- Email: [email protected]
The under-recognized differences in late outcomes following acute myocardial infarction among Asian ethnicities in Singapore
S20
Poster Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
(51%) presented during working hours. Within the OWH group 64% (58) of patients received thrombolysis, 8.9%(8) of patients received primary PCI (PPCI) and 26.7%(24) of patients did not receive reperfusion therapy. Of those that were thrombolysed during working hours 66.7% (16) achieved a door-to-needle time of less than thirty minutes compared with 67%(39) in the OWH Group. In reference to the patients receiving PPCI 62.5%(5) achieved a door-to-balloon time of less 90 minutes in the OWH group compared with 65.4%(34) in the IWH group. The overall in-hospital mortality rate was 4.9% (9/184). There was no significant difference with respect to In-hospital mortality with 4.3% (4/94) in the IWH group and 5.56% (5/90) in the OWH group (p=0.683). We also examined outcomes in patients receiving PPCI (n=60), patients receiving thrombolysis (n=82) and patients who did not receive reperfusion therapy (n=42). Using multivariate analysis and inhospital mortality as a primary end-point we found patients receiving PPCI at any time of the day had a better outcome compared with the patients who were thrombolysed (OR=0.091; 95% CI, 0.01–0.81) (p=0.032). Conclusion: In keeping with recent published data, the clinical outcome of patients presenting during out-hours vs. working hours appears similar. However, patients receiving PPCI at any time had a better outcome compared with those being thrombolysed.
P036 In the current era of ST-elevation myocardial infarction treatment, what patients are not reperfused? An observational analysis L. McGovern 1 , T.J. Kiernan 2 . 1 Cork University Hospital; 2 University Hospital Limerick, Ireland Background: The current treatment of ST-elevation myocardial infarction (STEMI) is mechanical reperfusion by primary percutaneous coronary intervention (PPCI) or systemic thrombolysis if PPCI is not available in a timely manner. Several reasons exist for STEMI patients not receiving reperfusion therapy. This patient cohort subsequently has poorer outcomes. As the patient population continues to increase in terms of age, we need to define, understand and critically evaluate theses patients that do not receive reperfusion therapy. Aim and objectives: To define the characteristics and presentation of STEMI patients not receiving reperfusion therapy. This analysis was undertaken at Cork University Hospital, Mercy University Hospital, Mallow General Hospital and South Infirmary Hospital in order to understand the reasons why certain STEMI patients do not receive PPCI or thrombolysis. Methods: The Coronary Heart Attack Ireland Register (CHAIR) was used to identify STEMI patients who did not receive reperfusion therapy between January 1st 2007 and December 31st 2011. A retrospective review of patients’ charts was performed. The contribution of non-reperfusion to patient mortality was also examined in terms of 30-day mortality and 1-year mortality post STEMI. Data was then analysed using SPSS. Results: 77 cases were included. Preliminary results indicate that most were female (N=47, 61%) with a median age of 80.39 years. 54.5% (N=42) had a past medical history of coronary heart disease with hypertension being the main risk factor (N=43, 55.8%). 48.1% (N=37) were considered independent in terms of ADLs. Patient mortality at 30 days post STEMI was 45.5%. This increased to 50.6% at 1 year. Conclusion: As the older demographic in our population increases, this patient cohort will become particularly significant. Mortality among this, predominantly female, patient cohort is high yet a significant number were considered independent in terms of ADLs. Based on Ireland’s current national strategy, PPCI is superior to thrombol-
ysis, therefore it would be interesting to prospectively evaluate patients not offered reperfusion from 2012 onwards.
