Prior Ischemic Heart Disease Research Articles

Short- and long-term prognostic performance of exercise ECG and myocardial perfusion SPECT.

Myocardial perfusion SPECT(MPS) and exercise electrocardiography(Ex-ECG) results are of prognostic importance for short-term follow up duration. However, the value of MPS or Ex-ECG findings for long-term risk assessment is less evident as underlying risk factors for ischemic heart disease (IHD) gain in importance. To assess the short- and long-term prognostic value of MPS and Ex-ECG in relation to known risk factors. An observational study of 908 patients (age 63 years, 49% male, 45% prior IHD) referred for MPS and Ex-ECG. Follow-up was divided into two periods (short-term: <5 years and long-term: >5 years). Cardiac events were defined as a composite of acute myocardial infarction, unstable angina, unplanned revascularization and cardiovascular death. The composite endpoint occurred in 95 patients (short-term follow up) and in 94 patients (long-term follow up). In multivariable models stress testing had a strong predictive value for short-term follow up (HR for MPS = 2.9, CI = 1.9-4.5, p < 0.001 and HR for Ex-ECG = 2.1, CI 1.3-3.3, p = 0.002), but no predictive value for long-term follow up (HR for MPS = 0.9, CI = 0.5-1.5, p = 0.70 and HR for Ex-ECG = 1.0, CI = 0.6-1.6, p = 0.92). Male sex and prior IHD were significant predictors regardless of follow up duration. Age, diabetes and decreased exercise capacity were risk factors for long-term follow up. The prognostic value of MPS and Ex-ECG results are strong for short-term follow up but diminish over time and do not contribute significantly in multivariable models after 5 years. Long-term prognosis is primarily governed by underlying risk factors and exercise capacity.

Characteristics and risk of stroke in emergency department patients with acute dizziness

BackgroundAcute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %–5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit. MethodsWe identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke. ResultsOut of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34–9.68) to 2.03 (95 % CI, 1.65–2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory. ConclusionsThe risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.

Major adverse cardiovascular events and hyperuricemia during tuberculosis treatment

Background Hyperuricemia is common during tuberculosis (TB) treatment, especially in association with pyrazinamide (PZA). This study investigated the relationship between major adverse cardiovascular events (MACEs) and hyperuricemia during TB treatment. Methods We conducted a single-center retrospective cohort study. From January 2010 through June 2017, we assessed all consecutive TB patients at Chonnam National University Hospital in South Korea. Hyperuricemia was defined as serum uric acid levels exceeding 7.0 mg/dL (men) and 6.0 mg/dL (women). Results Of the 1,143 patients included, PZA was administered to 1,081 (94.6%), and hyperuricemia was detected in 941 (82.3%). Eight patients experienced MACEs. Multivariate analysis using logistic regression indicated that prior ischemic heart disease was associated with MACE development (OR,14.087; 95% CI,3.304–60.061; P &lt; 0.000), while hyperuricemia was not (OR, 1.505; 95% CI, 0.184–12.299; P = 0.703). For patients without drug-resistant TB, the absence of hyperuricemia was associated with higher mortality (OR, 2.609; 95% CI, 1.066–6.389; P = 0.036), whereas hyperuricemia was associated with less worse outcomes (OR,0.316; 95% CI,0.173–0.576; P &lt; 0.000). Conclusions Although most patients treated with PZA developed hyperuricemia, it was not associated with MACE development. Hyperuricemia during TB treatment was associated with better outcomes, possibly due to consistent adherence to TB treatment.

Exercise ECG and myocardial perfusion SPECT show high prognostic value up to four years after examination

Abstract Background Abnormal results of myocardial perfusion SPECT (MPS) or exercise ECG (Ex-ECG) is known to be associated with increased risk of ischemic cardiac events. The predictive value of stress testing however, is influenced by underlying risk factors as well as follow up duration and may vary considerably over time. With traditional Cox proportional hazards analysis the time-varying effects are not sufficiently accounted for. Purpose To evaluate the prognostic longevity of MPS and Ex-ECG using statistical methods that allow hazard ratio changes over time. Methods 908 patients (age 63 years, 49% male, 45% prior ischemic heart disease (IHD)) referred for MPS were prospectively included. Ex-ECG was performed in conjunction with MPS. Registry data were used for follow up. The outcome was a composite of acute myocardial infarction, unstable angina, unplanned revascularization, and cardiovascular death. Cox proportional hazard analysis and smoothed hazard functions with splines were used for risk assessment during follow up. Results Ex-ECG or MPS were abnormal in 198 (22%) or 148 (16%) of patients respectively. The mean follow up time was 8.2±2.6 years and the composite end point was reached in 189 patients (21%). The Kaplan-Meier curves suggest an interaction with time with the risk of event for subjects with abnormal test results being highest in the 2-3 of years after which the curves are approximately parallel (Figure 1). In multivariable models the best fit (lowest Akaike information criterion (AIC) value) was obtained with a logarithmic interaction term for time. With this approach and controlling for known risk factors the hazard ratio (HR) drops to 1 after approximately four years for both Ex-ECG and MPS (Figure 2). Age (HR=1.04, p&amp;lt;0.001), sex (HR=2.0, p&amp;lt;0.001), IHD (HR=1.7, p&amp;lt;0.001) and reduced exercise capacity (HR=0.99, p&amp;lt;0.001) were independent significant predictors of risk. Conclusions The high risk associated with abnormal MPS and Ex-ECG results decrease rapidly over time and after approximately 4 years the predictive value is lost. Thus, the long-term impact on prognosis of stress testing appear questionable. The time-varying effects on risk are substantial and warrant statistical considerations when designing clinical follow up studies of chronic coronary syndrome.

