Perception of pharmacological prevention and subsequent non-adherence to medication in patients with ischaemic heart disease: a population-based cohort study

ObjectiveA patient-focused approach is advocated to embody risk of non-adherence to medication and subsequent adverse clinical outcomes following ischaemic heart disease (IHD). This study aimed to explore how patient perceived information on pharmacological prevention was associated with subsequent non-adherence to medication (measured by non-initiation, non-implementation and non-persistence) in patients with incident IHD.DesignCohort study.SettingDenmark.ParticipantsRegister-based cohort of 829 patients with incident IHD in 2013.MeasuresPerception covered whether patients’ experienced being adequately informed about their pharmacological prevention. Information on such was obtained from a survey and divided into ‘Well informed’, ‘Moderately informed’ and ‘Poorly informed’. Information on baseline characteristics, and reimbursed prescriptions of medication (antiplatelets, statins, ACE-inhibitors/angiotensin receptor blockers and β-blockers) during follow-up were obtained by linkage to nationwide public registers. Non-initiation and non-implementation of medication, measured as proportion of days covered, were analysed by Poisson regression. Non-persistence to medication, measured as risk of discontinuation, was analysed by multivariable Cox proportional hazard regression.Primary and secondary outcome measuresNon-implementation and non-persistence to medication up to 365 days of follow-up were primary outcomes. Secondary outcomes included non-initiation as well as non-implementation and non-persistence to medication at 180 days of follow-up.ResultsA dose–response association was in general found between perception of pharmacological prevention and risk of non-implementation and non-persistence. For example, the hazard of non-persistence to antiplatelets was 1.18 (95% CI 0.71 to 1.96) times higher for patients reporting 'Moderately informed' and 1.89 (95% CI 1.10 to 3.25) times higher for patients reporting 'Poorly informed', compared with patients reporting 'Well informed of perception of pharmacological prevention' up to 365 days of follow-up.ConclusionLower levels of perception of pharmacological prevention were associated with subsequent non-implementation and non-persistence to medication in patients with incident IHD.

483 Minoca in a young patient with elevated platelet count

Aims Ischaemic heart disease is rare in young women, especially in the absence of a positive family history and strong cardiovascular risk factors, such as insulin-dependent diabetes. However, the correct diagnosis of ischaemic heart disease in young population is mandatory, and the specific aetiology should be identified to ensure a proper treatment. Methods and results We present the case of a 35-year-old caucasian woman who underwent ambulatory cardiological evaluation after episodes of chest pain and worsening dyspnoea (NYHA class II). The patient was asymptomatic at rest, BP was normal, heart rate was 80/minute in sinus rhythm, with no clinical signs of acute heart failure. ECG showed sinus rhythm with Q wave (lead DIII) and negative T waves (inferior leads). At echocardiographic evaluation LV was severely dilated (EDVi 105 ml/mq, EDD 66 mm) with akinesia and scar in the infero-posterior wall determining moderate reduction in ejection fraction (LVEF 40%), associated with secondary moderate mitral regurgitation; the right ventricle, the other valves and the aortic root were normal. The young lady was then admitted to Cardiology Unit for further investigations. She underwent cardiac MRI, which confirmed LV dilatation and dysfunction (EDV 198 ml/mq, LVEF 42%), associated with akinesia and infero-postero-lateral wall scar, with transmural myocardial fibrosis in the same segments, and subendocardial fibrosis on the basal segment of the anterior wall. Analysis of blood samples revealed elevated haemoglobin levels (Hb: 17.5 g/dl, n.v. 12–16 g/dl) and extremely elevated platelet count (PLT 945 000/mmc, n.v. 130 000–400 000/mmc). Cardiac troponin I (cTnI) was negative on serial determinations. All findings were suggestive for subacute infero-posterior myocardial infarction. Coronary angiography was performed via radial access: the exam was negative for significant stenosis in any coronary segment, only mild stenosis of proximal dominant left circumflex (LCX) artery was identified; moreover, there were no angiographic signs of coronary dissection. Eventually, SCAD and aortic defects were ruled out by coronary CT scan, which was negative for both coronary and aortic dissection. New blood samples examinations confirmed high values of Hb and PLT. Low levels of EPO (1.4 mU/ml) and JAK-2 mutation V617F positivity suggested the clinical diagnosis of essential thrombocythemia, later confirmed by bone marrow aspiration. Hydroxyurea was prescribed, as well as haematologic follow-up. Conclusions This is an interesting case of ischaemic heart disease, confirmed by ECG, echocardiography, and cardiac MRI, in presence of non-obstructive coronary artery disease. The aetiology of this specific case of MINOCA is potentially to be sought in the haematologic disorder. It is possible to hypothesize that a platelet/RBC clot might have determined acute obstruction of the proximal dominant LCX artery, then followed by spontaneous recanalization. Only mild stenosis on the proximal vessel was identified, and stenting was considered not appropriate for this lesion.

