Risk Of Adverse Cardiac Outcomes Research Articles

Utilization Patterns and Outcomes from Iron Chelation in Elderly Patients with Low-Risk Myelodysplastic Syndrome

Introduction: Iron overload from red blood cell (RBC) transfusions is a source of morbidity and mortality in patients with myelodysplastic syndromes (MDS). Evidence supporting iron chelation therapy (ICT) in Low-Risk MDS (LR-MDS) is controversial on account of studies conducted in highly selected patients and limited clinical trial data. We conducted a large population analysis aimed at defining real-world ICT utilization in LR-MDS and associated outcomes. Methods: We included patients diagnosed with MDS from 2007 to 2017 in SEER-Medicare using ICD-O-3 codes, aged 66 or older, with continuous Medicare parts A, B, and D. Exclusion criteria included patients with high-risk histology (MDS with excess blasts), less than 2-year survival, without complete follow-up, or enrolled in HMO. ICT eligibility was defined as ICD-9/10 codes for transfusion-related iron overload and/or cumulative ≥20 RBC units within ≤2 years of MDS diagnosis. ICT was identified from HCPCS codes for deferoxamine or prescription records for deferasirox or deferiprone. Explanatory variables included age, sex, race, rurality, socioeconomic quintile, marital status, geographic region, MDS histologic subtype, year of diagnosis, Charlson comorbidity index (CCI), and MDS therapies, including erythropoietin-stimulating agents (ESA), hypomethylating agents (HMA), and lenalidomide, identified from HCPCS codes and prescription records. Outcomes were identified through validated algorithms using ICD-9/10 codes and included overall survival (OS), progression to acute myeloid leukemia (AML), and complications related to iron overload, comprising heart failure, non-ischemic heart disease, atrial fibrillation/flutter, and liver disease/cirrhosis. To control for confounding, we implemented 3 approaches: multivariable Cox-proportional hazards regression, propensity score matching (PSM) by conditional probability of receiving ICT, and cause-specific regression with competing risk of death. Results: We analyzed 2,564 LR-MDS patients who were eligible for ICT. The mean ± SD age was 81 ± 6 years and 56.2% were male. Only 393 (15.3%) of these patients received ICT. The initial agent of choice was deferasirox in 203 (51.7%), deferoxamine in 188 (47.8%), and deferiprone in 2 (0.5%). Median ICT duration was 7 months (IQR 1-20). Chelated patients were younger (median age 79 vs 81, p<0.01), more likely to have histology with ringed sideroblasts [RS] (17.8% vs 7%, p<0.01), had less comorbid burden (median CCI 1 vs 2, p<0.01), and were more frequently treated with ESA (42.8% vs 33%, p<0.01), HMA (59% vs 49.8%), and lenalidomide (27% vs 11.1%, p<0.01), than those not treated with ICT. Their median monthly RBC transfusion density was 4 (IQR 2-6). Factors predicting ICT use were histology with RS (OR=1.9, 95%CI 1.4 - 3.8), RBC transfusion density (OR=1.1 per 4 units/month, 95%CI 1.1-1.2), and therapy with ESA (OR=1.5, 95%CI 1.2-1.9), HMA (OR=1.3, 95%CI 1.1-1.8), or lenalidomide (OR=2.6, 95%CI 1.9-3.5). Among patients who received ICT, 352 (89.6%) were considered transfusion dependent (≥2 RBC units within 8 weeks before starting ICT). Of them, 278 (78.9%) achieved hematologic response (≥50% decrease in RBC units following ICT). ICT was associated with decreased risk of death (HR=0.52, 95%CI 0.46-0.59) in the multivariable model adjusting for all listed covariates. The PSM matched 379 chelated (96.4% case rate) with 729 non-chelated patients and yielded similar results for OS benefit from ICT (HR=0.53, 95%CI 0.46-0.61). Table 1 shows results for other outcomes. Across models, ICT was associated with 43-49% decreased risk of AML transformation and 23-32% reduced risk of adverse cardiac outcomes. Cardiac benefit was predominantly driven by a lower risk of heart failure. No significant association was observed between ICT and hepatic outcomes. Conclusions: Our results suggest that ICT is associated with fewer transfusions, improved OS, lower risk of AML, and less adverse cardiac outcomes in LR-MDS. Our older, unselected cohort better reflects real-world LR-MDS patients and builds upon OS benefit reported in more restricting settings. Given the link between clonal hematopoiesis, cardiovascular disease and LR-MDS, defining ICT's effect on molecular and clonal dynamics could clarify the mechanism behind improved cardiac outcomes.

