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Ivo Petrov*, Zoran Stankov, Gloria Adam

ACIBADEM City Clinic Cardiovascular Center, Sofia, Bulgaria

Seyedeh Maryam Hosseini¹, Cristina Pecci², Muhammad Ajmal³*

¹Internal Medicine Resident, University of Arizona, Tucson, Arizona

²Cardiology Fellow, University of Arizona, Phoenix, Arizona

³Cardiology Fellow, University of Arizona, Tucson, Arizona

Atrial Fibrillation (AF) is associated with an increased risk of thromboembolism due to formation of intracardiac thrombus mostly in left atrial appendage. Anticoagulant agents are used to reduce the risk of thromboembolism but have concerning bleeding side effect, making their use very challenging particularly in patients with high HAS-BLED risk score. WATCHMAN device (Boston Scientific, St. Paul, Minnesota) is a Left Atrial Appendage Occlusion (LAAO) device, which was tested in two major randomized trials. PROTECT AF (Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients with Atrial Fibrillation) trial, and PREVAIL (Prospective Randomized Evaluation of the WATCHMAN Left Atrial Appendage Closure Device in Patients with Atrial Fibrillation versus Long Term warfarin Therapy) trial, both evaluated WATCHMAN device’s safety and efficacy compared to warfarin. These trials showed WATCHMAN device to be non-inferior to warfarin. However, patients with history of intracranial hemorrhage were excluded from these trials due to concern of increased recurrent bleeding in presence of perioperative use of anticoagulation. Purpose of this review is to evaluate existing evidence and share our experience of LAAO in this high-risk population.

Chandreyee Datta, Ashish Bhattacharjee*

Department of Biotechnology, National Institute of Technology, Durgapur, India

Among different sources that contribute in the global oxidative stress, the vast majority of cellular reactive oxygen species (ROS) originate from mitochondrial compartments. Recently, monoamine oxidases (MAOs) are identified as a prominent source of ROS. Monoamine oxidases are localized in the outer membrane of mitochondria and exist as two different isoforms, MAO-A and MAO-B. MAOs are mitochondrial flavoenzymes responsible for oxidative deamination of biogenic amines and during this process, H₂O₂ and aldehydes are generated as intermediate products. The role of monoamine oxidase in cardiovascular pathophysiology has only recently gained some attention as it is demonstrated that H₂O₂ and aldehydes may target myocardial function and consequently cardiac function. Results obtained by different research groups showed that MAO-A plays a key role in the regulation of physiological cardiac function and in the development of acute and chronic heart diseases through two mechanisms: regulation of substrate concentration and intracellular production of ROS. In this review, we will focus on the role of MAO-A in the field of cardiac aging and related diseases.

Abbreviations

ROS: Reactive oxygen species; MAO: Monoamine oxidase; H₂O₂: Hydrogen peroxide; WHO: World Health Organization; TAC: Transverse aortic constriction; CLG: Clorgyline; Tyr: Tyramine; HF: Heart failure.

G.M. Lindsay¹*, N.A. Tayyib¹, H. Asfour^1,2, R. Pushpamala¹, E. Nomani¹, F.J. Alsolami¹

¹College of Nursing Studies, Umm Al-Qura University, Makkah, Saudi Arabia

²Faculty of Nursing, University of Alexandria, Alexandria, Egypt

Background: Coronary artery bypass grafting (CABG) is a major surgical intervention to relieve symptoms and promote survival for individuals with coronary heart disease (CHD). The benefits of the intervention are thought to be improved when underlying risk factors of CHD are ameliorated. However in current health care systems the long-term follow-up of patients following CABG is not centralized to allow for the determination of survival trends and their optimization. The survival of study participants who underwent CABG is compared with age and gender matched individuals from the general population. Differences in rates of survival are interpreted in terms of lifestyle choices and the impact of risk factors of CHD.

Method: Survival data were obtained from government records to 18 years post intervention on a cohort of patients underwent CABG and participated in a long-term follow-up program. Cardiac symptoms and risk factors of CHD were collected from consenting participants (44 women and 164 men) prior to CABG and at clinical assessments at one and eight-year follow-ups. Important clinical and lifestyle factors were identified and their impact on post-operative survival was quantified using a maximum likelihood technique. Male and female patients were investigated separately and a good fit between observed and simulated survival experiences was confirmed by Monte Carlo simulation.

