Traditional Cardiac Risk Factors Research Articles

Abstract 4142798: Differences in Clinical presentation in Spontaneous Coronary Artery Dissection vs. Type 1 Myocardial Infarction

Background: Spontaneous coronary artery dissection (SCAD) refers to the nontraumatic, non-iatrogenic, and nonatherosclerotic separation of the coronary artery wall leading to acute coronary syndrome. This condition predominantly affects women with minimal or no traditional cardiac risk factors. We aimed to determine the differences in clinical presentation between SCAD and Type 1 myocardial infarction (MI) in the Aurora Health Care community. Methods: A retrospective, matched cohort, multicenter community study was carried out on adult patients aged >18 years admitted to all Aurora Hospitals from January 2012 to December 2022. A total of 57 patients were diagnosed with SCAD during that period. SCAD group and Type 1 MI group were matched by age and gender at a 1:5 ratio using a propensity score-based matching. Outcomes between the SCAD and the Type 1 MI groups were compared using chi-squared tests or Fisher’s exact tests, and t-tests or nonparametric equivalents (Wilcoxon). Results: A higher percentage of Type 1 MI patients presented as NSTEMI compared to SCAD patients (70% vs. 59.6%, p=0.028). Although not statistically significant, SCAD patients had a higher occurrence of STEMI than Type 1 MI patients (42.1% vs. 32.6%, p=0.169). On admission, SCAD patients had a higher maximum troponin (12,000 vs. 3,550, p=0.012). Type 1 MI patients had higher HgbA1C (6 vs. 5.4, p=0.0008). Both patients had similar LDL levels, but Type 1 MI had lower HDL levels (44 vs. 48, p=0.024). ESR, CRP, and D-dimer levels showed no significant difference. LV ejection fraction was 53% in both groups, and the LV global longitudinal strain was similar. The Type 1 MI group exhibited higher grades of diastolic dysfunction (Grade 2 and Grade 3) and mitral valve disease. E/e was higher in Type 1 MI compared to SCAD (11.5 vs 8.8, p <0.0001). Type 2 SCAD was most prevalent at presentation, with the most frequently affected artery being LAD (47.4%) and the most frequently affected branch vessel being obtuse marginal (36.4%). The most common location was distal (59.6%), followed by mid (22.8%), with the diameter of the vessel involved mostly between 2-3.5 mm. Conclusion: This study observed that although more SCAD patients presented as STEMI with higher troponins, Type 1 MI patients were sicker overall. These differences in clinical findings can aid in diagnosis as the management of these two populations differ.

Novel deep learning algorithm demonstrates strong performance for detection and quantification of breast arterial calcification and associates with cardiovascular disease

Abstract Background Breast arterial calcification (BAC) on mammography is associated with cardiovascular disease (CVD).1, 2 Given mammography is widely used as part of national breast cancer screening programs, routine reporting of BAC could address current limitations of CVD detection in women. Fully automated artificial intelligence (AI) software can facilitate seamless integration of BAC assessment alongside standard radiological evaluation of mammograms. and advancement in AI imaging software may result in clinically significant, superior BAC detection. Purpose To evaluate the performance of a deep-learning, fully-automated BAC detection algorithm against gold standard human BAC detection, and to evaluate its association with cardiovascular risk and disease. Methods A cohort of 285 women (mean age 61) with 2D digital mammography and CVD assessment with either an anatomic or functional test were evaluated. Cardiovascular risk factors were obtained from medical records. Visual BAC (vBAC) was assessed as present/absent by independent reviewers and BAC was scaled by an algorithm incorporating size, length, density and location (aBAC, 0-100). Diagnostic performance of vBAC and aBAC were compared and expressed as area under the receiver operator characteristic curve (AUC). Cardiovascular risk factor and disease prevalence was compared between vBAC and aBAC with CVD status defined by either abnormal anatomical or functional testing. Results The prevalence of vBAC and aBAC were 30.5% and 59.6%, respectively. The algorithm showed excellent discrimination for BAC detection compared with vBAC (AUC 0.92 [95% CI 0.89-0.98]), with sensitivity 94% and negative predictive value 96%. Interpretation took on average 144 seconds/patient with vBAC and 10 seconds/patient with aBAC (p<0.001). We identified 88 discordant cases (vBAC negative, aBAC positive), which were all represented by ‘faint’ BAC scores (<25). aBAC detected a greater proportion of patients with traditional cardiac risk factors, particularly in women <65 years (Figure 1). CVD was present in 136 (48%), among whom 37.5% were detected by vBAC and 61.7% by aBAC. CVD was present in 42% of the 88 discordant cases. Increasing BAC score was associated with increased relative risk of CVD presence (Figure 2). Conclusion Algorithmic scoring of BAC demonstrates a high performance and is faster to perform when compared to vBAC. Furthermore, it identifies greater proportion of women with higher cardiovascular risk and those with prevalent CVD. Lastly, aBAC detects ‘faint’ (visually missed) lesions that may have significant clinical implications.

