Profile Of Patients Research Articles

Long term outcomes of patients with decompensated aortic stenosis undergoing urgent transcatheter aortic valve implantation: a TAVI-NOR subs-study

Abstract Background Aortic stenosis (AS) is a progressive disease, which untreated leads to irreversible myocardial damage and potentially death. Patients with AS may present with acute decompensation (ADAS) even during active surveillance. Purpose In this TAVI-NOR sub-study, we investigate the clinical profile, risk factors, epidemiology and long-term outcomes of patients treated with TAVI after presenting with ADAS compared to stable patients who underwent elective TAVI (no ADAS). Method A total of 600 patients with severe AS consecutively treated with TAVI between January 2012 and July 2019 were enrolled in TAVI-NOR study. Predictors and long-term clinical outcomes were explored in binary logistic and Cox regression models. Results A total of 68 patients (11.3%) received urgent TAVI due to acute hospitalization with ADAS. Age (80±8.0 years vs 81±6.0 years, p=0.662), gender (56% males vs 50% males, p=0.361) and other comorbidities at baseline such as cardiovascular disease, chronic lung disease and atrial fibrillation (AF) were comparable in patients with ADAS and no ADAS (n=532) (p>0.05 for all). However, patients with ADAS had greater symptom burden (NYHA III-IV 81% vs 51%, p<0.001), lower blood pressure, higher heart rate and lower estimated glomeruli filtration rate (52.0±10.8 vs 54.6±9.8 mL/min/1.73m2, p<0.045). They had also higher prevalence of ECG left ventricular (LV) hypertrophy (40% vs 27%, p=0.027), more often reduced LV ejection fraction (<50%) (41% vs 16%, p<0.001), lower stroke volume (39±11 ml/m2 vs 42±11 ml/m2 vs, p=0.030) a trend of abnormal ECG (p=0.055) and longer hospital stay (11.5 ±8.7 days 6.6± 4.9 days, p<0.001). Patients with ADAS were comparable with no ADAS in terms of early short-term (<30 days) all-cause mortality (p>0.05). Although 1-year mortality was comparable (1.5% in ADAS vs 2.1% in no ADAS, p>0.99), mid- to late-term mortality rates were significantly higher in patient with ADAS receiving urgent TAVI, with 3-, 5- and 7 years mortality of 22% vs 11%, p=0.008; 46% vs 29%, p=0.005; 53% vs 39%, p=0.033, respectively. In a Kaplan-Meier analysis, event-free survival was significantly reduced for patients with ADAS undergoing urgent TAVI compared with stable patients undergoing elective TAVI HR 1.63, 95% CI 1.15-2.31, p=0.006), confirmed by a multivariable-adjusted model (HR 1.54; 95% CI 1.05-2.25, p=0.026) independent of age, gender, AF, LV ejection fraction and time from diagnosis to TAVI (Fig). Conclusion Patients with AS presenting with acute decompensation and treated with urgent TAVI had excellent short-term survival. This was irrespective of increased symptom burden, adversely remodeled and functionally reduced LV at baseline. These findings might explain the observed higher mid- and long-term mortality compared with stable patients undergoing elective TAVI. It is essential to identify patients at risk of acute decompensation and treat them timely before irreversible myocardial damage occur.

Clinical profile and outcomes of patients with chronic kidney disease on chronic hemodialysis hospitalized for acute coronary syndrome in a tertiary public hospital in the Philippines

Abstract Introduction Acute coronary syndrome (ACS) and end-stage renal disease (ESRD) are both prevalent globally. Of the many risk factors for ACS, chronic kidney disease (CKD) remains to be of great concern because the interplay of cardiac and renal disease is inherently complicated. Cardiovascular mortality rates are 10-30 times higher in the ESRD population. The risk for cardiovascular disease in CKD extends beyond the traditional risk factors. Purpose The guidelines for ACS may not be applicable to the ESRD population because the landmark ACS trials mostly excluded ESRD patients. Due to the gaps in knowledge regarding ACS in ESRD, our study sought to explore the clinical profile and outcomes of these patients in the our institution. Methods We did a retrospective cohort study among ESRD patients presenting with ACS in our institution from May 2021 to November 2023. The data was analyzed using univariate and bivariate statistics using PRISM software. Results A total of 48 patients with ESRD were admitted for ACS in this study - 8 with STEMI and 40 with NSTEMI. The mean age was 61 years old and 33 (68.8%) were male. The average length of hospital stay was 12 days. The most common comorbidities were hypertension (91.7%), heart failure (83.3%), and diabetes mellitus (60.4%). The most common cause of ESRD in our cohort is concomitant hypertensive and diabetic kidney disease (45.8%) with an average length of hemodialysis at 31 months. The most common chief complaints were chest pain (39.6%), dyspnea (29.2%), and decreased sensorium (10.4%). On admission, 18 (37.5%) presented with systolic BP >160mmHg, 7 (14.6%) presented with shock, and 4 (8.3%) presented with cardiac arrest. On electrocardiogram, 21 (43.8%) had left ventricular hypertrophy while 34 (70.8%) had cardiomegaly on chest radiography. On two-dimensional echocardiogram, the average left ventricular ejection fraction was 46% and 27 (90%) had segmental wall motion abnormalities. The most common angiographic finding was 3-vessel coronary artery disease (50%). Only 5 patients (10.4%) had an LDL-C greater than 55mg/dL. Among those with STEMI, 6 (75%) presented with Kilip II or more. While among those with NSTEMI, 27 (67.5%) had a TIMI risk score >2. Almost all patients received dual-antiplatelet therapy, high dose statin, and beta-blocker. The mortality rate was 43.8% with acute coronary syndrome being the most common cause of death. Conclusion Our study did not show significant associated predictors of mortality possibly due to the low sample size. Despite this, our study portrays that patients admitted for ACS with ESRD present with higher risk features reflected by derangement in vital signs, abnormal laboratories, significant imaging abnormalities, high prognostication scores, and high in-hospital morbidity.Predictors of Mortality

