Risk Of Major Cardiac Events Research Articles

Cardiovascular Risk in Users of Mirabegron Compared with Users of Antimuscarinic Treatments for Overactive Bladder: Findings from a Non-Interventional, Multinational, Cohort Study.

IntroductionDuring clinical trials, mirabegron, a β3-adrenoreceptor agonist, was associated with increased vital signs vs placebo in patients with overactive bladder.ObjectiveThe purpose of this study was to compare incidence rates of adverse cardiovascular (CV) outcomes following mirabegron or antimuscarinic use.MethodsWe conducted an observational post-marketing safety study utilising real-world data. The study population was identified within five sources: Danish and Swedish National Registers, Clinical Practice Research Datalink (UK), Optum (USA) and Humana (USA). Episodes of time when patients were new users of mirabegron or antimuscarinics (October 2012–December 2018) were sourced from prescriptions and matched on propensity scores. Occurrences of major adverse cardiovascular events (MACE), acute myocardial infarction (AMI), stroke, CV mortality and all-cause mortality were identified. Outcome incidence rates and hazard ratios from Cox models were estimated.ResultsOverall, 152,026 mirabegron and 152,026 antimuscarinic episodes were matched. The population consisted of 63.1% women and 72.6% were ≥ 65 years old. There were no appreciable differences in the incidence rates of MACE, AMI or stroke between users of mirabegron and antimuscarinics. Incidence rates of CV mortality (hazard ratio 0.83, 95% confidence interval 0.73–0.95) and all-cause mortality (hazard ratio 0.80, 95% confidence interval 0.76–0.84) were no higher with mirabegron vs antimuscarinics. Results restricted to episodes at high risk for CV events or stratified by age (< 65 years, ≥ 65 years) or prior overactive bladder medication use were consistent with overall findings.ConclusionsThis large, multinational study found no higher risk of MACE, AMI, stroke, CV mortality or all-cause mortality among users of mirabegron relative to users of antimuscarinics.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40264-021-01095-7.

Prognostic Significance of Left Ventricular Dyssynchrony Assessed with Nuclear Cardiology for the Prediction of Major Cardiac Events after Revascularization.

Objective This retrospective study was aimed at determining whether or not stress phase bandwidth (SPBW), a left ventricular (LV) mechanical dyssynchrony index, predicts major cardiac events (MCEs) and stratifies the risk of those in patients with coronary artery disease (CAD) who undergo revascularization. Methods Patients were followed up to confirm the prognosis for at least one year. The SPBW was calculated by a phase analysis using the Heart Risk View-F software program. The composite endpoint was the onset of MCEs, consisting of cardiac death, non-fatal myocardial infarction, unstable angina pectoris, and severe heart failure requiring hospitalization. Patients The study subjects were 332 patients with CAD who underwent coronary angiography and revascularization after confirming ≥5% ischemia detected by rest 201Tl and stress 99mTc-tetrofosmin electrocardiogram-gated single-photon emission computed tomography myocardial perfusion imaging. Results During the follow-up, 35 patients experienced MCEs of cardiac death (n=5), non-fatal myocardial infarction (n=3), unstable angina pectoris (n=11), and severe heart failure requiring hospitalization (n=16). A receiver operating characteristics analysis indicated that the optimal cut-off value of the SPBW was 52° for predicting MCEs, and the MCE rate was significantly higher in the patients with an SPBW >52° than in those with an SPBW ≤52°. Results of the multivariate analysis showed the SPBW and estimated glomerular filtration rate to be independent predictors for MCEs. In addition, the cut-off value of the SPBW significantly stratified the risk of MCEs according to the results of the Kaplan-Meier analysis. Conclusion Evaluating the SPBW before revascularization may help predict future MCEs in patients with CAD who intended to undergo treatment.

Assessment of the warranty period of a normal myocardial perfusion scintigraphy in patients with diabetes mellitus: 5 year follow-up of the prospective multicenter BARDOT trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Foundation for Research Background Asymptomatic diabetic patients with an abnormal myocardial perfusion scintigraphy (MPS) are known to be at an increased risk of major cardiac events (MACE) at 2-years follow-up. It remains unclear whether this finding holds true even for a follow-up of 5 years. Methods four hundred patients with type-2 diabetes without coronary artery disease were evaluated clinically and with MPS and followed up for 5 years. Major adverse cardiovascular events (MACE) were defined as cardiac death, myocardial infarction or late coronary revascularization. Results An abnormal MPS (SSS≥4 or SSS≥2) was found in 87 patients (21.8%). MACE within 5 years occurred in 14 patients with abnormal MPS (16.1%) and in 22 with normal scan (1.7%, p = 0.009); 15 deaths were recorded (3.8%). Patients with normal MPS had lower rates of MACEs than patients with abnormal scans (p = 0.016) (Figure 1A + B). Patients with abnormal MPS who had undergone revascularization had a lower mortality rate and a better event free survival from MI and revascularization than patients with abnormal MPS who had either undergone medical therapy only or could not be revascularized (Figure 1C + D). Conclusions Patients with normal MPS have a low event rate and may not need retesting within 5 years (warranty period). Patients with an abnormal MPS have higher event rates and may benefit from a combined medical and revascularization approach. Abstract Figure 1 A-D

