Higher Rate Of Cardiovascular Events Research Articles

Time-updated anion gap and cardiovascular events in advanced chronic kidney disease: a cohort study.

ABSTRACTBackgroundStudies examining associations between metabolic acidosis and cardiovascular events in chronic kidney disease (CKD) have shown conflicting results and have not differentiated between normal anion gap (hyperchloremic) acidosis and high anion gap acidosis. We aimed to examine the impact of normal and high anion gap acidosis, separately, on the risk of cardiovascular events among patients with CKD.MethodsThis retrospective cohort study included 1168 patients with an estimated glomerular filtration rate (eGFR) of 10–60 mL/min/1.73 m2 and available data on anion gap. We analyzed the association of time-updated high anion gap (anion gap ≥9.2) with the rate of cardiovascular events using marginal structural models (MSMs) to account for time-dependent confounding. We also analyzed the association between time-updated normal anion gap acidosis (anion-gap-adjusted bicarbonate level ≤22.8 mEq/L) and cardiovascular events.ResultsThe mean baseline eGFR of the cohort was 28 mL/min/1.73 m2. The prevalence rates of high anion gap in CKD stages G3a, G3b, G4 and G5 were 20%, 16%, 27% and 46%, respectively. During a median follow-up period of 2.9 years, 132 patients developed cardiovascular events (3.3/100 patient-years). In MSMs, high anion gap was associated with a higher rate of cardiovascular events [hazard ratio (HR) 1.87; 95% confidence interval (95% CI) 1.13‒3.09; P = 0.02] and the composite of cardiovascular events or all-cause death (HR 3.28; 95% CI 2.19‒4.91; P < 0.001). Normal anion gap acidosis was not associated with cardiovascular events (HR 0.74; 95% CI, 0.47‒1.17; P = 0.2).ConclusionsAmong patients with advanced CKD, high anion gap was associated with an increased risk of cardiovascular events.

Urinary N-Acetyl-β-d-Glucosaminidase (NAG) Levels and Risk of Cardiovascular Events in Diabetic Patients.

BackgroundCardiovascular diseases (CVDs) have a high incidence rate in population with diabetic patients. Studies on the association between urinary N-acetyl-β-d-glucosaminidase (NAG) levels, the biomarker of renal tubular damage, with cardiovascular (CV) events diabetic patients was still few.MethodsThe relationship between urinary NAG levels and CV events was analyzed in a prospective cohort including 357 patients with type 2 diabetes mellitus at a follow-up of 5 years.ResultsTwenty-six (7.3%) patients have CV events. Kaplan–Meier analysis suggested that diabetic patients with urine NAG levels ≥37.5 IU/L had a higher rate of CV events than those with urine NAG levels <37.5 IU/L (Log rank test, P = 0.021). Cox analysis revealed that elevated urine NAG levels significantly contributed to increased risk of CV events (HR = 1.43, 95% CI 1.23–1.93, P < 0.001) after adjusting for clinical confounding factors. Interestingly, we also found that “abnormal renal function” has an effect modification on the association between urine NAG levels and CV events. ROC-AUC analysis suggested that the urine NAG (AUC = 0.81, P < 0.001) had a better predictive value than eGFR (AUC = 0.74, P = 0.012).ConclusionElevated urine NAG levels are associated with higher risk of CV events in patients with type 2 diabetes. These results might further suggested that urinary NAG is a value urinary biomarker for early detecting CV events among diabetic patients.

Circulating Biomarkers and Cardiac Structure and Function in Rheumatoid Arthritis.