Incidence of MINOCA in the high-sensitivity troponin era: a meta-analysis

Abstract Background and Aim Myocardial infarction with non-obstructive coronary arteries (MINOCA) is often under-recognised in clinical practice. The reported incidence of MINOCA was estimated to be 6% of MI presentations by Pasupathy et al. in the era preceding adoption of high sensitivity troponin assays. We sought to investigate the incidence of MINOCA in the high-sensitivity troponin era as compared to incidence of MINOCA during the era of traditional cardiac biomarkers (standard troponin assays, CK, CK-MB). Methods A prospective systematic review and meta-analysis using MEDLINE and EMBASE to capture relevant papers from 1996-2022 was performed. Papers detailing incidence of MI-CAD and MINOCA as well as the utilised biomarkers were included. Patient demographics, presentation and recorded biomarkers were also analysed for pre-specified analysis. Results 47 studies detailing the results of 667 850 patients were included. 53 586 patients were identified to have MINOCA with a mean weight incidence of 9.1% (7.3-11.3, 95% CI). MI-CAD patients were more likely to be male (68.5% vs 39.3%, RR (0.59, 0.74)) and had higher incidence of traditional cardiac risk factors. Notably chronic kidney disease was not associated with higher incidence of MICAD over MINOCA (RR 0.72, 0.5-1.03). There were no significant trends in incidence of MINOCA according to median year of study recruitment (ß=-0.18, (-0.76, 0.4) p=0.537). MINOCA patients were more likely to present as NSTEMI (14.5% (11.3-18.3, 95%CI)) rather than STEMI (3.5% (2.7-4.7%)). MINOCA patients had lower cardiac biomarker elevations than patients with MICAD. Conclusions The incidence of MINOCA higher than previously estimated in the era of high sensitivity troponin. MINOCA patients are less likely to have traditional cardiac risk factors and more likely to present with NSTEMI and smaller cardiac biomarker elevations than patients with MI-CAD.MINOCA RateMINOCA vs MI-CAD Risk Factors

Fear of recurrence and its association with mental health outcomes after spontaneous coronary artery dissection (SCAD)

Abstract Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction, predominantly affecting younger women with few traditional cardiac risk factors. The condition is characterised by relatively high rates of recurrence. Recent qualitative studies demonstrate that SCAD survivors often experience fears about the future, particularly relating to SCAD recurrence and death. Research in psycho-oncology demonstrates that experiencing fear of cancer recurrence predicts worse outcomes for mental health and quality of life, an association that is also likely in cardiac patients. To date, no quantitative research has investigated fear of recurrence and its association with mental health in SCAD survivors. Purpose The aim of this study was to investigate the prevalence of fears relating to SCAD recurrence and the association of fear of recurrence with mental health outcomes. Methods 293 SCAD survivors completed an online questionnaire assessing the psychosocial impacts of SCAD. Participants rated whether they experienced these impacts ‘not at all’, ‘a small amount, ‘a moderate amount’ or ‘a large amount’ within the first six months of their SCAD. Items related to fears about the future, recurrence, and death were extracted for analysis. Participants also completed measures of anxiety (Generalised Anxiety Disorder-7), depression (Patient Health Questionnaire-9), distress (Cardiac Distress Inventory - Short Form), and mental health related quality of life (Short Form 12, mental health component). Results In the six months following their SCAD, 97.6% of survivors experienced some level of worry about having another SCAD, 95.6% were concerned about triggering another SCAD, 95.6% experienced fear of the future, and 82.6% experienced fear of dying. Reports of experiencing ‘a large amount’ of fear in these areas were 54.6%, 45.1%, 42.7%, and 30.4% respectively. The amount of worry reported about having another SCAD was significantly associated with increased levels of anxiety, depression, and cardiac distress, and reduced mental health quality of life. Conclusions Almost all SCAD survivors reported fears, worries, and concerns related to recurrence. Worry about SCAD recurrence was significantly associated with important mental health outcomes. Cardiac health professionals should monitor fears of recurrence in their patients, as a large amount of worry may be indicative of poor mental health, and referral to psychology services may be appropriate.Rates of fears of SCAD recurrence

The potential of autologous regulatory T cell (Treg) therapy to prevent Cardiac Allograft Vasculopathy (CAV) in paediatric heart transplant recipients.

Paediatric heart transplant is an established treatment for end stage heart failure in children, however patients have to commit to lifelong medical surveillance and adhere to daily immunosuppressants to minimise the risk of rejection. Compliance with immunosuppressants can be burdensome with their toxic side effects and need for frequent blood monitoring especially in children. Though the incidence of early rejection episodes has significantly improved overtime, the long-term allograft health and survival is determined by Cardiac Allograft Vasculopathy (CAV) which affects a vast number of post-transplant patients. Once CAV has set in, there is no medical or surgical treatment to reverse it and graft survival is significantly compromised across all age groups. Current treatment strategies include novel immunosuppressant agents and drugs to lower blood lipid levels to address the underlying immunological pathophysiology and to manage traditional cardiac risk factors. Translational researchers are seeking novel immunological approaches that can lead to permanent acceptance of the allograft such as using regulatory T cell (Tregs) immunotherapy. Clinical trials in the setting of graft versus host disease, autoimmunity and kidney and liver transplantation using Tregs have shown the feasibility and safety of this strategy. This review will summarise current knowledge of the latest clinical therapies for CAV and pre-clinical evidence in support of Treg therapy for CAV. We will also discuss the different Treg sources and the considerations of translating this into a feasible immunotherapy in clinical practice in the paediatric population.

Prognostic value of gut microbe-generated metabolite phenylacetylglutamine in patients with heart failure.

