0043: Prognosis of patients admitted with chest pain in emergency department and discharged with low risk of acute coronary syndrome

IntroductionChest pain is a frequent cause of admission to the emergency department (ED). The diagnosis and medical care of acute coronary syndrome (ACS) with ST-segment elevation (ST+ ACS) are more standardized than non ST-segment elevation ACS (NST ACS). There is very few series on patients classified as low ACS-diagnosis probability. We aimed to assess the 1-year outcome of patients admitted for chest pain in ED and discharged with low risk of ACS.MethodsThis restrospective study included all patients admitted in the ED of University Hospital Center of Limoges between January and March 2013 for chest pain, without ST-segment elevation and normal troponin level. Patients’ characteristics and initial diagnosis were collected in ED records. Final diagnosis was obtained by phone one year later, from general practitioners or alternatively directly from the patients themselves.ResultsAmong the 244 patients studied, 38 (15.6%) were lost during follow-up. Mean age was 50±17 years, 58% being males. Among the 41% of cases in whom the initial diagnosis (i.e. ED discharge) was modified during follow-up, 9% (n=8) were diagnosed with coronary disease, and 38% (n=32) with panic attack. Major adverse cardiac events rate was 2.4% (n=5) in the whole population, and 60% of them were directly discharged to home. In the ED, the detection of a cardiovascular etiology of chest pain was accurate with good specificity (96%) but lower sensibility (61%). Of note, the rate of false negative patients was 8.5%.ConclusionLow probability NST SCA diagnosis is complex in the ED and may frequently lead to erroneous diagnosis associated with therapeutic delay. Nevertheless, cardiac disorders are uncommonly misdiagnosed. A systematic, individualized and close monitoring after ED discharge is mandatory

0327: Echocardiography improves the risk prediction of peri-operative outcomes in patients undergoing coronary bypass surgery? A prospective study

ObjectiveTo assess the performance of transthoracic echocardiographic (TTE) parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG) and to compare their pronostic value to that obtained by the Society of Thoracic Surgeon (STS) score.Materiels and MethodsWe prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalized for CABG. A preoperative TTE was performed for each patient. Primary endpoint was 30-days mortality or major morbity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. Secondary end-point was prolonged hospitalization>14 days.Results172 patients were included (mean age 66.1±10.2 years, 12.2% were women). The primary end-point occurred in 33 patients (19.2%) and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary end-point were an increased left atrial volume (>31mL/m2) (OR=3.186, IC 95%=1.266; 8.015, p=0.014) and a decreased tricuspid annular plane systolic excursion (TAPSE<20mm) (OR=2.709, IC 95% 1.144; 6.410, p=0.023). The addition of these two parameters to the STS score improved significantly the model performance (figure) with a better risk prediction (Integrated Discrimination Improvement=7.44).ConclusionIn patients undergoing CABG, preoperative TTE is mandatory as it provides an additional prognostic value to the STS score.Abstract 0327 - Figure: Incremental prognostic value of TT

0579: Particularities of the epidemiology of hypertension in the elderly in Central Africa: the EPIDEMCA study

BackgroundThe epidemiology of hypertension in the elderly is rarely reported in Africa and little is known about its specificities.ObjectiveTo study the prevalence of hypertension and associated factors in older people in Central Africa.MethodsIndividuals aged 65 years old and over living in two urban and two rural areas of the Republic of Congo (ROC) and the Central African Republic (CAR) were invited to participate into a comprehensive cross-sectional study assessing cognitive impairments and cardiovascular diseases. Demographic, clinical and biological data were collected. Hypertension was defined in case of self-reported on-going treatment and/or when averaged systolic blood pressure at rest was≥140mmHg and/or diastolic blood pressure was≥90mmHg.ResultsAmong 1990 participants (mean age=73 years; 62% females), the overall prevalence of hypertension was 61.1% (95% CI: 58.9-63.2), higher in ROC than in CAR (68.0% vs 53.7%, respectively; p<0.001) and higher in urban than in rural areas (64.7% vs 57.4%, respectively; p=0.001). Among hypertensive participants, 53.3% were unaware of their condition and only 17.3% received anti-hypertensive drug therapy. In multivariate analysis, increasing age and BMI, living in the ROC, the main lifetime occupation, presence of depressive symptoms and the number of meals per day remained significantly associated with an increased likelihood of hypertension. In contrast, smoking status, physical activity and an increasing number of stressful lifetime events were associated with a reduced likelihood for prevalent hypertension.ConclusionHypertension is highly prevalent in elderly people of Central Africa, and presents some particularities in relation to specific conditions in this region

