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Circulation, Volume 146, Issue Suppl_1, Page A15165-A15165, November 8, 2022. Introduction:Guidelines recommend the use of Dobutamine stress echocardiography (DSE) in case of low flow low gradient aortic stenosis (LFLG AS) when left ventricular ejection fraction (LVEF)
Circulation, Volume 146, Issue Suppl_1, Page A13156-A13156, November 8, 2022. Introduction:The presence of multiple high-risk prognostic features enhances risk-stratification of plaques prone to destabilization and major adverse cardiac events (MACE). Spatial superimposition of high-risk features (concordance) likely amplifies local risk. Local endothelial shear stress (ESS) and plaque structural stress (PSS) metrics predict MACE, but their spatial concordance and their location relative to the minimal lumen area (MLA) is unknown. If the highest-risk plaque area is distant from the MLA, then PCI of the MLA alone will leave high-risk plaque areas untreated.Purpose:To identify the site of high-risk features of low ESS and high PSS heterogeneity (HI) along the course of a plaque in patients who develop MACE, and the site of their spatial concordance relative to the MLA.Methods:We examined ESS, PSS, and PSS HI in 22 non-culprit lesions (NCL) leading to MACE, and 64 randomly selected control NCLs without MACE from the PROSPECT study. ESS was calculated by computational fluid dynamics and PSS by finite element analysis on co-registered lesions. We examined high-risk plaques with empirically-derived (ROC curve) ESS < 1.3 Pa and PSS HI > 0.29 in 16 lesions leading to future MACE, and 11 control lesions without MACE.Results:MACE outcomes were significantly more frequent in plaques with combined low ESS+high PSS HI vs plaques with low ESS alone (72.7% vs 27.3%, p
Circulation, Volume 146, Issue Suppl_1, Page A13331-A13331, November 8, 2022. Introduction:Statins are a cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), the leading cause of death in the US. Despite conclusive evidence to the efficacy and safety of statins, low adherence remains a public health challenge. Although patient, clinician, and health system barriers to statin adherence have been documented, the effect of national policies targeting prescription access remains largely understudied. This study sought to assess the effect of the 2016 US Preventive Services Task Force (USPSTF) recommendation of statins on racial/ethnic disparities in treatment adherence.Methods:Utilizing records of the novel All of Us Research Program, a dataset of historically underrepresented groups in health research, we compared statin use in adult ASCVD non-Hispanic White (NHW) patients before (2014-2016) and after (2017-2020) the USPSTF recommendation with Black and Hispanic patients. Statin use was measured as percent days covered (PDC). Trends were compared using a regression model with demographics and an indicator variable for the change in recommendation as covariates. Regression coefficients and p-values were analyzed to assess the effect of the policy.Results:The study included 94,883 unique statin prescription records belonging to a patient cohort of which 52% were female, 21% Black and 12% Hispanic, with a mean age of 61.93 years. There was poor statin adherence across all racial/ethinic subgroups (PDC < 0.80). Following the policy, PDC increased 3.1% overall (p
Circulation, Volume 146, Issue Suppl_1, Page A14764-A14764, November 8, 2022. Introduction:During the COVID-19 pandemic, stratification of patients with chest pain with low-to-moderate probability of CAD (LMCP) became problematic due to fear of infection. We analyzed the impact in volume trends of modalities for stratification in these patients -including stress echocardiography (S-TTE), cardiac computed tomography (CCT), and single-photon emission CT (SPECT)- before, during, and after the pandemicHypothesis:Usage of CCT increased during the COVID-19 pandemic due to the lower exposure of patients, during this test, to healthcare personnel.Methods: Retrospective chart review conducted between 2019 and 2021. We defined 3-time frames: pre-pandemic period (1/1/2019-12/31/2019), pandemic period (1/1/2020-12/31/2020), and post-pandemic period (1/1/2021-12/31/2021). The study included data of all 3 mentioned imaging modalities.Results:Our cohort included 19,637 LMCP patients evaluated using 1,369 CCTs (7%), 2,380 S-TTEs (13.6%) and 15,588 SPECTs (79.4%) -Fig 1a-. During the pre-pandemic period, CCT studies corresponded to 3.0%, while S-TTE and SPECT corresponded to 14.7% and 82.4%, respectively. In the post-pandemic period, CCT studies corresponded to 9.8%, while S-TTE and SPECT corresponded to 12.3% and 77.9%, respectively. An upward variation was observed regarding the utilization of CCT in the post-pandemic period compared to the pre-pandemic period (p
