Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Abstract P179: Depression Increases All-Cause Mortality in Post Cardiac Surgery Patients: A Meta-Analysis of Prospective Cohort Studies

Background: Studies have shown that depression is a prevalent condition among cardiac patients, especially after cardiac surgery, and that it's presance has been related to negative outcomes. The purpose of this study was to perform a meta-analysis to evaluate depression as a risk factor for all-cause mortality in patients status post cardiac surgery. Methods: A search of MEDLINE (1966 - October 2009) database was performed and we selected all prospective cohort studies in which depression was measured pre-operatively, postoperatively, or both by an established depression index with all-cause mortality recorded after a minimum follow up of 1 year. The pooled relative risk (RR) with corresponding 95% confidence interval (CI) was calculated for all cause mortality using the fixed effects method to evaluate the effects of depression on all-cause mortality in post cardiac surgery patients. Results: Our search strategy yielded 144 studies, of which only 6 met our inclusion criteria. The studies comprised of 1,906 patients, predominately white, males who have undergone coronary artery bypass grafting (64% or 1228 of 1906) or cardiac valve replacement (36% or 678 of 1906) and where evaluated for depression. The RR of all-cause mortality was 1.8; 95% CI (1.4-2.5) for patients with significant depression compared to patients without. Conclusion: Depression is associated with higher all-cause mortality in patients status-post cardiac surgery. All patients should be evaluated for depression after cardiac surgery and treated aggressively

Guidelines and Appropriate Use Criteria

Multiple documents have been published regarding the use of radionuclide imaging which attempt to outline the applications of SPECT and PET cardiac imaging and to offer guidance in not only how these techniques are performed but also when these tests should be used. These guidance documents, which include position papers, consensus documents, white papers, clinical practice guidelines (CPG), and appropriate use criteria (AUC) serve a number of purposes and are applicable to various health care providers. The focus of this chapter is on CPG and AUC, as these provide the basis for care optimization and reimbursement decisions and are the most widely accepted documents regarding radionuclideimaging utilization. Throughout this book, each chapter has focused on the best practice of nuclear cardiology, emphasizing methods that will not only improve image quality but also provide significant clinical value. This chapter will emphasize the selection of patients for radionuclide imaging and focus on how best to use these resources to improve the outcome of patients with known or suspected heart disease

Abstract 17248: Statin Therapy Increases Coronary Artery Calcification Scores

Introduction: Coronary artery calcification (CAC) assessment is a noninvasive test to determine atherosclerotic burden. There has been a discordance with the well-known lipid lowering and cardiovascular protection of statins and the progression of CAC in small trials with narrow inclusion criteria. We performed a subgroup analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) dataset to assess the impact of statins on patients with a baseline CAC score of 0. Hypothesis: Statin usage will cause patients to have a higher CAC scores despite lowering LDL and reducing cardiac mortality. Methods: A subgroup analysis (3235 patients) was performed on the MESA dataset to identify patients with a CAC score of 0 at baseline. Statin usage and cholesterol values were reviewed at 4 examination points. Multivariate regression was performed. Results: The number of patients using statins (Table 1) and lipid levels (Table 2) increased throughout the study as expected for an aging population. A consistently larger increase in CAC score was noted in patients receiving statins; this difference was demonstrated in all stratified groups by Framingham score (Table 3). Table 4 shows the results of multivariate linear regression. Excluding gender, statins had the largest impact on CAC; more than any established cardiovascular risk factor. Conclusion: This large subgroup analysis of the MESA dataset demonstrates that statins are associated with increasing CAC score. While this is in contrast to the well-established cardiovascular protection of statin therapy, it adds to the growing literature that statin use is associated with progression of CAC, even in low risk patients with baseline CAC of 0. One hypothesis for this finding is that statins promote coronary atheroma calcification which ultimately results in plaque stabilization and less likelihood for progression to unstable plaques. It is therefore necessary for clinicians to take into account statins when interpreting CAC scores

Abstract 17114: CHA 2 DS 2 -VASc Score is a Poor Predictor of Thromboembolic Events in Heart Failure Patients With and Without Atrial Fibrillation