Differences in clinical characteristics and outcomes between patients with left ventricular thrombus following non-anterior and anterior ST-elevation myocardial infarction

Abstract Background Left ventricular thrombus (LVT) is a serious complication following ST-elevation myocardial infarction (STEMI), and occurs more frequently in anterior compared to non-anterior myocardial infarction (MI).1 There is limited data on the clinical characteristics and outcomes in patients with LVT following non-anterior MI. Purpose We aimed to describe the clinical characteristics and outcomes of patients with LVT following non-anterior MI, and compare them against patients with LVT associated with anterior MI. Methods We retrospectively studied 217 consecutive patients with post-STEMI LVT from our tertiary centre’s echocardiography database between March 2011 and January 2021. Trans-thoracic echocardiography was performed at day 2 or 3 post-MI. We compared baseline co-morbidities and echocardiographic parameters between patients with LVT following non-anterior versus anterior MI. The Kaplan Meier method with log-rank test was used to compare rates of thrombus resolution, stroke and all-cause mortality between the 2 groups. Multivariable Cox regression models were constructed to correct for potential confounders. Results Mean age of the study population was 56.0 (IQR 48.0, 63.0) years old and 16/217 (7.4%) were female. LVT following non-anterior MI made up 24/217 patients (11.1%), and included lateral (n=3), inferior (n=15), inferoposterior (n=4) and inferolateral (n=2) MI. Patients with LVT associated with non-anterior MI were older and more frequently had a history of ischaemic heart disease (Figure 1). These patients also had a lower median left ventricular ejection fraction (LVEF) of 29% compared to their counterparts with anterior MI (mean LVEF 38%). Rate of anticoagulation was lower in patients with LVT associated with non-anterior MI (75.0% versus 92.2%). There were no differences in rates of thrombus resolution between the 2 groups (Figure 2). Patients with LVT following non-anterior MI had a higher incidence of stroke, however this observation was not present after correction for baseline embolic risk (CHA2DS2-VASc score) and rate of anticoagulation. Mortality rates were similar in patients with LVT following non-anterior MI versus anterior MI, after correction for baseline co-morbidities as well as in-hospital mortality – as this was more likely due to acute MI complications rather than longer term consequences of LVT. Conclusions Patients with LVT following non-anterior MI are older with a greater prevalence of prior ischaemic heart disease. These patients had a greater rate of stroke and mortality, although baseline co-morbidities and less frequent use of anticoagulation may have contributed to these findings. This needs to be clarified in future prospective studies.Figure 1:Baseline characteristicsFigure 2:Outcomes

The significance of historical troponin elevation in acute heart failure: Not as reassuring as previously assumed.

Historical cardiac troponin (cTn) elevation is commonly interpreted as lessening the significance of current cTn elevations at presentation for acute heart failure (AHF). Evidence for this practice is lacking. Our objective was to determine the incremental prognostic significance of historical cTn elevation compared to cTn elevation and ischemic heart disease (IHD) history at presentation for AHF. A total of 341 AHF patients were prospectively enrolled at five sites. The composite primary outcome was death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and/or acute myocardial infarction (AMI)/percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) at 90 days. Secondary outcomes were 30-day AMI/PCI/CABG and in-hospital AMI. Logistic regression compared outcomes versus initial emergency department (ED) cTn, the most recent electronic medical record cTn, estimated glomerular filtration rate, age, left ventricular ejection fraction, and IHD history (positive, negative by prior coronary workup, or unknown/no prior workup). Elevated cTn occurred in 163 (49%) patients, 80 (23%) experienced the primary outcome, and 29 had AMI (9%). cTn elevation at ED presentation, adjusted for historical cTn and other covariates, was associated with the primary outcome (adjusted odds ratio [aOR] 2.39, 95% confidence interval [CI] 1.30-4.38), 30-day AMI/PCI/CABG, and in-hospital AMI. Historical cTn elevation was associated with greater odds of the primary outcome when IHD history was unknown at ED presentation (aOR 5.27, 95% CI 1.24-21.40) and did not alter odds of the outcome with known positive (aOR 0.74, 95% CI 0.33-1.70) or negative IHD history (aOR 0.79, 95% CI 0.26-2.40). Nevertheless, patients with elevated ED cTn were more likely to be discharged if historical cTn was also elevated (78% vs. 32%, p = 0.025). Historical cTn elevation in AHF patients is a harbinger of worse outcomes for patients who have not had a prior IHD workup and should prompt evaluation for underlying ischemia rather than reassurance for discharge. With known IHD history, historical cTn elevation was neither reassuring nor detrimental, failing to add incremental prognostic value to current cTn elevation alone.

