Society Of Cardiology Guidelines Research Articles

Abstract 4137423: Can Machine Learning Help Prioritise Who to Screen for Elevated Lipoprotein(a) (Lp[a]) in the General Population vs a Screen all Approach? An Analysis from UK Biobank

Background: Elevated lipoprotein(a) [Lp(a)] is an inherited, currently non-modifiable risk marker that increases lifetime ASCVD risk. Guidance vary on Lp(a) levels at which risk increases; hence prevalence of “elevated” Lp(a) depends on putative thresholds e.g. >1.3 billion people globally have Lp(a)≥125 nmol/L. Lp(a) levels are >90% genetically determined and stable throughout life; hence measurement once in adulthood is recommended. Awareness of Lp(a) levels may change patient management with more intensive control of traditional risk factors. However, testing all adults is costly and the test is not universally available. Research Question: Can Machine Learning (ML) models reduce the number needed to screen (NNS) compared to population universal screening for identifying individuals with elevated Lp(a)? Aims&Objectives: To derive a model from ML to help prioritise individuals likely to have high levels for Lp(a) testing and compare its yield to universal screening at different Lp(a) cut-points. This approach could enable automatic screening of large databases like EHRs for Lp(a) testing. Method: We conducted a cross-sectional predictive analysis using UK Biobank, including individuals ≥40 years old with Lp(a) measurements, split into feature importance, derivation, and validation datasets. Eight ML classification algorithms were used for feature importance analysis and model derivation. Models' performance was evaluated in the validation set using sensitivity and NNS in comparison with the discrimination ability of the following guidelines across different populations: The 2019’s Heart UK and European Atherosclerosis Society (EAS) and Society of Cardiology guidelines, the 2022 EAS Consensus Statement, and threshold used in clinical trial —respective cut-offs: 90,430,125,200nmol/L. Results: 438,579 patients were included. The best ML models were neural networks with different weights. Regardless of the Lp(a) threshold used, ML models resulted in higher rates of high Lp(a) cases identified per million tests with lower NNS compared to universal screening (Table 1). Using higher Lp(a) thresholds (200-430nmol/L) increased models sensitivity with far fewer tests required to identify those with high Lp(a). Conclusion: ML models could reduce the number of tests needed to identify individuals with high Lp(a), increasing efficiency and potentially helping to prioritize Lp(a) testing, with a potentially scalable cost-effective option for health systems. Work supported by Novartis

Hypertension in the Polish elderly: Insights into prevalence, awareness, treatment, and control from the NOMED-AF study.

Hypertension is a significant global health issue, disproportionately affecting the elderly population. In Poland, the rapid aging of the population underscores the need for updating data on the epidemiology of hypertension in the elderly. This study aimed to investigate the prevalence, awareness, treatment, and control of hypertension among individuals aged 65 and older in Poland. The NOMED-AF study, a cross-sectional survey conducted from March 2017 to March 2018, enrolled a representative sample of 3014 participants aged 65 and over, using a multistage, stratified, and clustered sampling method. Data collection included standardized questionnaires and physical measurements carried out by trained nurses. Hypertension was diagnosed per the 2018 European Society of Hypertension/European Society of Cardiology guidelines. The study showed a hypertension prevalence of 82.5% in females and 78.3% in males aged 65 and older. Awareness of hypertension was high across all age and sex groups, with 86.2% of women and 83.4% of men being aware of their condition. Treatment rates were 84.8% in women and 80.5% in men. Optimal control of blood pressure among those treated was achieved in 40.3% of women and 45.6% of men. Women over 80 achieved optimal blood pressure control less frequently than men. The results highlight the high prevalence and suboptimal control of hypertension in Poland's elderly population, pointing to a significant public health challenge. Despite high rates of treatment, management of hypertension remains inadequate, which emphasizes the need for enhanced strategies in hypertension care, particularly for elderly women.

Evaluation of Cardiovascular Pharmacotherapy Guideline Adherence and Risk Factor Control in Portuguese Community Pharmacy Patients.

Background: Cardiovascular disease (CVD) remains the leading cause of death worldwide. Assessing the patients’ CVD risk, controlling the risk factors, and ensuring the guideline-adherent cardiovascular pharmacotherapy are crucial interventions to improve health outcomes. This study aimed to evaluate the potential of pharmacists to improve the adherence to pharmacotherapy guidelines and the achievement of risk factor goals among patients who attended a community pharmacy. Methods: We conducted a single-center cross-sectional study. We performed in-pharmacy point-of-care testing, blood pressure and anthropometric measurements, and reviewed patients’ pharmacotherapy, based on European Society of Cardiology guidelines. Results: Of the 333 patients, 63.1% were in the high/very high risk category, 91.9% showed at least two modifiable risk factors, and in 61.9% of patients the cardiovascular pharmacotherapy was non-adherent to the current guidelines, failing to reach treatment goals. The lipid-lowering therapy was the least guideline adherent, with a suboptimal use of statins. However, we found no statistically significant difference between the guideline-adherent and the non-adherent group in terms of risk factor control. The pharmacist recommended 603 interventions to adhere to the guidelines. Conclusions: Community pharmacists are able to identify opportunities to optimize cardiovascular pharmacotherapy and support the patients to achieve cardiovascular risk factor goals, based on evidence-based guidelines, contributing to the improvement of CVD management.

