Noncardiovascular Causes Research Articles

VDD pacemaker: An effective and reliable physiological pacing modality in elderly patients.

In elderly patients, single chamber pacing may be considered. For sinus rhythm patients, VDD pacemaker (PM), by preserving atrial sensing, is a more physiological mode than VVI devices. This study aims to evaluate the long-term performance of VDD PM in elderly patients with atrioventricular block (AVB). We conducted a retrospective, observational study of 200 elderly patients (≥75 years) with AVB and normal sinus rhythm who consecutively implanted VDD PM between 2016 and 2018. Baseline clinical characteristics were analyzed, complications related to pacemaker implantation were assessed and a 3-years follow-up (FUP) was made. Mean age was 84 ± 5years. After 3-years FUP, 90.5% (n=181) of the patients preserved their original VDD mode. Only 19 patients (9.5%) switched to VVIR mode, 5.5% (n=11) due to P-wave undersensing and 4% (n=8) due to permanent AF. Those patients had a less amplitude of sensed P wave at baseline [median value of 1.30 (IQR 0.99-2.0) versus 0.97 (IQR 0.38-1.68), p=0.04]. One third of the patients died during the FUP, 89% (n=58) from non-cardiovascular causes. All-cause, CV, and non-CV mortality did not relate with atrial sensing loss during FUP (p=0.58, p=0.38 and p=0.80, respectively). However, atrial sensing loss during FUP was associated with de novo atrial fibrillation (12.7%vs. 31.6%, p=0.038). VDD pacing is a reliable pacing modality in elderly patients even in long-term. The majority of VDD-paced elderly patients maintained their original VDD mode program, with good atrial sensing.

Multimarkers of metabolic malnutrition and inflammation and their association with mortality risk in cardiac catheterisation patients: a prospective, longitudinal, observational, cohort study

Complex and incompletely understood metabolic dysfunction associated with inflammation and protein-energy wasting contribute to the increased mortality risk of older patients and those with chronic organ diseases affected by cachexia, sarcopenia, malnutrition, and frailty. However, these wasting syndromes have uncertain relevance for patients with cardiovascular disease or people at lower risk. Studies are hampered by imperfect objective clinical assessment tools for these intertwined metabolic malnutrition and inflammation syndromes. We aimed to assess, in two independent cohorts of patients who underwent cardiac catheterisation, the mortality risk associated with the metabolic vulnerability index (MVX), a multimarker derived from six simultaneously measured serum biomarkers plausibly linked to these dysmetabolic syndromes. In this prospective, longitudinal, observational study, we included patients aged ≥18 years recruited into the CATHGEN biorepository (Jan 2, 2001, to Dec 30, 2011) and the Intermountain Heart Collaborative Study (Sept 12, 2000, to Sept 21, 2006) who underwent coronary angiography and had clinical nuclear magnetic resonance metabolomic profiling done on frozen plasma obtained at catheterisation. We aggregated six mortality risk biomarkers (GlycA, small HDL, valine, leucine, isoleucine, and citrate concentrations) into sex-specific MVX multimarker scores using coefficients from predictive models for all-cause mortality in the CATHGEN cohort. We assessed associations of biomarkers and MVX with mortality in both cohorts using Cox proportional hazards models adjusted for 15 clinical covariates. We included 5876 participants from the CATHGEN biorepository and 2888 from the Intermountain Heart study. Median follow-up was 6·2 years (IQR 4·4-8·9) in CATHGEN and 8·2 years (6·9-9·2) in the Intermountain Heart study. The six nuclear magnetic resonance biomarkers and MVX made strong, independent contributions to 5-year mortality risk prediction in both cohorts (hazard ratio 2·18 [95% CI 2·03-2·34] in the CATHGEN cohort and 1·67 [1·50-1·87] in the Intermountain Heart cohort). CATHGEN subgroup analyses showed similar MVX associations in men and women, older and younger individuals, for death from cardiovascular or non-cardiovascular causes, and in patients with or without multiple comorbidities. MVX made a dominant contribution to mortality prediction in patients with cardiovascular disease and in low-risk subgroups without pre-existing disease, suggesting that metabolic malnutrition-inflammation syndromes might have a more universal role in survival than previously thought. Labcorp.

All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis.

Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic inflammatory diseases associated with a higher risk of cardiometabolic comorbidities compared to the general population. Individual studies examining mortality in these patients have produced conflicting results. The present study was undertaken to perform a systematic review and meta-analysis to analyze the all-cause and cause-specific mortality in PsA and AS from the available literature. A comprehensive database search was performed for studies reporting all-cause or cause-specific mortality in patients with PsA and AS compared with the general population. Pooled relative risks (RRs) were calculated using a random-effects model. We included 19 studies (11 of PsA, 7 of AS, 1 of both). In PsA studies, there was no increased mortality compared to the general population (RR 1.12 [95% confidence interval (95% CI) 0.96-1.30]; n=10 studies). We found a higher all-cause mortality in female (RR 1.19 [95% CI 1.04-1.36]) but not in male (RR 1.02 [95% CI 0.66-1.59]) PsA patients. Cardiovascular-, respiratory-, and infection-specific mortality risks were significantly higher for PsA patients (RR 1.21 [95% CI 1.06-1.38], RR 3.37 [95% CI 1.30-8.72], and RR 2.43 [95% CI 1.01-5.84], respectively), but not cancer-related mortality (RR 1.01 [95% CI 0.91-1.11]). In AS, we found a higher risk of death from all causes (RR 1.64 [95% CI 1.49-1.80]; n=6 studies) and cardiovascular causes (RR 1.35 [95% CI 1.01-1.81]; n=3 studies) compared to the general population. All-cause mortality was high in both male (RR 1.56 [95% CI 1.43-1.71]) and female (RR 1.85 [95% CI 1.56-2.18]) AS patients. The included AS studies did not report mortality data for non-cardiovascular causes. This systematic review and meta-analysis showed a significantly increased risk of overall mortality in AS but not PsA. Cardiovascular-specific mortality was higher for both PsA and AS, which emphasizes the importance of early screening and management of cardiovascular risk factors.

Resultados a longo prazo após tratamento endovascular da aorta em pacientes com doenças da aorta torácica

Abstract Background Endovascular treatments for thoracic aortic diseases have been adopted rapidly, and long-term studies are relevant for durability evaluation. Objective To evaluate the long-term results of a prospective observational study of endovascular treatment in patients with thoracic aortic diseases who underwent percutaneous implantation of self-expandable endoprostheses. Methods Procedural success was defined as the absence of endoleak into the aneurysm or dissection-induced false lumen, no migration, and no conversion to open surgery. Intraoperative, postoperative, and late postoperative outcomes were evaluated in terms of complications, mortality, and evolution of the endoprosthesis over a follow-up of up to 179 months (median: 46 months). Results A total of 150 endoprostheses were implanted in 112 patients. Primary success was observed in 100 (82.14%) patients. Immediate mortality occurred in 7 patients (6.25%). Late mortality occurred in 31 patients (27.68%), 10 (8.93%) of whom died from cardiovascular causes, 12 (10.71%) from non-cardiovascular causes, and 2 (1.78%) from natural causes, while 7 (6.25%) had no diagnosis for cause of death. Types I, II, and IV endoleaks occurred during hospitalization in 4 (3.57%), 5 (4.46%), and 3 (2.68%) patients, respectively. Late types I and IV endoleaks occurred in 5 (4.46%) and 3 (2.68%) patients respectively. Twenty-two patients (19.64%) had clinical complications in the immediate postoperative period. Actuarial survival free from death from cardiovascular causes was 79.3% (95% confidence interval, 67.0-91.7%) at 132 months. Conclusions The low levels of intraoperative and postoperative complications demonstrate that endovascular treatment is safe and effective. The high rate of late survival for these critically ill patients indicates that the endovascular technique is beneficial for treatment of thoracic aortic diseases in terms of long-term outcomes.

Feasibility, effectiveness, and safety of edoxaban administration through percutaneous endoscopic gastrostomy: 12-months follow up of the ORIGAMI study.

Edoxaban proved to be safe and effective also in fragile patients, but its administration through percutaneous endoscopic gastrostomy (PEG) has not been previously investigated. The purpose of this study was to evaluate the feasibility and the preliminary safety and efficacy profiles of edoxaban administered via PEG in patients with an indication for long-term oral anticoagulation. ORIGAMI was a prospective, single-arm, observational study (NCT04271293). Patients with PEG and an indication for long-term anticoagulation were prospectively enrolled. Crushed edoxaban at approved doses was administered via PEG. The primary endpoint was the composite of cardio-embolic events consisting of ischemic stroke, systemic embolism, or symptomatic deep venous thrombosis/pulmonary embolism (DVT/PE). Secondary endpoints were the number of bleeding events and edoxaban plasma concentrations at steady state. We here report the 12-month results. A total of 12 patients were enrolled. The main indication for PEG implantation was amyotrophic lateral sclerosis (10/12). The primary endpoint of cardio-embolic events did not occur in any patients at 12 months. All patients were in the therapeutic range of steady-state edoxaban plasma levels. Three minor bleedings were observed, while no major bleedings occurred during the observational period. A total of five patients died. All deaths were from non-cardiovascular causes and were consistent with the natural history of the pre-existing severe disease. Our study suggests that edoxaban administration via PEG is feasible and appears safe and effective in fragile, comorbid patients, resulting in therapeutic plasma concentrations of edoxaban. [ClinicalTrials.gov], identifier [NCT04271293].