Whole Body FDG PET-CT in the Evaluation and Management of Cardiac Sarcoidosis and Isolated Cardiac Sarcoidosis

Introduction Sarcoidosis is a multisystem inflammatory disease defined histologically by the formation of non-caseating granulomas. Cardiac involvement can be seen in up to 5% of cases [1]. These patients are at a high risk for major cardiac events [1]. Diagnosing and monitoring Cardiac Sarcoidosis (CS) is not trivial but can be currently accomplished by a combination of cardiac MRI and cardiac FDG PET-CT scanning [2]. With appropriate patient preparation, cardiac FDG PET has a high sensitivity for detecting cardiac lesions but also extra-cardiac lesions and for monitoring the efficacy of treatment. Discussion Current standard clinical practice consists of acquiring dedicated, limited field of view cardiac FDG PET scans. This would cover the heart and immediately adjacent thoracic structures. Although this is of great value and used with great success to diagnose and monitor cardiac sarcoidosis, it fails to assess the patient’s disease in a holistic manner. Still with this limited field of view, several reports including ours have described a high rate of extra-cardiac findings. We reviewed a series of sixty-five PET-CT scans of 54 patients referred for CS evaluation. These were performed between September 2010 and April 2013 at Yale New Haven Hospital and we found extra-cardiac findings were present in 92.3% of scans (n=60). Overall disease distribution is summarized in (Table 1). Highlight some of these extra-cardiac findings (Figures 1-4). 52.3% of these patients were asymptomatic at the time of the scan. CS was diagnosed in 50.8% of patients (n=33). All the patients (100%) with CS had extra-cardiac findings. Additionally, extra-cardiac findings were present in 48.3% of the scans when there was no cardiac involvement. In our cohort, we had no cases of Isolated Cardiac Sarcoidosis (ICS).

Prognostic Role of Left Ventricular Intramyocardial Fatty Metaplasia in Patients With Previous Myocarditis (MYOFAT Study)

Left ventricular intramyocardial fat (LV-IMF) is often found in patients with previous irreversible myocardial damage and may be detected by cardiac magnetic resonance (CMR). No data are currently available about the prevalence of LV-IMF in patients with previous myocarditis. Our aim was to assess the prevalence of LV-IMF in patients with previous myocarditis by repeating after >3 years a follow-up CMR examination and to evaluate its clinical and prognostic role. Patients with clinical suspected myocarditis who underwent CMR within the first week from the onset of their symptoms and underwent repeated CMR were enrolled. LV-IMF was detected as areas of left ventricular intramyocardial "India ink" black boundary with or without a hyperintense core. Overall, in 235 patients with a definitive diagnosis of acute myocarditis, CMR was repeated after a median of 4 (3 to 6) years from symptom onset. LV-IMF positive patients (n = 35, 15%) presented greater ventricular volumes and more frequently a mid-wall late gadolinium enhancement than those without LV-IMF (both p < 0.05). Patients presenting major cardiac events (sudden cardiac deaths, resuscitated cardiac arrest, and appropriate implantable cardioverter-defibrillator-firing) at follow-up had a greater prevalence of LV-IMF than those without (55% vs 11%, p < 0.001). Patients with LV-IMF had a higher incidence myocarditis relapse (27% vs 9%, p = 0.003) and a greater risk of major cardiac events (p < 0.0001) than those without. At logistic regression analysis, LV-IMF was an independent predictor of major cardiac events. In conclusion, LV-IMF is not an uncommon finding in patients with previous myocarditis and is associated with worse ventricular remodeling and prognosis.

