Independent Predictors Of Events Research Articles

Nutrition status, obesity and outcomes in patients with atrial fibrillation

Introduction and objectivesA paradoxical protective effect of obesity has been previously reported in patients with atrial fibrillation (AF). The aim of this study was to determine the impact of nutritional status and body mass index (BMI) on the prognosis of AF patients. MethodsWe conducted a retrospective population-based cohort study of patients with AF from 2014 to 2017 from a single health area in Spain. The CONUT score was used to assess nutritional status. Cox regression models were used to estimate the association of BMI and CONUT score with mortality. The association with embolism and bleeding was assessed by a competing risk analysis. ResultsAmong 14 849 AF patients, overweight and obesity were observed in 42.6% and 46.0%, respectively, while malnutrition was observed in 34.3%. During a mean follow-up of 4.4 years, 3335 patients died, 984 patients had a stroke or systemic embolism, and 1317 had a major bleeding event. On univariate analysis, BMI was inversely associated with mortality, embolism, and bleeding; however, this association was lost after adjustment by age, sex, comorbidities, and CONUT score (HR for composite endpoint, 0.98; 95%CI, 0.95-1.01; P=.719). Neither obesity nor overweight were predictors of mortality, embolism, and bleeding events. In contrast, nutritional status—assessed by the CONUT score—was associated with mortality, embolism and bleeding after multivariate analysis (HR for composite endpoint, 1.15; 95%CI, 1.14-1.17; P<.001). ConclusionsBMI was not an independent predictor of events in patients with AF in contrast to nutritional status, which showed a strong association with mortality, embolism, and bleeding.The study was registered at ClinicalTrials.gov (Identifier: NCT04364516).

The value of diastolic speckle-tracking parameters in predicting outcome after surgical ventricular restoration

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): DZHK (German Centre for Cardiovascular Research) BMBF (German Ministry of Education and Research) Background. Parameters of speckle-tracking echocardiography (STE) are incorporated into the integrative assessment of left ventricular (LV) diastolic function 1. In this study we aimed to evaluate both established and novel STE parameters of LV diastolic function and their prognostic role in patients with LV anteroapical aneurysm planned for surgical ventricular restoration (SVR). Methods. We retrospectively examined data of 137 patients (60 ± 11 years, 25% women) with anteroapical LV aneurysm who underwent SVR and for whom preoperative echocardiography was available and feasible for STE and for conventional assessment of LV diastolic function by transmitral flow. STE parameters evaluated were: left atrial reservoir strain (LAS), early and late global diastolic strain rate (GLSRe and GLSRa), ratio of early-to-late diastolic strain rate (GLSRe/GLSRa), and ratio of early diastolic transmitral flow velocity (E) to GLSRe and to GLSRa. In 24 patients we evaluated an association of diastolic echocardiographic parameters with mean pulmonary artery pressure (PAPm) and mean pulmonary capillary wedge pressure (PCWPm) obtained invasively within 6 days of echocardiography. Preoperative echocardiographic parameters were assessed in whole cohort of patients for the association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. Results. During a median follow-up of 4.7 years (IQR: 1.4-8.1 years) events occurred in 59 patients. GLSRa, E/GLSRa and LAS demonstrated significant correlation with PAPm and PCWPm (Table 1). GLSRa with optimal cut-off value of ≤ 0.41 s-1 was able to detect PAPm &amp;gt;30 mmHg with sensitivity of 0.8 and specificity of 0.8 (AUC 0.85; 95% CI 0.68-1.0; p = 0.008). E/GLSRa ≥1.24 m was able to detect PAPm &amp;gt;30 mmHg with sensitivity of 1.0 and specificity of 0.8 (AUC 0.87; 95%CI 0.7-1.0; p = 0.005). There was significant difference in event-free survival between groups stratified by cut-offs for GLSRa (Fig. 1A) and E/GLSRa (Fig. 1B). After adjustment for important clinical (age, sex, plasma creatinine, atrial fibrillation) and echocardiographic parameters (fractional shortening and LV end-systolic volume index) GLSRa and E/GLSRa remained an independent predictors of events (HR 0.16; 95% CI: 0.03-0.86; p = 0.032 and HR 1.22; 95% CI: 1.03-1.43; p = 0.018) and demonstrated higher prognostic value compared to LAS, other STE parameters and conventional parameters of LV diastolic function. Conclusion. Late diastolic longitudinal strain rate and ratio of early diastolic transmitral flow velocity to late diastolic longitudinal strain rate demonstrated association with hemodynamic parameters in patients with LV anteropaical aneurysm and might be used for the evaluation of LV diastolic function. These parameters showed prognostic value for patients underwent SVR and could be implemented for preoperative evaluation of these patients. Abstract Table 1. Correlation data Abstract Figure 1. Survival curves

