- Email: [email protected]
Long Term Impact of Restrictive Filling Pattern post Acute Myocardial Infarction
S42
Heart, Lung and Circulation 2012;21:S1–S142
CSANZ 2012 Abstracts
ABSTRACTS
morbidity and mortality. While the cause of this is likely multifactorial, the effect of chronic kidney disease (CKD) on coronary vascular dynamic function remains poorly understood. Methods: Two groups with only minor coronary artery disease at angiography were evaluated; potential renal transplant recipients (n = 8, 51.9 ± 8.8 years); and control subjects with normal creatinine clearance (>60 ml/min) (n = 12, 53.9 ± 13.9 years). Coronary angiography and Doppler flow wire assessment was performed at baseline and during intracoronary infusion of acetylcholine (Ach), glyceryl trinitrate (GTN) and adenosine. Arterial lumen cross sectional area (CSA) in conjunction with coronary blood flow (CBF) and coronary flow reserve (CFR) were calculated. Results: Following administration of the endothelial dependent vasodilator Ach, no difference was observed between the groups for baseline (80.6 ± 34 vs. 107.9 ± 38, p = 0.11) or peak CBF (146.9 ± 77 vs. 189.7 ± 58, p = 0.21). Maximum change in CBF following Ach was similar between the groups (81.0 ± 68% vs. 89.8 ± 71%, p = 0.79). There was no difference between the groups in endothelium-independent vasodilation following intracoronary GTN (vessel CSA: 24.0 ± 49% vs. 24.3 ± 26%, p = 0.99). There was, however, a highly significant difference in microvascular function between the CKD and non-CKD cohorts, as measured by CFR (1.9 ± 0.4 vs. 3.0 ± 1.1, p = 0.01). Conclusion: This study demonstrates clear impairment of coronary endothelial-independent microvascular dilatation in subjects with ESRF. Such findings have important implications for the promotion of inducible myocardial ischaemia in advanced CKD, even in the absence of significant epicardial coronary stenoses. http://dx.doi.org/10.1016/j.hlc.2012.05.109 100 Ischaemic Tolerance and Conventional Preconditioning are Impaired with Chronic -Blockade while Chronic Opioidergic Preconditioning is Preserved L. See Hoe ∗ , J. Headrick, J. Peart Heart Foundation Research Centre, Australia Despite the need for adjunctive cardioprotective interventions to limit cell death with infarction and surgical ischaemia, no protective modalities have been effectively translated to the clinical setting. This reflects negative influences of age, disease and pharmaceuticals on more intensely studied interventions, derived from conventional ‘conditioning’ responses including ischaemic preconditioning (IPC) and postconditioning. Since a majority of ischaemic heart disease patients are subjected to chronic -adrenoceptor (-AR) blockade, we here assess impacts of prolonged 1 -AR blockade on myocardial ischaemic tolerance and efficacies of conventional IPC and novel sustained ligand activated preconditioning (SLAP) induced with five days of opioid receptor agonism (implanted morphine pellets). Young male C57/Bl6
mice were administered the 1 -AR-blocker atenolol for four weeks (0.5 g/L in drinking water) before subcutaneous implantation of morphine (SLAP) or placebo pellets five days prior to analysis of ischaemic outcomes ex vivo (Langendorff hearts subjected to 25 in. ischaemia/45 in. reperfusion). Post-ischaemic contractile function was substantially impaired in control (placebo) hearts, with <70% recovery of ventricular force and significant diastolic dysfunction. Cell death, reflected in washout of cellular lactate dehydrogenase (LDH) was increased. Chronic -AR blockade with atenolol significantly worsened contractile dysfunction and LDH release. IPC protection (induced with three cycles of 90 s occlusion/120 s reperfusion) was negated by -AR treatment, whereas SLAP improved post-ischaemic outcomes irrespective of -AR blockade. Data indicate that chronic 1 -AR blockade impacts negatively on both intrinsic ischaemic tolerance and preconditioning responses whereas novel SLAP retains protective efficacy. http://dx.doi.org/10.1016/j.hlc.2012.05.110 101 Long Term Impact of Restrictive Filling Pattern post Acute Myocardial Infarction X. Brennan 1,2,∗ , L. Hee 2 , J. Chen 1 , C. French 1,2 , C. Juergens 1,2 , L. Thomas 1,2,3
Allman 2 , J.
