Macrophage infiltrates in coronary plaque erosion portend a worse cardiovascular outcome in patients with acute coronary syndrome

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R.A Montone ◽  
V Vetrugno ◽  
M Camilli ◽  
M Russo ◽  
M.G Del Buono ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Vulnerable Plaque ◽  
Cardiac Death ◽  
Cox Regression ◽  
Plaque Rupture ◽  
Culprit Lesion ◽  
Coronary Syndrome ◽  
Fibrous Cap ◽  
Plaque Erosion

Abstract Background Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS). Inflammatory activation is considered a key mechanism of plaque instability in patients with plaque rupture through the release of metalloproteinases and the inhibition of collagen synthesis that in turns lead to fibrous cap degradation. However, the clinical relevance of macrophage infiltration has never been investigated in patients with PE. Purpose In our study, we aimed at assessing the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value. Methods ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site and in non-culprit segments along the culprit vessel was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03–2.58) years]. Results We included 153 patients [median age (IQR) 64 (53–75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. In particular, culprit lesion analysis demonstrated that patients with PE with MØI had a significantly thinner fibrous cap [median (IQR) 100 (60–120) μm vs. 160 (95–190) μm, p<0.001], higher prevalence of thrombus [41 (80.4%) vs. 64 (62.7%), p=0.028], lipid plaque [39 (76.5%) vs. 50 (49.0%), p<0.001], TCFA [20 (39.2%) vs. 14 (13.7%), p=0.001], and a higher maximum lipid arc [median [IQR] 250.0° (177.5°-290.0°) vs. 190.0° (150.0°-260.0°), p=0.018) at the culprit lesion compared with PE without MØI. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p=0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression model, PE with MØI [HR=2.95, 95% CI (1.09–8.02), p=0.034] was an independent predictor of MACEs. Conclusion Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with a more aggressive phenotype of coronary atherosclerosis with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up. These findings are of the utmost importance in the era of precision medicine because clearly show that macrophage infiltrates may identify patients with a higher cardiovascular risk requiring more aggressive secondary prevention therapies and a closer clinical follow-up. Prognosis Funding Acknowledgement Type of funding source: None

scholarly journals Plaque erosion is associated with less systemic atherosclerosis than other plaque types of acute coronary syndrome

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Kato ◽  
Y Minami ◽  
K Asakura ◽  
M Katamine ◽  
A Katsura ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Aortic Arch ◽  
Plaque Rupture ◽  
Intima Media Thickness ◽  
Atheromatous Plaque ◽  
Culprit Lesion ◽  
Coronary Syndrome ◽  
Plaque Erosion ◽  
The Status ◽  
Chest X Ray

Abstract Background Previous studies have demonstrated that plaque erosion is associated with less atheromatous plaque at both culprit and non-culprit lesion than other plaque types of acute coronary syndrome (ACS). However, the status of systemic atherosclerosis in patients with plaque erosion remains to be elucidated. Purpose To clarify if plaque erosion is associated with less systemic atherosclerosis than other plaque types of ACS. Methods A total of 239 consecutive patients with ACS who underwent optical coherence tomography (OCT) imaging of the culprit lesion were enrolled. Patients were classified into either plaque erosion (PE, n=45) or non-plaque erosion (non-PE, n=194) including plaque rupture and calcified nodule based on OCT findings of the culprit lesions. The status of systemic atherosclerosis was assessed by the findings of carotid echography, the severity of aortic arch calcification (AAC; grade 0–3) on chest X-ray, brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABPI). Results The maximum intima media thickness (IMT) was significantly thinner in the PE group than in the non-PE group (1.9±0.8 vs. 2.3±0.9 mm, p=0.023) (Panel A). The prevalence of heterogeneous plaque and calcified plaque was significantly lower in the PE group than in the non-PE group (25.0 vs. 50.4%, p=0.010, 18.8 vs. 38.5%, p=0.037, respectively). The prevalence of AAC grade was significantly different between the two groups with a tendency toward lower AAC grade in the PE group than the non-PE group (Panel B). The mean baPWV (1588.1±420.6 vs. 1686.5±363.5 cm/sec, p=0.186) and ABPI (1.1±0.1 vs. 1.1±0.1, p=0.270) was comparable between the two groups. Conclusion Plaque erosion was associated with less atherosclerosis in carotid artery and aortic arch than non-plaque erosion. These findings may help further clarify the distinct pathophysiology of plaque erosion. Funding Acknowledgement Type of funding source: None

