Stable Patients Research Articles

Main versus segmental hepatic artery angioembolization in patients with traumatic liver injuries: A Western Trauma Association multicenter study

IntroductionHepatic angioembolization is highly effective for hemorrhage control in hemodynamically stable patients with traumatic liver injuries and contrast extravasation. However, there is a paucity of data regarding the specific location of angioembolization within the hepatic arterial vasculature and its implications on patient outcomes. MethodsA post-hoc analysis of a multicenter prospective observational study across 23 centers was performed. Adult patients undergoing main hepatic artery angioembolization or segmental hepatic artery angioembolization within 8 hours of arrival were included. The primary outcome was liver-related complications, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. Secondary outcomes were liver-related complication interventions, length of stay, and mortality. ResultsA total of 55 patients underwent hepatic angioembolization, with 23 (41.8%) undergoing main hepatic artery angioembolization and 32 (58.2%) receiving segmental hepatic artery angioembolization. Both groups were comparable in age, vitals, mechanism of injury, liver injury grade distribution, and injury severity score (all P > .05). The main hepatic artery angioembolization group had greater rates of overall liver-related complications (65.2% vs 31.2%, P = .039), specifically perihepatic fluid collection (26.1% vs 6.3%, P = .040) and bile-leak/biloma (34.8% vs 12.5%, P = .048). Main hepatic artery angioembolization had greater rates of 2 or more liver-related complications (47.8% vs 9.4%, P = .001) and readmission within 30 days (30.4% vs 9.4%, P = .046). No significant differences were observed in hospital length of stay and mortality (all P > .05). ConclusionsMain hepatic artery angioembolization is associated with increased rates of liver-related complications, multiple liver-related complications, and readmission within 30 days compared with segmental hepatic artery angioembolization. Thus, main hepatic artery angioembolization should be reserved for use only when segmental hepatic artery angioembolization is not feasible, albeit with significantly increased morbidity.

Impact of Trauma Verification Level on Management and Outcomes of Combined Traumatic Brain and Solid Organ Injuries: An NTDB Retrospective Review.

Level-I and level-II trauma centers are required to offer equivalent resources since "The Orange Book." This study evaluates differences between level-I and level-II management of solid organ injury (SOI) with traumatic brain injury (TBI). We conducted a retrospective review of the National Trauma Data Banks from 2013 to 2021 of adult (≥18years), blunt trauma patients with both TBI and SOI treated at level-I or level-II trauma centers. 48,479 TBI and SOI patients were identified, 32,611 (67.3%) at level-I centers. Unadjusted incidence of laparotomy was higher at level I (14.5% vs 11.7%, P < 0.001), and angiography rates were similar (3.3% vs 3.4%, P 0.717). Sub-group analysis of stable patients (SBP ≥100) showed an increase in nonoperative management at level II (87.3% vs 88.7%, P < 0.001) and decrease in laparotomy (9.9% vs 8.3%, P < 0.001). On logistic regression (LR), severe TBI, high-grade SOI, and level I trauma status were predictors of laparotomy. Logistic regression showed mild/moderate TBI with high-grade SOI and level II were associated with use of angiography. Unadjusted mortality rates were slightly different (14.8% vs 13.4%, P < 0.001), but there was no association with trauma level on LR. Nonoperative management was seen more at level-II centers with laparotomy at level I. Subgroup analysis showed no difference in mortality in trauma levels. Matched patients for level I and II showed no statistical difference in management. Patients were treated similarly at both levels with similar outcomes and mortality.

Does regression of skin thickening predict improvement of internal organ involvement and survival in patients with diffuse cutaneous systemic sclerosis? A EUSTAR analysis

ObjectivePatients with diffuse cutaneous systemic sclerosis (dcSSc) frequently show spontaneous improvement of skin fibrosis. Our aim was to examine whether an improvement in skin fibrosis predicts lower likelihood of visceral organ progression and better survival.MethodsPatients from the European Scleroderma Trials and Research (EUSTAR) cohort with dcSSc, baseline modified Rodnan skin score (mRSS) ≥7, and valid mRSS at 12±3 months follow up were included. Regression/progression of skin fibrosis was defined as a decrease/increase in mRSS >5 points and≥25% from baseline to follow up. The outcomes included progression of lung, renal, cardiac and gastrointestinal manifestations using consensus derived definitions and all-cause death. Regressive, stable and progressive patients were compared by univariate, Kaplan-Meier survival curve and Cox regression analysis.ResultsOf 1257 included patients, 883 (70.2%) were stable, 282 (22.4%) regressive, and 92 (7.3%) progressive. Regressive patients, adjusted for baseline mRSS, baseline immunosuppression, baseline FVC, and disease duration, showed a significantly lower probability of FVC decline ≥10% than progressive patients (p=0.00003), lower probability of all-cause mortality during follow up (p=0.035) compared to progressive patients. .Improvement of skin fibrosis was not associated with progression of other organ manifestations.ConclusionWe found that regression of skin fibrosis is associated with a lower probability of lung progression and better survival at follow up. The link between the disease course of skin and lung fibrosis in SSc can help to better stratify patients in clinical practice and enrich for ILD progressive patients in clinical trials.