Phenylacetylglutamine (PAGln) is a phenylalanine-derived metabolite produced by gut microbiota with mechanistic links to heart failure (HF)-relevant phenotypes. We sought to investigate the prognostic value of PAGln in patients with stable HF. Fasting plasma PAGln levels were measured by stable-isotope-dilution liquid chromatography-tandem mass spectrometry (LC-MS/MS) in patients with stable HF from two large cohorts. All-cause mortality was assessed at 5-year follow-up in the Cleveland cohort, and HF, hospitalization, or mortality were assessed at 3-year follow-up in the Berlin cohort. Within the Cleveland cohort, median PAGln levels were 4.2 (interquartile range [IQR] 2.4-6.9) μM. Highest quartile of PAGln was associated with 3.09-fold increased mortality risk compared to lowest quartile. Following adjustments for traditional risk factors, as well as race, estimated glomerular filtration rate, amino-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, left ventricular ejection fraction, ischaemic aetiology, and HF drug treatment, elevated PAGln levels remained predictive of 5-year mortality in quartile comparisons (adjusted hazard ratio [HR] [95% confidence interval, CI] for Q4 vs Q1: 1.64 [1.07-2.53]). In the Berlin cohort, a similar distribution of PAGln levels was observed (median 3.2 [IQR 2.0-4.8] μM), and PAGln levels were associated with a 1.92-fold increase in 3-year HF hospitalization or all-cause mortality risk (adjusted HR [95% CI] for Q4 vs Q1: 1.92 [1.02-3.61]). Prognostic value of PAGln appears to be independent of trimethylamine N-oxide levels. High levels of PAGln are associated with adverse outcomes independent of traditional cardiac risk factors and cardio-renal risk markers.

Epidemiological Profile of Myocardial Infarction with Non-Significant Stenosis of Coronary Arteries (MINOCA)

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) remains a puzzling clinical entity characterized by clinical evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography (stenosis < 50%). This pathology is poorly understood, several studies are underway for a better understanding of this disease. The aim of our work was to review the literature and assess the epidemiology, clinical features, prognosis and etiologies of MINOCA. Methods: Descriptive, prospective study, spread over a period of 36 months from January 2018 to December 2020 involving a total number of 585 patients undergoing coronary angiography at the cardiology department of CHU Tlemcen, for a reason for acute myocardial ischemia. We defined the patients as having acute myocardial ischemia with obstructive coronary artery disease (MI-CAD) if there was revascularization or plaque ≥ 50% and as having MINOCA if there was <50% obstruction or a mechanism without plaque. Patients who received thrombolytics before angiography were excluded. We studied the epidemiological, clinical and prognostic profile of the MINOCA population then compared them to patients with obstructive coronary artery disease and finally we established an etiological analysis of the MINOCA population. Results: The number of MINOCA cases in our sample of 585 AMI patients was 10.25% vs. 525 (89.74%) cases of AMI-CO, it was more common in men (78.3% vs. 21, 7%; odds ratio at 3.61) and in the youngest patients. MINOCA patients were more likely to be without traditional cardiac risk factors (7.9% vs. 2.1%; P <0.001) but more predisposed to non-traditional risk factors than AMI-CO patients (3.7% against 1.8%; P = 0.026). Smoking is the only traditional risk factor frequent in the MINOCA population versus MI-CAD (P at 0.001). Depression, stress, drug addiction, DVT history and autoimmune disease history are more frequent in the MINOCA population versus MI-CAD (P <0.05) STEMI are more found in the MINOCA population versus MI-CAD (P = 0.000) In terms of prognosis, the MINOCA population had a better prognosis: less risk of recurrence than the MI-CAD population 6.7% versus 10.45% (P = 0.03) also less mortality 0% versus 4.6% (P = 0.007). Conclusion: The patients with MINOCA were more men, smokers, depressed, stressed, drug addicts with hypercoagulable states compared to patients with obstructive coronary artery disease (MI- CAD) however they had a better quality of life and a good prognosis.

Incidence and predictors of sudden cardiac arrest in cardiac amyloidosis: a 5-year retrospective analysis

Abstract Background Despite recent advances in treatment, cardiac amyloidosis (CA) portends a poor outcome. Clinical manifestations of CA are variable and often nonspecific, which makes the diagnosis challenging. Failure to recognize early cardiac involvement may result in devastating complications such as sudden cardiac arrest (SCA). Electrocardiography (ECG) is a widely available and affordable modality that can aid with risk stratification. Purpose We aimed to study patient demographics and identify clinical and electrocardiographic (ECG) predictors of SCA in patients with CA. Methods We queried the Nationwide Inpatient Sample database between 2016–2020 to identify hospitalizations for CA who were then subcategorized based on SCA, using the ICD-10 diagnosis code. The primary outcome was to assess clinical and ECG predictors of SCA. Both groups were compared for association using the chi-square test, following which multivariate regression analysis was performed to identify predictors of SCA. In addition, we performed a temporal trends analysis of CA hospitalizations and SCA during this study period. Results A total of 103,620 weighted hospitalizations for CA were identified of which 1935(1.9%) suffered a SCA. Baseline characteristics and comorbidities were largely equivalent except for a history of heart failure which was significantly higher in the SCA group(63.3% vs 46.8%, p < 0.001). Interestingly, traditional cardiac risk factors like smoking, hypertension, diabetes, and obesity did not correlate with increased risk of SCA. African American (AA) race had a higher incidence of SCA(30.2% vs 23.4%, p < 0.001). A multivariate regression analysis was performed to identify predictors of SCA and account for potential clinical as well as demographic confounders. Higher rates of SCA were observed in male sex, age < 40 years, and AA race as outlined in figure 1. The presence of heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and tachyarrhythmias such as atrial fibrillation, atrial flutter, ventricular tachycardia and ventricular fibrillation were associated with significantly higher odds of SCA. In addition, right bundle branch block, left bundle branch block, first-degree AV block, complete heart block and fascicular blocks were independently predictive of higher rates of SCA. As expected, the rates of ICD implantation were higher in the SCA group (7.2% vs 0.9%, p < 0.001. There is an increasing trend in hospitalizations for cardiac amyloidosis from 2017 to 2020 as highlighted in figure 2. Conclusion Among patients with cardiac amyloidosis, young age, AA race, ECG evidence of AV nodal dysfunction, distal conduction disease, and tachyarrhythmias is associated with an elevated risk of SCA. These findings could improve risk stratification, prompt further targeted evaluation with advanced imaging modalities and help in early identification of amyloid patients with cardiac involvement.Figure 1Figure 2