Prospective relationship between occupational physical activity and risk of ischaemic heart disease: are men and women differently affected?

High occupational physical activity (OPA) seems to increase risk of cardiovascular diseases among men. However, findings are mixed, and it is not known if women are differently affected. Therefore, the aim of this study is to investigate the relationship between OPA and risk for ischaemic heart disease (IHD), and whether it differs across sex. This prospective cohort study was based on 1399 women and 1706 men, aged 30-61 years, participating in the Danish Monica 1 study in 1982-84, actively employed, without prior IHD and answering an OPA question. The information on incidence of IHD, before and during the 34-years follow-up, was retrieved by individual linkage to the Danish National Patient Registry. Cox proportional hazards models were used to investigate the association between OPA and IHD. Compared to women with sedentary work, women in all other OPA categories had lower hazard ratio (HR) for IHD. Among men, the risk of IHD was 22% higher among those with light OPA, and 42% and 46% higher among those with moderate OPA with some lifting or strenuous work with heavy lifting, respectively, compared to men with sedentary OPA. Compared to women with sedentary work, HR for IHD was higher among men in all OPA categories. There was statistically significant interaction between OPA and sex. Demanding or strenuous OPA seems to be a risk factor for IHD among men, whereas a higher level of OPA seems to protect women from IHD. This emphasizes the importance of taking sex differences into account in studies of health effects of OPA.

Predicting Patients With Troponin Positive Chest Pain and Unobstructed Coronary Arteries With Electrocardiogram, Troponin Kinetics and GRACE Score.

Troponin positive chest-pain with unobstructed coronary arteries (TPCP-UCA), occurs in 6% of cases of patients presenting with acute coronary syndrome (ACS). Whilst TPCP-UCA patients are known to be younger with less cardiovascular risk factors when compared to obstructive coronary disease (MICAD), no validated methods exist to reliably delineate these two conditions prior to coronary angiography. We analysed 142 patients with MICAD and 127 patients with TPCP-UCA from 2015 to 2019. Several key predetermined clinical, biochemical and electrocardiograph (ECG) parameters, as well as Global Registry of Acute Coronary Events (GRACE) score, were collected for all patients. All TPCP-UCA patients underwent cardiac magnetic resonance imaging (cMRI). Patients with TPCP-UCA were younger than MICAD (44 vs 68 yrs, p<0.01), and with less cardiac risk factors of hypertension (31% vs 68%, p<0.01), hypercholesterolaemia (23% vs 56%, p<0.01), diabetes (11% vs 45%, p<0.01), prior ischaemic heart disease (8% vs 42%, p<0.01) and smoking history (29% vs 50%, p<0.01). Peak troponin (MICAD 2,084.5 ng/L vs TPCP-UCA 847.0 ng/L, p=0.02), serial-to-initial troponin ratio (MICAD 13.5 vs TPCP-UCA 5.1, p<0.01), and peak-to-initial troponin ratio (MICAD 69.6 vs TPCP-UCA 14.0, p<0.01) were all higher in the MICAD group. GRACE scores were significantly different across the two cohorts (TPCP UCA 74 vs MICAD 106, p<0.01), with a receiver operator characteristic (ROC) curve statistic of 0.794 (95% CI 0.739-0.850). On ECG analysis, MICAD had greater prevalence and sum of ST depression (40% vs 19% p<0.01; 1.6 mm vs 0.44 mm, p<0.01) and T wave inversion (37% vs 17%, p<0.01), whilst TPCP-UCA had greater presence of PR depression (20% vs 3% p<0.01), and longer repolarisation (T wave peak to end 89 ms vs 83 ms, p=0.04; T wave peak to end/corrected QT 0.208 ms vs 0.193 ms, p=0.03). All TPCP-UCA patients underwent cMRI. Aetiology was found in 82% of cases, with the leading diagnosis being myocarditis (58%), followed by infarction (8%), whilst 18% had a normal cMRI. TPCP-UCA is an important differential for patients presenting with ACS, and has several key demographic, biochemical and electrocardiographic differences. The present findings are hypothesis generating, thus prospective studies are required to determine and validate potential clinical utility.

Breast Cancer Radiation Therapy and the Risk of Acute Coronary Events: Insights From a Process-Oriented Model

Acute coronary events (ACEs) are considered the most important side effect of radiation therapy (RT) for breast cancer, but underlying mechanisms still have to be identified. Process-oriented models mathematically describe the development of disease and provide a link between mechanisms and subsequent risk. Here, this link is exploited to learn about the underlying mechanisms from the observed age-time patterns of ACE risk. A process-oriented model of atherosclerosis and subsequent ACEs was applied to a contemporary breast cancer cohort of 810 patients with measurements of coronary artery calcification. Patients with prior ischemic heart disease were excluded. The process-oriented model describes disease development as a series of different stages. Different variants of the model were fitted to the data. In each variant, one stage was assumed to be accelerated in relation to mean heart dose. During a mean follow-up of 9.1 years, 25 ACEs occurred. The model reproduced the prevalence and associated risk of coronary calcifications. Mean heart dose significantly improved the fit only when implemented as affecting a late stage of atherosclerosis on already-existing complicated lesions (achieving P=.007). This can be understood by atherosclerosis being a slowly progressing disease. Therefore, an increase in ACEs a few years after RT requires advanced atherosclerosis at the time of RT. Risk of ACE increases within a few years in patients with advanced atherosclerosis at RT. Therefore, patients should be assessed for cardiovascular risk, and older patients need to be considered for heart-sparing techniques.