Results: Cardiac symptoms were exhibited by 75.8% of women and 68.3% of men (χ2=0.712, p=0.3988) one-year post operation, and by 84.2% of women and 70.2% of men eight-years post operation (χ2=1.556, p=0.212). Male long-term survival at 54.3% after 18 years was significantly better than 36.4% for females (χ2=4.449, p=0.035), but both were worse than 73.0% and 71.5% (p=0.6114) respectively for gender and age-matched cohorts from the general population.

Important risk factors for women were post-operative smoking and post-operative hypertension reducing annual post-operative survival by 3.9% and 2.7% respectively and by 6.6% when both present. Equivalent important risk factors for men are post-operative smoking and unrelieved/recurring cardiac symptoms reducing annual survival rates by 2.4% and 1.2% respectively and by 3.6% when both present.

Conclusion: Eighteen year survival post CABG was significantly better for men than women, but both were worse than that for the general population. Post-operative smoking was the most significant risk factor associated with decreased rates of survival followed by unrelieved/recurring cardiac symptoms for men and persisting hypertension for women.

Sanjeet Singh¹*, Sudeep Das De¹, Ahmad Al-Adhami¹, Yasser Hegazy¹, Kirsty Graham², Giuseppe Bozzetti³, Fraser Sutherland¹, Philip Curry¹, Nawwar Al-Attar¹, Zahid Mahmood¹

¹Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, UK

²Enhanced Recovery Nurse Practitioner, Golden Jubilee National Hospital, UK

³Department of Anaesthesia and Critical Care, Golden Jubilee National Hospital, UK

Enhanced Recovery After Surgery (ERAS) incorporates multi-modal interventions that synergistically improve patient outcome. Its goals include improving patients functionally pre-operatively, reducing the stress of surgery intra-operatively to facilitate early return to daily activities. We conducted a pilot study at our unit recruiting patients undergoing elective coronary artery bypass grafting (CABG) into the Cardiac ERAS (C-ERAS) pilot and compared them with the patients undergoing CABG meeting the ERAS criteria but who not included the C-ERAS pilot (Control).

Materials and Methods: 122 C-ERAS patients were compared to 91 control patients who underwent CABG only from the period of July 2015 to September 2016. All C-ERAS patients received pre-operative counselling by a dedicated ERAS Practitioner to manage expectations of the patient journey, health promotion and pre-operative optimisation advice. Emphasis was made on educating the patient on daily goals for recovery and patients were followed up daily by the ERAS practitioner post-operatively.

Results: There were 122 patients in the C-ERAS group and 91 patients in the control group. The mean age was 63.6±9.9 years. 181(85%) of the patients were males. After adjusting for the abovementioned confounders, C-ERAS patients had a shorter length of stay that was statistically significant. (2.36 days shorter (95% CI; 1.01-3.7 days; p<0.01). The difference in mean bed day costs was £1153.70 (95% CI, £553.70-£1753.7; p<0.01) less in the C-ERAS cohort.

Conclusion: This study highlighted that C-ERAS is a safe and feasible pathway to reduce in-hospital stay with no difference in complications and readmission rates compared to routine management of patients. There was also a significant cost saving with the C-ERAS pathway mimicking the results in enhanced recovery programmes in the other surgical specialities.

List of Abbreviations

C-ERAS Cardiac Enhanced Recovery After Surgery

CABG Coronary Artery Bypass Grafting

BMI Body Mass Index

NYHA New York Heart Association Functional Classification of Symptoms

CCS Canadian Cardiovascular Society grading of angina pectoris

LV Left Ventricle

ICU Intensive Care Unit

Deepti Bhandare¹*, Anupama Kottam²

¹Department of Cardiology, AdventHealth Sebring, Florida

²Department of Cardiology, Detroit Medical Center, Michigan

The clinical presentation of cardiac sarcoidosis (CS) ranges from an incidentally discovered condition to heart failure and sudden death. The diagnosis of CS is tough, and as a result, CS is often under-recognized in clinical practice. CS is mostly noted in the setting of systemic sarcoidosis, though isolated CS can occur. Frequently clinical criteria require the diagnosis of extracardiac disease in order to establish the diagnosis of CS in the absence of having a positive endomyocardial biopsy. While endomyocardial biopsy provides a high specificity for diagnosing CS, this invasive test has a limited sensitivity. There is incomplete knowledge of disease development and a deficient consensus on the ideal methods for disease recognition. We discuss CS in general, the clinical disease, diagnostic algorithms, latest guidelines and management.

