Independent Predictor Of Major Cardiovascular Events Research Articles

Fragmented QRS as a Predictor of Cardiovascular Events in Patients with Type 2 Diabetes Mellitus: A 36-Month Follow-Up Data.

Major cardiovascular events (MACE) are more common in type 2 diabetes mellitus (T2DM) patients, and early diagnosis can prevent significant morbidity and mortality. The aim of this study was to investigate the predictiveness of fragmented QRS (fQRS) showing MACE in T2DM patients. A total of 227 T2DM patients (mean age 52, 51% male) without any cardiovascular disease who came to the cardiology outpatient clinic between March 01 and July 31, 2019, were included in the study. The patients were divided into 2 groups according to fQRS on electrocardiography (ECG), and 36 months of follow-up was done. The development of acute coronary syndrome, coronary revascularization, and cerebrovascular accident were accepted as MACE. More MACE was seen in the group with fQRS on ECG (P =.026). Although there were more fQRS in patients with proteinuria, it was not statistically significant (P =.069). More myocardial infarcts (7.9%) and more cerebrovascular events (6.3%) were seen in the group with fQRS. While revascularization was performed on 3 patients in the fQRS group, revascularization was not performed on the patients in the non-fqrs group. In multiple Cox regression analysis, fQRS showed an independent predictor of MACE [P =.025, hazard ratio = 2.42 (1.117-5.221)], more MACE was seen in the fQRS (+) group in the kaplan-meier analysis (P =.022). More MACE was seen in the fQRS group in T2DM patients without a previous history of cardiovascular events. Fragmented QRS was found to be an independent predictor in showing MACE. Care should be taken in terms of MACE development in T2DM patients with fQRS.

Predictors of major adverse cardiovascular events in patients with severe aortic stenosis awaiting aortic valve replacement

Abstract Background Severe aortic stenosis (AS) is a progressive disease associated with an increased risk of heart failure (HF) and mortality if left untreated. Aortic valve replacement (AVR) is the treatment of choice. However, it is not always immediately available, and some patients have experienced major cardiovascular events (MACE) while waiting for AVR. The identification of reliable predictors of MACE can help clinicians risk-stratify severe AS patients and tailor their management to prevent adverse outcomes. Purpose We aimed to evaluate predictors of MACE in real-world patients with severe AS who are waiting for AVR. Methods We conducted a prospective registry of consecutive patients discussed in the Heart Team meeting of a single centre, between January 2018 and June 2021. All patients with severe AS were included. For each patient we recorded demographic data, blood test results, echocardiogram parameters, and MACEs (a composite of death, HF hospitalization, non-fatal acute myocardial infarction, and non-fatal stroke). MACEs were recorded until the patient underwent AVR. The median follow-up time was 187 days (IQR 59-352). Results Overall, 235 patients were included (mean age 76.7±10.7 years, 48.1% male). Previous HF hospitalization (HR 2.77, 95% CI 1.66 – 4.62), HF symptoms with New York Heart Association (NHYA) class ≥3 (HR 2.64, 95% CI 1.58–4.39), and the presence of left ventricular dysfunction (HR 2.86, 95% CI 1.71–4.78) were independent predictors of MACE (Figure 1). The presence of pulmonary hypertension (HR 2.16, 95CI 1.27–3.66), but not right ventricular dysfunction (HR 2.34, 95CI 0.45–12.08, p=0.31), was associated with MACE until AVR. Concomitant moderate to severe tricuspid regurgitation (HR 10.88, 95CI 1.41–83.94) and moderate to severe mitral regurgitation (HR 5.91, 95CI 1.50–23.34) were associated with a worse prognosis, even when adjusted for other relevant MACE predictors. Laboratory data such as serum creatinine, haemoglobin, and NT-proBNP levels were not associated with the occurrence of MACE in this population (HR 1.00). Past medical history of hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease were not associated with MACE. Age was a limited predictor of MACE (HR 1.03, 95CI 1.00 – 1.06, p=0.04). Conclusion Previous HF hospitalization, NYHA class ≥3 symptoms, left ventricular dysfunction, and pulmonary hypertension were independent predictors of MACE in patients with severe AS awaiting AVR. Additionally, concomitant moderate to severe tricuspid and mitral regurgitation were also associated with worse prognosis. These findings may help identify those at high risk of MACE who would benefit most from early intervention and close monitoring.

The new score predicts 1-year poor outcome in patients with successful percutaneous coronary intervention: Naples prognostic score

Aims: This study investigated the relationship between Naples prognostic score (NPS) and 1-year poor clinical outcomes in patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI).
 Methods: The study included 121 patients who had NSTEMI and received successful PCI treatment. The researchers calculated NPS using the neutrophil/lymphocyte ratio, lymphocyte/monocyte ratio, serum albumin level, and total cholesterol. The patients were divided into two groups based on their NPS scores: those with scores of 0.1 and 2 and those with scores of 3 and 4. The study compared the occurrence of major cardiovascular events (MACE) such as 1-year all-cause mortality, 1-year nonfatal recurrent MI, and stroke between the two groups.
 Results: Patients with high NPS scores were observed to have significantly higher all-cause mortality than those with low NPS scores (23.9% vs. 9.3%, p=0.029). When the MACEs of the patients were compared, significantly higher MACE was observed in the high NPS group (39.1% vs. 18.7%, p=0.013).
 In multivariate logistic regression analysis, creatinine (OR:4,914, CI 95%: 1.310-18,433, p=0.018) and NPS 3-4 (OR:2.565, CI 95%: 1.093-6.017, p=0.030) were independent predictors of MACE.
 Conclusion: Composite MACEs of non-fatal recurrent MI, cerebrovascular accident, and all-cause death were higher at one year in patients with high NPS who underwent successful percutaneous intervention. High NPS is an indicator of MACE.