FREQUENT CAUSES OF 30-DAY READMISSION FOLLOWING A FIRST EPISODE OF HEART FAILURE IN OLDER ADULTS

Abstract Older adults with heart failure (HF) have a greater propensity to experience poor clinical outcomes, hospital readmission, and functional decline. It is important that healthcare workers are aware of the comorbidities that may lead to poor outcomes. A deeper understanding of potential causes of readmission will help in adequate prevention. Employing an all-payers claims database, we aimed to examine the diagnoses related to 30-day readmission in patients aged 65-75 with an Elixhauser-Comorbidity Index score < 4 upon the first episode of HF. Exclusion criteria included in-hospital death, readmissions for the same condition, and discharge against medical advice. Using ICD codes 9-10, a cohort of 323,678 patients (mean age: 70, SD: 3.22; male: 60%) with the first episode of HF between 2015-2019 were identified. We found 7,729 (2.4%) readmissions within 30 days and examined the frequency of 118 diagnoses as the primary cause. Cardiovascular etiologies including HF, hypertension, arrhythmias, and coronary artery disease were the most prevalent causes of readmission (40.64%), with HF being the most frequent (13.25%). Non-Cardiovascular causes included pulmonary (5.94%), sepsis (7%), renal (3.8%), and cerebrovascular (1.58%). Metabolic, liver, gastrointestinal diseases, and other infections accounted for 19.32%. Understanding the diagnoses related to readmissions in different populations is crucial for improving care, conducting research, and lowering costs. We focused on the first episode of HF in a relatively healthy older population to control for confounding factors. Further studies considering demographics, HF characteristics, and baseline comorbidities are needed.

Drivers of mortality in patients with chronic coronary disease in the low-dose colchicine 2 trial

BackgroundLow-dose colchicine significantly reduces the risk of cardiovascular events in patients with chronic coronary disease. An increase of non-cardiovascular death raised concerns about its safety. This study reports cause-specific mortality and baseline predictors of mortality in the Low-Dose Colchicine 2 (LoDoCo2) trial. MethodsPatients with chronic coronary disease were randomly allocated to colchicine 0.5 mg once daily or placebo on a background of optimal medical therapy. Cause-specific mortality data were analysed, stratified by treatment status. Multivariate analyses were performed to examine the predictors of mortality as well as cardiovascular and non-cardiovascular death. ResultsAfter a median 28.6 months follow-up, 133 out of 5522 participants (2.4%) died. Forty-five deaths were cardiovascular (colchicine versus placebo: 20 [0.7%] versus 25 [0.9%], HR, 0.80; 95% CI, 0.44–1.44), while eighty-eight deaths were non-cardiovascular (53 [1.9%] versus 35 [1.3%]; HR, 1.51; 95% CI, 0.99–2.31). Forty-eight deaths were due to cancer (26 [0.9%] versus 22 [0.8%]), thirteen end-stage pulmonary disease (9 [0.3%] versus 4 [0.1%]), eight infection (4 [0.1%] versus 4 [0.1%]), five dementia (4 [0.1%] versus 1 [0.0%]) and five related multiple organ failure (3 [0.1%] versus 2 [0.1%]). Multivariable analysis demonstrated age > 65 years was the only independent baseline characteristic associated with non-cardiovascular death (HR, 3.65; 95% CI, 2.06–6.47). ConclusionsDuring the LoDoCo2 trial, assignment to colchicine was not associated with an adverse effect on any specific causes of death. Most deaths were related to non-cardiovascular causes, underscoring the importance of comorbidities as drivers of all-cause mortality in patients with chronic coronary disease.

The Importance of Controlling Comorbidities in HFpEF and How They Influence Disease Evolution

Heart failure (HF) is a disease with high morbidity and mortality in Brazil and in the world, and HF with preserved ejection fraction (HFpEF) accounts for more than half of cases. Effective pharmacological treatment options for HFpEF are scarce, with poor outcomes and an annual mortality of 10 to 30%. Mortality from noncardiovascular causes is high, which is to be expected given the high number of comorbidities (). The syndromic diagnosis is composed of several etiologies and diseases, each one [...]

The Efficacy and Safety of Direct Oral Anticoagulants versus Standard of Care in Patients without an Indication of Anti-Coagulants after Transcatheter Aortic Valve Replacement: A Meta-Analysis of Randomized Controlled Trials.

Transcatheter aortic valve replacement (TAVR) is now considered the mainstay of aortic stenosis management; however, the optimal antithrombotic therapy in patent without indications for an oral anticoagulant (OAC) is yet to be identified. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of direct oral anticoagulant (DOAC) treatment versus the standard of care in patients without indications of OACs after TAVR. We synthesized randomized controlled trials (RCTs) from Web of Science, SCOPUS, EMBASE, PubMed, and Cochrane until 18 August 2022. We used the risk ratio (RR) for dichotomous outcomes with the corresponding 95% confidence interval (CI). We registered our protocol in PROSPERO with ID: CRD42022357027. Three RCTs with 2922 patients were identified. DOACs were significantly associated with higher incidence of all-cause mortality (RR: 1.68 with 95% CI [1.22, 2.30], p = 0.001), mortality due to non-cardiovascular causes (RR: 2.34 with 95% CI [1.36, 4.02], p = 0.002), and the composite outcome of death, myocardial infarction, or stroke (RR: 1.41 with 95% CI [1.13, 1.76], p = 0.002). However, DOACs were associated with decreased incidence of reduced leaflet motion (RLM) (RR: 0.19 with 95% CI [0.09, 0.41], p = 0.0001) and hypoattenuated leaflet thickening (HALT) (RR: 0.50 with 95% CI [0.36, 0.70], p = 0.0001). DOACs were effective to reduce RLM and HALT; however, the clinical effect of this is still controversial. DOACs were associated with worse efficacy and safety outcomes, including all-cause mortality. Further RCTs investigating the optimal antithrombotic regimen after TAVR.