Abstract 11829: Association of Adult Congenital Heart Disease and Serial Echocardiographic Parameters With Adverse Cardiac, Obstetric, and Neonatal Outcomes

Background: Risk factors for adverse cardiac, obstetric and neonatal outcomes in pregnant women with adult congenital heart disease (ACHD) are not well-defined. Objective: To assess the association of ACHD and serial echo parameters with adverse cardiac, obstetric and neonatal outcomes. Methods: ACHD patients with prenatal care and delivery at a tertiary care center from 2007-2022 were included. Serial echos during pregnancy and adverse cardiac outcomes (arrhythmia, heart failure, ICU admission) were reviewed. Adverse obstetric (pregnancy-induced hypertension, abruption, hemorrhage) and neonatal outcomes (small-for-gestational age, preterm delivery, NICU admission, fetal/neonatal demise) were compared between the ACHD cohort and an age- and gravidity-matched non-ACHD cohort. Logistic regression was used to calculate the odds ratio (OR) for adverse outcomes. Results: Of 188 ACHD patients (mean age 30.9 ± 5.9 years), 74.4% had moderate or greater anatomic complexity. 11.7% of ACHD patients had an adverse cardiac outcome. Adverse obstetric and neonatal outcomes were more common in ACHD patients (23.9% vs 10.4%, p < 0.001; 35.3% vs 17.0%, p < 0.001, respectively). Systemic ventricular dysfunction, systemic atrioventricular valve dysfunction, and decline in systemic ventricular function during pregnancy were associated with increased risk of adverse cardiac outcomes. ACHD was associated with increased risk of adverse obstetric and neonatal outcomes (OR 2.8, 95% Confidence Interval [CI] 1.7 - 4.8; OR 2.8, 95% CI 1.8 - 4.5, respectively). Echo predictors of adverse cardiac outcomes were not associated with increased risk of adverse obstetric or neonatal outcomes. Conclusion: ACHD is associated with adverse cardiac, obstetric and neonatal outcomes. Echo parameters are predictive of adverse cardiac, but not obstetric or neonatal outcomes. Large-scale studies are needed to identify drivers of adverse obstetric and neonatal outcomes in this population.

Abstract 17607: Clonal Hematopoiesis of Indeterminate Potential (CHIP) is an Independent Risk Factor for Cardiomyopathy in Patients With Solid Malignancy

Background: Somatic mutations linked to clonal hematopoiesis of indeterminate potential (CHIP) are associated with increased risk of cardiomyopathy (CM) and all-cause mortality in the general population. However, this relationship is less clear in patients with solid malignancy, and it is unclear if knowing CHIP status can identify patients at risk for adverse cardiac outcomes. Objectives: To determine the association between CHIP and the development of CM in patients with solid malignancy, as well as overall survival (OS). Methods: CHIP mutation status was determined by next-generation sequencing of DNA from peripheral blood samples of 173 participants with solid malignancy. A somatic variant pipeline using MUTECT2 selected for somatic CHIP variants with a variant of allele frequency between 2-40%. CHIP association with the outcomes of OS and CM was assessed using Kaplan-Meier survival and Cox regression analyses. Results: Participants’ median age was 63 years, and 76% were female. CHIP mutations were detected in 39% of participants, most commonly in DNMT3A, TET2, and IDH2 genes. Majority were breast cancer patients 54% (n= 94). More patients with CHIP had diastolic dysfunction (21% vs 9%, p=0.037) compared to those without CHIP. After a median follow-up of 36 months, those with CHIP had an earlier time to death and earlier time to CM. Cox regression analysis showed that metastatic disease (HR 2.92, P=0.003) and male gender (HR 2.35, P=0.03) were independent risk factors for death, and CHIP (HR 2.120, P=0.02) was an independent risk factor for CM (Figure). Conclusions: Our study showed that solid malignancy patients with CHIP had worse outcomes with shorter time to death and shorter time to CM, with CHIP being an independent risk factor for CM. CHIP assessment can help us identify patients who may be at greater risk for adverse cardiovascular events during and after cancer therapy and who may warrant closer monitoring.

Neopterin as a Potential Biomarker for the Early Diagnosis of Heart Failure: A Systematic Review and Meta-analysis.

Neopterin (NEO) is an inflammatory biomarker with proposed diagnostic value in cardiovascular diseases. Some correlations have been discovered between NEO levels and the incidence, severity, and adverse outcomes of heart failure (HF). However, there are discrepancies in the results reported in the literature. We conducted a systematic review and meta-analysis of studies comparing urinary and blood NEO concentrations between individuals with HF, cardiac insufficiency, or dilated cardiomyopathy (DCM) with control groups or those monitoring the role of NEO concentrations as a predictive marker of adverse outcomes in HF patients. A total of 24 studies that met the inclusion criteria were reviewed. The studies demonstrated the alteration of NEO in blood or urine samples in subjects with HF, cardiac insufficiency, or DCM compared with control groups. Also, reviewing the studies suggested a link between reduced ejection fraction, higher NYHA classes, and a higher risk of adverse cardiac outcomes with increased NEO levels. The meta-analysis of three studies revealed a significant increase in serum NEO levels in HF cases compared to that in healthy controls with an effect size of 3.72 (95 % CI 0.16 to 7.28; p = 0.04). Meta-analysis demonstrated a significant difference between serum NEO levels of HF cases and healthy subjects. This evidence implies the potential of serum NEO as a valuable diagnostic biomarker in HF patients. Also, the review of the studies revealed the prognostic potential of NEO. Further research is required to assess the usefulness of NEO as a diagnostic/prognostic biomarker for HF.