464-P: The Triglyceride–Glucose Index and Type 2 Diabetes Are Mutually Independent Predictors of Major Cardiovascular Events in Patients with Coronary Artery Disease

The triglyceride-glucose index (TyG) is a validated biomarker of insulin resistance. Its power to predict major cardiovascular events (MACE) in patients with established coronary artery disease (CAD) is unclear and is addressed in the present study. We enrolled 1032 consecutive patients with angiographically proven CAD. Prospectively, cardiovascular events were recorded over a mean follow-up period of 10.1±5.1 years. At baseline, the TyG index was significantly higher in patients with T2DM (n=346) than in nondiabetic subjects (9.3±0.7 vs. 8.7±0.5; p<0.001). During follow-up, 435 of our patients suffered MACE. The event rate was significantly higher in patients with T2DM than in nondiabetic subjects (48.7 vs. 39.4%; p=0.005). The TyG index in Cox regression models adjusting for age, sex, hypertension, smoking, body mass index, and LDL cholesterol independently predicted MACE in the total study population (standardized adjusted HR 1.40 [1.20-1.65], p<0.001); HRs in patients with T2DM and in nondiabetic subjects were 1.51 [1.18-1.93], p=0.001 and 1.16 [0.89-1.50], p=0.271, respectively, with no evidence of an interaction between TyG and T2DM (p=0.440). With T2DM additionally entered into the regression model, TyG on tee total study population predicted MACE independently from the presence of T2DM (HR 1.32 [1.10-1.57], p=0.003) while T2DM remained independently predictive of MACE after adjustment for TyG (HR 1.29 [1.04-1.59]; p=0.020). From our data we conclude that the TyG index and T2DM are mutually independent predictors of MACE in patients with established CAD. Disclosure T. Plattner: None. A. Vonbank: None. A. Mader: None. L. Sprenger: None. M. Maechler: None. B. Larcher: None. A. Leiherer: None. A. Muendlein: None. H. Drexel: None. C.H. Saely: None.

260-OR: The ApoB/LDL-C Ratio Predicts Major Cardiovascular Events in Cardiovascular Disease Patients Independent of Type 2 Diabetes Status

A high ApoB/LDL-C ratio reflects small LDL particle size which like type 2 diabetes (T2DM) is associated with insulin resistance. Whether the ApoB/LDL ratio and the presence of T2DM are mutually independent predictors of major cardiovascular events (MACE) is unclear and is addressed in the present study. We enrolled a large high risk cohort of 1689 patients with established cardiovascular disease (1391 patients with angiographically proven stable CAD and 298 patients with sonographically proven peripheral artery disease). T2DM was diagnosed according to current ADA guidelines. Prospectively, MACE including death from cardiovascular cause, non-fatal stroke and non-fatal myocardial infarction were recorded over a mean follow-up period of 9.6±5.1 years. At baseline, the ApoB/LDL-C ratio was significantly higher in patients with T2DM (n=561) than in subjects who did not have T2DM (0.82±0.19 vs. 0.74±0.15 p<0.001). During follow-up, 668 patients suffered MACE. The Apo B/LDL-C ratio predicted MACE in univariate analysis (HR=1.12 [1.04-1.20] p= 0.002), and the event rate was higher in patients with than in those without T2DM (49.1% vs. 34.9%; p<0.001). In a multivariate adjusted Cox regression model both the ApoB/LDL-C ratio and T2DM significantly predicted MACE in a mutually independent manner, with standardized adjusted HRs of 1.17 [1.05-1.30]; p=0.005 and 1.49 [1.26-1.75]; p<0.001, respectively. We conclude that in subjects with established cardiovascular disease the ApoB/LDL-C and T2DM are mutually independent predictors of MACE. Disclosure B.Larcher: None. C.H.Saely: None. M.Maechler: None. L.Sprenger: None. A.Mader: None. A.Vonbank: None. T.Plattner: None. A.Leiherer: None. A.Muendlein: None. H.Drexel: None.