Abstract 13150: Risk Factors Associated With Major Adverse Cardiovascular Events Following First-Ever Ischemic Stroke: An Observational Study Using Linked Data From an Australian Stroke Registry

Introduction: Survivors of stroke are at increased risk of experiencing subsequent major adverse cardiovascular events (MACE). We aimed to determine the incidence of MACE within two years following first-ever ischemic stroke and identify associated factors. Methods: Patient-level data from the Australian Stroke Clinical Registry (2009-2013) were linked with emergency department and hospital admission data. Patient comorbidities were identified in the emergency and admissions data using published algorithms. Adults with no prior history of acute cardiovascular events were followed for two years post-discharge, or until first occurrence of MACE, whichever occurred earlier. Multivariable competing risks regression, accounting for deaths due to non-cardiovascular causes, was used to determine factors associated with MACE post-stroke. Results: Among 5,994 patients with first-ever ischemic stroke (median age 73 years, 45% female), 17% were admitted for MACE (129/100,000 person-years). MACE incidence was greatest in the first year following stroke (157/100,000 person-years). Compared to participants aged ≥65 years, the median time to first MACE was 37 days earlier for those aged <65 years. As there was a significant interaction (p<0.05) between age and other factors in predicting MACE incidence, subsequent analyses were stratified by age group. Being discharged to inpatient rehabilitation (sub-distribution hazard ratio [SHR]: 0.63; 95% Confidence Interval (CI): 0.44-0.90) was associated with reduced risk of MACE in patients aged <65 years only. Whereas, in those aged ≥65 years, MACE was associated with being female (SHR: 1.04; 95% CI: 1.03-1.05), initial stroke severity (SHR: 1.33; 95% CI: 1.15-1.54), smoking (SHR: 1.41; 95% CI: 1.14-1.71), and atrial fibrillation (SHR: 1.31; 95% CI: 1.14-1.51). Being treated in a large hospital (>300 beds) was associated with a lower risk of MACE in those aged <65 (SHR: 0.68; 95% CI: 0.44-0.90) and ≥65 years (SHR: 0.74; 95% CI: 0.62-0.87). Conclusion: MACE presentations are common within two-years of stroke, with most events occurring in the first year. We have identified factors (e.g., use of rehabilitation among younger patients) to consider when designing interventions to prevent MACE after stroke.

Re-hospitalisation after transcatheter aortic valve implantation: the HOSPITAVI study

Abstract Background Previous studies have shown increased re-hospitalisation rates for patients treated with transcatheter aortic valve implantation (TAVI) within the first post-procedural year. Most of these may be due to pre-existing co-morbidities, periprocedural complications, or suboptimal post-discharge plan. However, data on re-hospitalisation causes and associations with the TAVI procedure are limited. Purpose The aims of this study were to assess the incidence and cause of re-hospitalisation in patients with severe, symptomatic aortic stenosis treated with TAVI. Methods All patients who underwent TAVI at our centre between 2016 and 2020 were followed at patient-level during the first year after index admission. The risk of re-hospitalisation was calculated after discharge from index admission. All patients' medical records were reviewed to validate the cause of re-hospitalisation and mortality according to The Valve Academic Research Consortium 3 definitions. Results In total, 1,482 consecutive patients had undergone TAVI from 2016 to 2020, of whom 79 patients were excluded due to aortic regurgitation, conversion to surgical aortic valve replacement during index admission or residing abroad. Thus, the total study population consisted of 1,403 patients with a median age of 80 years (IQR: 75–84 years). Median length of stay for the post-procedural index admission was 2 days (IQR: 1–3 days). The total rate of all-cause re-hospitalisation per 100 patient years was 2.7 within the first 30 days, 1.1 from day 31 to 90, and 0.8 from day 91 to the first-year post-discharge. Within the first post-discharge year, 48.6% of the patients were re-hospitalized at least once, of which 26.2% (CI: 23.9–28.5%) of the first re-hospitalisations were of cardiovascular cause compared to 22.4% (CI: 20.2–24.6%) of non-cardiovascular cause. Median length of stay for the first re-hospitalisation was 3 days (IQR: 2–7 days). The most common cardiovascular causes were arrhythmias (28.1% of which 40.6% led to permanent pacemaker implantation), heart failure (14.4%), and neurological events (14.4%). The most common non-cardiovascular causes were infectious diseases (18.3% with pneumonia accounting for 40.4% of these admissions). The first re-hospitalisation was elective in 14.8% of the admissions, primarily due to percutaneous left atrial appendage closure, cancer, or osteoarthritis. Conclusion Almost half of the patients treated with TAVI between 2016 and 2020 were re-hospitalized within the first year after the index admission. First post-procedural re-hospitalisation was more often due to cardiovascular than non-cardiovascular cause with arrhythmias accounting for approximately 30% of cardiovascular re-hospitalisations. Further work is needed to explore whether the rate and causes of hospitalisations differ in the general population and to potentially establish a risk model to predict patients at high-risk of re-hospitalisation. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston ScientificAbbott