Cirrhotic cardiomyopathy: Appraisal of the original and revised criteria in predicting posttransplant cardiac outcomes.

Cardiovascular disease (CVD) significantly contributes to morbidity and mortality after liver transplantation (LT). Cirrhotic cardiomyopathy (CCM) is a risk factor for CVD after transplant. CCM criteria were originally introduced in 2005 with a revision proposed in 2020 reflecting echocardiographic technology advancements. This study assesses the two criteria sets in predicting major adverse cardiac events (MACE) after transplant. This single-center retrospective study reviewed adult LT recipients between January 1, 2009, and December 31, 2018. Patients with insufficient pre-LT echocardiographic data, prior ischemic heart disease, portopulmonary hypertension, or longitudinal care elsewhere were excluded. The primary composite outcome was MACE (arrhythmia, heart failure, cardiac arrest, and/or cardiac death) after transplant. Of 1165 patients, 210met the eligibility criteria. CCM was present in 162 patients (77%) per the original criteria and 64 patients (30%) per the revised criteria. There were 44 MACE and 31 deaths in the study period. Of the deaths, 38.7% occurred secondary to CVD. CCM defined by the original criteria was not associated with MACE after LT (p=0.21), but the revised definition was significantly associated with MACE (hazard ratio [HR], 1.93; 95% confidence interval, 1.05-3.56; p=0.04) on multivariable analysis. Echocardiographic variable analysis demonstrated low septal e' as the most predictive variable for MACE after LT (HR, 3.45; p<0.001). CCM, only when defined by the revised criteria, was associated with increased risk for MACE after LT, validating the recently revised CCM definition. Abnormal septal e', reflecting impaired relaxation, appears to be the most predictive echocardiographic criterion for MACE after LT.

Randomised comparison of achieve and traditional circular mapping catheters in cryoballoon ablation: results at up to a decade

Abstract Funding Acknowledgements Type of funding sources: None. Background A single-centre trial randomised patients to the use of the Achieve mapping catheter or a traditional circular mapping catheter during cryoballoon procedures for paroxysmal atrial fibrillation (AF) in 2011-2014. Long-term outcomes from the cohort were determined in 2021. Purpose To evaluate the determinants of long-term outcome of ablation for paroxysmal AF. Methods Patient and study procedure characteristics and clinical outcomes were determined, including mapping catheter assignment, model of cryoballoon used, AF recurrence, repeat ablations required, findings at repeat ablation long term survival of the patient. Results Of 102 patients in the original study, 98 had long-term (4.11+/-2.82 years) follow up data available. 35 patients (35.7%) had AF recurrence, giving a long-term success rate at 64.3% after 1 ablation, increasing to 81.6% after repeat ablation. Of the study cohort n=8 (8.16%) died at a median of 4.9 years after ablation (IQR:1.7-5.7). 25/98 (25.5%) patients had a second ablation and 7 (7.1%) had a third or more ablations. Those who had AF recurrence were older, with a higher prevalence of prior ischaemic heart disease and cardiac device implantation (p=0.02-0.03). After multi-variate analysis, a prior implanted cardiac device was the only significant predictor of recurrence (p=0.03). Conclusion Long-term outcomes after a 1st time PAF cryoablation were similar regardless of the type of mapping catheter used, the generation of cryoballoon, and traditional procedure endpoints. AF recurrences were more often detected in older patients with a history of ischaemic heart disease and implanted cardiac devices.

Comparison of Clinical and Laboratory Features in RT-PCR Positive and RT-PCR Negative Covid-19 Patients Admitted in High Dependency Unit in a Tertiary Care Hospital, SGRH, Lahore

