Subsequent Cardiovascular Events Research Articles

Retinal artery occlusion as indicator of stroke in diabetes

Abstract Background Diabetes is associated with multiple complications in organs throughout the body, including an increased risk cardiovascular disease (1). Furthermore, an association between retinal artery occlusion and diabetes have been described as well (1,2). Early predictors of complications associated with diabetes would be useful for a better prognosis of the disease. Purpose Based on data from the Danish registries, the aim of this study was to investigate whether RAO is a predictor of stroke in diabetic patients. Methods We included 992 diabetic patients with incident RAO from the Danish National Patient Register with incident RAO between 1st of January 2000 and 31st of December 2018. Each of these cases were matched on age at index, sex, and time since diabetes diagnosis with 5 random diabetes patients with no subsequent diagnosis of RAO. Survival analyses were used to estimate and contrast the risk of stroke in diabetic RAO patients compared to diabetic patients with no prior diagnosis of RAO. The included analyses were all performed at 1 and 5-year follow-up. Results At 1-year follow-up, the incidence rate of stroke in diabetic RAO patients was 10.0 per 100 person years (PY) (95% CI: 8.13–12.10). The incidence for the controls at this time point was much lower at 1.82 per 100 PY (95% CI: 1.47–2.25). After 5-years of follow-up a large difference persisted, where the cumulative incidence was 19.3% (95% CI: 16.5–22.2%) for the RAO patients compared to 7.4% (95% CI: 6.5–8.2%) for the controls. The hazard rate ratio for stroke was 5.48 (95% CI: 4.06–7.39) after 1-year follow-up and 3.17 (95% CI: 2.60–3.86) after 5-year follow-up. The results support the use of RAO as a predictor of stroke in diabetic patients. Cardiovascular diseases contribute substantially to the morbidity and mortality in diabetic patients (3,4), underlining the need for especially a predictor of cardiovascular complications in these patients. To our knowledge, the predictive usage of RAO for cardiovascular complications in diabetic patients have not been investigated previously. Small occlusions, which could indicate systemic atherosclerosis, may not always be symptomatic. Therefore, the condition may not be diagnosed before more severe events occur. Conversely, RAO usually cause visual impairments, making RAO suitable as a potential predictor of subsequent cardiovascular events. The incidence rates of stroke suggest that diabetic RAO patients should be especially monitored the first year after their RAO diagnosis, but the monitoring would be beneficial even 5 years after the RAO diagnosis to continuously evaluate risk factors and instigate early intensified treatment. Conclusion The data of this study identified a substantial larger risk of stroke in diabetic RAO patients than diabetic patients with no RAO diagnosis, indicating RAO could be a predictor of stroke in diabetic patients. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Obel Family Foundation

MM-146 Using Data Science to Characterize Patterns in Cardiovascular Clinical Data: Topological Analysis of Baseline Characteristics in Patients With Relapsed/Refractory Multiple Myeloma Enrolled in Carfilzomib Trials

Oncology clinical trials amass vast amounts of patient data, providing the opportunity to leverage machine learning. Patients with multiple myeloma (MM) often have cardiovascular risk factors and/or established cardiovascular disease. We used topological analysis to identify characteristics at baseline associated with subsequent cardiovascular adverse events (AEs) in patients with relapsed/refractory MM (RRMM). Retrospective data were pooled from the investigational arm (carfilzomib-treatment) of phase 3 trials (ASPIRE, ARROW, FOCUS, ENDEAVOR) for this post-hoc exploratory analysis. Variables included baseline demographics, vital signs, electrocardiogram results, laboratory values, and comorbidities. Topological data analysis (an analytic approach akin to dimensionality reduction, distinct from traditional multivariate modeling) was used to reveal AE occurrence micropatterns. A decision algorithm accounting for both posterior and prior AE probability was used to find risk factors meeting pre-specified clinical criteria. In the pooled population (n=1,484), grade ≥3 cardiovascular AEs analyzed were cardiac failure (5.1%), ischemic heart disease (IHD, 2.2%), and hypertension (9.2%). Using this modeling approach, patient clusters with higher or lower AE posterior probabilities were derived (cardiac failure: 31.1% [higher probability]/68.9% [lower probability]; IHD: 38.5%/61.5%; hypertension: 32.1%/67.9%), with AE rates enriched in the high-probability group (cardiac failure AE rate was 4x higher in the high-probability group than the low-probability group [10.8% vs. 2.4%]). Grade ≥3 cardiac failure clustered in patients with baseline comorbidity of congestive heart failure, moderate-to-severe chronic kidney disease, prolonged mean QRS ≥120 msec, glucose ≥7.9 mmol/L, and/or Asian race. Grade ≥3 IHD clustered in patients with prior myocardial infarction, glucose ≥7.9 mmol/L, activated partial thromboplastin time ≤20 seconds, and/or creatinine clearance ≤60 mL/min. Grade ≥3 hypertension clustered with systolic blood pressure ≥140 mmHg and/or Asian or African race. This novel topological analysis found that cardiovascular AEs in RRMM patients enrolled in carfilzomib trials clustered into groups with known risk factors. Characteristics associated with cardiovascular AEs were detectable by standard clinical assessment or laboratory tests. Study limitations include the lack of comparator arm, small number of Asian patients (n=102), and that this novel methodology has not been validated in clinical settings. These findings suggest that topological analysis may be a useful tool for leveraging machine learning in clinical trials.