Assessment of the risk of cardiovascular complications in cancer surgery

Cardiac complications of non-cardiac surgeries are an actual and unresolved interdisciplinary problem of clinical medicine today. The incidence of cardiovascular events after non-cardiac surgery is higher than in the general population and does not tend to decrease. The risk of cardiac complications in cancer surgery is the highest. Evidence-based approaches to risk assessment and prevention of cardiovascular events in surgical patients with malignant neoplasms have not been developed. In current clinical guidelines on the prevention, prognosis and treatment of cardiac complications of non-cardiac surgeries, the aspects of this problem in surgical oncology are not considered separately.The aim of this review was to analyze the current sources of literature on the prediction of cardiovascular complications in surgical treatment of cancer patients. The distinctive features of cancer surgery and additional factors causing an increased risk of adverse cardiac outcomes in patients with malignant neoplasms are described. The article presents the results of large cohort studies on the search for reliable predictors of cardiac complications in non-cardiac surgery and on the development of stratification scales and algorithms for preoperative risk assessment. Particular attention is paid to the possibilities and prospects of using these predictive tools in the surgical treatment of cancer. The surgical risks of interventions for malignant neoplasms are described, as well as methods for calculating cardiac risk and functional status assessment that have been validated in oncological patients cohorts. The data of recent studies on the role of serum biomarkers of myocardial damage and increased cardiovascular risk (cardiac troponins and brain natriuretic peptide) in predicting postoperative cardiac events in non-cardiac surgery are presented. Further prospects for the inclusion of biomarkers in risk stratification systems in patients with malignant neoplasms are discussed.

Two-Year clinical outcomes after coronary bifurcation stenting in older patients from Korea and Italy.

Older patients who treated by percutaneous coronary intervention (PCI) are at a higher risk of adverse cardiac outcomes. We sought to investigate the clinical impact of bifurcation PCI in older patients from Korea and Italy. We selected 5,537 patients who underwent bifurcation PCI from the BIFURCAT (comBined Insights from the Unified RAIN and COBIS bifurcAtion regisTries) database. The primary outcome was a composite of target vessel myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis at two years. In patients aged ≥75 years, the mean age was 80.1 ± 4.0 years, 65.2% were men, and 33.7% had diabetes. Older patients more frequently presented with chronic kidney disease (CKD), severe coronary calcification, and left main coronary artery disease (LMCA). During a median follow-up of 2.1 years, older patients showed similar adverse clinical outcomes compared to younger patients (the primary outcome, 5.7% vs. 4.5%; p = 0.21). Advanced age was not an independent predictor of the primary outcome (p = 0.93) in overall patients. Both CKD and LMCA were independent predictors regardless of age group. Older patients (≥75 years) showed similar clinical outcomes to those of younger patients after bifurcation PCI. Advanced age alone should not deter physicians from performing complex PCIs for bifurcation disease.

Abstract P165: Key Tenets for Lifestyle Programs Aiming to Improve Hypertension Control and Cardiovascular Health

Introduction: Promoting lifestyle changes, such as consuming a healthier diet, engaging in exercise, and quitting smoking can help control hypertension (HTN) and reduce the risk of adverse cardiac outcomes. To support public health practitioners and health care providers, the Centers for Disease Control and Prevention’s (CDC) Division for Heart Disease and Stroke Prevention (DHDSP) sought to develop a set of key tenets of lifestyle programs that support successful implementation and impact on HTN-related outcomes. Hypothesis: No a priori hypotheses. Methods: We conducted rapid evaluations of three lifestyle programs identified first through a broad call for nominations and then a panel of experts for final selections. We also performed a literature review to assess the landscape of lifestyle programs focused on managing HTN. To build upon these findings, a rigorous mixed-methods evaluation of a local YMCA’s (St. Louis Gateway Region) implementation of a Blood Pressure Self-Monitoring (BPSM) program was conducted to describe program characteristics and innovations and assess HTN outcomes. Results: The evaluation of a local YMCA included 333 participants with HTN (2018-2020) and reported a statistically significant average reduction of 2.6 mmHg in SBP from baseline to 16-week follow-up. Based on comprehensive findings from the project, DHDSP identified the following four key tenets for an effective program: 1) Implementing programs in community settings provides an opportunity to offer programming where people are already gathering and can build trust and commitment. Findings from rapid evaluation of a program held at churches and other community locations demonstrated increased BP control rates from 66.2% to 71.5% at 12-week follow-up. 2) A team-based approach with clinical and non-clinical staff allows for more impactful and effective implementation. Evaluation results demonstrated completion of a program with trained lifestyle coaches was associated with a decrease of 7.3 mmHg in SBP and 5.7 mmHg in DBP over a 16-week period. 3) Programs with shorter durations (between 3-24 weeks) allow for those not able to commit to a longer program to still benefit from learning to control BP and reduce other risk factors. Findings from rapid evaluation of a three-week program resulted in increased BP control from 28.4% to 61.3% by end of program period. 4) Targeting multiple lifestyle behaviors provide the opportunity to closely match participant needs with the type of activities that work best for them. Rapid evaluation of a 12-week program focused on exercise, diet, and reducing stress demonstrated an increase in BP control from 76.9% to 82.2%. Conclusion: Findings can be used as a resource to link patients to effective BP control and management programs that have implemented these key tenets. Strategies highlighted may also provide considerations for replication in other communities.