Abstract 2510: Culprit Lesion Remodeling Affects Long-Term Clinical Outcome in Patients with Acute Coronary Syndrome: A Prospective, Multicenter Three-Vessel Intravascular Ultrasound Study

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Hiroyuki Okura ◽  
Haruyuki Taguchi ◽  
Yoshio Kobayashi ◽  
Satoru Sumitsuji ◽  
Mitsuyasu Terashima ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Clinical Outcome ◽  
Intravascular Ultrasound ◽  
Plaque Rupture ◽  
Culprit Lesion ◽  
Free Survival ◽  
Coronary Syndrome ◽  
Remodeling Index

Single center studies have shown that plaque rupture and positive remodeling are prognostic predictors of acute coronary syndrome (ACS). A total of 119 patients with first ACS events were enrolled in a multicenter, prospective, 3-vessel intravascular ultrasound (IVUS) registry. Pre-intervention IVUS imaging was performed in 98 patients. Remodeling index was defined as lesion site external elastic membrane cross sectional area (EEM CSA) divided by the proximal reference. Arterial remodeling was defined as either positive (PR; remodeling index >1.05) or intermediate/negative (IR/NR; remodeling index <1.05). Plaque rupture was a cavity that communicated with the lumen with an overlying residual fibrous cap fragment. Major adverse cardiac events (MACE) were death, myocardial infarction (MI), and target lesion revascularization (TLR). During follow-up (mean 3 years), 20 TLR events and 5 deaths were documented; but recurrent MI was not observed. Patients with PR had significantly lower MACE-free survival than patients with IR/NR (Log rank, p=0.03). Similarly, patients with plaque rupture showed a non-significant trend toward lower MACE-free survival (Log rank, p=0.13). By multivariate logistic regression analysis, culprit lesion PR was the only independent predictor of follow-up MACE. Culprit lesion remodeling is a strong predictor of long-term clinical outcome in patients with ACS.

scholarly journals Potential relationship between high wall shear stress and plaque rupture that cause acute coronary syndrome: insights from optical coherence tomography based computational fluid dynamic simulation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Y Fukuyama ◽  
H Otake ◽  
F Seike ◽  
H Kawamori ◽  
T Toba ◽  
...  
Keyword(s):  
Optical Coherence Tomography ◽  
Shear Stress ◽  
Acute Coronary Syndrome ◽  
Wall Shear Stress ◽  
Plaque Rupture ◽  
Optical Coherence ◽  
Lumen Area ◽  
Segmental Analysis ◽  
Coronary Syndrome ◽  
Fibrous Cap