Abstract 14088: Ventricular Longitudinal Function by CMR Predicts Heart Failure Associated Morbidity in Patients With Heart Failure and Reduced Ejection Fraction

Ventricular longitudinal function measured as basal-apical atrioventricular plane displacement (AVPD) or global longitudinal strain (GLS) are potent predictors of mortality and could potentially be predictors of morbidity in heart failure (HF). We hypothesize that decreased AVPD and GLS are associated with increased morbidity measured. Patients with HFrEF (EF≤40%) referred to a CMR exam were considered for inclusion. Ventricular longitudinal function, ventricular volumes and myocardial fibrosis or infarctions were analyzed. National registries provided data on cause of cardiovascular hospitalizations and cardiovascular mortality and this was used as a composite endpoint. A time-to-event analysis capable of including reoccurring events were employed with 5-year follow-up. HFrEF patients (n=287, age 62±12, 78% male) had EF 26.5% (SEM 0.5), AVPD 7.8 mm (SEM 0.1) and GLS -7.5% (SEM 0.2). There were 578 events in total and the vast majority was HF hospitalizations (n=418). Other major events were revascularizations (n=64), cardiovascular deaths (n=40) and myocardial infarctions (n=21), and 155 (54%) patients experienced at least one event (Mean 2.0, range 0-64). Patients in the bottom AVPD or GLS tertile (&lt;6.8mm or &gt;-6.1%) experienced over 3 times as many events compared to the top tertile (&gt;8.8 mm or &lt;-8.4%, p&lt;0.001) (Figure 1). In multivariate analysis adjusted for significant variables, AVPD and GLS remained as independent predictors of events (HR 1.12 per-mm-decrease and HR 1.13 per-%-increase) (Table 1). In conclusion, ventricular longitudinal function, measured either as AVPD or GLS, have independently prognostic implications for morbidity in HFrEF patients.

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.

Study of Safety and Efficacy of Novel Sirolimus-Eluting Stent Incorporating Properties of Drug Coating Balloon Among Real World Patients Focusing Younger Population (

ObjectiveAim of study was to evaluate safety and efficacy of abluminal Mitigator DES + Sirolimus Eluting Stent (Envision Scientific, Surat, India) incorporating novel technology of fusion coating of bioresorbable polymer on both abluminal surface of stent and exposed parts of balloon among real world patients specially focusing younger patients (<35 years).Method1293 patients received Mitigator DES + at LPS Institute of Cardiology, Kanpur, India. Primary outcome was target lesion failure (TLF)- composite of cardiovascular death, target vessel myocardial infarction (TVMI), and target lesion revascularization (TLR) and secondary end points including peri-procedural device failure (failure of stent delivery, change of stent, stent fracture), target vessel failure (TVF), and patient oriented composite end point (POCE)-composite of all deaths, MI, and revascularization and stent thrombosis (ST) at 1-year follow-up.ResultYounger population comprised of 374 (29%) patients. Various indications of interventions were STEMI (n = 614; 47.4%), NSTEMI (n = 416; 32.2%), UA (n = 161; 12.5%), and CCS (n = 102; 7.9%). TLF at 1 year in young and overall population were 3.4% and 3.5% respectively which was driven by TVMI and TLR in 1.3% and 1.1% patients respectively. POCE was observed in 9.5% in each group mainly contributed by any revascularization (3.9%). Device failure was significantly lower in young group than overall population (1.3% vs. 2.2%; p = 0.04) which was mainly driven by stent delivery (1.1%) and edge dissection (0.5%). Definite and probable ST was 1.3% and 1.7% respectively which was not significant. Young patients showed insignificantly lower TLF, TVF, ST and POCE and significantly lower device failure (1.3% vs. 2.6%; p = 0.04) when compared to patients >35 years. On multivariate regression analysis, complex lesion, in-stent restenosis, failure of stent delivery and edge dissection were independent predictors of events or device success rate.ConclusionMitigator DES+™ is safe among real world patients, including young population.

