Independent Predictor Of Cardiac Events Research Articles

Defining The Incidence And Patient Profile Of Incidental Coronary Artery Calcification On Non-cardiac Computed Tomography: An Opportunity To Identify Subclinical Coronary Atherosclerosis.

Introduction: Coronary artery calcification (CAC) is an independent predictor of cardiac events. The increased use of thoracic Computed Tomography (CT) has made coronary calcification a common incidental finding, although the frequency remains unknown. We aimed to identify the incidence of CAC found on routine non-ECG gated CT scans, and risk factors associated with these findings.

Late Gadolinium Enhancement-Dispersion Mapping: A New Magnetic Resonance Imaging Technique to Assess Prognosis in Patients With Hypertrophic Cardiomyopathy and Low-Intermediate 5-Year Risk of Sudden Death.

Late gadolinium enhancement (LGE) is an important prognostic marker in hypertrophic cardiomyopathy and an extent >15% it is associated with high risk of sudden cardiac death. We proposed a novel method, the LGE-dispersion mapping, to assess heterogeneity of scar, and evaluated its prognostic role in patients with hypertrophic cardiomyopathy. One hundred eighty-three patients with hypertrophic cardiomyopathy and a low- or intermediate 5-year risk of sudden cardiac death underwent cardiac magnetic resonance imaging. A parametric map was generated from each LGE image. A score from 0 to 8 was assigned at every pixel of these maps, indicating the number of the surrounding pixels having different quality (nonenhancement, mild-enhancement, or hyperenhancement) from the central pixel. The Global Dispersion Score (GDS) was calculated as the average score of all the pixels of the images. During a median follow-up time of 6 (25th-75th, 4-10) years, 22 patients had hard cardiac events (sudden cardiac death, appropriate implantable cardioverter-defibrillator therapy, resuscitated cardiac arrest, and sustained ventricular tachycardia). Kaplan-Meier analysis showed that patients with GDS>0.86 had worse prognosis than those with lower GDS (P<0.0001). GDS>0.86 was the only independent predictor of cardiac events (hazard ratio, 9.9 [95% CI, 2.9-34.6], P=0.0003). When compared with LGE extent >15%, GDS improved the classification of risk in these patients (net reclassification improvement, 0.39 [95% CI, 0.11-0.72], P<0.019). LGE-dispersion mapping is a marker of scar heterogeneity and provides a better risk stratification than LGE presence and its extent in patients with hypertrophic cardiomyopathy and a low-intermediate 5-year risk of sudden cardiac death.

Long-term prognostic value of low-dose normal stress-only myocardial perfusion imaging by wide beam reconstruction: A competing risk analysis

BackgroundA normal stress myocardial perfusion single-photon emission computed tomography (MPS) is associated with a good clinical outcome. New iterative algorithms, such as wide beam reconstruction (WBR), which improve image interpretation with half-dose or half-time acquisition, have been proposed for cardiac MPS. The aim of this study was to assess the long-term predictive value of a low-dose normal stress-only MPS with WBR using conventional Anger camera in patients with known or suspected coronary artery disease (CAD). Methods and ResultsA total of 2106 patients with known or suspected CAD and normal perfusion at half-dose stress-only MPS protocol were followed for a mean of 6.6 ± 2.7 years. MPS data were reconstructed with WBR iterative algorithm. End-point events were cardiac death or nonfatal myocardial infarction. Noncardiac death was considered the competing event. During follow-up, 149 cardiac events occurred with an annualized event rate of 1.2%. Independent predictors of cardiac events at Cox analysis were age, male gender, diabetes mellitus, previous myocardial infarction and the need for pharmacologic stress testing. At Fine-Gray analysis the cumulative incidence of cardiac events progressively increases with age and in the presence of diabetes for any combination of gender and stress type. Survival tree analysis confirmed that long-term prognosis considerably varies according of risk factors profile. ConclusionsLow-dose normal stress-only WBR MPS has a reliable long-term prognostic value in patients with suspected or known CAD. This finding supports the introduction of such a method into clinical practice with a consistent dose optimization in the interest of patients and exposed staff.

Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection.

Background Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. Methods A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. Results The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection ( p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9–4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1–2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3–4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50–4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1–3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6–3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5–8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2–3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70–6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). Conclusions Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.