Pulmonary artery thrombosis in Behcet's syndrome: a case series

Abstract Background Behçet's syndrome (BS) is a complex multisystemic vasculitis that affects vessels of all sizes and kinds, with a high tendency towards thrombosis. Arterial disease is rare and manifests primarily in the form of pulmonary artery aneurysms (PAA), but also of pulmonary artery thrombosis (PAT) in 1/3 of the cases. Purpose Our work aims to depict the profile and outcomes of BS patients presenting with PAT. Methods This retrospective, descriptive, and monocentric study was conducted between 2000 and 2022, among 531 adult patients diagnosed with BS (ISG and/or ICBD criteria). All cases of documented PAT were included. Results 16 cases of PAT were recorded (3%). The mean age of the patients was 34 ± 6 years (19-58), and the sex ratio (M/F) was 4.7:1. Cardiovascular risk factors were mainly active smoking (12%) and high blood pressure (6%). PAT was the revealing manifestation of BS (30%), or occurred after a median of 4.5 years following BS onset. Patients were mostly asymptomatic (69%), or presented with dyspnea (35%), hemoptysis (31%), and thoracic pain (25%). On chest CTA, PAT was often bilateral (78%) and proximal (46%). PAA were frequently observed (25%), being consistently bilateral, multiple, proximal and distal at the same time. Deep venous thrombosis was found in the lower extremities (19%), superior vena cava (27%), and inferior vena cava (6%). Cardiac involvement was also commonly associated (40%), mostly consisting of right intracardiac thrombosis (37%). Concomitant extracardiovascular involvements included mucocutaneous (87%), ocular (26%), articular (25%), and digestive (6%) lesions. Inflammatory parameters were raised in most patients (80%). Hemostasis parameters were within normal ranges and screening for inherited and acquired thrombophilia was negative in all cases. Patients were treated with colchicine (97%), glucocorticoids (93%), cyclophosphamide (47%), azathioprine (47%), and a TNF-a-inhibitor (6%). Curative anticoagulation with low-molecular-weight heparin followed by oral antivitamin K was often prescribed (60%). No surgery or endovascular procedure was performed. Relapse and death were recorded in respectively 15% and 26% of the cases. Conclusion In contrast to common thrombotic diseases, PAT in BS is attributed to vasculitis rather than hypercoagulability, resulting in distinct clinical features. The diagnosis should be promptly considered in young men who present with concurrent thrombotic lesions and PAA. Early and appropriate management is imperative to enhance patient outcomes.Left proximal PAT in a BS patient

Trends in Patient Characteristics and Cardiothoracic Surgeries over 14 Years (2010–2023): A Single Center Experience

Background: as transcatheter technologies have advanced, the patient population that is referred to open heart surgeries has shifted. This study’s objective was to evaluate recent trends in the characteristics of patients undergo surgical valvular interventions and coronary revascularizations (CABG) in our center over a period of 14 years. Methods: this is a retrospective analysis of ecological trends in the age, sex, and risk profile (Charlson comorbidity index—CCI) of patients who, from January 2010 to December 2023, underwent CABG, aortic valve replacement (AVR), or mitral valve repair or replacement (with or without tricuspid valve intervention). The data were extracted from electronic clinical files using MD-Clone software. Results: for the CABG procedures, the respective data for 2010 and 2023 were: mean ages 68.0 and 64.6 years; 79.7% and 83.1% males; and mean CCI scores 3.16 and 2.51. The p-values for the cumulative differences over the study period were 0.001, 0.005, and 0.013, respectively. The respective data for isolated AVR were mean ages of 69.2 and 62.9 years; 64.1% and 59.1% males; mean CCI 3.64 and 2.32; p-values: <0.001, 0.229, and 0.019. The respective data for mitral valve procedures were mean ages of 63.6 and 59.8 years, 71.4% and 65.5% males; mean CCI 2.90 and 1.79; p-values: 0.84, 0.422, and 0.318. Conclusions: over a 14-year period, changes were evident in the age, sex distribution, and CCI for operations performed in our center. These changes most likely resulted from accumulated data regarding the advantages and detriments of treatment strategies, mostly of CABG vs. percutaneous coronary intervention; major advancements in transcatheter technologies, mostly in transcatheter AVR; and clinical guidelines facilitating a more collaborative decision-making, open-minded, and personalized approach.

Failure of primary prophylaxis: statin use, risk profile, and outcomes in contemporary patients treated with PCI for first atherosclerotic event

Abstract Background Atherosclerosis and coronary artery disease (CAD) are potentially preventable through lifestyle modifications and the use of medical cholesterol-lowering drugs in individuals at risk. However, guidelines for optimal use of statins are debated, and not enough is known about the real-world barriers to effective CAD-prevention. Understanding the mechanisms of prophylactic treatment failure in patients who undergo PCI for their first atherosclerotic event could help improve primary prevention strategies. Purpose To 1) examine the relative contribution of failure mechanisms of medical prophylaxis in patients undergoing PCI for their first atherosclerotic event, 2) examine how clinical characteristics differ between patients with different failure mechanisms, and 3) examine whether long-term outcomes after PCI differ depending on the mechanism of prophylactic failure. Methods A retrospective study was conducted to study electronic healthcare records for all patients ≥18 years treated with PCI at Gentofte Hospital, Denmark in 2019. Data was extracted from electronic health care records. Patients with first atherosclerotic event were divided into cardiovascular risk groups based on the ESC/EAS guidelines and further into four different prophylactic failure mechanism groups based on cardiovascular risk, statin indication, statin use and whether the risk-based LDL-C treatment goals were reached. Results 507 patients were treated with PCI for their first atherosclerotic event. 54% were categorized as low-moderate cardiovascular risk. 41% were not on statin and did not have class I indication for statin treatment (strategy failure). 26% were not on statin treatment despite class I indication for statin treatment (implementation failure). 18% were on statin treatment but had not reached their LDL-C target (efficiency failure), and 16% were on statin treatment, and had reached the LDL-C target (efficacy failure). Patients with strategy failure, were more likely to be younger, mostly males, and often had a smoking history. Patients with implementation failure, were typically elderly, with relatively few comorbidities. The frequency of death, myocardial infarction, stroke, or repeat revascularization over 4 years was 15.3%, with no statistically difference between the groups (p =0.3). Conclusion In this cohort study, patients treated with PCI for first atherosclerotic event were often classified as low or intermediate risk, and a majority had not been on statin treatment before. Improved primary prevention should focus on at-risk groups that are either not included in current recommendation for statin treatment, especially young smokers, or patients not receiving treatment despite recommendations, especially older patients with few medical contacts.Cardiovascular risk & failure mechanismKaplan-Meier MACE