Introduction: Corona virus disease 2019 (COVID-19) is currently diagnosed mainly using reverse transcriptase polymerase chain reaction (RT-PCR). Yet a significant proportion of patients have negative RT-PCR result. A comparative study of RT-PCR negative patients with RT-PCR positive patients will help understand clinical characteristic and differences of this diseased population. Objective: To compare the clinical and laboratory features of RT-PCR Positive and RT-PCR negative patients admitted in high dependency unit. Patients and methods: In this retrospective cohort study, the data of 128 patients (59 patients with RT-PCR positive result and 69 patients with RT-PCR negative results) was obtained. These patients had been admitted in high dependency unit of a community hospital. Demographics, clinical characteristics and laboratory abnormalities were noted and a comparison was done using statistical analysis. Results: In our study-total 128 patients were enrolled out of which 68 (53.1%) were males and 60 (46.9%) were females. 59 (46.1%) patients were RT-PCR positive and 69 (53.9%) patients were RT-PCR negative. Median age was 55.34 years (18 to 95). No significant difference was noted in most of clinical symptoms (fever, sputum production, rhinorrhea, dyspnea, myalgia, nasal congestion, vomiting, diarrhea, urinary symptoms, altered level of consciousness), comorbidities (diabetes mellitus, hypertension, prior lung disease, prior ischemic heart disease, prior kidney disease), laboratory abnormalities (elevated creatinine, elevated liver enzymes, elevated ferritin, elevated C-reactive protein, elevated d-dimers, elevated procalcitonin, abnormal electrocardiogram). Cough was significantly found to be more prevalent in RT-PCR positive patients (p=0.042) and severe disease was also more prevalent in these patients significantly (p=0.000). Conclusion: Our study shows that patients admitted and diagnosed to be suffering from COVID-19 infection had remarkable similarities in clinical features and laboratory parameters regardless of RT-PCR status, however RT-PCR positive patients suffered from more severe pneumonia as compared to RT-PCR negative patients. Keywords: COVID-19, RT-PCR positive, RT-PCR negative

Performance of Coronary Angiography in the Detection of Coronary Artery Disease in Patients with Systolic Left Ventricular Dysfunction and No Prior Ischemic Heart Disease.

The diagnosis of ischemic cardiomyopathy is not well established. Our objective is to determine predictive variables of coronary disease in unselected patients with ventricular dysfunction. This study is a retrospective cohort study of consecutive patients with left ventricular dysfunction and no known history of ischemic heart disease. We analyse the demographic variables, clinical data, electrocardiogram, and echocardiogram that are associated with the presence of coronary stenosis on coronary angiography. A total of 536 patients with left ventricular dysfunction were studied, with 135 (25.2%) of them having significant coronary lesions. In the multivariate logistic regression analysis, age ≤ 50 years, female gender, and the presence of atrial fibrillation on the electrocardiogram (ECG) were predictors of the absence of coronary lesions. Diabetes, hypercholesterolemia, the existence of Q waves in the ECG, and segmental alterations in contractility in the echocardiogram were predictors of coronary heart disease (C-Statistics 0.771, 95% CI 0.727 to 0.814). The information obtained from the clinical history, the ECG, and the echocardiogram of patients with ventricular dysfunction allows us to select subjects in whom coronary angiography has shown poor performance in diagnosing coronary disease.

Association between higher serum uric acid levels and plasma N-terminal pro-B-type natriuretic peptide concentrations in patients with coronary artery disease and without overt heart failure

BackgroundThe association between serum uric acid (SUA) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations in patients with coronary artery disease (CAD) is unclear. MethodsWe retrospectively studied 171 patients with suspected or established CAD and without overt heart failure who were consecutively admitted to our Division of Cardiology from February to August 2016. Plasma NT-proBNP concentrations were measured using a chemiluminescent immunoassay method. A conventional echocardiography and coronary angiogram were also performed in all patients. ResultsPatients in the 3rd SUA tertile had higher median plasma NT-proBNP concentrations compared with those belonging to 2nd or 1st SUA tertile, respectively (443 [IQR: 222–1381] vs. 224 [99–487] vs. 162 [68–307] pg/mL; p < 0.001). After adjustment for age, sex, body mass index, hypertension, diabetes, chronic kidney disease, prior ischemic heart disease, prior heart failure, medication use, and left ventricular ejection fraction (LVEF), patients belonging to the 3rd SUA tertile had an increased risk of higher plasma NT-proBNP concentrations (adjusted-standardized beta coefficient: 0.310, p < 0.001). Almost identical results were found when patients treated with allopurinol (n = 14), or those with prior HF (n = 8) were excluded from the analyses. ConclusionsThese results show that increased SUA levels are strongly associated with higher plasma NT-proBNP concentrations in patients with suspected or established CAD and without overt heart failure, independent of established cardiovascular risk factors, LVEF, medication use and other potential confounders.