CRT-100.92 Natural History of Adapted Leaman Score Assessing Coronary Artery Disease Progression Over 7 Years by Computed Tomography Angiography

Computed Tomography Angiography (CTA) is being progressively used to stratify the cardiovascular risk in coronary artery disease (CAD) patients. Computed Tomography - adapted Leaman Score (CT-LeSc) has been shown to be an independent predictor of cardiac events in CAD patients with score >5 (high

Fragmented QRS complex in patients with systemic lupus erythematosus at the time of diagnosis and its relationship with disease activity.

Cardiovascular disease is an important contributor to the mortality rate of patients with systemic lupus erythematosus (SLE), which is related to SLE disease activity. Fragmented QRS (fQRS) complexes, defined by additional spikes in the QRS complex, are useful for identifying myocardial scars on electrocardiography and can be an independent predictor of cardiac events. We aimed to assess the relationship between disease activity in patients with SLE and fQRS at the time of diagnosis. Forty-four patients with SLE were included. Patients with cardiac diseases, other rheumatic diseases, and prior treatment at the time of electrocardiography measurement were excluded. The appearance of fQRS represented exposure. The primary outcome was SLE Disease Activity Index 2000 (SLEDAI-2K). Multiple regression analysis was conducted to assess the association between fQRS and SLEDAI-2K adjusted for age, sex, and time from the estimated onset date to the date of diagnosis. Among patients with SLE at diagnosis, 26 (59.1%) had fQRS. The median SLEDAI-2K was 18 (interquartile range [IQR], 12-22) and 9 (IQR, 8-15) in the fQRS(+) and fQRS(-) groups, respectively. SLEDAI-2K was significantly higher in the fQRS(+) group than in the fQRS(-) group (regression coefficient, 2.69; 95% confidence interval, 0.76-4.61; p = 0.008). Our results suggested that fQRS(+) patients with SLE had high disease activity. fQRS could likely detect subclinical myocardial involvement in patients with SLE and predict long-term occurrence of cardiac events.

P1544 Independent prognostic significance of non invasive left atrial stiffness in outpatients with heart failure and reduced ejection fraction

Abstract Background and Aim Left atrial (LA) stiffness is an important marker of cardiac pump function, especially in patients with heart failure (HF) and preserved ejection fraction (HFpEF). The aim of this study was to evaluate the relationship between LA stiffness and cardiac events (CE) in HF patients with reduced ejection fraction (HFrEF). Methods This study included 136 consecutive HFrEF outpatients (mean age: 65 ± 11 years). A complete conventional and tissue Doppler imaging study was performed. The LA dimension and function were measured. Non invasive LA stiffness was calculated with the following formula: LA stiffness = E/e’ratio/LA strain. The cardiac events were HF hospitalization and cardiac death. Results During a median follow up of 55 ± 37 months, 51 patients had CE, they had higher NYHA functional class (p = 0.001), higher LV end-diastolic dimension (p = 0.001), higher LV end-systolic dimension (p = 0.04), lower EF (p &amp;lt; 0.001), higher E/A ratio (p = 0.01) and reduced TAPSE (p = 0.001) compared with patients without CE. LA volume index was higher (p = 0.001), LA strain was reduced and LA stiffness was increased in patients with CE compared to those without CE (p = 0.0001, p &amp;lt; 0.0001, respectively). LA stiffness exhibited the closest relationship with E/e’ ratio (r = 0.67, p &amp;lt; 0.001). Survival analyses showed that LA stiffness [HR: 4.026 (1.300–12.468), p = 0.001] was the most powerful independent predictor of cardiac events[C1] . On ROC curve analysis, a LA stiffness &amp;lt; 0.82% was 81% sensitive and 73% specific (AUC 0.81, p &amp;lt; 0.001) in predicting clinical events (Figure 1). Conclusion In this cohort of outpatients with HFrEF, LA stiffness proved the most important predictor of clinical outcome. [C1] Abstract P1544 Figure.