Circulation, Volume 146, Issue Suppl_1, Page A10116-A10116, November 8, 2022. Introduction:The relationship between low body mass index (BMI) and prognostic factors for patients with coronary artery disease, commonly observed in elderly individuals in Japan, is important. Few studies have evaluated the prognosis for patients with low BMI after percutaneous coronary intervention (PCI). We analyzed the risk associated with low BMI for patients after PCI using a multivariable-adjusted model and data from a prospective cohort registry.Methods:This prospective, multicenter registry included 5965 consecutive patients with coronary artery disease who underwent successful PCI. The patients were followed-up clinically for up to 3 years or until the occurrence of major adverse cardiac events. The primary endpoint was defined as a composite of all-cause death and nonfatal myocardial infarction.Results:During the follow-up period, primary events occurred in 639 (10.7%) patients. A risk analysis of the primary endpoint adjusted for the multivariable model showed a significant increase in risk for elderly individuals, underweight individuals[HR 1.43 (95% CI, 1.10-1.85),P< 0.001], those with diabetes mellitus (DM), peripheral artery disease, low left ventricular ejection fraction or acute coronary syndrome (ACS), and smokers. A stratified adjusted risk analysis based on BMI levels showed that the risk associated with underweight status was significantly pronounced for male patients, those aged 60-74 years, those with DM or ACS.Conclusions:Underweight patients with several risk factors were at significantly increased risk after PCI. Furthermore, the risk associated with low BMI was significantly more pronounced for men, individuals aged 60-74 years, patients with DM or ACS.
Circulation, Volume 146, Issue Suppl_1, Page A9618-A9618, November 8, 2022. Introduction:Many patients with acute coronary syndrome (ACS) presented with elevated troponin level and reversible changes in the thallium scan. When they patients underwent coronary angiogram, the results showed patent coronary arteries. WHY?Hypothesis:Could abnormal coronary flow explain ACS, abnormal thallium and patent coronary arteries?Methods:Patients with newly diagnosed ACS and abnormal Thallium scan underwent a new dynamic coronary angiogram. 10 patients without ACS, normal EF and no coronary artery disease served as control. In this new technique, the contrast and blood flow were recorded at 15 images per second. The first image was of the index artery completely filled with contrast. The subsequent images showed the blood in white color moving in over a background of black contrast. The arterial phase started when the blood began moving in and ended when the contrast disappeared from the distal arterial vasculature as the contrast was replaced by blood. The machine learning (ML) program had 2 models (built on Python). Model 1 was built based on U-net and Densenet-121 for vessel segmentation. Model 2 was used for classification of flow. The model 2 was trained based on the convolutional neural network. The data to be collected was the duration of the arterial phase and the recurrence of ACS within one year follow-upResults:45 patients with ACS (elevated troponin level (50-100mg), reversible stress thallium), underwent coronary angiogram. The angiograms of 10 control patients showed a normal arterial phase (AP) of 1.56 sec. It was prolonged at 2.5sec in 45 patients with ACS (p