Cardiovascular event risk estimated after coronary revascularization and optimal medical therapy: J-ACCESS4 prognostic study

BackgroundAn assessment of cardiac events and survival using quantitative gated myocardial single-photon emission computed tomography (SPECT) (J-ACCESS) associated several risk factors with cardiac events in Japan. The clinical course after revascularization and/or optimal medical therapy (OMT) was followed in patients with coronary artery disease (CAD) at moderate-to-high risk estimated by software incorporating the J-ACCESS risk model. The present study aimed to determine the relevance of changes in estimated risk to outcomes of these therapies.MethodsThis study included 494 patients with possible or definite CAD who underwent initial pharmacological stress 99mTc-tetrofosmin myocardial perfusion SPECT (MPS) before and eight months after therapy. Major cardiac event risk during 3 years of follow-up was calculated using an equation based on that in the J-ACCESS study. Patients with ≥ 10% cardiac event risk estimated at the first MPS (n = 31) were analyzed and followed up for at least 1 year.ResultsEstimated risk was reduced by ≥ 5% in 14 patients (45%) after therapy. During a follow-up period of 22.1 ± 6.7 months, one patient without such reduction had a major cardiac event. Mean %summed stress scores significantly decreased from baseline to follow-up in patients with and without risk reduction. Left ventricular ejection fraction (LVEF [%]) at rest was significantly increased at the second, compared with the first MPS between patients with, than without risk reduction (57 ± 17 vs. 45 ± 16%, p = 0.001 and 50 ± 11 vs. 49 ± 9%, p = 0.953, respectively).ConclusionsA reduction in cardiac ischemia and an increase in LVEF by revascularization and/or OMT were necessary to avoid cardiac events among patients with moderate-to-high estimated risk, and changes in event risk were quantifiable.

Contemporary approaches to bifurcation stenting

Bifurcation lesions are common and associated with higher risks of major cardiac events and restenosis after percutaneous coronary intervention (PCI). Treatment requires understanding of lesion characteristics, stent design and therapeutic options. We review the evidence for provisional vs 2-stent techniques. We conclude that provisional stenting is suitable for most bifurcation lesions. We detail situations where a 2-stent technique should be considered and the steps for performing each of the 2-step techniques. We review the importance of lesion preparation, intracoronary imaging, proximal optimization (POT) and kissing balloon inflation

C jak COVID-19 — powikłania układu sercowo-naczyniowego u młodego pacjenta

The authors present the case of a 27-year-old patient with cardiovascular complications after undergoing severe acute respiratory syndrome-related coronavirus 2 infection. The first symptoms included muscle aches and somnolence, severe sore throat, and enlargement of submandibular and cervical lymph nodes, followed by dyspnoea and chest pain with body temperature 37.5°C. Because of the medical profession, the patient underwent a routine reverse-transcription polymerase chain reaction test for coronavirus infection, which was positive, before returning to work. In an electrocardiogram, it was observed pathological Q waves in II, III, aVF, V6, and 1 mm of ST elevation in V1–V3. The laboratory tests showed normal levels of cardiac troponin T, creatine kinase MB fraction, and N-terminal pro-B-type natriuretic peptide. Transthoracic echocardiography revealed the hypokinesis of the middle and apical segment of the anterior and lateral wall with preserved left ventricular ejection fraction (LVEF) — 54%. The magnetic resonance imaging (MRI) revealed the normal volume and global left ventricular systolic function (LVEF 52%) with segmental wall motion abnormalities. Subepicardial banded foci of late gadolinium enhancement (LGE), located in the lower right and left ventricular segments of the basal, central and apical segments of the inferior wall suggested inflammatory aetiology of changes found. It may be assumed that the suspected myocarditis was caused by coronavirus disease 2019 (COVID-19) infection. Since LGE was present in the inferior wall, the patient may be considered having a low risk of major cardiac events and heart failure hospitalizations, referring to the ITAMY study. In patients without a history of cardiovascular diseases with COVID-19, cardiac MRI may reveal preserved, mid-range, or reduced LVEF. The patient requires further follow-up. The coronavirus is the most dangerous for the elderly, but it can also affect the hearts of otherwise healthy people, including young adolescents.

Bilateral internal mammary grafting: Are the advantages obvious?