288 The effects of cardiovascular diseases and treatment on clinical course of hospitalized COVID-19 patients

AimsSignificant concern has been raised about the effect of pre-existing cardiovascular diseases (CVD), cardiovascular (CV) risk factors and CV therapies on COVID-19 course. On the other hand, COVID-19 could worse pre-existing CVD or trigger the development of new-onset CVD. The aim of this study was to evaluate the relationship between pre-existing CVD, CV risk factors, and CV therapy with the clinical course of hospitalized COVID-19 patients.Methods and resultsConsecutive hospitalized COVID-19 patients admitted to the Cardiovascular COVID-19 Unit at Policlinico Umberto I of Rome between December 2020 and April 2021 were enrolled. All patients underwent a cardiovascular evaluation including troponin, electrocardiogram (ECG), and echocardiogram. Data on medical history, pre-existing CVD, CV risk factors, and therapy were collected. Admission to the Intensive Care Unit (ICU) or Cardiac Intensive Care Unit (CICU), as well as the development of new-onset CVD, were considered as endpoint of the study. Among n = 229 patients enrolled, 22 (10%) died. Nearly half of patients (112, 49%) were admitted to the ICU/CICU. The presence of prior ischaemic heart disease nearly doubled the probability of hospitalization in the ICU/CICU (HR: 2.09, 95% CI: 1.132–3.866, P 0.018). In regards of therapy, beta blockers reduced the likelihood of admission in the ICU/CICU (HR: −1016, 95% CI: 0.192–10.682, P 0.002). However, neither the use of RAAS blockers, heparin or dexamethasone influenced the risk of ICU/CICU admission (respectively, HR: 0.85, 95% CI: 0.498–1.450, P 0.551; HR: 0.768, 95% CI: 0.435–1.356, P 0.363; HR: 0.861, 95% CI: 0.453–1.635, P 0.647). N = 89 patients (39%) experienced a new onset CVD including arrythmias (18.3%) with nearly half experiencing atrial fibrillation, acute coronary syndrome (10.9%), acute pulmonary embolism (5.3%), heart failure (HF) (3%), and myocarditis and pericarditis (1.3%). A pre-existing diagnosis of HF substantially increased the likelihood of new onset CVD (HR: 2.380, 95% CI: 1.004–5.638, P 0.049). However, treatment with heparin or dexamethasone reduced the risk of new onset CVD (HR: 0.482 95% CI: 0.268–0.867, P 0.015; HR: 0.487, 95% CI: 0.253–0.937, P 0.031, respectively).ConclusionsOur study found that hospitalized COVID-19 patients who have at least one CV risk factor or pre-existing CVD had a greater likelihood of being admitted to the ICU/CICU and experiencing new onset CVD.

CPX-351 for Acute Myeloid Leukaemia: Real World Results Are Comparable to Trial Outcomes and Exceeds Them in Non-Adverse Risk Patients- a Multicentre Experience from West Midlands Hospitals on Behalf of West Midlands Research Consortium ( WMRC) UK

Patients with secondary AML or MDS derived AML have poor outcomes compared to de-novo AML. The benefits of intensive chemotherapy without anticipated transplant consolidation have been previously doubted. Outcomes in USA trial centres have not often been closely replicable in real world settings. From November 2018 CPX-351 has been available in the UK for secondary AML, therapy related AML, AML with MDS related Karyotype (AML-MRC) and licensed but not funded for AML with myelodysplastic related changes.ObjectivesHere we report our experience specifically on patient outcomes and toxicity across 5 Hospitals in West Midlands, UKMethodsPatients receiving CPX 351 outcomes were evaluated retrospectively from 2018 to 2021. Baseline genetics, CPX 351 indications, patient's comorbidities, overall survival, remission status, number of cycles delivered, early mortality, reasons for early discontinuation, intensive care admission and time for neutrophil recovery (>0.5) was recorded. Time-to-event outcomes reported here are from a data cut on 01-06-21ResultsIn a total cohort of 57 patients baseline characteristics are shown on table 1 and compared with the original trial CPX-351 group. Median follow up was 376 days (range 21 to 1248 days).The mean age was 63, 17 patients were under 60, 31 males and 26 females.The most common indication for CPX-351 was AML with antecedent MDS/MPN 51% (N=29), therapy related 14% (N=8), MDS related karyotype (AML-MRC) 19% (N=11) and 16% (N=9) other patients.Mean Charleston co-morbidity score was 2.7 (range 0-6), 10.5% (N=6) had previous non myeloid malignancies, 8.7% (N=5) had prior ischaemic heart disease, only 3.5% (N=2) had ejection fractions under 50%.The most common mutations were TP53 21% (N=12), ASXL1 15.7% (N=9), TET2 15.7% (N=9), IDH2 10.5% (N=6), RUNX1 10.5% (N=6), SRSF2 7% (N=4), JAK2 3.5% (N=2), FLT3 5% (N=3), NPM1 5%(N=3) and IDH1 5% (N=3).MRC cytogenetic risk was adverse in 19 patients (33%), intermediate in 35 patients (61%) and favourable in 3 patients (5%).30 patients (53%) had adverse European Leukaemia Network classification, 17 (30%) had intermediate and 10 (17%) had favourable.30-day mortality was 3/57 (5%), 60-day mortality was 6 (10.5%) comparable to the 5.9% and 10.6% rates for the original trial. 9% or 5/57 patients were admitted to ITU with 2 survivors beyond 60 days. Neutropenic fever requiring antibiotics was 100% whereas only 5/57 (9%) had radiological evidence of fungal infection. Only one patient died from COVID 19.The mean time to neutrophil recovery was 35 days with a range of 12 to 84 days.29 patients completed 1 cycle, 25 completed 2 cycles, only 3 completed 3 cycles. The reasons for stopping were death, refractory disease, drop in performance status, alternative chemotherapy chosen or moving to transplantation (39%).Composite remission rate including CRi was 61% 36/57, adverse ELN group demonstrated 50% 15/30, intermediate 76% 13/17 and favourable 80% 8/10. Mutated P53 was associated with a 50% 6/12 rate whereas in wild type P53 the remission rate was 60% 30/45.Overall median survival from diagnosis was 429 days [95% CI 274 to 788 days]. To compare with the original trial, we removed the under 60s and those with less than 1 year follow up, in this cohort of 30 patients the median survival was 289 days (9.5 months) with 95% CI of 255 to 476 days.P53 mutated patients had an estimated median survival of 257 days versus wild type p53 with 524 days hazard ratio of 2.418 (CI 1.077 to 5.248) with p value of 0.032. Median survival for ELN groups was 373 days (adverse), 413 days (intermediate) and not reached for favourable.Of the 36 patients who achieved a remission, 22 went on to receive an allogenic transplant with follow from 254 to 1248 days, median survival estimated 706 days (95% CI 429-not reached). Patients in remission who haven't received a transplant have a similar estimated survival of 788 days (305-not reached) pending longer follow up.ConclusionThis is the first UK multicentre analysis to show comparable results to the landmark trial (median survival 9.5 months in equivalent cases). The improved overall remission rate 61% versus the 47% in the trial and the longer median survival 14 months versus 9.5 months in the trial is expected given the younger age and increase in favourable risk genetics. This study therefore supplies further data of CPX-351 efficacy in younger patients not included in the original studies and may now be used as a standard comparator arm. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Rate of Heart Failure Following Atrial Fibrillation According to Presence of Family History of Dilated Cardiomyopathy or Heart Failure: A Nationwide Study.