P1512 Combination of mitral annular peak systolic and early diastolic velocities with early transmitral peak flow velocity: a new prognostic echo index in patients with acute coronary syndrome

Abstract Background One of the novel echocardiographic indices reflecting left ventricular (LV) diastolic filling is the combination of mitral annular peak systolic (s’) and early diastolic velocities (e’) with early transmitral peak flow velocity (E); E/(e’ x s’). This index is reported to be useful to predict a prognosis of heart failure patients regardless of their LV ejection fraction (LVEF).Purpose: The aim of this study was to examine whether or not E/(e’ x s’) could predict cardiac events in patients with acute coronary syndrome (ACS).Methods: We studies consecutive ACS patients hospitalized in our institution between December 2009 and February 2012. They underwent echo examination within 7 days after admission. By use of Doppler tissue imaging, e’ and s’ were respectively calculated by averaging the peak velocities measured at both septal and lateral mitral annulus in 4-chamber view. The exclusion criteria were as follows: atrial fibrillation, significant valvular diseases and inadequate echo images. Cardiac events were defined as re-hospitalization due to recurrent ACS and/or heart failure, and cardiac mortality.Results: In total, 168 patients were eligible for this study (mean age 67 ± 11 years, mean LVEF 51.7 ± 10.3 %). Median follow-up period was 22.5 months. During the follow-up, cardiac events occurred in 27 patients (16.1%). Between the patients with cardiac events and those without, there were significant differences in LV end-systolic volume (44.2 ± 29.1 vs 33.2 ± 13.6 ml, p &amp;lt; 0.05), LV mass index (122.4 ± 38.9 vs 107.5 ± 26.4 g/m², p &amp;lt; 0.05), left atrial volume index (31.7 ± 9.2 vs 27.6 ± 9.4 ml/m², p &amp;lt; 0.05), LVEF (45.7 ± 13.5 vs 52.9 ± 9.2 %, p &amp;lt; 0.05), s’ (5.1 ± 1.6 vs 7.1 ± 1.7 cm/sec, p &amp;lt; 0.001), e’ (4.8 ± 1.3 vs 6.0 ± 1.9 cm/sec, p &amp;lt; 0.05), E/e’ (16.4 ± 6.6 vs 12.5 ± 4.9, p &amp;lt; 0.05), E/(e’ x s’) (3.78 ± 2.52 vs 1.94 ± 1.08, p &amp;lt; 0.001), and serum B-type natriuretic peptide (334.7 ± 420.1 vs 113.8 ± 177.2 pg/ml, p &amp;lt; 0.05). While Cox proportional hazard multivariate analysis detected that E/(e’ x s’) and E/e’ were independent predictors of cardiac events, E/(e’ x s’) was more powerful than E/e’ (p = 0.0002 vs p = 0.0072). ROC analysis revealed that 2.35 of E/(e’ x s’) was the optimal cutoff values to predict cardiac events in ACS patients (AUC 0.79). Patients with E/(e’ x s’) &amp;lt;2.35 had significantly better prognosis than the rest (p &amp;lt; 0.0001, Log-rank; Figure)Conclusion: E/(e’ x s’) could be a useful echo marker to predict cardiac events in ACS patients. Abstract P1512 Figure.

P1525 Residual functional mitral regurgitation post-MitraClip is associated with worse hemodynamics and predicts poor outcome at 2-year follow-up

Abstract Background Percutaneous mitral valve repair using MitraClip offers symptomatic benefit and improves rest and exercise hemodynamics in patients with severe functional mitral regurgitation (MR). Recent randomized trials have shown contradictory results regarding the impact of MitraClip on mid-term survival in functional MR. It is unknown whether improved hemodynamics are related to patients" outcome. Purpose To assess whether residual MR and altered resting and exercise hemodynamics are predictors of outcome in patients with functional MR treated with MitraClip. Methods Consecutive patients (n = 45, 72 ± 10years, left ventricular ejection fraction (LVEF) 34 ± 9%) with symptomatic severe functional MR were prospectively evaluated by Doppler echocardiography at rest and during symptom-limited exercise on a semi-supine bicycle pre- and 6 months post-MitraClip procedure. LVEF, MR severity, cardiac output (CO), systolic pulmonary artery pressure (SPAP) and a flow-corrected SPAP/CO ratio were assessed at rest and peak exercise. 2-year follow-up clinical data were collected from patient records. Results During 2-year follow-up post-MitraClip, 15 patients (33%) experienced major cardiac events (hospitalization for heart failure (n = 14) and/or cardiac death (n = 5)). Age, gender, a history of coronary artery disease, diabetes, baseline MR severity and baseline SPAP/CO ratio at rest and during exercise were not related to a worse event-free survival. In contrast, patients with events at 2-year follow up had more often a history of hospitalization for heart failure (73 vs. 37%, p = 0.029), lower baseline LVEF (30 ± 8 vs. 36 ± 10%, p = 0.041), more residual MR at 6 months post-MitraClip (MR jet area/left atrial area 27 ± 14 vs. 15 ± 10%, p = 0.004) and higher SPAP/CO ratios at rest and during exercise 6 months post-MitraClip (13.9 ± 5.3 vs. 9.9 ± 3.4mmHg/L/min, p = 0.007 and 13.6 ± 4.9 vs. 9.4 ± 4.6mmHg/L/min, p = 0.009, respectively). When corrected for baseline LVEF, residual MR 6 months post-MitraClip remained an independent predictor for worse 2-year outcome. Residual MR was moderately correlated to a worse SPAP/CO ratio 6 months post-MitraClip (Pearson Rho 0.518, p &amp;lt; 0.001). Conclusions In patients with functional MR treated with MitraClip, residual MR at 6-month follow-up is associated with impaired hemodynamics, and is an independent predictor of cardiac events at 2-year follow-up.