1 University
of New South Wales, Australia Hostipal, Australia 3 University of Sydney, Australia 2 Liverpool
Background: This study evaluates the long term (five years) prognostic value of a restrictive filling pattern (RFP) following ST-elevation myocardial infarction (STEMI). Previous studies in this area failed to use rigorous echocardiographic definitions of RFP and only included short term follow-up. Methods and results: One hundred STEMI patients who underwent primary or rescue angioplasty and had a transthoracic echocardiogram within six weeks post AMI were retrospectively identified. Subjects were identified as either having a restrictive filling pattern (n = 24) [DT < 150 ms, E/A > 2.0, E < 5] or non restrictive pattern (n = 76). Primary endpoints included cardiac and all cause mortality, heart failure and MACCE (major adverse cardiac and cerebrovascular events). There was no difference in age, gender, cardiovascular risk factors and infarct location between the two groups. Nine out of 16 of the patients that died during follow-up were from the RFP group. Multivariate Cox regression analysis found that RFP was the strongest predictor of cardiac (hazard ratio 29.06, p = 0.01) and all cause mortality (hazard ratio 4.29, p = 0.01). Age was also an independent predictor of all cause mortality (hazard ratio 1.072, p = 0.002). Left ventricular mass was predictive of heart failure (hazard ratio 1.02, p = 0.02) along with ejection fraction (hazard ratio 0.9, p = 0.01). Conclusion: This study has confirmed the prognostic value of RFP over the longer term following STEMI. Our
study additionally demonstrates the value of echocardiographic evaluation of diastolic function post STEMI. http://dx.doi.org/10.1016/j.hlc.2012.05.111 102 Low Coronary Arterial Wall Shear Stress is Associated with Endothelial Dysfunction and Expansive Arterial Remodeling In Vivo: Implications for Plaque Vulnerability R. Puri 1 , D. Leong 1 , S. Nicholls 2 , G. Liew 1 , A. Nelson 1 , A. Carbone 1 , B. Copus 1 , D. Wong 1 , J. Beltrame 1 , S. Worthley 1 , M. Worthley 1,∗ 1 University
of Adelaide, and Royal Adelaide Hospital, Australia 2 Cleveland Clinic, United States Objectives: To investigate in vivo relationships between segmental wall shear stress (WSS), endotheliumdependent vasoreactivity and arterial remodeling in patients with stable coronary disease. Background: Low WSS has been implicated in the development and progression of coronary atherosclerosis. Endothelial dysfunction predicts incident coronary events. The interplay between these entities, coupled with plaque morphology in humans in vivo has yet to be explored. Methods: Twenty-four patients with minor angiographic coronary arterial disease (<30% stenosis severity) underwent intracoronary (IC) salbutamol provocation during intravascular ultrasound (IVUS)-upon-Doppler guide wire imaging. Macrovascular response [change in segmental lumen volume (SLV) at baseline and following IC salbutamol], plaque burden [percent atheroma volume (PAV)], remodeling indices (RI), eccentricity indices (EI) and WSS were evaluated in 172 consecutive 5-mm coronary segments. Results: Baseline WSS was directly related to endothelium-dependent epicardial coronary vasomotion (% change SLV, coefficient 17.2, p = 0.004), and inversely related to RI (coefficient −0.23, p = 0.02) and EI (coefficient −10.0, p = 0.001). Baseline WSS was lower in segments displaying endothelial dysfunction (defined as any change in SLV ≤ 0) compared with preserved function (0.66 ± 0.33 vs 0.71 ± 0.22 N/m2 , p = 0.05). Independent of plaque burden, segments with the lowest tertile of WSS displayed lower endothelial function. High plaque burden segments harbouring the lowest tertiles of WSS were associated with vasoconstriction, expansive arterial remodeling and greater plaque eccentricity. Conclusions: In patients with stable coronary syndromes and minor angiographic coronary disease, coronary segments with low in vivo WSS values display functional and morphological features of plaque vulnerability. http://dx.doi.org/10.1016/j.hlc.2012.05.112
CSANZ 2012 Abstracts
S43
