Abstract Introduction Evidence of benefit in the use of mechanical circulatory support devices (MCS) in patients with acute myocardial infarction (AMI) is scarce. We aimed to evaluate the clinicalcharacteristics, prognosis and factors associated with the use of MCS in patients with AMI due to left main (LM) occlusion. Methods We performed a retrospective multicenter study of 128 consecutive patients with AMI with ≤12h of presentation with LM occlusion submitted to immediate reperfusion between January 1, 2008, until December 31, 2020 in three terciary hospitals of Portugal. Among this cohort, we divided patients into two groups according to the use of MCS devices. Results Regarding the baseline characteristics no statistically significant differences were found, except for the presence of cerebrovascular disease (2.9% in group with vs 16.9% in group without MCS, p=0.007) and peripheral artery disease (8.8% in group with vs 22% in group without MCS, p=0.037). We observed that the use of MCS devices was statistically different between the three centers (47.8%, 42%, 8.7%, p<0.001). No differences were found at presentation for ST-segment elevation vs non-ST segment elevation AMI (p=NS). The presence of cardiogenic shock (72.4% vs 45.8%, p=0.002), cardiac arrest (27.5% vs 23.7%, p=0.034) and more severe thrombolysis in myocardial infarction (TIMI) flow at presentation (55.1% vs 35.6%, p=0.015) were more frequent in group with MCS. The rate of 1-year cumulative mortality was high in both groups (31/59=52.5% in the group without vs 47/69=68.1%, p=NS). Also, no statistically significant differences were found in terms of survival, but we observed a trend to higher mortality in those who received MCS as Kaplan-Meier survival curves show (log rank=0.062). Finally, in multivariable analysis, older age [odds ratio (OR), 0.935; 95% CI, 0.87–0.99], the presence of diabetes (OR, 0.223; 95% CI, 0.056–0.88), peripheral artery disease (OR, 0.070; 95% CI, 0.009–0.566) and extra-hospitalar cardiac arrest (OR, 0.06; 95% CI, 0.007–0.543) were characteristics associated with lower odds of receiving MCS. Contrarily, male sex (OR, 5; 95% CI, 1–20.4) and the presence of cardiogenic shock (OR, 5.7; 95% CI, 1.42–23) were factors associated with higher use of MCS. Conclusion The use of MCS does not seem to modify prognosis in patients admitted withAMI due to left main occlusion. Only cardiogenic shock and male gender were predictors of MCS use. Funding Acknowledgement Type of funding sources: None.
Abstract Funding Acknowledgements Type of funding sources: None. Introduction and objective Acute coronary syndrome (ACS) patients with unprotected left main coronary artery (LMCA) occlusion are at increased risk of mortality. Most studies have shown an association between LMCA occlusion and cardiac arrest. We aimed to evaluate the clinical characteristics and the prognosis of patients with ACS due to LMCA occlusion with cardiac arrest at presentation. Methods We performed a retrospective multicenter study of 128 consecutive patients with ACS due to LMCA occlusion admitted in three Portuguese tertiary hospitals between 2008 and 2020. Patients were divided according to the presentation with cardiac arrest. Results Among this cohort, 26% patients presented with cardiac arrest. Regarding baseline characteristics, they were younger (58 vs 65 years; p=0.001) but no other significant differences were found. Cardiac arrest was associated to shorter symptoms-to-balloon time (150 vs 195 minutes; p=0.042) and higher recourse to fibrinolysis (12.1% vs 0%, p=0.004). They also had higher prevalence of cardiogenic shock (88% vs 51%; p<0.001) and need for aminergic support (91% vs 64%; p=0.004). Furthermore, in-hospital (79% vs 45%; p=0.001) and 5-year (97% vs 73%; p=0.008) mortality were significantly higher, as predicted by Kaplan-Meier survival curves (p=0.002; log-rank test). Finally, in multivariable analysis, younger age [odds ratio (OR),1.12;95% CI,1.04-1.20] and lower median symptoms-to-balloon time (OR, 1.35;95% CI,1.02-1.82) were independently associated to cardiac arrest at presentation. Conclusion In our real-world cohort, more than one quarter of patients with ACS due to LMCA occlusion presented with cardiac arrest, which correlates to a higher incidence of cardiogenic shock, as well as higher short- and long-term mortality. Only younger age and lower symptoms-to-balloon time were independently associated to cardiac arrest. Despite cardiac care improvements, technological evolution, and better patient/system-delay times, this is still a subpopulation with poor prognosis. Further studies are needed to find innovative strategies that can make a difference in this subgroup of patients.
