Higher BNP Levels Research Articles

Prognostic Value of Serum BNP in Patients with NSTEMI and Its Correlation with Extent of Coronary Artery Disease

Background: BNP biomarker is found to have positive correlation to coronary artery disease (CAD). So it may have diagnostic and prognostic value. The aim to predict the prognostic value of serum BNP level as biomarker and the severity of CAD in NSTEMI with normal left ventricular systolic function, as regards both SYNTAX score and GRACE score. Methods: We enrolled patients with NSTEMI and normal LV systolic function (LV EF ≥50%). Grace score was calculated. All patient underwent BNP analysis, echocardiography and coronary angiography within 24 to 72 hours of admission. SYNTAX score was calculated.Results: Sixty-four patients with NSTEMI with mean GRACE score 140.41 ±28.5 and mean SYNTAX score 17.39 ±9.8 were enrolled. BNP level was 135.17 ±37.9ng/dL. According to the level of serum BNP, Patients were divided into 2 groups, first group with high BNP (>80 ng/dl) and second group with low serum BNP level. The results show significant differences between both groups regarding GRACE score (p =0.001) and SYNTAX score (p =0.001).Also there were significant positive correlations between BNP and age (p =0.001), Grace score (p =0.001), and SYNTAX score (p =0.001). At a cutoff of 141pg/dL, the BNP yielded a sensitivity of 83% and specificity of 75% for prediction of SYNTAX score of more than 32.Conclusion: Serum BNP level as abiomarker provides independent prognostic value in NSTEMI patients. Patients with high serum BNP level were more likely to have higher GRACE and SYNTAX scores. Serum BNP level had a good diagnostic accuracy in predicting SYNTAX score.

Comparison of Efficacy of Oral and Intravenous Iron Replacement Therapy in Children with Systolic Heart Failure and Iron Deficiency

Purpose Iron deficiency (ID) is associated with increased risk of ventricular assist device implantation, transplant, or death in children with systolic heart failure (HF). Oral iron replacement is standard therapy for ID. However retrospective studies in children with HF estimate its efficacy at ∼50%. There are no data comparing the efficacy of oral and intravenous (IV) iron therapy in children with systolic HF. Methods In July 2019, we instituted a screening and treatment protocol for ID in children with systolic HF. We performed a retrospective analysis of patients who were screened with this protocol between 07/2019 and 10/2020. ID was defined as the presence of ≥2 of the following 4 criteria on serum iron testing: iron 300 ng/mL, transferrin saturation Results Forty patients with systolic HF (21 male, median age 4.5 years, 28 cardiomyopathy and 12 congenital heart disease) met inclusion criteria. Nine received oral iron while 31 received IV iron. Post-therapy iron studies were available for 6/9 of the oral iron cohort and 28/31 of the IV iron cohort. The oral and IV iron cohorts were similar in terms of demographics, etiology or chronicity of HF, renal dysfunction, and mechanical ventilation. Pre-treatment serum BNP was higher in the IV iron cohort (median 1092 vs 55, p = 0.028) compared to the oral iron cohort. At 3 months, iron therapy was effective in 50% (3/6) of the oral iron cohort, compared to 86% (24/28) of those on IV iron (p = 0.086). By 6 months, ID was effectively treated in 50% (3/6) of patients on oral iron, compared to 89% (25/28) of patients on IV iron (p = 0.053). Demographics, etiology or chronicity of HF, BNP, renal dysfunction, and mechanical ventilation were not associated with efficacy of iron therapy at 3 or 6 months. Conclusion IV iron tended to be more effective than oral iron in treating ID in children with systolic HF, despite the IV iron cohort having higher BNP levels and being presumably sicker. This is the first pediatric data on the topic, although statistical significance was limited by small sample size. Larger studies are needed to guide effective therapy for ID in children with systolic HF.

Incidence and Clinical Findings Associated to Incomplete Hemodynamic Unloading of the Left Ventricle under LVAD Support

Purpose Normalization of hemodynamics plays an important role in achieving an optimal clinical benefit after LVAD Implantation. However the hemodynamic optimization during follow-up continues to be a challenge. We assessed the likelihood of effective hemodynamic unloading of the Left ventricle (HLVU) during LVAD support, when the current standard recommendations for LVAD speed optimization were applied in the clinical practice, and its association with different clinical and echocardiographic (TTE) conditions. Methods Retrospective study that included consecutive patients who had primary received an LVAD as bridge to heart transplantation (BTT) and underwent a right-side catheterization (RHC) at least 3 months after the LVAD implantation as part of the screening process for BTT candidacy.Routinely ambulatory follow-up consisted in clinical, TTE and hematological examination.LVAD rotor speed was optimized during each follow-up visit according to the current clinical recommendations. Results 104 p (87% male, 55+/-6 years, 42% HeartWare LVAD, 58% HM3 LVAD) were studied. Incomplete HLVU was defined if the pulmonary capillary wedge pressure was above 15 mmHg (hPCWP), and it was present in 29 p (28%). Patients with hPCWP were older, had worse postoperative renal function, higher BNP levels, received fewer renin-angiotensin-Aldosteron blocking agents(RAB) and required higher dose of diuretics (p 300 pg/dl could predict hPCWP with 78% accuracy, 74% specificity and a 78% sensitivity (p Conclusion An incomplete HLVU under LVAD support is common in the clinical practice, when the current standard recommendations are applied. Our study highlights the negative effect of age and renal dysfunction in the likehood of effective HLVU and the potential contribution of the RAB to achieve this goal.The BNP levels and the magnitude of the echocardiographic reverse LV remodeling seem to be useful non-invasive tools to evaluate the degree of effective LV unloading during follow-up.

