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An investigational bionic pancreas that makes insulin dose decisions based on patient body weight and meal announcements without carbohydrate counts did a better job of keeping blood glucose within target ranges than standard care in a recent trial.
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Circulation, Volume 146, Issue Suppl_1, Page A10949-A10949, November 8, 2022. Background:Little is known about the association between standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes, dyslipidemia, and smoking) and clinical outcomes among patients with STEMI.Methods and Results:STEMI patients who underwent primary PCI were enrolled. Primary endpoint was all-cause death. Between 1999 and 2015, 126 (6.4%) of 1,963 patients with STEMI had no SMuRFs. Patients without SMuRF were significantly older and more likely to be female. During median follow-up period of 4.8 years, cumulative incidences of death were significantly higher in patients without SMuRF (log-rank p
Circulation, Volume 146, Issue Suppl_1, Page A12922-A12922, November 8, 2022. Introduction:We have recently shown (Alavi et al. Circulation, (2021)144: A13745-A13745) that adverse effects of nicotine delivered chronically by electronic cigarette (EC) vapor or standard cigarettes on left ventricular systolic function can be captured using intrinsic frequency (IF) method applied on carotid waveforms. Here, we propose a hybrid IF-machine learning (ML) method to detect nicotine effect on cardiovascular system using a carotid waveform.Methods:Total number of n=117 young healthy adult male and female Sprague Dawley rats (49% (n=57) female, weight ~200-250 g) were randomized and exposed to: 1) purified air, n=32; 2) EC vapor without nicotine (EC NIC-), n=26; 3) EC vapor plus nicotine (EC NIC+), n=27; and 4) standard cigarette smoke from reference combustion cigarettes (3R4F), n=32. All the exposures (nose-only) took place for duration of 5 hours/day, 4 days/week for total of 8 weeks. Third-generation type EC from VaporFi, tank model: Volt 2 was used. E-liquid was tobacco flavored with a 50/50 propylene glycol/glycerin ratio. Similar nicotine amount as the standard cigarette was delivered to the rats of EC NIC+ group. After 8 weeks of exposure, IFs were computed from invasively measured carotid waveforms. A support vector machine (SVM) classifier with radial basis function kernel was trained using IF data from 83 rats to detect (non)-nicotine groups. Thek-fold cross-validation (k=10) was used to avoid overfitting. The remaining rats were used for generalization test (n=14) and stratified blind test (n=20).Results:Our SVM model showed positive and negative predictive values of 66.7% and 76.9%, respectively. Sensitivity and specificity were 82.4% and 58.8% for test data (Fig1).Conclusions:Our results suggest that nicotine delivered by ECs or cigarettes can be detected by a physics-based ML model from a single carotid waveform. This method can potentially be used for detecting adverse effect of nicotine on cardiovascular system noninvasively.
Circulation, Volume 146, Issue Suppl_1, Page A13415-A13415, November 8, 2022. Introduction:Chemoradiotherapy (CRT) has been associated with increased incidence of cardiovascular (CV) adverse events (CAE) including coronary events. Coronary calcium scoring (CAC) has shown to predict coronary events beyond the traditional CV risk factors. This study examines whether CAC, measured on standard, non-gated, non-contrast chest CT (NCCT) imaging, predicts the development of CAE in patients with non-small cell lung cancer (NSCLC) treated with CRT.Methods:Patients with NSCLC who were treated with CRT at MD Anderson Cancer Center from 7/2009 until 4/2014 and who had at least one NCCT scan within 6 months from their first CRT were identified. CAC scoring was performed on NCCT scans by an expert cardiologist and a cardiac radiologist following the 2016 SCCT/STR guidelines (software: Syngo.Via, Siemens Healthcare). CAE were graded based on the most recent Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. CAE were also grouped into i. coronary/vascular events ii. arrhythmias iii. heart failure or iv. pericardial disease. All CAE were adjudicated by a board-certified cardiologist.Results:Out of a total of 193 patients, 45% were female and 91% were white. Median age was 65 years (IQR: 58-72) and median BMI was 27 kg/m2(24-32). Of 193 patients, 142 (74%) had CAC > 0 Agatston units (AU), 93 (48%) had CAC >100 AU and 36 (49%) CAC >300 AU. Twenty-nine patients (15%) developed a grade >2 CAE during a median follow up of 26.2 months (12.7-53.5). Of those, 11 (38%) were coronary/vascular events. In the multivariate cox regression analysis, controlling for mean heart dose and pre-existing heart disease, higher CAC was independently associated with development of a grade >2 CAE (HR: 1.04, 95% CI: 1.01-1.08, p=0.022) and with worse OS (CAC >100 AU, HR: 1.64, 95% CI: 1.11-2.44, p=0.013). In a sub-analysis evaluating the type of the CAE, it was the coronary/vascular events that were significantly associated with higher baseline CAC (median: 676 AU vs 73 AU, p=0.035).Conclusions:CAEs are frequent in patients with NSCLC treated with CRT. CAC calculated on “standard of care” NCCT can predict the development of CAEs and specifically coronary/vascular events, as well as OS, independently from other traditional risk factors and radiation mean heart dose.