BackgroundIt is poorly understood why some patients with atrial fibrillation develop heart failure (HF) and others do not. We examined the rate of developing HF in patients with atrial fibrillation with and without first‐degree family members with HF or dilated cardiomyopathy (DCM).Methods and ResultsUsing Danish nationwide registries, patients born after 1942 diagnosed with atrial fibrillation in the period 2005 to 2015 were identified and followed for up to 5 years. Patients with pre‐existing HF, DCM, and/or ischemic heart disease diagnoses were excluded. Exposure was defined as a first‐degree relative with HF or DCM. The rate of developing the composite end point of HF or death, and the components, was estimated with multivariable Cox proportional hazard regression models. We included 10 605 patients. A total of 17% had a family member with DCM/HF. Having a family member with HF/DCM was associated with an increased 5‐year risk of the composite of HF/death (cumulative incidence, 9.2% [95% CI, 7.8–10.7] versus 5.6% [95% CI, 5.0–6.1]; adjusted hazard ratio [HR] 1.36 [95% CI, 1.13–1.64]). (HF 8.4% [95% CI, 7.0–9.8] versus 4.5% [95% CI, 4.1–5.0]); (adjusted HR, 1.49 [95% CI, 1.22–1.82]). However, familial HF/DCM was not significantly associated with an increased 5‐year risk and rate of death (0.8% [95% CI, 0.4–1.2] versus 1.1% [95% CI, 0.8–1.3]); (adjusted HR, 0.80 [95% CI, 0.46–1.39]).ConclusionsIn patients with incident atrial fibrillation without prior ischemic heart disease or HF diagnoses, 1 of 6 had a first‐degree relative with HF, and having such a family history of HF/DCM was associated with an 87% increase in 5‐year incidence of HF compared with those without.

Inflammatory risk factors are not associated with coronary artery calcification in patients with myeloproliferative philadelphia-negative neoplasms

Abstract Background Myeloproliferative Philadelphia-negative Neoplasms (MPNs) are hematological cancers associated with chronic inflammation and endothelial dysfunction, conditions that may lead to development of premature atherosclerosis. Purpose To investigate whether biomarkers of inflammation and endothelial dysfunction are associated with the degree of atherosclerotic burden, measured by Coronary Artery Calcium Score (CACS), in patients with MPNs. Methods Patients with a validated MPN diagnosis; essential thrombocythemia (ET), polycythemia vera (PV) or myelofibrosis (MF), were recruited between 2016 and 2018 from one single specialized hematologic center. Patients filled out a standardized questionnaire on medical history, current medication, alcohol and smoking habits and family medical history. They were examined by cardiac computed tomography (CT), Endothelial Peripheral Arterial Tone (EndoPAT), and a range of blood analyses. The atherosclerotic burden was evaluated by CACS. High sensitivity C-reactive protein (hs-CRP) and Neutrophil:Lymphocyt Ratio (NLR) were used as indicators of chronic inflammation. EndoPAT was applied to evaluate endothelial dysfunction, which is linked to development of atherosclerosis. The JAK2V617F-mutation is a common gene mutation in MPN-patients. It affects the gene coding the Janus kinase 2 (JAK2) protein, and can be detected by qPCR of peripheral blood or bone marrow. The JAK2V617F-mutation is a risk factor associated with both chronic inflammation and endothelial dysfunction. Multivariable logistic regression analyses were used to identify associations between potential risk factors and a higher CACS value. Results Among 170 included patients, 161 patients completed cardiac CT (mean age 65.5 (SD 10.5), 52% men). Baseline data is presented in Table 1. JAK2V617F-mutation was found in 137 (85%) patients, 53 patients (35%, n=152) had hs-CRP&amp;gt;2.0 mg/L, 107 (67%, n=160) had NLR&amp;gt;2.15 and 32 (21%, n=154) had an abnormal EndoPAT. Overall, 66 patients (41%) had a CACS&amp;gt;100, with no significant difference between ET (41%), PV (42%) and MF (50%) (p=0.3). In patients with a history of ischemic heart disease (IHD), 92% had CACS&amp;gt;100, compared to 37% in patients without prior IHD (p=0.0003). Five independent factors associated with a CACS&amp;gt;100 were identified; age (OR: 1.3 [95% CI 1.1–1.4]), male sex (OR: 15.2 [95% CI 4.0–57.7]), prior IHD (OR: 15.9 [95% CI 1.2–202.4]), smoking (OR: 3.3 [95% CI 1.1–10.1]), and abnormal EndoPAT (OR: 4.8 [95% CI 1.1–20.0]) (Figure 1). Hs-CRP, NLR and JAK2V617F-mutation status were not significantly associated with CACS &amp;gt;100. Conclusion In this cohort of patients with MPNs, markers of chronic inflammation like hs-CRP and NLR were not associated with higher CACS, nor was the JAK2V617F-mutation. Traditional risk factors of cardiovascular disease seem to be sufficient to identify MPN patients with increased atherosclerotic burden, but measuring endothelial dysfunction provides additional information. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Department of Cardiology, Zealand University Hospital, Region Zealand, Denmark Table 1. Baseline characteristicsFigure 1. Odds ratio for CACS &amp;gt;100