Abstract Background The direct relationship between plaque rupture (PR) that cause acute coronary syndrome (ACS) and wall shear stress (WSS) remains uncertain. Methods From the Kobe University ACS-OCT registry, one hundred ACS patients whose culprit lesions had PR documented by optical coherence tomography (OCT) were enrolled. Lesion-specific 3D coronary artery models were created using OCT data. Specifically, at the ruptured portion, the tracing of the luminal edge of the residual fibrous cap was smoothly extrapolated to reconstruct the luminal contour before PR. Then, WSS was computed from computational fluid dynamics (CFD) analysis by a single core laboratory. Relationships between WSS and the location of PR were assessed with 1) longitudinal 3-mm segmental analysis and 2) circumferential analysis. In the longitudinal segmental analysis, each culprit lesion was subdivided into five 3-mm segments with respect to the minimum lumen area (MLA) location at the centered segment (Figure. 1). In the circumferential analysis, we measured WSS values at five points from PR site and non-PR site on the cross-sections with PR. Also, each ruptured plaque was categorized into the lateral type PR (L-PR), central type PR (C-PR), and others according to the relation between the site of tearing and the cavity (Figure. 2). Results In the longitudinal 3-mm segmental analysis, the incidences of PR at upstream (UP1 and 2), MLA, and downstream (DN1 and 2) were 45%, 40%, and 15%, respectively. The highest average WSS was located in UP1 in the upstream PR (UP1: 15.5 (10.4–26.3) vs. others: 6.8 (3.3–14.7) Pa, p&lt;0.001) and MLA segment in the MLA PR (MLA: 18.8 (6.0–34.3) vs. others: 6.5 (3.1–11.8) Pa, p&lt;0.001), and the second highest WSS was located at DN1 in the downstream PR (DN1: 5.8 (3.7–11.5) vs. others: 5.5 (3.7–16.5) Pa, p=0.035). In the circumferential analysis, the average WSS at PR site was significantly higher than that of non-PR site (18.7 (7.2–35.1) vs. 13.9 (5.2–30.3) Pa, p&lt;0.001). The incidence of L-PR, C-PR, and others were 51%, 42%, and 7%, respectively. In the L-PR, the peak WSS was most frequently observed in the lateral site (66.7%), whereas that in the C-PR was most frequently observed in the center site (70%) (Figure. 3). In the L-PR, the peak WSS value was significantly lower (44.6 (19.6–65.2) vs. 84.7 (36.6–177.5) Pa, p&lt;0.001), and the thickness of broken fibrous cap was significantly thinner (40 (30–50) vs. 80 (67.5–100) μm, p&lt;0.001), and the lumen area at peak WSS site was significantly larger than those of C-PR (1.5 (1.3–2.0) vs. 1.4 (1.1–1.6) mm2, p=0.008). Multivariate analysis demonstrated that the presence of peak WSS at lateral site, thinner broken fibrous cap thickness, and larger lumen area at peak WSS site were independently associated with the development of the L-PR. Conclusions A combined approach with CFD simulation and morphological plaque evaluation by using OCT might be helpful to predict future ACS events induced by PR. Funding Acknowledgement Type of funding source: None

P2651Seasonal variations in the pathogenesis of acute coronary syndromes

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
O Kurihara ◽  
M Takano ◽  
E Yamamoto ◽  
T Yonetsu ◽  
T Kakuta ◽  
...  
Keyword(s):  
Plaque Rupture ◽  
Culprit Lesion ◽  
Coronary Syndrome ◽  
Plaque Erosion ◽  
Four Seasons ◽  
Incidence And Mortality ◽  
Calcified Plaque ◽  
Coronary Syndromes ◽  
Underlying Mechanisms ◽  
Underlying Pathophysiology

Abstract Background Seasonal variations in acute coronary syndrome (ACS) has been known with the winter being the peak in incidence and mortality. However, underlying pathophysiology for this variation has not been studied. Purpose We sought to compare pathobiology of the culprit lesions assessed by optical coherence tomography (OCT) among the four seasons. Methods Patients with ACS who underwent OCT were recruited from 6 countries in the Northern Hemisphere. The prevalence of 3 most common pathologies, plaque rupture, plaque erosion and calcified plaque, and other features of coronary plaques were compared among the four seasons. Results In 1113 patients with ACS, 284 (25%) patients were admitted in spring, 243 (22%) patients in summer, 290 (26%) patients in autumn and 296 (27%) patients in winter. The proportion of underlying 3 pathologies was significantly different in each season (prevalence of plaque rupture, plaque erosion, calcified plaque was 50%, 39%, and 11%, respectively in the spring; 44%, 43%, and 13% in the summer; autumn: 49%, 39%, and 12% in the autumn; 57%, 30%, and 13% in the winter; P=0.039). The proportion of plaque rupture was higher in winter but lower in summer, and that of plaque erosion was higher in summer, but lower in winter. Maximum and minimum temperatures on the day of OCT procedure were significantly lower in the plaque rupture group than in the plaque erosion group (P=0.02 and P=0.012, respectively). In the rupture group, the prevalence of hypertension was significantly higher in winter, but in the erosion group, it was not different among the four seasons. Figure 1. The proportion of culprit lesion characteristics were significantly different among the 4 season groups. (P=0.039) The proportion of plaque rupture was significantly higher in winter but lower in summer. In contrast, the proportion of plaque erosion was higher in summer, but lower in winter. Conclusions Seasonal variation of the underlying mechanisms of ACS reflects different pathobiology. The proportion of plaque rupture is highest in winter and the proportion of plaque erosion is highest in summer. A different approach may be needed for the prevention and treatment of ACS depending on the season of its occurrence.

