Low-intermediate Risk Patients Research Articles

Carotid Plaque Score is Associated with 10-year Major Adverse Cardiovascular Events in Low-Intermediate Risk Patients Referred to a General Cardiology Community Clinic.

Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE). Patients ≥40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery (ICA) were given 1 point per segment if plaque present (plaque score 0 to 6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8,472 patients, 60% were females (n = 5,121). Plaque was more prevalent in males (64% vs 53.9%; P <0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9 % vs females 6.0%; P = 0.004). Having both maximal CCA IMT <1.00 mm and plaque score = 0, was associated with less events. A plaque score <2 was associated with a low 10-year event rate (4.1%) compared to 2-4 (8.7%) and 5-6 (20%). A plaque score ≥2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

New risk model by right ventricle - pulmonary arterial coupling and inferior vena cava from echocardiography in patients with conventional low-intermediate risk pulmonary artery hypertension under targeted treatment.

Accurately stratifying patients with pulmonary arterial hypertension (PAH) is very important, and traditional risk scores still have internal heterogeneity. This study aimed to construct a risk stratification model that can accurately identify clinical worsening (CW) events in conventional low-intermediate risk patients with pulmonary hypertension under targeted drug treatment by using echocardiographic parameters. This study is a single-center, prospective study, including 105 PAH patients who underwent regular follow-up at Guangdong Provincial People's Hospital from October 2021 to April 2023. The primary endpoint was the occurrence of CW, including death, hospitalization due to pulmonary hypertension, escalation of targeted drug therapy, and worsening of PAH. The predictive value of the echocardiography-based three-strata risk model was assessed using Kaplan-Meier curves and COX regression analysis. A total of 98 PAH patients were ultimately included in this study. The median follow-up duration was 26 months (range 7-28 months). The echocardiography-based three-strata model included the ratio of tricuspid annular plane systolic excursion and pulmonary artery systolic pressure (TAPSE/PASP) and inferior vena cava (IVC). The echocardiography-based three-strata model had higher diagnostic value (C-index=.76) compared to the 2022 ESC/ERS three-strata model and four-strata model (C-index=.66 and C-index=.61, respectively). PAH patients with lower TAPSE/PASP and wider IVC showed a higher CW rate compared to patients with higher TAPSE/PASP and normal IVC (HR=15.1, 95%CI:4.4-51.9, p<.001). The echocardiography-based three-strata model based on TAPSE/PASP and IVC can effectively improve the stratification of low-intermediate risk PAH patients under targeted treatment.

Kiosk 6R-TC-10 - Sex Specific Left Ventricular Remodelling Patterns and Long-term Cardiovascular Risk in Low-intermediate Risk Patients

Kiosk 6R-TC-10 - Sex Specific Left Ventricular Remodelling Patterns and Long-term Cardiovascular Risk in Low-intermediate Risk Patients

Utilizing risk-stratified pathways to personalize post-hepatectomy discharge planning: A contemporary analysis of 1,354 patients

BackgroundWhile risk-stratified post-hepatectomy pathways (RSPHPs) reduce length-of-stay, can they stratify hepatectomy patients by risk of early postoperative events. Methods90-day outcomes from consecutive hepatectomies were analyzed (1/1/2017–12/31/2021). Pre/post-pathway analysis was performed for pathways: minimally invasive surgery (“MIS”); non-anatomic resection/left hepatectomy (“low-intermediate risk”); right/extended hepatectomy (“high-risk”); “Combination” operations. Time-to-event (TTE) analyses for readmission and interventional radiology procedures (IRPs) was performed. Results1354 patients were included: MIS/n= ​119 (9 ​%); low-intermediate risk/n= ​443 (33 ​%); high-risk/n= ​328 (24 ​%); Combination/n= ​464 (34 ​%). There was no difference in readmission (pre: 13 ​% vs. post:11.5 ​%, p ​= ​0.398). There were fewer readmissions in post-pathway patients amongst MIS, low-intermediate risk, and Combination patients (all p ​> ​0.1). 114 (8.4 ​%) patients required IRPs. Time-to-readmission and time-to-IR-procedure plots demonstrated lower plateaus and flatter slopes for MIS/low-intermediate-risk pathways post-pathway implementation (p ​< ​0.001). ConclusionRSPHPs can reliably stratify patients by risks of readmission or need for an IR procedure by predicting the most frequent period for these events.