103 Low Level Troponin Release in Day-case PCI Patients is Common and Does Not Preclude Same-day Discharge I. Webb 1,2,∗ , M. Simmonds 1,2 , P. Larsen 1,3 , S. Harding 1,2 1 Wellington Cardiovascular Research Group, Wellington, New Zealand 2 Cardiology Department, Wellington Hospital, Wellington, New Zealand 3 Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
Introduction: Same-day discharge following PCI reduces bed occupancy, is cost effective and popular with patients. Low-level elevations of troponin T (TnT) following PCI are common. Outcomes following same-day discharge of PCI patients with low-level TnT elevation are currently unknown. Methods: We prospectively studied a cohort of 885 patients undergoing elective PCI between 2006 and 2010. All patients routinely had TnT levels measured 6–8 h post-intervention. Decisions regarding the suitability of same-day discharge were made 6 h post procedure. Patients with a suboptimal angiographic result, evidence of peri-procedural ischaemia/infarction (prolonged chest pain, ECG changes or TnT > 0.15 ng/mL) or access site complications were admitted. Demographic, procedural and outcomes data at 24-h and 30-days were recorded. Results: Of 774 TnT negative patients, 698 (90.2%) were discharged home on the same day (group 1). Postprocedural TnT elevation (>0.03 g/mL) was observed in 101 (11.4%) patients, of whom 52 were discharged home same day (group 2). The mean TnT level in this group was 0.07 g/mL. There was no MACE (death, MI, stent thrombosis or TVR) within 24 h of discharge in either group 1 or group 2. Readmission for any reason within 24 h was uncommon and did not differ between group 1 and group 2 (0.7% vs 1.9%, p = 0.23). Similarly, 30-day outcomes were comparable between groups, with no MACE events in group 2. Conclusion: Peri-procedural TnT elevation is common following day-case PCI. Where appropriate clinical guidelines are in position, same-day discharge of patients with low-level TnT release is safe and not associated with adverse events. http://dx.doi.org/10.1016/j.hlc.2012.05.113
ABSTRACTS
Heart, Lung and Circulation 2012;21:S1–S142
Heart, Lung and Circulation 2012;21:S1–S142
CSANZ 2012 Abstracts
ABSTRACTS
morbidity and mortality. While the cause of this is likely multifactorial, the effect of chronic kidney disease (CKD) on coronary vascular dynamic function remains poorly understood. Methods: Two groups with only minor coronary artery disease at angiography were evaluated; potential renal transplant recipients (n = 8, 51.9 ± 8.8 years); and control subjects with normal creatinine clearance (>60 ml/min) (n = 12, 53.9 ± 13.9 years). Coronary angiography and Doppler flow wire assessment was performed at baseline and during intracoronary infusion of acetylcholine (Ach), glyceryl trinitrate (GTN) and adenosine. Arterial lumen cross sectional area (CSA) in conjunction with coronary blood flow (CBF) and coronary flow reserve (CFR) were calculated. Results: Following administration of the endothelial dependent vasodilator Ach, no difference was observed between the groups for baseline (80.6 ± 34 vs. 107.9 ± 38, p = 0.11) or peak CBF (146.9 ± 77 vs. 189.7 ± 58, p = 0.21). Maximum change in CBF following Ach was similar between the groups (81.0 ± 68% vs. 89.8 ± 71%, p = 0.79). There was no difference between the groups in endothelium-independent vasodilation following intracoronary GTN (vessel CSA: 24.0 ± 49% vs. 24.3 ± 26%, p = 0.99). There was, however, a highly significant difference in microvascular function between the CKD and non-CKD cohorts, as measured by CFR (1.9 ± 0.4 vs. 3.0 ± 1.1, p = 0.01). Conclusion: This study demonstrates clear impairment of coronary endothelial-independent microvascular dilatation in subjects with ESRF. Such findings have important implications for the promotion of inducible myocardial ischaemia in advanced CKD, even in the absence of significant epicardial coronary stenoses. http://dx.doi.org/10.1016/j.hlc.2012.05.109 100 Ischaemic Tolerance and Conventional Preconditioning are Impaired with Chronic -Blockade while Chronic Opioidergic Preconditioning is Preserved L. See Hoe ∗ , J. Headrick, J. Peart Heart Foundation Research Centre, Australia