Abstract 13684: Comparison Between Men and Women With Severe Obesity for Risk of Adverse Outcomes of Myocardial Ischemia: An Exercise Stress Echocardiographic Study

Background: Obesity and sex have a complex relationship with myocardial ischemia. We explored the association of sex and severe obesity with adverse cardiovascular outcomes in patients with ischemic exercise stress echocardiography (EXE). Methods: We retrospectively studied 142 patients with ischemic ExE [Age: 65±11 years, 70(49%) women, EF: 57±8%, body mass index (BMI): 28±6 kg/m 2 ]. Severe obesity (BMI>35 kg/m 2 ) occured in 48 (34%) patients. Patients were stratified based on obesity and sex (4 groups, women, and men with and without severe obesity), followed for median of 1.5 years, and compared for clinical, exercise variables and occurrence of composite outcomes (death, acute coronary syndrome, cardiac hospitalization and repeat ischemia testing). Results: In our study, 28(20%) women and 20(14%) men had severe obesity, and 42(29%) women and 52(37%) men had no severe obesity. Groups were not different for age, risk factors, exercise characteristics, and resting LV function. Outcomes occurred in 85(60%) patients and were more prevalent in women with severe obesity compared to women without or men with or without severe obesity [21(75%), 17(40%), 11(55%), and 35(67%), p=0.014]. Sex and severe obesity did not predict outcomes in isolation [HR: 1.13 (95%CI:0.74 to 1.73), 1.48 (95%CI:0.95 to 2.3), respectively, figure 1A, B]. Survival analysis showed that women without severe obesity were at lowest risk, men were at similarly elevated risk irrespective of severe obesity, and women with severe obesity were at highest risk for composite outcomes [p=0.037, figure 1C, HR: 2.5 (95% CI: 1.3 to 4.8)]. After adjusting for clinical, exercise, and echocardiographic variables, women with severe obesity remained at high-risk [HR: 2.2, (95% CI: 1.06 to 4.36)]. Conclusion: In patients with ischemic ExE, women with severe obesity are at higher risk for adverse cardiac outcomes. Future studies are needed to understand the pathophysiologic mechanisms underlying this association.

Validated Model for Prediction of Adverse Cardiac Outcome in Patients With Fabry Disease

BackgroundThe cardiac manifestations of Fabry disease are the leading cause of death, but risk stratification remains inadequate. Identifying patients who are at risk of adverse cardiac outcome may facilitate more evidence-based treatment guidance. Contemporary cardiovascular cardiac magnetic resonance biomarkers have become widely adopted, but their prognostic value remains unclear. ObjectivesThe objective of this study was to develop, internally validate, and evaluate the performance of, a prognostic model, including contemporary deep phenotyping, which can be used to generate individual risk estimates for adverse cardiac outcome in patients with Fabry disease. MethodsThis longitudinal prospective cohort study consisted of 200 consecutive patients with Fabry disease undergoing clinical cardiac magnetic resonance. Median follow-up was 4.5 years (IQR: 2.7-6.3 years). Prognostic models were developed using Cox proportional hazards modeling. Outcome was a composite of adverse cardiac events. Model performance was evaluated. A risk calculator, which provides 5-year estimated risk of adverse cardiac outcome for individual patients, including men and women, was generated. ResultsThe highest performing, internally validated, parsimonious multivariable model included age, native myocardial T1 dispersion (SD of per voxel myocardial T1 relaxation times), and indexed left ventricular mass. Median optimism-adjusted c-statistic across 5 imputed model development data sets was 0.77 (95% CI: 0.70-0.84). Model calibration was excellent across the full risk profile. ConclusionsThis study developed and internally validated a risk prediction model that accurately predicts 5-year risk of adverse cardiac outcome for individual patients with Fabry disease, including men and women, which could easily be integrated into clinical care. External validation is warranted.

Cardiac sarcoidosis outcome differences: A comparison of patients with de novo cardiac versus known extracardiac sarcoidosis at presentation

BackgroundSarcoidosis is a systemic disease characterized by granulomatous inflammation. Cardiac involvement is associated with increased morbidity. However, differences in clinical characteristics and outcomes based on initial sarcoidosis organ manifestation in patients with cardiac sarcoidosis (CS) have not been described. MethodsA retrospective cohort of 252 patients with CS at an urban, quaternary medical center was studied. Presentation, treatment and outcomes of de novo CS and prior ECS groups were compared. Survival free of primary composite outcome (left ventricular assist device implantation, orthotopic heart transplantation (OHT), or death) was assessed. ResultsThere were 124 de novo CS patients and 128 with prior ECS at time of CS diagnosis. De novo CS patients were younger at CS diagnosis (p = 0.020). De novo CS patients had a more advanced cardiac presentation: lower left ventricular ejection fraction (LVEF) (p < 0.001), more frequent sustained ventricular arrhythmias (VA) (p = 0.001), and complete heart block (p = 0.001). During follow-up, new VA (p < 0.001), ventricular tachycardia ablation (p < 0.001), and OHT (p = 0.003) were more common in the de novo CS group. Outcome free survival was significantly shorter for de novo CS patients (p = 0.005), with increased hazard of primary composite outcome (p = 0.034) and development of new VA (p = 0.027) when compared to ECS patients. Overall mortality was similar between groups. ConclusionPatients presenting with CS as their first recognized organ manifestation of sarcoidosis have an increased risk of adverse cardiac outcomes as compared to those with a prior history of ECS. Improved awareness and diagnosis of CS is warranted for earlier recognition.