Abbreviations

CS: Cardiac Sarcoidosis; CMR: Cardiac MRI; PET: Positron Emission Tomography; EMB: Endomyocardial Biopsy; HRS: Heart Rhythm Society; ACC: American College of Cardiology; AHA: American Heart Association; LGE: Late Gadolinium Enhancement.

Deepti Bhandare¹*, Christa Finer²

¹Department of Cardiology, Advent Health Sebring, Sebring, Florida

²Medical Student, 4th year, Lake Erie College of Osteopathic Medicine, Bradenton, Florida

The leisure intake of cannabis has shortly amplified in the past years corresponding with its decriminalization and legalization. The natural cannabis has been substituted by synthetic cannabinoids and cannabimimetic in several formulae, which are stronger. In spite of irresistible public insight into the safety of these substances, a growing quantity of grave cardiovascular adverse events are reported in sequential relation to recreational cannabis intake. A multifaceted interface between the active ingredients, the endo-cannabinoid system, and the autonomic nervous system is responsible in the pathophysiology. Tolerance to the properties of cannabis can develop with repetitive contact due to receptor desensitization. Effects of cannabis may be heightened or transformed by affiliated use of other illicit drugs or drug treatment indicated for the treatment of cardiovascular diseases. Nonetheless, the recent cannabis epidemic would significantly increase global burden of cardiovascular diseases.

Deepti Bhandare¹*, Thomas Shimshak²

¹Department of Cardiology, Advent Health Sebring, Sebring, Florida

²Department of Interventional Cardiology, Advent Health Sebring, Florida

Readmission for Acute Myocardial Infarction [AMI] significantly contributes to preventable morbidity and healthcare costs. Nearly 1 in 6 patients hospitalized with AMI have an unplanned readmission within 30 days of discharge, accounting for over $1 billion of annual US healthcare costs. We developed a unique integrated product in our hospital called “Transition of Care” program [TOC] with the help of technology and services from Patient Engagement Advisors. The TOC program was based on the notion that engaging patients in their self-care journey by provision of extended set of products and facilities, nutrition, medications, and services to meet their care and recovery needs across the continuum of care.

The TOC program led to the subsequent reduction in the AMI readmission and significant cost savings by avoiding Medicare penalties. AMI readmission rates were reduced to less than 20% since implementation and have fallen below expected rates. This has translated to more than $ 400,000 savings in penalties as the actual readmission rate has been under the expected rate.

It also led to improved clinical follow up in the post AMI patients and improvement in clinical parameters in patients with chronic conditions like diabetes and hypertension. The TOC program extends health care beyond the four walls of the medical care facility and never truly discharges the patient.

Abbreviations

AMI: Acute Myocardial Infarction; ACS: Acute coronary syndrome; TOC: Transition of Care; PEA: Patient Engagement Advisors; AHS: Advent Health Sebring; TS: Transition specialist; PNS: Patient Navigation System; SNF: Skilled nursing facility; ALF: Assisted Living facility; UDMI: Universal Definition of Myocardial Infraction

Hamideh Amirfakhryan*

Faculty of Health Science, University of South Wales, UK

Vaccination against atherosclerosis as a potential effective approach has been under investigation for more than 20 years. Different antigens have been tested in animals with a great success. Lipid-related antigens like Ox-LDL, PCSK9, non-lipid related antigens like interleukins, HSPs β2GPI, DNA vaccination and whole cell vaccination are some examples of successful examinations in animals. Plant-based vaccination which has some advantages over traditional methods has been attracted the scientists´ attention recently. Despite the very substantial struggles and promising results during these years, vaccination against atherosclerosis could not be utilized for the treatment of atherosclerosis in human in part due to the lack of clinical trials to access its safety and efficacy. In fact, designing clinical trials with a sufficient number of participants together with a sufficient duration of follow up to explore the influence of vaccine on the prevention and treatment of atherosclerosis seems to be an imperative requisiteness. It looks investing on clinical trials must be a priority to achieve a clear sight regarding the new, tempting, and promising strategy for vaccination against atherosclerosis.