External validation study of the 2014 European Society of Cardiology Guidelines in relation to 2020 ACC/AHA guidelines on sudden cardiac death prevention in hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Strategies for reliable selection of high-risk hypertrophic cardiomyopathy (HCM) patients for prevention of sudden cardiac death (SCD) with implantable cardioverter-defibrillators (ICDs) are still debated. Purpose Assess the sensitivity of sudden death risk strategies (2014 ESC SCD 5-year risk score and 2020 ACC/AHA risk factor strategy) in predicting lethal arrhythmic events (LAE), appropriate ICD shocks, SCD or out of hospital cardiac arrest among a cohort of HCM patients Methods Sixty-five patients (42±17 y) with a clinical diagnosis of HCM were enrolled in our institution from 1990 to 2021. Among them, 28 patients (43%) underwent a genetic test and a pathogenic/likely pathogenic sarcomeric variant was detected in 23 cases (82%). Patients were managed according to the best available treatment strategy for HCM in the different clinical eras. Results Of the 65 patients, 28 cases (43%) received an ICD, including 23 for primary and 5 for secondary prevention. During a follow-up period of 15 years (median, 15 [6, 21], range 1 to 33 years, 1014 patients/year), a total of 10 LAE were observed (0.98%/year). According to ESC SCD 5-year Risk Score, 7 (10%) were at high risk, 14 (22%) at intermediate to high risk, and 44 (68%) at low risk. Median SCD 5-year risk score of 3.5% ± 2.1. ACC/AHA risk factors categorized patients as 35 (54%) at high risk, 24 (37%) at intermediate to high risk, and 6 (9%) at low risk. A total of 4 (2.8%) patients experiencing SCD events were misclassified as low-risk patients by the ESC SCD Risk Score, whereas none by the ACC/AHA model. Of the 7 patients categorized as high risk by the ESC SCD Risk Score, 2 (29%) experienced a LAE, whereas of the 35 patients at high risk by the ACC/AHA, 9 (26%) suffered a LAE. No difference in the area under the curve was showed for the 2020 ACC/AHA SCD risk stratification strategies with respect to 2014 ESC SCD 5-year-risk score (0.72; 95% CI 0.60–0.83, 0.66; 95% CI 0.49–0.84, p =0.55). Conclusions In this HCM cohort followed up over an extended period of more than 15 years, LAE remained relatively low (0.98%/year). SCD risk stratification recommended by the 2014 ESC SCD 5 year risk score did not showed a better discrimination than that of 2020 ACC/AHA stratifications, despite the latter proved to be more sensible in the identification of the low risk patients. More than half of our cohort was classified with a recommendation by the 2020 ACC/AHA for an ICD implantation. A larger multicenter, independent, and prospective study with long-term follow-up is warranted to better elucidate these results.

Outcome of ST-segment elevation myocardial infarction (STEMI) patients with significant non-infarct related artery (IRA) lesions

Abstract Funding Acknowledgements Type of funding sources: None. Background Multivessel disease is common (50%) in patients presenting with ST-segment elevation myocardial infarction (STEMI), and this is associated with a higher mortality compared to single-vessel disease. The optimal timing for revascularisation of significant non-infarct related artery (IRA) (non-culprit) lesions in STEMI patients remains controversial. The two main approaches include immediate revascularisation during the primary percutaneous coronary intervention (PPCI) or deferred (48 hours after the index procedure) percutaneous coronary intervention (PCI). The European Society of Cardiology guidelines recommend consideration of immediate non-IRA PCI in STEMI patients with cardiogenic shock, while revascularisation of other patients with non-IRA significant lesions should be considered prior to hospital discharge. Purpose To determine the optimal timing of intervention of significant non-IRA lesions in patients presenting with STEMI. Methods Coronary angiograms of nationwide STEMI patients who underwent a PPCI between 2013 and 2017 were reviewed to determine whether a significant non-IRA lesion was present (defined as >70% stenosis, or >50% of left main stem). The patients were divided into Group 1: immediate PCI of the non-IRA lesion during the PPCI, and Group 2: deferred PCI of non-IRA lesion prior to hospital discharge. Patients were followed up till end 2020 to determine whether a major adverse cardiovascular event occurred (death, myocardial infarction [MI], hospitalization due to pulmonary oedema and revascularization with repeat PCI and coronary artery bypass [CABG]). Chi-square and Fisher’s exact test were used for statistical analysis. Results 1080 patients underwent a PPCI between 2013 and 2017. 578 patients were excluded as they had no bystander disease, and a further 340 were excluded as they underwent CABG or medical treatment for the non-IRA lesions. From the remaining cohort, 55 patients were stratified to group 1 and 107 patients in group 2. There were no significant differences in baseline characteristics (Picture 1). Picture 2 demonstrates the distribution of non-IRAs which required PCI. Patients who had immediate non-IRA lesion PCI had a significantly higher mortality (Group 1, 21.8% vs Group 2, 8.4%, p=0.016) and more admissions with pulmonary oedema (Group 1, 10.9% vs Group 2, 0.9%, p=0.006). Group 1 patients were found to have a higher occurrence of cardiac arrest during the PPCI (10.9% vs 0.9%, p=0.006) and cardiogenic shock (12.7% vs 3.7%, p=0.046). There were no differences with regards to angina (p=0.386), MI (p=0.426) or re-vascularisation with repeat PCI (p= 0.090) or CABG (p=0.114). Conclusion STEMI patients who underwent immediate PCI to non-IRA lesions had a poorer outcome with higher rates of mortality and pulmonary oedema admissions compared to the deferred PCI cohort. Large randomised controlled trials are required to determine the optimal timing for intervention of significant non-IRA lesions.