029. Management of Injury to The Right Lung Due to Penetrating Trauma to The Chest: A Case Report

Background: Thoracic trauma is a significant cause of mortality, in fact, many patients with thoracic trauma die after reaching the hospital. However, many of these deaths can prevented with prompt diagnosis and treatment. Less than 10% of blunt chest injuries and only 15 to 30% of penetrating chest injuries require operative intervention. Most patients who sustain thoracic trauma can be treated by technical procedures within the capabilities of trained clinicians. Case: We reported a case of 44-year-old female having a penetrating wound in her left chest because of her ex-husband stabbed her with a knife. The patient felt pain and the vital signs were stable, from the physical examination there were no abnormalities found. The surgeons did anterior thoracotomy and evacuated the knife within 2 hours since the patient arrived in the ER, and turned out the knife injured the right lung and there was bronchopleural fistula appeared. The surgeons did repair of the fistula and debridement of the wound and primary suturing carried out. The patient discharged 3 days after hospitalized with good clinical condition. Conclusion: This case report presents a successful management of a stable patient with penetrating chest trauma.

Traumatic Abdominal Wall Hernia, often missed diagnosis in blunt trauma and delayed elective repair: A Case Report

Background: Traumatic Abdominal Wall Hernia (TAWH) is a rare type of hernia following blunt abdominal trauma that can easily missed. Always have high clinical suspicion following blunt trauma. Ultrasound scans and CT scans are particularly useful investigation to diagnose TAWH and associated abdominal injuries. Surgical repair is the definitive management of TAWH. Case description: This report presents a case of a 57-year-old male who presented abdominal wall hernia following blunt trauma to the abdomen and the diagnosis and management of TAWH. Conclusion: The timing of surgery depends on the concomitant injury. Delayed elective repair may be safe and cause less postoperative complications in stable patients. Delayed repair carries the risk of bowel incarceration and strangulation.

Assessment of Oral Bacterial Microflora in Patients with Stable Chronic Obstructive Pulmonary Disorders

Background &amp; Objectives: Chronic obstructive pulmonary disorder is an inflammatory disease characterized by the progressive deterioration of pulmonary function and increasing airway obstruction, includes chronic bronchitis and emphysema. The oral cavity has been considered a potential reservoir for respiratory pathogens. Oral bacteria may play a vital role in the exacerbation of chronic obstructive pulmonary diseases. Hence, we intend to study the bacterial microflora of oral cavity in stable COPD patients. Methods: In this study 20 patients aged between 20 to 60 years diagnosed with stable COPD and 20 normal healthy controls were selected based on the set inclusion and exclusion criteria. A detailed case history, physical examination and investigations and all the subjects were examined for gingival and periodontal status by recording the Oral hygiene which comprises debris index and calculus index and periodontal index and Quantitative oropharyngeal cultures were obtained by oral washing using isotonic saline as the collecting fluid. Results: A significant higher score of OHI(S) and PI was observed in COPD patients. There is a direct correlation between periodontal pathogens with the severity of COPD. Conclusion: The predominant organisms found in the oropharyngeal secretions were porphyromonas gingivalis and haemophilus influenza, in COPD patients.

Effect of primary pci in asymptomatic stemi patients presenting 12 to 48 hours of symptom onset, on myocardial viability assessed by spect tc 99m sestamibi scan epitome99