Circulation, Volume 146, Issue Suppl_1, Page A10266-A10266, November 8, 2022. Introduction:Various T-wave characteristics have been shown to be predictive of ventricular diastolic dysfunction and sudden cardiac death in adults. However, specific T-wave morphologies and their predictive potential in pediatric patients is unknown.Hypothesis:Machine learning derived T-wave characteristics will be different between children with pulmonary arterial hypertension (PAH) and healthy controls. Furthermore, T-wave characteristics will be predictive of clinical functional worsening in PAH patients.Methods:Principal component analysis (PCA) was applied to ECGs collected for children with PAH (n=155) at the time of diagnostic catheterization and matched healthy controls (n=47) to describe basic T-wave characteristics. Patients (25 mmHg in the absence of obstructive left heart disease. Interpreted T-wave features were then compared between PAH and control groups. Identified T-wave measurements underwent survival analysis using standardized PAH functional class worsening as a clinical endpoint.Results:Identified T-wave principal components were 1) T-wave height and 2) early or late incidence of T-wave peak (FIGURE- 1A). The second principal component was associated with PAH diagnostic specificity (94%). Time from T-wave peak to T-wave end (TpTe) as measured in leads V4 to V6 was significantly higher in children with PAH (all P < 0.001) (FIGURE - 1B). V4 derived TpTe value > 132 ms and V5 derived TpTe value > 135 ms were associated with the higher probability of clinical functional worsening (P = 0.018 and P = 0.002, respectively) (FIGURE – 1C).Conclusions:T-wave features derived from standard ECG are 1) different between children with PAH and their healthy peers and 2) predictive of clinical functional worsening.
Circulation, Volume 146, Issue Suppl_1, Page A11680-A11680, November 8, 2022. Background:Patients who have undergone orthotopic heart transplant (OHT) undergo frequent endomyocardial biopsies (EMBx) to assess for rejection. Difficulty crossing the superior venous caval anastomosis and tricuspid valve often complicates these procedures. We studied a new approach in which a peel-away sheath is placed in the right internal jugular vein through which a Swan-Ganz catheter is then inserted and advanced. Following right heart catheterization, the peel-away sheath is removed and a long biopsy sheath is advanced over the Swan-Ganz catheter, which is then removed, leaving the long sheath behind for advancement of the bioptome into the right ventricle.Objective:To compare fluoroscopy (fluoro) time, procedure time, and complications between a modified and standard approach to EMBx.Methods:We included patients who underwent OHT and had EMBx data available for review at two University-affiliated institutions. We excluded EMBx cases that combined a left heart catheterization. We compared fluoro time and procedure time between modalities using mixed effects gamma regression with operators and patients both included as random effects.Results:We analyzed 964 (198 modified, 766 standard) EMBx cases in 71 patients who underwent OHT from 2017 to 2022. The mean patient age was 53.9 at time of OHT; 14% (n=10) were female. Median fluoro time was 2.8 and 4.9 minutes, and median procedure time was 27 and 29 minutes, for the modified and standard approach, respectively. Cases performed using the modified approach had a shorter fluoro time by 28%, and a shorter procedure time by 7% as compared to the standard approach (Ratio=0.72, 95% CI: 0.62 ~ 0.84, p
Circulation, Volume 146, Issue Suppl_1, Page A9695-A9695, November 8, 2022. Introduction:Previous studies found that a substantial proportion of ST-elevation myocardial infarction (STEMI) patients with no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, hypercholesterolemia, smoking) at admission, had unexpected higher mortality compared with those with SMuRFs. However, little is known about what contributed to the excess risk of SMuRF-less patients.Methods:This study used a two-stage random sampling design to create a nationally representative sample of patients admitted with STEMI in China, from 2001 to 2015. We compared patient characteristics, treatments, and in-hospital mortality rates between SMuRF-less patients and those with SMuRFs, and established stepped mixed effect models on in-hospital mortality, to explore the potential contributors to different mortality risks (if exist).Results:Among 16541 patients included (aged 65±13 years, 30.0% women), 3288 (19.9%) were SMuRF-less. Compared with patients with SMuRFs, SMuRF-less patients were older (69 vs 65 years, p