Background: Rheumatoid arthritis (RA) increases the risk for abnormalities of the cardiac structure and function, which may lead to heart failure (HF). Studying the association between circulating biomarkers and echocardiographic parameters is important to screen patients with RA with a higher risk of cardiac dysfunction.Aim: To study the association between circulating biomarkers and echocardiographic parameters in patients with RA.Methods: Echocardiography was performed in 355 patients with RA from RA Porto cohort and the associations between echocardiographic characteristics and 94 circulating biomarkers were assessed. These associations were also assessed in the Metabolic Road to Diastolic Heart Failure (MEDIA-DHF) [392 patients with HF with preserved ejection fraction (HFpEF)] and the Suivi Temporaire Annuel Non-Invasif de la Santé des Lorrains Assurés Sociaux (STANISLAS) (1,672 healthy population) cohorts.Results: In the RA Porto cohort, mean age was 58 ± 13 years, 23% were males and mean RA duration was 12 ± 10 years. After adjustment and multiple testing correction, left ventricular mass index (LVMi), left atrial volume index (LAVi), and E/e′ were independently associated with biomarkers reflecting inflammation [i.e., bone morphogenetic protein 9 (BMP9), pentraxin-related protein 3 (PTX3), tumor necrosis factor receptor superfamily member 11a (TNFRSF11A)], extracellular matrix remodeling [i.e., placental growth factor (PGF)], congestion [i.e., N-terminal pro-brain natriuretic peptide (NT-proBNP), adrenomedullin (ADM)], and myocardial injury (e.g., troponin). Greater LVMi [hazard ratio (HR) (95% CI) per 1 g/m2 = 1.03 (1.02–1.04), p < 0.001], LAVi [HR (95% CI) per 1 ml/m2 = 1.03 (1.01–1.06), p < 0.001], and E/e′ [HR (95% CI) per 1 = 1.08 (1.04–1.13), p < 0.001] were associated with higher rates of cardiovascular events. These associations were externally replicated in patients with HFpEF and asymptomatic individuals.Conclusion: Circulating biomarkers reflecting inflammation, extracellular matrix remodeling, congestion, and myocardial injury were associated with underlying alterations of cardiac structure and function. Biomarkers might be used for the screening of cardiac alterations in patients with RA.

Abstract 10249: Association of Eligibility for a Sodium-Glucose Co-Transporter 2 Inhibitor and Cardiovascular Outcomes in Patients with Atrial Fibrillation

Introduction: Heart failure (HF) is the leading cause of death in patients with atrial fibrillation (AF). Although sodium-glucose co-transporter 2 inhibitors (SGLT2i) reduce HF in a broad range of populations, they have not been studied specifically in patients with AF. Objective: We aimed to determine the proportion of AF patients who are eligible for an SGLT2i based on co-morbidities, and compare their risk of cardiovascular outcomes to ineligible patients. Methods: We pooled data from two randomized controlled trials (RCTs) of AF patients (RE-LY and ACTIVE-W). Among patients assigned to the anticoagulation arms, those meeting the inclusion criteria from at least one of the large Phase 3 SGLT2i RCTs were included in the “SGLT2i-eligible” and the others in the “SGLT2i-ineligible” group. Eligibility indications were diabetes mellitus + cardiovascular disease (DM+CVD), HF with reduced ejection fraction (HFrEF), and renal disease. We examined a primary outcome of cardiovascular death and hospitalization for HF, and compared study outcomes between SGLT2i-eligible and ineligible groups. Results: A total of 21485 AF patients (mean age: 71.2±8.8, 36.1% women, Median CHA 2 DS 2 -VASc Score = 3, IQR 2-4) met inclusion. The proportion of AF patients eligible for treatment with an SGLT2i was 23.6%, with 8.9%, 22.6%, 9.1% being eligible for Empagliflozin, Dapagliflozin, and Canagliflozin, respectively. Renal disease (17.6%) was the most common eligibility indication, followed by DM+CVD (9.0%) and HFrEF (5.3%). After a median follow-up of 1.9 years, the incidence of cardiovascular death/hospitalization for HF (10.9% vs. 6.3%, p&lt;0.001), cardiovascular death (5.2% vs. 2.4%, p&lt;0.001), hospitalization for HF (6.8% vs. 4.2%, p&lt;0.001), hospitalization for AF (6.7% vs. 5.4%, p&lt;0.001), and thromboembolic events (4.9% vs. 3.9%, p=0.003) was significantly higher in the SGLT2i-eligible than the ineligible group. Conclusion: The majority of AF patients are not eligible for an SGLT2i. Although these patients are lower-risk than eligible patients, they still have high rates of cardiovascular events. RCTs are needed to test the efficacy of SGLT2is in AF patients.