Abstract 13306: Substantial Variation in the Rate of Coronary Artery Disease Among Ontario Immigrants

Immigrants constitute a substantial proportion of the population in Western Europe and North America. Although prior studies have suggested that a "healthy immigrant effect" exists, little is known about the extent and variation of stable obstructive coronary artery disease (CAD) among immigrants. We evaluated the association of country of origin and the rates of stable CAD among immigrants. We assembled a cohort of immigrants and non-immigrants who received elective cardiac catheterization in Ontario, Canada, between April 1, 2012 and March 31, 2021. Immigrants were categorized by their country of origin into 7 regions: Africa, Caribbean, Latin America, Western Countries, East Asia, South Asia, and Middle East. Our main outcome was the rate of obstructive CAD (left main stenosis ≥50% or major epicardial vessel stenosis ≥70%). Multivariable logistic regression analyses adjusting for age, cardiac risk factors, and socioeconomic status was used to study the association of country of birth with presence of CAD. The study included 208,363 non-immigrants and 36,139 immigrants: 13,503 from South Asia, 6,839 from Western Countries, 5,036 from East Asia, 4,374 from the Middle East, 2,481 from Latin America, 2,320 from Caribbean, and 1,586 from Africa. Obstructive CAD was found in 47.1% of immigrants and 47.4% of non-immigrants. Immigrants from South Asia had the highest rate of obstructive CAD at 53.7% and those from the Caribbean had the lowest rate at 32.5%. South Asian men and women had the highest odds of obstructive CAD compared to non-immigrants (Figure). Despite the conventional belief that immigrants have better health status, we found that immigrants in Canada had higher odds of obstructive CAD than non-immigrants. In addition, significant variation exists among patients by country of origin even after accounting for the traditional cardiac risk factors.

Myocardial Work in Apical Hypertrophic Cardiomyopathy

Pressure-strain loop analysis is a novel echocardiographic technique to calculate myocardial work indices that has not been applied to patients with apical hypertrophic cardiomyopathy (ApHCM). We hypothesized that myocardial work indices differ between patients with ApHCM and those with non-apical HCM (non-ApHCM). This study aimed to (1) evaluate myocardial work indices in patients with ApHCM compared to those with non-ApHCM, (2) describe associations with relevant clinical variables, and (3) examine associations with significant late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR). We retrospectively identified 48 patients with ApHCM and 69 with non-ApHCM who had measurements of global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). We evaluated available CMR data on 34 patients with ApHCM and 51 with non-ApHCM. Multivariable regression models correcting for traditional cardiac risk factors were used to evaluate the associations of myocardial work indices with relevant clinical variables. Median GLS (-11% vs -18%, p < .001), GWI (966 mmHg% vs 1803 mmHg%, p < .001), and GCW (1050 mmHg% vs 1988 mmHg%, p < .001) were significantly impaired in patients with ApHCM compared to those with non-ApHCM. Increasing NT-ProBNP, abnormal ultra-sensitive troponin, and increasing maximal LV wall thickness were significantly associated with reduced GWI and GCW in patients with ApHCM (p < .05). GCW had only modest accuracy (AUC 0.70) to predict LGE in patients with ApHCM. However, in patients with non-ApHCM, GLS was the strongest predictor of LGE (AUC 0.91), with a -17% cutoff yielding 81% sensitivity and 80% specificity. Myocardial work indices are significantly impaired in patients with ApHCM compared to those with non-ApHCM and correlate with important clinical variables. GLS, GWI, and GCW are more strongly predictive of fibrosis in patients with non-ApHCM than ApHCM.

Celiac Disease and the Risk of Cardiovascular Diseases.