Impact of COVID-19 on Medical Supply in Adults With Congenital Heart Disease.

IntroductionIn March 2020, the World Health organization declared COVID-19 a global pandemic. One year later, the direct and indirect burden of the COVID-19 pandemic become more visible. In this context, there is concern about the allocation of medical resources and medical treatment of other diseases than COVID-19. Particularly, patients with chronic diseases need constant medical and pharmacological treatment. Therefore, we evaluated a large cohort of patients with adult congenital heart disease (ACHD) regarding postponed medical appointments and their possibilities to receive medical treatment during the COVID-19 pandemic.MethodsThis cross-sectional study included 559 patients with ACHD (mean age 37.32 ± 11.98; 47% female). Clinical characteristics, answers to questionnaires concerning lifestyle, psychological well-being, addictive behavior and adherence were related to postponed medical appointments and limited access to medical care.ResultsOne hundred and nine patients (19.5%) reported problems getting necessary medical treatment or visiting a physician. Higher anxiety levels (p = 0.004) emerged as the main factor associated with medical undertreatment. The main risk factors for postponement of least one medical appointment (n = 91) were higher depression (p = 0.013) and anxiety (p = 0.05) symptoms as well as female sex (p ≤ 0.0001) and documented arrhythmias (p = 0.007) indicating a particular risk group of cardiovascular complications. In contrast, frequent physical activity identified patients at lower risk.ConclusionIn ACHD anxiety and depressive symptoms handicap patients to receive medical care. Postponement of medical appointments additionally relates to female sex and documented arrhythmias. The latter indicates that patients at high risk of adverse cardiac outcome avoid routine medical care. Our data may lead policy makers to develop strategies for the provision of medical services to particular vulnerable patient groups, and to optimize management of both future pandemics and daily routine.

Mechanical Prosthetic Valve Thrombus in a Term Pregnant Woman Presenting as Acute Heart Failure: Case Report and Review of Literature

Abstract Cardiovascular disease in pregnancy contributes to a significant proportion of death worldwide. Though pregnancy-associated myocardial infarction and aortic dissection are the common causes of adverse cardiac events in developed countries, rheumatic heart diseases continue to be the important reason for cardiovascular morbidity and mortality in developing countries. The risk of adverse cardiac outcome is dependent on the type and severity of valvular abnormality, functional status, left ventricular function, and pulmonary arterial pressure. Managing a pregnant woman with a mechanical heart valve prosthesis is challenging because of the difficulty in achieving optimal anticoagulation in the presence of hypercoagulability. Mitral valve thrombus is a life-threatening event and women can present with acute heart failure or thromboembolic events. We report successful management of a 26-year-old primigravida with rheumatic heart disease diagnosed to have huge thrombus on mechanical prosthetic mitral valve presented with acute heart failure at 36 weeks. She received multidisciplinary care and underwent concurrent cesarean section followed by thrombectomy under cardiopulmonary bypass. She had a good recovery following surgery and the complexity surrounds the management merit the presentation with a review of management strategies for a women with mechanical prosthetic heart valve in pregnancy.

Validation of the CARPREG II risk stratification model and the WHOm scale in pregnant women with heart disease