Unique regional risk profiles and cardiovascular outcomes of patients with acute coronary syndrome in the absence of standard modifiable risk factors: a systematic review and meta-analysis

Abstract Background With differences in prevalence, risk profile, cardiovascular complications, and mortality of patients with acute coronary syndrome (ACS) in the absence of standard modifiable risk factors (SMuRF-less) worldwide, this study examines the regional differences and the unique risk profiles of this often-understudied group of patients. Purpose We hypothesize that differences in non-traditional risk factor profiles may lead to unique ACS-related presentations, complication rates, and secondary preventative strategies across regions. Hence this study was undertaken to assess the cross-regional comparisons of patient characteristics, risk profile, angiographic characteristics that may provide insights into disparate cardiovascular outcomes observed in the SMuRF-less ACS population. Methods Medline and Embase databases were searched in November 2022 to identify relevant literature relating to the prevalence of risk factors in SMuRF-less patients with ACS. A single-arm meta-analysis of proportion and means was conducted on baseline and presentation characteristics, outcomes and complications, management, and risk factors in SMuRF-less ACS patients, stratified according to geographical region (Asia-Pacific, Europe, and North America). Risk of bias was assessed using the Newcastle-Ottawa scale. Results A total of 25 studies comprising of 1,393,184 individuals with ACS were included, of which 242,929 patients were SMuRF-less. Within this SMuRF-less ACS group, mortality rates were similar across the regions (Asia-Pacific:15.8%, Europe:17.5%, p=0.861), cardiac arrest (6.3%, 95%CI:2.3% to 16.3%, p=0.001) and major bleeding (5.2%, 95%CI:2.9% to 9.2%, p=0.001) were more prevalent in Asia-Pacific, and heart failure more common in Europe (21.7%, 95%CI:18.2% to 25.7%, p<0.001). Prevalence of chronic obstructive lung disease (21.4%, 95%CI:21.2% to 21.6%, p<0.001) and peripheral artery disease (3.8%, 95%CI:3.1% to 4.7%, p=0.001) were highest in SMuRF-less ACS patients from North America, chronic liver disease most prevalent in those from Asia-Pacific (3.5%, 95%CI:2.2% to 5.6%, p<0.001) and family history of coronary artery disease highest in SMuRF-less ACS patients from Europe (25.2%, 95%CI:24.8% to 25.7%, p=0.024). Significantly lower rates of guideline-directed medical therapy prescriptions were observed for SMuRF-less ACS patients in Asia-Pacific compared to other regions. Conclusion This regional analysis highlights the different risk profiles, cardiovascular outcomes, and specific needs of individuals presenting with ACS in the absence of cardiovascular risk factors, across Asia-Pacific, Europe, and North America. Whilst unravelling novel pathomechanistic pathways of atherosclerosis will prove beneficial on a global scale, understanding the unique regional profile of these individuals will aid policymakers strategize effective and tailored clinical pathways in the management of SMuRF-less ACS.Graphical AbstractKey Outcomes

Accelerometer-measured physical activity pattern in older patients with frailty and heart failure

Abstract Background Physical activity (PA) assessed by accelerometers represents a novel method to understand the PA profile of older patients with heart failure (HF). We hypothesized that PA level and pattern vary in HF patients across the spectrum of frailty status. Aim To report the duration, intensity and volume of PA in older patients with HF according to frailty status. Methods We recruited 150 HF patients≥65 years from a hospital-based HF clinic between March and October 2023. Frailty was assessed using the Short Physical Performance Battery (SPPB); patients with SPPB 10-12, 7-9, 4-6 and ≤3 was classified as robust, mildly, moderately and severely frail respectively. To evaluate PA profile, all patients wore a wrist accelerometer on their non-dominant hand for 7 days (24 hours/ day). PA parameters including average acceleration over 24 hours (proxy of volume of activity); time spent in inactive, light, moderate and vigorous intensity activities; intensity gradient (more negative gradient equates to poorer intensity profile) and time of most active continuous bouts of PA, were compared amongst frailty groups. Results 146 participants with good quality accelerometer data were included in the analysis; median age 80 (range 65-94 years), 65% male. Thirty-eight percent had heart failure with reduced ejection fraction (HFrEF); 21% had NYHA class III/IV symptoms; median NT-proBNP was 2040 ng/L (IQR = 1110 - 4930). Frail patients were more likely to be older with more comorbidities; they also had more severe HF symptoms and higher NT-proBNP. Frail patients had lower volume of PA compared to robust patients, evidenced by lower average acceleration (milligravity-mg) over 24 hours [20.4 (robust); 16.0 (mildly frail); 13.5 (moderately frail); 13.2 (severely frail), p<0.001]. PA intensity profile was poorer in frail patients compared to robust patients [median intensity gradient: -2.72 (robust); -2.92 (mildly frail); -3.00 (moderately frail); -3.07 (severely frail), p<0.001]. (Table 1) Frail patients spent more time inactive compared to robust patients [median time spent inactive (minutes): 654 (robust); 689 (mildly frail); 780 (moderately frail); 720 (severely frail), p<0.001]. The median time (minutes) spent in light [225 (robust); 190 (mildly frail); 164 (moderately frail); 159 (severely frail)] and moderate to vigorous activity [62 (robust), 23 (mildly frail), 15 (moderately frail) and 13 (severely frail), p<0.001] were significantly shorter in frail compared to robust patients. (Figure 1) The most active continuous bout of PA of patients across the frailty spectrum appeared to between 10 AM to 2 PM. Conclusion The duration, volume and intensity of PA was generally low in older patients with HF. Worse frailty status was associated with longer duration of physical inactivity, shorter duration of light, moderate or vigorous activity, poorer PA intensity profile and lower volume of PA.