Celiac disease (CD) is a chronic autoimmune disorder that affects the small intestine in genetically predisposed individuals. Previous studies have investigated the potential link between CD and cardiovascular disease (CVD); however, the findings have been inconsistent. We aimed to provide an updated review of the literature on the association between CD and CVD. PubMed was searched from inception to January 2023 using keywords including CD, cardiovascular disease, coronary artery disease, cardiac arrhythmia, heart failure, cardiomyopathy, and myocarditis. We summarized the results of the studies, including meta-analyses and original investigations, and presented them according to the different forms of CVD. Meta-analyses published in 2015 provided mixed results regarding the relationship between CD and CVD. However, subsequent original investigations have shed new light on this association. Recent studies indicate that individuals with CD are at a higher risk of developing overall CVD, including an increased risk of myocardial infarction and atrial fibrillation. However, the link between CD and stroke is less established. Further research is needed to determine the link between CD and other cardiac arrhythmias, such as ventricular arrhythmia. Moreover, the relationship between CD and cardiomyopathy or heart failure, as well as myopericarditis, remains ambiguous. CD patients have a lower prevalence of traditional cardiac risk factors, such as smoking, hypertension, hyperlipidemia, and obesity. Therefore, it is important to discover strategies to identify patients at risk and reduce the risk of CVD in CD populations. Lastly, it is unclear whether adherence to a gluten-free diet can diminish or increase the risk of CVD among individuals with CD, necessitating further research in this area. To fully comprehend the correlation between CD and CVD and to determine the optimal prevention strategies for CVD in individuals with CD, additional research is necessary.

MINOCA: HYPERTENSION IS NOT AN IMPORTANT RISK FACTOR

Objective: We studied the epidemiological, clinical and prognostic profile of the MINOCA population then compared them to patients with obstructive coronary artery disease and finally we established an etiological analysis of the MINOCA population. Design and method: Descriptive prospective study spread over a period of 36 months from January 2018 to January 2021 involving a total number of 585 patients undergoing coronary angiography at the cardiology department of CHU Tlemcen for a reason for acute myocardial ischemia. We defined the patients as having acute myocardial ischemia with obstructive coronary artery disease (AMI-CO) if there was revascularization or plaque &gt; 50% and as having MINOCA if there was &lt; 50% obstruction or a mechanism without plaque. Patients who did not have coronary angiography or who received thrombolytics before angiography were excluded.® Results: Of 585 patients undergoing angiography, 525 (89.74%) had AMI-CO, 60 (10.25%) had a MINOCA. Men were 4 times more likely to have MINOCA than women (78.3% versus 21.7%; odds ratio at 3.61). MINOCA patients were more likely to be without traditional cardiac risk factors (7.9% vs. 2.1%; P &lt; 0.001) but more predisposed to non-traditional risk factors than AMI-CO patients (3.7% against 1.8%; P = 0.026). Smoking is the only traditional risk factor frequent in the MINOCA population versus AMI-CO (P at 0.001). Hypertension is not an important risk factor for MINOCA (38% versus 51%; P = 0.066). Depression, stress, drug addiction, DVT history and autoimmune disease history are more frequent in the MINOCA population versus AMI-CO (P &lt; 0.05). STEMI are more found in the MINOCA population versus AMI-CO (P = 0.001). In terms of prognosis, the MINOCA population had a better prognosis: less risk of recurrence than the AMI-CO population 6.7% versus 10.45% (P = 0.03) also less mortality 0% versus 2.3% (P = 0.237). Conclusions: The patients with MINOCA were more men, smokers, depressed, stressed, drug addicts with hypercoagulable states compared to patients with obstructive coronary artery disease (AMI-CO) however they had a better quality of life and a good prognosis.

In this June issue

In line with several other journals we co-publish the Australian Commission on Safety and Quality in Health Care Low Back Pain Clinical Care Standard. It describes the early clinical management of people who present with a new acute episode of low back pain. The background to how the standard was developed and finalised are described in an introductory editorial. Coronial findings and royal commissions have repeatedly identified deficiencies in the emergency health care provided to prisoners in Australia. These deficiencies are operational, clinical and stigmatic and not limited to a single prison or jurisdiction. Applying a health quality of care framework focused on prevention and chronic health management appropriate assessment and escalation when urgent medical assistance is requested, and a structured audit framework could avoid future preventable deaths in prisons. We publish an editorial on this topic to accompany the paper written by a team from Victoria and Queensland. A group from the neurosurgery department of the Royal Brisbane and Women's Hospital report that the availability of cranial access equipment outside Queensland tertiary centres is limited. Inter-hospital transfers are likely to persist in Queensland and so improving access to cranial access equipment in hospitals where it is currently lacking is highly warranted. They surveyed senior theatre nurse or surgical service directors from rural and regional Queensland hospitals located outside the local catchment of a tertiary centre and had a CT scanner. Questions regarded availability, location and storage conditions of mechanical cranial access kits, as well as last usage, and associated patient outcomes. Life-threatening thoracic trauma requires emergency pleural decompression, and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children is challenging, even for experienced clinicians. A team from Melbourne report that the Mid-Arm-Point (MAP) technique, a procedural aid for use with injured adults, is also a safe site for pleural decompression in children <4 years and with a very minor modification is safe in children ≥4 years. An excellent study from Queensland describes the demographics, presentation characteristics, clinical features and cardiac outcomes for Aboriginal and Torres Strait Islander patients who present to a regional cardiac referral centre ED with suspected acute coronary syndrome (ACS). The authors conclude this cohort with suspected ACS have a high burden of traditional cardiac risk factors, regardless of whether they are eventually diagnosed with ACS. These patients may benefit from assessment for coronary artery disease regardless of age at presentation. In a nice paper, James Mallows explores the concept of collegiality, something considered to be any extra-role behaviour that is discretionary, not recognised by a formal reward system and that promotes the effective functioning of the organisation. There are few studies examining collegiality in the medical profession and none looking at collegiality among emergency physicians (EPs). He explores the perceptions of different ED health care professionals on the meaning of collegiality among EPs, the benefits of collegiality and behaviours they identify as indicative of collegiality. He identifies distinct themes and behaviours indicative of collegiality among EPs. Promoting these behaviours could improve staff well-being, ED efficiency, patient safety and productivity. Continuing with the previous theme, team culture underpins team performance. Psychological safety is a critical component of team culture for high performing teams. A group from the Gold Coast Hospital decided to explore this further. They conclude that familiarity of team members and leaders is critical to the development of psychological safety within the ED. Fostering familiarity should be a focus for frontline leadership each shift and a priority in broader departmental decisions for those seeking to enhance the psychological safety of their teams. The focus in this issue is on the anaesthetic component of the Fellowship training programme.