Despite the need for adjunctive cardioprotective interventions to limit cell death with infarction and surgical ischaemia, no protective modalities have been effectively translated to the clinical setting. This reflects negative influences of age, disease and pharmaceuticals on more intensely studied interventions, derived from conventional ‘conditioning’ responses including ischaemic preconditioning (IPC) and postconditioning. Since a majority of ischaemic heart disease patients are subjected to chronic -adrenoceptor (-AR) blockade, we here assess impacts of prolonged 1 -AR blockade on myocardial ischaemic tolerance and efficacies of conventional IPC and novel sustained ligand activated preconditioning (SLAP) induced with five days of opioid receptor agonism (implanted morphine pellets). Young male C57/Bl6
mice were administered the 1 -AR-blocker atenolol for four weeks (0.5 g/L in drinking water) before subcutaneous implantation of morphine (SLAP) or placebo pellets five days prior to analysis of ischaemic outcomes ex vivo (Langendorff hearts subjected to 25 in. ischaemia/45 in. reperfusion). Post-ischaemic contractile function was substantially impaired in control (placebo) hearts, with <70% recovery of ventricular force and significant diastolic dysfunction. Cell death, reflected in washout of cellular lactate dehydrogenase (LDH) was increased. Chronic -AR blockade with atenolol significantly worsened contractile dysfunction and LDH release. IPC protection (induced with three cycles of 90 s occlusion/120 s reperfusion) was negated by -AR treatment, whereas SLAP improved post-ischaemic outcomes irrespective of -AR blockade. Data indicate that chronic 1 -AR blockade impacts negatively on both intrinsic ischaemic tolerance and preconditioning responses whereas novel SLAP retains protective efficacy. http://dx.doi.org/10.1016/j.hlc.2012.05.110 101 Long Term Impact of Restrictive Filling Pattern post Acute Myocardial Infarction X. Brennan 1,2,∗ , L. Hee 2 , J. Chen 1 , C. French 1,2 , C. Juergens 1,2 , L. Thomas 1,2,3
Allman 2 , J.
1 University
of New South Wales, Australia Hostipal, Australia 3 University of Sydney, Australia 2 Liverpool
Background: This study evaluates the long term (five years) prognostic value of a restrictive filling pattern (RFP) following ST-elevation myocardial infarction (STEMI). Previous studies in this area failed to use rigorous echocardiographic definitions of RFP and only included short term follow-up. Methods and results: One hundred STEMI patients who underwent primary or rescue angioplasty and had a transthoracic echocardiogram within six weeks post AMI were retrospectively identified. Subjects were identified as either having a restrictive filling pattern (n = 24) [DT < 150 ms, E/A > 2.0, E < 5] or non restrictive pattern (n = 76). Primary endpoints included cardiac and all cause mortality, heart failure and MACCE (major adverse cardiac and cerebrovascular events). There was no difference in age, gender, cardiovascular risk factors and infarct location between the two groups. Nine out of 16 of the patients that died during follow-up were from the RFP group. Multivariate Cox regression analysis found that RFP was the strongest predictor of cardiac (hazard ratio 29.06, p = 0.01) and all cause mortality (hazard ratio 4.29, p = 0.01). Age was also an independent predictor of all cause mortality (hazard ratio 1.072, p = 0.002). Left ventricular mass was predictive of heart failure (hazard ratio 1.02, p = 0.02) along with ejection fraction (hazard ratio 0.9, p = 0.01). Conclusion: This study has confirmed the prognostic value of RFP over the longer term following STEMI. Our
study additionally demonstrates the value of echocardiographic evaluation of diastolic function post STEMI. http://dx.doi.org/10.1016/j.hlc.2012.05.111 102 Low Coronary Arterial Wall Shear Stress is Associated with Endothelial Dysfunction and Expansive Arterial Remodeling In Vivo: Implications for Plaque Vulnerability R. Puri 1 , D. Leong 1 , S. Nicholls 2 , G. Liew 1 , A. Nelson 1 , A. Carbone 1 , B. Copus 1 , D. Wong 1 , J. Beltrame 1 , S. Worthley 1 , M. Worthley 1,∗ 1 University