Prognostic value of left-ventricular hemodynamic forces by echocardiography in patients with non-ischemic dilated cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Dilated cardiomyopathy (DCM) is a non-ischemic heart disease with reduced left-ventricular (LV) ejection fraction (LVEF) bearing high risk for heart failure (HF) and death (1). The evaluation of the LV by transthoracic echocardiography (TTE) is essential for diagnosis, prognosis, and follow-up, but conventional TTE parameters do not allow for proper risk assessment (2). Hemodynamic forces (HDF) by TTE may provide important information on LV mechanics (3), but their prognostic value in DCM is unknown. Purpose To test whether HDF provide prognostic value beyond conventional echocardiography parameters in DCM patients. Methods In this retrospective longitudinal study, we included patients diagnosed with DCM between 2015 and 2019 who underwent TTE and had coronary artery disease ruled out by coronary angiography. Patients were excluded from this analysis if at first available TTE were hospitalized or symptomatic for HF, had moderate-severe valvular heart disease, had atrial fibrillation during TTE evaluation, and if follow-up was <12 months. Major cardiovascular events (MACE) were considered as a composite of all-cause death, HF hospitalization, and need for ambulatory intravenous diuretic therapy (HF decompensation). LV HDF were analyzed on conventional TTE apical 2-, 3-, and 4-chamber view images with a prototype software (Medis Suite Qstrain, The Netherlands). HDF were decomposed into apex-base (HDFab) and lateral-septal (HDFls) components, and HDF angle (combination of both components, ranging from 0° to 90°) was computed (4). Results A total of 109 patients were included, but 12 patients were subsequently excluded for suboptimal TTE image quality. Thus, 97 patients were included in the study: 67 (69%) were males, mean age was 62±14 years, median follow-up was 4.2 [3.1–5.1] years, and mean LVEF was 39.2±8.6%. Mean HDFab, HDFls, and HDF angle were 5.73±1.94%, 1.65±0.53%, and 67.5±5.7°, respectively. MACE occurred in 19 patients (19.6%). Patients experiencing MACE had higher HDF angle (70.8±4.7 vs. 66.8±5.6°, p = 0.006), lower HDFls (1.31±0.41 vs. 1.71±0.53%, p = 0.003) but similar HDFab (5.4±1.7 vs. 5.8±2.0%, p = 0.393) compared with patients without MACE. On Cox univariate analysis age (HR 1.09 [95% CI 1.04–1.15], p<0.001) and HDF angle (HR 1.16 [95% CI 1.04–1.30], p = 0.007) were associated with MACE, while other conventional TTE parameters, including LVEF and LV longitudinal strain, were not. HDF angle was an independent predictor of MACE after adjusting for age, LVEF, and LV longitudinal strain on separate multivariate Cox analyses. HDF angle > 70° was consistently associated with worse prognosis (HR 2.68 [95% CI 1.09–6.60], p = 0.032). Conclusions HDF angle is an independent predictor of MACE onset in non-ischemic DCM patients. Higher HDF angle may be a marker of late worsening in myocardial performance in patients with reduced LVEF.

Long-term prognostic value of changes in left ventricular global longitudinal strain in patients with heart failure with preserved ejection fraction.

Left ventricular (LV) global longitudinal strain (GLS) has emerged as a more sensitive index than LV ejection fraction (LVEF) for detecting subclinical LV dysfunction. We examined whether changes in GLS values are associated with the long-term prognosis of patients with a preserved LVEF and acute decompensated heart failure (HF). We studied 100 consecutive patients (mean age: 71years) who were hospitalized for HF with preserved ejection fraction (HFpEF) and had a preserved LVEF (≥ 50%) in both the acute and stable phases. We performed two-dimensional speckle-tracking echocardiography in the acute (GLS-acute) and stable (GLS-stable) phases at a median of 2 and 347days after admission, respectively, and calculated the rate of change of the absolute value of GLS-stable with respect to that of GLS-acute. An improved GLS was defined as a rate of change in GLS ≥ 16%, and a non-improved GLS was a rate of change < 16%. The primary endpoint was the occurrence of major cardiovascular events (MACE). During a mean follow-up period of 1218days, MACE occurred in 26 patients, including 8 all-cause deaths and 18 readmissions for HF. The rate of change in GLS for patients with MACE was lower than compared to those without MACE (10.6% vs 26.0%, p < 0.001). Multivariate Cox regression analyses indicated the rate of change in GLS was an independent predictor of MACE (p < 0.001). A non-improved GLS was correlated with a high risk of MACE. Changes in GLS values could be useful for the long-term risk stratification of patients hospitalized for HFpEF and persistently preserved LVEF.

Prognostic Value of Logistic Clinical Syntax Score in Coronary Bifurcation Lesions Treated with Double Stent Technique

Introduction: In this study, we aimed to investigate the relationship between the preprocedural logistic clinical SYNTAX score (Log CSS) and major cardiovascular events (MACE) in patients with true bifurcation lesions who underwent revascularization with the double stent strategy. Patients and Methods: A total of 233 non-ST elevation myocardial infarction (NSTEMI) patients who underwent revascularization with a double stent strategy were retrospectively included in the study. Anatomical SYNTAX score (SS) and log CSS were calculated. The patients were divided into two groups according to the cut-off value determined by ROC analysis. The prediction of two-year MACE with Log CSS was evaluated. Results: MACE developed in 33.9% of patients with high Log CSS and 8.5% of patients with low Log CSS (p&lt; 0.001). In the Kaplan-Meier survival analysis, the long-term survival of the high Log CSS patients was significantly lower than the low Log CSS group (Log-rank p&lt; 0.001). In multivariate COX analyses, high Log CCS (HR= 3.781; 95% CI= 1.706-8.377; p= 0.001) was the strongest independent predictor of MACE. Conclusion: Log CSS can be a simple and useful tool to predict the development of MACE in patients with true bifurcation lesions revascularized by percutaneous coronary intervention.