Human epididymis protein 4: a novel predictor of ischemic cardiomyopathy

BackgroundThe prognostic value of human epididymis protein 4 (HE4) in patients with ischemic cardiomyopathy (ICM) is unknown.MethodsA total of 103 patients with ICM were prospectively enrolled in this study from Hunan Provincial People’s Hospital between February 2019 and June 2019. All patients were tested for HE4 levels at baseline and follow-up. Endpoints of the study included cardiovascular death and heart failure-related hospitalization.ResultsA total of 96 patients with ICM were included for analysis. After a mean follow-up period of 263 (153–313) days, cardiovascular events were observed in 45 patients. Serum HE4 levels in patients with events were significantly higher than those in patients without events [188.70 (113.35–326.82) pmol/L versus 92.90 (61.50–123.20) pmol/L, P < 0.001]. Multivariate Cox regression analysis revealed that HE4 [χ2: 9.602, hazard ratio (HR): 1.003, 95% confidence interval (CI): 1.001–1.005, P = 0.002] and age [χ2: 4.55, HR: 1.044, 95% CI: 1.003–1.085, P = 0.033] were independent predictors of events. After adjusting for age and sex, the risk of events in patients with HE4 > 100.2 pmol/L was higher than that in patients with HE4 ≤ 100.2 pmol/L [HR: 3.372, 95% CI: 1.409–8.065, P < 0.001].ConclusionHE4 is an independent predictor of cardiovascular death and heart failure-related rehospitalization in patients with ICM.

Additive prognostic value of coronary flow and heart rate reserve during vasodilator stress echocardiography in hypertrophic cardiomyopathy

Abstract Background Coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) during vasodilator stress echocardiography (SE) assess coronary microvascular function and cardiac sympathetic reserve respectively. Both CFVR and HRR can be impaired in hypertrophic cardiomyopathy (HCM). Objectives To evaluate the prognostic value of CFVR and HRR during vasodilator SE in HCM. Methods We enrolled 244 HCM patients (age=51±15 years, 116 men) studied with vasodilator SE from 1999 to 2019 in 5 certified centers. Stress modality was either adenosine (Ado, 0.14 mg/kg/min in 2', n=171) or dipyridamole (Dip, 0.84 mg/kg in 6', n=73). Left ventricular outflow tract obstruction was present at rest in 80 patients (33%). We assessed CFVR in left anterior descending coronary artery (by TTE in 225, and TEE in 19 patients) and HRR (peak/rest heart rate). Abnormal values of HRR were based on receiver operating characteristics for Ado and Dip separately calculated. All patients completed the follow-up. Results CFVR was 2.17±0.46 for Dip and 2.13±0.43 for Ado (p=ns); HRR was 1.36±0.19 for Dip and 1.10±0.16 for Ado (p&amp;lt;0.001). An abnormal CFVR (&amp;lt;2.0 for both Ado and Dip) was present in 28 patients for Dip and 73 for Ado (38% vs 43%, p=ns). An abnormal HRR (≤1.34 for Dip and ≤1.03 for Ado) was present in 39 patients for Dip and in 70 patients for Ado (53% vs 41%, p=ns). During a median follow-up of 67 months (interquartile range: 29–103 months), 97 spontaneous events occurred in 71 patients: 29 all-cause deaths, 32 new hospital admission for acute heart failure, 3 sustained ventricular tachycardias, 32 atrial fibrillations and 1 heart transplantation. Event rate was 2.5%/year in patients with normal CFVR and HRR, 4.7%/year in patients with only one abnormal criterion and 10.9%/year in patients with abnormal responses of both criteria (see figure). At multivariate analysis, abnormality of both CFVR and HRR (Hazard ratio 4.033, 95% CI 1.863–8.729, p&amp;lt;0.001) was independent predictor of events. Conclusions A reduced CFVR and blunted HRR during vasodilator SE identify distinct phenotypes and show independent value in predicting outcome in HCM patients. Funding Acknowledgement Type of funding sources: None. Figure 1. Kaplan-Meier spontaneous event-free survival curves based on HRR and CFVR. Kaplan-Meier survival curves (considering spontaneous events) in patients stratified with the abnormal HRR and/or CFVR. Number of patients at risk per year is shown.

Long-Term Prognostic Value of the Response to Therapy Assessed by Laboratory and Imaging Findings in Patients with Differentiated Thyroid Cancer.