Jan F.C. Glatz*, Joost J.F.P. Luiken, Miranda Nabben

Department of Genetics & Cell Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands

There is growing recognition of the importance and multiple roles of substrate energy metabolism in both cardiac health and disease. Cardiac diseases are frequently accompanied by altered myocardial metabolism, while chronic changes in the type of myocardial substrate utilization are found to elicit cardiac contractile dysfunction. Examples are the increased glucose utilization, at the expense of fatty acids, in cardiac hypertrophy and ischemic heart failure, and the increased fatty acid utilization, at the expense of glucose, in obesity and diabetes-related cardiac dysfunction. Modulation of cardiac metabolism has emerged as a suitable therapeutic intervention in cardiac disease. Insights obtained during the past decade have revealed sarcolemmal substrate transport, facilitated by CD36 for fatty acids and by GLUT4 for glucose, to represent the main rate-governing kinetic step of substrate utilization, over-ruling intracellular sites of flux regulation. This suggests that manipulating the presence of substrate transporters in the sarcolemma may be an effective approach for metabolic modulation therapy. The present mini-review provides a short summary of the functioning of substrate transporters CD36 and GLUT4 in the heart, and discusses their application as targets for metabolic intervention.

Abbreviations

CD36: Cluster of Differentiation 36

FABPc: Cytoplasmic Fatty Acid-Binding Protein

FABPpm: Plasma Membrane Fatty Acid-Binding Protein

FATP: Fatty Acid Transport Protein

GLUT4: Glucose Transporter-4

SR-B2: Scavenger Receptor B2

VAMP: Vesicle-Associated Membrane Protein

v-ATPase: vacuolar-type H+-ATPase

Bodo Hoffmeister¹*, Abner Daniel Aguilar Valdez²

¹Department of Respiratory Medicine, Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

²Department of Endocrinology, Clinic Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

Falciparum malaria has a unique and complex pathophysiology. While sequestration of parasitized and non-parasitized erythrocytes leads to a progressive obstruction of the microcirculation, a marked systemic inflammation with endothelial dysfunction and consecutive increase in vascular permeability develops. Furthermore, most patients with severe disease present with some degree of hypovolemia. Due to the reduction in pre-load, direct myocardial suppression and increase in after-load acute falciparum malaria exerts diverse effects on the cardiovascular system. Increasing numbers of aging tourists and immigrants with chronic co-morbidities travel to countries where falciparum malaria is endemic. Age has consistently been described as a prominent risk factor for both severe disease and death from imported falciparum malaria in several large studies. Although for long suspected age-related chronic disorders have only recently been identified as risk factors for severe disease. Herein, we review the current concepts of the impact of age-related chronic medical conditions on the severity of imported falciparum malaria.

Jamie Kitt¹, Rachael Fox², Katherine L Tucker³*

¹Radcliffe Department of Medicine (Cardiovascular Division), University of Oxford, UK

²University of Melbourne, Melbourne, Australia

³Nuffield Department of Primary Care, University of Oxford, UK

Hypertension is a key risk factor for cardiovascular disease. Globally, approximately a third of people with hypertension remain undiagnosed, and of those diagnosed, about half are not taking antihypertensive medication. The World Health Organization has estimated that globally hypertension directly or indirectly causes the deaths of at least nine million people every year.

There is a trend towards self-monitoring of blood pressure (BP), where patients are empowered to be involved in hypertension screening and diagnosis. Novel technology, including smartphones and Blue-tooth^® enabled telemonitoring, are new tools that are likely to be increasingly important in hypertension management. Several studies have shown the benefit of self-monitoring of BP coupled with co-interventions (such as telemonitoring) in improving BP management. However, these new technologies must be properly assessed and clinically validated prior to widespread implementation in the general population, or within special groups. In this mini-review, we examine how technology might improve the detection and management of hypertension.