Abstract 12440: Type 2 Diabetes, Chronic Kidney Disease, and Major Cardiovascular Events in Patients With Established Cardiovascular Disease

Introduction: Type 2 diabetes (T2DM) and chronic kidney disease (CKD) both confer a high risk of cardiovascular disease (CVD), and these conditions frequently coincide. The single and joint effects of T2DM and CKD on major cardiovascular events (MACE) in patients with established cardiovascular disease are unclear. Hypothesis: We hypothesize that T2DM and CKD are independent predictors of MACE in patients with established cardiovascular disease. Methods: We prospectively investigated 1738 patients with established cardiovascular disease - angiographically proven coronary artery disease (CAD) or sonographically proven peripheral artery disease (PAD) - over 10.0±4.7 years. Results: MACE occurred more frequently in T2DM patients (n=575) than in non-diabetic subjects (42.5% vs 29.8%, p&lt;0.001) and in patients with CKD (eGFR &lt;60ml/min/1.73m 2 ; n=302) than in those who did not have CKD (52.2% vs 30.1%, p&lt;0.001). When both, T2DM and CKD were considered, 996 subjects had neither T2DM nor CKD, 440 had T2DM but not CKD, 172 did not have diabetes but had CKD, and 130 had both T2DM and CKD. Compared to the incidence of MACE among patients with neither T2DM nor CKD (26.5%), MACE occurred more frequently in patients with T2DM who did not have CKD (38.2%; p&lt;0.001) as well as in non-diabetic patients with CKD (48.0%; p&lt;0.001); the incidence of MACE was highest in patients with both, T2DM and CKD (57.8%; p&lt;0.001), in whom it was higher than in those with T2DM but not CKD (p&lt;0.001) or those without T2DM but with CKD (p=0.007); the incidence of MACE was higher in non-diabetic CKD patients than in T2DM patients who did not have CKD (p=0.040). In Cox regression analysis, T2DM (HR=1.53 [1.29-1.83]; p&lt;0.001) and CKD (HR=1.85 [1.51-2.26]; p&lt;0.001) proved to be mutually independent predictors of MACE after adjustment for age, sex, BMI, hypertension, history of smoking, LDL-C, HDL-C and HbA1c. Conclusions: We conclude that T2DM and CKD in patients with established cardiovascular disease are mutually independent predictors of MACE. Cardiovascular disease patients with both CKD and T2DM are at an extremely high risk for MACE.

Abstract 11824: Chronic Kidney Disease, Type 2 Diabetes and the Risk of Major Cardiovascular Events in Coronary Artery Disease versus Peripheral Artery Disease Patients

Introduction: Chronic kidney disease (CKD) is a paramount indicator of cardiovascular risk and is highly prevalent in patients with established cardiovascular disease, especially among those with type 2 diabetes (T2DM). Peripheral artery disease (PAD) confers an even higher risk than coronary artery disease (CAD). Hypothesis: We hypothesize that cardiovasculr risk compares between PAD and CAD when analyses are stratified by the presence of CKD. Methods: We prospectively recorded major cardiovascular events (MACE) over 10.0±4.7 years in 1356 patients who had stable CAD, of whom 18.4% had CKD, and in 382 patients with PAD, of whom 20.9% had CKD. Four groups were analyzed: CAD patients without CKD (CAD/CKD-; n=1106), CAD patients with CKD (CAD/CKD+; n=250), PAD patients without CKD (PAD/CKD-; n=316) and PAD patients with CKD (PAD/CKD+; n=66). Results: The incidence of MACE was lowest in CAD/CKD- patients (27.2%) and significantly higher in CAD/CKD+ patients (49.6%; p&lt;0.001), in PAD/CKD- patients (40.9%; p&lt;0.001), and in PAD/CKD+ patients (56.9%; p&lt;0.001), who in turn were at a higher risk than CAD/CKD+ or PAD/CKD- patients (p=0.015 and p&lt;0.001, respectively). The risk of MACE did not differ significantly between CAD/CKD+ and PAD/CKD- patients (p=0.063). In Cox regression analysis after multivariate adjustment including gender, age, BMI, hypertension, history of smoking, LDL-C, and HDL-C the presence of PAD versus CAD (HR=1.51 [1.25-1.84]; p&lt;0.001), CKD (HR=1.85 [1.51- 2.26]; p&lt;0.001) and T2DM (HR=1.53 [1.29-1.83; p&lt;0.001) were mutually independent predictors of MACE. Conclusions: We conclude that CKD, T2DM and the presence of PAD versus CAD are mutually independent predictors of MACE.