Circulation, Volume 146, Issue Suppl_1, Page A10083-A10083, November 8, 2022. Introduction:Recent interest has focused on STEMI patients (pts) without standard modifiable risk factors (SMuRF-less), noting that they are surprisingly common (14-27%). These studies have reported them to have a worse, or at best similar, in-hospital/short-term prognosis. However, relatively little attention has been paid to the prevalence and prognosis of SMuRF-less patients with non-ST elevation myocardial infarction (NSTEMI). The aim of our study was to identify the proportion and outcomes of SMuRF-less NSTEMI pts in a large US healthcare population.Methods:Pts with NSTEMI between 2001-2021 presenting to Intermountain Healthcare catheterization laboratories were included. SMuRF included a clinical diagnosis of, or treatment for, hypertension, hyperlipidemia, diabetes, and/or smoking. 60-day and long-term major adverse cardiovascular event (MACE) outcomes were defined as death, myocardial infarction, and heart failure hospitalization and were tested using Cox proportional hazard regression.Results:NSTEMI pts totaled 8196, of which1458 (17.8%) were SMuRF-less. SMuRF-less pts were younger, more frequently male, had fewer comorbidities, and were slightly less likely to have PCI/CABG than NSTEMI pts with SMuRF (Table 1). 60-day MACE for SMuRF-less pts were lower (adj HR 0.55, p
Circulation, Volume 146, Issue Suppl_1, Page A13056-A13056, November 8, 2022. Introduction:There has been growing evidence comparing Coronary Computed Tomography Angiography (CCTA) versus the standard of care(SOC) in patients with suspected stable coronary artery disease (CAD). We aimed to perform a systematic review and meta-analysis to compare CCTA versus SOC in patients with stable CAD.Methods:We searched multiple databases for randomized controlled trials (RCTs) comparing CCTA with SOC with various functional testing approaches for the evaluation of stable CAD. We used a random-effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included all-cause mortality, myocardial infarction (MI), hospitalization for unstable angina (UA), invasive angiography, revascularization, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG).Results:We identified 6 RCTs with a total of 19,881 patients with stable CAD, of which 9,995 underwent CCTA and 9,886 underwent UC. There were no significant differences between CCTA and SOC in terms of all-cause mortality (RR: 0.91; 95% CI: 0.70-1.19; p=0.64), MI (RR: 0.78; 95% CI: 0.58-1.05; p=0.70), hospitalizations for UA (RR: 1.20; 95% CI: 0.95-1.51;p=0.64), invasive angiography (RR: 0.11; 95% CI: 0.32-1.61; p
Circulation, Volume 146, Issue Suppl_1, Page A11854-A11854, November 8, 2022. Introduction:In the SPRINT trial, intensive blood pressure control reduced all-cause mortality and major adverse cardiovascular events in individuals at high risk for cardiovascular events. However, it is unclear whether individuals with polyvascular disease, compared to individuals without established atherosclerosis, similarly benefit from intensive blood pressure control.Methods:We performed a post-hoc analysis of the SPRINT trial to determine the efficacy of intensive versus standard blood pressure control on the primary composite outcome (myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death); and secondary outcomes (cardiovascular death, myocardial infarction). Individuals were stratified by severity of atherosclerosis: no known atherosclerotic disease (Framingham Risk Score > 15%), subclinical atherosclerosis, symptomatic single-bed atherosclerosis, and symptomatic polyvascular atherosclerosis. Uni- and multivariable Cox regression models were used to compute the crude and adjusted hazard ratios. Interaction between intensive vs standard blood pressure control and atherosclerotic burden was evaluated.Results:In the SPRINT trial, 6,837 individuals had elevated Framingham Risk Score, 128 had subclinical atherosclerosis, 1,207 had symptomatic single-bed atherosclerosis, and 254 had symptomatic polyvascular disease. There was graded increase in risk of primary composite outcome and secondary outcomes with more atherosclerotic burden, even when controlling for differences in baseline characteristics (Figure). There was no interaction among groups between treatment assignment and primary or secondary outcomes.Conclusions:This post-hoc analysis of SPRINT trial demonstrates a higher risk of adverse in patients with escalating atherosclerotic burden. Individuals derive benefit from intensive blood pressure control regardless of burden of atherosclerosis.