Circulation, Volume 146, Issue Suppl_1, Page A12136-A12136, November 8, 2022. Background and Objectives:Previous studies have shown that a multiple blood biomarker strategy prior to aortic valve replacement (AVR) may be useful for risk stratification in patients undergoing surgical AVR (SAVR). The usefulness of this approach in patients with low-flow low-gradient aortic stenosis (LF-LG AS) has not been examined. The objective of this study was to determine the prognostic value of combined measures of multiple blood biomarkers in patients with LF-LG AS treated conservatively or by AVR.Methods:168 patients were prospectively enrolled in the TOPAS (Truly or Pseudo-severe Aortic Stenosis) study at our institute. Clinical and echocardiographic data were collected for each patient. Eight biomarkers of myocardial stress, inflammation, renal function (brain natriuretic peptide, creatine kinase-mb, interleukin-6, alanine transaminase, lactate dehydrogenase, alkaline phosphatase, procalcitonin, ferritin) were measured from blood samples collected at baseline. The cohort was divided into 3 groups according to the number of elevated biomarkers. Uni- and multivariable survival analyses were performed to evaluate the association between the number of elevated biomarkers and all-cause mortality.Results:Mean age was 73 years (68% male). After a median follow-up of 3.41 years, 69 (35%) patients died. Patients with 0-3, 4-6, and >6 elevated biomarkers had 8 years survival estimates of 75%, 52%, and 19%, respectively (log-rank p6 elevated biomarkers had an increased risk of all-cause mortality as compared to the group of patients with 0-3 elevated biomarkers (referent group), HR=3.82, p
Circulation, Volume 146, Issue Suppl_1, Page A13226-A13226, November 8, 2022. Introduction:Evidence regarding associations between overall low-carbohydrate diets (LCDs) and the risk of developing type 2 diabetes (T2D) remains to be mixed. In the current analysis, we aimed to prospectively assess associations of various LCDs that emphasize different quality of protein, fat, and carbohydrate with T2D risk in U.S. men and women.Methods:A prospective cohort study was conducted in 203,541 men and women participating in the Nurses’ Health Study (NHS), NHSII, and Health Professionals Follow-Up Study who were free of T2D, cardiovascular disease, and cancer at baseline and were followed for up to >30 years. Five LCD scores based on sources of protein, fat, and carbohydrate differentiated by their qualities were derived every four years based on dietary assessments by a validated food frequency questionnaire.Results:During 5,095,048 person-years of follow-up, 19,675 T2D cases were documented. In the multivariable model, a higher overall LCD score was associated with higher T2D risk in a dose-response manner: the hazard ratio (HR) comparing highest vs. lowest quintile was 1.28 (95% confidence interval: 1.22-1.34;P-trend
Circulation, Volume 146, Issue Suppl_1, Page A10423-A10423, November 8, 2022. Introduction:Nationwide broadband internet access is a major federal priority. The bipartisan infrastructure law invested $65 billion into equitable broadband expansion, driven by concern that broadband access is a social determinant of health. However, the difference in health outcomes between counties with low vs. higher broadband access has not been studied, and could provide insights on the implications of expansion efforts.Objectives:We evaluated demographic factors, health resources, and cardiovascular disease (CVD) burden in counties with low broadband access compared to those with higher access.Methods:We assessed all 3,142 US counties in 2019 and identified those with low broadband access, defined as 25 Mbps download / >3 Mbps upload, using the US Broadband Usage Percentages Dataset. We linked these data to the American Community Survey, American Health Resource File, PLACES, and CDC WONDER for demographic, health resource, CVD risk factor and outcomes, and mortality data respectively.Results:There were 461 counties with low broadband access and 2,650 counties with higher access. Compared to those with higher broadband access, counties with low broadband access had lower high school graduation rates (47% vs 54%, p