Abstract 10471: Prognostic Significance of Soluble Programed Cell Death Ligand-1 on Cardiovascular Outcomes in Patients with Atherosclerotic Cardiovascular Disease

Background: Programmed Death-1(PD-1) and its ligand, PD-L1 regulate T cell proliferation and secretion of cytokines, leading to immunotolerance. A previous experimental study reported increased expression of PD-L1 in myocardium. Hence, PD-L1 could be associated with atherosclerotic cardiovascular disease (ASCVD). We hypothesized that serum soluble PD-L1 (sPD-L1) could be associated with cardiovascular events. We prospectively investigated the association between the serum levels of sPD-L1 and cardiovascular outcomes in patients with ASCVD. Methods: We prospectively measured sPD-L1 in patients with ASCVD admitted to Kumamoto University Hospital using a commercially available enzyme-linked immunosorbent assay kit and observed the occurrence of cardiovascular events between December 2017 and June 2019. The primary outcome was a composite of death from any cause, death from cardiovascular causes, nonfatal myocardial infarction, unstable angina pectoris, stroke, and heart failure hospitalization. We excluded patients complicated with cancer, hemodialysis, active collagen diseases, and inflammatory diseases. Results: Finally, 446 patients with ASCVD were enrolled. Median follow-up period was 322 days. A total of 153 events were recorded. Kaplan-Meier curve revealed that the higher sPD-L1 group (sPD-L1 ≧155pg/dL, median) showed significantly higher rate of cardiovascular events than the lower sPD-L1 group (19.2% vs. 28.1%, log-rank test: P =0.044). Univariate Cox proportional hazards analysis showed that creatinine, low density-lipoprotein cholesterol, B-type natriuretic peptide (BNP), and higher sPD-L1 (≧155pg/dL) were significantly associated with cardiovascular events. Multivariable Cox proportional hazards analysis by significant factors from univariate analysis identified that higher sPD-L1 [hazard ratio (HR): 1.699, 95% confidence interval (CI): 1.023-2.823, P =.041) and BNP (HR: 1.001, 95% CI: 1.000-1.001, P =0.036) were significantly and independently associated with cardiovascular events. Conclusions: The higher levels of sPD-L1 were significantly associated with near future cardiovascular events in patients with ASCVD, suggesting sPD-L1 could be a novel prognostic predictor in patients with ASCVD.

Impact of COVID-19 infection on short-term outcome in patients referred to stress myocardial perfusion imaging.

PurposeWe assessed the impact of COVID-19 infection on cardiovascular events in patients with suspected or known coronary artery disease (CAD) referred to stress single-photon emission computed tomography myocardial perfusion imaging (MPS).MethodsA total of 960 consecutive patients with suspected or known CAD were submitted by referring physicians to stress MPS for assessment of myocardial ischemia between January 2018 and June 2019. All patients underwent stress-optional rest MPS. Perfusion defects were quantitated as % of LV myocardium and expressed as total perfusion defect (TPD), representing the defect extent and severity. A TPD ≥ 5% was considered abnormal.ResultsDuring a mean follow-up of 27 months (range 4–38) 31 events occurred. Moreover, 55 (6%) patients had a COVID-19 infection. The median time from index MPS to COVID-19 infection was 16 months (range 6–24). At Cox multivariable analysis, abnormal MPS and COVID-19 infection resulted as independent predictors of events. There were no significant differences in annualized event rate in COVID-19 patients with or without abnormal MPS (p = 0.56). Differently, in patients without COVID-19, the presence of abnormal MPS was associated with higher event rate (p < .001). Patients with infection compared to those without had a higher event rate in the presence of both normal and abnormal TPD.ConclusionIn patients with suspected or known CAD, the presence of COVID-19 infection during a short-term follow-up was associated with a higher rate of cardiovascular events.