Simple SummaryIn patients with differentiated thyroid cancer (DTC), the American Thyroid Association dynamic risk stratification system has been proposed to identify patients at higher risk of recurrence during follow-up. This system is based on a combination of serum thyroglobulin determination and neck ultrasonography obtained 12-months after radioactive iodine (RAI) therapy. Radioiodine diagnostic whole-body scan (WBS) is performed less frequently due to its low sensitivity. In this retrospective study we assessed the long-term predictive value of the response to therapy at 12 months, evaluated by serum thyroglobulin determination and neck ultrasound, and estimated the potential additional impact of diagnostic WBS in patients with DTC treated with surgery and RAI therapy. Our findings could help in the identification of DTC patients at higher risk of recurrence that could benefit from a closer follow-up.This study assessed the long-term predictive value of the response to therapy, evaluated by serum thyroglobulin (Tg) determination and neck ultrasound, and estimated the potential additional impact of diagnostic whole-body scan (WBS) in patients with differentiated thyroid cancer (DTC) treated with surgery and radioactive iodine (RAI) therapy. We retrospectively evaluated 606 DTC patients treated with surgery and RAI. Response to 131I therapy at 12 months was assessed by serum Tg measurement, neck ultrasound, and diagnostic WBS. According to American Thyroid Association (ATA) guidelines, patients were classified as having a low, intermediate or high risk of recurrence and at 12 months as having an excellent response (ER) or no-ER. Follow-up was then performed every 6–12 months with serum Tg determination and imaging procedures. With a median follow-up of 105 months (range 10–384), 42 (7%) events requiring further treatments occurred. Twenty-five patients had additional RAI therapy, 11 with structural disease in the thyroid bed, eight in both thyroid bed and neck lymph nodes, four had lung metastases and two had bone metastases. The other 17 patients had additional surgery for nodal disease followed by RAI therapy. The ATA intermediate and high risk of recurrence, post-operative and pre-RAI therapy Tg ≥ 10 ng/mL, and the absence of ER at 12 months were independent predictors of events. Diagnostic WBS at 12 months permitted the identification of only five recurrences among the 219 ER patients according to serum Tg levels and ultrasound. In DTC patients, the response to therapy at 12 months after RAI therapy could rely on serum Tg measurement and neck ultrasound, while diagnostic WBS was not routinely indicated in patients considered in ER.

Relation between myocardial blood flow and cardiac events in diabetic patients with suspected coronary artery disease and normal myocardial perfusion imaging

BackgroundWe assessed the prognostic value of structural abnormalities and coronary vasodilator function in diabetic patients referred to a PET/CT for suspected coronary artery disease (CAD). MethodsWe studied 451 diabetics and 451 nondiabetics without overt CAD and normal myocardial perfusion. Myocardial blood flow (MBF) was computed from the dynamic rest and stress imaging. Myocardial flow reserve (MFR) was defined as ratio of hyperemic to baseline MBF and was considered reduced when < 2. ResultsDuring a mean follow-up of 44 months 33 events occurred. Annualized event rate (AER) was higher in diabetic than nondiabetic patients (1.4% vs 0.3%, P < .001). Diabetic patients with reduced MFR had higher AER compared to those with preserved MFR (3.3% vs 0.4%, P < .001). At Cox analysis, age, BMI and reduced MFR were independent predictors of events in diabetic patients. Patients with diabetes and reduced MFR had lower event-free survival compared to nondiabetic patients and MFR < 2 (P < .001). Event-free survival was similar in patients with diabetes and normal MFR and those without diabetes and reduced MFR. ConclusionsDiabetic patients with reduced MFR had higher AER and lower event-free survival compared to those with preserved MFR and to nondiabetic patients.

The prognostic value of right ventricular longitudinal strain and 3D ejection fraction in patients with dilated cardiomyopathy.

Several studies showed that right ventricular (RV) dysfunction is a powerful predictor in heart failure (HF). Advanced echocardiographic techniques such as speckle-tracking imaging and three-dimensional (3D) echocardiography proved to be accurate tools for RV assessment, but their clinical significance remains to be clarified. The aim of this study was to evaluate the role of two-dimensional (2D) RV strain and 3D ejection fraction (RVEF) in predicting adverse outcome in patients with non-ischemic dilated cardiomyopathy (DCM). We prospectively screened 81 patients with DCM and sinus rhythm, 50 of whom were enrolled and underwent comprehensive echocardiography, including RV strain and 3D RV volumetric assessment. Patients were followed for a composite endpoint of cardiac death, nonfatal cardiac arrest and acute worsening of HF requiring hospitalization. After a median follow-up of 16 months, 29 patients reached the primary endpoint. Patients with events had more impaired RV global longitudinal strain (− 10.5 ± 4.5% vs. − 14.3 ± 5.2%, p = 0.009), RV free wall longitudinal strain (− 12.9 ± 8.7% vs. − 17.5 ± 7.1%, p = 0.046) and 3D RVEF (38 ± 8% vs. 47 ± 9%, p = 0.001). By Cox proportional hazards multivariable analysis, RV global longitudinal strain and RVEF were independent predictors of outcome after adjustment for age and NYHA class. RVEF remained the only independent predictor of events after further correction for echocardiographic risk factors. By receiver-operating characteristic analysis, the optimal RVEF cut-off value for event prediction was 43.4% (area under the curve = 0.768, p = 0.001). Subjects with RVEF > 43.4% showed more favourable outcome compared to those with RVEF < 43.4% (log-rank test, p < 0.001). In conclusion, 3D RVEF is an independent predictor of major adverse cardiovascular events in patients with DCM.