Abstract 12422: Non-Alcoholic Fatty Liver Disease and Type 2 Diabetes Are Mutually Independent Predictors of Major Cardiovascular Events in Patients With Established Cardiovascular Disease

Introduction: Non-Alcoholic Fatty Liver Disease (NAFLD) is associated with insulin resistance, type 2 diabetes (T2DM) and cardiovascular disease. However, data on NAFLD in patients with established cardiovascular disease (CVD) are scarce. Hypothesis: We hypothesize that NAFLD and T2DM are independent predictors of the incidence of major cardiovascular events (MACE). Methods: In a large series of 1517 patients with established CVD (1199 patients with angiographically proven coronary artery disease and 318 patients with sonographically proven peripheral artery disease), using the validated fatty liver index for the diagnosis of NAFLD. Results: At baseline, the prevalence of NAFLD was significantly higher in patients with T2DM than in non-diabetic subjects (61.3% vs. 39.8%; p&lt;0.001) respectively. Prospectively, we recorded 498 MACE over a mean follow-up period of 10.0±4.5 years. The risk of MACE was higher in NAFLD patients than in those who did not have NAFLD (49.5 vs. 43.5%; p=0.020) and in patients with T2DM than in non-diabetic subjects (41.4 vs. 28.1%; p&lt;0.001). Cox regression models adjusting for conventional cardiovascular risk factors proved NAFLD and T2DM to be mutually independent predictors of MACE, with adjusted hazard ratios of 1.34 [1.06-1.69] p=0.013 and 1.59 [1.32-1.92]; p&lt;0.001, respectively. Conclusions: We conclude that NAFLD and T2DM are mutually independent predictors of MACE in patients with established CVD.

The predictive value of carotid artery strain and strain-rate in assessing the 3-year risk for stroke and acute coronary syndrome in patients with metabolic syndrome

Abstract Purpose The goal of this study is to see if carotid strain and strain rate can predict major cardio-vascular events (MACE) in people who have metabolic syndrome (MS) over a 3-year period of time. Methods In this prospective observational research, we enrolled 220 adult MS patients (60.7±7.5 years old, 53% male). Bilateral 2D common carotid carotid artery (CCA) speckle-tracking ultrasound was used to determine the peak circumferential strain (CS) and the peak circumferential strain rate (CSR). Clinical outcomes were assessed throughout a three-year follow-up period. Results After a 3-year follow-up period follow-up, 14 (7%) experienced MACE: Eight (4%) suffered an atherothrombotic ischemic stroke, four (2%) had acute coronary syndrome, and two (1%) were hospitalized for heart failure. Univariate regression analysis of the clinical and echocardiographic features of the MS patients found that age, systemic hypertension, diabetes mellitus, and the CCA circumferential strain and strain rate were significantly associated with the risk of MACE. Multivariate logistic regression identified two independent predictors of MACE in patients with MS, namely the CCA-related CS (%) and CSR (1/s), P&amp;lt;0.01. The ROC curve analyses of these independent predictors of MACE indicated appropriate sensitivities and specificities. CS (AUC = 0.806, sensitivity = 82.6%, specificity = 79.2%, P&amp;lt;0.0001); CSR (AUC = 0.779, sensitivity = 82.6%, specificity = 72.4%, P&amp;lt;0.0001). The cut-off values were ≤2.9% for carotid CS and ≤0.35 s–1 for carotid CSR. Using these cut-off values, we obtained Kaplan-Meier survival curves, and these showed that MACE, ischemic stroke, and ACS-free survival was significantly lower among the MS patients with lower carotid CS and CSR (P&amp;lt;0.0001). Conclusion Carotid CS and CSR were independent predictors of major cardio- and cerebrovascular events in prospectively monitored MS patients without established cardiovascular disease. Carotid deformation could be valuable as an early prognostic indicator for the cardiovascular risk in this population group. Funding Acknowledgement Type of funding sources: None.

Shedding light on the grey zone: characterisation and predictors of poor outcome in patients with suspected myocardial infarction triaged to the observe zone

Abstract Background To facilitate a rapid triage of patients with suspected myocardial infarction (MI), the European Society of Cardiology (ESC) recommends the application of a 0/1h-algorithm based on cardiac troponin. Patients, in whom neither rule-in nor rule-out of MI is possible, are assigned to the observe zone. Management of these patients can be challenging due to their heterogeneous nature. We aimed to characterize patients in the observe zone and identify predictors of incident cardiovascular events in these patients. Methods Patients with suspected MI presenting to the emergency department of a German tertiary center were prospectively enrolled. High-sensitivity cardiac troponin I (hs-cTnI) was measured at baseline and after 1 hour. Based on the ESC 0/1h algorithm, patients were stratified into rule-in, rule-out and observe zones. The final diagnosis was adjudicated according to the 4th Universal Definition of MI. We performed uni- and multivariable Cox regression analyses to identify predictors of major cardiovascular events (MACE), defined as the composite of all-cause mortality, recurrent MI and cardiac hospitalisation at 1 year in the observe zone. Results We included 2491 patients, of which 1046 (42.0%) were triaged to the rule-out zone, 512 (20.6%) to the rule-in zone and 933 (37.4%) to the observe zone. Observe patients were significantly older (median age 71 years vs. 56 years for rule-out vs. 69 years for rule-in) and more often male than patients in the rule-in and rule-out zone, respectively (67.1% vs. 58.8% vs. 66.6%). Cardiovascular risk factors were comparably frequent in observe and rule-in patients, but significantly more common than in rule-out patients. Angiography and consecutive percutaneous interventions during the index presentation were performed less frequently in observe patients (22.6% and 9.2%) than in rule-in patients (62.5% and 36.5%) but more often than in rule-out patients (9.9% and 3.8%). Among observe patients, 50 (5.4%) were diagnosed with MI and 452 (48.4%) with acute or chronic myocardial injury. At 1 year, the rate of MACE in the observe zone was significantly higher (25.0%) than in rule-out patients (12.2%) but only slightly lower than in rule-in patients (29.7%). Univariable and consecutive multivariable analyses with a backward selection process identified atrial fibrillation, hs-cTnI at 1h, hypertension, diabetes and a higher NYHA class as independent predictors of MACE (Table 1). Conclusion About one third of patients with suspected MI are categorized into the observe zone. These patients had almost comparably poor outcome as rule-in patients. Atrial fibrillation, hs-cTnI at 1h, hypertension, diabetes and a higher NYHA class were identified as predictors of an impaired outcome. These predictors could contribute to improving the identification of subjects at high risk in the observe zone and thereby facilitate management of these patients. Funding Acknowledgement Type of funding sources: None.