Introduction: Recent evidence suggests that the CHA 2 DS 2 -VASc score could be used to predict thromboembolic events (TE) (both CVA and noncerebral thromboembolism) in heart failure (HF) patients without atrial fibrillation (AF). This non-American cohort study had several limitations. We performed a retrospective analysis using the national Veteran Affairs database to externally validate the findings. Hypothesis: The CHA 2 DS 2 -VASc score can be used equally to predict TE in HF patients with or without AF. Methods: A retrospective cohort of the national Veteran’s Affairs database was used to identify HF patients discharged between 2002-2010. Rates for TE were calculated at both 1 and 5 years. C-statistics were calculated to test the performance of CHA 2 DS 2 -VASc in predicting the rate of TE in HF patients with and without AF. Patients who developed AF during the follow-up period (crossovers) and those on anticoagulation where excluded. Negative predictive value was calculated using cutoff value of 1. Results: A total of 77,601 patients were included in this analysis: 51,667 without AF and 15,630 with AF. 10,294 crossover patients were excluded. Baseline characteristics and medications are listed in Table 1. Event rates are reported in Table 2—there is a small trend towards higher incidence with increasing score in both groups. However, C-statistics were overall poor but similar for predicting TE in both groups (Table 3) Conclusion: Our analysis suggests CHA 2 DS 2 -VASc is a poor predictive model for TE in HF with or without AF. We found that previous conclusions regarding the predictive ability of CHA 2 DS 2 -VASc are not generalizable to our large American cohort. Like previously published studies, we show that the predictive ability of CHA 2 DS 2 -VASc was similar in both HF patients with or without AF, despite excluding patient receiving anticoagulation. This suggests that AF may not be the main predictor of TE in HF patients. There is a need for better predictive models for TE in HF

Hepatocellular Carcinoma to the Right Ventricle

Hepatocellular carcinoma (HCC) is the sixth most prevalent cancer in the world, but metastatic disease to the heart is rare. We present a case of a 63-year-old man with history of hepatitis C and cirrhosis, which had progressed to HCC. The patient had undergone two prior liver transplantations. He presented to the hospital complaining of worsening lower extremity edema. His exam was also pertinent for jugular venous distension, a 3/6 crescendo-decrescendo murmur, and hepatosplenomegaly. A transthoracic echocardiogram showed a large irregular lobulated mass in the apex of the right ventricle with a mobile pedunculated component. An MRI of the heart revealed a 4.4 × 3.4 × 4.0 cm mass within the right ventricular apex, which was subsequently biopsied and found to be moderately differentiated HCC with myocardial fragments. The patient opted out of any further therapy, or intervention, and was enrolled in hospice care

Pseudo-pulmonic stenosis in non-hodgkin's large B-cell lymphoma

There have only been a few cases reported of right ventricular outflow tract obstruction secondary to diffuse large B-cell lymphomas. Mediastinal masses rarely cause extrinsic compression of the heart resulting in hemodynamically significant obstruction. We report a rare case of right ventricular outflow tract obstruction secondary to diffuse large B-cell lymphomas. Echocardiography has been found to be a useful modality in the prompt identification of mediastinal masses and their effects on the otherwise healthy heart

Cardiovascular risk factors predict who should have echocardiographic evaluation in long COVID

Abstract Background The need for echocardiograms among patients with long COVID is debatable. Our aim was to evaluate the prevalence of left ventricular (LV) dysfunction and identify predictors. Methods We conducted a cross‐sectional study and included all consecutive patients enrolled in our post‐COVID clinic. We included patients who had an echocardiogram and had no previous known heart disease. We defined LV dysfunction as a low ejection fraction or grade II to grade III diastolic dysfunction on an echocardiogram with evidence of elevated filling pressures. We calculated the prevalence of heart disease and predictors of heart disease using logistic regression. Results We included 217 post‐COVID patients enrolled in the clinic. The prevalence of LV dysfunction is 24%; 95% CI 18–30. Predictors of heart disease include older age and a previous history of hypertension and diabetes or having an intermediate or high ASCVD score. Patients with low ASCVD score did not have low ejection fraction on the screening echocardiograms. Conclusion Our study found a considerable number of patients with LV dysfunction. Older patients with cardiovascular risk factors are at risk of long COVID associated heart disease