Identification and validation of ventricular rhythmic risk subgroups in hypertrophic cardiomyopathy by clustering analysis including left ventricular strain analysis

Abstract Background The excess mortality in hypertrophic cardiomyopathy (HCM) patients is mainly attributed to the occurrence of ventricular arrhythmia (VA).The prediction of VA remains challenging and could be improved. Purpose The study aimed to characterize the VA risk profile in HCM patients through clustering analysis combining conventional parameters with information derived from left ventricular longitudinal strain analysis (LV-LS). Methods 434 HCM patients (65% men, mean age 56 years) were retrospectively included from two referral centers and followed longitudinally (mean duration 6 years). The validation cohort included 177 HCM patients from an other tertiary French center. Mechanical and temporal parameters were automatically extracted from the LV-LS segmental curves of each patient in addition to conventional clinical and imaging data. A total of 287 features were analyzed using a clustering approach (k-means). The first endpoint for VA included suspected SCD, aborted cardiac arrest, appropriate ICD therapy (AIT), sustained ventricular tachycardia (SVT) and non-sustained ventricular tachycardia (NSVT) during follow-up. Results From the derivation cohort, 4 clusters were identified with a higher rhythmic risk for clusters 1 and 4 (VA rates of 26%(28/108), 13%(13/97), 12%(14/120), and 31%(34/109) for cluster 1,2,3 and 4 respectively) (Figure 1). These 4 clusters differed mainly by the LV mechanics. Patients from cluster 4 had a severe and homogeneous decrease of myocardial deformation (global longitudinal strain (GLS) -11%, normal value ≥ -20%) associated with LV and left atrium (LA) remodeling (left atrial volume index (LAVI) 46.6 vs. 41.5 ml/m², p=0.04 and LVEF 59.7 vs. 66.3%, p < 0.001) and impaired exercise capacity (% predicted peak work 58.6 vs. 69.5%; p= 0.025). Patients from cluster 1 showed a marked deformation delay and temporal dispersion on the segmental analysis associated with a moderate decrease of the GLS (-15.3%; p <0.0001 for GLS comparison between clusters). Patients from clusters 2 and 3 had a small GLS decrease (GLS -17.2 and -16.3%, respectively) with a less severe phenotype for cluster 2 and older patients for cluster 3 (mean age 62.1 vs. 54.1 years; p < 0.0001). The clustering analysis in the validation population resulted in the creation of 4 clusters overlapping the derivation cohort with similar characteristics (Figure 2). Clusters 1’ and 4’ had a higher incidence of ventricular arrhythmia with a VA rate of 22%(5/23), 18%(16/88), 0%(0/17), and 20%(10/49) for clusters 1’,2’,3’ and 4’ respectively. Conclusion Machine-learning-based cluster analysis processing LV-LS parameters in HCM patients identified 4 clusters with specific LV-strain patterns and different rhythmic risk levels. In the future, the automatic extraction and analysis of LV strain parameters could help to improve the risk stratification for SCD in HCM patients.Clustering analysisExternal validation

Aerobic exercise capacity improvement of patients with human immunodeficiency virus one year post-treatment initiation by integrase inhibitors

Abstract Background Infection by Human Immunodeficiency Virus (HIV) leads to chronic inflammation and subsequently to the early development of cardiovascular (CV) disease in young adults. Initiation of antiretroviral therapy (ART) usually leads to patient’s body weight and blood pressure increase. Cardiopulmonary exercise test (CPET) evaluates aerobic exercise capacity and subsequently cardiovascular and respiratory function. Aim of this study is the investigation of any treatment-induced changes in aerobic exercise capacity in treatment naïve young HIV patients’ at 1-year post HIV treatment initiation by different ART agents. Methods We studied 46 recently diagnosed and treatment naïve young HIV patients (37+10 years, 87% males, 62% smokers) at baseline and 1-year post ART initiation (integrase or protease inhibitors). Twenty-six (26) patients were randomly treated by the newer integrase inhibitor Dolutegravir (Group A, mean age=36+9 years, 100% males, 77% smokers) while 19 patients by the older protease inhibitor Darunavir/Cobicistat (Group B, mean age=37+10 years, 90% males, 47% smokers). All patients were submitted in CPET at baseline and 1-year post ART initiation. We estimated any changes in body mass index (BMI), systolic blood pressure (SBP) and CPET parameters (peak VO2, Oxygen pulse, WorkLoad, VE/VCO2) at 1-year post ART initiation. Results At baseline and 1-year re-evaluation, we found no differences between groups regarding age, BMI and CPET parameters. In the whole HIV population, we found an increase in body weight (76+12 vs. 82+15kg, p<0.001), SΒΡ (124+12 vs. 132+14mmHg, p<0.001), WorkLoad (176+35 vs. 186+35watt, p<0.001) and peak VO2 (2171+437 vs. 2299+491ml/min, p=0.03) at 1-year re-evaluation. In Group A, body weight (p<0.001), SBP (p=0.07), WorkLoad (p=0.006) and peak VO2 (p=0.01) were increased while in Group B, body weight (p<0.001), SBP (p=0.001) και WorkLoad (p=0.01) were also increased. Conclusions Aerobic exercise capacity is improved 1-year post-treatment initiation by the newer integrase inhibitor Dolutegravir in treatment-naïve HIV patients despite the adverse BMI and SBP increase. The newer Dolutegravir probably exhibits a more favorable CV profile in HIV patients compared to the older Darunavir/Cobicistat.Re-evaluation 1-year post ART initiation

First time evaluation of myocardium microRNA profile in Anderson-Fabry disease: implications in the pathological processes