Predictive capacity of the brain natriuretic peptide in the screening of heart failure in a high altitude population

BackgroundHeart failure (HF) is growing in importance as a significant cause of disease and mortality. When It is suspected, it can be ruled out if BNP values are below 100 pg/mL. Diagnostic certainty can be obtained if echocardiogram shows reduced ejection fraction, diastolic dysfunction or right-sided heart disease. Physiological changes at high altitude are known to affect BNP values. This study pretends to evaluate BNP values when used for HF diagnosis in Huancayo, Perú, a high altitude population located at 3,250 m above sea level. MethodsThis is a cross-sectional, diagnostic test type study. A total of 83 medical charts of patients with suspected HF, admitted to the Emergency Room and Internal Medicine Service of Ramiro Prialé Prialé National Hospital, were reviewed. Data processing was performed with SPSS program for Windows version 21.0. Pearson's Chi Square test was used for categorical variables analysis and ANOVA for continuos variables. P values under 0.05 were considered significant. Results and conclusionsMedium age was 74 years. Patient’s characteristics that were associated with confirmed HF and high BNP levels were the following: presence of fatigue, night cough, elevated heart rate, shortness of breath, history of lung fibrosis and decreased oxygen arterial saturation (p < 0.05) Pulmonary hypertension, mitral and tricuspid regurgitation, and cor pulmonale were also associated with higher BNP levels. Most subjects had BNP values >100 pg/mL, with low specificity for HF diagnosis (11.5 %). Individuals without heart failure had mean BNP values above 300 pg/mL; while individuals with cor pulmonale had a mean of 975 pg/mL. BNP values were high in patients with or without HF. A cut-off point of ≥130pg/mL is proposed to increase specificity. The predictive capacity of BNP for HF identification at this high altitude population is low because of a high number of false positive results.

Association of high BNP level with heart failure in patients presenting with STEMI.

Objective: The objective of this study is to to determine the association of high BNP level with heart failure in patients presenting with STEMI. Study Design: Cohort Study. Setting: Department of Cardiology, Punjab Institute of Cardiology, Lahore. Period: 01 January 2017 to 30 June 2017. Material &amp; Methods: After meeting the inclusion criteria 150 patients were enrolled. Informed consent and demographic information was taken. Then patients divided in two groups, high and normal BNP groups. Then patients were admitted in cardiology wards and were followed-up there for 5 days. Patients evaluated for symptoms of heart failure and underwent echocardiography for confirmation of presence or absence of heart failure. All the collected data was entered and analyzed on SPSS version 21. Results: In this study the mean age high BNP group was 48.87± 10.18 years while the mean age in normal BNP group was 48.99±12.15 years. Male to female ratio of the patients was 2:1. The heart failure occurred in 19(12.67%) patients. There is 1.58 times higher risk of heart failure in high BNP than normal BNP i.e. RR=1.58[1.14-2.19]. Conclusion: This present study concluded that high BNP level is strongly associated with heart failure in patients presenting with STEMI.

Early surveillance of anthracycline induced cardiotoxicity in children using echocardiography and biomarkers: A prospective study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR Background Anthracyclines, which are commonly used in cancer treatment can induce myocardial damage, result in heart failure during treatment and have cardiac effects even decades after treatment. Monitoring of cardiotoxicity during treatment is largely based on the use of echocardiographic functional markers like ejection fraction and more recently myocardial strain imaging. Some studies have also looked at the utility of biomarkers like troponin and BNP. The utility of this surveillance strategy remains controversial as larger prospective studies are lacking. Purpose The aim of this study was to prospectively describe the impact of anthracycline treatment on echocardiographic functional parameters and cardiac biomarkers (high sensitivity troponin T and NT-Pro BNP) during the treatment period and twelve months after completion of treatment. In the current study we wanted to look at whether monitoring parameters during treatment were predictive of left ventricular function 12 months after treatment. Methods This was a prospective multi-centre nested case-control study of 256 children diagnosed with cancer requiring anthracycline therapy. Baseline functional echocardiographic parameters and cardiac biomarkers were obtained prior to starting anthracycline therapy, during the treatment protocol, and 12 months after treatment completion. Patients were assigned to one of two comparison groups based on the fractional shortening at the12-month echocardiogram: patients in group 1 had normal fractional shortening, (FS ³ 28%) while patients in group 2 had reduced fractional shortening (FS &amp;lt; 28%). Results A total of 917 echoes were performed, 376 of these occurred during the treatment period. FS was reduced in 27 (7%) of echoes obtained during the treatment period with 22 patients developing new onset dysfunction. Twelve months after treatment completion 232 patients had normal FS (Group 1), while 24 patients showed reduced FS (Group 2). Both groups had normal systolic function and cardiac biomarkers at baseline, however patients in group 2 were older at diagnosis (13.2 years (11.8-16) vs 6.5 years (3.4-13.2), p = 0.003) and received a higher cumulative anthracycline dose (200 mg/m2 (143-318) vs 125 mg/m2 (75-200), p= 0.005). One third (8/24) of patients in group 2 had at least 1 abnormal echo during the treatment period compared to 7% (16/232) in the normal group P &amp;lt; 0.001. The proportion of patients with at least one abnormal biomarker during this period however, was similar between groups. Conclusion(s) Patients receiving higher accumulative anthracycline doses and those with abnormal FS during the treatment period are at higher risk of having reduced cardiac function 12 months after treatment. High sensitivity troponin and NT-Pro BNP levels during the treatment period fail to discriminate patients at risk of developing early reduced systolic function. The relationship of these early results to long term cardiac function remains to be demonstrated.