P239 Are patients with acute pericardial syndromes adequately screened for connective tissue diseases? Results from a single-centre study and comparison to European Society of Cardiology Guidelines

Abstract Background/Aims Pericardial syndromes (PS) comprising pericarditis, pericardial effusions, cardiac tamponade, and constrictive pericarditis, can be presenting features of connective tissue disease (CTD) including lupus (SLE) and rheumatoid arthritis (RA). PS comprise 0.1% of all hospital admissions and 5% of acute non-cardiac chest pain. PS occur as single episodes but recur in 30% of patients within 18 months after the first episode. The 2015 European Society of Cardiology (ESC) pericardial disease guidelines recommend assessment of NSAID response with follow-up and tests in those who are NSAID non-responders or who have recurrent PS. We audited the management of patients presenting with PS in a tertiary referral centre, using the 2015 ESC guideline standards to determine if investigations to uncover autoimmune diseases as a cause of PS were performed. Methods We obtained data on all patients coded with PS presenting to St George’s Hospital Emergency Department between Jan 1st, 2019, and October 31st, 2020. We also searched data including patients’ length of stay, test results including blood tests, imaging (X-ray, ultrasound, CT and MRI), initial management, outpatient follow-up, recurrence numbers and identifiable cause. Data were compared to the 2015 ESC guidelines. Results We identified 132 PS cases, of which 37 (28%) had recurrent pericardial disease. Of these, 15 (41%) were screened for connective tissue disease with antinuclear antibody (ANA) testing. Of those tested, nine (60%) had a positive ANA (titre 1/80 or greater), with three (33%) positive for extractable nuclear antigens (anti-Ro, anti-Sm and anti-RNP). Only 14 patients (38%) with recurrent disease had rheumatoid factor (RhF) tested, with four of these (29%) positive, while one of eight (12.5%) patients tested was anti-CCP antibody positive. Only 13 of 37 recurrent cases (35%) had both ANA and RhF tested. Furthermore, 37 of all PS cases (28%) were not followed up after initial presentation, while only five (14%) of recurrent cases received any follow up. By contrast, presumed infection tested serologically was found in only 7.8% of all cases tested, most commonly Mycoplasma or raised ASOT. Conclusion A high proportion of recurrent PS patients screened in our study had a positive ANA, ENA or RhF suggesting screening can identify new potential CTD, including SLE or RA. These patients require different treatment strategies to infectious PS. We demonstrated screening was inconsistent despite the absence of obvious infective causes in most cases and limited to 41% of patients with recurrent disease, which present the highest risk of association with CTD. ESC guidelines recommend all patients be followed up after 1 week, yet few high-risk patients received any outpatient review, from any speciality. There is a pressing need to ensure potential cases of CTD presenting as PS are not missed as doing so may prolong symptoms and worsen outcome. Disclosure D. Srikantharajah: None. V. Joseph: None. A. Kaul: None.

Evaluating sacubitril/valsartan as a treatment option for heart failure with reduced ejection fraction and preserved ejection fraction

ABSTRACT Introduction Sacubitril/valsartan is the first-in-class angiotensin-receptor neprilysin inhibitor approved in 2015 for the treatment of heart failure with reduced ejection fraction (HFrEF). On 16 February 2021, the Food and Drug Administration acknowledged that “Benefits are most clearly evident in patients with left ventricular ejection fraction below normal,” thus potentially extending the use in subjects with heart failure and preserved ejection fraction (HFpEF). Areas covered The authors outline the regulatory history, pharmacokinetics, pharmacodynamics, and risk-benefit profile of sacubitril/valsartan in HFrEF and HFpEF. A critical cross-trial comparison is presented, including sodium-glucose cotransporter 2 inhibitors (SGLT2i), together with an insight into the latest European Society of Cardiology guidelines, where the new category of heart failure with mildly reduced ejection fraction is introduced. Expert opinion Sacubitril/valsartan is a foundation of the pharmacological armamentarium in HFrEF to counteract the neuro-hormonal changes and reverse cardiac remodeling, together with beta-blockers, SGLT2i and mineralocorticoid receptor antagonists. The optimal sequence algorithm is an evolving issue, and the authors provide the reader with their personal perspective. A multidisciplinary management is encouraged to minimize the therapeutic inertia and manage tolerability issues, thus supporting adherence. Pragmatic trials, pharmacovigilance, and high-quality real-world evidence are crucial toward personalized safe prescribing of sacubitril/valsartan.

Acceptance and safety of femoral versus radial access for percutaneous coronary intervention (PCI): results from a large monitor-controlled German registry (QuIK)

BackgroundIn 2015 and 2018, European Society of Cardiology guidelines for percutaneous coronary intervention (PCI) favoring radial access over femoral access were published. These recommendations were based on randomized trials suggesting that patients treated radially experienced reduced bleeding complications and all-cause mortality. We aimed to assess acceptance and results of radial access in a real-world scenario by analyzing all PCI cases in the Quality Assurance in Invasive Cardiology (QuIK) registry.MethodsThe QuIK registry prospectively collects data on all diagnostic and interventional coronary procedures from 148 private practice cardiology centers in Germany. Major adverse cardiac and cerebrovascular events (MACE) were defined as myocardial infarction, stroke, or death during hospitalization.ResultsFrom 2012 to 2018, 189,917 patients underwent PCI via either access method. The rate of radial approach steadily increased from 13 to 49%. The groups did not differ significantly with respect to age or extent of coronary disease. Femoral approach was significantly more common in patients with ST elevation myocardial infarction and cardiogenic shock. Overall, there were significant differences in MACE (radial 0.12%; femoral 0.24%; p < 0.0009) and access site complications (radial 0.2%; femoral 0.8% (p < 0.0009).ConclusionOur data reveals an increase in use of radial access in recent years in Germany. The radial approach emerged as favorable regarding MACE in non-myocardial infarction patients, as well as favorable regarding access site complication regardless of indication for percutaneous intervention.

691. Infective Endocarditis with an Indication for Cardiac Surgery in a Tertiary Care Educational Hospital: Does Cardiac Surgery Improve Outcomes?