MDS-Comorbidity Index using register data has prognostic impact in Swedish MDS patients

Comorbidities influence the mortality in patients with myelodysplastic syndromes, and a growing body of evidence suggest that comorbidity history should be used in addition to established prognostic indices. A comorbidity index specific for MDS, the MDS-CI, was introduced a decade ago. In this study we aim to construct an MDS-CI version based on diagnoses from register data only, to expand its use beyond the clinical setting to retrospective and register based studies. We further test this version on a Swedish population-based MDS cohort of 2947 patients, and compare its prognostic accuracy to that of Charlson Comorbidity Index. Our register based MDS-CI divided patients into three risk groups of similar proportions as have been published for the original MDS-CI. Compared to low risk patients, intermediate and high risk patients had 50 % and 70 % higher mortality, respectively. The prognostic value of MDS-CI was equal to that of Charlson comorbidity index. Adding MDS-CI to the established prognostic factors IPSS-R and age increased the prognostic accuracy. In summary, we demonstrate that MDS-CI can be adequately estimated from diagnoses recorded in registers only, and that it is a useful tool in any future study on myelodysplastic syndromes with a need to adjust for comorbidities.

Non-contrast computed tomography findings for identification of chronically occluded coronary artery bypass grafts.

Detecting occlusions of coronary artery bypass grafts using non-contrast computed tomography (CT) series is understudied and underestimated. To evaluate morphological findings for the diagnosis of chronic coronary artery bypass graft occlusion on non-contrast CT and investigate performance statistics for potential use cases. Seventy-three patients with coronary artery bypass grafts who had CT angiography of the chest (non-contrast and arterial phases) were retrospectively included. Two readers applied pre-set morphologic findings to assess the patency of a bypass graft on non-contrast series. These findings included vessel shape (linear-band like), collapsed lumen and surgical graft marker without a visible vessel. Performance was tested using the simultaneously acquired arterial phase series as the ground truth. The per-patient diagnostic accuracy for occlusion was 0.890 (95% confidence interval=0.795-0.951). Venous grafts overall had an 88% accuracy. None of the left internal mammary artery to left anterior descending artery arterial graft occlusions were detected. The negative likelihood ratio for an occluded graft that is truly patent was 0.121, demonstrating a true post-test probability of 97% for identifying a patent graft as truly patent given a prevalence of 20% occlusion at a median 8.4 years post-surgery. Neither years post-surgery, nor number of vessels was associated with a significant decrease in reader accuracy. Evaluation of coronary bypass grafts for chronic occlusion on non-contrast CT based off vessel morphology is feasible and accurate for venous grafts. Potential use cases include low-intermediate risk patients with chest pain or shortness of breath for whom non-contrast CT was ordered, or administration of iodine-based contrast is contraindicated.

Abstract 10484: Carotid Plaque Score Adds Discriminatory Benefit to the Stress Echo for Major Adverse Cardiovascular Events in Low-Intermediate Risk Cardiac Patients

Introduction: Carotid plaque is recommended for cardiac risk stratification for intermediate risk patients but has not been integrated into cardiology community clinics to help refine testing and reduce risk for major adverse cardiovascular events (MACE). The purpose was to determine the clinical usefulness of carotid plaque score (PS) to guide management of low-intermediate risk patients. Methods: Patients 40-75 years who received a carotid ultrasound were followed up to 10 years for MACE (cardiovascular death, myocardial infarction, stroke). Low-intermediate risk participants (n = 9,114) with no known cardiovascular disease were included. Administrative data holdings housed at IC/ES were used for event follow-up. Kaplan-Meier curves and Cox proportional hazard ratios determined relative risk. Combining plaque score (Rotterdam method, plaque presence within carotid segments, PS 0 to 6) with stress echo (SE) was assessed in a subset of participants (n = 624). Results: The optimum threshold for PS = 2 for 1-year MACE (AUC = 0.738). The population rate of MACE over 10 years was 4%. In participants referred for SE, PS of &lt;2 was associated with an excellent 5-year outcome irrespective of the SE result (PS&lt;2 = 0.9% MACE, normal SE = 1.6% MACE). A PS of ≥2 and an abnormal SE was associated with increased risk (MACE = 11%). The hazard ratio for MACE increased with PS from 1.08 to 9.86 (PS = 1 and 6; reference PS=0). Combining SE with PS (either test positive) increased the sensitivity of the SE from 36% to 71%, with an excellent specificity (SE alone = 94% vs SE+PS = 87%). Conclusions: In low-intermediate risk patients, if a PS is &lt;2, cardiac testing for atherosclerotic risk is not required for up to 5 years. However, patients with a PS of ≥2 should undergo a stress echo. Combining SE with PS adds discriminatory benefit in identifying risk for MACE. This simple stratification parameter can be easily integrated in community cardiology clinics to prioritize patients requiring further testing.