Abstract Funding Acknowledgements Type of funding sources: None. Introduction The optimal lead position for right ventricle (RV) pacing is still a matter of debate. Several studies compared 2D-echocardiography left ventricle ejection fraction (LVEF) and LV global longitudinal strain (LVGLS) by speckle-tracking imaging (STI). However, these parameters present limitations, such as load dependency. Recently, myocardial work (MW) has emerged as an alternative tool for myocardial systolic function assessment. Purpose To compare LV MW and LVGLS between patients with RV outflow tract/septum pacing (Group1) and RV apical pacing (Group2). Methods Prospective single-center study of patients with permanent pacemaker (PMK) followed at our cardiac device’s outpatient clinic between july and november of 2022. Patients were divided into two groups according to RV pacing site. Moderate/severe valvular disease, LVEF<50%, segmental wall-motion abnormalities, pulmonary hypertension, cardiomyopathies, or RV dysfunction were exclusion criteria. STI-based LVGLS analysis and MW parameters were obtained (GWI:Global Work Index; GCW:Global Constructive Work; GWW:Global Wasted Work; GWE:Global Work Efficiency). RV pacing was required at the moment of imaging. A 12-lead ECG was also performed. Blood pressure (BP) was simultaneously measured. Results Our cohort comprised 30 patients in group 1 and 25 patients in group 2. The 2 groups were well-matched, except for the median time since PMK implantation, which was significantly higher in Group2 (5.3years vs 0.9years, p<0.001). The QRS was significantly narrower in Group1 (Group1:129ms±9 vs Group2:165ms±15, p<0.001). LVEF was similar in both groups (Group1:58%±7.5 vs Group2:60%±7.5, p = NS). Likewise, both systolic and diastolic BP were comparable (p = NS), but LVGLS was significantly higher in Group1 (15±3.3 vs 13±3.7, p = 0.043). Except for GWI which was also significantly higher in Group1 (1553mmHg%±581 vs 1238mmHg%±516, p = 0.040), no significant differences were found in the other parameters of MW among the groups (all p = NS). Conclusion Our results point to LVGLS being significantly lower in the group of RV apical pacing. Despite most parameters of MW didn’t differ between groups, GWI also showed significant impairment. These findings should be regarded as preliminary and further larger studies are needed to ascertain the value of this new tool in understanding the impact of pacing depolarization site on LV mechanics.