Stay Home! Stay Safe! First Post-Discharge Cardiologic Evaluation of Low-Risk–Low-BNP Heart Failure Patients in COVID-19 Era

Background. The COVID-19 pandemic has had a deep impact on periodic outpatient evaluations. The aim of this study was to evaluate the impact of low brain natriuretic peptide (BNP) values in predicting adverse events in heart failure (HF) patients in order to evaluate implications for safe delay of outpatient visits. Methods. This was a retrospective study. One-thousand patients (mean age: 72 ± 10 years, 561 women) with HF and BNP values <250 pg/mL at discharge were included. A 6-month follow-up was performed. The primary endpoint was a combination of deaths and readmissions for HF within 6-month after discharge. Results. At 6-month follow-up, 104 events (10.4%) were recorded (65 HF readmissions and 39 all-cause deaths). Univariate Cox analysis identified as significant predictors of outcome were age (p < 0.001, hazard ratio [HR] = 1.044), creatinine (p = 0.001, HR = 1.411), and BNP (p < 0.001, HR = 1.010). Multivariate Cox regression confirmed that BNP (p < 0.001, HR = 1.009), creatinine (p = 0.016, HR = 1.247), and age (p = 0.013, HR = 1.027) were independent predictors of events in HF patients with BNP values <250 pg/mL at discharge. Patients with BNP values >100 pg/mL and creatinine >1.0 mg/dL showed increased events rates (from 4.3% to 19.0%) as compared to those with lower values (p < 0.000, HR = 4.014). Conclusions. Low pre-discharge BNP levels were associated with low rates of cardiovascular events in HF patients, independently of the frequency of follow-up.

Prognostic Impact of Nonobstructive Coronary Artery Disease Detected by Coronary Computed Tomographic Angiography.

Coronary computed tomographic angiography (CCTA) is a promising technique for ruling out coronary artery disease (CAD) in patients with chest pain. We aimed to investigate the prognostic impact of nonobstructive CAD on CCTA. We retrospectively reviewed patients who underwent CCTA between 2010 and 2016 at our institution. We divided them into 3 groups: (1) patients with no CAD, (2) patients with nonobstructive CAD, and (3) patients with obstructive CAD. We investigated the incidence of the primary outcome (combination of death, nonfatal myocardial infarction, unstable angina, and late revascularization). A total of 989 patients were included: 540 patients had CAD, which was obstructive (≥50% stenosis) in 256 cases. During the follow-up period, 99 events occurred (32 [7%] in patients without CAD, 26 [9%] in patients with nonobstructive CAD, and 41 [16%] in patients with obstructive CAD; P < .001). The presence of nonobstructive and obstructive CAD was an independent predictor of events (HR: 2.33 [1.15-4.69], P < .001; and 4.02 [1.98-8.13], P = .019, respectively) compared with no CAD. Nonobstructive CAD on CCTA is associated with a 2-fold increase in risk of coronary events compared with patients with no CAD.

Baseline CHA 2 DS 2 ‐VASc score and prognosis in octogenarians with non‐ST segment elevation acute coronary syndrome

CHA2 DS2 -VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We sought to study if this score predicts outcomes in elderly patients with Non-ST segment Elevation Acute Coronary Syndromes (NSTEACS). The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEACS aged ≥80 years. Data to calculate CHA2DS2-VASc Score were available in 523 patients (98.3%). They were classified according to CHA2DS2-VASc Score: group 1 (score ≤4), and 2 (5-9). We studied outcomes in terms of mortality or readmission at 6 months follow-up. A total of 266 patients (51%) had a high CHA2DS2-VASc Score (group 2). They were more often women, with more cardiovascular risk factors like hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, p=0.001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment and frailty) and Charlson index were worse in this group (all, p=0.001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, p=0.001), and developed new onset AF more often during admission (12.4% vs. 6.6%, p=0,024). At six months follow-up, patients in group 2 had higher reinfarction, all-cause mortality, and mortality or readmission rates. A CHA2DS2-VASc Score >4 was associated with mortality or readmission at 6 months (HR 2.07, p<0.001). However, after adjusting for potential confounders, this last association was not significant (p=0.175). A CHA2DS2-VASc score >4 is present in half of octogenarians with NSTEACS and is associated with poorer outcomes. However, it is not an independent predictor of events and should not replace recommended tools for risk prediction in this setting.