P066 The under-recognized differences in late outcomes following acute myocardial infarction among Asian ethnicities in Singapore L. Carvalho 1 , G. Fei 2 , Q. Chen 2 , L.L. Sim 2 , D. Foo 4 , O.H. Yee 5 , G. Leong 6 , A.M. Richards 1 , T. Chua 2 , M. Chan 1 . 1 Yong Loo Lin School of Medicine-NUS National University of Singapore, Singapore; 2 National Heart Centre, Singapore; 3 Department of Surgery, National University of Singapore, Singapore; 4 Tan Tock Seng Hospital, National Heart Centre, Singapore; 5 Khoo Teck Puat Hospital, Singapore; 6 Changi General Hospital, Singapore Objective: Evaluate disparities in long-term AMI outcomes among Asian ethnicities and the effect on background population mortality risk. Methods: We conducted a nationwide study of 15,151 patients hospitalized for AMI from January to 31st December 2005 managed under the publicly-funded restructured healthcare system in Singapore. Outcomes out to 1st March 2012 were compared among Chinese, Malay and Indian Singaporean patients with a mean follow-up of 7.8 years among all groups. Multivariate adjustment for GRACE risk score, discharge medications and 30-day revascularization was performed using Cox regression. The relative survival ratio was computed by dividing the observed cardiovascular (CV) event-free survival of AMI patients with the expected CV event-free survival of a comparable general population match by race, age and sex. Results: Chinese pts were the oldest while Indian patients were the youngest. The median GRACE risk score was highest among Chinese followed by Malay and Indian pts: 144 (25th percentile 119, 75th percentile 173), 138 (115, 167) and 131 (109, 160) respectively. Inhospital mortality was highest among Chinese (9.8%) followed by Malay (7.6%) and Indian (6.5%) pts, P<0.0001, while late mortality was highest among Malay (46%) followed by Chinese (43%) and Indian pts (36%), P<0.0001 (Table 1). Compared with Chinese pts, the adjusted late cardiovascular mortality hazard ratio was 1.36 (95% confidence interval 1.25–1.47) among Malay and 1.05 (95% confidence interval 0.94–1.16) among Indian pts. Table 1. Baseline clinical characteristics, treatment and outcomes by ethnicity
Clinical characteristics Age (years) Women Diabetes mellitus Family history of premature coronary Heart disease Prior MI ST-elevation MI Treatment Primary PCI Fibrinolysis Outcomes 3 year Relative Survival Ratio* (95% CI) 5 year Relative Survival Ratio* (95% CI) 8 year Adjusted Hazard Ratio † (95% CI)
Chinese (n=10,100)
Malay (n=3,005)
Indian (n=2,046)
64 (54–74) 29 35 11
61 (51–71) 27 42 15
58 (49–70) 23 51 22
11 47
11 46
15 47
23.9 19.2
20.3 21.3
27.0 21.6
0.76 (0.75–0.77) 0.73 (0.72–0.74) 1.00
0.73 (0.71–0.75) 0.69 (0.66–0.71) 1.36 (1.25–1.47)
0.82 (0.80–0.84) 0.79 (0.76–0.81) 1.05 (0.94–1.16)
All values presented as percentages, unless otherwise noted. Median and interquartile ranges are reported for continuous variables. Abbreviations: CHD, coronary heart disease; MI, myocardial infarction; PCI, percutaneous coronary intervention. *Relative Survival Ratio compared with background population; † 7.8 year Hazard Ratio with Chinese as the reference group.
Conclusion: Although Chinese pts had the highest baseline risk and
Poster Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
in-hospital mortality, Malay pts had the highest late cardiovascular mortality. These data suggest that ethnic-specific interventions are needed to improve overall post-MI outcomes in Singapore.