Circulation, Volume 146, Issue Suppl_1, Page A13104-A13104, November 8, 2022. Introduction:Reduced serum levels of glycosylated apolipoprotein J (ApoJ-Glyc) have been proposed as a marker for the early detection of myocardial ischemia with a potential prognostic value.Objective:The EDICA clinical trial assessed the performance of ApoJ-Glyc as a biomarker for the early detection of myocardial ischemia in patients attending the A&E department with chest pain suggestive of acute coronary syndrome (ACS) and investigated -as a secondary pilot objective- its prognostic value.Methods:EDICA -a multi-centre, international, diagnostic study (NCT04119882) assessed 404 patients. Based on clinical variables and diagnostic tests, 291 patients were considered to have had a “non-ischemic” event and 113 an “ischemic” event. Blood samples were obtained for the assessment of high-sensitivity troponin and ApoJ-Glyc at admission and at 1h and 3h thereafter. GRACE Risk Score was calculated in all ischemic patients. Patients were followed up for 6 months after presentation and the occurrence of MACE (cardiac death, recovered cardiac arrest, re-infarction, cardiac failure, new admission for ACS after discharge, or unplanned revascularization for cardiac ischemia after discharge) was recorded. ApoJ-Glyc serum levels were analyzed with a novel ELISA targeting a specific glycosylated variant of ApoJ (ApoJ-GlycA2).Results:Among the patients in the ischemic group, 8.8% had MACE at 6-months and these showed a 26% mean reduction in ApoJ-GlycA2 levels 3h post-admission compared with levels at presentation. This reduction was not observed in patients without MACE. Patients in the highest GRACE Risk Score tertile ( >118 points) showed a progressive decrease in ApoJ-GlycA2 levels after presentation compared with patients in the lower risk tertiles (mean decrease: 41% at 1h, P=0.01 and 35% at 3h, P=0.02 when compared with admission levels).Conclusions:A progressive decrease in ApoJ-Glyc levels after A&E admission appears to not only identify patients with ischemic events but also those at higher risk of suffering serious recurrent cardiovascular events at 6-months’ follow-up. Further studies in larger cohorts of patients are warranted to validate the potential role of ApoJ-Glyc in risk stratification in the context of cardiac ischemic events.
Circulation, Volume 146, Issue Suppl_1, Page A11655-A11655, November 8, 2022. Objective:Low molecular weight heparin (LMWH) has been established for the treatment of cancer-associated thromboembolism (CAT). Recent guidelines suggest Direct Oral Anti-Coagulants (DOACs) may have a role in the management of CAT, however these recommendations were conditional. This study aims to compare DOACs with LMWH and Vitamin K Antagonists (VKAs) in CAT.Methods:We conducted a meta-analysis of studies through a systematic search of four electronic databases (PubMed, Scopus, Web of Science, and Cochrane) published before January 25, 2022. Our criteria included studies in patients with all cancer types who received DOACs, VKAs, or LMWH for prevention or treatment of CAT. We analyzed outcomes including recurrent venous thromboembolism, major bleeding, clinically relevant non-major bleeding (CRNMB), and all-cause mortality. The quality assessment of the included RCTs was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The network meta-analysis was performed using the netmeta package in R software.Results:A total of 55 studies were included; 18 RCTs, and 37 cohort studies. DOACs (RR= 0.72, 95% CI [0.63; 0.83]) and LMWH (RR= 0.78, 95% CI [0.64; 0.94]) had a significantly lower risk of major bleeding than VKAs. There was also a significantly decreased risk of clinically relevant non-major bleeding (CRNMB) with LMWH than DOACs (RR= 0.63, 95% CI [0.55; 0.73]) and DOACs compared to VKA (RR= 0.83, 95% CI [0.72; 0.95]). With regards to recurrent venous thromboembolism risk (VTE), DOACs showed a significantly lower risk compared with either LMWH (RR=0.70, 95% CI [0.59; 0.83]) or VKA (RR=0.66, 95% CI [0.54; 0.80]).Conclusion:We conclude that DOACs are more effective in the management of CAT when compared to LMWH and VKA. DOACs and LMWH have significantly lower risk of major bleeding when compared to VKA. More research is needed to determine the best anticoagulation strategy for distinct types of cancers.