Computed tomography coronary angiography in non-ST-segment elevation myocardial infarction.

Electrocardiography and high-sensitivity cardiac troponin testing are routinely applied as the initial step for clinical evaluation of patients with suspected non-ST-segment elevation myocardial infarction. Once diagnosed, patients with non-ST-segment elevation myocardial infarction are commenced on antithrombotic and secondary preventative therapies before undergoing invasive coronary angiography to determine the strategy of coronary revascularisation. However, this clinical pathway is imperfect and can lead to challenges in the diagnosis, management, and clinical outcomes of these patients. Computed tomography coronary angiography (CTCA) has increasingly been utilised in the setting of patients with suspected non-ST-segment elevation myocardial infarction, where it has an important role in avoiding unnecessary invasive coronary angiography and reducing downstream non-invasive functional testing for myocardial ischaemia. CTCA is an excellent gatekeeper for the cardiac catheterisation laboratory. In addition, CTCA provides complementary information for patients with myocardial infarction in the absence of obstructive coronary artery disease and highlights alternative or incidental diagnoses for those with cardiac troponin elevation. However, the routine application of CTCA has yet to demonstrate an impact on subsequent major adverse cardiovascular events. There are several ongoing studies evaluating CTCA and its associated technologies that will define and potentially expand its application in patients with suspected or diagnosed non-ST-segment elevation myocardial infarction. We here review the current evidence relating to the clinical application of CTCA in patients with non-ST-segment elevation myocardial infarction and highlight the areas where CTCA is likely to have an increasing important role and impact for our patients.

Comparison of Risk of Serious Cardiovascular Events after Hemorrhagic versus Ischemic Stroke: A Population-Based Study

Patients with ischemic stroke are considered a very high risk population for subsequent cardiovascular events and guidelines recommend intensive preventive strategies. However, there is no clear recommendation that patients with hemorrhagic stroke should also be regarded as a very high cardiovascular risk population. To compare the risk of subsequent cardiovascular morbidity/mortality between patients with incident hemorrhagic and ischemic stroke. Patients aged ≥18 years with incident hemorrhagic or ischemic stroke between 1998 and 2017 and no prior history of serious vascular event were identified from UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics data. The cohort included 32,091 patients with an overall follow-up of 381,237 person-years (median: 11.8 years). After adjusting for potential confounders, patients with incident hemorrhagic stroke had no significantly different risk of subsequent cardiovascular morbidity compared with patients with incident ischemic stroke-coronary heart disease (CHD; hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.56-1.32), recurrent stroke (HR: 0.92, 95% CI: 0.83-1.02), peripheral vascular disease (PVD; HR: 1.15, 95% CI:0.56-2.38), or heart failure (HR: 1.03, 95% CI: 0.61-1.74). Patients with incident hemorrhagic stroke had significantly higher risk of subsequent cardiovascular disease (CVD)-related mortality (HR: 2.35, 95% CI: 2.04-2.72) and all-cause mortality (HR: 2.16, 95% CI: 1.94-2.41). Propensity-score matched analysis of 1,039 patients with hemorrhagic stroke and 1,039 with ischemic stroke showed similar risk in subsequent cardiovascular morbidity-CHD (stratified HR [sHR]: 0.92, 95% CI: 0.55-1.54), recurrent stroke (sHR: 0.93, 95% CI: 0.82-1.02), PVD (sHR: 1.04 95% CI: 0.45-2.41), or heart failure (sHR: 0.71, 95% CI: 0.39-1.27). The risk of subsequent cardiovascular events is similar between patients with incident hemorrhagic and ischemic stroke. Patients with previous hemorrhagic stroke should be regarded as a population at very high risk for subsequent CVD.

Coronavirus Disease 2019 Severity and Risk of Subsequent Cardiovascular Events.

Little is known about the relationship between coronavirus disease 2019 (COVID-19) severity and subsequent risk of experiencing a cardiovascular event (CVE) after COVID-19 recovery. We evaluated this relationship in a large cohort of United States adults. Using a claims database, we performed a retrospective cohort study of adults diagnosed with COVID-19 between 1 April 2020 and 31 May 2021. We evaluated the association between COVID-19 severity and risk of CVE >30 days after COVID-19 diagnosis using inverse probability of treatment-weighted competing risks regression. Severity was based on level of care required for COVID-19 treatment: intensive care unit (ICU) admission, non-ICU hospitalization, or outpatient care only. A total of 1 357 518 COVID-19 patients were included (2% ICU, 3% non-ICU hospitalization, and 95% outpatient only). Compared to outpatients, there was an increased risk of any CVE for patients requiring ICU admission (adjusted hazard ratio [aHR], 1.80 [95% confidence interval {CI}, 1.71-1.89]) or non-ICU hospitalization (aHR, 1.28 [95% CI, 1.24-1.33]). Risk of subsequent hospitalization for CVE was even higher (aHRs, 3.47 [95% CI, 3.20-3.76] for ICU and 1.96 [95% CI, 1.85-2.09] for non-ICU hospitalized vs outpatient only). COVID-19 patients hospitalized or requiring critical care had a significantly higher risk of experiencing and being hospitalized for post-COVID-19 CVE than patients with milder COVID-19 who were managed solely in the outpatient setting, even after adjusting for differences between these groups. These findings underscore the continued importance of preventing severe acute respiratory syndrome coronavirus 2 infection from progressing to severe illness to reduce potential long-term cardiovascular complications.

