Frequency of venous thromboembolism risk factors in hospitalized patients with pulmonary embolism in routine Russian practice

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Ryazan State Medical University Despite advances in the diagnosis and treatment of Pulmonary Embolism (PE), it remains one of the most common causes of death among cardiovascular diseases. Purpose. To study the prevalence of the Venous Thromboembolism (VTE) risk factors (RFs) among patients with PE in the typical Regional Vascular Centers in Russia. Materials and Methods. The study was conducted within the framework of the Russian SIRENA Register. А retro- and prospective analysis of the clinical cases (n = 107, median age 63 (52-74) years, 39.3% of men) of PE treated at the Regional Vascular Centers from 01 May 2018 to 31 May 2019 (13 months) was performed. Results. It was revealed that 72.9% of patients had multiple RFs. The average number of strong RFs per PE patient is 1.1, moderate RFs – also 1.1, weak RFs - 2.4. Strong (± moderate and weak) RFs were registered in 26.2% of patients. The most common strong RFs is a history of VTE (22.4% of the PE cohort). Moderate (± low) RFs were observed in 31.8% of PE cases. The most common moderate RFs is malignant neoplasms (17.8%, n = 19; 7 out of 19 had metastases, 5 out of 19 received chemotherapy). In the 40.2% of patients, only weak RFs were identified. The most prevalent were arterial hypertension (70.1%), old age (59.8%) and obesity (46.7%). As a result, 6.5% of PE patients did not have any RFs, and 67.3% of PE patients did not have reversible RFs. Сonclusion. A high frequency and multiple character of VTE RFs were registered in PE patients in routine clinical practice. The greatest frequency is common cardiovascular RFs, which allows to consider VTE as part of the cardiovascular continuum. In a small number of PE patients, no known VTE RFs were detected, which determines the need to study other possible conditions that contribute to the PE development. Two-thirds of patients do not have reversible VTE RFs, which leads to the need for active anticoagulant prevention of PE in these patients.

Co-design of cardiac rehabilitation delivery in the aftermath of COVID-19, putting the patient view back in the picture

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Research and Development PhD Fellowship Background Poor uptake and adherence to Cardiac Rehabilitation (CR) is a longstanding problem exacerbated by the Covid-19 pandemic. Since lockdown, several alternative formats have been utilised to adapt to social distancing requirements, but evaluation of these is needed1. Purpose This study uses Experience Based Co-Design to identify novel approaches to delivering CR in a post COVID-19 era. Methods Using a co-design approach 58 participants were recruited, these included staff, patients who attended, dropped out or did not attend CR. Interviews and focus groups were recorded, transcribed, and analysed using template analysis. The results will be depicted through video at a co-design workshop where innovative approaches will be discussed and prioritised by the study participants. Results The main themes developed from interview and focus group include 1. Staff & hospital treatment, 2. Patient characteristics, 3. Emotional state, 4. What Cardiac Rehabilitation is, 5. Time, location and delivery, 6. Self-Care and finally, 7. Technology. These themes are conveyed through a 15-minute trigger video along with quotations to stimulate discussion. Anticipated outcome will be 4-5 approaches which can be adapted for implementation. Conclusion The forthcoming co-design workshop will present findings to patients and staff in a virtual setting allowing valuable co-ownership of the outcomes. This presentation will describe an innovative process that has redesigned CR using the perspective of all stakeholders and sought to maximise choice and flexibility for a post-COVID climate.

Influence of frailty syndrome on anxiety and depression of patients with atrial fibrillation

Funding Acknowledgements Type of funding sources: None. Background. Atrial fibrillation (AF) is a chronic disease whose somatic symptoms cause patients to feel anxiety. Anxiety and depression are associated with recurrent episodes of AF and may exacerbate the symptoms of arrhythmia, increasing the risk of sudden complications and death. The evidence suggests that frailty leads to cognitive decline and increased prevalence of anxiety and depression. However, there is little information on what increases the risk of frailty syndrome in atrial fibrillation. The aim of the study was to determine the impact of frailty syndrome on anxiety and depression in patients with AF. Material and methods. The study was conducted on 158 patients with AF (including 78 women) aged 70.4 ± 7.6 years. Standardized tools were used: the Edmonton frailty scale (EFS) and the hospital anxiety and depression scale (HADS-M) to assess and compare anxiety, depression, and frail and non-frail patients with AF. Results. The average ESF score was 8.555.0. 53.2% had frailty syndrome, 10.1% were vulnerable and 36.7% had no frailty syndrome. Mean level of anxiety was 10.253.0 and depression was 9.83.85. In comparative analysis patients with frailty syndrome had more often high level of anxiety (73.8% vs. 18.9%, p < 0.001) and high level of depression (72.6% vs. 2.7%; p < 0.001) in comparison to patients without frailty syndrome. In multivariate analysis the independent determinants of frailty syndrome were longer duration of AF (β=4.649, p = 0.001), anxiety (β=2.4727, p = 0.036) and depression (β=5.5712, p < 0.001). Conclusions. Patients with AF have high level of FS and anxiety and depression, and FS exacerbates the symptoms of anxiety and depression. Independent determinants of frailty syndrome are longer duration of AF, anxiety and depression.