Implementation of a heart failure clinic in a non-cardiovascular center in Mexico

Abstract Introduction The incidence and prevalence of Heart Failure (HF) has been increasing throughout these years, with it, the need to implement HF clinics. In Latin America, it is rare to find non-cardiovascular centers with the capacity, human resources, and infrastructure to make this project sustainable, viable and useful for patients. Our center is a highly concentrated hospital in the country, with patients referred from different areas of Mexico. This makes it a unique site of multiple rare pathologies in the general population. Objectives To determine if there is a relationship between the implementation of a HF clinic and the decrease in mortality, the rate of rehospitalization of patients with HF over 6 months, as well as to implement and optimize the therapy of mainstay drugs for HF and the timely referral of the hospitalized or ambulatory patient, for follow-up, control, and education of HF. Methods A prospective descriptive study was designed with analytical intent. 80 patients with a diagnosis of HF were included. A comprehensive system was used to collect objective and subjective patient data through a database. The information was obtained from the review of medical records and by telephone follow-up of the patients. Each patient was evaluated at the first consultation with Brain Natriuretic Peptide (BNP) values, iron profile, troponin I, blood cytometry and complete blood chemistry. Follow-up appointments included BNP, nitrogen products and VExUS protocol for drug titration, study of reversible causes of HF, assessment of ejection fraction evolution, decision making regarding the indication of devices such as implantable defibrillator and resynchronizer, and scheduled appointments according to functional class and unscheduled appointments in case of alarm signs. Results Of the 80 total patients included in our registry during the first 6 months, we found the presence of Heart failure with reduced ejection fraction (HFrEF) in 66% of our patients, of whom 46% were reclassified as recovered Heart failure with recovered ejection fraction at the end of these first 6 months. In patients with HFrEF at least 94% receive a complete scheme of 4 drugs considered pillars in the treatment of this disease, (MRA, iSGLT2, ARNI/iECA or ARA-ll and β-blocker) 6% did not tolerate this quadruple therapy mainly due to episodes of hypotension. During our first 6 months, there were no deaths due to cardiovascular causes; however, mortality due to non-cardiovascular causes was 0.8%. Rehospitalizations due to HF decompensation was 3%. Intermittent administration of levosimendan was necessary in 2% of patients to improve conditions prior to major surgical events. Conclusion The implementation of a HF clinic decreases mortality due to cardiovascular causes, rehospitalizations due to HF decompensation, and increases adherence to optimal treatment, follow-up, and patient self-care. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The National Institute of Medical Sciences and Nutrition Dr. Salvador Zubiran Secretary of Health of Mexico

Practical management of frailty in older patients with heart failure: Statement from a panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology.

The heart failure (HF) prognosis in older patients remains poor with a high 5-years mortality rate more frequently attributed to noncardiovascular causes. The complex interplay between frailty and heart failure contribute to poor health outcomes of older adults with HF independently of ejection fraction. The aim of this position paper is to propose a practical management of frailty in older patients with heart failure. A panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology conducted a systematic literature search on the interlink between frailty and HF, met to propose an early frailty screening by non-geriatricians and to propose ways to implement management plan of frailty. Statements were agreed by expert consensus. Clinically relevant aspects of interlink between frailty and HF have been reported to identify the population eligible for screening and the most suitable screening test(s). The frailty screening program proposed focuses on frailty model defined by an accumulation of deficits including geriatric syndromes, comorbidities, for older patients with HF in different settings of care. The management plan of frailty includes optimization of HF pharmacological treatments and non-surgical device treatment as well as optimization of a global patient-centred biopsychosocial blended collaborative care pathway. The current manuscript provides practical recommendations on how to screen and optimize frailty management in older patients with heart failure.

A 15-year follow-up study of radiofrequency catheter ablation for atrial fibrillation in patients with tachycardia-bradycardia syndrome.

