- Email: [email protected]
Prevalence and echocardiographic predictors of treatment non-responders in patients with systolic heart failure
S6
Oral Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
cording to the log book. The ESMI group demonstrated significantly better improvements in physical limitation (p<0.01), treatment satisfaction (p<0.001), and disease perception (p<0.001) of SAQ than the C and PE groups, while no significant difference in angina stability and angina frequency of SAQ was found among the three groups at each time point. These significantly positive effects were maintained at the 3- and 6-month follow-up periods. Conclusion: The TTM-based ESMI has positive effects on angina in CHD patients. The findings suggest that it is feasible and important to provide a structured patient education programme guided by the TTM for CHD patients in China.
Heart Failure A011 Prevalence and echocardiographic predictors of treatment non-responders in patients with systolic heart failure
Figure 1
tion than LD pre-treatment (48.7% vs. 54.5%, p=0.012; 56.7% vs. 61.3%, p=0.024), respectively (see Figure 1). Conclusion: 300 mg LD cannot afford equivalent antiplatelet effect as compared with 75 mg MD in either CYP2C19 *2 LOF carriers or non-carriers in patients received clopidogrel prior to PCI. Difference should be taken into account during further study design as well as the clinical practice.
A009 The effect of a TTM-based exercise stage-matched intervention on angina in patients with coronary heart disease: a randomized controlled trial L.X. Zhu 1 , S.C. Ho 2 , J.W.H. Sit 3 . 1 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 2 School of Nursing, The Hong Kong Polytechnic University, Hong Kong; 3 The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong Background: Angina is one of the most common symptoms reported by patients with coronary heart disease (CHD). Previous studies have shown that regular exercise has promising effects on the management of angina. The transtheoretical model (TTM) has been demonstrated to be a successful model for changing exercise behaviour in various populations from adolescents to the elderly. However, there have been few studies to examine the effect of the TTM-based exercise intervention on angina in CHD patients. Aim: To examine the effects of a TTM-based exercise stage-matched intervention (ESMI) on angina in patients with coronary heart disease Methods: A total of 196 subjects were recruited and randomly assigned to either a Conventional (C) Group (n=67), a Patient Education (PE) Group (n=64), or a ESMI Group (n=65). Angina was assessed by patients’ records on a log book and the Seattle Angina Questionnaire (SAQ). Data collection was carried out at baseline (T0), postintervention (T1), at the 3- (T2) and 6-month follow-up period (T3). Data analysis was conducted based on the intention-to-treat principle. The Kruskal-Wallis test and Friedman test were used to analyze data between and within groups. Results: A total of 150 subjects completed the whole study. No significant differences in frequency, severity, and duration of anginal attacks were found among the three groups at each time point ac-
F. Fang 1 , P.W. Lee 1 , X.X. Luo 1 , Q. Shang 1 , Z.H. Zhang 1 , M. Liu 1 , Q. Zhang 2 , C.M. Yu 1 . 1 Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China; 2 Division of Cardiology, West China Hospital, Sichuan University, China Objective: Although effective drug treatments have improved notably the mortality of chronic heart failure (CHF), it is common observed that not all patients respond as well as others and some not at all. This study aimed to investigate the prevalence and transthoracic echocardiographic determinants to CHF treatment non-responder. Methods: One-hundred and twenty-two CHF patients (74±13 years, 74 males) defined as left ventricular ejection fraction <50%) were prospectively enrolled and transthoracic echocardiography was performed at baseline and 6 month at follow-up. Mitral septal annulus velocity was measured with spectral pulse-tissue doppler (E’) and LV filling pressure was calculated by the ratio of mitral inflow to septal E’ (E/E’). The definition of treatment non-responder was death, re-hospitalization or unchanged left ventricular end-systolic volume (volume increase <10% vs. baseline). Results: At 6-month, there were total 66 non-responders (54.1%). Compared to responders, they were older, had lower septal E’ and higher LV filling pressure despite having similar gender distribution and LV volumes and function (Table). Univariate predictors for non-responder were age [hazard ratio (HR): 1.042, 95% confidence interval (CI): 1.010–1.075, p=0.009] and septal E’ (HR: 0.673, 95% CI: 0.500–0.904, p=0.009). In multiple analysis, only septal E’ was the independent predictor of non-responder (HR: 0.681, 95% CI: 0.508–0.814, p=0.11). Receiver Operating Characteristic (ROC) curve revealed that a cut-off value of septal E’ <4 cm/s was 70% sensitive and 78% specific in predicting non-responder (area under the curve: 0.70). Parameters Age, years Gender, male (%) Left ventricular end-diastolic volume, ml Left ventricular end-systolic volume, ml Left ventricular ejection fraction, % Mitral E wave, cm/s Mitral A wave, cm/s LV septal E’, cm/s LV septal E/E’
Responders (n=56)
Non-responders (n=66)
P value
71±14 33 (59%)
77±11 41 (62%)
χ2 =0.129
123±48 83±39 34±9 0.95±0.38 0.74±0.37 4.3±1.7 23.3±9.3
123±59 83±46 34±8 0.87±0.30 0.67±0.29 3.5±1.2 27.4±11.5
p=0.431 0.960 0.913 0.753 0.232 0.356 0.005 0.047
0.021
Conclusion: More than half of CHF patients have no response to the
Oral Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
treatment, which could be predicted by the early diastolic mitral annulus velocity.