Lipid lowering therapy patterns and the risk of cardiovascular events in the 1-year after acute myocardial infarction in United Arab Emirates.

AimIn United Arab Emirates, cardiovascular disease (CVD) is a leading cause of mortality and 22% of CVD deaths are attributable to acute myocardial infarction (MI). Adherence to guidelines for lipid management is incompletely described in the Middle East. This study aimed to characterize lipid lowering therapy (LLT) patterns and the risk of subsequent cardiovascular events (CVEs) in the first year after MI.MethodsThis was a retrospective cohort study using the Dubai Real-World Claims Database, including all patients discharged with MI between January 01, 2015 and December 31, 2018, followed-up until December 31, 2019.ResultsIn the first year after MI, 8.42% of 4,595 patients included experienced at least one recurrent MI (rate 6.77 events/100 person-years [PYs]), 2.94% had one revascularization (cumulative rate 0.55 events/100 PYs) and 2.66% had one hospitalization due to unstable angina (cumulative rate 5.16 new events/100 PYs). The majority (60.40%) of the patients presented with LDL-C levels ≥ 70 mg/dL after MI. In the first year after MI, 93.45% of the patients received LLT, mainly high-intensity statin (67.79%); with a minority of patients receiving statin + ezetimibe (4.55%), PCSK9i (0.20%) or ezetimibe alone (0.07%).ConclusionPatients hospitalized with MI in Dubai present an increased risk of CVEs in their first-year post-discharge. Majority of the patients presented with LDL-C levels above 70 mg/dL, which indicates suboptimal lipid control with existing LLT, particularly in high-risk patients.

The position of renal denervation in treatment of hypertension: an expert consensus statement.

Hypertension is an important risk factor for cardiovascular disease. In the Netherlands, there are approximately 2.8million people with hypertension. Despite treatment recommendations including lifestyle changes and antihypertensive drugs, most patients do not meet guideline-recommended blood pressure (BP) targets. In order to improve BP control and lower the risk of subsequent cardiovascular events, renal sympathetic denervation (RDN) has been introduced and studied as anon-pharmacological approach. While early data on the efficacy of RDN showed conflicting results, improvements in treatment protocols and study design resulted in robust new evidence supporting the potential of the technology to improve patient care in hypertensive subjects. Recently, 5randomised sham-controlled trials demonstrated the safety and efficacy of the technology. Modelling studies have further shown that RDN is cost-effective in the Dutch healthcare setting. Given the undisputable disease burden along with the shortcomings of current therapeutic options, we postulate anew, clearly framed indication for RDN as an adjunct in the treatment of hypertension. The present consensus statement summarises current guideline-recommended BP targets, proposed workup and treatment for hypertension, and position of RDN for those patients with primary hypertension who do not meet guideline-recommended BP targets (see central illustration).

Time-resolved trajectory of glucose lowering medications and cardiovascular outcomes in type 2 diabetes: a recurrent neural network analysis

AimTreatment algorithms define lines of glucose lowering medications (GLM) for the management of type 2 diabetes (T2D), but whether therapeutic trajectories are associated with major adverse cardiovascular events (MACE) is unclear. We explored whether the temporal resolution of GLM usage discriminates patients who experienced a 4P-MACE (heart failure, myocardial infarction, stroke, death for all causes).MethodsWe used an administrative database (Veneto region, North-East Italy, 2011–2018) and implemented recurrent neural networks (RNN) with outcome-specific attention maps. The model input included age, sex, diabetes duration, and a matrix of GLM pattern before the 4P-MACE or censoring. Model output was discrimination, reported as area under receiver characteristic curve (AUROC). Attention maps were produced to show medications whose time-resolved trajectories were the most important for discrimination.ResultsThe analysis was conducted on 147,135 patients for training and model selection and on 10,000 patients for validation. Collected data spanned a period of ~ 6 years. The RNN model efficiently discriminated temporal patterns of GLM ending in a 4P-MACE vs. those ending in an event-free censoring with an AUROC of 0.911 (95% C.I. 0.904–0.919). This excellent performance was significantly better than that of other models not incorporating time-resolved GLM trajectories: (i) a logistic regression on the bag-of-words encoding all GLM ever taken by the patient (AUROC 0.754; 95% C.I. 0.743–0.765); (ii) a model including the sequence of GLM without temporal relationships (AUROC 0.749; 95% C.I. 0.737–0.761); (iii) a RNN model with the same construction rules but including a time-inverted or randomised order of GLM. Attention maps identified the time-resolved pattern of most common first-line (metformin), second-line (sulphonylureas) GLM, and insulin (glargine) as those determining discrimination capacity.ConclusionsThe time-resolved pattern of GLM use identified patients with subsequent cardiovascular events better than the mere list or sequence of prescribed GLM. Thus, a patient’s therapeutic trajectory could determine disease outcomes.

Associations of New-Onset Atrial Fibrillation With Risks of Cardiovascular Disease, Chronic Kidney Disease, and Mortality Among Patients With Type 2 Diabetes.