of Adelaide, and Royal Adelaide Hospital, Australia 2 Cleveland Clinic, United States Objectives: To investigate in vivo relationships between segmental wall shear stress (WSS), endotheliumdependent vasoreactivity and arterial remodeling in patients with stable coronary disease. Background: Low WSS has been implicated in the development and progression of coronary atherosclerosis. Endothelial dysfunction predicts incident coronary events. The interplay between these entities, coupled with plaque morphology in humans in vivo has yet to be explored. Methods: Twenty-four patients with minor angiographic coronary arterial disease (<30% stenosis severity) underwent intracoronary (IC) salbutamol provocation during intravascular ultrasound (IVUS)-upon-Doppler guide wire imaging. Macrovascular response [change in segmental lumen volume (SLV) at baseline and following IC salbutamol], plaque burden [percent atheroma volume (PAV)], remodeling indices (RI), eccentricity indices (EI) and WSS were evaluated in 172 consecutive 5-mm coronary segments. Results: Baseline WSS was directly related to endothelium-dependent epicardial coronary vasomotion (% change SLV, coefficient 17.2, p = 0.004), and inversely related to RI (coefficient −0.23, p = 0.02) and EI (coefficient −10.0, p = 0.001). Baseline WSS was lower in segments displaying endothelial dysfunction (defined as any change in SLV ≤ 0) compared with preserved function (0.66 ± 0.33 vs 0.71 ± 0.22 N/m2 , p = 0.05). Independent of plaque burden, segments with the lowest tertile of WSS displayed lower endothelial function. High plaque burden segments harbouring the lowest tertiles of WSS were associated with vasoconstriction, expansive arterial remodeling and greater plaque eccentricity. Conclusions: In patients with stable coronary syndromes and minor angiographic coronary disease, coronary segments with low in vivo WSS values display functional and morphological features of plaque vulnerability. http://dx.doi.org/10.1016/j.hlc.2012.05.112
CSANZ 2012 Abstracts
S43
103 Low Level Troponin Release in Day-case PCI Patients is Common and Does Not Preclude Same-day Discharge I. Webb 1,2,∗ , M. Simmonds 1,2 , P. Larsen 1,3 , S. Harding 1,2 1 Wellington Cardiovascular Research Group, Wellington, New Zealand 2 Cardiology Department, Wellington Hospital, Wellington, New Zealand 3 Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
Introduction: Same-day discharge following PCI reduces bed occupancy, is cost effective and popular with patients. Low-level elevations of troponin T (TnT) following PCI are common. Outcomes following same-day discharge of PCI patients with low-level TnT elevation are currently unknown. Methods: We prospectively studied a cohort of 885 patients undergoing elective PCI between 2006 and 2010. All patients routinely had TnT levels measured 6–8 h post-intervention. Decisions regarding the suitability of same-day discharge were made 6 h post procedure. Patients with a suboptimal angiographic result, evidence of peri-procedural ischaemia/infarction (prolonged chest pain, ECG changes or TnT > 0.15 ng/mL) or access site complications were admitted. Demographic, procedural and outcomes data at 24-h and 30-days were recorded. Results: Of 774 TnT negative patients, 698 (90.2%) were discharged home on the same day (group 1). Postprocedural TnT elevation (>0.03 g/mL) was observed in 101 (11.4%) patients, of whom 52 were discharged home same day (group 2). The mean TnT level in this group was 0.07 g/mL. There was no MACE (death, MI, stent thrombosis or TVR) within 24 h of discharge in either group 1 or group 2. Readmission for any reason within 24 h was uncommon and did not differ between group 1 and group 2 (0.7% vs 1.9%, p = 0.23). Similarly, 30-day outcomes were comparable between groups, with no MACE events in group 2. Conclusion: Peri-procedural TnT elevation is common following day-case PCI. Where appropriate clinical guidelines are in position, same-day discharge of patients with low-level TnT release is safe and not associated with adverse events. http://dx.doi.org/10.1016/j.hlc.2012.05.113
ABSTRACTS
Heart, Lung and Circulation 2012;21:S1–S142