The impact of nutrition on the development and progression of peripheral artery disease: A systematic review

This systematic review sought to identify and summarize existing evidence for the impact of nutrition on the development, progression, and outcomes of peripheral artery disease (PAD). We performed a systematic literature search of available studies published between January 1974 and December 2019. Randomized controlled trials (RCT), observational studies, and cross-sectional studies reporting either the primary or secondary prevention of PAD with nutritional intake were included. The quality assessment was performed for the RCTs, without pooling a meta-risk estimate. Among a total of 8502 records screened, 186 full texts were assessed for eligibility, and 82 studies (30% RCT) were analyzed. The nutrients were structured in fruits, vegetables and antioxidants, fats and oils, dietary fiber, meat, proteins, vitamins and trace elements, and diets and lifestyle. The findings of the current systematic review indicate that the Mediterranean diet, nuts, and polyunsaturated fat are associated with a lower incidence of PAD and saturated fat, cholesterol, and processed meat were associated with higher rates of cardiovascular events in patients suffering from PAD. The current review found evidence of a beneficial impact of the Mediterranean diet including nuts in this target population. More RCTs and high-quality registries are needed that focus on nutritional habits among patients with PAD to design appropriate preventive programs.

Predictors of clinical outcome after rotational atherectomy-facilitated percutaneous coronary intervention in hemodialysis patients.

Percutaneous coronary intervention (PCI) in hemodialysis patients with severely calcified and diffused lesions is associated with extremely high rates of major adverse cardiovascular events (MACE), even when facilitated by rotational atherectomy (ROTA). Potential risk factors for MACE with ROTA-facilitated PCI in hemodialysis patients should be identified. We retrospectively analyzed a consecutive cohort of patients from the Sapporo Cardiovascular Clinic database, who were on maintenance hemodialysis with severe calcified lesions and treated with ROTA-facilitated PCI. Clinical and interventional procedure characteristics were collected and compared between patients with and without MACE, defined as all-cause death, hospitalization due to heart failure, definite stent thrombosis, or target lesion revascularization (TLR) at 1-year follow-up. The individual outcomes of MACE and TLR in the cohort were presented as Kaplan-Meier percentages. Cox regression analyses were performed to identify independent predictors of MACE. A total of 138 patients undergoing hemodialysis and followed up for 362.50 (243.75, 382.25) days. Sixty-one patients in the cohort had MACE, most of which were TLR (47.5%, 29/61). Cumulative all-cause death at 30-day and 1-year follow-up were 6.52% and 18.8%, respectively. Patients with right coronary artery (RCA) lesions, in-stent restenosis (ISR) lesions, and were more likely to have MACE, even with larger reference vessel diameter and greater acute gain after PCI. Cox regression analysis demonstrated that ISR lesion was positively associated with both MACE (HR 3.21, 95% CI: 1.59-6.48) and TLR (HR 5.08, 95% CI: 1.78-14.47), latter of which was also proved to be significantly related to greater acute gain (HR 1.95, 95% CI: 1.12-3.39). In subgroup analysis, RCA was found to be positively associated with MACE in de novo lesion (HR 2.83, 95% CI: 1.28-6.28). We found that the overall prognosis of ROTA-facilitated PCI in hemodialysis patients was poor. ISR was a significant risk factor for MACE, especially TLR.

Stent Selection for Primary Angioplasty and Outcomes in the Era of Potent Antiplatelets. Data from the Multicenter Randomized Prague-18 Trial

Drug-eluting stents (DES) are the recommended stents for primary percutaneous coronary intervention (PCI). This study aimed to determine why interventional cardiologists used non-DES and how it influenced patient prognoses. The efficacy and safety outcomes of the different stents were also compared in patients treated with either prasugrel or ticagrelor. Of the PRAGUE-18 study patients, 749 (67.4%) were treated with DES, 296 (26.6%) with bare-metal stents (BMS), and 66 (5.9%) with bioabsorbable vascular scaffold/stents (BVS) between 2013 and 2016. Cardiogenic shock at presentation, left main coronary artery disease, especially as the culprit lesion, and right coronary artery stenosis were the reasons for selecting a BMS. The incidence of the primary composite net-clinical endpoint (EP) (death, nonfatal myocardial infarction, stroke, serious bleeding, or revascularization) at seven days was 2.5% vs. 6.3% and 3.0% in the DES, vs. with BMS and BVS, respectively (HR 2.7; 95% CI 1.419–5.15, p = 0.002 for BMS vs. DES and 1.25 (0.29–5.39) p = 0.76 for BVS vs. DES). Patients with BMS were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, p = 0.045) and at one year (HR 2.1; 95% CI 1.19–3.69; p = 0.01); they also had a higher composite of cardiac death, reinfarction, and stroke (HR 1.66; 95% CI 1.0–2.74; p = 0.047) at one year. BMS were associated with a significantly higher rate of primary EP whether treated with prasugrel or ticagrelor. In conclusion, patients with the highest initial risk profile were preferably treated with BMS over BVS. BMS were associated with a significantly higher rate of cardiovascular events whether treated with prasugrel or ticagrelor.