PO-05-159 IMPACT OF ARRHYTHMIAS IN PATIENTS ADMITTED WITH SARCOIDOSIS: A NATIONWIDE PERSPECTIVE

Sarcoidosis is a chronic granulomatous disorder with multiorgan involvement. Cardiac sarcoidosis is characterized by the growth of granulomas in any part of the heart which portends a poor prognosis. These granulomas can cause conduction abnormalities. However, less is known about the in-hospital outcomes in patients with sarcoidosis who have concurrent arrhythmias. We aimed to identify whether arrhythmia impacted these outcomes. Objective was to study the impact of arrhtymias on in-hospital outcomes in patients with sarcoidosis. We queried the National Inpatient Sample (NIS) database of 2018- 2020. Adults admitted with a primary or secondary diagnosis of sarcoidosis were included. This population was stratified into those with and without arrhythmia {atrial fibrillation [AF], atrial flutters, SVTs, heart blocks [first, second degree, complete heart blocks (CHB)], ventricular tachycardia [VT] and fibrillation [VF]}. Demographics and association with other comorbidities was studied. Multivariate regression analysis was performed to identify the impact of arrhythmias taking mortality as primary outcome and total hospital cost as secondary. A total of 383385 hospitalised patients had sarcoidosis. Of those, 85205 (22.22%) had arrhythmias. Mean age was 59 years and 54.03% were females. Traditional cardiac risk factors like diabetes mellitus (39.79% vs 37.61%, p<0.05),and hyperlipidemia (48.39% vs 38.79%, p<0.01) were more prevalent in the cohort of sarcoid patients with arrhythmias. The prevalence of valvular abnormalities(25.12% vs 16.85%,p<0.01), CAD (33.32% vs 17.72%, p<0.01) and old myocardial infarction (8.9% vs 5.32%, p<0.01) was also significantly higher in these patients. After adjusting for covariates, the odds of mortality was higher with VF, VT, CHB and AF in adult patients with sarcoidosis (table 1). The total hospital charge was also considerably more in sarcoid patients with concomitant VF, VT, CHB and AF (table 1). This study concludes that patients with sarcoidosis have a higher prevalence of risk factors like diabetes and hyperlipidemia and also how the presence of underlying arrhythmias leads to significantly worse outcomes in terms of mortality and in-hospital cost. These findings necessitate the need for further research to understand the pathophysiology of arrhythmias in Sarcoidosis cohort. This will further help in guiding therapeutic interventions to prevent the burden of arrhythmias in patients with sarcoidosis to improve patient outcomes.

Alterations of HDL's to piHDL's Proteome in Patients with Chronic Inflammatory Diseases, and HDL-Targeted Therapies.

Chronic inflammatory diseases, such as rheumatoid arthritis, steatohepatitis, periodontitis, chronic kidney disease, and others are associated with an increased risk of atherosclerotic cardiovascular disease, which persists even after accounting for traditional cardiac risk factors. The common factor linking these diseases to accelerated atherosclerosis is chronic systemic low-grade inflammation triggering changes in lipoprotein structure and metabolism. HDL, an independent marker of cardiovascular risk, is a lipoprotein particle with numerous important anti-atherogenic properties. Besides the essential role in reverse cholesterol transport, HDL possesses antioxidative, anti-inflammatory, antiapoptotic, and antithrombotic properties. Inflammation and inflammation-associated pathologies can cause modifications in HDL’s proteome and lipidome, transforming HDL from atheroprotective into a pro-atherosclerotic lipoprotein. Therefore, a simple increase in HDL concentration in patients with inflammatory diseases has not led to the desired anti-atherogenic outcome. In this review, the functions of individual protein components of HDL, rendering them either anti-inflammatory or pro-inflammatory are described in detail. Alterations of HDL proteome (such as replacing atheroprotective proteins by pro-inflammatory proteins, or posttranslational modifications) in patients with chronic inflammatory diseases and their impact on cardiovascular health are discussed. Finally, molecular, and clinical aspects of HDL-targeted therapies, including those used in therapeutical practice, drugs in clinical trials, and experimental drugs are comprehensively summarised.

ASSOCIATION OF DURATION AND INTENSITY OF EXERCISE WITH SEVERITY OF PHENOTYPIC EXPRESSION IN HYPERTROPHIC CARDIOMYOPATHY

ASSOCIATION OF DURATION AND INTENSITY OF EXERCISE WITH SEVERITY OF PHENOTYPIC EXPRESSION IN HYPERTROPHIC CARDIOMYOPATHY

Cardiology co-management of rheumatoid arthritis patients with coronary artery disease as an intervention reduces hospitalization rates and adverse event occurrence.