BackgroundIn this retrospective cohort study, it was aimed to compare the clinical characteristics and outcomes of IE cases without and with an indication for cardiac surgery in terms of whether they have been operated or not, in a tertiary-care educational hospital. MethodsPatients that were followed up for definite IE (diagnosed according to modified Duke criteria between March 2007 and November 2020) with an indication for cardiac surgery according to European Society of Cardiology Guidelines, comprised the study group. Subjects were evaluated in terms of whether these cases have been operated or not, demographic features, underlying diseases, risk factors, clinical and laboratory findings, therapy responses, complications, and mortality. The timing of surgery is defined as emergency; surgery performed within 24 hours, urgent; within a few days, elective; after at least one-two weeks of antibiotic therapy. Statistical analysis was performed via Chi square and Student T tests and a p value < 0.05 was considered significant.ResultsA total of 90 patients with an indication for surgery, 33.3% patients in underwent surgery, 66.6% patients in not underwent surgery group fulfilled the study criteria. The most frequently seen complaints in patients were fever (91.1%), cold-shiver (56.6%), weight-loss (27.7%), dyspnea (25.5%), and tachycardia (20%). Heart murmur was detected during cardiac auscultation of 44 patients. Mean blood leukocyte count, C-reactive protein and erythrocyte sedimentation rate were 12324 ± 6558/mm3 (1408-30330), 11.46 ± 8.38 mg/dl (0.18-34.6) and 61.43 ± 33.4 mm/h (2-130), respectively. There was no significant difference between two groups in terms of cardiac/non-cardiac risk factors, age, gender, etiologic agents, laboratory findings, septic embolisms and complaints (Table 1). In total IE with an indication for surgery mortality was 27.7%. Mortality rate was significantly less and heart murmur was significantly higher in cases who underwent surgery than those did not undergo surgery (p: 0.0447). Table 1. Comparison of basic characteristics of patients in the two operated / unoperated cohorts. ConclusionThese data support the importance of the guidelines’ criteria for cardiac surgery in the management of IE. Assuming that only 1/3 of the surgery needing cases received surgery, more interventions are needed to decrease the barriers against surgery. Disclosures All Authors: No reported disclosures

Abstract 9715: Feasibility of Using Machine Learning to Establish a Risk Prediction Model for Sudden Cardiac Death in Patients with Hypertrophic Cardiomyopathy

Introduction: Risk stratification for sudden cardiac death (SCD) is a great challenge in managing hypertrophic cardiomyopathy (HCM). Hypothesis: This study attempted for the first time to build a machine learning (ML) model for SCD risk prediction. Methods: The present study consisted of 1631 consecutive adult HCM patients without a history of SCD events. Extreme gradient boosting (XGBoost) was applied for ML model construction. We compared the predictive performance of the ML model with that of conventional models by calculating C-statistics and interpreted the ML model output using the SHapley Additive exPlanation (SHAP) value. Results: Fifty patients reached SCD endpoints during a median follow-up of 4.6 years. The C-statistic of the ML model was 0.745 [95% confidence interval (CI), 0.723-0.766], which was significantly higher than that of the model recommended in the 2014 European Society of Cardiology guidelines (C-statistics =0.609; 95% CI 0.585-0.623) and the model recommended in the 2020 American College of Cardiology/American Heart Association guidelines (C-statistics =0.628; 95% CI 0.604-0.652). The ML model incorporated 12 features as predictors, including 5 conventional SCD risk markers (NSVT, quantification of LGE, family history of SCD, LVEF 50%, unexplained syncope), WBC, creatine, uric acid, TBIL and cholesterol, NT-proBNP and family history of HCM. Using SHAP values, we quantified the contribution of each feature within the ML model to the final prediction and visualized the relationship between features and SCD risk. Conclusion: Our study constructed an ML model for the prediction of SCD risk in patients with HCM and provided a clinically intuitive interpretation. The ML model showed better discrimination performance than conventional models, demonstrating the feasibility of ML in SCD risk prediction for patients with HCM.

Optimal management of patients with ST-segment elevation myocardial infarction with delayed admission to the percutaneous coronary intervention center (more than 12 hours)

The success of myocardial infarction (MI) treatment largely depends on the timely delivery of quality health care, primarily on the blood flow restoration through the infarct-related artery. This review presents the results of several meta-analyzes and studies, including our own data, which indicate that delayed revascularization (&gt;12 h from the onset) performed in patients with ST-segment elevation MI leads to an increase in the short- and long-term survival, a decrease in the incidence of cardiovascular events and severity of myocardial remodeling. For example, the analysis from the V. P. Polyakov Samara Regional Clinical Cardiological Dispensary showed the higher mortality rate in patients with ST-segment elevation MI admitted &gt;12 hours from the onset, who received conservative treatment (7,9%) than in those with the invasive management (0,5%) (hazard ratio, 14,8; 95% confidence interval, 1,7- 124,7; P&lt;0,05). However, at present, there is no complete clarity regarding the strategy of managing such patients. According to the current European Society of Cardiology guidelines on myocardial revascularization (2018), the class of recommendations reaches IIA, which means the conflicting data and/ or disagreement about usefulness/efficacy of a particular treatment method, but weight of evidence/opinion is in favor of usefulness/efficacy.