Long Term Outcomes of Post-Implantation Syndrome After Endovascular Aneurysm Repair

The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis. One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan–Meier plots and a multivariable model was constructed to correct for confounders. The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 – 8.3), similar in both groups (p = .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p = .63). However, Kaplan–Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p = .005). Sac dynamics were similar in both groups. The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous.

Atrial fibrillation is an independent predictor of cardiovascular events in patients with primary aldosteronism

Abstract Background A higher risk of cardiovascular events has been reported in patients with hypertension due to primary aldosteronism (PA) than essential hypertension. This study sought to determine the independent predictors for the risk of cardiovascular events in hypertensive patients with PA. Methods The Japan Primary Aldosteronism Study (JPAS) has retrospectively recruited 3,654 patients with PA between January 2006 and January 2019 as a nationwide registry and we evaluated the differences between patients with and without AF from these data. The patients underwent general laboratory test, electrocardiography, echocardiography, diagnostic confirmatory tests including saline-loading, captopril-challenge, and upright furosemide-loading tests and adrenal venous sampling (AVS). We evaluated the cardiovascular events including myocardial infarction, stroke, heart failure and renal failure, with a mean follow-up duration of approximately 4 years. Results The prevalence of AF was 2.4% (88/ 3,654). PA patients with AF were older (60.3 vs 52.8 years old), more male (77.3% vs 46.6%) and had longer duration of hypertension (14.3 vs 8.3 years) than those without AF. Each prevalence of cerebral infarction (12.5% vs 3.5%), chronic kidney disease (12.5% vs 4.8%), coronary artery disease (CAD) (10.2% vs 1.7%), heart failure (5.7% vs 0.7%) and left ventricular hypertrophy evaluated by echocardiography (46.4% vs 31.9%) was higher in PA patients with AF. Patients with AF had more kinds of antihypertensive drugs (1.3 vs 1.1). There was no significant difference of basal plasma aldosterone concentration (PAC), plasma renin activity, each confirmatory tests, lateralized ratio in AVS after stimulation with adrenocorticotropic hormone (ACTH) and laterality between the 2 groups. Logistic regression analysis showed that age, cardiothoracic ratio (CTR), past history of CAD and heart failure were independent determinants for AF. PA patients with AF had higher rates of cardiovascular events compared to those without AF (Figure, P&amp;lt;0.005). Multivariate Cox regression analyses demonstrated AF in addition to adrenal PAC before ACTH stimulation, age, hypokalemia and duration of hypertension as independent prognostic factors for cardiovascular events (hazard ratio [HR] 1.993, 95% confidence interval [CI] 1.042–3.815, P&amp;lt;0.05; HR 1.ehab724.231608, 95% CI 1.ehab724.231604–1.ehab724.231612, P&amp;lt;0.0005; HR 1.03, 95% CI 1.012–1.048, P&amp;lt;0.005; HR 1.748, 95% CI 1.242–2.461, P&amp;lt;0.005; HR 1.029, 95% CI 1.013–1.044, P&amp;lt;0.0005, respectively). Conclusions This study provides evidence that comorbid AF is associated with older age, male sex, X-ray CTR and prevalence of CAD and heart failure. Furthermore, AF is an independent predictor of cardiovascular events in patients with PA, in addition to the adrenal venous concentration of aldosterone, hypokalemia, older age and duration of hypertension. Earlier recognition and intervention of AF can prevent cardiovascular events in PA. Funding Acknowledgement Type of funding sources: None. Figure 1

Clinical outcomes with drug-eluting stents, bare-metal stents, and bioresorbable scaffolds implanted in patients with AMI treated with primary PCI. Data from the Prague-18 trial

