A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURO bservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry

Aims: Given the advances in atrial fibrillation (AF) management and the availability of new European Society of Cardiology (ESC) guidelines, there is a need for the systematic collection of contemporary data regarding the management and treatment of AF in ESC member countries. Methods and results: We conducted a registry of consecutive in- and outpatients with AF presenting to cardiologists in nine participating ESC countries. All patients with an ECG-documented diagnosis of AF confirmed in the year prior to enrolment were eligible. We enroled a total of 3119 patients from February 2012 to March 2013, with full data on clinical subtype available for 3049 patients (40.4% female; mean age 68.8 years). Common comorbidities were hypertension, coronary disease, and heart failure. Lone AF was present in only 3.9% (122 patients). Asymptomatic AF was common, particularly among those with permanent AF. Amiodarone was the most common antiarrhythmic agent used (~20%), while beta-blockers and digoxin were the most used rate control drugs. Oral anticoagulants (OACs) were used in 80% overall, most often vitamin K antagonists (71.6%), with novel OACs being used in 8.4%. Other antithrombotics (mostly antiplatelet therapy, especially aspirin) were still used in one-third of the patients, and no antithrombotic treatment in only 4.8%. Oral anticoagulants were used in 56.4% of CHA 2DS2-VASc = 0, with 26.3% having no antithrombotic therapy. A high HAS-BLED score was not used to exclude OAC use, but there was a trend towards more aspirin use in the presence of a high HAS-BLED score. Conclusion: The EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot Registry has provided systematic collection of contemporary data regarding the management and treatment of AF by cardiologists in ESC member countries. Oral anticoagulant use has increased, but novel OAC use was still low. Compliance with the treatment guidelines for patients with the lowest and higher stroke risk scores remains suboptimal. © The Author 2013

The role of cardiac magnetic resonance in MINOCA diagnosis

Abstract Introduction Absence of obstructive coronary disease does not imply absence of acute myocardial infarction (AMI). Hence, it can be designated as Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). Performing Cardiac Magnetic Resonance (CMR) can be essential for establishing a final diagnosis, according to the presence and pattern of late gadolinium enhancement (LGE). Purpose The aim of this study is to evaluate the diagnostic and prognostic impact of CMR in patients with a possible diagnosis of MINOCA. Methods A 7-year prospective study, which included all patients proposed to CMR with a presumptive diagnosis of MINOCA due to acute chest pain, troponin raise and absence of angiographically significant coronary disease (luminal stenosis of &amp;lt;50%). All patients performed functional, anatomical evaluation and LGE assessment. We analysed clinical characteristics, electrocardiographic presentation, echocardiographic and invasive coronary angiography results. A presumptive diagnosis was elaborated after invasive coronary angiography and comparison was made with the definitive one after CMR. Results A total of 96 patients were included, 50% were male, with a mean age of 48±20 years old. Clinical history of hypertension was observed in 51.0% patients, 35.4% had dyslipidaemia, 7.3% with diabetes, obesity was present in 22.9% of patients and smoking habits in 30.2%. At admission, 44.8% had ST segment elevation, so emergent invasive coronary angiography was performed. The mean highest troponin I was 7.34±9.18 ng/mL. Late gadolinium enhancement was observed in 53 (55.2%) of patients. After CMR realization a final diagnosis of MINOCA was made in only 8 patients (8.4%) and in 51 patients (53.1%) CMR evaluation allowed a diagnosis modification, with impact on patients' management and prognosis. A definitive diagnosis of myocarditis was seen in 46.9% (n=45) of cases, of Takotsubo's myocardiopathy in 13.5% (n=13), and hypertrophic cardiomyopathy in 3.1% (n=3). In 27 (28.1%) of patients, late gadolinium enhancement was not found. This diagnosis adjustment had an impact on treatment in 34.4% (n=33). Conclusion CMR is a pivotal technique on MINOCA patients' management. Our study portrayed the importance of performing CMR, allowing initial diagnosis modification in half of the cases, with important therapeutic in one third of patients and prognostic implications, related to diagnosis and target treatment adverse effects. Funding Acknowledgement Type of funding sources: None. </jats:sec

Iron deficiency – a factor in left ventricular ejection fraction depression post-myocardial infarction