IntroductionRheumatoid arthritis (RA) is a systemic autoimmune disease with important cardiovascular (CV) implications. CV disease represents over half of RA patient deaths and causes significant morbidity. CV manifestations in RA can be complex, raising concerns for adequate patient management and provider-dependent roles.MethodsThis is a retrospective study of patients diagnosed with RA and coronary artery disease (CAD). Patients were identified and filtered via EPIC Database search engine. Parameters were set from January 1, 2014, to December 31, 2020. Inclusion criteria consisted of patients who met diagnostic criteria for both RA and CAD. A total of 399 patients met criteria.ResultsOf the 399 identified patients, 272 were female (68.2%) and 127 were male (31.8%) with a median age of 73 (range 26–98). The population was further divided into two groups: those with established cardiology care versus those without. Patients without cardiology follow-up experienced significantly more hospitalizations (RR 1.63 95% CI 1.12, 2.38), higher rates of adverse events including myocardial infarction (MI) (RR 4.82 95% CI 1.94, 11.98), heart failure (HF) (OR 15.81 95% CI 3.54, 70.52), and stroke (RR 2.55 95% CI 1.29, 5.03). Patients not followed by cardiology also had numerical increases in CV death (4 deaths compared to none in those with cardiology follow) and all-cause mortality (HR 1.03 95% CI 0.63, 1.67).ConclusionPatients with regular cardiology follow-up demonstrated fewer cardiac-related adverse events. This suggests that co-management may have a role in adverse cardiac event risk reduction and should therefore be an early consideration. Key Points• Rheumatoid arthritis patients demonstrate higher rates of coronary disease compared to the general population. Traditional cardiac risk factors may not be entirely responsible for this phenomenon• Hospitalization rates and adverse event occurrence are significantly higher in patients with single-provider care (rheumatology only) compared to dual provider care (rheumatology and cardiology)• Cardiology co-management should be an early consideration in the management of RA patients• Early screening, risk stratification of coronary disease, and utilization of appropriate treatment algorithms are important to decrease morbidity and mortalitySupplementary InformationThe online version contains supplementary material available at 10.1007/s10067-022-06335-4.

Non-traditional factors affecting referral for coronary angiography following SPECT myocardial perfusion imaging

BackgroundThe use of myocardial perfusion imaging (MPI) in the management of coronary artery disease (CAD) is well established. Although prior studies have shown disparities in the use of invasive angiography in patients with acute MI, data on factors affecting referral to angiography post-MPI are lacking. We sought to evaluate the primary determinants of referral to invasive angiography post-MPI and specifically assess the role of non-traditional non-clinical factors such as race/ethnicity, socioeconomic factors, insurance status, and marital status. MethodsAll patients without known CAD who underwent stress SPECT MPI over 15 years were reviewed and the performance of coronary angiography within 90 days of their MPI was recorded. Multiple factors were analyzed for an association with referral to angiography, including exercise and MPI results, baseline demographics, traditional cardiac risk factors, and non-traditional factors such as ethnicity, insurance, marital and socioeconomic status. In a secondary analysis, these factors were assessed with regard to abnormal MPI results. ResultsOut of 27,895 total patients, 2,150 (7.7%) underwent invasive coronary angiography. On multivariate analysis, inpatient location, positive ECG response, and abnormal MPI results were the strongest predictors of angiography. Non-traditional factors such as race/ethnicity and insurance status had a significant association with referral to angiography with Caucasians (OR 1.42, 95% CI 1.18-1.71, P < .0001) and those with private insurance (OR 1.35, 95% CI 1.13-1.62, P = .001) or Medicare (OR 1.30, 95% CI 1.08-1.56, P = .006) having higher rates of angiography despite controlling for traditional risk factors and test results. ConclusionOur study results indicate that non-traditional factors such as race/ethnicity and insurance status influence patient management decisions and impact the performance of downstream cardiac invasive testing after stress MPI. Higher rates of angiography in Caucasians, privately insured and Medicare patients were seen despite controlling for traditional risk factors and abnormal test results. Further research is needed to better understand these disparities, especially in the current healthcare environment.

EXERCISE CAPACITY AND MORTALITY RISK IN A WIDE AGE SPECTRUM COHORT OF 750,302 VETERANS

Objective: Most studies that have evaluated the association between exercise capacity and the risk of all-cause mortality have focused on middle-aged Caucasian populations. We assessed mortality risk associated with fitness in male and females across a wide spectrum of age (30–95 years) and ethnicities. Design and method: In this retrospective cohort study, we included male and female Veterans who completed an exercise treadmill test (ETT) between 1999–2020. We assigned participants to one of ten age-specific fitness categories based on peak metabolic equivalents (METs) achieved during the ETT. The primary endpoint was all-cause mortality adjusted for age, body-mass index, ethnic origin, sex, cardiovascular disease, cardiovascular risk factors and medications. We assessed mortality from Veterans Affairs records up to Dec 31, 2020. We compared groups with Cox proportional hazard model. Results: We assessed 750,302 Veterans, ages 30–95 years (mean 61.3 years, SD 9.8 years). During a median follow-up of 9.8 years (IQR 5.6–14.0), 164,288 died with an average yearly mortality rate of 22 deaths per1,000 person-years. The exercise capacity-mortality risk association was independent, inverse, and graded for all ages, ethnicities, and men and women. Compared to the least fit group for each age decile, mortality risk was 50% lower at peak exercise capacities of approximately 10.0 METs for those 30–49 years, 8.0 METs for septuagenarians, and 7.0 METs for octogenarians. The lowest mortality risk was observed at approximately 14.0 METs with no additional decline or increase in risk beyond this level. Being unfit, defined having exercise capacity below the median (&lt;8.5 METs), was associated with &gt; 2 times higher mortality risk compared to fit (&gt;8.5 METs), and was higher than the risk of the traditional cardiac risk factors examined. Conclusions: Higher Exercise Capacity is independently associated with lower mortality risk for all ages, ethnicities, and gender. An exercise capacity &lt; 8.5 METs carried a greater risk than that of the traditional cardiac risk factors. Approximately 50% lower risk was noted in all age categories, commensurate to an exercise capacity achievable by most individuals within a given age category.