Abstract Background Drug-eluting stents (DESs) are the recommended choice of stents for primary PCI. Purpose/Methods The study aimed to determine why interventional cardiologists used non-DESs and how they had influenced the patient prognosis. The efficacy and safety outcomes of the different stents were also compared in treated with either prasugrel or ticagrelor. Results Of the PRAGUE 18 study patients, 749 (67.4%) were treated with DESs, 296 (26.6%) with BMS, and 66 (5.9%) with BVS. Cardiogenic shock at presentation and the left main disease, especially as culprit lesion, and right coronary artery stenosis were the reasons for BMS selection. The incidence of the primary net-clinical EP (CV death, nonfatal MI, stroke, major bleeding, or revascularization) at 7 days was 2.6% vs. 6.5%, and 3.0% in the DESs, BMSs, and BVSs, respectively (HR 2.7; 95% CI 1.419–5.15, P=0.002 for BMS vs. DES and 1.25 (0.29–5.39) for BVS vs. DES, P=0.76). Patients with BMSs were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, P=0.045), and at one year (HR 2.1; 95% CI 1.19–3.69; P=0.01); they also had higher composite of cardiac death, re-MI and stroke (HR 1.66; 95% CI 1.0–2.74; P=0.047) at one year. BMSs were associated with significantly higher rate of primary EPs either treated with prasugrel or ticagrelor. Conclusion Patients with the highest risk profile were preferably treated with BMS the contrary to BVS. BMSs were associated with a significantly higher rate of cardiovascular events either treated with prasugrel or ticagrelor. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Charles University Cardiovascular Research Program P-35 and Q-38, Charles University, Czech Republic

Hospital readmissions and economic burden associated with multivessel disease in the early period following acute myocardial infarction

Abstract Background There is emerging evidence that particularly high rates of major adverse cardiovascular events (MACE) occur in the 90-day period after acute myocardial infarction (AMI). Post-AMI MACE are associated with additional resource utilization and economic burden for healthcare systems, with multivessel disease (MVD) conferring a 3- to 4-fold increase in risk of recurrent MACE in the first year post AMI vs. single vessel disease. Thus, characterizing the prevalence and outcomes of patients with MVD and various comorbidities is crucial to predict and mitigate clinical risk and associated costs. Purpose To describe post-AMI readmissions and economic burden in MVD patients at 30, 90, and 365 days. Methods This was a retrospective cohort study (1st January, 2008 to 31st December, 2018). Patients with MVD were identified by a confirmed diagnosis code from a longitudinal, representative UK population health dataset comprising primary care data from the Clinical Practice Research Datalink (CPRD), which was linked to secondary care data from the Hospital Episode Statistics (HES) and Office of National Statistics (ONS) databases. Patients who experienced at least one AMI after their first recorded MVD diagnosis were defined as MVD+. A MACE was defined as any one of non-fatal MI, non-fatal stroke, or cardiovascular death. Readmissions were defined as non-elective admissions with a MACE outcome diagnosis occurring up to 28 days from a previous admission with the same treatment speciality. Results The study population included 78,128 MVD+ patients (4.2% of the total patient population). In the MVD+ cohort, 3,753 (4.8%) patients were readmitted with at least one MACE event or other non-elective admission within the cardiovascular specialty: 2,394 (63.8%), 2,562 (68.3%), and 2,830 (75.4%) readmissions occurred within 30, 90, and 365 days, respectively. The mean length of hospital stay per patient, per readmission for MACE within 30, 90, and 365 days was 7.22, 7.46, and 7.74 days, respectively. The mean cost per MACE admission within 90 days of index AMI was £3,926.52. Non-fatal MI was the most common reason for readmission at all timepoints. Percutaneous transluminal balloon angioplasty and saphenous vein graft procedures (coronary artery bypass graft, CABG) were among the most common cardiac procedures in MVD+ patients, at 70,276 (22.7%) and 15,418 (5.0%), respectively. Conclusions In patients with MVD who suffer an AMI, there is high resource utilization and cost, particularly in the first 90-days post AMI; therefore, the 90-day post-AMI period represents significant economic costs to healthcare systems. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): CSL Behring

Aldosterone and Primary Aldosteronism: Star Performers in Hypertension Research

Aldosterone and Primary Aldosteronism: Star Performers in Hypertension Research

Long Term Outcomes of Post-Implantation Syndrome After Endovascular Aneurysm Repair

The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis. One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for confounders. The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 - 8.3), similar in both groups (p= .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p= .63). However, Kaplan-Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p= .005). Sac dynamics were similar in both groups. The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous.