Abstract 12963: The Prevalence and Predictors of Transthyretin Amyloidosis in Patients Underwent Transcatheter Aortic Valve Implantation

Background: Several studies have recently reported that transthyretin (ATTR) amyloidosis is present in patients with aortic stenosis (AS). We aimed to 1) examine the prevalence of ATTR amyloidosis in AS patients undergoing transcatheter aortic valve implantation (TAVI), 2) compare clinical characteristics between AS patients with and without ATTR, and 3) identify predictors of ATTR amyloidosis in AS patients. Methods and Results: We prospectively analyzed consecutive 32 patients with severe AS who underwent screening tests for ATTR in prior to TAVI. To detect ATTR, we performed cardiac technetium-99m pyrophosphate ( 99m Tc-PYP) scintigraphy in 24 patients and biopsies of fat tissue from the puncture site in 24 patients. Of 32 AS patients who were screened for ATTR, 6 (18.8%) patients were diagnosed as ATTR by cardiac 99m Tc-PYP scintigraphy (n=2) and fat biopsy (n=5). Compared with non-ATTR patients, ATTR patients presented higher levels of B-type natriuretic peptide (BNP, 242.3 vs. 1101.4 ng/ml, P=0.004), lower left ventricular ejection fraction (LVEF, 62.3 vs. 45.5%, P=0.002) and lower mean pressure gradient of AS (50.2 vs. 32.0 mmHg, P=0.016). In contrast, age, sex, STS score, clinical frailty scale, prevalence of chronic kidney disease and atrial fibrillation, and levels of hemoglobin, albumin, estimated glomerular filtration rate and troponin I were comparable between the two groups. Other echocardiographic parameters including interventricular septal wall thickness, posterior wall thickness and aortic valve area did not differ between the two groups. To detect ATTR among AS patients, receiver operating characteristic (ROC) analysis demonstrated that area under the curve of BNP, LVEF, and mean pressure gradient was 0.814, 0.766 and 0.846, respectively. Although TAVI was successfully completed in all patients, and there was no procedural complication in both groups, one of ATTR patients re-hospitalized due to decompensated heart failure 3 weeks after TAVI. Conclusion: In AS patients undergoing TAVI, especially in cases of low-flow low-gradient pattern and high BNP levels, screening of ATTR should be considered. In this population, cardiac 99m Tc-PYP scintigraphy and fat biopsy are useful to detect latent ATTR non-invasively.

Limitations of sexual activity in patients with chronic heart failure

Abstract Background Limitation of sexual activity may potentially have a great impact in the quality of life of patients with chronic heart failure (HF), although the burden of sexual limitation and its clinical drivers are not completely understood. We aimed to characterize the impact of sexual limitation and how it relates to different measures of HF severity, in patients with HF. Methods We prospectively selected a cohort of patients followed in our ambulatory HF Clinics, with HF and currently or previously documented left ventricular ejection fraction (LVEF) ≤40%, aged between 18 and 80 years, with NYHA class I-IV. Clinical, laboratorial, imaging and ergometric data was collected. A questionnaire characterizing sexual activity of the patient was filled by her/himself before consultation with the physician, while alone in a private room. Results A total of 65 patients were selected, 75% of which were male, with mean age 61±11 years, 32% were in NYHA I or II, and 21% had a resynchronization system. Mean BNP was 520±850 pg/mL, LVEF was 39±12% and peak oxygen consumption (pVO2) was 17.2±5.3 mL/min/m2. Limitations of sexual activity were reported in 40 (62%) patients, including erectile dysfunction (25%), fatigue (11%), reduction of libidum (8%), fear of HF symptoms during sexual activity (5%), absence of sexual partner (5%), and other reasons (8%). Of these 40 patients, 22 (55%) reported severe or very severe sexual limitation. Only 2 (3%) patients actively searched for clinical aid. Patients with sexual limitations were older (63±12 vs 56±11 years), were in higher NYHA classes (One-Way ANNOVA), had higher levels of BNP (775±1051 vs 181±212 pg/mL) and lower glomerular filtration rates (66±19 vs 86±23 mL/min) (all p&amp;lt;0.05). Other major variables such as ischemic etiology, diabetes, resynchronization therapy, LVEF and pVO2 were not associated with the presence or severity of sexual limitations, although there was a numerical trend for lower pVO2 (16.5±5.8 vs 19.0±4.0 mL/l/min/m2, p=0.20). NYHA class ≥II (β 6.5, 95% CI 0.4–10.5) and BNP levels (β 1.03, 95% CI 1.01–1.06) were independent predictors of sexual dysfunction. Conclusions Sexual limitation was highly prevalent among patients with HF, was often severe and the most frequent reason was erectile dysfunction. Simple and highly accessible parameters, such as age, NYHA class, BNP levels and renal function, are related to the presence of sexual limitation. More attention should be payed to sexual limitation in patients with HF considering the high burden and the large room for improvement. Funding Acknowledgement Type of funding source: None