Abstract Background Anderson Fabry disease (AFD) is an X-linked lysosomal disorder, characterized by progressive sphingolipid storage and organ dysfunction. Cardiac involvement is characterized by left ventricular hypertrophy, inflammation and fibrosis and is leading cause of mortality. MicroRNAs (miRNAs) are emerging as promising biomarkers in medicine, as they are dysregulated in many human diseases, offering opportunities to improve our understanding of disorders and discover new therapeutic targets. However, so far, only a few studies have evaluated the role of miRNAs in Fabry disease, and cardiac tissue miRNAs have never been assessed. Purpose To determine the specific tissue miRNA profile analyzing myocardial tissue of AFD patients and to evaluate their relationship with the severity of cardiac involvement. Methods 19 AFD patients (10 females [53%]; median age 53 years [IQR 43-63]) undergoing right ventricular endomyocardial biopsy (n=15) or surgical septal myectomy (n=4), standard cardiac magnetic resonance (1.5T, cines for maximum wall thickness (MWT) and indexed LV mass (LVMi) calculation) and high-sensitivity Troponin I (TnI) dosage were included and compared to 7 endomyocardial biopsies of controls. Myocardial samples were fixed in formalin and embedded in paraffin. RNA was extracted from 3-5 slides of tissue and used to generate small RNA libraries (Qiagen) for Next Generation Sequencing analysis on Illumina sequencer. Raw data were normalized and analyzed using DEseq2 pipeline. Correlations were performed using Pearson r; a p < 0.05 was considered statistically significant. Results In AFD group median MWT was 13 mm [IQR 8-17], LVMi was 72 g/m2 [IQR 46-97]. TnI was increased in 9 patients (47%) and NT-proBNP in 8 (42%). 6 patients were on specific AFD treatment. We identified 9 miRNAs differentially expressed in AFD patients compared to controls; miRPath analysis revealed that these miRNAs are associated to pathways involved in AFD pathogenesis (autophagy and mTOR signalling, HIF-1, apoptosis, TGF-beta signalling and inflammation) (figure 1). Moreover, we found 10 miRNAs that were differentially expressed in maximal wall thickness (<10 mm, 10-15 mm, >15 mm) groups (figure 2), in particular 3 miRNAs that progressively increased at the increasing of thickness. Among these miRNAs, miR-21-5p showed the strongest correlation with myocardial hypertrophy (r=0.869, p value<0.001 for MWT; r=0.905, p<0.001 for LVMi) and with cardiac damage (r=0.831, p<0.001 for TnI). Additionally, miR-21-5p had a modest correlation with age (r=0.518, p=0.05) and did not differ between patients on specific AFD treatment and patients not treated (p=0.660). Conclusions This study for the first time evaluated the myocardial miRNA profile in AFD patients and identified miR-21-5p as a cardiac biomarker correlating with clinical heart involvement, both in terms of left ventricular hypertrophy (MWT, LVMi) and myocardium damage (troponin).Figure 1Figure 2

Effect of a cardiovascular post discharge sms support program on healthcare utilisation - the hearthealth program

Abstract Background Cardiovascular disease (CVD) is a leading cause of mortality worldwide[1]. Targeting modifiable risk factors is key to primary and secondary prevention of CVD but many barriers to good risk factor control exist[2]. SMS message programs have shown to be an efficient modality to deliver information to improve knowledge and risk factor profiles for CVD patients[3]; however, their impact on healthcare utilisation has not been thoroughly examined. The HeartHealth program is a text message post-discharge support program delivered to CVD patients. It comprised regular semi-personalised text messages providing CVD information, advice, and support to patients over a 6-month period. Purpose This study aimed to examine the impact of the Heart Health program on healthcare service utilisation. Methods Patients ≥18 years old who recently attended cardiology clinics or were discharged from a cardiology unit, between April 2020 and April 2022 were invited to the program. We compared healthcare utilisation rates in patients who enrolled into the HeartHealth text program (intervention group) to contemporaneous patients who did not enrol in the program (control group). The primary outcome was the incidence rate of all-cause healthcare utilisation events (composite of ED presentations and/or hospital admissions for any medical cause) in the 6 months post-discharge. The secondary outcomes were incidence rates of CVD events and unplanned CVD events. All analyses were adjusted for demographic and co-morbidity variables. Results 11542 patients were included in analysis (intervention: 4324, control: 7218), mean age 58.8 years, 60.7% were male, and 78.3% with English as their preferred language. HeartHealth Intervention participants had lower rates of the primary outcome of healthcare service events compared to control participants (mean number of events 0.43 intervention vs 0.52 control, adjusted rate ratio [RR], 0.91 [95% CI, 0.83-0.99], p=0.033, Table 1). The intervention was significantly more effective in older patients compared to younger patients (RR, 0.82, [95% CI, 0.72-0.93] in patients aged ≥65 years, compared to patients <65 years, RR, 0.98, [95% CI, 0.87-1.10]; p-value for interaction =0.043, Figure 1). The subset of CVD events and unplanned CVD events were numerically lowering in the intervention group compared to the control, but the risk ratio not statistically significantly different in adjusted models (Table 1). Conclusion This analysis demonstrates that a text message post-discharge support program for CVD patients decreased the need for healthcare service utilisation for all medical causes. Future randomised controlled trials are required to further support these findings.Figure 1:Adjusted interaction analysisTable 1:Adjusted Incidence of events

Clinical outcomes of edoxaban treatment without parenteral anticoagulation therapy for acute venous thromboembolism: Insight from the COMMAND VTE Registry-2

Abstract Background Direct oral anticoagulants (DOACs) including edoxaban are currently widely used all over the world. Each DOAC has a specific usage for the treatment and second prevention of venous thromboembolism (VTE) in the acute phase as well as in the chronic phase. Edoxaban is recommended to be administered after an appropriate initial treatment including parenteral anticoagulation therapy such as heparin. However, because of the rapid anticoagulant effect of edoxaban after oral intake, some physicians could administer edoxaban initially without parenteral anticoagulation therapy in the daily clinical practice, which has not been investigated so far. Purpose The purpose of this study is to explore the effectiveness and safety of edoxaban treatment for VTE without initial parenteral anticoagulation therapy. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. Of those, 1842 patients received edoxaban including 848 patients with pulmonary embolism (PE) and 994 patients with deep vein thrombosis (DVT) alone, who were divided into 2 groups based on the presence or absence of initial parenteral anticoagulation therapy with heparin. Propensity score matching (PSM) was performed to adjust for potential baseline differences in the 2 groups. Results PE and DVT patients with initial parenteral anticoagulation therapy with heparin accounted for 623 (73.5%) and 244 (24.5%), respectively. After the PSM, 195 pairs of PE patients and 226 pairs of DVT patients were matched. In PE patients, those matched by the PSM were relatively mild cases compared to the unmatched cases (simplified PESI score=0: 25.9% vs. 12.4%, P<0.001). Whereas, in DVT patients, those matched were relatively severe cases compared to unmatched cases (isolated distal DVT: 24.1% vs. 71.0%, P<0.001). In the matched cohort, there was no significant difference in baseline characteristics between the 2 groups, including simplified PESI score in PE patients and thrombus location profile in DVT patients. In both PE patients and DVT patients, the 30-day cumulative incidences of all-cause death were not significantly different between the 2 groups (PE patients: 3.7% vs. 2.6%, P=0.56; DVT patients: 2.7% vs. 4.5%, P=0.31). Similarly, the 30-day cumulative incidences of recurrent VTE and major bleeding were not significantly different between the 2 groups (recurrent VTE: PE patients: 0% vs. 0.5%, P=0.32; DVT patients: 0.6% vs. 0.9%, P=0.99; major bleeding: PE patients: 1.5% vs. 3.2%, P=0.32; DVT patients: 2.2% vs. 3.2%, P=0.54) Conclusion In this current real-world VTE registry, a certain number of patients received edoxaban without parenteral anticoagulation therapy, who did not show a signal of worse clinical outcomes.