Prognostic impact of left ventricular ejection fraction recovery in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: analysis of an 11-year all-comers registry

Left ventricular ejection fraction (LVEF) recovery after an ST-segment elevation myocardial infarction (STEMI) identifies a group of patients with a better prognosis. However, the association between long-term outcomes and LVEF recovery among patients with STEMI undergoing primary percutaneous coronary intervention (PCI) has not yet been well investigated. Our study aims to detect differences in long-term all-cause and cardiovascular mortality between patients who recover LVEF at 1-year post-PCI and those who do not, and search for predictors of LVEF recovery. This is a retrospective, single-centre study of 2170 consecutive patients admitted for STEMI in which primary PCI is performed. LVEF was determined at admission and at 1-year follow-up. The primary outcomes were long-term all-cause and cardiovascular mortality. Among the 2168 patients with baseline LVEF data, 822 (38%) had a LVEF < 50% and 1346 (62%) ≥ 50%. Among those with LVEF < 50%, LVEF data at 1-year were available in 554, and 299 (54.0%) presented with complete recovery (LVEF ≥ 50%). LVEF recovery was associated with a reduction in long-term all-cause and cardiovascular mortality (P < 0.0001). Female sex, treatment with ACEIs, lower creatinine levels, infarct-related artery different from the left main or left anterior descendent artery, and absence of prior ischaemic heart disease were independently associated with LVEF recovery. Nearly 40% of patients with STEMI undergoing primary PCI presented with LVEF depression at hospital admission. Among them, LVEF recovery at 1-year occurred in more than 50% and was independently associated with a significant decrease in long-term all-cause and cardiovascular mortality.

Clinical Profile of Patients Presenting with Acute Myocardial Infarction in United Arab Emirates: A Tertiary Care Center Government Hospital Experience

Background: Acute myocardial infarction (AMI) is one of the major causes of hospitalization and mortality worldwide. There has been limited data available to characterize AMI presentation, contemporary patterns of medical care, and outcomes in Dubai, United Arab Emirates. Methods: A single-center observational registry for patients with AMI was used. All patients admitted to Dubai Hospital with AMI (ST elevation and non-ST elevation) with positive troponin from the mid of August 2017 till the end of April 2018 were included in this registry. Clinical data, prior history, demographics, treatments, and outcomes were recorded from the patient’s electronic medical file of the hospital. Result: A total of 329 patients (male 92%, mean age 53.6 years) were included in our registry. The use of ambulance service was only 25%. Electrocardiogram findings of ST-segment elevation myocardial infarction (STEMI) were found in 57% and non-STEMI in 43%. History of prior ischemic heart disease was present in 21% of all cohort, diabetes in 36%, hypertension in 38%, and the current smoking rate was 35%. Reperfusion therapy was provided to 94% of the patients with STEMI; only 32% of them had primary angioplasty, and medical reperfusion was performed in 68%. One-third of them received thrombolysis within 30 min, and primary percutaneous coronary intervention (PCI) was provided to 38% within 90 min. All the patients received aspirin and adenosine diphosphate inhibitors within the first 24 h. The majority of the patients received other key medicines like beta-blocker, statin, and anticoagulant agents within 24 h. The in-hospital mortality rate was about 3%. Conclusions: Using data from the registry may provide an overview of the current status of AMI in Dubai. Medical reperfusion therapy is the most common reperfusion modality in our center, and this will raise the question of whether we need to launch a 24-h primary PCI program in our center.