Abstract Background Guidelines on revascularization of asymptomatic stable STEMI patients presenting 12-48 hours of symptom onset are limited. We utilized TC-99mSestaMIBI scan to study the impact of primary PCI on myocardial viability by deriving myocardial salvage index (MSI) from area at risk (AAR), prior to revascularization and final infarct size (FIS) at follow up, in asymptomatic stable STEMI patients presenting between 12-48 hours of symptom onset to PCI. Purpose Evidence contributing lack of symptoms to a non-viable myocardium is lacking and it would be unethical to randomize patients with myocardial infarction (&amp;lt; 48 hours old) to a control arm or a non-intervention arm without evaluating the possibility of salvageable myocardium. Our study aims to inculcate evidence based management of late presenting stable asymptomatic STEMI patients. Methods We enrolled 141 patients presenting with STEMI (12-48 hours), from January 2021 to December 2023, who then underwent TC-99mSestaMIBI scan, followed by revascularization of IRA with 138 patients completing the designed study with follow-up scan at 3 months. Subjects were subcategorised into cohort A(12-24 hrs.), B(25-36 hrs.), and C(37-48 hrs.) according to the duration of symptom onset. Results A substantial MSI of &amp;gt; 0.50 was achieved by 36 %, 8% and 5 % of patients from cohort A, cohort B, and cohort C respectively. Although the AAR was comparable throughout cohorts, on post HOC analysis a statistically significant reduction in the final infarct size was seen among patients in cohort A vs C [Q = 4.72 (p = .00309)], while a reduction of FIS in cohort B and cohort C were obvious but statistically insignificant. Myocardial salvage index was smaller in late presenters, with no statistically significant difference among cohort B &amp; cohort C [Q = 0.96 (p = .77697)]. Delaying the timing of Primary PCI from symptom onset was associated with larger AAR (R= - 0.01) &amp; FIS (R= 0.35) although with a lower correlation coefficient. While evaluating MSI against timing of Primary PCI, a moderately negative (R= - 0.41) relation exists, indicating a linear correlation to reduced myocardial salvage Index with delay in the timing of primary PCI to symptom onset. Conclusion Asymptomatic stable STEMI patients presenting 12-24 hours of symptom onset to PCI, benefited from primary PCI with lesser final infarct size and larger MSI. Despite a comparable AAR across cohorts, MSI fell sharply among patients undergoing primary PCI 24-48 hours of symptom onset with a larger final infarct size, warranting viability guided revascularization. Although primary PCI improved final LVEF and MSI in patients with ischemic heart failure, parameter gain alone was insufficient in endeavoring a positive clinical impact.

The coronary angiography-derived index of microcirculatory resistance predicts perioperative myocardial injury in stable coronary artery disease patients undergoing PCI

Abstract Background Coronary microvascular dysfunction (CMD) assessed by the index of microcirculatory resistance (IMR) is associated with perioperative myocardial injury(PMI).The angiography-derived index of microcirculatory resistance (caIMR) is a novel and accurate alternative of IMR. Objective This study aims to evaluate the predictive value of caIMR on PMI in stable coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI). Methods Consecutive stable CAD patients undergoing elective PCI of a single lesion were recruited. caIMR were measured before and after revascularization.Total creatine kinase-MB (CK-MB) and high sensitivity Troponin T (hsTnT) levels were measured before and within 24 hours after PCI. Results A total of 65 patients were enrolled, twenty-six patients fulfilled the diagnostic criteria of PMI. Post-PCI caIMR values in the PMI group were significantly higher than those in the control group (27.02±3.70 vs. 15.91±3.43U, P&amp;lt;0.001). Pearson correlation analysis demonstrated that increased post-PCI caIMR values have a significant positive correlation with peak hsTnT (r = 0.803, P&amp;lt;0.001) and peak CK-MB (r = 0.512, P= 0.001). Multivariate logistic regression analysis showed the post-PCI caIMR was independent predictors of PMI(OR,1.731;95% CI:1.348-2.023; P&amp;lt;0.001).The ROC analysis suggested that the best cutoff value of post-PCI caIMR was 25.17U to diagnose PMI(AUC=0.951, sensitivity 88.5%, specificity 97.1%%). Conclusions The post-PCI caIMR can accurately predict PMI in stable CAD patients receiving elective PCI, supporting its use in clinical practice.

The effect of empagliflozin on right ventricular function in heart failure patients with reduced ejection fraction: analysis from the randomized empire hf clinical trial

Abstract Background Reverse remodeling of the left ventricle (LV) has been proposed as a key mechanism to the cardio-protective effects of sodium-glucose-transporter-2 (SGLT2) inhibitors in patients with heart failure and reduced ejection fraction (HFrEF). Deterioration of the right ventricular (RV) function is associated with poor outcome, whereas improvement in RV dysfunction has been correlated with improved outcomes in HFrEF patients. The impact of SGLT2 inhibitors on the RV remains unclear. Purpose The aim of this post-hoc study of the Empire HF trial was to investigate the effect of Empagliflozin on RV function assessed by echocardiography in patients with HFrEF after 12 weeks of treatment compared to placebo. Methods The Empire HF trial was a double-blind, placebo-controlled, randomized clinical trial, in which 190 stable HFrEF patients with a LV ejection fraction (LVEF) ≤40% were randomized (1:1) to receive Empagliflozin 10 mg once daily or matching placebo for 12 weeks. Echocardiographic images were analysed blinded to treatment allocation. Exploratory outcomes were changes in right ventricular function. Statistical analyses were performed using mixed-effects linear models adjusted for age, sex and baseline variables. Results Baseline characteristics were well balanced between the two groups; mean age 64 (SD±11) years; males: 85%; mean LVEF 29 (SD±8) %, RV free wall strain (RVFWS): -16.7 (SD±6)%, NYHA-functional class II: 78% and ischemic HFrEF etiology: 51%. No significant between-group differences were detected in RV free wall strain (RVFWS), tricuspid annular plane systolic excursion (TAPSE) or S’ RV free wall (all P&amp;gt;0.05), Figure 1. When stratified into baseline tertiles of RVFWS, patients in the lowest tertile showed a significant improvement in the Empagliflozin group compared to placebo (treatment effect: -4.4 % [95% CI: -8.0 to -0.8]; P=0.018), Figure 2. There was no correlation between the effect of Empagliflozin on RVFWS in the lowest RVFWS tertile and other changes such as LVEF (P=0.845), plasma volume (P=0.710) or weight loss (P=0.639). Conclusion In this randomized, short-term trial, Empagliflozin did exert a significant effect on RV function in stable HFrEF patients in the overall study population, but notably improved RVFWS in patients in the lowest tertile of RVFWS at baseline after 12 weeks of treatment. Additional research is required to confirm these explorative findings, and to better understand the impact of SGLT2i on RV function and identify patients who could potentially experience therapeutic and prognostic benefits by RV improvement.