Background. The use of one internal thoracic artery has long been considered a gold standard for coronary artery bypass grafting. However, despite the benefits, the frequency of using both internal mammary arteries remains low. The relationship between improving coronary artery bypass grafting results and the risk of complications after surgery using two internal thoracic arteries are yet to be resolved.Aim. We compared immediate and mid-term outcomes of coronary artery bypass grafting using one and two mammary arteries.Methods. Two hundred and thirty-one (231) patients with coronary artery disease, after microscope-assisted coronary artery bypass surgery, were categorised into two groups: group I — patients had received one internal mammary artery during surgery (n = 177), and group II — patients had received two internal mammary arteries during surgery (n = 54). Propensity-score matching was applied to reduce differences between groups, therefore two groups of 50 patients were obtained after matching.Results. Operations with bilateral internal mammary grafting in comparison to single internal mammary grafting were associated with longer operating times (group I: 167.5 [150-190] min., group II: 205 [190–220] min., p &lt; 0.001) and increased aortic cross-clamp times (group I: 37.5 [32–45] min., group II: 44 [39–48] min., p = 0.012), but cardiopulmonary bypass duration was similar (group I: 65.5 [56–78] min. and group II: 69 [58–78] min., p = 0.95). No differences were observed for adverse event frequencies (i.e. death, myocardial infarction, acute cerebrovascular accidents and repeated revascularisation) and sternal wound complications in the early- and long-term post-operation. The grafts patency in groups I and II before discharge was 98.0 vs. 92.5 % (p = 0.195) and 94.6 vs. 92.5 % (p = 0.582) for mammary and venous grafts, respectively. At follow-up time (29.5 ± 18.7 months), group I was associated with significantly improved actuarial overall survival (p = 0.021) and were composite survival free from cardiac-related mortality, myocardial infarction, repeat revascularisation and stroke (p = 0.008). Complete revascularisation was associated with a reduced risk of major cardiac events (OR, 0.41; 95% CI: 0.20–0.85).Conclusion. Bilateral internal mammary artery coronary artery bypass grafting in comparison with single internal mammary grafting was associated with increased operation times, similar grafts patency, early and late outcomes, but no overall improved survival and composite freedom from major adverse cardiac events in the mid-term. Complete revascularisation may be considered an independent prognostic factor after coronary bypass surgery and may be more clinically relevant than both internal thoracic arteries. Received 29 April 2020. Revised 8 September 2020. Accepted 9 September 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

The risks of major cardiac events among patients with psoriatic arthritis treated with apremilast, biologics, DMARDs or corticosteroids.

People with PsA are at increased risk of cardiovascular disease. The objective of this study was to quantify the risk of myocardial infarction (MI), stroke and revascularizations in people with apremilast-treated PsA compared with patients receiving other PsA treatments. We conducted a cohort study of 68678 patients with PsA treated with apremilast, TNF inhibitor (TNF-i) biologics, IL-17 or -12/23 biologics, conventional DMARDs or CS in the United States MarketScan database. Cohort entry was date of first study drug after 21 March 2014. Cases were patients with MI, stroke or revascularization. We calculated incidence rates (IRs) and incidence rate ratios for each outcome by exposure. We identified 292 MI, 151 stroke and 475 revascularizations cases. IRs for MI were lowest for users of TNF-i biologics [1.4 per 1000 person-years (PY)] and similar for all other treatments, including apremilast, ranging from 1.8 to 3.8 per 1000 PY. IRs were similar for all treatments for both stroke (0.1-1.6 per 1000 PY) and revascularization (3.1-5.1 per 1000 PY). IRs for apremilast were 2.5 per 1000 PY for MI, 1.6 per 1000 PY for stroke and 3.3 per 1000 PY for revascularization. In patients with treated PsA, IRs of MI, stroke and revascularization were low for all systemic treatments evaluated. Although the number of events was small, apremilast exposure did not signal potential acute cardiovascular harm and was not associated with a material increase in the risk of these serious cardiac events.

High-sensitivity troponin I predicts major cardiovascular events after noncardiac surgery