scholarly journals Prevalence and Impact of Fibrinolytic Dysregulation in Patients with Acute Coronary Syndromes

2020 ◽  
Author(s):  
Huaibin Wan ◽  
Zhihao Wu ◽  
Zhenbang Lie ◽  
Daqiang Li ◽  
Shaohui Su
Keyword(s):  
Acute Coronary Syndrome ◽  
Cox Regression ◽  
Coronary Thrombosis ◽  
Major Adverse Cardiovascular Events ◽  
Prognostic Information ◽  
Cox Regression Analysis ◽  
Coronary Syndrome ◽  
Poor Outcomes ◽  
Fibrinolysis Shutdown

Abstract Background：Dual antiplatelet therapy can reduce coronary thrombosis and improve the prognosis in patients with acute coronary syndrome (ACS). However, there was limited prognostic information about fibrinolytic dysregulation in patients with ACS. This study is aimed to evaluated the prevalence and impact of fibrinolytic dysregulation in patients with acute coronary syndrome (ACS).Methods：We retrospectively analyzed coagulation and fibrinolysis related indexes of ACS in hospitalized adults with rapid thrombelastography between May 2016 and December 2018. All of the follow-up visits were ended by December 2019. The primary outcome was the occurrence of major adverse cardiovascular events (MACEs), which included unstable angina pectoris, non-fatal myocardial infarction, non-fatal cerebral infarction, heart failure and all-cause death. Results：338 patients were finally included with an average age of 62.5 ± 12.8 years old, 273 (80.5%) were males, 137(40.5%) patients were with STEMI. Fibrinolysis shutdown and hyperfibrinolysis were observed among 163 (48.2%) and 76(22.5%) patients, respectively. During a total of 603.2 person·years of follow-up period, 77 MACEs occurred (22.8%). Multivariate Cox regression analysis indicated that age [HR: 1.031 95% CI: 1.007-1.056, P = 0.012] and LY30 [HR: 1.097, 95% CI: 1.013-1.188, P = 0.023] were independently correlated with the occurrence of MACEs. The hazard ratios pertaining to MACEs in patients with LY30＜0.8% and ＞3.0% compared with those in the physiologic range(LY30: 0.8-3.0%) were 2.275 [HR: 2.275, 95% CI: 1.241-1.241, P = 0.003] and 1.196 [HR: 1.196, 95% CI: 0.679-2.109,P=0.535], respectively.Conclusions: Fibrinolytic dysregulation is very common in selected patients with ACS, and hyperfibrinolysis (HF) (LY30 >3%) is associated with poor outcomes in patients with ACS

P6394Neutrophil activation patterns in acute coronary syndrome with intact fibrous cap - results from the OPTICO-ACS study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D Meteva ◽  
C Seppelt ◽  
Y Abdelwahed ◽  
H Rai ◽  
B E Staehli ◽  
...  
Keyword(s):  
Cell Death ◽  
Acute Coronary Syndrome ◽  
Endothelial Cell ◽  
Neutrophil Granulocytes ◽  
Culprit Lesion ◽  
Activation Markers ◽  
Activation Patterns ◽  
Coronary Syndrome ◽  
Fibrous Cap ◽  
Endothelial Cell Death