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

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

Interleukin 21, plasminogen activator inhibitor 1 and fractalkine improve risk stratification in elderly patients with pulmonary embolism

Abstract Background The importance of clinical parameters for predicting short-term mortality in hemodynamically stable patients with pulmonary embolism (PE) is acknowledged within the Pulmonary Embolism Severity Index (PESI) Score. Little is known about the value of novel biomarkers in this context. Given the pathophysiology of PE, markers related to inflammation and thrombosis, such as interleukin 21 (IL-21), fractalkine and plasminogen activator inhibitor 1 (PAI1) are of particular interest. Purpose To identify new protein biomarkers that improve 90d mortality prediction compared to the PESI score in elderly PE patients. Methods 1003 patients with venous thromboembolism aged ≥65 years were recruited between 2009 and 2011 from 9 hospitals in Switzerland (SWITCO65+ cohort). Among these, 778 patients were excluded due to missing data, deep venous thrombosis only, blood sample taken &amp;gt;1 day after diagnosis, no initial anticoagulation, systolic blood pressure &amp;lt;90 mmHg, withdrawal within 1 day or denying further use of data; 225 patients were prospectively included. Outcome was independently adjudicated up to 1 year after the index event. To identify candidate proteins, untargeted proteomic analyses (OLINK) were conducted in cases with 90d all-cause mortality (n=20) matched 1:2 (age, sex) to controls without events (n=40). 26 candidate proteins were then validated in all 225 PE patients using ELISA and Mesoscale analyses. Using ROC analyses, the most promising proteins to predict death within 90d were identified within this cohort. Optimal biomarker cut-off levels were derived using the Youden Index and survival analyses were computed. To evaluate the predictive value of these biomarkers, hazard ratios (HR) were calculated after adjusting for age, sex, and BMI. AUC-ROC analyses were performed to assess the biomarkers’ value for risk prediction compared to the PESI score. Results Baseline characteristics (Figure 1) did not differ between patients who died within 90d and those who did not, except for median PESI score (108 [95 – 125] vs. 87 [79 – 101], p&amp;lt;0.001). Optimal biomarker cut-off values were: IL-21: 56.17pg/ml, PAI1: 36.82pg/ml, fractalkine: 66’515pg/ml. Increased levels of IL-21 and PAI1 were associated with increased mortality (HR IL-21 = 1.5 [95% CI: 0.99 - 2.79], HR PAI1 = 2.6 [95% CI: 1.7 – 4.8]), whereas patients with elevated fractalkine levels were at lower risk to die within 90d (HR fractalkine = 0.37 [95% CI: 0.16 - 0.60]). For prediction of 90d mortality, the three assessed biomarkers showed a higher AUC than the PESI score. Combining the PESI score with the biomarkers did not further improve the AUC (Figure 2). Conclusions The protein biomarkers IL-21, PAI1 and fractalkine improve prediction of 90d mortality in elderly, hemodynamically stable PE patients compared to the PESI score. These biomarkers highlight the contribution of inflammation and thrombosis in the pathophysiology of PE and warrant further investigation.Baseline CharacteristicsROC Curves for Biomarkers and PESI Score

Mini nutritional assessment is a predictor of mortality and morbidity in patients with pulmonary arterial hypertension