The Intersection of Type 2 Myocardial Infarction and Heart Failure.

BackgroundType 2 myocardial infarction (T2MI) is common and associated with high cardiovascular event rates. However, the relationship between T2MI and heart failure (HF) is uncertain.Methods and ResultsWe identified patients with T2MI at a large tertiary hospital between October 2017 and May 2018. Patient characteristics, causes of T2MI, and subsequent HF hospitalizations were determined by physician chart review. We identified 359 patients with T2MI over the study period; 184 patients had a history of HF. Among patients with ejection fraction (EF) assessment (N=180), the majority had preserved EF (N=107; 59.4%), followed by reduced EF (N=54; 30.0%), and mid‐range EF (N=19; 10.6%). Acute HF was the most common cause of T2MI (20.9%). Of those whose T2MI was precipitated by HF (N=75), the mean EF was 53.0±16.8% and 16 (21.3%) were de novo diagnoses of HF. Among patients with T2MI who were discharged alive with available follow‐up (N=289), 5.5% were hospitalized with acute HF within 30 days, 17.3% within 180 days, and 22.1% within 1 year. In subgroup analyses, among patients with T2MI with prevalent or new HF (N=161), the rate of HF hospitalization at 1 year was 34.2%, considerably higher than those with T2MI and no HF diagnosis at discharge (7.0%; N=9/128).ConclusionsIndex presentations of HF or worsening chronic HF represent the most common causes of T2MI. ≈1 in 5 patients with T2MI will be readmitted for HF within 1 year of their event. Strategies to prevent HF events after a T2MI are needed.

The Relationship between C-Reactive Protein and Cardiovascular Events in Patients with Obstructive and Nonobstructive Coronary Artery Disease

Background and Objectives: Patients with nonobstructive coronary artery disease (NOCAD) have an increased risk of cardiovascular events (CVEs) compared to that in individuals with normal or near-normal coronary arteries (NNCAs) and even a similar risk to that in individuals with obstructive coronary artery disease (OCAD). However, the predictors for a worse outcome in patients with NOCAD are not fully determined. This study aimed to investigate the association of high-sensitive C-reactive protein (hs-CRP) and CVEs in patients with NOCAD. Materials and Methods: In total, 4662 patients with coronary artery angiography were enrolled and followed up for CVE. Patients were classified as having NNCA ( 3 mg/L). Proportional hazards models were used to assess the risk of CVEs. Results: Over an average 13403 person-year follow-up, 338 patients experienced CVEs. Patients with NOCAD and OCAD had a higher rate of CVE than those with NNCA (P

Aldosterone/Direct Renin Concentration Ratio Versus Aldosterone/Plasma Renin Activity for Diagnosis of Primary Hyperaldosteronism: Case Presentation