Atrial fibrillation (AF) frequently occurs in patients with type 2 diabetes (T2D); however, the longitudinal associations of new-onset AF with risks of adverse health outcomes in patients with T2D remain unclear. In this study, we aimed to determine the associations of new-onset AF with subsequent risks of atherosclerotic cardiovascular disease (ASCVD), heart failure, chronic kidney disease (CKD), and mortality among patients with T2D. We included 16,551 adults with T2D, who were free of cardiovascular disease (CVD) and CKD at recruitment from the UK Biobank study. Time-varying Cox regression models were used to assess the associations of incident AF with subsequent risks of incident ASCVD, heart failure, CKD, and mortality. Among the patients with T2D, 1,394 developed AF and 15,157 remained free of AF during the follow-up. Over median follow-up of 10.7-11.0 years, we documented 2,872 cases of ASCVD, 852 heart failure, and 1,548 CKD and 1,776 total death (409 CVD deaths). Among patients with T2D, those with incident AF had higher risk of ASCVD (hazard ratio [HR] 1.85; 95% CI 1.59-2.16), heart failure (HR 4.40; 95% CI 3.67-5.28), CKD (HR 1.68; 95% CI 1.41-2.01), all-cause mortality (HR 2.91; 95% CI 2.53-3.34), and CVD mortality (HR 3.75; 95% CI 2.93-4.80) compared with those without incident AF. Patients with T2D who developed AF had significantly increased risks of developing subsequent adverse cardiovascular events, CKD, and mortality. Our data underscore the importance of strategies of AF prevention to reduce macro- and microvascular complications in patients with T2D.

Maximum home blood pressure and cardiovascular outcomes in patients with type 2 diabetes: KAMOGAWA-HBP study.

The maximum blood pressure was reported as a possible marker of organ damage. We previously showed that maximum home blood pressure was significantly associated with development of diabetic nephropathy. In the same cohort of patients with diabetes as in the previous study, this study aimed to evaluate the prognostic blood pressure values for the onset of first cardiovascular events. This retrospective cohort study included 1082 patients with type 2 diabetes (47.0% female, median age 65.0) without a history of macrovascular complications. Blood pressure measurements were performed in triplicates every morning and evening for 14 consecutive days from the start of the study. Cox hazards model was used to evaluate the risk of primary endpoint, which was defined as the onset of first major cardiovascular event. The primary endpoint occurred in 119 patients (incidence rate, 15.7/1000 person-years) during an average of 7.0-year follow-up. The adjusted hazard ratios (95% confidence interval [CI]) of maximum morning systolic blood pressure (SBP) and maximum evening SBP for cardiovascular events were 1.12 (1.01-1.24) and 1.19 (1.07-1.31), respectively, adjusted by sex, duration of diabetes, body mass index, hemoglobin A1c, low density lipoprotein cholesterol, smoking status, and use of antihypertensive medications. The cutoff values of maximum blood pressure for the events were 150 mmHg in the morning (hazard ratio, 1.73; 95% CI, 1.07-2.81) and 157 mmHg in the evening (hazard ratio, 2.30; 95% CI, 1.46-3.61), using the Youden's index. Maximum home blood pressure is a predictor of subsequent cardiovascular events in patients with type 2 diabetes.

Association Between Gout Flare and Subsequent Cardiovascular Events Among Patients With Gout

Gout is associated with cardiovascular diseases. The temporal association between gout flares and cardiovascular events has not been investigated. To investigate whether there is a transient increase in risk of cardiovascular events after a recent gout flare. A retrospective observational study was conducted using electronic health records from the Clinical Practice Research Datalink in England between January 1, 1997, and December 31, 2020. A multivariable nested case-control study was performed among 62 574 patients with gout, and a self-controlled case series, adjusted for season and age, was performed among 1421 patients with gout flare and cardiovascular event. Gout flares were ascertained using hospitalization, primary care outpatient, and prescription records. The primary outcome was a cardiovascular event, defined as an acute myocardial infarction or stroke. Association with recent prior gout flares was measured using adjusted odds ratios (ORs) with 95% CIs in a nested case-control study and adjusted incidence rate ratios (IRRs) with 95% CIs in a self-controlled case series. Among patients with a new diagnosis of gout (mean age, 76.5 years; 69.3% men, 30.7% women), 10 475 patients with subsequent cardiovascular events were matched with 52 099 patients without cardiovascular events. Patients with cardiovascular events, compared with those who did not have cardiovascular events, had significantly higher odds of gout flare within the prior 0 to 60 days (204/10 475 [2.0%] vs 743/52 099 [1.4%]; adjusted OR, 1.93 [95% CI, 1.57-2.38]) and within the prior 61 to 120 days (170/10 475 [1.6%] vs 628/52 099 [1.2%]; adjusted OR, 1.57 [95% CI, 1.26-1.96]). There was no significant difference in the odds of gout flare within the prior 121 to 180 days (148/10 475 [1.4%] vs 662/52 099 [1.3%]; adjusted OR, 1.06 [95% CI, 0.84-1.34]). In the self-controlled case series (N = 1421), cardiovascular event rates per 1000 person-days were 2.49 (95% CI, 2.16-2.82) within days 0 to 60; 2.16 (95% CI, 1.85-2.47) within days 61 to 120; and 1.70 (95% CI, 1.42-1.98) within days 121 to 180 after a gout flare, compared with cardiovascular event rates of 1.32 (95% CI, 1.23-1.41) per 1000 person-days within the 150 days before or the 181 to 540 days after the gout flare. Compared with 150 days before or the 181 to 540 days after a gout flare, incidence rate differences for cardiovascular events were 1.17 (95% CI, 0.83-1.52) per 1000 person-days, and adjusted IRRs were 1.89 (95% CI, 1.54-2.30) within days 0 to 60; 0.84 (95% CI, 0.52-1.17) per 1000 person-days and 1.64 (95% CI, 1.45-1.86) within days 61 to 120; and 0.38 (95% CI, 0.09-0.67) per 1000 person-days and 1.29 (95% CI, 1.02-1.64) within days 121 to 180 after a gout flare. Among individuals with gout, those who experienced a cardiovascular event, compared with those who did not experience such an event, had significantly higher odds of a recent gout flare in the preceding days. These findings suggest gout flares are associated with a transient increase in cardiovascular events following the flare.