Abstract Introduction Iron deficiency was shown to affect functional capacity and ejection fraction in patients with heart failure and reduced ejection fraction. Myocardial infarction is an important cause of reduced left ventricular ejection fraction (LVEF). Moreover, there is some evidence of the iron deficiency as a factor to predict cardiovascular and non-cardiovascular mortality. Purpose Evaluate the presence of iron deficiency in patients with acute coronary syndromes (ACS) admitted to the intensive cardiac care unit and its eventual association with LVEF and mortality. Population and methods We performed a prospective study in which ACS patients were divided into groups according to the presence or absence of iron deficiency. We collected demographic data, comorbidities, as well as determination of troponin I, haemoglobin and criteria for absolute and functional iron deficiency (ID) and other data related to the use of mechanical ventilation, need for aminergic support, LVEF and death. Results From 148 patients we included 78 patients who met the criteria for being analysed. 49 patients had iron deficiency (51% had absolute iron deficiency and 49% had relative iron deficiency). There were no differences between groups in terms of myocardial infarction with or without ST segment elevation (p=0.609 and p=0.329, respectively), hypertension (p=0.926), diabetes (p=0.882), obesity (p=0.343), dyslipidaemia (p=0.482), smoking (p=0.876), valvular heart disease (p=0.888), acute and chronic renal failure (p=0.800 and p=0.888, respectively) and LVEF (p=0.886). There were no differences in need for aminergic support (p=0.984), ventilation (p=0.315) and death (p=0.704). We found that in the sub-population of patients without anaemia (Hb&amp;gt;12g/dL), the proportion of patients with depressed LVEF (inferior to 50%) and relative iron deficiency was significantly higher than those with preserved LVEF (48.1 vs 13.8%, p=0.005). Furthermore, we also found that in this sub-population, patients with myocardial infarction without ST segment elevation had higher proportion of absolute iron deficiency (45.0 vs 19.4%, p=0.043). Conclusion Our study showed that the prevalence of iron deficiency in ACS patients is 62.9% (n=49). Moreover, in patients without anaemia, this results seems to point out that the presence of iron deficiency may be related with LVEF, at least during the acute event. Further studies with a higher sample size are warranted to either establish or discard this association. Furthermore, a follow-up of this patients can further enlighten us as to the role of iron deficiency in long term LVEF and mortality. Funding Acknowledgement Type of funding sources: None. </jats:sec

Modified zwolle score with delta-creatinine: enhancing the safety of early discharge after STEMI

Abstract Introduction The Zwolle score (ZS) is recommended to identify low-risk patients eligible for early discharge after acute ST-segment elevation myocardial infarction (STEMI), but as only one-third of STEMIs have a low ZS, the discharge is often postponed. Creatinine variation (Δ-Cr) also provide prognostic information after STEMI. Purpose The authors intend to study the “modified Zwolle Score” (MZS) model, which encompasses Δ-Cr as a variable that may enhance the discriminative power of the standard ZS. The outcome is 30-day mortality, time range that starts right after the ACS. Methods This is a retrospective study with data from a national multicentre registry. We have included 3.296 patients with STEMI. Zwolle score was calculated for each patient. It is defined as shown in figure 1. Δ-Cr was defined as maximum serum creatinine minus admission serum creatinine. A Δ-Cr≥0.3 was assigned 2 points in the Modified Zwolle Score, after interpretation of odds ratio via multivariate analysis. For prediction quality assessment, we have performed ROC curve analysis with both scoring systems versus 30-day mortality. Regarding survival analysis, we have performed Kaplan-Meier curves with Log-rank analysis. We have also registered complications during hospital stay. Results The sample mean age is 63±14, and it is composed by 76.8% of males. The majority of patients presented Killip Class I (87.3%). The STEMI was anterior in 49.7% of patients and inferior in 49.8% of patients. The mean admission time was 5 days. Intrahospital mortality was 3% and 30-day mortality was 4%. The mean ZS was 3.1±2.8 points, the mean MZS was 3±2.1 points and the mean Δ-Cr was 0.2±0.6mg/dL. The ROC curve analysis between ZS and early mortality revealed a c-statistic of 0.810 (CI 0.796–0.823), whereas the ROC curve between MZS and early mortality revealed a c-statistic of 0.853 (95% CI: 0.841–0.865). The ROC curves comparison showed superiority of the MZS c-statistic, with a difference between AUC of 0.043 (p&amp;lt;0.001, 95% CI: 0.024–0.063). Regarding low-risk patients, 30-day mortality was 3.3% using ZS (0–2 points) and 2.4% using modified ZS (0–2 points). Fifty patients (1.5%) died between 3rd and 10th day after ACS: original ZS low-risk criteria registered 0.09% and modified ZS low-risk criteria 0.06% fatalities. Kappa coefficient for intergroup concordance was good (0.73). Conclusion We conclude that by adding Δ-Cr to the standard ZS, a renal function parameter that was lacking in the ZS, its predicting capacity regarding early mortality in patients admitted with STEMI was increased. Comparing both scores, low-risk patients defined by MZS registered less complications, 3–10 day mortality and 30-day mortality than low-risk patients defined by the original ZS. This fact may lead to better distinction of patients who will benefit from early discharge. Zwolle Score, ROC curves and survival Funding Acknowledgement Type of funding source: None </jats:sec