Abstract Background In up to one third of all cases, acute coronary syndrome occurs without signs of plaque rupture. Instead endothelial cell erosion is considered to be the hallmark of acute coronary syndrome with intact fibrous cap (IFC-ACS), with matrix metalloproteinase 9 (MMP9) directly linked to this pathology. The main source of MMP9 immediately after ACS are the neutrophil granulocytes. Therefore, their molecular activation patterns and subsequent MMP9 production are the objectives of the ongoing, translational OPTICO-ACS-Study, aiming to compare the mechanisms and prognosis of IFC-ACS and ACS with ruptured fibrous cap (RFC-ACS). Methods Local and systemic blood samples were simultaneously obtained from the site of the ACS-causing culprit lesion (LOC) using an aspiration catheter and from the systemic circulation (SYS). Using optical coherence tomography (OCT) the ACS-causing culprit lesion was characterized and two patient groups, patients with ACS caused by intact (IFC-ACS) and by ruptured fibrous cap (RFC-ACS) were compared. Each group consists of twenty patients (n=20) matched by age, gender and diabetes. Neutrophil counts and expression of activation markers were immediately quantified by whole-blood flow cytometry. Release of active MMP9 into the plasma was assessed by fluorescence-based zymography. Activation profiles of freshly isolated neutrophils, including MMP9 activity and effect on endothelial cell death, in response to toll-like receptor 2 (TLR2) stimulation was studied. Results Local neutrophils of patients with IFC-ACS show significantly higher expression of TLR2 in comparison to RFC-ACS neutrophils (LOC: 1866±382.1 vs. 1498±426.9; IFC-ACS vs. RFC-ACS, p=0.03). MMP9 activity is significant higher (p=0.01) in plasma obtained from the culprit site of IFC-ACS (74.1 U/ml±4.1) compared to those of RFC-ACS patients (70.0 U/ml±5.1) indicating secretion and activation of the enzyme during IFC-ACS. Importantly, in patients with IFC-ACS, TLR2-stimulation using Pam3CSK4 triggers higher activity rates of MMP9 only in neutrophils isolated directly from the culprit site (LOC), but not systemically (+27%±17.2% IFC-LOC vs. IFC-SYS; p=0.003). This effect was not observed in RFC-derived neutrophils. Inhibiting TLR2 by a monoclonal antibody, strongly reduced secretion of activated MMP9 only in the local neutrophils from IFC-ACS-patients (−54.6%±6.5% in IFC-LOC-anti-TLR2 vs. IFC-LOC-vehicle; p=0.008), but not from systemic IFC-neutrophils, nor from RFC-neutrophils. Furthermore, LOC IFC-ACS neutrophils aggravate endothelial cell death upon TLR2-activation in comparison to LOC RFC-ACS neutrophils (58.4±4.96% vs. 20±1.89%, IFC-ACS vs. RFC-ACS; p=0.0023). Conclusion We newly describe differential kinetics of MMP9 release by neutrophils in ACS patients with IFC versus RFC. Our data support a role of a TLR-2 activated and neutrophil-MMP9-mediated mechanism leading to endothelial cell erosion in patients with IFC-ACS. Acknowledgement/Funding DZHK (German Centre for Cardiovascular Research); BIH (Berlin Institute of Health)

Seventeen-Year Mortality following the Acute Coronary Syndrome: Gender-Specific Baseline Variables and Impact on Outcome

Cardiology ◽  
2019 ◽  
Vol 143 (1-2) ◽  
pp. 22-31
Author(s):  
Annica Ravn-Fischer ◽  
Elisabeth Perers ◽  
Thomas Karlsson ◽  
Kenneth Caidahl ◽  
Marianne Hartford
Keyword(s):  
Acute Coronary Syndrome ◽  
Cardiogenic Shock ◽  
Cox Regression ◽  
Late Mortality ◽  
Killip Class ◽  
Coronary Syndrome ◽  
Gender Specific ◽  
Long Term Mortality