Alterations of gut microbiome profiles as potential markers in patients developing acute coronary syndrome

Abstract Background Imbalanced gut microbiota or gut dysbiosis leads to systemic inflammation, one of key contributors to the development and progression of atherosclerosis. A recent study revealed the association of the gut microbiota and the severity of coronary artery lesions in patients with acute coronary syndrome (ACS). However, the gut microbiota profile in ACS patients in comparison with patients with high-risk cardiovascular disease (CVD) has not been thoroughly investigated. Purpose We aimed to compare the profiles of gut microbiome between patients with ACS and patients with high-risk CVD, as well as to determine the association between gut microbiota and CVD risk factors. Methods This cross-sectional study enrolled 24 stabilized ACS patients within 24 hrs of hospitalization and 59 outpatients in CVD clinics, as a control group. Echocardiography was done in those patients. Blood was collected for biochemical analysis, and fecal samples were collected for gut microbiome analysis via 16S RNA sequencing. Results The demographic data showed no significant differences between groups in CVD risk factors (age, levels of systolic and diastolic blood pressure, fasting glucose, high- and low-density cholesterol, and triglycerides). However, patients with ACS had greater cigarette use and alcohol consumption than the control group. For gut microbiome, both alpha and beta diversity levels of ACS group were significantly higher than those in a control group (Figure 1A-B). Differential abundance analysis by ANCOM-BC revealed significantly increased level of bacteria in the Atopobiaceae family in ACS patients, compared to controls (Figure 1C). Since Atopobiaceae was reported to be positively associated with percent atheroma volume (PAV), a marker of plaque deposit in the arteries, we found an increased number of Atopobiaceae which was positively associated with serum Troponin T level (Figure 1D), systemic inflammation (Figure 1E), and a trend to negatively correlated with LV ejection fraction. Conclusion Our findings suggested that alterations of gut microbiota occurred in ACS patients, and an increase in gut Atopobiaceae level could potentially be the predictive marker of the development of ACS in CVD patients.Figure 1

Concomitant cardiac arrest on cardiogenic shock patients. Differences in clinical profile and outcomes with non-cardiac arrest patients. The Shock CAT Study

Abstract Background Mortality on cardiogenic shock (CS) remains undesirable, although CS patients with or without concomitant CA may have different prognoses and clinical profile. Purpose The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mid-term mortality in CS patients with and without cardiac arrest on admission in a Mediterranean cohort. Method Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS), in-hospital and 6 months mortality were analysed comparing patients with and without CA at admission. Results A total of 382 CS patients (p) were included: CA 34.8% (n=133 p) and non-CA 65.2% (n=249 p). CA patients were younger than non-CA (61.9 vs 67.4 years, p<0.001) with higher prevalence of men (82% vs 71.8%, p= 0.024). Acute coronary syndrome was the main CS cause (60.7%) and ST elevation myocardial infarction (STEMI) was higher in CA patients than non-CA (55.6% vs 42.6%, p<0.001). In CA group, time to recover of spontaneous circulation was 24 min (IQR: 14-40 min) and hypothermia was performed in 55% of cases. CA patients had less prevalence of cardiovascular risk factors (hypertension, diabetes and dyslipidaemia) and lower pH at admission (7.19 vs 7.31, p<0.001) and higher lactate peak (6.9 vs 5.0, p=0.001) than non-CA patients. MCS was implanted in 35.3% of all CS patients, with lower use in CA patients (23.3% vs 41.8%, p<0.001), mainly due to lower intraaortic balloon pump (19.5% vs 35.5%, p=0.001), without differences in the use of extracorporeal membrane oxygenation (ECMO) (11.4% vs 8.7%, p=0.40) or Impella (10.6% vs 12.8%. p=0.54). Cardshock score was higher in CA patients than non-CA (4.68 vs 4.2, p=0.038), without differences in IABP score (2.31 vs 2.20, p= 0.621) or SCAI D/E (42.1% vs 33.3%, p= 0.090). In-hospital mortality was higher in CA patients (42.9% vs 27.7%, p=0<0.001). Moreover, 6-months mortality remains higher in CA than non-CA patients, although without statistical significance (47.7% vs 38.3%, p=0.079). Conclusions In a Mediterranean CS cohort, concomitant CA patients were younger, with higher prevalence in men with STEMI. MCS had a lower used in CA patients, although without differences in ECMO or Impella. In-hospital mortality was 35% higher in CA patients than non-CA, although 6-months mortality only trend to be higher in CA group.

Comparative assessment of phenotypic markers in patients with chronic inflammation: Differences on Bifidobacterium concerning liver status.

The relationship between systemic lupus erythematosus (SLE) and low-grade metabolic inflammation (MI) with the microbiota is crucial for understanding the pathogenesis of these diseases and developing effective therapeutic interventions. In this context, it has been observed that the gut microbiota plays a key role in the immune regulation and inflammation contributing to the exacerbation through inflammatory mediators. This research aimed to describe similarities/differences in anthropometric, biochemical, inflammatory, and hepatic markers as well as to examine the putative role of gut microbiota concerning two inflammatory conditions: SLE and MI. Data were obtained from a cohort comprising adults with SLE and MI. Faecal samples were determined by 16S technique. Statistical analyses compared anthropometric and clinical variables, and LEfSe and MetagenomeSeq were used for metagenomic data. An interaction analysis was fitted to investigate associations of microbiota with fatty liver index (FLI) depending on the inflammatory condition. Participants with low-grade MI showed worse values in anthropometry and biochemicals compared with patients with SLE. The liver profile of patients with MI was unhealthier, while no relevant differences were found in most of the inflammatory markers between groups. LEfSe analysis revealed an overrepresentation of Bifidobacteriaceae family in SLE group. An interactive association between gut Bifidobacterium abundance and type of disease was identified for FLI values, suggesting an effect modification of the gut microbiota concerning liver markers depending on the inflammatory condition. This study found phenotypical and microbial similarities and disparities between these two inflammatory conditions, evidenced in clinical and hepatic markers, and showed the interactive interplay between gut Bifidobacterium and liver health (measured by FLI) that occur in a different manner depending on the type of inflammatory disease. These results underscore the importance of personalized approaches and individual microbiota in the screening of different inflammatory situations, considering unique hepatic and microbiota profiles.