Nutritional risk index is an independent predictor of one-year mortality after primary angioplasty for ST-segment elevation myocardial infarction, regardless of age, frailty and clinical severity

Abstract Background Undernutrition is a common feature of elderly and hospitalized patients with cardiovascular diseases and is associated with adverse events. Purpose Assess the impact of nutritional risk index (NRI) in one-year mortality in ST-segment elevation myocardial infarction (STEMI) patients following primary angioplasty (PA). Methods Cohort of 319 consecutive patients (64.4 years [54.3–75.2]; 21.9% women) admitted to a general ICU after a PA for STEMI. NRI was calculated as 1.519 × serum albumin (g/L) + 41.7 × (actual body weight [kg]/ideal weight [kg]). Patients were dichotomized in no to mild (NRI ≥97.5) and moderate to severe (NRI &amp;lt;97.5) nutritional risk. We used Kaplan-Meier and Cox survival models. Results Patients with NRI &amp;lt;97.5 were older, mainly women, had a higher GRACE 2.0 and required more inotropic agents (P=0.001) and mechanical ventilation (P=0.002) during admission. They had lower CK and higher BNP levels, despite the lack of differences in LVEF and MI location (P=0.164) (Table 1). One-year mortality rate was higher in patients with NRI &amp;lt;97.5 (P&amp;lt;0.001), mainly from cardiogenic shock (P&amp;lt;0.001) (Table). After Cox regression analysis, moderate to severe nutritional risk showed a 3.10-fold higher risk of one-year mortality (95% confidence interval [CI], 1.21 to 7.90, P=0.018), independently of age, female gender, frailty (Clinical Frailty Scale ≥4), GRACE 2.0 and LVEF (Figure 1). Conclusion Moderate to severe NRI was associated with one-year all-cause mortality in patients undergoing PA for STEMI, regardless of age, female gender, frailty and clinical severity. The prognostic impact of NRI in mortality suggests the need to include its assessment in clinical examination of STEMI patients. Figure 1. Kaplan-Meier and Cox survival curves Funding Acknowledgement Type of funding source: None

Prognostic value of brain natriuretic peptide vs history of heart failure hospitalization in a large real-world population.

BackgroundIn heart failure (HF) patients, both natriuretic peptides (NP) and previous HF hospitalization (pHFH) have been used to predict prognosis.HypothesisIn a large real‐world population, both NP levels and pHFH have independent and interdependent predictive value for clinical outcomes of HFH and all‐cause mortality.MethodsLinked electronic health records and insurance claims data from Decision Resource Group were used to identify HF patients that had a BNP or NT‐proBNP result between January 2012 and December 2016. NT‐proBNP was converted into BNP equivalents by dividing by 4. Index event was defined as most recent NP on or after 1 January 2012. Patients with incomplete records or age < 18 years were excluded. During one‐year follow up, HFH and mortality rates stratified by index BNP levels and pHFH are reported.ResultsOf 64 355 patients (74 ± 12 years old, 49% female) with available values, median BNP was 259 [IQR 101‐642] pg/ml. The risk of both HFH and mortality was higher with increasing BNP levels. At each level of BNP, mortality was only slightly higher in patients with pHFH vs those without pHFH (RR 1.2 [95%CI 1.2,1.3], P < .001); however, at each BNP, HFH was markedly increased in patients with pHFH vs those without pHFH (RR 2.0 [95%CI 1.9,2.1], P < .001).ConclusionIn this large real‐world heart failure population, higher BNP levels were associated with increased risk for both HFH and mortality. At any given level of BNP, pHFH added greater prognostic value for prediction of future HFH than for mortality.

Predictors of Recurrence after Catheter Ablation of Paroxysmal Atrial Fibrillation in Different Follow-Up Periods.