Cardiogenic shock without hypotension in acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiogenic Shock(CS)complicates 10%of Acute Myocardial Infarction(AMI), being the main cause for intra-hospital death in these patients.Although early revascularization has contributed to increase survival,mortality still presents high, being 40-50%.CS usually presents with inadequate cardiac output and persistent hypotension.However,after large AMI,peripheral hypoperfusion can occur with sustained or borderline systolic blood pressure(SBP). Purpose Characterize patients(pts)with CS after AMI in the absence of hypotension(defined as SBP &amp;lt; 90mmHg),and assess impact in mortality. Methods We evaluated 528pts presenting with CS in context of AMI.We considered 2groups:Group 1-Pts who had SBP ≥90mmHg,without any inotropic drug or assist device and 2-Pts with SBP &amp;lt; 90mmHg.We registered age,gender,co-morbidities,presentation,coronary anatomy and treatment strategies.We evaluated in-hospital mortality and complications:re-infarction,mechanical complications,high-grade atrioventricular block(AVB),sustained ventricular tachycardia,atrial fibrillation,resuscitated cardiac arrest and stroke. Results AMI presenting as Cardiogenic Shock without hypotension(CSWH)was found in 51%of pts(n = 272),of whom 69%were male.They were younger(between age of 45-64years old in 34%of cases vs 25%,p = 0.040)and had higher body mass index (27.3 ± 4.5vs 26 ± 4.1,p = 0.001).Hypertension was a similarly distributed comorbidity.In group 1,pts were previously more frequently under beta blocker medication (25.2%vs 17.7%,p = 0.047).In this group,mean left ventricular (LV)ejection fraction was 39 ± 13%,a quarter having severely depressed LV function(&amp;lt;30%).Although STEMI was the most common presentation in both sets(73.5% vs 87.1%,p &amp;lt; 0.001),NSTEMI was more prevalent in CSWH(23.9%vs12.1%,p &amp;lt; 0.001).Those pts presented more,at admission,with dyspnea(14.9%vs5.5%,p &amp;lt; 0.001)and in sinus rhythm(81.9%vs69%,p &amp;lt; 0.001).In this group,ICU admission was less frequent(19.4%vs27.2%,p = 0.036),and only about half of pts were medicated with inotropic drugs(vs 78.1%,p &amp;lt; 0.001).However,difference in intra-aortic balloon use wasn’t found.CSWH presented with multivessel disease in 63.8%of pts,being LAD more frequently the culprit vessel(42.4% vs 30.7%,p = 0.030),but fewer left main artery(LM)(4.2%vs14.0%,p = 0.003).Group 1 had fewer prevalence of vessel occlusion,which was particularly true for LM(3.8%vs11.5%,p = 0.015) and circumflex(12.4%vs20.7%,p = 0.047),and were less often submitted to revascularization.Group 1 had fewer AVB(9.8%vs22.4%,p &amp;lt; 0.001).Rates of other complications were similar.In-hospital mortality was higher in classic CS(33.1% vs 43.8%, p= 0.012). Conclusion Cardiogenic Shock without hypotension was found in about half of pts with CS due to AMI.A majority of these were younger and globally had a less severe event and complications.Even though CSWH was associated with one third of in-hospital mortality,it was lower than in pts with hypotension. </jats:sec

P1722A new predictive score for mortality and cardiogenic shock in patients with ST-elevation myocardial infarction