A012 The clinical correlates and prognostic impact of LGE on cardiac magnetic resonance imaging in patients with dilated cardiomyopathy X.P. Li 1 , W. Hua 1 , S. Zhang 1 , S.H. Zhao 2 . 1 Cardiac Arrhythmia Center; 2 Department of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, P.R. China Purpose: Current risk stratification approaches of patient with dilated cardiomyopathy (DCM) are limited. Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) is a risk factor for mortality in patients with cardiomyopathy. The purpose of this study was to examine the association between LGE and survival in patients with DCM. Methods: A retrospective cohort study was undertaken in 293 patients with DCM. CMR, standard demographics, echocardiography and routine blood testings were obtained shortly after admission. Results: Of 293 patient with DCM, 49.5% (n=145) had LGE, 50.5% (n=148) had no-LGE. With follow-up 3.2 years, all-cause mortality rates were higher in patients with LGE than patients with no-LGE (21.4% vs. 9.5%, P<0.001). Patients with LGE were further subgrouped by the location of LGE, 61 patients in ventricular septum (VS), 73 in the location other than VS and 11 in diffused location. There was a significant difference in all-cause mortality rate among the three subgroups and no-LGE (VS-LGE 19.7%, Other than VSLGE 20.5%, diffuse-LGE 36.4%, P<0.001). Cox multivariate analysis showed that the present of LGE, QRS duration and left atrium were the independent predictors of all-cause mortality in patients with DCM. Conclusion: LGE is an independent predictor of increased all-cause mortality in patients with DCM, the patients with diffuse-LGE had higher risk for all-cause mortality.
Hypertension A013 Effectiveness of a community-based medication counseling service on enhancing medication adherence among patients prescribed antihypertensive agents: a randomized controlled trial K.Q.L. Liu 1 , M.C.S. Wong 1 , H.H.X. Wang 1 , C.L.S. Lee 1 , M.W.M. Kwan 1 , G.K.Y. Lee 1 , Y. Cheung 2 , B.P. Yan 3 , C.M. Yu 3 . 1 School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; 2 Hospital Authority, Hong Kong; 3 Division of Cardiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Purpose: Poor adherence to antihypertensive agents diminishes benefits of therapies and bears a substantial public health burden. This study evaluated effectiveness of a community-based medication counseling service on enhancing adherence to antihypertensive agents among patients in primary care setting. Methods: A randomized controlled trial was conducted in one health center from January to September 2012, targeting at adult taking antihypertensive medications and assessed as suboptimal adherence according to 8 itemed Morisky Medication Adherence Scale. 318 pa-
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tients were randomly allocated into two groups, usual care from physicians in control group and additional pharmacist-led medication counseling service in intervention group. Major outcomes were changes of systolic and diastolic blood pressure as well as Morisky score from baseline to 3- and 6-months in both groups. Differences were compared using ANOVA with repeated measures. Results: 231 patients (62.8% women; aged 62.4 [9.35] years old), taking 1.55 (0.892) medications with a duration of 6.97 (6.38) years of medication use, completed six months follow-up periods. Patients experienced improvement in Morisky score from 5.07 (1.21) to 6.63 (1.31) and from 5.12 (1.01) to 6.49 (1.23) in intervention and control groups, respectively. Moreover, there were statistically significant differences in Morisky scores and diastolic BP between time points (F=164.029, df=1.912, p<0.005 and F=3.883, df=1.913, p=0.023, respectively), but not for systolic BP. However, when adding group factor into analysis, differences between two groups vanished in each outcome variable. Conclusion: A longer-run comprehensive pharmacy care programme composed of clinical pharmacist education and continuous counseling service shall be delivered in primary care setting.