Characterization and quality of care indicators in patients with acute myocardial infarction without ST segment elevation

Abstract Introduction The definition of the quality of care in healthcare services is paramount to implement the resources necessary to grant the best quality of care according to the current guidelines. Recently, the European Society of Cardiology's guidelines for the management of acute coronary syndromes without ST segment elevation (NSTEMI) were published, and defined the quality indicators to be evaluated in such patients. Purpose To characterize the level of care given to the population of patients with NSTEMI included in the a national registry since 2011, according to the new guidelines directives. Population and methods We evaluated 12193 patients with NSTEMI. For each year the following variables were analyzed: age, gender, cardiovascular and non-cardiovascular comorbidities, clinical presentation (rhythm, blood pressure, Killip-Kimball Class), left ventricular ejection fraction (LVEF), treatment during admission and discharge, and time to invasive coronary angiography (ICA). Besides this, a comparing between years was made to analyze differences according to the quality indicators established in the guidelines. Results In 2019, 83.9% of patient with LVEF &amp;lt;40% were treated with IECA/ARA II and 80.6% were prescribed a betablocker at discharge. No statistically significant differences were found across the year with respect to IECA/ARA II at discharge (p=0.495), and beta-blocker at discharge (p=0.812). In terms of P2Y12 inhibitors during the hospital admission, there was a statistically significant increase in its use when comparing 2019 to 2014, 2015, 2016 and 2017 (p=0.019 for 2014 and p&amp;lt;0,001 the following years), with prescription in 90.4% of the patients in 2019. At discharge 88.3% of the patients were prescribed a P2Y12 inhibitor in 2019 and there was also a statistically significant increase in its prescription when compared to the previous years (from 2011 to 2017 with a p&amp;lt;0.001). When it comes to the prescription of statins at discharge there was a statistically significant difference between groups, driven mostly by an increase compared to the year 2012 (95.6% vs 90.8%, p=0.005). Only 16% of patients were subjected to ICA within 24h of admission during the year 2019. No statistically significant difference was found between other years (p&amp;gt;0.100 when comparing between years). Discussion The most striking feature that can be improved is the amount of patients subject to ICA within the first 24h after diagnosis. When it comes to the P2Y12 inhibitors it is also clear that there has been an increase in its prescription during the admission and at discharge. To sum up, it is clear that there is still some margin to improve care, of at least 10–20% in most parameters. This data portrays a picture of the measures and steps to take in order to provide the adequate care according to the latest guidelines. Funding Acknowledgement Type of funding sources: None.

Immediate implementation of three 2019 European Society of Cardiology guidelines in daily practice

Abstract Background The prognosis of patients depends on their cardiovascular risk. In the 2019 ESC guidelines [I, II, III] new health targets were defined. The manifestation of cardiovascular disease, diabetes mellitus and its complications and renal function had to be considered. This is a real challenge in daily practice. Purpose Could the five modifiable health targets blood pressure, hbA1c, LDL, weight loss and smoking cessation be changed in primary and secondary prevention immediately after the release of the 2019 ESC guidelines in a prospective observational trial in primary care? Methods Patients from 40 to 75 years of age were identified from 03 SEP to 02 DEC 2019 and followed up three to six months later, until 02 JUN 2020. The CV-risk was calculated. For the informed patient, the best evident therapy was recommended and best support, including lifestyle and diabetes counselling and sport programs provided, as needed. With diabetics, achievements were discussed with the German diabetes pass. Results 303 patients were identified as 63.7% males, 74.9% diabetics, 69.3% impaired renal function, 64.7% in primary prevention. The calculated CV-risk was higher in the elderly (74.2% were ≥60 years of age). 78.2% had a high or very high CV risk. Renal function declined with ageing (Table 1). Blood pressure and HbA1c values remain stable. LDL values, below 100 mg/dl at start, were reduced in all CV-risk groups after 3–6 months. One third (33.6% of n=217) reached their LDL target. In secondary prophylaxis the LDL value was reduced above 10 mg/dl and 29% of n=72 reduced LDL value below 55 mg/dl. In the highest CV-risk group 22.6% dropped LDL &amp;lt;55 mg/dl. The number of reached health targets raised from 2.1 to 2.5 during the observation. At least 36% of patients reached more health targets (Table 2). Conclusions It is difficult to reach LDL targets in Europe documented in an ESC/EAS Survey [IV]. In the START Registry [V] only 3.2% of the very high-risk patients reached LDL values below 55 mg/dl. The proportion of patients with very high-risk that reached an LDL value below 55 mg/dl could nearly be doubled in this observation. But many patients do still not reach at least three of five health targets and nearly two thirds should lower their LDL value further especially in secondary prophylaxis. Disease management programs should be empowered to ask for reached health goals. New therapeutic options are available as PCSK-9 inhibitors, small interfering RNA molecules (inclisiran), ATP-Citrat-Lyase inhibitors (bempedoinic acid) to reduce LDL values in addition to statins or without. Antisense oligonucleotides (pelacarsen) can change prognosis for patients with very high liporotein(a) values. Abbreviations: CV, cardiovascular; CKD, chronic kidney disease; CHD, coronary heart disease; PAD, peripheral artery disease; TIA, transient ischemic attack; ICA, internal carotid artery; UNK, unknown. Funding Acknowledgement Type of funding sources: None. Table 1. Observed populationTable 2. Reached health targets

Polygraphy as a new screening method for obstructive sleep apnea in patients with atrial fibrillation?