Prognostic value of coronary vascular dysfunction assessed by rubidium-82 PET/CT imaging in patients with resistant hypertension without overt coronary artery disease

PurposeThe identification of coronary vascular dysfunction may enhance risk stratification in patients with resistant hypertension (RH). We evaluated if impaired coronary vascular function, assessed by rubidium-82 (82Rb) positron emission tomography/computed tomography (PET/CT) imaging, is associated with increased cardiovascular risk in patients with hypertension without overt coronary artery disease (CAD).MethodsWe studied 517 hypertensive subjects, 26% with RH, without overt CAD, and with normal stress-rest myocardial perfusion imaging at 82Rb PET/CT. The outcome end points were cardiac death, nonfatal myocardial infarction, coronary revascularization, and admission for heart failure.ResultsOver a median of 38 months (interquartile range 26 to 50), 21 cardiac events (4.1% cumulative event rate) occurred. Patients with RH were older (p < 0.05) and had a higher prevalence of left ventricular hypertrophy (p < 0.001), a lower hyperemic myocardial blood flow (MBF), and myocardial perfusion reserve (MPR) (both p < 0.001) compared to those without. Conversely, coronary artery calcium content and baseline MBF were not different between patients with and without RH. At univariable Cox regression analysis, age, RH, left ventricular ejection fraction, coronary artery calcium score, and reduced MPR were significant predictors of events. At multivariable analysis, age, RH, and reduced MPR (all p < 0.05) were independent predictors of events. Patients with RH and reduced MPR had the highest risk of events and the major risk acceleration over time.ConclusionThe findings suggest that the assessment of coronary vascular function may enhance risk stratification in patients with hypertension.

Prognostic value of pericoronary adipose tissue and coronary vascular function by cardiac 82Rb PET/CT imaging in patients with suspected coronary artery disease and normal myocardial perfusion imaging

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pericoronary adipose tissue, due to its proximity to coronary arteries, has been proposed contribute to the progression of coronary atherosclerosis. Purpose The aim of this study was to evaluate the prognostic value of pericoronary fat thickness (PCFT), coronary artery calcium (CAC) score and myocardial perfusion reserve (MPR) by hybrid 82Rubidium (82Rb) PET/CT imaging in patients with suspected coronary artery disease (CAD) and normal myocardial perfusion imaging (MPI). Methods A total of 640 patients without overt CAD and with normal rest-stress 82Rb PET/CT MPI were studied. PCFT was calculated on CT images as the maximum fat thickness (mm) between heart surface and visceral epicardium surrounding the main coronary arteries. CAC score was categorized as 0, &amp;lt;400 or ≥400. MPR was considered reduced when &amp;lt;2. Endpoints events were cardiac death, nonfatal myocardial infarction and coronary revascularization. Results During a follow-up of 42 ± 13 months, 29 events occurred (cumulative event rate 5%). Patients with events were older (66 ± 13 vs. 60 ± 13 years, p &amp;lt; 0.01), had higher PCFT (13 ± 2 vs 11 ± 2 mm, p &amp;lt; 0.001), higher prevalence of CAC score ≥400 (48% vs. 21%, p &amp;lt; 0.01), and lower MPR (2.1 ± 0.7 vs. 2.7 ± 0.7, p &amp;lt; 0.001) compared to those without. A higher prevalence of MPR &amp;lt;2 was observed in patients with events (48% vs. 18, p &amp;lt; 0.001) compared to those without. Patients with reduced MPR had higher PCFT compared to those with normal MPR (12 ± 2 vs. 11 ± 1 mm, p &amp;lt; 0.01). A PCFT value of 11.2 mm was the best trade-off between sensitivity and specificity to detect a reduced MPR. Event rate was higher in patients above this threshold compared to those below (8% vs. 1.5%, p &amp;lt; 0.001). At Cox univariate analysis, age (p &amp;lt; 0.05), PCFT &amp;gt;11.2 mm (p &amp;lt; 0.001), CAC score ≥400 (p &amp;lt; 0.01), and MPR &amp;lt;2 (p &amp;lt; 0.001) were predictors of events. At multivariate analysis, only PCFT &amp;gt;11.2 mm and MPR &amp;lt;2 were independent predictors of events (both p &amp;lt; 0.01). At incremental analysis, adding PCFT &amp;gt;11.2 to a model including clinical data and MPR &amp;lt;2 increased the global chi-square from 26 to 35 (p &amp;lt; 0.01). Classification tree analysis produced 3 terminal groups. For patients with MPR &amp;lt;2, no further split was needed (event rate 12% vs. 3%, p &amp;lt; 0.001). On the contrary, patients with MPR ≥2 were further stratified by PCFT (event rate 7% in patients with and 0.3% in those without (p &amp;lt; 0.001) PCFT &amp;gt;11.2. Conclusions In patients with suspected CAD and normal stress MPI, coronary vascular dysfunction and high PCFT are associated with increased cardiac risk. PCFT could help in identifying patients at higher risk of events. Combined evaluation of anatomical and functional vascular abnormalities by 82Rb PET/CT might allow a better risk stratification.