427-P: Nonalcoholic Fatty Liver Disease and Type 2 Diabetes Are Mutually Independent Predictors of Major Cardiovascular Events in Patients with Established Cardiovascular Disease

Non-Alcoholic Fatty Liver Disease (NAFLD) is associated with insulin resistance, type 2 diabetes (T2DM) and cardiovascular disease. However, data on NAFLD in patients with established cardiovascular disease (CVD) are scarce. Here, we therefore aimed at investigating the association of NAFLD with T2DM as well as its impact on the incidence of major cardiovascular events (MACE) in a large series of 1517 patients with established CVD (1199 patients with angiographically proven coronary artery disease and 318 patients with sonographically proven peripheral artery disease) , using the validated fatty liver index for the diagnosis of NAFLD. At baseline, the prevalence of NAFLD was significantly higher in patients with T2DM than in non-diabetic subjects (61.3% vs. 39.8%; p&amp;lt;0.001) respectively. Prospectively, we recorded 498 MACE over a mean follow-up period of 10.0±4.5 years. The risk of MACE was higher in NAFLD patients than in those who did not have NAFLD (49.5 vs. 43.5%; p=0.020) and in patients with T2DM than in non-diabetic subjects (41.4 vs. 28.1%; p&amp;lt;0.001) . Cox regression models adjusting for conventional cardiovascular risk factors proved NAFLD and T2DM to be mutually independent predictors of MACE, with adjusted hazard ratios of 1.34 [1.06-1.69] p=0.013 and 1.59 [1.32-1.92]; p&amp;lt;0.001, respectively. We conclude that NAFLD and T2DM are mutually independent predictors of MACE in patients with established CVD. Disclosure L.Sprenger: None. M.Maechler: None. A.Vonbank: None. B.Larcher: None. A.Mader: None. A.Leiherer: None. A.Muendlein: None. H.Drexel: None. C.H.Saely: None.

326-OR: Type 2 Diabetes, Chronic Kidney Disease, and Major Cardiovascular Events in Patients with Established Cardiovascular Disease

Type 2 diabetes (T2DM) and chronic kidney disease (CKD) both confer a high risk of cardiovascular disease (CVD) , and these conditions frequently coincide. The aim of this study was to investigate the single and joint effects of T2DM and CKD on major cardiovascular events (MACE) in patients with established cardiovascular disease. We prospectively investigated 1738 patients with established cardiovascular disease - angiographically proven coronary artery disease (CAD) or sonographically proven peripheral artery disease (PAD) - over 10.0±4.7 years. MACE occurred more frequently in T2DM patients (n=575) than in non-diabetic subjects (42.5% vs. 29.8%, p&amp;lt;0.001) and in patients with CKD (eGFR &amp;lt;60ml/min/1.73m2; n=302) than in those who did not have CKD (52.2% vs. 30.1%, p&amp;lt;0.001) . When both, T2DM and CKD were considered, 996 subjects had neither T2DM nor CKD, 440 had T2DM but not CKD, 172 did not have diabetes but had CKD, and 130 had both T2DM and CKD. Compared to the incidence of MACE among patients with neither T2DM nor CKD (26.5%) , MACE occurred more frequently in patients with T2DM who did not have CKD (38.2%; p&amp;lt;0.001) as well as in non-diabetic patients with CKD (48.0%; p&amp;lt;0.001) ; the incidence of MACE was highest in patients with both, T2DM and CKD (57.8%; p&amp;lt;0.001) , in whom it was higher than in those with T2DM but not CKD (p&amp;lt;0.001) or those without T2DM but with CKD (p=0.007) ; the incidence of MACE was higher in non-diabetic CKD patients than in T2DM patients who did not have CKD (p=0.040) . In Cox regression analysis, T2DM (HR=1.53 [1.29-1.83]; p&amp;lt;0.001) and CKD (HR=1.85 [1.51-2.26]; p&amp;lt;0.001) proved to be mutually independent predictors of MACE after adjustment for age, sex, BMI, hypertension, history of smoking, LDL-C, HDL-C and HbA1c. We conclude that T2DM and CKD in patients with established cardiovascular disease are mutually independent predictors of MACE. Cardiovascular disease patients with both CKD and T2DM are at an extremely high risk for MACE. Disclosure L.Sprenger: None. M.Maechler: None. A.Vonbank: None. B.Larcher: None. A.Mader: None. A.Leiherer: None. A.Muendlein: None. H.Drexel: None. C.H.Saely: None.