Electric myocardial inhomogeneity and stroke: connection and specifics

Funding Acknowledgements Type of funding sources: None. Background. The inconsistency of the literature data on the influence of different hemispheric localization of Cerebrovascular accident (CVA) on the development of cardiac arrhythmias suggests the expediency of further study of the so-called "zones" of the cerebral cortex associated with electrical instability of the myocardium. It is known that dispersion of QT interval and fragmented myocardial activity belong to the markers of electrical instability of the heart and are associated with arrhythmogenesis. The aim of the study. To study the severity of abnormalities of the parameters of electrical instability of myocardium in right and left hemispheric stroke localization in patients with hypertension. Material and methods. 111 patients with left hemispheric localization of ischemic stroke and 75 patients with right hemispheric stroke were examined. Hemorrhagic stroke was observed in 17 patients in the left hemisphere and in 13 patients in the right hemisphere. The average age was 58,2 ± 7,48 years. For all strokes, men prevailed (64% vs. 36%). For the first day of the stroke, all patients were evaluated for QT dispersion and fragmented myocardial activity on the device "Polyspectro-8EX" (Russia). Research results. Evaluation of the parameters of electrical instability of myocardium in patients with stroke revealed more pronounced disorders in hemorrhagic stroke of left hemispheric localization (Table 1). In ischemic stroke, the severity of electrophysiological parameters, reflecting the instability of the myocardium depending on the hemispheric localization, indicates the absence of differences. Conclusions. 1.The most pronounced disturbances in the parameters of electrical stability of the myocardium is observed in hemorrhagic stroke. 2.The severity of myocardial electrical instability in ischemic stroke is not associated with the localization of the focus.

Cardiac magnetic resonance in COVID-19 positive and probable cases: A report from a high volume CMR centre in Ireland

Funding Acknowledgements Type of funding sources: None. Introduction Coronavirus disease 2019 (COVID-19) infection can have multisystem involvements. The inflammation sequelae can cause myocarditis. The COVID-19 pandemic has impacted Ireland significantly. Understanding of myocardial involvement in COVID-19 is not fully elucidated but has been reported. The Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic in Ireland is a high volume CMR centre with approximately 4500 cases per year and accepting referral from all hospital in Ireland. These analyses are to describe the CMR findings in COVID-19 positive and probable cases attending the centre. Methods Consecutive 65 referrals with mention of "COVID-19" from March 2020 to December 2020 was assessed. 56 cases were included in this analysis. Cases were categorised as COVID-19 positive cases or probable (viral illness like symptoms) cases. The demography and CMR parameters were collected. Serial imaging of selected cases was included. Descriptive analyses methods were applied. Results In the period of 10 months, there was 49 COVID-19 positive cases (65.3% male; median age 49 [32 : 61] years) and 7 COVID-19 probable cases (42.9% male; median age 39 [37 : 59] years). In the COVID-19 positive cases, 25 had normal CMR, 11 has evidence of myocarditis, 1 with pericarditis, 2 with infarction/ischaemia, 3 with dilated cardiomyopathy, 2 with hypertrophic cardiomyopathy and 5 with other findings. There were 3 COVID-19 positive cases with serial imaging showing resolving myocarditis (100% female; median age 41 [30 : 47] years). 2 professional athletes with COVID-19 positive test showed no evidence of myocarditis. There are no significant differences in the age of male COVID-19 positive versus female group (p= 0.0752). Different demography and CMR parameters and tissue characterisation are described in Table 1 and Table 2. Conclusions The prevalence of myocarditis in this cohort is approximately 1 in 5 (21.4%). Within the COVID-19 positive cases, the prevalence is 22.4%. These observations may reflect selection bias for CMR referral in those with cardiac symptoms or cardiac enzymes leak.