Percutaneous Coronary Intervention A014 Percutaneous coronary intervention (PCI) enhances transmission of accelerative waves in coronary arteries O. Narayan, D. Wong, M. Leung, I.T. Meredith, J. Cameron. Monash Heart, Australia Background: Coronary wave intensity analysis (CWI) enables separation and quantification of proximal and distal originating waves in the coronary circulation. The systolic forward going compression wave and diastolic backward going suction wave predominantly accelerate coronary flow. We hypothesized that the peak intensity of these waves would be reduced distal to a coronary stenosis, proportionate to ischaemia severity predicted by Fractional Flow Reserve (FFR). Moreover, we sought to determine if augmentation of early diastolic suction contributed to enhanced flow following PCI. Methods: Simultaneous intracoronary pressure and velocity measurement was performed during adenosine induced hyperemia in 17 patients with pressure/flow wires positioned distal to the target lesion. FFR was measured as the ratio of mean pressure distal to the lesion to mean aortic pressure. Coronary artery wave speed was calculated utilising the “Single point sum-of-squares” method. CWI profiles were generated. We calculated the peak amplitudes of both compression and suction waves distal to the lesion before and after PCI and correlated these to FFR. Results: Significant correlations existed between FFR and peak intensity of both waves (R=0.73, P=0.001 and R=0.55, P=0.02 respectively). Percentage increases in peak intensity of both waves after PCI was correlated with FFR (R=0.61, P=0.01 and R=0.49, P=0.046 respectively). Following target lesion PCI, peak intensities of both waves increased by a mean 170.4% and 226.6%. The degree to which the intensities of these waves was augmented following PCI was significantly associated with the severity of ischaemia as predicted by baseline FFR. Conclusion: Increased ischaemia severity (determined by FFR) was associated with proportionate reductions in peak intensity of the backward going suction wave and the forward going compression wave. The improvements seen in wave transmission post PCI were proportional to baseline FFR. These findings suggest that impaired early diastolic suction represents a major, previously unrecognised mechanism driving ischaemia in coronary artery disease.
Oral Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
cording to the log book. The ESMI group demonstrated significantly better improvements in physical limitation (p<0.01), treatment satisfaction (p<0.001), and disease perception (p<0.001) of SAQ than the C and PE groups, while no significant difference in angina stability and angina frequency of SAQ was found among the three groups at each time point. These significantly positive effects were maintained at the 3- and 6-month follow-up periods. Conclusion: The TTM-based ESMI has positive effects on angina in CHD patients. The findings suggest that it is feasible and important to provide a structured patient education programme guided by the TTM for CHD patients in China.
Heart Failure A011 Prevalence and echocardiographic predictors of treatment non-responders in patients with systolic heart failure
Figure 1
tion than LD pre-treatment (48.7% vs. 54.5%, p=0.012; 56.7% vs. 61.3%, p=0.024), respectively (see Figure 1). Conclusion: 300 mg LD cannot afford equivalent antiplatelet effect as compared with 75 mg MD in either CYP2C19 *2 LOF carriers or non-carriers in patients received clopidogrel prior to PCI. Difference should be taken into account during further study design as well as the clinical practice.