Steven Douedi¹*, Abbas Alshami¹, Gina Francisco Ashforth¹, Obiora Maludum², Michael P. Carson¹

¹Department of Medicine, Jersey Shore University Medical Center, New Jersey, United States

²Department of Cardiology, Jersey Shore University Medical Center, New Jersey, United States

Intravenous immunoglobulins (IVIGs) are immunomodulating agents prepared using pooled plasma from thousands of human donors. These IVIGs have been used to treat a wide range of autoimmune, infectious, and idiopathic diseases. Their use in idiopathic thrombocytopenic purpura (ITP) was first described in 1981 and was found to be an effective alternative to splenectomy. The standard dose of IVIG in patients with ITP is 400 milligrams per kilogram body weight (mg/kg) daily for 5 days however recent data has shown a dose of 1 gram/kilogram/day for 2 days may be more effective. Side-effects during IVIG infusions have been reported in about 5 to 15% of patients. Cardiac related side-effects such as arrythmias, hypotension, and even myocardial infarction, being rare, have also been documented but are usually seen in patients with underlying cardiac pathologies. This article presents a 61-year-old male with no history of cardiac disease or arrhythmias who developed symptomatic bradycardia thirty minutes after intravenous immunoglobin infusion requiring multiple atropine injections and dopamine infusion over a 7-day hospitalization. The bradycardia resolved afterwards, and cardiac workup did not identify any underlying pathology.

Injoon Lee¹*, Matthew P. Cauchi², Jason Foerst^1-3, Gary Swank^1,2

¹Section of Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

²Interventional Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

³Structural Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

Currently no literature exists regarding the safety and feasibility of transcatheter aortic valve replacement (TAVR) after aortic cusp dissection. Aortic dissection is a rare, albeit potentially fatal complication related to percutaneous coronary intervention, especially when dealing with heavily calcified coronary disease involving the left main. Rapid stratification of patients in need of early invasive repair versus conservative observation is crucial to patient morbidity and mortality. We present a case of an elderly female with severe aortic stenosis who underwent TAVR after complex intervention of heavily calcified multi-vessel coronary artery disease involving the left main and bifurcation with high-risk Impella protected rotational atherectomy and culotte stenting complicated by left coronary cusp dissection and was managed conservatively without long-term sequelae. This case highlights the achievability of TAVR after aortic cusp dissection that was treated with conservative methods.

Injoon Lee¹*, Matthew P. Cauchi¹, Amitabh Parashar²

¹Virginia Tech-Carilion Clinic School of Medicine, Department of General Cardiovascular Disease, Roanoke, VA, USA

²Salem Veterans Affairs Medical Center, Department of Cardiology, Salem VA, USA

Background: Identifying and treating ST-elevation myocardial infarction (STEMI) in a timely manner is crucial in reducing the patient’s morbidity and mortality. However, sometimes STEMI can be caused by other pathologies such as aortic/coronary dissection, thromboembolism, septic emboli, or trauma. We present a case of a pan-aortic dissection (AD) with multi-system organ failure and shock presenting as anterior spinal cord syndrome, inferior myocardial infarction and stroke.

Case Presentation: A 62-year old woman with history of tobacco abuse and depression, presented to the Emergency Department (ED) for altered mental status. The patient was initially found outside of her home, unresponsive and bradycardic, with subsequent 12-lead electrocardiogram (EKG) demonstrating an inferior STEMI with right ventricle (RV) involvement and presumed cardiogenic shock. In the ED, the patient was awake with intermittent, though profound aphasia, as well as near complete loss of motor and sensory function in her lower extremities. She remained hypotensive and had weak peripheral pulses bilaterally in the upper and lower extremities. Emergent brain imaging was negative for ischemia, but chest imaging revealed circumferential mural thrombus extending from the aortic root into the descending aorta consistent with pan-AD and was taken urgently to the operating suite. Unfortunately, the patient died before surgical intervention could be performed.

Conclusion: This case report highlights a rare case of STEMI, stroke, cardiogenic shock and ultimately death caused by pan-AD. Timely identifying the underlying pathology in patients who present with more than typical STEMI symptoms is essential in providing potential lifesaving therapy.

Learning Points

• Aortic dissection symptoms can present with cardiovascular & neurological symptoms, end-organ compromise along with chest and/or abdominal pain.