Peri-operative cardiac events in patient undergoing surgery for gynecologic malignancies are associated with long-term cardiovascular outcomes (489)

Objectives: Cardiovascular (CV) disease is a leading cause of mortality in older women, but there is limited data on women with gynecologic cancer. Cancer and CV disease have significant pathophysiologic overlap, and both independently increase the risk of the other. Cancer patients have a 5-fold increased risk of major stroke or myocardial infarction, and patients who have perioperative cardiac events in noncardiac surgeries have significantly increased mortality. We aimed to characterize the incidence of perioperative events and long-term outcomes in women undergoing surgery for gynecologic malignancy. Methods: A retrospective cohort analysis was performed from January 1, 2013, to December 31, 2019, of all patients with gynecologic malignancies who had either a perioperative (within 30 days of surgery) or subsequent cardiac event. Events were abstracted from the electronic medical record using ICD codes. Demographic, medical history, comorbid conditions, oncologic course, and event-based data were analyzed using SAS 9.4. Results: One hundred seventy-four patients met the inclusion criteria; 76 (45.3%) had ovarian cancer, 69 (40.0%) had uterine cancer, and 23 (13.7%) had cervical/vulvovaginal cancer. The average age was 67.4 years, 63.0% were white, 35.3% were Black, and 1.2% were Asian. Fifty-four (31.0%) patients experienced a perioperative CV event. Arrhythmia was most common (23.6%), followed by heart failure exacerbation (4.6%) and NSTEMI (4.6%). Of these patients, 35.2% had not been identified to be at increased cardiac risk preoperatively. Among the patients who had a perioperative event, 46.7% were diagnosed with a new chronic CV condition. After 30 days of follow-up, 45.4% of patients had a new CV event: arrhythmia was most common (17.8%), followed by heart failure exacerbation (16.7%) and stroke/ TIA (5.2%). Of these patients, 33 were diagnosed with at least one chronic CV condition, including heart failure (51.5%), atrial fibrillation (30.3%), CAD (6.1%), and pulmonary hypertension (6.1%). Fifteen patients who had perioperative events had a subsequent CV event. Conclusions: Perioperative cardiac events related to surgery for gynecologic malignancy, though rare, may represent a sentinel event for CV health and represent an opportunity for early intervention. Almost half of the patients with a CV event were diagnosed with a new chronic CV condition, and almost one-third had a subsequent CV event. Additional studies should focus on the long-term sequelae of perioperative CV events in gynecologic oncology patients and their interaction with oncologic outcomes. Objectives: Cardiovascular (CV) disease is a leading cause of mortality in older women, but there is limited data on women with gynecologic cancer. Cancer and CV disease have significant pathophysiologic overlap, and both independently increase the risk of the other. Cancer patients have a 5-fold increased risk of major stroke or myocardial infarction, and patients who have perioperative cardiac events in noncardiac surgeries have significantly increased mortality. We aimed to characterize the incidence of perioperative events and long-term outcomes in women undergoing surgery for gynecologic malignancy. Methods: A retrospective cohort analysis was performed from January 1, 2013, to December 31, 2019, of all patients with gynecologic malignancies who had either a perioperative (within 30 days of surgery) or subsequent cardiac event. Events were abstracted from the electronic medical record using ICD codes. Demographic, medical history, comorbid conditions, oncologic course, and event-based data were analyzed using SAS 9.4. Results: One hundred seventy-four patients met the inclusion criteria; 76 (45.3%) had ovarian cancer, 69 (40.0%) had uterine cancer, and 23 (13.7%) had cervical/vulvovaginal cancer. The average age was 67.4 years, 63.0% were white, 35.3% were Black, and 1.2% were Asian. Fifty-four (31.0%) patients experienced a perioperative CV event. Arrhythmia was most common (23.6%), followed by heart failure exacerbation (4.6%) and NSTEMI (4.6%). Of these patients, 35.2% had not been identified to be at increased cardiac risk preoperatively. Among the patients who had a perioperative event, 46.7% were diagnosed with a new chronic CV condition. After 30 days of follow-up, 45.4% of patients had a new CV event: arrhythmia was most common (17.8%), followed by heart failure exacerbation (16.7%) and stroke/ TIA (5.2%). Of these patients, 33 were diagnosed with at least one chronic CV condition, including heart failure (51.5%), atrial fibrillation (30.3%), CAD (6.1%), and pulmonary hypertension (6.1%). Fifteen patients who had perioperative events had a subsequent CV event. Conclusions: Perioperative cardiac events related to surgery for gynecologic malignancy, though rare, may represent a sentinel event for CV health and represent an opportunity for early intervention. Almost half of the patients with a CV event were diagnosed with a new chronic CV condition, and almost one-third had a subsequent CV event. Additional studies should focus on the long-term sequelae of perioperative CV events in gynecologic oncology patients and their interaction with oncologic outcomes.