A009 The effect of a TTM-based exercise stage-matched intervention on angina in patients with coronary heart disease: a randomized controlled trial L.X. Zhu 1 , S.C. Ho 2 , J.W.H. Sit 3 . 1 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 2 School of Nursing, The Hong Kong Polytechnic University, Hong Kong; 3 The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong Background: Angina is one of the most common symptoms reported by patients with coronary heart disease (CHD). Previous studies have shown that regular exercise has promising effects on the management of angina. The transtheoretical model (TTM) has been demonstrated to be a successful model for changing exercise behaviour in various populations from adolescents to the elderly. However, there have been few studies to examine the effect of the TTM-based exercise intervention on angina in CHD patients. Aim: To examine the effects of a TTM-based exercise stage-matched intervention (ESMI) on angina in patients with coronary heart disease Methods: A total of 196 subjects were recruited and randomly assigned to either a Conventional (C) Group (n=67), a Patient Education (PE) Group (n=64), or a ESMI Group (n=65). Angina was assessed by patients’ records on a log book and the Seattle Angina Questionnaire (SAQ). Data collection was carried out at baseline (T0), postintervention (T1), at the 3- (T2) and 6-month follow-up period (T3). Data analysis was conducted based on the intention-to-treat principle. The Kruskal-Wallis test and Friedman test were used to analyze data between and within groups. Results: A total of 150 subjects completed the whole study. No significant differences in frequency, severity, and duration of anginal attacks were found among the three groups at each time point ac-
F. Fang 1 , P.W. Lee 1 , X.X. Luo 1 , Q. Shang 1 , Z.H. Zhang 1 , M. Liu 1 , Q. Zhang 2 , C.M. Yu 1 . 1 Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China; 2 Division of Cardiology, West China Hospital, Sichuan University, China Objective: Although effective drug treatments have improved notably the mortality of chronic heart failure (CHF), it is common observed that not all patients respond as well as others and some not at all. This study aimed to investigate the prevalence and transthoracic echocardiographic determinants to CHF treatment non-responder. Methods: One-hundred and twenty-two CHF patients (74±13 years, 74 males) defined as left ventricular ejection fraction <50%) were prospectively enrolled and transthoracic echocardiography was performed at baseline and 6 month at follow-up. Mitral septal annulus velocity was measured with spectral pulse-tissue doppler (E’) and LV filling pressure was calculated by the ratio of mitral inflow to septal E’ (E/E’). The definition of treatment non-responder was death, re-hospitalization or unchanged left ventricular end-systolic volume (volume increase <10% vs. baseline). Results: At 6-month, there were total 66 non-responders (54.1%). Compared to responders, they were older, had lower septal E’ and higher LV filling pressure despite having similar gender distribution and LV volumes and function (Table). Univariate predictors for non-responder were age [hazard ratio (HR): 1.042, 95% confidence interval (CI): 1.010–1.075, p=0.009] and septal E’ (HR: 0.673, 95% CI: 0.500–0.904, p=0.009). In multiple analysis, only septal E’ was the independent predictor of non-responder (HR: 0.681, 95% CI: 0.508–0.814, p=0.11). Receiver Operating Characteristic (ROC) curve revealed that a cut-off value of septal E’ <4 cm/s was 70% sensitive and 78% specific in predicting non-responder (area under the curve: 0.70). Parameters Age, years Gender, male (%) Left ventricular end-diastolic volume, ml Left ventricular end-systolic volume, ml Left ventricular ejection fraction, % Mitral E wave, cm/s Mitral A wave, cm/s LV septal E’, cm/s LV septal E/E’
Responders (n=56)
Non-responders (n=66)
P value
71±14 33 (59%)
77±11 41 (62%)
χ2 =0.129
123±48 83±39 34±9 0.95±0.38 0.74±0.37 4.3±1.7 23.3±9.3
123±59 83±46 34±8 0.87±0.30 0.67±0.29 3.5±1.2 27.4±11.5
p=0.431 0.960 0.913 0.753 0.232 0.356 0.005 0.047
0.021
Conclusion: More than half of CHF patients have no response to the
Oral Presentation Sessions / International Journal of Cardiology 163S2 (2013) S1–S30
treatment, which could be predicted by the early diastolic mitral annulus velocity.
A012 The clinical correlates and prognostic impact of LGE on cardiac magnetic resonance imaging in patients with dilated cardiomyopathy X.P. Li 1 , W. Hua 1 , S. Zhang 1 , S.H. Zhao 2 . 1 Cardiac Arrhythmia Center; 2 Department of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, P.R. China Purpose: Current risk stratification approaches of patient with dilated cardiomyopathy (DCM) are limited. Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) is a risk factor for mortality in patients with cardiomyopathy. The purpose of this study was to examine the association between LGE and survival in patients with DCM. Methods: A retrospective cohort study was undertaken in 293 patients with DCM. CMR, standard demographics, echocardiography and routine blood testings were obtained shortly after admission. Results: Of 293 patient with DCM, 49.5% (n=145) had LGE, 50.5% (n=148) had no-LGE. With follow-up 3.2 years, all-cause mortality rates were higher in patients with LGE than patients with no-LGE (21.4% vs. 9.5%, P<0.001). Patients with LGE were further subgrouped by the location of LGE, 61 patients in ventricular septum (VS), 73 in the location other than VS and 11 in diffused location. There was a significant difference in all-cause mortality rate among the three subgroups and no-LGE (VS-LGE 19.7%, Other than VSLGE 20.5%, diffuse-LGE 36.4%, P<0.001). Cox multivariate analysis showed that the present of LGE, QRS duration and left atrium were the independent predictors of all-cause mortality in patients with DCM. Conclusion: LGE is an independent predictor of increased all-cause mortality in patients with DCM, the patients with diffuse-LGE had higher risk for all-cause mortality.