• Clinicians should have high degrees of suspicion when myriad of symptoms are present in hemodynamically unstable patients.

• Aortic dissection can have numerous complications including death if not properly diagnosed and treated accordingly.

• Treatments of aortic dissection differs based on its type, hemodynamic status of the patient and any signs of end organ dysfunction.

Manuel Toscano*

Medical Resident, Internal Medicine Department, Hospital de Cascais, Lisboa, Portugal

Andrea De Martino¹, Giosuè Falcetta¹, Aldo D. Milano², Uberto Bortolotti¹*

¹Cardiovascular Surgery Divisions, University of Pisa, Italy

²Department of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy

Stented bioprostheses have been extensively used clinically to replace diseased cardiac valves with the clear advantage over mechanical prostheses of avoiding the use of chronic anticoagulation in most cases. During the past five decades, however, based on clinical and pathological experience, tissue calcification and cusp tears were identified as the main determinants of failure of porcine and pericardial bioprostheses, respectively. Tissue treatments to mitigate dystrophic calcification together with structural modifications in valve design have produced a current generation of bioprosthetic valves which show excellent overall performance and considerably increased durability when compared with old models. Further ongoing research aims to provide even more durable bioprostheses in order to allow reduction of the age threshold for implantation also in younger subjects, helping to contrast effectively the rapidly expanding role of catheter-based interventions.

Xiatian Chen^1,2, Ziqian Liu^1,2, Zhe Li^1,2, Jinning Gao^1,2, Zhongjie Yu^1,2, Peifeng Li¹*, Lynn Htet Htet Aung¹*

¹Center for Molecular Genetics, Institute for Translational Medicine, Qingdao University, Qingdao, 266000, Shandong, China

²School of Basic Medicine, Qingdao University, Qingdao, 266000, Shandong, China

Long non-coding RNAs (lncRNAs) have gained more attention in recent years as a potential new regulator of nearly all biological regulation. LncRNAs are over 200 nucleotides in length, and it can interact with other non-coding RNAs or specific proteins to influence the gene expression. Cardiomyocyte apoptosis is associated with cardiovascular diseases. Accumulating studies have uncovered novel lncRNAs-mediated regulation of cardiovascular diseases; however, the knowledge of the mechanisms by how to act is still limited. This review highlights the role of lncRNAs involved in cardiomyocyte apoptosis with a focus on the regulatory axis. These examples may provide helpful insights on how lncRNAs interfere with cardiomyocyte apoptosis.

Wei Ting Cheng, Na Yoon Kim, Prashant Bhattarai, Murui Han, Archita Venugopal Menon, Jonghan Kim, Ban An Khaw*

Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, MA. USA

A rat model of iron loading anemia resulting in hypertrophic cardiomyopathy was used to assess the composition of cardiac isomyosin by ELISAs and immunohistochemistry relative to the chronological age of these animals and their normal controls. Cardiac myosin extracts of homozygous Belgrade (b/b) rats that develop hypertrophic cardiomyopathy were compared to those from the heterozygous (b/+) control rats at 4.5 and 11.5 weeks of age. Confirmation of the ELISA data in the increase in β-isomyosin in 11.5 weeks old b/b rat hearts were obtained by immunohistochemical staining relative to 4.5 weeks old b/b hearts and control 4.5 and 11.5 weeks old b/+ hearts. Quantitation and immunohistochemical demonstration of an increase in the β-isomyosin isoform can be confirmed in hypertrophic cardiomyopathy in iron loading anemia model.

Jessica Franchino-Elder¹, Adrienne Gilligan², Xue Song²*, Briain O Hartaigh¹, Caroline Henriques², Amy Sainski-Nguyen², Cheng Wang¹