Abstract Background Myocardial injury after noncardiac surgery (MINS) is common and is associated with postoperative major cardiac events and 30-day mortality. We have previously established the diagnostic criteria for MINS with the 4th-generation cardiac troponin T assay (TnT) and 5th-generation high-sensitivity TnT assay (hsTnT) based on prognostically relevant thresholds. Little is known about diagnostic criteria for MINS using the high-sensitivity troponin I (hsTnI) assay. Purpose To determine hsTnI thresholds associated with 30-day major cardiac events and death after noncardiac surgery. Methods We performed a nested prospective biobank cohort study of 4545 patients from the VISION Study. Patients were aged ≥45 years and underwent in-patient noncardiac surgery under regional or general anesthesia. Patients had samples collected and frozen preoperatively, and on postoperative days 1, 2 and 3. We measured hsTnI on thawed preoperative and postoperative samples. We used iterative Cox proportional hazard models to determine peak postoperative hsTnI thresholds independently associated with major cardiac events (i.e., composite of death, non-fatal cardiac arrest, congestive heart failure within 30 days and non-fatal myocardial infarction from postoperative days 4–30). Results Major cardiac events occurred in 89/4545 (2.0%) patients. Peak hsTnI values of &amp;lt;75 ng/L, 75 ng/L to &amp;lt;1000 ng/L, and ≥1000 ng/L were associated with an incidence of major cardiac events of 1.2% (95% CI 0.9–1.6), 7.1% (95% CI 4.8–10.5) and 25.9% (95% CI 16.3–38.4), respectively. Compared to peak hsTnI &amp;lt;75 ng/L (reference), hsTnI values 75 ng/L to &amp;lt;1000 ng/L and ≥1000 ng/L were associated with adjusted hazard ratios (aHR) of 4.53 (95% CI 2.75–7.48) and 16.17 (95% CI 8.70–30.07), respectively. No change from preoperative hsTnI to peak postoperative hsTnI significantly improved the model when included on top of the identified thresholds. Incidence of major cardiac events was 31/343 (9%) in patients with postoperative peak hsTnI ≥75 ng/L versus 52/4178 (1%) in patients with postoperative peak hsTnI &amp;lt;75 ng/L (aHR 5.76; 95% CI 3.64–9.11). A postoperative peak hsTnI ≥75 ng/L was associated with increased risk of major cardiac events either in the presence (aHR 9.35; 95% CI 5.28–16.55) or absence (aHR 3.99; 95% CI 2.19–7.25) of clinical features of myocardial injury (e.g., chest pain, ischemic electrocardiography changes). Conclusion A hsTnI elevation within the first 3 days after noncardiac surgery independently predicts major cardiac events at 30 days. A peak postoperative hsTnI ≥75 ng/L was associated with a 6-fold increase in the risk of subsequent major cardiac events at 30 days as compared to peak postoperative hsTnI&amp;lt;75 ng/L. This hsTnI threshold can be used to diagnose MINS. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Siemens Healthcare Diagnostics Inc. Canadian Institutes of Health Research

Improving Identification of Patients at Low Risk for Major Cardiac Events After Noncardiac Surgery Using Intraoperative Data.

Risk-stratification tools for cardiac complications after noncardiac surgery based on preoperative risk factors are used to inform postoperative management. However, there is limited evidence on whether risk stratification can be improved by incorporating data collected intraoperatively, particularly for low-risk patients. We conducted a retrospective cohort study of adults who underwent noncardiac surgery between 2014 and 2018 at four hospitals in the United States. Logistic regression with elastic net selection was used to classify in-hospital major adverse cardiovascular events (MACE) using preoperative and intraoperative data ("perioperative model"). We compared model performance to standard risk stratification tools and professional society guidelines that do not use intraoperative data. Of 72,909 patients, 558 (0.77%) experienced MACE. Those with MACE were older and less likely to be female. The perioperative model demonstrated an area under the receiver operating characteristic curve (AUC) of 0.88 (95% CI, 0.85-0.92). This was higher than the Lee Revised Cardiac Risk Index (RCRI) AUC of 0.79 (95% CI, 0.74-0.84; P < .001 for AUC comparison). There were more MACE complications in the top decile (n = 1,465) of the perioperative model's predicted risk compared with that of the RCRI model (n = 58 vs 43). Additionally, the perioperative model identified 2,341 of 7,597 (31%) patients as low risk who did not experience MACE but were recommended to receive postoperative biomarker testing by a risk factor-based guideline algorithm. Addition of intraoperative data to preoperative data improved prediction of cardiovascular complication outcomes after noncardiac surgery and could potentially help reduce unnecessary postoperative testing.

Genotype Predicts Outcomes in Fetuses and Neonates With Severe Congenital Long QT Syndrome.

This study sought to determine the relationship between long QT syndrome (LQTS) subtype (LTQ1, LTQ2, LTQ3) and postnatal cardiac events (CEs). LQTS presenting with 2:1 atrioventricular block or torsades de pointes in the fetus and/or neonate has been associated with risk for major CEs, but overall outcomes and predictors remain unknown. A retrospective study involving 25 international centers evaluated the course of fetuses/newborns diagnosed with congenital LQTS and either 2:1 atrioventricular block or torsades de pointes. The primary outcomes were age at first CE after dismissal from the newborn hospitalization and death and/or cardiac transplantation during follow-up. CE was defined as aborted cardiac arrest, appropriate shock from implantable cardioverter-defibrillator, or sudden cardiac death. A total of 84 fetuses and/or neonates were identified with LQTS (12 as LQT1, 35 as LQT2, 37 as LQT3). Median gestational age at delivery was 37weeks (interquartile range: 35 to 39weeks) and age at hospital discharge was 3weeks (interquartile range: 2 to 5weeks). Fetal demise occurred in 2 and pre-discharge death in 1. Over a median of 5.2 years, there were 1 LQT1, 3 LQT2, and 23 LQT3 CEs (13 aborted cardiac arrests, 5 sudden cardiac deaths, and 9 appropriate shocks). One patient with LQT1 and 11 patients with LQT3 died or received cardiac transplant during follow-up. The only multivariate predictor of post-discharge CEs was LQT3 status (LQT3 vs. LQT2: hazard ratio: 8.4; 95% confidence interval: 2.6 to 38.9; p<0.001), and LQT3, relative to LQT2, genotype predicted death and/or cardiac transplant (p<0.001). In this large multicenter study, fetuses and/or neonates with LQT3 but not those with LQT1 or LQT2 presenting with severe arrhythmias were at high risk of not only frequent, but lethal CEs.