Abstract The physiological changes of pregnancy imply a state of haemodynamic stress, which increases the risk of maternal-fetal complications in women with cardiac pathology. Risk stratification models allow clinical decisions to be guided and optimal diagnostic, follow-up and management strategies to be established according to each estimated category in order to reduce adverse outcomes. Objective To validate the CARPREG II and WHOm risk prediction models in a population of pregnant women with heart disease. Materials and methods Validation and comparison study of a risk prediction model in a prospective cohort of pregnant women with heart disease assessed between 2016 and 2019 by a cardiobstetric team in an average income country. The CARPREG II score was established and patients were classified according to the WHOm risk scale. We assessed cardiovascular and perinatal outcomes and determined the calibration and level of discrimination of these tools. Results In a cohort of 328 pregnant women (27±7 years), 33% (n=110) had congenital heart disease, followed by arrhythmias in 30% (n=98), valvular pathologies in 14% (n=46) and cardiomyopathies in 9% (n=29). In 56% of the pregnancies, the route of delivery was caesarean section, 84% of these by obstetric indication. A cardiac event occurred in 15%, with left heart failure (5.3%) and arrhythmias (2.3%) being the most frequent. The frequency of maternal death of cardiac origin during the study was 1.6%. Neonatal outcomes occurred in 37% of gestations (preterm delivery (16%) and low weight for gestational age (8.4%)) and obstetric events in 12.5%: pregnancy-induced hypertension (9%) and postpartum haemorrhage (2.3%). NYHA functional class III-IV or cyanosis (OR 12 95% CI 3.1 - 46.4) and left ventricular dysfunction (LVEF &amp;lt;55%) (OR 3 95% CI 1 - 10.9) were the most statistically significant risk predictors. Discrimination of both models was adequate (AUC-ROC of 0.74 95% CI 0.64 - 0.84) for the CARPREG II risk index and 0.77 for the WHOm scale (95% CI 0.69 - 0.86) (Figure 2). Calibration is also good in the study population (Hosmer- Lemeshow goodness-of-fit 0.6 and 0.1, respectively). By including in the CARPREG II model the variables ejection fraction and pulmonary artery systolic pressure in their numerical and not dichotomised form, a discrete improvement in the predictive ability of the scale is evident (AUC-ROC 0.81 95% CI 0.71–0.91). Conclusions The CARPREG II and WHOm risk stratification models have good ability to discriminate the risk of adverse cardiac outcomes in pregnant women with heart disease and fit our population. To improve the predictive power of CARPREG II, the variables pulmonary hypertension and left ventricular dysfunction could be used numerically and not dichotomised as in the original model. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): San Vicente Foundation University Hospital, Cardio-obstetric Center

Predictive value of laboratory markers in the development of cardiac events in patients with stable coronary artery disease after elective endovascular revascularization.

Aim To reveal a relationship between preprocedural laboratory data and adverse cardiac outcomes (CO) in patients with stable ischemic heart disease (IHD) following elective endovascular revascularization (ER).Material and methods This study included 225 patients with IHD admitted for treatment to the Research Institute of Cardiology of the Tomsk National Research Medical Center. The study included patients with documented IHD and hemodynamically significant coronary stenoses requiring elective ER. Patients were divided into groups based on the presence of complications: group 1, 98 patients with adverse CO and group 2, 127 patients without adverse CO. Besides evaluation of complaints, history, and objective status, general clinical and biochemical tests were performed for all patients. Concentration of glycated hemoglobin (НbА1с) was measured by immunoturbidimetry (DiaSys Diagnostic Systems). Serum concentrations of insulin, interleukin-6 (IL-6), endothelin 1 (ET-1), and homocysteine were measured by enzyme immunoassay. Blood lipid profile was determined by enzymatic colorimetry (DiaSys). Content of non-high-density lipoprotein (non-HDL) cholesterol (CS) was calculated as: CS - HDL CS. Insulin resistance (IR) was assessed by the HOMА-IR index. IR was diagnosed at the index of 2.77. Statistical analyses were performed with Statistica 10.0 and Medcalc 19.2.6 software.Results A one-way regression analysis identified predictors for adverse CO following ER. The most significant predictors were fibrinogen (odds ratio (OR), 1.430; 95 % confidence interval (CI), 1.027-1.990), HbA1c (OR 1.825; 95 % CI, 1.283-2.598), homocysteine (OR, 1.555; 95 % CI, 1.348-1.794), ET-1 (OR, 94.408; 95 % CI, 16.762-531.720), triglycerides (TG)/glucose ratio (OR 1.815; 95 % CI, 1.155-2.853). Based on selected factors, logistic regression models were constructed. However, not all models had a high prognostic power. Only concentrations of ET-1 and homocysteine showed a high prognostic capability in respect of the adverse outcome (88.3 and 85.7 %, respectively).Conclusion For patients with IHD, the prognostic capability of ET-1 and homocysteine with respect of the risk for adverse CO following ER was the highest compared to other markers. The results of the study are completely consistent with data of literature and can be successfully used in clinical practice for optimizing the medical care of patients after elective ER.

249 Labor length and adverse cardiac outcomes among women with congenital heart disease

Women with congenital heart disease (CHD) are at high risk for peripartum morbidity, yet data is limited on the impact of labor on morbidity. Our objective was to evaluate whether exposure to labor and duration of labor were associated with rates of adverse maternal cardiac outcomes among women with CHD. This was a secondary analysis of a retrospective cohort study of women ≥18 years with CHD who received prenatal care and delivered at the Hospital of the University of Pennsylvania between 1998-2014 with a singleton gestation. Only the first pregnancy was counted for women who delivered more than once. Pregnancies that ended in termination or loss <24 weeks gestation were excluded. A composite adverse maternal cardiac outcome included any cardiac event during pregnancy or <6 months post-partum (specific outcomes listed in Figure), compared among women who did and did not labor. 168 women were included; 34 (20.2%) underwent planned cesarean delivery (CD) without labor and 134 (79.8%) labored. The overall rate of adverse cardiac outcome was 20.2%; 23.5% in the planned CD group and 19.4% in those that labored, regardless of mode of delivery (p=0.6). The most common adverse events were heart failure (13.7%) and arrhythmia (7.7%). As shown in the Figure, women who delivered in <24 hours (regardless of mode of delivery) had a lower rate of adverse cardiac outcome than those that delivered after ≥24 hours of labor, though not statistically significant (p=0.06). When adjusting for confounders including NYHA class, systemic ventricular dysfunction, and mode of delivery, women with labor length ≥15 hours had a 3.7-fold higher odds of adverse cardiac outcome (aOR 3.7 [1.1-12.9]). In this retrospective cohort of women with CHD, exposure to labor was not associated with an increased risk of adverse cardiac outcome. However, among those who labored, longer labor was associated with an increased risk, regardless of mode of delivery. Attention should be paid to the duration of labor in women with CHD, as achieving a vaginal delivery does not mitigate the risks of prolonged labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prognostic Impact of Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance in Myocarditis: A Systematic Review and Meta-Analysis.