Localization of ST-elevation on ECG is associated with regional myocardial fibrosis in acute myocarditis

Funding Acknowledgements Type of funding sources: None. Introduction Both ST elevation (STE) on ECG and late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) are related to poor outcome in myocarditis. Purpose We evaluated if there is an association between regional STE and LGE pattern in patients with suspected myocarditis. Methods 51 patients (42 male, 32 ± 13 years old) underwent 12-lead ECG and CMR with LGE due to suspected myocarditis. >1mm STE was assessed in the antero-septal (V1-V4, aVR), inferior (II, III, aVF) and lateral (I, aVL, V5-V6) localizations. LGE was quantified as visual presence score (VPS) (1-17) and visual transmurality score (VTS) (1-68) on CMR, according to the 17-segment AHA model. STE and LGE were correlated using linear regression analysis. Results 31% of the patients had STE on admission ECG and a median VPS of 3 (IQR: 1-5) and VTS of 6 (IQR: 3-11) on CMR. STE showed an association with VPS and VTS in univariate and multivariate analysis (p < 0.001 all). STE was most frequent in the lateral and inferior leads (48% and 31%) which correlated with regional VPS and VTS in univariate model (p < 0.05 all), and remained significant in multivariate analysis for VPS (p < 0.05 both). STE was less frequent in the antero-septal region (21%, where no association between LGE and STE could be revealed (p > 0.05 all). Conclusions Inferior and lateral STE in myocarditis is associated with regional LGE on CMR, which is an indicator of myocardial fibrosis and possible poor outcome. Our results need not be validated on larger cohorts with follow-up.

Overcoming claustrophobia in cardiovascular magnetic resonance with medical hypnosis

Funding Acknowledgements Type of funding sources: None. Background the role of Cardiovascular Magnetic Resonance has gained the more and more importance in the field of cardiovascular disease. Claustrophobia remains a frequent cause of failure to complete a CMR. It is estimated that 2 million scans worldwide cannot be performed annually either due to premature termination or refusal of the patient to be scanned due to claustrophobia. In this setting, medical hypnosis may prove useful to overcome this main limitation. Methods we propose an observational study of consecutive patients referred to CMR and known for severe claustrophobia. Patients were proposed to undergo CMR examination with the help of medical hypnosis according to Milton H. Erickson’s method or with administration of mild sedation (lorazepam 2.5 mg). Results 20 severe claustrophobic patients were considered in the study. 1 patient was excluded due to psychiatric condition, 1 patient undergo to general anesthesia, 5 patients refused the examination. Among the 13 patients, 10 underwent medical hypnosis while 3 patients accepted to undergo to CMR examination with the administration of lorazepam 2.5 mg. All patients treated with medical hypnosis were able to complete the examination with a great tolerance and no sign of stress or anxiety were reported. CMR protocol was performed according to clinical request and was not different form non-claustrophobic patients. None of the patients treated with lorazepam 2.5mg was able to complete the exam. Conclusion we prove medical hypnosis to be safe and effective in controlling patients’ anxiety, allowing optimal diagnostic imaging quality without the need to adapt the examination. Further studies in larger populations are needed to confirm our results.

Implementation of Rapid CMR Protocol in the COVID-19 era: improving scanning efficiency and increasing scanning capacity

Funding Acknowledgements Type of funding sources: None. Background During the COVID-19 pandemic, many non-urgent elective cardiac MRI (CMR) appointments were cancelled to minimise the risk of infection to patients coming to hospital. At the time of the first lockdown, our scanning schedule allowed on average 228 scans/month. Non-urgent elective studies were cancelled from April-June 2020, resulting in 684 scans added to the waiting list. Upon reactivation of our clinical CMR service, we developed a service quality improvement initiative consisting of using a ‘Rapid CMR’ protocol to reduce scanning time without compromising the test’s diagnostic accuracy, increase our scanning capacity and improve efficiency in reducing the backlog of requests. Purpose To demonstrate the increased scanning capacity generated by the adoption of the "Rapid CMR" protocol. Methods The Rapid CMR protocol was implemented in November 2020 to all scans requiring cines, late gadolinium enhancement ± adenosine stress (non-stress and stress studies). The protocol was modelled on prior published experiences[1,2]. Patients who underwent these scans with additional imaging (e.g. T2-STIR imaging) were excluded. Data was collected from Nov 2020 to Jan 2021 and compared with the same time period the previous year when the standard protocol was used (cf. Image 1). Data collected included scan duration (time from first to last image), whether the Rapid CMR studies maintained diagnostic quality (yes/no), and the did-not-attend (DNA) rate. Results With the Rapid CMR protocol 254 patients were scanned (114 non-stress, 140 stress), compared with 286 patients scanned with standard protocol in November 2019 to January 2020 (155 non-stress, 131 stress). Median scanning time in minutes for non-stress was 29 (IQR 25-34; Rapid) vs 37 (IQR 33-41; standard); (p < 0.001). For stress studies the median scanning time in minutes was 32 (IQR 28-36; Rapid) vs 41 (IQR 29-45; standard; (p < 0.001). The rate of suboptimal imaging due to patient factors (such as breathing or arrhythmia) was similar for each protocol (14.4% Rapid, 20.2% standard; p = 0.04). All Rapid studies were of diagnostic quality (Table 1). Saving c.8 minutes per scan led to an improved scanning time and schedule capacity of 21%. Fewer patients were scanned with the Rapid protocol due to pandemic related issues: patient reluctance to accept appointments (unfilled slots), cleaning measures between patients (on average ∼5 mins per slot reducing overall capacity), and a higher DNA rate: 15.3% (Rapid) vs 6.5% (standard); p < 0.001. Conclusion The Rapid CMR protocol resulted in a statistically significant reduction in scanning time (-8 min for both stress and non-stress CMRs) increasing our schedule capacity and improving efficiency by 21%, whilst maintaining diagnostic quality. The implementation of the Rapid CMR protocol is a feasible and effective strategy to tackle the backlog of CMR clinical request accumulated during the pandemic.