Catheter ablation for atrial fibrillation (AF) in patients with tachycardia-bradycardia syndrome (TBS) can be a major therapeutic option to replace permanent pacemaker implantation (PMI). However, the very long-term outcome of more than 15 years in these patients has not been elucidated. From 2002 to 2008, 25 consecutive TBS patients (62 ± 7.9 years old, 68% male) with both AF and symptomatic sinus pauses (>3.0 s) were performed radiofrequency AF ablation. These patients were followed for 15 ± 2.7 years. The median longest sinus pause before the ablation procedure was 6.0 s (4.4-8.0). Following 1.6± 0.8 ablation procedures, 18 (72%) patients remained free from AF. Three (12%) patients died due to noncardiovascular causes, and seven (28%) patients underwent PMI due to symptomatic sinus pause after recurrent AF in five patients and progression of sinus node dysfunction in two patients. The median duration from the first AF ablation to PMI was 6.3 years (range: 9 days to 11.0 years). Five and two patients required PMI more than 5 and 10 years after the first ablation procedure, respectively. AF ablation prevented PMI in 72% of TBS patients for a 15-year follow-up. However, in consideration of the long duration of PMI, a continuous careful long-term follow-up was warranted.

Reduction of heart failure guideline-directed medication during hospitalization: prevalence, risk factors, and outcomes.

Optimal management of heart failure with reduced ejection fraction (HFrEF) includes titration of guideline-directed medical therapy (GDMT) to the highest tolerated dose within the licensed range. During hospitalization, GDMT doses are often significantly altered, although it is unknown whether the cause of hospitalization influences this. We recruited 711 people with stable HFrEF from specialist heart failure clinics and prospectively assessed events occurring during first unplanned hospitalization. Dose changes of ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), beta-blockers, mineralocorticoid receptor antagonists, and loop diuretics were recorded during 414 hospitalizations, categorized as due to decompensated heart failure, other cardiovascular causes, infection, or other non-cardiovascular causes. Most hospitalizations resulted in no change to GDMT. ACEi/ARB dose was reduced in 21% of hospitalizations and was more common during non-cardiovascular hospitalization (25.4% vs. 13.9%; P=0.005). ACEi/ARB dose reduction was associated with older age and lower left ventricular ejection fraction at study recruitment, and poorer renal function, lower systolic blood pressure, higher serum potassium, and less frequent care from a cardiologist during admission. People experiencing ACEi/ARB reduction had worse age-adjusted survival after discharge, without differences in heart failure re-hospitalization. De-escalation of beta-blockers occurred in 8% of hospitalizations, most often due to other non-cardiovascular causes; this was not associated with post-discharge survival or re-hospitalization with heart failure. De-escalation of HFrEF GDMT is more common during non-cardiovascular hospitalization and for ACEi/ARB is associated with reduced survival. Post-discharge care plans should include robust plans to consider re-escalation of GDMT in these cases.

Application of occlusive devices in endovascular repair of Stanford type B aortic dissection with insufficient landing zones

OBJECTIVES: Occlusion of intimal tear with occlusive devices is an alternative or adjuvant method for endovascular repair of Stanford type B aortic dissection (TBAD) with insufficient landing zones. This study aimed to evaluate the efficacy and safety of using occluders in highly selective TBAD patients inappropriate for conventional thoracic endovascular aortic repair (TEVAR). METHODS: All patients undergoing TEVAR between July 2009 and July 2015 were retrospectively reviewed and patients treated with only or adjuvant occlusive devices were included in the study. Demographic data, clinical characteristics, perioperative data, and follow-up were collected and analyzed. RESULTS: A total of 10 TBAD patients treated with occluders were included in the study. The mean age was 56.8 ± 12.7 years old and the majority of the patients were male (7/10). Only occluders were applied to seal the proximal tears in seven cases, while occluders combined with other endovascular techniques were used in three cases. No 30-day mortality operative reintervention was required in two cases. Eight patients were followed up for 10.0 ± 4.1 years and two cases were lost to follow-up. Three patients died during the follow-up period; one patient died of stroke, while the other two patients died due to noncardiovascular causes. One reintervention was performed due to endoleak 2 years after the surgery. CONCLUSIONS: The early and long-term outcomes of the 10 patients show that treating difficult aortic lesions unfit for traditional TEVAR with occluders is effective and safe. The technique may provide a treatment alternative in highly selective TBAD patients unfit for traditional TEVAR.

Patient profiles on outcomes in patients hospitalized for heart failure: a 10-year history of the Malaysian population.