Diabetes Mellitus P037 Evaluation of ventricular–vascular coupling in patients with type 2 diabetes mellitus using 2-dimensional speckle tracking imaging Z.J. Li, X.H. Luo. Department of Ultrasound, Shanxi Academy of Medical Sciences & Shanxi DAYI Hospital, China Objective: To detect the change of myocardial longitudinal strain and ventricular–vascular coupling in diabetic patients with different ventricular systolic function using STI, and to explore the relationship between myocardial strain and ventricular–vascular coupling. Methods: Eighty patients with type 2 diabetes mellitus were divided into two groups according to ejection fraction (EF), DMN group with normal EF (EF≥50%) and DMA group with reduced EF (EF<50%). Forty-two volunteers were divided into the control group. The stroke work (SW), rate–pressure product (RPP), systemic vascular resistance index (SVRI), left ventricular end-systolic elastance (Ees), effective arterial elasticity (Ea) and heart ventricular–vascular coupling index (VVI) were measured and calculated by conventional echocardiography. Besides, the longitudinal strain at left ventricular basement (LSBA), papillary muscle (LSPM) and cardiac apex (LSAP) planes were assessed with STI. Results: 1. Changes in vascular function: compared with control group, in DMA group Ea, VVI, RPP and SVRI all increased, while Ees decreased; in DMN group RPP increased. Furthermore, in DMA group, Ea, VVI, RPP, and SVRI were higher than those were in DMN group, whereas Ees was lower than that in DMN group. 2. Relationship between strain and coupling index: LSBA, LSPM, and LSAP all had a negative correlation with VVI and multiple linear regression analysis showed that SLAP and SW were independent predictors for VVI. The area under the receiver operating characteristic curves for identification of DMN and control groups with LSBA, LSPM and LSAP were 0.857, 0.862 and 0.832 separately and had no statistical significances among three planes. Conclusion: There was a ventricular–vascular coupling in diabetic patients with normal EF while a ventricular–vascular uncoupling in diabetic patients with decreased EF. Myocardial longitudinal strain could reflect the ventricular–vascular coupling, and LSAP was an independent predictor for coupling. Different segments of myocardial strain had a certain order to “respond” the state of ventricular– vascular coupling, and the cardiac apex segment might be the earliest.
Heart Failure
P039 The predictive value of left ventricular end-diastolic pressure for patients with diastolic heart failure
S21
Methods: Left ventricular end-diastolic pressure (LVEDP) for Patients with the follow up study in diastolic heart failure was examined by left cardiac catheter. Cardiac composite end point events were cardiac death and re-admission. According to the follow-up results, the LVEDP level of Cardiac composite end point events group were compared with no Cardiac composite end point events group, and cut-off Point of the LVEDP level acquired by work characteristic curve (ROC). According to cut-off Point of the LVEDP level. We divided two groups and used Kaplan-Meier method analysis survival of two groups; Multivariate analysis was Performed with Cox regression analysis. Results: A total of 171 patients were followed up to 15.7±3.43 months. The LVEDP level in Cardiac composite end point events group [17.5 (9.4, 20.1) mmHg] were higher than no Cardiac composite end point events group [12.5 (7.4, 16.3) mmHg] (p=0.032). Through Working characteristic curve (ROC), The cut-off Point of LVEDP level were 15.1 mmHg. In multivariate Cox analysis, only Log LVEDP (R: 0.9898; p=0.002)) and Log BNP (R: 0.693; p=0.008) remained as the significant predictors of cardiac events among ten possible facors of gender, age, body mass index (BMI), diabetes, hypertension, NYHA, log BNP level, left atrial inside diameter (LA), left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), tissue doppler mitral valve ring early diastolic velocity ratio (E/E’) and left cardiac catheterization test Log LVEDP. The correlation of Log LVEDP were Stronger Log BNP.
Figure 1
Conclusion: LVEDP for the clinical prognosis of patients with diastolic heart failure has a good predictive value. Log LVEDP and Log BNP is independent influencing factors for the cardiac composite end point events.
P040 Evaluation of global left ventricular systolic function in patients with heart failure using three-dimensional speckle-tracking echocardiography
L.J. Pan, H. Gong, Y.J. Shi. Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, No.1508, Longhang Road, Jinshan District, Shanghai, China
X.X. Luo, F. Fang, P.W. Lee, S. Li, Z.H. Zhang, Y.Y. Lam, J.E. Sanderson, J.S.W. Kwong, C.M. Yu. Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital and Institute of Vascular Medicine, Li Ka Shing Institute of Health Sciences, S.H. Ho Cardiovascular Disease and Stroke Centre, The Chinese University of Hong Kong, Hong Kong, China
Objective: To evaluate the clinical prognosis by Left ventricular enddiastolic pressure for Patients With diastolic heart failure.