Circulation, Volume 146, Issue Suppl_1, Page A10411-A10411, November 8, 2022. Introduction:The HEART score is an effective method of risk stratifying emergency department (ED) patients with chest pain. The low rate of major adverse cardiovascular events (MACE) in patients with a moderate risk HEART score referred from an urgent care (UC) center for an expedited outpatient cardiology evaluation was first described by this group in 2020. This is a follow up study with a total of 446 patient over a 36 month period.Hypothesis:Patients with a moderate risk HEART score who present to the ED are usually hospitalized for further evaluation. The safety of outpatient evaluation of these patients is not well studied. We assessed the hypothesis that there is a low rate of MACE when patients with a moderate risk HEART score were referred from an UC for an expedited outpatient cardiology follow up.Methods:A cross sectional study was performed from 2/14/2019 through 3/30/2022 in 5 UC centers of 446 patients who presented with chest pain or anginal equivalent and a HEART score of 4 to 6 in Las Vegas, Nevada. A streamlined disposition protocol was adopted by all UC providers for an expedited outpatient cardiology instead of ED referral. The population was followed for 6 weeks with a primary endpoint of MACE (death, myocardial infarction (MI), revascularization) determined by electronic medical records review and direct phone contact with patients. Outcomes were confirmed in 93% of patients.Results:The average age was 65 years with 52% female and 48% male. 395 patients (89%) were seen by a cardiology provider, 346 patients (88%) were seen within 3 days. 265 stress tests (67%), 42 coronary CT angiograms (11%) and 19 invasive coronary angiograms (5%) were ordered. 8 patients (2%) were found to have MACE: 2 had routine surgical revascularization, 4 had non-fatal MI followed by revascularization, 2 patients died: 1 was urgently referred for mitral valve replacement and died after surgery from renal failure and COVID, the other patient died from COVID pneumonia. There were no ischemic cardiac deaths.Conclusion:In conclusion, patients with a moderate risk HEART score referred from UC for an expedited outpatient cardiology evaluation had a low rate of MACE and no ischemic cardiac deaths due to delay of care.
Circulation, Volume 146, Issue Suppl_1, Page A12668-A12668, November 8, 2022. Case Presentation:A 65-year-old female with a history of hypertension, hyperlipidemia, microscopic colitis, fibromyalgia, left hand dupuytren’s contractures, Grave’s disease and seronegative rheumatoid arthritis presented to the outpatient office for evaluation of right sided stabbing and heavy chest pain. ECG showed sinus bradycardia without any ST segment changes. She had an Echo and exercise stress Echo prior to her office visit. Her echo showed normal left ventricular size and systolic function with no regional wall motion abnormality and thickened aortic valve with mild aortic stenosis (peak transvalvular gradient 9.9 mmHg and mean 5.9 mmHg). Her stress echo was negative for ischemia although submaximal (exercised for 6.05 minutes, achieving only 75% MPHR, and double product of 18720). It was then decided to pursue a coronary CTA given the suboptimal nature of her stress testing and intermediate pretest probability of coronary artery disease. This revealed mild-to-moderate non-obstructive CAD and thickening of her left coronary cusp. The thickening was concerning for Libman-Sacks endocarditis vs native aortic valve thrombosis (see figure). Her Antinuclear antibody (ANA) titers was 1280. She was started on therapeutic anticoagulation with a plan for repeat imaging in six months.Discussion:Coronary cusp thickening represents a variety of differentials and has comparable structural and clinical qualities. Atypical chest pain in our patient led to the incidental finding of left coronary cusp thickening. In the presence of elevated ANA and her autoimmune disorder, Libman-Sacks endocarditis vs native aortic valve thrombosis was suspected hence the initiation of anticoagulation. Both have a propensity for fatal outcomes including, but not limited to myocardial infarction, embolic events, cardiogenic shock, or death. Follow-up imaging with a resolution of thrombus would confirm the diagnosis of native aortic valve thrombus.