Prognostic factors in heart failure patients with cardiac cachexia.

ObjectiveTo clarify whether cardiac cachexia (CC) alters the prognostic impact of other general risk factors in patients with heart failure (HF).MethodsThis was an observational study. CC was defined as the combination of a body mass index of < 20 kg/m2 and at least one of the following biochemical abnormalities: C-reactive protein > 5 mg/L; hemoglobin < 12 g/dL; and/or albumin < 3.2 g/dL. We divided 1608 hospitalized HF patients into a CC group (n = 176, 10.9%) and a non-CC group (n = 1432, 89.1%). The primary endpoints were cardiac event and all-cause death.ResultsThe presence of CC showed significant interactions with other risk factors including cancer, estimated glomerular filtration rate (eGFR), and sodium in predicting these endpoints. Multiple Cox proportional analysis revealed that use of â blockers [hazard ratio (HR) = 1.900, 95% confidence interval (CI): 1.045–3.455, P = 0.035) and eGFR (HR = 0.989, 95% CI: 0.980–0.998, P = 0.018) were independent predictors of cardiac event in the CC group, while age (HR = 1.020, 95% CI: 1.002–1.039, P = 0.029) and hemoglobin (HR = 0.844, 95% CI: 0.734–0.970, P = 0.017) were independent predictors of all-cause death. The survival classification and regression tree analysis showed the optimal cut-off points for cardiac event (eGFR: 59.9 mL/min per 1.73 m2) and all-cause death (age, 83 years old; hemoglobin, 10.1 g/dL) in the CC group.ConclusionsIn predicting prognosis, CC showed interactions with several risk factors. Renal function, age, and hemoglobin were pivotal markers in HF patients with CC.

The Impact of Femoropopliteal Artery Calcium Score after Endovascular Treatment

The coronary artery calcium score is a widely known independent predictor of cardiac events. Tibial artery calcification had been reported as an amputation risk, but the femoropopliteal artery calcium score is rarely known. A retrospective analysis was performed using the data collected from the patients who underwent endovascular treatment for the femoropopliteal artery between January 2010 and December 2017. The femoropopliteal artery calcium scores on preprocedural computed tomography were calculated according to the Agatston definition. The mean value of total of femoropopliteal artery calcium scores was used to divide the scores into two groups. The prognostic value of the calcium score was analyzed based on primary patency, clinically driven target lesion revascularization, major amputation, and all-cause death. In total, 132 consecutive limbs that underwent successful endovascular intervention were analyzed in this study; 44 and 88 limbs were assigned to the high and low calcium score groups, respectively. There were no significant differences between the two groups in terms of patient and lesion characteristics, except for chronic kidney disease (7% vs. 25%, P<0.01), hemodialysis (80% vs. 25%, P<0.01), and coronary artery disease (73% vs. 53%, P=0.03). Compared with the low calcium score group, the high calcium score group had a significantly higher rate of loss of primary patency and clinically driven target lesion revascularization at one year, based on the Kaplan-Meier curve (55% vs. 81%, 44% vs. 8%, both P<0.01). There were no significant differences between the two groups in terms of major amputation and death. Multivariate analysis revealed that hemodialysis [hazard ratio (HR): 1.9; 95% confidence interval (CI): 1.01-5.28; P=0.04] runoff grade 0 (HR: 2.9; 95% CI: 1.02-10.9; P=0.04), lesion length>200mm (HR: 3.9; 95% CI: 1.1-13.7; P=0.03), and calcium score per 100 increase (HR: 1.05; 95% CI: 1.02-1.08; P<0.01) were predictors of clinically driven target lesion revascularization. As per receiver operating characteristic analysis, the best cutoff value of target lesion calcium score for target lesion revascularization was206. A high femoropopliteal artery calcium score might increase loss of patency and the risk for clinically driven target lesion revascularization.