Purpose: With three-dimensional echocardiographic systems (3DSTE), left ventricle (LV) can be evaluated globally without the in-
Poster Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
(51%) presented during working hours. Within the OWH group 64% (58) of patients received thrombolysis, 8.9%(8) of patients received primary PCI (PPCI) and 26.7%(24) of patients did not receive reperfusion therapy. Of those that were thrombolysed during working hours 66.7% (16) achieved a door-to-needle time of less than thirty minutes compared with 67%(39) in the OWH Group. In reference to the patients receiving PPCI 62.5%(5) achieved a door-to-balloon time of less 90 minutes in the OWH group compared with 65.4%(34) in the IWH group. The overall in-hospital mortality rate was 4.9% (9/184). There was no significant difference with respect to In-hospital mortality with 4.3% (4/94) in the IWH group and 5.56% (5/90) in the OWH group (p=0.683). We also examined outcomes in patients receiving PPCI (n=60), patients receiving thrombolysis (n=82) and patients who did not receive reperfusion therapy (n=42). Using multivariate analysis and inhospital mortality as a primary end-point we found patients receiving PPCI at any time of the day had a better outcome compared with the patients who were thrombolysed (OR=0.091; 95% CI, 0.01–0.81) (p=0.032). Conclusion: In keeping with recent published data, the clinical outcome of patients presenting during out-hours vs. working hours appears similar. However, patients receiving PPCI at any time had a better outcome compared with those being thrombolysed.
P036 In the current era of ST-elevation myocardial infarction treatment, what patients are not reperfused? An observational analysis L. McGovern 1 , T.J. Kiernan 2 . 1 Cork University Hospital; 2 University Hospital Limerick, Ireland Background: The current treatment of ST-elevation myocardial infarction (STEMI) is mechanical reperfusion by primary percutaneous coronary intervention (PPCI) or systemic thrombolysis if PPCI is not available in a timely manner. Several reasons exist for STEMI patients not receiving reperfusion therapy. This patient cohort subsequently has poorer outcomes. As the patient population continues to increase in terms of age, we need to define, understand and critically evaluate theses patients that do not receive reperfusion therapy. Aim and objectives: To define the characteristics and presentation of STEMI patients not receiving reperfusion therapy. This analysis was undertaken at Cork University Hospital, Mercy University Hospital, Mallow General Hospital and South Infirmary Hospital in order to understand the reasons why certain STEMI patients do not receive PPCI or thrombolysis. Methods: The Coronary Heart Attack Ireland Register (CHAIR) was used to identify STEMI patients who did not receive reperfusion therapy between January 1st 2007 and December 31st 2011. A retrospective review of patients’ charts was performed. The contribution of non-reperfusion to patient mortality was also examined in terms of 30-day mortality and 1-year mortality post STEMI. Data was then analysed using SPSS. Results: 77 cases were included. Preliminary results indicate that most were female (N=47, 61%) with a median age of 80.39 years. 54.5% (N=42) had a past medical history of coronary heart disease with hypertension being the main risk factor (N=43, 55.8%). 48.1% (N=37) were considered independent in terms of ADLs. Patient mortality at 30 days post STEMI was 45.5%. This increased to 50.6% at 1 year. Conclusion: As the older demographic in our population increases, this patient cohort will become particularly significant. Mortality among this, predominantly female, patient cohort is high yet a significant number were considered independent in terms of ADLs. Based on Ireland’s current national strategy, PPCI is superior to thrombol-
ysis, therefore it would be interesting to prospectively evaluate patients not offered reperfusion from 2012 onwards.