Abstract Background Malnutrition has been demonstrated as a predictor for unfavorable clinical outcomes in chronic heart failure, and may affect patients with pulmonary arterial hypertension (PAH). The Mini Nutritional Assessment (MNA) is a reliable indicator for nutritional status assessment, but its relationship with mortality risk and hospitalization in PAH patients has not yet been investigated. Purpose The study aimed to determine whether the MNA has prognostic value in stable patients with PAH. Methods A prospective multicenter study was performed. All patients completed the MNA at study entry in outpatient clinic or during planned hospitalization. The primary endpoint was all-cause mortality. Secondary end-point was the composite end-point of all cause death or PAH-related hospitalizations. Patients with malnutrition (MNA ≤17 points) or at risk of malnutrition (MNA 18-23,5 points) were considered as having abnormal nutritional status for statistical analysis. Results 182 PAH patients were included to the study (mean age 60 ± 17 years; 73% females; 57% idiopathic PAH). Abnormal nutritional status was identified in 68 (37%) patients. Median and the range of follow up period was 23 months and 0–32 months, respectively. 34 (18.7%) patients died, 53 (29.1%) were hospitalized due to PH, and 57 (31.3%) achieved the composite secondary end-point. Kaplan-Meier survival curves revealed significant differences in overall survival between patients with abnormal MNA and normal MNA, p &amp;lt;0.0001, and significant differences in composite risk of death and PAH-related hospitalization, p=0.02. In the multivariate Cox regression analysis including age, sex, and main risk factors (COMPERA 2.0 score, TAPSE/PASP, right atrial pressure, cardiac index, mix oxygen saturation), abnormal MNA remained significantly associated with all-cause mortality (HR 2.86 [95%CI: 1.29–6.38], p=0.01) and the composite end-point HR 2.39 [95% CI: 1.05–5.42], p=0.04) in PAH patients. Conclusions Using MNA as a routine screening tool allowed the detection of abnormal nutritional status in more than one third of PAH patients. Nutritional status assessed by the MNA was an independent predictor of all-cause death and the composite end-point of all-cause death and PAH-related hospitalization in patients with PAH.

Early coronary revascularization among stable patients with non-ST-segment elevation acute coronary syndromes: the role of diabetes and age

Abstract Background Diabetes mellitus affects 10-30% patients hospitalized with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and two-fold higher mortality risk compared to non-diabetics. Despite higher post-PCI complications in diabetic patients, guidelines advise early invasive NSTE-ACS treatment for all, based expert opinion, and limited evidence. Purpose To investigate the impact of an early coronary revascularization (&amp;lt;24 hours) compared with initial conservative strategy on clinical outcomes in diabetic patients with NSTE-ACS who are in stable condition at hospital admission. Methods The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Patients with cardiac arrest, hemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using logistic regression and inverse probability of treatment weighting models. Primary outcome measure was all cause 30-day mortality. Risk ratios (RRs) and odds ratios (ORs) with their 95% CIs were employed. Results Of the 7,589 NSTE-ACS patients identified, 2,343 were diabetics. The data show a notable reduction in mortality for the elderly undergoing early revascularization compared to those receiving an initial conservative strategy both in the diabetic (3.3% versus 6.7%; RR: 0.48; 95% CI: 0.28-0.80) and nondiabetic patients (2.7% versus 4.7%: RR: 0.57; 95% CI: 0.36-0.90). In multivariate analyses, diabetes was a strong independent predictor of mortality in the elderly (OR: 1.43; 95% CI: 1.03-1.99), but not in the younger patients OR: 1.04; 95% CI: 0.53-2.06). Conclusions Early coronary revascularization does not lead to any survival advantage within 30 days from admission in young NSTE-ACS patients who present to hospital in stable conditions with and without diabetes. An early invasive management strategy may be best reserved for the elderly. Factors beyond revascularization are of considerable importance for outcome in elderly diabetic subjects with NSTE-ACS.

Adjustment of the SMART risk score by bioactive adrenomedullin enables a more accurate prediction of mortality in patients with ASCVD

Abstract Background Bioactive adrenomedullin 1-52 (bio-ADM) is a dynamic blood biomarker for real-time assessment of endothelial function. Bio-ADM was recently shown to be a prognostic marker in patients with acute heart failure and cardiogenic shock. The SMART (Second Manifestations of Arterial Disease) score is a validated tool for risk assessment in patients with established atherosclerotic cardiovascular disease (ASCVD). The aim of this study was to assess whether measurement of bio-ADM adds incremental value to the SMART score in stable patients with ASCVD. Methods Circulating bio-ADM levels were assessed in n=695 stable patients with ASCVD in an all-comer cohort. Endpoints evaluated were all-cause mortality and cardiovascular mortality; follow up was 3 years. Results Bio-ADM was higher in non-survivors (all-cause death: n=54, median 33.1 pg/mL) compared to survivors (n=641, median 17.9 pg/mL; p&amp;lt;0.0001). Univariable Cox regression analyses showed bio-ADM to be associated with adverse outcome [standardized hazard ratio (HR) of bio-ADM values: All-cause death: 2.4, 95% confidence interval (CI): 2.0-2.9; p&amp;lt;0.001, cardiovascular death: 2.5, 95% CI: 1.9-3.3; p&amp;lt;0.001]. This association remained significant in various multivariable Cox regression models. Bio-ADM was found to be a strong marker for mortality (c-index: 0.80, Chi²: 54.1) and proved to be superior to other markers including hs-Troponin T (c-index: 0.61, Chi²: 2.0) and eGFR CKD-EPI 2021 (c-index: 0.687, Chi²: 33.5). Addition of bio-ADM to the SMART score significantly improved model performance in predicting mortality (SMART score: c-index: 0.717, Chi²: 24.73; SMART score + bio-ADM: c-index: 0.832, Chi²: 63.24; Delta c-index: 0.115; Delta Chi²: 38.51; all p&amp;lt;0.001) and showed net reclassification improvement in risk categorization with 11.6% in the group of survivors and 9.8% for non-survivors. Conclusion Bio-ADM provides incremental added value (improved discrimination, calibration and reclassification) on top of the SMART risk score in patients with ASCVD.