AimsHeart failure (HF) affects an estimated 38 million people worldwide and is the leading cause of hospitalization among adults and the elderly. Evidence suggests that there may be regional and ethnic differences in the prevalence, outcomes and management of HF. The aim of this study was to understand the disease burden and treatment patterns of patients hospitalized for HF in multi‐ethnic Malaysia.Methods and resultsA retrospective, non‐interventional study was conducted utilizing 10 years of medical records from the National Heart Institute Malaysia (IJN) from 1 January 2009 to 31 December 2018. Of the 4739 patients in the IJN database, 3923 were eligible and were included in this analysis. The study recorded a high male prevalence (72.3%) with a mean age of 62.0 (±13.26) years. The 30‐day and 1‐year rehospitalization rate was 6.8% and 24.7%, respectively. In‐hospital mortality was 7.2% with 27.0% due to cardiovascular causes and 14.2% non‐cardiovascular causes. The 30‐day and 1‐year rehospitalization rates were significantly higher in patients with lower systolic blood pressure (SBP, P < 0.001 and P = 0.002), diastolic blood pressure (DBP, P < 0.001 and P = 0.017), sodium (P < 0.001 and P = 0.029) and estimated glomerular filtration rate (eGFR, P < 0.001 and P = 0.002) and higher urea (P < 0.001 for both), serum creatinine (P < 0.001 and P = 0.003), and uric acid (P < 0.001 for both), respectively. Risk of hospitalization within 1 year varied significantly by ethnicity and was relatively higher in Indian (28.3%), followed by Malay (24.4%) and Chinese (21.9%; P = 0.008). In‐hospital mortality within 1‐year post‐index date was higher in patients with lower weight (P = 0.002), body mass index (P = 0.009), SBP (P < 0.001), DBP (P < 0.001), sodium (P < 0.001), eGFR (P < 0.001) and higher heart rate (P = 0.039), urea (P < 0.001), serum potassium (P = 0.038), serum creatinine (P < 0.001), and uric acid (P < 0.001). In‐hospital mortality within 1‐year post‐index date was also higher in patients with severe or end‐stage chronic kidney disease (CKD) compared with mild/moderate CKD (P < 0.001) and in patients with HF with reduced ejection fraction (HFrEF) compared with those with mid‐range or preserved ejection fraction (P < 0.001). The most commonly prescribed HF medications at discharge were loop diuretics (89.2%), β‐blockers (68.5%), mineralocorticoid receptor antagonists (56.2%), angiotensin‐converting enzyme inhibitors (31.5%), and angiotensin receptor blockers (20.8%).ConclusionsThis study provides a greater understanding of the characteristics, treatment patterns, and outcome of hospitalized HF patients in a leading referral centre in Malaysia and will aid the implementation of meaningful interventions to improve patient outcome for HF patients.

EFFECT OF CHRONIC KIDNEY DISEASE ON PROGNOSIS OF PATIENTS WITH ACUTE CORONARY SYNDROME

Objective: Chronic kidney disease (CKD) is associated with worse prognosis in acute coronary syndromes (ACS). We sought to investigate the prognostic effect of conservative management of ACS in CKD patients in a tertiary University Hospital. Design and method: Two hundred and one patients (mean age 66.5 ± 13.6 years, 150 males) admitted to our Hospital with ACS from 2016–2017 were included in the study. CKD was defined by an estimated glomerular filtration rate (eGFR) &lt; 60 ml/min/m2, as assessed by the Modification of Diet in Renal Disease (MDRD) equation. We grouped patients into four groups according to their CKD status and whether they underwent coronary angiography or not. Patients were followed for a median of 2 years post the index event. The primary outcome was all-cause death and secondary outcomes were cardiovascular and non-cardiovascular death. Results: The majority of patients (n = 120, 60%) presented with non-ST elevation ACS (NSTE-ACS), whereas 81 patients as ST-elevation myocardial infarction (STEMI) (40%). 135 patients (68%) had history of hypertension. Fifty-four patients (27%) were identified as CKD patients. Overall, 29 patients (14.4%) did not undergo coronary angiography. Patients at a higher age and with CKD were more likely to not undergo angiography. Thirty-seven (18.4%) died during follow-up (25 non-cardiovascular deaths and 12 cardiovascular deaths). Patients with conservative treatment and CKD had the worse prognosis (Hazard ratio [HR] = 11.00, 95% Confidence intervals [CI] 4.00 to 30.24, p &lt; 0.001) followed by non-CKD patients with conservative treatment (HR = 4.37, 95% CI 1.20 to 15.90, p = 0.025) compared to non-CKD patients treated invasively (reference group) after adjusting for age, gender, STEMI/NSTE-ACS diagnosis. Results were similar for non-cardiovascular death, whereas regarding cardiovascular death only the group with CKD and conservative treatment had a lower survival compared to the reference group (HR = 26.5, 95% CI 2.9 to 241.7, p = 0.004) Conclusions: Patients with ACS and CKD have higher mortality from both cardiovascular and non-cardiovascular causes than patients without CKD. Regardless of CKD status, conservative management of ACS was associated with higher long-term mortality versus invasive management in all patients.

Cost Effectiveness of Inclisiran in Atherosclerotic Cardiovascular Patients with Elevated Low-Density Lipoprotein Cholesterol Despite Statin Use: A Threshold Analysis.