Abstract Background Obstructive sleep apnea (OSA) is a modifiable risk factor of atrial fibrillation (AF) but is underdiagnosed in these patients. According to the 2020 European Society of Cardiology guidelines for the diagnosis and management of AF, it seems reasonable to test for OSA in symptomatic AF patients before initiation of rhythm control therapy. A good OSA screening pathway is lacking in the guidelines and in daily clinical practice in most centers today. Polysomnography (PSG) is the gold standard for diagnosing OSA but it is not an ideal screening method, due to its expensiveness, labour-intensiveness and limited availability. Purpose The aim of this study was to validate and examine the performance of different (cardiorespiratory) polygraphy (PG) devices, used with their automated algorithm to detect OSA in an AF cohort, compared with PSG as gold standard. Methods Prospective study with three PGs (ApneaLink Air (ALA), SOMNOtouch RESP (STR) and SpiderSAS (SpS) combined with ResMed Airview-, SomnoMedics DOMINO- and Microport SYNESCOPE software respectively) in consecutive AF patients who were referred for a PSG evaluation. Patients received the three devices with instructions for use after their PSG and were requested to use each one during three consecutive nights at home. Severity of OSA was classified according to the Apnea-Hypopnea Index (AHI) with &amp;lt;5 events/hour= no OSA, 5–14= mild-, 15–30= moderate-, &amp;gt;30= severe OSA. Results A total of 100 AF patients presenting for PSG were included (64.0±8.6 years, 73% male, 87% non-permanent AF, mean Body Mass Index 30.6±5.9 kg/m2, mean CHA2DS2-VASc score 2.4±1.7, mEHRA≥2 in 64%; mean AF history 5.4±5.6 years). PSG diagnosed ≥mild OSA in 90% of patients, ≥moderate in 69%, and severe OSA in 33%. Successful PG execution to determine the AHI, i.e. ≥4 hours of data on automated analysis, was obtained in 72.0%, 73.0% and 79.0% of patients with the ALA, STR and SpS respectively. In screening for clinically relevant OSA (i.e. at least moderate OSA), the PGs had an area under the curve of 0.802, 0.761 and 0.803 for the ALA, STR and SpS respectively (Figure 1). Conclusions This first analysis shows that PGs combined with an automated algorithm for AHI determination, can be used as OSA screening tools in AF patients before referral for PSG. Further optimisation is likely by choosing an appropriate AHI cut-off value for each PG. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This study is supported by the Antwerp University Cardiology Research Fund, and is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Figure 1

The effect of P2Y12 inhibitor pretreatment vs. no pretreatment on ischemic outcomes among patients with NSTE-ACS: an updated meta-analysis and meta-regression pooling 106,405 patients from 12 studies

Abstract Background Recent European Society of Cardiology guidelines for the management of non-ST elevation acute coronary syndromes (NSTE-ACS) do not recommend routine pretreatment with P2Y12 inhibitors in patients in whom coronary anatomy is not known and an early invasive management is planned. Purpose To determine if updated pooled data is in line with the latest recommendations, we investigated the impact of P2Y12 pretreatment on short-term ischemic outcomes among patients with NSTE-ACS. Methods MEDLINE and EMBASE databases were systematically searched to find interventional or observational studies that investigated the use of P2Y12 inhibitors as a pretreatment vs. no pretreatment in patients presenting with NSTE-ACS. Studies that reported short-term outcomes during hospitalization or up to 30 days were included. The primary outcome was a composite of ischemic events consisting of death, myocardial infarction, stroke, and unplanned revascularization. Random-effects meta-analysis was performed with prespecified subgroup analyses concerning more potent P2Y12 inhibitor use and drug-eluting stent (DES) uptake &amp;gt;50%. For the primary analysis, the odds ratio (OR) with 95% confidence intervals (95% CI) were reported. Heterogeneity across studies was inspected by I2 statistic. Meta-regression assessed the potential interaction of variables including percutaneous coronary intervention (PCI) receipt, NSTE-ACS subtype, DES uptake &amp;gt;50%, and potent P2Y12 inhibitor use with the primary outcome. Results Twelve studies were included (6 RCTs, 5 registry-based studies, and 1 prespecified analysis of an RCT) providing a total of 106,405 patients with pooled 4,076 ischemic events (2,775 in the pretreatment and 1,301 in a no-pretreatment group). Most of the studies were older than 10 years and used clopidogrel as a pretreatment while the average rate of PCI receipt was 79%. Low-to-moderate heterogeneity was detected among studies. Although pretreatment with P2Y12 inhibitors reduced the likelihood of short-term ischemic events across all studies included, in contemporary NSTE-ACS cohorts with high penetration of DES platforms and agents more potent than clopidogrel, this effect was not sustained (OR 0.905, 95% CI 0.741–1.107 – Figure 1 and OR 0.846, 95% CI 0.645–1.109 – Figure 2). Of all variables, the use of potent P2Y12 inhibitors was independently associated with a reduction of the primary outcome in meta-regression analysis (coefficient −0.879, 95% CI −1.316 to −0.442, P&amp;lt;0.0001). Conclusions Our pooled 2021 data reinforces the current evidence as early P2Y12 pretreatment was not associated with significant short-term ischemic benefits in contemporary NSTE-ACS cohorts while the use of potent P2Y12 agents independently interacted with the primary outcome. Finally, factors such as receipt of early PCI, use of modern DES platforms, and more potent antiplatelet inhibition administered periprocedurally will likely obviate the need for pretreatment in this population. Funding Acknowledgement Type of funding sources: None. Figure 1. Ischemic events and DES useFigure 2. Ischemic events and P2Y12 type

Predictors of mortality in patients with intermediate risk pulmonary embolism

Abstract Introduction Information about treatment and outcome of patients with pulmonary embolism (PE) intermediate risk remains limited. Little is known about the benefits of reperfusion therapy in patients with intermediate risk PE and evidence of right ventricular dysfunction. Objective To evaluate clinical outcomes and predictors of mortality in patients admitted to ICU with pulmonary embolism and intermediate risk. Methods In a prospective single-center study 103 normotensive patients with an established diagnosis of pulmonary embolism confirmed by pulmonary CT were included. All patients met intermediate risk criteria according to the European Society of Cardiology guidelines (ESC 2019) for pulmonary embolism using severity index [PESI] with signs of right ventricular dysfunction and elevated cardiac biomarkers. The average age of patients was 67.6 years (95% CI, 65.1–70.5), 42 (41%) of them were men. Thrombolysis with standard dose of alteplase was performed in 54 (52%) patients. CT scan and echocardiography were done for all patients. Results Outcome data were collected for all patients through the 30-day and 180-day follow-up. During 30 days follow up 14 patients died (13,6%, 95% CI, 6,9–20%). The all-cause mortality rate after 180 days was 22,2% (95% CI, 13,5–31%) - 22 patient. In the thrombolysis group only 2 patients died after 180-day follow-up, mortality rate was 4,4% (95% CI, 1,7–10,6%), the mortality rate in patients not treated by thrombolysis was 40% (95% CI, 25,3–54,7%). Thrombolysis was associated with a significant decrease in mortality [OR 0.07 (95% CI, 0.01–0.31)]. In the thrombolysis group 2 patients (4.1%; 95% CI, 1.1–10%) had a non-fatal major bleeding event. The presence of chronic heart failure [OR 6 (95% CI, 1.8–20.2)] and previous stroke [OR 4.3 (95% CI, 0.9–21.1)] were higher among non-survivors when compared to survivors (p≤0.05). TAPSE less than 16 mm was found to be negatively associated with survival [OR 5.5 (95% CI, 0.9–40.3)], p=0.02. Conclusion In our study thrombolysis in patients with pulmonary embolism and intermediate-risk was associated with improved prognosis. Predictors of mortality were the presence of CHF, previous stroke and TAPSE of less than 16 mm. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier mortality curves. p&amp;lt;0.05