Automatic telephonic follow up in heart failure by a natural language processing artificial intelligence: pilot program

Abstract Introduction Heart failure (HF) burden on public health is substantial and efficient patient management strategies are needed. Traditional methods of HF monitoring face limitations in scalability and effectiveness. Artificial Intelligence (AI) might offer novel solutions for enhanced resource management and alleviation of healthcare burdens. Purpose To study the feasibility of implementing automatic remote monitoring via phone calls operated by AI in a HF unit. Methods We conducted a non-randomized, open, pilot trial employing an AI technology based on natural language processing for autonomous telephone outreach for the follow up of HF patients. 86 patients from a tertiary hospital HF unit undergoing pharmacological titration and education were enrolled. The AI conducted weekly calls to gather symptomatology, vital signs, and health status changes, which were then displayed on a virtual platform featuring alerts preconfigured by the research team. These alerts guided patient communication and intervention as deemed necessary by a specialized nurse. Results Characteristics of patients are shown in Table 1. The AI followed these patients for a median of 251.5 days. 2773 telephonic calls were performed. We estimate an equivalent to 1445h of work (17.2 days/month). Adherence was high during the study, with 98% of the calls completed. 1427 alerts were generated, being the most frequent weight change (251; 17.6%), orthopnea (220; 15.4%) and fatigue (187; 13.1%). It led to 487 remote interventions, most of them consisting in calling the patient for assessment (409; 84.0%), but also in adjusting medication remotely (34; 7.0%). See Figure 2. A HF telemedicine specialized nurse required 205min per week for alert review, 2.38min/patient-week. 2 patients died, one from cardiovascular causes, and 7 patients had a HF hospitalization, 42.9% with previous alarms. 20 events of worsening HF were recorded, comprising hospitalization, emergency visit or IV diuretic administration. Oral diuretic dose was increased in 22 occasions, 15 of them remotely in response to an alert raised by the AI operator. At 6 months functional class globally improved (p = 0.028), but NTproBNP increased (p=0.0472). Quality of life was evaluated at baseline and at 6 months, with no change in EQ5D5L (median 0.717, change -0.005, p 0.71) or PHQ4 (median 2.88, change -0.29, p 0.7792), but KCCQ12 total score worsened (median 74.49, change -2.32, p 0.048). Experience was rated with 8.97/10 in a satisfaction questionnaire. All patients recommended the program, remarking a closer follow up, better communication and a safety feeling. Conclusions AI enables closer monitoring of patients with HF, maintaining contact with stable patients while also allowing for resource allocation and tracking of higher-risk patients or those experiencing changes in symptoms. A randomized clinical trial comparing to standard follow-up is needed to evaluate this promising technology.Table 1Figure 2

Residual ischemia location after STEMI by CMR and association with non-culprit coronary artery disease

Abstract Background Many ST-segment elevation myocardial infarction (STEMI) patients present with non-culprit coronary artery disease. In cases with incomplete revascularization, stress cardiac magnetic resonance (sCMR) could help detect and locate residual ischemia. Purpose We aim to evaluate the usefulness of sCMR to detect and locate residual ischemia in STEMI patients after discharge and correlate the findings with angiographical non-culprit coronary lesions, if any. Methods Reperfused, stable STEMI patients submitted to undergo sCMR within the first year after STEMI were included in the cohort. Index coronary angiography was revised, culprit and non-culprit coronary artery disease were registered, and significant stenoses were defined as ≥50% by visual assessment. Residual ischemia on sCMR (by first-pass vasodilator stress perfusion) was analysed and categorized as either absent or present in anterior, lateral, and inferior territories. Unrevascularized non-culprit coronary lesions were correlated with territories with residual ischemia on sCMR and lesions in subsequent coronary angiography. A p-value &amp;lt;0.05 was considered statistically significant. Results The study group was made up of 234 patients who underwent sCMR within the first year after STEMI (mean age 58.95±11.85 years, 78.2% male, 48.7% anterior infarction). Residual ischemia by sCMR was noted in 63 (26.9%) patients. In the 95 patients (40.6%) who underwent complete revascularization during index admission, residual ischemia by sCMR was seldom detected (n=14, 14.7%) and distributed on anterior (n=8), lateral (n=3) and inferior (n=4) territories. More than half of the cohort (n=139, 59.4%) depicted unrevascularized non-culprit coronary lesions, and residual ischemia was detected in 49 (35.3%) patients. Non-culprit lesions on left anterior descendent artery (n=62) associated with ischemia in 38.7% of cases (n=24), most commonly in the anterior territory (n=17, 70.8%). Similar findings were noted for lesions on circumflex artery (n=66), which depicted residual ischemia in 34.8% (n=23) of cases and most frequently in the lateral territory (n=13, 56.5%); and lesions in right coronary artery (n=45), which depicted residual ischemia in 42.2% (n=19) of cases, most commonly in the inferior territory (n=13, 68.4%). Significant coronary stenosis was found in most patients who underwent subsequent coronary angiography after residual ischemia detection (41 out of 47, 87.2%). Conclusions One third of STEMI patients with incomplete revascularization and non-culprit coronary artery disease depict residual ischemia on sCMR, the location of which generally correlates with index coronary anatomy and significant stenosis in subsequent coronary angiography. Residual ischemia is infrequent in patients with complete revascularization, but not inexistent. sCMR should be considered in selected STEMI patients according to coronary anatomy and/or symptoms to guide therapy.Stress CMR and ischemia location