Circulation, Volume 146, Issue Suppl_1, Page A13945-A13945, November 8, 2022. Introduction:Patients without standard modifiable cardiovascular risk factors (SMuRF; hypertension, diabetes, hypercholesterolaemia, smoking) have worse outcomes in Type 1 acute myocardial infarction (AMI). The relationship between type 2 AMI (T2AMI) and outcomes in patients with and without SMuRF is unknown. This study aimed to determine the prevalence, characteristics and clinical outcomes of patients hospitalized with T2AMI based on the presence of SMuRF.Methods:All hospitalizations with a primary discharge diagnosis of T2AMI in the National Inpatient Sample were stratified according to SMuRF status (SMuRF and SMURF-less). Primary outcome was all-cause mortality while secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and ischemic stroke. Multivariable logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).Results:Among 17,595 included hospitalizations, 1,345 (7.6%) were SMuRF-less. After multivariable adjustment, SMuRF-less patients were more likely to develop all-cause mortality (aOR 2.43, 95% CI 1.83 to 3.23), MACCE (aOR 2.32, 95% CI 1.79 to 2.90) and ischaemic stroke (aOR 2.57, 95% CI 1.56 to 4.24) compared to their SMuRF counterparts (Figure 1).Conclusions:T2AMI in the absence of SMuRF was associated with worse in-hospital outcomes compared to SMuRF-less patients. Further longitudinal studies are necessary to define the impact of SMuRF on longer term T2AMI outcomes.
Circulation, Volume 146, Issue Suppl_1, Page A11994-A11994, November 8, 2022. Background:Patients in AUGUSTUS (n=4614) taking apixaban without aspirin had less bleeding and fewer hospitalizations with no significant increase in ischemic events than those taking VKA, aspirin, or both. It is safe and efficacious to reduce apixaban from 5 mg to 2.5 mg twice daily in patients with AF and ≥2 of the following: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL. Data on reduced versus standard dose apixaban in patients with AF and ACS and/or PCI are limited.Methods:We assessed how many patients receiving apixaban 2.5 mg met the dose reduction criteria. We compared major or CRNM bleeding, death or rehospitalization, and death or ischemic events in those who appropriately received 2.5 mg apixaban, inappropriately received 2.5 mg apixaban, and appropriately received 5 mg apixaban. We determined the association of apixaban versus warfarin on bleeding and ischemic events in patients appropriately assigned 2.5 mg apixaban and appropriately assigned 5 mg apixaban.Results:Of 2290 patients assigned apixaban, 229 received 2.5 mg and 98 (43%) of those met reduced dose criteria. Rates of major/CRNM bleeding, death or rehospitalization, and death or ischemic events were higher in patients appropriately receiving 2.5 mg apixaban (13.7%, 34.7%, 12.2%) compared with those inappropriately receiving 2.5 mg apixaban (10.5%, 32.5%, 12.3%) and appropriately receiving 5 mg apixaban (11.0%, 23.0%, 5.7%). Compared with VKA, 2.5 mg apixaban, when used appropriately, resulted in similar or greater benefits than 5 mg apixaban for major/CRNM bleeding, death or rehospitalization, and death or ischemic events (Table).Conclusion:Of those in AUGUSTUS who received 2.5 mg apixaban, fewer than half met the reduced dose criteria. In patients with AF and recent ACS or PCI, appropriate use of reduced dose apixaban was associated with a lower risk of bleeding and similar rates of rehospitalization and ischemic outcomes compared with VKA, similar to that for standard dose apixaban.