Trends in cardiology follow-up and long-term care for patients who experienced cardiac events after surgery for gynecologic malignancies (490)

Objectives: Cardiovascular (CV) disease is a leading cause of mortality in older women, but there is limited data regarding women with gynecologic cancer. Oncologic diagnoses represent an independent elevated risk for CV events, and perioperative cardiac events are associated with a significantly higher risk of long-term CV disease. However, formal co-management or facilitated entry to care are limited between gynecologic oncology and cardiology. We aimed to characterize referral rates for cardiology care and follow-up for women with gynecologic malignancy who experienced perioperative or subsequent CV events. Methods: A retrospective cohort analysis was performed from January 1, 2013, to December 31, 2019, of all patients with gynecologic malignancies who had either a perioperative (within 30 days) or subsequent cardiac event. Events were abstracted from the electronic medical record using ICD codes. Demographic, medical history, comorbid conditions, oncologic course, and event-based data were analyzed using SAS 9.4. Results: One hundred seventy-four patients met the inclusion criteria; 76 (45.3%) had ovarian cancer, 69 (40.0%) had uterine cancer, and 23 (13.7%) had cervical/vulvovaginal cancer. The average age was 67.4 years, 63.0% were White, 35.3% were Black, and 1.2% were Asian. Fifty-four patients had a perioperative CV event. Of these patients, 63.8% were recommended for cardiology referral, and 70.3% had documented follow-up. Total 46.7% of patients received a new chronic CV diagnosis via this pathway. During the follow-up period, 52 patients had a CV event. Of these, 60.5% were recommended for cardiology referral, and 86.3% had documented follow-up. Almost 54.1% received a new chronic CV diagnosis. Of patients who had a perioperative CV event but were not recommended for cardiology follow-up, 29.4% had a subsequent CV event. Conclusions: As the survivorship of women with gynecologic malignancies improves, the interactions between oncologic care and CV health represent an opportunity to improve collaboration. Approximately half of the patients with perioperative or followup CV events were diagnosed with an underlying CV condition. Approximately one-third of patients who did not receive follow-up at the first event experienced a second event. Establishing a pathway for care may decrease the rate of these events and prevent morbidity. Furthermore, increasing evidence suggests that these events impact oncologic outcomes and overall mortality. Objectives: Cardiovascular (CV) disease is a leading cause of mortality in older women, but there is limited data regarding women with gynecologic cancer. Oncologic diagnoses represent an independent elevated risk for CV events, and perioperative cardiac events are associated with a significantly higher risk of long-term CV disease. However, formal co-management or facilitated entry to care are limited between gynecologic oncology and cardiology. We aimed to characterize referral rates for cardiology care and follow-up for women with gynecologic malignancy who experienced perioperative or subsequent CV events. Methods: A retrospective cohort analysis was performed from January 1, 2013, to December 31, 2019, of all patients with gynecologic malignancies who had either a perioperative (within 30 days) or subsequent cardiac event. Events were abstracted from the electronic medical record using ICD codes. Demographic, medical history, comorbid conditions, oncologic course, and event-based data were analyzed using SAS 9.4. Results: One hundred seventy-four patients met the inclusion criteria; 76 (45.3%) had ovarian cancer, 69 (40.0%) had uterine cancer, and 23 (13.7%) had cervical/vulvovaginal cancer. The average age was 67.4 years, 63.0% were White, 35.3% were Black, and 1.2% were Asian. Fifty-four patients had a perioperative CV event. Of these patients, 63.8% were recommended for cardiology referral, and 70.3% had documented follow-up. Total 46.7% of patients received a new chronic CV diagnosis via this pathway. During the follow-up period, 52 patients had a CV event. Of these, 60.5% were recommended for cardiology referral, and 86.3% had documented follow-up. Almost 54.1% received a new chronic CV diagnosis. Of patients who had a perioperative CV event but were not recommended for cardiology follow-up, 29.4% had a subsequent CV event. Conclusions: As the survivorship of women with gynecologic malignancies improves, the interactions between oncologic care and CV health represent an opportunity to improve collaboration. Approximately half of the patients with perioperative or followup CV events were diagnosed with an underlying CV condition. Approximately one-third of patients who did not receive follow-up at the first event experienced a second event. Establishing a pathway for care may decrease the rate of these events and prevent morbidity. Furthermore, increasing evidence suggests that these events impact oncologic outcomes and overall mortality.

Predicting Sensitivity to Adverse Lifestyle Risk Factors for Cardiometabolic Morbidity and Mortality.

People appear to vary in their susceptibility to lifestyle risk factors for cardiometabolic disease; determining a priori who is most sensitive may help optimize the timing, design, and delivery of preventative interventions. We aimed to ascertain a person’s degree of resilience or sensitivity to adverse lifestyle exposures and determine whether these classifications help predict cardiometabolic disease later in life; we pooled data from two population-based Swedish prospective cohort studies (n = 53,507), and we contrasted an individual’s cardiometabolic biomarker profile with the profile predicted for them given their lifestyle exposure characteristics using a quantile random forest approach. People who were classed as ‘sensitive’ to hypertension- and dyslipidemia-related lifestyle exposures were at higher risk of developing cardiovascular disease (CVD, hazards ratio 1.6 (95% CI: 1.3, 1.91)), compared with the general population. No differences were observed for type 2 diabetes (T2D) risk. Here, we report a novel approach to identify individuals who are especially sensitive to adverse lifestyle exposures and who are at higher risk of subsequent cardiovascular events. Early preventive interventions may be needed in this subgroup.