¹Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA

²IBM Watson Health, Cambridge, MA, USA

Among patients with non-valvular atrial fibrillation (NVAF), switching from warfarin to novel oral anticoagulants (NOACs) is common, yet clarifying the differences in the effect of NOACs on all-cause healthcare resource utilization (HCRU) are unknown. Adult NVAF patients who switched from warfarin to dabigatran, apixaban, or rivaroxaban were identified in MarketScan databases between 10/2010-12/2015. Patients had 12 months pre-period (index date was 1st NOAC claim) and were followed up to 12 months until medication discontinuation, end of enrollment, inpatient death, or 12/2016. Overall, 8,679 and 5,761 dabigatran switchers were matched (1:1) to rivaroxaban and apixaban switchers (mean age 73-74 years). Compared with rivaroxaban switchers, a lower proportion of dabigatran switchers had an inpatient (IP) visit (20.0% vs. 21.6%, p=0.008). Dabigatran switchers had lower per-patient-per-month (PPPM) total outpatient (3.87 vs. 4.06, p=0.002), emergency department (ED; 0.48 vs. 0.52, p=0.026), outpatient office (1.17 vs. 1.22, p<0.001), and other outpatient (2.71 vs. 2.83, p=0.043) visits compared with rivaroxaban switchers. A similar proportion of dabigatran and apixaban switchers had an IP visit (20.7% vs. 21.2%); compared with apixaban switchers, dabigatran switchers had significantly more PPPM IP visits (0.23 vs. 0.21, p=0.031) but significantly lower ED visits (0.47 vs. 0.52, p=0.016). Post-discharge 30-day readmission rates were comparable among warfarin-to-NOAC switching groups. Time to readmission was longer for dabigatran versus rivaroxaban switchers (8.2 vs. 7.8 days, p<0.001), but comparable with apixaban patients (8.1 vs. 8.4 days). Switching to dabigatran after warfarin discontinuation may lower HCRU among NVAF patients compared with switching to rivaroxaban or apixaban.

Aidan (Jia Sheng) Yu¹*, James Nguyen¹, Anthony Brown²

¹Royal Brisbane and Women’s Hospital Butterfield Street and Bowen Bridge Road, Herston, Queensland, 4029, Australia

²Gold Coast University Hospital, 1 Hospital Blvd, Southport QLD 4215

Background: The soon to be implemented state-wide introduction of high-sensitivity troponin assays will allow the use of a lower threshold in identifying patients with acute myocardial infarction (AMI). Whether this assay will be too sensitive and therefore produce increased false positive results is still unclear. We aim to investigate whether a significantly elevated cardiac troponin using the current troponin assay (cTnI) will result in a clinical diagnosis of AMI.

Methods: A retrospective study was performed at a Queensland Hospital with all cTnI ordered across a single month reviewed. Patients who were diagnosed with Non ST-Elevation Myocardial Infarction or ST-Elevation Myocardial Infarction were labelled as having an AMI.

Results: In total, 944 investigations were ordered for 628 patients. Using the hospital laboratory cutoff of >0.040 μg/L(>99th percentile) for significance, a positive result was obtained in 105 patients (16.7%) and a negative result in 523 patients (83.3%). The positive troponin results were attributed to AMI (20%), congestive heart failure (20%), sepsis (19%), tachyarrhythmias (16.2%), renal failure (8.6%), airway disease (8.6%), pulmonary embolism (3.8%) and others - pericarditis, post angioplasty etc (3.8%). cTnI was found to be highly sensitive (100%, 95%CI 84-100%) and specific (86%, 95%CI 83-89%) for AMI. However, only 21 (3.3%) of 628 patients investigated received a diagnosis of AMI. The positive predictive value was poor (20%, 95% CI 13-29%), with the negative predictive value absolute (100%, 95% CI 99-100%).

Conclusion: Current troponin assays were found to be highly sensitive and specific in diagnosing AMI. However, its poor positive predictive value may be contributed by inappropriate requests.

Christina Koumantzia, Nikolaos Saridakis, Andreas Eleftheriou*

Department of Neurology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden

Background: Pleuropericardial cysts (PPCs), account for 5 - 10% of all mediastinal tumours, are rare lesions occurring in approximately 1 in 100000 persons and are usually congenital and rarely acquired. They are detected post-mortem or incidentally on routine chest X-ray (CXR) and in most cases multi detector Computer Tomography is used to confirm the diagnosis. As benign course and clinical latency are characteristic features of such cysts and the occurrence of complications is rare, the majority of them can be left untreated.

Methods: The aim of the study is to review the literature regarding PPCs and create a table which summarises all the published cases in order to draw a conclusion about the epidemiology, as well as the diagnostic and therapeutic approach to PPCs exclusively. We reviewed retrospectively the clinical manifestation, diagnostic and therapeutic approach in 101 cases of PPCs since the 19^th century.