Circulation, Volume 146, Issue Suppl_1, Page A13086-A13086, November 8, 2022. Introduction:Conventional right ventricular apical pacing can cause electrical-mechanical dyssynchrony. For this reason, physiological pacing was considered and became the background for the development of his bundle pacing (HBP). Recently, left bundle branch area pacing (LBBAP), which overcomes the shortcomings of HBP, has been implemented.Hypothesis:Initially, LBBAP was achieved through a lumen-less lead, and it has been reported that LBBAP using a standard stylet-driven lead (SDL) is also available. The purpose of this study is to establish the feasibility and mid-term outcome of LBBAP using SDL, and to investigate the predictors of success.Methods:This study enrolled a total of 119 patients who underwent LBBAP from December 2020 to February 2022. LBBAP was performed with a 5.6Fr stylet-driven pacing lead with an extendable helix (Solia S60, Biotronik, SE & Co, KG). We analyzed the initial outcomes of the procedure, including the success rate and complications, and identified predictive factors that affect them. lead parameters were assessed in follow up.Results:Total success rate of lead implantation of LBBAP with conventional stylet-driven lead was 95.8% for entire period and showed increase in success rate as the number of procedures increased. In the multivariate analysis, The larger the RA size, the greater the number of trials (Estimates = 1.770 [1.10 – 2.44], p =
Circulation, Volume 146, Issue Suppl_1, Page A11864-A11864, November 8, 2022. Background:The left atrial thrombus (LAT) formation is associated with thromboembolic events in atrial fibrillation (AF) patients.Objective:We investigated the incidence and associated factors of LAT in patients with AF who already on standard anticoagulation therapy.Methods:Medical records of 1,122 AF patients (mean 59.4 ± 11.0 years old, 58.3% male) who were on standard anticoagulation and underwent transesophageal echocardiography (TEE) from 2009 to 2019 were evaluated. Baseline clinical and echocardiographic data were analyzed. The main outcome of the study was the presence of LAT on TEE. The associated factors of the LAT were analyzed.Results:Warfarin and non-vitamin K oral anticoagulants (NOAC) were used in 74.4% and 25.6% of the patients. Among these patients, LAT was found in 60 patients (5.3%). The significant predictors of the LAT on TEE were elders ( >75 years old, Odd ratio [OR] 1.99 [95% confidence interval 0.88-4.24]), persistent/permanent AF (OR 2.63 [1.45-4.95]), high CHA2DS2-VASc score (≥3 points, OR 2.06 [1.15-3.74]), low left ventricular ejection fraction (
Circulation, Volume 146, Issue Suppl_1, Page A14099-A14099, November 8, 2022. Introduction:Speckle tracking echocardiography (STE) can be an useful tool for detecting early and subtle myocardial changes in patients with systemic lupus erythematosus (SLE)Hypothesis:The present study aimed to perform systemic review and meta-analysis of the studies based on the assessment of the left ventricular (LV) systolic function with LV ejection fraction (LVEF) and LV global longitudinal strain (LV GLS).Methods:Data were analysed according to an established protocol of the Cochrane Collaboration steps and meta-analysisResults:A total of 850 papers were collected, of those 10 papers including 174 442 SLE patients and 45 608 723 controls with heart failure, also 20 papers including 1121 SLE patients and 1010 controls with measured LVEF and 9 papers including 462 patients and 356 controls with measured LV GLS were selected. Studies have shown, that patients with SLE were characterized with higher prevalence of heart failure as compared to controls (Fig1). Patients with SLE exhibited lower levels of LVEF as compared to controls too (Fig.1), some included studies have shown that the difference in terms of LVEF between groups is not always significant. LV GLS was more deteriorated in SLE patients as compared to controls (Fig.2a, 2b), moreover some studies showed significant association between deteriorated LV GLS and cardiovascular events.Conclusions:Patients with SLE are characterized with high prevalence of heart failure. LV systolic function as measured by LVEF and LV GLS is significantly more affected in SLE patients. Data suggest that LV GLS may improve risk-stratification in patients with SLE.