Early cardiovascular events and cardiovascular death after renal transplantation: role of pretransplant risk factors

The purpose of this study was to verify the risk factors present in patients on the kidney transplant waiting list that may interfere with the incidence of cardiovascular (CV) events and death during the first 12months after transplantation. Based on the data collected prospectively during pretransplant workups, a retrospective study was conducted including 665 patients followed up until death or completing 12months posttransplantation. Endpoints were the composite incidence of CV events and death. The prevalence of diabetes, LV hypertrophy, and CV disease at baseline was high; 14% of patients had angina, 26% an abnormal myocardial scan, and 47% coronary artery disease. CV events occurred in 53 patients (8.4%) and in 29 (55%) caused death. The independent predictors of events were age ≥ 50years (HR 2.292; CI% 1.093-4.806), angina (HR 1.969; CI% 1.039-3.732), and altered myocardial scan (HR 1.905, CI% 1.059-3.428). Altered myocardial scan (HR 2.822, 95% CI 1.095-6.660) was also one of the independent predictor of CV death. The incidence of CV events and death were predicted by variables associated with myocardial ischemia, a potentially modifiable risk factor. Patients with pretransplantation myocardial ischemia should be considered at a higher risk of developing early CV complications and managed accordingly before, during, and after kidney transplantation.

Usefulness of strain imaging to determine prognosis in pulmonary hypertension

Abstract Introduction Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterization (RHC). Purpose To describe classical and myocardial deformation echocardiographic parameters in patients with established PH and to identify prognostic variables Methods We prospectively enrolled 76 patients with mPAP ≥25 mmHg undergoing RHC between 2017 and 2018. All subjects underwent transthoracic echocardiography (TTE) according to the latest ASE/EACVI guidelines the same day of the RHC. Strain analysis was carried out by speckle-tracking echocardiography (QLAB 10.7, Philips). Clinical events during the follow-up were: acute heart failure hospitalization, cardiac transplant and all-cause mortality. Results Mean age was 59±12, 43.4% were women and 49 patients (64.5%) belonged to group 2 of PH. The median follow-up was 288 (ICR 92–534) days. Total number of events was 42 (55.3%, 9 deaths). Variables associated to events are shown in Table 1. All classic LV and RV systolic function and strain parameters were associated with a worse prognosis, being free-wall RV longitudinal strain (RVLS) the only one that remained as a prognostic factor in mutivariate analysis. Other variables associated with a worse prognosis were PCP&amp;gt;15 mmHg and NT-proBNP&amp;gt;1800, the latter being independent predictor of events. The attached figure shows event-free survival curves for the global population divided according to whether or not they belong to group II PH. Conclusions Our data highlight the prognostic value of free-wall RVLS and NT-proBNP in patients with established PH. NT-ProBNP was only useful in group II PH while free-wall RVLS identified patients with a higher risk of events in both groups, mainly in patients with heart disease Free event survival Curves Funding Acknowledgement Type of funding source: None

What is the risk of a patient with severe aortic stenosis while waiting for aortic valve intervention?