419-P: Chronic Kidney Disease, Type 2 Diabetes, and the Risk of Major Cardiovascular Events in Coronary Artery Disease vs. Peripheral Artery Disease Patients

Chronic kidney disease (CKD) is a paramount indicator of cardiovascular risk and is highly prevalent in patients with established cardiovascular disease, especially among those with type 2 diabetes (T2DM) . Peripheral artery disease (PAD) confers an even higher risk than coronary artery disease (CAD) . How cardiovascular risk compares between PAD and CAD patients when analyses are stratified by the presence of CKD is unclear and is addressed in the present study. We prospectively recorded major cardiovascular events (MACE) over 10.0±4.7 years in 1356 patients who had stable CAD, of whom 18.4% had CKD, and in 382 patients with PAD, of whom 20.9% had CKD. Four groups were analyzed: CAD patients without CKD (CAD/CKD-; n=1106) , CAD patients with CKD (CAD/CKD+; n=250) , PAD patients without CKD (PAD/CKD-; n=316) and PAD patients with CKD (PAD/CKD+; n=66) . The incidence of MACE was lowest in CAD/CKD- patients (27.2%) and significantly higher in CAD/CKD+ patients (49.6%; p&amp;lt;0.001) , in PAD/CKD- patients (40.9%; p&amp;lt;0.001) , and in PAD/CKD+ patients (56.9%; p&amp;lt;0.001) , who in turn were at a higher risk than CAD/CKD+ or PAD/CKD- patients (p=0.015 and p&amp;lt;0.001, respectively) . The risk of MACE did not differ significantly between CAD/CKD+ and PAD/CKD- patients (p=0.063) . In Cox regression analysis after multivariate adjustment including gender, age, BMI, hypertension, history of smoking, LDL-C, and HDL-C the presence of PAD versus CAD (HR=1.51 [1.25-1.84]; p&amp;lt;0.001) , CKD (HR=1.85 [1.51- 2.26]; p&amp;lt;0.001) and T2DM (HR=1.53 [1.29-1.83; p&amp;lt;0.001) were mutually independent predictors of MACE. We conclude that CKD, T2DM and the presence of PAD versus CAD are mutually independent predictors of MACE. Disclosure L.Sprenger: None. M.Maechler: None. A.Vonbank: None. B.Larcher: None. A.Mader: None. A.Leiherer: None. A.Muendlein: None. H.Drexel: None. C.H.Saely: None.

The Predictive Value of Carotid Artery Strain and Strain-Rate in Assessing the 3-Year Risk for Stroke and Acute Coronary Syndrome in Patients with Metabolic Syndrome

Purpose: The goal of this study is to see if carotid strain and strain rate can predict major cardio-vascular events (MACE) in people who have metabolic syndrome (MS) over a 3-year period of time. Methods: In this prospective observational research, we enrolled 220 adult MS patients (60.7 ± 7.5 years old, 53% male). Two-dimensional common carotid carotid artery (CCA) speckle-tracking ultrasound was used to determine the peak circumferential strain (CS) and the peak circumferential strain rate (CSR). Clinical outcomes were assessed throughout a three-year follow-up period. Results: After a 3-year follow-up period follow-up, 14 (7%) experienced MACE: Eight (4%) suffered an atherothrombotic ischemic stroke, four (2%) had acute coronary syndrome, and two (1%) were hospitalized for heart failure. Univariate regression analysis of the clinical and echocardiographic features of the MS patients found that age, systemic hypertension, diabetes mellitus, and the CCA circumferential strain and strain rate were significantly associated with the risk of MACE. Multivariate logistic regression identified two independent predictors of MACE in patients with MS, namely the CCA-related CS (%) and CSR (1/s), p &lt; 0.01. The Receiver operating characteristic (ROC) curve analyses of these independent predictors of MACE indicated appropriate sensitivities and specificities. CS (AUC = 0.806, sensitivity = 82.6%, specificity = 79.2%, p &lt; 0.0001) and CSR (AUC = 0.779, sensitivity = 82.6%, specificity = 72.4%, p &lt; 0.0001) with cut-off values of ≤2.9% for carotid CS and ≤0.35 s-1 for carotid CSR. Using these cut-off values, we obtained Kaplan-Meier survival curves, and these showed that MACE, ischemic stroke, and ACS-free survival was significantly lower among the MS patients with lower carotid CS and CSR (p &lt; 0.0001). Conclusions: Carotid CS and CSR were independent predictors of major cardio- and cerebro-vascular events in prospectively monitored MS patients without established cardiovascular disease. Carotid deformation could be valuable as an early prognostic indicator for the cardiovascular risk in this population group.