Prevalence and Associated Factors of Electrocardiogram Abnormalities in Patients With Systemic Lupus Erythematosus: A Machine Learning Study.

Electrocardiogram (EKG) abnormalities are predictive of subsequent cardiovascular events. Cardiac involvement is common in systemic lupus erythematosus (SLE). We aimed to determine the prevalence of EKG abnormalities in SLE patients and to examine the factors associated with EKG abnormalities with machine learning approaches. Consecutive SLE patients' records were retrieved from the database of the hospital for the cross-sectional study. Abnormal EKGs with clinical significance were grouped by the presence of tachyarrhythmias, atrioventricular block, nonspecific ST segment changes, T wave abnormalities, ventricular hypertrophy, axis deviation, bundle branch block, and QT interval prolongation. Associated factors of the most common EKG abnormalities were assessed by comparing logistic regression and 4 other machine learning approaches. In the present study, 299 patients were enrolled, with 128 showing clinically significant abnormalities on EKG. T wave changes (52.3%), nonspecific ST segment-T wave (ST-T) changes (26.6%), and prolonged QT interval (8.6%) were the most prevalent abnormalities among patients with abnormal findings on EKG. Random forests models had the best performance in the discovery of associated factors. Age, disease duration, antinuclear antibody titer, disease activity (as measured by the Systemic Lupus Erythematosus Disease Activity Index 2000) were associated with nonspecific ST-T changes, prolonged QT interval, and T wave changes. Hypertension, positivity for anti-SSA antibodies, and secondary Sjögren's syndrome were influential factors for nonspecific ST-T changes, prolonged QT interval, and T wave changes, specifically. ST-T and T wave changes were the most common abnormalities seen on EKGs of SLE patients. Our finding suggests that age, longer disease duration, higher disease activity, hypertension, anti-SSA antibody positivity, and secondary Sjögren's syndrome are important and influential factors in these EKG abnormalities.

O070 Can the compass trial recommendations be implemented following symptomatic carotid endarterectomy (CEA)?

Abstract Introduction The paradigm changing COMPASS trial (1) demonstrated that in stable atherosclerotic disease, low-dose Rivaroxaban and Aspirin has a significantly greater protective effect on subsequent cardiovascular events (death, stroke or myocardial infarct) than antiplatelet medication alone. This included carotid endarterectomy patients. We assessed our success at implementing COMPASS in our symptomatic CEA patients Methods At the four-week virtual post-CEA review, in suitable patients the general practitioner was advised to change from single antiplatelet to COMPASS regimen. At 6-month follow-up the success and safety of the conversion was assessed. Results For 18 months up to February 2021, 47 patients underwent successful CEA. 29 were recommended for COMPASS, 3 were lost to follow up and 15 were not suitable (6 on DOAC for AF/VTE, 9 complex drug regimen). At 6 months 18 of 29 patients were on the COMPASS regimen (9 not started; 2 withdrawn due to bruising). All patients reported compliance to the regimen. There were no reported haemorrhagic events. 1 patient (not in the COMPASS group) had further multi-territory cerebrovascular events. Conclusion COMPASS is well tolerated in this cohort. Conversion from established drug regimens has yet to gain traction. The benefits on future cardiovascular events post-CEA is yet to be determined. Take-home message Changing post-op medications after a carotid endarterectomy can reduce the later risk of Cardiovascular events. We demonstrate it is possible to successfully do this, but should aim for a higher rate of uptake. (1): N Engl J Med 2017; 377:1319–1330 DOI: 10.1056/NEJMoa1709118

Association of changes in cardiovascular health levels with incident cardiovascular events and mortality in patients with atrial fibrillation.

Risk factor management is crucial in the management of atrial fibrillation (AF). We investigated the association of changes in cardiovascular health (CVH) levels after AF diagnosis with incident cardiovascular events and mortality. From the Korea National Health Insurance Service database, 76,628 patients newly diagnosed with AF (2005-2015) with information on health examinations before and after AF diagnosis were assessed. According to the change in the 12-point CVH score before and after AF diagnosis, patients were stratified into four groups: consistently low (score 0-7 to 0-7), high-to-low (8-12 to 0-7), low-to-high (0-7 to 8-12), and consistently high (8-12 to 8-12) CVH levels. Risks of cardiovascular events and death were analyzed using weighted Cox regression models with inverse probability of treatment weighting (IPTW) for balance across study groups. The mean age of study participants was 58.3years, 50,285 were men (63.1%), and the mean follow-up was 5.5years. After IPTW, low-to-high (hazard ratio [95% confidence interval], 0.83 [0.76-0.92]) and consistently high (0.80 [0.74-0.87]) CVH levels were associated with a lower risk of ischemic stroke than consistently low CVH. Low-to-high (0.66 [0.52-0.84]) and consistently high (0.52 [0.42-0.64]) CVH levels were associated with a lower risk of acute myocardial infarction. Maintaining high CVH was associated with reduced risks of heart failure hospitalization (0.85 [0.75-0.95]) and all-cause death (0.82 [0.77-0.88]), respectively, compared with consistently low CVH. Improving CVH levels and maintaining high CVH levels after AF diagnosis is associated with lower risks of subsequent cardiovascular events and mortality.

Gender Differences in the Risk of Adverse Outcomes After Incident Diabetic Foot Hospitalization: A Population Cohort Study.