106 The effective study: development and application of a question-driven, time-effective cardiac magnetic resonance scanning protocol

Aims Long scanning times impede cardiac magnetic resonance (CMR) clinical uptake. A ‘one-size-fits-all’ shortened, focused protocol [e.g. only function and late-gadolinium enhancement (LGE)] reduces scanning time and costs, but provide less information. We developed two question-driven CMR and stress-CMR protocols, including tailored advanced tissue characterization, and tested their effectiveness in reducing scanning time while retaining the diagnostic performances of standard protocols. Methods and results Eighty-three consecutive patients with cardiomyopathy or ischaemic heart disease underwent the tailored CMR. Each scan consisted of standard cines, LGE imaging, native T1-mapping, and extracellular volume. Fat/oedema modules, right ventricle cine, and in-line quantitative perfusion mapping were performed as clinically required. Workflow was optimized to avoid gaps. See Figure 1 for protocol details. Time target was <30 min for a CMR and <35 min for a stress-CMR. CMR was considered impactful when its results drove changes in diagnosis or management. Advanced tissue characterization was considered impactful when it changed the confidence level in the diagnosis. Images’ quality was assessed. A ‘control group’ of 137 patients was identified among scans performed before February 2020. Compared to standard protocols, the average scan duration dropped by > 30% (CMR: from 42 ± 8 to 28 ± 6min; stress-CMR: from 50 ± 10 to 34 ± 6min, both P < 0.0001). Independent on the protocol, CMR was impactful in ∼60% cases, and advanced tissue characterization was impactful in > 45% of cases. Quality grading was similar between the two protocols. Tailored protocols did not require additional staff. Conclusions Tailored CMR and stress-CMR protocols including advanced tissue characterization are accurate and time-effective for cardiomyopathies and ischaemic heart disease.

582 Changes on diastolic and atrial functions following a single bout of two different exercise modalities in patients with hypertension and ischaemic heart disease

Aims Concurrent aerobic plus resistance exercise (RAE) and high intensive interval exercise (HIIE) are both effective on inducing post-exercise hypotension (PEH) in patients with hypertension. However central haemodynamic changes associated to PEH in hypertensive subjects with underlying ischaemic heart disease (IHD) have been poorly investigated. To compare the acute effects produced by these two exercise modalities on left ventricular diastolic function and left atrial function. Methods and results Twenty untrained male patients with history of hypertension and IHD under stable pharmacological therapy were enrolled. Each patient underwent three exercise sessions: RAE, HIIE, and a control session without exercise each lasting 45 min. Echocardiography examination was performed before and between 30 and 40 min from the end of the exercise sessions. In the first hour post exercise, BP values decreased in a similar way in RAE and HIIE and were unchanged after control. Compared to pre-session, E/E1 ratio increased after HIIE and remained unchanged after both RAE and control sessions (between-sessions P 0.002). PALS increased slightly after RAE (+1.4 ± 1.1%), decreased after HIIE (−4.6 ± 2.4%). and was unchanged after control. (between-sessions P 0.03). PACS was mildly increased after RAE, was reduced after HIIE, and was unchanged after control. Atrial volume was unchanged after both sessions. Left ventricular and left atrial stiffness increased significantly after HIEE while remained unchanged after RAE and control. Stroke volume and cardiac output increased after RAE, decreased after HIIE, and were unchanged after control. Conclusions Single sessions of RAE and HIIE determined similar PEHs in hypertensive subjects with IHD, while they evoked different central haemodynamic adjustments. Given its neutral effects of on diastolic and atrial functions, RAE seems more suitable for reducing blood pressure in hypertensive patients with IHD.

Anti-inflammatory therapy in ischaemic heart disease: from canakinumab to colchicine

Four large trials have recently evaluated the effects of anti-inflammatory drugs in the secondary prevention of major cardiovascular events (MACE) in over 25 000 patients followed for 1.9–3.7 years. CANTOS tested subcutaneous canakinumab [an anti-interleukin (IL) 1β antibody] 300 mg every 3 months against placebo in patients with a history of myocardial infarction (MI) and serum C-reactive protein (CRP) >2 mg/L, demonstrating efficacy in preventing MACE but increased rates of fatal infections. COLCOT (in patients with recent MI) and LoDoCo2 (in patients with chronic coronary syndromes) tested oral colchicine (an NLRP3 inflammasome inhibitor) 0.5 mg daily vs. placebo, demonstrating prevention of MACE with a slightly increased risk of pneumonia in COLCOT (0.9 vs. 0.4%) but not in LoDoCo2. CIRT tested oral methotrexate (an anti-rheumatic anti-nuclear factor-kB) 15–20 mg per week against placebo in ischaemic heart disease patients with diabetes or metabolic syndrome, without significant reduction in MACE rates or in circulating IL6 or CRP levels, and with increased risk of skin cancers. In summary, canakinumab and colchicine have shown efficacy in preventing MACE in ischaemic heart disease patients, but only colchicine has acceptable safety (and cost) for use in secondary cardiovascular prevention. Clinical results are expected with the anti-IL6 ziltivekimab.

What role for PCI in stable ischaemic heart disease?

Commentary on: Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020;382:1395–1407.Series co-ordinator: Dr Teck Khong, DTB Associate Editor Clinical Pharmacology, St George's, University of London, UK