Changes in echocardiographic and analytical parameters after iron replacement in stable heart failure patients. FER-STRAIN study

Abstract Background Iron deficiency replacement with intravenous ferric carboxymaltose (FCM) has demonstrated to improve clinical and prognostic parameters in patients with heart failure with reduced left ventricular ejection fraction (HFrEF). Improvement of myocardial contractility is proposed as possible hypothesis and strain could behave as an early and high sensitive parameter to assess this improvement in myocardial deformation due to increased iron availability after replacement of iron deficiency. Purpose Evaluate the effect of iron deficiency replacement with FCM in the strain of both ventricles in patients with stable HFrEF. Methods We performed an observational, analytical, longitudinal and prospective study that included 73 patients with stable HFrEF who presented iron deficiency without anemia defined as serum ferritin &amp;lt;100 ug/L or between 100 and 300 ug/L if the transferrin saturation was &amp;lt;20%. They were randomized 2:1 to iron replacement with FCM or control group. A central core lab, blinded to the treatment/control groups performed 3D echocardiograms and strain analysis. Analytical parameters and biomarkers were determined basal and four weeks after the randomization. Results Mean age of the study population was 70 years old, 77% were male, 75% had high blood pressure, 70% dyslipidemia and 41% diabetes. Of the total, 51 patients were assigned to the replacement group and 22 patients to the control group. Mean left ventricular ejection fraction (LVEF) was 33%, without basal differences between both groups. Four weeks after the randomization, a significant improvement of LVEF of 2.47±2.32% (p=0.018) was observed in the replacement group, as well as in the left ventricle global longitudinal strain (LV-GLS) of -0.96±2.08% (p=0.006). In blood tests, a significant improvement of ferritin (130.9±111.98mg/L, p&amp;lt;0.000), hemoglobin (0.3±0.7g/dL, p=0.027) and medium corpuscular volume (1.7±2.16fL, p=0.005), and also an increase of the biomarker myeloperoxidase (40.16±138.36pmol/L, p=0.02) were detected in the treatment group. Nevertheless, these changes were not observed in the control group. Conclusions In patients with stable HFrEF replacement of iron deficiency with FCM is associated with an improvement of myocardial contractility, of LVEF measured by 3D and LV-GLS.Variation of parametersLV-GLS before and after FCM

Echocardiographic profiles of patients with CPCPH and IPCPH in HFpEF: insights from the PHHF study

Abstract Background The 2022 ESC/ERS guidelines changed the definition of post-capillary pulmonary hypertension (pcPH) in heart failure (HF) by lowering the level of mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR). Yet, the echocardiographic profile of HF with preserved ejection fraction (PEF) patients according to their mPAP and RVP is not known. Objectives To investigate the echocardiographic profile of HFPEF patients according to their mPAP and RVP. Methods Stable HF patients with the need for right heart catheterization were enrolled from 2010 to 2018 and prospectively followed-up in this multicenter study. All patients had a right heart catheterization and an echocardiography within the 24 hours. PcPH was characterized by a pulmonary wedge pressure exceeding 20 mm Hg and mean mPAP greater than 20 mm Hg, from an isolated state when PVR was less than 2 Wood units (WU, IpcPH) to a combined form when PVR exceeded 2 WU (CpcPH). Results Out of 662 HF patients included in PHHF study, 268 (40%) were classified as having HFpEF (35% male, median age 71 yo). Compared to IpcPH patients, CpcPH patients had higher tricuspid regurgitation peak velocity (sPAP, 3.53 vs 3.00 m/s, p&amp;lt;0.01), lower S tricuspid tissue Doppler velocity (10 vs. 11 cm/s, p 0.01) and TAPSE (18 vs. 21 mm, p&amp;lt; 0.01) and lower TAPSE/sPAP ratio (0.3 vs. 0.4, p&amp;lt;0.01). There were no differences between groups regarding both right ventricle and right atrial diameter and area. Conclusion In HFpEF patients with PH, CpcPH patients had worse right ventricular function despite similar remodeling when compared to IpcPH patients