TCTAP A-082 Impact of a Novel Nutrition Index for Predicting Mortality in Low-Intermediate Surgical Risk Patients With Transcatheter Aortic Valve Replacement

TCTAP A-082 Impact of a Novel Nutrition Index for Predicting Mortality in Low-Intermediate Surgical Risk Patients With Transcatheter Aortic Valve Replacement

Transcatheter Aortic Valve Leaflet Thrombosis: Prevalence, Management, and Future Directions.

We review the pathology, prevalence, diagnosis, hemodynamics, risk factors, prognosis, and treatment of leaflet thrombosis (LT), and suggest future directions in this field. The latest meta-analysis showed the prevalence of overall LT is 5.4% (clinical LT of 1.2% and subclinical LT of 15.1%). Either subclinical or clinical LT is not associated with risk of mortality; however, clinical LT is associated with increased risk of stroke. Although LT can be reduced by oral anticoagulation therapy (OAT), routine use of OAT as primary prevention for high-risk patients is not recommended due to increased risk of mortality. Four-dimensional computed tomography plays an important role in the diagnosis of LT and the accumulation of qualitative or qualitative assessments of hypoattenuated leaflet thickening would provide more clues to clarify effective OAT strategies. In addition, further studies are warranted to evaluate the efficacy of other anticoagulants in low-intermediate risk patients.

Prognostic Impact of Mismatch Repair Deficiency in High- and Low-Intermediate Risk, Early-Stage Endometrial Cancer Following Vaginal Brachytherapy

Mismatch repair deficiency (dMMR) is found in approximately 25% of endometrial cancers (EC), yet it remains unknown how this information should be incorporated into adjuvant treatment paradigms. Ongoing trials are investigating the potential use of immunotherapy in conjunction with radiotherapy for the adjuvant treatment of dMMR patients with high-intermediate risk (HIR) features. We hypothesized that dMMR status is associated with higher rates of recurrence in both low-intermediate risk (LIR) and HIR subgroups. We examined the impact of dMMR status on prognosis among patients with early-stage endometrioid EC treated with vaginal brachytherapy (VB).We performed a retrospective review of 198 patients who were treated with adjuvant VB for FIGO stage I or II endometrioid EC and had known MMR status. Both LIR and HIR patients (per GOG 249 criteria) were included. Patients with non-endometrioid and mixed histologies and patients treated with pelvic radiotherapy were excluded. Patient, tumor, and treatment characteristics were compared between patients with proficient mismatch repair (pMMR) and dMMR using c2 tests for categorical variables and t-tests for continuous variables. Recurrence free survival (RFS) and overall survival (OS) were analyzed with Kaplan-Meier estimates, the log-rank test, and Cox proportional hazards regression.Patients with dMMR compared to pMMR were more likely to have grade 2-3 tumors (75% vs. 57%, P = 0.012), lympho-vascular invasion (40% vs. 25%, P = 0.023), and HIR classification (65% vs. 49%, P = 0.038). There were no other differences in clinicopathologic or treatment characteristics. Median follow-up time for dMMR and pMMR patients was 37.5 and 37 months, respectively. Three-year RFS was inferior for dMMR compared to pMMR patients (75% vs. 96%, P = 0.001). dMMR patients compared to pMMR had similarly reduced 3-year RFS both within the LIR (74% vs. 100%, P = 0.026) and HIR (75% vs. 91%, P = 0.038) subgroups. Three-year OS was excellent across all categories and was not different between dMMR/pMMR patients (98% vs. 97%, P = 0.653) or HIR/LIR patients (97% vs. 97%, P = 0.999). On multivariable Cox regression, dMMR status was the only significant prognostic variable for RFS (HR 3.774, CI 1.495-9.526, P = 0.005), though it was not significant for OS. While failures were more likely in the dMMR cohort, salvage rates were high, and treatment included surgery (29.4%), pelvic RT (41.2%), chemotherapy (70.6%), and immunotherapy (47.1%).Following VB, patients with dMMR have poorer RFS compared to pMMR patients regardless of HIR/LIR risk classification. Increased monitoring for early salvage intervention and/or expansion of eligibility to clinical trials incorporating immune checkpoint inhibitors should be considered for both HIR and LIR patients with dMMR.