Background and objectives: Pulmonary vein (PV) reconnection is a major reason for recurrence after catheter ablation of paroxysmal atrial fibrillation (PAF). However, the timing of the recurrence varies between patients, and recurrence >1 year after ablation is not uncommon. We sought to elucidate the characteristics of atrial fibrillation (AF) that recurred in different follow-up periods. Materials and Methods: Study subjects comprised 151 consecutive patients undergoing initial catheter ablation of PAF. Left atrial volume index (LAVi) and atrial/brain natriuretic peptide (ANP/BNP) levels were systematically measured annually over 3 years until AF recurred. Results: Study subjects were classified into four groups: non-recurrence group (n = 84), and short-term- (within 1 year) (n = 30), mid-term- (1–3 years) (n = 26), and long-term-recurrence group (>3 years) (n = 11). The short-term-recurrence group was characterized by a higher prevalence of diabetes mellitus (hazard ratio 2.639 (95% confidence interval, 1.174–5.932), p = 0.019 by the Cox method), frequent AF episodes (≥1/week) before ablation (4.038 (1.545–10.557), p = 0.004), and higher BNP level at baseline (per 10 pg/mL) (1.054 (1.029–1.081), p < 0.0001). The mid-term-recurrence group was associated with higher BNP level (1.163 (1.070–1.265), p = 0.0004), larger LAVi (mL/m2) (1.033 (1.007–1.060), p = 0.013), and longer AF cycle length at baseline (per 10 ms) (1.194 (1.058–1.348), p = 0.004). In the long-term-recurrence group, the ANP and BNP levels were low throughout follow-up, as with those in the non-recurrence group, and AF cycle length was shorter (0.694 (0.522–0.924), p = 0.012) than those in the other recurrence groups. Conclusions: Distinct characteristics of AF were found according to the time to first recurrence after PAF ablation. The presence of secondary factors beyond PV reconnections could be considered as mechanisms for the recurrence of PAF in each follow-up period.

P980Evaluation of the outcomes of radiofrequency catheter ablation in patients with ischemic ventricular tachycardia

Abstract Background Ablation of ventricular tachycardia (VT) is an effective and safe treatment option in symptomatic patients under antiarrhythmic drugs or patients with frequent ICD therapies. Purpose We aimed to evaluate outcomes of VT catheter ablation in patients with ischemic VT. Methods All of the patients who underwent VT catheter ablation between June 2014 and November 2018 were included. Results 128 patients (120 male, 8 female) were included and mean age was 65 ± 10 years. Mean ejection fraction was 28.6 ± 8.2 %. Baseline characteristics were listed in Table-1. Mean follow-up was 22.3 ± 6.4 months. 52 (46.6 %) patients were admitted with electrical storm. Acute success rate was 96.6%. Complications including transient ischemic attack, deep venous thrombosis, pericardial effusion and inguinal hematoma were developed in 6 patients. Recurrence of VT was occured in 44 (34.4 %) patients and the presence of PCI history and admission with electrical storm were predictors of recurrence. All cause mortality was occured in 39 patients and predictors of all cause mortality was detected as follows; diabetes, NYHA stage &amp;gt;2, lower levels of EF and higher BNP levels. Cardiovascular mortality was developed in 28 patients and predictors were defined as, lower levels of EF, higher BNP levels and number of shock after index ablation. VT recurrence was not found to be related with both cardiovascular and all cause mortality. Conclusion VT ablation is a safe and effective option in patients with ischemic VT who are symptomatic despite optimal medical treatment. Admission with electrical storm and history of PCI were predictors of VT recurrence after ablation. Higher levels of BNP, lower EF values are related with both all cause and cardiovascular mortality. Table-1 Gender, male, (%) 120(93,8) Age(year) 65,5 ± 9,7 HT 93(72,7) DM 35(27,3) AF 41(32,0) NYHA class(pre-ablation) IIIIII IV 71(55,5)27(21,1)25(19,5) 5(3,9) Previous PCI 83(64,8) Previous Cardiac surgery CABG AVR MVR 72(56,3) 70(54,7 1(0,8) 4(3,1) LV EF (%)≤3031-40 ≥41 28,6 ± 8,290(70,3)28(21,9) 10(7,8) Electrical storm 52(40,6) LV EDD (mm) 63,8 ± 8,5 Baseline characteristics

Artificial Intelligence Uncovered Clinical Factors for Cardiovascular Events in Myocardial Infarction Patients with Glucose Intolerance.

Glucose intolerance (GI), defined as either prediabetes or diabetes, promotes cardiovascular events in patients with myocardial infarction (MI). Using the pooled clinical data from patients with MI and GI in the completed ABC and PPAR trials, we aimed to identify their clinical risk factors for cardiovascular events. Using the limitless-arity multiple testing procedure, an artificial intelligence (AI)-based data mining method, we analyzed 415,328 combinations of < 4 clinical parameters. We identified 242 combinations that predicted the occurrence of hospitalization for (1) percutaneous coronary intervention for stable angina, (2) non-fatal MI, (3) worsening of heart failure (HF), and (4) all causes, and we analyzed combinations in 1476 patients. Among these parameters, the use of proton pump inhibitors (PPIs) or plasma glucose levels > 200 mg/dl after 2 h of a 75 g oral glucose tolerance test were linked to the coronary events of (1, 2). Plasma BNP levels > 200 pg/dl were linked to coronary and cardiac events of (1, 2, 3). Diuretics use, advanced age, and lack of anti-dyslipidemia drugs were linked to cardiovascular events of (1, 3). All of these factors were linked to (4). Importantly, each finding was verified by independently drawn Kaplan-Meier curves, indicating that the determined factors accurately affected cardiovascular events. In most previous MI patients with GI, progression of GI, PPI use, or high plasma BNP levels were linked to the occurrence of coronary stenosis or recurrent MI. We emphasize that use of AI may comprehensively uncover the hidden risk factors for cardiovascular events.