Circulation, Volume 146, Issue Suppl_1, Page A15106-A15106, November 8, 2022. Introduction:Inadequate ventricular sensing at implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) is troubling and might cause inappropriate ICD interventions and complications. We aimed to evaluate the value of ventricular mechanics features in predicting low sensing value by emerging cardiovascular magnetic resonance-feature tracking (CMR-FT) in ACM patients.Hypothesis:CMR-FT characteristics prior to ICD implantation might assist in predicting low R wave amplitude.Methods:We retrospectively enrolled ACM patients receiving CMR examinations prior to ICD implantation at our center from January 2011 to July 2021. The strain parameters of LV and RV were analyzed by CMR-FT. The R wave amplitude (RWA) was obtained within 24 hours of completion of the ICD implantation and its association with CMR strain parameters was analyzed.Results:We enrolled 83 ACM patients with a median RWA of 8.0 mV (Interquartile range IQR:5.4-12.1 mV) and impedance within the normal range. 18 (21.7%) patients were found with low RWA (
Circulation, Volume 146, Issue Suppl_1, Page A15713-A15713, November 8, 2022. Introduction:Chest pain is a common presentation to the Emergency Department (ED). Current international guidelines emphasise the importance of triage pathways involving patient-centric algorithms. In 2019, a front-door ED pathway (Figure 1) was created to direct low-risk chest pain towards ambulatory care. We aimed to characterise clinical outcomes with this pathway in a real-world UK ED cohort presenting with cardiac chest pain.Methods:The chest pain pathway stratified patients as low-, intermediate- and high-risk at presentation. Patients presenting to the ED at our institution in London, UK, were consecutively included in two groups: a pre-pathway group prior to implementation of the chest pain pathway and a post-pathway group following implementation. Baseline demographics were compared using Pearson’s χ2test for categorical variables and unpaired t-tests for continuous variables. Primary endpoints were 30-day readmissions, and all-cause mortality. Multiple logistic regression models were constructed to assess the impact of the pathway on the primary outcomes, adjusting for age, sex, risk category and HEART score.Results:Baseline demographics were similar between pre-pathway and post-pathway groups, except for presence of a smoking history (p= 0.04). Smoking was therefore adjusted for in multivariable analyses. Approximately 10% (13/136) of post-pathway patients avoided hospital admission and were triaged towards ambulatory care. There was no significant difference in 30-day readmissions: 18/139 post-pathway vs 12/167 pre-pathway (OR 1.79, 95% CI 0.79 – 4.22,p= 0.17); or all-cause mortality: 2/167 pre-pathway vs 5/139 post-pathway (OR 2.96, 95% CI 0.49 – 25.68,p= 0.26).Conclusions:This novel chest pain pathway demonstrated a 10% reduction in hospital admissions without concurrent increases in 30-day readmissions or all-cause mortality. This is likely to reduce burdens on hospital resources and patient flow whilst maintaining safety.
Circulation, Volume 146, Issue Suppl_1, Page A14754-A14754, November 8, 2022. Introduction:Atypical atrial flutters (AFL) are a heterogeneous group of reentrant arrhythmias and can be challenging to map. Peak frequency (PF) mapping is a novel method of identifying local conductivity and may help identify critical portions of myocardial substrate supporting reentry.Hypothesis:The critical isthmuses of left atrial (LA) AFLs demonstrate a combination of low-voltage and high PF.Methods:LA omnipolar voltage and PF maps were generated using the EnSite Precision Mapping System and HD-Grid catheter in 13 patients undergoing AFL ablation. For the purpose of this study, mapping was performed during AFL and normal voltage was defined as ≥ 0.5 mV, low-voltage (LV) 0.1 – 0.5 mV, and scar < 0.1 mV. PF distributions were analyzed in each tissue type. Conduction velocity (CV) was characterized across PF with correlational analysis. The 1-cm radius from sites of arrhythmia termination with ablation were analyzed to characterize mean PF and voltage in nearby myocardial tissue.Results:Mean age was 65.8 ± 9.3 years and 54% were female. A total of 37,331 points were analyzed. Sites of slow conduction included the mitral isthmus (46%), LA roof (23%), pulmonary vein antra (15%), posterior wall (8%), and anterior wall (8%). In normal voltage tissue, mean PF was 337.7 ± 115.4 Hz. LV and scar tissue had left-skewed PF distributions and lower mean PF (p< 0.0001). While CV had no trend across PF in tissue with normal voltage (R2, 0.0002 to 0.1), there was moderate conduction slowing at higher PF in LV tissue (R2, 0.07 to 0.30). In PF-LV overlay maps, all termination sites resided in regions of LV and high PF (Figure). Of the 1-cm areas neighboring termination, 77% had significantly higher PF than the global LA (p< 0.05), of which 80% had significantly lower mean voltage (p< 0.01) or mean voltage < 0.5 mV.Conclusions:Sites of arrhythmia termination can be identified in LV tissue at higher PF. Low-voltage, high-PF areas may be critical targets during catheter ablation of atypical AFL.