Incremental prognostic value of calcified vs non-calcified plaque burden on computed tomography angiography and myocardial perfusion imaging

Abstract Funding Acknowledgements Type of funding sources: None. Background Coronary computed tomography angiography (CCTA) is currently guideline-endorsed for diagnosing suspected coronary artery disease (CAD) in low-intermediate risk patients. Single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has an established role in both the accurate detection of ischemia and identification of patients at high risk of future cardiovascular events. Recent studies have shown that the burden of atherosclerotic plaque is an independent predictor of cardiovascular events, and that this effect depends on the degree of calcification. Purpose To compare the incremental prognostic value of calcified vs non-calcified plaque burden to CCTA anatomic assessment and SPECT physiologic assessment in patients evaluated with both tests. Methods Consecutive patients who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected CAD were included. Ischemia on SPECT was defined as summed difference score &amp;gt; 0 using perfusion graded on a 5-point scale. Anatomically obstructive CAD by CCTA was defined as ≥50% in the left main artery and ≥70% stenosis severity in proximal, mid and distal branches of the left anterior descending, left circumflex and right coronary artery without including side branches. Segment involvement score was defined as the sum of segments with plaque irrespective of the degree of stenosis using an 18-segment coronary artery model. A Hounsfield unit threshold of &amp;gt; =130 was used to classify plaques composition as calcified/mixed (C-SIS) vs non-calcified plaque (NC-SIS). Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.) Results A total of 956 patients were included. (Mean age 61.1 ± 14.2 years, 54% men, 89% hypertension, 81% diabetes, 84% dyslipidemia). Obstructive stenosis (left main ≥ 50%, all other coronary segments ≥ 70%) and ischemia were observed in similar number of patients (14%). After a median follow-up of 31 months, 102 patients (11%, 29.2 events per 1000 person-year) experienced a MACE. In multivariable Cox regression models, C-SIS, but not NC-SIS significantly predicted outcomes and improved risk discrimination in models with CCTA obstructive stenosis (HR 1.14 95% CI 1.08 - 1.20 p= &amp;lt;0.001; Harrel’s C 0.74, p = 0.011) and SPECT ischemia (HR 1.14 95% CI 1.08 - 1.20, p &amp;lt; 0.001; Harrel’s C 0.76, p = 0.015). Conclusion In the current study of high-risk patients with suspected CAD, calcified plaque burden, but not non-calcified plaque incrementally added to measures in predicting incident cardiovascular outcomes

The current diagnosis and treatment of patients with aortic valve stenosis.

Aortic valve stenosis (AS) is the third most frequent cardiovascular abnormality after coronary artery disease and hypertension. A bicuspid aortic valve is the most common cause for AS until seventh decade and calcific valve degeneration is responsible thereafter. In symptomatic patients, The risk of death increases from ≤1%/year to 2%/month. An echo valve area ≤1cm2, peak transaortic velocity ≥4m/s, mean valve gradient ≥40mmHg and/or computerized tomography valve calcium score >2000Agatston units (AU) for males or more than 1200AU for females indicate severe AS. AS stages and management are discussed. Valve replacement is based on surgical risk, valve durability/hemodynamics, need for anticoagulation and patient preferences. EuroSCORE ≥20%, Society of Thoracic Surgeons Predicted Risk of Mortality ≥8% and co-morbidities indicate high surgical risk. Surgery is recommended for low-intermediate risk patients. Transcatheter aortic valve implantationis an alternative in older patients at low, intermediate, high or prohibitive risk. Transaortic valve implantation/replacement trials are summarized.