Clinical outcomes in adult athletes with hypertrophic cardiomyopathy: a 7-year follow-up study

ObjectiveCurrent guidelines recommend precautionary disqualification from competitive sports in patients with hypertrophic cardiomyopathy (HCM). We assessed the incidence of cardiovascular events in a cohort of patients with HCM engaged in...

Prognostic Value of Left Ventricular Dyssynchrony Assessed with Nuclear Cardiology in Patients with Known or Suspected Stable Coronary Artery Disease with Preserved Left Ventricular Ejection Fraction.

Left ventricular (LV) mechanical dyssynchrony assessed with phase analysis of electrocardiogram (ECG) -gated single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is useful for predicting major cardiac events (MCEs) in patients with cardiac dysfunction. However, there is no report on its usefulness in Japanese patients with known or suspected stable coronary artery disease (CAD) with preserved LV ejection fraction (LVEF).We retrospectively investigated 3,374 consecutive patients with known or suspected CAD who underwent rest 201Tl and stress 99mTc-tetrofosmin ECG-gated SPECT MPI and had preserved LVEF (≥ 45%), and followed them up to confirm their prognosis for three years. The composite endpoint was the onset of MCEs consisting of cardiac death, non-fatal myocardial infarction (MI), unstable angina pectoris, and severe heart failure requiring hospitalization. LV mechanical dyssynchrony was evaluated with phase analysis with the Heart Risk View-F software to obtain the phase bandwidth and standard deviation.During the follow-up, 179 patients experienced MCEs: cardiac death (n = 42); non-fatal MI (n = 34); unstable angina pectoris (n = 54); and severe heart failure (n = 49). Results of the multivariate analysis showed age, a history of MI, diabetes mellitus, summed stress score, and stress phase bandwidth to be independent predictors for MCEs. In Kaplan-Meier analysis, prognoses were significantly stratified with the tertiles of stress phase bandwidth.LV mechanical dyssynchrony assessed with ECG-gated SPECT MPI is useful for predicting a prognosis and stratifying the risk of MCEs in Japanese patients with known or suspected stable CAD with preserved LVEF.

P1481STRAIN REPOLARISATION ON ECG, NOT LEFT VENTRICULAR MASS, ASSOCIATES WITH CARDIOVASCULAR OUTCOMES IN A PROSPECTIVE COHORT OF HAEMODIALYSIS PATIENTS

Abstract Background and Aims Cardiovascular disease is common in chronic and end stage kidney disease. Left ventricular hypertrophy (LVH) has been identified as contributor to cardiovascular risk in this population. The aim of the study was to assess whether the combined use of electrocardiography and echocardiography in assessing LVH in a haemodialysis population can provide improved risk stratification. Method Prospective study of 192 prevalent maintenance haemodialysis ( HD) patients 12 lead ECGs were performed on a mid week non –dialysis day. Electrocardiographic strain was defined as a down slopping convex ST segment with inverted T waves in leads V5 and / or V6. Transthoracic echocardiographic was performed immediately after ECG .LV mass was indexed to body surface area (LVMIBSA). LVH was determined if LVMI &amp;gt;116g/m2 for male patients, and &amp;gt;100g/m2 for female patients. The primary study endpoint was major cardiac events (MACE). A secondary endpoint was all cause mortality. Results 192 patients included in the final analysis, 137 (71.4%) male.. The mean ejection fraction (EF) was 60.6± 11.1 % and the mean LVMI (BSA) was 115.0± 36.8 g/m2. During a mean follow up period of 2.4 ± 1.0 years, 50 patients reached a MACE end point and 62 patients died. On univariate Cox regression analysis, the factors associated with MACE were the presence of ECG strain (HR 2.961, CI: 1.254 – 6.990, p= 0.013)) URR (HR 0.968, CI: 0.942 – 0.994, p=0.015) and history of CAD (HR: 2.397 CI: 1.363 -4.2515, p= 0.002). In multivariate Cox regression analysis adjusting for baseline cardiovascular phenotype and dialysis parameters ECG strain remained significantly associated with MACE. Conclusion The presence of electrocardiographic strain increases the risk for MACE independently of LVH in haemodialysis patients. ECG strain has potential to be a simple bedside prognostic biomarker and even therapeutic target in haemodialysis patients.