Coronary calcification by computed tomography in patients with paroxysmal and persistent atrial fibrillation undergoing catheter ablation

Abstract Introduction Cardiac computed tomography (CCT) is routinely performed for pulmonary vein isolation (PVI) planning in patients with paroxysmal or persistent atrial fibrillation (AF). This imaging method can also identify coronary artery calcium (CAC). Purpose To evaluate the prevalence of CAC in patients with paroxysmal and persistent AF undergoing catheter ablation. Methods Cross-sectional study including patients with AF/atrial flutter (AFL) undergoing CCT for ablation procedure planning from 2017 to 2019. Baseline clinical and demographic data were collected and CAC score was assessed using the Agatston method. Patients with paroxysmal and persistent AF/AFL (defined according to 2020 European Society of Cardiology guidelines for the diagnosis and management of AF) were compared. Results A total of 474 patients were included (441 with AF and 33 with AFL), with a mean age of 57±12 years, of which 295 (62%) were males. CHA2DS2-VASc score was ≥1 (male) or ≥2 (female) in 278 (64%) patients and most patients had a low to moderate cardiovascular risk (259, 80%). CAC was identified in 254 (54%) patients. AF/AFL was paroxysmal in 348 (75%) patients and persistent in 116 (25%). Baseline characteristics and cardiovascular risk factors were similar between groups except for diabetes mellitus (33 [10%] vs 22 [20%], p=0.012) and valvular heart disease (13 [4%] vs 18 [16%], p&amp;lt;0.001) that were more prevalent in patients with persistent AF/AFL. Patients with persistent AF/AFL had higher left atrial volume and left ventricle mass (36±8 vs 43±12 ml/m2, p&amp;lt;0.001 and 90±22 vs 96±22 g/m2, p=0.041). CAC was more frequently present in patients with persistent AF/AFL (175 [50%] vs 72 [62%], p=0.028), especially CAC score &amp;gt;100 (58 [17%] vs 35 [30%], p=0.002). After multivariate analysis, CAC score&amp;gt;100 remained an independent predictor of persistent AF/AFL (OR 2.12, 95% CI 1.18–3.82, p=0.013) along with higher left atrial volume (OR 1.06, 95% CI 1.03–1.08, p&amp;lt;0.001). Conclusion In this study, coronary artery calcium was present in more than half of AF/FLA patients undergoing catheter ablation. Patients with persistent AF/AFL showed higher calcium scores and this could derive from chronic, more advanced disease. Especially in those patients, opportunistic CV risk screening and CAC-guided clinical management might be clinically useful. Funding Acknowledgement Type of funding sources: None.

Prognostic impact of achieving LDL cholesterol guidelines-recommended target in secondary prevention: a real-world study

Abstract Background Lipid management plays a key role in secondary prevention after acute coronary syndrome. The 2019 European Society of Cardiology guidelines recommend a more ambitious target than the previous guidelines version (i.e., to achieve LDL cholesterol [LDL-C] &amp;lt;55 mg/dL, and to reduce it ≥50% form baseline vs LDL-C&amp;lt;70 mg/dl or reduced ≥50% form baseline). Currently, data on the reduction of cardiovascular events in patients achieving the 2019 goals in a real-world population are missing. Purpose The aim of this study was to determine the risk of major adverse cardiovascular events (MACE) during follow-up in post myocardial infarction (PMI) patients according to the achievement of the guidelines-recommended goals in terms of LDL-C reduction. Methods We conducted a retrospective analysis of a monocentric observational registry prospectively enrolling patients admitted to our hospital for ST segment elevation myocardial infarction and followed-up in our dedicated PMI ambulatory. The analysis considered the patients enrolled between January 2011 and February 2019. Demographical and clinical data were extracted from a dedicated digital database, and the clinical events occurred during follow-up were obtained by telephone interviews or clinical records. We considered a combined endpoint of MACE defined as all-cause death, non-fatal MI, non-fatal stroke and unplanned revascularization. LDL-C was collected at baseline and at 1, 6 and 12 months after the event. The lower value collected at follow-up was used to define the achievement of the target goals. We conducted a Kaplan-Meier analysis and log-rank test comparing patients who achieved LDL-C &amp;lt;55 mg/dL and ≤50% from baseline (group 2019) vs those with LDL-C &amp;lt;70 mg/dL or ≤50% from baseline (group 2016). Continue variable are presented as median (interquartile range). Results A total of 1201 patients (23% female) were included in our analysis. Median age was 63 (54–72) years, 56% had hypertension, 17% diabetes, and 38% were smoker. Baseline LDL-C was 123 (97–148) mg/dL, the median LDL-C at follow-up was 63 (52–78) mg/dL, significantly reduced from baseline (P&amp;lt;0.0001). Between 6 and 12 months 83% of patients were treated with statin therapy alone (73% high intensity), and 17% with the addition of ezetimibe. The 2016 target was achieved in 828 patients (69%), while 270 patients (22.5%) obtained also the 2019 target. Median follow-up was 60 (40–77) months. The net incidence of MACE was 12.9% in group 2019 vs 23.7% in group 2016 (HR 0.61; 95% CI 0.42–0.88; P log-rank=0.0087; Number Needed to Treat=9; see Figure). Conclusion Our data from a real-world cohort of PMI patients emphasize the importance of achieving the guideline-recommended secondary prevention goals of LDL-C&amp;lt;55 mg/dl and ≤50% from baseline in order to reduce MACE. Funding Acknowledgement Type of funding sources: None.