Direct measurement of cardiac stiffness using echocardiographic shearwave imaging during open-chest surgery: A pilot study in human.

Cardiac stiffness is a marker of diastolic function with a strong prognostic significance in many heart diseases that is not measurable in clinical practice. This study investigates whether elastometry, a surrogate for organ stiffness, is measurable in the heart using ShearWave Imaging. In 33 anesthetized patients scheduled for cardiac surgery, ShearWave imaging was acquired epicardially using a dedicated ultrasound machine on the left ventricle parallel to the left anterior descending coronary artery in a loaded heart following the last cardiac beat. Cardiac elastometry was measured offline using the Young modulus with customized software. Overall, the ejection fraction was 61±10%. E/A and E/e' ratios were 1.0±0.5 and 10.5±4.1, respectively. Cardiac elastometry averaged 15.3±5.3kPa with a median of 18kPa. Patients with high elastometry >18kPa were older (P=.04), had thicker (P=.02) but smaller LV (P=.004), had larger left atria (P=.05) and a higher BNP level (P=.04). We distinguished three different transmural elastometry patterns: higher epicardial, higher endocardial, or uniformly distributed elastometry. Elastometry measurement was feasible for the human heart. This surrogate for cardiac stiffness dichotomized patients with low and high elastometry, and provided three different phenotypes of transmural elastometry with link to diastolic function.

Artificial Intelligence Uncovered Clinical Factors for Cardiovascular Events in Myocardial Infarction Patients with Glucose Intolerance in the Cohort of Two Large-Scale ABC and PPAR Clinical Trials

Background: Glucose intolerance (GI), defined as either prediabetes or diabetes, promotes cardiovascular events in patients with myocardial infarction (MI). Using the pooled clinical data from patients with MI and GI in the completed ABC and PPAR trials, we aimed to identify their clinical risk factors for cardiovascular events. Methods: Using the limitless-arity multiple testing procedure, an artificial intelligence (AI)-based data mining method, we analyzed 415,328 combinations of <4 clinical parameters. Findings: We identified 242 combinations that predicted the occurrence of hospitalization for (1) percutaneous coronary intervention for stable angina, (2) non-fatal MI, (3) worsening of heart failure (HF), and (4) all causes, and we analyzed combinations in 1,476 patients. Among these parameters, plasma glucose levels >200 mg/dl after 2 hours of a 75g oral glucose tolerance test or the use of proton pump inhibitors (PPIs) predicted the coronary events of (1, 2). Plasma BNP levels >200pg/dl predicted coronary and cardiac events of (1, 2, 3). Diuretics use, advanced age, and lack of anti-dyslipidemia drugs were predictors of cardiovascular events of (1, 3). These factors were linked to (4). Importantly, each finding was verified by independently drawn Kaplan–Meier curves, indicating that the determined factors accurately predicted cardiovascular events. Interpretation: In most previous MI patients with GI, progression of GI or PPI use predicted the occurrence of coronary stenosis; recurrent MI and high plasma BNP levels predicted the subsequent worsening of HF. We emphasize that use of AI is effective to comprehensively uncover the clinical risk factors of cardiovascular events. Trial Registration: This study was a sub-analysis of the ABC Study (Alpha-glucosidase-inhibitor Blocks Cardiac Events in Patients with Myocardial Infarction and Impaired Glucose Tolerance; ClinicalTrials.gov identification number: NCT00212017) and the Pioglitazone Protects DM Patients Against Re-Infarction Study (PPAR; Clinicaltrials.gov identification number: NCT00212004 and UMIN: No. 000091). Funding Statement: Grants-in-Aid from the Ministry of Health, Labour and Welfare of Japan; Grants-in-Aid from the Ministry of Education, Culture, Sports, Science and Technology of Japan; and Grants-in-Aid from the Japan Agency for Medical Research and Development. Declaration of Interests: No relationship to industry for K.S., H.F, Y.M.,J.K., S.I, and T.W. MK reports grants from Japanese government, grants from Japan Heart Foundation, grants from Japan Agency for Medical Research and Development , personal fees from Daiichi-Sankyo, personal fees from Pfizer, grants and personal fees from Ono, personal fees from Bayer, grants and personal fees from Novartis, grants and personal fees from Bheringer, grants and personal fees from Tanabe-Mitubishi, personal fees from Japan Medical Data Center, grants and personal fees from Takeda, grants and personal fees from Astra Zeneca, outside the submitted work. Ethics Approval Statement: Approval was obtained from the institutional review boards and ethics committees of all involved hospitals and all patients provided written informed consent. The study was performed in accordance with the principles of the Declaration of Helsinki and the Japanese Ethical Guidelines for Clinical Research.