Prognostic value of ST segment elevation in aVR in patients with non ST elevation myocardial infarction

Although the presence of an ST segment elevation in the aVR lead was more common in patients with multivessel and/or left main disease, its long-term prognostic value is poorly understood. This study aims to describe the association of an ST segment elevation in AVR with the occurrence of MACE following a non ST elevation myocardial infarction (NSTEMI). A total of 340 patients admitted for NSTEMI were included. Patients were classified as having an ST elevation or having a normal ST segment in aVR based on the admission ECG. The primary endpoint was the onset of major cardiovascular events (MACE) at 1 year. Among 340 patients, 20 patients (5.3%) had ST segment elevation in aVR. Patients with ST elevation had a higher rate of multivessel disease. The ST elevation in AVR was not an independent predictor of in-hospital mortality in patients with NSTEMI (OR: 6.58, 95% CI 1.23-30.22 P = 0.061). However, patients with ST segment elevation in aVR had a higher rate of MACE at 1 year (38% vs. 13%, P = 0.03). The ST segment elevation was an independent predictor of MACE at 1 year (OR 4.31; 95% CI 1.3-14.32; P = 0.03). Based on these results, the ST segment elevation, as a simple marker, appears to be an independent predictor of MACE at 1 year in patients admitted with NSTEMI and may be a useful endpoint in risk stratification for the occurrence of MACE in these patients.

Abstract 10549: Clinical Significances of Left Atrial Volume vs Function in Nonischemic Cardiomyopathy

Introduction: Left atrium (LA) structure/function is reported to provide incremental prognostic information in patients with heart failure. However, its clinical impact is not fully elucidated in nonischemic cardiomyopathy (NICM). Therefore, we explored the clinical significance in patients with NICM, especially by clarifying the different roles between LA volume and emptying fraction. Methods: Consecutive patients with NICM who underwent cardiac magnetic resonance were analyzed and followed. Cox regression models were used to estimate hazard ratios (HRs) for major cardiovascular events (MACE) related to LA volume and emptying fraction. Results: Among the 625 patients with NICM including left ventricle non-compaction, dilated cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, and cardiac amyloidosis (mean age; 64.4 ± 14.2 years, and female; 39.7%), 133 had a history of AF at baseline. Baseline AF was associated with both higher LA volume and lower emptying fraction independently; however, it was not associated with increased MACE (P = 0.245). New-onset AF developed in 5.9% of the patients during a median follow-up of 20.3 months, with maximum LA volume as its strong and independent predictor (P &lt; 0.001, the area under the ROC curve AUC of 0.795). It was superior to LA emptying fraction (Figure A). In Kaplan-Meier analysis, patients with new-onset AF showed increased MACE compared with those of sinus rhythm or baseline AF (P = 0.002). New-onset AF and LA emptying fraction were independent predictors of MACE (HR: 2.28, 95% CI: 1.20-3.97, and HR: 0.98, 95% CI: 0.96-0.99, respectively) after adjusting for age, gender, body mass index, and diagnosis. Maximum LA volume alone was not associated with MACE (Figure B). Conclusions: Both LA volume and function were independently associated with baseline AF in patients with NICM. Maximum LA volume predicted the incidence of new-onset AF best, and only LA emptying fraction was associated with a worse prognosis.

Abstract 8920: Type 2 Diabetes, Chronic Kidney Disease and Major Cardiovascular Events in Patients with Established Coronary Artery Disease

Introduction: Both type 2 diabetes (T2DM) and chronic kidney disease (CKD) confer a high risk of cardiovascular disease (CVD), and these conditions frequently coincide. Hypothesis: We hypothesize that there are single and joint effects of T2DM and CKD on major cardiovascular events (MACE) in a high-risk population of patients with established coronary artery disease (CAD). Methods: We prospectively investigated 1460 patients with angiographically proven CAD over 10.4±4.8 years, of whom 454 (30.8%) had T2DM and 251 (17.1%) had CKD. Results: MACE occurred more frequently in T2DM patients than in non-diabetic subjects (40.4% vs 28.7%, p&lt;0.001) and in patients with CKD (eGFR &lt; 60ml/min/1.73m 2 ) than in those with an eGRF ≥60ml/min/1.73m 2 (51.6% vs 28.3%, p&lt;0.001). When both, T2DM and CKD were considered, 863 subjects had neither T2DM nor CKD, 346 had T2DM but not CKD, 148 did not have diabetes but had CKD, and 103 had both T2DM and CKD. When compared with the incidence of MACE among patients with neither T2DM nor CKD (25.3%), MACE occurred more frequently in patients with T2DM who did not have CKD (35.8%; p&lt;0.001) as well as in non-diabetic patients with CKD (47.6%; p&lt;0.001) and occurred most frequently in patients with both, T2DM and CKD (57.4%; p&lt;0.001), in whom the incidence of MACE was higher than in those with T2DM but not CKD (p&lt;0.001) or those without T2DM but with CKD (p=0.025); the incidence of MACE was higher in non-diabetic CKD patients than in T2DM patients who did not have CKD (p=0.041). In Cox regression analysis, T2DM (HR=1.46 [1.20-1.78]; p&lt;0.001) and CKD (HR=1.81 [1.45-2.27]; p&lt;0.001) were mutually independent predictors of MACE after multivariate adjustment. Conclusions: We conclude that T2DM and CKD are mutually independent risk factors for MACE in patients with established CAD. CAD patients with both CKD and T2DM are at an extremely high risk for MACE.