Somatostatin Analogues for the Prevention of Pancreatic Fistula after Open Pancreatoduodenectomy: A Nationwide Analysis

Purpose: Somatostatin analogues (SA) are varyingly used to try to prevent development of a pancreatic postoperative fistula (POPF) after pancreatoduodenectomy. Some centers do not use SA, some use it only in high-risk patients, and others in all patients. The aim of this study was to evaluate the effect of different protocols for SA use on the incidence of POPF after pancreatoduodenectomy in the Netherlands. Method: The Dutch Pancreatic Cancer Audit (DPCA) is a national, mandatory audit that registers all patients after pancreatoduodenectomy. Consecutive patients undergoing elective open pancreatoduodenectomy for all indications were included from the DPCA (2014-2017). Patients were divided into six groups depending on the SA protocol: no SA, octreotide, lanreotide, pasireotide, octreotide only in high risk patients, and lanreotide only in high risk patients. Primary endpoint was POPF (grade B and C). The updated alternative Fistula Risk Score (uaFRS) was used to analyze the occurrence of clinically relevant POPF across various risk scenarios (low-intermediate risk (<20%) and high risk (≥20%)). Results: Overall, 1992 patients were included with a POPF rate of 13.1%. POPF occurred less often when octreotide was administered in high risk patients only (9.4%) or if a lanreotide protocol was used (10.0%) compared to other protocols (varying from 12.7-19.1%, p=0.001). Sub-analysis in 577 patients (56.7%) with a high uaFRS showed a significantly lower rate of POPF when treated with lanreotide (10.0%) compared to the other protocols (varying from 18.9%-27.4%) (p=<0.001). In the 440 patients (43.3%) with a low-intermediate uaFRS the rate of POPF did not differ significantly between the six protocols. Multivariate regression analysis, controlling for male sex, BMI, soft pancreatic tissue, a pancreatic duct smaller than 3mm, ASA score III/IV, neuroendocrine tumor pathology, demonstrated lanreotide to be significantly associated with a low OR for POPF (OR 0.387, 95% CI 0.180-0.834) compared to no SA use. Conclusion: This nationwide retrospective study suggests that the use of lanreotide in patients undergoing pancreatoduodenectomy is beneficial in reducing the rate of POPF. However, perioperative mortality is unaffected. Since SA appear not to be beneficial in low-intermediate risk patients, the use of lanreotide may be reserved for patients at high risk of POPF.

Abstract 13628: Absence of Coronary Artery Calcium in Ruling Out Obstructive Cad on Coronary Computed Tomography Angiography (ccta) Among Patients With Stable and Acute Chest Pain: A Systematic Review

Introduction: Coronary computed tomography angiography (CCTA) is a class IIA recommendation in low-intermediate risk patients with suspected acute coronary syndrome (ACS) and a normal or nondiagnostic cardiac biomarker and ECG. However, there is little consensus on whether absence of coronary artery calcium (CAC) can safely identify patients with stable and acute chest pain (CP) who can avoid more advanced downstream testing. In this study, we conducted a systematic analysis investigating utility of CAC zero in ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP undergoing coronary CT angiography (CCTA). Methods: We searched online databases (PubMed, MEDLINE) for original research articles published between 2005 and 2020 examining the relationship between CAC and significant stenosis on CCTA (defined as &gt;50% coronary luminal narrowing) among patients with stable and acute chest pain. Results: A systematic review of published articles revealed 18 studies including 27,719 patients with stable CP and 12 studies including 7,184 patients with acute CP undergoing simultaneous CCTA and CAC scoring. Overall, 12,664 (45%, 95% CI: 39%-50%) patients with stable CP and 4,327 (56%, 95% CI: 48%-64%) patients with acute CP had CAC zero. The pooled prevalence of obstructive CAD among those with CAC=0 was 3% (95% CI: 2%-4%) among stable CP patients and 2% (95% CI: 1%-3%) among acute CP patients. The negative predictive values for any CAC ruling out obstructive disease were 97% (95% CI: 96-98%) and 98% (95% CI: 96-100%), respectively (Figure). Conclusions: Among over 34,000 patients with stable and acute CP patients undergoing CCTA, the absence of CAC was associated with a very low likelihood of obstructive CAD. These findings support role of CAC zero in a value-based healthcare delivery model as a gatekeeper for more advanced testing.