The year in cardiology 2014: peripheral circulation

In 2014, the debate on the indication of revascularization in case of asymptomatic carotid disease continued, while another one regarding the use of surgery vs. stenting addressed some new issues regarding the long-term cardiac risk of these patients. Renal arteries interventions trials were disappointing, as neither renal denervation nor renal artery stenting was found associated with better blood pressure management or outcome. In contrast, in lower-extremities artery disease, the endovascular techniques represent in 2014 major alternatives to surgery, even in distal arteries, with new insights regarding the interest of drug-eluting balloons. Regarding the aorta, the ESC published its first guidelines document on the entire vessel, emphasizing on the role of every cardiologist for screening abdominal aorta aneurysm during echocardiography. Among vascular wall biomarkers, the aorta stiffness is of increasing interest with new data and meta-analysis confirming its ability to stratify risk, whereas carotid intima-media thickness showed poor performances in terms of reclassifying patients into risk categories beyond risk scores. Regarding the veins, new data suggest the interest of D-dimers and residual venous thrombosis to help the decision of anti-coagulation prolongation or discontinuation after the initial period of treatment for deep vein thrombosi

0274: Prognostic impact of pulmonary arterial pressure in patients with aortic stenosis and preserved left ventricular ejection fraction

BackgroundThe prognostic impact of pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused only on patients with preserved left ventricular ejection fraction (LVEF). We therefore aimed to investigate the impact of PAP, derived from our large catheterization database, on survival in severe AS with preserved LVEF.Methods and resultsBetween 2000 and 2010, 749 patients (74±8y, 57% of males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization, including right heart hemodynamic assessment. Pulmonary hypertension (PH) was defined as mean PAP>25mmHg.Systolic and mean PAP were 34.5±12 and 21.9±9mmHg, respectively. Overall, 29% (n=215) of patients had PH, and these patients were significantly older (p<0.0001), with lower LVEF (p<0.0001) and higher heart rate (p=0.016) than those without PH. In addition, they more frequently had, hypertension (p<0.0001), diabetes (p=0.001), coronary artery disease (CAD, p<0.0001) and chronic pulmonary disease (p=0.043). Aortic valve replacement (AVR) was performed in 91% of patients and 30-day mortality was 4.3%, significantly higher in patients with PH (7.7 vs. 3.4%, p=0.014). In logistic regression analysis, after adjustment for age, gender, LVEF, CAD and mean transaortic pressure gradient, mean PAP was an independent predictor of increased 30-day mortality (OR=1.06, 95% CI: 1.02-1.1, p=0.004). Overall long-term survival was significantly reduced in patients with PH as compared to those without PH (10-year survival: 41±8 vs. 61±3%, p<0.0001). In multivariate analysis, after adjustment for all cofactors, PH was an independent predictor of mortality (HR=1.5, 95% CI: 1.1-2.1, p=0.037).ConclusionIn patients with severe AS and preserved LVEF, PAP is an independent predictor of both 30-day and long-term mortality. In order to improve the prognosis of these patients, AVR could be considered before the occurrence of severely elevated PAP

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0–100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings: In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8–98·1) in Iceland, followed by 96·6 (94·9–97·9) in Norway and 96·1 (94·5–97·3) in the Netherlands, to values as low as 18·6 (13·1–24·4) in the Central African Republic, 19·0 (14·3–23·7) in Somalia, and 23·4 (20·2–26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1–93·6) in Beijing to 48·0 (43·4–53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6–68·8) in Goa to 34·0 (30·3–38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation: GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view—and subsequent provision—of quality health care for all populations

The year 2017 in cardiology: aorta and peripheral circulation

International audienc

The Global Epidemiological Transition in Cardiovascular Diseases:Unrecognised Impact of Endemic Infections on Peripheral Artery Disease

An epidemiological transition in the prevalence of peripheral artery disease (PAD) is taking place especially in low- and middle-income countries (LMICs) where an ageing population and adoption of western lifestyles are associated with an increase in PAD. We discuss the limited evidence which suggests that infection, potentially mediated by inflammation, may be a risk factor for PAD, and show by means of an ecological analysis that country-level prevalence of the major endemic infections of HIV, tuberculosis and malaria are associated with the prevalence of PAD. While further research is required, we propose that scientists and health authorities pay more attention to the interplay between communicable and non-communicable diseases, and we suggest that limiting the occurrence of endemic infections might have some effect on slowing the epidemiological transition in PAD