Background: Gender differences in outcome and its predictors in patients with acute coronary syndrome (ACS) continue to be debated. Objectives: To assess long-term mortality and explore its association with the baseline variables in women and men. Methods: We followed 2,176 consecutive patients (665 women and 1,511 men) with ACS admitted to a single hospital and still alive after 30 days for a median of 16 years 8 months. Results: At the end of the follow-up, 415 (62.4%) women and 849 (56.2%) men had died (unadjusted hazard ratio [HR] for women/men 1.18 (95% confidence interval [CI], 1.05–1.33, p =0.005). After adjustment for age, the HR was reversed to 0.88 (95% CI, 0.78–1.00, p =0.04). Additional adjustment for potential confounders yielded a HR of 0.86 (95% CI, 0.76–0.98, p = 0.02). Using multivariable Cox regression, previous heart failure, previous or new-onset atrial fibrillation, and psychotropic drugs at discharge were significantly associated with increased long-term mortality in men only. Known hypertension, elevated creatinine, and inhospital Killip class >1/cardiogenic shock were significantly associated with mortality only in women. For late mortality, hypertension and inhospital Killip class >1/cardiogenic shock interacted significantly with gender. Conclusion: For patients with ACS surviving the first 30 days, late mortality was lower in women than in men after adjusting for age. The effects of several baseline characteristics on late outcome differed between women and men. Gender-specific strategies for long-term follow-up of ACS patients should be considered.

P5656Heart failure clinical phenotypes and outcomes in patients with atrial fibrillation: an analysis from the eurobservational research programme in atrial fibrillation long-term general registry

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Proietti ◽  
C Laroche ◽  
A Tello-Montoliu ◽  
R Lenarczyk ◽  
G A Dan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Regression Analysis ◽  
Cox Regression ◽  
Adverse Outcomes ◽  
Cox Regression Analysis ◽  
Coronary Syndrome

Abstract Introduction Heart failure (HF) is a well-known risk factor for atrial fibrillation (AF). Moreover, HF is associated with worse clinical outcomes in patients with known AF. Recently, phenotypes of HF have been redefined according to the level of ejection fraction (EF). New data are needed to understand if a differential risk for outcomes exists according to the new phenotypes' definitions. Purpose To evaluate the risk of major adverse outcomes in patients with AF and HF according to HF clinical phenotypes. Methods We performed a subgroup analysis of AF patients enrolled in the EORP-AF Long-Term General Registry with a history of HF at baseline, available EF and follow-up data. Patients were categorized as follows: i) EF<40%, i.e. HF reduced EF [HFrEF]; ii) EF 40–49%, i.e. HF mid-range EF [HFmrEF]; iii) EF ≥50%, i.e. HF preserved EF [HFpEF]. Any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death, CV death and all-cause death were recorded. Results A total of 3409 patients were included in this analysis: of these, 907 (26.6%) had HFrEF, 779 (22.9%) had HFmrEF and 1723 (50.5%) had HFpEF. An increasing proportion with CHA2DS2-VASc ≥2 was found across the three groups: 90.4% in HFrEF, 94.6% in HFmrEF and 97.3% in HFpEF (p<0.001), while lower proportions of HAS-BLED ≥3 were seen (28.0% in HFrEF, 26.3% in HFmrEF and 23.6% in HFpEF, p=0.035). At discharge patients with HFpEF were less likely treated with antiplatelet drugs (22.0%) compared to other classes and were less prescribed with vitamin K antagonists (VKA) (57.0%) and with any oral anticoagulant (OAC) (85.7%). No differences were found in terms of non-vitamin K antagonist oral anticoagulant use. At 1-year follow-up, a progressively lower rate for all study outcomes (all p<0.001), with an increasing cumulative survival, was found across the three groups, with patients with HFpEF having better survival (all p<0.0001 for Kaplan-Meier curves). After full adjustment, Cox regression analysis showed that compared to HFrEF, HFmrEF and HFpEF were associated with risk of all study outcomes (Table). Cox Regression Analysis HR (95% CI) Any TE/ACS/CV Death CV Death All-Cause Death HFmrEF 0.65 (0.49–0.86) 0.53 (0.38–0.74) 0.55 (0.41–0.74) HFpEF 0.50 (0.39–0.64) 0.42 (0.31–0.56) 0.45 (0.35–0.59) ACS = Acute Coronary Syndrome; CI = Confidence Interval; CV = Cardiovascular; EF = Ejection Fraction; HF = Heart Failure; HR = Hazard Ratio. Conclusions In this cohort of AF patients with HF, HFpEF was the most common phenotype, being associated with a profile related to an increased thromboembolic risk. Compared to HFrEF, both HFmrEF and HFpEF were associated with a lower risk of all major adverse outcomes in AF patients.

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