Low Von Willebrand Factor: Cut-Off Value for Diagnosis and Risk Score to Predict Bleeding Incidence

Introduction Although large studies have recently provided valuable insights on the diagnosis, bleeding phenotype, and treatment outcomes of VWD patients, these aspects remain poorly understood in individuals with low VWF. Firstly, there is no clear evidence which cut-off value should be used to diagnose low VWF. Although 0.50 IU/mL is the most recommended cut-off value, some centers use the lower limit of normal (0.60 IU/mL). Secondly, the incidence of post-surgical bleeding, postpartum hemorrhage (PPH) and traumatic- or spontaneous bleeding after diagnosis of low VWF are still unknown. Lastly, it is hard to predict which individuals with low VWF have an increased bleeding risk. Therefore, we investigated the bleeding phenotype of individuals with historically lowest VWF levels of 0.31-0.50 IU/mL and 0.51-0.60 IU/mL, and the incidence of post-surgical bleeding, PPH and traumatic- and spontaneous bleeding after their initial diagnosis of "low VWF". Methods We performed a retrospective cohort study from January 2007 to November 2019 at the Erasmus MC, University Medical Center Rotterdam. All patients evaluated for the presence of a bleeding disorder with VWF antigen (VWF:Ag) and/or VWF activity (VWF:Act) and/or VWF collagen binding (VWF:CB) levels between 0.31-0.60 IU/mL, were included. Patients with VWF:Ag and/or VWF:Act and/or VWF:CB ≤0.30 IU/mL, acquired VWD and those with a concomitant bleeding disorder were excluded. For each individual we collected data from electronic patient files on baseline characteristics, reason for referral, family history of bleeding disorders, ISTH-BAT and laboratory measurements at diagnosis. Retrospective follow-up started from initial date of low VWF diagnosis through November 2019, during which we collected data on surgical procedures, pregnancies, and incidence of spontaneous- and traumatic bleeding. Results We included 439 patients; 269 patients with historically lowest VWF levels 0.31-0.50 IU/mL and 170 patients 0.51-0.60 IU/mL. Mean age at diagnosis was 28.8 ±17.7 years. Most patients were female (74.3%) and had blood group O (76.4%, Table 1). The bleeding score (BS) was similar in patients with historically lowest VWF levels of 0.31-0.50 IU/mL (3.7 ±3.0) and 0.51-0.60 IU/mL (4.0 ±2.9, p=0.209, Table 1). During the mean follow-up period of 6.3 ±3.7 years, 259 surgical procedures were performed in 146 patients, 81 deliveries in 56 women, and 109 spontaneous- or traumatic bleedings in 71 patients. The incidence of post-surgical bleeding was 7 (2.7%) during follow-up, whereas 8 deliveries (10%) were complicated by PPH. Overall, 65 out of 439 patients (14.8%) had a bleeding episode requiring treatment during follow-up, resulting in an incidence of bleeding requiring treatment of 0.5 ±1.9 per patient per decade. No difference was found in the incidence of bleeding requiring treatment between patients with historically lowest VWF levels of 0.31-0.50 IU/mL and 0.51-0.60 IU/mL (Figure 2A, p=0.154). We found that referral for a personal bleeding diathesis, a younger age at diagnosis and an abnormal BS at diagnosis were strong and independent risk factors for bleeding requiring treatment during follow-up, respectively HR=2.32 (95%CI: 1.16-4.63), HR=1.18 (95%CI: 1.01-1.38) and HR=1.77 (95%CI: 1.04-3.01). These risk factors were combined to develop a risk score to identify low VWF patients with an increased risk for bleeding requiring treatment (Figure 2B). The risk score performed excellent to differentiate in bleeding requiring treatment between low risk, intermediate risk and high risk patients (p&amp;lt;0.001, Figure 2C). The number of patients with bleeding requiring treatment was 8/126 (6.3%) in patients with low risk, 18/143 (12.6%) in intermediate risk and 39/170 (22.9%) in high risk patients (p&amp;lt;0.001). Likewise, the incidence of bleeding requiring treatment per patient per decade was 0.22 ±1.08 in low risk, 0.28 ±1.25 in intermediate risk and 0.87 ±2.61 in high risk patients (p=0.004, Figure 2D). Conclusion To conclude, there is no difference in the bleeding phenotype of individuals with historically lowest VWF levels of 0.31-0.50 IU/mL and 0.51-0.60 IU/mL. Therefore, the cut-off value to diagnose low VWF should be set at 0.60 IU/mL. Furthermore, the risk score developed in the current study may assist to identify low VWF patients with low, intermediate and high risk for future bleeding. Disclosures Atiq: SOBI: Other: travel grant; CSL Behring: Research Funding. Kruip:Boehringer Ingelheim: Research Funding; Pfizer: Research Funding; Bayer: Research Funding; Daiichi Sankyo: Research Funding; SOBI: Research Funding; Bayer: Speakers Bureau. Cnossen:Takeda: Research Funding; Shire: Research Funding; Baxter: Research Funding; Bayer: Research Funding; Sobi: Research Funding; CSL behring: Research Funding; Nordic Pharma: Research Funding; Novo Nordisk: Research Funding; Pfizer: Research Funding. Leebeek:CSL Behring: Research Funding; Shire/Takeda: Research Funding; Uniqure: Consultancy; Shire/Takeda: Consultancy; Novo Nordisk: Consultancy; SOBI: Other: Travel grant; Roche: Other: DSMB member for a study.