BackgroundInclisiran is a novel, cholesterol-lowering therapy, with a long duration of effect, administered every 6 months (subcutaneously by a healthcare professional). In the ORION-10 trial in US patients with atherosclerotic cardiovascular disease (ASCVD) in addition to maximum tolerated statins, with or without ezetimibe, inclisiran demonstrated statistically significant reductions in low-density lipoprotein cholesterol (LDL-C) of up to 51%. This is the first peer-reviewed publication to investigate the price at which inclisiran is cost effective in the US.ObjectiveThe aim of this study was to determine the maximum price at which inclisiran is cost effective in addition to standard of care, in US patients with ASCVD, versus standard of care alone, at different willingness-to-pay thresholds.Design, Setting and ParticipantsA lifetime Markov model from the US health system perspective, including 15 health states, was used to evaluate the cost effectiveness of inclisiran. The following states were separated by time from a previous cardiovascular event (0–1 years, 1–2 years, 2+ years [‘stable’]): initial, unstable angina, myocardial infarction, and stroke. Additional states included revascularization and death (cardiovascular or non-cardiovascular causes). Baseline risk of cardivoascular events were from US database sources or published literature. Reductions in LDL-C from inclisiran were from the ORION-10 trial. LDL-C reduction was used to adjust baseline risk of cardiovascular events, based on established relationships between 1 mmol/L reduction in LDL-C and decreases in cardiovascular events, from the Cholesterol Treatment Trialists studies. The population included adults with a history of ASCVD, and LDL-C ≥ 70 mg/dL, despite maximum tolerated doses of statin therapy.InterventionsInclisiran as an adjunct to standard of care, compared with standard of care alone.Main Outcomes and MeasuresThe threshold price of inclisiran.ResultsInclisiran as an adjunct to standard of care resulted in threshold annual inclisiran prices of $6383, $9973, and $13,563 at willingness-to-pay thresholds of $50,000, $100,000, and $150,000 per quality-adjusted life-year, respectively. Probabilistic sensitivity analysis showed that at a threshold of $100,000 per QALY, inclisiran had a 100% probability of being cost effective, with an annual price below $9000. At the publicly available price of $3250 per dose, inclisiran was found to have an incremental cost-effectiveness ratio just above the $50,000 per QALY threshold, of $51,686.Conclusions and RelevanceThis study identified the price at which inclisiran is cost effective for the US health system, at generally accepted willingness-to-pay thresholds.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40256-022-00534-9.

Catheter ablation of well tolerated ventricular tachycardia in patients with structural heart disease: long term follow-up of 62 cases without automatic defibrillator implantation

Abstract Funding Acknowledgements Type of funding sources: None. Background The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered correlated to a poor prognosis, based on historical data in patients with heterogeneous heart disease and clinical presentation; therefore the recommendation for implantation of automatic implantable cardioverter defibrillator (AICD) is strong. Information about prognosis of patients with SMVT is still limited, but recent studies have established that these patients represent a low-risk subgroup for sudden death that could benefit from radiofrequency (RF) ablation of the arrhythmic substrate and the AICD implantation could be deferred during the follow up. Purpose Patients with well-tolerated SMVT, SHD and left ventricular ejection fraction (LVEF) over 30% can benefit from a primary VT ablation strategy without the immediate need for AICD implantation. Methods We reviewed consecutive SHD patients with LVEF over 30% admitted for the occurrence of SMVT and who were treated by RF ablation as a first-choice therapy in a single Italian center, between 2009 and 2020 and who were discharged without AICD implantation. The primary outcome of the study was a composite of all-cause death and recurrence of VT. The secondary outcome was death from all causes. Patients with similar characteristics but who underwent AICD implantation during the same period served as control group. Results Clinical and electrophysiological features of 62 patients were analyzed (Table 1). In the study group, 88% were male; the median age was 72 years (IQR 55-81) and the median LVEF was 50.0% (IQR 40.0-55.0). The estimated success rate of ablative procedures (defined as VT no longer inducible) was around 82%. After a median follow-up of 38.8 months (IQR 15.6-76.1), the primary outcome occurred in 24 patients and the secondary outcome in 11 patients. All-cause mortality was 17%, corresponding to an annual mortality rate of 4.3%. Ten patients died for non-cardiovascular causes and one for advanced heart failure. No patient in the study died from sudden death. During the follow-up, 10 patients (16.1%) underwent AICD implantation due to VT relapse. At 36 months, between study and control groups, there was no difference in either the primary composite outcome (HR 1.03, 95% CI 0.45-2.21, p = 0.98) or in the secondary outcome (HR 1.4, 95% CI 0.48-4.54, p = 0.49). Conclusions Patients with well-tolerated SMVT, SHD and LVEF over 30% represent a subgroup of patients at lower risk that can benefit of RF ablation as a first-choice therapy. Delay in AICD implantation, after a possible VT relapse or clinical worsening, appears to represent a safe therapeutic strategy. Therefore, it is ethical and desirable to start a prospective randomized clinical trial to evaluate the benefit and cost-effectiveness of this strategy, as an alternative to AICD implantation.