Abstract Introduction New therapies for heart failure with reduced ejection fraction (HFrEF) have been recently developed. It is still unclear the proportion of patients of clinical practice that will benefit from them. We aimed to examine the representativeness of the VICTORIA and GALACTIC-HF trials among a contemporary cohort of HFrEF patients followed at an HF outpatient clinic. Methods We performed a retrospective, cross-sectional, single-center study of 100 consecutive HFrEF patients from our HF outpatient clinic (January-June 2020). VICTORIA eligibility criteria were an LVEF <45%; NT-proBNP ≥1000 pg/mL if sinus rhythm (SR) or ≥1600 pg/mL if atrial fibrillation (Afib); and prior hospitalization in the last 6 months or IV diuretic therapy in the last 3 months. GALACTIC-HF eligibility criteria were an LVEF <35%, hospitalization or emergency room visit in the last 12 months; NT-proBNP >400 ng/mL if SR or ≥1200 pg/mL if Afib or atrial flutter. Results The mean age of our patients was 62±12 years and only 24% were female. The etiology of HF was ischemic in 42% of the patients, 86% of patients were in NYHA II class and 5% in NYHA III-IV. The mean LVEF was 34±5% and the median NT-proBNP was 482 pg/mL [172–1120]. Regarding treatment, 92% of patients were on betablockers (BB), 67% on ACEI/ARBs, 25% on ARNI, 81% on MRA and 30% on iSGLT2. The use of implantable cardioverter-defibrillators was 38% and 20% of patients were resynchronized. The proportion of patients meeting VICTORIA and GALACTIC-HF eligibility criteria was 11% and 21%, respectively. But excluding the criteria of recent hospitalization the representativeness of the VICTORIA trial increased to 28% and the GALACTIC-HF to 44%. The patients that met VICTORIA eligibility criteria were older (60±11 y vs 10±12 y; p=0.006), had worse functional class (NYHA III-IV: 18% vs 3%; p=0.03), were less likely to be treated with an MRA (55% vs 85%; p=0.013) and an iSGLT2 (0% vs 34%; p=0.02). Those that met GALACTIC-HF eligibility criteria had a lower LVEF (31±3% vs 35±6%; p=0.01), were less likely to be treated with an iSGLT2 (35% vs 10%; p=0.02) and more likely to be treated with a loop diuretic (86% vs 65%; p=0.06). Conclusions In a contemporary optimally treated HFrEF cohort only a small proportion of patients met the eligibility criteria used in VICTORIA and GALACTIC-HF trials, which identified older patients with more advanced disease. Funding Acknowledgement Type of funding sources: None.
Abstract Introduction Modern pharmacological treatment of heart failure with reduced ejection fraction (HFrEF) dramatically improves its prognosis. However, the increasingly complexity and associated costs might threat their effective uptake in clinical practice. We aimed to study the pill burden and out-of-pocket costs of cardiovascular drug therapy of a contemporary cohort of HFrEF patients. Methods We performed a retrospective, cross-sectional, single-center study on a convenience sample of 100 consecutive HFrEF patients assessed at our HF outpatient clinic (January-June 2020). The pill burden was assessed by the number of prescribed different cardiovascular drugs and pills per day. The out-of-pocket (OOP) costs were defined using the total patients co-payment of cardiovascular medications per month of treatment, taken in account the exemptions provided by the Portuguese National Health System (NHS). The included drug classes were antiplatelets, anticoagulants, statins, HF drugs (Beta-blockers [BB], angiotensin-converting enzyme inhibitors [ACEi]/ angiotensin receptor blockers [ARBs]/ angiotensin receptor-neprilysin inhibition [ARNI], mineralocorticoid antagonists [MRA], sodium glucose cotransport inhibitors [iSGLT2], digoxin, loop diuretic) and antiarrhythmics. Results The mean age was 62±12 years and only 24% were female. The etiology of HF was ischemic in 42% of the patients, 86% were in NYHA II class and 5% in NYHA III-IV. The mean LVEF was 34±5% and the median NT-proBNP was 482 pg/mL [172–1120]. 92% of patients were on BB, 67% on ACEI/ARBs, 25% on ARNI, 81% on MRA and 30% on iSGLT2. The use of implantable cardioverter-defibrillators was 38% and 20% of patients were resynchronized. The number of cardiovascular (CV) drugs per day was 5.4±1.6 per patient and the number of CV pills per day was 6.6±2. Most patients (65%) had low income and had the maximal exemption on medication costs provided by NHS. Overall, the mean OOP costs was €16.1 per month of treatment and the mean OOP costs for patients exempted and not exempted was €12.9 and €22.3, respectively. The mean OOP costs of evidence-based HF-modifying drugs (BB, ACEI/ARBs, ARNI, MRA, iSGLT2) was €10.1 and the mean OOP costs of evidence-based HF-modifying drugs for patients exempted and not exempted were €7.9 and €14.2, respectively. However, for patients on ARNI the mean OOP costs was almost 3 times higher (€33.6). Conclusions In this optimally treated contemporary cohort of HFrEF, the pill burden due to cardiovascular therapy only is high (7 pills/day). With the exception of patients on ARNI, the overall OOP costs of HF-modifying prognostic drugs are low. Funding Acknowledgement Type of funding sources: None.
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