Identifying high thrombotic risk in atrial fibrillation patients undergoing percutaneous coronary intervention: is there a benefit of triple therapy?

Abstract Introduction Patients requiring concomittant use of oral anticoagulants for atrial fibrillation and dual antiplatelet therapy after percutaneous coronary intervention (PCI) are at increased risk of bleeding and mortality. Omittance of aspirin (dual antithrombotic therapy, DAT) reduces bleeding as compared to triple antithrombotic therapy (TAT), but might not ascertain antithrombotic efficacy, especially in high-risk patients. Purpose To identify a subgroup of patients at high thrombotic risk that might benefit most from TAT over DAT. Methods The study was performed in a combined cohort of two randomised controlled trials (WOEST, RE-DUAL PCI) comparing TAT versus DAT after PCI. A Cox proportional hazards model predictive for the composite thrombotic endpoint of cardiovascular death, myocardial infarction (MI), stent thrombosis, and ischaemic stroke was built by stepwise selection of plausible predictor variables. Area under the receiver operating curve (AUC) was obtained, and clinical outcomes (thrombotic endpoint, bleeding [BARC 2,3+5], and all-cause mortality) were compared between the highest quintile of predicted thrombotic risk (high risk) and the remainder of patients (low-intermediate risk). Within the different risk groups, effect of TAT versus DAT was compared. Results A total of 3288 patients in the combined WOEST and RE-DUAL cohorts were included in this analysis. Approximately half underwent PCI for acute coronary syndrome. In 250 patients (7.6%) the composite thrombotic endpoint occurred during the first year. The final Cox proportional hazards model predicting thrombotic events contained: left ventricular ejection fraction, 3-vessel disease, MI at index PCI, peripheral artery disease, prior stroke, left circumflex coronary artery stenting, a history of MI, PCI to a bypass graft, and platelet count. The discriminatory capacity of the ischaemic model was fair (AUC 0.68, 95% confidence interval 0.64–0.71). Incidence of thrombotic events and mortality was higher in the high-risk as compared to low-intermediate risk patients (15.8% vs 5.6%, and 8.4% vs 3.2%, respectively, both p&amp;lt;0.001), whereas bleeding was comparable (20.5% vs 19.6%, p=0.60). No statistically significant effect of TAT over DAT was seen with regards to the thrombotic endpoint in both high and low-intermediate risk patients (13.9% vs 17.0%, p=0.36, and 6.5% vs 5.0%, p=0.11, respectively). Bleeding was significantly reduced with DAT versus TAT in both high and low-intermediate risk patients (minus 12.8% and 8.1%, both p&amp;lt;0.02). For low-intermediate risk patients a statistically significant increase in mortality was found with TAT versus DAT (4.2% vs 2.5%, p=0.02), whereas this was not found in high-risk patients (7.2% vs 9.1%, p=0.47). Conclusions No significant antithrombotic advantage of TAT over DAT was found in high-risk patients. However, TAT increased bleeding risk in all patients, and increased mortality in low-intermediate risk patients. Funding Acknowledgement Type of funding source: None

Coronary artery calcium testing in low-intermediate risk symptomatic patients with suspected coronary artery disease: An effective gatekeeper to further testing?