Abstract Introduction Acute Myocardial Infarction with ST elevation (STEMI) presents a high rate of potentially fatal complications and in-hospital mortality. Objective To test the predictive capacity for Cardiogenic Shock (CS) and In-hospital Mortality (MIH) of a new risk score in patients (Pts) with STEMI. Population and methods Evaluated 5765 Pts with STEMI without CS at admission. The new score, was derived by previous studies in this population, and was calculated according to the following criteria: age ≥65 years (1 point), heart rate ≥100bpm (2 points), systolic blood pressure &lt;100mmHg (2 points), blood glucose at admission above 180 mg/dL (1 point) and creatinine at admission &gt;1.5mg/dL (2 points). The population was divided into three subgroups: group A low score (0–2 points), group B intermediate score (3–5 points) and group C score (6–8 points). The endpoints defined were CS during hospitalization, in-hospital mortality and combined end-point of MIH and CS. The relationship between each of the possible scores (from 0 to 8) and the various end-points was determined, and the sensitivity and specificity of the score as a predictor of MIH and CS was defined as the area under the ROC curve (ASC). Results After the application of the score, 3 subgroups were obtained: group A with 4819 Pts (83,6%), group B with 884 Pts (15,3%) and group C 62 Pts (1,1%). Patients of group C had a higher MIH (Group C: 45,2% vs B: 11,4% vs A: 2,0%, p&lt;0,001), higher CS (C: 29,5% vs B: 12,0% vs A: 2,3%, p&lt;0,001) and a higher combined end-point of MIH and CC (C: 53,2% vs B: 17,8% vs A: 3,4%, p&lt;0,001) during hospitalization. The proposed score revealed a high predictive capacity of MIH (ASC 0,802, 95% CI 0,775–0,830, p=0,001), of CS (ASC 0,763, 95% CI 0,731–0,795, p=0,001) and for the combined endpoint (MIH and CC) ASC 0,781, 95% CI 0,756–0,806, p=0,001). The logistic regression models showed that Pts with a high score (group C) presented a 41-fold higher risk of MIH (OR 41,3; p&lt;0,001) and 18-fold higher CS (OR 18,0; p&lt;0.001) than patients with low score (group A). It was also found that the risk associated with an increase in one point score unit was 100% (OR 2,0 p&lt;0.001) for MIH and 82% (OR 1,82, p&lt;0,001) for CS. Conclusion This new score, with the use of practical and friendly variables, demonstrated a high predictive capacity of MIH and CS. </jats:sec

P2265Cardiogenic shock without severe left ventricular dysfunction after ST-elevation acute myocardial infarction: population characterization and impact in prognosis

Abstract Background The presence of cardiogenic shock (CS) after ST-elevation acute myocardial infarction (STEMI) is associated with a high mortality. Traditionally, severe left ventricular dysfunction is assumed to be the main predictor of CS, however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction. Purpose To characterize the population of patients (Pts) with CS after STEMI but without severe left ventricular dysfunction and assess their impact in mortality. Methods From a national multicenter registry, we evaluated 7181 Pts with STEMI and ejection fraction (EF) &gt;30%, and excluded all pts with STEMI and an EF&lt;30%. We considered 2 groups: Group 1 – Pts who developed CS and Group 2 - Pts who didn't developed CS. We registered age, gender, cardiovascular and non-cardiovascular co-morbidities, electrocardiographic presentation, vital signs at admission, reperfusion strategies, reperfusion times and coronary anatomy. We evaluated the following in-hospital complications: Re-Infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT) atrial fibrillation (AF) and stroke. We compared the in-hospital mortality. Results The presence of CS without severe left ventricular dysfunction was observed in 5,2% pts (n=376), being CS present at admission in 51,2% of these pts. The mean EF was lower in group 1 pts (44% ± 11 vs 51±11%, p&lt;0,001). Patients in group 1 were older (70±14 vs 63±13 years, p&lt;0,001), more females (39,4% vs 23,3%, p&lt;0,001), had a higher prevalence of previous valvular heart disease (2,7% vs 1,0%, p=0,005), heart failure (4,8% vs 1,4%, p&lt;0,001, peripheral artery disease (5,5% vs 2,9%, p=0,004), chronic kidney disease (6,4% vs 2,7%, p&lt;0,001) and chronic pulmonary obstructive disease (8,2% vs 3,1%, p&lt;0,001). At admission, Group 1 pts had more atrial fibrillation (10,4% vs 4,4%, p&lt;0,001) and received less reperfusion (77,7% vs 83,0%, p=0,008), without differences in the type of reperfusion or times to reperfusion. The presence of multivessel disease (60,0% vs 45,7%, p&lt;0,001) and left main disease (6,6% vs 2,4%, p&lt;0,001) were more prevalent in Group 1 pts. Group 1 pts had more in-hospital complications: Re-Infarction (3,5% vs 0,7%, p&lt;0,001), AF (22,1% vs 5,0%, p&lt;0,001), mechanical complications (9,6% vs 0,5%, p&lt;0,001), high atrial ventricular block (26,7% vs 3,7%, p&lt;0,001), VT (10,6% vs 1,9%, p&lt;0,001), stroke (1,9% vs 0,6%, p=0,01) and major bleeding (10,4% vs 1,5%, p&lt;0,001). In-hospital mortality was much higher in Group 1 pts (26,6% vs 1,4%, p&lt;0,001). Conclusions Cardiogenic shock is present in 5,2% of STEMI pts without severe ventricular dysfunction. These pts were older, more frequent female, had higher morbidities and in-hospital complications. Even without severe ventricular dysfunction, cardiogenic shock in these patients was associated with much higher in-hospital mortality. </jats:sec