Results: Our statistical analysis led to the following results: mean age of initial detection: 48.7 ± 17.2 years, female:male ratio: about 3:2, presence of symptomatology: 37/101 cases, most common location: right cardiophrenic angle (RCPA), most common method of initial detection: CXR in 49/101 cases, mean maximal diameter: 8,3 ± 3 cm.

Conclusion: The management of a pleuropericardial cyst should be based on an algorithm in which the cyst's size, shape and compressibility along with clinical presentation and patient's fitness and preferences are be taken into consideration. When interventional is required, surgical resection by means of traditional open surgery or minimally invasive methods are considered to be the gold standard and along with percutaneous aspiration are the methods that have mostly been used.

Caitlin Stieber, Kimberly Malka, Joshua M. Boucher, Lucy Liaw*

Center for Molecular Medicine, Maine Medical Center Research Institute, United States

Perivascular adipose tissue (PVAT) is an adipose depot that surrounds blood vessels in the human body and exerts local paracrine signaling. Under physiologically healthy conditions, PVAT has an anti-contractile effect on vessels, but in obesity this effect is lost. During metabolic disease, adiponectin secretion is dysregulated, influencing nitric oxide bioavailability and macrophage infiltration and inflammation, all of which mediate PVAT signaling. However, based on the location in the body, and the type of adipocyte present, PVAT has different relationships with risk factors for disease. Imaging studies in patients with cardiovascular disease have demonstrated important associations between PVAT structure and pathology, yet insight into molecular pathways regulating human PVAT function are still lacking. This review focuses on our current understanding of human PVAT and its secretory role in the vascular microenvironment. A current area of priority is defining molecular differences in the secretome between PVAT depots, as this could inform the treatment of diseases that occur in anatomically restricted locations. In addition, understanding progressive changes in PVAT structure and function during metabolic disease is required for effective targeted therapies.

G.M. Lindsay*, P.R. Ponaiah, I. Nomani, S.M. Lamadah, N.A. Tayyib and A. Johargy

College of Nursing, Umm Al-Qura University, Taif Road, Makkah, Saudi Arabia

Background: The applicability of the Short Form (SF36) questionnaire to disparate populations led us to use this tool to investigate how health-related quality-of-life (HRQoL) for patients who underwent coronary artery bypass grafting (CABG) is related to gender, age and survival.

Method: SF36 data and the presence of cardiac symptoms were collected from 44 women and 166 men prior to surgery and from consenting survivors at one and eight-year follow-ups. Survival data were collected from government records for 18 years post operation. Paired t-tests, Pearson correlation coefficients, chi-squared tests and the log-rank test were used to investigate connections between HRQoL and age, presence of angina/breathlessness and survival within and across genders.

Results: HRQoL improved significantly for males and females in almost all health domains at the one year follow-up. At the eight year follow-up most female domain scores showed further improvement whereas the majority of male domain scores declined. Cardiac symptoms were present in 75.8% of women and 68.3% of men (χ2=0.7120, p=0.3988) at the one-year follow-up, and 84.2% of women and 70.2% of men at the eight-year follow-up. Male long term survival (53.6% after 18 years) depended significantly on retaining post-operative improvements in HRQoL to the medium term (p<0.002 in 4 of 8 domains). Female long term survival (40.9%) was significantly less than male survival (p=0.0108) and depended on maintaining a steady upward trend in HRQoL over the medium term. Age was not a determinant in HRQoL following CABG. Long term male and female survival was not significantly different and approached those of age and gender matched samples from the general population.

Conclusion: Strategies to improve HRQoL in women may support improved survival by reducing excess short term female mortality, but the effectiveness of the same strategy for men is less apparent.

Mit Patel*, Injoon Lee, Neel Parikh, David Sane, Thomas Bishop

Virginia Tech Carilion School of Medicine, USA

Pericardial cysts are rare anomalies that are usually benign and asymptomatic. A prompt intervention is necessary when patients present with concerning clinical features. We report a case of pericardial cyst causing obstructive shock in a patient that underwent bowel resection after small bowel obstruction. Our patient underwent emergent cyst aspiration which alleviated the shock.