Patients with acute myocarditis (AM) are at increased risk of adverse cardiac events after the index episode. Late gadolinium enhancement (LGE) detected by cardiovascular magnetic resonance in patients with AM plays an important diagnostic role, but its prognostic significance remains unresolved. This systematic review and meta-analysis sought to assess the prognostic implications of cardiovascular magnetic resonance-derived LGE in patients with AM. Data search was conducted from inception through February 28, 2020, using the following Medical Subject Heading terms: Myocarditis, CMR, Magnetic Resonance Imaging, Magnetic Resonance. From 2422 articles retrieved, we selected 11 studies reporting baseline cardiovascular magnetic resonance assessment and long-term clinical follow-up in patients with AM. Hazard ratios and CIs for a combined clinical end point were recorded for LGE presence, extent (>2 segments or >10% of left ventricular [LV] mass or >17g) and location (anteroseptal versus non-anteroseptal). A combined end point comprised all-cause mortality, cardiac mortality, and major adverse cardiovascular events. Hartung and Knapp correction improved robustness of the results. Prespecified sensitivity analyses explored potential sources of heterogeneity. The meta-analysis was conducted according to the Meta-analysis of Observational Studies in Epidemiology guidelines. LGE presence (pooled hazard ratios, 3.28 [95% CIs, 1.69-6.39], P<0.001 [95% CIs, 1.33-8.11] after Hartung and Knapp correction) and anteroseptal LGE (pooled-hazard ratios, 2.58 [95% CIs, 1.87-3.55], P<0.001 [95% CIs, 1.64-4.06] after Hartung and Knapp correction) were associated with an increased risk of the combined end point. Extensive LGE was associated with worse outcomes (pooled-hazard ratios, 1.96 [95% CIs, 1.08-3.56], P=0.027), but this association was not confirmed after Hartung and Knapp correction (95% CIs, 0.843-4.57). LGE presence and anteroseptal location at baseline cardiovascular magnetic resonance are important independent prognostic markers that herald an increased risk of adverse cardiac outcomes in patients with AM. Registration: https://www.crd.york.ac.uk/PROSPERO/ Unique identifier: CRD42019146619.

Impact of revascularization in patients with post-infarction left ventricular aneurysm and ventricular tachyarrhythmia.

BackgroundVentricular arrhythmia is a leading cause of cardiac death among patients with post‐infarction left ventricular aneurysm (PI‐LVA). The effect of coronary revascularization in PI‐LVA patients with ventricular tachyarrhythmia remains unknown. This study aims to investigate the impact of revascularization therapy on clinical outcomes in these patients.MethodsA total of 238 PI‐LVA patients were enrolled, and 59 patients were presented with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Patients were classified into 4 groups by treatment strategies (medical or revascularization) and the presence of VT/VF: group 1 (n = 57): VT/VF− and revascularization−; group 2 (n = 122): VT/VF− and revascularization+; group 3 (n = 34): VT/VF+ and revascularization+; and group 4 (n = 25): VT/VF+ and revascularization‐. The clinical outcomes were compared, and the primary endpoint was cardiac death or heart transplantation.ResultsPatients were followed up for 45 ± 16 months, and 41 patients (17.2%) reached the primary endpoint. Kaplan–Meier analysis showed that in VT/VF− patients, revascularization associated with higher cardiac survival compared with medical therapy (log‐rank p = .002), but in VT/VF+ patients, revascularization did not predict better cardiac outcome (log‐rank p = .901). Cox regression analysis revealed PET‐EF (HR 4.41, 95% CI: 1.72–11.36, p = .002) and moderate/severe mitral regurgitation (HR 2.32, 95% CI: 1.02–5.30, p = .046) as independent predictors of adverse cardiac outcome in patients with VT/VF.ConclusionPI‐LVA patients with VT/VF are at high risk of adverse cardiac outcome, and coronary revascularization does not mitigate this risk, although revascularization was associated with higher cardiac survival in PI‐LVA patients without VT/VF.

Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias

BackgroundAn association between paroxysmal supraventricular tachycardias (PSVT) and elevated cardiac troponin I (cTnI) has been reported in small studies, even in the absence of significant coronary artery or structural heart disease. We sought to explore the prognostic significance of elevated cTnI among patients presenting with PSVT. MethodsThis is a retrospective single-center observational study conducted between January 2014 and Decemebr 2016. 165 patients (60% men, mean age 55 ± 17 year-old) with an acute episode of regular supraventricular tachyarrhythmia were admitted to the emergency department at Rambam Medical Center. 131 patients had at least one serum cTnI value measured. Of those, 57 had a positive result, defined as serum cTnI of more than 0.028 ng/dL. ResultsMultivariate analysis showed that heart rate > 150 beats per minute (bpm) on admission (OR = 3.9; 95% CI 1.1.6–9.5; p < 0.003) and history of coronary artery disease (CAD) (OR = 3.4; 95% CI 1.2–10.1; p = 0.026) were the only independent predictors of cTnI elevation. After mean follow-up period of 23 ± 7 months, the combined primary outcome of death, coronary intervention (PCI) or myocardial infarction (MI) occurred in 7 patients (12.3%) out of 57 patients with positive cTnI and in zero patients with negative cTn (p = 0.002). Cox proportional hazard model showed that elevated cTnI on admission was an independent predictor of adverse outcomes only in patients with known coronary artery disease (CAD) (HR = 3.3, p = 0.05). ConclusionElevated cTnI among patients presenting with PSVT appears to have prognostic significance only in patients with history of CAD. In this patient group elevated cTnI is associated with increased risk of adverse cardiac outcomes. We therefore believe serum cTnI should be measured selectively, such as in patients with symptoms of ischemic chest pain and a high pretest likelihood of having CAD.

Long-Term Adverse Cardiac Outcomes in Patients With Sarcoidosis

BackgroundIt is estimated that 5% of patients with sarcoidosis have clinically manifest cardiac involvement, although autopsy and imaging studies suggest a significantly higher prevalence of cardiac involvement. There is a paucity of contemporary data on the risk of adverse cardiac outcomes, particularly heart failure (HF), in patients with sarcoidosis. ObjectivesThe purpose of this study was to examine the long-term risk of HF and other adverse cardiac outcomes in patients with sarcoidosis compared with matched control subjects. MethodsIn this cohort study, all patients age ≥18 years with newly diagnosed sarcoidosis (1996 to 2016) were identified through Danish nationwide registries and matched 1:4 by age, sex, and comorbidities with control subjects from the background population without sarcoidosis. ResultsOf the 12,042 patients diagnosed with sarcoidosis, 11,834 patients were matched with 47,336 subjects from the background population (median age: 42.8 years [25th to 75th percentile: 33.1 to 55.8 years], 54.3% men). The median follow-up was 8.2 years. Absolute 10-year risks of outcomes were as follows: HF: 3.18% (95% confidence interval [CI]: 2.83% to 3.57%) for sarcoidosis patients and 1.72% (95% CI: 1.58% to 1.86%) for the background population; the composite of ICD implantation, ventricular arrhythmias, and cardiac arrest: 0.96% (95% CI: 0.77% to 1.18%) for sarcoidosis patients and 0.45% (95% CI: 0.38% to 0.53%) for the background population; the composite of pacemaker implantation, atrioventricular block, and sinoatrial dysfunction: 0.94% (95% CI: 0.75% to 1.16%) for sarcoidosis patients and 0.51% (95% CI: 0.44% to 0.59%) for the background population; atrial fibrillation or flutter: 3.44% (95% CI: 3.06% to 3.84%) for sarcoidosis patients and 2.66% (95% CI: 2.49% to 2.84%) for the background population; and all-cause mortality: 10.88% (95% CI: 10.23% to 11.55%) for sarcoidosis patients and 7.43% (95% CI: 7.15% to 7.72%) for the background population. ConclusionsPatients with sarcoidosis had a higher associated risk of HF and other adverse cardiac outcomes compared with matched control subjects.

525 Overnight Criteria Led Discharge for Intermediate Risk Chest Pain: A Review of Safety at a Tertiary Cardiac Referral Centre

To assess the feasibility and safety of an overnight emergency department (ED) led discharge protocol, with subsequent outpatient testing for patients with intermediate risk, troponin-negative chest pain. Patients were discharged directly from ED if they had 2 negative serial troponins, 3 hours apart (High Sensitive STAT Troponin-I assay, Abbott Laboratories). Patients were required to have normal serial ECGs, routine blood tests and a chest X-ray. Outpatient functional testing was performed as per the local Chest Pain Assessment Unit Guideline. The primary outcome was re-hospitalisation for chest pain, myocardial infarction or death at 90 days assessed by phone follow-up or using state-wide electronic records where patients were not contactable. Between September and November 2019, 61 intermediate risk chest pain patients (mean age 59±12y, 54% female, 15% with known CAD and 59% with ≥2 CV risk factors) were discharged from ED. Of the 61 patients, 3%(2/61) were not offered testing due to recent negative stress testing and 15%(9/61) failed to attend their appointments. The remaining 50 patients underwent functional testing or CT coronary angiography at a median time of 6.5 days. Follow-up was available in all patients (87% via phone and 13% by electronic records) and none experienced the primary outcome of re-hospitalisations for chest pain, myocardial infarction or death at 90 days. Our initial data suggests protocol driven, routine overnight ED discharge of intermediate risk chest pain patients with appropriate outpatient testing and follow-up is both feasible and safe with low risk of adverse cardiac outcomes.