Prediabetes and progression to diabetes among adult survivors of childhood cancer in the St. Jude Lifetime Cohort.

10548 Background: Cardiac death among survivors of childhood cancer occurs at &gt; 10 times the rate expected in the general population. Modifiable cardiovascular risk factors, including diabetes, increase risk for major cardiac events in a near multiplicative fashion. Thus, prevention of progression from prediabetes to diabetes could improve long-term cardiac morbidity and mortality. However, little is known about prediabetes in survivors. Methods: Prevalence of prediabetes (fasting glucose 100-125 mg/dL or HbA1c 5.7-6.4%) and diabetes were assessed in 3529 5+ year survivors ≥18 years of age and compared to 450 community controls stratified by age and matched for race/ethnicity, sex, and BMI using Chi-squared statistics. Logistic regression estimated risk factors for prediabetes and cox proportional hazards regression for progression from prediabetes to diabetes among survivors with multiple visits, reported as odds (OR) and hazard ratio (HR), respectively, with 95% confidence intervals (CI). Results: Among 3529 survivors (median age 30 years, range 18-65), the prevalence of prediabetes overall was 29.2% (95% CI 27.7-30.7) and diabetes was 6.5% (5.7-7.3). In each age strata, survivors had significantly higher prevalence of prediabetes and diabetes than controls with over 50% of middle-aged survivors (35-44 years) having prediabetes or diabetes (Table). In a multivariable model, therapy-related risk factors for prediabetes included high pancreatic tail dose (≥20 Gy: 2.9 [1.8-4.8]) and moderate prescribed cranial radiation dose (OR [95% CI] &gt; 0- &lt; 20 Gy: 1.4 [1.1-1.8], 20- &lt; 30 Gy: 1.4 [1.0-1.9]) independent of age, sex, race/ethnicity and BMI. Among 695 survivors with prediabetes and longitudinal follow-up, median 5.1 years, 68 (10%) progressed to diabetes. After adjustment for age, sex, race/ethnicity and BMI, risk of progression from prediabetes to diabetes was increased by the presence of insulin resistance (HR 4.9 [95% CI 2.3-10.6]) or prior treatment with hematopoietic cell transplant (HR 2.9 [1.1-7.7]) or total body irradiation (HR 4.6 [1.6-13.5]). Conclusions: Survivors of childhood cancer have a high prevalence of prediabetes and high rates of progression to diabetes. Strategies that prevent progression to diabetes should be considered to decrease diabetes risk and subsequent cardiac morbidity and mortality in this high-risk population. [Table: see text]

Comparative Study between Diabetic and non- Diabetic Patients Regarding Prevalence of Coronary Artery Disease and Plaque Composition by Multi-detector CT Coronary Angiography

Abstract Diabetes is known to be a major cardiovascular risk factor associated with significantly increased morbidity and mortality and particularly increased risk of major cardiac events especially myocardial infarction as a manifestation of highly incident coronary artery disease (CAD).This can lead to decreased life expectation and life quality. Major cause for myocardial infarction is plaque rupture. Prevalence of obstructive and non-obstructive plaques is increased in diabetic patients. Background and Objectives The prevalence of coronary heart disease in diabetic patients compared to non- diabetics and evaluating the composition of the plaque in diseased individuals in both groups by usage of multislice computed tomography (MSCT) angiography . Subjects and Methods A total of 80 consecutive MSCT angiography examinations were performed between August 2017 and June 2018. Of these, the patients were evaluated for the presence and type of atherosclerotic plaque and severity of luminal narrowing. Results Eighty (40 in the diabetic group and 40 in the non-diabetic group) patients underwent MSCT angiography with DM prevalence of 0.212 (95% Cl for AOR 0.056 -1.896). Among them, 20 patients (50 %) in the diabetic group and 14 patients (35 %) in the non-diabetic group had +ve coronary heart disease, 33.3 % had significant and moderately significant coronary narrowing on diabetic group and 31.3 % in non-diabetic group on MSCT angiography. Diabetic patients had more soft plaque compared with non-diabetic patients. Conclusion DM is not an independent factor for the disease occurrence in coronary artery disease but is a dependent factor in the association of other risk factors such as smoking ,hypertension and dyslipidemia.