Aldosterone/Direct Renin concentration ratio versus Aldosterone/Plasma renin activity for diagnosis of Primary Hyperaldosteronism: Case presentation. Introduction: Primary hyperaldosteronism (PA) is the most common cause of secondary hypertension. Endocrine Society guidelines recommend using aldosterone-to-renin ratio (ARR) for screening of PA1. This ratio can be obtained using two different methods. The first is plasma aldosterone concentration (PAC) divided by plasma renin activity. ARR greater than 20 is suggestive of PA. Further testing is required for confirmation. Due to limitations and challenges in obtaining PRA, another method of measurement was developed in which the direct renin concentration (DRC) is measured. There have been inconsistent recommendations regarding what ratio is appropriate using this assay to diagnose hyperaldosteronism. The aim of this case presentation is to review a patient with PA in whom both measurement methods were used and compared for screening. Case Presentation: A 45-year woman with past medical history of Graves’ disease and hypertension presented with hypokalemia. Blood pressure was well-controlled on amlodopine for 3 years. PAC and DRC were measured. PAC was 21.2 ng/dL and DRC 2.8 pg/ml with ARR 7.6. This was repeated and confirmed (PAC 19.6 ng/dL and DRC 3.9 pg/ml with ARR 5). Plasma Renin Activity (PRA) was measured. PAC was 36.3 ng/dL and PRA was 0.19 ng/ml/hr (ARR 191), suggestive of hyperaldosteronism. Further workup including a CT scan of the abdomen with IV and oral contrast demonstrated an enhancing 1.8 cm nodule in the left adrenal gland. Adrenal vein sampling was performed. Left adrenal vein aldosterone level was 1400 ng/dl and on the right, 33.1 ng/dl. The patient was treated with left laparoscopic adrenalectomy. The pathological evaluation of the specimen demonstrated a 2.5 cm adenoma of benign etiology. Later follow-up showed the patient was normokalemic with PAC of 3.1. Conclusion: Patients with PA despite controlled hypertension, experience higher rates of cardiovascular events, hence early and accurate diagnosis is essential. PRA measurement has multiple limitations including inter-laboratory variations, higher cost, availability in only advanced laboratories and values influenced by blood pressure medications. Therefore, some institutions have replaced it with direct renin concentration (DRC) which is cheaper and more widely available. DRC has limitations with fewer positive ARR results. When the clinical suspicion is high, PRA is the more precise study to calculate ARR. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. John W. Funder, Robert M. Carey, Franco Mantero, et al. The Journal of Clinical Endocrinology & Metabolism, Volume 101, Issue 5, 1 May 2016, Pages 1889–1916, https://doi.org/10.1210/jc.2015–4061.

Association of Serum Nonesterified Fatty Acids with Cardiovascular Event in Patients with Chronic Kidney Disease.

BackgroundChronic kidney disease (CKD) has been suggested to be associated with a high risk of cardiovascular diseases (CVD). The study aimed to evaluate the prognostic significance of nonesterified fatty acid (NEFA), also well known as free fatty acid, on predicting cardiovascular events in patients with CKD.MethodsA total of 957 hospitalized patients with CKD in a stable clinical condition were enrolled at baseline. Then, the serum NEFA levels were measured. These included patients were prospectively followed up for a median of 10.2 years (range=0.4–11.5 years). We assessed whether serum NEFA levels at baseline can predict cardiovascular event during the follow-up.ResultsA total of 278 (29.1%) patients experienced cardiovascular events during follow-up. The Kaplan–Meier curve demonstrated that patients with higher serum NEFA levels (≥19.8 mg/dl) had a higher rate of cardiovascular events than patients with lower NEFA levels (<19.8 mg/dl). Multivariate Cox regression analysis suggested that elevated serum NEFA levels (HR=1.62; 95% CI 1.40–2.16, P<0.001) were independently associated with increased risk of cardiovascular events after correction for clinical confounding factors.ConclusionElevated serum NEFA levels were associated with higher risk of cardiovascular events and may be a new parameter predicting cardiovascular events in patients with CKD, which may strengthen its potential effect in clinical practice.

The Predictive Value of High-Sensitive Troponin I for Perioperative Risk in Patients Undergoing Gastrointestinal Tumor Surgery

Background: The incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment. Methods: 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited. The primary endpoint was in-hospital all-cause mortality and the combined endpoint including death, acute myocardial infarction, cardiac arrest and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment. Findings: Compared with patients with normal hs-cTnI (≤0.028ng/ml), those with elevated hs-cTnI were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly prolonged in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22.6% versus 4.2%, P ＜0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612 - 0·963, P = 0·015] and for combined endpoint was 0·822 [95%CI 0·766 - 0·879, P ＜0·001], which was larger than revised cardiac index. Hs-cTnI＞0·028 ng/ml was associated with higher cardiovascular event rate according to the stratification of the revised cardiac index. In multivariate logistic analyses, hs-cTnI was the strongest independent predictor for the combined endpoint [odds ratio (OR) 7·454 (95%CI: 3·872-14·348); P < 0·001]. Interpretation: High sensitivity troponin I provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides strong prognostic information incremental to revised cardiac index. Funding: The Fundamental Research Funds for the Central Universities and the National Natural Science Foundation of China. Declaration of Interest: No potential conflict of interest was reported by the authors. Ethics Approval Statement: The study has been approved by the local ethical boards of the sixth affiliated hospital of Sun Yat-sen University.