P2240CTA derived plaque characteristics and cardiac events in deferred lesions by invasive FFR

Abstract Background Fractional flow reserve (FFR) based strategy for coronary artery disease (CAD) is widely accepted. However, cardiac events could occur at deferred lesions after FFR. We previous reported that CT derived high risk plaque (HRP) and residual stenosis were the independent predictors of cardiac events. Purpose The purpose of this study was to investigate if plaque characteristics on CTA could predict cardiac events in deferred lesions after FFR. Methods We included 211 vessels of 193 patients who were deferred revascularization after CTA and invasive FFR. The presence of HRP and the stenosis grading on CTA were analyzed. Results Median follow-up period after CTA was 623 days (IQR 302–945). HRP and obstructive stenosis were detected in 58 (27.5%) and 87 (41.2%) lesions, respectively. Cardiac events were occurred in 10 lesions at 440±167 days in average (range: 150–770 days). Multivaliate cox hazard regression analysis revealed that HRP (HR8.01, p=0.0032) and obstructive stenosis with ≥70% (HR 34.93, p&lt;0.0001) were the independent predictors of cardiac events after adjusted for age, sex, and FFR≤0.8. Of 21 lesions with both HRP and obstructive stenosis, 29% lesions resulted in cardiac events in 2 years. Conclusions Even in the deferred lesions by invasive FFR, lesions with HRP and obstructive stenosis showed high rate of cardiac events. These lesions should be treated with intensive medical therapy to prevent cardiac events.

P1493Prognostic significance of right ventricular function during exercise in patients with non-obstructive hypertrophic cardiomyopathy

Abstract Background Hypertrophic cardiomyopathy (HCM) is a heterogeneous condition that may present crucial complication including life-threatening arrhythmia and sudden cardiac death. However, the risk stratification of HCM without left ventricular outflow tract (LVOT) obstruction had not been fully elucidated. Moreover, although recent studies have revealed the right ventricle (RV) involvement of HCM, the prognostic importance of RV function during exercise is unclear. Purpose To investigate the prognostic significance of RV function in patients with non-obstructive HCM using exercise stress echocardiography (ESE). Methods and results This study conducted on 100 HCM patients (age 62.9±13.6 years, 63% men) with preserved left ventricular ejection fraction who underwent ESE using semi-supine bicycle ergometer. Ten patients with significant LVOT obstruction (≥30mmHg) were excluded and 9 were also excluded because of the inadequate imaging quality or insufficiency of data. Among remaining 81 non-obstructive HCM patients, 9 patients suffered from HCM related cardiac events including cardiac death, unexpected hospitalization, life-threatening arrhythmias, and new-onset of syncope during the mean follow up period of 2.6±1.6 years. A multivariate Cox Hazard analysis revealed that low tricuspid annular plane systolic excursion during exercise (Ex-TAPSE, cut-off: 24mm) was an independent predictor of cardiac events. (hazard ratio: 18.66, 95% confidence interval: 3.66–338.46, P&lt;0.001) The estimated cumulative cardiac event free survival using the Kaplan-Meier method was significantly lower in patients with reduced Ex-TAPSE (&lt;24mm) than those with preserved Ex-TAPSE (Log-rank, P&lt;0.01). K-M curve according to Ex-TAPSE Conclusion Ex-TAPSE had a strong predictive value of clinical outcomes in non-obstructive HCM patients. Right ventricular function during exercise may have crucial role in the risk stratification of non-obstructive HCM.