Computed tomography for quantification of coronary artery calcium (CAC) is a simple non-invasive tool to assess atherosclerotic plaque burden. CAC is highly correlated with coronary atherosclerosis and is a robust predictor of cardiovascular outcomes. Recently, the 2018 ACC/AHA Cholesterol Guidelines endorsed the use of CAC scores in asymptomatic, intermediate risk individuals where the decision to initiate stain therapy is uncertain. However, whether quantification of CAC may play a role in the assessment of symptomatic individuals remains a matter of debate. In this review, we examine the evidence for the use of CAC in low-intermediate risk patients with chest pain. This appraisal places a particular focus on the growing body of literature supporting the negative predictive value of a CAC score of zero to rule out significant coronary artery disease in those without high-risk features. We also evaluate current guidelines, limitations, and future research directions for CAC scoring in this important subgroup of patients.

Is There A Role For CCTA For CAD In TAVR Evaluation? Accuracy And Outcomes Analysis In A Low-intermediate Risk Severe Aortic Stenosis Cohort

Introduction: Coronary artery disease (CAD) evaluation via coronary computed tomography angiography (CCTA) is well established, however the role of CCTA for evaluation of CAD in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) is uncertain due to technical limitations in patient preparation (eg withholding beta-blockers, nitroglycerin and expected calcified plaque). This study evaluated the accuracy of CCTA for CAD in predominantly low-intermediate surgical risk patients (pts) undergoing evaluation for TAVR.

SPECT Versus PET Myocardial Perfusion Imaging in Patients with Equivocal CT.

The most pertinent clinical question in post-coronary computed tomography angiography (CCTA) patients is the assessment of the physiological significance of an anatomically identified stenosis. The clinical application of radionuclide MPI using single-photon emission computed tomography (SPECT) versus positron emission tomography (PET) in the evaluation and management of patients with an inconclusive CCTA is reviewed using a case-based approach. Recent evidence suggests that CCTA is the most sensitive non-invasive test to exclude angiographic CAD and may be an effective first-line test especially among symptomatic low-intermediate risk patients. However, in the presence of angiographic atherosclerosis, its specificity and positive predictive value for identifying flow-limiting stenosis are modest. Radionuclide myocardial perfusion imaging offers accurate quantitative assessment of myocardial ischemia, which helps with risk stratification and patient management especially the potential need for revascularization. Routine accurate quantifications of myocardial blood flow and flow reserve are major advantages of PET MPI, which are especially useful when used in patients at intermediate-high clinical risk.

Abstract 323: Assessment of Coronary Artery Calcium on Routine Non-gated Chest Computed Tomography to Risk Stratify Patients Presenting With Chest Pain

Background: Coronary artery calcium (CAC) scoring is an important tool for cardiovascular risk stratification. CAC scoring in both asymptomatic and symptomatic, low-intermediate risk patients has also shown prognostic utility and has a high negative predictive value for obstructive coronary artery disease (CAD). Patients who present with chest pain frequently undergo non-gated chest computed tomography (CT) to evaluate for non-cardiac etiologies. In fact, several studies have demonstrated that a CAC score from a non-gated chest CT correlates well with a dedicated calcium-scoring CT. However, the predictive value on CAD through assessing the presence (CAC&gt;0) or the absence of calcium (CAC=0) detected on non-gated chest CT in patients presenting with chest pain is unknown. Methods: Low-intermediate risk patients (n=92) presenting to the emergency department with chest pain who underwent non-gated chest CT and were subsequently evaluated with either a cardiac stress test or invasive coronary angiography were included. Dichotomous CAC was assessed in a blinded fashion and classified as CAC=0 or CAC&gt;0. Obstructive CAD was defined as either: ischemia on stress testing or any coronary artery stenosis greater than 70% (left main coronary artery stenosis greater than 50%) on invasive coronary angiography. Results: CAC=0 on non-gated chest CT was found in 59.2% (n=42). Patients with CAC=0 had a significantly lower age and TIMI score compared to patients with a CAC&gt;0. (p&lt;0.01 ) Patients with a CAC&gt;0 were found to more likely have obstructive CAD on subsequent testing: cardiac stress test (Likelihood ratio[LR]:6.42, p=0.022); and invasive angiography (LR:12.46, p=0.002). There were no patients with a CAC=0 that were found to have obstructive CAD on invasive coronary angiography, resulting in a 100% sensitivity and 100% negative predictive value. Conclusion: Patient who presents with chest pain frequently undergo evaluation with a non-gated chest CT to assess non-cardiac etiologies. Exclusion of CAC on non-gated chest CT may be useful as an adjunct for further risk stratification to avoid potential adverse events and cost associated with further testing.