Hypertension A013 Effectiveness of a community-based medication counseling service on enhancing medication adherence among patients prescribed antihypertensive agents: a randomized controlled trial K.Q.L. Liu 1 , M.C.S. Wong 1 , H.H.X. Wang 1 , C.L.S. Lee 1 , M.W.M. Kwan 1 , G.K.Y. Lee 1 , Y. Cheung 2 , B.P. Yan 3 , C.M. Yu 3 . 1 School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; 2 Hospital Authority, Hong Kong; 3 Division of Cardiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Purpose: Poor adherence to antihypertensive agents diminishes benefits of therapies and bears a substantial public health burden. This study evaluated effectiveness of a community-based medication counseling service on enhancing adherence to antihypertensive agents among patients in primary care setting. Methods: A randomized controlled trial was conducted in one health center from January to September 2012, targeting at adult taking antihypertensive medications and assessed as suboptimal adherence according to 8 itemed Morisky Medication Adherence Scale. 318 pa-
S7
tients were randomly allocated into two groups, usual care from physicians in control group and additional pharmacist-led medication counseling service in intervention group. Major outcomes were changes of systolic and diastolic blood pressure as well as Morisky score from baseline to 3- and 6-months in both groups. Differences were compared using ANOVA with repeated measures. Results: 231 patients (62.8% women; aged 62.4 [9.35] years old), taking 1.55 (0.892) medications with a duration of 6.97 (6.38) years of medication use, completed six months follow-up periods. Patients experienced improvement in Morisky score from 5.07 (1.21) to 6.63 (1.31) and from 5.12 (1.01) to 6.49 (1.23) in intervention and control groups, respectively. Moreover, there were statistically significant differences in Morisky scores and diastolic BP between time points (F=164.029, df=1.912, p<0.005 and F=3.883, df=1.913, p=0.023, respectively), but not for systolic BP. However, when adding group factor into analysis, differences between two groups vanished in each outcome variable. Conclusion: A longer-run comprehensive pharmacy care programme composed of clinical pharmacist education and continuous counseling service shall be delivered in primary care setting.
Percutaneous Coronary Intervention A014 Percutaneous coronary intervention (PCI) enhances transmission of accelerative waves in coronary arteries O. Narayan, D. Wong, M. Leung, I.T. Meredith, J. Cameron. Monash Heart, Australia Background: Coronary wave intensity analysis (CWI) enables separation and quantification of proximal and distal originating waves in the coronary circulation. The systolic forward going compression wave and diastolic backward going suction wave predominantly accelerate coronary flow. We hypothesized that the peak intensity of these waves would be reduced distal to a coronary stenosis, proportionate to ischaemia severity predicted by Fractional Flow Reserve (FFR). Moreover, we sought to determine if augmentation of early diastolic suction contributed to enhanced flow following PCI. Methods: Simultaneous intracoronary pressure and velocity measurement was performed during adenosine induced hyperemia in 17 patients with pressure/flow wires positioned distal to the target lesion. FFR was measured as the ratio of mean pressure distal to the lesion to mean aortic pressure. Coronary artery wave speed was calculated utilising the “Single point sum-of-squares” method. CWI profiles were generated. We calculated the peak amplitudes of both compression and suction waves distal to the lesion before and after PCI and correlated these to FFR. Results: Significant correlations existed between FFR and peak intensity of both waves (R=0.73, P=0.001 and R=0.55, P=0.02 respectively). Percentage increases in peak intensity of both waves after PCI was correlated with FFR (R=0.61, P=0.01 and R=0.49, P=0.046 respectively). Following target lesion PCI, peak intensities of both waves increased by a mean 170.4% and 226.6%. The degree to which the intensities of these waves was augmented following PCI was significantly associated with the severity of ischaemia as predicted by baseline FFR. Conclusion: Increased ischaemia severity (determined by FFR) was associated with proportionate reductions in peak intensity of the backward going suction wave and the forward going compression wave. The improvements seen in wave transmission post PCI were proportional to baseline FFR. These findings suggest that impaired early diastolic suction represents a major, previously unrecognised mechanism driving ischaemia in coronary artery disease.