% vs. 13.7%; and anxiety/depression 22.7% vs. 15.7%; all P < 0.05), leading to a decrease in utility [baseline 0.744 ± 0.26, follow-up 0.674 ± 0.36; difference -0.07 (95% CI [-0.126,-0.013], P = 0.02)]. Multivariate analysis showed that the effect of progression on utility is mediated by a large effect of adverse events [stroke (-0.27 (95% CI [-0.43,-0.11]); P = 0.001], heart failure [-0.12 (95% CI [-0.20,-0.05]); P = 0.001], malignancy (-0.31 (95% CI [-0.56,-0.05]); P = 0.02] or implantation of an implantable cardiac defibrillator [-0.12 (95% CI [-0.23,-0.02]); P = 0.03)], as well as symptomatic AF [-0.04 (95% CI [-0.08,-0.01]); P = 0.008]. AF progression is associated with a decrease in HRQoL. However, multivariate analysis revealed that AF progression itself does not have a negative effect on HRQoL, but that this effect can be attributed to a minor effect of the associated symptoms and a major effect of associated adverse events.

Symptomatic atrial fibrillation and risk of cardiovascular events: data from the Euro Heart Survey.

Atrial fibrillation (AF) is associated with a wide range of clinical presentations. Whether and how AF symptoms can affect prognosis is still unclear. Aims of the present analysis were to investigate potential predictors of symptomatic AF and to determine if symptoms are associated with higher incidence of cardiovascular (CV) events at 1-year follow-up. The Euro Heart Survey on Atrial Fibrillation included 3607 consecutive patients with documented AF and available follow-up regarding symptoms status. Patients found symptomatic at baseline were classified into still symptomatic (SS group; n = 896) and asymptomatic (SA; n = 1556) at 1 year. Similarly, asymptomatic patients at baseline were classified into still asymptomatic (AA group; n = 903) and symptomatic (AS group; n = 252) at 1 year. Demographics, as well as clinical variables and medical treatments, were tested as potential predictors of symptoms persistence/development at 1-year. We also compared CV events between SS and SA groups, and AS and AA groups at 1-year follow-up. Both persistence and development of AF symptoms were associated with an increased risk of CV hospitalization, stroke, heart failure worsening, and thrombo-embolism. AF type, hypothyroidism, chronic heart failure, and chronic obstructive pulmonary disease (COPD), were independently associated with an increased risk of symptomatic status at 1-year follow-up between SS and SA groups. Persistence or development of symptoms after medical treatment are associated with an increased risk of CV events during a 1-year follow-up. Type of AF, along with hypothyroidism, COPD and chronic heart failure are significantly associated with symptoms persistence despite medical treatment.

P283The influence of progression of atrial fibrillation on quality of life: a report from the euro heart survey

P283The influence of progression of atrial fibrillation on quality of life: a report from the euro heart survey