P2462Left atrial appendage wall velocity evaluated by transthoracic echocardiography is a feasible parameter for predicting cardiac prognosis in patients with heart failure

Abstract Background It was reported that left atrial (LA) remodeling is occurred in patients with heart failure (HF), and increased LA volume index (LAVI) is a feasible predictor for poor prognosis of HF. It was reported that LA remodeling is associated with LA appendage (LAA) dysfunction. We previously reported that LAA wall motion velocity (LAWV) obtained by transthoracic echocardiography (TTE) can noninvasively evaluate LAA dysfunction. However, it remains to be determined whether LAWV is useful for predicting poor prognosis in patients with HF. Purpose We investigated whether LAA dysfunction assessed by LAWV is associated with poor prognosis in patients with HF. Methods We performed TTE at discharge in 217 consecutive patients who hospitalized for HF (126 males, 71±13 years) and prospectively followed them up. LAWV was measured using Doppler tissue imaging at the LAA tip from the parasternal short-axis view on TTE imaging. Results There were 86 patients with cardiac events including 14 cardiac deaths and 72 rehospitalizations for HF during a median follow-up period of 404 days (interquartile range 168–748 days). LAWV was significantly lower in patients with cardiac events than in those without. LAWV was significantly decreased with advancing left ventricular diastolic dysfunction grade. Kaplan-Meier analysis demonstrated that significantly higher cardiac event rate was observed in patients with low LAWV (log-rank test, P=0.004). Cox multivariate hazard analysis revealed that LAWV was an independent predictor for cardiac events after adjusting for confounding factors (hazard ratio 0.57, 95% confidence interval 0.40–0.82, P&lt;0.05). Further, we categorized the patients into 3 groups based on the median of LAWV and left atrial volume index (LAVI), and Kaplan-Meier analysis showed that patients with both low LAWV and high LAVI had the highest rate of cardiac events among 3 groups (log-rank test, P&lt;0.001; Figure). Figure 1 Conclusion LAWV may be a feasible parameter for predicting cardiac prognosis in patients with HF.

CARDIAC COMPLICATIONS OF DIABETICS IN SEPSIS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Although much is known about long-term sequelae of diabetics, little has been said about their course in sepsis. Previous research has failed to show an increased incidence of acute cardiovascular dysfunction (Esper et al, 2008). In general cardiovascular complications and infections are leading causes of morbidity and mortality amongst diabetics (Tancredi et al 2015, Bhansali et al, 2003). We propose that increased incidence of acute cardiovascular events will also be found in the setting of sepsis requiring hospitalization in a medical intensive care unit (MICU) and that previous studies may have missed the comprehensive spectrum of cardiac events they may experience. METHODS: A retrospective review of the electronic medical record was done among patients admitted to the MICU between 2011 and 2015. ICD codes billed during admission were used to measure principal admission diagnoses and acute cardiovascular events during admission. In hospital mortality was also collected. Only patients with a chief admission diagnosis that was an infectious disease were included (N= 1720) and this was used as a proxy for sepsis. The primary endpoint measured was relative risk of new onset cardiovascular events in diabetics versus non-diabetics among patients admitted to the MICU for sepsis. The secondary endpoint was relative risk of mortality during admission. This was quantified using two different Chi-Square Tests for Independence. We proposed that diabetics with sepsis were more likely than non-diabetics with sepsis to have cardiac events or to die during hospitalization. RESULTS: A between group analysis was done for septic diabetics versus septic non-diabetics using a Pearson Chi Square test comparing overall acute cardiac events and mortality. Patients with diabetes and sepsis were more likely to have a cardiac event during admission (65.2% vs 54.7%, p<0.0001) compared with septic patients without diabetes. Moreover, septic diabetes were more likely to die during admission than septic patients without diabetes (13.1% vs 9.1%, p =.01). CONCLUSIONS: In sepsis in the critical care setting, diabetes serves as an independent predictor of cardiac events and death during admission. CLINICAL IMPLICATIONS: Our study highlights the importance of close monitoring of diabetics for cardiac events when critically ill and for having a low threshold to evaluate cardiac complaints. These findings build upon our previous findings with our diabetic cohort of increased incidence of pulmonary embolus, arrhythmias, acute coronary syndromes and heart failure exacerbations while in the MICU. We suggest increased vigilance for diagnosing pulmonary emboli and acute coronary syndromes in this population when critically ill. Diabetics should have a lower threshold for prophylactic anticoagulation, need continued use of telemetry and should receive aspirin and statins if there is no contraindication to these medicines. DISCLOSURES: No relevant relationships by Robert Balk, source=Web Response No relevant relationships by Sarah Peterson, source=Web Response No relevant relationships by Rachel Wilson, source=Web Response No relevant relationships by Rebecca Wilson, source=Web Response

SCN5A mutations in 442 neonates and children: Genotype-phenotype correlation and identification of higher-risk subgroups