Prognostic value of the myocardial salvage index measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging after ST-segment elevation myocardial infarction: A systematic review and meta-regression analysis.

In all patients with ST-segment elevation myocardial infarction, risk stratification should be performed before discharge. The measurement of therapy efficiency with magnetic resonance imaging has been proposed as part of the risk assessment, but it has not been adopted widely. This meta-analysis was conducted to summarize published data on the prognostic value of the proportion of salvaged myocardium inside previously ischemic myocardium (myocardial salvage index) measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging after ST-segment elevation myocardial infarction. Random and mixed effects models were used for analyzing the data of 10 studies with 2,697 patients. The pooled myocardial salvage index, calculated as the proportion of non-necrotic myocardium inside edematous myocardium measured by T2-weighted and T1-weighted late gadolinium enhancement MRI, was 43.0% (95% confidence interval: 37.4, 48.6). The pooled length of follow-up was 12.3 months (95% confidence interval: 7.0, 17.6). The pooled incidence of major cardiac events during follow-up, defined as cardiac death, nonfatal myocardial infarction, or admission for heart failure, was 10.6% (95% confidence interval: 5.7, 15.5). The applied mixed effects model showed an absolute decrease of 1.7% in the incidence of major cardiac events during follow-up (95% confidence interval: 1.6, 1.9) with every 1% of increase in the myocardial salvage index. The heterogeneity between studies was considerable (τ = 21.3). Analysis of aggregated follow-up data after ST-segment elevation myocardial infarction suggests that the myocardial salvage index measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging provides prognostic information on the risk of major cardiac events, but considerable heterogeneity exists between studies.

508 Puerperal thrombosis on mitral valve prothesis

Abstract Introduction Replacement of a diseased heart valve with a prosthetic heart valve exchanges the native disease for prosthesis-related complications. Valve thrombosis can occur in mechanical prosthetic valves. The significant morbidity and mortality associated with this condition permits rapid diagnostic evaluation. A combination of transthoracic and transoesophageal echocardiography (TEE) is required to assess the haemodynamic effect of thrombosis, leaflet motion and thrombus size. Mechanical valves offer excellent haemodynamic performance and long-term durability, but the need for anticoagulation increases maternal and foetal mortality and morbidity, and the risk of major cardiac events during pregnancy. Case report A 23-year-old gravida 0 woman was admitted to the emergency obstetric care. At the age of 18 months, she underwent valve replacement surgery in the mitral position (St. Jude Medical Standard size 25mm), this requires use of warfarin after surgery. Although she was advised otherwise; the patient became pregnant. She had an increased risk of maternal cardiovascular complications [Modified World Health Organization classification (mWHO) III] and obstetrics complications. The warfarin treatment was discontinued, and it was started low molecular weight heparin (LMWH) 100IU, twice daily subcutaneously, on gestation 36 week. The last administration was 2 days before the admission (&amp;gt;48h before delivery). So, on gestation week 39, she was admitted to the department of Obstetrics. Then, as cardiotocography showed decreased foetal heart rate, an emergency caesarean section was performed. A healthy baby was delivered. After delivery, we perform an immediate two-dimensional transthoracic echocardiography (2D TTE), as there was a high-risk of valve thrombosis, and it showed an apparent normal prosthetic excursion but a high mean pressure gradient (25mmHg) – elevated transprosthetic gradient. It was not well visualized the occlude motion of the mechanical valve by 2D TTE, so we perform a TEE to answer the clinical question, if there was a dysfunction due to an acute process (i.e. thrombus). It revealed an obstruction – reduced mobility of one disc and elevated velocities by CW doppler (30mmHg), and a presence of thrombus (1.3X0.8mm). The anticoagulation with intravenous UFH was started immediately, but anticoagulation failed, and she underwent valve replacement surgery (St. Jude Medical standard size 27mm. Conclusion Our patient had a very-high risk of complications maternal cardiovascular complications - WHO risk classification III - because the risk of valve thrombosis is markedly increased during pregnancy. The risk is lower with adequate dosing of anticoagulant therapy, but our patient was not which increased the risk of thrombosis. Finally, it is important to notice that it is recommended to manage pregnancy in women with mechanical valves in a centre with a pregnancy heart team. Abstract 508 Figure. Valve thrombosis