P066 The under-recognized differences in late outcomes following acute myocardial infarction among Asian ethnicities in Singapore L. Carvalho 1 , G. Fei 2 , Q. Chen 2 , L.L. Sim 2 , D. Foo 4 , O.H. Yee 5 , G. Leong 6 , A.M. Richards 1 , T. Chua 2 , M. Chan 1 . 1 Yong Loo Lin School of Medicine-NUS National University of Singapore, Singapore; 2 National Heart Centre, Singapore; 3 Department of Surgery, National University of Singapore, Singapore; 4 Tan Tock Seng Hospital, National Heart Centre, Singapore; 5 Khoo Teck Puat Hospital, Singapore; 6 Changi General Hospital, Singapore Objective: Evaluate disparities in long-term AMI outcomes among Asian ethnicities and the effect on background population mortality risk. Methods: We conducted a nationwide study of 15,151 patients hospitalized for AMI from January to 31st December 2005 managed under the publicly-funded restructured healthcare system in Singapore. Outcomes out to 1st March 2012 were compared among Chinese, Malay and Indian Singaporean patients with a mean follow-up of 7.8 years among all groups. Multivariate adjustment for GRACE risk score, discharge medications and 30-day revascularization was performed using Cox regression. The relative survival ratio was computed by dividing the observed cardiovascular (CV) event-free survival of AMI patients with the expected CV event-free survival of a comparable general population match by race, age and sex. Results: Chinese pts were the oldest while Indian patients were the youngest. The median GRACE risk score was highest among Chinese followed by Malay and Indian pts: 144 (25th percentile 119, 75th percentile 173), 138 (115, 167) and 131 (109, 160) respectively. Inhospital mortality was highest among Chinese (9.8%) followed by Malay (7.6%) and Indian (6.5%) pts, P<0.0001, while late mortality was highest among Malay (46%) followed by Chinese (43%) and Indian pts (36%), P<0.0001 (Table 1). Compared with Chinese pts, the adjusted late cardiovascular mortality hazard ratio was 1.36 (95% confidence interval 1.25–1.47) among Malay and 1.05 (95% confidence interval 0.94–1.16) among Indian pts. Table 1. Baseline clinical characteristics, treatment and outcomes by ethnicity
Clinical characteristics Age (years) Women Diabetes mellitus Family history of premature coronary Heart disease Prior MI ST-elevation MI Treatment Primary PCI Fibrinolysis Outcomes 3 year Relative Survival Ratio* (95% CI) 5 year Relative Survival Ratio* (95% CI) 8 year Adjusted Hazard Ratio † (95% CI)
Chinese (n=10,100)
Malay (n=3,005)
Indian (n=2,046)
64 (54–74) 29 35 11
61 (51–71) 27 42 15
58 (49–70) 23 51 22
11 47
11 46
15 47
23.9 19.2
20.3 21.3
27.0 21.6
0.76 (0.75–0.77) 0.73 (0.72–0.74) 1.00
0.73 (0.71–0.75) 0.69 (0.66–0.71) 1.36 (1.25–1.47)
0.82 (0.80–0.84) 0.79 (0.76–0.81) 1.05 (0.94–1.16)
All values presented as percentages, unless otherwise noted. Median and interquartile ranges are reported for continuous variables. Abbreviations: CHD, coronary heart disease; MI, myocardial infarction; PCI, percutaneous coronary intervention. *Relative Survival Ratio compared with background population; † 7.8 year Hazard Ratio with Chinese as the reference group.
Conclusion: Although Chinese pts had the highest baseline risk and
Poster Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
in-hospital mortality, Malay pts had the highest late cardiovascular mortality. These data suggest that ethnic-specific interventions are needed to improve overall post-MI outcomes in Singapore.