Plasma BNP Levels and Diuretics Use as Predictors of Cardiovascular Events in Patients with Myocardial Infarction and Impaired Glucose Tolerance.

Although impaired glucose tolerance (IGT) promotes cardiovascular events, our Alpha-glucosidase-inhibitor Blocks Cardiac Events in Patients with Myocardial Infarction and Impaired Glucose Tolerance (ABC) study showed that alpha-glucosidase inhibitors do not prevent cardiovascular events in patients with myocardial infarction (MI) and IGT. The aim of the present study was to identify potential clinical factors for cardiovascular events in patients with MI and IGT. Using the limitless-arity multiple testing procedure, an artificial intelligence (AI)-based data mining method, we analyzed 385,391 combinations of fewer than four clinical parameters. We identified 380 combinations predicting the occurrence of (1) all-cause hospitalization, (2) hospitalization due to worsening of heart failure (HF), (3) hospitalization due to non-fatal MI, and (4) hospitalization due to percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for stable angina among 385,391 combinations in 853 patients. Among these, either plasma BNP levels ≥ 200 pg/dl or diuretic use exclusively predicted (1) all-cause hospitalization, (2) hospitalization due to worsening of HF, and (3) hospitalization due to a non-fatal MI, with plasma BNP levels ≥ 200 pg/dl being the sole predictor of hospitalization due to PCI and CABG. Importantly, each finding was verified by independently drawn Kaplan-Meier curves, revealing the unexpected role of plasma BNP levels in the progression of coronary stenosis determined as the necessity of PCI and CABG for stable angina. In patients with MI and IGT, high plasma BNP levels predicted the occurrence of coronary stenosis, recurrent MI, and worsening of HF, whereas diuretic use did not predict the progression of coronary stenosis but non-fatal MI and worsening of HF.

P1292 Prevalence and mechanisms of mitral regurgitation and its association with advanced heart failure in patients with a systemic right ventricle

Abstract Background Although tricuspid regurgitation in patients with cardiac diseases is an established predictor of adverse outcomes, prevalence, mechanisms and clinical/prognostic value of non-systemic mitral regurgitation (MR) in patients with congenitally corrected transposition of great arteries (ccTGA) or simple transposition after Mustard or Senning procedures (TGA) are still poorly understood. Purpose To assess prevalence, mechanisms of MR and its association with severity of heart failure in patients with a systemic right ventricle (SRV). Methods From our digital echocardiographic database, we have identified all patients with a SRV who underwent echocardiography between 2014 and 2018. Severity of MR, size and function of SRV and subpulmonary LV were assessed from the latest echocardiographic studies. Results 157 patients fulfilled inclusion criteria (89 post-Mustard/Senning, 68 ccTGA), median age 40.6 (33.1; 46.8) years, 57% male, median BNP 79.5 [38.3; 173.3] ng/l. More than trivial MR was present in 44 (28.0%), further classified as mild, moderate and severe in 26 (16.6%), 15 (9.6%) and 3 (1.9%), respectively. Principal mechanisms of MR included (i) device lead interference with the leaflet(s) in 26, (ii) organic pathology of mitral valve in 5 (2 prolapse, 2 cleft and 1 parachute mitral valve) and (iii) systolic leaflet(s) tethering ± annular dilatation in 4; no obvious cause of MR was identified in 10 patients. Presence of more than trivial MR was significantly associated with NYHA class 3-4 (Chi-square 25.74, p &amp;lt; 0.0001). Patients with MR also had higher BNP levels, larger LV with poorer systolic function and were more likely to have pulmonary stenosis (Table). MR was less common in patients post-Mustard/Senning procedures compared to ccTGA (p &amp;lt; 0.0001, Table); however, patients from the former group were more likely to have severe heart failure (Figure). Conclusions Non-systemic MR in patients with a SRV is relatively uncommon, but when present is associated with LV dilatation and systolic dysfunction, raised BNP levels, and heart failure symptoms. Predominant underlying mechanisms were device leads, organic pathology, and valve tethering. MR should be routinely assessed in SRV patients, particularly those with previous Mustard/Senning procedures, and be taken into account in decision making and timing interventions. Characteristics of 157 patients with SRV Parameter No/trivial MR (N = 113) Mild-severe MR (N = 44) P value Age, years Mustard/Senning ccTGA Pulmonary stenosis NYHA class 3-4 ICD/Pacemaker lead 39.5 (33.1; 45.7) 75 (66%) 38 (34%) 13 (12%) 7 (6%) 31 (27%) 44.4 (32.7; 52) 14 (32%) 30 (68%) 12 (27%) 17 (39%) 32 (73%) 0.105 &amp;lt;0.0001 &amp;lt;0.0001 0.022 &amp;lt;0.0001 &amp;lt;0.0001 LV EDDi, cm/m2 LV FAC, % MAPSE, mm SRV EDAi, cm2/m&amp;sup2; TAPSE, mm 2.11 (1.9; 2.45) 48 (42; 52.5) 18 (14; 22) 17.6 (15.0; 20.2) 12 (9; 15) 2.5 (2.0; 2.9) 40 (34; 48.8) 14.6 (11.5; 16.5) 17.5 (14.4; 22.2) 10.5 (9; 13) 0.0007 0.0011 0.0005 0.754 0.435 BNP 68 (35.3; 104.3) 177 (62.5; 345.3) &amp;lt;0.0001 Values are reported as median (25th; 75th percentile) or n(%) Abstract P1292 Figure. SRV patients with more than trivial MR