To clarify the clinical characteristics and outcomes of children with SCN5A-mediated disease and to improve their risk stratification. A multicentre, international, retrospective cohort study was conducted in 25 tertiary hospitals in 13 countries between 1990 and 2015. All patients ≤ 16 years of age diagnosed with a genetically confirmed SCN5A mutation were included in the analysis. There was no restriction made based on their clinical diagnosis. A total of 442 children {55.7% boys, 40.3% probands, median age: 8.0 [interquartile range (IQR) 9.5] years} from 350 families were included; 67.9% were asymptomatic at diagnosis. Four main phenotypes were identified: isolated progressive cardiac conduction disorders (25.6%), overlap phenotype (15.6%), isolated long QT syndrome type 3 (10.6%), and isolated Brugada syndrome type 1 (1.8%); 44.3% had a negative electrocardiogram phenotype. During a median follow-up of 5.9 (IQR 5.9) years, 272 cardiac events (CEs) occurred in 139 (31.5%) patients. Patients whose mutation localized in the C-terminus had a lower risk. Compound genotype, both gain- and loss-of-function SCN5A mutation, age ≤ 1 year at diagnosis in probands and age ≤ 1 year at diagnosis in non-probands were independent predictors of CE. In this large paediatric cohort of SCN5A mutation-positive subjects, cardiac conduction disorders were the most prevalent phenotype; CEs occurred in about one-third of genotype-positive children, and several independent risk factors were identified, including age ≤ 1 year at diagnosis, compound mutation, and mutation with both gain- and loss-of-function.

Late gadolinium enhancement on cardiac magnetic resonance combined with 123I- metaiodobenzylguanidine scintigraphy strongly predicts long-term clinical outcome in patients with dilated cardiomyopathy.

Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) is limited in its ability to detect diffuse interstitial fibrosis, which is commonly found in idiopathic dilated cardiomyopathy (DCM). On the other hand, Washout rate (WR) by cardiac 123I- metaiodobenzylguanidine (123I-MIBG) scintigraphy which evaluates cardiac sympathetic nervous function, is a useful tool for predicting the prognosis in DCM. We investigated the predictive value of the combination of two different types of examinations, LGE on CMR and WR by 123I-MIBG scintigraphy for outcomes in DCM compared with LGE alone. One-hundred forty-eight DCM patients underwent CMR and 123I-MIBG scintigraphy. Patients were divided into 4 groups according to the presence or absence of LGE and WR cut-off value of 45% for predicting prognosis based on receiver operating characteristic curve analysis. Cardiac deaths, re-hospitalization for heart failure, implantation of a left ventricular assist device, and life-threatening ventricular arrhythmias were defined as clinical events. Forty-two DCM patients reached the clinical events during the median follow-up for 9.1 years (interquartile range, 8.0–9.2 years).Multivariable Cox regression analysis identified WR≥45%+LGE positive group as an independent predictor of cardiac events (HR 3.18, 95%CI 1.36–7.45, p = 0.008). Notably, there was no significance in the cardiac event-free survival rate between the WR<45%+LGE positive and WR≥45%+LGE negative groups (p = 0.89). The combination of WR by 123I-MIBG scintigraphy and LGE on CMR, which evaluate different type of cardiac deterioration, serves as a stronger predictor of long-term outcomes in DCM patients than LGE alone.

Prognostic impact of mitral L-wave in patients with hypertrophic cardiomyopathy without risk factors for sudden cardiac death.

Hypertrophic cardiomyopathy (HCM) with severe diastolic dysfunction is a major cause of heart failure and sudden cardiac death (SCD) associated with lethal arrhythmia. Although various risk factors for cardiac events have been reported in HCM patients, previous studies have reported that some HCM patients exhibit either no risk or a low risk of SCD experienced cardiac events. The mid-diastolic transmitral flow velocity curve (mitral L-wave) is an echocardiographic index of left ventricular compliance, and it has been reported as one of the parameters of advanced diastolic dysfunction assessed noninvasively. However, little is known about the association between the mitral L-wave and long-term clinical outcomes in HCM patients without SCD risk factors. Between July 2005 and February 2016, 112 patients were diagnosed with HCM and 96 patients without risk factors were enrolled. After excluding 3 patients whom we could not detect L-wave more than once, 93 patients (mean age 57.7 ± 13.1years, 33 females) were divided into the following two groups, according to the presence or absence of the mitral L-wave: Group L (+) (with the mitral L-wave) and Group L (-) (without the mitral L-wave). The correlations between the mitral L-wave and rates of cardiac events were investigated. The mitral L-wave was present in 14 (15.1%) patients [Group L]. During the follow-up period [4.7 (2.9-7.5) years], patients experienced 7 cardiac events. Kaplan-Meier survival analysis showed that the event-free rate was significantly lower in Group L (+) than in Group L (-) (log-rank P = 0.002). Additionally, in multivariate analysis, L-wave positivity was identified as independent predictors of cardiac events. Existence of the mitral L-wave can predict cardiac events, even in HCM patients without SCD risk factors.