Getting to the bottom of research funding: Acknowledging the complexity of funding dynamics

Research funding is an important factor for public science. Funding may affect which research topics get addressed, and what research outputs are produced. However, funding has often been studied simplistically, using top-down or system-led perspectives. Such approaches often restrict analysis to confined national funding landscapes or single funding organizations and instruments in isolation. This overlooks interlinkages, broader funding researchers might access, and trends of growing funding complexity. This paper instead frames a ‘bottom-up’ approach that analytically distinguishes between increasing levels of aggregation of funding instrument co-use. Funding of research outputs is selected as one way to test this approach, with levels traced via funding acknowledgements (FAs) in papers published 2009–18 by researchers affiliated to Denmark, the Netherlands or Norway, in two test research fields (Food Science, Renewable Energy Research). Three funding aggregation levels are delineated: at the bottom, ‘funding configurations’ of funding instruments co-used by individual researchers (from single-authored papers with two or more FAs); a middle, ‘funding amalgamations’ level, of instruments co-used by collaborating researchers (from multi-authored papers with two or more FAs); and a ‘co-funding network’ of instruments co-used across all researchers active in a research field (all papers with two or more FAs). All three levels are found to include heterogenous funding co-use from inside and outside the test countries. There is also co-funding variety in terms of instrument ‘type’ (public, private, university or non-profit) and ‘origin’ (domestic, foreign or supranational). Limitations of the approach are noted, as well as its applicability for future analyses not using paper FAs to address finer details of research funding dynamics.

Impact of air pollution on mortality due to cerebrovascular diseases

Funding Acknowledgements Type of funding sources: None. Background The short-term effect of air pollution on cardiovascular mortality is well-documented but a scarce number of studies focus on cause-specific mortality in low-polluted areas. Purpose We decided to distinguish deaths due to cerebrovascular disease (CbVD) from a region widely known as the Green Lungs of Poland to assess the short-term effect of air pollution on CbVD mortality. Methods The analysis with almost 4,500,000 person-years of follow-up with a time-stratified case-crossover design was performed. Results are reported as odds ratio (OR) associated with an increase in interquartile range (IQR) of air pollution. Results In the overall analysis of the studied region PM2.5 had an impact on increased CbVD mortality at LAG 0 (OR 1.046, 95% CI 1.013 – 1.080, P = 0.006), LAG 0-1 (1.048, 1.002-1.082, P = 0.040), and LAG 0-3 (1.052, 1.015-1.090, P = 0.006). The influence of PM10 was noted at LAG 0 (1.041, 1.002-1.082, P = 0.040). CbVD mortality in Bialystok was increased by exposure to PM10 at LAG 0 (1.05, 1.00-1.09, P = 0.048) and CO at LAG 1 (1.07, 1.00-1.14, P = 0.04). Additionally, an effect of CO was observed in cold season at LAG 1 (1.09, 1.02-1.17, P = 0.02), LAG 0-1 (1.08, 1.00-1.016, P = 0.04), and LAG 0-3 (1.09, 1.01-1.18, P = 0.04). In Suwalki, an impact of PM2.5 was also observed. Conclusions A short-term increase in air pollutants concentrations, especially in PM2.5 and CO, had an influence on CbVD mortality. Mortality rates were significantly increased in cold season. We also found heterogeneity in the influence of major contributors on mortality between analyzed cities.