POS0821 CORONARY ARTERIAL INVOLVEMENT CAN BE OBSERVED IN A SIGNIFICANT SUBSET OF TAKAYASU’S ARTERITIS PATIENTS BY CORONARY CT-ANGIOGRAPHY

BackgroundBesides the aorta and its main branches, coronary arterial involvement is also seen at a substantial rate in patients with Takayasu’s arteritis (TAK). Computerized tomography (CT)-angiography, as a non-invasive assessment tool, has started to be used instead of conventional angiography in the evaluation of coronary arteries. However limited data is available for its role in TAK patients.ObjectivesIn this study, we aimed to assess the coronary arterial involvement by coronary CT-angiography in TAK patients with or without symptoms and to compare clinical characteristics of patients with or without coronary arterial involvement.MethodsPatients with TAK (n=49, F/M: 40/9, mean age: 42.61±9.95 years) followed in Marmara University Vasculitis Clinic and underwent coronary CT-angiography with or without cardiac symptoms were evaluated retrospectively. Data of four patients who were not suitable for coronary CT-angiography but underwent conventional angiography were also included. CT angiography findings in the coronary arteries were defined as osteal stenosis, stenosis, calcific plaque and aneurysm and patients were categorized into two groups as those with or without coronary artery pathology. Demographic data, cardiac symptoms, clinical findings, BMIs, angiographic Hata and Goel classifications, treatments received for TAK, acute phase reactants and lipid levels were compared.ResultsCoronary artery pathology was detected in 14 patients (28.7%). Only 9 patients had a history of angina and 6 had cardiac symptoms in this group. Calcific plaque was present in 11 (22.5%), coronary artery stenosis in eight (16.3%) and aneurysm, osteal stenosis and occlusion in one patient each (2.0%). RCA was involved in 20.4%, LAD in 28.6%, LMCA in 22.4%, CX in 26.6% and more than one coronary arterial involvement in 26.5% of patients. In patients with coronary artery involvement, age (p=0.02), age at TAK diagnosis (p=0.004) and number of anti-hypertensive drugs (p=0.011) were significantly higher than those without coronary artery involvement. History of angina (p=0.004) and statin use (p=0.001) were also significantly higher in patients with coronary artery abnormalities, whereas HDL levels were significantly lower (p=0.037). No significant differences were observed between the groups when gender, smoking history, diabetes, BMI, ITAS2010 scores, biological therapy use, angiographic classifications, aortic involvement, presence of cardiac symptoms, CRP, ESR, total cholesterol and LDL levels were compared (Table 1).Table 1.Comparison of patient groups with and without coronary artery involvement (BMI: Body Mass Index, SD: Standard Deviation, ITAS: Indian Takayasu Activity Score, LDL: Low Density Lipoprotein, HDL: High Density Lipoprotein)Presence of Coronary Arterial Involvement (n=14)Absence of Coronary Arterial Involvement (n=35)p valueAge49.29 (8.23)39.94 (9.39)p=0.02Gender (F/M)10/430/5p=0.254Disease duration, years7.43 (6.42)8.46 (6.25)p=0.608Age at TAK diagnosis41.21 (12.58)31.37 (9.18)p=0.004Diabetes mellitus3/141/35p=0.065Family history4/147/35p=0.706Smoking history8/1425/35p=0.122BMI (kg/m2)25.08 (2.53)25.17 (4.68)p=0.930Biological therapy4/1415/34p=0.317CRP (mg/L) mean (SD)4.45 (3.4)8.68 (24.08)p=0.642ITAS2010 mean (SD)0.57 (0.94)0.51 (1.15)p=0.869LDL (mg/dL) mean (SD)102 (41.96)112.44 (35.79)p=0.398HDL (mg/dL) mean (SD)46.23 (12.78)55.12 (12.62)p=0.037Cardiac Symptom6/142/35p=0.159Aorta involvement8/1418/35p=0.717Statin use10/146/34p=0.001Number of antihypertensives1.79 (0.89)0.85 (1.18)p=0.011Acetylsalicylic acid use10/1424/34p=1Angina history9/146/35p=0.004ConclusionCoronary artery involvement which is an important cause of morbidity and mortality can be detected non-invasively by coronary CT-angiography in up to 1/3 of patients with Takayasu’s arteritis, also in patients without angina and cardiac symptoms. Traditional cardiac risk factors are present more commonly in this group.Disclosure of InterestsNone declared