Diabetes Mellitus P037 Evaluation of ventricular–vascular coupling in patients with type 2 diabetes mellitus using 2-dimensional speckle tracking imaging Z.J. Li, X.H. Luo. Department of Ultrasound, Shanxi Academy of Medical Sciences & Shanxi DAYI Hospital, China Objective: To detect the change of myocardial longitudinal strain and ventricular–vascular coupling in diabetic patients with different ventricular systolic function using STI, and to explore the relationship between myocardial strain and ventricular–vascular coupling. Methods: Eighty patients with type 2 diabetes mellitus were divided into two groups according to ejection fraction (EF), DMN group with normal EF (EF≥50%) and DMA group with reduced EF (EF<50%). Forty-two volunteers were divided into the control group. The stroke work (SW), rate–pressure product (RPP), systemic vascular resistance index (SVRI), left ventricular end-systolic elastance (Ees), effective arterial elasticity (Ea) and heart ventricular–vascular coupling index (VVI) were measured and calculated by conventional echocardiography. Besides, the longitudinal strain at left ventricular basement (LSBA), papillary muscle (LSPM) and cardiac apex (LSAP) planes were assessed with STI. Results: 1. Changes in vascular function: compared with control group, in DMA group Ea, VVI, RPP and SVRI all increased, while Ees decreased; in DMN group RPP increased. Furthermore, in DMA group, Ea, VVI, RPP, and SVRI were higher than those were in DMN group, whereas Ees was lower than that in DMN group. 2. Relationship between strain and coupling index: LSBA, LSPM, and LSAP all had a negative correlation with VVI and multiple linear regression analysis showed that SLAP and SW were independent predictors for VVI. The area under the receiver operating characteristic curves for identification of DMN and control groups with LSBA, LSPM and LSAP were 0.857, 0.862 and 0.832 separately and had no statistical significances among three planes. Conclusion: There was a ventricular–vascular coupling in diabetic patients with normal EF while a ventricular–vascular uncoupling in diabetic patients with decreased EF. Myocardial longitudinal strain could reflect the ventricular–vascular coupling, and LSAP was an independent predictor for coupling. Different segments of myocardial strain had a certain order to “respond” the state of ventricular– vascular coupling, and the cardiac apex segment might be the earliest.
Heart Failure
P039 The predictive value of left ventricular end-diastolic pressure for patients with diastolic heart failure
S21
Methods: Left ventricular end-diastolic pressure (LVEDP) for Patients with the follow up study in diastolic heart failure was examined by left cardiac catheter. Cardiac composite end point events were cardiac death and re-admission. According to the follow-up results, the LVEDP level of Cardiac composite end point events group were compared with no Cardiac composite end point events group, and cut-off Point of the LVEDP level acquired by work characteristic curve (ROC). According to cut-off Point of the LVEDP level. We divided two groups and used Kaplan-Meier method analysis survival of two groups; Multivariate analysis was Performed with Cox regression analysis. Results: A total of 171 patients were followed up to 15.7±3.43 months. The LVEDP level in Cardiac composite end point events group [17.5 (9.4, 20.1) mmHg] were higher than no Cardiac composite end point events group [12.5 (7.4, 16.3) mmHg] (p=0.032). Through Working characteristic curve (ROC), The cut-off Point of LVEDP level were 15.1 mmHg. In multivariate Cox analysis, only Log LVEDP (R: 0.9898; p=0.002)) and Log BNP (R: 0.693; p=0.008) remained as the significant predictors of cardiac events among ten possible facors of gender, age, body mass index (BMI), diabetes, hypertension, NYHA, log BNP level, left atrial inside diameter (LA), left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), tissue doppler mitral valve ring early diastolic velocity ratio (E/E’) and left cardiac catheterization test Log LVEDP. The correlation of Log LVEDP were Stronger Log BNP.
Figure 1
Conclusion: LVEDP for the clinical prognosis of patients with diastolic heart failure has a good predictive value. Log LVEDP and Log BNP is independent influencing factors for the cardiac composite end point events.
P040 Evaluation of global left ventricular systolic function in patients with heart failure using three-dimensional speckle-tracking echocardiography
L.J. Pan, H. Gong, Y.J. Shi. Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, No.1508, Longhang Road, Jinshan District, Shanghai, China
X.X. Luo, F. Fang, P.W. Lee, S. Li, Z.H. Zhang, Y.Y. Lam, J.E. Sanderson, J.S.W. Kwong, C.M. Yu. Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital and Institute of Vascular Medicine, Li Ka Shing Institute of Health Sciences, S.H. Ho Cardiovascular Disease and Stroke Centre, The Chinese University of Hong Kong, Hong Kong, China
Objective: To evaluate the clinical prognosis by Left ventricular enddiastolic pressure for Patients With diastolic heart failure.
Purpose: With three-dimensional echocardiographic systems (3DSTE), left ventricle (LV) can be evaluated globally without the in-