Epidemiological profile of patients consulting for smoking cessation in Tunisia from 2020 to 2023

Abstract Background Tobacco addiction poses a significant global health challenge, contributing to various diseases and premature mortality. The main objective of our work was to describe the epidemiological profile of smokers seeking assistance at the smoking cessation departement of the ‘Abderrahmane Mami’ hospital. Methods We conducted a retrospective study involving smokers who attended the smoking cessation department between January 2020 and December 2023. Data were collected from the consultants’ records. The descriptive study was conducted using IBM SPSS 25 software. Results The number of consultants was 440 during the years of the study. The study population was predominantly male (75.2%). The average age of the consultants was 45.41 ± 13.9 years [14-89 years]. The education level of the patients was predominantly university-level (42.4%), followed by secondary education (33.6%). Cardiovascular history was the most common (22.42%). More than half of the consultants (n = 279; 63.4%) had tried to quit smoking at least once. More than half of the smokers followed (57.9%) were highly dependent on nicotine (Fagestrom score ≥ 7). The mean score of the hospital anxiety and depression scale was 8.03 ± 5.398 for anxiety and 5.44 ± 5.185 for depression. Conclusions Our study provides informations about the epidemiological profile of individuals seeking tobacco cessation support during the study period. The findings underscore the diverse demographic and clinical characteristics of this population. Understanding these profiles can provide information for the development of effective anti-tobacco programs. Key messages • Tailored interventions are essential to meet the diverse needs of people seeking smoking cessation, optimizing the impact on public health. • Understanding cessation seeker profiles crucial for effective strategies.

A mcgyvering way to left bundle branch area pacing : using the treadmill test machine ECG system and modified V1 / V6 leads connected to the pacing system analyser for left bundle branch area pacing

Abstract Background Left bundle branch area pacing (LBBaP) is a novel pacing modality which provides physiological synchronisation of both the ventricles. However, its use and adoption requires the presence of a standardised electrophysiological (EP) system with 12 lead ECG to show left bundle branch area capture. Purpose The aim of the study was to assess the feasibility and outcomes of using the conventional treadmill test (TMT) machine 12 lead ECG system and modified V1 and V6 leads connected to the pacing system analyser (PSA) to demonstrate conduction system capture during left bundle branch area pacing (LBBaP). Methods LBBaP was attempted by a single operator in a mixed cohort of patients at peripheral hospitals lacking the standardised EP system. The presence of LBB area capture was tested with the aid of the 12 lead ECG system connected to the standard TMT machine (1). Conduction system capture was also assessed using modified V1 and V6 leads connected to the PSA for measurement of V6 left ventricular activation time (LVAT)(2) . The baseline clinical, procedural, pacing, electrocardiographic parameters, echocardiographic response (> 10% improvement in ejection fraction {EF}) and clinical response to LBBaP were assessed. Results LBBaP was attempted in 19 patients and was successful in 18 patients (94.7%). Patient characteristics include age 66.7 +/- 11.47 years, female 47.37%, male 52.63%, ischaemic cardiomyopathy 10.52% and non-ischaemic cardiomyopathy 5.26% .The mean baseline EF and QRS duration was 45%+/-14% and 130.18 +/-10.45 milliseconds(ms) respectively. LBBaP threshold was 0.59 +/-0.168 volts and R wave amplitude was 12+/-3.5 millimetres , which remained stable during the mean follow up of 15.9 +/-13.67 months. The mean fluoroscopic duration was 11.57 +/-2.58 minutes and procedural time was 108.78+/-29.20 minutes. LBBaP resulted in impressive narrowing of the QRS duration to 102.39 +/-10.55 ms (p<0.001) with LVAT of 68.94 +/-9.94 ms. LVEF improved in the patients with cardiomyopathy from 33.4 +/- 5.77 % to 48.2+/-12.37 % (p=0.028) .Clinical and echocardiographic response was noted in 87.5% of patients with cardiomyopathy. Conclusion The 12 lead ECG system with the standardised TMT machine in conjunction with the modified V1 and V6 leads connected to the PSA is a feasible alternative to the EP system to perform successful left bundle branch area pacing.ECG leads connected during LBBapClinical profile of patients

Clinical characteristics and treatment patterns of new users of dapagliflozin for heart failure with reduced ejection fraction: an observational study programme across 12 countries (EVOLUTION HF)

Abstract Background Clinical trials have shown that dapagliflozin, a sodium–glucose cotransporter-2 inhibitor (SGLT-2i), reduces cardiovascular mortality and worsening heart failure (HF). Adoption of new therapies has historically been slow despite robust evidence. Furthermore, treatment profiles of patients in real-world settings are scarce. Purpose EVOLUTION HF is a multinational study programme that aims to describe clinical characteristics and treatment patterns among patients initiating dapagliflozin for HF with reduced ejection fraction (HFrEF) in routine clinical practice. Methods The EVOLUTION HF primary data study programme consists of prospective, observational, descriptive studies of new users of dapagliflozin for HFrEF in 12 countries (Italy, Portugal, UK and the Central and Eastern Europe and Baltic [CEEBA] region [Bulgaria, Croatia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania and Slovenia]). Patients with type 1 diabetes or prior SGLT-2i treatment were excluded. Clinical characteristics were obtained from electronic health records. A total of 2170/2555 (85%) patients were enrolled from November 2021 to November 2023; 1736 patient profiles were assessed using descriptive statistics in this interim analysis. Results In total, 256, 228, 125 and 1127 new dapagliflozin users were analysed from Italy, Portugal, the UK and the CEEBA region, respectively (Table 1). Across the 12 countries, mean patient age in the studies was 65–70 years. Patients were predominantly male (67–76%) and generally had HF with an ischaemic aetiology (35–56%) and New York Heart Association functional class II (52–85%). Mean left ventricular ejection fraction in the studies was 29–32% and estimated glomerular filtration rate was 61–77 mL/min/1.73m². Hypertension and atrial fibrillation were common comorbidities. Mean time between HF diagnosis and dapagliflozin initiation in the studies was 23–52 months. Background therapy included angiotensin receptor-neprilysin inhibitors (36–72%), angiotensin receptor blockers (4–12%) and angiotensin-converting enzyme inhibitors (9–33%). At 6 and 12 months after dapagliflozin initiation, respectively, treatment discontinuation rates across the CEEBA region were 5.22% (59/1131) and 4.66% (50/1072). Conclusions The EVOLUTION HF primary data study programme provides novel insights into clinical characteristics and treatment patterns in patients with HFrEF initiating dapagliflozin in real-world practice across a broad European population. At dapagliflozin initiation, a large proportion of patients were receiving other HF therapeutics, suggesting dapagliflozin is one of the later therapies to be initiated. Indeed, this study identified a substantial delay (23–52 months) in dapagliflozin initiation following HF diagnosis. Treatment discontinuation rates following dapagliflozin initiation were also low, reinforcing the findings of the EVOLUTION HF secondary data studies.