Abstract Introduction Severe symptomatic aortic stenosis is associated with high mortality without intervention. However, true waiting times for aortic valvular intervention (AVI) and the risks associated with it are not known. Objectives To measure the waiting time between referral and AVI. To determine the impact of the waiting time for AVI by assessing the occurrence of adverse events during this period. To assess predictors of adverse outcomes during this period in view to identify patients (pts) who may require earlier AVI. Methods Retrospective single-center study of consecutive outpatients referred for AVI (either surgically or transcatheter (TAVI)) since 2014 to 2018. The primary endpoint was hospitalization due to heart failure or death from any cause, occurring in the waiting time for AVI. Cox regression analysis was performed. Results Were included 120 pts (54% male, mean age 75±9 years). 113 (94%) pts had high-gradient aortic stenosis. They were mainly in NHYA class II (56%). Fatigue was the main symptom (83%). The median NT-proBNP value was 819 (IQR 319–1780) ng/L. The mean peak velocity was 4.5±0.5 m/s, median gradient of 45 (IQR 42–54) mmHg, mean VTIs ratio of 0,21±0.04, with a mean estimated valvular area of 0.7±0.2 cm2 (0.4±0.1 cm2/m2). During a mean follow-up of 24±14 months since referral, 108 (90%) pts were submitted to AVI (75 pts underwent surgery; 33 pts underwent TAVI). The median waiting time for AVI was 4 (IQR 2–6) months (0–35 months). The median waiting time for surgery was 3 (IQR 2–6) months and for TAVI was 4 (IQR 3–8) months (p=0.25). The primary endpoint occurred in 19 (16%) pts: 13 (11%) pts were hospitalized due to heart failure and 7 (6%) pts died. The median time between referral and the occurrence of the primary endpoint was 3 (IQR 1–9) months. In univariate analysis, age &amp;gt;80 years, NHYA class ≥3, prior stroke and NT-proBNP were positively associated with the occurrence of the primary endpoint (p&amp;lt;0.05). After multivariate analysis, prior stroke (HR 5; 95% CI 1.2–24; p=0.03) and NT-proBNP (HR 1/unit; 95% CI 1–1.001; p=0.01) were independently associated with events occurrence. NT-proBNP was an independent predictor of events with a good discriminative value (area under the ROC curve 0.73; 95% CI 0.61–0.83; p=0.004). NT-proBNP cut-off value of &amp;gt;1207ng/L identified pts with an event while waiting AVI with a sensitivity and specificity value of 69 and 73%, respectively. Left ventricle ejection fraction, severity parameters of aortic stenosis, systolic pulmonary artery pressure, concomitant coronary artery disease and the time between diagnosis and referral were not associated with the primary endpoint. Conclusion Mortality and worsening of heart failure while waiting for aortic valvular intervention occurred frequently. Factors such NT-pro-BNP and personal history of stroke can help to identify pts who may benefit from earlier intervention. Funding Acknowledgement Type of funding source: None

Clinical outcomes of calcified nodules detected by optical coherence tomography: a sub-analysis of the CLIMA study.

The goal of the present post hoc analysis of the CLIMA registry was to establish the relationship between calcified nodules (CNs) with (CND) or without (CNWD) disruption of the superficial intimal fibrous layer and one-year occurrence of target lesion myocardial infarction (MI) and/or cardiac death. CND and CNWD were identified based on the presence or absence of superficial irregularities indicative of disruption of the intimal fibrous layer, with possible overlying local thrombus. In total, 222 CNs were found in the 1,776 non-culprit LAD plaques. CND had larger maximum calcific arc and smaller lumen area. Cardiac death and MI occurred in 20% of patients in the CND group versus 2.7% in the CNWD group and 3.3% in the group without CN (p<0.001). This figure was mainly due to the 13.3% incidence of cardiac death in the CND group versus 2.0% in the CNWD group and versus 2.2% in the group without CN (p<0.001). The presence of CND was confirmed as an independent predictor of events (HR 6.58, 95% CI: 2.7-15.8, p<0.001). The presence of CND was associated with a high one-year incidence of cardiac death and/or target lesion MI.

Average pixel intensity method for prediction of outcome in secondary mitral regurgitation.

Echocardiographic grading of secondary mitral regurgitation (SMR) severity is challenging and involves multiple guideline-recommended parameters. We previously introduced the average pixel intensity (API) method for grading SMR. In this study, the clinical outcome in SMR based on the API method for grading MR was compared with conventional grading methods. 231 patients with systolic heart failure and reduced ejection fraction (ischaemic/non-ischaemic) and SMR were prospectively enrolled. MR was graded using all guideline-recommended parameters and the API method, which is based on the pixel intensity of the continuous wave Doppler signal. The primary outcome was MACE (major adverse cardiac event). The API method was applicable in 98% of patients with SMR (n=227). During a median follow-up of 24 months, 98 patients (43%) had a MACE (cardiovascular mortality (n=50, 22%), heart failure hospitalisation (n=44, 19%), mitral valve surgery (n=11, 5%), percutaneous mitral intervention (n=12, 5%), heart transplantation (n=5, 2%)). On log-rank test, the API method was highly significant in predicting clinical outcome. On multivariable Cox proportional hazard analysis, SMR grading with the API method was an independent predictor of clinical outcome (along with NYHA class and right ventricular systolic pressure; p<0.001), increasing the event risk by 9% per 10 au API rise (p=0.001). In the same multivariable analysis, proximal isovelocity surface area (PISA)-effective regurgitant orifice area or PISA-regurgitant volume were not independent predictors of events (p=0.18 and 0.26, respectively). SMR grading with the API method is an independent predictor of clinical outcome and provides prognostic information in addition to clinical and other echocardiographic variables.