The impact of exogenous ketone body suppletion on energy and pH balance in skeletal muscle during exercise in chronic heart failure patients: a prospective randomized double-blind cross-over study

Abstract Background Heart Failure (HF) is characterized by impediments in exercise capacity. Disruptions in the energy metabolism of skeletal muscle contribute to this condition. Pre-clinical and clinical evidence showed that reductions in carbohydrate and FA metabolism in HF may be partially overcome by a compensatory increase in ketone body oxidation and suggest that suppletion of ketone bodies (KB) may improve energy metabolism in HF. Purpose We tested the effect of exogenous KB suppletion on energy and pH balance during cycling exercise using 31P Magnetic Resonance (MR) Spectroscopy of the exercising quadriceps muscle in patients with HF. Methods In a randomized, double-blind, placebo-controlled cross-over study, 14 stable HF patients with reduced ejection fraction and diminished exercise capacity underwent maximal exercise testing in a MR scanner fitted with a cycling ergometer after KB or placebo treatment. Phosphocreatine (PCr) and inorganic phosphate (Pi) resonance amplitudes and frequencies were measured continuously in the quadriceps muscle during rest, exercise and recovery using in-vivo 31P MR spectroscopy (Figure 1). Results Patients had a median age of 66 [53 – 75] years, were 14% female, had a median LVEF of 37% [27 – 40] and circulating NT-pro BNP levels of 411 [182 – 946] pg/mL. Peak oxygen uptake (VO2) was 18.2 [15.2 – 20.3] ml/kg/min, which is 68% [62 – 78%] of predicted. After treatment, exercise performance in terms of cycling duration and workload were comparable between treatment arms (Figure 2). Quadriceps acidification during exercise was larger after KB suppletion compared to placebo (ΔpH: -0.2 [-0.3 - -0.1] vs -0.1 [-0.3 - -0.1] respectively; p=0.041) while quadriceps energy depletion during exercise was not altered by treatment (ΔPi/PCr 0.77 [0.55 – 2.51] vs 0.66 [0.46 – 0.81] respectively; p=0.087). Post-exercise mitochondrial oxidative function was similar between treatment arms (KB: PCr resynthesis rate 48 sec [25 – 59] versus placebo: 42 sec [36 – 63]; p=0.767). Conclusions Ketone body suppletion increased acidification and did not improve energy balance in skeletal muscle during exercise or mitochondrial function during recovery in patients with chronic HF. These results question the value of ketone bodies as treatment to boost muscular energy metabolism during exercise in HF.31P MRS Spectrum during exercise in HFExercise and energy parameters

Effects of body mass index on worsening of heart failure and all-cause death in patients with heart failure and reduced left ventricular ejection fraction: a 10-year follow-up study

Abstract Background/Introduction Obesity in patients with heart failure (HF) with reduced ejection fraction (HFrEF) is common, and with the emergence of effective anti-obesity drugs, a better understanding of the relation between BMI and clinical outcome in HFrEF is needed. Purpose This study aimed to analyse whether a body mass index (BMI) above 27 kg/m2 (cut-off used in trials) is associated with a greater rate of all-cause death and HF hospitalization in patients with HFrEF. Methods We included 1,017 medically optimized according to existing HF guidelines at the time and clinically stable HF patients with a left ventricular ejection fraction of &amp;lt;45% from the NorthStar study. Patients were included between 2005 and 2009 and followed for 10 years using Danish nationwide registries. The outcomes of interest were all-cause death and hospital discharge for HF (overnight stay). Descriptive statistics were grouped according to tertiles of BMI. The association between BMI as a continuous variable and the outcomes of interest was analysed using restricted cubic splines in Cox proportional-hazards models. Reported were hazard ratios (HR) with 95% confidence intervals (CI) adjusted for relevant prognostic covariates (reference: BMI = 27 kg/m2). Results At enrolment, the median age was 69 years, 75% were men, and the median BMI was 26.3 kg/m2 (Table 1). Patients in the upper 3rd BMI tertile were younger (median age 67), had a lower level of NT-proBNP level (median 737.5 pg/ml) and a higher proportion of diabetes (29.9%). During 10 years of follow-up, HF hospitalization occurred in 683 patients (61.7%), and 623 patients died (56.3%). A BMI above 27 kg/m2 was associated with a higher rate of HF hospitalization (significantly from BMI 35.2 kg/m2: HR 1.30 [CI 1.00-1.68]; Figure 1). Similar findings were observed for all-cause mortality (significantly from BMI 35.7 kg/m2: HR 1.27 [CI 1.00-1.62]) Conclusion In patients with HFrEF, a BMI above 27 kg/m2 was associated with a higher rate of HF hospitalization and all-cause death. Efforts to find effective and safe approaches to reducing weight in obese patients with HFrEF are warranted.Figure 1