Clinical and laboratorial profile of patients with ATTR cardiomyopathy: comparison between wild type and p.Val142Ile forms in the Brazilian population

Abstract Background In Brazil, besides the wild type (wt) form, transthyretin amyloid cardiomyopathy (ATTR-CM) is predominantly caused by hereditary form with Val142Ile mutation. Considering that both forms occur in elderly people, the clinical presentation may be similar. We sought to compare the clinical presentation of patients with wt and Val142Ile mutation in a Brazilian cohort of ATTR-CM patients. Methods Among the 642 patients enrolled in REACT/SP, 283 presented ATTR-CM, being 85 wt and 90 Val142Ile patients. We compared the main clinical characteristics between groups. Results The wt in comparison to Val142Ile patients, respectively, presented: older age (78.4+/-8.5 vs 74.2+/-8.1 y.o., p = 0.0009); similar proportion of males (82% vs 81%, p=0.85); lower proportion of blacks (11% vs 39%, p=0.0001); similar prevalence of heart failure (HF) symptoms (85% vs 79%, p=0.33); higher prevalence of syncope (13% vs 2%, p=0.008) and Pacemakers (PM) implantation (8% vs 1%, p=0.027); similar prevalence of neuropathy manifestations (38% vs 51%, p=0.17); lower creatinine (1.5+/-0.8 vs 2.1+/-2.1 mg/dL, p=0.02) and NT-ProBNP levels (2860.0+/-2843.3 vs. 5488.3+/-5455.6 pg/ml, p=0.0001); reduced interventricular septal thickness (15.6+/-3.3 vs 17.0+/-3.3 mm, p= 0.006), posterior left ventricular (LV) posterior wall thickness (14.2+/-2.4 vs 16.2+/-4.4 mm, p=0.0003), higher LV ejection fraction (52.0+/-10.1 vs 48.2+/-13.6%, p=0.038), higher global LV longitudinal strain (8.6+/-8.7 vs 3.4+/-9.8, p=0.0003), smaller LV diastolic diameter (45.9+/-6.1 vs 43.0+/-7.3 mm, p=0.005) at 2D-Echocardiogram. Conclusions In the Brazilian population wt and Val142Ile patients had similar clinical presentation regarding HF and neuropathy symptoms, but higher prevalence of syncope and PM in wt patients. Conversely, Val142Ile patients presented more severe amyloid cardiac infiltration.

Clinical and genetic profiles of patients with hereditary and wild type transthyretin amyloidosis: the transthyretin cardiac amyloidosis registry in the state of Sao Paulo, Brazil REACT-SP

Abstract Introduction Transthyretin amyloidosis (ATTR) is a multisystem disease caused by the deposition of fibrillar protein in organs and tissues. ATTR genotypes and phenotypes are highly heterogeneous. Purpose We designed the Transthyretin Cardiac Amyloidosis Registry in the state of São Paulo (REACT-SP), aiming to describe the demographic, genetic, clinical, and diagnostic test results and treatment of patients with ATTR. Methods We present data on physical signs and symptoms, cardiac and neurological assessments, and genetics in patients enrolled in the Transthyretin Cardiac Amyloidosis Registry in the state of São Paulo, Brazil. Results Six hundred-forty-four patients were enrolled, 505 with the variant form (ATTRv) and 139 with wild-type (ATTRwt). Sixteen different mutations were detected, the most common being Val50Met (48.3%) and V142Ile (40.8%). Overall, more than half of the patients presented cardiological involvement, and the difference in this proportion between the ATTRv and ATTRwt groups was significant (43.9 vs. 89.9%; p<0.001). The neurological phenotype also differed between ATTRv and ATTRwt (56.8 vs. 31.7%; p<0.001). The mixed phenotype was found in 25.6% of the population, without a significant difference between the forms of amyloidosis. A group of patients remained asymptomatic (10.4%), with a lower proportion of asymptomatic ATTRwt patients. The median time between the onset of symptoms and diagnosis was 1,853 (IQR 1277–2997) days, which was longer in ATTRv patients than in ATTRwt patients (p<0.001). Sinus rhythm was reported in 74.2%, atrial fibrillation in 17.0%, low voltage in 28.6%, repolarization abnormalities in 39.8%, and pseudo infarction in 27.4%. Echocardiography showed median Left Ventricular Ejection Fraction (LVEF) was 60%, Interventricular Septum (IVS) 14 mm, Posterior Wall Thickness (PWT) 13 mm, Left Atrium (LA) 41 mm, Left Ventricular Diastolic Diameter (LVDD) 45 mm, Left Ventricular Systolic Diameter (LVSD) 30 mm, basal Right Ventricular Diastolic Diameter (RVDD) 35 mm and Left Ventricle (LV) longitudinal strain 9.1%. There was some degree of LV diastolic dysfunction in 38.4%, apical sparing in 31.3%, and thrombus or masses in 1.0%. Late Gadolinium Enhancement (LGE) was absent in 29% and was subendocardial in 35.5%, transmural in 13.7%, mesocardial in 13.7%, and epicardial in 8.2%. Conclusions This study details the clinical and genetic spectrum of patients with ATTR in São Paulo, Brazil. This preliminary analysis highlights the considerable phenotypic heterogeneity of neurological and cardiac manifestations in patients with variant and wild-type ATTR.