Diabetic Foot Disease (DFD) is more prevalent among males and is associated with an excess risk of cardiovascular events or mortality. This study aimed at exploring the risk of cardiovascular events, renal failure, and all-cause mortality after incident DFD hospitalizations, separately in males and females, to detect any gender difference in a cohort of 322,140 people with diabetes retrospectively followed up through administrative data sources in Tuscany, Italy, over the years 2011-2018. The Hazard Ratio (HR) for incident adverse outcomes after first hospitalizations for DFD, categorized as major/minor amputations (No.=449;3.89%), lower limbs' revascularizations (LLR: No.=2854;24.75%), and lower-extremity-arterial-disease (LEAD) with no procedures (LEAD-no proc: No.=6282;54.49%), was compared to the risk of patients having a background of DFD (ulcers, infections, Charcot-neuroarthropathy: No.=1,944;16.86%). DFD incidence rate was higher among males compared to females (1.57(95% CI:1.54-1.61) vs. 0.97(0.94-1.00)/100,000p-years]. After DFD, the overall risk of coronary artery disease was significantly associated with the male gender and of stroke with the female gender. LEAD-no proc and LLR were associated with the risk of stroke only in females, whereas they were found to be associated with the risk of coronary artery disease among females to a significantly greater extent compared to males. The incident of renal failure was not associated with any DFD category. Amputations and LEAD-no proc significantly predicted high mortality risk only in females, while LLR showed reduced risk in both genders. Moreover, females had a greater risk of composite outcomes (death or cardiovascular events). Compared to the background of DFD, the risk was found to be 34% higher after amputations (HR: 1.34(1.04-1.72)) and 10% higher after LEAD-no proc (HR:1.10(1.03-1.18)), confirming that after incident DFD associated with vascular pathogenesis, females are at an increased risk of adverse events. After incident DFD hospitalizations, females with DFD associated with amputations or arterial disease are at a greater risk of subsequent adverse cardiovascular events than those with a DFD background.

Design, methods and baseline characteristics of the Beijing Hospital Atherosclerosis Study: a prospective dynamic cohort study.

BackgroundThe atherosclerotic coronary artery disease (CAD) risk assessment based on conventional risk factors have only moderate performance, and residual risks still exist. Thus, we reported here a cohort study that aims to identify and validate the new biosignatures (especially the metabolomics, lifestyle biomarkers and biological age), and elucidate their predictive effect on CAD and subsequent cardiovascular events.MethodsThis prospective, single-center, cohort study commenced in March 2017 and seeks to examine patients undergoing coronary angiography (CAG) at the Beijing Hospital. Patients’ baseline demographic and medical history data are captured by questionnaires. Blood samples are taken before CAG for clinical laboratory tests and metabolomics analyses. Traditional CAD risk factors are analyzed by routine assays. CAD-related metabolites from different metabolic pathways and lifestyle biomarkers are measured by liquid chromatography-tandem mass spectrometry methods. Biological ages are calculated based on the laboratory and metabolomics data. The enrolled patients attend annual follow-up examinations for 10 years. The primary end points are the composite end points of major adverse cardiovascular events, including death from any cause, non-fatal myocardial infarction, and non-fatal stroke. Quality management and control are carried out through the entire research process, including standardized baseline and follow-up investigation, intra- and inter-run quality controls for laboratory measurements, etc.ResultsBaseline data of the enrolled 2,970 patients from 2017 to 2020 were collected and are presented in this article. Among them, there were more males (62.5%) than females, and the patients tended to be old and overweight. The percentages of diagnosed hypertension and diabetes were 67.3% and 35.2%, respectively. A total of 8.5% had a family history of premature CAD. Their lipid profiles were within the normal range, probably due to the use of statins.ConclusionsThis study has successfully initiated an investigation into the roles of new biosignatures in predicting CAD among Chinese Han patients undergoing CAG. To the best of our knowledge, this cohort is the first study systematically focusing on the association of lifestyle biomarkers and biological age with CAD risk. Findings from this study will provide biomarkers to discriminate the presence of CAD and to predict subsequent cardiovascular events.

Myocardial infarction in pregnancy: Current topical issues in diagnostics and treatment

Lately due to the increase of childbearing age of women, high prevalence of cardiovascular diseases, and, presumably, due to the usage of some medications, there was an increase in myocardial infarction (MI) cases in pregnant women. Risk factors and pathophysiological mechanisms of MI in pregnant women differ from the general population, and are heterogeneous. Pregnancy and childbirth can be defined as ‘physiological stress’ for the cardiovascular system, which can cause MI. Abrupt changes in hemodynamics and increased coagulation state during pregnancy, in childbirth or in the early postpartum period can provoke sudden constriction (vasospasm) of a coronary artery (CA), as well as non-atherosclerotic spontaneous CA dissection, which leads to a critical decrease in the supply of oxygen to the heart muscle. The frequency of hemodynamically significant atherosclerosis of CA is also increasing. The incidence of maternal, perinatal mortality and obstetric complications is higher than in women without history of acute coronary syndrome. Over the past few decades, the diagnosis and treatment of myocardial infarction improved, the number of primary percutaneous coronary interventions in pregnant women increased, and there is now less inpatient mortality. However, due to the absence of large randomized clinical trials on the MI in pregnant women it is impossible to develop a unified algorithm for the management and preventive measures for this condition, thereby it is difficult to select an optimal treatment tactic, and hard to predict subsequent cardiovascular events. In this article we analyzed current data on MI during pregnancy, childbirth, and the postpartum period.