Adherence to the 4S-AF Scheme in the Balkan region: insights from the BALKAN-AF survey

Abstract Background Current European Society of Cardiology guidelines on atrial fibrillation (AF) propose a structured characterization of AF in order to facilitate the evaluation of patients by physicians at all healthcare levels. The 4S-AF structured scheme includes four domains: stroke risk, symptoms, severity of AF burden and substrate severity. Purpose To evaluate the adherence to the 4S-AF scheme in patients with high risk of stroke (CHA2DS2-VASc score ≥3 in females or ≥2 in males) in the post-hoc analysis of the BALKAN-AF dataset. Methods Prospective enrolment of consecutive patients with electrocardiographically documented AF was conducted in seven Balkan countries. Results Of the 2,712 enrolled patients, 2,712 (100.0%) had data on CHA2DS2-VASc score. 162 (6.0%) had truly low risk of stroke (CHA2DS2-VASc score of 0 in males and 1 in females). 2099 (77.4%) of patients had high risk of stroke and 613 (22.6%) individuals had low or intermediate risk of stroke (CHA2DS2-VASc score &amp;lt;3 in females or &amp;lt;2 in males). 75 (46.3%) of patients with truly low stroke risk and 1555 (74.1%) of patients with high risk of stroke were offered oral anticoagulants (OAC). Of the 2,712 patients, 2,677 (98.7%) had data on European Heart Rhythm Association (EHRA) symptom score. Among 2,099 patients with high risk of stroke, 703 (33.4%) individuals had EHRA symptom score of 3 or 4. 207 (29.4%) of patients with EHRA symptom score of 3 or 4 and high risk of stroke were offered rhythm control strategy. 620 (55.2%) of patients with first diagnosed AF or paroxysmal AF with high risk of stroke were offered rhythm control strategy. 1927 (91.8%) of patients with high risk of stroke had ≥2 comorbidities. Mean left atrial diameter in patients with high risk of stroke was 46.5±7.8 mm. Conclusions OAC overuse was seen in patients with truly low stroke risk, whist OAC underuse was evident in patients with high risk of stroke. The proportion of highly symptomatic patients (EHRA 3 or 4) with high risk of stroke who were offered rhythm control strategy was low. The proportion of patients with first diagnosed AF or paroxysmal AF with high risk of stroke who received rhythm control was small. The majority of AF patients with high risk of stroke had ≥2 comorbidities. Overall, treatment decision-making was not based on the 4S-AF scheme. Funding Acknowledgement Type of funding sources: None.

Frequency and predictors of physical trauma during reflex syncope

Abstract Background Reflex syncope is a common and generally benign condition; however, the occurrence of secondary trauma can be a potentially harmful complication. Identification of characteristics and conditions associated with trauma after syncope are important for clinicians. Purpose We aimed to investigate the frequency and predictors of secondary injury during reflex syncope in a large dataset from a tertiary syncope unit. Methods All patients referred with an episode of transient loss of consciousness between December 2017 and November 2020 were evaluated. Patients who received a diagnosis of reflex syncope based on 2018 European Society of Cardiology guidelines entered the study. Clinical characteristics, conditions surrounding syncope, and – in patients with a history of previous episodes – a detailed history of up to three prior syncopal attacks were documented. The primary outcome was the presence of any clinically relevant injury that was related to syncope. In a secondary per-episode analysis, the outcome was a combination of traumatic injuries related to the current and past syncopal episodes. Results Among 1258 consecutive patients with reflex syncope (Mean age: 42.3 years; 49.6% female), 239 (23.3%) had evidence of trauma in their initial visit. Female sex (prevalence ratio [PR]: 1.24; P=0.037), body mass index ≥25 kg/m2 (PR: 1.28; P=0.016), previous injury caused by syncope (PR: 1.63; P&amp;lt;0.001), occurrence of syncope in morning hours (PR: 1.90; P&amp;lt;0.001), occurrence of syncope at home (PR: 1.61; P&amp;lt;0.001), absence of prodromes (PR: 1.32; P=0.024), and standing position at the time of syncope (PR: 1.61; P&amp;lt;0.001) were associated with injury. Although family history of syncope was not related to injury, history of syncope in brother showed a significant association with secondary trauma (PR: 2.19; P=0.003). In multivariable logistic regression, five characteristics (previous injury after syncope, occurrence of syncope in the morning, occurrence of syncope at home, absence of prodromes, and standing position at the time of syncope) were independent predictors of injury. In the absence of all five conditions, the risk of injury was &amp;lt;3%. In the secondary per-syncope analysis, of 2849 syncopal episodes, 1028 (36.1%) were associated with trauma. Having syncope in the morning (PR: 1.34; P&amp;lt;0.001), occurrence of syncope at home (PR: 1.51; P&amp;lt;0.001), absence of prodromes (PR: 1.34; P&amp;lt;0.001), and standing position at the time of syncope (PR: 1.55; P&amp;lt;0.001) were again associated with injury. Conclusions Secondary trauma after reflex syncope is a common complication. Specific conditions at the time of syncope are associated with traumatic injuries, suggesting that interventions to avoid syncopal attacks in those conditions might reduce secondary trauma. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Tehran University of Medical Sciences