Left Ventricular Relaxation Half-Time as a Predictor of Cardiac Events in Idiopathic Dilated Cardiomyopathy and Hypertrophic Cardiomyopathy With Left Ventricular Systolic and/or Diastolic Dysfunction

Diastolic dysfunction preceding systolic dysfunction is considered an important interaction in cardiomyopathy with poor prognosis. The aim of this study was to compare left ventricular (LV) isovolumic relaxation with the other parameters as a potential prognostic marker for patients with idiopathic dilated cardiomyopathy (IDC) and hypertrophic cardiomyopathy (HC). A total of 145 patients with IDC and 116 with HC were evaluated for hemodynamic parameters; LV pressure was directly measured by a micromanometer catheter, and relaxation half-time (T1/2) was used to determine LV isovolumic relaxation. The median follow-up period was 4.7 years. The mean ages of the patients with IDC and HC were 52.0 ± 12.0 and 57.1 ± 12.4 years, respectively. Each patient group was further divided into 2 groups based on the median value of T1/2: (1) <41.0 ms (D-L group) and ≥41.0 ms (D-H group) (2) <38.5 ms (H-L group) and ≥38.5 ms (H-H group). Kaplan-Meier analysis showed a significantly higher probability of cardiac events in the D-H group than in the D-L group (p = 0.001) and in the H-H group than in the H-L group (p = 0.028). Further, Cox proportional hazard regression analysis revealed that T1/2 was an independent predictor of cardiac events for patients with IDC (hazard ratio 1.109; p = 0.007) and HC (hazard ratio 1.062; p = 0.041). In conclusion, regardless of the type of cardiomyopathy, T1/2 as a measure of LV isovolumic relaxation function was found to be associated with the occurrence of cardiac events.

A novel clinical risk prediction model for myocardial infarction, coronary revascularization, and cardiac death according to clinical, exercise, and gated SPECT variables (VH-RS).

To create a risk score for cardiac events (CE) according to clinical, exercise, and gated SPECT variables. We analysed 5707 consecutive patients; 3181 patients (age 64.2 ± 11 years, male 59.6%) with suspected coronary artery disease (CAD) [without previous myocardial infarction (MI) or coronary revascularization (CR)] and 2526 patients (age 63.3 ± 11 years, male 81.7%) with established CAD (with previous MI or CR). To create the Vall d'Hebron Risk Score (VH-RS), first we analyse the predictors of CE (non-fatal MI, CR, and/or cardiac death), then the probability of CE for every patient according to the predictive variables. According to risk we stratified patients into four risk levels: very low risk (VLR), low risk (LR), moderate risk (MR), and high risk (HRi) using Multiple Cox Regression analysis models. Finally, we validate the VH-RS in another prospective cohort of 734 patients. In patients with suspected CAD; age (P < 0.001); gender (P = 0.001); hyperlipidaemia (P < 0.001); nitrates (P = 0.04); ejection fraction (EF) (P = 0.001); summed stress score (P < 0.001); METs (P < 0.001); exercise angina (P = 0.006); and mm of ST segment depression (P = 0.004) were the independent predictors of CE (C-statistic: 0.8; P < 0.001). In patients with established CAD, EF (P < 0.001); summed difference score (P = 0.001); age (P < 0.001); smoker (P = 0.002); nitrates (P = 0.003); exercise angina (P = 0.001); METs (P < 0.001); and mm of ST segment depression (P = 0.011) were the independent predictors of CE (C-statistic: 0.7; P < 0.001). The risk score obtained from these variables allows the stratification of patients into four risk levels: VLR, LR, MR, and HRi. The cardiac risk stratification by mean of clinical, exercise, and gated SPECT variables is an objective aid to assessing an individual's cardiac risk.