P679 Subpulmonary left ventricular dysfunction is associated with severity of heart failure in patients with systemic right ventricle

Abstract Background Dysfunction of systemic right ventricle (SRV) in patients with congenitally corrected transposition of great arteries (ccTGA) or simple transposition (TGA) is commonly associated with exercise intolerance, heart failure and death. However, the relevance of subpulmonary left ventricular (LV) function in these settings is unknown. Purpose To examine the relation between severity of heart failure and echocardiographic parameters of subpulmonary LV size and function in patients with SRV. Methods We identified all patients with SRV from our digital echocardiographic database between 2014 and 2018. The size and function of SRV and subpulmonary LV were assessed in the most recent examination. Clinical data were collected from electronic patient records. Results We included 157 patients with SRV, median age 40.6 [33.1; 46.8] years, 57% male. 133 (85%) patients had NYHA functional class 1-2 and 24 (15%) NYHA class 3-4. Patients with NYHA class 3-4 were older, had larger SRV and subpulmonary LV with poorer function and higher BNP level (Table, Figure A). LV fractional area change (FAC) had higher sensitivity and specificity in differentiation of patients with severe heart failure than SRV FAC (Figurel B) with LV FAC cut-off value &amp;lt;39.2% showing the highest accuracy in prediction of NYHA class 3-4 (Se 83% and Sp 88%) and 86% Sp in predicting BNP &amp;gt; 100 ng/l. LV end-diastolic diameter and area, MAPSE and FAC significantly correlated with BNP level (p &amp;lt; 0.0001; p = 0.001; p = 0.007; and p = 0.0002, respectively). In Multivariate Cox regression analysis LV FAC and RV FAC were the only independent associates of NYHA class 3-4 (HR 0.69 [95%CI 0.55-0.86], p = 0.001 and HR 0.71 [95%CI 0.55-0.93], p = 0.012, respectively), while age, degree of tricuspid regurgitation and BNP were not. Conclusions Subpulmonary LV dysfunction is strongly associated with NYHA class 3-4 heart failure in patients with SRV. LV FAC is more accurate than SRV FAC in predicting heart failure symptoms. Subpulmonary LV should be accurately assessed in all SRV patients and be taken into account in clinical decision making and timing for interventions. Characteristics of 157 patients with SRV Parameter NYHA Class 1-2 (N = 133) NYHA Class 3-4 (N = 24) P value Age, years 39.1 (31.9; 45.7) 46.5 (43.9; 58.1) &amp;lt;0.0001 RV EDAi, cm2/m2 17.4 (15.2; 20.1) 21.8 (17.5; 25.6) 0.0002 RV FAC, % 29.5 (23; 35) 22 (20; 27) &amp;lt;0.0001 LV EDAi, cm2/m2 12.0 (10.1; 14.1) 16.4 (11.6; 19.1) 0.0008 Reduced LV function by eyeballing 3 (2%) 18 (75%) &amp;lt;0.0001 BNP, ng/l 66 (35; 109) 356 (196; 512) &amp;lt;0.0001 Data presented as median (25th; 75th percentiles) Abstract P679 Figure.

The Story of a Stone Heart – Another Side of Cardiooncology

Abstract A 38-year-old man was admitted to our department with moderate exertional dyspnea, fatigue and a syncope during exercise. The medical history revealed: left pulmonary sarcoma at the age of four, treated with radiotherapy, chemotherapy and left total pneumonectomy. At admission, laboratory tests showed high BNP (1426 pg/ml), normal calcium and parathormon levels. The transthoracic echocardiography found normal left ventricular (LV) systolic function with severe calcifications of the papillary muscles, mitral annulus, apical segments of the inferior septum and inferior wall (panel A - arrows; panel D) associated with severe mitral regurgitation (panel B). It also revealed severe tricuspid valve regurgitation, severe pulmonary hypertension (estimated to 120 mmHg, panel C) and small amount of pericardial fluid. A thoracic computed tomography described severe cardiac calcifications (panels E and F, arrow), a hypertrophic right lung herniated in left hemythorax and no other pathological findings in the remnant lung tissue. The pneumological evaluation noted a severe restrictive dysfunction. In this case, pulmonary hypertension was most probably determined by the left cardiac disorders (severe mitral regurgitation postradiotherapy, LV diastolic dysfunction due to severe myocardial and papillary muscle calcifications), most probably related to thoracic radiotherapy during childhood.

Educational intervention to improve appropriate digoxin therapeutic drug monitoring: a quasi-experimental study

ObjectivesOur previous retrospecive study evaluating the appropriateness of serum digoxin concentration (SDC) measurements revealed errors in the timing of blood specimen collection in 98% of the tests. The aim of...